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Cited by 84Eating Disorders and BehaviorsSports Performance and TrainingLower Extremity Biomechanics and Pathologies

Low energy availability in female athletes: from the lab to the field

Heikura, Ida A., Stellingwerff, Trent, Areta, Jose L.·2022·European Journal of Sport Science
DOI 10.1080/17461391.2021.1915391
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Abstract

Decades of laboratory research have shown impairments to several body systems after only 4–5 days of strictly controlled consistent low energy availability (LEA); where energy availability (EA) = Energy Intake (EI) − Exercise Energy Expenditure (EEE)/Fat‐Free Mass. Meanwhile, cross‐sectional reports exist on the interrelatedness of LEA, menstrual dysfunction and impaired bone health in females (the Female Athlete Triad). These findings have demonstrated that LEA is the key underpinning factor behind a broader set of health and performance outcomes, recently termed as Relative Energy Deficiency in Sport (RED‐S). There is utmost importance of early screening and diagnosis of RED‐S to avoid the development of severe negative health and performance outcomes. However, a significant gap exists between short‐term laboratory studies and cross‐sectional reports, or clinically field‐based situations, of long‐term/chronic LEA and no definitive, validated diagnostic tests for RED‐S exist. This review aims to highlight methodological challenges related to the assessment of the components of EA equation in the field (e.g. challenges with EI and EEE measures). Due to the uncertainty of these parameters, we propose the use of more chronic “objective” markers of LEA (i.e. blood markers). However, we note that direct extrapolations of laboratory‐based outcomes into the field are likely to be problematic due to potentially poor ecological validity and the extreme variability in most athlete's daily EI and EEE. Therefore, we provide a critical appraisal of the scientific literature, highlighting research gaps, and a potential set of leading objective RED‐S markers while working in the field. Highlights: Direct application of short‐term laboratory‐based findings in the field is problematic. Calculation of energy availability (EA) in the field is methodologically challenging and prone to errors. The use of several biomarkers may allow the detection of early exposure to low EA in the female athlete.

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  • In the real world, athletes experience exposure to LEA (purposefully or inadvertently) in various manners along the continuum from adaptable to problematic.

    “In the real world, athletes experience exposure to LEA (purposefully or inadvertently) in various manners along the continuum from adaptable to problematic.”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [40]

    The Figure 2 legend describes several ways athletes may experience LEA in real-world settings, and the Introduction describes a continuum from health to disease. Our copy does not say whether exposure is purposeful or inadvertent, or specifically describe an adaptable-to-problematic continuum. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Emerging definitions highlight short-term LEA as a few days to weeks, medium-term as weeks to months and long-term as months to years.

    “Emerging definitions highlight short-term LEA as a few days to weeks, mediumterm as weeks to months and long-term as months to years.37 40”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [40]

    The Introduction defines medium-term LEA as weeks to under three months and long-term LEA as more than three months to years, matching the claim broadly. It defines short-term LEA as less than seven days, however, so the claim's 'few days to weeks' extends that category beyond the paper's definition. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Endocrine changes due to low energy availability include triiodothyronine alterations and decreases in leptin, which affect the metabolism and systemic availability of carbohydrate.

    “Endocrine changes due to LEA include triiodothyronine (T3) alterations and decreases in leptin, which affect the metabolism and systemic availability of CHO [44].”

    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 [44]

    Section 3.1 reports that low energy availability reduces leptin and downregulates T3. Section 4.2 says reduced carbohydrate availability can affect leptin and T3, which in turn affect resting metabolic rate. It does not say these hormonal changes affect the systemic availability of carbohydrate; the carbohydrate relationship it describes runs in the other direction. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Protocols to undertake EA assessments or EA-based diet prescription will continue to be challenged by the errors associated with accurately measuring EI, EEE and other contributing components (eg, FFM, resting metabolic rate (RMR)).

    “Also, protocols to undertake EA assessments or EA-based diet prescription will continue to be challenged by the errors associated with accurately measuring EI, EEE and other contributing components (eg, FFM, resting metabolic rate (RMR)), 40 49 129”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [40]

  • Low energy availability, mediated by reduced carbohydrate availability, affects leptin and triiodothyronine concentrations, which can suppress resting metabolic rate.

    “LEA, mediated by reduced CHO availability, affects leptin and triiodothyronine (T3) concentrations, which, in turn, can suppress the resting metabolic rate (RMR) [44].”

    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 [44]

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Authors
Heikura, I. A., Stellingwerff, T., & Areta, J. L.
Affiliations
  • University of Victoria (CA)
  • Research Institute for Sport and Exercise Sciences Liverpool John Moores University Liverpool UK
Corresponding author
Heikura, Ida A.
ORCID
Venue
European Journal of Sport Science
Publisher
Wiley
Published
2021-05-03
Volume
22
Issue
5
Pages
709-719
ISSN
  • 1536-7290 (ISSN-L)
  • 1746-1391
DOI
10.1080/17461391.2021.1915391
OpenAlex
W3150555068
Cited by
84
References
66
Citations by year
2026: 17 · 2025: 13 · 2024: 20 · 2023: 22 · 2022: 8 · 2021: 4
FWCI
9.21
Type
journal article
Language
en
Open access
closed
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • European Journal of Sport Science (publishedVersion)
  • PubMed (publishedVersion)
  • Liverpool John Moores University (acceptedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
  • Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
Keywords
low energy availability, relative energy deficiency in sport, female athletes, energy intake, exercise energy expenditure, menstrual disorders, bone health, female athlete triad, biomarkers, ecological validity
MeSH terms
Relative Energy Deficiency in Sport, Energy Intake, Cross-Sectional Studies, Energy Metabolism, Female, Humans, Female Athlete Triad Syndrome, Athletes

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