Bonus BOOM for ALS: Boston Marathon-Sports Performance & Medical Research | Kristin Whitney

Welcome to Biomechanics on our minds. My name is Melissa Baswell and I'm Hannah O'Day and we're PhD students at Stanford University. This podcast is brought to you by the International Society of Biomechanics. It's time for boom! Welcome to Boom! Are we really here? Are we here? I hope not being next to each other. It's true. We both have our microphones on. Hannah is our boom shirt on and it's happening. We're back. It's happening. Boom is loud in our hearts. Our hearts are booming. Yes, special surprise episode. I don't know if it's, I think, honestly, it's most, most special for us. I feel excited to be back and to be doing this with you. Oh, me too. I know. We're just saying, why do we not do this more often? Yeah, we always talk about how we just catch up and put with our microphones and us doing our stuff. What kind of view? I mean, with all of you. I guess I'm sure you'll hear all of that a lot. But this did come together very serendipitously. Hannah, I can share more about why we're having this special episode, which I'm very proud of for and really excited about. Well, as some of you listeners may know, listen, I did our PhDs together and in my PhD focused a lot on neuromuscular disorders and met a lot of incredible people. I was just sitting with neuromuscular disorders and tried to help them improve their walking. But aside from the research, I mostly just learned their stories. And it was just so incredible to meet these folks with really rich lives and who were willing to volunteer their time. And also just like share their lives with us as researchers and as people. I was missing a little bit of the sort of clinical connection I had had in my PhD. So I was just soul searching a little bit and I was remembering one of our favorite questions of like, why did you want to be a biomechanist? And I think it really stems from that drive to help others, both Melissa and I have that in our stories. And we've heard so many amazing people with that in their stories. And so I guess in connecting back to that, I stumbled upon the ALS associations page for the Boston Marathon. They sponsor people to run the Boston Marathon. They get bips from the Boston Athletic Association in return for having volunteers fundraise for the ALS association. And I had actually run with them back in 2018 the Chicago Marathon. And so reached out to the organizers of that team. And through also some serendipity ended up chatting with them and going through the process and having some really nice conversations that led me to be on their team today. So I'm really excited to be running for them and fundraising for them. And just around the same time I was getting the word that I was going to be able to work with that team. Melissa and I got an email. I think it even went to an email. Melissa, do you even have access to that email? From Dr. Kristen Whitney, who is an incredible clinician at Boston Children's and Harvard. And so we have actually reached out to her back being connected to her through the Wusai Human Performance Alliance years ago. Yeah, we reached out to work with her on that series because she's known for a really seminal study looking at runners in the Boston Marathon actually. And we had reached out to her about the preprint. She had a really nice publication, but they hadn't had it fully published yet. So they were waiting until the full publication. And so she had reached back out saying, oh, by the way, you know, it's fully published. I'm ready to do my boom episode. Yeah, and you forwarded to me and I think I was like, well, should we just do fit? Mostly it's like, well, I miss Hannah. So this forces us to be on a call together. So I think that that seems the right move. But then it just aligns so well with what you're doing. And first of all, you're such a baddie for running the marathon. And then in on top of that, doing it for such a good cause. And I know you're not someone who likes to ask for things. And but I think this is such a special opportunity to give to an important cause and raise awareness. And I'm happy that we can be a part of it with boom. And it was also so weird that we had our old boom editing platform. And I was like, yeah, we'll have to edit it ourselves. Whatever it's going to take a while, but that's fine. And then Hannah was like, no, we have one more episode left. And I was like, how did all this is lining up? We have to do it. And so here we are. And we are one had it left to edit our. It left. So don't get too excited. But yeah, yeah, we're excited. We had a great conversation with Kristen. Again, she's assistant professor on orthopedics and sports medicine at Harvard Medical School and director of the injured runners clinic at Boston Children's Hospital. And her journey with the Boston Marathon too. And with running was also just really inspiring. Really interesting also very serendipitous as you know, as we were just talking about serendipity. So I hope everybody enjoys the interview and our conversation with her, you know, as much as we did. Maybe before we get started, Hannah, could you share it? Could you share how we can give to yet to the foundation and support you and the mission in the marathon? Melissa is always lifting me up. So thank you, Melissa. Yes, I the ALS Association is a great association. It has been around for decades and is raising funds for people living with ALS and also research going toward better understanding and treating ALS. I have a page where I have some fun photos and a link or a button to donate and we'll share that in the episode notes for this or the info and on whatever podcast platform that you're listening to this on you can donate to me can donate to other folks that are running. You can donate to the ALS Association directly, but if you donate to me, I would appreciate that. You have lots of options. Or if you just want a link to look at fun pictures of Hannah, it's also available, but you know, if you're going to do that, you should probably donate to her. Yeah, there's a separate link in website for that. My wallet, no, no. Yeah. And one thing I appreciate about the last marathon is that they have a high bar for everything as it's an elite race in itself. And I don't think I'll ever quite make the elite qualifying times that are required to actually run the boss marathon. But I said, if I can't qualify with my legs, I will try with my heart. So here we are. It was so cute. I didn't hear that one yet. And you just run it on me. Then it all this recording. And I'm actually sweating a little bit because that was cute. It's been it's been too long since Melissa's heard one of my bad puns. I know my kids are so punless. And it's sad. It's so sad. Well, what is that? I, you just sign up for voice memos every morning with one of my puns. So congratulations. Have anyone else wants one of those you can donate directly to me? I have a Venmo account. Yeah, maybe Melissa, you get one of those like mass text things every day. And you can sign up for Hannah's daily fun. And then for an extra fee, you can sign up for my response to her puns. Oh my gosh. Which will just be sarcastic. So you can really get the best of them. Honestly, I only do my puns formalizes response. So you might as well just skip the pun and get the response. No, but thank you. Yes. We'll share that link. And I would I would speak out the URL to you. What else do you have all that? So go to the show now. It's a look out pan this page and thank you Hannah for doing such amazing things and making a difference in people's eyes. Oh my gosh. Thank you for constantly being a great support and partner in doing good. Hope you all enjoy the interview. All right. Welcome. Kristen. We are really excited with Mr. Whitney who is an assistant professor in orthopedic and sports medicine at Harvard Medical School and the director of the injured runners clinic at Boston Children's Hospital. He's also the Boston Marathon Medical Tracking Program team. We talked more about later in episode and I really excited to learn more about what that entails. So thank you so much for being here with us today. Thank you so much for having me. It's a pleasure to join you. Yeah, we're so so excited to have you here and hailing from Boston one of my favorite places. We always start with a question on we usually ask people when they first knew they wanted to be a biomechanist and so you want to. You're a biomechanist, you're a physician, you're a team captain, so we'll hear lots about those things, but just start with when did you first know you wanted to be a doctor in this field? - Thank you for asking out. So I guess looking back at things, I think my interest in medicine sort of evolved over time. I think my earliest memories of sort of a respect for the profession of medicine was when I was pretty young. So the backstory is that when I was in the grade school around age eight got very sick. I was diagnosed with what's called systemic juvenile idiopathic arthritis, or at the time it was called juvenile rheumatoid arthritis, where essentially you have arthritis involving many, many joints in the body. You have daily fevers, systemic symptoms, malaise, and it goes on for years in chronic condition that is pretty rare in the pediatric population. And so I became pretty sick around the age of eight, and took some time for the diagnosis to be established as it can be. I mean, a lot of these kids with a systemic JIA. And once I was diagnosed, it became apparent to my parents that there weren't great treatments at the time. The kind of only treatment at the time was like high-dose systemic steroids on a daily basis, which as we know can help with symptoms and have negative effects on the growing skeleton. So my parents sought out additional avenues for my medical treatment and ended up learning about a large-scale research study that was being done at Beth Israel, a medical center in Boston, and by a group of rheumatologists. So I was one of 10 kids that I got enrolled in this pilot study for this new medication. And my folks would drive me to Boston every weekend from where we lived in Central Connecticut, a couple hour drive. I would see researchers there for clinical exams, and I would take the same medicine. So the research team was great. My local clinicians were great. It took great care of me. I was super fortunate. And by the age of about 10, my symptoms, after two years of this daily illness, my symptoms were seated. And in the hindsight, so it was a small pilot study, hard to say, it was attributable to the medication, was I just fortunate enough to outgrow systemic JIA, which some kids do on their own. But I went into remission from that, and went on to live a healthy, active life. So very, very fortunate. So years and years go on, happy kid. We're all good. And during high school, I got involved in sports, which I loved, a lot of fun there, and ended up being involved on the track team. I just signed up needed something to do after school. I wanted to hold out a nowhere, I seemed to have a knack for running. And I ended up out of nowhere was expecting, but I ended up, you know, sometimes being at the head of the pack and did pretty well with races. And I had some success there, you know, you've got all conference, all state, whatnot. And it's a small town, so local paper every time you win a race, you know, your name gets in the paper. And then what I saw was, you know, my parents always, you know, were my biggest fans and my grandparents too, were in their high 70s, the 80s at the time. And every time I was in this local town paper, my grandparents would of course, cut out the newspaper clippings, and they would mail it to my rheumatologist back in Boston. And they were so proud, you know, of how well I was doing, and they would take these new newspaper clippings, you know, and we'll stamp on it mailbox, you know, the old fashioned way. I'm excited to Boston. And I think I just saw that in how much it meant to my family and my grandparents and my parents that, you know, we have been fortunate enough to have this treatment team on my side and how much they care. And this was years later at that point. And they're still sending, you know, the doctor's updates. And I just saw like how much you can mean to people as a clinician who takes care of people in their hard days. And so I think that really stuck with me. And I think it's actually like seeing just that really sweet act and how the impact that these rheumatologists had on my family and how grateful they were, you know, and seeing that impact that made me interested in becoming a clinician and like playing that kind of special role in people's lives. - What a journey and like what a way to turn your experience and like challenges that you face in things, like into such a positive thing. Thank you so much for sharing it with us. - Absolutely. I was really lucky, really lucky that I think have a great team around me. And I tried to be that great team for patients now. - I was excited to hear more about that team too. - Yeah, honestly, that gave me goosebumps at some points because it was just, it's such a big reminder about what an impact you can have on people's lives. And I think that that can happen in a, you know, a lot of professions, but I think especially in medicine and especially with children who are faced with, with diseases or conditions that are really painful and really affecting their quality of life and how they're growing up. And so yeah, that really is, and I sure as a parent or a grandparent that is incredibly painful to see as well. So like you said, it's just you can have a big impact just being there for the patient. And it's interesting that you said, you're not even sure if the treatment was the reason that you recovered, maybe not even knows, but regardless of whether or not you even had that certainty your parents and grandparents are still so appreciative. - Absolutely, 'cause I think at the end, you end up being just as grateful for like the bedside manner that someone offers your child or your loved one. You know, you're just as grateful as the, it's just as much of a treatment and just as much of a way of providing care as the medication and the medical treatment itself. So it definitely stuck with my family. - There's so many things that you do that I want, that we want to learn about. I don't even really know where to start, but maybe we could just start with a current project that you're working on that you're most excited about. - Great, so a few things going on. Right now we are looking at an analysis on our 22 Boston Marathon cohort data subset where we're looking at athletes and their training behaviors and how that linked to their running performance. We also are active in partnering with the Boston Athletic Association and the Boston Marathon Medical Program in looking at some of the epidemiology of medical encounters that occur at the Boston Marathon where we're actually looking over a prior years and to go through thousands and thousands of medical records and characterizing epidemiology of encounters for medical compromise that happened at the race and looking at different respectors for medical encounters on the age sex-specific differences to try and better characterize the kind of care delivered during the marathon. It's self, then I've got a couple other projects going on in terms of looking at running biomechanics and biomechanics associated with overuse injuries, specifically bone stress injuries. So, dabbling both from the race medicine standpoint as well as running related biomechanics. - I think it's so cool that you're not only like at the biomechanics and mechanistic level of understanding of running, but also at the like sort of like policy translation, like affecting real people level two in cohort at large at the Boston Marathon. - Yeah, it's great. And I love taking that sort of like different level of evaluation on injuries and sports medicine and going super granular to sort of more a bird's eye. I think it's a lot of fun. - Right, which I guess bring me to the thought, I think we'll talk a little bit more about the paper you published recently, but first your role as the Boston Marathon Medical Tracking Program is a team captain, like what led you there? What's been fun? What's been surprising to learn in that role? What is the role? Lots of questions, I'm curious about it. - Okay, so this is a little bit of a long story, but I thought I would just sort of like give a little bit of color here. So I'll talk about what the role is and then I'll kind of back into what led me to involve it with the Boston Marathon and specifically into this role. So as a team captain for the marathon, the Boston Marathon Medical Tracking Team, what myself and my co-captains do is we are responsible for the implementation of a web-based medical tracking system that we utilize at the Boston Marathon. So at the Boston Marathon and at many marathons, there's a very large medical program. Boston, we're proud to have probably the largest and most sophisticated medical program of all the world marathon majors. At Boston we have 30 total medical stations. There are 26, so Boston's a point to point course. There's 26 medical stations along the course, distributed along the course, the length of the course, then for very large medical stations located around the finish area, with hundreds of beds at those finish area medical stations in the ability to provide ICU level care for individuals who encounter race-related medical compromise. Now, the role in the medical tracking system is it's a novel system that's been ruled out over the past few years, where we are able to track athletes who get checked in and out of these medical stations for medical care and track their level of acuity when they get triage in the medical tents, and then also track their disposition. So are they returned back to the race where they treated and they got to jump back out on the race course or were they transported to a local hospital or somewhere in between where maybe they weren't able to finish the race and they are halfway through and they might need to jump on the marathon's intra-event medical transport system, which is a passing system that brings you back to a home base if you're not able to finish. So every year, well over 1,000 more, like around 1,500 runners are treated as patients the Boston Marathon on race day. Yeah, so it's a large number and and the Incidents is similar on that other on marathons as well, but so Yes, exactly thousands of people are treated and The so for the first time we're able to track those individuals by a web-based system to Identify where they're located when they're in the medical tents and or if they're getting transported So that the purpose is for two reasons one is for informing the race operations center about the patient volume at these medical stations if any certain medical stations is becoming Overwhelmed during needs for resources or needs more staffing, you know what's going on out there and what's the level of acuity It's also extremely helpful for family reunification. So it's really really scary when you're out there cheering for a loved one during the marathon And you know say you're tracking them on the race timing up and you see that they're not progressing and you You're not sure where they are or how they're doing. So now with the Boston Marathon Medical Program can help Families with as if they're looking for a loved one. They can go query at an information kiosk or Using communicating with some of our staffing volunteers looking for their loved one and their loved one can be located And if they're in a certain medical tent if they've been transported to a hospital or otherwise and the family can be informed of where where their loved one is at And this is totally new and really kind of cutting edge for race medicine to be able to have that A level of information which it's so clearly so helpful for family members and for runners And there's a lot of barriers. I think to being able to implement this type of technology It's a huge volume of data all with a that many many patients a lot going on all at once So so that's what we're able to offer through the um medical tracking system And um it is a credit to the Boston Marathon medical program and through the Boston Athletic Association that they've kind of you know Had the motivation to roll this type of program out because it's a game changer for folks as far as Sort of what led me to this so there's a little bit of a longer story bear with me But so my involvement with the Boston Marathon Has sort of evolved over time. I um in a Boston Marathon runner myself had run the marathon seven times I started when I was a senior in college And just absolutely fell in love with the Boston Marathon and you know I've participated with as a Boston qualifier many times with charity teams a couple times and So I've always loved the marathon. It's sort of become one of the staples and my sort of sport related calendar My involvement on the medical side for the Boston Marathon started almost by sort of happen stance So I'd in 2013 I was a medical student at Boston University and Boston Medical Center third year medical student where You're on rotation. So it's sort of monthly rotations. You were you say you do a sampling maybe it's uh, you know Pediatrics one month or surgery one month and um, you know, you name a different subjectual to through the year So um at that point I already run the Boston Marathon a number of times um I was Boston qualified in 2013 so I had registered for the race and I had a bed as a Boston qualifier to go out and run Start the race in April But as it as it turns out as a medical student you don't get a lot of days off Uh So it's very very hard to get a day off from medical school rotations when you're in those clinical rotations The dayoffs are a few and far between so although I had my bed and this was I think it would be my fifth boss marathon I was not able to Get permission to have the day off from my rotations um, so not uncommon, you know, I so But so as it came about um, so I was starting it was my first day of my surgery rotation at Boston Medical Center And I was actually assigned on what's called a vascular surgery Uh, so it was my first day of vascular surgery rotation where you know, we all report for duty at four three or five in the morning And you go through rounds and that was the day of the Boston Marathon where there was the course interruption due to Terrace attack with the Barmings um at the finish line uh, and so that's when there was extremely heroic efforts by the individuals on the medical team stationed at the course in the finish area as well as the local law enforcement first responders and crowds and and Boston The whole Boston community um responding to those in need who had been injured in the bombings from the Boston Medical Center side Boston Medical Center is one of the largest Tra level one trauma centers in New England So Boston Medical Center was on the receiving end of dozens and dozens of patients that were injured at the marathon Finish line, which is only a couple miles from Boston Medical Center. And so I was on vascular surgery under the supervision of a wonderful vascular surgeon dr. Jeffrey Kalesh who performed a number of vascular surgeries on many patients coming in from the marathon Liman mutations were needed for as a life-saving measure And I was part of that vascular surgery team that helped provide that care for patients coming in from the marathon that day and in the weeks after Through you know, and they're on all of their operative care and post operative care um and as they started to go through some of the early rehabilitation too and You know uh meeting many of their families and and being involved as their care team was you know A really meaningful experience for me. So that was third year medical school and you know I went on in the future and ran the marathon the Boston marathon is more times and I proceeded through my medical training and my medical training brings me to a love of sports medicine And I joined sports medicine fellowship at Boston Children's Hospital I'm where I so I'm working today and my fellowship director Loan Behold is Pierre Damcourt who is a wonderful man And he is one of the marathon medical directors. I'm for the Boston marathon and he leads the troops and troops of medical volunteers every year Boston Children's Hospital sports medicine Ultimately um is a really kind of longstanding presence uh the Boston marathon medical program The chief and founder of our practice doctor Lyle McAley has been a volunteer at the finish line for over 50 years Dr. Adam court is one of the marathon medical directors and Through my involvement at Boston Children's Sports Medicine. I started volunteering each year on At the actual race at the finish line as an event medical doctor and so that brought me into I guess that would be 15 when I started being like actually on site at the the Boston marathon every year as a medical volunteer Where I've worn a number of hats, you know, yeah as either a physician at the finish line um I've been involved in race ops, which is sort of a more bird's eye logistics organization Few and then when I got more and more involved in the race operations and that's when I was sort of invited to lead the rollout of this new medical tracking initiative And coordinate the not only like the The technical infrastructure there but also coordinate our 100 volunteers that Need that medical tracking there's 1800 clinicians actually doctors nurses PAs PT's alpha trainers that volunteer at the marathon every single year and Yeah, it's a ton to coordinate um and so um so I help with the medical tracking and that's kind of like then Ben my baby and sort of like rolling that out recently and in addition to helping out in in some other hats too in the op-send But that's kind of what brought me to be so involved with the marathon and and get to help out with some of the the logistics and some of the medical Program organization. Wow. What a journey and I think yeah, it's just it's I love hearing stories really And then I did this and I did that and it just like keeps Leading down this path that you wouldn't have known how it would have turned out at that time But like how they're sort of like connected on so many different things is pretty incredible And it feels like those are the stories really like you're yeah, I've meant to be there and and serve in that way and Yeah, it's and I think also the yeah the coincidences within that story I mean, it's just really really unbelievable. So thank you for sharing all that with us Absolutely, I think um, you know, just a lot of really great people and mentors along the way and just such a great group to be involved in and these folks who who either who provide medical care at the Boston marathon I think it's what has drawn me in year after year to volunteer is the community of that medical programs awesome people And so that's I think sort of an magnet for me year after year and why I want to be involved in and then what the marathon means to the Boston community as well Yeah, that makes a lot of sense. I feel like making decisions based on You know people that inspire you and community feel like it's hard to go wrong You know, I feel like those are the ones that it makes me think about I'm enjoying the lab I did for my PhD like when I looked at the people And I was like, okay, those are the people that I want to be like, you know, it's been more time with them and you know Like I think follow the things that You know, the opportunities that they have or come up through them. It's pretty amazing what meeting incredible people and having those people in your life can can do Absolutely, I agree Well speaking of incredible people you and a team of really incredible researchers scientist clinicians sports health professionals shared your paper in the British Journal of Sports Medicine which we We're alluding to it's finally that time to to talk more about that Saparon low energy availability in the Boston marathon athletes You mentioned as a larger study of its kind which is pretty incredible Could you tell us a little bit more about sort of the impact of this study for you all and maybe you know what felt like the most surprising or impactful from it. Yeah absolutely and so I'll talk about kind of our core findings and then I want to talk about our research team as well. So our study performed at the 2022 Boston marathon. It was largest study of its kind in terms of a medical research study performed out in marathon event where we enrolled 1,030 Boston marathon athletes including 546 female athletes so 53% females 47% males and essentially what we did is we enrolled athletes for that we're registered for the marathon to participate. They completed an extensive pre-arrase survey where they were asked about a re-of-questions including information about their medical history their fueling and sort of dietary intake behaviors attitudes towards nutrition their training patterns and they were providing consent for us to then follow their performance their timing performance on race day as well as there any medical encounters that they had during the marathon. So the timing data was just tracked by way of the standard marathon timechips that everyone has on the back of their bibs and then the medical encounter data was tracked by our medical tracking system and standard more in-depth paper medical records. So by the responses that were provided through the pre-arrase survey and which included a subset of questions that are validated survey questions considered to be indicators of low energy availability meaning chronic underfueling and insufficient dietary intake and nutritional intake to match and sporadic athletic performance as well as daily energy needs. Are those are those questions to identify if they're underfueling or does an athlete know if they are underfueling is it like them saying yeah I am or is it you asking questions to know that they are I guess great so it's super great question it is so it can be a mix certain like low energy availability low energy availability indicators may be physical symptoms or signs of chronic low energy availability or underfueling for example in women menstrual irregularity or lack of periods during intense training cycles is a classic indicator of underfueling or it could be behavioral indicators such as a desire to cut weight or a desire to control one's diet in a very strict way. In the sporting community there's thought to be a mix of reasons for problematic low energy availability and it can be unintentional so just lack of knowledge of nutritional needs in endurance training and difficulty in keeping up with the high volume of endurance training in just like getting enough food in and that might manifest in unintentional low energy availability or in some cases it may be intentional low energy availability where folks have disordered eating behaviors or true eating disorders where they're trying to cut weight and that has sort of some underpinnings in these classic sport cultural assumptions of things like lighter is faster and this push toward leadness in a lot of endured sports and particularly running so it can be a mix and all of the indicators that we use from the survey are well validated in other literature on low energy availability and so we're carefully chosen to sort of tease out who among our thousand thirty participants had these indicators of low energy availability or chronic underfueling. That makes sense yeah. So yeah so from that so we identified those groups it's sort of a really kind of interesting burgeoning area of research in the the support medicine world. First of all we looked at the prevalence of low energy availability indicators in this group. Super common okay over 40% of women surveyed and roughly 18% of men surveyed had indicators of low energy availability so very common that is consistent with other studies that have been done on low energy availability in the the interest community and then what was really sort of the groundbreaking about our study is that we looked at their performance outcomes and what we saw was and that's really what hasn't been done before in the space and we saw that those with these low energy availability indicators had significantly slower race times compared to their healthy counterparts so even when we control for age, gender, calculated BMI, training level, marathon experience, whether they were Boston time qualifiers or registered through charity teams you know their miles of training all of it those who did not have these low energy availability indicators the healthy group performed much better than those who had signs of low energy availability. We also looked at the medical encounter incidents during the race itself so the group with low energy pre-race low energy availability the indicators had twice the risk of requiring medical support at the marathon's medical stations during the event and almost three times the risk of a major medical encounter meaning serious or life threatening conditions such as severe electrolyte disturbances and fluid disorders so those with low energy availability indicators they performed worse and they were much more likely to require medical attention on race day. We had a number of other findings too that were consistent with some some higher literature in the running population but our low energy availability group had a much higher risk of pre-race and during training overload injuries like bone stress injuries and illnesses in the six months before the race all which we we think may contribute to some of the performance changes that we saw on race day but this was really I think a landmark study because it's the first real world endurance event large scale study that has been able to demonstrate some of these negative performance and health effects of low energy availability previously there's been wonderful studies in small cohorts or lab-based studies that support these some like health negative health and performance effects of low energy availability but we really brought it to scale to highlight it for the the marathoning population and it's just incredible like you're saying the size the scale it powers the findings that you're having and as I like that you're also opening door that it's sort of the first of hopefully many yeah that's kind right definitely for Boston to set that tone for your medical team for your awesome research team to set that tone and you're like trailblazing for the field I think I think that is just to it speaks to the hard work that's been done in laying the foundation of a lot of this stuff on smaller studies where they've gone into the lab you know they've validated these surveys compared with biomarkers of low energy availability and they've allowed some of these like screening surveys to exist that we know are well validated in this athlete population it allows us to bring some of these screening methods on to scale for large-scale research studies but also for large-scale you know future population health interventions and the education interventions so I think we definitely stand on the the shoulders of giants in terms of being able to bring this study to scale and and have such a large enrollment and child develop the power that we were able to perform a analysis looking at these types of race performance outcomes in a large scale and it's so cool I love how your practicing position you clearly are well read and first in the literature and you're it's it's clear how that sort of is informing your clinical practice like but I'm curious if the reverse is also true like how treating athletes and and being on these interdisciplinary teams how does that inform the research and directions that you take yeah I mean I think it absolutely does you know as a think that hearing and seeing athletes stories as a clinician be it at the actual sidelines on the marathon Monday or in clinic you see the types of things that people are struggling with and you start to sort of ask questions about the contributing factors to either their race-related illnesses or their chronic overload injuries and it sort of I think it sparks the generation of research questions and it also I think fuel and so do I interest in in hypothesis driving really in terms of how could we create a study to demonstrate some of these concerning themes that we notice as care providers in a way that we hope will a study will generate actionable takeaways for for runners so now we we've proven hey low energy availability is puts you at health risks in in a number of ways it it made and it can negatively affect performance and I think it just further fuels opportunity for interventions yeah that makes no sense and then as you're talking about actionable takeaways what would be one piece of advice or resource that you would share with athletes who have or struggling with low energy availability I think that's a great question I think I think a core goal of is to flip the culture that is so [BLANK_AUDIO] in endurance sports and particularly running and endurance running of this sort of myth that clinical lighter is faster is a sort of just pervasive assumption in endurance sports that somehow on an individual basis like losing weight is going to make you a better runner. Looking thinner is going to equate in some way to being better on race day. And I think we want to disassociate that very ingrained assumption because if you think about it, the number that matters is the time on the clock. It doesn't matter like what the number is on the scale. So focusing on how you're doing and how you're feeling from a performance standpoint is the number one thing. I think getting the word out about our findings and educating coaches, athletic trainers and folks working with these athletes to change the narrative and have that weight has nothing to do necessarily with performance on an individual basis. And that's been something that's really been pushed on a lot of athletes and we're hoping to put it into. I think as far as you know for folks who maybe struggling with low energy belly belly, I think that first of all knowing how common it is in the endurance running community. And again, it can be for intentional reasons like, you know, you thought you should be trying to cut calories or drop weight or it can be unintentional where you just, you know, weren't aware of how many calories you needed to get in to make up for your long run schedule and an awareness of how common that is and how risky the endurance, these endurance training plans can be in terms of low energy availability. So I think an awareness of some of the the symptoms isn't poor and particularly for women, any changes in menstrual cycle patterns, light periods or missing periods for males, there's libido changes, got to be tied to lower testosterone levels, gastrointestinal symptoms, mood related changes, decrease energy levels. Those are all kind of things to be aware of if you're in training for endurance sports that you may be experiencing these things because of problematic low energy bill, but in problematic underfueling. And, you know, and then trying to address it. First of all, at the basics is when you're training more and you're working out more, you need to increase your calorie counts, you need to fuel more and getting those very diet in terms of macro micronutrients, getting lots of carbohydrates and increasing your carbohydrates intake, particularly during hard training cycles, healthy fats are important, proteins of course, and in increasing your nutritional intake to match your increasing endurance training is super important. I think that working with a sports dietitian or any dietitian or working with your physician, if you are experiencing any of these symptoms to develop a personalized and specific fueling program is really important, but I think it's just important to be aware of some of the symptoms and that it's not necessarily necessarily expected or normal to be experiencing some of these things and it can be prevented just by tweaking your fueling strategy and your nutrition intake. I love how born out of a lot of what you're saying is education and how you and your teams are really doing that. I think just the education, the awareness, knowing what's normal, what's not, and also talking about it normalizing it like all of that is so key. Absolutely. I think normalizing is very, very important and because it is almost just like part and parcel for endurance sports is needing to address the fueling aspect. We got to have gas in the tank in order to perform well as well as maintain normal physiologic function. Yes, yes, you figured out how to tell people how to gauge that tank. Yes, exactly. Exactly. Well, I want to know more about all of the things you're doing, but we are coming up on our last couple of questions here. Could you tell us a little bit more about the study team you worked with on the Boston Marathon paper? Absolutely. So I think a strength of this study and the reason that we were able to put a product together that had the amount of the kind of impact it did is our interdisciplinary research team. So first of all, Dr. Kate Ackerman, who is the senior author on the paper director of the Wu-Sai female athlete program, brought a tremendous vision to the study in terms of bringing something to scale and looking at the athlete performance outcomes with her background in the military availability related research. She would really was a visionary to put all of this in motion. And then you brought together this sort of rock sarcast of co-investigators. First of all, lead investigators in the world of low energy availability research and relative energy deficiencies for related research, transdelling, worth Louise Burke, Anthony Hackney, Brian Holtzman, Ida Hacura, having their lands and where they are in sort of the forefront of developing the International Olympic Committee, Reds recommendations, and sort of their expertise in the world of low energy availability research was absolutely integral to developing an impactful study questionnaire and interpretation of our findings. Then we had our extremely experienced marathon medicine team, Aaron Baggish, peer-dum-core, Sophia Dyer, Chris Trojanos, who are at the cutting edge of race medicine leadership, not only at the Boston Marathon, but really setting the bar for endurance medicine and race medicine as a whole globally. And then our research team Alex Lemke, who did all of our data analysis and our in-house research team Grace Savi and Kaya Adelzade, who were absolutely integral in implementation of the study and being able to help with recruitment and putting this all into motion during a busy Boston marathon race weekend, they were incredible. And then we have got Laura Riesen, Nicole Farmsworth, who are experts in sports nutrition and clinical experts in fueling for performance. So we had all of these great thinkers come together and bring their different sort of strengths and expertise on the study to make this happen. And we were just super, super fortunate to bring these different worlds together and tie it all together to be able to implement our study. So it was it would not have been possible and it wouldn't have been so so meaningful without our whole group. I just feel like you're on so many amazing teams. It's just so cool to hear. And I love how gracious you are and how thoughtful you are in sharing all of those amazing contributions and perspectives from your truly rock star cast. It was a huge team effort. So anyway, it would not have been possible without every single person in the the offer group. So I'm extremely grateful to just, you know, be be among such a great team. Yeah. And thank you. Yeah. Thank you so much for highlighting that. And one thing we often like to talk about on boom is fails or sometimes we call them a fail or things that we didn't expect at least, right, to come up. Could you share a fail to a fail? Yeah, absolutely. Okay. So I do think it's important to to learn from personal failures. Yeah. So and I think it's broad goods perspective. So as I so I mentioned, I run the Boston Marathon seven times. I run 11 Marathons in total. And you know, I think that looking back on, you know, the progress of my career and running, I've learned some lessons to hard by. I think part of, you know, what maybe interested in in a series of researches. So as I mentioned after the, you know, 2013 Boston marathon, I was involved in the medical response team. So in the following year, you know, I'm still a medical student, I was determined to run the Boston Marathon the the following year. So flew out to South Dakota on one weekend, I out off from medical school to run the Sioux Falls South Dakota marathon to obtain a Boston qualifying time. You got a bib for the following year for the Boston Marathon and registered for the race. Then, you know, I have the Boston Marathon on the calendar in April. I'm still a medical student where medical school is really busy. Anyone who's been in any sort of graduate schooling program knows your low on sleep, your working all the time, your missing meals, because you're working long shifts or not prioritizing self care. And certainly during medical school didn't make kind of appropriate planning for a gradual ramp up in my training. Just sort of did a crash crash training plan and Bowen behold developed a big stress fracture in my pelvis. Okay, common story. I was put on crutches for four weeks prior to the marathon. I had to abstain from training. I was still determined to run the marathon in 2014. Of course, I off crutches for about three days before the marathon. I'd been cross-reading and whatnot, but I did start the race and get through it. But, you know, I'm I'm run walking the whole way. I'm still like actively recovering from an injury. I probably finished in about an hour and a half slower time that my typical would be, but I did finish. And at the time, I was, you know, in my 20s, I thought of it as sort of a perseverance or demonstration of a personal perseverance. I think in hindsight, and knowing, and knowing now, I think that it was sort of a failure in the sort of self care and some of the foundations that these endurance athletes need to have a successful endurance running pursuit. But it also taught a lot about athletic identity, which is a big deal for a lot of our endurance athletes. People are very tied to their their plans and their reasons for running. It can put folks at risk of injury and of a medical compromise during races. And I try and look back on that. I was lucky to finish the race. But I think in hindsight, I think it gives a lot of color to some of the things that our patients are experiencing sometimes when they're encountering these overload injuries and the things that they're grappling with from living busy lives and needing to fuel appropriately, sleep appropriately in order to achieve their performance goals. And then, and I think it's given me more empathy in terms of some of the decision making folks make and their training plans and their, their angles. - That makes it to the sense. And I feel like so many of us can probably relate to that story in one way or another. Like I feel like I think about that in sports for sure, especially in running and trying to push their injuries, the run certain races and training for marathons. I don't think I ran a marathon that hasn't led to a stress fracture, but it's just like, you know, it's just like, why? - I do that, but even just in life, we're trying to push for certain goals or achievements. And sometimes we really don't prioritize our health and our wellbeing in those times. And I feel like there's a lot to learn from sport in terms of how we also, you know, go after goals and treat our bodies and our health in day-to-day life. So thank you. Yeah, for sharing all of that. - Yeah, absolutely. I think it's important because I think everyone has the reason, be it, you know, athletes infected with injury and they don't want to let their team down. And so they don't want to sit out that next game when they probably should or it can be folks who are running marathons as part of a charity team, which is a super noble thing. And, you know, they're out there running for a reason, be it a loved one affected by any illness and they're raising money for a charity involved with that. And they don't want to let folks down. And so everyone has their reason for their goals and what they're trying to achieve. And I think that it can be really tough to experience injury in the setting of trying to do these different sport related goals. And I think that it's just important to meet people where they're at, walk with people, you know, through their injury course and try and be as supportive as possible. But really it's prevention is the name of the game, right? And I think the more we know, I always say in light of some of our findings, I say, if we knew better, we could do better. - Mm-hmm. - So, you know, if all it took was, you know, ramping up and really paying attention to that fueling piece and the sleep piece, which we know is an important part of bone stress injury prevention, you know, doing those things. And if we knew better, we could do better. And I think that is true when it comes to energy availability and that's what we're trying to get the word out about. - Yeah, that makes it to my sense. Thanks again for sharing all that. If people want to follow you and your work, what is the best way to do that? - So I'm on Instagram as well as Twitter. My Instagram is Kristen with me. I am Chris K.R.I.S.C.I.N. Whitney at dot MD and Twitter is Kristen Whitney. - Perfect. And for our last question, what are you most excited about for the future of performance research? - Ooh, I am excited about first of all, performance in low energy availability. As you mentioned, I think that this is gonna be the first of many studies where we're able to look at low energy availability and its effect on performance. And then particularly a lot of the research attention that's being newly focused on the post-pronum athlete and mom's returning back to sport. Because I think that the more focused and development there is in understanding and supporting women, post-partum in their return to sport. It's really gonna escalate women's sports to be able to have young women who are postpartum be able to successfully return to sports and have these mature athletes in the game to increase the level of play. I think it's gonna be exciting. I myself have a five month old. So I'm super supportive and super interested in that. It's really fun to see like all these high level athletes getting back now once they've become moms. And I think it's just gonna be really exciting to see in the women's sports world. - Yeah, that's awesome. I can agree more. I thought it was really exciting. And I think also keeps women excited. I think it doesn't feel like having a family or kids closes any doors or getting older even closes doors. There is so much that, but I feel like there hasn't necessarily been the research or the support there to know that or the education to be able to encourage women or to teach them how to how to best do that. So it is exciting to see them. - Yeah, absolutely. - We're gonna have a next generation. - Yeah. - We are on the frontier and I love it. And thank you, Kristen, for sharing so, so much about all the many frontiers you're blazing. The awesome teams you're doing it with. And just keep doing awesome stuff. And yeah, because this has just been such an awesome episode. So thank you so much. - So great to talk with you all. Thanks for connecting and really appreciate your time chatting today. Thanks very much. - Thanks, Kristen. - Wow. - Wow. I miss Hannah. I miss Hannah just starting off with, wow. - Wow. - It's just, my brain is just still processing all of the great things from the interview. - Yeah, no doubt. - All I can do is wow. - Yeah. - Well, you can say as well, truly. I couldn't agree more. - That was so fun hearing about Kristen's journey and then about all the impactful work she's doing with the Boston marathon. And I feel like as a runner, and most I know you're a runner too, I feel like can appreciate all of that support and knowing that all of that is there safe guarda you as you run unless you do your thing. - Yeah, yeah, definitely. I know, marathon's are a big physical exertion. So that obviously comes with risks too and it's really rewarding, but it's also pretty incredible. The amount that's ongoing during the race and even in running research in general continues to make strides. - Oh my gosh. Did it just happen folks, boom. - I'm so happy. - I feel like I'm around you for 10 minutes and then I'm like, okay. (laughing) - And you're like time to turn it off. (laughing) - I don't think there's anymore to say now that that's been said so. - Well, I think so. Well, we love being back. If you wanna donate to the ALS Association and you can do that in the show notes and we're really grateful for any and all support both financial and emotional as well. - Yes, emotional and moral support, please. - It's all important and just to clarify, I keep saying donate to me. It's not to me. It's not to Hannah. - To my page for the ALS Association. - Correct, yes. - Yeah. - All funds will go. - All the funds will go. - Is it ALS? - Association, including in fact, you know, maybe we'll have a pun off and like that will help us raise some money too. So look out for that. - Wow. I will add a little doubt. - I thought that Melissa's joined the pun game. - Yeah. - That was a one and done type of situation so I could add ourselves. - Oh, okay, okay. I think you probably have some exciting things you wanna do today, including donate to the ALS Association. We're gonna wrap this one up. - Well, thank you for listening. - Should we boom? - Let's do it. - Bye, we can. - Bye, we can. - Bye, we can. (upbeat music) (upbeat music)