Closing the Gender Gap in Sports Research with Emily Kraus, MD and Megan Roche, MD

This week’s podcast features a discussion with Stanford Female Athlete Science And Translational Research (FASTR) Program Director Dr. Emily Kraus and Lead Researcher Dr. Megan Roche. The FASTR program 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. The program hopes to “inspire female athletes to learn more about their bodies and embrace what makes them strong and unique. Through proper education surrounding fueling, recovery, mental health, and more [they] encourage the development [of] lifelong athletes.”

Dr. Kraus is a Clinical Assistant Professor at Stanford Children’s Orthopedic and Sports Medicine Center. She specializes in Physical Medicine and Rehabilitation sports medicine. She is involved in several 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.

Dr. Kraus also spends time performing gait analysis at the Stanford Run Safe Injury Prevention Program and serves as a medical advisor for the Adaptive Sports Injury Prevention Program at the Palo Alto VA.

She has completed seven marathons including the Boston Marathon twice and one 50k ultramarathon.

Dr. Roche has a medical degree from Stanford University but is now a Ph.D. candidate in Epidemiology and Population Health at Stanford focusing on bone health in athletes and the genetic predictors of sports injury. Dr. Roche is a post-doctoral research fellow at the Stanford Center on Longevity and is helping launch Stanford’s Lifestyle Medicine Initiative.

Dr. Roche is a five-time national trail running champion, a North American Mountain Running Champion, and a six-time member of Team USA. She is a co-author of the book “The Happy Runner” and a co-founder of Some Work All Play, a coaching group centered around finding long-term fulfillment in the process of running.

In this episode, you’ll learn about low energy availability, bone health, proper fueling and more!

“When we talk about low energy availability, when we talk about the female athlete triad and relative energy deficiency in sport, there’s a lot of arrows that you can draw to mental health. They’re bi-directional. They’re feeding into each other in multiple different ways. And I think for every athlete, again, I’m going to hold up my ‘it depends’ flashcard, it’s so different. What is driving low energy availability might be different for every athlete. Like as Emily mentioned, sometimes it’s totally inadvertent and athletes don’t know it, but I think for athletes that are struggling with it, it’s about ideally working with a counselor or therapist to untangle what are the underlying reasons that they might be more prone to experiencing these thoughts, or what even are some of the cultural reasons within sport. So ideally there’s a therapist or a counselor on board. I know that’s not possible given access and needs and I think this is where having productive conversations, if that’s not the case, with coaches, teammates, fellow athletes, and really just I hope we’re making a cultural shift in sports that people feel open talking about mental health…”
– Dr. Megan Roche

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Key Takeaways

How Drs. Emily Kraus and Megan Roche started working together
The push to study female athletes
What is low energy availability
How this also applies to men
How sex hormones affect bone health
What does proper fueling look like
How mental health impacts low energy availability
Early symptoms of low energy availability
Bone health and longevity as an athlete
Genetic predictors of sports injury

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Transcript

Sonya Looney: Emily and Megan. I don’t know. You guys are so accomplished. I’m like, do I call you doctors. There’s MDS and PhDs and medical degrees and all kinds of multi-time trail running National Championships. There’s just all kinds of amazing women power on this podcast right now.

Megan: Oh, thank you. Well, Emily and Megan is great. That’s how we roll in meetings. And just so excited to get to chat with you, Sonya. I feel like talking about women’s athletics and female athletes with you. You’ve just been crushing in the athletic world and just, I don’t know, bringing a lot of light on your podcast. And so I feel like I’ve been excited about this conversation for weeks. So thank you for doing this with us.

Emily: Yes honor to be on Sonya. And sometimes I do call Megan the boss, so you can call her that if you want.

Sonya: All right. So the first voice was the boss. That’s Megan. And the second voice is Emily. So I’m really excited today to talk about bone injuries and to talk about low energy availability and diet and women and also men and trans women, like, all kinds of awesome things to talk about today. So first of all, I guess, how did Megan, you and Emily, how did you guys find each other and start working together?

Megan: I love this story. And actually, I probably tell this story. Emily might be sick of it by now because I tell it at a lot of different meetings when we’re first presenting. But about seven or eight years ago now, which feels like a long time, I stumbled into a musculoskeletal clinic in the Bay Area, and Emily was working as a preceptor there. And I was a med student hungry for information and for learning more. And Emily was just so great. She took me under her wing. She was very just like, teaching me the information, teaching me the ways, and then we connected up for research after, and the rest is history. Just really grateful for Emily’s mentorship and all of her support along the way.

Emily: One of our first meetings was actually on a run around Stanford campus. It’s like the quintessential, like, two athletes, people interested in sports medicine, going on a run, nerding out, talking about different research ideas and different career directions. And it’s been really great to see Megan. I was in fellowship at the time, and now I’m practicing sports medicine. Megan was in med school at the time, and she’s now getting her PhD in epidemiology. So it’s just really fun to see how our journeys have taken us and almost kept intertwining throughout the whole process. And I learned a lot from Megan. She’s so hard working, and I feel like we have a good synergy when we work together on projects.

Sonya: Both of you seem to be, I don’t know the right word, but just amazing at building community amongst female athletes. Like, just what I know of both of you, and just what I see online, too, you’re both so encouraging and so inspiring in so many different ways to women. And you bring women together and you build them up, and it’s just amazing to see that.

Megan: Thank you. I don’t know if we could compile wisdom. We’re just really going to that idea of making things fun and hearing that feedback. I feel like for us is the best feedback that we could get. So thank you for that. But I think as we have gone through this research process, we realized how fun it is to do the research together. These topics, understanding female athlete physiology is truly beautiful, and it’s cool and inspiring what female athletes can do. And I think we’ve realized that as researchers and also realize that far too often the language isn’t always centered around that. And so that’s been a big push of how we communicate. And I think female athletes and coaches and parents are really clamoring for information in that way. And so when we launch FASTR which I’m sure we’ll talk about coming up, that was a big part of it. And we were really inspired to see athletes just respond to the fun nature of those conversations and talking about this in a way that breaks it down. And it’s inspiring for young people and athletes.

Emily: I feel like there’s such an intersection between really understanding your body well. And I think as athletes, we’re just hungry for information and data, and sometimes it’s really overwhelming to know where to look. And so we go to Google, we go to blogs, we go to other people’s, other women’s, personal experiences with a certain injury or a certain process like pregnancy and getting back to sport. And I think sometimes it can be really hard to navigate what has the science and evidence behind that and what is a little bit more like a personal experience that could have science and evidence behind it. And so I think even through our peers in our community, we’ve learned, oh gosh, there’s so many gaps, and it kind of reinforces and inspires us to keep moving forward and pushing forward with a lot of our research goals and kind of future visions.

Sonya: I guess my next question is kind of where to start, because I read, and there’s an outside article that was written about you guys in your program FASTR, and it said that women accounted for only 3% of study participants in sports performance studies. And there are so many misconceptions about generalizing all of these studies on women, and there are so many different areas we could go. So where do you like to start whenever you start talking about this?

Megan: I think we like to start just acknowledging the progress that’s been made. So I think over the last couple of years, there’s been a really big push to start studying female athletes in specific, both at Stanford, through the programs that we are working on, but also across other institutions and across even business partnerships, academic partnerships, coaches. There’s just, as I mentioned before, people are really clamoring for this information. So I think we’ll start to see those stats kind of starting to turn over time, which is really exciting. But the big reason that it’s so important is because, yes, there is this dire need. There’s this gender gap in science. And the challenge is that if female athletes aren’t being included in studies, it really becomes hard to generalize that science and make it strong and applicable to female athletes. So although we’re inching forward and although we’re making a lot of progress, I think there’s still a lot more progress to be done and still a lot of progress, too, as I was mentioning, as it relates to language, as to how we talk about this and how we talk about it with coaches, parents, athletes, and across all spectrums and all generations. And I think those conversations are exciting, but there’s also a lot more work that needs to be done.

Emily: And I think it really just this opportunity through FASTR has allowed us to dive in at a kind of a deeper level in both the scientific components, actually doing the research, but then finding a way to really translate it, I guess maybe to transition to FASTR and kind of explain a little bit more about that. So FASTR came from a research initiative through the Wu Tsai Human Performance Alliance, and their focus involved six different institutions who came together and are doing some great research on health and human performance and athletes of all ages. And one of their big pushes is on female athlete research. So our program FASTR stands for Female Athletes Science and Translational Research, and it’s through Stanford. And I pulled Megan on really early on as a research lead, and I’m the director for that. But Megan is right that there is this gap that’s trying to be addressed through research, and some of the challenges are studying the female athlete we need to factor in. Are they on hormonal contraception? What is their hormonal profile at this time? And the challenge in the past is there have been studies on female athletes, but sometimes the approach that they’ve taken isn’t standardized, and it’s unique for that particular study. So it’s hard to maybe understand it in the broader sense. And so there are some really good papers even within the last year that have really started to create protocols for how do we study a female athlete to take into these beautiful hormones and these fluctuations in hormones in a way that we can really take some good takeaways for both injury risk reduction and performance and even from coaching to training and even in the medical clinic?

Sonya: Yeah. It seems like the low energy availability problem is kind of the backbone of all this. So can you talk about what that is? Because people might have heard of RED-S, you might have heard of RED-S, you might have heard of low energy availability. They might have heard of the male or the female triad. And they’re probably like, what is all this stuff? I know it’s important, but what is it?

Emily: Yeah, I can dive into that. And it’s interesting. We do a lot of education as part of the FASTR platform. So it’s fun to try to break this down in a way that people can understand it because it can be really confusing and overwhelming. So low energy availability can occur from a couple of different methods, I guess, or different approaches. So an athlete may be overtraining, they may be under fueling, there may be a combination of overtraining and under fueling, maybe through an acute increase in training or just a change in dietary habits. And this can be completely unintentional, especially with younger athletes. I see this more unintentional underfunding happened when they go through transitions, whether it’s the transitions of going from JV to diversity or from middle school to high school or even high school to college. But I think there can also be some cultural influences to that under fueling that can take an athlete into a more intentional under fueled state. And that’s where we really run into kind of more longer term problems because of the challenge of reversing that. And the longer an athlete may be under fueling or in this low energy availability state, that can lead to depression or imbalances of hormones, and that can lead to suppression of certain sex hormones like estrogen and progesterone. And that can, over time, lead to a loss of period or irregular periods or a delayed period in a young athlete. And so those two pieces are parts of the female athlete triad. And the third one is the low energy availability, the irregular periods. And then the third is how that affects our bone health, so that prolonged suppression can lead to impairments or imbalances in bone remodeling, leading to greater bone breakdown and impaired bone formation. And so over time, especially as athletes, if we’re having impaired bone remodeling, that can lead to increased risk of bone stress injuries or stress fracture, stress reactions. And that’s oftentimes when the athlete lands in my clinic, is they come in with a stress reaction, and they’re like, oh, yeah, I missed my period for the last few months with my increase in training. And they are in this low energy availability state. And just to kind of go beyond that with RED-S. So relative energy deficiency in sport is really an expansion of the triad if you look at the different circular models in the RED-S diagram, even has the female athlete tried as part of that, but it also covers all these other potential health and performance consequences that can be from this low energy availability state. So we really cover both of those topics a lot with our education, but we really try to hone in on this low energy availability as that foundation. And so really working on trying to address the why that athlete got there, whether it was training or fueling or even just some images about body image and the way that they should look in their sport. So I know that’s a long winded explanation, but I think we all feel really strongly about getting this information out there in a way that’s easy to understand and seems like relatable to that athlete.

Megan: And I like how you phrase that, too, as low energy availability is the foundation of all these different processes, because as you can see on, Emily, that was such a fantastic example of how low energy availability causes all of these different downstream cascades and different processes. And for every athlete that might be different, like an athlete may present first with a bone stress injury, or they may present first with lots of periods, or they may present first with performance impact. And I think when you have low energy availability as the foundation, it becomes very clear that there’s just so many different processes that low energy availability impacts. And talking about it in different ways with different athletes becomes kind of paramount and key because it impacts athletes just across these different spectrums. But I think what we found is that really highlighting that performance component is something that athletes can grasp on to, because sometimes an athlete might not be as motivated by injury or some of these other variables. But when you start talking about it in the lens of performance that I think it’s very challenging to have strong performance without fueling the body well, I think that’s something that athletes, coaches can really grasp on to you in a tangible way.

Sonya: How does this also apply to men?

Emily: Great question. So the female athlete triad has been around for decades as far as this idea and some of the science behind the female athlete triad. But just recently, there have been more papers and even just more clinical cases. For example, in my clinic, of male athletes who present with very similar triad presentation, except instead of impaired, irregular periods, males present with this mouthful of a word, hypogonatotropic hypogonatism, which is also suppression of certain sex hormones like testosterone and impaired sperm function and development of sperm. And I think that that’s something that is even more taboo to talk about at times with athletes is that there is an equivalent in presentation of male athletes. And the challenge is also that the fueling and the energy availability state might be a little different as far as what is that threshold to lead to that sex hormone suppression? But the relative energy deficiency in sport does Compass both males and females. So I think this is important information that can be taken away as far as fueling and fueling strategies and just this kind of this pressure to fit this mold and this look within the sport.

Sonya: So how does suppression of sex hormones affect bone health?

Megan: Yeah. That can happen actually over longer periods of time or over shorter periods of time. And what we understand is that when you’re not getting inadequate energy availability, it causes perturbations in many, many different hormones, estrogen and testosterone being the base of those. And estrogen is foundational for bone turnover, for bone development, for bone remodeling. It’s actually interesting to think about that as we go through life as athletes, our bones are constantly remodeling and responding to stress and turning over in ways that are productive for bone development and bone growth. And so these hormones are foundational for providing that remodeling stimulus. The other thing, too, that we talk about with athletes is that a lot of bone development happens at a young age. So adolescence is a crucial time for peak growing development. And so that’s also a common time that athletes might struggle with low energy availability. And so it becomes very important to have these conversations young so that athletes can set that foundation for bone development and for strong bones going forward. But as we talk about it with athletes, we talk a lot about things that can build strong bones. So calcium, vitamin D, strength training, strong muscles pool on bones and create stronger bone foundation. So when we say find your strong, that has applications for both body image and bone building as well.

Sonya: Yeah. I was actually wondering why the focus was on seemingly younger female athletes, but I also wanted to ask about peri-menopausal and menopausal women because it seems like there’s new research emerging and lots of women who are crushing it into their later years. How does this apply to these peri-menopausal and post menopausal women?

Emily: That’s a great question, Sonia. And I think that you highlight this exciting trend and transition from both the focus on the science. Let’s better understand these physiologic changes and not be afraid of them. Menopause shouldn’t be a scary word. It should be this word of, okay, we’re going to understand it and maybe adapt or change training to really optimize that. And there are a lot of hormonal changes and sex hormone suppression that’s happening. That’s interestingly, very, very similar scenario as far as maybe an athlete who has sex hormone suppression through low energy availability just at a different time and may be accelerated at a different pace. And so these athletes, menopausal, peri-menopausal athletes do need to, I think, factor in different bone building activities in a different way than maybe a kind of pre-menopausal athlete just to make sure that they’re able to maintain the bones that they have and not maybe go into that low energy availability stage, which then could really affect specifically, it kind of accelerates that bone breakdown with the bone remodeling process in a way that could be even more detrimental. But I think that from what I’ve worked with with athletes who are kind of going through some of those transitions, kind of more on a one on one basis, not from a coaching, but more clinically is encouraging more resistance exercise and strength training, discussing other type of weight bearing activity, maybe adjusting or adding in more recovery time and more just kind of not whether rest days or lower intensity days to allow their bodies to kind of fully recover. But I’m curious. Megan is kind of wearing the hat of a coach as well as a scientist and researcher with a medical background.

Megan: Oh, I’m impressed because you’re talking about the clinical recommendations, and that’s exactly what I would recommend as a coach, too. The other thing I would add in there, too, is just adequate protein intake. So that becomes especially important in this period of puzzle menopausal years to support strong bone development, support strong muscles that are again helping to build those strong bones. And also for athletes that are doing a lot of run training, that’s when I tend to incorporate a little bit more cross training in there as well. And so it’s really an individual approach. It sounds very similar, actually, to the clinical approach and individual coaching approach, but really focusing on those varied movement patterns and having that multi directional movement to help support strong bones.

Sonya: We’ve talked about how proper fueling is incredibly important for a number of reasons, but I think a lot of people are wondering, well, what is proper fueling look like so that I can avoid this. And I’m sure that the answer is it depends. And also you mentioned higher protein needs, and seniors especially need more protein as well. So what does proper fueling look like? And can you give a couple of different examples for some scenarios?

Megan: That’s an amazing question and one that I get often I need like an it depends flashcard for this question because you nailed it. It truly does depend. It depends so much on an individual’s characteristics, so many different parts about their training, their background, their goals, even genetics. There’s just a wide spectrum of things to consider on this topic. What I tell athletes is just empower yourself with the strongest care team that you can. So if you are concerned about this topic or if you really just want to think about fueling for performance, working with a registered sports dietitian is huge. I’ve had athletes have big performance gains off of that and then also health gains, too. So I think that’s the time when it’s really about talking with a care team. But athletes who are not working with a care team, I think it’s about erring on the side of caution. I would rather have an athlete be cautious with fuel and just fuel their body to feel like they’re fueling strong performance. So to be eating enough always and to just work towards the idea that food can be fun, which I know is not the case for every single athlete. But that’s how I frame it with athletes that aren’t working with an RD is just thinking about delicious, nutritious meals that are inspiring and just are tasty to have after having a big training session.

Emily: I get a lot of athletes who come in and they’re so stressed about micro and macronutrients and this exact ratio of carbs, protein and fats or healthy fats or just any fats. I think that oftentimes what I’m hearing and what I talked to sports dietitians about is especially endurance athletes aren’t eating enough carbs for whatever reason. Either there is just this almost cultural pressure to restrict carbs still just through different fad diets, or it’s kind of integrated within the team culture to some degree, which is wild to think about because carbs is like that is our fuel and our energy to get us across the finish line and also just making sure that they’re fueling more often. So different types of intermittent fasting is really popular and I really don’t encourage, especially our younger athletes, to even think about that. They need to be fueling their body consistently and often, and that’s very good, hearty meals throughout the day and multiple snacks, and also just making sure that they’re packing snacks throughout the day so that they don’t get caught before practice or after a practice without anything.

Sonya: I read that you specifically address mental health when it comes to…when people come in with an injury or they come in with some form of disordered eating. So when you tell an athlete to eat enough, always eat carbohydrates, eat protein, but then they’re like, well, I may or may not have access to a sports dietitian, but I want to be light because I’m a cyclist, I’m a runner or whatever. How do you address those kind of conflicting feelings?

Megan: I really appreciate that you’re tying in the idea of mental health because I think when we talk about low energy availability, when we talk about the female athlete triad and relative energy deficiency in sport, there’s a lot of arrows that you can draw to mental health. And they’re bidirectional; they’re feeding into each other in multiple different ways. And I think for every athlete, again, I’m going to hold up my it depends flashcard. It’s so different. Like, what is driving low energy availability might be different for every athlete. As Emily mentioned, sometimes it’s totally inadvertent and athletes don’t know it. But I think for athletes that are struggling with it, it’s about ideally working with a counselor or a therapist to untangle what are the underlying reasons that they might be more prone to experiencing these thoughts or what are even some of the cultural reasons within sport. So ideally, there’s a therapist or a counselor on board. I know that’s not possible given access and needs. And I think this is where having productive conversations, if that’s not the case with coaches, teammates, fellow athletes, and really just I hope we’re making a cultural shift in sports that people feel open talking about mental health and we’re working to change stigma around the idea of like there is this ideal body type, because in reality, there’s so many different body types that excel in sport. And I think that the more we can make that in just a natural part of sport, in the way that we talk about sport, it will get better. But certainly we need support from mental health counselors as well in that process.

Emily: I feel like we often see these athletes and they start, they’re really strong. Maybe they crushed a training block or had a really good outcome at a race and they were probably at a good energy balance. And then all of a sudden it’s almost like this desire and they’re striving for a bit more, a bit more, and they’re almost flying closer and closer to the sun and restricting to the point that they’re falling deeper into this low energy availability state. And sometimes you even see they may have a couple of kind of good workouts and some good performance, but ultimately, and I feel like I see it, whether it’s through training or through an injury or through just a performance drop, that they do crash. And it’s heartbreaking to see because it’s very much preventable. And I think through better communications and even role models within the sport, some of that can change. And I love Kate Courtney just had a great article. I think it may have been a podcast, but the messaging was I don’t train to get skinny. I train to be awesome on my bike. And I think that consideration of using fuel to really power your body through that training as opposed to using a slightly lighter weight to get up the hill a little bit faster, ultimately that’s not going to be the most effective way and it’s going to lead to more detrimental outcomes.

Sonya: Yeah. And I think that again, just bringing up that this isn’t just about adolescent females, this affects everybody. So what are some earlier symptoms that people can look for, like before they lose their period or notice they’re struggling with their sex hormones? How can you even tell if you’re starting to play with that fire?

Megan: That’s a really important question and something I think that a lot of clinicians, coaches, parents should be on the lookout, athletes themselves. Oftentimes what I see first in the coaching world is actually just almost apathy. So not wanting to get out the door, feeling like training and working out is consistently a struggle and just really struggling with that motivation. And certainly that can happen for a wide number of reasons, not just low energy availability, but when that becomes more consistent, I start thinking about low energy availability and some of these struggles. Other things we see, as we mentioned, changes in the menstrual cycle, even like blood biomarkers, can start to change early. So increased levels of cortisol, perturbations and estrogen testosterone, other markers that we see are increased rates of injury, not just stress injuries, bone stress injuries, but also muscular skeletal injuries or weird injuries that you can’t quite predict as a coach or an athlete. And then the other point would be changes in performance as well. So sometimes that doesn’t always happen at first. But sometimes I do see that within the first few weeks of low energy availability. So it’s quite different by athlete and it usually becomes unique individual consideration. But certainly the impacts are broad reaching and that’s why it’s important to address early.

Emily: Megan, I think you summarized that wonderfully. These athletes start to disconnect socially a little bit more and kind of back to that apathy component, but irritability, whether it’s even just beyond within sport and from an overtrained state, but just kind of throughout the day and maybe even like affecting their work and some of their other relationships. And some other kind of lab values, we do see some metabolic suppression too. So sometimes the thyroid function can start to decrease and often, not always, we’re not getting our thyroid levels checked unless there are other kind of underlying conditions, but sometimes I do see that take an earlier dip. And back to like that menstrual regularity, it could even just be kind of a reduction in flow or kind of shorter duration, less days. So that’s something to think about. But also in teenage athletes who have a lot of hormones circulating even from men waning erections or even a loss of libido and sex drive could also be part of those signs that an athlete may notice.

Sonya: And what about trans athletes?

Megan: That’s a great question that’s also dependent upon trans athlete situation in terms of their overall hormonal context. But I think for all athletes, it’s really just about deviations from the norm. So if an athlete all of a sudden experiences some of these symptoms that are different from the norm, that’s when we start to have red flags. And I think this is where I really take the approach in the coaching world to have athletes kind of keep a little training journal about how they’re feeling in life and how they’re feeling in training. And I think this is where taking both subjective and objective data from how an athlete is feeling helps quite a bit. And I think that helps for all athletes. And it’s just kind of about taking your detective card and trying to figure out what might be at play there.

Sonya: And it sounds like the care team thing. You guys have mentioned this multiple times. Nobody does this by themselves. So having a care team that you trust is really important.

Emily: Sonya, I was going to mention that too. It’s like I feel like having somebody to talk to about these things, whether it’s that coach, whether it’s a doctor that can really kind of speak that language is super helpful. And I would say even more so with trans athletes, sometimes that the understanding of that athlete hormonal profile and where they are kind of in that as an athlete and his or her body can add these extra barriers to finding the right care and the right answers and someone just to navigate it. I think we’re learning from a lot of information that it’s not just like a blanket statement for low energy availability or a different training plan. And so we have to take each athlete as an individual. And I think that’s something that even within our research that we’re trying to focus on, too, that you are an individual athlete, you have your unique body and really embrace that uniqueness.

Sonya: Yeah. I think that’s why the education part is so important and what the work you guys are doing with FASTR is so amazing, because that education piece, that’s how you know how to say, well, it depends. And there is no blanket statement and just understanding what it is and then if you might be experiencing this or even if you have some of the anxieties that are leading to this, like you said, Megan, it’s a bi directional arrow.

Megan: And kind of on that point, we did a survey during a couple of my time frame is all off probably a year and a half ago, and it was looking at some of these pride risk factors and mental health symptoms like depression and anxiety symptoms. And we did see that this relationship with higher tried risk factors being associated with more depression and anxiety symptoms. And so it’s something that kind of makes sense. Like if an athlete is having some disordered eating behaviors or some restrictive eating habits, they may also have some degree of anxiety and depression around that. But even having understanding that to provide the right resources, whether it is I’m seeing a mental health specialist or even just some of the information that they get access to, it could be super helpful in providing the right care and the right answers for them.

Sonya: So I want to switch over to bone health and talk about what are some good exercises that people can do to strengthen bones, because lots of people listening are cyclists, and there’s also runners listening, but cycling is not considered a weight bearing exercise.

Megan: I’m so glad you’re bringing this up and actually something that Emily and I chat about a lot. And I think cyclists are interested in this information. I think it’s becoming a lot more just commonplace to talk about bone building and the importance of that and the importance of bone building to be a lifelong athlete, too. And the importance of that longevity as an athlete for cyclists. I think this is a great time to work in trail running. I think cyclists often excel on the trails because of their natural strength and because of their natural powers. I’ve seen that with you, Sonya. So I think trail running is great. The eccentric and concentric muscle contractions on uphills and downhills make for strong muscle building stimulus, which again, helps to support strong bones. Getting in the gym, not being afraid to lift heavy. I think Kate Courtney, I follow her, and she is such a boss in the gym. I’m like, I want to deadlift. I want to squat. I want to bench press exactly like Kate Courtney. And she’s a great example of cyclists just not being afraid to lift heavy in the gym. And thinking about that from performance benefits, but also from bone building benefits, too, and then certainly protein intake too. So that’s kind of my overall approach for cyclists.

Sonya: What if people hate the gym?

Emily: I feel like I’m a great example of this. If there’s one thing to go in a training week if I have a busy week, it’s like lifting weights and going to the gym. And I think a lot of people probably express the same sentiments, especially as endurance athletes. But I realized so much that it’s like I have to prioritize it. There are different ways. Kate works with Matt Smith at Ever Athlete. He’s a chiropractor and kind of a strength and conditioning specialist, and he does a lot of more free weight, and so it doesn’t require expensive a ton of gym equipment. And I think that’s a good starting point. I also think that incorporating plyometrics and different jumping tasks is also super important. Whether it’s little box jumps or kind of step ups and step downs, all can be really valuable. And it’s kind of finding something that’s fun that you’re actually going to do, maybe having a buddy that can hold you accountable to it and throwing in some great music and doing 15-30 minutes twice a week. And that’s I think especially like post getting off the bike and even just doing it right away. I mean, not ideal. You’d probably want to do it on a different day, but just doing something to start to load the bones and help kind of build some of that bone mass, especially in the cyclist.

Megan: I will say I run with Kate Courtney once a week now, so she gets out and runs a few miles each day. We do some trail running, and she’s so darn fit. I finally would be able to have the extra fitness to feel strong. But she also has her dog. Her dog is our pace setter, but she’s a great example of really kind of bone building from a lot of different angles.

Sonya: Yes, I like that you said it’s like 15 to 30 minutes twice a week. It doesn’t have to be this massive time commitment. Does band work help with that too, like resistance bands?

Emily: Yeah, absolutely. And I think resistance bands help, too, with I like cyclists to do a lot of mobility through the hips, and resistance bands can help with that, too. So it’s kind of twofold. You get the strength gains, you get the mobility through the hips, and there’s something fun and not as, I don’t know, resistance bands to me don’t feel quite as daunting. And so it’s great as a warm up. And that’s the other thing, too, is they can be done. I have a lot of runners, and cyclists do them just for five minutes pre and post ride, and that’s a great way just to keep things building without this overwhelming stimulus. And again, music and strength bands go together well. So throw some Beyonce with some resistance bands and it helps a lot.

Megan: One other thing I just thought of is if you are a cyclist trying to get into running, doing, like a run walk progression, do not feel ashamed. There’s nothing wrong with doing a wrong run walk. And you can do a lot. Like, you can go on a great run that incorporates a minute or two of walking. And it feels so much better than trying to run for a sustained period of time. And I think it’s also just really enjoyable. And a lot of cyclists that I talk to when they go on runs like, wow, this is so nice. It’s like my feet are on the ground. I get to look at all this nature and trees that you’re flying by, usually on the bicycle.

Sonya: Running dosage is very potent.

Megan: Yes. I feel like cyclists who get into running sometimes and actually all athletes who get into running sometimes, you forget how sore you are at first. Like, the soreness from running is just so different and unique from the ground contact. But I promise it gets better. And what I tell cyclists is there’s a lot of aerobic engine potential there. So it’s kind of fun to think about the crossover benefit and just the potential for cyclists to be strong runners, and vice versa, too, for runners to be strong cyclists. And I think there’s a lot of crossover benefit from both. And it’s fun to see athletes kind of dabbling in both and also excelling in both worlds, too.

Sonya: Yeah, I can attest to that. I was running I stopped in pregnancy because it was just hurting too much. But yeah, I was working with you guys, and I was running three or four days a week, and that made me stronger on my bike. And I was actually really surprised to see how much extra torque I had on my bike from the trail running.

Megan: You were crushing. I got excited every time I saw a trail running video of you, I got really excited. But you have been my longtime bike inspiration. So I think the other cool thing about incorporating biking as a runner or running as a biker is that there’s also I feel like that neuromuscular development. So for me, mountain biking is way scarier and way harder than trail running. I think for me, if I can get out on the mountain bike and then I go trail run, it feels way easier in comparison. So I think there’s a lot of cross benefits, too, in just like developing those technical skills and seeing them apply to both sports.

Sonya: I actually wanted to ask about mountain biking being a weight bearing sport because there is lots of jostling, bumping, G forces, things like that. So is that a little bit better for your bones?

Emily: I feel like the research on it. There are a couple of studies. I’d have to go back and look at the quality and the design of those studies as far as mountain biking, for bone mineral density and kind of building bone mass. I would say overall, I feel like the older mountain bikes were probably better because they had less shock absorption and you’re just like bouncing on everything and feeling it all. But even with these newer, more cush mountain bikes that I ride on, I feel like I get more kind of muscle strength from that as far as just like I feel in my glutes more, I feel it in my quads in a different way than I ride on a road bike. So I’d say it’s probably better than a road ride, but I would still say you need some weight bearing. Well, you need to get off the saddle and get out of the saddle to do some other activities to build the bones. But for those people that are very religious to their bicycles, I would say that getting on a mountain bike would be a fun way to add a little bit more perturbation into the bones.

Megan: Emily, I’m thinking we should do a study that looks at the difference between road cycling, mountain biking, and cyclocross, because I feel like cyclocross might actually even build bones a little bit more just given jumping off and on the bike, which is seemingly I don’t know how people do that so fast and so well. So I feel like there could be a really interesting bone building study there. And thank you. I feel like we’re generating notes from this podcast already on research studies.

Sonya: So jump on and off the bike with lots of practice getting your crotch rocked over, worked over.

Emily: I’ve made that mistake before. Yeah, not pleasant.

Sonya: I also wanted to ask about supplements. So I heard calcium and vitamin D mentioned. But how does something like iron affect bone health?

Emily: Yeah, I think it’s so interesting. There was a good article probably like six or seven years ago now looking at the interplay between iron deficiency and bone health, and there has been some research on how it affects growth hormone and other kind of, I think, insulin growth factor and even like thyroid function. But as far as it directly relating to sex hormones, we haven’t found any really concrete relationships. There have been some like rat or animal studies that looked at this. However, I feel like I’ve noticed whether it’s even just iron deficiency leading to a more fatigue-able state and then loading the body in a different way. As far as the runner who’s training super fatigue and so they’re landing differently and potentially even putting more load into the bones. I do see that oftentimes with my bone stress injuries, there could be an iron deficiency or an iron deficiency anemia at play, too. And there could also be just that under fueling that’s contributing to that iron deficiency. So it’s a little complicated as far as why that’s happening. And also complicating this is I feel like runners even more than other athletes through just maybe the kind of low level inflammatory state, have challenges in absorbing iron in a way that other athletes don’t have challenges. So I often see lower levels and try not to try to have them supplement through their diet alone. But sometimes you have to recommend an iron supplement on top of that.

Megan: Emily, you describe that so well. And I think to make it even more complicated, too. The other thing about iron is that oftentimes when I see a panel and an isolate may be iron deficient, I have the inclination that something else might be abnormal on the panel as well. And that gets us the idea that all of these different processes are interrelated, too. And so if an athlete comes to me with iron deficiency anemia, usually it’s like, okay, well, what’s vitamin B 12 levels. What’s vitamin D? What are their thyroid levels, as you mentioned, Emily. And so it’s about also just doing that deep dive and investigation and all of those different processes impact bones and overall physiology.

Sonya: Well, the listeners can say goodbye to Emily because she has to hop off. But Megan’s going to stay for a little bit longer to field all of my questions here, not all, but hopefully some. But Emily, thanks so much for coming on the show. And where can people find you?

Emily: Thank you so much, Sonya. So they can find me. Probably the easiest just through our new website, FASTR.stanford.edu. I also have social media, but our Instagram is fun. It has a nice Fuel Up Friday. I know this will get probably posted at a different time, but we have a really great recipe that you should check out every Friday. And this one, we’re particularly excited about.

Megan: Emily is a boss. She’s off to do a presentation for a research team. She’s our fearless leader. So just really grateful before you go, Emily, just so grateful for your mentorship.

Emily: And, you’re in good hands with the boss. Yeah.

Sonya: Thank you so much. So I want to talk about age because we said earlier you build most of your bones when you’re an adolescent. But then we’re saying even as you age, you can still build bone density. Is there a time where you stop building bone density?

Megan: Not necessarily stop building bone density. So bones are constantly, always turning over. And I’ve seen I’ve worked with athletes who might be in their 30s and 40s and are dealing with osteoporosis and osteopenia and they have through a lot of work, through strength training, through proteins or all of these different components, through proper eating, they have worked to restore their bone mass. And so certainly if you are an athlete dealing with osteoporosis osteopenia, there’s a lot of hope in terms of taking those measures to work and improve your bone density. So certainly, while bone density is important in the adolescent years, there’s a lot of things that you can do to improve bone density. We just largely say the adolescent years are that peak bone mass building time that really helps set that trajectory in motion.

Sonya: Do you think that most people should go get a DEXA scan to see what their bone density is?

Megan: I don’t think necessarily so. I think when we start thinking about DEXA scans, if an athlete is presenting with a stress fracture, presenting with multiple repeat stress fractures, especially not every stress fracture is created equal, too. So certain stress fractures might be higher risk for low bone density. So stress fractures in the pelvis, stress fractures in the spine or certain more hormonal sensitive areas might indicate that bone mineral density is a little bit lower. So it really depends on the conversation between an athlete and their care team when they’re dealing with stress fractures. Other situations that we would think about DEXA scans are if an athlete has a significant family history of low bone mineral density. So we know that genetics account for anywhere between 50% to 80% of overall bone mass, which is substantial when you think about that. And certainly we can modify those overall genetic risk factors through how we’re treating our bodies. But if you think about it in that way, that’s a pretty substantial portion. So athletes with stress fractures, athletes with family history, and then also athletes that have had a clinical eating disorder or disordered eating for a period of time, it might be helpful to understand how the bones are trending and how they’re looking.

Sonya: That was actually something I was going to ask you about because you’ve done some research focus on genetic predictors of sports injury. How can people even know, aside from just asking about family history, if they have these genetic predictors?

Megan: There are some newer clinical tests out there. I did some consulting for a company that’s called AxGen that actually does you can very similar to 23 and Me, you can spit in a test tube and send it out and they’ll tell you your genetic predictors or your genetic risk for bone mineral density. And the bone mineral is actually quite strong. So that’s based off of 200,000 different spots in your genome. So it’s incorporating a lot of genetic information into that overall algorithm that spits out that result. But I think increasingly there will be a lot more conversations about working genetics into the clinical world because if you could spit into a test tube and you don’t have to go get a DEXA scan, I think it really helps kind of sort out and clarify who might be at higher risk. But certainly there are places that you can check. I expect that maybe like 23 and Me some of these other genetic companies down the road will start to incorporate it as well.

Sonya: So there’s kind of one little area that I want to add in at the end here I was thinking about low energy availability and overtraining because you can be overtrained without having low energy availability. So what are the main differences here? And I guess just like, what comments do you have on that?

Megan: This is a fantastic point to bring up. So increasingly more and more we’re starting to look at the connection between overtraining and low energy availability. That a lot of cases of what we call overtraining and sport, which overtraining and sport is something that we need a lot more research on. It’s very challenging to research overtraining because you can’t just like clinically induce that in someone. It’s something that is a little bit more challenging to study. But from what we’re understanding now on the more limited research that we have is there are these connections between under fueling and overtraining. And perhaps a lot of the causes of overtraining are just actually under fueling at that training level. And specifically, Emily brought up earlier the importance of carbohydrates, specifically carbohydrates. So we’re thinking more and more that low carbohydrate intake might actually predispose athletes to overtraining. And of course, this is so dependent upon an athlete’s, how quickly are they ramping up training? How much training volume are they doing per week? What does that look like? But certainly, again, I talk about bidirectional arrows a lot. There’s a lot of bidirectional arrows between those. And I think we’re just learning to untangle that more and more in research.

Sonya: Yeah, it was funny back in the day I wanted to do a PhD and I thought I want to do a PhD in overtraining, and I would go to different labs and the lab PhDs like, yeah, that’s too broad of a topic, too hard to research. And I was like, that would just be the best thing ever to do a PhD in because everybody struggles with this as an excited athlete.

Megan: There’s still time. I think you should do it. I think the challenging thing is it’s almost at this point a diagnosis of exclusion. So athletes are dealing with all of these different symptoms, and you go to a doctor and you get checked off for a number of different other disease processes or disorders. And so it becomes more of a diagnosis of exclusion. So it’s very challenging to diagnose, which is one of the challenges with it. But also too, when you study it, it’s just hard to recruit people who are overtrained and hard to – how do you recruit athletes who are overtrained? How do you have this criteria for defining who are overtrained? Are they still continuing to train as you’re studying. There’s so many different and I think this is actually why it makes for a great research project is because you have to answer and define all of those inclusion and exclusion criteria in a way that I think would just really bolster our research process.

Sonya: And probably just all the elements. There’s so many variables. I feel like overtraining is an umbrella, and then there’s just so many different things that go underneath that umbrella that can affect this word that we’re calling overtraining. And it probably would just even change that word.

Megan: It would. And actually, it’s funny because it’s so similar to when we talk about low energy availability and then, like all the different cascading processes that are involved with low energy availability. It’s so similar to overtraining. And that’s why I think you start to think about the relationships between low energy availability and overtraining. But I have seen some of the weirdest symptoms in athletes who have had over training syndrome, and I think once you start seeing them repetitively, you realize that perhaps we don’t even understand the full reachings of how overtraining impacts even like the Neuromuscular system or the MSK system, muscular skeletal system, or the endocrine system. And what are the connections to between all of those systems as well?

Sonya: And I also just had a point I wanted to make earlier, and it was about athletes comparing themselves to other athletes and what you think someone should look like. I remember when I was a new cyclist, I would look at other pro professional women and think, well, I should look like them. And if I don’t look like them, then I’m not like it’s imposter syndrome at a body image level. But also if you look at female marathon runners, like, oh, if I don’t look like them, then I’m not a real runner. And I had this runner on the podcast. Have you heard of Fiona Oakes?

Megan: Yes. She’s amazing.

Sonya: Yeah. And she says I’m not talented. Like, she always says that. So I asked her, well, why do you think you’re not talented? Like, you’ve done a 238 marathon, you’ve set four Guinness Book of World Records. Like, you’ve done all these amazing things. And she said, because I don’t look like the other runners. So she thinks she’s not talented because she doesn’t have the same body type as the other runners. So there’s so much involved with body image and how it impacts us from whether we think we’re talented or what we eat. And I think just highlighting more bodies and showing more bodies, doing amazing things and that your body is your body and everybody’s body weight to perform is going to be a different body weight to perform. Everybody’s needs are going to be different. But it’s just so hard because the media will put out – these are the most amazing women or men or whatever who are doing these things – and then you think, well, I have to look like that, otherwise I’m not that and it’s just not the case.

Megan: Thank you for highlighting that. I think there’s so much that’s involved, and I think we’re seeing now that athletes can perform at so many different body types, and those body types are probably ideal for the athletes themselves. But I think it can be challenging as an athlete to conceptualize that if you feel like it’s not the norm and there are these different norms that I think we’re working to push against in certain sports. But I think this also gets back, it’s very similar to bone density, where I think we all have a genetic predisposition to a certain type of body. And that’s a beautiful thing. Like, we are humans to be different. And I think embracing those differences and understanding that they come from a genetic standpoint is valuable because if we try to fight our genetic predisposition, that just causes all of these risks for low energy availability, for poor performance, for just challenging, like the natural state of what we’re supposed to be. So I think it’s important that we just celebrate the fact that, yes, we’re different. That’s the part that makes us fundamentally human. But at the same point in time, too, we can perform at different body types and just continuing to highlight them.

Sonya: Well, thanks so much for coming on the podcast. This is actually your second time on the podcast, so people can go listen to the one that I recorded with you and David, which is really fun. And people should definitely check out the Swap podcast, too, because it’s the one that I listen to every single week.

Megan: Thank you so much. I’ve been pumped. This has been circled on our calendar for a long time. And I know you’re coming up on pregnancy on your due date as we record this. And I’m just in awe of everything you’ve done as an athlete and everything you’ve done through pregnancy and just how you’ve uplifted female athletes in that process. And so I feel like it’s so fitting to talk about this conversation with you. So thank you for elevating the field, too.

Sonya: Yes. You’re always so amazing at acknowledgements. I noticed that’s one of the many ways you lift other people up is with these very detailed, specific acknowledgments, instead of just saying you’re awesome, like you have these very detailed acknowledgements, and that really helps people feel really good about themselves. So thank you.

Megan: Thank you. Well, I mean, I follow you. This comes from, I almost feel like a… in some sense because I followed all of your mountain biking skills. I’ve now followed your journey through pregnancy and beyond. And so I feel like it’s coming. I have all these detailed notes on you because I just love following your journey. So that’s where it’s coming from.

Sonya: I’m actually going to throw in one little thing for the listeners is that we didn’t talk about breastfeeding and low energy availability and I actually think that I had low energy availability for probably eight months during breastfeeding. And I had to eat like, 4000 calories a day plus in order to, and I was in this hole forever, and I still didn’t even know what was going on. So I actually think that I was having some sort of low energy availability problem.

Megan: I appreciate you bringing that up because 100% athletes who are breastfeeding have wildly different dietary needs and those are wildly increased. And so I think that’s actually a great time to meet with a registered dietitian because there’s also so many nuances, too, in terms of vitamins and minerals and what you’re taking in. And I think also just eating a ton during that period of time helps a lot Because the body we talked about in the beginning that female athlete physiology is cool. Athletes who are breastfeeding and training at the same time. Think about all that you’re doing in life and that’s a lot of energy that’s required all right.

Sonya: So that was a little nugget I threw it at the end. But where can people find you specifically if they want to follow your journey? Because you’re freaking awesome and people need to like, aside from all of the what you guys call sexy science on your podcast, like all the amazing running things that you’re doing and coaching and you’re just a general inspirational figure. So where can people find you?

Megan: Oh, thank you. @meg_runs_happy – it’s my Instagram handle. There’s a lot of mountains, pictures of mountains, food, dogs, all kinds of things. Also Stanford FASTR, which Emily referenced earlier. It’s an awesome research program and we have great clinical research coordinators Abby and Ellie, who are helping us launch that and then Swap running is just where I do a lot of my coaching and researching with my husband David.

Sonya: Well, thanks so much for coming on the show.

Megan: Thank you. This was so fun. Thanks for making my day.

Closing the Gender Gap in Sports Research with Emily Kraus, MD and Megan Roche, MD

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