Howard J Luks
SUMMARY KEYWORDS
people, metabolic, longevity, orthopedic surgeon, metformin, lactate, soft tissues, shoulder pain, patients, diseases, poor, health, longer, diabetes, book, day, pain, howard, website, ferocious
SPEAKERS
Jack Heald, Howard J Luks, Dr. Philip Ovadia
Jack Heald 00:00
Hey, welcome back to yet another episode of the Stay Off My Operating Table podcast with Dr. Philip Ovadia. We are joined today by the very first orthopedic surgeon I've ever met who wasn't trying to cut on me, Dr. Howard Luks. Phil, take it from here and tell us why this guy's on our show.
Dr. Philip Ovadia 00:19
Well, Jack, we have found another surgeon who is trying to keep people off his operating table as well. So, I think it's certainly going to be a great guest and a great contributor to the ongoing discussion that we've been having. So, with that, I'm going to welcome Howard and let him give us a little bit of his background, and introduce himself to our audience. And then we're going to get going with a pretty fascinating discussion.
Howard J Luks 00:51
Thanks, gentlemen. So, as you said, my name is Howard Luks. I'm an orthopedic surgeon in New York. I’ve been a surgeon for 25 years, been an athlete for 45 to 50 years. And with my training, the adaptations that were necessary to maintain my training level, I just started to see things change. And I just started to see changes in peers of my age who weren't necessarily aging well. So, I started to do a lot of investigating and my own research and writing on my website. And it became clear that I was witnessing a root cause that we were missing out on. And we were addressing diseases at the top level, we were missing the bottom level or the roots. So, I started to dive into that on my website, I found a lot of interest in those writings. So decided to write a book about it. I believe that's how we met online.
Dr. Philip Ovadia 01:55
Yeah, and I certainly want to get into the book, but I guess go into a little bit more sort of that journey as to how you, as an orthopedic surgeon, recognized our failures to be addressing root cause. Because, without getting too offensive, of course, the standard perception of an orthopedic surgeon is hammer, nail, drill, don't really think about anything besides the broken bone or damage the joint in front of you.
Howard J Luks 02:29
Well, I'm glad I can break that mold. It became clear sitting across from people throughout the day on Lisinopril, Atorvastatin, Rosuvastatin, Metformin, that I was seeing this big growth in metabolic disease, and metabolic syndrome. And in researching that, it turns out, there was a strong association with rotator cuff disorders, rotator cuff tears, with osteoarthritis. And it became clear that poor metabolic health affects every one of our tissues in our body, right?
Jack Heald 03:14
Hold on, I just wanted to, I gotta ask you to repeat that, because you've heard something that I've never heard connected. Rotator cuffs injuries?
Howard J Luks 03:23
So, most people who present to an orthopedic surgeons' office with shoulder pain, and are found to have a rotator cuff tear, they don't have that tear or that pain because of an injury. They woke up with it, or they pulled their arm suddenly, and their shoulder pain started. And if an MRI is obtained, you may find these small little rotator cuff tears. It's not that you actually tore it one day, it's simply that the tissue wore out, or it degenerated. Is that an age-appropriate change? Is that an age-appropriate change accelerated by poor metabolic health and function? The answer is yes. It probably is in combination with poor metabolic health, cholesterol deposition, uric acid deposition, lots of metabolic changes will cause deposits in our rotator cuff tendons, poor vascularity, and result in tearing, fraying more easily than in people who are healthy.
Jack Heald 04:31
And you have a specific definition of what that means to be healthy, I guess. All right. I didn't mean to interrupt you, but that one was... I hadn't heard that before. Okay. Carry on.
Howard J Luks 04:42
After I started to recognize these associations, I started to write about it and I started to share them with people in my office and that started to turn into a longer evaluation, a longer discussion, a more detailed discussion and in many people, a much happier patient. It turns out that we were able to affect people's lives on a more general basis than their shoulder as I was able to draw the associations between what was going on. And while they were in my office, as well as in their other doctor's offices for their hypertension, their cardiac disease, type 2 diabetes, etc. And I found that I was in a unique position to discuss metabolic health with them, because I was seeing them quite frequently for their shoulder or knee related issues. And that launched into more writings and eventually a book.
Jack Heald 05:51
So, I realized this may not be an accurate assumption, but my assumption is that the bulk of the patients who are seeing an orthopedic surgeon are probably, especially one who specializes in sports medicine, as it says on your website, is that you're seeing people who are pretty fit. And yet you're describing – that doesn't sound like you're seeing people who are pretty fit.
Howard J Luks 06:16
Yeah, so fitness is very subjective, right? You can be active, you can be a runner, you can be a cyclist, but you have a resting lactate of 1.8, your LDL is 180. And you have other markers of concern. So, yes, I treat young students with injuries, ACL tears, shoulder dislocations, etc. But many adults, interestingly enough, are in my office with pain. And I'll ask them if they were active in sports, and they're like, sure, I played football, baseball, maybe even some basketball. And when I asked when they last did it, it was in high school. So, they remember their days of activity gone by and reflect upon them well, and in their mind, they're still an athlete. And this is somehow still a sports related injury.
Jack Heald 07:26
And I assume, I assume it's not.
Howard J Luks 07:30
Well, half the people that I'm going to see with knee pain or shoulder pain, might play tennis, might kite surf, might hike, or jog, or run. So, they're associating their pain with an injury caused by their sport or activity of choice, but that's not necessarily the case in the end.
Dr. Philip Ovadia 07:55
And what kind of reception did you or do you get from your colleagues both in ortho, both your fellow orthopedist but also the family medicine doctors who you are now pointing out to them that the patient who's in front of you with an orthopedic issue really has a metabolic health issue? What kind of... How has that been received, as you've sort of interacted with the rest of the healthcare system?
Howard J Luks 08:29
It's tricky. As an orthopedist, I don't know any other orthopedist who focus on metabolic disease and concerns as much as I do. It certainly affects your RV use when you're spending a long time seeing a patient with shoulder pain, because you're trying to explain to them some strategies, how they can avoid dying an early death. The primary care doctors... I'm a private practitioner now. I left my academic appointment and place of work of 20 something years over a year ago. And every primary care practitioner in my area is nailed down by a large hospital system. So, I'm primarily a word-of-mouth practice, but there are a few primary care doctors left and I try to work with them. I try and call them about these patients. I try to touch base; I may be planning a knee replacement on someone and their A1C is 8.1. And they're only on 500 milligrams of metformin once a day.
Jack Heald 09:48
What does that mean for us non doctors?
Howard J Luks 09:51
So, hemoglobin A1C is a means of determining how well controlled your blood sugar is. When you have diabetes, A1C should be five or under five and a half or under. Even in a non-diabetic and your risk of complications, your risk of infection, your risk of failure of joint replacement issues with anesthesia go up dramatically as your A1C goes above seven. So, we won't operate on anyone electively who has an A1C above seven.
Jack Heald 10:29
And what about the Metformin? I've heard you mentioned that a couple of times, what's that about?
Howard J Luks 10:32
So, metformin was one of the earlier medications used to treat early insulin resistance and cheap blood sugar control. There are other medications around although it's still used by many, there reaches a point where the disease becomes severe enough and well entrenched enough that people don't respond to it.
Jack Heald 10:55
Okay. All right. So, the A1C is the marker of is the marker that indicates poor insulin receptivity and the Metformin as a way to help them treat that. Sure, okay.
Dr. Philip Ovadia 11:06
And so how often today, would you say, that someone comes to you, and they're thinking they need a knee replacement, let's say, or hip replacement, and basically, they just need their metabolic health corrected? And you do so and they're back in your office a few months later saying, I don't need the knee anymore. My knee feels great now. And talk about how often do you see that today, knowing what you now know, versus how often that would have been the case 20 years ago, when you were getting your practice.
Howard J Luks 11:45
I can have this talk about metabolic health with shoulder pain and knee pain patients all day long. But if they can't sleep because of their shoulder pain, they don't really care as much about the metabolic health issue right now as they do about their ability to sleep. And the metabolic health concerns and its effect on soft tissues, cartilage, and bone is really an issue that we need to conquer when people are young before all these substances have had time to accumulate and raised to a certain burden within the soft tissues. So, I will work hard to get people more comfortable. Obviously, we know that people with insulin resistance and type 2 diabetes have a higher pain sensitivity and higher pain scores, versus people with similar disease or changes in their shoulder, and they don't have type 2 diabetes. So, we will employ strategies to get that pain diminished. At the same time, we employ strategies to improve the metabolic health. I've had many strong winds in the office with people with mild to moderate osteoarthritis, where it's clear the inflammation is far more severe than the diseases on X rays or other imaging studies. And with employing some traditional measures, such as anti-inflammatories and getting them on for sepa, if their triglycerides are high, dealing with getting their A1C down, we are able to control their inflammation to a large degree. It's been pretty surprising and after a round or two of physical therapy, many are quite comfortable again.
Jack Heald 13:43
I want to follow up on what you just said about catching it when they're young before this, they've accumulated this load. That implies to me that the longer you remain in a state of ill metabolic health that we're accumulating crap in our joints? Did I understand that right?
Howard J Luks 14:06
Yes and no. So metabolic disease, as we know like heart disease and elevated Apo B or LDL or LP(a). These are area under the curve issues. So, it's a time-dependent issue, the length of time that your artery walls have been exposed to elevated lipoproteins, it will be lipoproteins and elevated uric acid levels, etc. So, it's the same thing for your soft tissues and for your joints. The longer that your tissues and joints are exposed to this disease burden, metabolic issues, the larger the consequences.
Jack Heald 15:00
So, the damage is cumulative.
Howard J Luks 15:04
Absolutely. And it accumulates slowly over time
Jack Heald 15:08
to the vascular system.
Howard J Luks 15:11
I mean, look at Gerald Shulman.
Jack Heald 15:13
Cumulative, both the vascular system and the soft tissue of our bodies.
Howard J Luks 15:16
Sure, and your brain and your cardiac system, etc. Look at the studies from Gerald Shulman out of Yale where he's finding evidence of, of insulin resistance in young, thin, non-active college-aged students. That's alarming, because if this is an AUC issue, an area under the curve issue, and it's starting that young, think about the consequences for that 20 years down the road when they're only 40. The risk of dementia, cardiac disease, various orthopedic conditions, diabetes, kidney failure, loss of eyesight, the list goes on and on. It's really striking.
Dr. Philip Ovadia 16:07
Yeah, and this is something that we've touched upon obviously. My focus ends up being on the cardiac aspects of this. But again, we now see that you can look at all these different disease processes that the healthcare system traditionally views as completely independent. No one really thinks heart disease with joint degeneration, yet there is a common link between them. And then like you said, you can then bring in the Alzheimer's and the kidney disease aspect of it, and all of these things that ended up going together. And I think for the healthcare system, in general, for us, as practitioners, we are going to have much greater successes, if we can bring that all together. We can educate the patients about these common root causes for all of these different conditions. And we can be much more successful in preventing and reversing these things as we focus on the underlying metabolic health issues.
Howard J Luks 17:19
Absolutely. And it actually informs the discussion and it makes it easier for people to understand, right? If they understand the concept of metabolic syndrome, and that they have one condition as opposed to four different diseases, then they can sit back and say, okay, I can handle this, I can handle fixing one problem, as opposed to heart disease, dementia, risk, hypertension, etc.
Jack Heald 17:55
That is a brilliant...
Dr. Philip Ovadia 17:58
I’m sure you’ve probably heard during medical school, and I'm forgetting the name of the principal, Jack probably noted that, that if there's one explanation that can explain all of the problems that the patient's having, that's much more likely to be the cause than 4 different things that lead to all these problems that patients end up having.
Howard J Luks 18:24
Absolutely correct.
Dr. Philip Ovadia 18:25
So, let's talk about the new book, “Longevity...Simplified: Living a Longer, Healthier Life Shouldn't be Complicated.” Love the title and tell us a little bit more about what people are going to learn from that book.
Howard J Luks 18:40
Yeah. So, the concept is that longevity advice can be simplified. There is a root cause for many of the chronic diseases that are going to come for us. I wanted to get across the concept that these diseases are area under the curve issues that they are often interrelated and can complement or worsen each other's presence. And I want to keep people out of rabbit holes at a strict elimination diet away from buying supplements that aren't going to work or sweating and throwing up on a peloton. So, I wanted to provide them with really a simple, actionable advice. It's been clear in my career that most people don't like to exercise, right? So those of us who run and bike and participate in triathlons, fantastic, but we're 1 in 10, 1 in 5 perhaps. Most people view exercise as sweaty, painful, and obnoxious and they just don't want to do it. But they are willing to move more. They're willing to move off and occasionally with ferocious intent. They don't need in most instances to radically change their diet, but they can take in fewer simple carbs, more complex carbs, more satiating fats, etc. And I put this writing together in a simple format to inform everyday folks, like you and me, of the simple strategies that are necessary to try and enable us to live a longer, healthier life, better health span, as I talk about.
Jack Heald 20:39
Ferocious intent. What's that look like? For the 90% of us who aren’t.
Howard J Luks 20:49
So, for me, it's running up a hill really hard. For others, it may be doubling your pace with walking, they may be walking up four or five flights of stairs into instead of two. It's whatever you perceive to be a higher a higher threshold or a higher effort.
Jack Heald 21:14
How does this relate to the heart rate training theory that's gained currency over the last 20 years?
Howard J Luks 21:25
Yeah, so it's low heart rate training or zone 2 training as it's called. We have different energy systems in our body. Our mitochondria, which provide the energy to ATP manufacturing or production, prefer to burn fat. They are more efficient when burning fat. They have a much higher store of energy as fat. We have an infinite amount of it of energy stored in our body if we could burn fat. We burn glucose through glycolysis. As our effort increases, as we leave zone 2, so the upper end of zone 2 is called the first lactic acid threshold or LT1. As you transition out of zone 1 and 2, and into zone 3 and above, you start to rely more and more on glycolysis. You'll create lactate, there's a hydrogen ion associated with that. It changes the acidity of the muscle environment, and it leads to being tired. With metabolic health, if your metabolic health is poor, if you're insulin resistant, you have very poor mitochondrial flexibility. Mitochondrial flexibility means that if you have good mitochondrial flexibility, you're able to burn fat at low efforts, and you will switch over to glycolysis as the need arises. People with very poor mitochondrial flexibility, those have poor metabolic health, type 2 diabetes, etc., they have very poor mitochondrial flexibility, and they will start burning glucose as soon as they start walking. That can be manifested in blood test by a blood lactate measurement. Hopefully, the average lactate is 0.81 at rest. And you can maintain that even with walking. And for some of us even with jogging. I've tested people in my office and some will switch over to glycolysis soon as they get up from a table and start walking, where they come in with a resting lactate of 2.
Jack Heald 23:51
And this, the underlying cause here is just poor metabolic health?
Howard J Luks 23:57
Correct. And low heart rate training will stimulate... You have to stimulate those mitochondria at a level that they're capable of functioning with fat oxidation, burning fat. And if you push too hard, you're going to go into glycolysis which pushing really hard, some will say and push back and say, “look you are stimulating mitochondrial biogenesis or the production of new mitochondria.” But no, you need to exercise your heart at a low enough heart rate that you're not short of breath, you can still talk and converse in full sentences without having to stop and hold your breath or catch your breath. If you do measure lactate, your blood lactate is low. So, you're burning fat. You're asking your muscles to produce more mitochondria, more blood flow of capillaries to the muscles, and you’re building your metabolic health?
Jack Heald 25:12
So, think I've got that.
Dr. Philip Ovadia 25:13
Yeah. And that makes a lot of sense. Do you routinely measure resting lactate levels and people?
Howard J Luks 25:22
I actually have, yes. Not routinely, because the strips are expensive. But I've done it many times, especially if I want to want to nail home a point.
Dr. Philip Ovadia 25:35
Very interesting. And talk to us a little bit about longevity...
Howard J Luks 25:41
how you pause for a second, let me close my door.
Jack Heald 25:47
I don't think I've got a way to pause this recording. That's fascinating.
Howard J Luks 25:54
So, I bet that I'm not the best guest, I guess.
Jack Heald 25:58
That's all right. All right, hosting is sucked as well.
Dr. Philip Ovadia 26:02
We'll get through it together. So, talk to us a little bit about the framework of longevity, because the problem in measuring or interventions targeted towards longevity in humans is by the time you know the answer as to whether it worked or not, it's a little bit too late. So how do you think of longevity and how do you tie day to day life to the ultimate goal of longevity?
Howard J Luks 26:35
Right? I at this point, I like to rely on improving my health span, or squaring off the lifespan curve. I don't want to hit my 50s and start to decay, I don't want to be on 4 or 5 medications, all with their side effects and risks. I don't want to hit my 60s and beyond with frailty, with sarcopenia. And sarcopenia is age program muscle loss. So, beginning at 40, 38, you start to lose 1 to 3% of your muscle mass a year, you get a corresponding loss of muscle strength. It's very hard to get that back. But it's very easy to prevent it. Which is why I rely on resistance training a few times a week. So, I want to be able to hit my later decades walking erect, walking tall, being cognitively intact, on as fewer medications as possible, with the lowest risk of cardiac disease dementia, type 2 diabetes, and so on. Do I want to live to 120? I don't know the answer to that. Perhaps if my kids do, but yeah, it's hard to define longevity for me any more than healthy aging. I think going to 100 is fine for me. As long as I'm walking around, like my dad playing tennis four days a week. I think that sounds wonderful.
Jack Heald 28:27
I gotta tell you, you've excited the ex-athlete in me. I quit playing basketball 20 years ago, because the pain was bigger than the pleasure. And every time I get out on a basketball court and put a ball in my hand, I'm reminded of that, but to think about the reality that this pain in my knee and my ankle could just simply be excess inflammation. And that's pretty darned exciting. I would love to be able to do those kinds of things that I used to love doing and do them with less pain. So, I think that's... And ferocious intent. So, real quickly talk to us. Tell us, is the book available now?
Howard J Luks 29:26
Yes, the book is available.
Jack Heald 29:29
All the normal places. Alright. Give us the name of the book one more time. We'll make sure this shows up in the show notes. Longevity Simplified. That seems pretty straightforward. Looking forward to it.
Howard J Luks 29:46
It is straightforward. It's interesting their reactions to it. I have obviously those who rely on more strict longevity protocols, saying it's short on facts. I have those who are interested in simpler advice, and the first advice to get them up out of the chair that they've received in 20 years. We were just loving it. So, it's very interesting to get this back. As you know Philip, it's not possible to read or write a book for everyone.
Jack Heald 30:25
I tell my clients that there's 30% that people are gonna hate you no matter what you do. So that's just life. That's good. All right. Phil, anything else?
Dr. Philip Ovadia 30:42
No. Just I think people will certainly look forward to getting the book. I think the simplification part of it is going to be a key differentiator from a lot of what's out there talking about longevity these days, because a lot of it gets pretty complicated pretty quickly.
Jack Heald 31:04
And now I understand why Peter Attia came up.
Dr. Philip Ovadia 31:08
Yes.
Jack Heald 31:09
I get it. Okay.
Dr. Philip Ovadia 31:11
Very good. Howard. Are there I guess, give us some let people know how they can connect with you how best to contact you. And we'll make sure to get all that in the show notes as well.
Howard J Luks 31:27
Twitter is my only social network. Each J – L – U – K - S. And my website of course, howardluksmd.com
Jack Heald 31:36
Outstanding. Easy stuff. We'll get that on the website. I have a stack of books so big. I was on a call this morning and it was kind of a get-to-know-you call and they said if you were on a desert island for 30 days, you could only take three things, what would it be? And my thought was I could get all those books read that I've been wanting to. That sounds like heaven to me. 30 days alone on a desert island. So, but obviously I've got another book I'm gonna have to put on the stack. All right, well, if this discussion of metabolic health and maybe simplifying a better life lived longer has interested you, I encourage you listeners to go ahead and go to Dr. Luks website and also go to Philip Ovadia's website. Ifixhearts.co Take that metabolic health quiz and kind of put a number to where you're really at. You can follow Dr. Ovadia on Twitter @ifixhearts and access his concierge medical service. Is it okay to call it that? It is telemedicine service. Concierge telemedicine at Ovadiahearthealth.com. Until next time, we'll see you.