The Female Athlete Triad and RED-S in Sport | National Fellow Online Lecture Series

It is 1400, uh, Eastern Time, or 2 o'clock. I'm, I'm used to talking military speak. Um, so we are not going to waste any time. We are excited for today's lecture. I am going to just, uh, go ahead and get this thing rolling. So, as all of you know, uh, today's topic is the female athlete triad and relative energy deficiency syndrome. And I find this topic very interesting. I'm very excited to hear this talk personally. I know everyone else is as well. I know a lot of people are going to be tuning in asynchronously because of ongoing things. We, we don't see a, a really extensive list of participants right now, but that's no worries because so many people are going to be watching on their own schedule. This is going to be a popular one, I know.

So, before I introduce our speaker for today, I just want to do a little bit of housekeeping and welcome to everyone who's on this call right now and, and also watching on YouTube later. This is the AMSSM Online Lecture Series, which is, uh, been put together by the fellow, I'm sorry, the Education Committee, um, for the, uh, for the primary purpose of helping our fellows prepare for the CAQ. It is not intended to replace the didactics that go on in each individual program. This is a supplement to, uh, to all of that important training that everyone's receiving. So, um, and I do not, uh, let's see here, my slides are not advancing for some reason, but that's okay. I'm not going to worry about that. So, if you have questions, I would ask you to submit them through the chat feature, and I, as moderator, will be, uh, watching those come in, and I will be, uh, presenting those, uh, questions to our speaker as, as the time ends. The, the talk will be about 45 minutes. It's not a super hard stop like we have at a live conference, um, but we're gonna, uh, have a roughly 45-minute talk, uh, from Dr. Krauss, and then we will, uh, proceed with a roughly 10-minute Q&A period. We do ask that those of you who are dialed in, uh, as listeners, that you would kindly, uh, complete the speaker feedback and evaluation form. Those are useful, uh, for, for us and for the speakers, so we do pay attention to those. It will be, there will be a SurveyMonkey link that is sent out by Andy Meyer from AMSSM, and we really appreciate Andy for making these things possible. He really does a lot of the behind-the-scenes work and making this thing roll. So, shout out to Andy, thank you.

Okay, without further ado, um, we have as our speaker today, Dr. Emily Krauss. And Dr. Krauss works at Stanford University. Uh, she is a Physical Medicine and Rehabilitation physician with, uh, fellowship training in sports medicine, and she has a very extensive, uh, resume when it comes to this particular topic. Uh, she is currently a Clinical Assistant Professor at Stanford Children's Orthopedic and Sports Medicine Center. She's involved with multiple Stanford IRB-approved research projects, including the Healthy Runner Project, which is a multi-center prospective interventional study focused on bone stress injury prevention in collegiate middle and long-distance runners. Dr. Krauss also spends time, and I'm reading, I can't do better than that she's written it, it's such a nice bio here, um, and, uh, she is, uh, spends time with 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. So, I imagine that's some amputees and wounded warriors out there. We, we thank you for your work with them. That's fantastic. Uh, she has, uh, research and clinical interest since endurance sports medicine, injury prevention, running biomechanics. These are areas of interest of mine too. I would love to, uh, to chat with you sometime about those things. But, um, and she's a runner. She is, uh, she walks the walk, and she is a distance runner. She has completed nine marathons, including the Boston twice, which is an accomplishment, and she's also run a 50k ultra marathon. So, these are her passions, and I, we look forward to to hearing her talk about the female athlete triad. I do want to just say that I, I've spent, um, five years of my career in Air Force basic training where we see stress fractures every day. It's an endless flow, and, um, so I know that the military really can benefit from your expertise in this area, and maybe we need to figure out a way to bring some of that out and collaborate more. But anyway, without further ado, Dr. Krauss, I'm going to stop sharing my screen and we'll allow you to bring yours up.

Can you hear me all right? Um, so Nate, I'm sorry, I think I actually stole your screen, so that's why you're gonna advance your slide. So, um, can you see my screen right now? Yes, I can see your camera. Oh, yes, your slides. I'm, I'm, yes, uh, yes, we see your slides. Thank you. Go ahead. Wonderful. Um, thank you. Thanks for this opportunity. Um, yes, I have run, I, one 150k, that was, that was it. That was all that I needed. Um, but I'm really honored to be here talking about a topic that I'm very passionate about, and hopefully, I, um, honor all of the, the researchers, um, above me that have put all the work into really helping us better understand the female athlete, including the female athlete triad and relative energy deficiency in sport. So, let's get started, and I hope I'm done. You might have to be timekeeper and cut me off at some point to allow for enough Q&A. Um, I have no financial disclosures. Um, but I do have a number of great mentors, and I do want to give a shout out to them. I'm Dr. Frederickson, Dr. Nadiv, Dr. Ackermann, Dr. Ten40, um, so many others that are putting in so much, um, research in on this, and, um, we'll try to give shout outs, um, when, um, I present on some of their material.

So, a day in the life. I'm sure you are all busy, and thanks for carving some time out of your afternoon to listen in. Um, I work both in a sports medicine clinic. Clinic this morning, thankfully it finished on time. I do a lot of community outreach and lectures, which I think is really important, and I'll touch on that a little bit more kind of halfway through or later on in the lecture. Honor to do research and present at conferences like AMSSM and ACSM. Sideline coverage, a little limited right now, of course, but I have been lucky to do some fun sideline coverage. This was from my fellowship training at Stanford, and then lots and lots of teaching and mentorship opportunities, which is really great to kind of build and inspire the, the future of our field in sports medicine. So, and then I also, I'm definitely kind of a weekend warrior, sometimes a weekday warrior when I can squeeze it in. I'm from, proud and to multiple nieces and nephews, and I chase a lot of sunrises and sunsets when I can. All right.

So, I want to start off with a little history lesson. Um, this may be, um, information, new information for you, maybe old. Hopefully, you get a bit of everything here. But, um, the first, um, women's sports in the Olympics were in 1900, and this included, um, tennis, sailing, croquet, equestrian, and golf. And you can see some fun pictures here of all those sports, um, being kind of captured. Shortly after that, Ron Pierre de Coubertin, the father of the modern Olympics, stated that women's sports are against the laws of nature and the most unaesthetic site human eyes could contemplate. No matter how tough in a sports woman maybe, her organism is not cut out to sustain certain shocks. As you can imagine, that probably wasn't the reaction that, um, was hoped for, and, um, women were not discouraged from that, um, by any means. And what followed were a grad, really a continuous increase in sports participation over on the next hundred years. And you can see, um, even now, the female sports participation has definitely increased and kind of almost equaled male participation, but, um, it is not equal. And, um, each year, I think we see kind of a more 50/50. But, um, you can see, um, projecting into Tokyo 2020, which didn't happen, was supposed to be around 48.8 percent. But an interesting, back in 1928, um, the Amsterdam Olympics, the first, um, track and field events for women, um, took place. Um, at the end of, at the finish line, um, many women, uh, collapsed at the finish line. And after that, it was so appalling that women were not able to participate in, um, running events beyond 200 meters for the next 32 years, which I found interesting. I don't know how many times any of you have fallen or collapsed after a hard workout or a big run, but I feel like, um, it's different times now, and I'm really, um, inspired to see on this continuous change.

Speaking of inspiration, um, for the sake of time, I don't know if I'll share this all, but there was a really great Nike commercial a couple of years ago about "Dream Crazier." But I'm going to get it started just because I don't know, it kind of pumps you up, and I feel like we all need to be pumped up a little bit more, especially during a somewhat crazy week. If we show emotion, we're called dramatic. If we dream of equal opportunity, we're delusional. When we're too good, there's something wrong with us. And if we get angry, we're hysterical or irrational or just being crazy. But a woman running a marathon was crazy. Officials tried to pull her off. Of course, a woman boxing was crazy. A woman dunking, coaching an NBA team, competing in a hit job, or winning 23 Grand Slams, having a baby, and then coming back for more. Crazy, crazy, crazy, crazy, and crazy. So if they want to call you crazy, fine. Show them what crazy can do. Yeah, I don't know. Every time I watch it, I get a little excited and pumped up. So maybe that was just more for my own motivation during, give this talk, um, to keep the energy up. Um, but I think that that just kind of just was telling of the, of the movement and the progress that's made, but I still think there's room to go with that. Um, in Title IX, Educational Assistance Act of 1972, stated that institutions receiving federal aid must provide equal opportunity for women and men's programs and activities receiving financial assistance, which includes sports. After this, there was a huge increase, as you can imagine, in both high school and female collegiate athletic participation, with the greatest increase in high school sports. It's been, um, really great to be able to work in the high school setting and see high school athletes come in because I think, um, as I'll talk about, and there's a lot of adaptations that happen and potential to kind of change some habits and patterns that maybe I'm developing in these young developing athletes.

So, there are sex differences between male and female athletes, just from a physiologic standpoint, with average body fat composition being about 26% for males, 14% females, 14% for males, with less lean muscle mass in females. Increased overall energy costs, including O2 consumption with weight-bearing exercise. The total cross-sectional area of muscle is about 60% in all females, 80% in adult males. More physiologic differences: females have smaller hearts, faster heart rates, lower blood volume, less hemoglobin, fewer red blood cells, smaller thorax and lungs, and lower VO2 max. So, those metabolic costs can really make a huge difference as far as what recommendations are for fueling, training, and to kind of optimization. And there are a lot of some really great literature coming out to kind of, kind of go into those sex differences from a coaching perspective, but I think as physicians, we also need to be really well-versed on really understanding, um, those differences as well.

So, speaking of, um, sex differences in sports medicine, is a book that came out a few years ago. Um, Dr. Casey, Dr. Rowe, Dr. Press, editors of this, and it's a really good read. I would recommend, um, skimming through that. I did capture, like, a couple of, um, figures from their, um, book that I thought was a nice review. Kind of gives me flashbacks, med school, and the different hormonal axes, and those, I'm endocrine. It's what I wanted to really highlight was the influence of estrogen and progesterone on all of these different systems in our body, including bone health, but also ligament laxity, muscle recovery, and muscle repair. And, um, even just the nervous system. I will not be testing you on these axes. Similarly, testosterone has similar influences, I'm a little bit different. I won't get into the nuts and bolts of this. You can see that, um, both, um, all those sex hormones and can, can play a role in bone health, and it's really important to be able to understand what can lead to changes in those levels, um, based on different ways where an athlete is kind of training or fueling. And you can see that there is a big difference around puberty, which is around 8 to 14 years of age in girls and 9 to 14 years of age in boys. You can see this, um, spike in estrogen and progesterone at that time. You can see testosterone kind of stays about the same, and female, obviously changes and continues to, um, change in males, or it's going to stay and fluctuate in males.

Switching gears a little bit, I wanted to start off with a case presentation. So, maybe this, you've seen something similar, maybe you could say, an 18-year-old female recruit, presents in your clinic complaining of pain in her right buttocks. And that can be a number of things. I feel like sometimes I get a pain in my buttocks, it's on a bad day at work, but this, um, athlete describes an adult ache in the superior aspect of her buttocks, progressively increasing in severity throughout her run. She thinks maybe it's just like, um, some like a joint thing or maybe a little, um, like loop strain, maybe she thinks it's a tendon, meninopathy or kind of high hamstring issue. She states that it resolves, um, shortly after she stops running. She denies any radiation, radiating pain, um, down the lower extremities, no numbness, kneeling, or other neurologic changes. No history of injury, previously. Her physical exam is only notable for, um, some tenderness right along that kind of inside, kind of along the SI joint. Otherwise, no, no real, um, positive findings on your various sports exam. Um, as you're, as a student sports medicine physician, you ask some additional questions, which is very important. She is a freshman collegiate runner. This is her, um, of course, first year. And over the summer, she reported an overall increase in training and intensity based on some mileage requests that her, um, coach had, um, given her. And, um, she was, I'm just trying to be really compliant and do what her coach told her to do. She did admit to losing her period over the summer. She reported that she got her first period when she was around 16, and it was pretty regular, and throughout those couple of years, she admits to being afraid of eating any carbs, and is also, um, newly practicing veganism for personal reasons. So, you end up getting an X-ray, and the X-ray was revealing. So, due to your, um, suspicion based on some of the history findings, you end up getting an MRI, and you find this, uh, stress fracture of the right sacral ala. That one's pretty significant. And you, or maybe this athlete asks, why is this happening to an otherwise young, healthy female athlete? Oh, I also like, um, names and gifts, but I think I think they're pretty minimum on this one, but you see enough of my presentations, I do a lot of them. I think it's important to also, I mean, I've been talking about, um, mainly the female athlete, but I think it's important to understand that this nut is not just a female issue, and I'm really excited to kind of see the research, um, develop in in this area as well.

So, just briefly, I'm going to just define the female athlete triad and relative energy deficiency in sports, including the most recent enhancements in terminology. Explain the relationship between the triad, RED-S, and injuries, especially bone stress injury. And then discuss how sports medicine physicians like you all can best screen and prevent the negative consequences of, um, triad and fetish.

So, diving right in. So, um, the female athlete triad, this was first established in the position statement in 2007 and 2014. And, um, 2007, excuse me, was a position stand through the ACS. So, it was defined as osteoporosis, amenorrhea, and disordered eating. Um, in 2014, this definition evolved into low energy availability with or without an eating disorder, functional hypothalamic amenorrhea, and osteoporosis at the extreme. But then it was also, um, presented in this nice figure, which kind of shows, uh, more of a continuum and the fact that there may not be a full-blown eating disorder, full-blown RED-S female athlete triad occurring. Um, there may be more subclinical findings, and that's really our job is to try to catch these athletes in this area. And I think it happens not when they come in with the injury, screening processes, which we'll talk about on what's been underway.

So, in 2014, um, the, uh, position stand, um, was revised and kind of renewed, refreshed, and this was in regards to, um, treatment and return to play specifically. So, their focus was to provide clinical guidelines for physicians, athletic trainers, healthcare, healthcare providers for both on screening and diagnosis, and really kind of detail out some of these, um, questions that we have about when to screen, what kind of imaging, what kind of information, what kind of questions should we be asking? And through this, also, there was a cumulative risk assessment tool, which I'll be sharing a little bit later, that can be helpful in that screening process.

So, um, in 2015, one of our AMSSM colleagues, one of my co-founder or fellow seniors, um, Dr. Tim Forde and Dr. Frederickson, um, wrote a review article or opinion article in 2015, um, reviewing the parallels of the female athlete triad and male athletes, with the primary difference being, um, at the extreme hypogonadotropic hypogonadism, kind of more in the adult form, but also, um, different changes in sperm count and decreased libido were also undescribed with that. So, just, um, I will say, I'll give a shout out to the female and male athlete triad.org, and I used several of those, their figures because they're so, um, snazzy and really easy to read. Um, so in this particular figure, you can see that their energy deficiency, as far as low energy availability, remains impaired bone health remains, but also this reproductive suppression, which can be demonstrated as reduced testosterone, um, or abnormal sperm. Now, of course, I don't know how many of us are measuring, um, or exploring or studying on sperm count, so that's a little bit of a challenge with, um, just detecting this in the male athlete. There aren't as many questions that can be asked or more as asked as easily. Another, um, just kind of combination of both female and male athlete triad, and one figure from the female male healthy triad.org, I don't believe this is in any of the position stands or position statements, but it does just, um, kind of capture this continuum, once again, on, kind of the spectrum that takes place.

So, in 2014, the International Olympic Committee came out with a consensus statement called "Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport." This is an expansion of the female athlete triad to fully address the consequences of low energy availability. It covers, um, a broader array of both physiologic and performance outcomes in both women and men, and I'm really, um, calls for more research, especially in this, um, update in 2018, is really calling for more research on the impact of race, ethnicity, and disability, and how that can play a role in overall risk, as well as, um, screening, and also just calling for just more research in general on these important and patient populations.

So, um, the relative energy deficiency in sport is defined as impaired physiological functioning caused by relative energy deficiency, and includes, but it is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. This idea, so you can see right here that the female athlete triad is still unpresent, and you can see that there are other, um, manifestations, um, from physiologically onto all these other systems. And, um, the overall, kind of underlying cause is this low energy availability or this relative energy. Um, interestingly enough, there are also these, um, thoughts of the, um, performance effects of relative energy deficiency, and sometimes this is the carrot that gets the athlete in maybe a little earlier, is, um, some of these like decreased concentration, irritability, impaired judgment, just overall fatigue, and not really a pinpoint why that is. Um, so I think that this, the combination of the, the two is, is really important to take into consideration.

So, going into some other definitions. Energy availability is simply defined as the amount of energy, which is calories per kilogram of fat-free mass per day, available for physiologic processes and ADLs after subtracting energy use for exercise and sporting activities. This is kind of the bare minimum that an athlete needs to carry out their physiologic processes that are not involved with sports or, um, physical activity. So, defining this a little further, there are a number of studies that have identified this absolute minimum need to carry out those is 30 kilocalories per kilogram of fat-free mass per day. This is the threshold for where detrimental physiological changes and reproductive function, metabolism, and bone occur. But really, there's more of a recommended need that's established that is around 45 kilocalories per kilogram of fat-free mass per day. Most of these studies, I will say, um, are on female athletes and females, physically active women, and this is their kind of the adequate energy availability, and to really kind of perform at their best, both like from a kind of a bone health and a reproductive standpoint. This has been applied to male and female endurance athletes as well, but I think more research is coming out out of some some grid institutions and Penn State and with Dr. De Souza and her lab, and among others too, about the importance of, um, really thinking that there may be even extreme or different levels of this, this energy availability need, and it's really important to think about that, how that energy availability is different, maybe from that athlete's norm. I think that kind of goes back into that relative energy deficiency in that, that spectrum that they're dropping from, and I think if we just look at those extreme numbers, we're going to miss some really athletes that may be still at high risk, that may not fit the perfect profile of what we would expect to see.

This was a nice, um, infographic created by, um, Dr. um, Nikki K, published in BJSM. BJSM is great for their infographics as well. It just kind of helps kind of break down this energy availability concept and this map energy mismatch with energy demand. So, it can look like, um, intentional low energy availability, so insufficient calories in, and that can lead to this low EA picture. However, can also be overtraining, and maybe this unintentional low energy availability. The athlete that goes from a high school sport to a collegiate sport, they don't realize that in addition to mileage, maybe their intensity is training, maybe they're the amount of, maybe they're doing weights, maybe they're doing more kind of plyometrics and strength training, and they're not thinking about how that is going to influence their fueling needs. And that's low EA forces, forces the body to trigger these hormonal responses that affect normal life processes, leading to negative health and performance.

Here's another, um, great, um, graphic. Back to that axis. So, this low EA since leads to decreased release of gonadotropin-releasing hormone, leading to drops in FSH, LH, in addition to TSH, and leads to drop in these, uh, sex hormones, suppressing reproductive function, increasing bone resorption, affects overall basal metabolic rate, leads to adaptations in adipose tissue, as well as other kind of energy conserving and measures and effects, and heart rate, blood pressure, and potential performance and effects as well. And I think it's important also to just discuss, um, this because athletes often have this almost converse or positive outcome initially with, um, sometimes losing some, losing weight. They may have some performance benefit and performance gain. We're talking about when they lose weight in, in the context of this low EA state. And I think it's important for those athletes to realize that this is, this will likely be short-lived, and whether it's, um, just overall fatigue or an actual, um, injury of some sort, and will likely, um, return. And having that discussion, that frank discussion, and having learning how to deliver that type of information without having an athlete, participate their support and fear is really important, and I think is an art that I'm still learning how to do.

So, I'm diving next into disordered eating. Of course, this is a spectrum of abnormal behavior. Restricted eating patterns, like I mentioned before, may not necessarily lead to a full-blown eating disorder, but it can be those early signs that if not intervened quickly, can get to that point. So, this idea, limited caloric intake plus high training can lead to this chronic energy deficit. And another thing on this, um, chronic energy deficit that we really see some early, um, signs of this, even with kind of shorter periods of, um, these, um, this low energy availability. So, it doesn't take much time for those hormones to start getting suppressed, even if, even before the kind of irregular periods or other findings happen, maybe in the female athlete population, at least.

So, signs and symptoms of disordered eating that could maybe catch your eye: a preoccupation with being thin or high drive for thinness, an idea that I'm thinner is faster, this conscious effort to restrict food intake, high dietary cognitive restraint, dieting, meal skipping, anxiety, shame, guilt about eating certain foods, even with carbs, which is even shocking with a, even the endurance athlete can sometimes be afraid of consuming too many carbs, chronic weight fluctuations, rigid routines around food and exercise, compulsive eating, and using exercise, fasting, food restriction to to punish or make up for food consumed. Who are the athletes that are at higher risk? I think it's important to know these, but also know that these can come in all shapes and sizes and all sports too. So, aesthetic lean sports, sports that emphasize appearance that are often, um, subjectively judged: diving, gymnastics, ice skating, dance. Weight class sports, sports that require an athlete to be at a specific weight to compete: wrestling, boxing, and rowing. And then gravitational sports in which weight less is advantageous for success, advantageous in quotations: running, ski jumping, high jump, pole vault, cycling. Also, I think sports that, just aesthetic clothing. So, I also put volleyball in this. Um, I thought an athlete this week, she's a volleyball player and was also experiencing some early disordered eating habits, and I do think that part of that was, um, just based on kind of body image and how she was looking in her practice clothes.

So, prevalence of disordered eating and eating disorders is more prevalent in athletes than non-athletes. 20% of elite female athletes met criteria for an eating disorder compared to only 9% of female controls. Another study found that 60% of female college gymnasts have disordered eating behaviors. In a study of 486 young female swimmers, age 19-18, found 62% skipped meals, 77% ate smaller meals to lose weight, 13% were vomiting to lose weight, laxatives and diuretics were used. So, these are questions that need to be asked. And, um, it's fascinating to think even just with, um, parental guidance or supervision with some meals that this is still, um, still happening. And, um, we may think that, um, it's a problem that's improving, but I just had a chat with an adolescent medicine physician just yesterday, and she said eating disorders and disordered eating are through the roof through this pandemic. So, unfortunately, a lot of them aren't falling in our clinics because force participation is just a little different right now, and maybe they're not developing on some of the injuries that maybe we could have caught them a little sooner. So, I think this is our opportunity to do different types of outreach to these, um, high schools or different clubs that you're working with, and almost proactively get out to them and just say, hey, we're here, important information for you to use, to try and prevent some of this, um, kind of downhill spiral. And also, just overall mood and mental health is another, um, big, big issue around during these current times.

So, what questions should you be asking in clinic? So, this is from the 2014, um, female athlete triad coalition consensus statement. I think it's a great start. Um, some of these questions you can put in your intake form. You should be having period-related questions on your intake forms, that way you never forget. I think all these other questions are important. Sometimes you won't get honest answers, and I think trying to develop a good rapport, explaining why you're asking these questions and the importance of, importance of that is also really valuable.

So, I'm switching gears a little bit to another component of the triad on the spectrum of menstrual cycle disturbances. Here's a nice review of the different fluctuations during the different stages of the menstrual cycle. I think it's important to realize that even if an athlete is not having, still having her periods, she may be anovulatory. So, I like to review this. Thank you again, female and male half the triad people, for creating this nice, um, figure. So, ovulation occurs and cycle is unchanged, that's ideal, that's an ovulatory cycle. However, there can be these luteal phase defects right around here, and that can lead to shortened luteal phases, decreased luteal progesterone, with ovulation still occurring, and cycles remain, and cycles remaining unchanged. There could be anovulation where there's no evidence of ovulation, but cycle length may remain unchanged. There can be oligomenorrhea, which is a little more, um, easier to ask about and easier for athletes to, to catch or to at least share, where menses can occur in cycles of 36 to 90 days, but aren't inconsistent, unpredictable. I will say those first year or two after that first menses, there can be just inconsistent, unpredictable menstrual cycles that are part of kind of that normal, kind of presumption or normal normal physiology. So, it's important to kind of tease that out, but there also can be some low energy availability during that time as an athlete is kind of training in a new body. So, I don't think that you should just chalk that up to only the normal, um, first couple of years of their cycle and leave it at that. And then amenorrhea has no menses for three months or 90 days or greater than 90 days.

So, reviewing just some estrogen deficiency effects on bone. This is an infographic I created to try and help explain bone remodeling. I think it was more confusing than, and more fun for me to create than, um, helpful, but that's trial and error in trying to find teaching tools. So, estrogen deficiency leads to impaired skeletal muscle oxygenated metabolism. It leads to, um, changes in renal calcium homeo, intestinal and renal, renal calcium homeostasis. It can, it inhibits osteoclast apoptosis and stimulates osteoblast apoptosis. Other, in other words, it promotes bone absorption, inhibits bone formation, and it can lead to other, um, bone loss. And there can be additional bone loss effects from suppression of those, of those other hormones that I provided in the figure a few slides back with IGF-1, leptin, and total T3, that can also kind of combat, compound, and affect bone health that way. In addition to these nutrition variables and and hormones, there are other determinants of peak bone mass. Genetics does, um, play a role, and I think asking about history of osteoporosis in the family is important. There are other unmechanical forces, as I'm native mentioned, I do have an interest in overall biomechanics, and especially with running, and how that can lead to different loads into the bone. Um, so those are questions that you may want to ask, but I think, um, kind of factoring that into like the big picture, and there are other risk factors including them different medications and like really kind of asking those questions as far as overall medications and other medical comorbidities that are important to just kind of be comprehensive when you're thinking about the overall bone health workup.

Really important for me, especially working with younger athletes, peak bone mass is attained during childhood adolescence. Is a major determinant of bone mass and fracture risk later in life. Super important to be asking and really, um, thinking about these information or thinking about this and when an athlete is in those developmental years. We build about 90% of our peak bone mass by age 18, and if a young adult's bone, mental bone mineral density is just 10% higher than the mean, it may decrease stress fracture and fracture risk and delay the age of crossing the osteoporosis threshold by 13 years. So, I don't think it's, uh, I don't want an athlete to get discouraged if maybe they had some disordered eating or a delay in overall, kind of growth and bone development during their adolescent years, but I think it's important to keep that in mind, and they may need to be treated a little differently as far as overall training load and how they approach, um, just overall kind of training, training volume, and just nutrition and during those, especially early phases of maybe introduction into a sport or return to a sport during an off-season.

Overall bone accrual and growth, 26% of final bone, final bone mass is acquired between ages of 11 and a half and 13 and a half in girls, and 13 to 15 in boys. And really, um, kind of really kind of sending this home, early puberty represents a really critical time to participate in sports, to emphasize weight-bearing and high-impact exercises, really kind of going back into that, going to that sports diversification. I don't know if you've had us, um, talk on, but sports specialization is, um, still a problem.

So, what are the impact loading effects on them? High impact and multi-directional impact loading activities enhance bone density and bone geometry, especially in anatomic locations directly loaded by those sports participation. Long-distance running may lead to modest improvements in bone mineral density and geometry over non-impact sports and sedentary individuals. There are a number of different, um, studies that have explored this, but I'll give a shout out to Dr. Frederickson studying fall sports participation, including all sports participation in adolescence, that led to a 50% reduction in developing a stress fracture, bone stress injury in both sexes, and they found this was dose-dependent with a reduction of about 13% per year played. Females with menstrual regularities, however, did not see these same benefits from ball sports. So, it's really full picture. I know it may sound like, why are we talking about bone health so much in female athlete triad and RED-S, but there's so much overlap into, um, kind of encouraging these types of activities and really not missing some of these other important factors such as regular periods and nutrition with this.

So, what about hormone replacement? We get this question a lot. I made this an infographic after I was, um, struggling to find ways to educate athletes in my clinic, and I felt like I was a broken record talking about hormone replacement, or just was shocked at how many athletes were still, still thought that it was normal, or they were getting prescribed oral contraceptive pills for the sake of missed periods or irregular periods only. And, um, oftentimes, I mean, there are a number of different reasons that females can get placed on hormonal contraception, but they are also placed on those, um, for other reasons other than birth control, and it's not always the best answer. And so, I created just a couple of just, um, scenarios that athletes can hopefully get some better understanding or some clarity on.

So, um, I get this a lot. Most of my teammates lose their period during the track, cross-country season, so it must be normal. And unfortunately, that is not a normal response to training, and it really needs to be delivered that information from all different levels, so the coaches, the parents, the athletes, and the athletic trainers. And hear this, it shouldn't be a stigma that, um, the, or it shouldn't be a rite of passage that an athlete loses their period during, um, during training, like that's a sign that they're really working hard. Fueling should be matching those exercise efforts to maintain that, and that's, um, that period is a great sign that things are, I'm still in check, not the only sign, but it's a good indicator and an easier indicator than others.

Many of you may have may remember this, um, article, opinion article that was written in the New York Times by Mary Cain in November of 2019. I really admire her for being brave and sharing her story of some of her her personal experiences. I think it's helpful to, um, if you haven't seen it, there's a nice, uh, seven-minute video on, um, in the New York Times about it. And it just, I think it really led to this, um, boom in discussion, or an increase in discussion on the topic, and how important it is to, um, be really making sure that the, the coaches understand, um, the influence and the effects of what the way that they're coaching and the way that they're emphasizing or de-emphasizing certain aspects, and trying to encourage a healthier body image within all sports. Lauren Fleshman, feminist approach to coaching, um, a great article in the New York Times, just in October of 2020. If you haven't read that, that's another good one. White Fleshman never believed she never reached her full potential as an athlete to, in part, to focusing too much on her body size. And if the scale moved to the wrong direction, she said. So, these are just a more, just reasons to just kind of have a, like really just reinforce this information, and I just admire these, um, big, um, influential on people within the sports that are stepping up. And these are some of the health problems that she described during her, um, kind of younger, um, training years. And then the last one, I lost my period during the track and cross-country season, and my doctor wants to put me on the pill. Unfortunately, that may be a saying that your hormones are working properly because of low EA that can lead to missed periods. It should be rest. It also should be other things should be explored: other causes, PCOS, other chronic diseases, thyroid dysfunction, and pregnancy should also be considered. The fine print here, endocrine society has recommended against the use of COCs for the sole purpose of improving BMD. However, there is, um, good research about short-term transdermal estrogen with cyclic oral progesterone for addressing low bone mineral density after addressing all other lifestyle factors. Dr. Ackermann and her team have, um, really done some, some great research on this, trying to compare it to different, um, other, comparing transdermal estrogen, comparing OCPs versus none, and they did see improvements in overall BMD, I believe over on the year was the most, the latest on literature that she published.

Okay, so how do we evaluate bone health? Bone strength is determined by bone mineral content, bone mineral density, and bone quality. Bone quality is determined by microarchitecture, geometry, and size. And there are a lot of really cool fancy tools that we can use to try and study that, like high-resolution peripheral quantitative CT scans, but the reality is, it's not very easy to implement in a regular clinical setting. So, BMD is currently used to evaluate bone health. Through, um, DEXA, excuse me, DEXA is used to measure bone mineral density to evaluate bone health. We use Z-scores. Important to understand, we use these scores, two, for children, pre-menopausal women, and men under the age of 70. Um, and this is comparison to age and sex-matched controls. Might be less than 60. Um, I, this is also from the 2014 female athlete triad coalition. When do you order a DEXA? I don't recommend just ordering a DEXA without really knowing what you're going to do with that. If there are a number of higher risk factors, triad risk factors, that is one indication. Greater than two mod, greater than or equal to two moderate risk factors. And then other populations where, um, they may have a history of multiple, um, peripheral fractures, different medications that may impact bone health. Um, I had a kid who is, uh, on chemo and was also, um, on dexamethasone for, excuse me, on prednisone for, um, over a year. He was in, um, in high school. No other kind of eating disorder tendencies, but his own bone health was, um, compromised. His bone mineral density was low, and in that case, um, I think it was important to get, to get that, to get the DEXA. And so, I think making sure that you have some type of consistency and you know what you're going to do with that information, especially in the adolescent or young athlete. I think pediatric DEXAs are sometimes more difficult to interpret because bone age differs from different athletes, and being able to kind of adjust that scoring if necessary based on their bone age, because you can imagine if a female who's 16 or 17 that hasn't yet had her period, she may, she's going to have a different bone age than a 16 or 17-year-old who had her period when she was 12 or 13. So, just use this as your reference. They won't go through all of it for the sake of time. And then interpretation, this is also, um, reference there. I think it's important to be very careful how you use the word osteoporosis. I think low bone mineral density or lower bone minerals, it's unexpected. It's, um, it's easier for an athlete, delivery, but I think it's important to emphasize the importance and that this is, um, this is serious and needs to be addressed.

On three different methods. So, just to, I'm going to make sure that I have enough time for Q&A. So, this is an important one because just overall screening. So, here is the female athlete cumulative risk assessment and a male equivalent breakdown that I often use with my athletes, just to kind of help them understand. It's, I think it's a little bit more challenging to implement in the high school population, as it is a more, and like used for, um, athletes greater than 18, and sometimes athletes that are around 14 or 15, they can't really say, or 14, they can't really say that they have delayed monarchy yet. But I do use this, and it's been used, um, in research, and there are different, um, return to play, um, systems that you can use based on this. This is from the cumulative risk assessment tool from the female they tried coalition, and then we have found, um, studies that have found that the cumulative risk assessment scores predicted future bone stress injury in females and in males as well, and found that each one-point increase in serious score was associated with a 37% increase in prospective bone stress injury risk in males. And so, I think that's, uh, more more validation that it can be helpful to to use these screening tools, and it's a start, and you can get a lot of that information from those pre-participation physicals.

This is the cumulative risk assessment tool that's, um, used with the relative energy deficiency in sports, the RED-S CAT. I like the, the red, yellow, and green lights to kind of help also help a physician and really identify when, when you should not allow this athlete to, uh, get toe that starting line or return to practice. And of course, these are, these have potential, um, serious, um, medical concerns, and I really need to be addressed as, um, the consequences can be, I'm really drastic. But this middle ground is really where I think we can make that the biggest headway, because often times these, when it gets to this point, it's sometimes even out of our hands and needs a more multidisciplinary approach. But this yellow light and these, these athletes can be addressed in our clinics, if done consistently and with the right, the right approach. And then you can see using these written contracts, I think can be really helpful, having close following, and then sometimes there needs to be other follow-up supervision. So, this, um, treatment contract, um, is really nice. I think it's a good example. You can create your own treatment contracts, but I think it's good to have something in writing. This, when I was going through this and preparing this talk, it just really inspired me to do more.

of this and kind of take that time so things are kind of more kind of set out, written out, and you can really kind of work with the athlete and maybe the parents, if you're working with the parent too, to come up with some acceptance, come up with acceptable goals. I will say that I didn't, don't think I mentioned in the, like in the low EA calculation, it's really hard to get, um, down to get an understanding of dietitian. But once you start getting more comfortable, kind of getting an idea of their kind of overall caloric intake and caloric needs, it can be helpful to, um, kind of start that discussion that, "Hey, I think you are under-fueling here." But, um, there are some strategies like, "You're skipping breakfast. That's a great way to kind of jumpstart your day and I'm a great way to kind of give you those energy levels for the rest of the day."

Um, one thing that I did just want to talk about is this study that I did with Paige Scorsese, graduating med students, and this year on, uh, a pilot study on female athletes and looking at iron supplementation. We actually tried to see if there was a relationship between iron deficiency and female athlete triad, and we found out that over almost half of them were supplementing with iron and were unable to really bring any conclusions from that. I think what was really fascinating was the number of disordered eating tendencies, 76% in this pilot study. Um, that's definitely of concern and just highlights this need to, um, have these discussions. And, um, there are a lot of them. We're still having some degree of regular periods, um, as well. So, um, just reinforcing this importance of kind of using these risk scores to initiate that discussion.

Um, all right, so almost, so, um, questions to ask, um, of course, we're used to this by now, but really making sure that you do a good review of systems. Um, their bone stress injury history, fracture history, um, fracture location does matter. Didn't really get into this today, but they're more higher risk, lower risk, and how that's really defined as, um, I think an evolution, I'm in thought, but, um, I think they're, they're more trabecular-rich sites versus cortical bone-rich sites that could, um, lead to, um, kind of delays in return to play, delays in healing, and there's also different vascular supplies that could also be considered as high risk. Um, different medications, menstrual history, sexual function, asking about libido, asking males about morning erections, as that can be an indicator of that lower testosterone. Um, training, dietary, and family history, of course. Um, what to look for in this is kind of more in that line of disordered eating and eating disorder, um, territory, but it's important to be thinking about that delayed sex development, of course, in an adolescent athlete. Look at making sure that you're thinking about orthostatics too, and, um, getting that blood pressure and pulse on those athletes. And then, um, just optimizing bone health, thinking about weight-bearing activity with adequate recovery and caloric intake is super important. Um, general calcium, vitamin D recommendations, ideally focusing on getting all those nutrients through the diet. Oftentimes supplements are not needed, especially except for if an athlete is on kind of warm and extreme, like vegan diets, and they just be really mindful of, um, getting their kind of overall, kind of iron and B12 and some other nutrients as well.

Some other factors to consider. I had to throw this in there: biomechanics that could also be affecting overall load, overall training load, recovery. Asking about mental health, asking about different stressors, asking about their sleep. And I'm going to leave it at that. Gives us about seven minutes for some Q&A. I know I kind of breezed through those last pieces, but, um, I just want to thank everybody for taking a listen today, and it's really honored to be able to do this research. Again, there are numerous different, um, really amazing researchers out there and clinicians out there that are kind of paving the way for younger researchers and to try to, um, continue to study this. But I think it goes well beyond that, and just being able to kind of speak this language and being able to care for these athletes optimally is our goal, and being able to get that information to the right people is a big goal of mine too.

All right, newsroom. Fantastic. Those are some awesome photos there. Thank you. I am like, I, I have a playground here, and I know that I'm very, very fortunate to have that, um, year-round. I'm in this sleeveless shirt right now, so I shout out to anybody who's in some, some cooler temps and cooler weathers. Um, I do miss, I'm from Nebraska, and I do miss the fall and winter seasons changing, though. Very cool. Fantastic talk. Thank you so much, uh, Emily. And, um, I have like 1800 questions that I'd like to ask, but, um, we won't have time for that many. I do have a couple that are, um, from our, our, uh, audience. Uh, we have, um, gentleman asking, uh, this is, uh, from Jacob Turnbull. Jacob, thanks for your question. Um, is there an app or tool that you use, um, that would help the athlete monitor their caloric intake?

You know, I think it's like this double-edged sword. I think it's really important for an athlete to understand how much, how much they're fueling, but I don't want it to become an obsession. Um, depending on the, the degree of disordered eating that's taking place, uh, there may be a more of like a, kind of a consistent plan as far as, kind of what the, what the plates look like. I do think that as far as, um, different tools or apps, um, the IOC nutrition part of their website, and I can even share this too, there's a way for me to share it, but, um, has like healthy plates and different healthy, healthy training plates based on different, um, levels of their, kind of a more of a moderate day or a rest day, and then different ratios because it's more than just, kind of that caloric intake that's important. And I think it's really important to, kind of meet those caloric needs, but I think if an athlete just goes towards that and finds ways to, kind of check that box without maybe having it like that healthy approach to, um, kind of balancing out their diet, they may get GI distress, they may be frustrated, they may feel bloated and full, and they may not have as much buy-in. But the more I work with this, um, sports dietitian, the more I just, I realize that there are such good strategies as far as fuel timing and ways to, kind of do that throughout the day. So I'm kind of skirted around your answer as far as using one-to-one app. I mean, there are like calorie tracking apps out there, but I think even more so is, um, having an athlete, kind of like, fill their plate, fill their plate with, um, good, um, kind of the rainbow of foods from checking from different boxes, carbs, protein, um, healthy fats, and using those, um, the IOC and healthy plates is a good start.

Excellent. Thank you. Um, the next question is from Laura Matson. Thank you, Laura. Um, for return to play, do you generally look for menses to resume as a precursor, um, or as a criterion for return to play? Also, when periods return, do you have any practices for return to obvious return of ovulation, or do you try to check through that at all?

You know, I think, um, what I normally do is if it's, if it's like a two or three-month timeframe of an athlete being amenorrheic or unmissed a period, um, and if there aren't any higher risks, if they, if their overall risk is kind of in that, kind of if you do the cumulative risk assessment tool, they're, um, they don't have severe, um, eating disorder behaviors that I think need to lead to that activity adjustment, I am okay with them returning, like maintaining their sport as long as we're on the same page as their fueling plan and understanding that that fueling plan, if they're going to stay training at that same level, they may need to really adjust their, um, their fueling over time to increase their intake to get that, um, energy availability back on track. Now, this is if we're talking about over a year or two, then I think it's time to have it, like a really, like frank discussion, okay, we're going to really need to dial back on overall activity level. I struggle, um, if there's not an eating disorder that I'm worried about them kind of over-exercising. I struggle to take away all physical activity because I think that the mental health consequences of that are pretty severe. So, um, I think adjusting and maybe adjusting overall mileage if they're a runner or, um, kind of time, like number of hours, like really cutting back the number of hours, um, to, and maybe even shifting focus on getting stronger, working on kind of building up that base while they, um, kind of get into that more balanced is what they need. I think it's, it's exciting when an athlete gets their period back and they're excited about it, they feel like that buy-in, um, will help them in the future. So I think making sure that they understand that this is an important part, we're not ignoring it, but, um, we're willing to work with them and kind of balancing that activity time. So, kind of individual-based is my answer. And I don't, as far as, kind of temperature tracking and ovulation, um, I should have a better answer to that. I don't, um, I don't do anything with ovulation and that tracking right now. I think it is really challenging, and I think it just requires really, really close monitoring and different, like, kind of tracking labs is great on, in a research, um, studying, but I think it's hard to implement, um, out outside.

Yeah, great. Yeah, that highlights the importance of individualizing and taking care of each, you know, knowing our patient well. Um, as far as when they're ready to return to play, I have a few other questions. I don't see any more coming in from the audience, so I'll just shout out to the fellows and others who are on. If you have questions, go ahead and, um, and send them out. One thing that I think people might be interested in knowing is what is the role of the dietitian, and if you have a dietitian, how do you get them involved if that person is available to you? And, um, and if you don't have a dietitian, how can you, um, you know, I guess take on some of that role yourself if you're taking care of an athlete that doesn't have access to that?

Yeah, I think, um, one, I feel really lucky to have to work with a dietitian. I wish I could work with her more because I think I would, you find opportunities to pull her in because you realize how many athletes aren't fueling properly, and it doesn't mean that they're under-fueling, but they're just eating the wrong things at the wrong time and probably not performing at their best and maybe even leading to increased injury risk. But for a lot of athletes, one, um, what usually happens is I try and do like dual visits on the same day, and so I'll meet with an athlete first, and then I'll kind of do this handoff and be like, "Okay, I think, um, this is where, where you need to like, maybe focus. You're going to get more into this." But, um, sometimes feeding and are giving the, the dietitian some cues as far as like an interesting family dynamic and that I think that there might be some like underlying stress at home, life can be helpful, um, context, um, for, for a dietitian just leading into it, just so that they can really, um, develop a rapport because, and you can tell somebody to, to eat the right certain things until they're, until you're blue in the face, but if they don't, they don't really buy into it and figure out that this is going to help them reduce injury risk, but also potentially perform better, I think it's really important. And I think that I'm working with a dietitian and underst, like sharing the labs with them that you're concerned about, so maybe a lower ferritin level, um, sub-optimal vitamin D, um, and the degree of maybe, um, the free T3 or free T4 is off, um, is really, um, important to think about too. And I'm also kind of talking about for me, understanding ways that I can better communicate with athletes who do practice veganism and who are vegetarian. I don't think, I don't think it's it's helpful for us to say, "Stop being a vegetarian" or "Just eat some red meat." I think being able to really, um, kind of relate to them and like use that right terminology and and find ways that they can still check all those boxes, but they need to be more on top of it, and they need to be, um, take that, take on that responsibility. Um, if they don't have that dietitian, there are, there are some more like, like there are some nutritionists out there that will do, um, virtual consultations. I think that's, um, that's helpful. I mean, that can be pretty costly though. What could be done is if there are, if you have access to a team and you have a dietitian that's willing to work with you, or there are some ways just to kind of gather some information and some basics, um, like the IOC has a ton of different handouts on specifics on this, um, you can share that information with the team and kind of use that as at least a starting point if the access and the resources aren't as available. So I have given a couple of just nutrition talks to different teams where I knew that they probably wouldn't be on board with uncoming to see a dietitian out of their own, on their own.

Yeah, that's very helpful. Uh, thank you. I, um, let's see. I'm seeing, uh, what is the, a question coming in from, uh, from Anne Kuavara. Thank you, Ann. Uh, what is the typical prognosis or treatment length times for female athlete triad or RED-S? If there is, and that's probably very individualized, but, um, this is probably not a quick treatment course. When do people recover?

I feel like, I mean, it depends on how, how severe everything is, but, um, I think anecdotally, and I mean, I would, I'd love to see some studies on this as far as like that treatment and resumption, and maybe there are some out there, and I apologize if I offended anybody that didn't have that published on this, you're like, "What? Dr. Krauss didn't see this?" but, um, it can take up to a year to really kind of get things back into a good place. And I think for, um, athletes, especially athletes that have multiple bone stress injuries and are recovering and kind of re-injuring, I think really kind of setting that expectation that this isn't going to be a month or two and you're back to running and, um, completely back to your normal, normal training. There are habits that need to be changed, and this is, and there may be, you may need to be running, um, with a different body, body type to some degree, and and that body type is going to be stronger and maybe more resilient down the road, but in the next year or so, you may notice that you feel sluggish, and you're, you're not as poppy, and you don't have that response that you had before. I think having them trust the process and keep going with you. And SJ had a question as far as intervals of meeting depending on the severity. I mean, if this is like a more disordered eating concern, meeting them like once a week, at once every two weeks at the beginning until they have a good buy-in with a diet is recommended, but I think beyond that, having them follow up, especially if they're, um, that they're healthy and not injured, and you're not kind of following them for an injury, um, having them come back in a month or two, um, to see it, see how they how they've responded is would be a good frequency. But that answered your question.

Absolutely, absolutely. Yeah. Um, when I, uh, was was at basic training for the Air Force, we, um, you know, this, it's just a constant steady stream of young people coming in with lower extremity pain, and many of them are novice athletes, to put it, you know, kindly, many of them are couch potatoes, honestly. What we get is a little cross-section of America because we get, uh, just, uh, you know, a subset of all these, uh, high school graduates who are coming out, they sign up for the military, and they come to do a great thing to serve their country, and then they come to basic training, and they realize they weren't physically or nutritionally prepared. So, I, I, we see so much bone stress, it is, it is absolutely astounding. But, uh, you know, many of which go undiagnosed. But, what I wanted to say is, um, we see prevalence of, uh, iron deficiency upwards of like 80% of females, and it's, um, as far as a ferritin level under, um, I think 45, and we see, um, even a quarter, roughly a quarter of our females have a ferritin level that's under 15, and, um, basically undetectable. And that's a one out of four. And, um, that to me, that tells me it's a societal issue, and these people are just not, um, uh, nourishing themselves in the, uh, properly. Do you have any thoughts on this? You know, how much is this, um, a societal issue? I think that, you know, if it's that prevalent that it's affecting a lot of our, our, our youth that are out there on soccer fields and track clubs and cross-country teams everywhere, and I just see it as such a, such a prevalent, uh, issue, and I don't know what the answer is, but, yeah, yeah, I agree. I agree with you.

Um, I remember reading, listening to a talk by Benjamin, and at Kona at a Kona Ironman conference a couple of years ago about iron deficiency and non-anemic iron deficiency, and how that can just be, be a big fatigue generator for, for an athlete, and how it's often a sign of other things being being off. And yeah, I think there is a big, um, like potentially under-fueling or improper fueling concern. But I do also, um, question about just, um, kind of the chronic inflammatory, chronic inflammation of, uh, of training. And I'm not as well-versed as far as like all of the specifics, but, um, I, I think that an athlete's overall iron intake, and this doesn't have to mean supplementation, but overall iron intake does need to go up with, um, with increased training intensity, especially, especially running. And that doesn't, I don't think it's all about like foot strike hemolysis. I think that's probably a very small portion of that. Um, they may play a certain role depending on how heavy your foot strike. But, and I don't think it's because of, um, kind of menses or heavy, um, cycles. And so I think it's, but it's, I really advise against blindly supplementing or getting the ferritin and just supplementing without tackling some of these other, um, nutritional pieces that I think are going to be a better, um, better approach to those types of issues down the road. Kind of like, um, not like putting a band-aid on it with a supplement. Um, I think the supplement will kind of help bridge, but I think it's the starting point of a bigger discussion.

Yeah, uh, okay. I have one last question, and I think we're, we're a little bit over time. I hope I want to respect your time, Emily, and, uh, we just appreciate you so much for being on, uh, today and sharing with us. Do you have time, more time for one more?

I do. Okay. Okay, good. Yeah. Can you see the questions? Okay. All right. So, you know what's coming, but, uh, for those who are not looking at the and reading it, um, how and when do you prefer to get psychiatry involved when this disordered eating pattern is intentional and likely an eating disorder diagnosis?

Yeah, I think this is a really good question, and I think it's, it's so helpful if you already have that infrastructure in place where you've got like a psychiatrist or psychologist, or I mean, like in that, like collegiate, like a D1 setting, I feel like they've got got those resources. But when you're out in clinical practice, um, right now, our, um, psych and eating disorder team is backed up because things are so, um, so prevalent right now, and it's even worse than than usual. And so I think for these, when I start, so if I, if I get an athlete and I identify, okay, this is, um, this is outside of the realm of, um, disordered eating, this is, this is getting into eating disorder, and they need more, um, intensive treatment, um, my, my threshold is pretty, pretty quick too, or pretty low to reach out, and sometimes reach out directly to the psychiatrist because they can often work, work an athlete. And, um, I think even maybe more important than that with that is finding like an adolescent medicine or an eating disorder group who already has has that system in place. Sometimes, um, this, it doesn't need to be an intense in-person or kind of a day, day treatment center, depending on the degree of the eating disorder, it can be just a very quick follow-up. But, and ideally, um, working with a dietitian, working with that physician who specializes, that specializes in this, and a therapist or psychologist. So if the psychiatrist is a little more difficult to get into, oftentimes getting into that, that type of eating disorder group or treatment group is probably even more beneficial and can sometimes be a quicker end. But in the meantime, I think making sure you maybe kind of have more frequent follow-up because sometimes there is that big weight, and you don't want to lose that, um, lose that, lose that athlete. And, um, of course, asking other mental health questions and really kind of going through that depression screen and anxiety screen during those times, so, um, you are very aware and you can make those changes and escalate if necessary.

Yeah, awesome. Thank you. And, um, I think that, uh, covers all of our questions. I, I know that I have multiple other things, but we'll save it for another time. So, um, thank you so much, uh, Dr. Krauss, for for joining us and sharing, uh, your, your, your passion, your knowledge, and and your, your experience with this, uh, fantastic lecture. I know this is going to get a lot of views on the YouTube channel. So, um, thank you again. Thank you everyone for joining, and, uh, we will call it a day. Um, again, just one more reminder, there's a SurveyMonkey link here in the chat feed. If you don't mind, just clicking on that, it's a real short survey. We can, we, we always appreciate feedback. So, thanks again, everyone, and signing off.

Yes, yes, thank you. It's an honor. Thank you so much.