Understanding Energy Deficiency in Dance
On our previous Episode Dr. Davenport and I talked about some of the more Taboo topics in dance medicine such as pain science surrounding injuries, and a dancer’s concern over weight being taken during screening. When I sat down to really think over these questions I thought back to my own experiences as dancer and athlete and what was my mindset and go to in dealing with weight and injuries. I took a step back to think deeper about what am I seeing clinical from many of the dancers on my table, and what is the one thing I am always watching out for when a dancer is dealing with a chronic injury like a tendinopathy, an acute injury like a stress fracture, or something that just seems out of the normal. When I dug down deep into these questions I found that sometimes it is a biomechanical issue but many times there is an underlying energy deficiency that is contributing. This is a topic that I have become passionate about over the years because once this is addressed there can be such a turn around in the dancers overall physical and mental health.
On Today’s episode I am joined by Dr. Emily Kraus who is a sports medicine physician out of Stanford. Emily is the Director of the Stanford Female Athlete Science and Translational Research program, known as FASTR. The FASTR program seeks to help close the gender gap in sports science research with an emphasis on early identification and interventions to prevent injury and identify ways to optimize performance in female athletes. We sat down to discuss relative energy deficiency in sport better known as RED-S, we talked over common clinical presentations that clinicians may be able to identify, what clinical tests and measures can be used, and how energy deficiency can affect the athlete physically and mentally.
Tell us a little about you:
Dr. Emily Kraus is a Physiatrist working out of the Stanford Children's sports medicine center
Focusing on orthopedics and young athletes
Has an interest in overuse and bone injuries in the female athlete, allowing for life long participation in sport and allowing for her patients to stay active
Director of the FASTR program at Stanford focusing on bridging the gap in female athlete research
Wants to make sure that athletes can stay informed about best practices for overall health and longevity in sport
What is the difference between RED-S and the Female Athlete Triad
Start with low energy availability
Occurs when an athlete is not consuming enough fuel (food, calories), to cover the exercise needs and body natural processes
If this happens over a longer period of time it can lead to a chronic low energy state that can cause things like the female athlete triad
The female athlete triad is comprised of 3 interrelated conditions
Low energy availability caused by:
Under fueling unintentional or intentional
Disordered eating or eating disorder
Over training
Hormonal suppression or menstrual irregularities
Irregular periods
Loss of period
Delayed period- menses that does not begin until after the age of 15
Impaired bone health
Loss of bone mineral density
History of bone stress injuries
Stress fractures or reactions
Coined in the 80’s-90’s
In 2014 the International Olympic committee came out with consensus statement on Relative Energy Deficiency in Sport (RED-S)
Takes the female athlete triad and expands it to encompass more health and performance outcomes
Impaired immune system
Impaired gut functions
Impaired metabolic rate
Decreased cardiovascular health
Different performance effects
Increased fatigue
Decreased strength
General decrease in performance
decreased endurance
increased risk of injury
poor response to training
impaired cognitive function
decreased coordination
decreased concentration
Irritability
Depression
Decreased glycogen stores
Decreased muscle strength
Terminology can depend on whether the athlete is presenting with just the triad components, such as loss of period, and bone stress injury, or are there some other components of RED-S like fatigue that are coming into play
RED-S description covers both female and male athletes
There is new research looking at a Male Athlete Triad
Looks at testosterone and other male hormone suppression
Gonado hypertrophic hypogonadism
It can be much harder to identify this deficiency in men due to lack of period every month, many times it is not caught until the dancer ends up with a stress fracture/reaction
Dance is a beautiful, artistic, and athletic sport that is very subjective, and many times based around fitting into someone’s ideal image, do you feel that this predisposes dancers to developing RED-S?
Athletes who engage and emphasize leanness are more at risk for developing habits that can lead to decreased fueling or disordered eating or over training patterns
What are some of the clinical signs that should clinicians (PT, ATC’S, sports psychologists) be watching out for?
Can present in many different way, sometimes once it has gotten to an irregular period stage it is late in the game and there are some consequences such as
Impaired bone health
Overall drop in hormones
Early warning signs can be:
Irritability
Fatigue
Under performing in sports and life activities such as academics
Immune suppression
Thyroid suppression
Signs for Males who may have RED-S
Loss of morning erection- especially for males in pubertal stages
Decreased libido- depending on age
If these are being identified it could be a flag for the clinician to take a deeper dive into:
What does the training look like, or overall load on the dancers body
How many hours/day
How many days/week
How intense is the training
How much cross conditioning is the dancer doing
What does their nutrition look like, are they actually taking in enough fuel to support their level of activity
An overloaded system overtime will take a toll on the body's ability to fully manage its energy stores, and can suppress the overall metabolism of the body
What would be a common Clinical case scenario?
Female-
Young female dancer who is presenting in the clinic with a pain in the second or third metatarsal.
We look at overall pointe shoe fit/ quality of the shoe (not dead) and mechanical stresses that could be leading to this pain in the metatarsal.
I consider the dancers overall training load, including total hours dancing, hours dancing on pointe, hours in rehearsals, any cross conditioning a dancer may be doing.
If all of that seems to be within normal limits I begin to dig in a little deeper;
I usually find a history of:
having a period and then losing it
The dancer is usually stressed during audition season.
They are concerned about their weight/appearance and receiving/maintaining a contract with a company, or continuing to perform solo roles at their studios
Some will actually admit to eating very little, or they are relying heavily on liquid meals
Other common clinical presentations
Dancer who is coming in for repeated injuries
Vague hip symptoms with femoral neck stress injury
Dancer who comes in with knee issue, than achilles issue, than hip issue
the dancer has been in a boot for 3-4 weeks and follow up imaging is showing that the fracture is just not healing, or moving along very slowly
Concerns is that the dancer is not able to heal/ fully recover from the injury in a time frame that you would expect
This is more than just an overtraining effect
Many times with these dancers/athletes who present with RED-S there is not a drastic body image change
May times low energy availability will slow down the metabolism to conserve energy so a dancer may actually report that they are gaining weight
How does a physician diagnose someone with RED-S?
RED-S is not the initial go to when diagnosing, low energy availability is not the only thing that can cause period irregularities, also have to rule out thyroid dysfunctions
If there is a suspicion for RED-S you can complete a blood draw to look at:
Hormone levels
Estrogen
LH/FSH
Thyroid
Suppressed T3, and free T3
Likes to look for a trend not just a single snapshot
Will look for certain vitamins and minerals
Vitamin D
Iron
vegetarian/vegan athletes
Lab tests for Iron
CBC
Ferritin
May be appropriate to treat relative anemia in an athlete with a level below 30
If there is restrictive or focused eating pattern at play there could be a deficiency that could lead to decreased ability to heal and recover from the injury
Will refer out to sports dietician to further the discussion on fueling in regards to:
Total fuel needed to sustain activity levels and allow for appropriate recovery
Timing of fueling
For improved energy levels
If there are concerns of an eating disorder or intense pressure make sure to refer out to a mental health professional
There is so much benefit to treating the mind and body together
Training load for a Dancer with RED-S
Depends on the state of the athlete
If there is major concern that they are in a very low energy availability state and they are resistant or having difficulty consuming the amount of food necessary to fuel the body that it is appropriate to back off the training load by 25-50%
There is a concern that the injury that the dancer may get due to low energy availability may take them out longer and impair them from performing at their best
Goal is to get them back into a good energy state and get them back stronger than before
May need to refocus away from high intensity work for a while and get in with a PT to focus on foundational strength and address some of imbalances and deficits that may have build up and also lead to this injury
Focusing on the life long dancer instead of just the next couple of months
Set expectations for the dancer that we are not trying to shut them down, we are trying to work with them and get them back stronger
As a clinician we may need to be very clear in our communication not only to the individual in front of us, but help them in the communication with their teachers/studios/artistic directors/ballet masters
How do dancers react when you tell them how much they should be eating?
Often times dancers will look at a clinician like they have lost their mind
Many times it will take more than just another snack to fulfill the necessary energy requirement
Usually hear concerns over feeling bloated, feeling like there's food or liquid sloshing in their stomach, they don’t feel good after they eat and then have to dance
Have to remind the athlete that they have put their body into a conservation/hibernation mode
Also let them know that you can train the gut/body to take on the food and utilize it
It's not going to happen overnight, but it will improve
This is where working with a sports nutritionist who understands fueling and timing and which macronutrients are going to be best utilized can be incredibly beneficial
As clinicians we are trying to get away from focusing on a number on the scale and bring focus to overall health, and how the dancer is feeling, return of menstrual cycle
Also need to encourage dancer to continue fueling on rest days
Consider them R&R days- recover and refuel
metabolism is still in an elevated state, it doesn’t stop because you are not dancing or cross training that day, so you need to continue to refuel appropriately
Birth Control
Are doctors still using birth control as a way to correct a missing period?
Unfortunately yes
Not Emily choice for primary treatment of a lost period
Seen more commonly in patients with irregular cycles to regulate and make it more consistent
May use another form of hormone replacement that isn't by the birth control pill
If a dancer is on birth control can that mask signs of RED-S or increase risk?
Yes
It gives us false reassurance that everything is ok
If the dancer is going to be on the pill they need to pay close attention to
How much are they eating
Are they feeling increased fatigue
Are they noticing other imbalances
Harder to use hormonal testing due to replacement on BC
Do male dancers with RED-S present with the same injuries as females?
More bone health problems
Severity of bone stress injury is greater
Ususally see more atypical bone stress injurries
Proximal tibial
Distal femur
Femoral neck
May be a combination of biomechanical issues and low bone mineral density
Is some research on increase in general overuse injuries but not specific to tendinopathy or tendon rupture
Thoughts around tracking metrics with wearable devices like apple watch, whoop, fit bit ect?
Emily and Kat both use Whoop to track training and sleep
Emily likes the whoop for sleep tracking, as it can hold someone more accountable to better sleep
Can help in understanding when overtraining may be occuring and when more rest/recovery needs to be prioritized
Emily and Kat have similar concern of athletes becoming too tied to a recovery score, or HRV number, or certain metric
Really important to listen to your body
You don’t necessarily want to let a metric dictate your training and forget to look internally to how you feel
In devices that have caloric tracking
Not recommended for use with athletes
Many times this number is not accurate
Don’t want to let your device dictate what you can and cannot eat
Focus on your body’s cues
There is a lot of data that comes through on the wearables, watches and apps, and we have to be careful about what’s truly necessary
Might be more beneficial for an athlete to:
Journal- how are you feeling at certain phases of your cycle, how you felt during that dance class/rehearsal/show
Use a menstrual cycle app
We really do need more research on understanding how to use these devices in the athletic population
Where can our listeners find you?
Instagram
Emilykrausmd
Twitter
emilykrausmd
Stanford FASTR
standfordFASTR on instagram