Stanford Doctor: Why Active Women & Female Athletes Are Damaging Their Bone Health

Introduction to Bone Health

0:00Hi, everyone. Welcome to Proof of Practice. And it's exciting because we have finally gotten together. Today, we're going to be talking about bone health. I'm here with Abby Smith-Ryan and Amber Taylor. I'm Gabby Reese. And our guest today is Dr. Emily Krause. Thank you so much for joining us. She is a doctor of research, Stanford FASTER program. And we're going to be talking about the importance not only for young athletes, but also opportunities

0:31to avoid fragility, fractures, and things like that as we age. So whether you're a teenager, a parent of an athlete, or somebody who's just interested in staying healthy and strong

Importance of Bone Health

0:41forever, this is a conversation that will support you. So Emily, welcome to the show. Thank you so much for having me. So let's get right into it. Emily, talk to us about what you're doing at FASTER up at Stanford. Yeah. So a little background. I'm a sports medicine physician and researcher at Stanford and direct the FASTER program, which stands for female athlete science and translational research. And so I split my time between seeing athletes and treating injuries, as well as trying to optimize their performance. And then our FASTER program is funded by the WUSAI Human Performance

1:14Alliance. And we're all about trying to close the gender gap in sports science. And we do that through doing good research and also by translating the science.

Bone Injuries in Young Athletes

1:25I just have to ask really quickly, are we seeing more sort of bone injuries, fractures, things like that in young athletes than before? Is it because more girls are participating, they practicing longer, they're competing more often, or are there actually changes? You know, like in our world, testosterone has dropped and other things. So are we seeing any correlations or any differences? Yeah. I mean, I think we can approach it from a couple of different angles. One, I think that we're talking about it more. And so through that, we are detecting more bone

1:58stress injuries and having conversations about it. Female athletes are at higher risk of bone stress injuries. And that includes stress reactions as well as stress fractures. Those are overused bone injuries. And that's a season ender. So whether they're a gymnast with a stress fracture of their spine or a runner with a stress fracture of the tibia, they're out for probably their end season. And there are a lot of important risk factors and indications of what that could mean overall with their body. I'm going to jump in, Emily. So from a research perspective, when we talk about

Female Athlete Triad

2:30female athletes are at greater risk, can you tell us why? So I'm thinking about like, what is the data that we have yet? Where are the gaps? And why do we see it more in female athletes? So a lot of these female athletes, unfortunately, it's a lot about nutrition. And these athletes are trying to fuel their bodies, but either through social pressures or just through training high amounts of volume or through high volume training, they are not fueling enough. And over time, that can cause hormonal suppression, specifically around reproductive hormones. And that

3:04can suppress a specific hormone, estrogen, among others, which is super important for bone health. And over time, that can cause low bone density and increased risk for bone stress injuries. And so we call that the female athlete triad. In addition to the female athlete triad, there's also a condition called REDS, which is an expansion of the female athlete triad to encompass a number of other health and performance consequences. Yeah, I remember you've talked a little bit about REDS before and in a lot of research. Can we talk more about what REDS means? Like we were talking before starting recording, I remember

3:37when I was running track and cross country, it was a status symbol to be 90 pounds and have no period and then come later to learn that that can really hurt you. Can you talk more about what REDS is and what it means?

Relative Energy Deficiency in Sport

3:50Absolutely. So REDS stands for Relative Energy Deficiency in Sport. And as I mentioned, it expands on the triad. So the underpinning or underlying theme is this low energy availability. And so that might mean under fueling or training high amounts of volume, but not fueling enough to support your body for the amount of exercise the body's doing or just to support daily life. And that can cause a number of health and performance consequences in addition to impaired bone health. Menstrual cycle dysfunction can also suppress immune function, cardiovascular function,

4:24can affect sleep and performance. So as a follow-up from what you said too, so nutrition and training seem to be the biggest causes. And it sounds like women, females are, they're a little bit more sensitive to that. So how do you, like, I think most of these women are trying to do the right thing. What do you tell them from a clinical perspective and maybe put on your clinical hat and your mom hat? And what do we tell our female athletes, whether they're young or midlife? Like how, how do you know if you're eating enough to prevent some of these downstream effects?

4:57I think that it's helpful to get resources. So we often are working with sports dietitians and they can help calculate low energy availability and what that athlete's fueling needs are. I will also say with young athletes, it is a critical time to fuel your body well, to support your bones. Adolescence is critical bone building time to achieve peak bone mass. And that's in your late teens and early twenties specifically is when we see the best bone gains. And if that doesn't happen,

5:29these athletes can be at a lower overall bone density for life. So I, sorry, I'm going to ask, I'm thinking about myself, young Abby, and I don't know if you know this, but I had nine stress fractures all in my left leg as a collegiate distance runner. And so I think back of, I wasn't trying to restrict food. I just couldn't eat enough to keep up with what I was doing. And it was almost like, you know, type a, like let's go all in. And so I didn't know anything about relative energy deficiency. Like what would you tell someone in that perspective? I think

6:03so many people are trying to do the right thing and you mentioned resources, but any practical takeaways or like intangible feelings or signs and symptoms before we lose our period or pain, anything that you could give us that you, you look at work? I touched on it a little bit, but we talked about menstrual cycle dysfunction and this, like losing the period being a big indicator of a fueling mismatch, but there are a lot of other signs that can also be indicators. They're a little less specific. So it could be fatigue, could be

6:35recurrent illnesses, could be just performance plateau. They're just not performing at the level that they think they should. And the fatigue isn't recoverable. So they take a rest day, they take some time off and they're still not able to get that recovery that they would expect. So those are some other signs. We also see some changes in just some hormones and some hormonal suppression. But that's what we're seeing clinically. And it's, it's harder to detect. And we don't have the wearable technology at the place where we can find those earlier biometric

7:09indicators. Did you ever, like, I remember thinking back of GI distress, like I had massive GI pain. And of course you don't want to eat more. Is that a sign and symptom or is it just me?

GI Distress and Iron Deficiency

7:21Yes, yes, it is. I would say, so with the relative energy deficiency in sports conceptual models, there is a health figure and then there's a performance figure. And then with the health figure, there are all of these different spokes. And one of the spokes is to the GI system. So GI distress could be constipation, could be bloated, and it can be really nonspecific. And so what we're seeing clinically is that these athletes are often siloed and seeing different specialists. So they might see their endocrinologist, they might see a GI specialist, maybe even a hematologist

7:56for anemia. And so it's really hard. And so they think that they have all of these problems. And then when we put the pieces together, we're seeing that low energy availability is a common thing. When I think of it like a sport like volleyball, you can, you can, there's a lot more range. You can get away with things. You can play with a little more weight and mass. When you're talking about gymnastics specifically or long distance running, it's, it's the amount of hours or the amount of miles. So if you have an athlete that comes in and goes, Hey, I have to also keep a certain weight for running or even kind of physique appearance in, in gymnastics or ice skating or

8:32something like that, because we're beat over the head about protein. So maybe they're trying to get their protein, but where are we seeing a lot of the gaps that not only in the athletes, but even kind of the general population that is contributing to this? Yeah, I think there's a common misconception. One that leaner is always faster, especially for our young athletes. We need to, we need to work that out of them. We need to really work with them to say, you need to work with your body and you need to fuel your body for your sport. And that means

9:02fueling enough always. And so sometimes we see athletes who they skip breakfast because they go straight to their, their morning practice. And, and there's been this common theme that fasted training is okay, but it's not okay for female athletes because it can start to suppress some really important hormones that can impact their, their performance and start to slow down their metabolism. I'll also say that there's some research that talks about carbohydrate intake and making sure that those athletes are consuming enough carbohydrates at every meal,

9:36every snack and ensuring that they're hitting those macronutrient goals is, is really critical. And, and I try and shift away from talking about overall body composition, especially in the young developing athlete, because they need to be getting their period and getting their period consistently. And if we're not seeing that, I am concerned that they're not developing to the, to the degree and to the level that they could be due to not fueling enough. What about healthy fats? Is that something that's a really important for bone health? And cause I

10:10know with your hormones, there's a real correlation, which obviously would impact estrogen and other things. So is it hard to encourage people? It's such a funny word because fat has really been demonized and we know, okay, how important it is, but yet a lot of people, women, and a lot of athletes kind of try to avoid it. I see fat phobia, carb phobia, sugar phobia, all of that in my clinic. And so I'm, I'm trying to get these athletes to have a healthy relationship with all food, with the fats,

10:43with, with carbohydrate, with protein and, and hitting those important goals. And I'm not a dietitian, so I can't get super specific with each meal and each snack. But for my female, for my young female athletes, I'm saying consume three meals, two to three snacks a day. And that means finding those breaks, figuring out a time to pack the snacks and work it in. And then as far as hormonal health, we want to def, we want to make sure that they're consuming enough of those fats to optimize those important hormones and make sure that all those hormones have the important factors for optimal

11:16levels too. What about supplements? I have, I mean, it's so funny because for me, I feel like you're not doing the basics. I feel like supplements is like putting it into a dumpster fire. Expensive pee. Yeah. But, but there could be certain things that maybe give you a little bit of extra support if you are trying to do all the right things. Are there things that you guys are seeing in your, in the lab when you're working with athletes that there are certain things that bridge the gap nicely? Yeah, both, both clinically and with research, we are seeing value in intentional supplementation.

11:48So I first encourage food, food first. So finding those micronutrients, those vitamins and minerals in your food, especially dairy products, if they can consume dairy products, depending on the type of food that they're consuming, just eating all the colors of the rainbow in there on their plate. But especially female athletes, we see iron deficiency can be pretty common. And so a lot, especially a lot of my endurance athletes, they're, they're running low. And so ferritin is a measure of iron stores. And so we're often encouraging those athletes to be supplementing

12:20with iron. And it's, it's about timing, timing with a lot of these supplements, there's an optimal time to take them. And so there's a lot of education that's happening both clinically and even just within our, our faster program and how we communicate this. So they're optimizing their levels, both in their diet, as well as within supplements. I have so many questions, but I'm going to, I'm going to ask one. I think one of the key things about iron, uh, obviously that can cause some GI distress. I'm just curious if you have really on the GI distress. Well, you know, if you're always running to the bathroom, um, but I mean, what would you tell

12:53people? A lot of people say always supplement with iron if you're an active female, yet you want clinical blood measures. Like what do you start with? And is there a baseline? And I've even heard some interesting data around, you should supplement with three weeks on one week off. Um, any insight, like what would you tell, tell the listeners? I try to keep it simple because I think if we over compliment or overcomplicate our protocols and just supplementation strategies, it's not going to happen. And I worry that athletes are going to forget, especially very overscheduled

13:24athletes. I will say that I'm a fan of testing levels first. That way you have a bit more of a precise idea of how much you should be taking. And would you test ferritin? I would test ferritin with additional other iron studies because fun fact, iron, um, ferritin specifically can be elevated in states of inflammation. So if an athlete's sick, of course, or even after a hard workout, they can have elevated ferritin levels that may confuse the picture. So I usually recommend some additional iron studies. And in addition to that, um, for GI related concerns, there are

14:00different forms of iron that are a little easier on the gut. And so usually I recommend iron bisclinate over ferrous sulfate. And the challenge is oftentimes when we're in the clinical setting, um, if you're prescribing a form of iron, it's usually in the ferrous sulfate form. And so I'm, I'm having to work with the parent and the athlete to find the optimal supplement for them and the optimum, optimal supplemental timing throughout the day. Okay. I'm dying to like write down what amount, what would you start with without knowing, like kind of knowing an active young

14:32female, they have a well-rounded diet. What would be a starting point? Usually the, the starting point is 100 milligrams of elemental iron is, is kind of the go-to. Now I will say that I have super absorbers and people that can absorb iron really well. And some people who can't, and I would love for any of the researchers out there to help better understand, and there are researchers out there that are doing iron-based research and supplementation-based research. And I think I find it fascinating. So in a couple of years, maybe even next year, I might have a different recommendation for you

15:04regarding supplementation. It's interesting people digest it differently or people take in different kinds of iron differently too. I just learned this, that you have microbes in your gut that will steal the iron also. Like there's all these things of why we have low iron or not. Oh, I didn't know that. Yeah. And I even heard, did you ever hear this, that foot striking athletes, right? Yeah. Like they call it foot strike hemolysis. Yeah. Wait, what is it? Keep going. This is you. Do you take iron? No, not anymore. I use that prescription. It tastes disgusting. Yeah. Well, if you have a foot, you explain it.

15:36Yeah. For the, for the runners. And there are a lot of contributors to iron deficiency, especially in female athletes. If they're, they're menstruating, if they're having a period, they're bleeding. And so that's one, one possible contributor. I will say inflammation from training. So if your gut is just not absorbing as optimally, that's going to impact iron absorption. And then there's a foot strike hemolysis for the runners where when they're striking and they're foot striking, it's breaking red blood cells and breaking, breaking cells. Aren't all runners foot strikers? Yes. Yes. Yes. As I run on my feet.

16:06You got on your feet. So, okay. Right. But it's, it's preferentially affecting you more than say a swimmer. Oh yeah. That makes sense. Or someone who's not doing impact. Interesting. Like even volleyball and basketball, because you're striking your foot when you jump every time, it's a pretty, pretty rigorous strike. Yeah. And so this can impact your iron. Yeah. I just heard something on jumping and bones too. So maybe away from iron. Yeah. Let's talk about that. Is it accurate that jumping is good for your bones? Is better for your bones than running? Yes. Because you have seven times your body weight with each step.

16:39So for any age, people should jump. Seven times. I know. I actually, I need to look up if it's actually truly seven times, but, but Gabby is on the right track. Yes. With jumping over running is going to have higher impact, but I'll also say if you're going to just jump out of the blue and start getting into this plyometric training, you're going to put yourself at risk for bone stress injuries and these overuse injuries. So you've got to ease into it. But I think I'm a big fan of

Jumping and Bone Health

17:05multi-directional movements, different sports, um, participating in both strength training, as well as impact training, whether that's running or plyometric. I'm going to stay kind of on jumping, but on the different ages, because you talked about all the injuries. I bet we all had all kinds of different stress fractures and injuries. If you got tons of injuries when you were younger or in your preteens or teens, and then you become a perimenopausal woman and you want to keep your bones healthy, what do you do? Like, how do you make up for all of the sins of your past of foot striking and

17:38not enough iron? Or being sedentary for that matter. Or being sedentary. Yeah. Yeah. I mean, I think that we kind of talked about these, like this critical time during adolescence to build bone and you guys like this. So you mess that all up. You mess that all up through maybe some fueling errors. And a lot of this is unintentional. So I'm not saying I'm not blaming anyone, but you go down the road. Now you are in your perimenopausal years, you're going to experience an estrogen decline that's going into late perimenopause and to postmenopause. And so with that, there's also a decline in bone mass.

18:11And so we worry about fragility fractures at that time. And so what do you do about it? It's not like you just have to like sit there and put yourself in a little bubble, but you can, I recommend continuing to move, getting into resistance exercise and resistance training, finding what works for you. There are some studies that are really showing that what we call osteogenic or bone building potential of the different types of exercise. But I think first and foremost, you just need to keep moving and move in a way that you're going to stay motivated to do. And so she's saying that we're not doomed. You're saying that the past are there, but there's data

18:47that shows that you can increase bone, especially through midlife, which, and I don't know how many midlife athletes you see, but I have a follow-up question to that. So we're talking about reds and young girls who are having periods. What we're looking at too, and I'd love your clinical perspective, is that transition from pre-menopause to peri, especially with late pregnancies and very active women. On this bridge of a lot of women are experiencing perimenopausal symptoms, but we really think it's probably symptoms of reds. Have you seen that frequency? So at like 35, 38,

19:22they're experiencing relative energy deficiency syndrome, but they think it's perimenopause. I think it gets really complicated. One, there's not a lot of science or research for reds in the perimenopausal athlete. Two, there are a lot of other causes of hormonal disruption during that time. Um, I'm, I, I'm, I'm just going to put it out there. I'm 40 and I have a one and a half year old. And so I was a late, you're, you have reds right now. I mean, I, yes, yes. When you're burning

19:55the candle from both ends and you think it's normal and you think it's normal. And I think that a lot of athletes and they're trying to train and they're trying to do the things are trying to follow all the recommendations, many of which we're recommending, but, but there's a point where you just, you got to fuel more and you got to find the time to fuel and find what works, works for you. And, and so I think that when we do need more, more science in that space, but I also think that there's more that we can do to communicate, Hey, don't follow that new social media craze or this focus on thinness, because right now we need to, we need to, to build your

20:31bones. We need to keep you healthy and, and optimize your hormonal state too. So I just want one follow-up question for that. So you have this, I know, I know. Okay. Just say I have another question. When you, it's, it goes back to Gabby's initial question of that's a life stage where women want to optimize body composition. Optimize is not the right word. They want body composition to be better than it is, or at least to maintain it. What would you tell a woman in that, that's 40 active juggling all the things. And you tell her just to eat more that,

21:05that's a little hard to chew on. No pun intended. Um, what would be a takeaway or like maybe from a physician perspective and an active woman perspective, what, what would you say? I think I would reframe it that you need to fuel your life and whether that is chasing your toddler around or that's going out for a run or a hike or doing your, your class CrossFit or whatever, um, whatever you like to do, you need to, you need to fuel that. And, and I think even as

21:35the, the 20 year old athlete, they're fueling your, their, their bodies for their training. And we're still, we're still training. We're training for life in a way that we want to continue to, to move in a way that we want to move in, in our fifties and sixties and seventies, as opposed to being worried about breaking our bones. And so I think fueling for life, fueling for optimal bone health and just reframing it from fueling to change your body composition to a way that you, you may not want to. Um, I think that's, that's the wrong way to look at it. And if we can have more women

22:06going that direction, as opposed to focusing on leanness and a certain physique, aesthetic physique, I think we'll all be better off for it. And, and I hope, I think that we can get there. I hope so. You do? I do. I do. I think we're in this way. It's so, it's such a unusually, it's so ingrained in us. Um, and now it's even worse because we see ourselves a million times more than like, for example, when I was a kid or a young adult, even there was no phone. And now that everybody,

22:37unfortunately is seeing images of themselves every single day. So it's so interesting. You have to really almost fight it. Like there's something inside that you have to sort of decide, Hey, I want to feel, I want to have vitality, life force, energy. I want to be mobile and independent forever. Um, and sort of all these ideas. And it's so interesting to see if we can, if we can, at least in moments, you know, kind of believe that shift versus, you know, how do I look? I think that that's a really hard thing for us all to get past.

23:12One thing on that, and this is a, and it's going to, it's about you, Gabby, but that I found that I do is every, and this is super weird and nerdy. So I'll overshare here because we're in a safe space every quarter. I go through everyone I follow on Instagram and I unfollow everything that makes me feel bad. And then I'll only follow people like you. Actually, I follow both of you as well. No, I follow you because your life is, it's inspirational and it's happy and it's still sport, but it's healthy and well, but all of the ones that are men and women, super skinny and

23:44only the supposed to, they kind of terrify me and make me feel bad about myself. So I just unfollow them every quarter. Well, it speaks to environment who you surround yourself with versus, you know, are you around people that want to be thin all the time versus strong and powerful? So going back to parents of these athletes or young people in general, I think, you know, some, so much growth and expansion and important parts of our foundational health happen when we're young, even though of course the body is regenerative. And if we have late practices and we don't start

24:15until, you know, we're in our thirties, there's so many opportunities there. Maybe we can just outline how a parent can support the athlete because also the parent can do it for themselves. And even bringing that to sort of their, even their, their general doctor, like what we can be looking for just to make sure that we're helping them stay on top of it. I think it's such a great question. It's like, what can, what can we do? What conversations can we have? And I think for parents, normalizing conversations around the period is one, um, encouraging good fueling practices and good

24:50nutrition practices. And that starts in the home, but, and then making sure that the pantry is stocked with all of those important macro and micronutrients, but then also in the clinical setting, and especially as a sports medicine physician, we need to also ask those questions. Even if it's an athlete coming in with an ankle sprain or, or something that seems unrelated, we should still be asking that athlete, are you having regular periods? When was your last period? How old were you when you had your first period? All that can play, play a role into their recovery,

25:21into their current state of, of health and, and performance. And then we haven't really talked about hormonal contraception, but a lot of these athletes, they're, they're not having periods because they're on hormonal contraception. And sometimes they're placed on hormonal contraception because of Mr. Irregular periods, which can be related to under fueling. And those questions weren't being asked when they were placed on the hormonal contraception. So I also think it's important for the parents and the clinician to understand why, why were you placed on

25:52those? Or do you know, and is this the optimal form for you? And is this the right time to be exploring that?

Hormonal Contraception and Bone Health

25:58Yeah, because what you're saying is that a lot of that, those contraceptions are hard on you. I mean, they're, I, I know unwanted pregnancies and stuff, but a lot of times you see they're using oral contraception as a, as a, like a one, a gunshot spray that it's like, oh, well, this will just kind of take care of that. Right. I think that they're, um, they can be prescribed in, in ways that might not be the best first approach, like first line. And for, for some athletes, um, they, they do want it to manage their periods or, um, control their periods in a way. But I would also say we need to make sure

26:33that that athlete is fueling enough. And when an athlete's on hormonal contraception, it is masking their regular hormonal production in a way that they may not know if they're having a, a regular menstrual cycle or not. I have to ask just because people have sons as well. I was going to ask you. I'm sorry. I thought you wanted to talk more about GI issues. I don't know. I, uh, I'm just curious, are we seeing, are young male athletes or, you know, middle-aged men, are, are they, is there

27:05something they're navigating or because they have testosterone and other hormones, they don't, they don't have to face this quite as much? Yeah. I do see male athletes in my clinic. And so I, I feel qualified to answer that question as well. And I do see these male athletes who are suffering from reds. Uh, we don't, they don't have the indicator of a period of course, but they do have a testosterone suppression. And as a clinician, I'll get that, those, those numbers and get those labs as a, uh, it helps explain to them what's happening in their body through under fueling, through high volumes of training.

27:37And I think that can have impacts and well beyond what their understanding, both for bone health, but also just overall reproductive health and definitely performance. And so usually when I see these athletes are coming in with it, with an injury, with a bone stress injury, and we've got to unpack the layers of how did you get here? How can we start to shift you in the right direction to fuel more? And, and it can be a long journey, but, um, to your points, uh, hormonal levels is, is helpful in that, in that case, actually getting your hormones checked. It's, it's so interesting

28:09because you wouldn't, you know, you wouldn't think it quite as much with men, but really the conversation about reorient, reorienting around not only the right kind of food, but maybe more of it. So I feel like coaches would be really helpful in this process too, because if it became a cultural kind of, of the team, it would make that process a lot easier. Um, but I also think everyone's overtraining. I see that. And I see a degree of overtraining. Well, you didn't say it, I said it.

28:40But I, I do see that. I feel that young athletes, they are in one sport all year round, repetitive motion over and over. I think culturally we've moved into a place where everyone is just got to win training. So, so much training. Yeah. And I think it's, it goes back to culture and what is, what is the environment that we're living in right now and what is the priority? And, and I think that it's gone away, especially in the younger athlete from free play and letting those athletes go outside and play pickup games. And which is still very important for, for bone

29:13health development, socialization, and it gets into very structured play. And that structured play is year round. And, and so with that, those athletes are doing sometimes repetitive movements, um, depending on the sport, um, swimming and even with, with running, but it also can lead to burnout. And we're, we're trying to not to get doom and gloom, but we're trying to keep athletes in sport. And so I, I grew up in a small town in Nebraska and so played all the different sports. And I, and I think it did protect me from some of the overuse injuries that I definitely

29:43would have developed if I would have just been running or just doing tennis. So move to Nebraska, jump around a lot, jump around, take iron, go back to estrogen a little bit, because I feel like we taught, you mentioned it, but the importance now you're seeing in research of estrogen, the connection of it. So especially for a middle-aged person, the importance estrogen has also on bone health. Yeah. Estrogen is good for bone. It helps build bone and it helps prevent bone breakdown. And whether that's the naturally circulating estrogen that we get, um, throughout the phases

30:18of the menstrual cycle or, um, in a form of like transdermal estrogen. And there is an indication, um, in certain athletes, uh, even in young athletes where I, I recommended prescribed transdermal estrogen with cyclic progesterone for low bone density in those athletes that are having a hard time normalizing their menstrual cycle. It's not a bandaid, but it's a, a supplement or something to help with their, um, recovery of, of bone density in that critical time. And I would say similarly in the perimenopausal time, I mean, I think really thinking about hormonal treatments and what can be

30:52valuable for that individual is, and having those conversations early with your clinicians is, is really important. So on that note, I think it's interesting. One, I think you're one of the first clinicians that have said that out loud, which is great. That's why you're here. But then also thinking about as a clinician, you use the evidence that exists, but then also practical experience. So putting on my research hat, can you tell me where you see the biggest gaps are, or what is the research that would really help inform you as a clinician, as you're kind of prescribing these things across the

31:27lifespan? Yeah, I think we need earlier indicators and earlier detectors. And I touched on this earlier with, with wearable data, but I see so much opportunity with using wearables to detect maybe earlier signs of low energy availability or that overtrained under fueled state. And we're not there yet. I'd love, um, with even within our faster team, we are exploring different types of wearable data and how we could implement that in an effective way and design that design that well. So that's one, one idea.

31:58Just to follow up, when you are seeing like things that make you excited, when I think about wearables, I think about the ones we're using in the lab, the, the aura, the whoop, the hormone trackers, like, are there ones that really come to your mind as like, this is what's really going to be helpful? Yeah. I mean, I think first of all, they need to wear it. Yeah. Okay. A wearable that will be used and really natural within just the, the daily life. Um, one that is going to pick up on hormone based changes and whether that's a proxy through, um, different biometrics, um, through

32:29HRV or through sleep changes or body temperature. But I think that if we can start to crack the code and get the right algorithm to get that earlier sign that instead of just says you're, you're over-trained and you're stressed and whatever else is communicated on your phone, but gives you some tips and say, Hey, are you feeling enough? Are you, you've trained 20 days in a row. Maybe you need to take some, some time off. And then an athlete understands the why behind that to implement some of those changes. I think the why is super critical because with so many, I love wearables. I love online social

33:03showing off sport, but it trains you to want to do it every day so that you can beat your previous day or your previous year. Or maybe that's just me. Maybe that's super unhealthy. Yeah. I'm like, F you, I'm doing a marathon. Too bad. Right. I mean, what if the wearable could say you are 10 steps away from a bone stress injury? Or, I mean, that would be helpful and here's what you should do. Yeah. Wouldn't that be nice to know? Please do that study. That would be very helpful to know. What is that? So this is like a real householder question. What does that look like? Like from one

33:36step to the next, if somebody was, let's say, two months of training out from a stress fracture, besides the fueling, is there anything sort of even more proactive that they could do to pull back from that situation and avoid it? Right. I mean, besides fueling or rest or modifying training, I mean, I think that there's, sleep is so huge. And so I'm making sure that those athletes are getting enough sleep, and especially my young athletes, they're not getting enough sleep and they're stressed. And

34:08it always, it worries me if there's a sleep issue that early and they're trying to continue to train through it. So I think that's like control the controllables. How can you control your sleep, your fueling, your recovery, making sure that you're really taking time off your feet? And maybe there are some other interventions that we could start to explore with research and different therapies. And I won't get too deep into the weeds because it's way too early, but I think that there probably are some interventions that we could explore to help with that too. Yeah. As a follow-up. So I have obviously an interest in bone, not what I studied. So thank

34:42you for your contributions, but I always found it interesting. And we looked at this, it's, it wasn't always bone density that was low. It was poor muscle quality because you had all these runners and endurance athletes, not lifting weights. And so as a follow-up, you know, maybe it's time off your feet, but actually improving the size and the quality of the muscle. And it doesn't mean don't train, but do something slightly different. Of course, the muscle researcher does a plug for muscle. That's why you go so well together. I feel like the muscle and the bone is this like symbiotic relationship that they both need to

35:15feed into each other. And I think, I'm so glad you brought up resistance training and strength training as a really good bone building activity. And that needs to happen. I would, I would say as another, um, add to, when you are thinking about risk, what is your strength training program and how can you build your bones that way? And I think a lot of times people hear, oh, you have to lift heavy, especially women. And they don't really realize that it doesn't mean heavy. You're not sitting there with plates and plates and plates. It just means you're lifting time under tension. You've got some load.

35:47Right. And it doesn't have, I don't think it has to be that daunting. Um, and so I, I always encourage people, maybe they don't know how either find a friend who is, knows what they're doing. They can kind of show you the ropes. It might even be worth hiring a trainer for a few sessions just to kind of understand the language. And my other favorite thing you hear is I don't want to get too big. Yeah. I hear that. And it's been my whole life to build my biceps, you know, like you're trying. So I really appreciate this conversation. I'm going to let the gens, if they have a free floating question, do you guys

36:18have a free floating question that would be curious to you? Yeah, sure. Fine. Fine. From the audience. Going back to estrogen, um, what sort of estrogen would you recommend for women over 50? What, what, what kind of intake? Okay. She's like, it's too late, Jen. No, it's not too late. I saw it on Instagram. It's not too late. No, no, no. It's not too late. I will. So the question is, if, if you were older, was you, you know, is it the, like what type of estrogen are you, are you able to talk about that?

36:50Yeah. I mean, full disclosure, I, I, I don't have as great of specialty in, um, perimenopausal prescription and medication, pharmacologic prescription, but I, um, would say that the patch or the transdermal estrogen is going to likely be your best bang for your buck. And hopefully there's some nods that I'm seeing here that can. I mean, there's options. There are options. Which I think is important. Yes, yes. There's cream. The pellets were sort of poo-pooed because it's real strong in the beginning, right? And then it's sort of, like, there's just certain ways. I was needing more of like a cream versus a patch.

37:23Oh, different doses. Do you like the cream more? I like the patch because I don't have to think about it. I think you need a perimenopausal specialist on your podcast. I think we do need that. I know. I want to, I'm not going to do it. I'll take all of it. My doctor calls it the happy patch and I love it. Do you not see a change when it runs out? But it's what you change it. It's every two, twice a week. Yeah. It's twice a week. It's every three or four days. I mean, you know, you could just. So you feel a change. Totally. Yeah. Yeah. So sleep, get your hormones checked, check your period as an indication. Fuel enough.

37:53Yes. What's your favorite? You talked about fueling. What's your favorite snack, food?

38:00What does Dr. Emily Krause eat? Bone marrow. What do I love? You know, I'm on a, I'm on like a morning waffle kick. Oh, any kind of waffle? Yeah. It's the Kodiak. Oh, I love the Kodiak. Yes. Okay. That's breakfast for dinner. Kodiak waffles. Yes. It's like super quick with Piper. Piper loves the Kodiak. I love the Kodiak. What is this? Is it like an Eggo? A new Eggo? Yeah. Yeah. It's cool. It's a healthier one. It's a healthier Eggo. It's a healthier Eggo. That's cool. Yeah. With a little nut butter. Yeah. Yeah. It's my like quick fuel. I'm like thinking about quick fuel these days. What's one thing about you we wouldn't know about reading your bio? Tell us something

38:35about you, Emily. Oh, my gosh. Well, I already gave the Nebraska fun fact. I didn't know that. I lived in Iowa. You did? Or grew up in Iowa. Okay. Okay. Yeah. So I think I'm going to tease that again. I grew up in a small town in Nebraska. Did you play sports? I played sports all through high school. I played basketball, tennis, cross country. I played golf in the summer. And I grew up playing volleyball. I have two older brothers that I just looked up to so much. And yeah. Now we live all across the country. The question from someone who is a parent who has a very active student-athlete daughter,

39:11very, you know, she's playing indoor volleyball and beach volleyball. And she, you know, my friends always saying like she feels like the sleep police, the kids begging to stay up till 1130 to do homework and then has to get up at 630 for school. You know, I think a lot of parents go, well, what is enough sleep? And I know you're not a sleep expert, but is there sort of a sweet spot? I recommend eight for male and female athletes. Any age? I mean, honestly, any age. Like if you can aim for eight.

39:42I heard you need less as you get older. Yeah. I don't know. I feel good. I feel better with eight, but that's for sure. I will also say that sleeping shorter durations during the week and then trying to make up for it on the weekend isn't a great strategy. Oh, I love a good nap time. Really? Like some small naps is good. She's saying you can't pack it in on the weekends. You can't pack it in. Oh, to make up for it. You want consistency. You want to aim for eight every night. And I will also tell that mother that if that athlete is overscheduled with the volleyball practices, the other extracurriculars, the

40:16homework, maybe something's got to give for a little bit, especially during really high stress times of the school year. Because I just worry that you're burning the candle from both ends. I worry about overuse injuries or just kind of feeling stressed about everything in life and suboptimal performance, a little energy deficit. And over time, I think that that can just build upon each other. So usually I recommend at least one rest day per week, just full day off and try not to do double training. So the two sports in the same day,

40:48it's become popular, but it's not going to be good for either sport they're playing. Something I always tell my college students too is as many years as I went to school, I never pulled an all-nighter. It's because you can't actually learn anything that late. And so sometimes I tell them, just go to sleep. You're going to learn it better anyway. Right, right. Turn the brain off. We actually had a really good study at Les Mills that was if people, it was about students and if they cram right before a test or if they do yoga or mindfulness, which one is going to help them

41:23perform better? And it's the yoga and mindfulness. I think it's kind of different but similar. Like you can try to cram it all in, but you'll get overwhelmed or exhausted and your brain's not functioning properly and you're anxious and the whole spiral. Totally. Yeah, it's a big, it's a big, hard one. Balance. Life lesson. Yeah. I'm still working on it. Dr. Emily Krauss, thank you so much for joining us and sharing what you're seeing in the lab. It helps not only the other athletes that you're working with, but all of us here. We really

41:53appreciate it. And just remind people if they want to go deeper into this, where they can find you and find some of this research. So they can go to faster.stanford.edu, F-A-S-T-R. And they can also follow us on Stanford Faster is our Instagram. And then they can also check out the WUSAI Human Performance Alliance. It's full of really great researchers and collaborators and some other projects along the topic. Well, thanks for joining us. And we look forward to learning more from you in the future. Thank you.

42:24Thanks for having me. Thanks, Emily. And 40's not old. Calm down.

42:31Please��ie Jebusier Show.

42:51Thanks for having me. Thanks for having me. There you go. Awesome. Thanks, everyone. Thanks for having me.