Contributing Factors to Low Energy Availability in Female Athletes: A Narrative Review of Energy Availability, Training Demands, Nutrition Barriers, Body Image, and Disordered Eating

Differences in perceived energy and macronutrient requirements across divisions in NCAA athletes

BACKGROUND

Sports nutrition is an impactful component to sports performance. The purpose of the current study was to investigate the sports nutrition knowledge of National Collegiate Athletic Association collegiate athletes and assess self-reported perceived requirements for energy and macronutrient intake. A secondary aim was to evaluate the awareness of physical and emotional perceptions associated with mindful eating.

METHODS

Participants included NCAA Division I (DI, n = 45), II (DII, n = 31), and III (DIII, n = 47) athletes. Athletes completed a validated questionnaire designed to assess sports nutrition knowledge and were asked questions about their perceived dietary energy and macronutrient requirements. Daily energy intake values were calculated using a recommended relative energy intake value of 40, 50, and 60 kcal/kg/day for low, moderate, and high activity levels, respectively. Carbohydrate recommendations were calculated using 4, 6, and 8 g/kg/day, protein recommendations were calculated using relative intakes of 1.4, 1.6, and 1.8 g/kg/day, and fat recommendations were calculated from a relative percentage of total predicted daily energy requirements, equating to 15, 25, and 30% of daily energy. Additionally, athletes completed a questionnaire to assess mindfulness regarding eating habits.

RESULTS

Overall, athletes answered 45.5 ± 13.5% of questions correctly on the nutrition questionnaire with significant differences observed between male (48.6 ± 13.6%) and female athletes (43.6 ± 13.2%; p = 0.044), as well as significant differences observed between DI athlete scores (38.8 ± 14.1%) and DII athletes (47.7 ± 11.4%; p = 0.002), and DI athletes and DIII athletes (51.71 ± 11.83%; p =  <0.001). All athletes significantly (p < 0.001) underestimated daily energy intake requirements (female, 2,112 ± 575 kcal/day; male, 3,283 ± 538 kcal/day). The mindfulness eating habits total score was significantly higher in male athletes (65.1 ± 6.5) compared to female athletes (60.9 ± 9.5; p = 0.009).

CONCLUSIONS

Division I, II, and III collegiate athletes have poor sports nutrition knowledge, with Division I athletes having exhibited lower scores compared to Division II and III athletes on the sports nutrition knowledge questionnaire. Athletes from all levels of collegiate sports underestimated their energy and macronutrient requirements. Differences in mindful eating habits among female and male athletes were also evident.

Differences in Knowledge of Female Athlete Triad and Relative Energy Deficiency in Sport in Female Cross-Country Athletes

BACKGROUND

The female athlete triad (Triad) and relative energy deficiency in sport (REDs) describe potential health and performance consequences of low energy availability.

OBJECTIVE

We surveyed female cross-country athletes to assess differences in educational impact scores (EIS; knowledge score × confidence score factor) of Triad and REDs. Associations between EIS and participant characteristics (eg, mileage [current and peak], years of running experience, age, bone stress injury history, division level participation, academic area of study, Triad or REDs diagnoses, and Triad or REDs education) were explored.

MAIN OUTCOME MEASURE(S)

An evidence-based online survey was developed and administered via Qualtrics to female collegiate cross-country athletes (n = 275; age = 20 ± 1 years).

RESULTS

A weak correlation existed between peak career mileage and EIS (r = 0.195; P = .010). Educational impact scores significantly differed in athletes with a related academic area of study versus those without (21.91 ± 5.16 and 16.11 ± 5.54, respectively). Educational impact scores significantly differed in athletes with Triad and REDs diagnoses (21.69 ± 5.85 and 22.58 ± 6.82, respectively) versus those without (16.80 ± 6.54 and 17.20 ± 6.34, respectively). Educational impact scores were higher in those who had received Triad education versus those who had not (21.03 ± 6.86 and 18.12 ± 6.82, respectively). A significant interaction between peak career mileage and Triad diagnosis was found (P = .005).

CONCLUSIONS

Significant education-based and diagnosis differences suggest that Triad diagnoses correlate with peak career mileage. These findings support the facilitation of education to improve not only the treatment but also the prevention of Triad and REDs.

A real-life snapshot: Evaluating exposures to low energy availability in male athletes from various sports

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.

Patterns of energy availability and carbohydrate intake differentiate between adaptable and problematic low energy availability in female athletes

Background

Problematic low energy availability (EA) is the underlying culprit of relative energy deficiency in sport (REDs), and its consequences have been suggested to be exacerbated when accompanied by low carbohydrate (CHO) intakes.

Objectives

This study compared dietary intake, nutrition status and occurrence of REDs symptoms in groups of female athletes, displaying different patterns of EA and CHO intake.

Methods

Female athletes (n = 41, median age 20.4 years) from various sports weighed and recorded their food intake and training for 7 consecutive days via a photo-assisted mobile application. Participants were divided into four groups based on patterns of EA and CHO intakes: sufficient to optimal EA and sufficient to optimal CHO intake (SEA + SCHO), SEA and low CHO intake (SEA + LCHO), low energy availability and SCHO (LEA + SCHO), and LEA and LCHO (LEA + LCHO). SEA patterns were characterised by EA ≥30 and LEA by EA <30 kcal/kg fat free mass, and SCHO patterns characterised by CHO intake ≥3.0 and LCHO <3.0 g/kg body weight for most of the registered days. Body composition was measured with dual energy x-ray absorptiometry, resting metabolic rate with indirect calorimetry and serum blood samples were collected for evaluation of nutrition status. Behavioural risk factors and self-reported symptoms of REDs were assessed with the Low Energy Availability in Females Questionnaire, Eating Disorder Examination Questionnaire Short (EDE-QS), Exercise Addiction Inventory, and Muscle Dysmorphic Disorder Inventory.

Results

In total, 36.6% were categorised as SEA + SCHO, of which 5/16 were ball sport, 7/10 endurance, 1/7 aesthetic, 2/5 weight-class, and 0/3 weight-class athletes. Of LEA + LCHO athletes (19.5% of all), 50% came from ball sports. Aesthetic and endurance athletes reported the greatest training demands, with weekly training hours higher for aesthetic compared to ball sports (13.1 ± 5.7 vs. 6.7 ± 3.4 h, p = 0.012). Two LEA + LCHO and one SEA + LCHO athlete exceeded the EDE-QS cutoff. LEA + LCHO evaluated their sleep and energy levels as worse, and both LEA groups rated their recovery as worse compared to SEA + SCHO.

Conclusion

Repeated exposures to LEA and LCHO are associated with a cluster of negative implications in female athletes. In terms of nutrition strategies, sufficient EA and CHO intakes appear to be pivotal in preventing REDs.

The "Young Athlete Body Project"-A pilot study evaluating the acceptability of and results from an eating disorder prevention program for adolescent athletes

BACKGROUND

The high frequency of eating disorders (EDs) in sports speaks of a need for early-stage preventive measures.

OBJECTIVES

This study evaluated the acceptability of an age, sex, and sports adapted version of the "Body Project" and changes in mental health symptoms.

METHODS

This noncontrolled pilot study included a class of athletes from 18 sports (N = 73, 13-14 years) at a sport-specialized junior high school in six small-group workshops. We interviewed 34 athletes on program acceptability, and all athletes responded to questionnaires at pretest, posttest, and 6-month follow-up including the Body Appreciation Scale 2-Children, Social Attitudes towards Appearance Questionnaire-4 revised, Eating Disorder Examination Questionnaire Short form-12 modified, and questions about body appearance pressure (BAP).

RESULTS

Athletes found the program acceptable and beneficial, but some missed physically oriented activities or did not identify with the focus, particularly boys. There were acceptable levels in mental health constructs before the workshops. There were temporary changes in the percentage of boys experiencing "BAP in society" by -14.8% points (95% CI: -.6 to .0, p = .04), % in total group experiencing "BAP at school" by +11% points (95% CI: .0-.2, p = .05), thinness idealization by girls (g = .6, p = .002) and total group (g = .4, p = .006), and muscularity idealization by boys (g = .3, p = .05) and total group (g = .23, p = .04).

DISCUSSION

Athletes experienced benefits from the Young Athlete Body Project. Seeing stabilization in outcomes may mean a dampening of the otherwise expected worsening in body appreciation and ED symptoms over time.

PUBLIC SIGNIFICANCE

Adolescent athletes are at risk for developing EDs. Due to lack of prevention programs for this group, we adapted and evaluated a well-documented effective program, the Body Project, to fit male and female athletes <15 years. The athletes accepted the program and experienced participation benefits, with stronger acceptance among girls. Our promising findings encourage larger scaled randomized controlled trials to further evaluate a refined version this program among very young athletes.

Best practice recommendations for body composition considerations in sport to reduce health and performance risks: a critical review, original survey and expert opinion by a subgroup of the IOC consensus on Relative Energy Deficiency in Sport (REDs)

BACKGROUND

The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating.

METHODS

We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey.

RESULTS

The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology.

CONCLUSIONS

The 'best practice' guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and REDs.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs

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.

Estimated Energy Expenditures and Energy Intakes of International Female Rugby Sevens Players in Five Days of a Training Camp and Competition Preparation

To understand the energy balance of international female rugby sevens (R7s) players in applied environments, this study estimated the energy intakes (EI) and total daily estimated energy expenditures (TDEE) during a five-day training camp (TRAIN) and phase of competition preparation (COMP) of equal duration. Tri-axial accelerometer devices were worn throughout both scenarios to estimate TDEE, whereas EI was estimated via self-reported food diaries. Energy deficits of -47% (TDEE_TRAIN: 14.6 ± 1.6 MJ·day^-1, EI_TRAIN: 7.7 ± 0.9 MJ·day^-1, p ≤ 0.001, d = 5.1) and -50% (TDEE_COMP: 15.5 ± 1.6 MJ·day^-1, EI_COMP: 7.7 ± 1.0 MJ·day^-1, p ≤ 0.001, d = 5.7) were observed throughout TRAIN (n = 11; age: 25 ± 4 years, height: 170 ± 6 cm, weight: 71 ± 7 kg) and COMP (n = 8; age: 25 ± 3 years, height: 172 ± 5 cm, weight: 72 ± 6 kg), respectively. Carbohydrate intakes were below the lower range of sports nutrition recommendations in both TRAIN (-62%; 2.3 ± 0.3 g·kg^-1 BM, p ≤ 0.001) and COMP (-60%; 2.4 ± 0.5 g·kg^-1 BM, p ≤ 0.001). For protein (TRAIN: 1.7 ± 0.4 g·kg^-1 BM, COMP: 1.5 ± 0.1 g·kg^-1 BM), intakes met the lower range of recommendations. Fat intake exceeded recommendations of the percentage of total EI (COMP: 39 ± 5%). Accordingly, the dietary strategies of international female R7s players may warrant optimization, as carbohydrate and fat intakes were less than optimal when compared to current performance-based sports nutrition guidelines.

Body Composition, Energy Availability, Risk of Eating Disorder, and Sport Nutrition Knowledge in Young Athletes

Young athletes may be at risk for low energy availability (LEA) or dietary habits that are indicative of eating disorders. Thus, the purpose of the current study was to investigate the prevalence of LEA among high school athletes and examine those at risk for eating disorders. A secondary aim was to examine relationships between sport nutrition knowledge, body composition, and LEA.

METHODS

94 male (n = 42) and female (n = 52) mean ± SD age: 18.09 ± 2.44 y; height: 172.6 ± 9.8 cm; body mass: 68.7 ± 14.5 kg; BMI: 22.91 ± 3.3 kg·m^-2) athletes completed a body composition assessment and electronic versions of the abridged sports nutrition knowledge questionnaire (ASNK-Q), brief eating disorder in athletes questionnaire (BEDA-Q), and the low energy availability for females questionnaire (LEAF-Q; females only).

RESULTS

52.1% of female athletes were classified as being at risk for LEA. Moderate inverse relationships existed for computed LEAF-Q scores and BMI (r = -0.394; p < 0.01). A total of 42.9% of males (n = 18) and 68.6% of females (n = 35) were at risk for eating disorders, with females being at greater risk (p < 0.01). Body fat percentage was a predictor (β = -0.095; p = -0.01) for eating disorder risk status. For every 1 unit increase in body fat percentage, athletes were 0.909 (95% CI: 0.845-0.977) times less likely to be classified as at risk for an eating disorder. Male (46.5 ± 13.9) and female (46.9 ± 11.4) athletes scored poorly on the ASNK-Q, with no differences between sex (p = 0.895).

CONCLUSIONS

Female athletes were at a greater risk for eating disorders. No relationships existed between sport nutrition knowledge and %BF. Female athletes with a higher %BF had a lower risk for an eating disorder and risk for LEA.

Eating Disorders and Disordered Eating in Competitive Cycling: A Scoping Review

This article reports on the findings from a scoping review on eating disorders and disordered eating in competitive cycling. The review was informed by a scoping review methodological framework as well as the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) reporting guidelines. PubMed, SPORTDiscus and Web of Science were used to identify relevant literature for review. Fourteen studies met the eligibility criteria and were included in the full review. A narrative synthesis was used to summarise the main findings and themes across the included literature. Findings from the review are presented under the following themes: cycling as an 'at-risk' discipline; power to weight ratio; energy requirements and risk of low energy availability; the social environment of cycling; nutrition support provision; relationship between eating disorders/disordered eating and exercise addiction; and recommendations made in identified literature. Overall, the literature suggests competitive cycling is a sport with a high prevalence of disordered eating and/or eating disorders and a sport with unique risk factors that contribute to this. Crucially, more research is needed in this area. The article concludes with the gaps in the literature highlighted, implications for future research, and applications to policy and practice suggested.