The Link Between Atherosclerosis And Spine Health

Scott Stoll, MD, FABPMR

Yes, sir. Living in Franklin, Tennessee.

Joel Kahn, MD, FACC

I did not know that. I did not know that was your home roots. Franklin, Tennessee. He was finally a member of the 1994 Olympic Bobsled Team. He is an athlete, and he is an author. There is just so much good to say. Thank you, Dr. Stoll.

Scott Stoll, MD, FABPMR

Joel, thank you. It is an honor to be with you.

Joel Kahn, MD, FACC

We are talking. Thank you. We are talking about reversing heart disease naturally. I always tell people that you cannot reverse something if you do not know you have it. The problem with heart disease is that a whole lot of people, maybe 40 to 50% of middle-aged adults, are walking around and do not know they have atherosclerosis. They feel good, or they have some other complaints they would never attribute to atherosclerosis, like, of course, blockages and cholesterol deposits in their arteries. I do not think anybody in the audience would connect the positive ability that low back pain, something you have dealt with thousands of times as a physical medicine, a rehab doctor might be a clue, might get you to me. You, Dr. Stoll, might get patients from me. Because, as most people do know, I have heard your lecture on this. I just pulled it up just for the fun of it. A brand new article has just been published. This is not the world’s best science, but it is what you sometimes get from the association between high cholesterol and lumbar degenerative disease, a medical survey. The bottom line is that people with high cholesterol have a 34% higher chance of complaining of serious, low back pain. Cholesterol causes low back pain. Okay, I am done talking. Fill us in. What an educated audience should know about this potential connection.

Scott Stoll, MD, FABPMR

Yes, thank you. It is very interesting. Just for the audience, I had spent most of my entire career doing sports-inspired, so I have seen tens of thousands of people with back pain. What is interesting is that when you see people back then, they come in. The typical workup often involves either an X-ray or an MRI. It is very common, the impression for a radiologist to see degenerative disc disease. On the pictures, either an X-ray or an MRI, you see, a normal disk would be a nice, plump disk. Then you can see on the x-ray this emaciated little disk between the two bones. The assumption in medicine. This is just happening as you get older. Same thing with heart disease and other diseases. These are the diseases of aging that just happen to us, and they are an inevitable, Part of the consequences of aging. But what is interesting is that you see people that come in who are in their 70s or 80s and you get X-rays and MRIs and they have relatively normal disks. Then you have to ask the question, Well, is it aging or is it something else? For you all, that is, that you are watching, it is something else. 

One of the just-to-take one step back in medicine today, and I am sure, as we have talked about, Dr. Kahn. We have an idea called reductionism and compartmentalization where we have broken down the body and diseases into small parts, which makes it easier to study the disease and develop treatments for it. But we forget as doctors that everything is connected to the entire human body. There is not one thing that is not connected to something else. One of the things that is rarely thought about in back pain is the connection between the health of your arteries and the health of that disc. Because the disc does not have a very good blood supply. The back part of the disc has a very poor blood supply. Blood supply comes from spinal arteries that originate off of the aorta. These little, tiny arteries pierce back towards the spine. Then there are small arteries that wrap themselves around that disc, and they supply blood flow to the disc. 

As your audience knows, they have heard some amazing lectures on the importance of healthy blood vessels. The health of those little blood vessels is critical because they not only bring oxygen and take away carbon dioxide to those disks, but they also provide all of the nutrition that is necessary to maintain the integrity of those disks. That disk that is bearing the weight every single day as we sit and lift that disk is designed to be spongy, filled with water, and healthy and vibrant. As we are bending and moving, the disk is absorbing energy and rebounding. But if that disk becomes emaciated, if it becomes dehydrated, if it is not getting the nutrients and the blood flow, then the disk begins to slowly break down. As the back part of that disk, which does not have a good blood supply, begins to break down, it can start bulging, and you will get small tears in the outer part of the back part of that disk. They are called radial tethers in the center of the disk. We are not supposed to eat this, your jelly donut. The center of it is the jelly. The outside of the donut is the back part of the disk. If you have a tear to that back part of the disk, the jelly leaks out and begins impinging on the nerves, causing this back pain and discogenic back pain, pinched nerves from the back.

Joel Kahn, MD, FACC

Wow. Your disks, and again, I order a lot of heart calcium C.T. scans looking for silent atherosclerosis. That is a topic we are going to talk about in several other segments of this summit. A good radiologist gives me a whole report. I have a lot of people between 40 and 50 going for a heart checkup, and many over 50. But I am amazed at how many are 40 to 50. The radiologist mentions degenerative joint disease already in the thoracic spine because that is the portion you are most likely to see. Very little neck and none of the lumbar area. It is common, so a blood flow issue could be a problem. How strong they are, we talk about associations. These are tough statistical terms and causations. Do you feel confident enough to say there could be a cause? Smoking, diabetes, high cholesterol, high blood pressure, and genetic factors could cause degenerative joint disease, which manifests as low back pain. Before you are in my emergency room.

Scott Stoll, MD, FABPMR

Yes, absolutely. There is back pain that is multifactorial, just like everything else in the body. You can have poor posture, or you can have slippage in the back. Other things can cause it. But when we look at some of the cadaver studies that look at those arteries of the spinal arteries going to the desk, they are loaded with atherosclerosis. We know from population studies on heart disease that, as she said earlier, 40 to 50% of the population will have severe heart disease. Potentially have a heart attack and die from it. A large percent of the population then equally has atherosclerosis of the spinal arteries that are feeding that disc. We can only imagine that, if you are supposed to have them, there are very small arteries that are bringing blood supply to that disc, which is bearing the weight of our body daily. If those tiny little arteries are occluded to the same degree that we see in the heart where people are having heart attacks, the disc is essentially having a disc attack. Looks like a heart attack. It is not getting enough blood supplies. Then, from day to day, if somebody is athletic, working, or a truck driver and they are sitting in that disc, not getting enough blood supply, it is inevitable that over time it will break down and contribute to significant back pain. There is a very strong correlation, especially based on the cadaveric evidence coming from autopsy studies back then.

Joel Kahn, MD, FACC

Yes. I was just playing around for a minute. I am sadly a multi-tasker, so I can listen to you and look around. But if this hypothesis is true, we are ready. I gave a shoutout to a very recent article about high cholesterol and low back pain being related, could smoking be related to low back pain? I pulled up a 2016 article that found exactly that. You would have to grade the hypothesis that we are talking about smoking, atherosclerosis, spinal disc degeneration, and low back pain. Sure enough, I just quickly, without any real preparation, read an article about diabetes and low back pain. Of course, the reality is that, as you said, we are talking about the whole patient isolating out one disease condition, and there are so many different factors that drive atherosclerosis. Autopsy studies will show it. Now, we are not doing disc angiography. There is no disc stenting, and there is no disc bypass, correct?

Scott Stoll, MD, FABPMR

That is correct. Yes. We are doing disc replacements. That is one of the things that we do.

Joel Kahn, MD, FACC

Now, you are a lifestyle medicine expert. Since you view the body as a system, you are approaching cardiovascular disease as part of it. Of course, it is a huge, important portion. 

Have you? Well, are you the Dean Ornish and the Caldwell associate of low back pain? Can we institute the lifestyle program and share a case study or two, or maybe more than that, so that people might feel better?

Scott Stoll, MD, FABPMR

Yes, absolutely. Yes. That has been so much of my career, and that is really where I learned about lifestyle medicine: applying nutrition and lifestyle medicine to my patient population in the musculoskeletal arena. I just wanted to take a quick step back and just highlight the fact that you mentioned that, when we looked at the genesis or epicenter of the relationship between atherosclerosis, smoking, diabetes, and degenerative diseases, as your audience has now learned from all of the amazing lectures that you have done, it is the endothelium that is being injured. That is the epicenter of all of these contributing factors. 

We know that sugar injures the endothelium, nicotine injures the endothelium, animal products injure the endothelium, stress causes elevated cortisol levels, and adrenaline injures the endothelium. Toxins from food injure the endothelium. That is why we can begin to see all of these broad associations, from sugar in the diet to diabetes with elevated blood sugar to tobacco to an unhealthy diet, obesity, and stress, all contributing to this strong association of degenerative diseases coming from injury to the spinal arteries that are supplying that disc. It is the health of the endothelium that leads to a health disc. As your audience is learning, the health of the endothelium depends on lifestyle intervention, which is not only good for the disc but also the joints in the knees, and the heart. It is good for the brain, and it is good for the entire body. 

Healthy, whole food, a plant-based diet, stress reduction, exercise, and a really good night’s sleep prepare for the health of that disc. I can share with you many cases of people who were able to resolve their discogenic back pain through a multifactorial lifestyle intervention, including stretching and strengthening. But the real power of that is that the anti-inflammatory component of the diet potently reduces inflammation and then increases the health of the endothelium, resulting in vasodilation that increases the production of nitric oxide. I had a young man who came to see me with his mother. He was 18 with back pain, which is quite a terrible thing to have. He was 18 with severe back pain. Someone along the way started him on Vicodin, which is an opioid medication that should never have been started on 18-year-olds. It causes chronic back pain while taking Vicodin. His mother had rheumatoid arthritis and was in severe pain. The psychosocial part of this case also made it very difficult because she was going through a very challenging divorce, was living in a camper, had very few financial resources, and did not have very good health insurance. She could not afford to take medications. They did not know how to manage this. 

I shared with them the hope of a lifestyle medicine intervention. A full-food plant-based diet will dramatically reduce inflammation for you as someone struggling with rheumatoid arthritis, and for your son, who has this physiogenic back pain. It will increase blood supply to your joints. It will increase the blood supply to his disc. I believe that in the next 4 to 6 weeks, through the implementation of this lifestyle intervention, we can get both of you off your medications. But one of the challenges was that she could not afford to go out and buy a lot of fruits and vegetables. But what I love is that when somebody sees a solution and believes it is for them, there are no barriers. They will find a way to make it happen.She believed that this was the solution for her and her son. She did not want to take medications. She did not want her son to be on Vicodin for the rest of his life. That motivation inside said; This is what I need to do. I have got to find a way. Would you know it, Joel? They went out, and they figured out that one of these nice supermarkets in town threw away their produce at two o’clock in the morning. They would wait by the dumpster. They would do a dumpster dive, and they would show me pictures of the produce they pulled out of the dumpster. It was beautiful, organic produce. They started making the meals and shared recipes with them. I saw her back in about six weeks, and all of her joint inflammation and synovitis were completely gone, and her son’s back pain had resolved simply through dietary intervention. 

We did not do any physical therapy. We did not, and she did not have any other interventions. It was just through diet and tapering off of his Vicodin. She did not require any medications for her rheumatoid arthritis. They gained vibrancy and strength, and because they felt well enough, they were able to deal with some of the other psychosocial issues in their family. It is just a powerful example, I think, on several levels. One; is what a diet can do when it is diet alone, reducing inflammation, treating back pain, and treating other musculoskeletal conditions. But two; that when we are passionate and believe that we have found a solution, there is always a way, there is always a way around barriers, and there is always a way to identify and find the resources that we need to bring health into our lives.

Joel Kahn, MD, FACC

That was a compelling case history. Also, listeners do not need to go to the resort to go dumpster diving. But you said, when you want to get healthy, you get desperate, and you do what you got to do. While you are giving a class to some trainees in a PM&R University and you are talking about low back pain, are you going to put it on the slide or two and encourage them to work that patient up for atherosclerotic risks, or at least get that patient referred to somebody useful or experienced with atherosclerotic risk factors?

Scott Stoll, MD, FABPMR

Yes, absolutely. It is like erectile dysfunction. That is, they always say a canary in the coal mine for heart disease. The same can be said of the degenerative disc diseases that you see. For extensive degenerative disc diseases, we can assume, based even on population statistics, that they have atherosclerotic heart disease and should be seen for an evaluation. It is a valuable intervention. You will not die from degenerative disc diseases, but you certainly could die from heart disease. You do not want to miss that one. It is a great opportunity to educate them on that relationship and get a good evaluation.

Joel Kahn, MD, FACC

Yes, as such a powerful teaching point, what do you think the number would be if we just took a random sample of the public aged 50 to 70 and asked, Do you have significant low back pain issues in your life? I do not know the answer. What do you think the number would be? It is more than one person.

Scott Stoll, MD, FABPMR

Yes, I think it is at least half of the population. That we have.

Joel Kahn, MD, FACC

At least half of the population has silent atherosclerosis. That great new data out of Spain shows that even starting at age 40, you will find it in about 40 to 45% of asymptomatic adults. I am unaware, and I was playing around a little because it is such an important, easy study. We looked at a thousand people who had coordinated great calcium scoring, the simple CT scan. There are more advanced C.T. scans, but that is a simple one. We did a questionnaire on low back pain, and we identified the following findings: I do not think that has been done yet. After what you have just said, I would encourage listeners who have low back pain to be in that atherosclerotic age range. I would not order a coronary calcium CT scan on the 18-year-old you are talking about; although it is so inexpensive, they probably could afford it, but it is just not the right test at that age. An ultrasound of the carotid might be an alternative, as they have done in some research projects on younger people. But I think your organization, The Plantrician Project, is glad to do that. I will get that mobile CT scanner at the next international meeting and do a back pain survey. Let us do that. But somebody knows about that.

Scott Stoll, MD, FABPMR

Would be fine. Let us do it. I would love it.

Joel Kahn, MD, FACC

Yes, I could probably arrange that. There are mobile CT scanners, and maybe we can get a little grant from good old John Mackey or something of that sort.

Scott Stoll, MD, FABPMR

That would be a fun study. I love it.

Joel Kahn, MD, FACC

We would have to then pull it up to the carnivore conference and come back.

Scott Stoll, MD, FABPMR

Later.

Joel Kahn, MD, FACC

Of atherosclerosis and the plant-based eaters, atherosclerosis in the general public. We have learned there are many causes of low back pain and inflammatory arthritic conditions. But we are learning for the first time that atherosclerosis is on the list of considerations. We are talking to the doctors and therapists, and I have patients in 40 physical therapy clinics. I got to go ring them up and say, You ought to be training your therapists to at least bring up the topic and get that person back with their primary care specialist and get screened. We have many other talks on how to screen for asymptomatic vascular disease during the summit. I will not pick Dr. Stoll’s brain when he is on the other side of the world today on that topic. But what I had asked is, Scott, do not go anywhere. We are going to take a quick break. We are going to say goodbye to our general listeners. Thank you so much. I know you learned a lot. Come back in a minute and go a little deeper on one more topic with Dr. Stoll before we probably put him to bed because it is late where he is and we appreciate him doing this from Abu Dhabi. I have to practice, so do not go anywhere. 

All right, Scott, are you ready for just a quick dive?

Scott Stoll, MD, FABPMR

Absolutely, Joel.

Joel Kahn, MD, FACC

Thanks for staying with us. It is late where you are. I appreciate you blowing us away with the conversation between back pain risk factors and atherosclerosis of the disks. But you are the co-founder of a significant organization. The Plantrician Project. Plantrician, P-L-A-N-T-R-I-C-I-A-N Project.org. You rolled out fairly recently a beautiful new logo, and I could not believe how many little boxes there are. There are different components. Take us back. How long ago was it that you said we needed an organization to bring together science and plant-based nutrition?

Scott Stoll, MD, FABPMR

Yes. In 2012, I was having dinner with my partner in The Plantrician Project, Tom Dunnam, and I was just commenting on how long it took me as a physician to really understand the science and then learn how to apply it in my practice. I said at the time at dinner, We really should start a conference to educate healthcare providers about the power of plant-based nutrition to prevent, suspend, and reverse disease. As he said, sure, let us do it. I have great ideas. Tom is great at logistics. So that was two parts of a team. Then Susan Benigas, who is now the executive director at ACR, American Culture Lifestyle Medicine, joined us and brought the marketing piece, which was essential. Myself, Tom Dunnam, and Susan Benigas launched our first conference in 2013 in Naples, Florida, the International Plant-Based Nutrition Health Care Conference. 

It was successful. We broke even, and we were able to wrap the conference inside a not-for-profit called The Plantrician Project, which was designed not just to provide a conference environment but also tools, resources, and education for all our healthcare providers through power plant-based nutrition. Because, as in medical school, 40% of medical school students receive no nutritional education. The other 60% receive, on average, about 19 hours. None of it has to do with the nutrition that you are teaching. Your audience knows more than medical school students and residents about nutrition and the link between heart disease and other diseases. We wanted to be an organization that would provide resources, tools, educational opportunities, and, most importantly, bring people together in the community because community is where transformation occurs. 

On top of the conference, we launched a journal called the International Journal of Disease Reversal and Prevention, which is a free journal. We wanted to remove all barriers to access, so there is no subscription fee for the journal. IJDRP.org. You can sign up, receive the journal, and follow the science. We also wanted to remove the barrier that is often present in publishing science. For most journals, you have to pay to have your articles reviewed. In some cases, nature, only 10% of the articles get past that first step, and it is thousands of dollars. We wanted to remove all those barriers. We made it free. 

We have created several free resources and downloadable Quickstart guides in five different languages that people can download. A pediatric quick-start guide to Transforming Health Care. Quick Start Guide We have our Quick Start guide coming out on gardening, which I am excited about. Then, this past year, we launched one of our really exciting initiatives called Plantrician University, recognizing again that one of the roots of the problem is education at the medical school, student, and college levels. We created again a free platform learning management system for every healthcare professional student in the world, from health coaches to physicians and everything in between so that any healthcare professional student can sign up for free and go through an educational and ongoing educational process to learn about the linkage between plant-based nutrition and disease reversal. Every month, we add new courses from amazing clinicians around the world. We have uploaded all of our lectures from our 10 years of conferences, and we are going to also create a platform starting next year to begin training the next generation of leaders and a mentoring platform. 

Because, as I see, so many of the leaders, the amazing people, the shoulders that we are standing on today are SC and Colin Campbell, John McDougall, Joel Fuhrman, Dr. Joel Kahn, and Dr. Scott Stoll. We are over 50 now, and so we need to begin working on cultivating that next generation, which I believe will be the generation that ushers in the age of lifestyle medicine. I am excited about that platform. Anybody interested, whether faculty or health care, a professional student, or a student in your life from college through medical school and residency, just send them to PlantricianUniversity.org or PlantricianProject.org, and they can sign up today and start their learning journey now.

Joel Kahn, MD, FACC

That is great. I am on your Web site, and just your quick start plant-based nutrition guides, which are free downloads, everybody. Rarely do you see free stuff, and you can get it in Spanish. You can get it in Chinese, Arabic, or Japanese. I am sure that I will expand. But the one that I know will be hot, I do not want to call a seller because they are free. But you have one for children, a pediatric plant-based nutrition quick start guide, which I think is a common topic that comes up. There is not necessarily a plant-based pediatrician in every community. At least you can get a first step through all this great work you are doing and then go deeper by searching all these Plantrician University lectures. What about one more, just throw out into the Culinary-Rx? What can people who are interested in improving their health through that aspect of The Plantrician Project?

Scott Stoll, MD, FABPMR

That is right. One of the things that we began to see and this well, is that when you recommend patients start cooking plant-based meals, they say things like, Well, how do I make oatmeal? Or how do I steam broccoli? We have lost this culinary wisdom that was usually passed on from generation to generation. Now that we live in a fast-food atmosphere. We designed a culinary education and plant-based education combination, which is called the Culinary-Rx. We worked with a company called Rouxbe, which is one of the largest online cooking schools. 

They teach chefs all over the world, including Michelin-starred chefs, how to prepare plant-based food. So we partnered with them to put together a beautiful program called Culinary-Rx. They teach Basic Knife Skills, Water Sauteing, How to Cook Broccoli, and Other Vegetables, and in combination, with some wonderful lectures from many physicians in this space. It is a delightful 12-week educational course. It is very doable. But it is a great foundation for anyone wanting to understand some of the science, as well as really basic culinary education that chefs would learn anywhere at any of these hotels and restaurants around the country.

Joel Kahn, MD, FACC

Everybody, go to PlantricianProject.org, a really beautiful website that is very easy to search around. Spend some time. If people want to find you. Do you still have a brick-and-mortar office, or are you at a higher level?

Scott Stoll, MD, FABPMR

I do. It is hard, for us doctors, to see patients, right? I still do see some patients in Nashville, Tennessee, at the Maxwell Clinic. I am delighted to see people there a couple of days a week.

Joel Kahn, MD, FACC

Maxwell. I have a license in Tennessee, so I have quite a few telemedicine patients in.

Scott Stoll, MD, FABPMR

That is great.

Joel Kahn, MD, FACC

Franklin and other communities are right near you, so we will try and get them down there soon. 

Well, thank you so much for taking your time. I hope you get a good night’s sleep. You have taught us a lot of interesting, innovative things in the canary in the coal mine. That is, it is not always something brand new you have never heard before in an interview like this. Thanks so much, and good travels.