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RED-S And Injury Prevention With Dr. Emily Kraus

About This Episode:

In this week’s episode, coach Corrine Malcolm interviews Clinical Assistant Professor at Stanford Children’s Orthopedic and Sports Medicine Center Dr. Emily Kraus. They sit down to discuss RED-S, bone health, and ways you can stay vigilant when it comes to your health so you can stay on the trail for the long run.

Episode Highlights:

  • What is RED-S?
  • Bone health in ultrarunners
  • What are the causes of low energy availability?
  • Common signs of low energy availability

Guest Bio – Dr. Emily Kraus:

Dr. Emily Kraus is a Clinical Assistant Professor at Stanford Children’s Orthopedic and Sports Medicine Center. She is board-certified in Physical Medicine and Rehabilitation (PM&R) sports medicine and takes a unique approach to the diagnosis, treatment, and prevention of sports injuries. She serves as the Director of the Stanford Female Athlete Program focused on female-specific translational research to answer fundamental physiological and sports performance questions important to improving the health and performance of girls and women, including the topics of bone health, the Female Athlete Triad, RED-S, running biomechanics, and mental health. Dr. Kraus also serves as the Medical Director of the Stanford Children’s Motion Analysis and Sports Performance Lab, focused on cutting edge biomechanics research with a strong clinical application.

She is involved in multiple Stanford IRB-approved research projects, including The Healthy Runner Project, a multicenter prospective interventional study focused on bone stress injury prevention in collegiate middle and long distance runners. She also has research and clinical interests in youth sports specialization, endurance sports medicine, injury prevention, running biomechanics, and adaptive sports.

Dr. Kraus proudly grew up a 3-sport high school athlete in small town Nebraska and is now an avid runner and cyclist, completing 9 marathons, including Boston Marathon twice and California International Marathon in 2019 with a time of 2:50. With staying physically active as one of her personal passions, she recognizes how sport participation plays a valuable role in the physical, emotional, professional, and social development of a child and adolescent and is committed to maintaining these ideals for the next generation of youth athletes.

Read More About Dr. Emily Kraus:


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Episode Transcription:

Please note that this is an automated transcription and may contain errors. Please refer to the episode audio for clarification.

Corrine Malcolm (00:06):

Our guest today is Dr. Emily Kraus. Dr. Crass is board certified in physical medicine and rehabilitation sports medicine, giving her unique approach to diagnosis, treatment, and prevention of sports injuries. Additionally, she focuses her research on bone health, specifically in runners and has been doing some incredibly cool multi-year research with the Western states endurance run, which was recently published. And even with all of that, Emily still finds time to get outside as an accomplished runner and an avid cyclist who I feel fortunate to have gotten to share many miles with today. We’ll be talking about red S or relative energy deficiency in sport, bone stress injuries, and how you the trail and ultra running community can stay vigilant when it comes to your health, allowing you to stay on the trail for the long run. Emily, thank you so much for joining us. Welcome to the show

Dr. Emily Kraus (00:57):

Kerryn. Thank you so much for having me. I’m honored to be here and truly enjoyed sharing the dirt on both two feet and two wheels with you, um, several times. And, um, I loved how you enhanced the Western states race experience through your animated commentary with Dylan Bowman. And I am really excited to share a conversation with you

Corrine Malcolm (01:19):

Today. I feel fortunate that you are such a huge part of our community, both broadly and trail and ultra running, but also here in the bay area. Um, keeping many of us on our feet. Um, and so I’m really, really excited to kind of talk about some things today kind of in broad strokes. Um, we can get nitty gritty. We’ll make sure that you’ll have to come back on essentially is what I think will end up happening. But today, um, I’d really like to talk at least to get started about red S cause I think it’s so important. And I think it’s something that we’re finally starting to get to, like, just learn a little bit more about, um, more recently, um, termed in 2014 kind of becoming part of our normal vocabulary, um, both in athletics at, uh, at, you know, kind of the general level, but also at the very high level.

Corrine Malcolm (02:07):

And so I think many of our listeners will be familiar with terms like the female athlete triad, again, that being, you know, kind of those three pillars of low energy availability, um, menstrual disturbance and low manner or low bone mineral density. But I don’t feel like that quite paints like a full picture in PR like particularly because male athletes are also prone to things like disordered or inadequate fueling, um, and bone stress injuries. And so I’m wondering if you can help, um, paint a picture for us about red S and what that means for all of us as athletes, um, independent of sex and gender.

Dr. Emily Kraus (02:40):

Awesome. I think that’s a great start and I would be happy to take a deep dive and try and paint that picture a little, a little more clearly, um, for the, um, listeners. Um, I think it can be really confusing to navigate for an endurance athlete and all the terminology. And I think especially now with all of this information that’s being delivered, um, a lot of runners are really eager to learn this information and I find it fantastic, and I want to support that as best as possible and give them the right information. So, um, the concept of low energy availability, which is part of the triad, um, is really at the foundation of the female athlete triad. And that term was, um, really originated in the 1980s and was coined to the 1990s. And so there’s been a lot of research on the female athlete triad over the last many decades, um, which is great and has really helped support a lot of, um, some of the findings that we’re seeing now, which affect both males, males, and females.

Dr. Emily Kraus (03:38):

And there is a term that, um, recently came out called the male athlete triad, um, which is similar to the female athlete triad aside from instead of menstrual disturbances. Um, males presents with a nice big term called hypogonadotropic hypogonadism, um, which is really, um, involves, um, reproductive suppression from that low energy availability state. Um, so back in 2014, like you mentioned, the international Olympic committee put out a consensus statement on relative energy deficiency in sport, or I’m sure we’ll say reds will say red S um, it’s really your choice, but, um, really what it captures is it expands further on the triad and those many negative physiological and performance consequences of low energy availability. Well, beyond the reproductive suppression that we see in the triad. So this can include, include effects on metabolism, on thyroid, on, um, recovery, um, from, from sports and from activity on the immune system, beyond what we feel, um, with, with just the regular demands of endurance training and many other consequences that we’re still learning about.

Dr. Emily Kraus (04:47):

And so you can imagine at the year of 2014, when this really, um, this idea and this term, um, came out into the community that a lot of athletes are confused of, um, is a triad is at reds. And it’s really just, um, Rez is an expansion of, um, what’s been built on with the triad and, um, we were doing a lot more research and still doing research on both to really understand how best to educate the athlete and really reduce the negative consequences of, of both. And, and really a lot that we’re thinking about is his injury and how can we stay healthy and how can we stay on top of our training and not get, um, uh, uh, significant devastated and devastating injuries such as, um, a bone stress injury. And, um, you, you mentioned as part of the triad that low bone mineral density and, um, the consequences of that low bone mineral density over time can be, um, a bone stress injury, which is also considered a stress reaction or stress fracture. So that’s the, the, the picture that I wanted to start painting, and I’m sure we’ll have to kind of dig some deeper dives into some of those topics, but, um, I hope that we can kind of set that foundation of understanding. So then we can kind of grow from that.

Corrine Malcolm (05:55):

Yeah, I think it’s so important, um, that they’ve been able to encompass male athletes in this as well outside of just female athletes in part, because I think, I think it was overlooked for a long time that we assumed that male athletes didn’t have didn’t struggle, struggled, disordered, eating, um, ordinance struggled with low, low energy availability. And so I think it’s important that we’ve kind of painted these, these pictures that are both, you know, they’re kind of adjacent to one another, but at the same time, they’ve got a lot of, a lot of overlap, but I think it’s, I, um, I don’t know if I mentioned this to you off, off air or not, but I actually, I had this like very heated discussion with a good friend recently, um, a physiology friend of mine about, about, um, you know, about reds or red S um, and low energy availability and eating disorders and kind of like, where is the overlap here?

Corrine Malcolm (06:40):

Is there an overlap? Um, and my biggest, like trying to get down to the bottom of this was the idea that, you know, he was in the mindset that almost like red S and disordered eating, um, were almost synonymous like that you couldn’t have one without the other. And I don’t like to me, um, you know, sitting here with my physiology hat on and my athlete hat on, um, and taking offense to this in a lot of ways, cause we can talk about my own bone stress injury later, um, is that I don’t identify as being a person who struggles with disordered eating, but clearly, you know, have some, you know, have some underlying, maybe low energy availability. And so I think it’s really important to recognize that those two things are separate. And I think it’s really interesting. Um, and I’d love to dive into this a little bit deeper about, you know, the risks I think in our sport in particular, right. Low energy availability, um, we’re at a high risk for that just given the demands of our sport. And so trying to maybe bring awareness, um, to our listeners about, you know, what, what is low energy availability? What does that look like in their daily life? And, and what are the, you know, obviously there are repercussions of that. Cause I think people think, well, I don’t eat enough, I’m safe, but I, I think that that’s like a very simplistic view of that topic.

Dr. Emily Kraus (07:53):

Yeah. I think, um, I’m so glad you brought that up and I feel like it’s, it is an important debate and people can get really, um, take things personally, if they get categorized into this, this red diagnosis, especially if they feel like that they’re, they’re fueling properly. And so I think kind of getting back to just definitions, let’s talk about what, what is energy availability and low energy availability. And so energy availability is defined as the leftover energy available energy available to support all of an athlete’s body functions. So once the energy expenditure of exercise running or whatever you do, um, is taken away from that energy intake, the energy availability is what’s leftover. And so low energy availability is when, um, that what’s left over is too low to maintain your basic kind of physiologic, um, supplying all the important organs that we need to, to function properly.

Dr. Emily Kraus (08:50):

And so that’s when that reproductive suppression, um, and those hormones really start to get affected. And that’s when some of those other consequences can happen such as, um, in that diagram of red S and, and triad. And so low energy availability can occur from a few different mechanisms. One, it can occur from insufficient energy intake. So this is often in that disordered eating intentional, um, restrictive energy intake, um, that can be problematic either through, um, just a personal choice or maybe some other body image concerns. Um, but, but that is in that disorder eating category as, as, um, as had been discussed. But on the flip side, an athlete may be hitting low energy availability from over-training or that overreaching. And so I often see this in these transitions and, um, a lot of my work is work scene. I work with younger athletes and they’re in their teenage years.

Dr. Emily Kraus (09:44):

So they may be going from middle school to high school. They may be going from JV to varsity where that training load increases and the transition from high school to college that usually is a volume increase. And you think about the transition from marathons to ultra marathons and sometimes, um, there is a good awareness of, of fueling and the need to really match those fueling needs, but sometimes even the, the best, most educated of athletes with the greatest coaching and all the great training plans, um, still hit that low energy availability state for too long. And that’s when, um, the problems arise. And what is really concerning is when those athletes who maybe started with an unintentional low energy availability, feel like they’re gaining an edge, maybe they’re, um, they feel like they’re getting faster, um, because they’re, they’re actually losing weight. And then they start to almost take that to the next level, fly closer and closer to the sun.

Dr. Emily Kraus (10:42):

And, and that’s when problems really arise, um, where they kind of do get into more of a chronic energy deficit or chronic low energy availability state. And, um, unfortunately it’s only a matter of time when they either get an injury or get significantly fatigued and into this over-trained state where their performance really does take a hit. And that’s really where we want to educate the athletes on the importance of taking a step back and really looking into, um, what, um, what the long-term consequences of of that is. So I think you, you kinda nailed it that, um, read us and disordered eating are not synonymous and that there is a spectrum of low energy availability, and there’s also a spectrum of disordered eating where, um, that may not reach a full blown eating disorder that we diagnosed in, um, in a more formal way. Um, but it still requires some, some time to really kind of look into that underlying etiology and see if we can reverse some of those, um, those patterns.

Corrine Malcolm (11:40):

That’s super interesting. And I think, um, my friend’s argument and he’s a brilliant physiologist and he’s someone that I love to like, you know, go to the mat with and just like, have these, have these kind of heated, but very, you know, practical discussions with his, his take was well, like, even if they aren’t so say they are eating enough, but, or, you know, it’s, it’s an over and over, you know, quote unquote, uh, training volume overload. He’s like, well, isn’t that just, um, anorexia Athletica? Like, isn’t it just like, maybe it’s the, that like, is that what they’re doing instead of not eating enough? And, you know, yes, there’s probably a percentage of the population who that is there that is, you know, where they mechanistically aren’t meeting those energy demands, but it was just super fascinating to try to pick apart these pieces of who falls into this category.

Corrine Malcolm (12:26):

And I think it’s really, you know, terrible, but fascinating to think about, you know, these, these long-term consequences as your body’s trying to keep you alive, right? Your body’s main purpose is to keep you alive. And when you do this thing over and over again, that your body does not feel is, is beneficial that maybe in, and you get into this chronic depletion state, um, that all of a sudden, you know, it’s going to cut the things that it doesn’t seem deem necessary. You know, those, those red flags that we’ve talked about about like, um, menstrual disturbances or, um, male males kind of under these hormonal fluctuations. Um, so I think it’s really interesting that your body’s like, Nope, don’t need that anymore. You know, which is a red flag for us, which I think is important. So it kind of, you know, going from there, how best do we identify that in athletes? How do we look at ourselves as athletes or coaches looking at their athletes, um, particularly in these points of transition where maybe you don’t know that athlete super well, um, they’re making a jump up in distance. Maybe you’re a new coach to them. Maybe, you know, they’re, you know, say I’m going from, you know, running on the roads to running my first ultra, how do I identify this potential place? Like how do, how do I see it and say, I don’t want to be here. I need to course correct. What does that look like?

Dr. Emily Kraus (13:47):

Yeah. I think you raise a lot of different, good rigor, great points. And I feel like we could take some deep dives into a lot of that as far as even the relationship with exercise and overexercising and, and what, um, what we’re doing when we’re going out and doing those long runs in that training, is that an, is that the right approach? And I think especially in the ultra running, um, population, there’s, there is that slippery slope of, of really kind of craving and almost an addiction to this sport in a way that’s unique and different than maybe what we experienced in other sports. And I will say those endorphins and that feeling of running in that community and in the trails is, is really powerful, but it can, um, it can be, can take over, take over, and it’s important to really, um, have that healthy relationship with sport.

Dr. Emily Kraus (14:34):

Um, but back to your question, as far as, um, how do we identify this, um, this low energy availability state, or how do we prevent that, um, to kind of get to that point. And, um, I think it’s, it’s challenging because that’s unique and it can manifest or present itself in a lot of different ways and differently in different athletes and different sports and males versus females, which is why it’s important to study that difference in research and why there’s a push to really close that gap and understanding, um, how reds manifest in a male athlete versus a female athlete. But in women it’s a little bit more straightforward. Um, it can look like the triad with reproductive suppression. So that could be a change in menstrual cycle where an athlete may completely lose her period. And we see that a lot, especially in those high school athletes where they don’t fully have that understanding and understand, understand that the period is cool and you want to have it every month.

Dr. Emily Kraus (15:26):

And that’s an important marker that’s your, your body is, is, um, functioning at its prime. Um, but it also can be just a lighter flow or just maybe a little bit of an abnormality in the cycle. And so that’s gets a little bit more nuanced. And the reality is when an athlete loses her period, that’s probably a little bit more extreme and that energy suppression, or that low energy availability state, as far as how long it’s been going on. So ideally we’re catching that, catching that earlier. Um, but then in men who don’t have periods, um, they, they see other manifestations or different presentation of that, um, that, uh, low energy availability. And so that could be, um, a decrease in sex drive or decrease in the libido. And women can experience this too, by the way, this is just a male thing. And, um, they also, um, could present with a loss of morning erections and, and, um, high school males, um, that is, that is, should be expected.

Dr. Emily Kraus (16:19):

And so that is something that we do ask in our clinic. And, um, some other presentations that are out of that reproductive sex hormone category include, um, fatigue. So fatigue, despite feeling adequately rested, maybe taking another day or two off, um, maybe a plateau and overall performance, um, despite having to kill our coach with a great training plan, um, there are other, um, blood blood levels that can be, um, there are other blood levels that can be suppressed if you do have an access to, um, to get lab draws or lab work done. So this could be thyroid suppression. This could be, um, sex, hormone, suppression, like I was describing kind of more of those physical signs. You can also see those labs signs as well. Um, and then if it gets to the extreme, there can be weight changes or a decrease in weight, but it doesn’t have to be, um, sometimes the body is adjusting and acclimating and already dropping or decreasing the metabolism.

Dr. Emily Kraus (17:17):

So, and I think may not notice this extreme weight loss or a change in weight, um, but their metabolism slows, which is not good for overall performance or just overall health and body functioning. So I think those are kind of the heavy hitters and the ones that towards the end are way less specific and they could be from a lot of different things. So sometimes an athlete will just attribute it to another cause, um, and maybe be misdiagnosed and where they actually, and maybe there’ll be even placed on a medication. Sometimes athletes will be placed on thyroid replacement when it’s actually, um, reds. Um, that’s, that’s presenting.

Corrine Malcolm (17:55):

Yeah, we’re placed on place on birth control. I think that’s been, that was like a very popular thing when I was in high school was, oh, you’re not getting, you’re not menstruating while we can put you on birth control. And that will, that will give you a period. And I feel like we are moving away from that slowly, at least in broad strokes. But I know that that has been a very common treatment amongst young athletic women. And I think that that is, I mean, I am, I am hoping desperately that that information is being presented now to physicians and clinicians and, um, and to the athletic population and coaches, because what a, what a thing to miss right. To, to artificially trigger this and not actually put a bandaid on it instead of actually identifying what’s going on. Like that to me is so scary in retrospect. Totally.

Dr. Emily Kraus (18:43):

And it’s still happening. I mean, I current, I mean, you just graduated a couple of years ago, right? I mean, it was just, it just yesterday, you were in high school. Right. But it’s, but it’s still happening. I still have high school athletes who come in and say, oh, my coach told me to be, um, to start birth control pills because I lost my period during training or, or my, my, my doctor did. And so there’s a lot of education that needs to happen at even at that basic level. And, and it just, it really, I mean, it breaks my heart when I have an athlete who, who thinks that one is maybe a Rite of passage to, to lose their period during, um, during a sport. Um, which is, was this idea that, um, you’re not training hard enough or you’re not pushing your body hard enough if you haven’t lost your period and that’s, that’s not true and that’s false. And, um, I think I’m trying to really hard shift that, that, um, that culture into realizing that fueling your body properly is, is cool. And it’s important. And it’s important for longevity in sports, and it’s important to build your bones. Um, those high school athletes need to be building their bones, um, to set them up for life and hormone replacement. There was a time and a place for it. But, um, miss periods due to low energy availability is not one of them. Yeah.

Corrine Malcolm (20:04):

I, I, I am baffled and scared that, that, that narrative still exists, um, amongst, amongst, you know, athletes right now. And I see it in, you know, routinely in my Instagram feed of people being like, I used to think this is a badge of honor. I used to think that this was, you know, such a, you know, it was good that, that, that this had happened to me. And I’m happy that this message is getting out there and that, um, you know, physicians like yourself are kind of championing it. And then athletes as well are leading by example and saying, Hey, like you don’t, you know, this is, this is not, not the way, but then, you know, so we’ve put athletes on birth control sometimes, or haven’t had have historically to try to give them their period. But what about, um, this is kind of tangental little bit, but what about, um, athletes?

Corrine Malcolm (20:49):

So we’re talking about Canary in the coal mines, right? Like you, if you’ve lost your period, that’s a bad sign, generally speaking. And it’s kind of like, that’s an end of the road, not end of the road, but it’s, it’s a, it’s a late stage, bad sign. So what about athletes who the 20, let’s say the 20% of women who are on like marina, so a hormonal IUD who generally lose the bleeding portion of their period. That doesn’t mean they don’t have a cycle, but what, you know, if they’re not getting that, that bleed every month, what are, what can they look towards, you know, besides just keeping logs, um, to know, to know that hopefully they are still, you know, having some sort of natural cycle.

Dr. Emily Kraus (21:30):

Yeah, that’s a great question. And I wish I had a really easy well-defined, well-researched answer to that. Um, I think that there is a lot of, um, it’s, it’s convenient. Um, the IUD and the marinas is a convenient method of, um, of contraception. Um, but there is, it does eliminate that convenience of knowing that regularity of, of the menstrual cycle. And so instead I think that sometimes females still go through, um, sometimes they’ll still have spotting with the marina. And so that there is that, that indicator, but some there they lose, um, bleeding altogether. And so it’s, it’s a little bit variable based, um, from, from athlete to athlete patient to patient. But I also think that sometimes you can also feel those other, um, physical manifestations of the menstrual cycle and the different stages, which can still take place. So I think that’s a good indicator if you’re still having some of that Grampy, those crampy symptoms, the bloating.

Dr. Emily Kraus (22:25):

And so if those are eliminated or you almost kind of feel, um, even just a little bit more neutral throughout the month, that might be a sign of, of something being off and kind of back to that whole, um, like the lack of libido and the lack of sex drive those, those natural fluctuations of hormones circulating throughout your body. Um, if those are being suppressed overall, there may be this kind of suppression and mood, which could manifest as fatigue or apathy. Um, but again, it’s so non-specific that, it’s hard to just pinpoint and say, oh, this is related to my fueling, but if you kind of go back and you kind of look at your, your log, you may notice as far as your refueling strategies or even just, um, training hours and hours out on the trails. Um, during that time you are going to hit an energy deficit and you are going to be low, but that refueling that day, and even the days after that are super important, despite whether or not you feel like you need, um, you feel hungry and you feel like you need to refuel. It’s just getting into those, those habits. And, and really either like being a good learner or being, um, UN kind of seeking out those resources, um, whether that is meeting with a registered dietician to just calculate those, those needs and those particular specific needs for you, or working with the coach to really come up with that fueling plan from the beginning and practice that from the beginning. So you don’t run into those issues down the, down the road.

Corrine Malcolm (23:51):

That’s so interesting. I think you, we kind of just grazed a very important topic, particularly for trail and ultra runners. I know specifically for me, but when I’m at altitude, I need more calories. Um, I intentionally taken some more calories, generally like a second dinner, kind of a snack before bed, um, host dessert, snack before bed. Um, and what I see in, in athletes that I coach and in myself is that I go for big, long runs on the weekend. And then I have a rest day on Monday. And I think it’s really easy to potentially fall into this, like, you know, this glitch where it’s like, well, I’m not training today, so I don’t need to eat as much. So can you talk a little bit, I know in research, this is oftentimes termed like day to day energy availability, or even inter day energy availability. Like how, how can we think about that as, as runners and coaches, as far as like making sure we’re adequately fueled, even in those micro kind of those micro those days in between? Yeah,

Dr. Emily Kraus (24:44):

I think, um, it’s so easy, especially when we talk about altitude, um, not just even like the whole overall under, just under fueling or not meeting those demands that an altitude puts on your body, but also even just talking about iron levels and talking about iron deficiency and those additional iron needs to kind of give your red blood cells that hemoglobin that extra capacity to deliver, deliver that oxygen. And we also see, so in addition to like planning ahead, like you said, with, um, just making sure that you incorporate the additional snacks you double, I mean, you really need to add in to kind of make sure that meal is really timed well, post post-training efforts, even when the appetite is suppressed, because I think that’s another challenge is after you do those hard long efforts, um, whether, and also with altitude and just a lot of components of, of the type of training that an ultra marathoner is doing, um, the, there isn’t this hunger to, to really kind of fill up the, that plate with really healthy, healthy meals.

Dr. Emily Kraus (25:50):

So I think one strategy would be to break it up more, make sure that you, right after that training, you get something in the system, but maybe it’s a, uh, a really good well-rounded smoothie, um, with a good kind of carbohydrate protein ratio. Um, and then after that, had that good full meal, that Hardy meal later on when maybe your stomach is a bit more can tolerate that. Um, but then adding in those additional snacks too. And, and really that, that rest day is not a day to, to really deprive the body. I mean, that’s the day when the refuel recover. I mean, that’s the importance of the rest day. So, um, taking advantage of that rest day and refuel day and, and use that to, to set you up for the rest of the week. So that way you’re not going into this, um, glycogen depletion into that next round of training.

Dr. Emily Kraus (26:39):

And I think that’s where athletes really maybe missed the Mark A. Little, and it may present in different ways where it’s just, they feel like they’re not responding to their training. There may be, um, a little bit, um, under maybe not hitting the marks as far as the, either the distance or the time, um, or just, or it could be an injury and it may not be a bone stress injury at that point. It could be another, another cranky nagging injury that, that, that comes up. So, so T factoring those, those pieces in whether it is, um, going out to altitude for a weekend, even if it is just a weekend or long weekend, um, take that into account and make sure that rest of the week, when you returned back from the mountains that you’re thinking about how you address that deficit, that was this past weekend.

Corrine Malcolm (27:26):

Yeah. I like the refuel day. I think I’m going to add that into all of my athletes training plans from here on out. It’s not going to say recovery day, it’s going to say recovery and refuel day. Cause I think that is so important to stress, to stress that because a lot of us do come out of those weekends and just a huge caloric hole and that doesn’t set us up well for, for training. It doesn’t set us up well for recovery. So I like that refuel day is going into everyone’s training peaks from here on, which is great. Okay. So switching gears, just a smidge, um, I’d love to talk more about the research that you all were able to publish recently for those of you that don’t know. Um, Emily and her team just finished up collecting data on their third year of research with the Western states endurance round, which is so exciting to have this big longitudinal or just like multi-year data collection, um, on trail and ultra runners, because we are a group of athletes who do not get researched all that often.

Corrine Malcolm (28:26):

And, you know, it’s hard for clinicians and physicians like yourself to, you know, figure out what to do with us because there isn’t data out there on out. So I’m really excited. And I would love to hear, um, more about what you guys have found so far. And this is really diving into that bone stress injuries and kind of risk factors for bone stress injuries and risk factors for, you know, male and female athlete triad. I just, you know, I would love for you to give us a synopsis of what that research has looked like, and then we can kind of just dig into it from there.

Dr. Emily Kraus (28:58):

Um, thanks. Thank you. Um, our team was really honored to be given the opportunity to do research for three years, almost consecutive and the kind of COVID year. It doesn’t really count, but 20 18, 20 19 and 2021, we were, um, conducting research. Um, and thanks to funding from the, from the Western states research foundation, which is a phenomenal foundation and big shout out to the board. And, um, they’ve been funding research for decades and a lot of the research and those articles that are published out there are from studies on Western states runners. And so thank you to all of the runners who continue to participate and sign up despite a lot of other distractions that can happen during a race weekend. The fact that they’re willing to do that helps contribute to the sport science. And also, I want to give a big shout out to Dr.

Dr. Emily Kraus (29:50):

Runner researcher podcast, or Megan Roach, who has been involved with this and research from the beginning as well, and has been, she’s such a hard worker. And, um, she’s also a joy to do research with and just, um, you know, an inspiration in and of herself. So back to the, the science. So our goal with this research was to explore, um, the occurrence or how often, um, triad, um, female and male triad risk factors occur in ultra marathon runner. So, um, we wanted to just look at that as a potential determinants of overall bone health. And we also looked at other associations between sex hormones and bone mineral density, and also looked at genetic risk factors the last couple of years. So, um, each year the runners would get contacted and recruited months before they would, um, if they agreed they would fill out an online survey and then, um, read or sign up for, um, a bone mineral density scan, um, onsite at, um, Olympic valley, um, in the days leading up to the event when they arrived just as, um, when they arrived to, um, to the Olympic valley and they would get their DEXA.

Dr. Emily Kraus (31:01):

And so the DEXA stands for dual energy. X-ray absorbs geometry, which is our one of our measurements of bone health. And then we would get lab draws, um, which, um, thanks to inside tracker. We were able to get a phlebotomist onsite for the last, um, two races. And, um, we got, um, T different sex hormone levels, including free and total testosterone. We got, um, a measure of iron, um, through a measure of ferritin and then estrodiol, and then we also got, um, vitamin D and then, um, the third part, um, which we did for the last two years was we, um, did genetic tests through a company called [inaudible]. And we looked at different markers for low bone mineral density and genetic markers for low bone mineral density and bone stress, injury risk. So we got all that information and, um, we thankfully got, um, uh, some preliminary data published in the clinical journal of sports medicine, which just got published right after the, the most recent, um, Western states.

Dr. Emily Kraus (32:05):

I was really hoping that it would get published before, so that we could, um, print out a bunch of them and just hand it out, like candy, like do something light reading before you go to bed. Um, so, but we did not, it was, um, shortly after. And so we presented those findings, um, in the paper and, um, we had 40 women at 83 men participate in the first two years, which is great. Um, and it’s about one fifth of the racing field and given the extent and how much, um, was involved with the race participation. I, um, I find that a fantastic number and the ratio of, to men is pretty, um, pretty, um, similar to what the ratio in the actual on Western states, um, is. So we found that about one third of women in our study had a history of stress fractures, which is about 37.5%.

Dr. Emily Kraus (32:55):

And one fifth of men at about 20.5% had history of phone, stress injury. And the overall, um, prevalence that’s been reported is about 25% of ultra marathon runners. Um, so our, our females actually had a higher overall number than the, um, kind of overall prevalence of, of bone stress injuries. And that’s a higher number than what we see even in the, um, high school and collegiate athletes. And the question is, you know, over the so many years of running, does that just kind of accumulate your overall, um, kind of risk and your number of years to sustain a bone stress injury, and it’s, it’s possible. But one of the findings that I found really interesting was the number of athletes, um, trying to lose weight for performance. So one of the questions in our survey was, um, are you trying to lose weight for performance and over 50% of women and 46% of men, um, reported yes.

Dr. Emily Kraus (33:47):

That they were trying to lose weight for performance. And it kind of goes back to that question of, um, with low energy availability and disorder eating. You know, I think there is that spectrum, um, where it’s, it’s okay to try to try to lose weight for performance, but there are a lot of methods and, um, healthy methods and unhealthy methods to get to that point. And unfortunately, without either through kind of a lack of education or lack of help and support, or the resources and that, that can very easily slip into those unhealthy habits and slip into that low energy availability state. And some of the other questions that we asked were a little bit more probing as far as some of those disordered eating patterns. And so we found that two thirds of females and about 45% of males, um, based on our, um, kind of screening process, um, we’re at moderate or high risk for disordered eating.

Dr. Emily Kraus (34:37):

And so it kind of goes back to that, um, bigger issue as far as, um, the education and, and really getting back into maybe even just a bit of the why, um, some of those questions were answered how they were, and there are limitations with, um, an online survey. Um, but I do think that this, because this was anonymous that, um, these were their, their true answers, but again, it’s, it’s a survey and these are, these questions are validated, but does it really dive into, um, some of the questions that we’re trying, trying to get to, and, and I think we’re still working through like the right questions for the right athletes. And one of the other interesting findings was looking at just overall sex hormones. So we got testosterone and estrogen estrogen levels in both males and females. And we actually looked at that relationship as it relates to their bone health with bone mineral density.

Dr. Emily Kraus (35:26):

And we’ve found that the higher sex hormone levels, so the higher testosterone and yes, women do have testosterone levels, is that a lower, lower level than the males, um, that the higher, the sex hormone levels, the higher the bone mineral density in, in female and female ultra marathon runners. So it kind of goes back to that point of finding ways to optimizing your hormone levels circulating throughout your body, to make sure to enable your bones to, um, remodel and reproduce, and kind of be their best versions of themselves at each decade of your life. And especially as we’re building birthdays and kind of getting into that, um, osteoporosis or excuse me, that menopausal time, um, later on, um, hopefully I’m talking to Corrine and I we’re we’re, we still got some, some time there, but, um, but with the ultra marathon population, there’s a spectrum as far as, as far as age, um, that do, um, participate in these races and they, they, we do, we did have some women in that perimenopausal time.

Dr. Emily Kraus (36:24):

And so taking that into account, um, doing everything that you can to optimize those levels, um, for as long as possible is going to be really important. And, um, we’re still, I’m fully trying to understand, um, what we can do to optimize bone health and this I’m highly active population, but I got to say, um, I had a really fun conversation with, um, Dr. Anthony, Dr. Tony Hackney, who’s this hormone physiologist at the university of North Carolina, and he’s done a lot of work on, um, kind of hormonal suppression and especially in athletes of all, all sports, but especially in an endurance sports as well. And, and we, we just talked about this, this need to really understand the, the ultra runner and what are like, are there a difference, um, is there, are there things that have allowed that to athlete to, to, to be a bit more resilient, to, to injury, to get, to get them to that start line, especially Western states.

Dr. Emily Kraus (37:23):

And I do think that there are some, either protective factors within the training within genetics that that did allow that athlete to, to get there. And, and I think we’re, we’re still trying to understand it through these, his questions through these hormonal profiles. And, um, we’re still trying to analyze the data from this past year, but, um, I’m excited to be able to present that and see if we can get a little bit of an understanding as far as, um, what are the, what is the unique risk profile for, for an ultra runner. So that way we can, um, provide the proper education for you all.

Corrine Malcolm (37:58):

That’s so interesting. And I think it’s, I feel like research generally speaking, if you’ve formatted a good, if you’ve, if you have formed a good research question and you are collecting the right data, the answers are almost like, well, duh, like this is what we think like, it’s, you know, it’s kind of like, it’s, it’s not to say it’s common sense, but you’re like, oh, of course, this is what we’ve found. And I think it’s really interesting that, you know, there’s, uh, almost a 50, 50% chance of these, one of these runners having some sort of disordered eating or high risk for it, almost a 50 50 chance of having a history with stress fractures and, um, you know, and a 50, 50 chance of those factors potentially playing, or, you know, chicken or the egg here, um, these hormone levels. And I just think that’s so fascinating. And I do, um, correct me if I’m wrong. What was the bone for bone density who had an, I mean, I think it was kind of, it was split, but who had males versus females in this, in the study? Um, what was the bone density like for those athletes as well? Oh,

Dr. Emily Kraus (38:55):

Great question. I glossed over that. I want to make sure I give the right the right number is it’s so bad that I, um, somebody gave me a hard time. Jason Cooper gave me a hard time. He’s like, you have to look up data for your own research. And I’m like, yes, I don’t want to misquote myself in this. That’s okay. Really embarrassing. So as far as, so this was another interesting piece. Thank you for bringing this up. Um, for bone mineral density, um, we kind of broke that down into low, moderate and high risk. And so we were using this, um, female athlete coalition, um, cumulative risk assessment tool to help break down low, moderate, and high risk. But in females only about 20% were at moderate or high risk for low bone mineral density compared to about 35% of males. So males had lower bone mineral density.

Dr. Emily Kraus (39:44):

They had less stress fracture risk, but not, not terrible. Um, and the question is just about one, like what’s the breakdown as far as, um, what bone mineral density markers do we need to give as far as, um, say for unsafe for a male runner versus a female runner two, we may be underpowered with this group to really say that, um, males had crappier bone mineral density than, than females, but is there, is there also a protective factor with that? If females had worse bone mineral density, would we be seen as stronger? We actually didn’t see as strong of a correlation with bone stress, injury and bone mineral density and the males and females, but it’s, it’s an interesting point. And, um, some of the questions as far as genetic risk and, um, but we did see some correlate, some relationships between genetic risk for bone mineral density and low bone mineral density and males, but we did not see that relationship with females. And, um, I think our question is, are there, are there other factors that are contributing to that relationship between bone mineral density? That’s just beyond the genetic piece. So are females more susceptible to those environmental factors, like low energy availability and low end that are they more sensitive to those changes and those hormonal changes than, than a, than a male, and will, can that almost change their trajectory as far as their genetic risk profile. And

Corrine Malcolm (41:16):

That’s so interesting. Yeah. That’s yeah, of course, of course we’ve got so much more research to do and which I think makes us very, very exciting. And I think there’s probably something there with hormonal or like sensitivity to hormonal changes, maybe with female athletes compared to male athletes, just because I feel like not to say that we are definitely not delicate by any means now, but you know, it seems like female athletes in general are more susceptible to the negative consequences of specific diets or of under fueling it’s into that. There’s a protective factor maybe, or testosterone in general is just less, um, less, um, I don’t know, susceptible to those like Mo like small changes maybe as opposed to, to female sex hormones. Um, but maybe, you know, hopefully when we

Dr. Emily Kraus (42:01):

Think about the menstrual cycle too, so there are those fluctuations that are just, um, we just, we don’t see in a, in a, in a male.

Corrine Malcolm (42:09):

Yeah. And I think it’s, I mean, I hope that this actually that we can from this, get this, you know, kind of a risk, a risk profile that could be a tool for, for athletes, for coaches. You know, I am a person who has had to come see you in your office, um, which is hilarious too, because for those of you who don’t know, Dr. Cross works out of a, uh, a pediatric ortho office. And so when I checked in, they asked who the patient was and I was like, I’m the patient? And they asked my birthday and I was like 1990. And they were like, are you sure? I was like, yep, I’m here. Um, so I do think that this becoming a tool for athletes and coaches could be really promising, um, because you know, when I look at, when I look at red S in general, I don’t see myself in that data very clearly, but you know, this winter got myself a really fancy, you know, bone stress injury in, in a big bone to, in a big bone that, you know, I think raises a lot of red flags as far as something must be going on and talking to folks too.

Corrine Malcolm (43:05):

It just, it turns out it takes a lot of energy to, to lay down bone over and over and over again in our sport. You know, I’ve, I don’t know how many steps I’ve put in into my legs over the last, you know, six years being an ultra runner. But I think that there are, you know, I think that having a, a risk factor tool that we can, you know, we can, and we could ask these questions, answer these questions honestly, um, could be really helpful for, for many of us, which I think would be just a wonderful thing to come out of, you know, three years of three years in much more research to come I’m sure. Yeah.

Dr. Emily Kraus (43:38):

Yes. We’re working on it. Kerryn it’s work in progress,

Corrine Malcolm (43:42):

No pressure, no pressure to solve bone stress injuries for all Shriners, but I would appreciate it immensely. Um, and I, I would like to dive into this deeper and deeper with you, but I’m gonna let you, I’m gonna, we’re gonna, we’ll, we’ll wrap up for today so that we can let you get back to your office and your patients who I’m sure are patiently waiting for you. And so that no one in your office, you know, gives me a hard time down the road either when I ask for more of your time, but I’d like to, we’re gonna sum it up here. And then I’ve got one last question for you. So, so big picture takeaways for everyone listening at home, we talked about red S today. Um, you know, really being cognizant of your energy availability and looking out for factors that any of us can track, you know, that that being menstrual abnormalities or for men, you know, things like morning erections, um, you know, being like being cognizant of fatigue, you know, a journal or an app that you can log this stuff in would be very, very beneficial and then be smart and thoughtful when it comes to, you know, like snacks in times of higher energy demand and using those refuel days to hopefully catch up after big long efforts.

Corrine Malcolm (44:46):

Um, and then obviously fantastic to hear about all the research that you’re doing, um, with ultra runners, because it is so, so important, and we will look for more publications to come for your team down the road. So our listeners are hopefully students of the sport. And I want to know if there’s one piece of advice you wish you could pass on to young and old athletes alike so that they do not end up in your office. Like me, what would that be? Just one, just one, just one for today. We’ll have you

Dr. Emily Kraus (45:16):

Back. Okay. All right. All right. Um, so to keep with the theme, I think, um, fuel is your friend kind of use, think about it as fuel. Think about it as a fueling you for performance, fueling you for reducing that, that injury risk fueling for, for life. Um, kind of think about all these other life stressors and whether it’s, um, traveling to altitude or, or just, um, kind of surviving a, a stressful week, um, think about that food is fuel and, and fuel often, especially as your training ramps up.

Corrine Malcolm (45:47):

Awesome. What wonderful advice that we can all he’d we made brownies last night. I’m excited to go have more brownies later. Um, Dr. Emily KRAS, thank you so much for your time today and your, and your willingness to share your knowledge with all of us. Um, anyone who’s listening to this volunteer to be a test subject at future ultras, um, researchers like Dr. Krause and her team need us to be their Guinea pigs. Um, with that, I’m gonna let you go, thank you so much. And I hope I get to ride a bike or run with you soon. Yes,

Dr. Emily Kraus (46:18):

Me too. Thank you, Corrine. And yes. Thanks for the shameless plug for more research subjects.

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