Episode 18 - Relative Energy Deficiency in Sport with Dr. Kate Ackerman

Reminder - new period recovery support space at http://noperiod.info/support!

In this episode, Florence and Nicola talk with Dr. Kate Ackerman, physician at the female athlete program at Boston Children's Hospital. They chat about:

Dr. Ackerman’s story and how she became interested in working with female athletesDr. Ackerman’s period history
Definition of an “athlete”
History of female athlete triad
All about REDS - symptoms, performance consequences, ways to diagnose REDS in those without a uterus
Female athlete team at Boston Children’s - including the mental side of recovery
Difference between hormone replacement therapy and birth control pills in bone density
Bone density and oral contraceptives versus transdermal estrogen therapy
Increased urinary incontinence (Nico’s blog post at http://noperiod.info/pee)
Wu/Tsai human performance alliance
Improving REDS screening tool to help people recognize issues

Find Dr. Ackerman at:
Humanperformancealliance.org
Femaleathleteconference.com
Childrens hospital.org female athlete program
Twitter @drkateackerman

To find support in your HA recovery:
Get the "No Period. Now What?" book at noperiod.info/book.
To make an appointment with Dr Rinaldi and get individual support to get your period back or improve your fertility, please go to noperiod.info/appointments
To make an appointment with Florence Gillet and get help with the body and mind changes happening in recovery please visit www.beyondbodyimage.com

You can find us on social media
No Period, Now What? on Instagram
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Amenorrhee_fr  (HA recovery 100% in French) on Instagram

Email us  via allin@noperiodnowwhat.com

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Editing by Steven Worlow
Original Music by the Andy Shulman Band "Lost & Found" available on Spotify.

Transcript

0:00

[Music] Welcome to All In, a straight shooting, science-based podcast about periods, fertility, and nurturing health outside of unrealistic beauty expectations. We will mostly but not exclusively focus on hypothalamic amenorrhea, H.A., a component of the female athlete triad and relative energy deficiency in sport. I'm Dr. Nicola Rinaldi, scientist and lead author of the book No Period Now What. I specialize in helping people understand how their eating, exercise, and lifestyle habits, keep them from hormonal health and their best life. My work focuses on regaining periods, improving fertility, and breaking free of the rules of underlying diet culture. My name is Florence Gillet, I'm a certified eating psychology coach and the founder of BeyondBodyImage.com. I specialize in mental recovery, helping people let go of toxic health beliefs to finally feel at ease in their bodies, at any size. Every two weeks the All In podcast brings you real recovery stories, expert insights, and new scientific research on H.A., hormonal health and fertility, with an unmissable touch of body respect and women's empowerment. Just a reminder that this podcast represents the opinions of the hosts and their guests, the content here should not be taken as medical advice, and it is for informational purposes only and because each person is so unique, please consult your healthcare professional for any medical questions. Music by the Andy Schulman band, available on Spotify. Hi Nicola, how are things going? Hi Florence, it's great to be talking with you again, life is great and I am so super excited to introduce today's guest, Dr. Catherine Kate Ackerman. Dr. Ackerman has her MD, MPH and FACSM. She is the medical director of the female athlete program at Boston Children's Hospital, associate director of the sports and/or can research lab at Massachusetts General Hospital, and associate professor of medicine and Harvard, like, oh my god, wow. She completed an internal medicine residency fellowships in sports medicine and endocrinology, and has been named the top sports medicine doctor in Boston by Boston Magazine. In 2019, 2020 and 21. She is currently the chair of the US Rowing Medical Committee and an amazing researcher. Her research focuses on the female athlete triad in aspects of relative energy deficiency in sport or RED-S. She has authored and co authored over 100 articles in book chapters related to sports medicine and endocrinology, rowing bone health and female athletes. Athletically Dr. Ackerman represented the US as a lightweight rower at the world championships and still competes with her teammates for life as a master's athlete. Kate, it's so lovely to talk with you and just reading through all that, it's amazing everything that you've done over the years. Can you tell us a little bit about what led you to working with female athletes and starting the female athlete program at Boston Children's Hospital? Sure. Well, thank you for having me. This is really fun. Nicola, I've met in at other times at our conference and we worked on some things together. So I guess my background, you know, in rowing and being an athlete really informed what I wanted to do. I was lucky, lucky and unlucky. I was on the national team while I was in med school, which I don't really recommend. Wow. So, but it was great to be training and seeing what services were available for our female athletes while I was on the team and then to also be able to see the gap and the fact that so many things that were happening in terms of medical care and sports medicine management in our female athletes were just based on the men. It wasn't really, you know, really specialized for women. So I was able to be in med school, see what was there, look up literature and see this big gap that there's so many answers that we don't have for women. We know that we are not just small men. We know that there are other things that make us different. So I got excited about the prospect of building a career around studying female athletes advocating for female athletes and absolutely wanted to tie my medical career into my interest in sports. And so it all sort of happened at the same time. I think one of the advantages of taking a little time off to pursue something else is that it gives you more time to think and inform what you want to do with your life. So I was really lucky that when I was back in med school and retired from rowing, I completely had a path. And then with the female athlete program, once I got to the point where I was doing a sports med fellowship, I realized that it would be neat to do this, really build a program within a sports medicine practice so that when somebody comes in with certain injuries that were still asking all the other important questions, you know, it's common to go to the sports medicine doctor with a stress fracture or, you know, an ankle sprain. But that's an opportunity to be interacting with that athlete and say, do you get normal menstrual cycles? Are there, are you, you know, having issues with eating and just kind of doing head to toe, asking a lot of important questions. So that's why we built the program to be a little bit more holistic for the female athlete. Cool. And did you experience any issues with your menstrual cycle when you were rowing? You know, it's funny. I think most people that become a lightweight rower don't know how to do it when they first start. So I learned to row at Cornell. We only had an open weight program, which I think was fantastic because I had to be scrappy. You know, I'm not super tall. I think I might exaggerate and say that I'm 5 foot 7. I'm a little shy of that. And so for a collegiate program, a D1 program that's a sort of small and the open weight team. So I had to work really hard to make it into the varsity and be competitive to be in the 1B. And then I realized, well, I have a smaller frame and there's this opportunity after college to continue to row. I wonder if I could be a lightweight. I wonder how that would look. And I had no idea if I'd do that. I just figured I would work out a lot more and I would eat less and I wouldn't eat after practice in the afternoon. And so that first summer, fortunately, I only missed one period, but I totally lost weight the wrong way. I didn't, you know, have any idea of how to do it. I cut out fat just because I had no guidance. So because of my frame and things, I didn't really suffer other than that one summer and miss one cycle in my whole life, other than when I was pregnant. But basically, I've seen so many people try to lose weight or try to keep a certain frame and they don't understand how they should be feeding their body. I definitely over time became a much more powerful athlete at a weight that's appropriate. I'm not with a sports dietitian and learn more about nutrition and fueling and the importance of all of that. So that's my experience in terms of what happened in person. Interesting. Yeah. I'm just wondering also for the one non-scientist here, and many of our listeners, you know, they have lost their menstrual cycle by being in an energy deficit, but without being a "athlete". So I'm just wondering if you have a specific definition when you run the female athlete program, what would be your definition of kind of athleticism in that sense? So I personally have a very broad definition. I think of it as a female athlete is somebody who is a woman who's physically active, at least for our clinic, the clinic purposes. For research purposes, we have to define it a little bit more strictly and for our studies, it's typically doing four hours a week of exercise and some sort of team setting for our studies. But I see women, girls of all ages and even women who are 65 years old and like to speedwalk and like to get their heart rate up. Interesting. As you know, we mostly framework on period recovery and we know the hypothalamic amenorrhea is a component of relative energy deficiency in sport, which Nicola mentioned before is RED-S. And we obviously talk about the myriad of benefits that you get through recovery outside of just having your period. Would you be able to tell us a little bit more about RED-S and how the amenorrhea fits into that condition from your perspective? Sure. So the female athlete triad is a term that was really started in the early 1990s and that was the traditional somebody who has low energy availability or a frank eating disorder. And then they have menstrual irregularity that leads to amenorrhea and no menstrual cycle for months at a time. And then that combination leads to low bone density. So that was the original triad. Over time, people realized that you can be on different, you know, as back drums of those different, those re entities. So someone could have mild, menstrual dysfunction or somebody could have slightly decreased bone density or they could have some energy restriction, but not have a frank eating disorder. So the triad sort of morphed and then over time, the international Olympic committee, which had its own female athlete triad position statement, decided to update their position statement. And the authors of that paper really many of them were clinicians and noticed, you know, we see relative energy deficiency. We see this lack of appropriate amount of energy in both women and in men. And we also see that it has other effects. So not only does low energy availability lead to menstrual dysfunction and poor bone health, it can lead to other endocrine changes, like a decrease in thyroid hormones, specifically T3. It can change the metabolic rate and slow the metabolism. It can have cardiovascular effects. It can lead to GI issues. And then the other thing that they really noticed was a lot of the performance consequences. And that's what I was excited to be able to share with my patients. Because some of my patients, especially my younger ones, don't really want to be thinking about osteoporosis. If they haven't had a stress fracture yet, that means nothing to them. We know that osteoporosis is really a disease of childhood because people should be building their bone density during adolescence to get to their peak bone mass. But if you tell a 15 year old, oh, you're going to get osteoporosis someday, they don't really care.

But if you say: 10:32

you're not getting your period because you're not fueling enough, all that training that you're doing is not effective and you can actually get slower rather than faster, that seems to resonate. So we do see that athletes suffer in terms of their performance. It doesn't always happen right away, which is why it's such a tough sell. They really need to sometimes take a while and learn the lesson the hard way because they get an injury or they start slowing down even with all their training. But we do see it catch up with them. We see that people don't recover as well from workouts. We can definitely see that it affects their mood when they're under fueled. That was one of the things that I noticed as a lightweight. I actually was annoyed that first summer that I was a lightweight and I lost weight and kind of overshot the weight loss. And I didn't even feel strong. I felt really thin and when people said, "Oh, you look great. Wow, you lost so much weight." Fortunately, I had enough self-confidence to think, "Well, I don't really want to hear that compliment because I feel like my brain is foggy. I don't feel awesome being at this weight." This isn't my ideal. So even your brain, you're not getting the right nutrients into your brain and people's mental health is really starting to suffer. They can't think as clearly and focus and things like that. The angle I really wanted to talk about was all the different health issues and the performance issues and I think that really helps sometimes because you might find one particular topic or one system that's affected that really resonates with an athlete. Yeah. One thing I thought was interesting was as you pointed out that it's not just biological females that are affected by low energy deficit, but it's obviously easier to tell in somebody with a uterus because if you stop having a period, that's a clear warning sign. What are some other things that people might notice? People without a uterus or even people who don't get amenorrhea to pay attention to, to help them with diagnosis and figuring out that they are underfueling? When we talk about men, this always makes people laugh or feel uncomfortable in the audience, but with men, young men and adolescent men typically get morning erections when they wake up. They wake up with a morning erection. If that disappears, that can very much be related to low energy availability. That's a sign that we can use in boys and men. Then in women and in men, sex drive, libido can actually decrease. Then when we start to talk about performance, people just might feel fatigued. That gets tricky when you're talking about adolescence and when you screen things like, have you had mood changes or feel fatigued? If you talk to any high school kid, they'll probably say, "Well, that happens. But if it's consistent, that can be a sign. Not responding well from workouts, changes in resting heart rate. If there's a lab panel, if they're very energy restricted, that T3 level can be low, white blood cell count can be low. So thinking about just changes in the whole feeling that the athlete has in terms of both their performance and their overall health and their energy level. I actually had my first male client not too long ago and it was a man who called me up and said, "My libido just went from 60 to 0 in about two weeks because I decided to go on this massive diet and exercise thing." It's tough also to think of the whole mental health side for men because there's such a big stigma related to it that I think if they experience mood changes or feeling a bit more depressed or off, I don't know that they would say it. It's just so difficult, I think, much more difficult for men than for women in a way. That was a tricky topic with the female athlete triad. What do we call it if it's low energy availability? I know some of the founders of the female athlete triad coalition thought, "Well, then maybe we should call it a male athlete triad." I personally like to say RED-S and say energy deficiency because we know it's not just a triad, it's many different systems. Applying a male thing that was already a female name might also be uncomfortable for men who are suffering from it. RED-S is universal. Normalizing it has helped my patients when I say relative energy deficiency. Think of it as a math equation where we're taking into consideration how much you're taking in, in terms of calories, and how much you're expanding, in terms of exercise. What's your lean masses and doing an equation where we can see in general where you would function well and how you might be missing the mark of how you're fueling and training right now? I find also the term RED-S is actually easier to understand that female athlete triad for non experts. We understand that you have a whole team that works with you and we were interested to know a little bit more about your team and why that model of working works so well. Number one, it's really nice to work with people that you really like. We've built a really fun team. I love our female athlete conference because it's like we have a team on steroids. We have so many people coming from all over the world to this conference and we're all excited about treating women. Our team is like that too. So we, on our female athlete program team, have an amazing physician assistant who works with me, a couple other physicians who focus just on our female athletes and particularly the energy issues here. We have two sports dietitians who are fantastic, two sports psychologists. One is actually a social worker and one is a psychologist and everybody comes from a bit of a different sporting background. So we all love exercise. We've all been athletes at different levels and most of us have done different sports. So one person played rugby, one person was a track and field athlete. Somebody else was a ballerina. Somebody else was a hockey player. I was a rower. It's nice that we bring people with different lenses and we all are really passionate about treating women and advocating for women. We do have some men in our group so we do love our he's for she's and they are athletes. And so it's just a really nice group. I can't emphasize enough how fun it is to work with people that you really care about. But then we also need just to be interdisciplinary. I learn from my colleagues. They learn from me. People sometimes will start asking me all these nutrition questions and I say, yeah, I can tell you the basics. I can look things up. I can write a review paper about it. But if you want me to go through your diet and talk about your micro and macro nutrients and give you a really good plan, you need to talk to our sports dietitians. And they're the ones who are going to really help inform you about this and then you're going to be able to work with them and make some adjustments as you're going through your energy recovery path. Yeah, fantastic. I think also particularly having the psychologist and social worker on the team makes a huge difference because I think that the mental aspect of recovery is often set aside by your typical general practitioner or OB/GYN who has 10,000 patients to see in a day and doesn't have the time to spend with somebody. So I think that's a really nice aspect of your program too. And I learned so much from them because they uncover things. You know, my position's assistant, Meg, uncover a lot of things because people open up to us, but they know how to manage it in a way that they were trained to manage it. So often when people have energy deficiency, it can be because of a variety of things. And it might just be, oh, I started training a lot and I didn't realize I was not getting a callers in or it might be I have major body image issues and I feel stressed out about how I look or you know this pandemic is making me feel like I have no control over anything. So at least I have control over food and I have high levels of anxiety or there's a trauma history. You know, all of those different things can get unearthed as you're feeding patient with RED-S and our experts in mental health know how to really approach that. There might be DBT or CBT or all sorts of different ways to attack the problem or attack the situation. So I have to completely respect when they're giving me advice about what's appropriate or how to approach a certain patient or how much to push them. I think that's why we have rounds on our patients. I really love that team approach and I hope that more hospitals and institutions start to incorporate something like that and working with their female and male athletes. I think one thing we'd love to chat a bit more about is some of the research and results that you and your team have published over the years. One study that I often discuss with people is your finding of the difference between hormone replacement therapy and oral contraceptives or birth control pills in terms of how they affect bone density. Can you tell us a little bit more about this work and also the role of the protein IGF1 which seems to be important in that distinction. Absolutely so in the old days not that long ago and sometimes still today when people don't get their period somebody might just say oh go on birth control it'll give you your period you'll be fine. And then oh by the way no one will bug you about not getting your period and we know that that is exactly the wrong thing to do. So when somebody doesn't have their period as a physician I have to determine why. It could be that they have a state of low energy availability. It could be that they have a mass in their pituitary. It could be they're making prolactin that's not causing them to get their period. It could be that they're pregnant. It could be a whole bunch of things. So it's my job first to determine why they're not getting their cycle and then if they're not getting their cycle because of low energy availability the best thing for them to do is to improve the energy availability. But that's often easier said than done so if you have somebody who's really under nourished and they are not going to get their period at their current weight. Sometimes you don't want to wait for that whole eating recovery to happen because we know that when somebody is in a state of low energy availability they're not having the best hormonal milieu to build bone. So in our adolescents for example there are about 20 different hormones that are affecting bone health and many of those hormones relate to energy availability and menstrual function. So if those hormones aren't churning around appropriately they're not building that bone mass that they need to, during adolescence and we're wasting time. So one of the hormones that's important is estrogen but when estrogen is taken as a pill in the form of birth control that oral contraceptive pill it actually has first pass through the liver and the liver is something where it converts growth hormone to IGF1. So IGF1 is a form of growth hormone and when the estrogen is taken as a pill it is first pass through the liver and that down regulates IGF1. That protein IGF1 is actually very important for bone. So in amenorrheic athletes they have decreased IGF1 but the first pass through the liver birth control pill can actually lower it even more. So when we give people transdermal estrogen or give them a little patch with estrogen on it that's absorbed through the skin it doesn't have first pass through the liver and it doesn't have that negative effect on IGF1. So in our study we studied athletes with menstrual dysfunction athletes with normal periods and then non-athletes and we followed them over the course of a year. We noticed the bone changes of those, we followed the amenorrheic ones over the course of the year. We noticed that the amenhorreic athletes we split them into the transdermal group, the birth control group and no therapy group. And when we looked at what happened with their bones the ones who are in transdermal estrogen had a nice increase in the bone density and the ones on the birth control pills actually did much worse. So in terms of an individual athlete they either had no change or their bone density got worse. So when you're talking about those amenorrheic athletes who you're trying to get better in terms of nutrition if it's going to take a while for them to get their period back during that transdermal estrogen is a bit of a band aid that can be helpful. But keep in mind you're only giving them one hormone back really you're giving them oestrogen. We also have them take 10 to 12 days a month progesterone and the purpose for that is not to help bones but to cause them to have a withdrawal bleed. So they're not building up their endometrial lining month after month otherwise they have a sloughing off of the lining and get random periods at different times that are inconvenient. So you want to just give them the progesterone and after 10 days a progesterone they should have a withdrawal bleed but estrogen is really the thing that's helping with the bones. So I have actually seen research that suggests the progesterone is important for bone density as well. It doesn't have as much of an effect. So for our purposes it was much more just to keep them from having this unstable endometrial lining that estrogen is more powerful overall. Okay. What would you say is a time frame that you would be concerned about somebody not having a period for? I mean if they're able to get their period back in say three to six months, is that reasonable do you think or what? Yeah. Yeah. It depends. Obviously it's not a perfect science and so you're kind of taking a guess the way. We did some endocrine society guidelines about this a few years ago hypothalamic amenorrhea guidelines and in general I'd say most practitioners and our expert panel thought that if after six months they don't have their cycle you can try transdermal estrogen. I'd say some of us also will start the transdermal estrogen sooner if their bone density is really low to begin with and if we just get this sense of resistance. So if somebody is pretty healthy and it's more just an education issue and they don't have to gain that much weight and their bone density is starting at a pretty good place. Usually then you can wait those six months. Okay. Thank you. So last year Nicola wrote a blog post explaining some of the reasons why someone who is experiencing HA might also need to urinate frequently. And you also recently published a study finding increased urinary incontinence in female athletes and the relationship this might have to low energy availability. Could you tell us a bit more about your findings? Yeah. So we did a study on our female athletes in our clinics. So we looked at a thousand female athlete patients who came in for all different reasons in sports clinic. They came in for concussion. They came in for ankle sprains. They came in for anything. Some of it was nutrition. Most of it was sports injuries. And basically we gave them surveys and asked them about different health and performance consequences. You can see in the RED-S model and we screened them and use a circuit marker for low energy availability. So we asked them if they had an eating disorder or disordered eating. We gave them the beta Q which is the brief eating disorder questionnaire for athletes. And then we gave them the ESP which is the eating disorder screen for primary care.

Number one, the first thing that's interesting overall was of those patients: 25:47

there were very few that answered all three questions saying yes. So there were about 68 patients who answered yes to all of them. But when you did the Venn diagram of, you know, how many did one questionnaire right or you screened positively on one questionnaire versus another. It was a pretty high number of our patients who had (almost 50% of our patients) some sort of disordered eating or eating disorder. So we then split those groups into those who screen positively. We use this again. It's a surrogate for low energy availability versus those who screen negatively. And the ones who screen positively were more likely to suffer some urinary incontinence whether it was slight moderate or severe. And so there is a validated survey that can be used to screen for that at the international consultation and incontinence urinary incontinence short form really rolls off the tongue. It's validated, it's a validated form with a lot of questions about urinary incontinence onset and duration. So those who had low energy availability definitely had more of those urinary incontinence symptoms. And a lot of that has to do with the different receptors that we have in our bodies. So estrogen isn't just about the menstrual cycle. There are receptors all over the body. We know even from a cardiovascular standpoint, estrogen also affects dilation and the vascular chair. So it's affecting the pelvis and all of this thing that is tied together. We're just finding more and more health consequences and effects of being in this energy deficiency state with this normal regulation. Yeah, it's amazing how much of our body is affected and we don't, you know, in many cases we don't realize for years, you know, especially when people are put on the birth control pills and told, "It's your period, you're fine." So I think that the more we can learn about the different symptoms and, you know, help share that with people, I think that's fantastic. I just wanted to ask it's a bit of a, you know, question that just jumped in my mind. If this is also something that would help being communicated to general practitioners who might see people coming into their office, as part of, well, this is also one of the symptoms that can somehow lead us to think that maybe there is energy deficiency. Absolutely. I mean, that was really the impetus for our starting, our female athlete conference is, I just felt there were certain professionals and coaches and athletes and parents who needed to hear about all these things. So our conference is about female athletes in general, but there definitely is a focus and always a few sessions on RED-S. And I just think that a lot of practitioners aren't aware of it, so they don't, they don't speak for it, you know, they might see an athlete and immediately look at an athlete, talk to the bottom and say, "Oh, well, you're pretty healthy, you work out, you look fit." Yeah, you look fit. You look fit. So that's the end of it. But I think one thing that was kind of neat about that study is we got together with a pediatric urologist at our hospital who worked on that paper with us. And so that paper that we were just discussing was in the journal of pediatric urology, so we're getting to a whole other population of medical professionals to kind of have a radar. That's great, because I mean, we, Nicola and I, we face so many people coming to us literally after having been told that everything is normal and nothing's wrong with them and it's just their period that's missing. And you're like, well, even that is not normal, but they're being told that by many medical practitioners that are their first point of call. And I think there's really a lack of knowledge. Absolutely. The other thing that I have found helpful in treating our athletes is using the Dexa, using the bone mineral density scan. So most people who are adults if they get a Dexa will have a spine and a hip scan. So this is a really easy task that takes a few minutes. It's used to screen for osteoporosis, typically in older people. But it only takes a few minutes. The radiation is the equivalent of flying from here to Colorado on a plane here, meaning often, or even less radiation. But when you can use that scanner as they do in kids and scan the whole body, or you specifically order a full body scan on an adult, you can get the bone density, the lean mass and the fat mass. And so what we're seeing is that it's not about BMI. It's really about this percent fat that an athlete has. So I might have a hockey player, with a BMI that was absolutely normal, 23.5, 24, really, really muscular athlete who is amenorrheic. And then when we did the Dexa and can see her scan, she had barely any fat on her body. So she didn't have any energy reserves. And so her hypothelamic amenorrhea was stemming from the fact that her body just had no reserves. So when she can see that image, and I don't need to talk about percent fat, but to show the image of your almost all muscle and bone, this is why we need you to gain weight. And it can't just be muscle weight. There needs to be a little bit of fat in there. Then your body will wake up. That can be instructive. And so even if she went to somebody who said you need to gain a little bit of weight, she could have stopped at a point and not gotten her period for years because she needed to keep going because it wasn't all related to her BMI. Right. Right. Absolutely. So this research is all fascinating. And thank you for sharing that study with us as well. Is there any other recently completed or ongoing research studies that you would like to tell us about? There's so many ongoing studies. Well, so we recently were really lucky to get funded by these very wonderful philanthropists, Claire Wu and Joseph Tsai. So I'm now part of the Wu Tsai Human Performance Alliance. And so it's a multi institutional endeavor. We were as a group given 220 million dollars to work with, which is insane. And since last year when I was very fortunate to be picked as one of the leaders of the council to put together proposals for projects, I was added to the council as the one physician, the one female and the person really focusing on translational research for women. So we now have a lot of things going on. We're trying to validate the RED-S screening tool, improve the RED-S screening tools. So the triad group has a screening tool and that could be pretty helpful. The RED-S group has a screening tool and that can be pretty helpful. But neither one of them is perfect. And neither one has been truly validated. So we're hoping to figure out a way that we have a tool that will help people kind of recognize this a little bit easier, but maybe determine other markers that are more helpful than others. We're doing work trying to determine is there some sort of teleologic approach is there's some sort of evolutionary thing that happens where one system or one hormone becomes the first marker and then the next one, like what is the order of things and is it the same in everybody is it the same in every population. We're working with some anthropologists, evolutionary biologists to kind of determine, okay, what are the markers and is it different for say a tribe in Africa versus somebody who's in a city in the US. So we've got some international work going on there. I could go on forever. We just have all these different pockets, the really nice thing about getting funding like that is you can start to pick your favorite people to work with. We're working with folks with up in Canada and the UK and in Australia. Folks at the six different institutions that I'm talking about with Wu-Tsai. So we started a female athlete western gateway over at Stanford. So I'm mentoring the director of that over there. So we'll have more resources in Stanford. We're studying track athletes and a lot of things to come in the space because I think we all just want to understand the mechanisms a little bit better. Absolutely. And the ideas in terms of treatment. One of the criticisms of those RED-S model was, you know, it's a spoken wheel model. You've got this energy deficiency and it shows you that there are a whole bunch of systems affected in the human body, a whole bunch of performance things affected. We are now trying to come up with the pathways of how each of those things is interrelated and how low availability directly or indirectly leads to those consequences. So that'll inform treatment. Oh, that's fantastic. Wow. I'm speechless. You can probably hear. I come from Belgium. I'm French speaking, you know, my mother tongue is French. And I cannot tell you the huge difference that we see in Europe compared to where you are doing research. I just hope and wish that there will be and I'm glad to hear there is international connection there, even though obviously it's most likely to be countries that all speak English and I totally get that. But I really hope that this this work can then, you know, reach other areas of the world because we are so behind. It's terrible. I see many, many, many women from France where women just don't even get a proper diagnosis. It's insane to me. Well, I'll tell you I very much love working with international people. That's probably the best thing that happened to my career was getting to travel and getting invited to some other countries to give some talks. That's those are my research colleagues all over. I only listed a few countries, but really the more the barrier we do with our IOC report all different countries is real, Norway. All sorts of places. Belgium, we will add it to the list. That would be great. I think Belgium, France definitely French speaking countries do need that information desperately and Nicola and I are working hard on translating the book in French because it's really, but I know it's just, you know, I'm specifically talking about that, but I know it's in many other countries and languages where there's just no knowledge at all about RED-S or H.A. Or being an athlete, you know, even though you're not maybe officially an athlete. So just being extremely active and that it can lead to low energy availability. So I'm really grateful that you do this work and I will keep you in mind definitely if people ask me who can we invite. So before you leave, we want to ask you first, like where can people find more about you and your work? So we have a few different websites. So if you go to the human performance alliance.org that talks about the Wu Tsai human performance alliance that talks about a lot of different things. So there are people doing very basic science. There are people doing things about tissue regeneration and injury recovery and things that aren't even specifically related to this, but that gives you some links to the rest of what we do. Our conference website is female athlete conference.com. And then if you go to children's hospital.org and then you take in the female athlete program, you can find this there too. You can Google me either Dr. Kate Ackerman or Kate Ackerman. Sometimes you'll get my sister-in-law who's also a Dr. Kate Ackerman. Sometimes you'll get me. I'm a little blonder thanks to my hair stylist. And you're on Twitter, right? What is your Twitter handle? Keep in mind sharing. Dr. Kate Ackerman. And you also mentioned that you might be looking for some people to join your team. Would you like to say anything about that? We could really use a scheduler. I have an amazing scheduler who is scheduling for too many of us and now she's my admin assistant too. And she's fantastic, but she's overworked. And I think our whole practice is looking for some really motivated people that want to help get into the fold. I think a lot of people think they need to have the perfect job when they graduate from college and absolutely get a research position or get something that's going to look great on their CV. I can say we've had awesome front desk people and schedulers who just being in that system, have gotten a lot of great opportunities and have gone on to become researchers or doctors or position assistants or nurse practitioners. So if people are interested at all in joining our group, we really could use some people doing things like front desk work and being a scheduler. So you could message me on Twitter if you're interested and we can send you the job links. You can also go to the Boston Children's Hospital website and see some of the job postings and just say that you're interested in something related to the female athlete program. Fantastic. I think you should ask a ritual question to Kate. All right. So we like to ask all our guests, how are you all in in your own life at the moment? Basically, just what are you putting your all into? So I am putting my all into building the first amazing comprehensive female athlete research and clinical center. So this is something that we are hoping to partner with some big companies that I can't mention right now working with Harvard Medical School and the whole Harvard ecosystem and Boston Children's to build this amazing center that really brings people together. And also has so much international input and collaboration. So I've been working on that ever since I first met our great Wu-Tsai donors and this is sort of another extension of that with other opportunities and other philanthropists to join in. There's so many things we need to answer for women. And so it's become my life mission to make sure that we get this center off the ground and then it's got longevity and we can really fill in the gaps and so many of these questions. So amazing. I have goosebumps. Super inspiring. Thank you so much for finding a bit of time to spend with us. Yes, with everything you're doing. This is so lovely to have you. Thank you. Happy to be here. All right. I hope you enjoyed this episode. We'll take a few minutes to reflect on it and how you have been all in this past week. It always strikes me how different each person's all in journey is. As I often say, there are many paths to H.A. and many paths out of it. Your journey is unique. That is so true. And if you need more support on your journey, you should definitely start with no period now what, which you can get at noperiod.info/book. And Florence and I both work with people on different aspects of period recovery and so much more. So if you'd like more personal advice and attention, you can go to noperiod.info/appointments to schedule a time to speak with me on fixing the issues underlying your missing periods and figuring out what those issues are. And I'm at BeyondBodyImage.com to work with me on the deeper emotional issues and your body image. I also run a French Instagram account. I'm in @amenorrhee_fr and obviously you can find Nicola at noperiod.info/appointments.com. We also have joined clients so you can access both our domains of expertise at the same time. If you enjoyed this podcast and found it helpful, please drop a survey to help more people find it. Also join the noperiod now what recovery support group at noperiod.info/support and let us know how all in is going for you. All In is not just about period recovery, it's about getting your life back. See you in two weeks! You were lost in battle, but did you got lost again? You were lost in battle, but if I just self-invent, take on that you've lived, about that little thing lost, place your in pain, and never get lost, never get lost again.[MUSIC][Music]