Recommendations and Nutritional Considerations for Female Athletes: Health and Performance
Open accessAbstract
Optimal nutrition is an important aspect of an athlete’s preparation to achieve optimal health and performance. While general concepts about micro- and macronutrients and timing of food and fluids are addressed in sports science, rarely are the specific effects of women’s physiology on energy and fluid needs highly considered in research or clinical practice. Women differ from men not only in size, but in body composition and hormonal milieu, and also differ from one another. Their monthly hormonal cycles, with fluctuations in estrogen and progesterone, have varying effects on metabolism and fluid retention. Such cycles can change from month to month, can be suppressed with exogenous hormones, and may even be manipulated to capitalize on ideal timing for performance. But before such physiology can be manipulated, its relationship with nutrition and performance must be understood. This review will address general concepts regarding substrate metabolism in women versus men, common menstrual patterns of female athletes, nutrient and hydration needs during different phases of the menstrual cycle, and health and performance issues related to menstrual cycle disruption. We will discuss up-to-date recommendations for fueling female athletes, describe areas that require further exploration, and address methodological considerations to inform future work in this important area.
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To determine energy availability, the calculation requires accurately measured fat-free mass, energy intake, and exercise energy expenditure of the athlete, in which errors of validity and reliability will undoubtedly occur.
“To determine the EA, the calculation requires accurately measured FFM, EI and exercise EE of the athlete, in which errors of validity and reliability will undoubtedly occur [150].”
From International society of sports nutrition position stand: nutritional concerns of the female athlete (2023) · cites this paper as [150]
The RED-S section (page not available in our copy) defines energy availability using energy intake, exercise energy expenditure, and fat-free mass, and says quantification outside the lab can be difficult. It does not say that validity and reliability errors will undoubtedly occur. (LLM, conf=0.86)
Experimental — accuracy not yet measuredEstablished energy availability thresholds may not be appropriate for reducing the risk of LEA in aging women due to changing estrogen and progesterone ratios in perimenopause, their absence in menopause, and known biological effects on resting metabolic rate and body composition.
“Established EA thresholds may not be appropriate for reducing the risk of LEA in aging women due to the changing ratios of estrogen and progesterone in perimenopause, the subsequent absence of estrogen and progesterone in menopause and the known biological impact on resting metabolic rate and body composition [150].”
From International society of sports nutrition position stand: nutritional concerns of the female athlete (2023) · cites this paper as [150]
The RED-S section says that no universal binary energy-availability threshold probably exists, supporting caution about established thresholds. The Health Consequences section also links low energy availability with reduced resting metabolic rate. Neither passage addresses whether thresholds are appropriate specifically for aging women or attributes that concern to hormonal changes in perimenopause and menopause and their effects on body composition. (LLM, conf=0.85)
Experimental — accuracy not yet measuredReduced muscle glycogen causes muscular fatigue and a drop in intensity below 60% VO2max.
“Reduced CHO availability is disadvantageous to exercise performance due to the following pathways: (1) reduced muscle glycogen causes muscular fatigue and a drop in intensity (<60% VO2max), and (2) reduced circulating CHO (e.g., blood glucose) for central neural nourishment impairs cognition [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
The Carbohydrate subsection of Nutritional Strategies for Endurance Athletes says reduced muscle glycogen leads to fatigue and a drop in intensity. It does not specify that intensity drops below 60% VO2max; its nearby VO2max figure concerns a different point about gluconeogenesis. (LLM, conf=0.88)
Experimental — accuracy not yet measuredWomen's lower CHO oxidation can significantly limit performance in exercise lasting <90 min.
“This is important to consider as it can significantly limit performance in exercise lasting < 90 min in duration [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
The Nutritional Strategies for Endurance Athletes section says women oxidize less carbohydrate than men at the same relative exercise intensity and that metabolic clearance can significantly limit exercise lasting under 90 minutes. It does not say that women’s lower carbohydrate oxidation is itself the limiting factor; it instead says fully replenished glycogen stores are sufficient to maximize performance in such events. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe current acute recommendation for carbohydrate intake for 4-6 h following a glycogen-depleting exercise session is at least 1.2 g carbohydrate/kg body weight/h.
“the current acute recommendation for CHO intake for 4–6 h following a glycogen-depleting exercise session is ≥1.2 g CHO/kg BW/h [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Because glucose metabolized from muscle glycogen cannot enter systemic circulation, carbohydrate availability in the muscles can be adequate while carbohydrate availability systemically is low.
“Since glucose metabolized from muscle glycogen cannot enter systemic circulation, CHO availability in the muscles can be adequate while CHO availability systemically is low [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
As estrogen is associated with decreased gluconeogenesis, reduced exogenous carbohydrate intake can compound unfavorable rates of gluconeogenesis.
“As estrogen is associated with decreased gluconeogenesis, reduced exogenous CHO intake can compound these unfavorable rates of gluconeogenesis [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
There is a bi-directional association between iron deficiency and low energy availability (LEA).
“There is a bi-directional association between iron deficiency and LEA.”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Energy-deficient athletes are at risk for iron deficiency due to decreased dietary intake, impaired absorption, and foot strike hemolysis.
“Energy-deficient athletes are at risk for iron deficiency due to decreased dietary intake, impaired absorption, and foot strike hemolysis [5,54].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Reduced CHO availability is disadvantageous to exercise performance.
“Reduced CHO availability is disadvantageous to exercise performance due to the following pathways: (1) reduced muscle glycogen causes muscular fatigue and a drop in intensity (<60% VO2max), and (2) reduced circulating CHO (e.g., blood glucose) for central neural nourishment impairs cognition [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Women oxidize less CHO and more fat at the same relative intensities of exercise compared to men.
“Women oxidize less CHO and more fat at the same relative intensities of exercise compared to men [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Consuming a high CHO snack 3-4 h before exercise can help mitigate the effects of reduced gluconeogenesis rates during the luteal phase and help protect against associated performance decrements.
“Despite no current recommendations for CHO intake before activity specific to female athletes, it is suggested that consuming a high CHO snack (e.g., granola bar, dried fruit, pretzels, and/or fruit juice) 3–4 h before exercise can help mitigate the effects of reduced gluconeogenesis rates during the luteal phase and help protect against associated performance decrements [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Iron deficiency from decreased dietary intake can promote energy deficiency by shifting ATP production away from oxidative phosphorylation.
“Additionally, iron deficiency from decreased dietary intake can also promote energy deficiency by shifting ATP production away from oxidative phosphorylation [5,54].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Gluconeogenesis rates are higher in the follicular phase compared to the luteal phase of the menstrual cycle at exercise intensities >50% of VO2max.
“Gluconeogenesis rates are higher in the follicular phase, compared to the luteal phase of the menstrual cycle, at exercise intensities > 50% of VO2max [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
Reduced circulating CHO (e.g., blood glucose) for central neural nourishment impairs cognition.
“Reduced CHO availability is disadvantageous to exercise performance due to the following pathways: (1) reduced muscle glycogen causes muscular fatigue and a drop in intensity (<60% VO2max), and (2) reduced circulating CHO (e.g., blood glucose) for central neural nourishment impairs cognition [5].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
The current recommended amount of carbohydrate for athletes is 55-75% of total calories.
“The current recommended amount of CHO for athletes is 55–75% of total calories [5,43].”
From Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review (2023) · cites this paper as [5]
The Carbohydrate subsection of Nutritional Strategies for Endurance Athletes gives intake recommendations in grams per kilogram and grams per hour, not as a percentage of total calories. Searches for 55–75% and carbohydrate recommendations expressed as a percentage of calories found no passage establishing the claimed range. (LLM, conf=0.74)
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- Authors
- Holtzman, B., & Ackerman, K. E.
- Affiliations
- Boston Children's Hospital (US)
- Corresponding author
- Ackerman, Kathryn E.
- Venue
- Sports Medicine
- Published
- 2021-09
- Volume
- 51
- Issue
- S1
- Pages
- 43-57
- ISSN
- 0112-1642 (ISSN-L)
- 1179-2035
- PMC
- PMC8566643
- OpenAlex
- W3201155639
- Cited by
- 111
- References
- 145
- Citations by year
- 2026: 20 · 2025: 31 · 2024: 35 · 2023: 15 · 2022: 9 · 2021: 1
- FWCI
- 3.20
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Sports Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- Gatorade Sports Science Institute
- Topics
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Muscle metabolism and nutrition
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
- Keywords
- female athletes, female athlete triad, menstrual cycle, menstrual cycle disruption, hydration, macronutrient requirements, estrogen and progesterone, body composition, menstrual suppression, sports nutrition, athletic performance
- MeSH terms
- Female, Humans, Menstrual Cycle, Sports, Exercise, Athletes, Sports Nutritional Physiological Phenomena
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