August 7, 2012

Nutritional biochemistry

What does lower back pain have in common with low carb eating?

Read Time 8 minutes

Strange question, huh? Before you get too excited, I’m not about to tell you that a low carbohydrate diet is a remedy for back pain.  Instead, I am going to explain a remarkably parallel experience I’ve had. I never made the connection until this week when a reader asked an unrelated question about lower back pain.

The best, worst experience of my life

As my third year of medical school was winding down, and I was just about to embark on a bold fourth year curriculum of back-to-back-to-back-to-back surgical sub-internships, I was on top of the world.  I was 27 years old, living in Palo Alto, California with my best friends, I had a wonderful girlfriend, I was working hard to prepare for my application to a surgical residency, and I still found time to work out like a wannabe Olympian.  What more could I ask for?

One sunny, June afternoon I got out of the pool after a good workout and felt a very strange pain in my lower back.  After riding my bike a few hundred yards to the weight room, it wasn’t getting better.  Actually, it was getting worse.  So bad, in fact, I did something I’d never done before – I decided to skip my workout and pedal home.

I iced my back, took some ibuprofen, and went to bed.  The next morning I woke up only to realize I literally could not get out of bed.  After struggling for some time I had to call my roommate to get me out of bed and help me to the bathroom.  I called my chief resident and apologized that I would not be able to come in to the hospital that day, and assured him I’d be fine the next day.  But I wasn’t.  Nor was I fine the day after or the day after.

A few days later I managed to limp my way into the hospital for rounds and with the help of the residents and nurses who were kind enough to give me intramuscular injections of a potent drug called toradol, I was able to survive, just barely.  The pain had gotten worse over the week and I was unable to sleep in any position except lying face down over a counter in an “L” shape.  But the worst was yet to come.

Within a few more days, not only was my back hurting, but I was also experiencing profound sensory pain in my left leg and left foot.  I realize this may sound hyperbolic, but I am not exaggerating at all when I say it felt like the skin was being torn off the bottom of my left foot.  The only way I could sleep was to tie my left foot in a plastic bag of ice to numb it and take 100 mg of Benadryl (enough to put a horse to sleep).  When the ice melted, I would wake up in pain and need to repeat the routine.

Within about 3 weeks of this back and leg pain, I was starting to worry that something very serious was going on.  I’d had a backache or two before, and in one case it even took a week to resolve.  But this was very different.  One night, when the pain was so bad I couldn’t mask it with any cocktail of drugs I finally relented and went to the ER.  After a thorough exam, the physician sent me to the MRI scanner (for those of you reading this outside of the U.S., it must sound crazy to think that a patient could have a MRI scan so quickly).

The MRI showed not only a large herniation of my L5-S1 disk (a bulging of the disk between my L5 and S1 vertebrae), but it also showed a free fragment of broken disk sitting directly on the S1 nerve root.  While the large bulging disk was likely the cause of my back pain, the free fragment pressing one of the largest nerves in my body was undoubtedly the culprit in my leg and foot pain.

The next morning I was taken to surgery by a (supposedly) talented and reputable neurosurgeon.  I was actually very relieved and excited, despite never having undergone surgery or general anesthesia before.  I was told this surgery would fix the problem immediately.  But it didn’t.  In fact, as it turned out, this was the beginning of a long, sordid ordeal, albeit with a positive take-away that is the point of my story.

I woke up from surgery and immediately realized the pain was still there, in my left foot.  Worse yet, I had trouble moving my right foot, which was completely fine before surgery.  Over the next few days it became clear I had developed something called a foot drop on my right side.  I would later learn the surgeon had operated on the wrong side and likely injured the nerve on the right side. Things had gone from bad to worse.

Compounding this, the surgeon who operated on me refused to believe my description of what I was experiencing and was convinced I was just being “soft” for complaining of persistent pain and a new problem.  After 2 weeks of further deterioration — and only when another physician examined me, and herself ordered another MRI — did my surgeon agree I still had a significant surgical lesion.

That night I went back to the operating room and, this time, operating on the correct side, the surgeon removed a 4-centimeter fragment of disc from my spinal canal that was still compressing my S1 nerve root (below).

back pathology specimen

The next three months proved to be what I would later describe as the “best, worst” experience of my life – an assertion I still maintain nearly 15 years later.  For a number of other reasons and complications I suffered that I won’t detail here for sake of time and space, I became completely debilitated after developing another complication called a facet arthropathy.  So much so that my mother flew to California to stay with me, just to feed me and drive me around to endless doctor appointments.

My dream of becoming a surgeon had quickly vanished along with any athletic aspirations I once had.  I worried whether I’d ever walk again and had begun to accept the fact that I may be addicted to pain killers for the rest of my life. [For anyone familiar with such medications, I was taking about 200 mg of oxycodone per day – about 40 times what a “normal” person would take following a painful dental procedure.]

Things I once took for granted – walking, being able to lean over the sink while brushing my teeth, sneezing without feeling like my kidneys were being ripped out – became distant and fading memories.

Fortunately, with the help of some remarkable doctors (which included several more trips to the operating room), kinesiologists, and physical therapists, I would slowly learn to move again without pain.  I had to train as hard and deliberately for this as I had for every other athletic endeavor I’d ever poured myself into.

I experienced firsthand what narcotic withdrawal is like and the depression that accompanies it.  I experienced firsthand what an arrogant surgeon can do to a patient.  I learned more about medicine in that year than at any other time in my medical training.

As a postscript to this story, I eventually made a remarkable recovery and was able to begin my surgical residency a year later with minimal pain.  Today my back is stronger than it was before this incident. Except for the few people I have shared this story with (until now), no one would ever know what I went through.  I move through the world like someone with a perfectly healthy and strong lower back.

I also gained a profound understanding of pain and addiction, which became one of the most valuable lessons I carried with me through my brief medical career.  It allowed me to understand what a heroin-addicted person goes through, when viewed through the lens of my own experience with the strongest painkillers.

A few years later I would become close friends with Drs. Marty Makary and Peter Pronovost when our paths crossed during my residency at Johns Hopkins.  Marty and Peter have become two of the biggest pioneers of patient safety and the avoidance of medical mistakes.  My story became one of many presented in Marty’s soon-to-be-released book, Unaccountable.

Years later, based on my experience and research I did while overcoming this injury, I gave many talks on the treatment and prevention of lower back injuries and have become a minor expert on the subject.  If anyone is interested, here is a link to one of my presentations (slides only, no video/audio).

What does this have to do with a low carb diet?

Today, when I pick up anything, whether it be a cotton ball or a piece of paper, I do it with my legs, not my back.  When I lean over the sink to brush my teeth, I support the weight of my torso with my arm.  When I get out of a car or out of bed I position myself not to torque my back.  When I need to lift a 265 pound barbeque out of my car, like I did a few months ago, my lower back is never under strain.  How did I learn to do this?  Through a very deliberate and long process of adaptation.  I had to re-learn how to move, how to sit, how to lift, how to sneeze.  Were it not for the long and painful road to recovery I endured, I may have never learned these things.

Many people who suffer back injuries never really recover.  When they do “recover” from one injury, the rate of relapse is very high.  While no two cases are identical, much of the reason for this lies in 2 factors:

  1. The injured person does not learn how to modify their behavior to avoid re-injury.
  2. The injured person does not take the necessary steps to strengthen and rehabilitate their back.

“Curing” a back injury is not a temporary thing or something that just happens because we wish it to be so. It is a very deliberate lifestyle change.  Over time, as we form habits, we can go from consciously thinking through every necessary behavior change – something easy to do when we are in pain – to a place where the behavior is more automatic. But this takes time.

In many ways, transitioning to a low carbohydrate diet is similar.  Consider the figure below.

4 stages

Just like with behaviors that predispose us to lower back injury, most people go through life just eating on autopilot, but eating the wrong things, the “default” things.  They graze in a reactionary manner without any understanding of how what they eat impacts their body.  They are eating in an unconsciously incorrect manner.

Many people learn that what they are eating is actually not ideal and not predisposing them to maximum health.  They move into a place of consciously incorrect behavior.  They realize drinking a Coke with fries and a candy bar is not good for them, despite still eating them.  Some of these people go one step further and actually make corrections – removing sugar and simple carbohydrates from their diet, for example – but doing so requires great effort and deliberate action.  They are now in the realm of consciously correct eating.

This is the place where most people get stuck.  It hurts.  It’s hard to do.  They get frustrated.  Maybe even ridiculed by friends and family.  Most turn back to consciously incorrect eating with brief periods of re-visiting consciously correct eating.  Hence, only a few people make their way into the final stage of unconsciously correct eating, just as only a few people with serious back injuries ever make it into a state of unconsciously correct movement.

Why?

Because it takes a lot of time and a lot of effort.  It’s different for everyone, but I know for me it took almost 2 years to get to the point of unconsciously correct eating.  I had spent 36 years mindlessly eating the wrong way, just as I had spent 27 years mindlessly moving the wrong way before injuring my back.

Sixty years ago it was quite easy to default into the correct way of eating because we were mostly surrounded by foods that supported such eating.  But, our food environment has changed dramatically and today’s default eating (e.g., high amounts of sugar, grains, highly refined carbohydrates) puts most of us – about 60 or 70% of us – at serious risk of metabolic disease.  One day, I believe, the work of NuSI and others will fix this problem, and through the elucidation of unambiguous science allow us to create a food environment that supports easier (and more affordable) default eating of the right foods.   However, until then we have to go through these stages.

If you find yourself feeling frustrated at how difficult it is to get from consciously eating well to unconsciously eating well, remember that you are on a journey.  If you are consistent and patient, if you remind yourself that you are embarking on a journey to change your life and not a short-term fix to look good in a bathing suit next month, you will embrace the right mindset to find the ‘sweet’ spot of unconsciously correct eating.

I will be the first to admit that this is not easy.  But, if you’re reading this, you’re already down the path and you’ll be better able to help the next person who struggles through the 4 stages of transition because you’ve experienced it yourself.

Photo by Meta Zahren on Unsplash

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285 Comments

  1. Wow Peter. I recently embarked on my career in public health (I graduated a year ago with my MPH). In this post, you have managed to touch upon the two topics that most interest me, patient safety and nutrition (topics that would likely consume the majority of my conversations if permitted). Thank you for sharing your story. I am sorry that you experienced such a difficult and complicated recovery–thanks in great part to the surgeon–yet I greatly appreciate your ability to reflect on it as one of the most educational experiences in your life.
    Your parallels between eating and appropriate lifting technique behaviors are insightful. It is so true that the process of transition most often happens over an extended period of time, on a continuum. I have always been fit and athletic, but have dramatically reduced my carbohydrate consumption over the past year. I am currently training for my first marathon and I will do it on a ketogenic diet. It’s so neat to be able to run 9 miles at 7:45mi/min. pace, on an empty stomach in the morning!
    Your blog has been such an excellent source of information and I have passed it along to many a friend and family member. For me as a public health professional (who has read both of Gary’s books and his articles about poor epidemiological methodology/science), I am both excited and hopeful for what NuSci will bring! Keep writing, stay balanced, and we all look forward to what comes next…

    • Thank you so much, Alicia. It’s so exciting to know there is a new generation of public health professional out there. You’ll definitely want to pick up a copy of Marty’s book and get to know Marty and Peter. If you haven’t already, you should get to know Leah Binder of the Leapfrog group. Along with folks like Marty and Peter, these people are seriously cleaning up hospitals to ensure the crap that happened to me (and stuff much, much worse) doesn’t happen to others.

  2. Really enjoying your blog. This post was particularly apropos to me because I just started a Whole30, with the hopes that the very difficult consciously correct eating that I’ve been doing will turn into unconciously correct eating. Having toyed with Tim Ferriss’s slow carb diet for a while (and suffering huge carb hangovers the days after the “cheat day”), I realized I needed to get clean of carbs, an addiction not unlike pain killers. In your experience, which was more difficult, getting off carbs or oxycodone? Thanks again. Always look forward to eating academy posts!

    Dave

  3. I sincerely appreciate all your posts Peter. I am a physical therapist by trade, but also have a great deal of interest in nutrition and exercise physiology. My question is somewhat unrelated to this post, but I was wondering what your thoughts were regarding the Paleo diet. I have read Robb Wolf’s “The Paleo Solution” and Loren Cordain’s “The Paleo Answer,” as well as both of Gary Taubes’ books. I now follow your blog, and I would love to hear your thoughts on the Paleo diet in your own words. Thanks so much.

    • Mike, it’s too much to get into right now, but the short answer is I’m really good friends with Robb Wolf and we are very, very aligned philosophically. The distinction, in my mind, is that the “paleo crowd” (I hate these labels) uses a more teleological approach, whereas folks like me and Gary arrive at the same conclusion looking at the evidence. In essence, it’s a great way to feel confident about the outcome. Both the evolutionary story and the science line up. Sure, there are minor differences — while I’m happy to write about some time — but the “higher order terms” all align.

  4. Fabulous post Peter – Thank You. I really appreciate when you talk about behavior change, since that is the nut we all need to crack to get on the other side of this crazy and mortally threatening high carb, sedentary lifestyle. I realized a while back (after reading “Younger Next Year”) that the difference between a guy who dies at 60 and one who dies at 90 is that the 90 year old got 50% more life. The most important game anyone ever plays is “beat the reaper”.

  5. Hey Pete, thanks for the story, it puts things into perspective. The bad back analogy spoke volumes to me. As a college kid I was a grunt for the soda industry. People don’t realize how hard those guys work; people in America are obsessed with soft drinks, and the amount of physical labor it takes to get those to the grocery shelf is unbelievable. Picking up 40-50 pound cases all day, pulling 2,000 pound pallets hundreds of feet at a time, lifting and stacking those things all day long plays terror on your back. I too woke up one morning and wasn’t able to stand up to go to the bathroom. I was not as bad off as you, but I had to roll onto my stomach and push myself up with my arms to stand up. From that day on I’ve seen a chiropractor on a regular basis. I now see him once a week for what happened 11 years ago. Thankfully, I caught it early and made no permanent damage, even if I do still need adjusted a lot. Point is, you’re absolutely right in all that you said, and moving from consciously correct to consciously incorrect is the hardest discipline for a human IMO. Continuing a habit is easy, and normal, but building a habit takes time, effort, and sweat. That spoke volumes to me Pete, thank you.

    PS – You didn’t mention what hurt your back, do you know exactly what it was, or was it multiple things?

    • Thanks for your story, Gary. I suspect my injury was caused by the sins of my youth. I used to do very heavy squats and deadlifts — perhaps with imperfect form — along with a lot of spinning kicks in martial arts. Perhaps the stupidest thing I used to do was stiff-leg deadlifts. No shortage of dumb things I did growing up.

  6. Peter, I am very sorry you had the “worst” part of that “best worst” experience, even if you did learn lots from it. But am I the only one who was struck by how long it took a doctor (you) to go in and be checked out? What a riot. Sleeping over a counter? I thought I was stubborn! I have to admit, I got quite a laugh out of that – not out of the pain you were in, please know that!

  7. Not that you need another subject to tackle but back pain is such a chronic problem with everyone having an opinion as to treatment. I have had lower back problems for 20 years and do an assortment of exercises but never have been sure that everything that I do is correct or best to develop the proper muscles. This is for sure an area that the medical community needs work.

  8. VERY interesting post, indeed.

    i used to have lower-back pain but it wasn’t that horrible, just chronic. it went away after i started using systemic enzymes, but whether i can credit their anti-inflammatory virtues or the anti-viral, i don’t know.

  9. Powerful post. I feel like a LOT of people don’t understand how difficult consciously correct behavior can be – especially for somebody getting back to health from obesity. The environment was not the only reason I overate, but it was a contributing factor. Even after eating around 100g of carbs per day for 7 months, I will slip back into old habits if I don’t watch what I’m doing. I call it my eating autopilot, and I kid that it was programmed by Augustus Gloop (of Willy Wonka fame).

    Because of this, I journal every single thing I eat – even if I lapse and eat a funnel cake. I feel like I’m slowly reprogramming that autopilot, but I wouldn’t be surprised if it took at least another year+.

  10. Peter,

    A bit off topic here, but along the lines of getting from unconsciously incorrect to unconsciously correct, we have a few nieces and nephews in their early teens who may be able to benefit from learning about nutrition as you present it. Do you know of any good sources or techniques for teaching kids about this topic?

  11. Hello Dr. Attia. Thank you for your story. I wondered, have you gotten over the “drop foot”, or is that damage permanent? I have an interest, I developed a drop foot problem following a cath procedure (through the groin) about 3 years ago.

    • Luckily the damage reversed with a quick follow up surgery and lots of rehab. I mean *LOTS* of rehab. If rehab were an Olympic sport, I would have likely been on the team.

  12. I had paralyzing back and leg pain and muscle stiffness when I gave up gluten. Why? because I foolishly substituted maize corn and ate a huge bowl of grits. Turns out I am also allergic to corn, and the symptoms from that mimic (well, they probably WERE) rheumatism and arthritis. Cut out all corn products and after a few months no trace of it.
    But for a while I was even reacting to corn-fed chicken and ascorbic acid made from corn glucose.
    I wonder how many people with these conditions die without learning what really caused them.

  13. Right Post at just the right moment. Thank You
    School is about to begin (I am a high school teacher), wanted to start with the “oohs” and “ahs” of “Wow, you look great!” “You’ve lost a lot of weight over the break!” and “That low-carb must really work!”Not going to happen. Still struggling with the weight, even though I have been religiously low carb, have meticulously recorded fat to protein percentages, adjusted the percentages to where I am at 47% protein 43% fat 5% carb (for the life of me cannot account for the rest, perhaps waste management?)
    Anyway, having quite the pity party for myself, until today.I have constantly started, stopped, lost, gained, all of my adult life, this time it is different. This time I know I am on the right track. This time my focus is not just weight, it is health and weight. This life style feels right. I am onboard this train for the long haul. You are a great conductor, an even better teacher, and an inspirational role model. Keep up the great work. Oh, by the way my long term goal (for this tall 5’2 1/2 inch, 219lb. frame? To participate and complete the Marine Mud Race at Camp Pendelton. Thank You

    • Ellen, that sounds like a lot of protein. What would those ratios work out to if you were, say, 50 gm/d carb, 100 gm/day protein, X gm/day fat (where X = whatever you need to not be starving)?

    • Ellen, please spend a little time reading up on the “Stop the Thyroid Madness” website and forum. My thyroid doc (I actually found an educated one — SELF-educated, not standard AMA issue! {eye roll} ) said that I could be doing the exactly right diet (he’s all low-carb, bless) and exercising my fingers to the bone — and as long as my thyroid and adrenals were screwed up — I wouldn’t lose an ounce! (And I didn’t!)

      And oh! oh! The JOY! The HEAVEN that comes after treating my adrenals (and thyroid — but the adrenals come first)! I used to wake up “hung over” — “no loud noises please, no bright lights” — and my coffee would ‘fix’ me (because it whips the adrenals to perform, the poor things!). I was stiff (“well, I’m old, fat, and sedentary, what did I expect?” — except I was doing four hours a week of water aerobics … and losing no weight!) and the soles of my feet hurt (turns out that’s often adrenal!). I woke up feeling like someone had taken a bat to my kidneys. (you know, “old, fat, and sedentary”). I treated my adrenals (and it took nearly three years with physiological (wee small) doses of hydro-cortisone) and now — no stiffness (well, except for after eating wheat and/or nightshades!), I can walk out in the sun without cringing like my eyes were bleeding, the guy with the nighttime bat has left the building… Amazing! But you have to self-educate, because your doc won’t know — and your endo will know even less! Just like with diet — the docs (no offense Peter and other docs here) know only what they were taught — or what they personally lived through and set out by themselves to become smart about!

  14. Hi Peter,
    I have followed a similar path to you (without the surgury) with a torn left upper trapzius and bulged S4/S5 disc (not related, seperate injuries). I have also partaken in the olympic sport of rehab for many years, most of them unsuccessful. But the parallels you draw between overcoming injury to live a “normal” life, or just the very best you can with diet / nutrition kind of summed up the last 15 years of my life. Sometimes you just have to do the boring, unpopular, monotonous, difficult things in life to make a difference. For some like you and me – it was mostly to rehab injury. For others, making these hard nutritional choices means gaining back a “normal” existance of controlled weight, blood sugar, cravings etc. Repetition of good habits is what leads to that magical unconsciously correct state, which upon reading this post, I realised I have been living for both the management of my injuries (at present pain free and very capable of high intense exercise) and nutrition. The difference between unconsciusly incorrect (which I think is where most of society is) and the state we are in is worth incalcuable value in health benefits, dollars, and most of all, quality years of life. It’s worth it.

    • Totally agree, Anthony. But it’s a windy narrow road, which is why I’m so committed to not making it so difficult for all those others stuck in stages 2 and 3.

  15. Peter, thanks for sharing your experience.
    I have often moved carelessly when picking things up and will pay much more attention now. Thankfully I have never had backproblems at 49 years old and I think I have my experience with horseback riding to thank for that. As part of my training for horseback riding I learned to comfortably sit and bounce on an exercise ball to help strengthen my core muscles that support the lower back and the muscles in the pelvis. I now use it instead of a desk chair and roll around on it a lot, so never sit still for more than a few minutes. When horseback riding with a correct seat the movement of the horse will encourage free movement in the lower back and pelvis and this can be very therapeutic as well as prevent lower back problems.
    The exercises you are describing are very similar to those covered by Pete Egoscue in his book “Pain Free”. I believe if everyone followed the guidelines in that book many chiropractors would be out of work.
    Concerning the low-carb for teenagers, my 15-year-old daughter has recently read Mark Sisson’s “The primal Blueprint” and a number of your blogs without any problems and she is not a traditional learner. She is currently reading the new book by Jeff Volek and Stephen Phinney “The Art And Science of Low Carbohydrate Performance” and it is motivating her to experiment with a close to ketogenic diet (no grain, no beans, no sugar, carbs around 40-80grams/day) while training for her high-school swim team season this fall. I just wish she had a coach who is knowledgeable in this area. I guess she is doing an experiment of one and we are looking forward to seeing if she can reach her goal of making state time this year. 🙂
    I’m also hoping to have her read Gary Taubes “Why we get fat” soon and if her athletic performance improves we hope to share the message as some of her teammates are overweight if not obese.
    She is the only swimmer on her team who is not constantly eating, a huge change from before she went low-carb when she was snacking on carbs all day, although the choices she had were what we thought at the time to be “healthy and organic whole grains and beans” primarily.
    Now the treats are homemade ice cream made with raw whole milk and Xylitol or raw cheesecake made with a ground nut and butter crust and cream cheese, cocoa powder and Xylitol.
    I never thought this would be possible for a teenage girl. I am so thankful that I can spare her the sugar/carb addiction and the resulting belly fat that I lived with for decades in spite of moderate exercise. 🙂

    • Birgit, I’d really like it if you’d share the ice cream and cheesecake recipes! Exactly the things I want to try at home.

    • Lex, I’m too lazy to ever use recipes and exact amounts are not necessary for these so this is very approximate. I have gradually reduced the amount of Xylitol as my taste buds are getting more sensitive to sweet tastes.
      For the ice cream: about 1 qt whole milk or half and half or heavy cream or any combination of those (the more cream the lower the carbs), about 1 1/2 to 2 1/2 tablespoons of Xylitol and any or several of the following for flavoring: 1-2 tsp. vanilla, almond oil, peppermint extract, cinnamon; 2 tbsp. of cocoa powder, a cup of nuts or berries of your choosing (mix in in the last 5 minutes), 1-2 egg yolks from pastured poultry (we use our own duck eggs), unsweetened coconut flakes, 85% cocoa dark chocolate pieces …
      For the cheesecake:
      crust: 2 cups ground nuts (any type, even sunflower seeds will work), 4-6 oz. melted butter, mix well, spread in springform that is lined with waxed paper, refrigerate while making the filling
      Filling: mix 3- 4 packages of softened cream cheese, 3-4 tbsp. Xylitol, juice of one lemon and lemon zest to taste or for chocolate cheesecake cocoa powder to taste, one raw egg yolk (optional), spread in springform, chill for 1-2 hours minimum, serve with a few berries
      Enjoy!

  16. In regards to medical mistakes, it seems to me that the medical industry does not have a strong culture of pro-activelly finding and correcting potential mistakes. I understand that physicians can be sued for malpractice if a mistake is determined, but in general they are not putting patient safety at the forefront. One of the articles linked had an incident where a nurse pointed out to the physician that there was no blockage in the artery where a stent was going to be placed. The doctor blew him off and implanted it anyway. He reported this and the hospital agreed that this doctor had done many unwarranted cardiac procedures. Was he rewarded for speaking up? Of course not! His contract was not renewed. We make computer chips where I work and if we screw something up in the manufacturing process the chips won’t work. The wafers we make can’t sue us so our approach is very proactive. We reward behavior that can find situations that could lead to scrap or yield loss. We also do this for workplace safety and it is amazing how much improvement can be made in your quality indicators if you focus on the right things and encourage everyone to speak up and particiate. I watched the trailer and read some of the Unnaccountable excerps on Amamzon. It seems the cuture in medicine is to bury or minimize the admission of mistaktes (and protect the repeat offenders causing them), allow doctors to perform intrusive procedures that are not warranted to boost hospital profits, and poor communication of the downside risks of the procedures to be performed. I think you would find about 80% of the medical problems would go away if they removed the bottom 10% of poorly performing doctors. Sadly, that’s not going to happen. I’m glad you made it out alive. Cheers, Dave

  17. Thanks for this article. I really enjoy your thoughtful approach to nutrition, even though I’m not a low carb guy.

    I will share a trick that may help others. I fail miserably whenever I change my diet all at once (in other words jump from stage 2 to stage 3). Instead, I take a piecemeal approach to changing my diet. For example, I might start with improving my breakfast or not breaking down and binging on donuts at 10:00 AM. Then I practice that one improvement until I get it to stage 4 (or at least very easy if not completely unconscious). Since it’s only a small piece of the diet that I’m changing at once it takes only a week or two of practice before I’m ready to make my next improvement.

    Overall I haven’t progressed any faster. I’ve been at my target weight for 3 years now and I’m still tinkering with my diet. However, focusing on one piece at a time not only makes each day easier, but it also provides regular milestones of success (even when the scale doesn’t cooperate) which really helps my motivation.

    • Looking at your “How to lose weight” section, I see you already have much the same idea (expressed more clearly), with your own stepwise transition. My only new insight is that even your smaller steps would be too much for me to handle all at once and I would have to break them down into many smaller pieces. So rather than thinking of myself as struggling to get from stage 2 to stage 3, I would see myself making steady progress from 2.0 to 2.1 and then to 2.2 and so on.

  18. Man, I really wish you had a recording of one of your presentations. This is one of those things I’m shocked there is no centralized knowledge resource for. Do you have anywhere to point me to? I’ve suffered from on again, off again back pain and tried a bunch of things to help. I think the biggest thing for me was almost completely eliminating sitting. I either lie down or stand up most of the time when I’m using my computer/working, and try to take breaks to go walking. How long did you spend doing the exercises for your back? What was your typical routine for the exercises you put in your slides? I have had small success’s with Egoscue and Rolfing, but only seem to reinjure my back with ease, usually through weight lifting or Martial Arts practice. If I’m dedicated to healing my back, how long should I avoid these activities during the healing process?

    As for low carb, I’m totally straddling phases 2 and 3, retreating to 2 when dealing with anxiety. I’ve kindof turned it into a game now though, to see how many days I can go without having too many carbs, and so far my record is 4 months. That and I weight myself weekly. It seems my streaks are getting longer while my cheating is getting smaller.

    I just want to say right now you’re serving as a kind of inspiration for me. Recovering from back pain and losing the weight while still getting stuff done is the kindof example I need to see to not give up. Many props, and look forward to seeing what’s coming next.

    • Anthony, it would take me 10 hours to properly answer all of your questions. I’m sure there are good resources out there, as many readers have put forth ideas. One point is clear, though. If you reduce your weight, you’ll reduce the load on your lower back. That part, I hope I’m able to help with.

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