Optimizing Joint Health
Daniel Kalish, DC, IFMCP, is the founder of the Kalish Institute, an online training program dedicated to the clinical and business success of integrative and functional medical practices. Since its inception in 2006, the Kalish Institute has helped more than 1,000 practitioners revolutionize their practice models. Kalish is currently on the faculty of the Institute for Functional Medicine’s Practice Implementation Program. He also works closely with Richard Lord, MD, to advance cutting-edge functional lab testing and interpretation.
In this interview with Element Senior Writer Sarah Cook, ND, Dr. Kalish delves into the integrative therapies he’s found to be most effective for supporting and optimizing joint health.
Joints give people the freedom to move through life without effort or constraint. But when joint health declines, stiffness and discomfort can limit activities of daily living. Millions of Americans struggle with joint problems, and many seek out natural ways to support their joint health.
Joint tissues are dynamic and continually renewing. This makes them vulnerable to the adverse effects of poor diet or inactivity, but it also makes them responsive to the beneficial effects of proper nutrition, appropriate exercise, and other therapeutic interventions.
SARAH COOK: How common are joint problems, and why is there a need for integrative approaches to support joint health?
DANIEL KALISH: Joint pain and back problems are two of the most common reasons for doctor visits. When you ask why we need integrative therapies to address this issue, two things come to mind immediately.
First is the opioid crisis. When patients go to the doctor with pain, they’re given pain medication which can be addicting. Misuse of opioid drugs is a major health crisis.
Second is the chronic disease crisis. Six out of 10 Americans live with one or more chronic diseases, and one of the contributors to many of these diseases is physical inactivity.
The best way to stay healthy is to be physically fit. When you look at risk factors for mortality, the number one way to predict when someone will die is muscle mass. To stay healthy into older age, we need to stay physically active and maintain muscle mass. And to do that, we need healthy joints.
Taking pain medication is not the best way to support joint health over time. Integrative approaches—like nutrition, exercise, and manual therapies—support the healthy structure and function of the joint tissue. Integrative approaches help people achieve and maintain strong, flexible, and mobile joints. This gives them the freedom to move and to enjoy the benefits of an active lifestyle over the years.
COOK: Joints don’t function in isolation. What body systems or metabolic pathways play a role in supporting optimal health of the joints?
KALISH: Joint tissues include ligaments, tendons, cartilage, synovial fluid, a joint capsule, and bone. These dynamic tissues, in their ongoing processes of breakdown and renewal, respond to metabolic changes in the body.
There are two sweeping categories of metabolic patterns that adversely affect joint health: inflammation and oxidative stress. These conditions may stem from the gut, from altered immune function, or because of diet, and often from some combination of these factors
COOK: What tests help identify metabolic patterns associated with joint problems?
KALISH: One of the tests I routinely order is a comprehensive stool profile that assesses biomarkers related to digestion, inflammation, and the gut microbiome. I use the results of this test to determine if we need to support intestinal health as part of an overall strategy to address inflammation in the body.
It used to be that we were only concerned about the overgrowth of pathogenic bacteria, yeast, or parasites in the gut. Now we’re learning that the entire gut microbiome, including commensal bacteria, exerts systemic effects on health. Evaluating the microbiome is on the cutting edge of integrative approaches to medicine.
The other test I routinely order is a blood and urine test of 125 nutrient biomarkers. The test includes a fatty-acid profile, which evaluates omega-3 fatty acids, omega-6 fatty acids, and markers of fat metabolism. The test also gives information about antioxidant status—including levels of coenzyme Q10, vitamin A, and vitamin E.
The other tests worth mentioning are lipid peroxides and 8-hydroxydeoxyguanosine (8OHdG). These are markers of oxidative stress and can tell us if a person needs more support for antioxidant defenses.
COOK: What are your top nutritional supplements to support joint health?
KALISH: Depending on the individual, we can support joint health by supporting antioxidant systems, a healthy inflammatory response, joint cartilage tissue, or the gut microbiome.
Antioxidant support. If testing shows that a person has a lot of oxidative stress, we can supplement a combination of antioxidants. Fat-soluble antioxidants include CoQ10, vitamin A, and vitamin E. Water-soluble antioxidants include vitamin C and glutathione precursors (like n-acetylcysteine). Pycnogenol is a specific antioxidant that has been shown to support joint health.*
If a patient doesn’t have access to extensive lab testing, a broad-spectrum antioxidant supplement is a good place to start for joint support. We often see results with antioxidant support alone.*
Healthy inflammatory response. Curcumin is one of my favorite supplements to support a whole-body, healthy inflammatory response.* Systemic enzymes can also be taken on an empty stomach for occasional joint support or exercise-induced discomfort.*
Omega-3 fatty acids are popular supplements to support a healthy inflammatory response, but I caution practitioners against recommending these without testing. Some people have low levels of omega-6 fatty acids and will feel worse when they take omega-3s. A better approach is to test fatty acids and support the enzyme systems for proper fatty-acid metabolism.
Support for joint cartilage. Supplements that support healthy joint cartilage include glucosamine sulfate, chondroitin sulfate, collagen II, and hyaluronic acid.*
It takes time to see effects from these supplements, so I give them three months before reassessment. If it seems that there’s some benefit at that point, I have patients continue to take the supplements for a year.
Support for the microbiome. A healthy microbiome supports healthy immune and endocrine function throughout the body. Depending on the results from stool testing, we can supplement prebiotics (e.g., inulin or fructooligosaccharides), probiotics, l-glutamine, or other nutrients for gastrointestinal support.*
COOK: What dietary patterns do you recommend for supporting joint health?
KALISH: We want to emphasize foods that reduce inflammation, and eat those with every meal. These are foods that are high in antioxidants, like vegetables and polyphenol-rich blueberries, cherries, and cranberries. I tell patients to eat the anti-inflammatory foods first—at the beginning of the meal.
To minimize the inflammatory response to foods, I recommend a plant-centered diet with about 10 percent animal products. We want to include vegetables at a high level. Too much meat, sugar, or alcohol in the diet can be inflammatory.
COOK: What exercises are safe and tolerable for people with joint problems?
KALISH: Exercise needs to be balanced between aerobic, strengthening, and stretching exercises. People can overdo any one of these, but I most often see people overdo aerobic exercise.
Aerobic exercise is beneficial for cardiovascular health, but it can pound the joints. It also becomes catabolic after about 20 minutes. We can mitigate or even eliminate these adverse effects by incorporating resistance and stretching exercises that strengthen and lubricate the joints involved in the aerobic exercise.
Resistance exercises build muscle mass and strengthen the joint capsule—so the joints can withstand the repetitive stress of aerobic exercise. For people who have had an injury or experience exercise-induced discomfort, TheraBands are a good alternative to weights for resistance training.
Stretching and flexibility exercises lubricate the joints so they can move more easily. Exercises like yoga or tai chi emphasize the free range of motion of the joints. People who have had an injury should work with instructors who are experienced in modifying the exercises to individual needs.
A good balance of exercises includes 20 minutes of aerobic exercise, 20 minutes of strength training, and 10 to 20 minutes of stretching. Too much aerobic exercise can damage the joint tissue; too much strength training can stiffen the joints; and too much flexibility training can make ligaments lax. The best way to minimize the risk of injury is to practice all three types of exercises in balance.
COOK: Along with exercise and nutrition, are there other therapeutic modalities that are useful for supporting joint health?
KALISH: I suggest a combination of manual therapies and soft-tissue therapies.
Manual therapies could be chiropractic or osteopathic manipulations. Soft-tissue therapies could be deep-tissue massage, active-release techniques, or trigger-point therapy. These therapies can give both immediate and lasting benefits for joint health.
COOK: Joint problems become increasingly common with advancing age. What are some ways to support joints before any damage is done?
KALISH: All of the strategies we discussed so far (supplementation, nutrition, exercise, and manual therapies) support healthy joint function over time. The only factor we haven’t touched on—and one that can have a profound effect on people’s experience of joint problems—is mental attitude.
I lived at a monastery in Thailand for a few years and spent 10 to 12 hours per day sitting in the lotus position. It was extremely painful, like having ice picks jabbed into my knees for hours on end. Then I had a moment of clarity, and the pain in my knees vanished. That was the moment I realized that our minds play an important role in the physical experiences of our body.
The more emotionally stressed a person feels, the worse their pain. The solution is to practice meditation, mindfulness, or some sort of spiritual practice. Once a person is in pain, however, it’s not easy to develop mindfulness or spiritual practice. That’s why I see meditation not as a treatment for pain, but instead as a way to support health and resilience before any pain or joint problems begin.
When we discuss meditation or spirituality with patients, we also need to be careful not to blame them for their symptoms or imply that their experiences of pain and discomfort are in their heads. Still, don’t shy away from discussing spirituality. People are whole. Joint problems are merely one manifestation of the complex interplay of body, mind, and spirit.