During her 2013 intern medical residency year, while working at a Nebraska veterans hospital, Dr. Emily Kraus found herself unable to climb stairs. She was training for a marathon and her running performance had also declined in recent weeks. She mainly attributed her fatigue to the realities of the internship year – long shifts, sleepless nights and nutrient-poor hospital meals. But that day, her symptoms became hard to ignore. She stopped, leaned over the banister, and took a few moments to catch her breath.
When she went to her doctor for a blood test, she was diagnosed with iron deficiency. After researching information on supplements and training protocols, Kraus quickly realized that there was little information on how to safely return to training as an anemic runner. In fact, there was little information on the physiology of the runners, period. “I felt silly, because I was interested in sports medicine, so I thought I had a good understanding and a good knowledge base,” she says. “But I was caught without adequate resources to navigate this file.” Kraus finally found the right supplementation and nutrition regimen to boost his iron levels and return to his previous training level, but only after a frustrating process.
Throughout her residency, Kraus worked with many female athletes, healing their injuries and bearing witness to the misconceptions they had about their bodies. These experiences, along with her personal health issues, eventually led her to ask deeper questions about the gaps in research on female athletes. After completing her internship in Nebraska, Kraus completed her residency in Stanford, California, where she began a career in sports medicine. In January, she joined forces with Dr. Megan Roche to launch the Stanford FASTR (Female Athlete Science and Translational Research), which focuses on the gender gap in human performance research, enabling female athletes of all levels and backgrounds to achieve longevity in sport.
Kraus and Roche have devoted much of their careers to understanding the physiology of the female athlete – Kraus as a sports medicine physician and clinical assistant professor at Stanford, and Roche as a doctoral candidate in epidemiology with a degree in Medicine from Stanford. They’re also both accomplished endurance athletes: Kraus is an avid marathon runner and cyclist, and Roche is a professional trail runner and trainer, five-time national champion and six-time Team USA member. With Kraus as Program Director and Roche as Principal Investigator, the FASTR team plans to disrupt the current landscape of female athlete research and create a healthier female running culture in the process.
“It’s about doing research,” says Roche. “But it’s also about how we frame it, talk about it, and empower female athletes through this research.”
It is well established that women are grossly underrepresented in sports science research. A 2014 review of 1,382 studies on exercise medicine found that only 39 percent of study participants were women. Isolate sports performance studies, and the gap only grows: women were only one 3 percent of study participants.
According to Kraus and Roche, studies too often exclude female athletes due to the complex nature of the menstrual cycle. Hormonal changes that occur throughout the menstrual cycle affect countless others health variables, from resting heart rate, to recovery metrics, and even the metabolic system. “I got frustrated as an athlete and as a coach, seeing that we’re doing some really impressive studies on exercise physiology,” Roche says. “But often we can’t generalize them or apply them to female athletes.”
When studies of male subjects are generalized to women, it can lead to misconceptions among female athletes and their coaches. In distance running, this includes misguided notions of what a female athlete’s body “should” look like and strict philosophies about how women should train and nourish themselves. (An example of this is fasting training, which can wreak havoc on women’s hormonal systems.) The impacts of these training approaches can be risky and, in some cases, can lead to the development of the female athlete triad or RED-S (relative energy deficit in sport), two related conditions characterized by insufficient nutrition, poor bone health and a range of other physical and mental health consequences. Kraus notes that symptoms of depression and anxiety are commonly found in athletes with low energy availability and other components of the triad and RED-S. “As a clinician, when I bring in an athlete with low energy availability, I also talk to them about mental health,” she says.
To reduce these risks, FASTR offers a three-pronged approach: identification, intervention and translation. Through multiple research projects, they will identify risk factors for bone stress injuries and other conditions faced by female athletes. Then they will intervene by improving the screening tools and resources available to prevent undernutrition and bone stress injuries. Finally, they will translate this research, making fueling, recovery, mental health and injury prevention information accessible to all athletes, coaches and physicians.
For one project, FASTR plans to collaborate with Boston Children’s Hospital Female Athlete Program compare the two screening questionnaires currently used to identify athletes at risk for the triad and RED-S, to determine when these tools are most effective and how they can be improved. At the same time, they will analyze the different protocols used by physicians to safely guide athletes back into sport after experiences with RED-S or the Triad. They hope to create a more streamlined plan that all clinicians can use to help athletes return to sport and prevent future undernutrition and bone injury.
Kraus and Roche are committed to including all types of female athletes in their program: NCAA athletes, high school athletes, cis women and trans women. “Inclusion should be the default in every sports environment,” says Roche. “It’s a matter of human rights.”
One of the first initiatives of the program is the FASTR Pilot study, a series of instructional videos for high school female runners. The purpose of these videos, Roche explains, is to present FASTR’s research to the intended audience in an accessible way: “How can we get these results into the hands of young athletes, parents, coaches and people who could use the information the most? How do we bridge this translation gap and make research accessible? The videos include insights from role models from a variety of sporting backgrounds – professional athletes, sports equity activists and other sport leaders. Among them is Latoya Shauntay Snellan ultrarunner known for her body-politics activism.
“The media often acknowledges cosmetic things – that I’m a black athlete or I’m a size athlete,” Shauntay Snell says. “But I am also a disabled athlete. When you have multiple layers to your athletic journey, it’s harder to see yourself represented. Through his FASTR content, Shauntay Snell hopes to foster a sense of belonging among young athletes.
For the FASTR team, research cannot achieve its full impact if it is not communicated in a way that empowers female athletes. “Runners sometimes get the idea that the physiology of the female athlete is a nuisance or a burden,” Roche says. “I’m excited to see research becoming more inclusive of female athletes, but also more positive – the rules are powerful, the physiology of female athletes is strong, and there are some interesting things happening in our bodies.”
Last fall, the University of Oregon women’s track and field team became the latest in a long line of collegiate running programs to face body shaming allegations and an environment conducive to eating disorders. The FASTR team envisions a better collegiate running culture, one in which female athletes are celebrated for their diverse bodies and where an emphasis is placed on nutrition and long-term health. To that end, one of FASTR’s projects will expand on an existing program: the Healthy Runner Project.
the Healthy Runner Project was started at Stanford and UCLA in 2016, to assess whether a nutritional intervention could improve bone mineral density and reduce bone stress-related injury in college distance runners. In the original study of 114 women, the athletes underwent a nutritional assessment, which included an online screening survey, one-on-one meetings with a dietician, and a DEXA scan to measure bone density. With the help of the dietitian, athletes set nutritional goals, such as adding snacks or increasing the nutrient density of snacks and meals they are already eating.
Fiona O’Keefe, a 2020 Stanford graduate and six-time All-American who now runs professionally for Puma, remembers the Healthy Runner Project as a routine. “It didn’t seem that unusual,” she said. “Hearing that it’s less common in other schools certainly makes me grateful that we have it in place.” After promising preliminary results at UCLA and Stanford, FASTR is in the early stages of expanding this project to other PAC-12 schools. The team hopes that the focus on nutrition and long-term health can become routine in all college running programs.
On paper, FASTR’s goal is to close the gender gap in sports science research. But Roche and Kraus also ask more important questions. Can something as historically rigid as medical research have a broad and inclusive effect: the longevity of all women in all sports?
Looking ahead, “hopefully there will be more runners,” Kraus says. “It means women stay healthy and don’t give up on sports or become discouraged due to injuries, body changes or other factors. This means that they are better informed about their bodies.
“I just want to make sports a fun and safe environment for everyone,” adds Roche. “I want science to inform best training practices so people can enjoy the sport for a long, long time.”