A high prevalence of low energy availability (LEA) has been reported in female football players. This is of concern as problematic LEA may evolve into a syndromic pattern known as relative energy deficiency in sport (REDs). Given the difficulties in accurately assessing LEA, our study shifts emphasis to measurable indicators of REDs, serving as proxies for health detriments caused by LEA. The present cross-sectional study aimed to quantify the risk of REDs and to assess the prevalence of indicators indicative of the syndrome. 60 players (tiers 3 and 4) from three Norwegian football teams were analyzed as a single cohort but also stratified based on player position and menstrual status. The proportion of players at risk for REDs was 22%, that is, 17% with mild, 3% with moderate to high, and 2% with very high/extreme risk, respectively. The majority of the cohort (71%) presented with no primary indicators, while 20%, 7%, and 2% presented with one, two, and three primary indicators, respectively. Regarding secondary indicators, 57% had none, 33% had one, and 10% had two indicators. For associated indicators, 30% had none, 42% had one, 18% had two, 8% had three, and 2% had four indicators. Player position did not affect the prevalence of REDs indicators. Among noncontraceptive users (n = 27), secondary amenorrhea (AME) was reported by 30%. These findings indicate that health and performance teams should prioritize universal health promoting strategies rather than selective or indicative strategies. Particularly, focus on nutritional periodization to secure sufficient energy availability, mitigating the risk of problematic LEA and REDs should be addressed.

Problematic low energy availability (LEA) is the underlying cause of relative energy deficiency in sport (REDs). Male specific etiology, as well as the duration and degree of LEA exposures resulting in REDs remain to be adequately described. The present study aimed to assess occurrences of LEA (energy availability [EA] <25 kcal/kg fat-free mass/day) in male athletes from various sports over 7 days. Associations between number of LEA days, physiological measures, and body image concerns were subsequently evaluated. The athletes recorded their weighed food intakes and training via photo-assisted mobile application. Body composition and resting metabolic rates were measured, and venous blood samples collected for assessments of hormonal and nutrition status. Participants also answered the Low Energy Availability in Males Questionnaire (LEAM-Q), Eating Disorder Examination-Questionnaire Short (EDE-QS), Exercise Addiction Inventory (EAI), and Muscle Dysmorphic Disorder Inventory (MDDI). Of 19 participants, 13 had 0-2, 6 had 3-5, and none had 6-7 LEA days. No associations were found between the number of LEA days with the physiological and body image outcomes, although those with greatest number of LEA days had highest EEE but relatively low dietary intakes. In conclusion, this group displayed considerable day-to-day EA fluctuations but no indication of problematic LEA.

UNASSIGNED: Low energy availability (LEA) causes pathophysiology of the female athlete\'s body affecting the bone and reproductive health and was observed to have a high prevalence in recreational female athletes previously. The aim of this study was to analyse the relationship between low energy availability in females questionnaire (LEAF-Q), bone mineral density (BMD), and postural stability in recreational athletes.
UNASSIGNED: Recreational female athletes (n = 24, age: 23.71 ± 2.94, Tier I) completed LEAF-Q, postural stability measurement during quiet stance (Zebris platform FDM; GmbH) and their BMD was measured using DXA (Hologic QDR Horizon A). Non-parametric statistical tests were used to analyse the relationships between LEAF-Q, BMD, and postural stability and to compare differences between participants divided by the LEAF-Q score and its subscales.
UNASSIGNED: Risk of LEA was observed in 50% of recreational athletes participating in this study. Up to 46% of participants perceived menstrual bleeding changes related to training and 37.50% experienced menstrual dysfunction. Body composition and body weight fluctuations were observed to affect postural stability and BMD. With the risk score for LEA, the BMD and postural stability were not negatively affected in recreational athletes. However, the high number of recreational athletes in the risk score for LEA and menstrual dysfunctions highlights the need for public health programs aimed to increase awareness of LEA and its health consequences and for open communication about the menstrual cycle. Future longitudinal studies observing LEA, BMD, menstrual function, postural stability, and their interrelationship in female athletes are needed to increase the knowledge of this topic.

UNASSIGNED: Low energy availability (LEA) is a state of inadequate energy reserves that results from a negative energy balance. This condition can lead to severe health risks such as amenorrhea and osteoporosis. Various causes for LEA, such as eating disorders and exercise addiction, have been reported in the literature. However, data in Saudi Arabia are lacking. This cross-sectional study measures the prevalence of LEA, eating disorders, and exercise addiction among adult females in Saudi Arabia and identifies possible associated risk factors.
UNASSIGNED: The sample comprised 119 female athletes who filled out an online survey adapted from the LEA in Females Questionnaire, the Eating Disorder Examination Questionnaire, and the Exercise Addiction Inventory.
UNASSIGNED: Participants showed a high prevalence of LEA (66.4%), eating disorder (33.6%), and exercise addiction (10.1%), confirming the association between normal weight and LEA in females living in Saudi Arabia (p < 0.00).
UNASSIGNED: With an increasing number of females in the country interested in following a healthy lifestyle, there is a need to raise the awareness of the population on the issues of LEA, eating disorders, and exercise addiction and their effects on the body by developing educational programs about energy intake and healthy physical activity routines.

Physique competitions are weight-sensitive sports in which stage presentation, aesthetic appearance and posing ability of the athletes are judged rather than physical performance. The aim of this study was to assess low energy availability among female physique athletes by using the LEAF-Q. The study involved 104 females who were physique athletes. Monthly cycle disorders were reported in 58.65% of the women, that is periods stopped for three consecutive months or longer (amenorrhea). This situation occurred before the research was conducted in 43.27% of athletes and during the research in 15.38%. The physique athletes claimed that menstruation changes occurred when there was an increased exercise intensity, frequency or duration. Absence from training due to injury was reported by 27.88% of the women. The LEAF-Q identified 46.15% of the physique athletes as at risk (score ≥ 8) of low energy availability and the physiological consequences related to RED-S. Women who had menstrual cycle disorders were younger and did more training per week. Among women with menstrual disorders, cramps or stomach ache which cannot be related to menstruation occurred more frequently (p = 0.004). Absence from training or lack of participation in competition due to injuries occurred more frequently in the score ≥ 8 group (p = 0.024) thank the ≤ score 8 group. In the score ≥ 8 group menstruation changes, that is less bleeding or cessation of menstruation (p = 0.035), occurred more frequently when there was an increase in exercise intensity, frequency or duration (p = 0.002).

BACKGROUND: Relative energy deficiency in sport (REDs) is a condition that is associated with negative health and performance outcomes in athletes. Insufficient energy intake relative to exercise energy expenditure, resulting in low energy availability, is the underlying cause, which triggers numerous adverse physiological consequences including several associated with musculoskeletal (MSK) health and neuromuscular performance.
OBJECTIVE: This commentary aims to (1) discuss the health and performance implications of REDs on the skeletal and neuromuscular systems and (2) examine the role that MSK training (ie, strength and plyometric training) during treatment and return to performance following REDs might have on health and performance in athletes, with practical guidelines provided.
CONCLUSIONS: REDs is associated with decreases in markers of bone health, lean body mass, maximal and explosive strength, and muscle work capacity. Restoration of optimal energy availability, mainly through an increase in energy intake, is the primary goal during the initial treatment of REDs with a return to performance managed by a multidisciplinary team of specialists. MSK training is an effective nonpharmacological component of treatment for REDs, which offers multiple long-term health and performance benefits, assuming the energy needs of athletes are met as part of their recovery. Supervised, prescribed, and gradually progressive MSK training should include a combination of resistance training and high-impact plyometric-based exercise to promote MSK adaptations, with an initial focus on achieving movement competency. Progressing MSK training exercises to higher intensities will have the greatest effects on bone health and strength performance in the long term.

OBJECTIVE: This study aimed to investigate the impact of short-term low energy availability (LEA) on vascular function in young, regularly menstruating women.
METHODS: Participants were 19 women, aged 22.9 ± 4.2 years, with body mass index 18-30 kg·m2. They were divided into two groups and completed two conditions in a crossover design: a 3-day control condition (CON) with an energy availability of 45 kcals·kgFFM-1·day-1 and a 3-day LEA condition of 15 kcals·kgFFM-1 day-1. Assessments were conducted during the early follicular phase of the menstrual cycle. Outcome measures included forearm blood flow (FBF), heart rate, blood pressure, arterial stiffness, resting energy expenditure (REE), metabolic blood markers and body composition.
RESULTS: Significant time-by-condition interactions were found for resting FBF (p = .004), REE (p = .042), triiodothyronine (p = .006), β-hydroxybutyrate (p = .002) and body mass (p < .001). Resting FBF was 1.43 ± 1.01 and 1.31 ± 0.61 (arbitrary units) at pre and post, respectively, in LEA and 1.52 ± 0.7 and 1.76 ± 0.57 at pre and post in CON. The LEA condition led to a decrease in triiodothyronine (pre: 1.54 ± 0.28, post: 1.29 ± 0.27 ng ml-1), REE (pre: 1588 ± 165, post: 1487 ± 160 kcals day-1) and body mass (pre: 61.4 ± 7.5, post: 59.6 ± 7.3 kg). Changes in resting FBF were significantly correlated with changes in REE in the LEA condition (r = 0.53; p = 0.02).
CONCLUSIONS: Short-term LEA modifies regional blood flow and this might contribute to the observed decreased in REE. Findings emphasize the need for careful management of energy availability in populations at risk of LEA.

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Energy imbalance exposes athletes to relative energy deficiency in sports (REDs) syndrome. Data on energy consumption, REDs, and bone mineral density (BMD) in adolescent acrobatic gymnasts, especially in males, are scarce. Our aim was to examine the eating habits, energy balance, body composition, and BMD of these athletes. In this study, 18 healthy adolescents participating in competitive acrobatic gymnastics completed a questionnaire, underwent a dual-energy X-ray absorptiometry scan (DXA), received a food log, and had their activities monitored for 3 days. Eighteen acrobats were enrolled (mean age: 14.3 ± 1.2 years; males: 6/18). The mean total body BMD Z-score was 0.4 ± 1.0. Top-position acrobats (7/18) had significantly lower total body BMD Z-scores than base-positioned acrobats (-0.2 ± 0.3 vs. 0.8 ± 0.3, p = 0.032), though their forearms were not significantly different (0.2 ± 0.5 vs. 0.8 ± 0.7, p = 0.331). No sex differences were found for BMD Z-scores, BMI, or energy availability. The BMD parameters of the acrobats were within the normal range for a healthy pediatric population, although three had low BMDs (<-1 SD) for healthy athletes. Total body and LS BMD Z-scores were significantly lower in top-position athletes compared to base-position athletes. These findings suggest personalized (top vs. base) training programs (high-impact training) that may achieve better health outcomes.

OBJECTIVE: This was a pilot study that examined the relationship between nutrition knowledge and risk for low energy availability (LEA) in NCAA athletes.
METHODS: Athletes (64.4 % female, 35.6 % male) completed the Abridged Nutrition for Sport Knowledge Questionnaire (A-NSKQ) and either the Low Energy Availability in Females Questionnaire (LEAF-Q) or Male Athlete Triad (MAT) screening questions.
RESULTS: Females at risk for LEA had higher nutrition knowledge, demonstrated by higher A-NSKQ scores, than those classified as low risk (16.5 vs 14.5, p = 0.01). There was a very weak correlation between MAT and A-NSKQ scores (R2 = 0.012).