Strong Bones, Strong Body, Stronger Second Half with Dr Jocelyn Wittstein - Part 2

23:30Dr. Mary Claire Haver:Long before anyone says the word menopause. Perimenopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. And too often, women are told nothing is wrong. I wrote the new perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The new perimenopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepawselife.com. Burnout Paradise is hailed as the wildest night out in New York City by Time Out New York.

24:15Dr. Mary Claire Haver:Now off-Broadway at the Astor Place Theater, it's a live show you'll never forget as the people on stage make a desperate attempt to complete a series of escalating tasks, all while running on treadmills. And if they don't complete their to-do list in one hour's time, you can get your money back. Get tickets today at burnoutparadise.com.

24:40Dr. Mary Claire Haver:In our clinic, we talk about lifestyle as well as HRT and, of course, some of the other drugs, the bisphosphonates, you know, if they're already diagnosed. But, you know, talk to me about the difference between exercise versus medications and what are the outcomes. Yeah. So certainly I don't want to imply that you're never going to need a medication. Like if you have osteoporosis and, you know, your FRAC score says you have a more than 3 % chance of having a hip fracture in the next 10 years, like you should probably be on some osteoporosis medication. What do all these things do for you? Lifestyle versus medication or hormone therapy.

25:15I do like to kind of just level things a little bit and think about, you know, what are your returns on investment? So if we look at, you know, the timeline for your effort and what you might get out of it, if you're doing, like let's say you initiate some impact exercise and, you know, over a six-month period, you might increase your hip bone density by 1%. That's a six-month investment. I mean, I think you should continue it, but you've got, so imagine that, 6%, 1%. If you were doing the Lift More Protocol, for instance, and over an eight-month period, we would expect you to see a 3 % increase in your lumbar spine.

25:53So think about that. That's eight months, 3%. If we think about estradiol therapy over two or three years, giving you a 3 % increase in your hip, 5 % in your lumbar spine region, generally something like that. So that's three years of using a medication to get 5 % increase-ish in your lumbar spine. You know, think about the impact of exercise. If you're doing an eight-month program and you're getting a 3 % increase, that's really impactful. So I just want to emphasize the timeline. With the exercise, you're also getting so many other benefits. So many other benefits. For your insulin resistance, for your muscle mass.

26:34Yes. And then medications like Zalendronate, like the Reclast, if you know the brand that, you know, once per year infusions of bisphosphonate, for example, those are going to increase your hip bone density about 5 percent, your vertebral, your spine bone density about 7 percent. You're going to get a 70 percent reduction in fracture risk. So I have the spine, 40 percent of the hip. You know, we don't have, like I said, with exercise, we don't have all those numbers. So that would be like three years of getting a once-a-year infusion. So those numbers are larger. But again, like if you just look at the scale of them, like the lifestyle things do quite a lot.

27:11And again, scale-wise, it's hard to say, okay, for hormone therapy, if you look at a meta-analysis, we know that this corresponding increase in bone density reduces our hip fracture risk by about 30 % or vertebral body fracture risk by about 40%. We don't have those exact numbers for like exercise. And you can't really take the numbers from medication and be like, this percentage equals this much fracture reduction. It doesn't work exactly like that. But my point is, if you just look at the scale of these things, 1 % gain is a really big deal. 3 % gain is a really big deal. And if we think about that, I think it just helps people value these exercise interventions more.

27:48Okay. If that makes sense.

27:49Dr. Mary Claire Haver:So my grandmother had multiple fractures, not hip, but she had forearm, had ribs, multiple falls, you know, spent the last three to five years with dementia. And then the last couple of years completely bed bound. And, you know, my mother is 88 and has Alzheimer's. So I'm sure her mother had it, too. Yeah. And on New Year's Day, had a UTI, hallucinated, thought she heard my dad calling her, got out of bed, fell, broke her hip. Delirium. has no cardiovascular issues whatsoever. So it was perfectly fine to survive the surgery and had her hip, you know, rotted and whatever the hell they did to it.

28:27Dr. Mary Claire Haver:And it still just scoots around in a wheelchair completely, you know, with her dementia. So talk to me about how I can, what would you recommend for me for avoiding this fate? I can handle the dementia, but talk to me about my bones. Yeah, the dementia, of course, you know, the benefits of exercise, which are huge. Like that is the most protective thing women can do to prevent dementia is exercise for our brains. But yeah, so for. Build me up. Build me a protocol. What I recommend and what I do is a couple of days a week of heavier strength training, making sure you're doing like large muscle groups.

29:07Again, similar to those lift more protocols. The balance work. I do some of that every day. Flexibility work. I like to. I don't have time to do like a yoga class every day, but I do incorporate that in my routines, again, because you do need joint mobility. And then I always try to build in agility. Sometimes I'll use agility work within my cardiovascular exercise. So I use it as part of the cardiovascular exercise because if we don't habit stack, we just like run out of time in the day. Yeah. And then, you know, dietary wise, you're a big fan of this. I know. And it's very important for actually reducing inflammation and helping our bones and joints is a high fiber diet, getting getting adequate fiber.

29:49And for me, that's a lot of variety of fruits and vegetables and seeds, nuts and legumes.

29:54Dr. Mary Claire Haver:All those things, yeah. And those foods generate basically short-chain fatty acids, which then impact the inflammatory pathways that contribute to bone resorption and your cartilage, you know, breaking down, actually. And I don't want to get too basic science-y, but there's a lot of that happening. Yeah. And then, you know, I use creatine monohydrate five grams per day. There is not a study showing that creatine specifically grows bone. It doesn't directly. But there are studies that when combined with strength training, you know, you can increase your gain. And secondarily, that has benefits for, you know, bone health.

30:32Oh, back to the exercise part, jumping. Yeah. I'm doing box jumps now. I love jumping. Now, the thing about box jumps is the jumping up is a soft landing, and then people step down. You want the jumping down.

30:43Dr. Mary Claire Haver:Yeah, and I have the little—I got the weightless jump ropes. Oh, yeah, the one I showed you. But they keep hitting me. I think my wrist angle isn't right, so I just need to go back to a regular jump rope. Yeah, you can do a regular jump rope. So, and again, the jumping, it doesn't have to be off a gigantic box. It could be an eight-inch step. And there's a really smart lady named Tracy Glisold who's done tons of basic science on how much impact is created from jumping off an eight-inch step with a rebound or heel drops, which also create that impact. Jumping, for sure, a few days a week. Okay.

31:14Dr. Mary Claire Haver:What about, I'm on HRT. Would you recommend that? Yes. And I think, for sure, menopausal hormone therapy that includes estrogel is protective of bone density for those who are candidates for it, definitely. There is some reasonable evidence, I think, behind, and I think you've highlighted it for, there's something called Fortabone, which is a hydrolyzed type 1 collagen. They have randomized prospective studies showing improvements in bone. I'm super excited. I was like, give me some of that. Yeah, and so I don't think that hurts anyone. What about, lots of questions I get on calcium, phosphorus, vitamin K.

31:49Dr. Mary Claire Haver:What are your thoughts on that? Yeah, I mean, most people have a hard time eating enough calcium. But yes, you want to get 1 ,200 milligrams of calcium per day, 400 milligrams of magnesium a day, 100 micrograms of vitamin K per day. Vitamin D, you want to get at least 600 units per day. You should not exceed 4 ,000 units per day if you don't have a deficiency. For various reasons and data that I've read, I do take 2 ,000 units a day. I'm not exceeding that upper limit of what's safe, But there are studies correlative or not that show, you know, vitamin D supplementation reduces risk of or is associated with less risk of dementia and depression.

32:30Also, at that level, at least 2 ,000 units per day is correlated with benefits for like reducing joint pain. So there are some side benefits of it. So while you do need about 600 units per international units per day, I do take the 2 ,000. So those are important aspects as well, the dietary aspects.

32:48Dr. Mary Claire Haver:I have a hard time absorbing, I guess. Yeah. So I take four. Oh, yeah. A lot of people do. And then low and diets that are like less inflammatory. So there's something called the Dietary Inflammatory Index, which unfortunately they're not like a— That's what I built the Galveston diet based on was that because I went back for nutrition. Yeah. And so that Dietary Index score, you know, we used to have a little quiz you could take on our website. Oh, I've taken the quiz, yeah. That would grade. Yeah, it's based on that. Yeah. So it's the poor man's version of that. And there are studies correlating, you know, a less inflammatory diet with less risk of fracture.

33:22So that is another reasonable thing to do. So back to my mom for a little bit.

33:27Dr. Mary Claire Haver:You've talked in the past about this connection between UTIs, like general urinary syndrome and menopause and hip fracture. Yes. I think it's worth for our listeners. I think this is underappreciated. I know this is what happened to my mom. You know, she was a setup. Oh, I've had so many people with this story or tell me this is what happened to their mom. So big picture, and I'm not saying this to scare people or anything, but when you hear about hip fractures, which, of course, 75 percent of them occur in women. And then, you know, statistically speaking, just if you have a hip fracture, depending on the study or population you're looking at, the one year mortality rate is some studies 15 percent, some studies 30 or two years out.

34:07I like to quote the 30. A third of women. Yeah. I know I try to always give nuance in numbers because some of the numbers sound more scary than others. So it's not always 30, but it can be 15 to 30 percent in a year. So, you know, we don't want people to have this happen. But like what is causing death? Actually, a lot of it is it can be urosepsis, a postoperative urinary tract infection. So you have this hip fracture. Sometimes you've needed a fully catheter. There's urinary retention from pain. People can't get out of bed. And I think aside from the fact that urinary tract infections are the number one complication after hip fracture surgery, and it can lead to readmissions, urosepsis, septic shock, things like that.

34:45I think many of them are actually present, you know, prior to the hip fracture. And so people who have general urecynteral menopause, they may have increased urinary frequency, they may have, you know, recurrent UTIs. And what happens if you have that and you're an older woman, you're getting up in the middle of the night a little confused, a little delirious, more than you normally would, and they trip and fall. I mean, almost every time you get called by the emergency room for hip fracture, It's like in the middle of the night. I should actually look and see if there's still in this. But I think most infections happen at night.

35:16And it's so often the story.

35:18Dr. Mary Claire Haver:I'm treated to SM. Yeah, getting up, tripping, falling. And then so there are patients that are diagnosed with a urinary tract infection preoperatively. You're not going to like, you can't delay surgery because outcomes are worse. Survival is worse if you delay more than a day or two. And so you got these people who either have the infection pre-op or develop it post-op. and it delays, you know, they're in the hospital for longer. Women who have a urinary tract infection diagnosed at the time of hip fracture have like four times the rate of septic shock postoperatively as compared to those who weren't diagnosed with a pre-op.

35:51I actually think many of them are underdiagnosed pre-op. So I think it contributes to the falling, contributes to the urosepsis after, probably, you know, contributes to death. And we know that vaginal estrogen prevents urinary tract infections. 50%. Yeah, prevents a lot of them. And so if we could reduce those, I swear we would reduce hip fractures and we would definitely reduce urosepsis. It's not like you can just give someone vaginal estrogen right after hip fracture surgery and expect them to have less UTIs because it takes six weeks or so to be effective. To grow back the mucosa. To change the microbiome.

36:25So we're not going to like magically make someone not get UTIs by putting them on that right after surgery. But I do think we should actually educate hip fracture patients. Hey, you have recurrent UTIs. I don't want you to break your other hip. You might benefit from being on vaginal estrogen. And that's something I'm actually working on with our trauma team right now. We're looking at how frequently our hip fracture population, we're looking at our last 500 hip fractures in women and how many of them were on vaginal estrogen. How many of them have the UTI pre-op and post-op? And if you look at reviews of hip fracture studies, you know, you'll see anywhere from like 10 to 40 percent of people having a UTI perioperatively.

37:01So it is it is a really large problem.

37:11Dr. Mary Claire Haver:Spring is here and the shopping list is long. Time to make a Lowe's run. Buy three bags, get three free of stay green one cubic foot garden soil. Plus, right now, members can earn four times the points on an eligible purchase. Start spring off strong with these deals and more. Our best lineup is here at Lowe's. Valid through 325. While supplies last. Soil offer excludes Alaskan and Hawaii. Loyalty program subject to terms and conditions. See lowes.com slash terms for details. Subject to change. Point boosters subject to exclusions and more terms apply. One-time only offer. REI Co-op knows when you're up at 4.30 a.m.

37:44on a Saturday for a long run and you're actually excited?

37:52Not everyone gets it, but we do. At REI, we're here for people who get outside. Gear up for your next run in-store or at REI.com. Eczema is unpredictable,

38:09Dr. Mary Claire Haver:but you can flare less with Epglis, a once-monthly treatment for moderate to severe eczema. After an initial four-month or longer dosing phase, about four in ten people taking EBCLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing. EBCLIS, LibriKizumab LBKZ, a 250 milligram per two milliliter injection, is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema. Also called atopic dermatitis that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies.

38:45EBCLIS can be used with or without topical corticosteroids. Don't use if you're allergic to EBCLIS. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EBCLIS. Before starting EBCLIS, tell your doctor if you have a parasitic infection.

39:00Dr. Mary Claire Haver:Ask your doctor about EBCLIS and visit EBCLIS.lily.com or call 1-800-LILY-RX or 1-800-545-5979. Since you're here this week while we're recording, this is the week that the box warning on vaginal estrogen has been struck and removed and just the normal warnings are there as there should be. You know, for those listening, vaginal estrogen is preventative. It can be prophylactic. It is safe and effective. Almost 99.9 % of women can use it and probably should for, you know, keeping the risk of UTI at bay and keeping their vaginal and vulvar health in tip-top shape. So they decrease their risk of delirium, of falling, and then a fracture, and then having a better post-op course if they do fracture.

39:47Dr. Mary Claire Haver:So I wanted to be clear about that. So women are going to want to know, what can I do for myself? How can they better advocate for themselves when their musculoskeletal pain isn't taken seriously? I know. I can't tell you how many times I see a patient who feels like they haven't been heard when their x-ray is normal or their MRI is normal or even if someone does recognize that they have frozen shoulder, they may hear, well, that just happens to women. You know, just recognizing, yes, it happens to women, but is there anything else we can do? So I think health literacy is so important. And I mentioned to you earlier when we were chatting, I actually had like never even been on Instagram before January and my 19 year old daughter, Chloe, who is Chloe on canvas on Instagram.

40:33Um, she's a cute little artist, but, um, she helped me make that page and I'm using it for health literacy because I think if people have awareness, they can be, you know, more of an advocate for them, for themselves. And I, like, I, I wrote this book with my coauthor, Sidney Niskorski, the complete don't understand their bodies. Like they don't understand arthritis and osteoporosis. Let me

40:59Dr. Mary Claire Haver:plug your book. It's excellent. You open it up. It's recipes. It's exercises. It is literally a how-to manual from the ground up on how to protect your bones and joints. So if you're like, okay, what do I do? 90 % of it is pictures of people doing exercises and recipes. And we tried to explain like, what is arthritis? What is osteoporosis? What are the things you can do to change your course because but again so it's not only for women but because arthritis is more of an issue for women and osteoporosis is like i do have a lot in there explaining that because i i just think if people don't understand like if women don't understand that yes i am going to be more prone to arthritis than a man at age 50 and i am going to be more prone to frozen shoulder um you know i think just having an understanding of that can help them advocate more for themselves or not let it go for so long because I think a frozen shoulder getting in there early is key and like just taking an index of your own symptoms like are are you having this increased joint pain or your frozen shoulder at the same time that you're having like vasomotor symptoms and general urinary symptoms and like talk to your women's health doctor about that I love my male orthopedic surgery partner so much and I have actually so many of them are now talking to women And I don't want to pick on my husband, Tal, but he's also an orthopedic surgeon.

42:15And we actually work with, we're like a rotation for our fellowship. So one fellow will come and work with both of us at the same time. And he supports medicine too. Yes. One day, one of the fellows told me, I think you need to help Dr. Lasseter. He's talking to women about the change. But I said, no, that's so great. He's asking women with shoulder pain about their symptoms and texting me. How do I refer to women's health? And some of my fellows are now doing this. And so I just think that because men don't go through menopause, like they're not going to experience this. They just they don't have the same lived experiences.

42:49They may have less awareness of this connection. But I think, you know, I'm trying to educate my trainees. I can't tell you how many of my, you know, Instagram is excellent. My male orthopedic residents are they come out of a room telling me someone's like menopausal history and whether or not they're on hormone therapy as part of the orthopedic history, which is really cool. So, but yeah, but for patients, I think if you're feeling dismissed or someone isn't listening to you, I mean, it's okay to get another opinion. Like, don't feel like you're, you know, stuck with one person. And I just, I think what happens is it's hard when an x-ray is normal, an MRI is pretty normal, but you're having increased joint pain.

43:27You know, we've talked about some of the things you can use, an anti-inflammatory diet, certain supplements, things like that. But I just think taking a look at the whole person and collaborating, stop siloing, collaborate with women's health. I'm not saying that magically going to hormone therapy is going to make your knee pain feel better. And that's what we're trying to study. But I think we need to kind of look at women as a whole person, not like a knee.

43:51Dr. Mary Claire Haver:And stop siloing women's health to the bikini area. Yeah. Yeah. Exactly. Well, I'm so happy you came with us today. You've educated our listeners so much. and I will go through on the show notes. They will have how to find you on social media, how to buy your book and how to find you. Get ready because you're about to get a lot more referrals for frozen shoulder at Duke. Get ready. Well, thank you for having me. And I like to say I am only an orthopedist. I am not an expert in all things women's health, but. You're changing the world. The most meaningful research relationships are my cross-collaborative ones.

44:30you know, with my women's health partners, with my biomechanics PhD, you know, with the PhD who does all of the biomarkers with me. I mean, we really have to be cross-collaborative to change, get rid of these disparities. Yeah.

44:45Dr. Mary Claire Haver:Excellent. Are you looking forward to menopause? I mean, I'm not fearing it. Funny story, my youngest, my now 18-year-old son was like, menopause sounds really terrible. And then my 20-year-old daughter said, I really don't want to go through menopause. And they're just talking. But I think I'm almost 48 and I feel like I'm getting into like a phase of life where I can have so much more, I don't know, like freedom of thought and independence and time. And I mean, I had my kids pretty early, so I do have more time now, but I don't dislike aging. You know, I change some of the ways, some of my, well, I don't exercise exactly in the same way as I used.

45:30So I don't do backflips on the floor only on a trampoline. But I, you know, I, I'm not fearful of it. I feel very, I feel empowered by the knowledge I have, but I have a strange amount of niche knowledge and I love to share it with people.

45:45Dr. Mary Claire Haver:And I think that you sharing that knowledge with, with your students, but also on social media is going to continue to just elevate this conversation and empower women in a way that We haven't been able to in medicine before. As a reminder to our audience, you can follow Dr. Whitstein on Instagram at jocelyn underscore Whitstein underscore MD. Her book, The Complete Bone and Joint Health Plan is available on Amazon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawselife.com.

46:25Dr. Mary Claire Haver:My upcoming book, The New Perimenopause, is available for pre-order on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also follow full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only.

47:03Dr. Mary Claire Haver:No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. At Blinds.com, it's not just about window treatments. It's about you, your style, your space, your way. Whether you DIY or want the pros to handle it all, you'll have the confidence of knowing it's done right. From free expert design help to our 100 % satisfaction guarantee, everything we do is made to fit your life and your windows. Because at Blinds.com, the only thing we treat better than windows is you. Visit Blinds.com now for up to 45 % off with minimum purchase, plus a professional measure at no cost.

47:42Dr. Mary Claire Haver:Rules and restrictions apply. Rinse knows that greatness takes time, but so does laundry. So Rinse will take your laundry and hand deliver it to your door, expertly cleaned. and you can take the time pursuing your passions. Time once spent sorting and waiting, folding and queuing, now spent challenging and innovating and pushing your way to greatness. So pick up the Irish flute or those calligraphy pens or that daunting Beef Wellington recipe card and leave the laundry to us. Rinse. It's time to be great.