#215 – How diet affects joint health, arthritis, & longevity | Dr. Howard Luks & Dr. Casey Means

We often think that arthritis, musculoskeletal pain, and degenerative joint issues are an inevitable result of aging—but this is far from the truth. Good metabolic health can have significant positive effects on bones, muscles, and joints, and can improve longevity. Conversely, poor metabolic health accelerates the degeneration of joints and tissues for many reasons, like the impact of high uric acid levels, lipid or cholesterol deposits, chronic inflammation, and poor blood flow to tissues. Surgeon Dr. Howard Luks and Levels Co-Founder and Chief Medical Officer Dr. Casey Means discuss musculoskeletal health, how it is related to longevity, how it’s linked to metabolic health, and how to decrease your risks for musculoskeletal pain, degenerative joint issues, and surgery.

Helpful links

Dr. Luks’ website

Longevity… Simplified: Living A Longer, Healthier Life Shouldn’t Be Complicated

05:14 – Dr. Casey Means’ personal experience with an orthopedic injury

Dr. Casey Means shares how she dealt with an orthopedic injury, and how she reached out to Dr. Howard Luks for advice on handling the issue without having to undergo surgery.

It’s very easy to think of cartilage as cheese on a cheese grater or sandpaper on wood, and that these horrible things are happening inside our knees when we run or when we move, or when we work out. What turns out is it’s not, and it turns out that osteoarthritis in the majority of situations is a failure of a biological repair mechanism. Cartilage is capable of repairing itself, but something screws up the pathway. Not quite sure what’s going on there. I am not a researcher in this space. I do follow it closely though, and it appears that there are Wnt—this Wnt pathway is one of the pathways involved in repair—there are new Wnt inhibitors, small protein molecules that they’re administering to people in phase three studies and they’re showing that they can halt and at times reverse early changes associated with arthritis. So the changes in an arthritic knee are much more complex. The ideology or the cause of osteoarthritis is far more complex than we were initially led to believe.

12:09 – The link between joint and metabolic health

Dr. Luks describes factors connecting metabolic and musculoskeletal health and explains how poor metabolic health may lead to the degeneration of your joints and tissues. People with diabetes, insulin resistance, or metabolic syndrome may have more pain with osteoarthritis than someone who is metabolically fit due to elevated A1C, high uric acid, systemic inflammation, or lipid or cholesterol deposits that prevent collagen repair.

We are more prone to having tendon tears [and] ligament tears in situations where we have poor metabolic health. We have glycosylated hemoglobin, right? Your hemoglobin A1C, that’s the glucose that’s floating around your body. It sticks to things. When it sticks to hemoglobin, your A1C goes up. It sticks to other things too. And if it does that in your eye, it leads to blindness. If it does it in your kidneys, it leads to kidney failure and on and on. Well, if it sticks in parts of your tendons and you have hyperuricemia or high uric acid, you have lipid or cholesterol deposits, then you’re taking away collagen—or the tissue that forms tendons and ligaments—so you have an increased risk of rupture because those tissues are weaker. Now, poor metabolic health, as you well know, causes an increase in systemic inflammation. That inflammatory burden is gonna affect our knees. So why? This is why people with diabetes or severe insulin resistance and metabolic syndrome have more pain with mild osteoarthritis than someone who’s metabolically fit or healthy. And this may be why osteoarthritis and other conditions which are inflammatory in nature, worsen a little more in people with poor metabolic conditioning and health.

18:19 – Maintaining activity may help improve musculoskeletal health despite osteoarthritic pain

Dr. Luks debunks the misconception that surgery and restricting movement are always the best ways to deal with joint pains. He cites a study conducted on runners and non-runners with the same degree of osteoarthritis, revealing that the sedentary group was more likely to have a knee replacement than the runners. His advice? Just keep moving.

Osteoarthritis by definition [and] by evidence, is less common in runners. Maybe that’s a self-selection bias because runners keep, keep, keep running. However, they did a study where they had a bunch of runners and non-runners [with] the same degree of osteoarthritis on x-rays. They allowed the runners to run at a self-selected pace. The sedentary people remained sedentary. [The] sedentary group was more likely to have a knee replacement than the group [who was] running. It turns out that the cartilage likes cyclical loading. Cartilage is not dead tissue. It’s not a sedentary tissue. It’s like a sloth. It doesn’t move quickly. It’s not exciting, it doesn’t beat, [and] it has a very slow metabolism. But it is capable of repair. There is a nourishment process that is going on that nourishment comes not from blood flow, but from substances in your joint fluid. [The] cyclical loading actually helps to get that nourishment and energy source into the cartilage, so maintaining a level of activity is super important. And because I care a lot about bones and fracture risk, it’s really important to stay active because of your bone quality and your osteoporosis risk. More important, if you are exercising and you’re used to exercising and you rest for as little as two weeks, you’ve [already] lost about 20% of your muscle strength.

27:53 – Cartilage cells, tendinopathy, and how metabolic health is linked to our tendon health, like with tennis elbow or shoulder pain

Dr. Luks delves deeper into joint cartilage, cartilage cells, and tendinopathies, outlining the mechanisms of how poor metabolic health contributes to orthopedic dysfunction.

Cartilage cells like to stay by themselves. They don’t like others. So they secrete this matrix, [which is seen] when you look at [the] cartilage—that’s the white substance. And [there are] mucopolysaccharides and other things in there. And that’s what forms this hard, gelatinous, smooth surface. Embedded in there are the cartilage cells. They do not have a blood supply. In a non-arthritic knee, they do not have a nerve supply. In the late stages of arthritis, we tend to develop nerves, et cetera. And that’s a source of pain, but that’s a different subject. So it has no source of nutrition coming from the underlying bone or from blood vessels through the bone into the cartilage. Blood vessels and nerves do not cross through the bone that the cartilage is attached to into the cartilage. So they are subject to the limitations of what’s in the joint fluid, whether it’s glucose, cytokines, [or] inflammatory mediators—IL-6 which is an inflammatory mediator. COMP is a protein that when it’s present is a sign of cartilage degradation. Interestingly, if you’re sedentary, your COMP levels go up. If you’re active, [the] COMP levels in your knee go down, same with IL-6 levels. So what is in your blood based on your metabolic fitness, health, and what you’re eating is what’s going to be filtered into your joint fluid, and that’s what’s going to be compressed into your cartilage. So we really are completely connected. We can’t think of cartilage as being different than a kidney, an eye, a heart, or a liver.

We can get tendinopathies. So that’s the reason why we have Achilles pain as a runner, patella tendon pain as someone who plays running sports; shoulder pain, that awful pain on the side of your shoulder when you reach up or at night when you roll over, that pain on the side of your hip that’s just killing you. These are tendinopathies. Tennis elbow is another tendinopathy. […] It can last nine to 12 months in many people. The tendon is made of collagen. It doesn’t want to be made of anything else because the strength of that tendon is going to be based on the alignment of that collagen. In other words, take a box of spaghetti, [and] take the spaghetti out. You see all these little fibrils, that’s collagen. Break it up and mix it around, that’s tendinopathy, where the fibers are going in different directions. There’s space between the fibers and there’s junk in there. Whether [it’s] because of glycosylation or cartilage, cholesterol deposits, [or] uric acid deposits. All this sludge or junk will occupy space where the tendon should be and it compromises the tendon’s integrity.

37:04 – The importance of blood flow and cellular repair

Dr. Luks and Dr. Casey Means discuss the interconnectedness of systems in the body, making it a dynamic entity of communication and collaboration, much of which is supported by the level of blood flow in the body.

I talk about the effects of blood flow with a lot of patients—everyone’s gonna have their moment, what’s going to stick in their mind [that] flips the switch, the light bulb moment that says, ‘Okay, I understand this. I get this right.’ That was the focus of my book. ‘You’ve heard all this before. You’ve heard this advice before, but here’s why it matters, and here’s how it’s all interconnected.’ So what happens to stick with men a lot? Why they wanna focus on their metabolic health is impotence. Boom. Right. I immediately get their attention because the incidents of impotence [are] huge. It’s a blood flow issue. It’s a blood vessel issue. It is related to your poor metabolic health. It is related to your cholesterol levels. It’s related. So yes, the same areas [and the] same issues can be reflected in our tendons, in various areas of our body, and [they] absolutely will have a role. Because every time you exercise, run, walk, or do things, [you] get these micro-injuries. So the tendon will get a little stretched, a little damaged, a little this [and that], but it’s okay. I mean blood vessels are there. They bring white cells. The white cells will remove the damaged tissue. Other cells will come in and lay down the building blocks into [a] new tissue and you’ve repaired it. But if you don’t have the building blocks there because there’s no blood flow, if you can’t clear the debris because you don’t have enough blood flow, you’re just escalating the problems.

46:58 – The importance of being your best medical advocate in modern medicine

Dr. Luks points out a crucial issue with how modern medicine is currently set up, emphasizing how this approach to healthcare neglects interconnected systems in the body. He encourages listeners to be in charge of their own health and advocate for their well-being better.

We’ve talked about this, but modern medicine is not built for this. We are complex bodies, but we don’t see [a specific] doctor that puts everything together for us, right? And therein lies a significant issue. You know, you see your cardiologist, [they’re] gonna adjust your blood pressure medicine. Your endocrinologist is gonna increase your metformin. Your primary care doctor will give you your flu shot. And I’m not crushing them. This isn’t their fault, right? This is how medicine is constructed. They have to perform. If they don’t perform, they don’t get paid. So they don’t have the time. […] I guess the take-home message of that statement is: Be your best advocate. You have to look deeper and think [about your health] in a more complex manner because I don’t think that modern medicine is gonna do that for you today.

50:09 – How Dr. Luks started learning about metabolic health and wrote his book, Longevity Simplified

Dr. Luks tells the story of his tenure as an orthopedic surgeon and how he branched out to writing about metabolic health in his late 30s. He shares that he came to the space through issues with his own health and longevity, and how it was a turning point for him as a doctor and scholar.

I’ve weighed 173 to 175 pounds since high school. And all of a sudden, at this point, I’m 196—still have those pants as a reminder in my closet. [There] wasn’t much in the literature back then about fatty liver, but I started to go down all these pathways, you know, what’s associated with fatty liver and its [causes]. And I said, ‘Oh, you know, this is your moment, you’re gonna turn 40 soon. Not quite sure why this is here, but it’s not good for you.’ So I cut out all the crap from my diet. We didn’t have keto or low-carb rabbit holes back then, but I just went on a whole-food diet. I ate real food, mostly veggies. [I] stopped drinking and started running more, exercising more. I was optimizing for my longevity. I’d started a website around that time, and at first, I was writing articles cause I wanted to share them, and tell people what I thought. And I started to read about fatty liver. I started to read about insulin resistance, cholesterol issues, et cetera. And then the more I read, the more I started to write. Then I started to publish these articles, the same thing I do in the training space. So eventually I wrote enough, and enough people said, ‘Look, you need to write a book.’ One thing had turned into another. I never really had the time to write a book, but then this little virus came around and I found the time to write the book. So I came to this through—like most people probably—my own issues with my health and threatened longevity or health span.

1:02:49 – The simple pillars of longevity

Create a caloric deficit, sleep well, eat real food, and get moving: these are the simple yet essential pillars for longevity that Dr. Luks highlights in the episode. He also emphasizes the phenomenon of sarcopenia, an age-programmed loss of muscle mass that can be managed by keeping a level of activity every day and engaging in resistance exercises.

[This is] the key right [here]. I don’t promise people years, I promise them good years. I mean, if I’m dealing with someone who’s had four or five decades of really bad habits, it’s gonna be hard to reverse all the downstream effects of that. But if we get them weight trained, we get them strong, we fix their balance, we fix their metabolic health so things don’t worsen, then we can affect significant change and we will see a far better terminal decade in that situation.

This is really important: sarcopenia. Sarcopenia should be a four-letter word because it sucks. It is age-programmed loss of muscle mass. Starting at the age of 35 to 40, we lose approximately 0.8 to 1% of our muscle mass per year. And that will correspond to a significant loss of muscle strength. It’s going to accelerate in your mid to late fifties and into your sixties and beyond. You cannot reverse sarcopenia. Once those muscle cells are gone, they’re gone. You can mitigate its decline and you can build muscle mass. So I tell people to push and pull heavy things. We need to do resistance exercises.

If you are the average person out there who hates to exercise and thinks of exercise as work, but you’re concerned about your health, you don’t need an assault bike, you don’t need a Peloton, you don’t need to overthink this. You need to eat well. You need to get yourself to go outside. You need to make your day a little harder. You need to try and sleep better. Try not to stress-eat as much. Try to find that little win, right? You put that cream in the coffee, have a donut in the morning, or a few Oreos at night. Just find that little win. It matters and it works in the end. If you’re an overachiever, great. So am I. Every now and then, we’re gonna have an injury and that’s why I’m here.

1:24:56 – Why you don’t need to be concerned about osteoarthritis

Dr. Luks points out that there are varying degrees of how osteoarthritis will affect a patient. For the vast majority, the case will be mild and can be managed with non-surgical treatments such as weight training, negating the misconception that osteoarthritis is a life sentence.

We focus on the fact that osteoarthritis, the ideology or the cause of osteoarthritis is more often than not biological, and that cartilage, nutrition, and health [are] based upon this repetitive loading. It likes the repetitive loading, so there’s no reason to stop being active. As we also discussed, we had runners who were less commonly resorting to knee replacements as opposed to non-runners with the same degree of arthritis. So we have to do away with the thought that osteoarthritis is a death sentence, that it’s a terminal disease—it’s not. [For] some of you, it’s reached the point where yes, you have no other options available, surgery, et cetera, can be very beneficial for you. Life-altering. But for the vast majority of people, that’s not the case. And if you can play two sets of tennis instead of three before you get sore, do it. If you can run two miles instead of four miles, or if you have to fast-hike or fast-walk instead of running, you’re gonna do that. You’re not gonna destroy your joints by staying active. Weight training is not going to destroy your joints. If the pain is mostly in the front of your knee, weight training is going to alleviate the pain in the vast majority of circumstances. So, take-home message, it’s not the end of your life. It’s not the end of your joint. And the more active that you stay, the happier your knee is gonna be. The stronger you keep your leg, the longer you keep your knee. [The] same goes for your shoulders.

1:32:00 – Trust your body by boosting its regenerative capabilities

Dr. Luks and Dr. Casey Means share sentiments on the frequency and volume of surgeries that could be lessened by simply taking care of your overall health and boosting your body’s regenerative capabilities. Dr. Casey Means goes into factors influencing the issue, such as consumerism and the western concepts of impatience and instant gratification.

Part of the equation in facing physical challenges like this is actually just tapping into a sense of patience and tapping into a sense of healthy coping because we are an instant gratification culture and in a sense, surgery does feed into both consumerism and also instant gratification. We get something, it’s high-value, it’s high-cost. So therefore we believe it’s valuable. It’s actually the opposite of high-value, right? It’s very high-cost [and will] possibly not [have] a great outcome. We have difficulty sitting with discomfort because of just our general western culture of thinking that discomfort is actually a bad thing versus a growth opportunity. I think a lot of this probably does come down to mindset. Another aspect of the psychology is also just a misconception of the body as a dynamic flowing entity that’s constantly capable of regenerating versus something that’s there to decay and hurt you and cause problems and this and that. So really, it gets down to a lot of like fundamental framing issues or [the] kind of modern [cultural] things that we struggle with in the western world like impatience and consumerism and lack of ability [to trust] the body.

I had to basically sit with a little bit of pain for an unknown period of time, like, ‘This could last six weeks, this could last four months. I have no idea, but I’m trusting in my body.’ And also the clicking, is it ever gonna go away? If I have surgery, I’m pretty sure the clicking will go away because the cartilage will be shaved off probably, but it might never go away. So kind of using that as a mindfulness exercise of, ‘I don’t know, but there’s no rush and I trust that my body can handle this,’ and do exactly what you basically recommend in your book, which was focus on what I can do, eat real food, [maintain an] anti-inflammatory diet, eat lots of fiber, move my body, start doing resistance training when I could, focus on the things in my life that are good and that are purposeful. Voila, four months later, [and I feel] better [but that might not] be the case for everyone.

Dr. Howard Luks (00:00:06):

What am I going to tell someone who’s 60 year old with a rotator cuff tear, take allopurinol and decrease your glucose? Well, if they want to live to 90, yes, but that’s not going to address the shoulder problem now, right? This is why the early we pay attention to this the better we’re going to be, because you don’t want to bring these tendons and this arthritic burden, inflammatory burden through your formative decades in the early adulthoods because they’re going to result in problems. The longer that you suffer from high cholesterol, the higher your A1C is and your glucoses over the longer period of time, the worst the downstream consequences are going to be for you, not only for your eyes, not only your risk of dementia, your risk of kidney failure, hypertension, NAFLD or fatty liver, but in my world, the higher the risk of tendon related issues, more severe pain, tendon tears and more significant pain with arthritis and other maladies.

Dr. Howard Luks (00:01:11):

I’m Ben Grinnell, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health, and this is your front row seat to everything we do. This is A Whole New Level.

Dr. Casey Means (00:01:37):

Hello, and welcome to A Whole New Level. This is Dr. Casey Means, co-founder and chief medical officer of Levels, and I am so thrilled to introduce our guests today, Dr. Howard Luks, who is a world renowned orthopedic surgeon. He’s an entrepreneur and he’s an author. He was the chief of sports medicine in arthroscopy at Newark Medical College for over 20 years and he’s also been named one of the top orthopedic surgeons in America by US News and World Reports. In his personal life, he has an avid trail runner, a cyclist, you can even find him on Strava. So look him up. And he recently came out with a book called Longevity Simplified: Living a Longer, Healthier Life Shouldn’t Be Complicated. And so if you think that longevity does sound complicated, this is a great episode for you because we’re going to break it down.

(00:02:27):

Dr. Luks is going to let us know how longevity can be accessible and easy for us to understand and really draw the links between whole body health and what’s happening with our joints and our muscles and our tendons as we age. And really help us understand that a lot of the things that we think about that are inevitable with aging like pain and reduced mobility and surgeries and injuries, they may not be inevitable. A lot of is modifiable and a lot of it comes down to our metabolic health so much of which we can control. So this is a very empowering episode and may just help us all live a healthier and more functional life of mobility and freedom. So excited to share this episode. So let’s jump right in.

(00:03:21):

Dr. Luks, welcome to A Whole New Level. Thank you so much for being here.

Dr. Howard Luks (00:03:25):

Thank you, Dr. Means, and please call me Howard.

Dr. Casey Means (00:03:29):

Okay, well, same with me. Please call me Casey. I was telling you before we started, I am really one of your biggest fans. I love what you are doing to change the way we think about a subspecialty like orthopedics or orthopedic surgery and really broadening understanding of joint health and musculoskeletal health. And I will tell the listeners briefly about some interactions we’ve had recently. We got connected through Levels and have done some content work together for the Levels blog, and I’ve shared your blog posts about the relationship between metabolic health and joint health with so many people.

(00:04:06):

But then more recently, I personally reached out to you because I think you’re the only orthopedic surgeon in the country that I feel super, totally philosophically aligned with because I was doing back squats and I ripped, like what a 1.5 centimeter piece of cartilage off my femoral head cartilage. And I went to the doctor, to the orthopedic surgeon and he told me with a strong recommendation that I should do this two stage very invasive surgery called a Macy procedure that would have me harvesting cartilage, growing it in a lab, putting it back in my knee. And it just did not feel right to me. It felt like a very turbo decision for a young person who was not actually in that much pain. So I emailed you and asked your recommendation and I would just love to put that question back to you in front of the podcast listeners like when you hear something like that, okay, someone’s had a cartilage defect in their knee. How do you approach something like that?

Dr. Howard Luks (00:05:13):

Yeah, great question. And it’s not as easy as you think to answer. We are so much more than a simple finding on an MRI. And what we fail to understand as well is what are findings very typical of active people who are squatting heavyweights, running distances in an orthopedic practice. Is it unusual to have a small lateral condo cartilage defect? It turns out, no. As I shared with you, I got MRIs of both knees long ago just because I wanted to see them. I was interested. I have meniscus tears and cartilage defects and bone marrow edema in both knees, yet I was actively running 30 to 40 miles a week and I still am. So we dove into your process and the fact that you had little to no pain and were ready to go back out and start working out and moving. And we realized that this may have been the day that you realized that you had a defect, but it may not have been the day the defect came about.

(00:06:25):

We didn’t see edema or inflammation in the bone. We didn’t see sharp edges around the defects, so there were a lot of hints there that maybe it wasn’t acute, maybe we were seeing the early part of a more, I hate the word degenerative process, but just one of those things that we accumulate through the decades, especially with poor metabolic health, et cetera, which we’ll touch on later. And look, you are feeling fine. It’s very hard to cut into a knee of someone who’s feeling fine and expose them to the risks of surgery, the risks of complications and the risks of just opening the knee. The knee doesn’t like that, no joint like that. And it will generate a little just because of that.

(00:07:10):

And I shared with you, I think that I was part of the original research done in New York City at the hospital for joint diseases on this cartilage based procedure. And we found a lot of these defects recurred, so if we were doing them on degenerative defects or defects that were coming about, not because of an acute trauma, but just over time that they would come back again a few years later. So I think we put out the fire, we put out the thought that, “Oh, my God, I have to fix this immediately.” And you step back and you’re doing fine. And we really don’t have research saying that we’re heading off arthritis or a problem in the future. I really hate the idea of trying to do something now because we might affect something in the future because we might not. And if something bad happens now because we did this, then you’re definitely going to have a problem in the future. And look at you, you’re doing wonderfully.

Dr. Casey Means (00:08:17):

Yeah, it was an amazing conversation because you shared with me what you said that you can take a lot of patients who are older or even young and do MRIs of their knees and some people may have structural architectural defects in the knee or in any joint. That doesn’t necessarily mean that they all have symptoms and-

Dr. Howard Luks (00:08:41):

Correct.

Dr. Casey Means (00:08:43):

… that is so fascinating cause I think that’s very different than how we typically think about from the surgical world of like, “Oh, there’s a structural problem, we must fix it.” And one of the things I think that you had mentioned in your note to me was that I actually have it in front of me, so I’m going to read what you said because I love it and I’d love for you to unpack it a little bit more. It turns out that cartilage issues and early osteoarthritis is often the result of a failure of the innate repair mechanisms that cartilage has. In other words, osteoarthritis is not a mechanical issue, it’s a biologic issue. So many people I think are thinking about osteoarthritis is like, “Oh, it’s bone on bone, it’s cartilages generation.” But what do you mean by a joint issue being more of a biologic issue than a mechanical issue? And where does that give us room to intervene in a different way?

Dr. Howard Luks (00:09:33):

Great question. Yeah. So for the longest time, you were told don’t run, it’s going to ruin your knees. If you have this sound, you’re grinding away cartilage. It’s very easy to think of cartilage as a cheese on a cheese grater or sandpaper on wood. And that these horrible things are happening inside our knee when we run or when we move or when we work out. Well, it turns out it’s not. And it turns out that osteoarthritis in the majority of situations is a failure of a biological repair mechanism.

(00:10:08):

Cartilage is capable of repairing itself, but something screws up the pathway. Not quite sure what’s going on there. I am not a researcher in this space. I do follow it closely though. And it appears that there are WNT, this is the WNT pathway, as one of the pathways involved in repair. And there are new WNT inhibitor, small protein molecules that they’re administering two people in phase three studies and they’re showing that they can halt at times reverse early changes associated with arthritis. So the changes in an arthritic knee are much more complex. The ideology or the cause of osteoarthritis is far more complex than we were initially led to believe.

Dr. Casey Means (00:11:04):

Of course, because I was thinking, okay, I want to do anything non-operative that I could possibly do before having someone cut into my knee, which is ironic as I trained as a surgeon, as you did. And I think there’s the group of us who know that’s a powerful tool, but also believe that, well, if there’s anything we can do to stay out of the operating room, that’s ideal because it is a very morbid act, right?

Dr. Howard Luks (00:11:29):

Correct.

Dr. Casey Means (00:11:30):

I think people, it’s almost like a rite of passage being in the western world. “Oh, I’m having my surgery for this or that.” But when you’re actually in that room, it’s a crazy thing that’s happening, right?

Dr. Howard Luks (00:11:39):

Absolutely.

Dr. Casey Means (00:11:39):

You’re cutting into someone’s body, huge inflammatory shots, huge stress response, so want to avoid it. And so I was doing some digging in my limited conception of thinking about, okay, well what’s going to lead the degeneration? Maybe failure of the regenerative pathways and maybe over inflammatory response so it’s not well regulated. And there are some papers, not strong research showing, okay, maybe fish oil or anti-inflammatory strategies can help with joint health. So how do you think about the various behavioral modulators of a healthy joint biology? And is there anything that you recommend for patients to essentially create conditions within the joint that lead to the more regenerative capabilities of our tissues?

Dr. Howard Luks (00:12:26):

Right. So what I try to get through to patients is our joints are no different than our liver, our heart, our brain, our pancreas, our eyes, our kidneys, et cetera. So as we’ll get into poor metabolic health, poor glucose control, fatty liver disease, which is now of epidemic proportions, lipid issues, et cetera, triglycerides, these are causing a cascade of events and our musculoskeletal system, our tendons, our ligaments, our bones aren’t sitting by in this unskates, we have a higher risk of osteoporosis. A 50-year-old woman, a 56-year-old woman is going to spend more time in the hospital because of osteoporosis than heart disease and breast cancer combined. Wow. One in three is going to suffer an osteoporotic fracture. One in five men is going to suffer an osteoporotic fracture, so men are going to suffer too. We are more prone to having tendon tears, ligament tears in situations where we have poor metabolic health.

(00:13:40):

We have glycosylated hemoglobin, right? Your hemoglobin A1C, that’s the glucose that’s floating around your body. It sticks to things. When it sticks to hemoglobin, your A1C goes up. It sticks to other things too. And if it does that in your eye, it leads to blindness. If it does it in your kidneys, it leads to kidney failure and on and on. Well, if it sticks in parts of your tendons and you have hyperuricemia or high uric acid, you have lipid or cholesterol deposits, then you’re taking away collagen or the tissue that forms tendons and ligaments. So you have an increased risk of rupture because those tissues are weaker. Now, poor metabolic health, as you well know, causes an increase in systemic inflammation. That inflammatory burden is going to affect our knees, this is people with diabetes or severe insulin resistance and metabolic syndrome have more pain with mild osteoarthritis than someone who’s metabolically fit or healthy. And this may be why osteoarthritis and other conditions which are inflammatory in nature worsen a little more in people with poor metabolic conditioning and health.

(00:14:55):

So to go back to your original question, which at my age, I’m glad I could remember, I really… Unless I have someone that I’m walking off a cliff where they’re just miserable and we’ve lost the chance to start earlier in the process. I can’t tell you how common it is. I have someone in front of me, A1C is AST/ALT because I do ask for labs, forties, triglycerides, it’s high. So poor metabolic conditioning. I actually bring a lactate meter to my office sometimes. So we’ll check the baseline lactates and we dive into the metabolic fitness and health. And they’re oftentimes just coming because something’s bothering them. They’re concerned, do I have a meniscus tear? Do I have this? And I’ll dive very deep into why they’re experiencing symptoms, why it’s not what their MRI shows and how we’re going to fix this and we’ll dive into nutritional STA strategies, exercise strategies. I am not going to stop their exercise. And so, it’s a tough way to practice medicine these days, isn’t it?

Dr. Casey Means (00:16:17):

It is. It’s definitely going against the grain because as we know, spending that time to understand a patient’s diet, lifestyle, motivation, barriers to healthy living takes a long time. It’s not financially incentivized. Whereas if you take them in for that really fast arthroscopic procedure and debrid some cartilage like that is going to bill gangbusters, it’s fast, they’re in and out. You don’t have to have those long conversations. I think we both know there’s such a bias, I think towards action because of the way our system is an incentivize. And I’d love to talk with you a little bit more about how that plays out since you are taking a slightly different route, a very different route in your practice by really focusing on the underlying biologic mechanisms that lead to outcomes that sometimes we think are really where operations are our main hammer.

(00:17:09):

But before we jump down that more systems that you wrote, I’d be curious to dig in a little bit more to the movement and exercise. You said you do not tell people to stop exercising even if they have a joint issue. And that was really empowering to me when you mentioned that because right when I hurt my knee, there was one of the most disconcerting symptoms was just this constant clicking every time I bent my knee and took a step and I’m like, “Oh, my gosh, this feels to me like it. I need to have surgery to cut off whatever is causing that clicking.” It’s a very uncomfortable sensation. And there was a little bit of pain, maybe two out of 10. And I will say now it’s four months later, I have zero clicking and absolutely zero pain and full range of motion. And I have been, and in part because of your prompting and other reading, I’ve been extremely active, not pushing through pain but not letting slight discomfort totally deter me.

(00:18:05):

And I think in my mind, before really understanding this a little bit better, I thought, “Okay, well, if I’m moving and exercising, it’s going to cause more inflammation in my knee. And that might be a bad thing.” But can you explain why that’s probably not the right way to think about it and how patients should have a framework for staying active despite maybe some joint issues?

Dr. Howard Luks (00:18:28):

Yeah, sure. So there’s lots to unpack there. First of all, throw this out there. There is no 40 something, 50 something or 60 something who’s walking out of an operating room and going to feel better in two weeks. Not going to feel better in six weeks. They may regret having the surgery in six or eight months. We just do not respond fast. So it’s almost never a quick, easy answer to something that’s bothering us. Next, it’s very hard to unsee your MRI. I have a post to my website of that very title and it’s very true because you’ve now seen, oh, my god, meniscus tear, right? If you throw a 40, 50 something in for an MRI, you’re getting back a report that shows six things, a little bit of this, a little tear of this, some fraying of this, and people don’t like that. So now every time the knee hurts going forward, it’s going to be of course, because of that little thing on the MRI.

(00:19:28):

Now, there are very few reasons to stop exercising. Unless, someone has a stress fracture or something that’s going to actually worsen, there is no reason to stop them. It is a common misconception that with osteoarthritis, you are causing more harm if you remain active. Yet the exact opposite is the case. Osteoarthritis by definition is less common by evidence, is less common in runners. Maybe that’s a self-selection bias because runners keep running. However, they did a study where they had a bunch of runners and non-runners, same degree of osteoarthritis on x-rays. They allowed the runners to run at a self-selected pace. The sedentary people remain sedentary. They were more likely the sedentary group was more likely to have a knee replacement than the group who’s running. It turns out that the cartilage likes cyclical loading.

(00:20:29):

Cartilage is not a dead tissue, it’s not a sedentary tissue, it’s like a sloth. It doesn’t move quickly, it’s not exciting, it doesn’t beep. It has a very slow metabolism, but it is capable of repair. There is a nourishment process that is going on, that nourishment comes not from blood flow but from substances in your joint fluid. So the cyclical loading actually helps to get that nourishment and energy source into the cartilage. So maintaining a level of activity is super important. And because I care a lot about bones and fracture risk, it’s really important to stay active because of your bone quality and your osteoporosis risk. More important, if you are exercising and you’re used to exercising, and you rest for as little as two weeks, you’ve lost about 20% of your muscle strain. So it’s pretty dramatic. Not only that, metabolically speaking, you’re more insulin resistant, the whole kit in the caboodle. So there are very few reasons to stop people from exercising.

(00:21:45):

Most people who are in my office, if you talk to them properly and you ask the right questions and if you listen to them, they’re more concerned that they’re not doing harm, they’re not there because the pain is so acute that they have to do something, they’re there because something hurts. Their best friend said if you continue running and playing tennis, you’re going to kill your knees. Their primary care might have said the same thing. So doctors are guilty of this too. So the main message to them is, “Look, you’re okay. We’re not going to get an MRI because it’s not going to change what I’m going to do, and the result that’s going to freak you out, I want you to stay active. I don’t want you to decondition. If the pain ever gets to the point where it is the reason why you need to stop, then we need to talk.

Dr. Casey Means (00:22:37):

That makes a lot of sense. Okay. So I guess I’m thinking about the listener here, maybe thinking, pretty much everyone has some ache and pain at some point in their life. So the person who’s got the rotator cuff pain or they’ve got the knee pain or they’ve got just something going on, and probably they’ve been encouraged to have surgery by their doctor because that’s the hammer that we’ve got. And so how do you think people should think through, “Okay, I’ve got some pain that’s come on recently.” What’s mental model that people should feel empowered to latch onto before making the decision to go under the knife? And are there any circumstances in which for something like a joint issue, like a tear or a ligament energy injury or something like that, or a cartilage injury that you would say, “No, actually the best option is to just have the surgery acutely.”

Dr. Howard Luks (00:23:37):

Yeah. So, when I’m seeing someone in my office that’s going to… I’m not telling people don’t come to the office, don’t come to see us, right? If you have a concern, I want to see you and I wanted to see what’s going on. And based on your complaints, right? Because as we were taught in medical school, if you listen to someone, you’re going to know the diagnosis, right? It’s actually true. And then your exam is going to confirm that we don’t need an MRI for a diagnosis. We often get it to confirm a diagnosis based on our suspicion. So based on your examination on your complaints, we’ll decide if an MRI is necessary or not necessary based on your symptoms, we’ll then decide on what the path forward for you should be to continue with your activities to slow down for a little bit, few weeks, speed up to do more resistance training, less aerobic work, maybe some more bike work or swimming as opposed to running.

(00:24:37):

What’s really important for people is to understand that more often than not, you have a lot of choices, you have trying to decide. Very little in my world is an emergency, period. So if I see people with an acute traumatic injury, terrible weakness of the shoulder, they can’t move it or I’m suspicious that they dislocated, I’m going to get an MRI. I want to know if you have a large rotator cuff tear. If it’s tiny, I’m probably not going to say to do something. If it’s huge and you’re young, I probably will advise it. But again, these are not life and death struggles in the orthopedic world. So you do have options and choices.

(00:25:19):

Knee injuries, right? If I’m concerned you had a patella dislocation, I’m going to MRI you because I want to make sure you don’t have a cartilage injury associated with that ACL tears. I’ll get it. Not only not to confirm the ACL tear, because my exam will tell me that, but to look for concomitant injuries to other structures that may need us to address them. But the vast majority of joint pains and aches, they do not require surgery. Many don’t require advanced imaging. They require us to listen to you, to examine you, and to come up with an appropriate plan. Not blowing you off. I’m not ignoring you. I’m going to distract you while mother nature heals you.

Dr. Casey Means (00:26:00):

I remember reading when I hurt my knee about [inaudible 00:26:04]-

PART 1 OF 4 ENDS [00:26:04]

Dr. Casey Means (00:26:03):

I remember reading, when I hurt my knee about chondrocytes, the cartilage cells. And it’s similar to how you say, that they’re not only sloth-like, but that they’re basically just these inert kind of cells that don’t regenerate and they are just dead almost.

(00:26:17):

Which I’m curious if you can tell us a little bit about … I know that some of the cartilage doesn’t get great blood flow, but you were mentioning that it’s actually some of the factors in maybe the fluid around the cartilage cells is actually giving some cellular signaling. I’d love for you to paint a picture of how cartilage cells are in terms of metabolic activity. Do they have mitochondria? Do they respond to regenerative or anti-inflammatory factors that might be circulating in the fluid around them? And are they this just dumb, dead tissue that we think about that once it’s injured, it’s injured. And I think the answer is no from what I’ve read, but I’d love for you to unpack it. And it also just reminds me of how I think we were taught in medical school a lot of these things that are very black and white around brain cells. Once they die, they never regenerate. And once you have a heart blockage, it never changes. And we get a lot of these messages in medicine of, once it’s done or there the cat is out of the bag. You can’t go backwards.

(00:27:24):

And I think something I’m starting to feel more and more, going into more of the metabolic health or regenerative world is like, there’s a lot more complexity to it than we actually realize. So I’d love to hear about that from maybe the standpoint of cartilage and yeah, just how you’re thinking about that.

Dr. Howard Luks (00:27:42):

The more you know, the more you realize you don’t know. Every time I think I’m out of the valley of despair of the Dunning-Kruger curve, you just slide a little closer back to that valley. I should be all the way up on the right somewhere. But you realize that medicine is far more complex, and basic pathophysiology and biology, there’s so much more in the textbooks now than there was when I studied, probably even more than when you studied. It changes every day.

(00:28:17):

We used to just think of cartilage as this smooth, rubbery substance, than, right, it was dead like a sloth. And it didn’t really do much and it just wore away over time. And it’s not exciting. Although I must say, when you put a scope in the knee or when you open the knee, it’s a beautiful substance. I mean it’s white, it should be white, pristine, perfect, smooth. There’s no surface in our body with less friction than joint cartilage on joint cartilage. It really is a wonderful tissue.

(00:28:56):

It doesn’t like to be sewn. It doesn’t like to be invaded. It doesn’t like to be hit because it has such a slow metabolism. So if you strike your knee against a dashboard in a car accident now, you may have some pain now that’s going to go away. Three years you may have a cartilage injury, it may show up on an MRI. It was because of that injury three years ago because it took so long for the ramifications of that injury to reveal themselves. Cartilage cells like to stay by themself, they don’t like others. And they secrete this matrix. And matrix is what, when you look at cartilage, that’s the white substance. And there’s mucopolysaccharides and other things in there. And that’s what forms this hard gelatinous smooth surface.

(00:29:46):

Embedded in there are the cartilage cells. They do not have a blood supply. In a non-arthritic knee they do not have a nerve supply. In late stages of arthritis we can develop nerves, et cetera, and that’s a source of pain but that’s a different subject. So it has no source of nutrition coming from the underlying bone or from blood vessels, through the bone into the cartilage. Blood vessels and nerves do not cross through the bone that the cartilage is attached to into the cartilage. So they are subject to the limitations of what’s in the joint fluid, whether it’s glucose, cytokines, inflammatory mediators, IL-6, which is an inflammatory mediator. COMP is a protein that, when it’s present, is a sign of cartilage degradation. Interestingly, if you’re sedentary, your COMP levels go up.

Dr. Casey Means (00:30:42):

Wow.

Dr. Howard Luks (00:30:43):

If you’re active, your COMP levels in your knee go down. Same with IL-6 levels. So what is in your blood, based on your metabolic fitness, health, and what you’re eating, is what’s going to be filtered into your joint fluid and that’s going to be compressed into your cartilage. We are completely connected. We can’t think of cartilage as being different than a kidney, an eye, a heart, or a liver.

Dr. Casey Means (00:31:14):

Oh, that’s amazing. So, so, so interesting. Let’s step tail off that and really get into a little bit of this relationship between metabolic health and joint health. And we’ve been focusing on knees, but I hope for people listening, we’re really talking about joints in general.

Dr. Howard Luks (00:31:28):

Correct.

Dr. Casey Means (00:31:28):

And I think that I’d love to hear the framework for how … You mentioned this a little bit earlier with uric acid and glucose and whatnot, but what are the mechanisms, like the actual mechanisms, that relate poor metabolic health to issues in our joint? And then on the flip side of that, how does improving or having optimal metabolic health change our outcomes for having pain throughout our lifetimes?

Dr. Howard Luks (00:31:58):

Sure. The reason why we see people with pain in the office is often two major groups, bony and soft tissue. The majority of bony issues, joint issues, are arthritic in nature. That’s osteoarthritis. And the majority of soft tissue issues are tendons, ligaments. Ligaments tear or they don’t. They’re very rarely a problem other than that. So a lot of shoulder pain is tendinous, a lot of hip pain is tendinous. You may have heard the term bursitis. It’s far less common than you think, it’s almost always the tendon that’s the problem.

(00:32:41):

We suffer from tendinopathies. So painful tendons, changes within the tendon. A tendon of a 50-year-old doesn’t look like the tendon of an 18-year-old. We can get tendinopathy, so that’s the reason why we have Achilles pain as a runner, [inaudible 00:33:00] tendon pain as someone who plays in running sports. Shoulder pain, that awful pain on the side of your shoulder when you reach up or at night when you roll over. That pain on the side of your hip that’s just killing you. These are tendinopathies. Tennis elbow is another tendinopathy. Why does everyone between the age of 15 and 65 get tennis elbow? We don’t know, but it does happen.

(00:33:29):

So tendinopathies, some of it may be pre-programmed into us. As I said, everyone gets tennis elbow. I’ve had it. It was a short course. Maybe my fitness had something to do with that because it can last nine to 12 months in many people. Tendon is made of collagen. It doesn’t want to be made of anything else, because the strength of that tendon is going to be based on the alignment of that collagen.

(00:34:01):

In other words, take a box of spaghetti, take the spaghetti out. You see all these little fibers, that’s collagen. Break it up and mix it around, that’s tendinopathy. Where the fibers are going in different directions, there’s space between the fibers, and there’s junk in there. Whether it’s hemoglobin … I’m sorry, whether it’s because of glycosylation or cholesterol deposits, uric acid deposits. All this sludge or junk will occupy space where the tendon should be, and it compromises the tendon’s integrity. If you overload a tendon, you will develop an overuse tendinopathy.

(00:34:47):

So most running injuries, I’m a runner, I like talking about runners, most running injuries are overuse injuries. We decided we’re going to run faster today or farther today and we don’t give ourselves enough rest. And a week later our tendon hurts. Well, if your tendon fibers aren’t properly aligned, if you have all this sludge and other substance in between those fibers, if the inflammatory burden in your system is higher, and probably if your repair mechanisms are somewhat suppressed by that inflammation, you have the perfect setup to have pain, fraying, tearing, et cetera.

(00:35:27):

Now, look, the blow back that I get online all the time when I talk about this, especially from other physicians in my line of work, is what am I going to tell someone who’s a 60-year-old with a rotator cuff tear? Take allopurinol and decrease your glucose? Well, if they want to live to 90, yes, but that’s not going to address the shoulder problem now. This is why, as I hope we’ll get into, the earlier we pay attention to this, the better we’re going to be. Because you don’t want to bring these tendons and this arthritic burden, inflammatory burden, through your formative decades and your decades in early adulthoods, because they’re going to result in problems. These are all area under the curve issues. The longer that you suffer from high cholesterol, yes, ApoB is causative of heart disease and it’s worse in the presence of inflammation. I had to say that.

(00:36:24):

The higher your A1C is and your glucose is over the longer period of time, again, area under the curve, the worst the downstream consequences are going to be for you. Not only for your eyes, not only your risk of dementia, your risk of kidney failure, hypertension, NAFLD or fatty liver. But in my world, the higher the risk of tendon-related issues, more severe pain, tendon tears, overuse injuries, and more significant pain with arthritis and other maladies.

Dr. Casey Means (00:37:04):

Beautifully said. I think that’s such a fascinating visual. I love the visual you gave of, here’s a tendon with all this collagen, and you want it to be in a nice structure formation. And if you start adding a bunch of excess uric acid, cholesterol deposits, glycation through excess glucose sticking to things, you start cross-linking all these things and causing problems in the structure that can make it basically more vulnerable to injury.

(00:37:31):

Which is funny, I was on a podcast last night and we were talking about glycation of collagen in the skin and how that’s part of the ideology of wrinkles. And so it’s just a fun thing to think about, of there aren’t that many of these mechanisms in the body and they show up in so many different cell types or different systems, and are causing dysfunction all the body. Glycation in the skin could look like wrinkles, glycation in the ligament could look like just a weaker dysfunctional tissue that’s more prone to injury. But bottom line, we want to get rid of these excess metabolic byproducts that ultimately disturb our tissue, and therefore create symptom and disease. And I love that framing.

(00:38:18):

And then another one that I … I went to a conference a couple years ago where there was an orthopedic person. This was actually when I was plant-based and I was fully planted-based. I still love plants, but I was hardcore and it was a plant-based physician nutrition conference. And one of the things that is so vivid that sticks out in my mind is he basically said that rotator cuff injuries are heart attacks of the shoulder. And so he was talking a lot about blood vessel, blood flow as part of these … The link between metabolism and our predisposition for basically injuries.

(00:38:53):

And I’d love for you to talk a little bit more about that, because we know that high insulin levels can cause some endothelial dysfunction and blood vessels maybe not dilating as well. So how does that play into how you think about metabolism’s relationship to injuries you’re seeing in your office?

Dr. Howard Luks (00:39:09):

Yeah, you’re absolutely correct, and he or she was absolutely correct. The downsides of excess glycation affects every tissue. No tissue gets a pass in this. And our cardiovascular system or our blood vessels, are terribly affected by the presence of Type 2 diabetes, high glucose levels, high inflammation, the hypertension. Our blood vessels thicken, they’re not as porous. Smaller blood vessels are going to close up, they’re going to disappear.

(00:39:48):

We have many areas in the orthopedic world that already have very limited blood flow, like parts of the Achilles tendon. That’s why tears almost always occur at the same level on Achilles tendon, parts of the rotator cuff. So if in the best of circumstances you have a marginal blood supply, because there are watersheds. You have an artery that’s coming up this way, you have an artery that’s coming up this way. In the perfect situation they overlap a little. You start to get arterial disease and you’ve lost blood flow to this area. Where there is no blood flow, there is no cell turnover. There’s no repair. You’re not bringing in the building blocks to repair that tissue. You’re not taking away the dead tissue. It’s a dead zone. And that’s at high risk for injury.

(00:40:48):

I talk about the effects of blood flow with a lot of patients, trying to find … Everyone’s going to have their moment. What’s going to stick in their mind that flips the switch, the light bulb moment that says, “Okay, I understand this. I get this.” That was the focus of my book. You’ve heard all this before, you’ve heard this advice before, but here’s why it matters and here’s how it’s all interconnected. So what happens to stick with men a lot, why they want to focus on their metabolic health, is impotence, boom. I immediately get their attention because the incidents of impotence is huge. It’s a blood flow issue. It’s a blood vessel issue. It is related to your poor metabolic health. It is related to your cholesterol levels. It’s related.

(00:41:41):

And so yes, the same issues can be reflected in our tendons and various areas of our body, and absolute will have a role. Because every time you exercise, run, walk, do things, we get these micro injuries. The tendon will get a little stretched, a little damaged, a little this, but it’s okay. I mean, blood vessels are there. They’ll bring white cells. The white cells will remove the damaged tissue. Other cells will come in and lay down the building blocks into new tissue, and you’ve repaired it. But if you don’t have the building blocks there because there’s no blood flow, if you can’t clear the debris because you don’t have enough blood flow, you’re just escalating the problems.

Dr. Casey Means (00:42:29):

Beautifully said. Love those visuals, so impactful. I just think this framing of the body is such a dynamic entity. It’s not just this thing that’s there, and it gets hurt so you have to fix it. It’s this dynamic, buzzing hive of communication. And I hear what you’re talking about is like, yeah, there’s different ways to screw up that communication. You can limit blood flow to the area. You can create blocks in communication by having all this deposits of debris. And so much of it, as you’ve so beautifully written about, is related to downstream of metabolic dysfunction. The blood vessel narrowing or lack of elasticity, the glycation and too much glucose sticking to things, too much oxidative stress, too much chronic inflammation, which we know can be driven by metabolic dysfunction, uric acid buildup, et cetera.

(00:43:25):

Do you find in your practice that when you dig into the metabolic issues with patients and they do have their light bulb moment and they make changes, do you tend to find better outcomes? What has your patient experience been like with some of this messaging and patients who have really adopted this? Or I know on the flip side, for your patients who are just super metabolically healthy, do you find that they tend to do better over time?

Dr. Howard Luks (00:43:51):

Yeah, great question. For me, these are my biggest wins in the office. They just are. Because frequently you’re not just changing one life, you’re changing the whole family’s life. Because they’re going to drag their spouse along. Because they’re active they’re going to bring their kids outside. Your kids aren’t going to listen to what you tell them to do, they’re going to emulate your behavior. And if you’re out there and active, they’re going to be active too.

(00:44:26):

Since these really are my favorite cases, I’m not saying I do it all without surgery. Sometimes that’s necessary, say, you need a knee replacement. But we’re going to fix … I’m not bringing you to the operating room with an A1C of seven, elevated inflammatory markers, elevated liver markers, et cetera. We’re going to get you on a path to wellness before we start, and it’s going to improve your recovery. And then you’re going to continue on that pathway, hopefully.

(00:45:02):

Look, can I convince everyone? No. Can I convince maybe 15 to 20% who stick with it? I can. And it does work, and it takes time. It’s hard. We’ve talked about this, but modern medicine is not built for this. We are complex bodies, but we don’t see any one doctor that puts everything together for us. And therein lies a significant issue. You see your cardiologist is going to adjust your blood pressure medicine, so your endocrinologist is going to increase your metformin. Your primary care doctor will give you your flu shot.

(00:45:45):

And I’m not crushing that. This isn’t their fault, this is how medicine is constructed. They have to perform. If they don’t perform, they don’t get paid. Yeah, so they don’t have the time. They don’t have the ability to sit there and spend an hour with someone with five diseases. So I try to spend the time that I have, and it’s usually more than 15 minutes, putting everything together, much like I do in the book. I have some handouts in the office of outtakes from the book. And if I see someone sit up and I see they’re interested, I’ll go deeper. And it’s not unusual to get some blood tests. And I got to tell you, it’s not unusual that I’m going to find someone with an elevated LP-little-A or early fatty liver. And I’m referring them to the appropriate specialist because I’m looking deeper into that.

(00:46:54):

I guess the take-home message of that statement is, be your best advocate. You have to look deeper and think in a more complex manner. Because I don’t think that modern medicine is going to do that for you today. It’s a terrible challenge for us.

Dr. Casey Means (00:47:13):

Yeah. And I think, you mentioned if you change that patient you’re changing the whole family. And I think the other thing there is that you change that patient’s maybe metabolic health through the doorway … They come to you through the doorway of orthopedics. You get them tied into why metabolism matters, but then you’re changing their whole body.

Dr. Howard Luks (00:47:32):

Correct.

Dr. Casey Means (00:47:32):

You’re getting at that root cause. And I can imagine that as a physician, burnout is at all-time high right now. It’s over 60% of physicians are burned out. Suicide is super high, da, da, da. And it’s like, I’ve thought a lot about this as someone who became very burned out in residency. And I think part of it is that we’re just don’t really feel like we’re making the impact we want to make.

(00:47:57):

It’s the revolving door. We don’t have time. The incentives aren’t aligned. People aren’t really getting better. There’s a lot of slow worsening over time, despite the interventions we’re recommending. And I can imagine that in the way that you’re practicing it probably … I would imagine it’s a lot of emotional work for you to go that extra level and deeper. But also, you see people getting better and you see their whole bodies getting better. And I imagine it’s really gratifying to see really good outcomes that, whole body outcomes, as well as joint outcomes and musculoskeletal outcomes.

(00:48:28):

But I’d be curious, what do your colleagues in the orthopedic field think about how you’re practicing? Because I see it as quite revolutionary. It’s tip of the sphere saying, “No, we don’t just have 42 subspecialties in medicine that all are doing different things. We have common pathways that are affecting all over the body. And if we attack them and approach them and reverse them, we’re going to do better. Maybe even prevent surgery.”

(00:48:53):

But that’s pretty revolutionary, how is your … Two questions,. One, so this will be a big answer I think. How did you become that way? And how have people responded, your colleagues and also your societies and maybe the departments you’ve worked of, or worked with?

Dr. Howard Luks (00:49:14):

All right. I’ll end with how I got into this,

Dr. Casey Means (00:49:18):

Okay, okay.

Dr. Howard Luks (00:49:20):

But economically speaking, the economics of building and training a surgeon is you should keep them operating all day long. So get an MRI with a positive findings, have them see the PA. The PA will tell them of that and they need an operation. They say hi to the surgeon. The surgeon operates on them and they see the PA and they’re gone.

(00:49:44):

I get that. I understand the economics. But yeah, I’ve just never bought into that. I was never the busiest surgeon. I could have been. I’ll have the four or five month backlog for surgeries, but only because … Look, I’ve been very lucky. I was very smart in terms of my saving, investing. I founded a company with two wonderful guys and we sold it. I was involved with others and had a few exits. So I’m working because I love it. It’s that simple. And I really enjoy these interactions with people. I love the feedback.

(00:50:33):

And sadly, my one regret is it doesn’t scale. Everyone says, I got a few messages today on Twitter, “Why don’t you fix this? Why don’t you …” What am I going to do? I talk to a lot of startups. I advise a lot of startups. I love working in this space. I like to help people connect the dots and I think I’m good at it. But I don’t know how you scale this practice of medicine. The way that medicine is today, you’re just not going to do it. I mean, healthcare is such a huge proportion of our GDP. Everything is aligned against decreasing the numbers of procedures.

(00:51:27):

Anyway, so it’s a challenge. I’ve had many different responses from colleagues, many who dismiss me as a snarky old guy. And many who say, “Hey, can you help me?” And so I probably have about 40 or 50 fellow physicians reaching out, saying, ” What do you think of this? Do you have an article on this? I’d like to explore this.”

PART 2 OF 4 ENDS [00:52:04]

Dr. Howard Luks (00:52:03):

What do you think of this? Do you have an article on this? I’d like to explore this. I’d like to know more about this. So that tells me that the message is resonating with a number of people.

(00:52:14):

I came to this in a different way than you did. You’re smarter than me. I trained pre-80 hour work restrictions. So it was just the most god awful experience I’ve ever been through. So I should have taken your path. But there weren’t even cell phones then, so I wouldn’t even have known how to meet another founder.

(00:52:46):

I enjoyed being an orthopedist. I was head of sports medicine at New York Medical College for 20 years. Helped train residents, really enjoyed that process. I’ve always liked teaching, not just patients, but colleagues and students. I was always active. I played every sport there was. I was always outside. I don’t sit still well, I enjoy running, trail running, hiking, etc. My dogs that are here with me.

(00:53:15):

And then I had my second child and we got a little overpowered at home. And work got a little busier, call schedules, with raising the child, etc. All of a sudden my weight’s up a little. Had a little belly pain one day. I was hanging out with the chair of radiology. It’s like, “Lay down.” It’s like, “Your gall bladder’s fine. You just have a little fat in your liver.” What’s this? And I’ve weighed 173 to 175 pounds since high school. And all of a sudden at this point, I’m in 196. Still have those pants as a reminder in my closet.

(00:54:03):

There wasn’t much in the literature back then about fatty liver, but I started to go down all these pathways, what’s associated with fatty liver, it’s cause.

(00:54:15):

And I said uh oh. This is your moment. You’re going to turn 40 soon. Not quite sure why this is here but it’s not good for you. So I cut out all the crap from my diet. We didn’t have keto or low carb rabbit holes, etc. back then. But I went on a whole food diet. I ate real food, mostly veggies. And stopped drinking and started running more, exercising more. I was optimizing for my longevity. I’d started a website around that time. And at first I was writing articles because I wanted to share them and tell people what I thought. I learn by writing. And so I started to read about fatty liver, I started to read about insulin resistance, cholesterol issues, etc. And then the more I read, the more I started to write. Then I started to publish these articles. Same thing I do in the training space.

(00:55:34):

And so eventually I wrote enough, enough people said, “Look, you need to write a book.” One thing had turned into another. I never really had the time to write a book, but then this little virus came around and I found the time to write the book. And there we are. So I came to this through, like most people, probably, my own issues with my health and threatened longevity, or health spent.

Dr. Casey Means (00:56:09):

And then how did you put the puzzle pieces together? You’re dealing with some fatty liver, you get things back on track, you become sort of a newfound metabolic health evangelist. And then how did you start making the link to the orthopedics world? Was it just starting to go on PubMed deep dives?

Dr. Howard Luks (00:56:28):

Yes.

Dr. Casey Means (00:56:28):

Was it starting to see some patterns? What made the connection between… Because some doctor might get sick and be like, “Oh, just like most 50 or 60 year olds, I have fatty liver and my glucose levels are going up. That’s great. I’m just going to keep practicing cardiology or neurology the exact same way I’ve always been done.” But you actually said, “Whoa, there’s a relationship here.” But that takes quite a different way of thinking. What was that link for you?

Dr. Howard Luks (00:56:57):

Yeah, that was very challenging because as you know from medical school, we’re not taught this way either. We’re not taught that everything’s connected. We’re not taught about nutrition, diet. We’re taught that exercise is good for you but not why.

Dr. Casey Means (00:57:12):

Right.

Dr. Howard Luks (00:57:13):

So yeah, it just took a lot of reading. I just like to read. I found this very interesting and I was incentivized. I had two little kids at this point, right? I’m a 38 year old with this fat in my liver. I have no idea what’s going on. I’m obviously overweight and I didn’t like what I was looking at when I looked down the runway. And the more I read, it just kept going. One thing just snowballed into another.

(00:57:49):

And I don’t know why I made the connection to the orthopedic space or the musculoskeletal space. One day I realized we’re not a different system than the rest of the body. Just because you have all this big stuff in the center, and things that beat and move, doesn’t mean that everything out in the periphery isn’t connected as well. And the more I started to read about it, the more I realized, hey, it is. And so I read more and wrote more.

Dr. Casey Means (00:58:17):

I love that. Yeah, that sounds so familiar. I think for me, being an ENT in the ENT world, it felt like such a little silo. You’re so separate from the rest of the body. Ear, nose, throat.

Dr. Howard Luks (00:58:32):

Right.

Dr. Casey Means (00:58:32):

These little teeny places and there’s just no real recognition of that it could possibly be related to anything else. And I remember for me it was this vivid… I vividly remember there was a New England Journal of Medicine article that had a beautiful illustration of the sinus tissue and all the cytokines that were upregulated in chronic rhino-sinusitis. And I was like, “Wait a minute. I’ve seen all these words before like TNF alpha and interleukin 6 and whatnot.” And I literally opened up one of my med school lectures about heart disease and diabetes. And I’m like, “It’s all the same cytokines.”

(00:59:12):

How is the nose inflammatory response the same as the systemic inflammatory response for this stuff? And then you start going down the rabbit hole. And I remember I just started Googling PubMed, sinusitis, diabetes, sinusitis, heart disease, sinusitis, obesity, sinusitis, dementia. And there were papers on all of them.

Dr. Howard Luks (00:59:30):

All connected.

Dr. Casey Means (00:59:31):

Basically showing that you have twice as high odds ratio for any of these metabolic associated diseases with sinusitis. And my head, it was one of those moments where you’re just like, “Wait, what?” How could these possibly be related? And then of course you can’t unsee that. Yeah. So it’s just, gosh. So it’s such a fun journey and there’s no subspecialty for which that type of epiphany type process can’t happen because like you said, we are a completely unified right system.

Dr. Howard Luks (01:00:05):

Right. And then you get to a point where you realize it’s all connected, but how far down this rabbit hole are you going to go?

Dr. Casey Means (01:00:12):

Yeah.

Dr. Howard Luks (01:00:13):

Right? I mean, I don’t know where to stop. It’s really fascinating. Everyone gets about 78 to 80 Thanksgivings in their life. I’ve had 60 come next year, so I don’t have much time left. I got to figure out what the next step is. How to try to figure out how this scales, how to get this message out there. How to teach others.

Dr. Casey Means (01:00:44):

Well, I think you have a lot of Thanksgivings left because you literally wrote the book on longevity and are truly crushing it. But I love that way of thinking. I think when you had an epiphany like you have, and there is that sense of urgency of how much can I impact during my time to hopefully let others be able to reap the benefits of this way of thinking. And your writing is so beautiful. Your blog has just been such a great resource and I recommend everyone check it out. And your book, of course. But to me that feels like one of the really big ways to impact in a way that has longevity.

(01:01:24):

But let’s shift gears and talk about longevity a little bit because I think it’s interesting how your career has evolved. And now you really wanted to focus on this topic for your full length book. So how do you see the relationship between the world you come from, which is orthopedics and musculoskeletal health, and the concept of longevity? Can you paint the relationship between those two things?

Dr. Howard Luks (01:01:48):

Yeah, absolutely. Well first off, I think orthopedists are in a fantastic position to identify folks who could benefit from this advice because we’re seeing them when they may just have some joint pain. But other disease states really aren’t escalating out of control. So I think that we can have an impact on them if we can paint the picture of where things are going.

(01:02:16):

And so I understand the process of sarcopenia, loss of muscle mass, loss of muscle strength. Which is going to dramatically increase the risk of falls, injuries from falls, decrease the ability to recover from falls, increase the risk of frailty.

(01:02:32):

You don’t have to plan on being hunched over a walker at the age of 75. You can be different. And I’m in such a unique position to be able to discuss this with people because you’re seeing an orthopedist, it’s easy to discuss muscles, bones, joints, and therefore function. And how function affects longevity and how longevity and health span affect function.

(01:03:00):

Look, you want to live… Not only do you want to live more years, you want far more quality in those years, right? You want to remain cognitively intact. We can’t forget that maybe half of cases of dementia are due to insulin resistance. It’s type 3 diabetes. We want to be functionally independent. We don’t want someone to hold the chair, pull our chair out, hold the door open.

(01:03:27):

It’s funny, I have a scribe in the office and they’re always like, “Why do you not help these older people up onto the bed?” Like, “They don’t want me to.” And they don’t unless they have to. And we watch people, how they get out of the chair. Do they have to lurch forward or can they just stand up? Can they step up onto the exam room table or do they lurch forward? Do they have a little bit of a shake? Are they catching their foot on the ground? There’s a lot to be seen and gathered by just watching people closely. And I try to turn this into practical, actionable, simple, useful advice.

(01:04:13):

And at a fairly young age, some people really get it. 35, 38, 40, especially if they’re seeing their parents degrade, it starts to make sense. And you can really hammer home the message that this approach to longevity and improved health span is really important. And again, if I see that light bulb moment, I see them sit up, okay, they’re interested, wait, I’ll push. If I don’t, I’m not going to push it. But I think I’m really in a great position to be able to start this process, wake them up to the concept of health span, healthy aging, staying and remaining active.

(01:05:02):

I love the thing that Peter Attia talks about, the octogenarian decathlon. That’s how I’ve worked out my whole life. I have these weight bags, I push them up, I do this, I lift rocks over my head and throw them. Complex movements. I just want to be able to do these things until I’m 80. I don’t want to have to stop. So I’m exercising now to be able to accomplish things I want to do when I’m 80 and beyond. You want to make your terminal decade a lot more pleasurable and full of a lot less chronic disease burden.

Dr. Casey Means (01:05:39):

Yeah. I love the concept of compression of morbidity.

Dr. Howard Luks (01:05:43):

Yes.

Dr. Casey Means (01:05:44):

It’s just so good, this idea that really, I think we’ve almost forgotten that the way it should be is that you’re going along with generally full function your entire life and then basically you drop dead. And you just maybe die in your sleep, but you’ve been living independently and you’re thriving, you’re mentally sharp. That is literally my dream and it should be our dream. I want to live a very functional life and then drop dead, hopefully at an old age.

(01:06:13):

And now of course, it’s literally the opposite of that. From infancy, from fetal life, literally from fetal life, we are now dealing with subcellular pathology of chronic disease and insulin resistance. And it’s just a diagonal line towards death of decreased function that was a more…

Dr. Howard Luks (01:06:35):

And epigenetics.

Dr. Casey Means (01:06:37):

And epigenetics. Yeah, exactly, what we’re inheriting. And so I just love this concept that you talk about and the health span. And I guess just sort of a big picture question, just knowing so much about longevity as you do, do you think that with the right way of living, the vast majority of people can compress morbidity? Can live a very long and functional life? And if you put in that work, you pretty much have a really good opportunity to have a very functional last decade?

Dr. Howard Luks (01:07:11):

That’s the key right there. I don’t promise people years, I promise them good years.

Dr. Casey Means (01:07:17):

Good years.

Dr. Howard Luks (01:07:18):

Right?

Dr. Casey Means (01:07:18):

Yeah.

Dr. Howard Luks (01:07:18):

I mean, if I’m dealing with someone who’s had four or five decades of really bad habits, it’s going to be hard to reverse all the downstream effects of that. But if we get them weight training, we get them strong, we fix their balance, we fix their metabolic health so things don’t worsen, then we can affect significant change. And we will see a far better terminal decade in that situation. I’m not buying into the ages of disease that we’re going to cure and we’re all going to live to 130. I’m not there yet.

Dr. Casey Means (01:07:57):

I guess what I’m getting at is I think a lot of people lean on this idea that it’s bad luck and it’s the way it is. And if we…

Dr. Howard Luks (01:08:04):

Right, no.

Dr. Casey Means (01:08:06):

… from a young age are doing the habits that you talk about, we’re giving ourselves… It’s not like lighting’s going to strike and we’re just… Most likely we’re not going to just out of the blue get super, super decrepit and sick. You make the investments and they tend to pay off.

Dr. Howard Luks (01:08:22):

Absolutely.

Dr. Casey Means (01:08:22):

And I’d love for you to walk through this plan that you really present in the book of what are the elements of the simple and actionable strategies that have the most yield in terms of maximizing our longevity?

Dr. Howard Luks (01:08:40):

It’s really simple.

Dr. Casey Means (01:08:43):

Love that.

Dr. Howard Luks (01:08:44):

Right? I like people to create a caloric deficit. Obviously if you’re a heavy trainer, if you’re a heavy runner, you’re running 50 miles a week, no. You have to feed your need. But otherwise, I’d like people to… We have an issue with caloric excess. Why can dieting be successful? Because it creates a caloric deficit. Why does intermittent fasting feeding work? Probably because it creates a caloric deficit. Why does keto work? Because in some people that it works on, it helps create a caloric deficit. So that’s the mainstay of maintaining a healthy weight.

(01:09:24):

I know you’re a fan sleep. We optimize our lifestyle for eating well. We might drink less. We might say, “Oh, I got to go walk for an hour today.” Why the hell aren’t you going to bed at 10 o’clock? Right? Look, we need seven to eight hours of sleep. There are no biological processes, there are zero biological processes that do not suffer from a lack of sleep. You increase your insulin resistance, you get further cognitive decline. You’re just not sharp…

Dr. Casey Means (01:10:00):

Cortisol.

Dr. Howard Luks (01:10:00):

You’re not reactive if you don’t sleep. Exactly. And so I optimize… And our body likes regimen. It wants to do it the same time. So it’s not going to be as happy if you go to sleep 10 o’clock this night, 12 o’clock, one o’clock, four o’clock, three o’clock. Look, I’m not saying you do this every night. I’m saying try. The more you keep a schedule, the better.

(01:10:27):

You need to wake up in the morning, go look at the sun for three minutes, no sunglasses, no nothing. Right? We got to set our biological clock. We have to give ourselves the best chance possible for success. And if you’re going to counteract or go against biology, you have a higher chance of losing that battle. So getting sleep and having a good wake up routine is super important.

(01:10:53):

I just tell people to eat real food. I went through a vegetarian phase. I went through a keto phase. I tried it. I wanted to see what it was all about. I think my cholesterol went to 400. I stopped that. So get your protein needs, get your vegetables. Fiber, fiber, fiber, fiber. Oh my God. How good is fiber for us?

Dr. Casey Means (01:11:19):

Miracle. Miracle.

Dr. Howard Luks (01:11:21):

You cannot imagine the importance of a healthy GI system. You make more dopamine and serotonin, the hormones that make you feel better, in your gut than you do in your brain. You will make more serotonin and dopamine in your gut and as a result of exercise than you will from taking that little pill. And what helps feed that gut and nourish it, fiber, period. It’s not just to bulk your stools and give you great poops. It actually does something. The bacteria digest it. All the different fibers turn into different short chain fatty acids. Those short chain fatty acids all have tremendous different effects on our body. So real food.

(01:12:09):

I like people to move. Yeah. Now here’s where we can over-complicate things, especially in the space that I play on in Twitter. Right? You have to do HITT, you have to do an assault bike, you have to… No, you need to move. We just need to move. We can’t escape the fact that all cause mortality improves with walking as little as 6-8,000 steps a day. There’s no magic to the 10,000 steps. 6,000 steps a day walking and your all cause mortality is improving. Some papers show that it continues to improve up to 10 to 12,000 steps. Some will show that it tends to peter out. There’s probably not a reverse J-curve effect on mortality, meaning that you can do too much, unless you’re an ultra runner and really pushing the extremes.

(01:13:01):

And very important, if you are the type of person who has a sedentary job, running five miles in the morning and then sitting all day is not how you accomplish being active. Your body will derive far more benefit from a little bit of activity throughout the day than it will from being active for a longer time or pushing harder in the morning and then being sedentary. Activating our muscles, and it doesn’t have to be a lot. Stand up from your desk, do five chair squats. Stand up for your desk, go walk out… Exactly. Go walk out to pick up the copies in the copy machine. Go climb a stairway or two. Make your day a little harder. Don’t park in the spot that’s closest to work. Park further away. Just make it a point to get those extra steps in because walking throughout the day is super important. And look, much along the lines of what we were talking about too, I’ve worn a CGM many times. I wear them in two week blocks and it’s really fascinating. I’ve done experiments, whether it’s with a banana or a soda or something. And I’ll sit there one night, I’ll just eat this and I’ll see what my glucose response is and then next day I’ll eat the same thing and I’ll go for a walk. Not jumping on the Peloton, anything, nothing complicated. I for a walk. And inevitably, the glucose variability and the response is blunted. Even simple walks are going to improve your overall health and wellbeing. So it’s not just your muscle activation, it’s not just your glucose response, it’s so important.

(01:14:45):

I like to tell people, push and pull heavy things. Okay, this is really important. Sarcopenia. Sarcopenia should be a four letter word because it sucks. It is age-programmed loss of muscle mass. Starting at the age of 35, 40, we lose approximately 0.8 to 1% of our muscle mass per year.

Dr. Casey Means (01:15:09):

Starting at 35?

Dr. Howard Luks (01:15:09):

In some. 35 to 40.

Dr. Casey Means (01:15:11):

I just turned 35. Okay.

Dr. Howard Luks (01:15:13):

That’s right.

Dr. Casey Means (01:15:14):

That’s motivating. It’s motivating.

Dr. Howard Luks (01:15:16):

And that will correspond to a significant loss of muscle strength. It’s going to accelerate in your mid to late 50s and into your 60s and beyond. You cannot reverse sarcopenia. Once those muscle cells are gone, they’re gone. You can mitigate its decline and you can build muscle mass. So I tell people to push and pull heavy things. We need to do resistance exercise.

(01:15:44):

And you need to do legs. I know when we were young, we did chest and arms. Okay, forget that. We need to do legs. Yes, you can do the chest and arms too. Not against it, but your legs are your biggest muscles. They are the muscles that you’re going to derive the biggest metabolic effect. The strength improvement, you’re going to get up from a chair, you’re going to breeze through movements, you’re going to ease your way upstairs. You’re going to be less tired, less fatigued, more fall resistant, more fall resilient. You’re going to improve your recovery.

(01:16:21):

The more muscle you put in your muscle bank at a younger age, the more you get to withdraw when you’re older. It is really hard to build new muscle. It is really easy to maintain muscle mass. So all that means, we need to prioritize leg strength, core strength for our balance. We need to maintain that muscle mass throughout our middle decades in preparation for our later decades if we want to remain active.

(01:16:58):

Now, this does not mean that a 70 or 80 year old should not start lifting weights, because an 85 year old, after one resistance exercise session, is going to build new muscle protein. So they should be active in pushing weights too. My parents hate me because I have them working with trainers…

Dr. Casey Means (01:17:20):

Of course.

Dr. Howard Luks (01:17:20):

… in their 80s. And listen, they remark about how much better they feel, how much easier it is to move around. So push and pull heavy things.

(01:17:29):

And now, really important, socialize. Oh my God, have a sense of purpose. What gets you out of bed in the morning? Call that friend, don’t text them. Try to build your social network. You don’t have to have a million friends. Have two or three that you can really rely on, that you really treasure listening to and talking to, that you can go out with, go hiking with, go running with. You’ll be far better off in the end if you build those relationships and maintain those relationships than if you didn’t.

Dr. Casey Means (01:18:03):

Wow, those are such…

PART 3 OF 4 ENDS [01:18:04]

Dr. Casey Means (01:18:03):

Wow, those are such beautiful pillars of longevity. And I really love the way you say them and frame them because they are simple but profound. And it’s not like you need to do 30 minutes of high-intensity interval training per day, and then you need to do this exact type of resistance training. You’re just push and pull heavy things, move your body, eat real food, it’s like the basics. And I think especially in the world we’re living in now where 90% of people are not even eating the recommended dose of fiber per day and what is it, over 90% of people aren’t getting recommended amount of exercise per day that we don’t need to… The margins are definitely important for people who are hyper optimizing, but-

Dr. Howard Luks (01:18:47):

Absolutely.

Dr. Casey Means (01:18:47):

… these are the key pillars to focus on. One thing I’m not seeing in here, I’m curious, how do you think about stress, trauma, psychological wellbeing? I think this probably fits into sense of purpose and socialization, but-

Dr. Howard Luks (01:19:07):

Yes.

Dr. Casey Means (01:19:07):

… how have you found that people who are in your practice who might be really hypervigilant or stressed, how does that affect health? Do you find that plays in?

Dr. Howard Luks (01:19:18):

It does, especially in the orthopedic space because the hypervigilant, the hyper stress will tend to narrowly focus on one problem and the effect that problem is having on them. When I was a trauma surgeon, it was very clear, we had these two very opposing groups. We would see people racked, they’d had multiple fractures. You spend all the night, you fix them, you see them once or twice and they’re like, “I’m out of here. I have things to do.” And then you see the others, “Oh, why me? I can’t believe this happened,” blah, da, da, da. Hypervigilant, a little stressed.

(01:20:04):

They require a lot more attention. And five or 10 years later, they’re still your patients. So it does have a role. This is an important group to deal with and to recognize and to help them find the outlets to try and help them de-stress that this is not such a big deal, that this is not going to require an operation. Your life is not over. But it’s the whole package. If we’re hypervigilant, if we’re hyper training, if we’re in the top 3%, we can’t just choose one or two of these things. It really-

Dr. Casey Means (01:20:49):

Well it’s such a good roadmap. I just love the way you position it and the way it’s really feels accessible. So I’ve been taking a lot of your time and so I want to get us to a couple more questions that are just, they’re a little bit off the wall, but I’m curious if you have any thoughts on them. You talked about fiber and clearly you have a passion for fiber and real food. Do we have any understanding in the musculoskeletal or orthopedics world about how microbiome affects our outcomes with those things? Is that something that’s been studied at all, or I know nothing about that sort of intersection. So if there’s anything interesting that you’ve come across, I’d love to hear.

Dr. Howard Luks (01:21:39):

Yeah. So I’ve communicated with a few microbiome scientists over the year, the last year. There are interactions, they are not well studied. They’re seeing in the blood sugar space, in your space, my God, pronounced effects with certain bugs in your colon. I imagine as the data becomes more precise and more elaborate and better structured, that we’re going to see a very clear relationship, we’d be too narrowly focused to think it’s not going to have an effect. Again, all glucose affects all tissues. Why would short chain fatty acids not affect all tissues?

Dr. Casey Means (01:22:31):

Yeah, absolutely. Yeah, that’s what I was wondering is, has there been that sort of short chain fatty acid levels and how that affects pain or something? My hunch, and this is what I’m hearing you say, is that it’s probably a matter of time before we start elucidating more of those specifics.

Dr. Howard Luks (01:22:47):

Absolutely.

Dr. Casey Means (01:22:48):

But mechanistically, there’s got to be proper relationship.

Dr. Howard Luks (01:22:50):

Well, they affect wellness, they affect your happiness, your anxiety levels, that is going to affect the level of pain that you’re going to have. So yes, it is going to be connected in some way, shape or form. Is it directly connected? Is it causing a change within our joint structure? I don’t know. I hope that it is.

Dr. Casey Means (01:23:17):

Yeah, there’s something in the book that we’ve talked a bit about osteoarthritis, but I just want to make sure we don’t end the episode without just digging into this one a little bit. But you have a section of the book that’s called, Why You Don’t Need to Be Concerned About Osteoarthritis. And I think just for people who might be listening who are looking down the barrel of getting older and really fearing, fearing this. I even have a little fear about it because basically the surgeon looked at me and said, “If we don’t do this surgery, you’re going to have osteoarthritis,” which I am not buying into because I feel amazing now and I believe in the regenerative capability of my body. And so I’m trying to really shut out that negativity. But why should people not be worried, concerned about osteoarthritis?

Dr. Howard Luks (01:24:02):

Okay, so there’s varying degrees of how the osteoarthritis will affect you. So by all means, if you’ve been suffering from it for 40 years and you’re crippled, et cetera, we’re going to help you probably with an operation. However, more commonly you have a mild joint ache, your shoulder hurts when you play tennis. It hurts when you kneel down, when you’re gardening, it hurts when you’re out hiking and you’re pushing hard up rocks. And you’re a little worried, you may talk to your doctor and they say, “Stop that. Don’t be active, don’t do this.” We focus on the fact that osteoarthritis, the etiology or the cause of osteoarthritis is more often than not biological. And that cartilage nutrition and health is based upon this repetitive loading. It likes the repetitive loading. So there’s no reason to stop being active. As we also discussed, we had runners who were less commonly resorting to knee replacements as opposed to non-runners with the same degree of arthritis.

(01:25:14):

So we have to do away with the thought that osteoarthritis is a death sentence, is a terminal disease. It’s not, in some of you, it’s reached the point where yes, you have no other options available, surgery, et cetera can be very beneficial for you, life altering. But the vast majority of people, that’s not the case. And if you can play two sets of tennis instead of three before you get sore, do it. If you can run two miles instead of four miles, or if you have to fast hike or fast walk instead of running, you’re going to do that. You’re not going to destroy your joints by staying active. Weight training is not going to destroy your joints, if the pain is mostly in the front of your knee. Weight train is going to alleviate the pain in the vast majority of circumstances. So take home message, it’s not the end of your life, it’s not the end of your joint. And the more active that you stay, the happier your knee is going to be. The stronger you keep your leg, the longer you keep your knee, same goes for shoulders.

Dr. Casey Means (01:26:20):

Love that. Such a hopeful message. Okay, two final questions. One is, what are your thoughts on some of the regenerative therapies that are happening in orthopedics like PRP or stem cells being injected into joints? Anything there that you’re particularly think is a strong avenue or is still emerging? Would love to hear your thoughts.

Dr. Howard Luks (01:26:42):

Yeah, so it’s a complex topic. Currently today, the issues with stem cells is you have to try and tell them what to do. Meaning that you can’t just inject the cell, you need to inject the instructions. So cells migrate through the body according to these instructions or these molecules that they sort of sense like a mouse that’s following the smell of cheese in the corner of your kitchen. These stem cells are exactly the same way. So if we take stem cells out of your bone marrow, clean them up, inject them into your knee joint, they’re going to sit there and look around at each other and what the hell am I supposed to do now? Because we haven’t figured out how to say, how to stick in the molecule that says, “Hey, go form cartilage.” Or, “Go form a meniscus.” Or, “Go form a ligament.”

(01:27:41):

Sometimes by injecting them in the ligament, you’ll get some factors and chemicals from the ligament itself. But cartilage is because has been a very challenging tissue for us to regrow. We’ve been studying this for four decades and we’re just not there. So now people who get stem cell injections or PRP injections and it’s really bone marrow aspirin that I’m talking about. They can derive pain relief from an injection, that pain relief can last 8, 10, 12, 14 months. It is not regenerating anything. So you’re not growing cartilage, you’re not decreasing the chance that you may need a knee replacement in the future. You shouldn’t pay $10,000 for it. PRP, similar, there’s studies and papers that show everything, but unfortunately there’s many different PRP systems out there. A lot of doctors don’t want to pay for systems. They’ll spin it down in their own centrifuge.

(01:28:50):

Some will take it really seriously and they’ll spin it in a specific system for a specific time. They’ll actually document how many platelets are in that injection. They’ll place it properly and you can feel better, again with an arthritic knee after or various types of tendon pain too. You might feel better after those injections. It may help with tendonopathy, it may help with tendon regeneration. Again, because if we’re putting stem cells into a tendon, we have those chemicals that will serve as that message to say, “Hey, make a tendon.” As opposed to being inside a joint where they really don’t know what to do. So I think the future is really bright. I don’t know when that future is going to arrive because we really have a long way to go before we figure out how we can message these cells.

Dr. Casey Means (01:29:54):

That’s that’s really, really helpful and feels really balanced insight into that because I think you could go to the websites, to the people doing platelet rich plasma or stem cells and it looks like the panacea. But I love that idea of like, “Yeah, we can inject some cells, but they need the instructions too. And we haven’t quite figured out exactly how to get them to do what we want.” And that’s fascinating. Okay, so last question, or just really just curious as someone who is a surgeon, but also someone who has really been focusing on the more biologic aspects of health. So both, you’re very much in the structural world of health, but also the biologic world of health. Do you think that there are a lot of surgeries in your field that probably could be avoided or prevented by people just optimizing their underlying biology and metabolic health? Is that a hunch that you have or that we could probably be doing a lot fewer if people took care of their bodies and followed the strategies you talk about?

Dr. Howard Luks (01:30:58):

Yes. I can’t tell you how many people I see for a new problem every week and like, “Hey, I saw you 10 years ago. You were my third opinion. You said stay out of the operating room. I did. I did great. So now why does my shoulder hurt, another joint?” Something I always say on Twitter, nothing gets better in six weeks. So let’s say your knee hurts and you’re a runner or you are working out and you happen to get an MRI and it shows a meniscus tear. Many runners, most runners my age have these degenerative poster horn medium meniscus tears, no flaps, loose pieces, et cetera. As I often say, injury can arise by taking out those pieces. If they’re not actually bothering the knee, there’s a good chance that it may not be what’s bothering the knee. Sometimes we’ll see a capsulitis or an inflammation of the tissue around the meniscus because maybe it’s shifted or moved a little.

(01:32:15):

You wait long enough, the majority of you are not going to need an operation for this. You just won’t. And there have been placebo controlled randomized trials of people who had degenerative posterior horn medium meniscus tears. One group went to sleep and had the operation, one group went to sleep and had two incisions placed but didn’t have the operation. They both got better. They’ve put them up against physical therapy and surgery. They both get better. There’s a lot at play here. Is it a placebo effect? Is it an intervention effect? A lot of orthopedic procedures up against placebo don’t fair well. But I’m not sure how much is going to be true for a lot of medicine. Maybe, I don’t know. The bottom line is that there are many findings on MRIs where it’s easy to convince someone you need an operation.

(01:33:26):

Many times you don’t. A lot of my friends and I will talk about this, especially the older ones because we are getting wiser that you’ll see people in the office with shoulder pain and you say, “Look, you got this tiny little tear, little bit of inflammation, some anti-inflammatories, a few months of physical therapy and you should be fine.” They go to therapy for three weeks, they hate it, they still have pain, they want an operation, you really shouldn’t have it. And then they get, anyway, so they choose to have it. They go forward with it and after four months of physical therapy, they feel great. They’re like, “See, I needed the operation.” “No, you needed the four months of physical therapy.”

(01:34:11):

You have to realize very few things get better in six weeks. Tennis elbow, David Ring, great hand surgeon out of [inaudible 01:34:24] Austin, I think. He wrote a great article about tennis elbow. You’re all going to get it. It’s going to go away in 99% of you. And if it doesn’t, there’s something else wrong other than the elbow. But it’s very easy to, some people are really bothered by it. We know steroid injections will often make it worse. It’ll change the tendinopathy and harm the tendon. So those are situations where you can try PRP injections, et cetera. But they did a randomized trial of surgery, the formal procedure versus just making an incision and not doing anything to the tendon and both groups got better. So was it a denervation effect? Was it a placebo response? We don’t know. So many times, many issues, if given enough time will resolve.

(01:35:25):

Sometimes they don’t. I am a surgeon, I do operate. I operate every week. So there are things that do require surgery. Oftentimes that’ll be up to you. Again, this is not life and death medicine and I just think we are more likely than not operating on too many things because as we get older, things show up on our MRI. It’s very easy to take an MRI report and say, ” Look at all these things wrong. I can fix them for you.” And oftentimes it’s easier to have you come into the office, something hurts, it’s going to take me longer to convince you that an MRI or surgery is not necessary than it is to advise here, sign here and we’ll fix this for you. It’ll take me longer and you may not agree with me and you may be more unhappy because I said, you don’t need an operation, that happens and I’m not always correct. And you may run somewhere else and have a different opinion and have a surgery and do wonderfully. Great. I am human, but I do think they’re operating on too many people.

Dr. Casey Means (01:36:44):

Wow. That is so powerful. One of the things I’m taking from what you just said is that part of the equation in facing physical challenges like this is actually just tapping into a sense of patience and tapping into a sense of healthy coping. Because we are an instant gratification culture and a sense surgery does feed into both consumerism and also instant gratification. We get something, it’s high value, it’s not high value, it’s high cost. So therefore we believe it’s valuable. It’s actually the opposite of high value. It’s a very high cost for possibly not a great outcome. And we have difficulty sitting with discomfort because of just our general western culture of thinking that discomfort is actually a bad thing versus a growth opportunity. And I think a lot of this probably does come down to mindset and a little bit of… And then another aspect of the psychology is also just a reconception of the body as a dynamic flowing entity that’s constantly, that is capable of regenerating versus something that’s there to decay and hurt you and cause problems and this and that.

(01:38:01):

So really, I think what you’re talking about, it gets down to a lot of fundamental framing issues or modern culture things that we struggle with in the western world of impatience and consumerism and lack of ability of trusting the body and all these things. So I love just everything you said and I think that there’s a lot of wisdom there. And it actually just incredibly speaks to me with just my recent journey that you have been a huge part of just in sharing your wisdom with me several months ago. Because as the knee, I had this opportunity on a silver platter to have this surgery. My insurance would’ve paid for it. I would’ve felt like I did something. And that could have made me feel good about like, “Oh, I’m taking charge of my health, I’m doing what the doctor recommended and all that stuff.”

(01:38:48):

And instead, I had to basically sit with a little bit of pain for an unknown period of time. This could last six weeks, this could last four months. I have no idea, but I’m trusting in my body and also the clicking, is it ever going to go away if I have surgery, I’m pretty sure the clicking will go away because the cartilage will be shaved off probably. But it might never go away. So using that as a mindfulness exercise of like, “I don’t know, but there’s no rush and I trust that something, that my body can handle this.”

(01:39:22):

And do exactly what you basically recommend in your book, which was focus on what I can do, which was eat a real food anti-inflammatory diet, eat lots of fiber, move my body, start doing resistance training when I could focus on the things in my life that are good and that are purposeful and fall off four months later. Of course, it’s better and that’s not going to be the case for everyone. But I think there’s a whole mindset thing here that I think is important for the American patient to think about, hear about, because a lot of it comes down to us and our ability to cope with uncertainty and have patience, I think.

Dr. Howard Luks (01:39:58):

And have faith. We have redundancy, we have capacity, and we have reserve. So not every inch of every tendon, ligament, muscle, whatever is necessary, we get by just fine. We are not going to look the same on the inside as we did when we were 20. Don’t look the same on the outside. I shouldn’t expect it to be on the inside. I’m wrinkled outside, I’m wrinkled inside too. It’s okay.

Dr. Casey Means (01:40:32):

Well, you are a huge inspiration for me. I’m so grateful of how you are trailblazing in the field of metabolic health, orthopedics, just so many different areas. You’re spreading your word on Twitter. I am so just grateful that you exist, Dr. Luks Howard, and thank you so much for being here. Let people know how they can find you on the internet and connect with you.

Dr. Howard Luks (01:40:54):

Yeah. Number one is Twitter. It’s my only place in the social world and my website, howardluksmd.com. It has my email there, so if you don’t abuse it, feel free to send me a message.

Dr. Casey Means (01:41:09):

Anything we missed today that you want to make sure to get across to the listeners?

Dr. Howard Luks (01:41:16):

There’s always more to say. Don’t overthink this. If you’re the average person out there who hates to exercise, thinks of exercises as work. But you’re concerned about your health, you don’t need an assault bike, you don’t need a peloton, you don’t need to overthink this, you need to eat well. You need to get yourself to go outside. You need to make your day a little harder. You need to try and sleep better. Try not to stress eat as much. Try to find that little win. You put that cream in the coffee, you have a donut in the morning or a few Oreos at night. Just find that little win, it matters. And it works in the end. If you’re an overachiever, great. So am I. Every now and then we’re going to have an injury and that’s why I’m here too.