CoChat
Sign Up
Cited by 91Eating Disorders and BehaviorsNutrition, Health and Food BehaviorSports Performance and Training

Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes

Open access
Sim, Alexiaa, Burns, Stephen F.·2021·Journal of Eating Disorders
DOI 10.1186/s40337-021-00396-7PMC PMC8011161
Open this paper in CoChat — free accountOpen PDF

Abstract

Background: A sustained mismatch between energy intake and exercise energy expenditure (EEE) can lead to Low Energy Availability (LEA), health and performance impairments characteristic of Relative Energy Deficiency in Sport (RED-S). Questionnaires can conveniently identify symptoms and/or LEA/ RED-S risk factors. This study aimed to systematically identify, and critique questionnaires used or developed to measure LEA/ RED-S risk in athletic populations. Methods: A systematic search was conducted using PubMed database. Full text articles were included if: (i) the questionnaire(s) in the study identified LEA and/or RED-S risk; (ii) studies developed questionnaires to identify LEA and/or RED-S risk; (iii) participants belonged to athletic population(s); and (iv) in English. Results: Thirty-three articles met the inclusion criteria and were reviewed, 13 questionnaires were identified. Eight questionnaires had undergone validation procedures, and three questionnaires included questions related to EEE. The most widely used validated questionnaires were Low Energy Availability in Females Questionnaire (LEAF-Q) (48% articles) and Eating Disorder Examination Questionnaire (EDE-Q) (12% articles). The LEAF-Q determines LEA risk from symptoms but cannot be used in males as nearly half of the items ( n = 12) relate to menstrual function. The EDE-Q serves as a surrogate marker of LEA risk in both sexes, as it measures a major risk factor of LEA, disordered eating. Better validation is needed for many questionnaires and more are needed to address LEA/RED-S risk in male athletes. Conclusion: These questionnaires may be effective in identifying intentional energy restriction but less valuable in identifying inadvertently failure to increase energy intake with increased EEE.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1186/s40337-021-00396-7

Cites

3 of 3 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

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?

  • Those scoring ≥8 of 49 possible points on the LEAF-Q are determined to be at heightened risk of LEA, and high scores are very common among female endurance athletes.

    “Those scoring ≥ 8 of 49 possible points are determined to be at a heightened risk of LEA, and high scores are very common among female endurance athletes [26].”

    From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [26]

    The Results section on the LEAF-Q states that a score of ≥8 out of 49 indicates LEA risk in female endurance athletes. It reports 44.1% Triad risk among female ultra-marathon athletes assessed with the LEAF-Q and another tool, but does not establish that high LEAF-Q scores themselves are very common among female endurance athletes generally. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 63

  1. [1]Loucks AB Thuma JR Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women J Clin Endocrinol Metab 2003 88 1 297 311 10.1210/jc.2002-020369 12519869 · DOI · Paper page
  2. [2]Burke LM Lundy B Fahrenholtz IL Melin AK Pitfalls of conducting and interpreting estimates of energy availability in free-living athletes Int J Sport Nutr Exerc Metab. 2018 28 4 350 363 10.1123/ijsnem.2018-0142 30029584 · DOI · Paper page
  3. [3]Loucks AB Kiens B Wright HH Energy availability in athletes J Sports Sci 2011 29 Suppl 1 S7 15 10.1080/02640414.2011.588958 21793767 · DOI · Paper page
  4. [5]Mountjoy M Sundgot-Borgen JK Burke LM Ackerman KE Blauwet C Constantini N Lebrun C Lundy B Melin AK Meyer NL Sherman RT Tenforde AS Klungland Torstveit M Budgett R IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update Br J Sports Med 2018 52 11 687 697 10.1136/bjsports-2018-099193 29773536 · DOI · Paper page
  5. [7]Koehler K Achtzehn S Braun H Mester J Schaenzer W Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes Appl Physiol Nutr Metab 2013 38 7 725 733 10.1139/apnm-2012-0373 23980730 · DOI
  6. [8]Mountjoy M Sundgot-Borgen J Burke L Carter S Constantini N Lebrun C Meyer N Sherman R Steffen K Budgett R Ljungqvist A Ackerman K RED-S CAT Relative energy deficiency in sport (RED-S) clinical assessment tool (CAT) Br J Sports Med 2015 49 7 421 423 10.1136/bjsports-2015-094873 25896450 · DOI · Paper page
  7. [9]Holtzman B Tenforde AS Parziale AL Ackerman KE Characterization of risk quantification differences using female athlete triad cumulative risk assessment and relative energy deficiency in sport clinical assessment tool Int J Sport Nutr Exerc Metab. 2019 29 6 569 575 10.1123/ijsnem.2019-0002 31034246 · DOI · Paper page
  8. [10]Koltun KJ Strock NCA Southmayd EA Oneglia AP Williams NI De Souza MJ Comparison of female athlete triad coalition and RED-S risk assessment tools J Sports Sci 2019 37 21 2433 2442 10.1080/02640414.2019.1640551 31296115 · DOI
  9. [11]Areta JL Taylor HL Koehler K Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males Eur J Appl Physiol 2021 121 1 1 21 10.1007/s00421-020-04516-0 33095376 PMC7815551 · DOI · Paper page
  10. [12]Heikura IA Burke LM Bergland D Uusitalo ALT Mero AA Stellingwerff T Impact of energy availability, health, and sex on hemoglobin-mass responses following live-high–train-high altitude training in elite female and male distance athletes Int J Sports Physiol Perform 2018 13 8 1090 1096 10.1123/ijspp.2017-0547 29431548 · DOI · Paper page
  11. [13]Logue D Madigan SM Delahunt E Heinen M Mc Donnell S-J Corish CA Low energy availability in athletes: a review of prevalence, dietary patterns, physiological health, and sports performance Sport Med 2018 48 1 73 96 10.1007/s40279-017-0790-3 28983802 · DOI · Paper page
  12. [14]Lieberman JL De Souza MJ Wagstaff DA Williams NI Menstrual disruption with exercise is not linked to an energy availability threshold Med Sci Sport Exerc. 2018 50 3 551 561 10.1249/MSS.0000000000001451 PMC5820163 29023359 · DOI · Paper page
  13. [15]Slater GJ Rice AJ Mujika I Hahn AG Sharpe K Jenkins DG Physique traits of lightweight rowers and their relationship to competitive success Br J Sports Med 2005 39 10 736 741 10.1136/bjsm.2004.015990 16183770 PMC1725043 · DOI
  14. [16]Melin A Tornberg AB Skouby S Faber J Ritz C Sjödin A Sundgot-Borgen J The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad Br J Sports Med 2014 48 7 540 545 10.1136/bjsports-2013-093240 24563388 · DOI · Paper page
  15. [17]Keay N Francis G Hind K Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sport Exerc Med 2018 4 1 e000424 10.1136/bmjsem-2018-000424 30364549 PMC6196965 · DOI
  16. [19]Joy E De Souza MJ Nattiv A Misra M Williams NI Mallinson RJ 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad Curr Sports Med Rep 2014 13 4 219 232 10.1249/JSR.0000000000000077 25014387 · DOI
  17. [20]Martinsen M Holme I Pensgaard AM Torstveit MK Sundgot-Borgen J The development of the brief eating disorder in athletes questionnaire Med Sci Sports Exerc 2014 46 8 1666 1675 10.1249/MSS.0000000000000276 24504432 · DOI
  18. [21]Fairburn C Beglin SJ Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994 16 4 363 370 7866415
  19. [22]Brook EM Tenforde AS Broad EM Matzkin EG Yang HY Collins JE Blauwet CA Low energy availability, menstrual dysfunction, and impaired bone health: a survey of elite Para athletes Scand J Med Sci Sports 2019 29 5 678 685 10.1111/sms.13385 30644600 · DOI · Paper page
  20. [23]Mond JM Hay PJ Rodgers B Owen C Beumont PJV Validity of the eating disorder examination questionnaire (EDE-Q) in screening for eating disorders in community samples Behav Res Ther 2004 42 5 551 567 10.1016/S0005-7967(03)00161-X 15033501 · DOI
  21. [24]Muscat AC Long BC Critical comments about body shape and weight: disordered eating of female athletes and sport participants J Appl Sport Psychol 2008 20 1 1 24 10.1080/10413200701784833 · DOI
  22. [25]Rose JS Vaewsorn A Rosselli-Navarra F Wilson GT Weissman RS Test-retest reliability of the eating disorder examination-questionnaire (EDE-Q) in a college sample J Eat Disord 2013 1 1 42 10.1186/2050-2974-1-42 24999420 PMC4081765 · DOI
  23. [27]Nevonen L Broberg AG Validating the eating disorder Inventory-2 (EDI-2) in Sweden Eat Weight Disord 2001 6 2 59 67 10.1007/BF03339754 11456423 · DOI
  24. [28]Bodell LP Brown TA Keel PK Weight suppression predicts bulimic symptoms at 20-year follow-up: the mediating role of drive for thinness J Abnorm Psychol 2017 126 1 32 37 10.1037/abn0000217 27808544 PMC5215971 · DOI
  25. [29]Thiel A Paul T Test–retest reliability of the eating disorder inventory 2 J Psychosom Res 2006 61 4 567 569 10.1016/j.jpsychores.2006.02.015 17011367 · DOI
  26. [30]Ackerman KE Holtzman B Cooper KM Flynn EF Bruinvels G Tenforde AS Popp KL Simpkin AJ Parziale AL Low energy availability surrogates correlate with health and performance consequences of relative energy deficiency in sport Br J Sports Med 2019 53 10 628 633 10.1136/bjsports-2017-098958 29860237 · DOI · Paper page
  27. [31]Tosi M Maslyanskaya S Dodson NA Coupey SM The female athlete triad: a comparison of knowledge and risk in adolescent and young adult figure skaters, dancers, and runners J Pediatr Adolesc Gynecol 2019 32 2 165 169 10.1016/j.jpag.2018.10.007 30395981 · DOI
  28. [33]Sawai A Mathis BJ Natsui H Zaboronok A Mitsuhashi R Warashina Y Mesaki N Shiraki H Watanabe K Risk of female athlete triad development in Japanese collegiate athletes is related to sport type and competitive level Int J Women's Health 2018 10 671 687 10.2147/IJWH.S175446 30464644 PMC6214308 · DOI
  29. [35]Foley Davelaar CM Ostrom M Schulz J Trane K Wolkin A Granger J Validation of an age-appropriate screening tool for female athlete triad and relative energy deficiency in sport in young athletes Cureus. 2020 12 6 e8579 10.7759/cureus.8579 32670715 PMC7358951 · DOI
  30. [36]Stunkard AJ Messick S The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger J Psychosom Res 1985 29 1 71 83 10.1016/0022-3999(85)90010-8 3981480 · DOI · Paper page
  31. [37]Siervo M Boschi V Papa A Bellini O Falconi C Application of the SCOFF, eating attitude test 26 (EAT 26) and eating inventory (TFEQ) questionnaires in young women seeking diet-therapy Eat Weight Disord 2005 10 2 76 82 10.1007/BF03327528 16114220 · DOI
  32. [38]Robertson S Mountjoy M A review of prevention, diagnosis, and treatment of relative energy deficiency in sport in artistic (synchronized) swimming Int J Sport Nutr Exerc Metab. 2018 28 4 375 384 10.1123/ijsnem.2017-0329 29722578 · DOI
  33. [39]Lavender JM De Young KP Anderson DA Eating disorder examination questionnaire (EDE-Q): norms for undergraduate men Eat Behav 2010 11 2 119 121 10.1016/j.eatbeh.2009.09.005 20188296 · DOI
  34. [40]Wagner AJ Erickson CD Tierney DK Houston MN Bacon CEW The diagnostic accuracy of screening tools to detect eating disorders in female athletes J Sport Rehabil 2016 25 4 395 398 10.1123/jsr.2014-0337 27632819 · DOI
  35. [41]Schaefer LM Smith KE Leonard R Wetterneck C Smith B Farrell N Riemann BC Frederick DA Schaumberg K Klump KL Anderson DA Thompson JK Identifying a male clinical cutoff on the eating disorder examination-questionnaire (EDE-Q) Int J Eat Disord. 2018 51 12 1357 1360 10.1002/eat.22972 30480321 PMC6310481 · DOI
  36. [42]Martinsen M Sundgot-Borgen J Higher prevalence of eating disorders among adolescent elite athletes than controls Med Sci Sport Exerc 2013 45 6 1188 1197 10.1249/MSS.0b013e318281a939 23274604 · DOI
  37. [43]Darcy AM Hardy KK Lock J Hill KB Peebles R The eating disorder examination questionnaire (EDE-Q) among university men and women at different levels of athleticism Eat Behav 2013 14 3 378 381 10.1016/j.eatbeh.2013.04.002 23910784 · DOI
  38. [44]Logue DM Madigan SM Heinen M McDonnell S-J Delahunt E Corish CA Screening for risk of low energy availability in athletic and recreationally active females in Ireland Eur J Sport Sci 2019 19 1 112 122 10.1080/17461391.2018.1526973 30303470 · DOI · Paper page
  39. [45]Nichols JF Rauh MJ Lawson MJ Ji M Barkai H-S Prevalence of the female athlete triad syndrome among high school athletes Arch Pediatr Adolesc Med 2006 160 2 137 142 10.1001/archpedi.160.2.137 16461868 · DOI
  40. [46]Thein-Nissenbaum JM Carr KE Female athlete triad syndrome in the high school athlete Phys Ther Sport 2011 12 3 108 116 10.1016/j.ptsp.2011.04.002 21802036 · DOI
  41. [47]De Souza MJ Hontscharuk R Olmsted M Kerr G Williams NI Drive for thinness score is a proxy indicator of energy deficiency in exercising women Appetite. 2007 48 3 359 367 10.1016/j.appet.2006.10.009 17184880 · DOI
  42. [48]Gibbs JC Williams NI Scheid JL Toombs RJ De Souza MJ The association of a high drive for thinness with energy deficiency and severe menstrual disturbances: confirmation in a large population of exercising women Int J Sport Nutr Exerc Metab. 2011 21 4 280 290 10.1123/ijsnem.21.4.280 21813911 · DOI
  43. [49]Smith KER Mason TB Murray SB Griffiths S Leonard RC Wetterneck CT Male clinical norms and sex differences on the eating disorder inventory (EDI) and eating disorder examination questionnaire (EDE-Q) Int J Eat Disord 2017 50 7 769 775 10.1002/eat.22716 28436086 PMC5741972 · DOI
  44. [50]Cotton M-A Ball C Robinson P Four simple questions can help screen for eating disorders J Gen Intern Med 2003 18 1 53 56 10.1046/j.1525-1497.2003.20374.x 12534764 PMC1494802 · DOI
  45. [51]Anstine D Grinenko D Rapid screening for disordered eating in college-aged females in the primary care setting J Adolesc Health 2000 26 5 338 342 10.1016/S1054-139X(99)00120-2 10775826 · DOI
  46. [52]Freund KM Graham SM Lesky LG Moskowitz MA Detection of bulimia in a primary care setting J Gen Intern Med 1993 8 5 236 242 10.1007/BF02600088 8505681 · DOI
  47. [53]Mcnulty KY Adams CH Anderson JM Affenito SG Development and validation of a screening tool to identify eating disorders in female athletes J Am Diet Assoc 2001 101 8 886 892 10.1016/S0002-8223(01)00218-8 11501862 · DOI
  48. [54]Morgan JF Reid F Lacey JH The SCOFF questionnaire: assessment of a new screening tool for eating disorders BMJ. 1999 319 7223 1467 1468 10.1136/bmj.319.7223.1467 10582927 PMC28290 · DOI · Paper page
  49. [55]Mintz LB O’Halloran MS Mulholland AM Schneider PA Questionnaire for eating disorder diagnoses: reliability and validity of operationalizing DSM-IV criteria into a self-report format J Couns Psychol 1997 44 1 63 79 10.1037/0022-0167.44.1.63 · DOI
  50. [56]Krebs PA Dennison CR Kellar L Lucas J Gender differences in eating disorder risk among NCAA division I cross country and track student-athletes J Sports Med 2019 2019 5035871 10.1155/2019/5035871 PMC6377974 30854400 · DOI
  51. [58]Yi J Tenfelde S Tell D Brincat C Fitzgerald C Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad Female Pelvic Med Reconstr Surg 2016 22 5 373 376 10.1097/SPV.0000000000000296 27403753 · DOI
  52. [59]Walsh M Crowell N Merenstein D Exploring health demographics of female collegiate rowers J Athl Train 2020 55 6 636 643 10.4085/1062-6050-132-19 32396472 PMC7319733 · DOI
  53. [60]Folscher L-L Grant CC Fletcher L Janse van Rensberg DC Ultra-marathon athletes at risk for the female athlete triad Sport Med - Open 2015 1 1 29 10.1186/s40798-015-0027-7 PMC4564455 26380807 · DOI
  54. [61]Parmigiano TR Zucchi EVM de Araujo MP Guindalini CSC de Aquino Castro R de Jármy Di Bella ZIK Pre-participation gynecological evaluation of female athletes: a new proposal Einstein (São Paulo) 2014 12 4 459 466 10.1590/S1679-45082014AO3205 25628197 PMC4879912 · DOI
  55. [63]Barrack MT Gibbs JC De Souza MJ Williams NI Nichols JF Rauh MJ Higher incidence of bone stress injuries with increasing female athlete triad–related risk factors Am J Sports Med 2014 42 4 949 958 10.1177/0363546513520295 24567250 · DOI · Paper page
  56. [64]Heikura IA Uusitalo ALT Stellingwerff T Bergland D Mero AA Burke LM Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes Int J Sport Nutr Exerc Metab. 2018 28 4 403 411 10.1123/ijsnem.2017-0313 29252050 · DOI · Paper page
  57. [65]Rauh MJ Barrack M Nichols JF Associations between the female athlete triad and injury among high school runners Int J Sports Phys Ther 2014 9 7 948 958 25540710 PMC4275199
  58. [66]Burke LM Close GL Lundy B Mooses M Morton JP Tenforde AS Relative energy deficiency in sport in male athletes: a commentary on its presentation among selected groups of male athletes Int J Sport Nutr Exerc Metab. 2018 28 4 364 374 10.1123/ijsnem.2018-0182 30040508 · DOI
  59. [67]Tenforde AS Barrack MT Nattiv A Fredericson M Parallels with the female athlete triad in male athletes Sport Med. 2016 46 2 171 182 10.1007/s40279-015-0411-y 26497148 · DOI
  60. [68]Torstveit MK Fahrenholtz IL Lichtenstein MB Stenqvist TB Melin AK Exercise dependence, eating disorder symptoms and biomarkers of relative energy deficiency in sports (RED-S) among male endurance athletes BMJ Open Sport Exerc Med 2019 5 1 e000439 10.1136/bmjsem-2018-000439 30792881 PMC6350749 · DOI
  61. [69]Terry A Szabo A Griffiths M The exercise addiction inventory: a new brief screening tool Addict Res Theory 2004 12 5 489 499 10.1080/16066350310001637363 · DOI · Paper page
  62. [70]Meyer C Plateau CR Taranis L Brewin N Wales J Arcelus J The compulsive exercise test: confirmatory factor analysis and links with eating psychopathology among women with clinical eating disorders J Eat Disord 2016 4 1 22 10.1186/s40337-016-0113-3 27547403 PMC4992271 · DOI
  63. [71]Ogden J Veale D Summers Z The development and validation of the exercise dependence questionnaire Addict Res 1997 5 4 343 355 10.3109/16066359709004348 · DOI

Cited by

Sorted by citations

Authors
Sim, A., & Burns, S. F.
Affiliations
Nanyang Technological University (SG)
Corresponding author
Burns, Stephen F.
ORCID
Venue
Journal of Eating Disorders
Publisher
Springer Science and Business Media LLC
Published
2021-03-31
Volume
9
Issue
1
Pages
41-41
ISSN
2050-2974 (ISSN-L)
DOI
10.1186/s40337-021-00396-7
PMC
PMC8011161
OpenAlex
W3139956251
Cited by
91
References
3
Citations by year
2026: 11 · 2025: 15 · 2024: 25 · 2023: 16 · 2022: 23 · 2021: 1
FWCI
2.17
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Eating Disorders (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • NIE Digital Repository (National Institute of Education, Nanyang Technological University) (acceptedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Nanyang Technological University
  • National Institute of Education, Nanyang Technological University
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
Keywords
low energy availability, relative energy deficiency in sport, athletes, questionnaire validation, LEAF-Q, Eating Disorder Examination Questionnaire, exercise energy expenditure, disordered eating, caloric restriction, male athletes, menstrual function

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