Newsletter #45: 🤸‍♀️ Less pain, more joy! Metabolically healthy joints 101

Let’s talk about improving joint pain by focusing on metabolic health 💪

This week’s newsletter was reviewed by board-certified orthopedic surgeon Dr. Howard Luks. Dr. Luks and I also recorded an episode on arthritis for the ‘A Whole New Level’ podcast which you can watch here. I’m resharing this article I wrote below from Metabolic Insights blog by Levels – which is an incredible resource for comprehensive metabolic health information.  

54 million American adults have arthritis 🤯 In today’s newsletter, I will cover:

• 🪛 How arthritis is not just a structural issue but a biological issue tied to metabolic health (which we can improve!)

• 😷 Expanding our thinking about surgery for some musculoskeletal issue

• 🥦 Dietary changes and supplements that can help joints 

• 🧘‍♀️ How the mind-body connection impacts joint pain!

In June 2022, I was doing heavy back squats in a CrossFit class, and the next day I had painful right knee swelling. An MRI showed I’d ripped 1.4 centimeters of knee cartilage off my femur bone. Darn! 🤦‍♀️

My orthopedic surgeon looked at my scan and immediately recommended a complex surgical procedure called a “matrix-induced autologous chondrocyte implantation,” or MACI procedure: The first stage of surgery would harvest cartilage and microfracture the bone to promote scarring. They would grow the cartilage in a lab and then do a second surgery to re-implant my cartilage into my knee. Undergoing this two-stage surgery would mean I wouldn’t walk normally for at least 3 months post-op and would have a 6 inch scar. (It also rings up at about $40,000, according to Healthline. 🤯)

My MRI results showing a full-thickness cartilage defect in my knee… 👎️

The rationale for this procedure was to reduce the risk of possible development of future arthritis. 

Arthritis is pain and inflammation in a joint, and since cartilage cushions the lining of most joints, a cartilage tear can theoretically contribute to inflammation and development of arthritis. However, my pain wasn’t too intense. So—against the surgeon’s strong recommendation (telling me, “If this were me, I’d have the MACI procedure”)—I decided to hold off on surgery. 

I consulted two additional board-certified orthopedic surgeons who have expertise in regenerative and holistic therapies. Both strongly encouraged me to wait on any procedure, do as much physical activity as I could tolerate, maintain a healthy weight, and continue a healthy, anti-inflammatory diet and lifestyle to support healing and regeneration of my knee joint.

I took that advice very seriously, and just four months later, I was fully pain-free, and have remained pain-free for the past two years, with zero limitation to my activity (I aggressively run, lift, backpack, bike, etc). 

My journey with my knee injury got me digging DEEP into the connections between joint health and metabolic health, which I talk about in Good Energy. The information is shocking, and extremely empowering; it reminds us that we are not bystander victims to an inevitable fate of pain, reduced mobility, dependence, surgery, and suffering. We can take actions to encourage the body to implement its innate healing pathways. 

This newsletter contains empowering information for anyone with joint pain or arthritis. Please share it with someone you know with these issues and encourage them to sign up for the newsletter! 

Let’s dive in 👇

♾️ Joint health and metabolic health are connected

Our joints are a framework of bones, cartilage, ligaments, and tendons. Cartilage cushions our bone ends from various forces, while ligaments provide joint stability. Tendons connect muscle to bone. These tissues work together to support us and help us move. Arthritis/osteoarthritis (OA), which affects more than 54 million adults in the U.S., is often called “degenerative” or “wear and tear” arthritis, but this language does us all a disfavor. In fact, it may be better to think of osteoarthritis as a metabolic disease where the tissue’s ability to make and use energy is impaired. The Venn diagram of metabolic issues and joint issues contains a huge overlap in mechanisms: things like chronic inflammation, blood flow problems, mitochondrial dysfunction, and more.

Additionally, experiencing obesity—which is associated with low-grade chronic inflammation—puts someone at a five times higher risk for both metabolic syndrome and osteoarthritis. It shouldn’t come as a surprise that Type 2 diabetes and osteoarthritis are two of the most common chronic conditions we face today and they are deeply interlinked mechanistically. Here are five connections:

Source: HowardLuksMD.com

1. High glucose (blood sugar) levels can damage tendon collagen. Our tendons are filled with collagen (structural protein) fibers intended to withstand force. When force or stress is applied, these fibers unkink and slide to adapt. Over time, high sugar levels in the blood lead to the build-up of advanced glycation end-products (AGEs) on collagen fibers — essentially sugar stuck to collagen — causing cross-linking and stiffening. Animal studies show that these AGEs can inhibit tendon mechanics by limiting the fibers’ ability to unkink and slide normally. Recent research indicates that AGEs cause degenerative rotator cuff changes. Healthy blood sugar = less advanced glycation end products. Know your blood sugar levels!

2. Insulin resistance leads to cartilage degradation: Research has shown that 82% of people with arthritis have an increase in blood insulin concentration and that insulin resistance—a hallmark of metabolic dysfunction and a signal that the cells can’t produce energy effectively—is mechanistically linked to cartilage issues. Key features of insulin resistance—including hyperglycemia, mitochondrial dysfunction, decreased AMPK activation, and chronic inflammation—are all associated with osteoarthritis. Strategies that increase insulin sensitivity—like calorie restriction, physical activity, and some diabetes medications—are protective against osteoarthritis.

3. Cholesterol deposits may weaken tendons: In a 2015 research review, study authors found a link between lipid levels and abnormal tendon structure or pain. The researchers theorize that high cholesterol may cause deposits that degrade the tendon matrix and drive inflammation. A recent study also found that cholesterol accumulation may reduce Achilles tendon function, potentially leading to injury. Dyslipidemia, a high level of lipids in the blood, is also associated with rotator cuff tears. And rotator cuff tendinopathy has a strong link to higher cardiovascular risk scores.

4. Worsening metabolic health causes inflammation: Chronic, unchecked inflammation reduces our body’s capacity to heal itself. Cholesterol and AGEs, as just discussed, can drive tendon and joint inflammation, but so can uric acid buildup in joints, which is also linked to insulin resistance. Research indicates that uric acid in synovial fluid, which surrounds joints, is linked to the cytokines (inflammatory proteins) interleukin-18 (IL-18) and interleukin-1 beta (IL-1β). In fact, uric acid-activated inflammasomes (inflammatory activators) produce these cytokines. Since IL-18 is linked with osteoarthritis progression, researchers theorize that the immune system is involved in osteoarthritis development. Oxidative stress, brought on by an imbalance in reactive oxygen species (ROS) production that can occur in metabolic dysfunction, also plays a role in osteoarthritis development and progression by driving inflammation via cytokines.

5. Reduced blood flow to tissues, like joints, tendons, and muscles increases the likelihood of pain and damage: One of the most interesting lectures I’ve ever been to was by Jimmy Conway, MD, an orthopedic surgeon. The lecture was called “Hidden Connections: Tendon Health and Nutrition.” Dr. Conway stated that “rotator cuff tears are a heart attack of the shoulder.” Whoa. Think about it: Metabolic health and insulin sensitivity determine how well our blood vessels function and how well they deliver oxygen to our tissues. If tissues (tendon, muscle, even cartilage) don’t get adequate blood flow, cellular dysfunction will arise, which leads to tissue dysfunction, like weak muscles, tendons, and ligaments. Good blood flow also delivers nutrients, hormones, signaling factors, and immune elements that can positively support tissue health. A well-oxygenated system is more resilient to damage—always. Metabolic health leads to better blood flow.

😷 An expanded view of surgery for musculoskeletal issues

While surgery is definitely sometimes needed to treat injuries or musculoskeletal conditions, it doesn’t necessarily need to be the first thing we jump to before non-invasive strategies. “Many of the issues that reveal themselves in our imaging studies are typical age-appropriate findings that do not require surgery,” notes Dr. Howard Luks, board-certified Orthopedic Surgeon. Millions of knee surgeries happen in the US every single year! I wonder how many might be prevented if we focused more on holistic health and the biology of the disease. 

And it’s important to remember that ALL surgery happens within the complex milieu and physiologic realities of a body, so anything we can do to optimize the body prior to surgery supports good surgical outcomes. For instance, optimizing blood sugar control around the time of surgery reduces postoperative infections and hospital stay length, and improves wound healing.

In some cases (but certainly not all), surgery may even do more harm than good. Other treatments may be just as effective while also being non-invasive. Plus, recovery from surgery can hinder our ability to move—at least for a while—potentially having detrimental effects on our metabolic health and well-being.

• Can surgery do more harm than good? Meniscus surgery is common for people with cartilage tears. The meniscus is a C-shaped cartilage structure that cushions the knee joint; each knee has two. In one study, researchers found that patients without osteoarthritis who underwent meniscus surgery had a higher risk of developing osteoarthritis and cartilage loss than those who did not undergo the procedure. The researchers found that all the 31 knees that had meniscus surgery during the previous year developed osteoarthritis, but only 59% of the 280 knees with meniscal damage that did not undergo surgery developed osteoarthritis. Of the surgery knees, cartilage loss occurred in nearly 81%, whereas it occurred in about 40% of those not operated on. As Dr. Luks says, “the fastest way to generate osteoarthritis in a knee is to cut into it and take something out.” 

• Is there a non-invasive option? A randomized-controlled trial in one of the top medical journals, NEJM, compared meniscus surgery outcomes to physical therapy outcomes. The researchers randomly assigned 351 patients to either undergo surgery or physical therapy. All patients were 45 years or older and had a meniscus tear along with mild-to-moderate osteoarthritis. At six-month follow-up, the researchers assessed the patients’ physical function scores. They found that those who underwent surgery had improved by an average of 21 points on the scale, whereas those in the physical therapy group had an average improvement of 18.5 points. Ultimately the results showed that improvement scores were rather similar between the two groups. About 30% of patients who underwent physical therapy then opted for surgery. At a 12-month follow-up post-op, improvement scores were still similar. The takeaway here is that surgery didn’t provide significantly enhanced function over physical therapy, and study authors concluded that “given that improvements in functional status and pain at 6 months did not differ significantly between patients assigned to arthroscopic partial meniscectomy and those assigned to physical therapy alone and that 70% of the patients in the physical-therapy group did not undergo surgery, these data provide considerable reassurance regarding an initial nonoperative strategy.”

• Plenty of people with structural issues in joints don’t have pain. Just because they have a torn piece of cartilage in their knee doesn’t mean a person will have pain or develop arthritis. Why? Because it is not just structural issues that contribute to symptoms, but also the biological issues of the joint like chronic inflammation, poor blood flow, or excessive pain-signaling activation. But these are all modifiable factors, so someone could have a structural issue but good joint biology, and therefore no pain. One study showed that 61% of people with incidental meniscus tears on MRI had no pain! Another study showed that 80% of people 60 years of age or older will show an incidental finding of disc degeneration on their spine MRI, even if they have no symptoms. Dr. Luks notes that when he was 50, he got an MRI of both knees just to see what was happening in there. He found that both knees had meniscus tears, and yet he is still a competitive runner, has no pain, and no arthritis! 

🏃‍♂️ Does movement make arthritis better or worse?

Osteoarthritis is not an inevitable part of aging or a consequence of exercise or movement. Instead, movement is one of the best things for our joints. In fact, Dr. Luks says exercise is one of the most effective treatments for early to moderate osteoarthritis. The idea that exercising would further worsen the joint is a fallacy. He explains that exercise has anti-inflammatory benefits. One study showed that exercise increases interleukin-10 (IL-10), an anti-inflammatory cytokine that helps preserve cartilage, and decreases cartilage oligomeric matrix protein (COMP), a marker associated with osteoarthritis. Additionally, the impact of exercise can stimulate chondrocytes, the cells that actually make cartilage.

Another study looked at the potential benefits of 15 weeks of exercise in 19 women aged 60 or older who had sarcopenia (age-related loss of muscle mass) or sarcopenia with osteoarthritis. After the program, the researchers found that levels of irisin (a protein) increased in the participants. Irisin has anti-inflammatory properties because it leads to a reduction in the release of pro-inflammatory cytokines. Not only that, irisin also helps protect against insulin resistance, Type 2 diabetes, and arteriosclerosis (cardiac plaques). And it encourages the “browning” of adipose tissue, or fat. Brown fat has more metabolic health benefits than white fat because it has a higher density of mitochondria. At the same time, participants’ levels of myostatin decreased. Myostatin (a protein) has been implicated in limiting muscle growth. Anti-inflammatory and cartilage-preserving IL-10 also increased, especially in the group with both osteoarthritis and sarcopenia. Tumor necrosis factor alpha (TNF-a) decreased in this group, as well. In animal models, TNF-a has been implicated in the progression of osteoarthritis and is a key pro-inflammatory molecule in the body associated with most chronic degenerative metabolic diseases like Type 2 diabetes and Alzheimer’s disease. Physical functioning scores improved in both groups of women in the study.

Muscle is thought to be the first tissue in the body to become insulin resistant, so moving the body and promoting muscle insulin sensitivity through regular consistent resistance training is a crucial way to manage whole-body glucose and insulin dynamics. The body is a unified system, so benefits that happen in the muscle can have wide-ranging effects on the whole body — including the joints — by promoting insulin sensitivity through tissue cross-talk.

🥦 Dietary changes and supplements may help the body heal

More research is needed on this topic, but since metabolic health and joint health are connected, improving metabolic health through diet may benefit your joints. Here’s what you can do:

1. Improve insulin sensitivity. Insulin resistance is associated with osteoarthritis. But you can greatly improve insulin resistance by dialing in diet and lifestyle changes. You can understand your insulin sensitivity with lab testing for the 5 basic biomarkers of metabolic health or more extensive testing through Function Health. To learn about improving insulin sensitivity, read Good Energy.

2. Eat more antioxidant-rich foods. Oxidative stress and resultant inflammation are linked to musculoskeletal and joint issues. Antioxidants are enzymes and molecules that can “scavenge” free radicals—unstable atoms with the potential to damage cells. They can also repair ROS-related damage. A diet rich in a rainbow of plant foods (fruits, vegetables, nuts, seeds, spices) will be high in antioxidants. You can learn more specifics about antioxidants in this post from Levels. 

3. Consider evidence-based supplements. One supplement with evidence of benefit is turmeric (a spice). A research review investigating 10 studies found that supplementation with turmeric improved pain and function in participants with knee osteoarthritis. In three studies, researchers were able to see a comparison between turmeric and non-steroidal anti-inflammatory (NSAID) medications. They found no difference in outcomes between the two. In all studies, no adverse events were reported regarding turmeric. NSAIDs, however, can increase bleeding and cardiovascular disease risk, and they may exacerbate asthma. In people with Type 2 diabetes, NSAIDs are also associated with an increase in hemoglobin A1c (a three-month average of blood sugar levels). Check out the Levels blog for some ideas on how to add more turmeric to your diet. I take around 2,000 mg of turmeric daily.
   Other research has shown that specific doses of omega-3 fatty acids, vitamin C, Acetyl L carnitine, alpha lipoic acid, and B vitamins may all improve or augment osteoarthritis and other joint pain. This makes sense in the context of these nutrients all being involved in key metabolic processes. Talk to your doctor before starting any supplements.

4. Microbiome derived molecules may help. Urolithin A is a postbiotic produced by bacteria in your gut microbiome. It’s synthesized after eating ellagitannins and ellagic acid-rich foods. These include pomegranates, berries, and nuts, like walnuts and pecans—all rich in polyphenols, a type of antioxidant. In a recent study that analyzed chondrocytes (cartilage cells) from healthy knees, the researchers found that chondrocytes treated with urolithin A had improved mitochondrial function. Mitochondrial dysfunction is a hallmark of Type 2 diabetes and osteoarthritis. Research indicates that not all gut microbiomes produce urolithin A effectively, so supplementation can be helpful (this is why I take and recommend Mitopure by Timeline). One randomized clinical trial of 66 people found that supplementation is safe.

🧘‍♀️ Mind-body connection to pain

Another thing I’ve learned through my joint injury journey and a history of back and neck pain (which I experienced during my surgical residency) is that there is also a strong relationship between mental health, metabolic health, and pain. Three books I’ve found helpful in understanding this more include:

1. Healing Back Pain: The Mind-Body Connection by John E. Sarno, MD

2. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk, MD.

3. Electric Body, Electric Health: Using the Electromagnetism Within (And Around You) to Rewire, Recharge, and Raise Your Voltage, by Eileen Day McKusick. 

Understanding and positively impacting our thought process and brain function can positively impact both our metabolic health and pain response.

☮️ Tolerating uncertainty in our health journey

We benefit from focusing on strategies that maximize the underlying physiology and biology of the body to support its healing and regenerative capabilities. This means optimizing metabolic health to support all aspects of health, including joint and musculoskeletal health. Even if your situation is one that requires pharmaceutical or surgical intervention (which sometimes is totally necessary!), a body that is healthier and more metabolically functional because of optimized daily habits around unprocessed food, exercise, sleep, stress, light, and toxin exposure will do better.

There is also something to be said for learning to lean into the discomfort of uncertainty. Having an option right in front of you—a pill or surgery—can feel like a silver bullet (and sometimes they can be!), while a non-invasive approach with an unknown endpoint for healing can feel uncertain and scary.

Certainly, in the couple of months after my knee injury, when I was limping and my knee was still swollen and making clicking and grinding sensations with every step, it was scary and disconcerting, and I shed more than a few tears of fear not knowing when I’d be back to full steam. But it’s worth considering whether our desire to reach for quick fixes is in part to minimize the discomfort of waiting and whether doing so can ultimately undermine the body’s ability to activate innate healing paths that benefit the whole system. 

📚 Book recommendation: Comfortable with Uncertainty: 108 Teachings on Cultivating Fearlessness and Compassion, by Pema Chödrön 

Part of healing—with or without surgery—is believing that your body can heal.

In many cases, surgery may be the necessary treatment and it may need to happen immediately. But alongside that, if we can find ways to encourage our body to heal itself, we should!

Wishing you good energy and a lifetime of healthy joints! 

💗 Dr. Casey

PS: January 19th marked the 4 year anniversary of my mom’s passing. Many of you have gotten to know my beloved mother, Gayle Brown Means, through Good Energy, where I write about her life, her fearlessness in the face of death, and her joyful impact. Nothing in my life has inspired me more than seeing my mama face the shock of stage 4 pancreatic cancer and exude profound curiosity, gratitude, peace, and joy in the 13 days between her diagnosis and her death. Every day I think: how can I live a life that builds that type of spiritual strength and fortitude? How, in the face of imminent mortality, can I have lived a life so rich and pure that I enter the next phase with no regrets? I am astounded how her story and her name have reached and inspired millions of people around the globe over the past year through podcasts and Good Energy.

On this 4 year anniversary of her death, if there is something I encourage each of us to embody from Gayle, it’s this: find the magic. What do I mean by magic? I mean the omnipresent elements of awe, serendipity, and joy that are noticeable in ordinary life if we are looking for it. My mom found the magic in life everywhere, every day, all the time… even in the face of death. Like her, we must believe it exists even in the darkest times, and SLOW DOWN enough to notice and appreciate it. My mom kept a gratitude journal every single night for years with her reflections on the day. Magic can be found in a beautiful flower on the sidewalk, a glowing harvest moon, a shooting star, the sparkling glint of sunlight on the ocean, a heart-filled conversation, a moment of delightful serendipity… anything. Stop, savor it, appreciate it. Her story - and the way she was able to face mortality - shows me that it matters.

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Friends!

My relationship with coffee has been complicated, with medical school and surgical residency being fueled by Venti-sized coffees day and night. The hidden cost of this caffeine dependency was steep: afternoon energy crashes, cortisol spikes, and hormonal issues.

Years on the caffeine rollercoaster—plus chronic stress—took a toll on my health, and when I left the surgical world, I knew I needed a change. The first time I tried to quit coffee, though, I was hit with massive withdrawal headaches, thwarting my plans.  

When I discovered Pique’s Nandaka Adaptogenic Coffee Alternative—I finally found a way to break free from coffee without sacrificing my morning ritual. 

Nandaka is unlike anything else I’ve tried. Its foundation is Peruvian ceremonial cacao, prized for its rich flavor and mood-boosting compounds. Grown and fermented by ancestral stewards of the land, this cacao growing at high elevation boasts a high level of naturally occurring cacao butter which Pique has figured out how to retain at a 30% level through a proprietary conching process that is unprecedented. This extraordinary cacao has incredible notes of lychee, wildflower, cherry, and crème. 

It’s then blended with an adaptogenic mushroom blend of reishi, chaga, lion’s mane, and cordyceps. But these aren’t just any mushrooms—they’re cultivated in pristine, natural environments to ensure maximized nutritional potency. Pique uses both the extracts and powders of fruiting body mushrooms only. No mycelium, ever, and no grain substrate. 

The Pu’er teas in Nandaka are also revered for their natural pre-and probiotics, which help optimize digestion, maintain a balanced microbiome, and support a healthy metabolism.

The science behind Nandaka is mind blowing. Each ingredient works synergistically:

• Slow-release caffeine (82 mg) from Pu’er tea gives you energy without jitters.

• Beta-glucans and triterpenes from reishi and chaga support stress management, hormone health, and immunity.

• Natural cacao butter is the perfect delivery system for the active ingredients in functional mushrooms, while keeping you full and satisfied and promoting a healthy gut and metabolism.

Nandaka helps my body feel balanced, rather than wired. It’s gentle and uplifting and has helped eliminate my afternoon energy slumps and I feel it has had a positive impact on my mood and hormonal health. 

I’ve made Nandaka part of my daily routine. Here’s how I prepare my daily cup:

I mix one packet of Nandaka with homemade organic soymilk (or grass-fed A2 milk), 5 grams of creatine, organic collagen powder, and a touch of local honey or allulose. I froth it all together, and it becomes a luxurious drink to sip on on my way to a morning workout, or a late morning cognitive boost.

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