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.


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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  1. I too have recently come back from a terrible back injury. Years of playing football and (improper) power lifting left me with two herniated disks in my lower back. After multiple MRIs and epidural injections, I was told that I should never lift anything heavier than a milk jug. I was also told that major back surgury was in my immediate future. The news was devastating. This was the start of my two year food binge. I also used my back as an excuse of why I could not exercise and before I knew what happened I was up to 280lbs.

    Fortunately in April 2012 I had a moment of clarity after discoving the work of Gary Taubes. I immediately changed by diet and began a walking/jogging program known as “couch to 5k”. My weight began to rapidly drop and I was also able to moderate weight training into my routine. Now I am 45 lbs lighter and I have almost no back pain. I do get the occasional flare up but that’s easily treated with OTC meds.

    I will not say that I “cured” myself with diet and exercise but I did put my condition into remission.

    Peter- please keep up the good work!

  2. Hi Peter,

    I would like to thank Elenor and JohnK for their input. Elenor I checked out the blog, but do not think I fit the criteria. JohnK, I did try the no cream route, but found it did not impact my weight. Like the Ice coffee idea, although never cared for the taste when I was younger.

    Peter, may I steal your conscious chart? I want to hang it in my classroom. It is a great tool for high schoolers to make them conscious of how they can change negative habits.

    Lastly, I long ago (college freshman biology) heard that the faster you lose weight, the more free radicals your body produces, which increase your risk of cancer? Fact or fiction?

  3. Modifying behavior to avoid further injury is something that I have been interested in since tearing a muscle in my calf a few years back. You are so right about being conscious of how you move and what you are eating, its a principle I have used for a few years and its working!

  4. Again a blockbuster post that is all at once alarming, informative and interesting! Thank you. Working on my mom and step-dad to stop thinking about eating low carb as a “diet” and to start thinking about it as a way of life. I think my mom understands but the other night my step day snuck out of the house to buy a snickers bar…heh.

    Peter on a more serious note do you know of any studies that would prove this comment taken from a very old post?

    3. Caffeine causes release of adrenaline, which causes the liver to break down glycogen, causing a temporary increase of blood sugar, which causes insulin to be released. Thus the dreaded blood sugar/insulin roller coaster.
    This I cannot find an answer for. Does this same process happen under ketosis?

    Thank you for any light you might shed in this direction.

    • I’m not entirely sure this statement is correct in all folks, and if it is, I’m not sure how temporary or transient it is. Caffeine is kind of complex and probably does some other things also, such as interfere with hormone specific lipase (HSL) to increase fat oxidation.

  5. Hi Peter,
    Thanks for sharing all this. Having had a lot of severe pain myself for so many years, I can relate to the struggles you had with pain and pain pills. My recent surgery made things worse. It took some time to get off the Dilaudid, and the physical aspect was only part of the challenge. I think that certain foods can be just as addictive for a lot of people, and I love the way you explained the process of changing a habit. For me, realizing that issues with insulin and blood sugar are probably what caused my problems in the first place made it a little easier to cut it out of my diet cold turkey. It’s become a non-negotiable, if only for the reason that I never want to deal with that kind of pain and/or surgery again. Thanks for your story.

    • Sorry to hear about your struggle. As crazy as it sounds, you’ll be better for it if you make the effort (which it sounds like you are) to learn from it and apply it to other areas of your life and to others with empathy.

  6. This is such an interesting article with such a painful & triumphant story! As a recovering vegetarian, I’ve swung on the grains and legumes pendulum from “in a relationship with grains & legumes” to “It’s complicated” to “In a relationship with meat”.

    As a Registered Dietitian, I’m constantly sniffing out dietary trends and working through the literature to make sense of the contradictions. In the anectodal world, people evangelize the profundities of their preferred diets, whether it’s vegan, paleo, or many things in-between. I’m beginning to find myself observing that there are a lot of right “diet” systems when followed in their entirety. Dr. Dean Ornish produced studies that low-fat, high carb diets reverse heart disease. Atkins diet also shows reversal of inflammation, triglycerides, and weight (preventing heart disease). This is simplified, as there are many studies we could discuss.

    What are your thoughts on contradictory diets working out? And since I’m new to you, I’ll ask what you may have already stated: do you think that a low-carb diet is the only true answer, or do you think it depends on individual biochemistry? I’m sincerely interested in helping people make sense of the confusion.

    Thank you for your feedback, and I’m delighted I’ve found you. I plan to follow you more!

    • Frances, make sure to really scrutinize these studies. For example, Ornish didn’t show that a “low-fat, high carb” reversed heart disease. That’s how the press (and he) report it. Read my post on “Why Weight Watchers is a Low Carb Diet” where I explain his study in detail. Very misleading conclusion, once you understand the actual intervention.

  7. Great article and the four step change process really resonates with me for personal and work issues – essentially it’s change management!

    Having had a bad back with a slipped (herniated) disk – nowhere near as bad as your experience – I sympathise – until folk have such back troubles they don’t realise how painful and disabling it can be. Well done for persevering!

    Low carb eating is a label for what we really mean which is “Proper Eating” or “Healthy Eating” – i.e,, eating what our bodies evolved and adapted to be healthy on. I remind myself of this to help me when I want to weaken and eat bread, wraps, pasta, sweets or chocolate. These are not treats or “extras” but essentially toxins or nutritionally deficient and should be avoided.
    Do I always succeed? No!

    • I still eat wraps. I get the flax roll ups made by Damascus Bakeries, which use organic flax flour. While a full wrap has six net carbs, at least the flax has omega 3s. I found out about these on the “Getting Started On A Low Carb Diet” web site. Other ways I cheat are having the Weight Watchers, Healthy Choice, and Lean Cuisine entres that are low in carbs (from ten to 25 carbs), snacking on a lot of peanuts, eating a lot of Smucker’s Natural peanut butter, and eating kiwis for breakfast.
      These choices have a lot to do with my version of the “low cost/low carb diet”. While it’s hardly perfect, I’ve lost fourteen pounds (and kept them off for a few months), almost completely eliminated sugar from my diet (and this from a man who thought of heaven as a large bag of gourmet jelly beans), and greatly reduced craving attacks.
      I haven’t gotten any blood work done yet (my health insurance only allows one check-up a year), but my doctor described my numbers as “wonderful!” back in November, before I started my low carb diet. My Triglycerides were 99, and my HDL was in the low 30s (one above the lowest number for the “safe” range); maybe not so “wonderful!” after all. My LDL was low, so my doctor was very happy, but what test should I ask for to measure my LDL-P, and is it covered by GHI health insurance?

      • If you can go through Health Diagnostic Labs (who send the NMR testing out to LipoScience), all carriers I have encountered will cover the test, except Kaiser.

  8. Thanks, Peter. I have a feeling they’re not going to be familiar with this type of testing, but I’ll do my best to explain it to them.
    Take it easy on the back in the future.

  9. Reading you story was like reading my own. My first back surgeon (highly recommended) did the same thing.. The MRI 2 days post surgery proved it and I went in for another surgery immediately. Unfortunately, I have severe nerve damage and live with constant pain in my back, left leg and foot on a daily basis. I took Lyrica for awhile to control the pain, but I think the side effects were worse so I decided to live with the pain. At 42 I am worried every day what 50, 55, 60+ will be like for me. I have a career that requires a lot of sitting, so I have to struggle with the pain of sitting as well. It is sad that we have to deal and cope with pain every day.. I am happy for you that you have found your way! Take Care. Tammy.

  10. Hey Peter, Great post! It was very hard to hear how much you went through. I have similar a carb/ back connection for you as well.

    Since the age of 12 when I started working out, I suffered with back and neck issues up to the age of 38. Frequently my back would go out and I’d collapse to the floor and crawl my way home. I would often have to go the emergency room because my neck was literally stuck to one side with such major spasms I could not move without fear of pain.

    10 years ago I ran into a chiropractor, Dr. Skip George who introduced me to functional training and I learned how to strengthen my core and not fear my back. In the old days all my doctors and chiropractors advised nothing but back stretches. Great idea: just flex my spine all day long! Talk about barking up the wrong tree! Dr. Stu Magill, Gary Gray, Gray Cook and Dr. John Sarno all contributed to my continuing knowledge on healing my back.

    It is a conscious effort as you mention that needs vigilance. One slip up and I know the consequences. When I decided to clean up my eating habits 10 months ago, I threw that silly idea of moderation out the window. Would I just sometimes decide not to do stupid things to my back? Of course not! Collapsing on the floor and writhing in pain is a great deterrent. So why would I ever consciously cheat and eat crap?

    The big connection for me since eliminating these inflammatory foods is that my constant rotating pain and inflammation journey came to an end. The 1 year of tennis elbow. The 1 year of hip bursitis, the 6 months of plantar fasciatis, the intermittent back or neck pain has been conspicuously absent since eliminating refined foods in general and carbs in particular. Coincidence? I think not.

    Thanks for a great blog. You make me think and inform with great intelligence and logic. Loved the workout at FQ10!!

  11. At about 50 years old I started having sciatica pain and it got to the point that I was laid up 3 or 4 times a year for a week or better with terrible muscle spasms(I even contemplated suicide during one episode). I finally had a CAT scan done and found that I had two herniated discs, luckily since I had no insurance I wasn’t able to have surgery done(I paid for the CAT scan out of pocket). I read an Adele Davis book and one of the things she recommended for sciatica was vitamin D. I had read a book by a doctor whose mother had a horrible case of arthritis that was cured by taking cod liver oil so I used cod liver oil for my vitamin D. My sciatica was gone within two weeks of starting cod liver oil. I still had occasional muscle spasms from damaged muscle tissue that I have heard called “hot spots” but no more sciatica. Since then I have told several people about cod liver oil and to date everyone that has tried it has had their sciatica go away as long as they keep taking cod liver oil.

    I have no idea what cod liver oil does but it also worked for my sled dogs that had intervertebral disc disease which can be a canine form of sciatica. Two of my best dogs had to be on steroids. The one that got steroids at least one week out of every month was able to go without steroids from the time he was 12 years old until he died at 16 years old. The other went without steroids from time he was 8 years old until he died at 16 years old and he had to have them for a month every year when we started training. I waited for a long time to put them on cod liver oil because they were getting a lot of fish oil from salmon and I thought that was enough. Not so, when I finally put them on cod liver oil they responded in less than two weeks. Long distance sled dogs will get a sore back the day after a 200 mile run but if they’re on cod liver oil they don’t get sore backs after long runs. No placebo effects in sled dogs. Incidentally, once they moved from the main team to the geriatric team at 10-12 years old, these dogs ran 6-20 miles a day until a few months before they died.

    Glad I found your site through Mark’s Daily Apple.

  12. I find myself extremely fortunate that I found out about eating very low carb at a pretty young age(I’m 20) and that I found this blog while I was researching before I jumped in head first. I’ve been in nutritional ketosis for about a month now and have lost 10 pounds but more importantly inflammation in trouble spots around my body (mostly my axilla) have gone down dramatically. (I was diagnosed with Hidradenitis Suppurativa about a year ago). I just wanted to say thank you for your efforts and for the knowledge you share with the world just for the sake of sharing it and not for monetary gain like so many people seem to do these days. I wish you and Gary the best of luck with NuSI.

  13. Peter, I only skimmed your post but I got the gist of it. Basically you’re talking about practice. Learning new things and unlearning old things. Well, we don’t really unlearn old things, we just become out of practice, because well, we don’t practice them anymore. Do you know the writer Malcolm Gladwell? He wrote a book, Outliers, it explains why some are better than others. To summarize, those who are better simply practiced more than others.

    But on to the point of your post, which is basically that if we want to stop doing the wrong thing, we gotta start doing the right thing in its place. However, if we’ve been doing the wrong thing for a long time, then it’s going to take some effort to stop doing it, and replace it with the right thing. Bending over the wrong way to pick up stuff, we do that all the time. I put out my back once by setting a tee in the ground on the first tee on a glorious morning. Yet for a couple years before that, I went to the gym and lifted heavy weights off the ground using almost the same identical method a few times a week with nary a problem. That day, I just got careless and fell back into the old – and wrong – way of doing things. Maybe I should have practiced setting a tee in the ground more often than just those few times that I do it when I play a round of golf.

    In that book, Gladwell explains that those who are better don’t simply play more often or do whatever it is they do more often. They practice. Long hours every day for years on end. To apply this to us and low-carb, if we want to be good at it, we gotta practice too. Not just eat (low-carb) and forget about it between meals as most of us have been doing since we’re on this planet. A good way to practice low-carb happens to be reading recipe books. Practice isn’t just about doing, it’s also about studying. But – and most here will find just the suggestion boring – we don’t just have to do it, we have to do it repetitively. That means we gotta eat, or prepare the same meal at every meal for several meals until we get it right, or at least right enough for our purpose. How do you think a cook becomes good at cooking? Just like anybody else – with practice, lots of practice. Now I doubt many here want to become a cook, but that’s alright, we don’t have to. As Gladwell explains, we don’t need a lot of practice to become good _enough_. We only need enough practice and that could be a couple hours every week, until we’re good at it, and then we can go on with the next thing we want to become good enough at. And reading – studying – is almost as good as doing when it comes to learning, we can get away with reading for that time we dedicate to practice. Then, doing becomes the test of that reading just to make sure we got it.

    But then it’s not all to learn something new. We also have to keep up with practice to maintain our ability – our skill – with this new stuff we’re doing. However, since we don’t need to learn something new, we can get away with a bit less practice and study from now on, just to make sure we still got it. If you’ve ever read something again a long time after you read it the first time, and then realized you’d forgot about this or that, well that’s what I’m talking about. If you keep up with some amount of practice and study, that won’t happen. You won’t grow out of practice.

    Anyway, good luck with NuSI. I think you guys will need lots and lots of practice and study to keep on top of things.

  14. Hi Peter.

    I was interested to read that you experienced serious back problems.

    I’ve heard that back pain is an inevitable aspect of human upright posture, perhaps like painful childbirth owing to brain size etc. I’m not so sure now. It is possible that there is a much more direct link with dietary carbs and back pain than just the process of changing personal habits. (Or even pain sensitivity as mentioned by an earlier poster.)

    It’s been established that chronic elevated blood glucose saturation of body tissues is a likely contributor to heart disease. Via the accumulating glycation of structural protein over decades of exposure, similar to the vulcanising cross-linking of natural rubber to become stiffer and harder wearing car tyres, changing the elasticity of coronary arteries. These small arteries are subjected to a very high flow rate and high pressure associated with their proximity to the aorta and heart muscles. This leads to relatively higher physical stresses on these artery walls compared to other arteries, and therefore downstream cardiovascular issues.

    It seems reasonable to assume similar effects on other tissues, despite less vascularisation and blood flow rate, that depend instead on random circulation of nutrient fluid. Such tissues might accumulate an escalated lagging average exposure to a pool of slightly elevated blood sugar concentration causing similar vulcanising cross-linking in structural tissues over the decades. I’m thinking of myopia via stiff lenses which don’t relax back into their normal, flatter shape, plus the flexible bags holding spinal disks together and the load bearing surfaces in our knee joints.

    These tissues might resemble the compounds lining self-sealing aircraft fuel tanks, with exactly the right combination of flexibility, strength, stiffness, stickiness, solvent tolerance, and slightly malleable flow in order to meld together and fuse fissures caused by shocks and stresses. If blood sugar exposure affects this precise degree of plasticity then it may be that a high carb diet directly contributes to common issues as knee and back trouble, which often spell the end of serious sports for many professional and amateur athletes.

    I think that short sightedness is a consequence of the lens being too stiff and not relaxing back into a thinner shape for longer focal length scenes, while long sightedness is the lens being too stiff to be easily squeezed into a fatter shape for short focal length objects. Either way it’s more or less the same thing: the lens material is too viscous and doesn’t flow the way it should.

    Apparently even older people who are myopic also tend to experience the same problem with long sightedness that arises with people who are not myopic. Myopia is typically triggered by prolonged short range focussing earlier in life. Often associated with reading. There’s a genetic factor, but possibly it’s the genetics of glucose metabolism that might be the underlying driver.

    I’d be interested to know if there was any evidence of whether low carb eating might reverse these effects over time. Not exactly the fountain of youth, but perhaps a way towards living a less grumpy and irritable old age. It would be nice not only to avoid the alzheimers and the forgetting where the spectacles were left, but also to retain the knees and back have the energy to be able to run around looking for the spectacles, as well as to not to even need the spectacles to lose in the first place.

    • I am not aware of any clinical trials that have explicitly tested this. One can make the case that fat loss could improve back pain for a number of reasons, but your suggestion is very interesting as a separate mechanism.

  15. I’m not sure where to post this, so please forgive me if this is not the ideal place. I ran across this site a few months ago and I have thoroughly read everything posted here. With a science/medical background, I believe I understand it fairly well. I would like to use the diet principles, but my attempts at weight loss have failed miserably and completely so far. I am a 56-year-old female with metabolic syndrome and lifelong morbid obesity, but not diabetes. I have lost significant weight in the distant past on low-carb diets (30-40lbs), but the last few attempts have not produced similar results. I have spent more than a month following the hard-core version of Peter’s low carb/high fat diet, in full-blown ketosis, with light to moderate exercise. I eliminated sugar and starches completely and my only carbs come from low-glycemic vegetables and flax. Not only have I failed to lose any weight, but I was slowly and steadily gaining. I have since tried cutting back severely on calories while maintaining the high fat to protein ratio. Stopped gaining, but still no weight loss. I guess my question would be, is this diet only effective for athletes, or people with very high calorie expenditures? The research posted suggests that it would be beneficial for everyone, but I simply cannot get it to work for me. I hate to give up, but I cannot afford to gain any more weight. Suggestions?

    • Sydney, I’m sorry to hear about your frustrations. I can’t really speak specifically to your situation because I would need to know so much more about the details. It’s certainly possible that a LC diet is not best for you. In fact, based on the A TO Z trial, and even Ludwig’s data, some portion of the population will do better on calorie restricted or fat restricted diets. Gardner’s data suggests this may be a function of IR, and he’s in the process and ramping up a larger study to investigate this.
      Since I can’t really do the troubleshooting, it might be worth checking out “The Art and Science of Low Carb Living” by Phinney and Volek, along with their second book about Performance before you abort plan.

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