Transcription
Runners who only run are often injured, usually due to emotional imbalance. I always perform this test to assess if their buttock muscles are strong enough to keep their pelvis straight and their knees from collapsing. It looks like I'm drunk! How are you doing this with your heels on?
Dr. Vonder Wright is a leading orthopedic surgeon and longevity expert, leveraging her expertise with elite athletes to revolutionize how we move, eat, and train to live longer, stronger, and better. I'm on a rampage to make bones sexy again because in the United States, at least 50% of women will develop osteoporosis, along with 2 million men. Osteoporosis is low bone density, and studies show people with low bone density experience higher rates of cognitive decline. It increases fracture risk; if you break your hip, 50% of the time you won't regain full function, and 30% of the time you'll die. Many factors contribute to bone fragility, including aging, insufficient bone building in youth, sedentary lifestyles, the myth of women needing to be tiny, and even breastfeeding (which causes a 20% bone density loss in the first six months for women). But it's not inevitable. I'll outline an "unbreakable" lifestyle focused on muscle, bone, and nutrition – but mindset is key.
I'm very excited… just to pause – is there a link between menopause and brain density? Yes, due to plummeting estrogen, critical for muscle, bone, tendon, ligament, and fat. Its absence can have dire effects.
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Dr. Vonder Wright, for those unaware, what do you do and for whom?
As a sports doctor, we've learned to work with high-performing athletes – those who consistently win and need to improve. Over 30 years, my focus has shifted from training periodization to a holistic approach. At the University of Pittsburgh, as medical director of the UPMC Lemieux Sports Complex (Pittsburgh Penguins), the approach was incredibly scientific – a full-time chef prepared every meal, even on planes. Split-second agility and peak brain function require attention to every detail. Over 30 years, my focus evolved from training science to nutrition and recovery. Dara Torres, for instance, trained very differently in her 20s versus her 40s after having a child – focusing more on recovery. I apply these lessons to athletes and high-performance professionals, even "mere mortals" like me. My work involves cognitive performance, ensuring peak brain function.
How much of your work crosses over into the cognitive realm?
I'm not a brain scientist, but I'm surrounded by experts. Personally and professionally, I deeply appreciate sleep's role. My earlier books focused on mobility; later, nutrition took precedence. Now, I prioritize sleep and recovery, as you can't perform optimally without a well-rested brain. Someone asked about morning workouts; my answer is to understand your brain's rhythm. My best deep work is between 5 a.m. and 2 p.m.; after 2 p.m., I can build a house but not write a book. I don't work out in the morning because I need that brain energy for deep work. I apply brain science practically, but I'm lucky to work with those who map brain activity using EEGs, showing which pathways are overstressed. You can train your brain like a muscle.
There's a company called Nestery that I have access to; they use EEG helmets to map brain activity in my Precision Longevity clients. Habits require little brain energy, while learning and stress consume much more. Nestery's training program helps re-allocate energy to neglected pathways, boosting efficiency. Brain scientists believe you can retrain your brain like a muscle, redirecting energy to neural pathways. We do this with athletes to maximize performance. What does "Precision Longevity" mean?
After understanding human DNA, medicine moved beyond a one-size-fits-all approach. Now, with genome sequencing, personalized health plans are possible. For example, if someone has a high load of senescent cells, their nutrition plan addresses that. We don't give everyone the same formula; we tailor it to individual needs and timing. I do the same with exercise. I don't prescribe 150 minutes of moderate exercise. I use lactate threshold testing to determine when mitochondria are most efficient (the "fat max") – we aim to work out at that level 80% of the time. This determines the ideal heart rate and nutritional gaps to fill.
Personalization also considers life stages. My needs in my 20s differ from my 30s, 40s, 50s, and 60s. Is this a useful way to think about it?
Absolutely. Every life stage differs. Take bones: we build bone until roughly age 28 (women) or 30 (men), reach a plateau, then density plummets in women due to hormonal changes. Men usually maintain density until their 70s, unless there are metabolic issues, autoimmune diseases, or steroid use. Bones are a prime example of how needs change over decades. Muscle is similar – easiest to gain until about 30. Gut function also changes with age, affecting nutrient absorption. Women in midlife may need methylated vitamins due to decreased gut efficiency. Each aging phase presents different needs.
Regarding bones: men maintain density longer than women. Why? Is it linked to menopause?
Men, due to testosterone and XY chromosomes, build more bone initially. The plummeting of estrogen, crucial for bone health, causes women to lose bone faster than men – about 20% by menopause. This can have dire consequences. It's all due to estrogen's role in bone density control.
Is bone density loss inevitable for women?
No. In 2004, we studied Masters athletes (40+) in the National Senior Games. We found that chronic exercise maintains bone density well into the 80s. We also found that high-impact activities (basketball, running, volleyball) were as crucial as uncontrollable factors (age, genetics) in maintaining bone density. Impacting bones stimulates bone growth. So, bone loss isn't inevitable; osteoporosis, fractures, and frailty are not inevitable consequences of estrogen loss. Many people don't think bones are important.
Why should we care about our bones? What's the cost of neglecting them?
I'm on a campaign to make bones sexy! Superficially, we think of bones in a few contexts: aesthetics ("great bone structure") or archaeology (revealing past lives). Bones are the last remnant, outlasting muscle and skin. We usually notice bones when they break, causing pain and frailty. One in two women will have an osteoporotic fracture. Women account for 70% of hip fractures, a major contributor to nursing home placement. If you break your hip, 50% of the time, you won't regain full function, and 30% of the time you'll die. These statistics aren't meant to scare, but to reflect reality.
Beyond fractures, bones are master communicators. We often view muscle, bone, adipose tissue, etc. as separate. They're derived from the same stem cell (mesenchymal) and communicate. When muscle releases irisin, it communicates with bone; when bone releases osteocalcin, it talks to the whole body, including the brain (neuroprotective effects), pancreas (insulin sensitivity), and muscles (glucose uptake). In men, it can influence testosterone production. We think of bones just as a framework, but they're master communicators.
Can you explain how bones release substances into the body?
Bones are structural, master communicators, and mineral storage. Calcium, for instance, is stored in bones. When needed, osteoclasts break down bone, releasing calcium into the bloodstream. The body maintains homeostasis; if calcium levels are high, it's excreted. This balance between bone building and releasing minerals is remarkable.
If I don't have enough calcium, will my bones become fragile?
Bone fragility (osteopenia) has multiple causes, including insufficient bone building in youth. I see young women (25-28) with brittle bones – possibly due to inadequate bone building, energy deficits from intense athletic activity without sufficient refueling, or sedentary lifestyles. The University of Wisconsin studied women's sports that build the strongest bones; gymnastics topped the list. Breastfeeding causes a 20% bone density loss in the first six months; women need 500mg of calcium daily to rebuild it. Finally, perimenopause (around age 45) causes estrogen fluctuations, leading to rapid bone loss. Estrogen controls bone absorption; without it, breakdown surpasses building.
You mentioned high-impact sports in youth for bone strength. Are there risks?
Yes, but the benefits outweigh the risks. We build mitochondria in youth through activity; sedentary children build bone, but not as effectively as those who are physically active. The same holds true in all life stages. High impact exercises at age 60 are still beneficial.
Regarding pregnancy and postpartum bone health, what should I do?
The 500mg calcium loss during breastfeeding must be replaced through food (prunes, dates, high-calcium dairy) or supplements. Don't starve yourself trying to lose "baby fat."
You mentioned the bone-brain axis. What is it?
Osteocalcin, released by bone, enters the brain, providing neuroprotective effects (reducing oxidative damage) and stimulating brain-derived neurotrophic factor (BDNF), which promotes neuron growth in the hippocampus (memory). Low bone density correlates with cognitive decline.
What's the critical decade for bone health?
35-45 for men and women. Estrogen declines in women, and it's crucial to establish healthy habits, including baseline labs (testosterone for men) for future reference. Build muscle with resistance training while hormones are high. This is the time to develop lifelong habits (smart nutrition, resistance training, cardiovascular fitness).
What about V02 max?
V02 max is a measure of fitness – how much oxygen you can utilize. World-class athletes have high V02 max; we want to maximize it in midlife to avoid the "frailty line." V02 max declines 10% per decade after midlife unless consistently built up.
What about osteoporosis?
Osteoporosis means low bone density, measured with a DEXA scan (comparing your bone density to that of a healthy 30-year-old). A T-score of 0- -1 is okay; -1 to -2.5 is osteopenia; -2.5 and below is osteoporosis (increasing fracture risk by 40%). Two million men have osteoporosis, and 50% of women will have osteoporotic fractures. It's preventable.
Why is DEXA scan access limited?
In the US, DEXA scans are often not covered until 65, when damage is often done. Even those with fractures should get DEXA scans, as past fractures predict future ones.
What are early warning signs of osteoporosis?
Family history (shrinking parents, hip fractures), medical conditions (steroid use, autoimmune diseases), and fractures (even minor ones) are warning signs.
Does smoking impact bone health?
Yes, smoking hinders bone healing and increases infection risk. Vaping may be even worse.
What's the link between Alzheimer's and bone health?
There's a correlation between Alzheimer's and osteoporosis (30% overlap).
How did your aunt's experience with Alzheimer's affect you?
It created a sense of urgency to maintain brain health. I work to preserve my brain health through diet, exercise, and lifestyle. Choosing between an able body and an able brain is impossible; I want both.
What's the connection between Alzheimer's and bone health?
Alzheimer's is considered the third phase of diabetes.
Your pancreas is no longer functioning, and this can lead to serious consequences. What many people aren't aware of, especially those who come to my clinic, is pre-diabetes.
If you don't mind, I'd like to digress a bit because it's crucial to address your question about prevention. I constantly see patients whose fasting glucose levels are elevated. They've had their labs drawn—they've done what we advised—and their fasting glucose is 110. Their hemoglobin A1c is nearing 6. Fasting glucose is the glucose remaining in your blood after 12 hours without eating. In a normally functioning pancreas and metabolic system, we want our fasting glucose to be around 85. If it consistently stays at 110, the literature shows a 70-100% chance of developing type 2 diabetes within 10 years.
But when I ask these patients if anyone told them they were pre-diabetic, they either say no or that someone suggested more exercise and a focus on diet. I believe the reaction to a pre-diabetes diagnosis should be to aggressively pursue a healthier lifestyle. A casual approach of "just exercise more" or "eat fewer carbs" isn't serious enough. We know from a preventative, precision longevity standpoint that we can prevent diabetes if we're serious about weight training, cardio health, and anti-inflammatory nutrition.
I don't view pre-diabetes casually. Ten years from pre-diabetes comes diabetes, and ten more years after that, it can be Alzheimer's. Preventing it by paying attention at 40 is crucial. 96 million people in the US have pre-diabetes—96 million! The American Diabetes Association, where I recently spoke, confirms this. That's a preventable condition that can also prevent Alzheimer's, yet it's often treated too casually. It's almost one in three people.
I'm a little obsessed with continuous glucose monitoring (CGM). I've been wearing one for 18 months. I recently reduced my exercise intensity, and it affected my blood sugar. My normal regimen includes heavy weightlifting four times a week, and on other days, I do HIIT training. My blood sugar is 85 when I follow this. Even a slight reduction in my routine caused my blood sugar to creep up. This is a daily lifestyle we all need. When patients are casually told they have something that could kill them, I think that’s insufficient.
What diet leads to better cognitive performance? I spend a lot of time speaking, whether on stage, in boardrooms, or writing books. I'm always seeking a 5% edge. The dietitians and chefs for the pro athletes I've worked with eat a well-balanced diet with lots of vegetables and high protein. They supplement with amino acids if needed. They don't focus on just one approach. This has given me an extremely sharp mind. The variability in my cognitive performance depends on sleep and carbohydrate intake. If I've had a lot of carbs or sugar, my brain and mouth feel disconnected. I found that eating only protein for breakfast and adding 50 grams of complex carbs around 10 AM helps my function with patients.
I eat 130 grams of protein a day. There's no upper limit, but I aim for at least 30 grams per meal. I eat protein-dense foods like Greek yogurt and beef jerky. I aim for a gram of protein per pound of ideal body weight. This helps maintain muscle, even without lifting as much as I'd like. I eat lots of vegetables but limit fruit to blueberries. I only eat complex carbs occasionally.
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Muscle and bone health are crucial for longevity. Even if you're 65 or 70 and haven't weight trained, it's never too late. Your body responds to strategic stress. Many people in their 60s, 70s, 80s, and beyond are powerlifting and bodybuilding. Start with bodyweight exercises, then progress to free weights, kettlebells, and resistance bands. A program can get sedentary people to a 5K in three months.
If you're trying to build muscle, even a 10-week break retains muscle memory. The minimum is a couple of days a week of progressive overload. For midlife men, it's eight reps, four sets; for women, four reps, four sets. The goal, especially for women, is to replace the anabolic stimulus of estrogen. Lighter weights and higher reps build hypertrophy, while heavier weights and lower reps build power and strength. I focus on power for longevity.
Why is muscle so important for longevity? Muscle is a key factor in preventing insulin resistance. Muscle contraction transcribes a protein called Klotho, a longevity protein. Mice without Klotho die young. Older master athletes have higher circulating Klotho than younger sedentary individuals. Other proteins released with muscle contraction include irisin, which affects bone and fat. Muscle performs various metabolic functions, contributing to longevity.
Are there any supplements to protect muscle mass as we age? You have to make Klotho yourself—you need to contract your muscles. Feed your muscles high-quality protein, aiming for one gram per pound of ideal body weight. Whey protein is a good source of leucine, an essential amino acid. Creatine supplementation (5 grams a day) is beneficial for muscle and brain health.
Despite all the information available, there's a knowledge deficit about health and a lack of action. Motivation is the key. Focusing on feeling better daily is more effective than long-term promises. Data, like body composition analysis, can be motivating.
There are many pervasive myths about menopause. Many women haven't heard of perimenopause (the decade leading up to menopause) or hormone replacement therapy (HRT). They feel ashamed to talk about it. The myth is that you must suffer. Lifestyle changes and HRT can improve the experience. Women should make their HRT decisions based on science, not fear, and start early.
You can make your decision very early. What I want people to do is educate themselves. I call it menopause literacy because we have a very low level of menopause literacy in this country. I want them to make their hormone replacement decision: Am I going to use them? Where am I going to get them? Can I find a clinician to help me?
Third, I'd like them to build their unbreakable lifestyle, as we discussed earlier. Develop these habits early, not when they're in the throws of menopause and feeling desperate. Start early with weightlifting, cardio including base training and sprint intervals, and anti-inflammatory nutrition. Make it a way of life. That way, when you're feeling bad, you're not trying to learn all these things at once.
There's a significant link between menopause and bone density because you lose critical hormones like testosterone and estrogen. Estrogen helps control osteoclasts, the cells that break down bone. Even in menopause, bone is still built, but breakdown outpaces building. Hormone replacement helps rebalance this. Around perimenopause/menopause, you can lose 15% of your bone density. Insurance often only pays for DEXA scans after age 65, which is far too late. I encourage everyone to get a DEXA scan once they start perimenopause, even if they have to pay for it. It's worth knowing your bone status.
What are some of the most obvious, pertinent musculoskeletal syndromes of menopause? My group and I created a nomenclature called the musculoskeletal syndrome of menopause. Women were telling me, unprompted, "Doc, I feel like I'm falling apart!" I noticed a pattern: frozen shoulder, etc. We've known for 30 years that inflammatory arthritis incidence is much higher in women after 50. Every musculoskeletal tissue is derived from the same stem cell, the mesenchymal stem cell. These stem cells are sensitive to estrogen. Without it, arthralgia (total body pain) occurs. I'm an athlete, and I could barely get out of bed! Estrogen is a huge anti-inflammatory agent. Women say, "My arm won't move!" This is due to inflammation from estrogen loss. In Asian cultures, it's called "the 50-year-old woman's shoulder." We know about sarcopenia (loss of lean muscle mass), bone density loss, and increased tendon/ligament problems. Collagen fibers have estrogen receptors.
We gathered the world's data (more research is needed) and published it as the musculoskeletal syndrome of menopause. This paper has been downloaded almost 300,000 times! Some top medical journals' best articles are downloaded about 10,000 times. The need to communicate what's going on is huge. I made it open access; please Google it. Give it to your doctors.
You mentioned arthritis. There are two kinds: rheumatoid (autoimmune) and osteoarthritis (wear and tear). Osteoarthritis happens from repetitive joint use, trauma, etc. It's loss of cartilage, causing pain, swelling, and stiffness. We can treat it conservatively or, eventually, replace joints.
To avoid musculoskeletal symptoms of menopause, should you take hormone replacement therapy? Every musculoskeletal tissue has estrogen receptors. When empty, you'll manifest some symptoms (80% of us do). Estrogen prevents bone and muscle loss and decreases inflammation. People can make their own decisions based on science, not fear.
I'm concerned about back pain, especially lower back pain. It's the leading cause of disability globally, affecting 69 million people. Prevalence is increasing due to aging and sedentary lifestyles. Back pain is endemic in the West. The Hadza tribe in Africa doesn't have it because they squat, don't sit in chairs, etc. We get low back pain from: 1) weak core muscles from sitting; 2) lack of exercise; 3) compression fractures. Low back pain is aching and stiffness. Nerve impingement (pain shooting down the leg) requires examination. Standing desks and walking treadmills help. Much work can be done standing. We only need to sit for deep work. Studies show that moving while learning improves retention.
What's your favorite study? Our first study on master's athletes answered: At what age do we slow down? We don't significantly slow down until after 70. Slowing down before 70 is due to lack of training, injury, or psychology, not biology. We think that the first twinge means we must slow down. This is a self-fulfilling prophecy.
You're working on a book, *Unbreakable: Go Strong, Live Long, Age with Power*. It focuses on women's longevity, addressing "time bombs" like metabolic dysfunction and the misconception that our DNA determines our destiny. It presents an unbreakable lifestyle (muscle, bone, nutrition, attitude). It also discusses building resilience and peak performance.
Anything else? Last week, I spoke at the American Diabetes Association about midlife and menopause and metabolic changes. Pre-diabetes is a major alarm, as these changes lead to diabetes and Alzheimer's. Perimenopause and pre-diabetes are nearly identical. The combination compounds metabolic changes and insulin resistance. Post-menopause, women have more diabetes and Alzheimer's. If we address these issues at 35, that's work worth doing.
My secondary reason for focusing on menopause is the women in my life, including my partner. If more men understood midlife changes—bodily, attitudinal, and sexual—we could save many marriages. There's a lack of knowledge among both men and women. Empathy is key.
How do you know when enough is enough? When you don't love it anymore, when it becomes a grind. It's when it's not feeding you. Thank you for your work, Dr. Vunda! Check out her website, Instagram, and pre-order *Unbreakable*!