Healthy Life Newsletter, March 2019
About epidural injections for back pain and sciatica :
From Dr. Mha Atma: Epidural injections of steroids are often recommended by doctors for patients with lower back pain and/or sciatica (leg pain). Despite mounting scientific evidence that they provide at best temporary relief and have significant risks, they are done frequently and are quite expensive (thousands of dollars per injection). So I’ve included the following article in full, which you might want to read, save and share with anyone you know who is dealing with this challenge. It is entirely understandable that when people are in a lot of pain they are often willing to try anything that might help, and also understandable that doctors may want to try anything that might help their patient feel better. But when a procedure is shown to not be worth the risk and expense, and when doctors keep recommending it ever more, we need to step back and find a better way. Other and safer solutions to back pain and sciatica can include: chiropractic, rehabilitative exercise (prescribed by your chiropractor and/or physical therapist), acupuncture, an anti-inflammatory diet and supplements, inversion, spinal decompression therapy, and on occasion micro-diskectomy (outpatient spinal surgery–more invasive than epidurals but, IF done only with those who haven’t responded to other treaments and are appropriate candidates, can be quite successful).
Steroids for Sciatica: More Trouble than They’re Worth
By Deborah Pate, DC, DACBR
Use of epidural steroid injections has increased dramatically in recent years, despite the fact that studies have failed to demonstrate evidence this procedure is clinically helpful (while other studies suggest it may actually be dangerous).
Considering that lack of evidence – not to mention the terrible 2012 outbreak of fungal meningitis / infections caused by contaminated vials used for epidural corticosteroid injections – it is prudent at least to take a critical look at this procedure as it relates to sciatica or pain affecting the sciatic nerve, which extends from the lower back down the back of each leg.
Small Relief, Big Potential Side Effects
In a recent meta-analysis of 23 randomized trials involving more than 2,000 patients in which epidural steroid injections were compared with placebo for sciatica, epidural steroid injections produced small, statistically insignificant short-term improvements in leg pain and disability (but not less back pain) compared to placebo. This improvement also was only over a short period of time – two weeks to three months. Beyond 12 months, there was no significant difference between groups.
Besides infection, there are other side effects associated with epidural steroid injections: bleeding, nerve damage and dural puncture. Then there are side effects associated with the steroid medication, which include the following: a transient decrease in immunity, high blood sugar, stomach ulcers, cataracts and increased risk of fracture.
A retrospective study published in the Journal of Bone and Joint Surgery looked at lumbar epidural steroid injection (LESI), and the potential impact on bone fragility and vertebral fractures (spinal fractures). Researchers identified a total of 50,345 patients who had medical diagnosis codes involving the spine; within that group, a total of 3,415 patients had received at least one LESI.
Three thousand patients were randomly selected from the 3,415 injected population and 3,000 additional patients were selected from the non-injected group as a control group. There was no significant difference between the injected and non-injected groups with respect to age, sex, race, hyperthyroidism or corticosteroid use.
When incidence of vertebral fractures was assessed, researchers discovered that an increasing number of injections was associated with an increasing likelihood of fractures, and each successive injection increased the risk of spinal fracture by 21 percent. Based on this evidence, LESIs clearly exacerbate skeletal fragility. They promote deterioration of skeletal quality similar to the use of exogenous steroids, which is the leading cause of secondary osteoporosis. In fact, the rate of vertebral fracture following epidural steroid injections may be underestimated.
Both European and American guidelines, based on systemic reviews, conclude that epidural corticosteroid injections may offer temporary relief of sciatica, but do not reduce the rate of subsequent surgery. This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates. Facet joint injections with corticosteroids seem no more effective than saline injections.
Rising Costs, Limited Benefits
Despite the limited benefits of epidural injections, Medicare claims show a 271 percent increase during a recent seven-year interval. Earlier Medicare claims analyses also demonstrated rapid increases in spinal injection rates. For patients with axial back pain without sciatica, there is no evidence of benefit from spinal injections; however, many injections given to patients in the Medicare population seem to be for axial back pain alone.
Charges per injection have risen 100 percent during the past decade (after inflation), and the combination of increasing rates and charges has resulted in a 629 percent increase in fees for spinal injections. Yet during this time, the Medicare population increased by only 12 percent.
It all begs the question: Why such a huge increase in the use of a procedure that has limited benefit?
Take-Home Points
Epidural steroid injections have little clinical benefit (short or long term) and are associated with significant risks.
Steroid injections cause deterioration of bone quality, elevating the risk of spinal fracture.
Use of epidural steroid injections has increased dramatically despite lack of evidence to justify the procedure.
Talk to your doctor of chiropractic for more information on sciatica and nondrug alternatives to your pain.
How to Start with Vitamin D
Scientists have found that most of the world is vitamin D deficient
[If you have not been taking vitamin D] you are most likely vitamin D deficient, as the average person in the US has a vitamin D serum level around 25 ng/ml. In today’s world it takes effort to get within the recommended range of 40-60 ng/ml because most people are predominantly inside use sunscreen when outdoors; rely on multi-vitamins with low dosage of vitamin D (due to incorrect RDA); and cannot get enough from food.
Why Is the RDA Too Low? Why Is Milk Not Enough?
The US RDA is too low because the Institute of Medicine (IOM) made an error in their analysis of the scientific data when they adjusted the RDA in 2010 and, their focus was entirely on bone health, not cancer, not diabetes, not pregnancy. We have initiated a petition to encourage the IOM and Health Canada to review the guidelines based on a paper describing their error as well as the need to get current with the new findings. Suffice it to say that governments have not yet caught up with the published science. When talking to your doctor do not be surprised if they think 20 ng/ml is enough, or if they discourage you from taking over 2000 IU/day of vitamin D supplementation. Please take them a copy of our Scientists’ Call to D*action showing the recommendation from 48 vitamin D researchers to aim for a 40-60 ng/ml target range
Why Do I Need More?
To understand why the amount necessary to prevent rickets is not enough for overall good health, you need to understand more about vitamin D and how it affects your body. Vitamin D is actually a hormone that affects over 3000 cell processes within your body. Without enough vitamin D circulating regularly in your blood, your body simply does not function as it was intended (ridding the body of intruders, fighting disease, repairing cells, etc.).
Around the 1960s scientists started doing studies on vitamin D and disease prevention. While these studies are not as prolific as the studies on bone health, there are many that have found that vitamin D serum levels well above 20 ng/ml, in the range of 40-60 ng/ml, are necessary to prevent a number of diseases and cancers. Some of these studies have been randomized control trials (RCTs) and others have been epidemiological studies (looking at trends to determine cause and effect).
In the past ten years, there have been some successful RCTs that showed how beneficial vitamin D supplementation is with pregnant women.
OK, I’m Convinced. Now What Do I Do?
The first thing to do is test your vitamin D level. You may check with your doctor for a test or join D*action. With D*action you will be asked to pay for a test kit of your choice that includes vitamin D and complete an online questionnaire to enroll in our study and share your data for our analysis. Then you will receive the kit and instructions in the mail. You will prick your finger and put blood on the blood spot card(s) and return it to us. A couple of weeks later you will receive a link via email to view your vitamin D serum level and other results included as part of the kit you purchased. We recommend you test your blood level every 6 months, especially when you are new - as you will most likely be changing your habits and/or diet to achieve a higher serum level. Doing this through D*action will help provide us with more data and help fund vitamin D research and education.
Right NOW is a perfect time to test your level (it’s been a dark, cold winter, and you’re about as low with your serum level as you will be for the year).
The article below was written 10 years ago near the start of the “Great Recession” but is just as or even more relevant now. Learning which foods to eat and not to eat to minimize chronic inflammation can be a life-changing experience. David Seaman is the author of my current favorite book on how to eat an anti-inflammatory diet, which is referenced at the end and which you can purchase in our office and or at the link at the end of the article.
Staying Healthy During Tough Economic Times
By David Seaman, MS, DC, DACBN
Many of us are feeling the economic crunch these days. Money is tight and the bills continue to arrive in our mailboxes. Stressful times such as these demand resiliency on our part, particularly in terms of our exercise and diet habits. Interestingly, a mentally stressed state can promote inflammation throughout the body. Avoiding mental stressors is not likely to be easy during these times, so we must consider the importance of avoiding inflammation caused by other factors, such as poor diet and lack of exercise.
When you hear the word inflammation, you probably think first about swelling, redness, pain, etc., that can occur following an acute injury, irritation or infection. In general, this is short-term, localized inflammation (confined to a certain area of the body). But inflammation can also occur without physical injury. This is general, body-wide (systemic) inflammation, and it can cause subtle biochemical injuries to body tissues, increasing the risk of developing a number of serious diseases over time.
We promote the development of systemic inflammation by avoiding exercise and remaining sedentary. Not surprisingly, we should exercise daily to help prevent inflammation, and we must also modify our dietary habits. Believe it or not, diet is actually the most important factor affecting inflammation. Scientific research suggests that most diseases are caused by chronic, diet-induced inflammation. The average American diet is high in calories and low in fiber and nutrients. Approximately 80 percent of the calories consumed by Americans are derived from refined flour products, refined sugar, refined seed oils (concentrated source of omega-6 and trans fats) and fatty meat. It is now common knowledge that eating excess calories from sugar and fat leads to postprandial (following a meal) inflammation, which is thought to function as an insidious promoter of heart disease, diabetes, osteoporosis, osteoarthritis, rheumatoid arthritis, Alzheimer’s disease, obesity, hypertension, asthma, depression, inflammatory bowel disease, psoriasis and cancer. That’s a long list of serious health conditions, all linked to a single culprit: inflammation.
Good Nutrition Is Inexpensive
Lean meat, fish, chicken, fruits, vegetables and nuts form the foundation of a diet that limits a postprandial inflammatory response. This is referred to as an “anti-inflammatory diet.” Not surprisingly, this diet is recommended to help prevent the above-mentioned pro-inflammatory diseases, the treatment of which represents a massive drain on financial resources, both personally and for businesses.
A common argument is, “I can’t afford to eat lots of fruits and vegetables,” or “Healthy foods are expensive.” I tend to strongly disagree with these arguments. A cup of coffee and a doughnut can cost up to $5. A 20 oz. bottle of soda costs more than $1. In contrast, a 5-pound bag of frozen carrots, broccoli and cauliflower costs $5 at Sam’s Club, and a 1-pound container of pre-washed organic salad greens costs about $4. Both of those items can be consumed over several days by several people.
A large sweet potato that can be split between two meals costs about 75 cents. While certain nuts are very expensive (macadamias, for example), many are very reasonable. Lean meats, fish and chicken are reasonably priced and can be added to the vegetables and sweet potatoes. Fresh fruit remains very reasonable and should be one of the snacks of choice.
Dark chocolate is inexpensive and can be mixed with raw nuts and raisins for a great snack or dessert. I often melt a 50-calorie piece of dark chocolate with a little coconut oil and add some nuts and raisins. I place this combination on a piece of wax/freezer paper and place it into the freezer for about 10 minutes. My reward is an anti-inflammatory candy bar.
It is not more expensive to eat healthy, anti-inflammatory foods, if one shops wisely. Certainly, preventing the expression of chronic disease will save countless dollars and heartaches associated with the accelerated morbidity and mortality associated with pro-inflammatory living. In short, we cannot afford to eat any other way but anti-inflammatory.
Inexpensive Supplements for Health Promotion
There are also key supplements that support the reduction of inflammation and free-radical generation, and they’re also reasonably priced. (Free radicals are unstable molecules that can damage surrounding molecules in the body. They have been linked to an increased risk of cancer, among other diseases.) The basic supplements include a multivitamin without iron, magnesium, fish oil and vitamin D. The total cost is approximately $60 to $80 per month, which is less than $3 per day. If you can only afford one supplement, vitamin D seems like the best choice because research has demonstrated that vitamin D insufficiency is pandemic. The next best financial choice for a supplement would be a multivitamin/mineral without iron. After that, fish oil should be added, and finally magnesium. If a fifth supplement can be afforded, probiotics are the best choice, as they have a strongly anti-inflammatory effect in the gut.
If money is not particularly an issue, additional supplements should be considered, including coenzyme Q10, lipoic acid, acetyl-L-carnitine, ginger, turmeric and garlic. These supplements help to promote ATP synthesis and reduce free radicals and inflammation.
The Bottom Line
While finances have been tight lately due to external economic forces, and may get worse in the near future, we can easily make this situation a lot worse by pursuing disease expression due to a pro-inflammatory lifestyle. Medical care for pro-inflammatory diseases is extremely expensive and generally preventable by adopting an anti-inflammatory diet that is no more expensive than one that is pro-inflammatory. Key supplements can be added based on financial ability.
We should consider that paying for expensive medical care will put most of us into debt even when economic times are good. So it makes no sense to pursue disease and expensive medical care with a pro-inflammatory lifestyle when economic times are not so good. In short, nutrition does not need to be compromised, even when the economy is down. Talk to your doctor for more information.
Foods That Promote Inflammation
High-fat meats (especially red meat)
Processed meats
Refined sugar and sugary snacks, sodas and cereals
Grain flour products (bread, pasta, and other food made from grain flour)
Refined grains (like white rice, instant oatmeal)
Candy and junk food
Trans-fats (found in margarine, crisco, non-“old fashioned” peanut butter like Skippy and Jiffy, some meats, and many processed foods) (watch labels for the words “partially hydrogenated”).
Foods That Discourage Inflammation
Salmon and other oily fish
Flax and pumpkin seeds
Nuts (raw or dry roasted)
Olive oil
All fresh fruits and vegetables
David Seaman, MS, DC, DACBN, is the author of The Deflame Diet. He has a master’s degree in nutrition from the University of Bridgeport, Conn., and lectures on nutrition for Anabolic Labs (www.anaboliclabs.com).