Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes
Open accessAbstract
We aimed to (a) report energy availability (EA), metabolic/reproductive function, bone mineral density, and injury/illness rates in national/world-class female and male distance athletes and (b) investigate the robustness of various diagnostic criteria from the Female Athlete Triad (Triad), Low Energy Availability in Females Questionnaire, and relative energy deficiency in sport (RED-S) tools to identify risks associated with low EA. Athletes were distinguished according to benchmarks of reproductive function (amenorrheic [ n = 13] vs. eumenorrheic [ n = 22], low [lowest quartile of reference range; n = 10] versus normal testosterone [ n = 14]), and EA calculated from 7-day food and training diaries (< or >30 kcal·kg −1 fat-free mass·day −1 ). Sex hormones ( p < .001), triiodothyronine ( p < .05), and bone mineral density (females, p < .05) were significantly lower in amenorrheic (37%) and low testosterone (40%; 15.1 ± 3.0 nmol/L) athletes, and bone injuries were ∼4.5-fold more prevalent in amenorrheic (effect size = 0.85, large) and low testosterone (effect size = 0.52, moderate) groups compared with others. Categorization of females and males using Triad or RED-S tools revealed that higher risk groups had significantly lower triiodothyronine (female and male Triad and RED-S: p < .05) and higher number of all-time fractures (male Triad: p < .001; male RED-S and female Triad: p < .01) as well as nonsignificant but markedly (up to 10-fold) higher number of training days lost to bone injuries during the preceding year. Based on the cross-sectional analysis, current reproductive function (questionnaires/blood hormone concentrations) appears to provide a more objective and accurate marker of optimal energy for health than the more error-prone and time-consuming dietary and training estimation of EA. This study also offers novel findings that athlete health is associated with EA indices.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
During the mid-luteal phase, resting metabolic rates increase while energy intakes are commonly at their highest levels.
“Accordingly, resting metabolic rates increase, while energy intakes are commonly at their highest levels [59,120].”
From International society of sports nutrition position stand: nutritional concerns of the female athlete (2023) · cites this paper as [59]
Heikura et al. found male distance runners and race walkers had relative risk of all-time fractures 0.6 vs 0.7 vs 3.2 for low, moderate, and high-risk REDs groups, respectively; p = 0.021 low vs high, p = 0.039 moderate vs high.
“• Males (n = 24): Relative risk of 0.6 vs. 0.7 vs. 3.2 for low, moderate, and high-risk of REDs groups, respectively; p = 0.021 low vs. high, p = 0.039 moderate vs. high”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [74]
Heikura et al. found no significant difference in all-time fractures between low-, moderate-, and high-risk REDs groups in female distance runners and race walkers (n = 35).
“Heikura et al. [74] National and world-class distance runners and race walkers (n = 59) All-time fractures: • Females (n = 35): no significant difference between low-, moderate-, and high-risk of REDs groups”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [74]
In the real world, the magnitude of LCA is likely to be even greater considering the emphasis on protein intake during periods of calorie restriction.
“In the real world, the magnitude of LCA is likely to be even greater considering the emphasis on protein intake during periods of calorie restriction.”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [49]
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 [49]
Findings show significant individualised responses concerning the type, prevalence and severity of the impairments of various body systems associated with this exposure.
“findings also show significant individualised responses concerning the type, prevalence and severity of the impairments of various body systems associated with this exposure, 8 11 49 78 166 167”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [49]
Results have confirmed the aetiology of REDs is problematic LEA.
“While results have confirmed the aetiology of REDs is problematic LEA”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [49]
The citation lists haven’t been fetched yet
References 49 · Cited by 318
- Authors
- Heikura, I. A., Uusitalo, A. L. T., Stellingwerff, T., Bergland, D., Mero, A. A., & Burke, L. M.
- Affiliations
- Australian Catholic University (AU)
- University of Helsinki (FI)
- Canadian Sport Centre Pacific (CA)
- Hypo2 High Performance Sport Center
- University of Jyväskylä (FI)
- Venue
- International Journal of Sport Nutrition and Exercise Metabolism
- Publisher
- Human Kinetics
- Published
- 2018-07-01
- Volume
- 28
- Issue
- 4
- Pages
- 403-411
- ISSN
- 1526-484X (ISSN-L)
- 1543-2742
- OpenAlex
- W2776102598
- Cited by
- 318
- References
- 49
- Citations by year
- 2026: 37 · 2025: 32 · 2024: 40 · 2023: 46 · 2022: 35 · 2021: 57 · 2020: 41 · 2019: 21 · 2018: 8
- FWCI
- 23.74
- Type
- journal article
- Language
- en
- Open access
- green
- urn.fi
- Locations
- International Journal of Sport Nutrition and Exercise Metabolism (publishedVersion)
- PubMed (publishedVersion)
- Jyväskylä University Digital Archive (University of Jyväskylä) (submittedVersion)
- Research Bank (Australian Catholic University) (submittedVersion)
- Funders
- Australian Catholic University
- Australian Institute of Sport
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Bone health and osteoporosis research
- Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
- Keywords
- energy availability, low energy availability, long-distance runners, bone injuries, fracture, amenorrhea, androgen deficiency, bone mineral density, triiodothyronine, female athlete triad, relative energy deficiency in sport, metabolic function, reproductive function, training diary, diagnostic criteria
- MeSH terms
- Adult, Amenorrhea, Athletic Injuries, Bone and Bones, Energy Intake, Cross-Sectional Studies, Energy Metabolism, Female, Humans, Male, Nutritional Requirements, Surveys and Questionnaires, Testosterone, Triiodothyronine, Bone Density, Malnutrition, Female Athlete Triad Syndrome, Young Adult, Athletes, Sports Nutritional Physiological Phenomena
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
