Understanding Relative Energy Deficiency in Sport (RED-S)—with Dr. Emily Kraus

In this episode of Fast Talk Femmes, we learn more about RED-S, its effects on female endurance athletes, and ways to prevent it.

Dr. Emily Kraus, Fast Talk Femmes podcast
Dr. Emily Kraus is a medical professional and talented endurance athlete. Photo: Chris Schierholtz

In our latest Fast Talk Femmes show, we’re joined by Dr. Emily Kraus as we dive into the complex topic of RED-S (Relative Energy Deficiency in Sport). As both a medical professional and accomplished endurance athlete, Dr. Kraus has a deep and impressive resume, and although she boasts expertise across a wide range of sports medicine topics, the focus of this show is primarily on RED-S.

RED-S can be described as a syndrome of poor health and declining athletic performance that occurs when athletes do not eat enough fuel to support the energy demands of their training and daily life. While it can affect athletes of any gender or ability level, it is especially prevalent among female endurance athletes—and it’s here that we truly tap into Dr. Kraus’ knowledge.

Dr. Kraus is a Clinical Assistant Professor of Sports Medicine at Stanford Children’s Orthopeadic and Sports Medicine Center. She’s also the Director of the Stanford Female Athlete Science and Translational Research (FASTR) Program and the Medical Director at the Motion Analysis and Sports Performance Lab.

In the show, she highlights the effects of RED-S on female endurance athletes and ways to identify it, as well as prevention strategies that female athletes and their coaches can employ to proactively avoid it. We refer to this paper—Patience Through Puberty—in the show.

Interestingly, through our discussion with Dr. Kraus, we discover that at the core of RED-S is the issue of energy availability, yet it is not as easy as simply calculating energy in and energy out. While wearables have allowed us to better quantify the complete picture of energy expenditure, energy intake continues to be a tricky thing to accurately calculate. Dr. Kraus helps us understand how we can be measure this in more practical ways.

RED-S was also discussed in episode 103 of Fast Talk Femmes: Fueling for Performance with Dr. Dana Lis.

To learn more on this topic, check out Running on Empty: Low Energy Availability and Effects on Performance.

Catch up on previous episodes of Fast Talk Femmes and subscribe for episodes on Apple PodcastsGoogle PodcastsOvercastSoundcloudSpotifyStitcher, or wherever you listen to your podcasts! 

Episode Transcript

Dede Barry  00:04

Hi, and welcome to Fast Talk Femme hosted by DeDe Barry and Julie Young. Our guest today is Dr. Emily Kraus. Dr. Kraus is a clinical assistant professor of Sports Medicine at Stanford’s Children Orthopedic and Sports Medicine Center. She’s the director of Stanford female athletes science and translational research faster program, which seeks to help close the gender gap in sports science research with an emphasis on early identification and interventions to prevent injury and identify ways to optimize performance in female athletes.

Dede Barry  00:37

She is also the director of the WuCy human performance Alliance at Stanford, which studies peak performance with the goal of enabling all people to achieve optimal health and well being. She’s the director of the motion analysis and Sports Performance Lab. Dr. Kraus is also an accomplished elite runner, a cyclist, and a passionate endurance athlete.

Dede Barry  00:58

Although Dr. Krauss has expertise across a wide range of sports medicine areas, the focus of our conversation today is primarily on relative energy deficiency in sport, also known as RED-S. Its effects on female endurance athletes, ways to identify it, and prevention strategies that female athletes and their coaches can employ to be proactive to avoid its pitfalls. Welcome, Emily!

Brittney Coffey  01:26

Hi, listeners. We’re so excited that you’re here to check out fast talk then, a new podcast series. It’s all about the female endurance athlete. Here at fast talk labs. We pride ourselves on being the pioneers of information and education in the endurance sports world for both athletes and coaches. If you like what you hear today, check out more at fast talk labs.com.

Julie Young  01:46

On today’s episode, we’re super excited to have Dr. Emily Kraus join us I met Emily at a mountain bike camp several years ago, and feel fortunate to be able to lean on Emily as a resource now with athletes that I coach, we are so lucky to grab a little bit of Emily’s time today because she is in high demand. Thanks for taking time out of your busy schedule to join us. Emily, would you tell listeners a little bit about your background and what you’re up to now?

Dr. Emily Kraus  02:18

Well, thank you so much for having me on your podcast, I can’t wait to start listening to all of them. I’m hopefully soon. Julie I gotta say that like flash that just flashed me back to when I first met you. And that was my first like true mountain bike camp event. I hadn’t done a lot of mountain biking prior. So I was very intimidated. And you came in with such common grace and good energy for all of us both kind of newer cyclists and more veteran cyclists. And I think I was just I kind of gravitated towards you. And we started to find all of these fun commonalities and common interests, including sports, nutrition, exercise physiology, and the female athlete. And I just I remember walking away and I was like, I hope I get to connect with Julie again at some point. And I think somehow fast forward, we found each other’s emails, and we stayed in touch. But that was this like almost that was meant to happen. I was and I’m still mountain biking. So it didn’t scare me away from the mountain bike. But I had to give you a shout out for that, that introduction to the sport. And here we are now. So kind of a little bit about me. So I’m not to give you my whole life story. But I did grow up in Nebraska, and in a small town. And so I was exposed to a lot of different sports growing up, which I think I carry on to my athletes now. And I encouraged them to sample a lot of sports in their younger years. And but I really, really enjoyed running the most. And so as I developed I started to do more cross country and more longer distance events in college and med school. And in middle school, I also got exposed to a lot of the sciences. So that really drove my interest in the health field. And so I was one of those rare birds who wanted to go into medicine by like the eighth grade and started to sample in shadow and found myself really interested in orthopedics and sports medicine, narrowed that down to more non orthopedic sports medicine and a field called physical medicine and rehab. And fast forward through college, which I did in Nebraska and in med school at Nebraska Medical Center. I landed at Stanford for residency in the field of physical medicine and rehab and did my sports medicine fellowship there as well. So now I’ve been practicing at Stanford children’s Orthopedics and Sports Medicine Center for about five or six years I have to do the math it’s kind of starts to blur together a little bit but around five years, and I get to see young athletes with overuse injuries. I work with athletes on presenting with fatigue or menstrual cycle irregularities, female athlete triad relative energy, deficiency in sport, all things that we’re going To dive into and talk about more today, and now I’m recently have been doing more research, I’ve always had an interest in research, but sometimes it’s hard to blend that in with your typical clinical practice. But now I’m directing a female athlete research program called faster. And I think we’ll also talk about that a little bit later as far as some projects that I’m working on. And I am still running and got introduced to the bike when I moved out to California. And so I do probably more riding on the dirt, both gravel and mountain bike.

Dede Barry  05:29

Emily, you have a really wide ranging background as both an athlete and a researcher, which I’m confident that the athletes I work with are really fortunate to be able to draw from you are considered by the sports science community to be one of the leading researchers and practitioners focused on rad s, can you explain right as to our listeners, its causes and its prevalence among female endurance athletes, and help us understand how concepts like low energy availability and female athlete triad are related.

Dr. Emily Kraus  05:57

Yeah, so important. And I love I feel like this, the concepts are getting talked about more and more. And I feel like there can be sometimes some confusion between the female athlete triad and relative energy deficiency and sport. So I like to just get us all on the same page before we dive deeper into more of the why and the management. So low energy availability is where I want to start because I think that’s the foundation of both the female athlete triad and relative energy deficiency and sport, or I’ll just kind of call it reds for the rest of the time. So when an athlete is either overtraining or under fuelling or some combination of that, this leads to energy conserving changes in the body, and that can lead to this low energy availability state, because these athletes, they don’t have enough food or fuel to account for all these other different bodily processes that are happening in the body, including growth and development. And so this chronic low energy availability state can lead to specific types of hormonal suppression. And in females, this can lead to menstrual cycle irregularity. So irregular periods, which can be a loss of a period, and an athlete who was maybe having regular periods before that, or in a young athlete, this can lead to delays and that first period of happening, and that’s called menarche. And over time, this hormonal suppression can also affect the bones. And that can affect bone remodeling, specifically from a hormone that we usually talk about estradiol or estrogen, and that estrogen suppression actually leads to greater bone breakdown and reduced bone formation. And so for a lot of our endurance athletes, we see overuse bone injuries or bone stress injuries. Sometimes athletes may be diagnosed with low bone mineral density. And so those three components of the female athlete triad, it’s that low energy availability, that menstrual irregularity, and then that impaired bone health. And then we go beyond that. So the relative energy deficiency of sport or reds is an expansion of the triad. And that really describes all of these other health and performance consequences from that low energy availability state. So in the International Olympic Committee, relative energy deficiency and sport consensus statements back in 2014, they have these two figures, one with a wheel of health consequences, and another with a wheel of the performance consequences. And so in addition to the different menstrual effects and the bone health effects, you can see immunosuppression, you can see effects in just gi function. In a developing athlete, you can see changes in their overall growth and development, they may have even stunted growth or kind of a lack of growth during certain parts of their typical growth and development phases, and then numerous other effects of pressed metabolism. And then there’s also those performance effects, which sometimes athletes maybe are drawn more to. And then as far as its prevalence among endurance athletes, we do see this, these higher rates of this low energy availability state in endurance athletes, it kind of makes sense, these athletes are the ones that are that are pushing their body the most, that are sometimes having the hardest time getting that fuelling in whether it’s from just total lack of knowledge, whether it’s from just this change in activity, or different exposures or stressors, or from more intentional under fueling, which some of these athletes do have this belief that they need to get leaner, and that’s going to make them faster. And there is it is a slippery slope that that athlete is going on, if that is the approach that they’re taking. And I often see these athletes when they go down that route, at some point they get burned, whether it’s an injury or just a really blunted performance or a decline in performance.

Julie Young  09:34

It seems to me that in terms of determining these issues, accurate measurement of energy availability is like it’s a huge factor. And it seems hard to measure energy intake. And the most accurate way to do that is weighing your food but how practical is that for most people? So how do you propose to your clients to accurately measure energy intake Yeah,

Dr. Emily Kraus  10:01

oh, that’s such a great question. And all the research studies explain how difficult it is to calculate energy availability in the field. So it’s one thing when you got in the lab, and everything’s very controlled, you see everything that that athlete is consuming, or it’s actually just given to that athlete. So there’s really no margin of error. In the field or in the wild, we’re relying on dietary recall, we’re relying on all these other methods to determine an athlete’s energy intake. And an athlete may under or over report just through that having accurate measurements of that, or they may do it on purpose, because they don’t, they want to avoid maybe some of those other more challenging conversations. And I also think that there’s some risk and using measurements of food or getting an athlete so calculated to such a degree of precision, that they get almost obsessed with that that part of their training, and especially with athletes who may have some degree of disordered eating, or whether they’re, they’re aware of it or not, it can take them to a more discerning path, that could be more problematic than beneficial. So when I think of an athlete, I try and do a little bit more of a bigger picture to start to see kind of where we are in this in this range. If they can kind of give me an account of what their typical day looks like their on a typical training day, or maybe their harder workout day, sometimes I can just get a little bit of an idea of like, alright, based on just my my measurements in my head, which I full disclosure, I’m not a sports dietitian, that can sometimes help me understand that they’re significantly under fueled or adequately fueled. And if they’re significantly under fueled, I’m already going to take them to that sports dietitian and have them have a deeper conversation to get some better strategies. So not kind of beat around your question a little bit. But I would say the really calculated measurements isn’t the right way. I want athletes to have a more healthy relationship with foods, so they don’t have any real restrictions or off limit foods, and ideally, having a variety of different foods as well. So that that healthy relationship, I think starts at a young age and and hopefully gets developed and fostered. And that really affects and can help improve their just ability to adapt and work with different stages of training down the road.

Julie Young  12:25

You know, I was thinking about this, when you said about measuring food and how that can take an athlete down kind of the wrong path. And I know a lot of the World Tour teams are, you know, implementing measurement of food and knowing exactly what the athletes are taking in and, and I was thinking about the effects or the power of environment on eating behaviors, whether that’s contributing to our obesity pandemic, or the absolute polar opposite of like athletes and the environment they live in, and how that can contribute to this restrictive eating.

Dr. Emily Kraus  12:58

Yeah, I think you highlighted a very important word. And it’s like, what is the environment that that is happening in? And what’s the culture like in that environment? Is it a supportive culture where there isn’t judgment about what an athlete’s putting on his or her plate? Or is that athlete going to get almost food shamed for getting a second helping of carbohydrates, or getting that extra fuel for that big, big training block or big, big workout tomorrow? And if we could shift that culture and environment to a point that it’s more supportive and a collective environment that’s about really promoting adequate fueling and fueling the body. But I think it could be a way I do think encouraging the measurements to then you can get a little bit more nuanced and say, Actually, I need a more protein this this day, I need I need some more carbs this day. But for some of these athletes, even that can be pretty triggering, and can take them down the wrong path.

Julie Young  13:52

That makes sense. And that’s I appreciate you putting it that way. It could be used as a positive as much as a negative. For sure. Yeah. Emily, I know a big part of your mission in your programming is education. Will you help educate our listeners on early symptoms and markers of reds?

Dr. Emily Kraus  14:11

Yeah, so I kind of went I broke down some of those circles. And in that figure, some of those were more in stage findings. For example, the bone stress injury, the the missed period. And for those athletes, that usually is after a period of weeks to months of hormonal suppression. So that’s weeks to months of low energy availability or fluctuation. So some of the earlier signs are a lot more nonspecific, more vague. I see fatigue, sometimes irritability. An athlete may not even realize it, but they’re just a little bit short. They have a shorter fuse, maybe some more mood disturbances than usual. I see plateaus and performance, despite excellent coaching and excellent kind of load progression for an athlete where they’re performing are underperforming and then expected an area where they should be really peaking and making some progress. I also see for athletes, they may have changes in in sex drive libido, sometimes they’re less open to that. But that is another finding or a symptom that an athlete may have. For athletes who may be looking for changes in weight. Sometimes we don’t see any weight changes. So I think that’s important to remember, an athlete may say, I don’t have reds, my weights been stable. And the same, I’ve weighed the same for this entire year. And sometimes that’s because of that, that hormonal suppression and that thyroid suppression where the metabolism is actually adapted and slow down based on that low energy availability state. So those are some that I see. And I would say even more just other injuries, other overuse, musculoskeletal injuries. And so there is some research that shown has shown a relationship between overall overuse injury risk and triad risk factors or female athlete triad risk factors.

Julie Young  15:59

Are there additional clinical markers that you use to diagnose reds?

Dr. Emily Kraus  16:04

Yeah, so one of the challenges with the research side not to get too deep into like the science, but it’s hard to define and diagnose low energy availability or reds because of all of these limitations and in calculating low energy availability well, so some of the research that has been shown pretty consistently, throughout a number of articles is that suppress thyroid function, specifically, we see suppression in total T three, could be an earlier sign of that low energy availability state, I do see other hormones suppressed down the road, but that could take several weeks longer. And that can be estrogen suppression, and like testosterone and some of the other sex hormones, there’s other bone turnover markers that can be suppressed. But those are a lot more expensive. And I don’t order them consistently. They’re more so for research purposes right now. And I think that if we did want to use them more in the clinical setting, we need to do a little bit more work to find out what the normative data really looks like. There has been some research also looking at potentially prolactin, but it’s not a consistent enough marker quite yet to use as an early detection for relative energy deficiency in sport. A couple of other measurements that I do conduct or do get from an athlete around that same time is just checking vitamin and mineral levels. So I’ll chuck an iron level through getting a ferritin. Often these athletes who are under fueling are iron deficient unless they’re already supplementing the newer athletes to reds, where they’re just really unintentionally under fueling an inadvertent under fueling state. I see iron deficiency a lot more than when athletes who are a little bit more on that disordered eating and eating disorder side of things, they’re already supplementing with iron because of maybe some earlier detection from a prior workup. Also check vitamin D levels, getting more B 12 levels to 15. And lower levels of that often due to just overall lower intake or maybe just not being as mindful about all the different nutrients that they think needs to be getting

Julie Young  18:07

  1. I did not realize that there were so many markers that could indicate low energy availability or reds, because you kind of get this feeling like oh, it’s just based on menstrual cycle kind of thing. And so much more than that.

Dr. Emily Kraus  18:21

All of these other effects. And those these athletes that maybe are recovering from more of that eating sort of disordered eating steak even have suppressed immuno function, so like their white counts are down. And that’s what makes me nervous, because then they’re just they’re so vulnerable to, to injury to illness. And I think that’s where I get a little more aggressive with my treatment strategy and making sure that they’re safe to participate in sport.

Julie Young  18:46

I just read an interesting paper. Maybe you saw it, it was produced by Kirsty Elliot Salle and Graham close and James Morton. And it was a case study about the soccer player.

Dr. Emily Kraus  18:55

Yes, I read that thank you, that you and you pass it along to me too, as I Dooley is on our game.

Julie Young  19:01

Well, I just I thought it was super interesting how one of their kind of conclusions or I guess, understandings from this case study was that the soccer player did present with secondary amenorrhea, but was in good energy balance. What they emphasized is the importance of considering multiple factors contributing to the issue, whether clinical psychological or physiological. And I know that’s a big part of your practice in terms of having that integrated team approach.

Dr. Emily Kraus  19:31

Yeah, yeah, I’m glad you brought that up. I think that even though I’m so I talk a lot about reds in the triad, it is what we call clinically a diagnosis of exclusion. There are a number of other possible causes and factors related to menstrual dysfunction and irregular periods that we need to be exploring. And there can be primary thyroid dysfunction or primary thyroid disorders that we need to rule out. And that suppressed thyroid I see could be from a number of other causes too. So making sure that you do the full workup and not just look at this one biomarker and just call it reds when it could be, could be a primary thyroid disease. There’s PCOS, polycystic ovarian syndrome. There’s other stressors, like you said. So exercise is a stress, but so is stress. And I have a lot of athletes that are students and student athletes. And I chatted with one girl, she’s a senior this year, or maybe Junior, she has a bunch of applications coming up. And I told her, you know, I’m like, I can’t write up the applications for you. I can’t do your homework for you. But you need to take that into account, in your training with your sleep and do your best to maintain that self care strategy, because that’s going to affect your hormones, just like fueling and our underfilling.

Dede Barry  20:51

Yeah, parceled out all the different factors that can affect performance has to be really challenging as a practitioner.

Dr. Emily Kraus  20:57

Yeah. Especially when I don’t have enough time to really go deep into those things. And it’s often like a conversation. And sometimes I find I’m like, Oh, they’re only sleeping five to six hours at night, this has got to change. And so we start there. And it’s amazing how starting to for athletes, like challenging the athletes to be advocates for their body and for their their own behaviors is a really beautiful thing when they start to track their menstrual cycle and they take more responsibility or more independent with their fueling and how they get those snacks and good meals and throughout the day.

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Dede Barry  22:02

One of the patterns I feel like I’ve often seen an endurance sport, especially sports where power to weight make a big differences. Athletes initially are restricting their diet to lose weight. And then for example, in a sport like cycling, they start climbing better and performing better. And then when their performance starts to drop, they have a hard time believing and connecting that it’s because of low nutritional intake or many of the other factors of red. So that’s another thing. I mean, because the psychological component of that is something that it seems like athletes have a really hard time overcoming. I’d be curious as to how you work with your athletes on that.

Dr. Emily Kraus  22:40

Yeah, it’s so hard. And yeah, you nailed it. Once that performance decline happens, they’re in denial that they have to put up maybe put on weight or eat more to actually overcome that when they feel like that’s how they got to that point through under fueling and at this current fueling state, and mental health and really pulling in that, that good psychologists that mental health specialist is so valuable. For my my practice, I don’t have a mental health specialist as part of my my core team yet I’m working on it. But I do refer out and I have a handful of people that I that I try and refer to on the challenges, a lot of them are pretty, pretty busy and saturated with work right now. But something that I have noticed is that some athletes are in denial about needing that help and needing that mental health support. And I think everyone would benefit from having a mental health specialist or a therapist to talk to, that’s not your friend, that’s not your your dog or, or some other other person that maybe isn’t skilled and professional in that field. And I think it just can do so much from a sports performance to getting a little more introspective and really unpeeling the layers of the onion to get to the core of some of these issues. And that can take work. And working with consistently with one therapist, I think can do wonders for an athlete overcoming some of those challenges. And I’m going to give a shout out right now to a good friend, Kate Courtney. Now Kate Patterson, who has been working with mental health specialists throughout all of her a lot of her training. And I think from like a sports performance kind of dealing with the successes as well as the not so fun times that are inevitable with sport. And she’s really open about how mental health is health.

Dede Barry  24:33

So Emily after Red’s diagnosis, what are the next steps that you recommend for athletes to recover? Because we’ve talked about the mental health aspect but can you touch on like you as a practitioner, what do you recommend? Yeah, so

Dr. Emily Kraus  24:45

once you kind of build the right team and have the right team for that athlete, and often it does involve some degree of nutritional support to ideally with this sports dietitian. It’s really important to address the low energy availability component and the why I was this athlete just training at altitude and not realizing that they need to adjust their their fueling strategies because maybe they’re not getting the hunger cues that they used to that they were getting at at sea level. Maybe it’s as simple as that. Or maybe it is maybe some some underlying disordered eating or a return of some disordered eating. That happened. That was there years ago. And you need some additional support from a mental health specialist. So I think figuring out the why, in addition to addressing the low energy availability is really important. It doesn’t always involve adjusting training volume, although I think it is helpful and probably more effective to address it more quickly. But some athletes are concerned or like, I can’t change my training. Right now, I’m really gearing up for this thing. I think it’s important to remind that athlete Well, if you gear up and you’re preparing for this, this event in this race, this this block, and you’re at a consistently under fueled state, you’re probably not going to perform and have the outcome and the results that you really want. So sometimes it’s just really focusing maybe for a period of weeks, it might be a month or two of adjusting that volume, really working on the fueling component. And I’ll get into some details as far as how maybe an athlete can do a better job with the fuelling and more efficiently. And so once that’s established, as far as what other types of fueling an athlete could focus on one, I think athletes need to avoid intermittent fasting or prolonged periods of a fasted state. So fueling more consistently throughout the day, and simple as not skipping breakfast, but really even just in between training blocks, and even factoring in if an athlete is doing two workouts, how they’re going to get that fueling and throughout. Or if they’re more on that very ultra endurance side, and they’re on the bike or they’re running for a longer period of time, how are they getting enough in their body during those training blocks, and during those on those days, really making sure that they’re getting enough carbohydrate intake and prioritizing carbohydrate intake as far as the type of fuel that they need to focus on more. So we do see some relationships between low carbohydrate availability and reds. And then we also see some relationship between just overall fiber intake, a lot of these athletes are actually taking in way too much fiber. And so they may be getting fuller faster. And really having these athletes be mindful as far as getting some more dense nutrients. And that’s going to help them maybe get to that end goal a little more quickly. And then managing those psychogenic stressors in their life, the outside stressors, if they’re at altitude, bringing them down from altitude, I’m trying to minimize some of those factors as much as possible during that recovery state

Dede Barry  27:39

are all of the effects of reds reversible.

Dr. Emily Kraus  27:42

So for the most part, I think that’s a question that’s probably like afterwards like to be determined or research is needed. But the the challenge is the bone component. So if an athlete for a more prolonged period of low energy availability is or during those peak bone building years, which is an adolescence, for this athlete is really acquiring a lot of their bone mineral density for the rest of their lives. That’s really the time where it’s important that an athlete is not in a low energy availability state for a long period of time. And so I would say the bone health component is somewhat reversible, or an athlete can maintain what they’ve got. But especially in the more severe eating disorder range, that can be really hard to work with for an athlete or really hard to reverse for an athlete. So for those athletes, that through medical workup, identify some degree of low bone mineral density, we may have to have this difficult conversation of all right, like we may have to adjust your your volume have an impact activity, especially in a runner and might need to have a little bit more cross training, a little more strength training or not impact activity layered in to avoid developing overuse, bone injuries, bone stress injuries, I’m down the road,

Julie Young  28:59

just listening to you, Emily, I’m just thinking, My gosh, this is so complex, just all the factors and whether the restricted eating is intentional or not, would be a big factor in how you treat this, but definitely not straightforward. And I’m assuming a big part of this is just taking time to learn each patient and really investigate as opposed to, as you mentioned, don’t jump to conclusions.

Dr. Emily Kraus  29:23

Yeah, I think I was just gonna say one of my learning moments. And I think this is just like through maturity and competence in the clinical setting. But I tried to be more direct and ask some of the hard questions off the bat. Not in a way that’s like, so the athletes in the hot seat, but I was like we just we need to have like the real talk and what are the athletes fears and sometimes it’s like fears, fear of injury or re injury, if they have a history of an injury, maybe it’s fear of gaining weight, maybe it’s fear of what their body is going to look at this other weight or how their body is going to perform. And once you start to get some of those fears that discussion, you can then direct the care and try and also help educate the athlete on maybe some misconceptions that they may have.

Dede Barry  30:08

But as a clinician to you’re always reliant on the openness of the athlete, right? And the communication skills, which can be challenging, right?

Dr. Emily Kraus  30:16

Totally. I mean, some athletes that are on teams, they’re like, I don’t want to share too much, because I don’t want to get restricted from play or some degree of provisional clearance. So there’s a trust discussion. And it’s like building that relationship with with them. I have a lot of young athletes, so I’m building relationship with the athlete and with the parent and seeing that dynamic between the athlete and the parent. So

Dede Barry  30:38

yeah, well, I’ve seen situations to where the the coaches very much play a role and the disordered eating, you know, encourage it, they almost in some cases, try and control it with athletes, which can be a really dangerous situation, and athletes live in fear of their coaches when that happens.

Dr. Emily Kraus  30:56

Yeah, I think that fortunately, I’m seeing a shift in the culture with a lot of coaches who are hungry for this information, they’re listening to the podcast, they’re snatching up the resources, we do a lot of social media posts. And I think we have a lot of coaches and parents and parents who are coaches who are who are following. And that excites me, because I almost feel like this next generation of learners and people that are hungry to take this information and, and be able to be a better coach and be a better kind of person for their athlete. I think that male coaches, it’s a little harder, talking about menstrual cycle, talking about these changes within the body hormones can be tough for a male male coach to a female athlete, but there are a lot of male coaches out there. And I am encouraging more female coaches in the world who, but I also think that those male coaches have a have a role. And whether it’s just providing the right resources, giving them some of our faster infographics to start the conversation. And if they feel comfortable talking about it great, otherwise, other individuals and just kind of creating an open environment for an athlete to be able to open up and know where to go, if they do have a problem. And I think that’s the thing is making sure the athlete knows that there may be a problem or an issue at hand. But then to giving those resources and giving those different ways that an athlete can can manage that whether through education, or through the right resources at the physician or the sports medicine team.

Julie Young  32:22

Emily, I know we’ve chatted about that with just athletes we’ve worked together with and just the importance of that consistency of message. You know, I’ve said this before, but like, for good or bad, we are in this age of a lot of information around but is it good information. And I think just you know, if we can get those people that are around that athlete, and especially I guess the younger athletes, just making sure that the message is the same and odd and I can probably attest to like being in those teams situations of where like leanness and you know, kind of feeling like everything you’re eating was under the microscope, you know, that’s a real thing. But I think to your point that, you know, if we can kind of flip that culture a little bit and provide better education that leanness and loss of menstrual cycle doesn’t lead to performance that, you know, keeping that that athlete healthy for the long term leads to performance, for sure.

Dr. Emily Kraus  33:15

We just posted and Julie, I know I shared this with you transgelin Worth patients during puberty post, which was beautiful, and it kind of broke down all these important stats. And one stat that really hit me was that females experience greater amounts of body dissatisfaction than males. And I think that’s important for a coach to recall, just take into account too as far as how he or she uses uses words, and that words matter. And so commenting on a physique, whether it’s a compliment, or like a joke, can really trigger an athlete and can take an athlete down a pretty bad negative spiral. And so making sure that even those conversations, and I think there was so much of a culture around that, and previously that I hope it’s shifting, but that that dialogue around around body and our team, our research team were very much about promoting body inclusivity. And that there are a lot of different body types that can participate in sport and just really trying to be open about that. And that each athlete is has a unique body that is uniquely hers and trying to remember that when introducing training or different types of coaching.

Julie Young  34:25

You know, I think EV Richards is a great role model for that she has such a strong physique, and so successful and I think Kristen Faulkner also just, you know, really strong healthy physique. So I think they’re great role models for that. Yeah. Emily, can you provide just some proactive measures for like female athletes and their coaches to help them prevent, avoid the pitfalls of reds?

Dr. Emily Kraus  34:50

Yeah, I think one being proactive having the conversation making sure that the knowledge is there, making athletes realize that they need to fuel their bodies But then now and for the future, so kind of back to that bone health component and making sure that they’re thinking about that and the importance of it. And also some of the like macro and micronutrients, making sure they’re not so restrictive on a certain type of food, or there’s some variety and almost exploration and sampling and making feeling fun. So it kind of that whole eat enough always philosophy, having athletes almost be hold themselves accountable. If they are, if their body is changing, if they’re noticing the fatigue, or their changes in their menstrual cycle, I think it’s also important that the athlete may not have missed her period. But if it changes if it’s a little bit lighter, or she can have a shorter duration, and less days, per, per month. So think having an athlete really track the menstrual cycle throughout training. And also keep in mind how that how that menstrual cycle changes during different phases into an intensities of training, I think can be super helpful, that feedback could even be helpful down the road for the coach two. So those are the ones that I think come to mind the most. And also just maybe be mindful of training, volume and intensity and how that athlete may respond to it differently based on their age. And whether they’re a young athlete or a little bit more experienced in that sport, and maybe in may have a greater or lesser effect. And when those changes,

Julie Young  36:17

I think it’s tricky, you know, just thinking about the volume, the training, it’s, it’s tough, because I think social media is a tough thing. People will look and see this person’s doing this, and this person is doing this, that I mean, it can be unhealthy in some respects. And I think, yeah, just understanding what works best for you. But I also think kind of you had mentioned this to like in terms of prevention, and it’s going back to basics and fundamentals, in some respect, you know, making sure, like you’d mentioned sleep is in place, and good nutrition and good hydration, and just keeping overall stress and check. I think sometimes we have this tendency to chase these really like, we think the solution is really complicated and fantastic. And it’s really not, it’s just going back to the fundamentals.

Dr. Emily Kraus  37:01

Yeah, there’s not this magic supplement or this this one pill that’s going to make the difference. Glad you brought up sleep and recovery. And I would say rest days are sometimes under appreciated. Me personally, I had a really hard time with rest days for a long time until I got a coach and it was a game changer. I realized that I finally was felt recovered for those workouts and just that extra just complete day off per week, which was so restorative for me. So having those athletes remember that being a rest day isn’t being lazy. It’s being a smart, smart athlete.

Julie Young  37:37

Yeah, I think rest days are the hardest sell for athletes and try to say rest is trading you know, and I think it is like just as you’ve said the education part is always explaining the why of things. Yes, Emily, I’d love to shift topics a little bit. I mean, I know all of your work is integrated. But I’d love for you to talk to us about the program. You’ve started at Stanford and direct the female athlete science and Translational Research Program, also known as faster,

Dr. Emily Kraus  38:04

really excited to share about faster, pretty new program only about a year and a half old. So yes, faster stands for female athlete science and translational research. This is part of a research initiative that is in close collaboration with the Harvard Female Athlete Program led by Dr. Kate Ackerman. And we are part of this multi institutional alliance called the bullseye human performance Alliance. And the alliance is focused on uncovering the biological principles that govern human performance. And I think we all could appreciate that the female athlete is underrepresented, and a lot of research studies and we need to change that through doing good science. But we also need to make sure that we’re translating that information in a way that gets to the athletes, to the coaches, to all these really important members of the athletes team to make sure that they’re optimizing their both health and performance. And so I direct this program, which has been an absolute honor, I feel very fortunate to be in this position where I have some some time dedicated to studying female athlete. I’m proud of my team lead researcher, Megan wrote, she is total badass, ultra runner and also went to med school and now is getting her PhD in epidemiology. And she’s also running coach. And then we have a couple of research coordinators Ellie diamond and Abby McIntyre, who are also amazing and do a lot of our social media work. And then Megan Highlands, our new operations manager, so shout out to all of them for all of their work. And then we are working on a lot of projects that are both doing some fundamental translational research on ultra marathon runners and female ultra marathon runners. We’re getting started on a longitudinal study, which I hope to share more about down the road. And then a lot of our other work is looking at different educational videos, videos that have highlight elite or inspiring female athletes, combined with Sport Science from experts can help change and improve knowledge on topics such as bone health, female athlete triad, reds, nutrition, mental health menstrual cycle, and how that improves both knowledge as well as behavior and mindset. And those athletes, we want to understand the best method to deliver this information and what we’re starting. And we’re piloting this study on female high school athletes, but we’re also exploring different ways to deliver the education to collegiate teams, using that team approach through a team talk. And I hope in the future, we’ll be able to share more, but we do have some preliminary work from our pilot study that shows a lot of improvements and acquisition of knowledge through even these short six to eight minute videos. It’s been such a whirlwind of a year. And the exciting part is we’re just getting started and the outreach and the overwhelming support from all people like parents, athletes, coaches, the sports scientists, it’s so cool to see it all come together. And I think our social media tries to cover all those topics in more quick hitting ways that I think are really digestible for the audience.

Dede Barry  41:20

This is really inspiring. I’m looking forward to following your progress.

Dr. Emily Kraus  41:25

I’m excited to give you some updates. Hopefully I’ll be on again and we can can share and nerd out similar to

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Dede Barry  42:25

Emily, thanks for joining us today to wrap up what are your key takeaways from today’s conversation that can help our listeners?

Dr. Emily Kraus  42:32

Well, if I had to narrow it down, I would say one, I really want to encourage athletes to eat enough always and that figuring out that fueling piece of training can really unlock performance doors for an athlete. I think I want athletes to know that it’s not just about the missed period, unexplained fatigue or irritability, or just sub optimal performance can be an early sign of Brad’s and then I also want to encourage the adolescence is peak bone building time. So really making sure that we’re thinking about nutrition, fueling and avoiding reds during those adolescent years, especially to make sure that we set that athlete for success for many years down the road.

Dede Barry  43:15

Emily, if you were to give one piece of advice to an inspiring endurance athlete, what would it be,

Dr. Emily Kraus  43:20

I would say to think about the long game. It’s not just about that next race or next event, it’s about being a lifelong athlete in sport. And this approach may look differently for each athlete. So taking that individual approach to her training, and not trying to play that comparison game would be my piece of advice.

Dede Barry  43:41

That’s a really great piece of advice. I think it’s really easy, especially in team sports, to always be comparing, but it’s important to focus on improvement and yeah,

Dr. Emily Kraus  43:52

like personal growth and like self growth and improvement. And I think these athletes, it’s, especially in the adolescent years, they do this comparison game. And I think it’s really hard when an athlete is going through stages of puberty and development at different times. And so they can’t make that comparison. And maybe they’re a little underdeveloped, from like a muscular standpoint. But that will come with hormones and with these different other just necessary parts and processes of the development.

Julie Young  44:23

I loved that paper by the way, Emily that you shared by selling worth and we’ll we’ll link to that paper. But I think that is such a valuable perspective on the patients during puberty and you know, girls development during puberty isn’t necessarily performance enhancing and having the right people around to maintain that perspective. For sure.

Dr. Emily Kraus  44:43

We loved it so much. We created an infographic out of it in our on our basketball website, and we’re just we’re so proud and I’ve been fortunate to work with Trent on some projects and collaborate with him and he just he wrote such a beautiful piece on that I was like a half share this, this needs to get to a lot of a lot of different eyes who needs to hear this information. Emily, thanks

Julie Young  45:06

so much for joining us today.

Dr. Emily Kraus  45:08

Thank you so much for having me. This was a really fun conversation. And we probably could have talked like for another hour on all these different, different topics, but I appreciate it and look forward to hearing more of your podcast.

Dede Barry  45:24

That was another episode of Fast Talk Femme. Subscribe to the Fast Talk Fam wherever you prefer to find your favorite podcasts. Be sure to leave us a rating and a review. The thoughts and opinions expressed on Fast Talk Femme are those of the individual. As always, we’d love your feedback. Get in touch via social. You can find Fast Talk Labs on Twitter and Instagram @fasttalklabs, where you’ll also find all of our episodes. You can also check them out on the web at fasttalklabs.com For Emily Kraus and Julie Young, I’m Dede Barry. Thanks for listening!