Low Energy Availability, Menstrual Dysfunction, and Low Bone Mineral Density in Individuals with a Disability: Implications for the Para Athlete Population

The Low Energy Availability in Females Questionnaire (LEAF-Q) was validated to identify risk of the female athlete triad (triad) in female endurance athletes. This study explored the ability of the LEAF-Q to detect conditions related to low energy availability (LEA) in a mixed sport cohort of female athletes. Data included the LEAF-Q, SCOFF Questionnaire for disordered eating, dual-energy X-ray absorptiometry-derived body composition and bone mineral density, Mini International Neuropsychiatric Interview, blood pressure, and blood metabolic and reproductive hormones. Participants were grouped according to LEAF-Q score (≥8 or <8), and a comparison of means was undertaken. Sensitivity, specificity, and predictive values of the overall score and subscale scores were calculated in relation to the triad and biomarkers relevant to LEA. Fisher’s exact test explored differences in prevalence of these conditions between groups. Seventy-five athletes (18–32 years) participated. Mean LEAF-Q score was 8.0 ± 4.2 (55% scored ≥8). Injury and menstrual function subscale scores identified low bone mineral density (100% sensitivity, 95% confidence interval [15.8%, 100%]) and menstrual dysfunction (80.0% sensitivity, 95% confidence interval [28.4%, 99.5%]), respectively. The gastrointestinal subscale did not detect surrogate markers of LEA. LEAF-Q score cannot be used to classify athletes as “high risk” of conditions related to LEA, nor can it be used as a surrogate diagnostic tool for LEA given the low specificity identified. Our study supports its use as a screening tool to rule out risk of LEA-related conditions or to create selective low-risk groups that do not need management as there were generally high negative predictive values (range 76.5–100%) for conditions related to LEA.

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Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes

International Journal of Sport Nutrition and Exercise Metabolism ◽

10.1123/ijsnem.2017-0313 ◽

2018 ◽

Vol 28 (4) ◽

pp. 403-411 ◽

Cited By ~ 52

Author(s):

Ida A. Heikura ◽

Arja L.T. Uusitalo ◽

Trent Stellingwerff ◽

Dan Bergland ◽

Antti A. Mero ◽

...

Keyword(s):

Bone Mineral Density ◽

Bone Mineral ◽

Effect Size ◽

Reproductive Function ◽

Low Energy ◽

Energy Availability ◽

Mineral Density ◽

Low Testosterone ◽

And Training ◽

Low Energy Availability

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−1fat-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.

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The Female Athlete Triad

10.1542/9781610021883-the_female ◽

2018 ◽

pp. 288-301

Author(s):

Jennifer L. Carlson ◽

Katherine B. Hill

Keyword(s):

Bone Mineral Density ◽

Disordered Eating ◽

Female Athlete ◽

Low Energy ◽

Energy Availability ◽

Female Athlete Triad ◽

Mineral Density ◽

Menstrual Dysfunction ◽

Bone Acquisition ◽

Low Energy Availability

In 2007, the female athlete triad was redefined to include (1) low energy availability with or without disordered eating; (2) menstrual dysfunction; and (3) decreased bone mineral density. Components of the triad are common during adolescence, a critical period for bone acquisition and growth, but the prevalence varies among athlete populations based on several factors. Screening for the triad should be a routine part of the preparticipation physical examination of adolescent athletes, and new recommendations exist for the screening and management of athletes at risk for complications from the triad. Awareness and education are critical for prevention and early intervention.

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Relationships Between Stress Fracture, Disordered Eating, Menstrual Dysfunction, And Low Bone Mineral Density Among Interscholastic Cross-country Runners

Medicine & Science in Sports & Exercise ◽

10.1249/01.mss.0000353526.67534.5c ◽

2009 ◽

Vol 41 ◽

pp. 82-83

Author(s):

Mitchell J. Rauh ◽

Michelle T. Barrack ◽

Jeanne F. Nichols

Keyword(s):

Bone Mineral Density ◽

Disordered Eating ◽

Stress Fracture ◽

Bone Mineral ◽

Mineral Density ◽

Menstrual Dysfunction ◽

Low Bone Mineral Density ◽

Cross Country ◽

Cross Country Runners

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Risk of Low Energy Availability in National and International Level Paralympic Athletes: An Exploratory Investigation

Nutrients ◽

10.3390/nu13030979 ◽

2021 ◽

Vol 13 (3) ◽

pp. 979

Author(s):

Kelly Pritchett ◽

Alicia DiFolco ◽

Savannah Glasgow ◽

Robert Pritchett ◽

Katy Williams ◽

...

Keyword(s):

At Risk ◽

National Level ◽

Relative Energy ◽

Low Energy ◽

Assessment Tools ◽

Energy Availability ◽

Mineral Density ◽

Menstrual Dysfunction ◽

Energy Deficiency ◽

Low Energy Availability

(1) Background: The purpose of this study was to examine the symptoms of low energy availability (LEA) and risk of relative energy deficiency in sport (RED-S) symptoms in para-athletes using a multi-parameter approach. (2) Methods: National level para-athletes (n = 9 males, n = 9 females) completed 7-day food and activity logs to quantify energy availability (EA), the LEA in Females Questionnaire (LEAF-Q), dual energy X-ray absorptiometry (DXA) scans to assess bone mineral density (BMD), and hormonal blood spot testing. (3) Results: Based on EA calculations, no athlete was at risk for LEA (females < 30 kcal·kg−1 FFM·day−1; and males < 25 kcal·kg−1 FFM·day−1; thresholds for able-bodied (AB) subjects). Overall, 78% of females were “at risk” for LEA using the LEAF-Q, and 67% reported birth control use, with three of these participants reporting menstrual dysfunction. BMD was clinically low in the hip (<−2 z-score) for 56% of female and 25% of male athletes (4) Conclusions: Based on calculated EA, the risk for RED-S appears to be low, but hormonal outcomes suggest that RED-S risk is high in this para-athlete population. This considerable discrepancy in various EA and RED-S assessment tools suggests the need for further investigation to determine the true prevalence of RED-S in para-athlete populations.

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The Prevalence of Disordered Eating, Menstrual Dysfunction, and Low Bone Mineral Density among US Collegiate Athletes

International Journal of Sport Nutrition and Exercise Metabolism ◽

10.1123/ijsnem.16.1.1 ◽

2006 ◽

Vol 16 (1) ◽

pp. 1-23 ◽

Cited By ~ 109

Author(s):

Katherine A. Beals ◽

Amanda K. Hill

Keyword(s):

Bone Mineral Density ◽

Disordered Eating ◽

Bone Mineral ◽

Collegiate Athletes ◽

Z Score ◽

Mineral Density ◽

Menstrual Dysfunction ◽

X Ray ◽

Low Bone Mineral Density ◽

Menstrual History

The purpose of this study was to examine the prevalence of disordered eating (DE), menstrual dysfunction (MD), and low bone mineral density (BMD) among US collegiate athletes (n = 112) representing 7 different sports (diving, swimming, x-country, track, tennis, field hockey, and softball) and determine differences in prevalence existed between athletes participating in lean-build (LB) and non-lean build (NLB) sports. DE and MD were assessed by a health, weight, dieting, and menstrual history questionnaire. Spinal BMD was determined via dual energy x-ray absorptiometry. Twenty-eight athletes met the criteria for DE, twenty-nine for MD, and two athletes had low BMDs (using a Z score below −2.0). Ten athletes met the criteria for two disorders (one with disordered eating and low BMD and nine with disordered eating and menstrual dysfunction), while only one athlete met the criteria for all three disorders. Using a Z score below −1.0, two additional athletes met the criteria for all three disorders and three more athletes met the criteria for a combination of two disorders. With the exception of MD, which was significantly more prevalent among LB vs. NLB sports (P = 0.053), there were no differences between the groups in the prevalence of individual disorders or combinations of disorders. These data indicate that the combined prevalence of DE, MD, and low BMD among collegiate athletes is small; however, a significant number suffer from individual disorders of the Triad.

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Low RMRratio as a Surrogate Marker for Energy Deficiency, the Choice of Predictive Equation Vital for Correctly Identifying Male and Female Ballet Dancers at Risk

International Journal of Sport Nutrition and Exercise Metabolism ◽

10.1123/ijsnem.2017-0327 ◽

2018 ◽

Vol 28 (4) ◽

pp. 412-418 ◽

Cited By ~ 17

Author(s):

Sarah Staal ◽

Anders Sjödin ◽

Ida Fahrenholtz ◽

Karen Bonnesen ◽

Anna Katarina Melin

Keyword(s):

Bone Mineral Density ◽

At Risk ◽

Disordered Eating ◽

Surrogate Marker ◽

Low Energy ◽

Energy Availability ◽

Mineral Density ◽

Energy Deficiency ◽

Ballet Dancers ◽

Low Energy Availability

Ballet dancers are reported to have an increased risk for energy deficiency with or without disordered eating behavior. A low ratio between measured (m) and predicted (p) resting metabolic rate (RMRratio < 0.90) is a recognized surrogate marker for energy deficiency. We aimed to evaluate the prevalence of suppressed RMR using different methods to calculate pRMR and to explore associations with additional markers of energy deficiency. Female (n = 20) and male (n = 20) professional ballet dancers, 19–35 years of age, were enrolled. mRMR was assessed by respiratory calorimetry (ventilated open hood). pRMR was determined using the Cunningham and Harris–Benedict equations, and different tissue compartments derived from whole-body dual-energy X-ray absorptiometry assessment. The protocol further included assessment of body composition and bone mineral density, blood pressure, disordered eating (Eating Disorder Inventory-3), and for females, the Low Energy Availability in Females Questionnaire. The prevalence of suppressed RMR was generally high but also clearly dependent on the method used to calculate pRMR, ranging from 25% to 80% in males and 35% to 100% in females. Five percent had low bone mineral density, whereas 10% had disordered eating and 25% had hypotension. Forty percent of females had elevated Low Energy Availability in Females Questionnaire score and 50% were underweight. Suppressed RMR was associated with elevated Low Energy Availability in Females Questionnaire score in females and with higher training volume in males. In conclusion, professional ballet dancers are at risk for energy deficiency. The number of identified dancers at risk varies greatly depending on the method used to predict RMR when using RMRratio as a marker for energy deficiency.

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