Health, Fitness & Personal Growth Tips for Women in Midlife: Asking for a Friend

Ep.179 Stronger Bones, Sharper Brain, Leaner Muscle: The Midlife Health Trifecta with Dr. Jocelyn Wittstein

• Michele Henning Folan • Episode 179

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Your bones, brain, and muscles are having the same conversation—and nutrition is the translator. Duke orthopedic surgeon Dr. Jocelyn Wittstein breaks down how midlife hormone shifts accelerate bone loss, cartilage wear, and muscle decline, and why training + food choices can improve all three at once. 

We cover earlier DEXA timing, the bone–brain crosstalk (osteocalcin, agility, balance), and a practical plan: progressive strength, safe impact/jump options (step drops, heel drops, rebounders), grip and toe work for fall prevention, and weighted vests/rucking basics. 

On the nutrition side, we get specific: prioritize protein, aim for food-first calcium, and use targeted support where appropriate—vitamin D, omega-3s, magnesium glycinate, collagen, and turmeric—to lower inflammation, protect joints, and support cognition. 

Expect clear modifications for cranky knees/shoulders, plus why consistent movement is linked to reduced dementia risk. This episode is your integrated blueprint to build bone, protect your brain, and keep muscle on your frame—so you stay strong, steady, and independent for decades. 

Actionable, hopeful, and BS-free—use this episode to build stronger bones, happier joints, and real confidence for the next 20 years.

Follow Dr. Jocelyn Wittstein at https://www.instagram.com/jocelyn_wittstein_md/

Her book, The Complete Bone and Joint Health Plan, is available at booksellers.

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Transcripts are created with AI and may not be perfectly accurate.

Disclaimer: This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your qualified healthcare provider with any questions regarding a medical condition.

Michele Folan:

The holidays are coming fast, and if you're not careful, it's easy to lose yourself in the shuffle. So this year, what if you did the opposite? What if you built a healthy foundation before the chaos hits? I'm Michelle Folan and my 21-day metabolism reset is designed to help you do exactly that. We'll tackle sugar cravings, dial in your nutrition, and get you moving in a way that fits your life. Beginner, I've got you. More advanced, there's plenty to challenge you to. This is your chance to hold space for you. To reset, recharge, and finish the year feeling strong, not stressed. Join me now. The link is in the show notes. Let's build momentum together. Health, wellness, fitness, and everything in between. We're removing the taboo from what really matters in midlife. I'm your host, Michele Folan, and this is Asking for a Friend. Did you know that one in two women over 50 will break a bone due to osteoporosis, often without a single warning sign? Or that 80% of us aren't getting the right screenings early enough to stop it? I've been there, staring at my own DEXA scan, heart racing, thinking, ugh, this can't be my story. But here's the truth: osteoporosis and joint pain don't have to steal your spark. Today we're joined by Dr. Jocelyn Wittstein, Duke orthopedic surgeon, author of the complete bone and joint health plan, and a powerhouse in women's bone health. She's here to unpack why midlife hormone dips hit our bones and joints hard, how simple moves like jumping and grip training can rebuild strength, and why normal labs might be lying to you. From her lift more-inspired workouts to dementia fighting nutrition, this conversation is packed with hope and how-tos to make your next 20 years unbreakable. So grab your cup of coffee or a weighted vest and let's dive in. Dr. Jocelyn Wittstein, welcome to Asking for a Friend. Hi, thank you for having me. Yes, I'm so glad we were able to get this together. This audience has a huge interest in bone health. I talk to clients daily who are like me, um, have either osteopenia or osteoporosis diagnosis. And so thanks for being here. I would love for you to tell our listeners a little bit more about you. I know you're way more than what I just described.

Jocelyn Wittstein, MD:

Um well, uh I'm not sure what all you want to know, but I um I am yes, I'm an orthopedic surgeon. Uh, I'm a mom. A five. Yeah, yeah. The the thumbnail version is um as an added fun bonus to our life. My husband is also um a full-time orthopedic surgeon, and his wife before me passed away of breast cancer. So when I married him, I married him in a five, eight, and eleven-year-old, and then we had two more kids. And so we have uh a family of seven, and um, we mostly talk about our children and bones and joints. Exciting. Very, very boring.

Michele Folan:

Bones for pillow talk.

Jocelyn Wittstein, MD:

Yeah, bones, joints, children, what kind of exercise we're gonna do and what we're gonna have for dinner, and our dog, yeah. So uh, but um we yeah, so we're kind of an orthopedic family. And um, I you know, I went to Cornell undergrad. I studied nutritional science there as part of my pre-medical education. So I've always had a love for nutrition. Uh I was a gymnast growing up, and I was a collegiate gymnast. And uh I went to med school at ECU, East Carolina University, originally thinking I wanted to be a pediatrician, and then decided actually I wanted to be a surgical subspecialist. Uh, I've always had a love for sports medicine, which is the sub-specialty of orthopedic surgery that I practice in. Uh, and then I you know, I did all of my orthopedic training at Duke. I did a fellowship there in shoulder and knee and sports medicine. Uh, worked for a while for a Columbia-affiliated organization up in New York State, came back uh to Duke, where I work now in 2017. Uh, and I'm an associate professor there. I teach and train medical students and residents and fellows. And I also um very active in research, so I collaborate with a lot of our PhDs on some NIH funded research, a lot of it related to post-traumatic arthritis. And I work regularly with our with my women's health colleagues on um some research kind of at the intersection of women's health and musculoskeletal health, which actually impacts adolescence all the way through, you know, menopause in terms of the sort of intersection between uh those two subspecialties. So there's um much more intersection than people realize.

Michele Folan:

Well, and you've probably treated some elite athletes, you know, where you've been, right? But you've you've kind of taken a little bit of a detour into women's health. What kind of yeah, you said you're doing some research, but what kind of made you more interested in, you know, uh postmenopause and and some of the joint and bone issues?

Jocelyn Wittstein, MD:

So I don't really think of it as a detour. I think of it as part of the whole spectrum. I mean, you women are very active throughout much of their lives. And, you know, I think if we treat women like as athletes or people just trying to stay active, there are different aspects of um their musculosal health that are impacted differently um throughout their entire life. So there's a health span for women, and I like to think that I think about all of that. Um, like in my younger patients, female athletes are more prone to ACL tears. And if you tear your ACL, you're also more prone to developing arthritis. But women go through pregnancy and then they're more prone to autoimmune types of um arthritis, actually at that point in life. And then you become a perimenopausal or menopausal woman, and you are prone to frozen shoulder and um faster progression of our arthritis than men, you know, of matched ages. Um, and of course, osteoporosis, and that may manifest in a distance athlete or an endurance athlete, you know, having more problems with their knees or stress reactions. Uh, and of course, as orthopedic surgeons, we all interact with patients who have false and trauma. And there are just multiple areas where women are affected disproportionately. So, osteoporosis is one. And it's actually a preventable disease as orthopedic surgeons. We usually catch it at the back end. So I think I don't want to say like my interest in bone health or joint health and how things maybe how both arthritis and osteoporosis disproportionately affect women is like kind of a a detour. I just think if it's part of the continuum of the health span of women, and there is throughout the life this intersection of, you know, the female sex and musculoskeletal health. It's just different things at times, if that makes sense.

Michele Folan:

No, it it certainly does. And, you know, there's there is a little bit of a sense of urgency, I think, because we, you know, we've got this window where we can prevent a lot of this if we take early action. But I think it's for women knowing when to take action is kind of the question there. You know, because you know, you may be asymptomatic, right, with osteoporosis and you don't know exactly, you know, when when you should start to get the bone scans and all of that. So speaking of which, if you have a family history, when would you recommend someone get their first DEXA scan?

Jocelyn Wittstein, MD:

Well, that's tricky because the family history part, I feel like if you have a mom, you could have a family history of osteoporosis. Yeah, right. Just like so many women, if you live long enough, you know, at least in previous years we have developed osteoporosis. So uh I think like an early family history is uh yeah, certainly a red flag. But uh yeah, this question, you know, we the standard of care is like age 65 for women, and that's definitely, I think, later than I would like it to be. I think people have like multiple risk factors, like testing earlier. I I think it's very reasonable to consider testing at menopause because you're about to, uh, without interruption of the process with hormone therapy, if you're able to use it, you are going to have a more rapid loss, or you know, like something on the order of 2% per year in terms of loss of bone density. So over a decade, like 20%. You know, you you really would like to know. I think we we should know, you know, where we are when we're starting that. And then I think that's most important for people who want to take that information and incorporate it into their decision making. And it can be a wake-up call for people as well. You know, if you're entering menopause, osteopenic, um, that can be very motivating sometimes. Yes, it can. Kind of take the bull by the horns. Um, so I mean, I think people who need to be screened earlier are people who, if you had energy defenselessly as a younger athlete, if you had previous stress fractures, if you're someone who's on like been on proton pump inhibitors for years and years, like someone who's had reflux for years and years has a greater risk of osteoporosis and fractures over time. People have been on steroid, people who've used a lot of nicotine really worry about. I sound like an old person, but these young people vaping all the time, so much nicotine exposure is not going to be good for their bone health as they uh as they age. Um, anyone, you know, with a history of um um elevated parathyroid hormone, uh, you know, so there are certainly some known risk factors that would tip you into being tested earlier. The people who need to be tested really young are people who had like definitely a history of energy deficiency syndrome, stress fractures, especially if that's prolonged. You know, those are like kind of the experiences at a younger age that can make you uh more at risk. But I it's hard to give an exact answer. I think for many women it would be better to get tested around menopause than 65. I think that's pretty clear.

Michele Folan:

Will that standard ever change? I mean, because 65 to me, it's like the horse is way out of the barn by then.

Jocelyn Wittstein, MD:

Well, I think it's becoming more and more apparent that osteoporosis can be preventable in so many cases. And so obviously, if you were trying to prevent something, you would like to catch it in an earlier phase than a later phase. I think more and more addressing osteoporosis is becoming more of a preventative effort than a reactive effort. You know, I we still do this, of course, because we need to, but if I if we have a patient who breaks their hip, we send them to our, you know, we we we have them test on the DEXA. I fully expect them to, I don't know what woman in their 70s with a hip fracture would not have osteoporosis. I mean, it's like pretty likely they're gonna test that way and they're gonna be treated, but we're also using that study to then like follow their response to treatment. So it's not that you, it's not that the studies aren't valuable then too, because you're more using them for like seeing maybe a response to treatment and and following them in that way. But it's yeah, it's not to screen you and see where you are and see what your preventative efforts might might do. And there's so many tests that having information is valuable because it's also motivating to people, or can be there are other tests that help allay, you know, fears sometimes, you know, the opposite, like um, like an like an MRI of your knee if you're having knee pain and it comes back as okay, I can keep being active and push through. But I I think a DEXA scan is a is is a different thing. It's like it can be motivating, even though you might not want to get a result that shows you have osteopenia, it can be kind of a sign that you are at a window where you can still do something. And I think that's also motivating for people.

Michele Folan:

Well, certainly motivated me.

Jocelyn Wittstein, MD:

Yeah, your story is one of those.

Michele Folan:

You right, exactly. Yeah, so but yeah, it was it was one of those things. I mean, I was certainly younger than 65 when I got that, when I got my first scan. So that's why I was asking, you know, just from your perspective. You know, perimenopause can hit hard, you know, because we we start to see the decline in estrogen. People get achy, you know, they knees and and whatever. You start to see some shoulder issues. I was talking to a client this morning that has rotator cuff issues. I don't know if it's frozen shoulder, but how does hormone decline contribute to arthritis versus osteoporosis? Are are are there correlations there?

Jocelyn Wittstein, MD:

Mm-hmm. Yeah, I mean, so it's unfortunate, but both things accelerate uh with estrogen withdrawal. And so our bone density is is very well very tightly linked to to estrogen. Our estrogen basically kind of inhibits our osteoclasts, make them not live as long. So there's like less breaking down of bone relative to making bone, and so we can maintain bone density better, and then in the absence of estrogen, the osteoclasts live longer and they break down bone at a greater rate than our osteoblasts build bone, and so less we get that accelerated, accelerated loss of bone density. But in our joints, yeah, uh estrogen has more of an anti-inflammatory effect, and you know, we know that just systemically, in the absence of estrogen, some of these inflammatory markers or cytokines are a little bit you know elevated. The same thing is happening in our joints, and there are estrogen receptors in the lining of the joints. And so if you don't have that anti-inflammatory effect, it's a more inflammatory environment. There is more cartilage breakdown, more rapid thinning of cartilage. And that definitely bears out in the differences. And if you if you look at like number of women with arthritis versus men, women needing knee replacements versus men, um, you know, women are affected by this much earlier than men. So, you know, I've referenced papers in the past that show that women have a 40% greater chance, you know, in their 50s of having knee arthritis than than men. And so that's probably hormonally mediated. Uh so unfortunately these two things are kind of happening at the same time. Similar pathologies, like frozen shoulder, it's not arthritis, but it's an inflammatory process in a joint. And, you know, to kind of support that hypothesis or or kind of thought process, our patients who are being treated with aromatase inhibitors, for instance, are very prone to frozen shoulder. There's the lining of the shoulder joint, is for some reason seems to be quite sensitive to the anti-inflammatory effects of estrogen. And there are even basic science studies showing that um estrogen has an effect of basically inhibiting fibroblast or this cells that kind of thicken the joint capsule and make it stiff. So all these things are happening at the same time. And then likewise, our musculature uh is you know muscle growth, repair. The stellate cells in the muscles are also uh stimulated by estrogen, and so it's harder to maintain muscle mass um as with estrogen withdrawal. And you know, these things kind of coalesce, uh, and then you get it's like wall wall.

Michele Folan:

It's like it's like we, you know, it's like we yeah, yeah. And so that brings me to my next question. Well, first of all, aromatase inhibitors tell the audience exactly what they are.

Jocelyn Wittstein, MD:

Um, they you know, kind of prevent the reaction that kind of creates like makes estrogen uh available in your body. Okay, okay.

Michele Folan:

All right.

Jocelyn Wittstein, MD:

So you you're diminishing the amount of of estrogen circulating in in the body. Um, so as part of like, you know, breast cancer um treatment. Got it. And yeah, so patients who are on those medications can have this can affect their bone and uh and their um joint health. And then, you know, other medications called CERMS, like selective estrogen receptor modulators, interestingly, like you know, can be protective of bone, but then you can still have side effects of the joint pain, and but they're can be protective against cancer. Um so uh of course, you know, sometimes those medications are are are necessary. And I'm I'm certainly, you know, not like a breast cancer doctor, but I do see a lot of patients that are you know going through treatment of that and experiencing um the side effects and you know just trying to stay active and it's really hard for them.

Michele Folan:

Yeah. And for those patients that absolutely cannot be on hormone replacement therapy, they can't be on estrogen, what other options do you have for them?

Jocelyn Wittstein, MD:

Well, I mean, I think the data on strength training and some impact exercises, you know, is very, you know, shows that like interventions other than medication are really effective. And, you know, if you look at some of the studies on, okay, let's talk about bone density and estrogen therapy over a few years, increasing, say, like your bone density by three and a half, four-ish percent, something like that. You know, we also know that some strength training interventions, like the Liftmore trial, showed over an eight-month period a 3% increase in lumbar spine bone density and a smaller percentage increase in the hip. So it's I don't want people to feel hopeless if they're someone who can't use uh estradiol, because some of, you know, if you just look at like percentage points of improvement in bone density, actually, some of these strength interventions show almost similar benefits in a shorter period of time, which is amazing. Um, for people who have the luxury to or lucky enough to use hormone therapy, certainly all these things can be cumulative. And, you know, I would never want someone to think that like just just hormone therapy would be like, you know, the golden ticket to not getting osteoporosis. Estradiol is prophylactic against, you know, osteoporosis, it stabilizes bone loss, like over a few years can increase bone density some, but these other interventions, which are not even medications, are actually quite helpful as as well. So uh it's just some people have less options, and you know, that's that's not ideal. And then there's new medications on the horizon. Um, there's you know, further research going on with Duave, you're probably aware of, which is a combined estrogen and CERM, which would be protective against bones and um showed, you know, reduced risk of invasive cancer. So, you know, I I think there's so much research happening and um potential options for people and also more of a shift towards shared decision making for people who do have some risks. And uh I I've really enjoyed following um Corinne Mann, you probably follow, and just her perspective on like shared decision making and kind of not treating people as like only their breast cancer risk and things like that. But so yeah, in a perfect world, like yes, cumulative benefits of estradiol, strength training, some impact training, your diet, you know, some supplements that may help, but it's not just hormone therapy.

Michele Folan:

Well, and I that's that's an important message because we have to get away from thinking that a pill is always gonna save us. You know? And so for me, sure, I'm on HRT, but I also am working my butt off in the gym. I I watch you, I you know, I I told you I was jumping off a step the other day at the gym. I was doing a compound, you know, compound jump. And this woman's like, what are you doing? I'm like, I'm working on my bones working on my bones. Yeah, Dr. Wittstein told me to do this. Um but but back to what I was saying before is that there is hope out there. And I know for a lot of women though, you get that osteoporosis diagnosis and you're a little scared. You're a little scared to do the bend over, you know, pick up, you know, do a deadlift, those types of things. What kind of coaching do you give patients? Do you send them to PT to learn how to lift appropriately and safely?

Jocelyn Wittstein, MD:

Yes. I mean, so many people haven't done strength training before, or maybe they haven't in a while. And um, you know, in many of the studies and the benefits of strength training, these are of course supervised. And you can't just go from not strength training to doing this like really heavy lifting. And I always like to say, like, we people who are not subjects in studies who were not screened to be in the study because they did or didn't meet exclusion criteria. Like in real life, some people have these exclusion criteria that wouldn't have let them even be in the studies, like maybe they had a knee surgery or have some you know limitations from another orthopedic condition. So we need to like take into account what your own limitations are. We need to take into account if you haven't been doing this heavier exercise or lifting, you have to start light and then you know build up. I mean, even in these controlled trials with guidance, like in the Lyftmore trial, there was kind of like a one to two month ramp up period from you know lighter to moderate to heavier lifting. And certainly there are a lot of studies showing the safety of these exercise interventions in osteopenic patients. You notice like a lot of the studies are on people with osteopenia. That's kind of a safer group to group to study, maybe not directly on people who already have osteoporosis. And that requires even more nuance so you don't hurt yourself. Like we want people to move and not be afraid to move and bear weight because that's what you need to do to like not lose more bone density, but we also don't want you to get an insufficiency fracture in the process. So it can really help to have some guidance of a physical therapist and then maybe kind of eventually, you know, transition you to a trainer who's knowledgeable and things like that.

Michele Folan:

Yeah, and I did go to a physical therapist because again, I was scared to death. I was like, oh my God. I, you know, I didn't know what I was dealing with. And and she really walked me through things, but there were like certain yoga poses she told me, yeah, you may not with with your lumbar issue, you may not want to do, I forget the yoga pose because I'm not like a lot of flexion. Yeah, yeah, yeah, yeah. And I I'm not a yoga person, so I don't know the actual pose name, but it's when you archer back, basically. So I and and that was all good. I'm I've been really intrigued with the jumping piece of this lately because I'm like almost everybody can do that.

Jocelyn Wittstein, MD:

Well, people actually kind of forget how to jump and skip. And like there are things that when you were a kid were really easy and natural. And when you go to do them sometimes as an adult, you've like almost lost like the neuroconnectivity to move in that way or something. And uh Well, you do. I mean, I really think you do. I've had people message me like the first like few days of like doing like the little drop jump off a step and a rebound jump. Like, I they're literally you say, like, I didn't know how to rebound, like I just like hit the ground and I didn't know how to do the second jump, and then they figure it out. And so, yep, it's not as natural as you think after a while, but I think it is just like biometrics can be a good thing, agility work to kind of keep your you know, brain connected to your muscles and move in that way.

Michele Folan:

Absolutely. I mean, the agility piece, the agility piece is certainly important, right? We we we've got to make sure we've we maintain our balance. That's part of all of this, and not wanting to fall, break a wrist or a hip. But there's one thing that I won't do, and that's box jumping, where I jump from the floor up onto something. Knowing me, I would fall and break a tooth. So I'm I that that to me.

Jocelyn Wittstein, MD:

I don't actually, yeah, that's not my favorite thing to recommend to people because there's a little potential risk.

unknown:

Yeah.

Jocelyn Wittstein, MD:

You can do like I call them like frog jumps, whatever. You can jump and just jump as high as you can and bring your knees up to your chest. But for the bone density part of it, it's actually not even the jumping up that matters, it's like the dropping down. You don't have to drop down from a huge height, like it can be um, like Tracy Clistold's work showed, you could just drop off of eight inches, or you could actually do just like a really big jump and land and a rebound. That helps as well. And and then for people who have, you know, they're like, oh, my knees are bad, my hips are bad, I can't do that. Like you can also do the heel drops where you go up on your tiptoes and drop down. You know, that can be a substitute, doesn't have all of that, like, you know, fast twitch muscle activation and playometric part to it, but you still get some impact on your bones.

Michele Folan:

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Jocelyn Wittstein, MD:

And so again, I just think people need to find things that work for them that they can do and not feel like some of these exercises are exclusive to people who can to only to the people who can like lift really heavy and only to the people that can do these crazy, crazy play metrics. Like it's great if you can do those things, and I like doing some of those things, but it it's I don't want people to like give up or feel intimidated by or like it's unapproachable to them because doing some of these modifications is is still actually helpful.

Michele Folan:

In one of your Instagram posts, you have a weighted handle jump rope without the rope.

Jocelyn Wittstein, MD:

Oh, yeah, it's fun. Yeah.

Michele Folan:

And I at first I feel like, oh my god, well, that would be great for someone who maybe worry. You don't want to trip and fall. Yeah.

Jocelyn Wittstein, MD:

Yeah. It's actually and it feels exactly the little weights. So, first of all, you get some grip exercise out of it and a little shoulder work and a little cardio, but the feeling of the weights like dropping down, it it actually feels like for even though I know there's not a rope there, it feels like there's a rope, and you can sense like when you should jump over it. It's very interesting. It's especially if you're someone who's I mean, I've had a lot of people ask me, like, I want to jump rope because it's good for agility and you get some jumping in and cardio and grip strength, all those things, but I'm afraid or I can't. I've had so many women tell me I can't jump rope. Like, I just can't remember how to do it. And so I guess that's a real thing. I know. So I think the um, yeah, the like cordless jump rope is it it actually kind of helps people with that. You could transition that way, but and it's quiet, you know, if you don't have a space or you're not trying to, you know, it's it's it's actually there's a lot of good advantages to it. How about rebounders?

Michele Folan:

Will you get much of an effect from jumping on a little mini trampoline?

Jocelyn Wittstein, MD:

This I get a lot of questions about this because a lot of people like to do it because it's easier on their knees. Um and it's fun and it's cardio. And there are limited numbers of studies on this. And one of them that I've talked about before and actually like did a little demonstration on is basically uh showed that if you compared people using the rebounder versus not, like over the course of the intervention, you know, at the end of the intervention, like there wasn't any difference between the two. But the people using the rebounders did see a little bit of an increase in their hip bone density. So kind of like as a comparison, there wasn't much change, but there seemed to be a little bit of benefit. And so I my take on that is I think that they're good for cardiovascular exercise. I think they're good for strength and agility and balance, like other parameters that might make you less likely to fall. And if anything, they may help your bone density a little bit, probably not as much as jumping on the ground. But again, this is a question of if you have knee arthritis and you can't jump on the ground, is it better to not do anything or to jump on the rebounder? It's probably better to, you know, jump on the rebounder, or maybe you can add the heel drops. And so I think, you know, there are like the most effective things and there are modifications that are like less effective, but that you can actually do without hurting yourself. And for a lot of people, that's where we need to land or be so that they don't get sidelined. Because if you hurt yourself, then you can't do any exercise for a period of time, and that's almost you know worse.

Michele Folan:

Yeah. All right. So then the next one, and then you know this one's coming. Weighted vests. Weighted vests, yeah. I knew it. Yeah.

Jocelyn Wittstein, MD:

Yeah. So yeah, I have weighted vests. I love adding them to my exercise. I also have a rucksack, which I I kind of like a little better because it's kind of a little bit more core work, but the I I really truly believe like in and of themselves, they're not a solution. But like anything, it's additive. Um, there's, you know, there's a small study that showed that um in a small subgroup of patients that had like a longer-term follow-up, that there was some improvement in bone density with using weighted best. But not, it was even that study wasn't in isolation. There were other aspects to the exercise program, like some impact and some strength training. And so it's probably not like an isolated thing. Now, even just walking is something that can reduce your risk of hip fractures. It doesn't necessarily change the arc of you know your bone density, but like something that you know, you have it's you're being mobile, you're um you're it requires balance, requires cardiovascular exercise. Like walking is regular walking is actually something that reduces your risk of falling and breaking a hip, even though it doesn't necessarily like increase your bone density. And, you know, along the lines of just walking, weight-bearing exercise in general, with or without a weighted vest, the the opposite of not doing those things is disuse. And the most extreme version of disuse is anti-gravity, like being an astronaut who that you know they lose their bone density very, very rapidly because they're just not even weight-bearing. So if you or if you're on crutches, I love this example. Like one of my friends, Tammy Scarpella, who's chief of worth of Pedics in sports medicine at Wisconsin, has done studies looking at like if you tore your ACL and you were on crutches for like even a short period of time and you had some modification of your weight bearing, like it in some parts of your bone, it takes like two years for it to get back to normal. So disuse is always like worse for your bone density than use. So if you're like, I can walk and I wear a weighted vest and I get extra cardiovascular exercise out of it, I jump on a rebounder because it makes my knees feel good and I can do it, and you're getting like balance and agility, increased strength, you know, less likelihood of falling. These are all good things. Yeah. I I just I don't want anyone to think like they have to walk with a weighted vest to prevent hip fracture. It's it's it is a really nice cardiovascular addition to your exercise.

Michele Folan:

Yeah, for sure. Yeah, that was a long answer. No, no, it's no, it's okay. I like to let people talk. So starting at what 5% of your body weight, maybe when you start 5%. Five or 10%.

Jocelyn Wittstein, MD:

I mean, I think if you're someone has any like back issues or like, you know, maybe if you've got like osteoporosis real um or spine, five percent might be better than 10%. But I feel like for me, if it's less than 10%, I don't feel like much difference in my cardiovascular output.

Michele Folan:

And then if you did have any kind of like spinal like stenosis or any disc issues, would would you recommend not using a weighted vest?

Jocelyn Wittstein, MD:

So yeah, interestingly, I was just listening to a spine surgeon talk about this. They uh and and not expressing much concern about it. I think they're not too heavy. I think if you're like kind of within the like five to ten percent of your body weight, I don't think it's actually that concerning.

Michele Folan:

Okay.

Jocelyn Wittstein, MD:

Um, of course, every individual is different. I think if you're gonna do like really heavy rucking and you have like an extruded disc, that's a different story than like adding five or ten percent of your body weight.

Michele Folan:

Okay, I just want to make sure, because I I I get these questions, so I'm like we're gonna ask the expert.

Jocelyn Wittstein, MD:

Yeah. And of course, the problem with these questions is that every individual has a unique situation. Like, do you have spinalesthesis? Do you have, you know, is it just bad discs? Do you have to facet arthritis? Is it right? Did you have a previous compression fractur? I mean, it's just uh it's it's really hard to give a broad answer always on some of these things.

Michele Folan:

Yeah, I know, I know. Okay. I would love to talk about grip strength and toe grip and how they can be predictors of falls and longevity. Can you address that a little bit?

Jocelyn Wittstein, MD:

Yeah. First of all, I love gripping exercises. I love hanging, I love carrying things, pull like I love gripping exercises. The question always is like, is it that strengthening your grip like improves longevity and makes you less likely to be frail and like less likely to have dementia? Or is it just a marker of your activity and you know how vigorous you are and other things you're doing? That's like a surrogate, you know, for something else. Um, like I don't know that you know, we know that like grip strength is sort of a marker of longevity, but if I do grip strengthening and get my grip stronger, am I gonna live longer? I don't know.

Michele Folan:

Right. That's probably maybe not the case. Chicken or the egg kind of a thing.

Jocelyn Wittstein, MD:

Chicken or the egg, although I do think it can help you be more like functional and independent um sometimes. And then in terms of like toe grip strength, that actually makes more sense to me because your your toe grip very much assists with your balance. And I always like to give being a former gymnast, you know, on TV when they show the gymnast on TV, they zone in on their foot on the beam and they're like gripping with their toes to not like you use your toe grip to maintain your keep yourself upright or to adjust. You use your foot intrinsic muscles to balance. If you're standing on one foot, like you'll feel your foot working if you're you know in a tree pose in yoga. You'll see your small, you'll you'll dig in with your toes. So foot strength definitely has an impact on our on our balance and can be related to to fall prevention. So I I think you know that has a clearer effect. And doing single leg balance work does engage those those muscles. There are little purposeful exercises you could do with your feet. I shared a study of one where they just did like towel scrunches and toe splaying, for instance, but and and you can improve your your strength in your feet, actually. So yeah, oh, I would think so. Right, yeah.

Michele Folan:

Heck yeah. Yeah, and and I did have um a gentleman on the podcast, and we talked a lot about agility and balance. And I just don't think our toes are something that we we think about when we're we're talking about balance. Okay, question. Someone asked me this the other day, and I said, Well, I will ask Dr. Wittstein this. Uh huh. Do we break a hip due to the fall or do we fall due to a broken hip?

Jocelyn Wittstein, MD:

Uh in general, the break happens when you fall. So you fall that causes the break. There are conditions that are like that. Like people will be like, I fell down the stairs and tore my quadriceps tendon. It was like, no, your quadriceps tendon tore, therefore you fell down the stairs. That's different. But yeah, you the hip breaks with the impact. Yeah. The fall. The fall causes the break. Yeah. Okay.

Michele Folan:

All right. I thought that was an interesting question. Yeah. It is a good question. Yeah. I I I like I like to ask these things. All right. Yeah. You have this tremendous book. And in there, you talk a lot about nutrition. And we talked a little bit about anti-inflammatory foods and that sort of thing, and how you we want to reduce inflammation. What are some of your go-to foods for not only anti-inflammatory, but also bone supporting?

Jocelyn Wittstein, MD:

Um, yeah, so so interestingly, there is a bit of a connection between inflammation and bone loss. Um, like some of the cytokines, which are inflammatory, like messengers basically, um, that contribute to like arthritis and joints and rheumatoid arthritis, also wear and tear arthritis, are are also involved in that pathway that leads to breakdown of bone as well. Interestingly, so inflammation, reducing inflammation may help both our bone and joint health. But food can also then be, you know, a source of all the micronutrients we need for bone health, which are, you know, not just calcium. So, yeah, like I think there are a lot of foods that check multiple boxes. Um, and I, you know, I like to think of it that way, like like salmon has vitamin D and some calcium, but omega-3s, which are anti-inflammatory. Boc Choy has calcium and fiber, which is anti-inflammatory, and um, you know, vitamin K, which you also need, you know, for your for your bone health. Tempe has vitamin K and protein and some calcium and fiber. And so that, you know, I I think there are, I I tried to sort of educate people on like what are some components of an anti-inflammatory diet, but what you also need for your for your bone health. And then we um my co-author is actually one of my former gymnastics teammates who's a registered dietitian who trained at Brown in Columbia and Sydney Nitskorski. She's a registered dietitian, also a personal trainer. So we kind of pooled our expertise and interest um to sort of bring all this together for people. So trying to kind of blend together aspects of an anti-inflammatory diet as well as helping your diet meet your bone health needs, and then um recipes that kind of bring those things together, exercises that are accessible to people, because sometimes people are just starting, you know, from scratch, but we want you to be able to progress them. A lot of frequently asked questions in there, which is um I I the frequently asked questions section is like everything my patients ask me, and everything Sydney's clients ask her, like boiled down into QA.

Michele Folan:

Oh, that's good. That's really good.

Jocelyn Wittstein, MD:

It's actually my favorite section.

Michele Folan:

Yeah. And so I agree with you. I think diet and getting those things through real food is the ultimate goal. But we don't. Some people don't, yeah. Yeah. So being realistic, I I want to talk specifically, first of all, about omega-3s. So if if we're not eating salmon every day, how like or like a few days a week, some source, yeah. What about supplements?

Jocelyn Wittstein, MD:

Are you okay with uh your Oh, I think fish oil supplements, the omega 3, I think those are great. And there are studies showing actually, like so many studies on the efficacy of anti-inflammatory supplements, are done on patients with rheumatoid arthritis because they have such elevated inflammatory markers. Not that I would ever suggest that if someone has like, you know, truly has rheumatoid arthritis, I'm not saying treat yourself with fish oil. Right. Um, because I just want to make a point, and I don't ever want to be misinterpreted this way, that osteoarthritis, where enteroarthritis and rheumatoid arthritis are very different, even though they have some common inflammatory pathways, like some of the same inflammatory cytokines that lead to cartilage breakdown and osteoarthritis exist in rheumatoid arthritis. Just but rheumatoid arthritis is a truly a systemic autoimmune condition where your body's cartilage is your joint cartilage is just getting destroyed by this autoimmune uh response in the in the joint.

Michele Folan:

Okay.

Jocelyn Wittstein, MD:

And there are medications that are disease modifying and can actually halt the progression of that. We don't have that with osteoarthritis. So just putting it out there, like if you have rheumatoid arthritis, uh, you know, we this is not something I would recommend just treating with an anti-inflammatory diet, but certainly it can help you. So, you know, omega-3 supplements, fish oil supplements, there are studies that show that these benefit patients with rheumatoid arthritis, like reduce knee inflammation, help with joint pain. Uh, and I kind of carry that advice over to osteoarthritis as well. So I I think the fish oil supplement is great. The the main thing I like try to get people to really try to get through their diet is calcium rather than supplement. But like everything, you have to thread the needle. If you're like, if you're someone who can't have any dairy and you struggle to get it in other ways, although there are ways, which we kind of go through in the book, but then using a supplement is okay. It's better to do that than be deficient. And uh, but the the main, you know, micronutrient that I really would like that we that we'd like people to get through food primarily is calcium, is calcium. There's a little evidence that calcium supplementations over time might be related to um, you know, heart disease. And then, of course, one of the other benefits of getting your calcium through food is that many of the sources have like so many of the other things that you need, especially if you're varying your sources, like if it's not just dairy, if it's also like cruciferous vegetables and certain, you know, other food components. I made a post on this yesterday. Like I I wish I could eat sardines, I just can't make all that. I can't think of that example. There, you know, the sardines have like with the little bones of you know, calcium and vitamin D and protein, and like I I wanna I wanna want to eat them. I just like I just don't sister.

Michele Folan:

I'm not eating them either. So um I love fish, but I'm not eating sardines. Yeah, and you know, supplements alone that can be a real mindfield because there's so much out there beyond vitamin D3, K2, calcium. Are there any others like magnesium for sleep or collagen? Um, anything there you recommend?

Jocelyn Wittstein, MD:

Yeah, I um I'll tell you what I take, and I think it's reasonably evidence-based. So I take magnesium glycinate, 400 milligrams at night. I do think that helps with sleep. Also, you know, one of the things that a lot of women will get in perimenopause is palpitations, and you'll go to cardiologists and have this whole workup, and there's nothing is found, you know. There, and um, and actually, so magnesium glycinate can help with that as well. Um uh, and then vitamin D, I I do take, you know, beyond the kind of daily value just because of some of the data on dementia prevention. So if you don't have a deficiency, you should not exceed 4,000 units a day, but I I take a 2,000 unit a day supplement. I do like collagen, um hydrolyzed collagen. I think there actually is evidence behind that for joint pain. I think that there's also evidence behind it as long as it includes type 1 collagen in the hydrolyzed collagen that that can um help you with your bone health. I don't take this regularly, but I also do think there's quite good evidence for turmeric supplements, you know, a thousand to 1500 milligrams a day, something in that range, in terms of acting as maybe a substitute for some people for NSAIDs. Um, there are a lot of studies that show that people who have some like nearthritis who would normally be dependent on motrin, ibuprofen, things like that, that they're able to, you know, get off of the NSAIDs by utilizing turmeric supplements. Uh, we talked about um the fish oil. If you're not someone, if you don't, you know, eat much fish. That's the I think that's reasonable to do for sure.

Michele Folan:

Okay. Those are all good. And just so you know, I take all this.

Jocelyn Wittstein, MD:

Yeah, I think that's that's a good, you know, nothing too crazy. You could you could take a lot of stuff. I mean, you could take beet extract, resveratrol, I mean quircetin, uh, so many things that really do have some evidence behind it. Like quircetin has some evidence behind it. That's something that's in apples and onions and coffee, like in our diet. But there's some evidence again, based on rheumatoid patients, that that's helpful, you know, with reducing inflammation and joint pain. But I just I don't want people to go take like too many supplements and yeah.

Michele Folan:

And and that's something I've had to kind of be mindful of because we used to make fun of my mom because she took so many supplements because she was always reading, you know, reading up on her, you know, information on supplements. And then I became my mother. I was then I was taking all those supplements. So I have I have whittled it down, but basically whittled it down to what you had suggested. I think at one point I was taking boron.

Jocelyn Wittstein, MD:

Yeah, so so uh boron, I mean it's in you know small amounts in our diet. You don't need very much of it. But the interest in boron is that it it extends the half-life of vitamin D and estrogen. I I don't routinely tell people to to supplement that, but um it is involved in in bone metabolism, yeah.

Michele Folan:

All right. Well, it was something I read and I started taking it, and then I was like, okay, I I gotta I gotta do some elimination here because I was just yeah just taking too much. Okay. So what 2025 myths about arthritis and osteoporosis or being too fragile would you like to debunk?

Jocelyn Wittstein, MD:

So just uh I think there's a little bit of like I don't want to say like fear-mongering, but there's just like a lot of hype right now, but like I just don't ever want people to hear hear messages and misinterpret them. So you will hear like 65 is too late, you know, for your bone density. And I think people hear that and they're like, oh no, I've missed the boat, it's too late for me. And then they're kind of like feeling helpless. And I I don't want that to be misinterpreted for people. I think people are maybe hearing messages like 65 is too late. That's kind of speaking to like maybe our current medical practices in the United States or standards or whatever. I want to be really clear that like a lot of the interventions that are studied are on women in their 60s, including strength training, some impact exercises, agility programs, showing benefits, showing improvement in bone density, showing reduction of um fracture risk. And, you know, so I think that concept that it's too late, I don't want to say it's never too late, but it's it's actually probably never too late to, you know, to start doing things that will positively impact your um your bone health. Other misconceptions I think are rapidly being debunked, that hormone therapy is only for hot flashes and night sweats, and that menopause is a transient thing that people go through. Whereas a lot of the long-term consequences are actually musculoskeletal, like, you know, more rapid development of arthritis, osteoporosis, difficulty maintaining muscle mass, things like that. And so, like, you know, just sort of wanting women to know that if you're able to take it, like estradiol therapy is prophylactic against, it's even an FDI-proved indication for hormone therapy. You're not even gonna have to like justify it. It's just it's prophylactic, you know, against osteoporosis. Myths about arthritis. Um, I think just a lot of people don't understand that once you have arthritis, it doesn't go away. You can't reverse arthritis, but it doesn't mean that you, you know, can't be active through it. You just have to find ways to work around it. I tell my patients all the time, it's like having a sports injury when you're a kid and you have to work around it, except for it just it's never going away. And um, we don't treat pictures, we don't treat x-rays, we treat people. So, like I have patients that have pretty significant arthritis that are able to find ways to strength train, they're ways they're able to find alternative forms of cardiovascular exercise. Like people maybe, you know, running doesn't cause arthritis, but once you have it, it can aggravate it. So sometimes I have to redirect my patients. I don't want them to just be like, I can't do this, I can't exercise. Well, you can try rowing, you know, like a lot of people tolerate using an erg machine or a rower, and that's a good cardiovascular exercise and it also stimulates bone density. So I think that people think either arthritis is something that they can, they don't understand that it doesn't go away, but then when they realize that it doesn't go away, they feel like they have to just stop being active. And it is there are a lot of activities you can do with arthritis that will hopefully not aggravate it and allow you to stay active.

Michele Folan:

Yeah, and I get that too, you know, because you it's that initial, like, mmm, you know, it's not well, it was me, but it you're you're kind of like feel like you're at a dead end, but you just have to just shift gears.

Jocelyn Wittstein, MD:

It's your new normal. It's not a dead end.

unknown:

Yeah.

Jocelyn Wittstein, MD:

Uh and and again, we've just talked about there are some supplements that help. You know, I think the key is to try to stay active and you know, maybe not expect yourself to be exactly the person you were forever, but like, you know, find ways to be active with your current, you know, parts the way they are in terms of your joint.

Michele Folan:

But you also, and you also talk about dementia prevention and the importance of exercise and getting aerobic activity. And so there's there's the other side of that too.

Jocelyn Wittstein, MD:

Yeah. Well, my mom died of dementia last year. And I'm sorry. Yeah, I mean, I have so many friends who've lost parents to dementia, and um so I constantly think about things I can do to not get dementia because I don't want to have dementia. And interestingly, there are a ton of things that benefit your bone and joint health that also are, you know, protective against dementia, like vitamin D supplementation can reduce joint pain, it's beneficial to your bone health, and has been associated with reduced risk of dementia. You know, regular exercise, um, you know, studies showing like something on the order of 150 minutes of moderate intensity exercise. And I don't think it all has to be cardiovascular, there's some studies that show benefits to cardiovascular exercise. There's certainly, I think there's also evidence there's benefit to strength training and and and there are mechanisms that that may work through, like if you're doing like exercises that stimulate your bones, whether it's through what we call joint reaction forces from the loading across the skeleton with like lifting weights versus ground reaction forces from jumping or impact. When we stimulate our bones, we stimulate the osteoblast. Osteoblasts make something called osteocalcin. Osteocalcin actually, you know, supports our neurotransmitters and our neural connections in our brain. So, you know, probably when you're doing agility and you're doing jumping, you're using your muscles, that hormone is also sending messages to your brain and reinforcing these like neural pathways, probably. So there's probably an actual hormonal connection. Um uh and yeah, so I think exercise is like the most consistent thing across the literature that has always been shown to reduce risk of dementia. So it's like kind of non-negotiable to me to, you know, I have this weird thing in my head that I have to, I've always felt like this. I no matter what, I have to get at least 30 minutes of exercise in in a day. It's just my non-negotiable somehow. If it's like 10 minutes three times, or 20 minutes and 10. I mean, I would like to do more than 30, but that I I cannot, I almost feel nervous if a day goes by that I didn't do 30 minutes of exercise.

Michele Folan:

Well, and I was gonna ask you like what one of your core self-care non-negotiables was. So besides your exercise. Okay, so okay, that's it.

Jocelyn Wittstein, MD:

It's such a stress reliever. It's just, you know, it gives you endorphins. Exercise can reduce pain. Did you know like actual exercise is like one of the treatments for fibromyalgia? It's like regular exercise. You know, it's there is like a real truly like mind-body connection with endorphins and things like that. So uh yeah, but yeah, I I um I feel terrible if I don't get to exercise regularly. And I me too. Yeah.

Michele Folan:

You know, now, now that I I realize that. So it, you know, because I do work out almost every day, at least take, you know, a three-mile walk or something. Um, if I don't do it, I feel like crap.

Jocelyn Wittstein, MD:

Yeah. And I used to, you know, when I was younger, interestingly, I used to think like my exercise ha well, I used to be like I have to do 30 minutes of something cardiovascular, and then I can also do more, like strength training. And but it was like, I now it's kind of funny. I will also like some days now, I as a 47-year-old, I will not do cardio. I'll do a little warm-up, I'll do a more extensive strength training routine on those days or some plometrics or jumping or grip exercises or whatever. And um, I mean, that is a workout. It's just kind of funny how you um shift over time. That it in it used to be like I had to do 30 minutes of cardio and then I would do other stuff if I had more time. And I I am, I think, more particular now about making sure I earmark certainly two days a week where there's a lot more um focus on the strength training. And then if I have time, I'll add on some more cardio, but at least get some, you know, maybe agility and balance and grip stuff in. But yes, I just I I cannot stand the way I feel if I don't get to exercise. Yeah, yeah.

Michele Folan:

It's I I and I want people to have that experience of oh my gosh, if I don't work out, I don't feel great. And that's that's my goal with my clients. Like that's a good goal. Yeah, it is a great goal. Dr. Wittstein, where can people find the complete bone and joint health plan and find your work?

Jocelyn Wittstein, MD:

Um, the book, which is by me and Sydney Niskorski, uh, is at Barnes and Nobles, also Amazon. And then, as you know, you can uh follow me on my Instagram account, which is just my it's just Dawson underscore Witstein underscore MD. And uh I'm believe it or not, I'm actually pretty new to social media. My 19-year-old daughter helped me make that account in January. But I I do I have I I really like health literacy, much like I really like to educate my patients. So I I uh I you know I just try to provide information that's um educational to people about their own, you know, bones and joints and things they can use to help themselves. And then um, yeah, then I I I practice full-time at at um I I live in Raleigh and I practice full-time uh Duke University School of Medicine.

Michele Folan:

Yeah. And I really recommend you all follow Dr. Jocelyn Wittstein on Instagram because she has so much information in there. And it doesn't mean, I mean, even if you don't have osteoporosis or joint pain, give her a follow because think about prevention. And I think you're gonna have a plethora of fabulous tidbits and how-tos in there as well. So, Dr. Witstein, thank you so much for being on Asking for a Friend.

Jocelyn Wittstein, MD:

Yeah, thank you for having me.

Michele Folan:

Thank you for listening. Please rate and review the podcast where you listen. And if you'd like to join the Asking for a Friend community, click on the link in the show notes to sign up for my weekly newsletter where I share midlife wellness and fitness tips, insights, my favorite finds, and recipes.