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Screening for Relative Energy Deficiency in Sport: Detection of Clinical Indicators in Female Endurance Athletes
Abstract
Purpose
The purpose was to evaluate the individual and combined use of the Low Energy Availability in Females Questionnaire (LEAF-Q) and the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q) to detect clinical indicators associated with Relative Energy Deficiency in Sport (REDs).
Methods
In this cross-sectional study, 50 female endurance athletes training ≥4x/week completed the LEAF-Q and BEDA-Q and were assessed for presence of selected REDs indicators. Athletes meeting the criteria for mild or more severe REDs severity/risk according to the International Olympic Committee REDs Clinical Assessment Tool Version 2 (IOC REDs CAT2) were classified as REDs cases. Diagnostic properties of the German versions of the LEAF-Q and BEDA-Q were assessed at different cut-offs using receiver operating characteristics calculations.
Results
Fourteen (28%) athletes were classified as REDs cases. The LEAF-Q had a sensitivity of 79% and a specificity of 50%, with a positive predictive value (PPV) of 38% and negative predictive value (NPV) of 86%. For detection of disordered eating behaviour/eating disorder (DE/ED), the BEDA-Q showed a sensitivity and specificity of 71% and 76%, respectively, with a PPV of 68% and NPV of 79%. Out of 14 REDs cases, nine (64%) scored positive in the LEAF-Q and BEDA-Q. Two athletes (14%) scored positive only in the LEAF-Q and one athlete scored positive only in the BEDA-Q. Two REDs cases remained undetected by both questionnaires.
Conclusions
Among German female endurance athletes, the LEAF-Q and BEDA-Q are good screening tools to detect REDs cases with mild or more severe severity/risk as classified according to the IOC REDs CAT2. Further clinical assessments should be initiated when athletes score positive in at least one of the questionnaires.
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Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee’s expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.
Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one’s environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee’s REDs Clinical Assessment Tool—V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and ‘weighted’ in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.
Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18-35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of REDS among female endurance athletes.
Background
A sustained mismatch between energy intake and exercise energy expenditure (EEE) can lead to Low Energy Availability (LEA), health and performance impairments characteristic of Relative Energy Deficiency in Sport (RED-S). Questionnaires can conveniently identify symptoms and/or LEA/ RED-S risk factors. This study aimed to systematically identify, and critique questionnaires used or developed to measure LEA/ RED-S risk in athletic populations.
Methods
A systematic search was conducted using PubMed database. Full text articles were included if: (i) the questionnaire(s) in the study identified LEA and/or RED-S risk; (ii) studies developed questionnaires to identify LEA and/or RED-S risk; (iii) participants belonged to athletic population(s); and (iv) in English.
Results
Thirty-three articles met the inclusion criteria and were reviewed, 13 questionnaires were identified. Eight questionnaires had undergone validation procedures, and three questionnaires included questions related to EEE. The most widely used validated questionnaires were Low Energy Availability in Females Questionnaire (LEAF-Q) (48% articles) and Eating Disorder Examination Questionnaire (EDE-Q) (12% articles). The LEAF-Q determines LEA risk from symptoms but cannot be used in males as nearly half of the items ( n = 12) relate to menstrual function. The EDE-Q serves as a surrogate marker of LEA risk in both sexes, as it measures a major risk factor of LEA, disordered eating. Better validation is needed for many questionnaires and more are needed to address LEA/RED-S risk in male athletes.
Conclusion
These questionnaires may be effective in identifying intentional energy restriction but less valuable in identifying inadvertently failure to increase energy intake with increased EEE.
Low energy availability (LEA) causes impaired physiological functioning. Cross-country running is a weight-sensitive sport, making athletes more prone to LEA. We aimed to estimate the prevalence of elite European cross-country athletes at risk of LEA using the LEA in Females Questionnaire (LEAF-Q) and to analyze demographic and physical characteristics that are associated with LEA. Athletes ≥ 18 years competing at the 26th European Cross-Country Championships (n = 602) were invited to complete a questionnaire (sociodemographic, training, anthropometric characteristics, and LEAF-Q). A total of 207 valid surveys were collected (83 females, 22.1 (4.0) years, and 124 males, 22.3 (4.1) years), and 16 surveys were excluded. A high prevalence of athletes at risk of LEA (64.3%) was observed, being higher in females than in males (79.5 and 54.0% respectively, p < 0.001). More than half of athletes (54.1%, n = 112) reported bowel movements once a week or more rarely, while 33 female athletes (41.3%) did not report normal menstruation. Overall, cross-country athletes are at high risk of LEA. Moreover, a high prevalence of gastrointestinal and menstrual impairments was reported. Hence, athletes should be followed by multidisciplinary teams to inform, prevent, and treat LEA and its effects.
Identification, evaluation and management of disordered eating (DE) is complex. DE exists along the spectrum from optimised nutrition through to clinical eating disorders (EDs). Individual athletes can move back and forth along the spectrum of eating behaviour at any point in time over their career and within different stages of a training cycle. Athletes are more likely to present with DE than a clinical ED. Overall, there is a higher prevalence of DE and EDs in athletes compared with non-athletes. Additionally, athletes participating in aesthetic, gravitational and weight-class sports are at higher risk of DE and EDs than those in sports without these characteristics. The evaluation and management of DE requires a cohesive team of professional practitioners consisting of, at minimum, a doctor, a sports dietitian and a psychologist, termed within this statement as the core multidisciplinary team. The Australian Institute of Sport and the National Eating Disorders Collaboration have collaborated to provide this position statement, containing guidelines for athletes, coaches, support staff, clinicians and sporting organisations. The guidelines support the prevention and early identification of DE, and promote timely intervention to optimise nutrition for performance in a safe, supported, purposeful and individualised manner. This position statement is a call to action to all involved in sport to be aware of poor self-image and poor body image among athletes. The practical recommendations should guide the clinical management of DE in high performance sport.
The term Relative Energy Deficiency in Sport was introduced by the International Olympic Committee in 2014. It refers to the potential health and performance consequences of inadequate energy for sport, emphasizing that there are consequences of low energy availability (EA; typically defined as <30 kcal·kg-1 fat-free mass·day-1) beyond the important and well-established female athlete triad, and that low EA affects populations other than women. As the prevalence and consequences of Relative Energy Deficiency in Sport become more apparent, it is important to understand the current knowledge of the hormonal changes that occur with decreased EA. This paper highlights endocrine changes that have been observed in female and male athletes with low EA. Where studies are not available in athletes, results of studies in low EA states, such as anorexia nervosa, are included. Dietary intake/appetite-regulating hormones, insulin and other glucose-regulating hormones, growth hormone and insulin-like growth factor 1, thyroid hormones, cortisol, and gonadal hormones are all discussed. The effects of low EA on body composition, metabolic rate, and bone in female and male athletes are presented, and we identify future directions to address knowledge gaps specific to athletes.
Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC.
Objective
The purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes.
Methods
One thousand female athletes (15–30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05).
Results
Athletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance.
Conclusion
These findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.
The syndrome Relative Energy Deficiency in Sport (RED-S) is a clinical entity characterized by low energy availability (LEA), which can negatively affect the health and performance of both male and female athletes. The underlying mechanism of RED-S is an inadequacy of dietary energy to support optimal health and performance. This syndrome refers to impaired physiological function including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health, with psychological consequences which can either precede (through restrictive dietary habits) or result from RED-S. The term RED-S extends beyond the condition termed the "Female Athlete Triad". Formerly known as synchronized swimming, artistic swimming is an Olympic sport requiring a high level of fitness as well as technical skill and artistry. The risk of RED-S is high in artistic swimming as it is an aesthetic, judged sport with an emphasis on a lean physique. RED-S is of significant concern in the sport of artistic swimming because of the potential negative effects on physical and mental health as well as consequences on athletic performance. This paper reviews health and performance consequences associated with LEA resulting in RED-S in artistic swimming. Medical and nutritional considerations specific to artistic swimming are reviewed and methods to help detect and manage RED-S are discussed. Prevention and management of RED-S in this athlete population should be a priority for coaches and the sport medicine professionals working with artistic swimming athletes should utilize the RED-S CAT, a Clinical Assessment Tool for screening and managing RED-S.
Low or reduced energy availability (LEA) is linked to functional hypothalamic oligomenorrhea/amenorrhea (FHA), which is frequently reported in weight-sensitive sports. This makes LEA a major nutritional concern for female athletes. The aim of this study was to describe dietary characteristics of athletes with LEA and/or FHA.
Endurance athletes (n = 45) were recruited from national teams and competitive clubs. Protocols included gynecological examination, body composition, eating disorder evaluation, and 7-day dietary intake and EA assessment. Athletes with disordered eating behavior/eating disorders (n = 11), menstrual dysfunction other than FHA (n = 5), and low dietary record validity (n = 4) were excluded. Remaining subjects (n = 25) were characterized by EA [optimal: ≥ 45 kcal (188 kJ)/kg fat-free mass (FFM)/day (n = 11), LEA: < 45 kcal (188 kJ)/kg FFM/day (n = 14)] and reproductive function [eumenorrhea (EUM; n = 10), FHA (n = 15)]. There was no difference in EA between
FHA and EUM subjects. However, FHA and LEA subjects shared the same dietary characteristics of lower energy density (ED) [(P = 0.012; P = 0.020), respectively], and fat content [(P = 0.047; P = 0.027), respectively].
Furthermore, FHA subjects had a lower intake of carbohydrate-rich foods (P = 0.019), higher fiber content (P < 0.001), and drive for thinness score (P = 0.003). Conclusively, low ED together with high fiber content may
constitute targets for dietary intervention in order to prevent and treat LEA and FHA in female athletes.
Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as 'Female Athlete Triad'. The term 'Relative Energy Deficiency in Sport' (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a 'triad' of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The 'Sport Risk Assessment and Return to Play Model' categorises the syndrome into three groups and translates these classifications into clinical recommendations.
Low energy availability (EA) in female athletes with or without an eating disorder (ED) increases the risk of oligomenorrhoea/functional hypothalamic amenorrhoea and impaired bone health, a syndrome called the female athlete triad (Triad). There are validated psychometric instruments developed to detect disordered eating behaviour (DE), but no validated screening tool to detect persistent low EA and Triad conditions, with or without DE/ED, is available.
The aim of this observational study was to develop and test a screening tool designed to identify female athletes at risk for the Triad.
Female athletes (n=84) with 18-39 years of age and training ≥5 times/week filled out the Low Energy Availability in Females Questionnaire (LEAF-Q), which comprised questions regarding injuries and gastrointestinal and reproductive function. Reliability and internal consistency were evaluated in a subsample of female dancers and endurance athletes (n=37). Discriminant as well as concurrent validity was evaluated by testing self-reported data against measured current EA, menstrual function and bone health in endurance athletes from sports such as long distance running and triathlon (n=45).
The 25-item LEAF-Q produced an acceptable sensitivity (78%) and specificity (90%) in order to correctly classify current EA and/or reproductive function and/or bone health.
The LEAF-Q is brief and easy to administer, and relevant as a complement to existing validated DE screening instruments, when screening female athletes at risk for the Triad, in order to enable early detection and intervention.
Design and validate a brief questionnaire able to discriminate between female elite athletes with and without an eating disorder (ED).
In phase I, 221 (89.5%) adolescent athletes participated in a screening including the Eating Disorder Inventory-2 (EDI-2) and questions related to ED. All athletes reporting symptoms associated with ED (n=96, 94.1%), and a random sample without symptoms (n=88, 86.3%) attended the ED Examination Interview. Based on the screening we extracted items with good predictive abilities for an ED-diagnosis to the Brief ED in Athletes Questionnaire (BEDA-Q) version 1 and 2. Version 1 consisted of 7-items from the EDI-Body dissatisfaction, EDI-Drive for thinness, and questions regarding dieting. In version 2, two items from the EDI-Perfectionism subscale were added. In phase II, external predictive validity of version 1 was tested involving 54 age-matched elite athletes from an external dataset. In phase III, predictive ability of posttest assessments was determined among athletes with no ED at pretest (n=53, 100%). Logistic regression analyses were performed to identify predictors of ED.
Version 2 showed higher discriminative accuracy than version 1 in distinguishing athletes with and without an ED with a receiver operating characteristics (ROC) area of 0.86 (95% CI, 0.78-0.93) compared to 0.83 (95% CI, 0.74-0.92). In phase II, the accuracy of version 1 was 0.77 (95% CI, 0.63-0.91). In predicting new cases, version 2 showed higher diagnostic accuracy than version 1 with a ROC area of 0.73 (98% CI, 0.52-0.93) compared to 0.70 (95% CI, 0.48- 0.92).
The BEDA-Q containing 9-items reveal good ability to distinguish between female elite athletes with and without an ED. The BEDA-Q's predictive ability should be tested in larger samples.
The relevance of hormonal assessment in anorexia nervosa (AN) management is still unclear. The short-term physical risk during undernutrition period of the disease is partially predicted by anthropometric and electrolytic parameters.
The objective of the study was to evaluate hormonal profiles in a large cohort of AN and their relationship with critical states.
This was an observational monocentric cross-sectional study performed in the endocrinological unit.
Participants included 210 young female subjects with restrictive-type AN and 42 female controls of comparable age.
The following hormonal parameters were measured: thyroid hormones, GH, IGF-I, cortisol, oestradiol, FSH, LH, SHBG, dehydroepiandrosterone sulfate, plasma metanephrines, and bone markers. Their relation with registered short-term evolution of AN subjects after hormonal assessment was evaluated.
Except for metanephrines and dehydroepiandrosterone sulfate, most of the hormonal abnormalities previously reported in AN were confirmed. The manifestation of these hormonal abnormalities started below different body mass index (BMI) levels, ranging between 17 and 15 kg/m(2), even though an important percentage of normal values for every parameter was still noticed for very low BMIs. All patients who developed critical states during the 3 months after the hormonal assessment presented with BMI less than 15 kg/m(2) and a very increased level of cortisol, GH, and increased values of metanephrines.
The hormonal response to undernutrition is heterogeneous in a large population with restrictive AN. In clinical practice, metanephrines, GH, and/or cortisol data could be used as important predictors for severe short-term outcome.
The objectives of the study were to examine the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), anorexia athletica (AA), and eating disorders not otherwise specified (ED-NOS) in both male and female Norwegian elite athletes and a representative sample from the general Norwegian population.
A 2-step study including self-reported questionnaire and clinical interview.
The entire population of Norwegian male and female elite athletes (n=1620) and controls (n=1696) was evaluated for the presence of eating disorders (EDs).
Based on the results of the questionnaire, all athletes and controls classified as at risk for EDs, and a representative sample of athletes and controls classified as healthy participated in the clinical part of the study to determine the number of subjects meeting the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for EDs.
More athletes (13.5%) than controls (4.6%; P<0.001) had subclinical or clinical EDs. The prevalence of EDs among male athletes was greater in antigravitation sports (22%) than in ball game (5%) and endurance sports (9%; P<0.05). The prevalence of EDs among female athletes competing in aesthetic sports (42%) was higher than that observed in endurance (24%), technical (17%), and ball game sports (16%).
The prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports. A collaborative effort among coaches, athletic trainers, parents, physicians, and athletes is optimal for recognizing, preventing, and treating EDs in athletes.
Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.
Eating disorders (ED), disordered eating (DE) and low energy availability (LEA) can be detrimental to health and performance. Previous studies have independently investigated the prevalence of ED, DE or LEA; however, limited studies have combined methods identifying risk within female runners. The aim of this study was to identify the prevalence of ED, DE and LEA in United Kingdom-based female runners and associations between age, competition level and running distance. The Female Athlete Screening Tool (FAST) and Low Energy Availability in Females Questionnaire (LEAF-Q) were used in a cross-sectional study design. A total of n = 524 responses eligible for analysis were received. A total of n = 248 (47.3%), n = 209 (40%) and n = 49 (9.4%) athletes were at risk of LEA, DE and ED, respectively. LEAF-Q scores differed based upon age (Age: H(3) = 23.998, p ≤ .05) and competitive level (Comp: H(1) = 7.682, p ≤ .05) whereas FAST scores differed based on age (Age: F(3,523) = 4.753, p ≤ .05). Tukey’s post-hoc tests showed significantly higher FAST scores in 18–24 years compared to all other age categories (p ≤ .05). Stepwise multiple regression demonstrated age and competitive level modestly predicted LEAF-Q scores (R²adj = 0.047, F(2,523) = 13.993, p ≤ .05, VIF = 1.0) whereas age modestly predicted FAST scores (R²adj = 0.022, F(1,523) = 12.711, p ≤ .05, VIF = 1.0). These findings suggest early identification, suitable screening methods and educational intervention programmes should be aimed at all levels of female endurance runners.
• Highlights
• A total of 524 female endurance completed a self-administered, online questionnaire screening for low energy availability, disordered eating and eating disorders risk.
• Age and competitive level modestly predicted low energy availability and age modestly predicted disordered eating and eating disorders in female endurance runners.
• A higher percentage of 18- to 24-year-old female endurance runners were at greater risk of low energy availability, disordered eating and eating disorders compared to other age categories.
• These findings highlight the need for regular screening in order to aid early interventions to prevent potential decrements in performance and health as endurance runners mature.
Objectives
Athlete health, training continuity and performance can be impeded as a result of Relative Energy Deficiency in Sport (RED-S). Here we report the point prevalence of symptoms described by the RED-S model in a mixed-sport cohort of Australian female athletes.
Methods
Elite and pre-elite female athletes (n=112) from eight sports completed validated questionnaires and underwent clinical assessment to assess the point prevalence of RED-S symptoms. Questionnaires included the Depression, Anxiety and Stress Questionnaire (DASS-21), Generalized Anxiety Disorder (GAD-7), Center for Epidemiological Studies Depression Scale (CES-D), SCOFF questionnaire for disordered eating, Low Energy Availability in Females Questionnaire (LEAF-Q), and a custom questionnaire on injury and illness. Clinical assessment comprised resting metabolic rate (RMR) assessment, dual-energy X-ray absorptiometry-derived body composition and bone mineral density, venous and capillary blood samples, and the Mini International Neuropsychiatric Interview (MINI 7.0.2). Descriptive prevalence statistics are presented.
Results
Almost all (80%) participants (age 19 (range 15–32) years; mass 69.5±10.3 kg; body fat 23.1%±5.0%) demonstrated at least one symptom consistent with RED-S, with 37% exhibiting between two and three symptoms. One participant demonstrated five symptoms. Impaired function of the immunological (28%, n = 27), haematological (31%, n = 33) and gastrointestinal (47%, n = 51) systems were most prevalent. A moderate to high (11%–55%) prevalence of risk of low energy availability was identified via RMR and LEAF-Q, and identified mental illnesses were prevalent in one-third of the assessed cohort.
Conclusion
Symptoms described by the RED-S model were prevalent in this cohort, supporting the need for improved awareness, monitoring and management of these symptoms in this population.
Energy deficiency in exercising women can lead to physiological consequences. No gold standard exists to accurately estimate energy deficiency, but measured-to-predicted resting metabolic rate (RMR) ratio has been used to categorize women as energy deficient. The purpose of the study was to (a) evaluate the accuracy of RMR prediction methods, (b) determine the relationships with physiological consequences of energy deficiency, and (c) evaluate ratio thresholds in a cross-sectional comparison of ovulatory, amenorrheic, or subclinical menstrual disturbances in exercising women ( n = 217). Dual-energy X-ray absorptiometry (DXA) and indirect calorimetry provided data on anthropometrics and energy expenditure. Harris–Benedict, DXA, and Cunningham (1980 and 1991) equations were used to estimate RMR and RMR ratio. Group differences were assessed (analysis of variance and Kruskal–Wallis tests); logistic regression and Spearman correlations related ratios with consequences of energy deficiency (i.e., low total triiodothyronine; TT 3 ). Sensitivity and specificity calculations evaluated ratio thresholds. Amenorrheic women had lower RMR ( p < .05), DXA ratio ( p < .01), Cunningham 1980 ( p < .05) and Cunningham 1991 ( p < .05) ratio, and TT 3 ( p < .01) compared with the ovulatory group. Each prediction equation overestimated measured RMR ( p < .001), but predicted ( p < .001) and positively correlated with TT 3 ( r = .329–.453). A 0.90 ratio threshold yielded highest sensitivity for Cunningham 1980 (0.90) and Harris–Benedict (0.87) methods, but a higher ratio threshold was best for DXA (0.94) and Cunningham 1991 (0.92) methods to yield a sensitivity of 0.80. In conclusion, each ratio predicted and correlated with TT 3 , supporting the use of RMR ratio as an alternative assessment of energetic status in exercising women. However, a 0.90 ratio cutoff is not universal across RMR estimation methods.
The impact of chronic high volume athletic training on thyroid hormone economy has not been defined. We investigated the status of the hypothalamic-pituitary-thyroid axis (H-P-T) in women athletes with regular menstrual cycles (CA) and with amenorrhea (AA). Their data were compared with each other and with those derived from cyclic sedentary women (CS) matched for a variety of confounding factors including the intensity of exercise, caloric intake, and body weight. Alterations of the H-P-T axis were observed in women athletes compared to CS. While serum levels of T4, T3, free T4, free T3 and rT3 were substantially reduced (P less than 0.01) in AA, only serum T4 levels were significantly decreased in CA. Further, remarkable differences were found between CA and AA in that serum levels of free T4 (P less than 0.01), free T3 (P less than 0.01), and rT3 (P less than 0.05) were significantly lower in AA than in CA. Thyroid binding globulin and sex-hormone binding globulin concentrations were within their norma...
Abstract The prevalence of disordered eating and eating disorders vary from 0-19% in male athletes and 6-45% in female athletes. The objective of this paper is to present an overview of eating disorders in adolescent and adult athletes including: (1) prevalence data; (2) suggested sport- and gender-specific risk factors and (3) importance of early detection, management and prevention of eating disorders. Additionally, this paper presents suggestions for future research which includes: (1) the need for knowledge regarding possible gender-specific risk factors and sport- and gender-specific prevention programmes for eating disorders in sports; (2) suggestions for long-term follow-up for female and male athletes with eating disorders and (3) exploration of a possible male athlete triad.
Purpose:
The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established.The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures.
Methods:
A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included.
Results:
Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 ± 3.5 yr, body mass index = 20.8 ± 2.6 kg·m; mean ± SD). A relatively small percentage of athletes (0%-15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%-57.8% vs 5.4%-13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes.
Conclusions:
Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem.
A multiple regression analysis of several factors influencing basal metabolic rate (BMR) was performed using data for 223 subjects from the classic metabolism studies published by Harris and Benedict in 1919. These data had previously been analyzed by Kleiber using metabolic body size, the three-fourths power of body mass, as a predictor of BMR. His prediction equations were separated by sex and each contained components for age and height. Factors in the present analysis included sex, age, height, body mass, and estimated lean body mass (LBM). Lean body mass was found to be the single predictor of BMR. A best estimate prediction equation: BMR(cal/day) = 500 + 22 (LBM) is proposed. The previously presumed influences of sex and age are shown to add little to this estimation.
This article examines the relationship between the female athlete triad of disordered eating, amenorrhea, and osteoporosis, disorders that may lead to significant morbidity, and even to a high rate of mortality.
To investigate the relationship between energy availability (dietary energy intake minus energy expended during exercise) and thyroid metabolism, we studied 27 untrained, regularly menstruating women who performed approximately 30 kcal.kg lean body mass (LBM)-1.day-1 of supervised ergometer exercise at 70% of aerobic capacity for 4 days in the early follicular phase. A clinical dietary product was used to set energy availability in four groups (10.8, 19.0, 25.0, 40.4 kcal.kg LBM-1.day-1). For 9 days beginning 3 days before treatments, blood was sampled once daily at 8 A.M. Initially, thyroxine (T4) and free T4 (fT4), 3,5,3'-triiodothyronine (T3) and free T3 (fT3), and reverse T3 (rT3) were in the normal range for all subjects. Repeated-measures one-way analysis of variance followed by one-sided, two-sample post hoc Fischer's least significant difference tests of changes by treatment day 4 revealed that reductions in T3 (16%, P < 0.00001) and fT3 (9%, P < 0.01) occurred abruptly between 19.0 and 25.0 kcal.kg LBM-1.day-1 and that increases in fT4 (11%, P < 0.05) and rT3 (22%, P < 0.01) occurred abruptly between 10.8 and 19.0 kcal.kg LBM-1.day-1. Changes in T4 could not be distinguished. If energy deficiency suppresses reproductive as well as thyroid function, athletic amenorrhea might be prevented or reversed by increasing energy availability through dietary reform to 25 kcal.kg LBM-1.day-1, without moderating the exercise regimen.
We tested two hypotheses about the disruption of luteinizing hormone (LH) pulsatility in exercising women by assaying LH in blood samples drawn at 10-min intervals over 24 h from nine young, habitually sedentary, regularly menstruating women on days 8, 9, or 10 of two menstrual cycles after 4 days of intense exercise [E = 30 kcal.kg lean body mass (LBM)-1.day-1 at 70% of aerobic capacity]. To test the hypothesis that LH pulsatility is disrupted by low energy availability, we controlled the subjects' dietary energy intakes (I) to set their energy availabilities (A = I - E) at 45 and 10 kcal.kg LBM-1.day-1 during the two trials. To test the hypothesis that LH pulsatility is disrupted by the stress of exercise, we compared the resulting LH pulsatilities to those previously reported in women with similar controlled energy availability who had not exercised. In the exercising women, low energy availability reduced LH pulse frequency by 10% (P < 0.01) during the waking hours and increased LH pulse amplitude by 36% (P = 0.05) during waking and sleeping hours, but this reduction in LH pulse frequency was blunted by 60% (P = 0.03) compared with that in the previously studied nonexercising women whose low energy availability was caused by dietary restriction. The stress of exercise neither reduced LH pulse frequency nor increased LH pulse amplitude (all P > 0.4). During exercise, the proportion of energy derived from carbohydrate oxidation was reduced from 73% while A = 45 kcal.kg LBM-1.day-1 to 49% while A = 10 kcal.kg LBM-1.day-1 (P < 0.0001). These results contradict the hypothesis that LH pulsatility is disrupted by exercise stress and suggest that LH pulsatility in women depends on energy availability.
Several factors may alter apparent resting metabolic rate (RMR) during measurement with indirect calorimetry. Likewise, numerous indirect calorimetry measurement protocols have been developed over the years, and the methodology employed could influence test results. As part of a larger project to determine the role of indirect calorimetry in clinical practice, a systematic review of the literature was undertaken to determine the ideal subject condition and test methodology for obtaining reliable measurement of RMR with indirect calorimetry. Food, ethanol, caffeine, and nicotine affect RMR for a variable number of hours after consumption; therefore, intake of these items must be controlled before measurement. Activities of daily living increase metabolic rate, but a short rest (< or =20 minutes) before testing is sufficient for the effect to dissipate. Moderate or vigorous physical activity has a longer carryover effect and therefore must be controlled in the hours before a measurement of RMR is attempted. Limited data were found regarding ideal ambient conditions for RMR testing. Measurement duration of 10 minutes with the first 5 minutes deleted and the remaining 5 minutes having a coefficient of variation <10% gave accurate readings of RMR. Individuals preparing for RMR measurement via indirect calorimetry should refrain from eating, consuming ethanol and nicotine, smoking, and engaging in physical activity for varying times before measurement. The test site should be physically comfortable and the individual should have 10 to 20 minutes to rest before measurement commences. A 10-minute test duration with the first 5 minutes discarded and the remaining 5 minutes having a coefficient of variation of <10% will give an accurate measure of RMR.
The purposes of this study were to examine the percentage of female elite athletes and controls with disordered eating (DE) behavior and clinical eating disorders (EDs), to investigate what characterize the athletes with EDs, and to evaluate whether a proposed method of screening for EDs in elite athletes does not falsely classify sport-specific behaviors as indicators of EDs. All athletes representing the national teams at the junior or senior level, aged 13-39 years (n=938), and age-group matched, randomly selected population-based controls (n=900) were invited to participate. From the screening data, a random sample of athletes (n=186) and controls (n=145) were subjects for a clinical interview. More athletes in leanness sports (46.7%) had clinical EDs than athletes in non-leanness sports (19.8%) and controls (21.4%) (P<0.001). Variables predicting clinical EDs, and thus candidates for valid screening procedures, were menstrual dysfunction in leanness athletes, self-reported EDs in non-leanness athletes, and self-reported use of pathogenic weight control methods in controls. Hence, statistically based risk factors are not universally valid, but specifically related to athletes and non-athletes, respectively.
Acknowledging that total body water (TBW) turnover is complex, and that no measurement is valid for all situations, this review evaluates 13 hydration assessment techniques. Although validated laboratory methods exist for TBW and extracellular volume, no evidence incontrovertibly demonstrates that any concentration measurement, including plasma osmolality (P(osm)), accurately represents TBW gain and loss during daily activities. Further, one blood or urine sample cannot validly represent fluctuating TBW and fluid compartments. Future research should (a) evaluate novel techniques that assess hydration in real time and are precise, accurate, reliable, non-invasive, portable, inexpensive, safe, and simple; and (b) clarify the relationship between P(osm) and TBW oscillations in various scenarios.
Binge eating: Nature, assessment, and treatment
- C G Fairburn
- Z Cooper
Fairburn CG, Cooper Z. The eating disorder examination. In: Fairburn, CG and Wilson, GT,
Eds, Binge eating: Nature, assessment, and treatment. New York: Guilford Press; 1993. p.
[Internet]. Fifth Edition. American Psychiatric Association; 2013 [cited 2024 Nov 13].
American College of Sports Medicine position stand. The female athlete triad
- A Nattiv
- A B Loucks
- M M Manore
Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position
stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867-82.