A World without Back Pain

Hello and welcome to the Nutrition Facts podcast, I’m your host Dr. Michael Greger. 

Now, I know I’ve made a name for myself in explaining how not to do certain things – just look at my books – How NOT to Die – and my upcoming book, How NOT to Diet.  But what I want to share with you is actually quite positive: what’s the best way to live a healthy life? Here are some answers.

Today, we imagine a world without back pain–a condition that has become one of the biggest problems for public health systems in the second half of the 20th century. The lifetime prevalence of people experiencing low back pain is reported to be as high as 84 percent, and chronic low back pain is present in about one in five, with one in ten being disabled by it.

In our first story –we hear how atherosclerotic plaque clogging the arteries feeding our spine may lead to low back pain, disc degeneration, and sciatic nerve irritation.

It’s an epidemic. Are people just lifting more heavy stuff? No. Mechanical factors, such as lifting and carrying, probably do not play a major role in the disease. Well then, what causes it? Atherosclerosis can obstruct the arteries that feed the spine and this diminished blood flow can result in various back problems. This can be seen on angiography, showing normal arteries on the left and clogged on the right, or on autopsy, where you can see the openings to the spinal arteries can get squeezed shut by these cholesterol-filled plaques on the right.

Autopsy, because back pain may predict fatal heart disease, just like clogs in the penile arteries—erectile dysfunction—can precede heart attacks, because it’s the same disease; clogged, crippled arteries throughout our body.

Now we have MRI imaging that can show the occlusion of spinal arteries in people with back pain, and the degeneration of the discs. Normal blood flow in someone without back pain, versus constricted blood flow in someone with. They showed that patients with long-term lower back pain had these kinds of arterial clogs, and those with high cholesterol appeared to suffer more severe symptoms. Those with narrowed arteries appear about eight and a half times more likely to have suffered from chronic back pain.

This makes sense. The discs in our lower back are the largest avascular tissue in the body, meaning our discs don’t have any blood vessels. Thus, its nutrition just kind of diffuses in from the margins, making it especially vulnerable to deprivation. Using MRIs you can measure the effects of impaired blood flow on that diffusion. Although disc degeneration has multiple causal factors, with genetic, occupational, and mechanical influences, alteration in nutrition has been proposed as the final common pathway. By age 49, 97% of the discs of those eating the standard American diet show at least grade 2 degradation.

Cholesterol plaques in the walls of the aorta can obliterate the orifices of lumbar and middle sacral arteries and may decrease blood flow of the lumbar spine and its surrounding structures. Structures with precarious nutrient supply, such as the intervertebral discs, may suffer and gradually degenerate from this lack of blood flow, as well as herniate. Not only is there a relationship between cholesterol levels and disc degeneration; there’s an association between cholesterol levels and disc herniation as well.

This compromised blood flow may also damage the nerve roots that come off the spine, causing sciatica. Sciatica is back pain that radiates down the legs, causing additional pain, numbness or weakness, and prolonged disability and may affect as many as 1 in 20 people. And independent of weight, and some other factors, clinical sciatica may be associated with cholesterol as well. See, the nerve roots, which are most commonly associated with sciatic pain, are supplied by some of the arteries most vulnerable to atherosclerotic plaque formation. Obliteration of these arteries by cholesterol buildup results in compromised nutrient supply to the nerve itself. And that lack of oxygen to the nerve may be playing a role in sciatica pain.

Reduced blood flow also hampers the removal of waste products, such as lactic acid, which can in turn irritate the nerve endings, causing pain and deterioration.

Because of this vulnerability, discs degenerate far earlier than do other musculoskeletal tissues; the first unequivocal findings of degeneration in the discs of the lower spines can be seen starting around age 11. By the early teen years you can already see the discs starting to degenerate. This makes sense. As I’ve talked about before, nearly all kids have the beginnings of atherosclerosis by age 10.

And sadly, low back pain is now common in children and adolescents as well, and it is becoming a real public health concern. And it’s getting worse. It’s like kids now getting disorders like adult-onset diabetes. Teenagers starting their lives out with a chronic disease. That’s why it’s never too early to start eating healthier.

In our next story –we hear the results of 8 randomized, double-blinded, placebo-controlled trials of ginger for muscle pain.

Previously, I explored the use of spinach for athletic performance and recovery, attributed to its “anti-inflammatory effects.” But, most athletes aren’t using spinach to beat back inflammation. They use drugs—typically nonsteroidal anti-inflammatory drugs, like ibuprofen, used by up to 95% of collegiate athletes, and even three-quarters of kids playing high school football, including prophylactic use, in an attempt “to prevent pain and inflammation before it occurs. However, scientific evidence for this approach is currently lacking, and athletes should be aware of the potential risks,” which include gastrointestinal pain and bleeding, kidney damage, and liver damage.

This is the study that freaked everyone out. A study of thousands of marathon runners, and “five times” the incidence of “organ damage” among those taking over-the-counter painkillers before the race. Nine were hospitalized: three with kidney failure after taking ibuprofen, four with gastrointestinal bleeding after aspirin, and two heart attacks, whereas none of the control group not taking painkillers ended up in the hospital. And, it looks like the drugs didn’t even help. “Analysis of the pain reported…before and after the race showed no real advantage” to taking the drugs; so, it appeared to just be all downsides.

What about using ginger instead? In that marathon study, the most common adverse effect of taking the drugs was gastrointestinal cramping. Ginger, in contrast to aspirin or ibuprofen-type drugs, may actually improve gastrointestinal function. For example, endurance athletes can suffer from nausea, and hey, ginger is prized for its anti-nausea properties. Yeah, but does it work for muscle pain?

There’s been at least eight randomized, double-blinded, placebo-controlled trials of ginger for pain—everything from osteoarthritis, to irritable bowel, to painful periods. Overall, ginger extracts, like the powdered ginger spice you’d get at any grocery store, were found to be “clinically effective pain-reducing agents with a better safety profile than the drugs.” In some of the studies, the ginger worked better than in others, which is thought to be due, in part, to the different doses that were used, as there’s a “strong dose-effect relationship.” The best results, in terms of reduction of pain, were with one-and-a-half or two grams a day, which is a full teaspoon of ground ginger.

The drugs work by suppressing an enzyme in the body called cyclooxygenase 2, which triggers inflammation. The problem is that the drugs also suppress cyclooxygenase 1, which does good things, like protect the lining of your stomach and intestines. So: “Since inhibition of COX-1 is associated with gastrointestinal irritation,” if only we could selectively inhibit the inflammatory one, that would offer kind of the best of both worlds. And, that’s what ginger seems to do. Here’s the effect of two ginger compounds against cyclooxygenase 1, the “good” one. No effect, but ginger can dramatically cut down on the pro-inflammatory one.

Okay, but does it work for muscle pain? Not acutely. You can’t just take it like a drug. If you give folks a teaspoon of ginger before a bout of cycling, no difference in leg muscle pain over the 30 minutes. “However, ginger may attenuate the day-to-day progression of muscle pain.” Taking ginger five days in a row appears to “accelerate the recovery of maximal strength” following a high-load weight-lifting protocol. Put all the studies together, and a single dose of ginger doesn’t appear to help, but a teaspoon or two for a couple days or weeks in a pumpkin smoothie or something, and you may be able to reduce muscle pain and soreness, and accelerate recovery of muscular strength.

Is fresh ginger preferable to powdered? Maybe not. There are all sorts of compounds in ginger with “creative” names, like gingerols, and gingerdiols, and gingerdiones, but the most potent anti-inflammatory component may be a compound called shogaol. And: “Interestingly, dried ginger contains more…than fresh,” justifying the medicinal uses of powdered ginger “for illnesses due to oxidative stress and inflammation.” Why not then just give the extracted shogaol component in a pill by itself? Each of the active ginger components individually reduces inflammation, some more than others, but the whole ginger is greater than the sum of its parts.

But, you can boost the shogaol concentration of whole ginger by drying it, as they are “the major gingerol dehydration products;” they’re created when ginger is dried. Heating ginger may increase shogaol concentration even more; so, could heated ginger work better against pain than raw? You don’t know, until you put it to the test: A study of 11 days of a teaspoon of raw ginger versus ginger that was boiled for three hours on muscle pain. A significant reduction in muscle soreness a day after pumping iron in the cooked ginger group, and the same benefit from the raw ginger. Either way, “daily consumption of raw and heat-treated dried ginger can result in moderate-to-large reductions in muscle pain following exercise-induced muscle injury.”

In our last story we learn how high cholesterol can lead to atherosclerosis in the vertebral arteries that nourish our spine, and result in disc degeneration and lower back pain—a leading cause of disability.

Every part of the body needs sufficient blood flow to function properly. Cholesterol can clog arteries in our inner and outer organs, causing heart attacks, strokes, and sexual dysfunction. But what about blood flow to our spine?

Our spines are very vascular, and cholesterol clogs in the vertebral arteries can lead to the degeneration of our disks and lower back pain—the second leading cause of disability. Autopsy studies confirm what happens when your cholesterol gets too high.

With the standard Western diet, atheromatous plaques may begin to appear early in adult life, and by the age of 20, roughly 10% of the population already has advanced lesions.

Smoking and high serum cholesterol levels were found to have the most consistent associations with disc degeneration and low back pain. Much of back pain-related disability appears to be an open or shut case, depending on our diet.

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