Best of: The future of female athletic health
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Hey everyone, it's your host Russ Altman from this future of everything. The world of women's sports is experiencing unprecedented growth, attention, recognition and investment. Elite athletes including Simone Biles, Caitlin Clark, Serena Williams and many others are having a significant impact on culture and more women than ever are participating in both professional and recreational sports.

Earlier this year, I sat down with Dr. Emily Krause to talk about the future of female athletic health, and we're rerunning that episode today. She shared a number of key differences between women and men in sport and illuminated that these differences are vastly understudied, although she herself is working to close that gap. This is an episode I shared with a number of athletes I know, and I hope you'll do the same.

Before we get started, another reminder to rate and review The Future of Everything. We love your reviews and they help us spread the word. You know, 2024 brought us the Olympics from Paris, France, and a little bit from Tahiti. And the performance of women was particularly impressive and showcased during the Olympics. And that raises the issue.

Do women and men train in exactly the same way? Do they fuel the same way? Do they recover the same way? And are they getting the same injuries? The answer is no. And we need to study more about female athletes because we're behind in the science of understanding the elite female athlete. Well, Emily Krause is a professor of orthopedics at Stanford University and an expert on the issues of women's health, especially in elite and endurance athletes.

She'll tell us that her studies have shown that everything from mental health, injuries, fueling, effects on the menstrual period, it's all different and we need to understand it better. Emily, you're an expert at female health, especially for elite and endurance athletes. What are the key health issues or at least some of the key health issues for that population? - Ross, thank you so much for having me. I'm really excited to have this conversation.

That's a big question, but I feel like we can start with, I'm a clinician, so I'm a physician in the clinic. So I see these female athletes in my clinic for a number of issues, including sports related injuries. And there are a number of injuries that are higher in female athletes than male athletes. For example, ACL tears. Yeah, I've heard this. The death season ending injury for athletes.

And especially in the high school population, even in the collegiate and professional population, we're seeing these numbers continue to tick up. And we still need to better understand the why and, of course, the prevention to try and keep those athletes in the game.

I also do a lot of bone health research, and so I see a lot of bone stress injuries, so overuse injuries to bone, including stress reactions and stress fractures. So I would say those are really key areas, and bone stress injuries are more common in female athletes than male athletes. And so that opens up another big question of hormonal health.

And these athletes are experiencing changes in their menstrual cycle, but they don't fully understand it and they can't navigate it or they haven't been educated in the way that they can use that to empower and inform their performance, their training, but also just help them prevent injuries like bone stress injuries and even potentially other ligament soft tissue injuries.

Okay, great. So that gives us plenty to talk about. And let's go to menstrual period hormonal issues because I know this is one of the things that you're passionate about. You know a lot about it.

And it's particularly an issue I can imagine. And in fact, I've had family members, you know, soccer players with stress injuries that, you know, kind of messed up their season. One of the things about it is that for an ACL or for bone stress, there's pain, there's symptoms, and you knew what it was like when things were normal. So you said there's been a change. My knee hurts. My leg hurts. It's

especially for people who are athletes who started when they were seven or eight years old, they might be having effects on their period, their menstruation, that they're not sure how much of this is the normal development of a teenager going from being a 10-year-old to being a 17-year-old versus this is an effect of their training and their devotion to athletics. So tell me what the issues there are. Let's unpack that a little bit. And how are we understanding all of this?

Absolutely. And we're seeing athletes that are getting into more competitive sports at a younger age. Right. So they're pre-pubertal. They haven't gone through all the transitions of puberty yet. And so their body is very different than what it's going to be post-puberty or during that puberty transition. So I

So I think a lot of female athletes struggle through those transitions because performance is going to change and trying to embrace those changes and make sure that the training allows for those changes to happen is really important.

What we sometimes see is delayed puberty or a delay in the first menstrual cycle with these female athletes. And some of them feel that that's normal or a rite of passage to specific sports. I see that more so in endurance sports like running or cross country, but I also see it in gymnastics. I see it in soccer. So a lot of times the conversations that I'm having with these female athletes is they're

encouraging them that this is this is a normal process and we we need that process to happen because there are Negative implications if they don't get their period until a later time So we're talking about 15 is this age mark that we usually use Okay, in your period before the age of 15 is normal getting your period after the age of 15 is is not normal And so during that time we need to think about why this could be happening. Yeah, are they over training? Are

Are they not fueling enough? Are they not fueling at the right times? Sometimes these athletes are so booked out through the day where they're going from, they're waking up, going to school, going straight to practice, sometimes a second practice with a team. And so they can't squeeze in those important meals. So a lot of times it's just,

education and reminding them that this is an important transition for their overall bone health, reducing injury risk, and just overall performance. I think that's an important- That's really great. And so I'm not an expert at any of this, but I do know enough to know that body fat composition is very important for a lot of hormonal processing, progesterone, estrogen, all of these things.

body fat plays a role and body fat is a big deal for an athlete. And so I'm sure there are kind of emotional cognitive issues in addition to the physical issues. And I'm sure that these come up in your practice. And how do you manage all that? Because are they thinking sometimes if I get my period, that means I'm too fat, which might be a very not good thing to think.

Yeah, I mean, that's a great question. And it's something that we have to really navigate is what is what is the ideal body type for sport? And and I try and remind these athletes and educate them that there isn't one specific ideal body type because each individual has a unique hormonal profile, unique anatomic profile, especially in females compared to males.

And we need to encourage that hormonal profile to really, really flourish in those hormonal levels to really reach that key point for optimal organ function, muscle function and development. But there is a stigma around getting the period. And what does that mean for the body? And I think the conversations around body composition, which includes hormones.

body fat, muscle mass, even just overall bone density can be a really touchy conversation, especially in some vulnerable years of that developmental transition. So I try and avoid those conversations. But if it does come up, I bring in my resources too, because I think really pulling in mental health specialists so that they can help that athlete can help navigate and

any body image issues that they may be experiencing quickly so it doesn't manifest into disordered eating, eating disorder behaviors that can really take them off of that trajectory of optimal health, optimal performance, and just...

overall injury risk and rates. Yeah, this really helps me see how complicated it is because you were just saying that because of their training, they may have issues with nutrition and fueling. And now you have this second overlay and you could imagine it could get very complicated. You certainly don't want to accuse them of A when the problem is B and it's possible that everything is mixed up. Well,

since we're on this topic, let's now advance fast forward, if you will, to women who are like in their twenties and thirties. So these are maybe even professional athletes. We just, the Olympics happened in 2024. Very exciting. We were exposed to some amazing athletes. But, but every now and then at an, even when you're watching the Olympics, you see a mom who's running the 800 meter or who's running a 5k or, or, or so what are the issues there? Are, are,

Are those women well-served? Do we have the science to tell them how to compete at these absolutely highest levels? Or are they basically experiments that we're learning more from them than they're learning from us?

Weren't the Olympics amazing this year? I had so much fun watching. Unbelievable. Bias, but I thought the female athletes that were performing and competing were so impressive. And Team USA walked away. Team USA won.

women walked away with a lot of medals and there was a lot of excitement around that. I agree. I agree. Riding on that momentum. But I completely agree with you. The resources for women, especially women during these phases of their life and these transitional phases such as

Puberty, pregnancy and postpartum, and even perimenopause, the P's as I call them, can be really challenging because the science just isn't there yet. And so for these women especially, there was a fencer who was a mom. And she made it to the round of 16. It was really inspiring. And there was a lot of talk around, is that safe? Is that appropriate? Yeah.

And I think that the challenge that we've seen and experienced is there's just isn't a lot of guidance and evidence. And so a lot of these these women are navigating these conversations and navigating this training on their own.

But we within our research group, we created a pregnancy and postpartum playbook specifically focused on that. That's a great I love that name. Just the name is great. And focus on the elite runner to start. But but really, a lot of the content is is for everyone and for all women who want to get back into into sport and to be exercising and moving.

And I think that that's a stepping stone and a starting point until we can get more research on this. And there are a lot of the studies that are out there are case studies or we're looking back, a retrospective study, looking at different athlete experiences. And I think that we can do better. And it definitely motivates me and my research team to help design better studies for all women, all female athletes, but also specifically in that postpartum.

This is great. And I've, my head is exploding with questions, but one real quick question on, especially these elite athletes that we may have watched at the Olympics, are they sharing, like they probably they're doing experiments with their own performance and they probably know in

ultimate detail, like the kinds of things they need to do or they need to stay away from. But is there's this become a competitive advantage that's hard to get out of them because they don't want to share the secrets? Or is that not the culture? And are they talking about it? And it's like, are all boats rising even in this very competitive world?

You know, I think I think the latter. I think all boats are rising because these women are trying to support the other women to get to that top. So it is a level playing field. And it's the it's the competitiveness and just who is the best, not who has the best resources. Right. Who has who hacked the data enough to get to get to the top?

That is the impression. Even on TV at these events, you can see that there is a friendship and a collegiality between the athletes that I don't remember when I was five years old seeing in the 1968 Olympics. And that is probably a great thing. Okay, so...

In the same vein, I wanted to ask about fueling because it is – and you mentioned it already. And I'm a sports fan. In fact, right now, I just – I watched the men's Tour de France last month and I'm now watching the women. It's unbelievable because they're using like 8,000 or 10,000 calories a day. And just replacing those calories is a logistical challenge.

But I've heard and they mentioned at the Olympics, too, that our understanding of how to recover from exercise and how to fuel has just become kind of it's become the key thing that many of the other things that we thought were less important were more important are now known to be not as important. So can you tell me where we are in the science of basic?

Basically nutrition, eating, calories, and recovery. Yes, yes. I mean, I think that we have evolved in our understanding of nutrition. And I think it's still evolving with some fad diets that come in and really cloud everybody and confuse everybody. Cherry juice. Yes, tart cherry juice or –

Or keto diets or time-restricted feeding or fasted training, especially for women. So I think that there are a lot of hot topics that we could probably go down a lot of rabbit holes on. But when we talk about recovery, and for me, recovery includes recovery fueling,

Really getting dialed with that, but also the sleep, the off days and all the other the body work, the mobility. And especially for these these longer stage races, I think that can get really challenging because their recovery window is huge.

pretty small. So every, every minute counts, every, every micro and macro nutrient counts and making sure that that athlete is set up. They're not getting pulled to media and losing this critical window for recovery of both mind, body, and all the systems. But I, I love where the science is going as far as nutrition, fueling and recovery and, and

Food is fuel. Fuel is a key ingredient for performance in addition to those rest and recovery days.

And I feel like the movement is away from just train, train, train and dig yourself into the ground into a big hole and then hope to adapt from that. There's a lot more strategic planning and strategic training, including periodization, off seasons, going completely off the bike or away from sport for a period of time, doing more strength training. I think that

Resistance and strength training has really gotten a lot of great attention, especially in sports where it hasn't in the past, where heavy lifting isn't scary anymore. It's actually a performance benefit and can protect the body from injury and really help with recovery too. Yeah.

Has there been sufficient attention paid to the differences in fueling nutrition recovery for men and women? Because I could imagine that there's been a lot of work. I'm just going to stipulate without any knowledge that men have been studied more than women. And the question is how transferable. I heard that at the Olympics, some of the athletes were complaining that there wasn't enough red meat available.

at the Olympic Village. And I didn't know, was that just a bunch of big weightlifting men or was that across the whole spectrum? So what do you know about, what do we know about the differences?

Yes, yes. So you are correct. There are differences and there is a discrepancy or a disparity in the science and the research on female athletes and nutrition. In fact, a study of six leading sports and exercise medicine journals over about a six-year timeframe, only 34% of the participants were women.

Only 6% of those publications were focused solely on women. So you can imagine if you look at just the nutrition science and the nutrition-related research on that, it's going to be even a smaller percentage and a smaller snapshot of that. So trying to have athletes then...

train optimally with the limited research that they have can be very challenging. Now, this is changing. I feel like over the past even couple of years, the work that we're doing within our research teams has started to really help with the progression and the progress and evolution of this. But there's still some major differences. And I referenced fasted training even. And that can cause a lot more hormonal disruption to a female athlete than a male athlete.

And so that's one of many examples of how there might be changes and differences in fueling. There definitely are common themes in both. And so sometimes we get too into the nuance and to the specifics when some of these athletes just need to eat.

And with the fuel in their body, they need the carbs, they need the protein, and they need enough of it throughout the day. And you highlighted an interesting fact as far as some of the lack of resources in the Olympic Village. And I think that was across the board. It was across the board. Yep.

Some protein issues, trying to get more protein. And I think they were trying to be very, very green and economically focused and eco-friendly with that Olympic Games. And sometimes they fell short in some areas, but I'm sure that they responded quickly and got the red meat or the protein. After all, it is France. They should have plenty of good meat in France. This is The Future of Everything with Russ Altman. More with Emily Krause next.

Welcome back to the Future of Everything. I'm Russ Altman, and I'm speaking with Emily Krause from Stanford University. In the last segment, we had a great discussion about some of the differences between men and women and some of the pressing health issues that are affecting female athletes. In this section, we're going to talk about some of the latest work out of Emily's lab. She's actually surveyed Olympic and elite athletes about how they think the research agenda in the future should go. And she's had some findings in her own research that are very important.

In this section, Emily, I want to ask you, what are the stuff that your lab is working on that's some of the most exciting kind of emerging knowledge that you guys are generating?

Yes, yes. One of the areas that we're really proud, a manuscript that just got published hot off the press about a month ago is from our Female Athlete Voice Project. And this was actually a survey-based study, but it was a special type of survey called a Delphi survey. So a little bit more intense, multiple rounds, and it involved Team USA athletes. So very timely around the Olympics. Oh, cool.

And we asked 40 female Olympic and Paralympic athletes what information, what sports science topics did they want to know to help improve their health, performance, and well-being? And also, where are the gaps in this information, both with the research but also the translation? They must have been thrilled. I'm serious to even be asked this question, right? Yes.

The response from the athletes was so positive and they were so excited. And I mean, these were long surveys, probably took them half hour, 45 minutes, very involved. And then we could also ask them what topics they wanted to know.

And so we got a list of 14 sports science topics from that that we published. And this is across a lot of different sports. Again, winter, summer, Olympic, Paralympic. And I think I think it just scratched the surface. I mean, we would love to dive into sports specific research agendas. But this was really exciting because a theme that came out last.

A number of times was around the menstrual cycle and the menstrual cycle as it relates to fueling, as it relates to performance and even hormonal contraceptives. Another gap in female athletes research space in the female athlete research space is on hormonal contraceptives and performance health,

do we need to be thinking about or customizing? I didn't even think about this, but they might have questions about even whether they work the way they're supposed to. Right, right. And what is the underlying hormonal profile when you're on a hormonal contraception, like an intrauterine device or the pill or another form? And so these athletes are hungry for information. And this was another testament of that with this publication and with the survey.

And so that was something that we were really proud to get out to the world and is a stepping stone for other groups to replicate that study in different populations. Now, I know that you do this work in the context of a bigger kind of performance kind of unit. Can you tell me about that unit? Yes, yes.

So all of this research is under and supported by the WUSI Human Performance Alliance, which involves six different institutes throughout the country, including Stanford. And we're trying to uncover these underlying principles that define human performance. And the female athlete is a big focus of this research alliance.

And through that alliance, we developed a program called FASTER, which stands for Female Athlete Science and Translational Research. Good name. Another good name. I see that you have a penchant for good names. And so we are really focused on the female athlete, closing that gender gap, and really focusing also on the translation of that information.

As we talked about already, there are a number of gaps in female athlete research from pre-puberty to perimenopause. So we're focusing a lot of our work on REDS, which stands for Relative Energy Deficiency. Yeah, I saw about that and I wanted to ask you about that because it wasn't immediately obvious to me what that is. So maybe now is the time. What is REDS?

Yes. So I talked a little bit about low energy availability or overtraining under fueling or a combination of that and how that can lead to delays and periods. But we're seeing that this low energy availability can affect numerous other systems in the body, both from a health standpoint and also a performance standpoint. And REDS captures that in this syndrome. But the challenge is a lot of those systems are still very understudied. So we're trying to better understand

What are the impacts on sleep? What are the impacts on even GI and GI changes? How does the gut respond to prolonged low energy availability?

To backtrack a little bit, a lot of the original research started around the female athlete triad, which is decades-old research that's been done. The triad consists of low energy availability, which affects the menstrual cycle, so irregular periods or missed periods.

and then has an effect on overall bone health. So I mentioned bone stress injuries earlier, and that's a big, big effect. It can be really impacted by low energy availability. And so REDS has expanded on that over the last,

six, eight years. And it's really opened up another area for us to research. So we target that different populations. A lot of times we were targeting endurance athletes. We studied ultra endurance athletes, ultra marathoners that are racing the 100 mile endurance race, Western States.

And we're also studying some other other groups as well. So one thing I want to ask about that is I know that your focus is on these these these athletes. My guess is you're learning general principles that will be very useful, not just for endurance athletes, but for really even people who are non-athletes or who are amateur like weekend warriors. Is that true?

Absolutely. A lot of the patients that are in my clinic are the weekend warrior type. I do see the elite athletes and I do see that high level. But we want to optimize health and performance for all athletes. And I think that's a really important distinction. This is not just information for the elite 1% of the athletic population. A lot of these takeaways are super important for all athletes.

And from fueling and protein intake. And so a lot of the areas that we focus on with education are what can you do? What are the what's a low hanging fruit that you can you can start right now that doesn't require demand a lot of resources, but just maybe some intentional time and and the right the right science and the right evidence based approach.

information. And going back to your survey, and you mentioned menstrual issues were one of the top ones. I'm sure that that gives your field like a research agenda for the next decade. I mean, it sounds like a kind of a landmark paper. And you don't have to agree with that or not. Of course, I believe I'm guessing you think it's a landmark paper, but it really sounds like it does because this is setting out this is what these people need. This is what they're asking for. Were there any huge surprises, things that you perhaps thought were important to them that they're not worried about or

Just anything else, because it sounds like a great survey. Yeah. You know, we were surprised by a couple of things. One, things like equipment weren't really brought up as well.

And even like technology wasn't a hot topic. And I think partly it was because we had so many different sports covered that it was hard to agree upon which equipment and what to focus on. So that one ranked a lot lower than we expected. But then an athlete suggested a couple of topics, including this focus on institutionalized sexism in sport. And so just the conversation around cultivating

culture and sports and, and coaches and coaching dynamics and how that can positively or negatively affect an athlete's experience. And this has been ripped from the headliner. We have seen coaches who have really had some bad practices and we've heard about equity for, for example, in, in soccer and in other topics about equity and pay. Yep. Yeah. So it just, that opened up a whole other area that we weren't really anticipating, but we

The thing is, it's all related. And if they're not getting paid well, they don't have the access to some of the resources that they need to recover, fuel well, and even just travel, trying to optimize their travel time to minimize sleep disruptions and their circadian rhythm. And all that goes down to resources and the inequities in the resources. Right.

Fantastic. So we can put a link actually to the paper in our show notes. My final question is really about you doing this great work. You're engaging, of course, the athletes who are your patients are getting the best benefit because they're right in front of you and you're giving them very personalized. But how has the reception of this kind of work been in the world in general, both among the elite athletes and among the weekend warriors and others? Yeah.

It's been so positive. And as I mentioned, they're hungry for more information. So as part of Faster, one of our big focuses is on the translation and the education. And so we'll do virtual and in-person team talks. And the amount of questions and the dialogue and the back and forth

It's just really exciting for us, and it inspires us to get more information out. And I think that the future is in education and empowering these athletes, these coaches, parents, weekend warriors with the right resources, the right tools to optimize themselves for success.

whether it's going out on a stroller on the walk or running your fastest hundred meter dash in the Olympics. So this is great. The stuff that you've learned and that you are learning is very relevant. It's relevant to the elite athletes. It's relevant to the weekend warriors. And it's really relevant to everybody. And people who get to meet with you are the luckiest. But how well has the rest of the community accepted this information? And how are you trying to figure out how to get it out into the world so that we can kind of float all boats? Yeah.

Great question. And I think we're still trying to figure that one out, whether we present at conferences. I think conferences are really, really valuable. There's actually a female athlete specific conference in Boston every two years. I think that's a great place for clinicians to go get the most up-to-date, cutting-edge information. But I also...

We have to do better as clinicians to share this information and find unique ways, whether it's putting out quick overviews and reviews so that they can quickly read through or some different training modules. So that is the future. And I'm super excited about the directions that we will be going. And I'm optimistic that...

all clinicians will be able to navigate at least where to refer and some basic information to get these. Plus, we all know that the patients are great. And if it gets on their radar, they will bring it to their doctor. So in a sense, getting to the patient or the clinician, either way, it'll bring it into that interaction. Yes, absolutely. Thanks, Emily Krause. That was the future of female athletic health.

Thanks for tuning into this episode. You know, we have more than 250 episodes in our archives, and therefore you can find a discussion on the topics of your choice and the future of almost everything. Please remember to hit follow in the app that you're listening to. That'll make sure that you don't miss any episodes and you're always clued in to the future of everything.

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