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Ep. 467 Bone & Joint Health Tips for Women 40+ with Jocelyn Wittstein

  • Team Cynthia
  • 2 days ago
  • 47 min read

Today, I am delighted to connect with Dr. Jocelyn Wittstein, a board-certified orthopedic surgeon and associate professor of Orthopedic Surgery at Duke who conducts NIH-funded research into post-traumatic knee arthritis. She has shared presentations at many prestigious medical conferences, and her work has appeared in peer-reviewed journals. 


In our discussion, we dive into many of the joint pain symptoms Dr. Wittstein sees in her perimenopausal and menopausal patients, and we look at the impact of specific, targeted supplementations, including curcumin, collagen peptides, and creatine monohydrate. We explore effusions, the effects of osteoarthritic risk factors like prior injuries, obesity, the perimenopause to menopause transition, and the impact of GLP-1s on joint symptoms and bone physiology. We discuss REDS (Relative Energy Deficiency Syndrome) and the causes of osteoporosis, and Dr. Wittstein also shares what she does to protect her bones and why she believes DEXA scans must get done early in the aging trajectory, why fractures can be problematic, and the significance of exercise and bone-building foods.


You will not want to miss today’s valuable and super action-oriented conversation with Dr. Jocelyn Wittstein.


IN THIS EPISODE, YOU WILL LEARN:

  • How women in their mid-40s and 50s often experience an acute increase in joint pain 

  • How hormone therapy can help women improve their bone health, prevent osteoporosis, and overcome joint pain  

  • Dr. Wittstein recommends supplements for reducing joint inflammation

  • Various foods that can drive inflammation and cause joint health problems  

  • How the inflammatory state of obesity impacts joint health

  • The benefits of GLP-1s for those with joint pain from inflammation

  • Why early bone density screening is essential for women in their 40s

  • How creatine monohydrate improves cognitive function and muscle mass

  • The value of strength training and balance exercises for improving joint health

  • The best foods and beverages for bone-building


Bio: Dr. Jocelyn Wittstein

I am an associate professor of orthopaedic surgery at Duke University Medical Center. I completed residency in 2009 and a fellowship in sports medicine in 2010 at Duke. Prior to medical school, I studied nutritional science at Cornell University. My practice focuses on sports medicine, with a particular interest in treating female athletes across the lifespan. I am currently president of the Forum: Women in Sports Medicine. I am part of the core leadership of the Duke Female Athlete Program. I am also a clinician researcher with NIH-funded studies of ACL and meniscus injuries and post-traumatic arthritis in knees. I am a co-author of the Complete Bone and Joint Health Plan, which was released on May 6, 2025. On a personal note, I am a former collegiate gymnast, lifelong athlete, and mom of 5. I live in Raleigh, NC, with my husband, Tal Lassiter, who is also an orthopedic surgeon.

“Anyone who had trauma to the knee in their teens and 20s is more prone to post-traumatic arthritis.”  


-Dr. Jocelyn Wittstein

Connect with Cynthia Thurlow  


Connect with Dr. Jocelyn Wittstein

The Complete Bone and Joint Health Plan, co-authored by Jocelyn Wittstein, MD, and Sydney Nitzkorski, MS, RD, is available on Amazon or Barnes and Noble, and from most bookstores.


Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 


[00:00:29] Today, I had the honor of connecting with Dr. Jocelyn Wittstein, who is a board-certified orthopedic surgeon and Associate Professor of Orthopedic Surgery at Duke. She's also conducting NIH-funded research into post traumatic knee arthritis. Her work has appeared in peer-reviewed journals and she has presented at numerous prestigious medical conferences. 


[00:00:49] Today, we spoke about many of the joint pain symptoms that she has patients reporting to her in perimenopause and menopause, the impact of specific-targeted supplementations including curcumin, collagen peptides, creatine monohydrate and others, the role of effusions, the impact of osteoarthritic risk factors including prior injuries, obesity, and the perimenopause to menopause transition, the role of GLP-1s, in particular, the impact she's seeing on joint symptoms, bone physiology, the impact of Red-S, which is the relative energy deficiency syndrome, as well as causes of osteoporosis, why she thinks DEXA scans need to be initiated earlier in the trajectory of aging? Why fractures can be problematic? The role of exercise, bone-building foods and her own story of how she helps protect her bones. Dr. Wittstein’s conversation is one that is truly invaluable and will be incredibly action oriented.


[00:02:00] Dr. Wittstein, I've been so looking forward to this conversation. Welcome to the podcast. 


Dr. Jocelyn Wittstein: [00:02:05] Thanks for having me. 


Cynthia Thurlow: [00:02:06] I know that osteoarthritis is something that is common to see as we get older, this kind of degeneration of our joints. When you're speaking to women in perimenopause and menopause, what are some of the common symptoms and concerns that women will express to you that will lead you into thinking that's probably what they're dealing with as opposed to inflammatory conditions that can also drive joint discomfort? 


Dr. Jocelyn Wittstein: [00:02:32] Well, one thing that brings women in, typically around the age of 50 or maybe even earlier, mid-40s, is that they're seeing an acute increase in the frequency, severity, number of joints that are bothering them without any change in their activity level. They're like “I'm doing what I always do. I play tennis or pickleball more common now-


[laughter]


[00:02:53] -or I run a few miles a few days a week, and I've done this for years and I've never had any joint pain. And all of a sudden, they're having this new-onset joint pain, again with no change or real uptick in their activity.” 


[00:03:05] And many times, they've seen multiple providers, and they're frustrated because they have x-rays that don't really show anything. It might be a knee x-ray that shows maybe slight joint space narrowing, suggesting their cartilage is getting a little thinner maybe, but no spurs. They may have an MRI. For instance, I like to use the knee as an example because it's so common. And well, there's no surgical intervention indicated. They don't have a meniscus tear or anything like that, but why are my joints hurting? And these are not people with rheumatoid arthritis, in general, that's a different subset of people that have an autoimmune condition that is truly an entirely systemic inflammatory condition. 


[00:03:44] And, so I think when you hear that story, you start to think, “Oh, maybe these are slightly increased levels of inflammation in the setting of declining estrogen.” We know that women are more likely to have joint pain as they enter menopause. And the early Women's Health Initiative studies even showed percentages as high as 77% of women presenting with joint pain. Impacts of utilizing hormone therapy in terms of ameliorating that. So, it's really that onset that's vague, no injury, “I haven't changed my activity and everyone says there's nothing wrong.” I would say is that picture that I hear.


Cynthia Thurlow: [00:04:21] Well, and it's so interesting because I think for so many of us as women, we are the caretakers to everyone. We are always prioritizing everyone else's needs. And I have so many women that have shared with me that they just minimize knee pain, ankle pain, hip pain, in particular, shoulder pain, which I'm sure will probably--


Dr. Jocelyn Wittstein: [00:04:39] Hands. People have hand pain, yeah. 

 

Cynthia Thurlow: [00:04:41] Hands, feet, all of these jointy things until they get to a point that maybe anti-inflammatory is not aren't really helpful or they don't want to be taking those chronically and habitually. And so, when you're looking or speaking to these patients in particular, what are some of the first-line therapies that you like to help them work through before they get to more expensive, more involved modalities of addressing joint pain?


Dr. Jocelyn Wittstein: [00:05:08] Yeah, well, one area I end up discussing with my patients a lot is what else is going on with you? First of all, are you having night sweats or hot flashes and disrupted sleep, other things like, “Oh, I see you're on a new lipid medicine or is your LDL creeping up.” I mean, I'm an orthopedic surgeon, but I just kind of like to see what else is going on with them. And sometimes they're obviously in a state of perimenopause or menopause and having those other more typical symptoms. And while we know joint pain and inflammation isn't an approved indication for hormone therapy, I do take the opportunity to often educate about the bone health benefits of hormone therapy. These other things that might benefit. 


[00:05:53] There is evidence from the early Women's Health Initiative studies showing that hormone therapy did diminish joint pain and withdrawal from it, then did show a rebound. And so, I tell women, I'm like, “If you're having other symptoms anyways and you're going to see your women's health doctor and you're thinking about hormone therapy, your bone and joint health may be another reason you decide to do it.” I don't prescribe those medications, but I want them to know that they may see benefit from that. 


[00:06:17] On the other hand, like, what else can they do? Sort of using steroid injections or other types of injections. My favorite supplement to tell people to start to reduce joint inflammation as a curcumin supplement, which has lots of good data behind it. That data comes from the early arthritic literature, like mild knee arthritis. But I see a lot of people get a lot of benefit from just adding a curcumin supplement, which is not hard to do and has other health benefits such as anti-inflammatory. 


[00:06:48] And then if someone is showing up with an effusion, like extra joint fluid, that's going to cause-- Again in the knee, you're going to get atrophy of your muscles and you get into this bad cycle of weakness, worsening pain, more weakness, and we want to break that, I'll occasionally, offer someone to drain their knee and inject it. Those are people who usually already have a little bit of more like structural change on an x-ray or an MRI. 


[00:07:12] And in general, I'll talk to people about trying to incorporate dietary changes that make their diet likely, a little bit more anti-inflammatory. I do like people to try collagen supplements. I think that those are helpful. And there's a couple of different types of collagen supplements, there's hydrolyzed collagen, hydrolyzed type II collagen, and there's an undenatured type II collagen that you'll see marketed as UC-II. And those work in different ways. And so, I tell people, “You could try one or both.” 


[00:07:43] And then the one everyone asks about is glucosamine chondroitin. And I think that glucosamine chondroitin doesn't have great evidence behind it. So that's one where I'll tell people, “You can try it if you want, but I would definitely try it for a month and then stop it and then try it again and see if you have a real benefit from glucosamine chondroitin. Because for the most part, the studies don't show that it's that helpful.” So, I also think that collagen supplements are really helpful for people with knee pain and also people have a little bit of early arthritis. 


[00:08:11] There are two basic types of collagen supplements for joint pain. One is hydrolyzed type II collagen. So, if you're using-- The type you're scooping and mixing into things. And if you're using one of those, they are different types that are offered, so certainly we want the hydrolyzed type I collagen for bone density, but you'd like to get some type II collagen in your supplement for joint pain. 


[00:08:34] And then there's another type of collagen supplement that works by a very different mechanism, which is called-- You'll see it on shelves in pharmacies, you'll see UC-II, like a 40-mg capsule, and that the UC stands for undenatured collagen. So, this is undenatured type II collagen, not broken down into peptides like the hydrolyzed type. And people are always like, “How would that work?” It's like you can't absorb it and that's true. It works by different mechanisms. Some sort of, like, oral tolerance-type mechanism where your GI tract is exposed to this, recognizes this undenatured type II collagen. And then what the basic science studies show is that subsequent to that, your body essentially is breaking down less type II collagen, so we see less breakdown products of type II collagen, almost like an exposure to it results in less breakdown of it, if that makes sense. So, patients who I have are like, “I just can't scoop that stuff and drink it and deal with the powder.” I’m like “You might want to try just the UC-II, that's pretty easy.” 


Cynthia Thurlow: [00:09:31] Well, I think it's nice to have options because there may be people who are occasionally using anti-inflammatory agents like Aleve or Motrin. They don't want to be taking them habitually, but understand there are so many supplements that can have benefits reducing inflammation and then adding in the lifestyle piece. And I think for a lot of people, when we're talking about anti-inflammatory nutrition, which you and your colleague do a really beautiful job discussing the value of lifestyle, which I think is so important and oftentimes left out of the conversation. 


[00:10:03] When you're speaking to women in middle age, they probably unknowingly a lot of the things that we think are benign and innocuous in our diets suddenly become a little less benign. So, I think about-- For some people it could be gluten or dairy or alcohol or sugar is a huge one. I'm oftentimes--


Dr. Jocelyn Wittstein: [00:10:20] Fried foods.


Cynthia Thurlow: [00:10:21] Yeah. 


Dr. Jocelyn Wittstein: [00:10:22] [crosstalk] -processed meats. 


Cynthia Thurlow: [00:10:23] Yep. 


Dr. Jocelyn Wittstein: [00:10:21] Yeah, I think a lot of people by the time I see them, they're making some changes. But I cannot tell you how often a patient will say to me at the end of a visit where we've done complex surgical counseling. They're coming in for an orthopedic problem, like they need the rotator cuff repaired or something and doing the consent form for surgery. And then I say, “Do you have any more questions?” Because I always finish visits with that and these are the things people ask me, “What should I eat?- 


Cynthia Thurlow: [00:10:49] Oh. 


Dr. Jocelyn Wittstein: [00:10:50] -What exercise should I do? And what supplements should I take?” And so, I mean, it's crazy how many times someone literally asked me “What should I eat?” I mean people are just-- They want to know what can reduce inflammation. And then on the other hand, people want to know what they can do to help their bone density. And so much of that comes from diet. Your dietary choices and exercise. So, it's a really common question even in a surgical clinic, which is fascinating to me. [laughs] 


Cynthia Thurlow: [00:11:20] I think the fact that you're open minded to kind of initiate that conversation to ask them if they have additional questions. I get the sense that you're probably an incredibly kind, compassionate person and therefore. 


Dr. Jocelyn Wittstein: [00:11:30] Time is behind in clinic for this, yes. [laughter] 


Cynthia Thurlow: [00:11:33] but your patients probably love you, but that kind and compassion piece allows them to feel like, “Okay, I can actually ask this physician this question because she's opened up the opportunity for that discussion.” When you're--


Dr. Jocelyn Wittstein: [00:11:46] They really like to ask me about everything.


[laughter]


Dr. Jocelyn Wittstein: [00:11:48] I've had patients ask me to be their primary care doctor, which is hilarious because I'm an orthopedic surgeon.


Cynthia Thurlow: [00:11:53] You're like, “Wait, wait, I'm your bone person, but thank you. I appreciate that vote of confidence.” When you're doing an intake with patients, are there things about their past medical history or their exercise history that will tip you off? Is it the growing older athletic population, the former collegiate level athlete? Are those the people that are perhaps coming to you a little earlier with joint problems? Because there's been a lot more wear and tear. And I think there's also that other subsect of the population of people that are obese or overweight and they just have joint problems just because it becomes a biomechanics issue. 


Dr. Jocelyn Wittstein: [00:12:31] Oh yeah, there's a few subset of people that develop arthritis earlier than others. One is, yes, if you were like a former contact athlete or soccer player, basketball, things like that. Anyone who's had trauma to their knee in their teen in 20 years, like a meniscus injury or an ACL tear, those people are more prone to posttraumatic arthritis, which is not just biomechanical, that's also inflammatory. And so those injuries set a little clock that ticks for about 15 years and then the arthritis starts to show up. 


[00:13:00] And then certainly we have people who are overweight and obesity is also an inflammatory state. And we're now learning so much about arthritis and obese people, it’s not-- That's also a combined mechanical overload, like literally overloading the cartilage and weightbearing joints. They also have arthritis and non-weightbearing joints. So that has more to do with the inflammatory metabolic state. 


[00:13:23] And we see that weight loss can benefit joints that are non-weightbearing and weightbearing. So, it's not just about overload with those people. And then of course, we have the perimenopausal women who are having an increased inflammatory state because of their dropping estrogen levels. So those are three groups of people that have inflammation as a source of their increased likelihood of joint pain.


[00:13:48] And then women in general, at age 50 or 30% more likely than men at the same age to have arthritis, probably related to these hormonal mechanisms. And we don't see a similar impact of arthritis on men until they're like 80 years old. So unfortunately, the women are getting short end of the stick [laughs] with bone density and arthritis. Yeah, those are, I would say a few groups of people that present earlier. 


Cynthia Thurlow: [00:14:12] And with the advent of the GLP-1s, are you seeing improvement in these kind of patient populations if they're utilizing the drugs? I know there's different ways to use them. Some people are microdosing that are perhaps not per se using them for weight loss predominantly, but that whole inflammatory reduction benefit-


Dr. Jocelyn Wittstein: [00:14:30] Yeah. 


Cynthia Thurlow: [00:14:32] -I would imagine would be significant and profound. 


Dr. Jocelyn Wittstein: [00:14:34] Yes. The effect of these medications on orthopedic conditions is fascinating and I think broader reaching than I think we learn more every day. But there are two populations where like anecdotally I see differences and there is basic science, reasons behind this. So, I have a large population of women that also have breast cancer and are on estrogen blocking agents, aromatase inhibitors. And so, they are going through that really powerful estrogen withdrawal. And those patients, they get frozen shoulder, they get joint pain and it's not going away. I've had some of them who are also on GLP-1 medications who have noticed significant benefit in their joint pain.


[00:15:13] And then of course, patients who are overweight utilizing these medications for weight loss, they're losing weight, which is benefiting their joints because of the increased mechanical load on the cartilage, that smooth gliding surface of the joint. But they're also having less joint inflammation. And there are studies showing that there are really like receptors for these medications that act on the lining of the joints that can then impact some of the inflammatory pathways that lead to cartilage breakdown. And interestingly, those medications also seem to upregulate osteocalcin production. And osteocalcin helps with bone building to overly simplify. It helps with the mineralization of bone, but it also goes on over to skeletal muscle and fat cells and the pancreas and helps with glucose control or insulin sensitivity, which brings down inflammation. 


[00:16:08] There are many pathways that these GLP-1 meds are acting on bone, bringing down inflammation, likely impacting joints. So, I definitely see that in people that they're benefiting from the weight loss and the reduction in inflammation in terms of help their joints. I don't think we really know all of the effects of these medications yet so. 


Cynthia Thurlow: [00:16:27] Well, it's so interesting because every opportunity I get to ask providers that are using them or working with patients that are on them already. I'm always curious about how each specialty is able to view the benefits of the drugs themselves. And I think for a lot of individuals, I think so many people think about it just about weight loss. And I think there's so much more to these drugs, especially the second-generation drugs with the GIP and the GLP-1 involvement. And how many people are just telling me they just don't have food cravings anymore, which then creates all these other profound benefits. Now let's pivot a little bit and talk—[crosstalk]


Dr. Jocelyn Wittstein: [00:17:03] Yeah. I don't prescribe those, but I put down in my realm of practice. But I'm always trying to understand, “Yeah, it’s just like hormone therapy, how it impacts my patients.” And for many people it's really helping their joints.


Cynthia Thurlow: [00:17:17] Yeah, I think that's a wonderful benefit. Let's talk a little bit about bones. I think that bones are oftentimes forgotten about until there's a fracture, there's a problem, there's pain involvement, there's an injury. And I think that many individuals probably don't realize that we hit peak bone and muscle mass in our 20s and up to maybe age 30. And so, when you're talking to younger patients, people that might be on oral contraceptives or Depo-Provera, really looking at the research about how that can impact bone development over time, what are some of the things that you're looking for that might be red flags, not just in younger patients, but in your other patient population? So, someone that probably never laid down good quality bone. 


Dr. Jocelyn Wittstein: [00:17:59] Right. So yes, that's true. We really do peak in our bone density by age 30. And so, I want to be clear, that doesn't mean that after the age of 30 you can't work on your bone density. And it's not like doomsday if you didn't figure out you need to strength train and do impact training until you were 50. It's just that you do have this unique opportunity before the age of 30 to build that bone bank and really increase your peak bone density. And a lot of things, like that can happen before the age of 30 that might reduce your ability to do so. One of them is overtraining and under fueling, which was traditionally referred to as the female athlete triad and women with disordered eating. 


[00:18:39] But you can have someone that's not like truly anorexic, for instance, but they're just chronically under fueled because they're over training. And men can also have energy deficiency. So, we now call this relative energy deficiency in sport. And so, girls who started menstruating and then like lose their cycle or have like a really, really delayed onset because of the overtraining and under fueling. And for instance, we see this sometimes in endurance athletes is a common phenomenon and they may like during college have some stress fractures and they recover and they keep training. And these people that are at risk for entering the age 30 and beyond with a lower peak and therefore if you decline from there, say at 1% per year or at menopause 2% per year, they're going to be really high risk for osteopenia, osteoporosis early on. You could have low bow density at the age of 21 if you had really severe energy deficiency. 


[00:19:36] And then you mentioned Depo-Provera, that is one of the contraceptives that does reduce bone density while you're on it. And there are studies that show that the bone density does rebound and return over time. It could take a couple years perhaps or maybe not for everyone. That drug concerns me when someone is taking it and then they have an injury in their reduced bone density state, I can't undo their injury in that state, and that's a real problem. So, that's probably my least-- And again, I'm an orthopedist, it's probably my least favorite contraceptive to see 18- or 20-year-old woman on in general. Obviously, I didn't make that decision with that person. There may be a reason why that was chosen, but it does affect bone density at least while they're on it. 


Cynthia Thurlow: [00:20:21] Yeah, it's really interesting. I just finished writing a book talking about the microbiome changes that occur in perimenopause and menopause. And when I was doing a ton of research about oral contraceptives, Depo-Provera, it certainly was clear to me that in the literature, teens and young adults are the ones that are most susceptible to the impact of not being able to lay down the same quality of bone. And I think, I'm the first person to say if you need good contraception, you do good contraception period. 


Dr. Jocelyn Wittstein: [00:20:50] Right. 

 

Cynthia Thurlow: [00:20:51] With that being said, I think that there's a lot of maybe missed opportunities to help patients understand, like just so you know long term, if you're taking these drugs for a period of time, it can impact the quality of your bone. And when I was in my teen years, I wasn't worried about bone, I wasn't even thinking about bone. And I think that's how many teenagers and young adults are thinking, they're going about their busy lives and they're like menopause is a thousand years away, and I'm not even thinking about. 


Dr. Jocelyn Wittstein: [00:21:17] Yeah. Although my teenage daughter just said to me, “Oh, my number one concern right now is menopause. It sounds awful,” [laughter] because I think she hears me talking about [crosstalk].


Cynthia Thurlow: [00:21:28] Yes. 


Dr. Jocelyn Wittstein: [00:21:29] I'm like, it shouldn't be your number. She's like, “The thing I most fear is menopause.” [laughs] 


Cynthia Thurlow: [00:21:33] Oh, how funny. But you know what? I don't even think-- But it's incredible, though, like our generation is having those conversations. I think that maybe I can only speak for my mother, but, like my mother's siblings, no one talked about menopause. And so, I think that it's wonderful that maybe teenagers even understand what that concept is. 


Dr. Jocelyn Wittstein: [00:21:52] Oh, yeah. My teenage son, we go work out every week together at the gym. And he said, “Mom, do you think your estrogen patch is making your joints feel better?” Because I started a-- [crosstalk]


Cynthia Thurlow: [00:22:00] Wow amazing. 


Dr. Jocelyn Wittstein: [00:22:01] -perimenopause. I’m like “Yeah, actually, I think it is,” but it's kind of funny he brought it up as a conversation. [laughs]  


Cynthia Thurlow: [00:22:09] That's amazing. That's amazing. And I think it just goes to show I have all boys, all teen boys and having conversations with them just to help them understand. Your dad will go through andropause, he's in it and I'm in menopause. And it's like women get-- And I tell them it's like women get shoved off a cliff. That's how dramatically the hormones fall. Whereas men, it's a little more gradual and kinder. 


[00:22:31] With that being said, I think that it speaks volumes of this generation is having those conversations with their parents, even if they're fearful of what that is to come. [Dr. Jocelyn laughs] So, when we're talking about Red-S. So, this relative energy deficiency syndrome, I think that is certainly really important. And that focuses in on this disordered eating, irregular menstrual cycles, and also bone loss. But there are other things that can set us up for being at risk for osteoporosis. And I think this is worth mentioning because some of these things we have control over and some of them we do not.


Dr. Jocelyn Wittstein: [00:23:04] Yeah. Thyroid conditions are one that can impact bone turnover and the way bone is formed, yeah medications, if you have a seizure disorder and you have to take a seizure medication for a long period of time, those can contribute to decreased bone density. If you have really bad reflux disease or get gastric ulcers and you need to be on proton-pump inhibitors chronically that can lead to lower bone density. So yeah, there are some things and that's how I like to describe them too, some things that are under your control and some of them aren't. And it's just good to know if you have some of those risk factors. 


[00:23:41] Like if you arrive at honestly even like 40 and you had any history of that sort of energy deficiency picture, now you're on a thyroid medication or maybe you've been on a proton-pump inhibitor from your GERD, like you're someone that should be screened with the DEXA scan much earlier than someone that doesn't have any of those conditions. This being said, I think the recommendation of waiting until 65 to be screened for osteoporosis is way too late because I think women need the information about where they're at with their bone density around the time that they're making a decision about using hormone therapy or not. Because I really think if women had that data would like inform their decision more about, do they want to use hormone therapy for prevention of osteoporosis? Like what if they found out they're osteopenic or near that? I really think that would help-- I think information helps people with decision making. I'm not saying every single person or woman needs to use hormone therapy, but it would be nice to know where you're at because if you take that DEXA scan test at the age of 65, you're not going to get started on hormone therapy that far beyond menopause, you'd like to do that within 10 years. So, the test is like mistimed with the decision making for something that is preventative. 


Cynthia Thurlow: [00:25:01] I agree and I think that it's both inexpensive and important because if it's run in a particular way, you can look at not just the quality of your bone, but you can also look at the fat free mass. It gives you some degree of- 


Dr. Jocelyn Wittstein: [00:25:17] Yeah, your body composition-


Cynthia Thurlow: [00:25:18] -body composition, which I think is so important.


Dr. Jocelyn Wittstein: [00:25:19] -you can get important information about the density within your lumbar spine versus your hip. And we know that impact exercise is more likely to help you gain bone density in your hip and strength training is more likely to help in the lumbar spine. These are both good things to do, but it would be nice to know the reason behind why you're doing things and what you really need to work on. 


Cynthia Thurlow: [00:25:41] Well, and I think it makes it easier for patient buy in. You're absolutely correct. That information allows us to make decisions that are fully informed. To your point about, if we're screening at 40 or 45, at least, then women can be properly counseled, like these are the things that you need to be doing to help protect your bones. And I think for a lot of people, and I speak from-- I have a lot of older female relatives and how many of them have fallen and fractured hips, and they're all sharp as tacks and still going even years past their original hip fracture. But I think for a lot of people, understanding that estrogen therapy can have huge therapeutic benefit for the prevention and improvement of bone quality. And I think one of the statistics in your book, you talk about 75% of women will experience a fracture that's quite significant. 


Dr. Jocelyn Wittstein: [00:26:34] Well, and when you look at hip fractures, three out of four of them occur in women and we know why. And I just think so many women don't understand that hormone therapy, that one of the actual approved indications for it is for prevention of osteoporosis.


Cynthia Thurlow: [00:26:50] Correct. 


Dr. Jocelyn Wittstein: [00:26:51] You would much rather prevent it than treat it, because treating it, these medications, like the bisphosphonate class of medications, it helps you maintain and gain a little bit of bone density. If you're on those medications for a few years, you'll gain about 6% bone density, but it's a different kind of bone. It's not necessarily organized in exactly the same way that bone would be formed if you were just forming it from activity and with maintaining your estrogen levels. 


[00:27:19] And there are some side effects of those medications, like some that are really concerning and rare, like jaw osteonecrosis and heartburn and some atypical fractures like the hip fractures that happen below the level of the hip joint. Those can be associated with those medications. But point is, you'd like to not get to the point that you need them at all by maintaining your bone density. 


[00:27:46] There are definitely major reductions in the risk for hip fractures and vertebral compression fractures, all the locations that people get, osteoporotic fractures. So, I just think that most women don't think of hormone therapy as something that's preventative of osteoporosis and fractures. They think about it for hot flashes and night sweats and things that will theoretically pass, not the long-term consequences that exist so.


Cynthia Thurlow: [00:28:10] Well, and it's so interesting, in my past life as a nurse in the ER of Inner City, Baltimore, I can't tell you how many compression fractures I saw in women, how many hips had to be reduced, sometimes in the ED itself or they went off for surgical intervention. And understanding that there's this whole generation of women that really, for the most part, lost the opportunity to be on HRT post WHI, and so I'm so grateful that things are kind of-- The pendulum is starting to shift back a little bit where we're having conversations to help educate women so that they can then go to their physician, their nurse practitioner, their PA and have a conversation about the appropriateness of therapy. And the thing that I find so interesting is there are lots of things we can do about bone health that are not per se, those drugs that have the side effects. Like I tell you, how many of my patients were on bisphosphates and they would say to me, “Oh, my dentist is now fearful to do dental surgery on me [Dr. Jocelyn laughs] because I’m on this drug.”


Dr. Jocelyn Wittstein: [00:29:08] That’s a rare complication. 


Cynthia Thurlow: [00:29:09] Yes.


Dr. Jocelyn Wittstein: [00:29:10] Now I do want to be clear. If you have osteoporosis, those medications will reduce risk of fracture. And there may be a time, if you're diagnosed so far into the process that you're more than -2.5 on your DEXA scan, those are important medications to have, for instance. And so, it's not that they're a never thing, it's just, yes, there are many things you can do to not end up in that place where you need them, but they are very important medications when we need them.


Cynthia Thurlow: [00:29:40] And the whole concept of sarcopenia and helping your patients understand that muscle loss begets frailty begets falls. Do you find that most of your patients are open to the concept of strength training? I think many people viscerally, if they haven't been strength training and they're 60, 70 years old, they're like, “No way, I can't do it.” Or do you find people are more open and receptive to discussions around that type of exercise therapy? I think women as a whole seem to be very open to doing cardiovascular exercise and less likely to be interested in strength training. I think that's shifting and changing.


Dr. Jocelyn Wittstein: [00:30:18] I think it's changing. And I talk to patients about that a lot. Again, the common scenario is someone coming in with new-onset knee pain and they can't run like they used to want to run, and that was their main form of activity was cardiovascular exercise and running. And also, to be clear, cardiovascular exercise is not bad. It's very good for our heart and our lungs. 150 minutes of cardiovascular exercise per week has been shown to help-- it's one of the things that prevents dementia. So, these are good things. But strength training is definitely beneficial when we can't necessarily. [laughs] Yeah, I guess what I should say is people get to this point where they do naturally shift away from some of the higher impact cardiovascular exercise. 


[00:31:03] And I am telling them like, “Strength training would help you have less joint pain.” But I take that opportunity to also tell them there are major metabolic benefits for you to strength training, like you're going to have better glucose control, you're going to be less likely to fall, the pushing and pulling and tugging on your bones from the strength training stimulates greater bone density. So, strength training programs in women who have decreased bone density will improve bone density a little bit, a few percent over the course of six to eight months has been shown. I always take that opportunity-- I always tell women who are struggling to do their usual cardio, like, “This is a good time to think about the benefits of strength training.” And I always tell them the other benefits related to their metabolic health and their bone density. So, I think it is something that people are open to adding on and taking on if you give them a little education about the benefits of it long term and give them a little instruction. 


Cynthia Thurlow: [00:32:03] I think that's really key in helping people understand that you're not telling them not to walk or do other forms of cardiovascular exercise, but you are encouraging them to get acquainted. And do you have resources or people that you like to refer individuals to, whether it's physical therapy or do you have personal trainers in your community that you refer out to? Because I find sometimes some hesitation because they'll hear from leading experts, lift heavy. And people are like, “Whoa, wait a minute, I don't even know how to lift.” You can’t start-- [crosstalk]


Dr. Jocelyn Wittstein: [00:32:33] Yeah, you can't jump into that. 


Cynthia Thurlow: [00:32:35] Exactly. Body weight exercise like helping people, where are the resources that you typically will send your patients to? I know that your book is a great, fantastic resource. Obviously, we'll link it in the show notes. But as a starting point, if people, they don't want to injure themselves. That's what I oftentimes will hear is “I don't want to hurt myself.” And we're like, “That is not what we're saying, but it's important to learn the basics. And maybe it is starting with body weight and then lighter weights and then working your way up so that you're being challenged.” 


Dr. Jocelyn Wittstein: [00:33:02] Yeah, I try to tell people just-- And there are benefits to the-- So, when you think about resistance training, strength training, there's like certainly the high intensity level where you're doing lower number of reps, higher weight, something at 80% or 85% of your one-time max. Most of my-- Many patients, they don't even know what their one-time max is. [Cynthia laughs] That's just not even a thing that they know. And so, I don't want them to start that heavy anyway because I don't want them to get tendonitis and things like that. But I usually will tell people to think about an amount of weight that they can do where they could get through like eight to ten repetitions, where they could do the eighth one with still maintaining really good form, but it's pretty hard for them. And I think that's-- And doing a few-- three or four sets of that, five or six exercises, you're like at that lower to medium intensity level, hopefully not going to get hurt, but they can start with that. 


[00:34:02] If they're coming to see me for knee pain, for instance, I'm going to definitely refer them to a physical therapist. Because one of the great things physical therapy can do for people-- Or hip pain or ankle or whatever, or shoulder with the joint that's giving them trouble, they can help them find ways to work around the joint pain and still strengthen. There are obviously multiple ways to strengthen your quads and your glutes. And there are some exercises that every time I do them, I irritate something and I'm like, “I don't do that.” 


[00:34:28] I don't do the knee extension machine because every time I do it bothers me. [laughs] I do my quads in different ways. So, I think physical therapy for someone who has a nagging joint situation is a great way to weave in a way to strengthen certain muscle groups. I think personal trainers can be helpful. There is a group of physicians around me that I have access to that I can refer people to that actually offers a program where they help people determine what is their 80% max? So that I think some people just don't know that baseline and give them a little guidance. That's like a functional medicine group near me and so I think those are like great things to offer to patients. 


[00:35:10] And then I tell them, yeah, “You can build up to heavier lifting, lower numbers.” And I think its people get overwhelmed, so if you think about like some key large muscle group exercises like squatting, deadlifting and overhead press, just think about like large muscle groups so they can-- food is good, but I do think people need to start light and build up. And that was the concept in the LIFTMOR trial, which is like a randomized perspective to study of menopausal women with reduced bone density, is they took a little while to build them up to the high intensity strength training. They started out with lower intensity, higher reps and then built their way up and included a little bit of impact. They did some like basically jumping chin ups with the bar. And like that program was shown to be very effective and people didn't get injured, but they took the time to ramp them up. 


Cynthia Thurlow: [00:36:01] I think that's really key. 


Dr. Jocelyn Wittstein: [00:36:03] I also think people just need to give themselves some grace. You can see like a lot of people on various platforms showing you how they do all this really hard stuff, really heavy. And if you get injured or an overuse injury doing those things and then you're out from the strength training for months because now you have tendonitis of your rotator cuff that you can't get over. You're not even doing the low or the intermediate level, so I think it's okay if you figure out that there are certain maneuvers or joints that just don't tolerate the highest of intensity. It's better to still be doing some resistance training. 


Cynthia Thurlow: [00:36:34] Yeah, some is better than none. And I love your kind messaging around giving yourself grace- 


Dr. Jocelyn Wittstein: [00:36:41] Right. [laughs]

 

Cynthia Thurlow: [00:36:42] -because I think social media is both a blessing and a curse because what might work for you and I, may not work for other people. And so, I always say that I think it's very important that we honor our own bio individuality. Now in terms of looking at stability and balance, which is super important, the whole concept of proprioception, where is your body in space and time, how much balance work do you typically, like, let's just say we're giving a general recommendation. How much balance work do you think is really important for us as we're aging? Especially if we're trying to avoid falls, tripping over things?


[00:37:16] I jokingly, I'm married to a former college athlete who calls himself-- He's like, I have cat-like reflexes and every once in a while, he'll slip, like everyone does. And sometimes it's graceful and sometimes it's not. But we have this ongoing joke of, this is why we do yoga, this is why we do Pilates, just so that we are remaining flexible, able to balance. And when you're talking to women of this age range, what are some of your recommended?-- How frequently should they be doing it? 


Dr. Jocelyn Wittstein: [00:37:47] Yeah. So, I think balance is really important. Also, a little bit of agility. And I like to not-- I think it's hard if you tell someone to carve out more time to do more things. [Cynthia laughs] So, I love to just stand in a tree pose and if I'm just waiting around for something, if I'm waiting in line somewhere, I'll just stand one leg and switch the other leg. But I honestly tell people-- I tell my patients while you're brushing your teeth, while you're doing your bottom teeth, stand on your right leg. When you switch the top, switch to your left leg. If you're waiting for a pot of water to boil, practice standing on one leg. Honestly- 


Cynthia Thurlow: [00:38:24] Practical.


Dr. Jocelyn Wittstein: [00:38:25] -when you're standing around, just practice. I don't think-- And who knows how much time that gives someone to do that. I just think the more we layer upon someone and minutes. Like, we're already saying you need 150 minutes of cardiovascular exercise and we'd like you to strength train two or three days a week. I think trying to just be practical about when you do that is good. Or I also tell people, “While you're doing, if you're doing biceps curls, stand on one leg, switch to the other, just kind of build it in.” 


Cynthia Thurlow: [00:38:55] Well, I love that because I think about the amazing Dr. Peter Attia, who I think everyone respects and appreciates his tenacity and his intellectual rigor. But if Peter Attia talks about how he does, two hours of Zone 2 and then does all this lifting. I have patients that will come to me and they're like-


Dr. Jocelyn Wittstein: [00:39:15] [crosstalk] good job.


Cynthia Thurlow: [00:39:16] -“I don't know where to fit that in.” Right, exactly. And I was like, “Just remember that what works for one may not work for all. And each one of us have differing commutes and time zone. Just depending on where your kids are in time and space, you may have more or less time to be able to exercise.” 


Dr. Jocelyn Wittstein: [00:39:30] And I also think we can't be so siloed about what-


Cynthia Thurlow: [00:39:33] Yes. 


Dr. Jocelyn Wittstein: [00:39:35] -different aspects of your body, for cardiovascular health, for dementia prevention, for bone and joint health. I can't say you should give up cardio. That's not good for your heart and lungs and perhaps your brain even. So again, if you look at what are like the-- For your long cardiac longevity, you need some high intensity interval training, something like a Norwegian 4x4. You need an endurance day. You need a few days of 30 minutes of something like Zone 2, where you're like a little bit breathy. So, I mean, I try to help my patients, like not black box things that they need for other reasons, so I want them to keep the cardio. 


[00:40:20] And then you have to think too, like, does someone have a little arthritis? And maybe they can't tolerate certain types of cardio, so maybe they can't like speedwalk a few miles because their knee swells or they can't run, so they can't get that kind of impact. So, we're saying, “Okay, let's bike, let's swim, let's elliptical.” But yeah, does that give you less benefit for your bone density? That's true, but let's-- Or maybe jumping makes your knees swell, so we're going to do less of that, but we're going to try to incorporate the strength training. And so, I don't think we can be so siloed and only think about just our one little part that we're helping someone with. 


Cynthia Thurlow: [00:40:53] I think that's important and I think it probably is very reassuring for listeners who may be thinking like, “I don't know how to fit one more thing into my lifestyle because of all the responsibilities that we have.” A lot of questions came in around frozen shoulder, which I know that you are very familiarized with. Let's talk about what it is. What are the things we can do to help prevent if we are prone to it? Because I think one of my male physician friends calls it, it's like the 50-year-old woman's shoulder. [crosstalk] 


Dr. Jocelyn Wittstein: [00:41:20] 50-year-shoulder, yes. Yeah, that's actually a common terminology in some cultures, Japanese and Asian, Chinese cultures, they have really literally referred to frozen shoulder as 50-year shoulder. And like my mom got it. People just expect to get it because it's so common. Yeah, so frozen shoulder is also known as adhesive capsulitis, traditionally referred to as idiopathic, meaning we don't know what causes it, but this is a condition that mostly affects women between the age of 40 and 60. If a man gets frozen shoulder, it's almost always in the setting of diabetes, or another inflammatory state or in the setting of a little bit of early arthritis that's just extra flared up. 


[00:42:06] But women often get this in the absence of diabetes, in the absence of any arthritis. And it's this innocuous onset of shoulder pain. No injury. Suddenly, the shoulder is really painful, loss of range of motion. At first it just hurts when you rotate your arm like to the side, like this end range, like you get to a point where you're like, “Oh, I just can't go any further, it hurts.” Women will describe they can't fasten their bra. They can't shave their opposite armpit because reaching across the body requires mobility. So, anything that is requiring like full range of motion is getting restricted.


[00:42:38] And after this initial inflammatory phase where it's painful and they're starting to lose range of motion, there's this frozen phase where it's very restricted, but the pain actually diminishes and it's not so painful anymore, but there's restriction of motion, and then there's a thawing phase where the range of motion gradually mostly returns over time, and so it's considered self-limited, meaning if we do nothing, this is eventually going to resolve, but who wants to go through like one to two years of this process? And I think--


[00:43:07] I've done a lot of research on this topic. I work with our Duke Women's Health Team, a good deal on this. And, I can't tell you that hormone replacement makes you necessarily less likely to get it or ameliorates it, but there's a lot of basic science to suggest that, certainly there are estrogen receptors in the lining of the shoulder joint. There are animal studies showing that blocking the effect of estrogen increases the fibrosis or stiffening and inflammation of the joint, having the activation of those receptors ameliorates that. There's a basic science study that shows that estrogen inhibits the fibroblast, which thicken and sort of scar down the lining of the shoulder joint. And then we've done some research on that. We need more numbers on to really attain significance, but trending towards more frozen shoulder and people not using hormone therapy. And we have a registry where we're like following people over time through women's health right now, currently, but I really believe this is hormonally mediated. And the other group of patients that suffer from this are breast cancer patients on aromatase inhibitor, so they're not getting the anti-inflammatory effect of estrogen on their shoulder joint and they get frozen shoulder. So, it can't possibly be idiopathic if this almost always affects women aged 40 to 60. [laughs] 


Cynthia Thurlow: [00:44:28] And that was one of my questions was anecdotally in your clinical experience, because I know there's ongoing research, women on HRT, are you seeing less of them that are impacted by the frozen shoulder as opposed to. As you mentioned, you're working with these breast cancer cohorts who are on medications to drive down any existing estrogen they have in their bodies. I was leaning towards, well, it would make sense to me intellectually but obviously since you're working in orthopedics, you would know best. 


[00:44:58] I think for a lot of people that are listening that are thinking about, “I've got joint discomfort and I've noticed since I've been on my estrogen patch that I have less joint pain.” I always like to mention that for me I noticed I started getting a little bit of right knee pain as I was in early menopause and going on estrogen completely took all of that away. And so, I do think the power of the N of 1, the power of looking at the improvements that you see not just in overall symptoms but in joint-related complaints can be quite significant. 


Dr. Jocelyn Wittstein: [00:45:30] Well, and as you know, only like 5% of women use menopausal hormone therapy. So, when we do this research, it's actually very challenging because we have such low numbers of cases of people that get frozen shoulder on hormone therapy and you already have a smaller subgroup when you're doing statistics, it just makes you need a really large group. Yeah, so you're already dealing with a smaller population and then within that small population you have very small numbers of people getting a condition. And so, it just takes time. 


[00:45:59] But yeah, I mean anecdotally, my own story. This is in a horrible form of irony. I developed adhesive capsulitis in my shoulder several months ago and I knew what it was really, quickly obviously, because I'm very aware of my body and I know exactly what adhesive capsulitis is. And I was in a little bit of a denial for probably a couple weeks and I just started losing motion. I was like, “Oh my gosh, I have a frozen shoulder. This could not be any more ironic. I'm a female orthopedic surgeon and I do research on this condition.” And so, I went and got a steroid injection in my glenohumeral joint done by one of my partners because that is a magical cure for people if you catch it within a few months, you can really stop the condition and reverse it and really make a big impact on someone's function and not make them go through like one to two years of freezing and thawing, and so I went and got that. 


[00:46:53] But I also went to see my women's health doctor who's also a woman who I do a lot of research with in women's health and I just decided and like I had some other things like LDL creeping up and like random nights right here and there. I don't want to bottom out and I also don't want to get frozen children on the other side. And so, I went ahead and started some transdermal estrogen. And I haven't needed another injection in my shoulder so far, I don't have-- I think I'm hyper aware of the basic science behind what estrogen does in joints. And for me that was really like a no brainer. It was just one of the things happening. So not that this is about me, but for example, when you think about what's going on, I saw my LDL creeping up, I got the adhesive capsulitis, the sleep stuff, it just made sense. 


Cynthia Thurlow: [00:47:41] Yeah, I think for so many people, it's also reassuring to know that as a clinician you were able to put those pieces together for yourself and you've seen such significant improvement. So, ladies, if you're listening to this and you suspect you might be suffering from the beginning stages, please get your shoulder looked at or any new-- [crosstalk] 


Dr. Jocelyn Wittstein: [00:47:59] Oh yeah, this is not something to sit on. Especially in conjunction with menopausal symptoms or perimenopausal symptoms because it's so common. It's honestly like the number one cause of shoulder pain I see in that age group. And other things like rotator cuff tears can occur and things like that and just basic tendonitis, but it's so common, what happens is women tend to, as you said, like take care of everyone else, not themselves. And so, they-- I mean, I cannot believe how late people present sometimes they'll come in with like no motion. And I'm just thinking, “How have you lived like this for the last six months?” So, it's not a thing to-- Like I make sure maybe take anti-inflammatory for a couple weeks and see if you get better, but don't feel silly going in to have it evaluated because you can really catch it early and stop it and you'll be so much better. 


[00:48:46] We see this all the time with women. They also tend to present later with like their knee arthritis. Like by the time they present to an orthopedic surgeon, it's farther along than-- So, there's just this tendency to kind of present a little bit later. 


Cynthia Thurlow: [00:49:01] What are the other types of like neck or knee issues that you see, maybe things that are nonsurgical, but are inflammatory or problematic for women at this stage of life? And I'm thinking about things that maybe you may evaluate the patient, they get referred for physical therapy, but more common things that you'll see maybe not at the point where they need surgery, but annoying, nagging, persistent symptoms? 


Dr. Jocelyn Wittstein: [00:49:24] Yeah, tennis elbow, lateral epicondylitis, which I think people get once they have a shoulder problem. So once people's shoulders start hurting, they get like what I call T-Rex arms a little bit. Like they kind of-- People don't want to move their shoulders so they're doing everything down here. And then they get lateral epicondylitis and that's hard to get rid of. And then they start to get like hand pain and so they'll kind of get like involvement of the whole upper extremity. 


[00:49:51] And then, yeah, I think hip and knee pain are also common. Sometimes trochanteric bursitis that like inflammation of the bursal sac on the side-- that's usually addressable with physical therapy. And a good physical therapist is invaluable if you have a nagging joint issue. They can really give you the best path forward with strengthening and how to be customized for your condition. And I think people sometimes don't have a lot of faith that physical therapy is going to be worth their time or worth the copay. But as an orthopedic surgeon, I would say, I cannot tell you how much I have learned about my own physical ailments from my physical therapist, so I would [crosstalk] unintelligible people. 


Cynthia Thurlow: [00:50:32] Yeah. They're invaluable. 


Dr. Jocelyn Wittstein: [00:50:34] Yeah, they're very valuable. Yeah. 


Cynthia Thurlow: [00:50:35] I was at an event last year and I tripped, like my sandal got caught on a tree root and I pitched myself forward. I didn't fracture or anything, but I actually got quite a bad sprain in my wrist. And I went to the hand and wrist physical therapist who was amazing, and I think I went twice a week for six weeks, and every other woman that was my age or older had a fractured wrist that they were recovering from. They all had surgically repaired- 


Dr. Jocelyn Wittstein: [00:51:01] Right. 


Cynthia Thurlow: [00:51:02] -and so I kept saying to her, like, “I don't want to complain, but oh my gosh, I can't believe how painful this was.” [Dr. Jocelyn laughs] And so, it became this thing where I said, “If I had never believed in physical therapy before,” which of course I did, I see the value, but personally, I think it's what got me back to a level of range of motion and functionality much faster than if I kind of blown it off and took anti-inflammatories for a couple weeks, which in and of itself I didn't want to be doing, but actually needed to. In terms of bone building foods. let's kind of pivot and talk a little bit about what are the-- 


Dr. Jocelyn Wittstein: [00:51:36] I want to just mention that when you talk about breaking wrists. 


Cynthia Thurlow: [00:51:38] Yes. 


Dr. Jocelyn Wittstein: [00:51:38] Before we get to food. The common areas, aside from compression fractures in the spine, distal radius fractures, these happen to women before the proximal humerus and before the hip. So, if you're a woman and you've had a distal radius fracture, if I were you, I would get a DEXA scan because we see these a little earlier than we see like the proximal humerus or the shoulder or the hip. I put those in the same group-


Cynthia Thurlow: [00:52:07] And I think, they’re so common. 


Dr. Jocelyn Wittstein: [00:52:08] -of likely related to diminished bone density. Yeah.


Cynthia Thurlow: [00:52:10] Yeah, they're very common. I think my mom, the year that I was pregnant with my youngest, this is 2007, tripped and fell. She was still working full time and she had plates and pins. She came down in a way that it wasn't just a cast and beget, it was-- you now need surgery. 


Dr. Jocelyn Wittstein: [00:52:27] Yeah. You’ve got to fix it.


Cynthia Thurlow: [00:52:29] Yep. Because she had osteoporosis. And to your point, if that's the sequela, like that is the starting point and then the future events are that you're fracturing your hip. And we know that can be a poor prognostic indicator for morbidity, mortality. Now, I have several female family members that have broken both hips and they are sharp as tacks and they're still mobile. But I tell them that we need to take all the rugs out of your--


Dr. Jocelyn Wittstein: [00:52:55] Oh yeah. 


Cynthia Thurlow: [00:52:56] I mean, we need to be so conscientious about the things we can do to protect you from those falls that seem so benign, but actually can be a sign that frailty piece is becoming problematic. 


Dr. Jocelyn Wittstein: [00:53:06] Right. Yeah. I didn't mean to interrupt you, but yeah.  


Cynthia Thurlow: [00:53:08] No, no, no. I am glad that you interjected that. I am grateful that I did not fracture. 


Dr. Jocelyn Wittstein: [00:53:12] Right. That’s good, yeah. You probably have [crosstalk] good bone density. Yeah. [laughs] 


Cynthia Thurlow: [00:53:16] Yes. Thankfully mine is still intact. But in terms of, I think this is important because there are many foods that are great nondairy calcium sources. I think there's a lot of habits that we think of as being benign that can impact bone health. And by that I'm referring to beverages that I think would be important to kind of touch on because I don't think we talk about this enough. 


Dr. Jocelyn Wittstein: [00:53:39] Yeah, too much soda, not good. Too much alcohol, not good. Coffee is actually okay. You could have a couple of cups of coffee. Coffee actually has a couple of substances that may help with bone density, but those substances can also raise your LDL a little bit. [laughs] So, I actually filter my coffee for that reason. Well, I do want my LDL down, but yeah. And then foods, I think that people always think all your calcium comes from milk and milk is a good source of calcium or dairy. Dairy has good bioavailability, but there are a lot of people who don't do well with dairy.  It's inflammatory for some people. And there are some plant-based sources of calcium that are really good. Cruciferous vegetables in general, the same family that broccoli and cauliflower and those are good. 


[00:54:31] My favorite example. Honestly, one of my favorite foods to cook and incorporate in meals and just I think is an unrecognized superfood is bok choy, which has really highly bioavailable calcium. And if you do the math, it's-- If you have a cup of cooked bok choy, you're getting the same amount of calcium as you are from a cup of milk. 


Cynthia Thurlow: [00:54:49] I love that. 


Dr. Jocelyn Wittstein: [00:54:50] Yeah, which some people don't realize that. Oh, every trip to the grocery store I buy bok choy. [laughs] And, then yeah, there's like misconceptions too, a lot of people think, “Oh, I don't eat dairy, but I eat a lot of spinach and a lot of almonds.” And to get enough calcium from almonds, you would have to eat so many almonds like you would be gaining weight from the amount of almonds you'd be eating. [laughs] And spinach is not really highly bioavailable because it has a high oxalate content, so you actually get-- you absorb very little calcium from spinach. So, it's just interesting. I think it's not something that people think a lot about that. Yes, your calcium doesn't all have to come from dairy and then not all plant-based calcium is created equal, it just depends on the bioavailability of it. We try to outline that for people. I try to make things really simple for people. 


Cynthia Thurlow: [00:55:44] No, you do a beautiful job and I think it just goes to show you that, we should be getting our nutrients from a variety of sources. And I find that a lot of women in particular are very sensitive to cow milk dairy as they're navigating perimenopause and menopause. Maybe they tolerate goat or sheep's milk, cheese or milk or yogurt. 


Dr. Jocelyn Wittstein: [00:56:02] Yeah. 


Cynthia Thurlow: [00:56:03] Cow milk dairy seems to be less well tolerated. And so, I always like to find nondairy options so that people know that, just another reason to get more vegetables into your diet and-


Dr. Jocelyn Wittstein: [00:56:13] Oh yeah [unintelligible 00:56:14]

 

Cynthia Thurlow: [00:56:15] -be conscientious about which ones. 


Dr. Jocelyn Wittstein: [00:56:16] My co-author is a registered dietitian and we're very integrated in our thought processes because, we were both gymnasts and known each other forever and it was very seamless working with her on this book and I studied nutritional science as an undergraduate at Cornell and it's always been an interest of mine. But I love like bringing together like sort of my orthopedic knowledge and her knowledge together and just trying to make things really straightforward for people. 


Cynthia Thurlow: [00:56:45] Well, and I think that's important because then it's actionable. I think when we make it complicated or we make it too nuanced, then people feel like they, [crosstalk] it's like I don't even know where to start. 


Dr. Jocelyn Wittstein: [00:56:55] Right. 


Cynthia Thurlow: [00:56:56] And so your book does a really nice job of breaking the information down and making it very accessible. Now before we end our conversation today, I would love to know-- I know you're a mom of five, what are the things that you do conscientiously as a mom and a middle-aged woman to support your muscle and bone health? Like what are the things for you as an orthopedic surgeon are the highest priority? 


Dr. Jocelyn Wittstein: [00:57:20] Yeah, definitely, dietary choices. I'm always thinking about like, “Yeah, am I getting enough calcium and vitamin D?” Always trying to get a variety of plant-based sources and some dairy. I do take a vitamin D supplement, 2,000 IU a day for both an anti-inflammatory component and bone health component. There's evidence that a supplement that level helps reduce joint pain as well. And vitamin D has a multitude of benefits, even maybe related to dementia prevention perhaps. And then I take a magnesium supplement, 400 mg of magnesium glycinate. Magnesium kind of helps vitamin D help us absorb calcium. One of my patients said to me the day like “Wait, I have to like eat enough calcium and I have to get vitamin D and now I have to have something to help my vitamin D?” I'm like, [Cynthia laughs] “Yeah, yes, now you can get magnesium through your diet of course.” But I think the magnesium supplement helps some with sleep as well. 


[00:58:17] And actually a lot of cardiologists will tell you for patients that have like random palpitations and they've had like an entirely normal monitor, they’ve not found--


Cynthia Thurlow: [00:58:24] Magnesium, yep. 


Dr. Jocelyn Wittstein: [00:58:25] It actually-- They often recommend magnesium glycinate. So, I think magnesium glycinate is great for various reasons, so I take that. And then in terms of bone density promoting activities, I definitely try to strength train two or three days a week. I am of the level and I don't have significant injuries. Well, I did, but I've worked through them. I tend to do a little bit of the heavier lifting, sort of the four sets of six to eight or I drop down as I go up higher in weight and like four large muscle movements and then some smaller stuff. I like to incorporate some impact a few days a week. There's a great study that showed a few times a week just doing about 30 jumps can help improve bone density about 1% in your femoral neck region. So, I like to do a little bit of impact activity that would be like some sort of jumping, like I'll do box jumps or drop jumps, things like that. 


[00:59:15] If you're someone who can't do jumping because it aggravates your knee, you can do pool-based jumping, that will help. You can do like a little bit of assisted jumping like they did in the LIFTMOR trial where they did jumping pullups, it doesn't have to be like full on high impact, it doesn't have to be a lot. So yeah, those are the things that I'm doing for bone density, strength training, some jumping, make sure I get enough calcium. I do a vitamin D supplement. I do a magnesium supplement. And I'm just going to continue doing that. And definitely, then when I do transition entirely to menopause, I will increase my dosing of my hormone therapy. But I'm intentionally not bottoming out because I don't want to experience that. I'm easing into my decline or buffering it. [laughs] 


Cynthia Thurlow: [00:59:59] Well, and I think that's really key, is that when I went through a little earlier than I had anticipated, and so I tell everyone that at that time, maybe, fiveish, sixish years ago, it was not as proactive to start before you went into menopause. And so, I'm always encouraging women, if your sleep is impacted, talk to your provider about progesterone. If you're having a lot of vasomotor symptoms and hot flashes and disruption and sleep well as genital urinary symptoms, which it's not a question of if, but when. We will all experience that if we're not on some type of replacement, have that conversation sooner rather than later. 


Dr. Jocelyn Wittstein: [01:00:35] And the other thing that I think a lot of women don't think about, which I also use, is 5 g of creatine a day. 


Cynthia Thurlow: [01:00:41] Creatine monohydrate is like a foundational supplement. It’s something that [crosstalk] 


Dr. Jocelyn Wittstein: [01:00:44] Yeah, there seems to be some cognitive benefits, certainly maintaining and improving muscle mass, which has a secondary effect on your bone density. I don't think that creatine monohydrate in and of itself, if you just took it and did no strength training would help with your bone density, but it then helps you with the benefits of strength training. And so, I think that is another thing in your armamentarium to help with bone density. It's indirect, but I think it helps. 


[01:01:09] And you notice I talk about dementia a lot. I think dementia is certainly part of frailty or just exercise-- Things that I'm aware of exercise and vitamin D supplementation and likely hormone therapy and possibly creatine, these may be ways to kind of help us maintain better cognition. So again, I try not to be too siloed. Even though I am an orthopedic surgeon, my main priority when I'm treating someone is to help them with their bone and joint problem, but all these things are so connected and overlap. 


Cynthia Thurlow: [01:01:43] Well and I think-- I mean, it's just being thoughtful. 


Dr. Jocelyn Wittstein: [01:01:44] Yeah. 

 

Cynthia Thurlow: [01:01:45] I can tell that you're a very thoughtful provider. And it's interesting, I think the preliminary research is suggesting to cross the blood brain barrier, women need a little bit more. So, 5 g a day is like a great starting point. If you're looking at bone and brain, you need anywhere from 8 to 10 g. And that was based on conversations with creatine researcher and he was saying, as they were-- You need a little bit more to cross that blood brain barrier. But I agree with you, even helping in some instances with sleep architecture, we have patients that are reporting significant improvement in sleep quality by virtue of taking higher doses. And I also use it for jet lag, just as an aside, I travel quite a bit and it's been really helpful. I just increase the dose pre and during and afterwards, and I tend to have a lot less jet lag. 


Dr. Jocelyn Wittstein: [01:02:30] Yes. Maybe I should increase my dose a little bit. 


Cynthia Thurlow: [01:02:33] Yeah, yeah, that's been-- I usually double it around travel and that helps a lot because otherwise I'm struggling, especially when I go west as opposed to East.


[01:02:40] Well, Dr. Wittstein, it's been such a pleasure connecting with you today. Please let listeners know how to get access to your new book, The Complete Bone and Joint Health Plan that you coauthored with your friend Sydney, who's a registered dietitian, follow you on social media or if they're in the North Carolina area and they'd like to work with you. You're based out of Duke University. 


Dr. Jocelyn Wittstein: [01:03:02] Yeah, I work at Duke. Sydney actually offers amazing high intensity strength and core circuit classes online, which are amazing. I do them. I do hers every Sunday. So, yeah, you can get the book on Barnes & Nobles or Amazon online or any really bookstore that you shop at, they can get that for you. And yeah, I have an Instagram page which is just @jocelyn_wittstein_md, where I honestly just try to offer people useful tidbits of information that relate to bone and joint health primarily and how that intersects with women's health oftentimes. 


Cynthia Thurlow: [01:03:37] Well, thank you for the work that you do and thank you for the conversation today. 


Dr. Jocelyn Wittstein: [01:03:41] Yeah, thanks. Thanks for having me. 


Cynthia Thurlow: [01:03:44] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend. 




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