Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport
Abstract
Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC. Objective: The purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes. Methods: One thousand female athletes (15–30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05). Results: Athletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance. Conclusion: These findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.
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Ackerman et al. found athletes with LEA had decreased coordination (OR 1.58, 95% CI 1.13-2.20, p = 0.007).
“decreased coordination (OR 1.58, 95% CI 1.13-2.20,p = 0.007)”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found athletes with LEA had decreased endurance performance (OR 1.47, 95% CI 1.08-2.02, p = 0.015).
“decreased endurance performance (OR 1.47, 95% CI 1.08-2.02,p = 0.015)”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found athletes with LEA had decreased training response (OR 2.13, 95% CI 1.53-2.97, p < 0.0005).
“They found that athletes with LEA had decreased training response (Odds Ratio (OR) 2.13, 95% CI 1.53-2.97,p < 0.0005)”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found female athletes with LEA were significantly more likely to have impaired bone health compared to peers with normal energy availability (OR 1.72, 95% CI 1.31-2.26, p < 0.0005).
“In Ackerman et al.'s study of 1,000 female athletes, those with LEA were significantly more likely to have impaired bone health compared to their peers with normal energy availability: OR 1.72, 95% CI 1.31-2.26,p < 0.0005 [44].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found no statistically significant difference in growth & development between athletes with low vs normal EA (OR 1.06, 95% CI 0.74-1.52, p = 0.75).
“Similarly, this study found no statistically significant difference in growth & development between athletes with low vs. normal EA: OR 1.06, 95% CI 0.74-1.52,p = 0.75 [44].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found athletes with LEA did not have a significantly increased risk of injury compared to those with normal EA (OR 1.12, 95% CI 0.87-1.45, p = 0.39).
“For example, Ackerman et al. found that athletes with LEA did not have a significantly increased risk of injury compared to those with normal EA in their study of 1,000 female athletes: OR 1.12, 95% CI 0.87-1.45,p = 0.39 [44].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found athletes with LEA had impaired judgment (OR 4.33, 95% CI 2.20-8.55, p < 0.0005).
“and impaired judgment (OR 4.33, 95% CI 2.20-8.55,p < 0.0005) [44].”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
Ackerman et al. found athletes with LEA had decreased concentration (OR 2.01, 95% CI 1.33-3.04, p = 0.001).
“decreased concentration (OR 2.01, 95% CI 1.33-3.04,p = 0.001)”
From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [44]
There is a wide range in the reported estimated prevalence of LEA/REDs indicators in female (23%-79.5%) and male (15%-70%) athletes across a variety of sports.
“There is a wide range in the reported estimated prevalence of LEA/REDs indicators in female (23%-79.5% [7][8][9][10][11][12][13][14][15][16] ) and male (15%-70% [12][13][14][15][16][17][18][19][20] ) athletes across a variety of sports”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [8]
Psychological indicators associated with problematic LEA and REDs are mood disturbances/fluctuations, cognitive dietary restraint, drive for thinness, reduced sleep quality and perfectionistic tendencies.
“Psychological indicators associated with problematic LEA and REDs are mood disturbances/fluctuations, 8 71 72 cognitive dietary restraint, 73 drive for thinness, 74 75 reduced sleep quality 50 76 and perfectionistic tendencies.77”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [8]
Depressive symptoms and affective disorders, subjectively reported reduced well-being, primary or secondary exercise dependence/addiction, anxiety related to injury and/or recovery, sport-specific issues such as difficulty coping with weight requirements and the development of EDs are additional adverse mental health outcomes associated with problematic LEA and REDs.
“Depressive symptoms and affective disorders, 8 78 79 subjectively reported reduced well-being, 73 primary or secondary exercise dependence/addiction, 80 81 anxiety related to injury and/or recovery, sport-specific issues such as difficulty coping with weight requirements 67 76 and the development of EDs 1 82 are additional adverse mental health outcomes associated with problematic LEA and REDs.”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [8]
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 [8]
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 [8]
Most of the research since the seminal REDs research has involved cross-sectional study designs investigating the prevalence of various LEA indicators.
“Although the seminal REDs research implemented randomised clinical trials with strict laboratory-controlled EA interventions in habitually sedentary females, 45 125 127 160 165 most of the research since has involved cross-sectional study designs investigating the prevalence of various LEA indicators (indirectly via questionnaires or directly via indicators).8 11 21 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 [8]
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- Authors
- Ackerman, K. E., Holtzman, B., Cooper, K. M., Flynn, E. F., Bruinvels, G., Tenforde, A. S., Popp, K. L., Simpkin, A. J., & Parziale, A. L.
- Affiliations
- Boston Children's Hospital (US)
- National University of Ireland (IE)
- Harvard University (US)
- Corresponding author
- Ackerman, Kathryn E
- ORCID
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2018-06-02
- Volume
- 53
- Issue
- 10
- Pages
- 628-633
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W2805766903
- Cited by
- 245
- References
- 6
- Citations by year
- 2026: 31 · 2025: 29 · 2024: 30 · 2023: 44 · 2022: 35 · 2021: 32 · 2020: 27 · 2019: 12 · 2018: 5
- FWCI
- 22.28
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- 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
- relative energy deficiency in sport, low energy availability, female athletes, female athlete triad, menstrual disorders, bone health, mental illness, cardiovascular dysfunction, gastrointestinal dysfunction, training response, endurance performance, self-report questionnaire
- MeSH terms
- Adolescent, Adult, Energy Intake, Cross-Sectional Studies, Energy Metabolism, Female, Humans, Menstruation Disturbances, Nutritional Status, Surveys and Questionnaires, Bone Density, Female Athlete Triad Syndrome, Athletic Performance, Young Adult, Athletes, Self Report, Sports Nutritional Physiological Phenomena
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