Balancing Faith, Culture, and Performance: Understanding the Role of Religion and Cultural Practices on Health Monitoring for Energy Deficiency in Female Footballers

Introduction: Female track and field athletes have increased risk of low energy availability (LEA), disordered eating (DE), and eating disorders (ED), which are associated with health and performance consequences. This study explored LEA, DE, and ED risk among United States female track and field athletes and assessed differences in proportions between risk and competition level and bone stress injury (BSI) risk. Methods: Female track and field athletes (n = 392, aged 18-68 years) completed an online survey including the Low Energy Availability in Females Questionnaire (LEAF-Q), Eating Disorder Examination Questionnaire (EDE-Q), and Female Athlete Screening Tool (FAST), and self-reported BSIs. Chi-square tests of homogeneity assessed differences in proportions between competition level and BSI and LEA, DE, and ED risk. Results: 49%, 48%, and 22% of participants had high risk for LEA, DE, and ED, respectively; and concurrent risk of LEA, DE, and ED was 27%. There was a significant difference in proportions between competition level and LEA risk (X2 (3, 387) = 11.93, p = 0.008, Φ= 0.176) and ED/DE risk (X2 (3, 387) = 11.65, p = 0.007, Φ= 0.213); and BSI and LEA risk (X2 (2, 392) = 8.58, p = 0.014, Φ= 0.148). Conclusions: This study demonstrated a considerable portion of US female track and field athletes had high risk of LEA, DE, and ED.

Background: Rates of low energy availability (LEA) in female footballers range from 12% to 66%, studies are limited, and no research has yet looked at the prevalence of LEA in a cohort of international players. Due to the negative consequences of LEA, more research is needed for a thorough investigation into prevalence rates and the associated risk factors of LEA within international environments. Methods: Twenty-two members of the New Zealand under 20 (U20) and National Women’s football teams (20.8 ± 3.5 years) participated in this study. Participants completed an online questionnaire composed of five independent validated surveys to assess LEA risk (Low Energy Availability in Females Questionnaire), eating disorder risk (Eating Disorder Examination Questionnaire), sleep quality (Athlete Sleep Score Questionnaire), nutrition knowledge, (Abridged Sport Nutrition Questionnaire), and mood (Profile of Mood States Questionnaire). Results: 59.1% (n = 13) of participants were identified as being at risk of problematic LEA. Players reporting menstrual disturbances (amenorrhea or oligomenorrhea) were 2.25 times more likely to be at risk of LEA than those who did not report a menstrual disturbance. Menstrual status (R = −.46, p = .030) and Profile of Mood States Questionnaire (r = −.46, p = .032) were significantly and positively associated with risk of LEA (R = −.46, p = .030). Conclusions: A significant proportion (59.1%) of players in the New Zealand national and U20 female football team are at risk of LEA. The positive and predictive relationship observed between mood disturbances, menstrual status, and risk of LEA suggests that regular monitoring of mood and menstrual cycle health may be used for the early identification of problematic LEA in national-level female footballers in New Zealand.

Low energy availability (LEA) affects the body’s physiological systems, which can negatively affect an athlete’s performance and recovery. Athletes that participate in high-intensity functional exercise may not have adequate dietary intake to match energy needs or obtain optimal amount of sleep to recover fully. PURPOSE: To examine the low energy availability (LEA) and sleep among male and female recreational athletes who engage in high-intensity functional exercise programs. METHODS: Thirty adults (age: 31.2 ± 8.1; males: n = 12, 176.9 ± 6.2 cm, 89.5 ± 15.1 kg; females: 164.7 ± 7.1 cm, 69.9 ± 11.1 kg) participated in a larger cross-sectional study. Participants completed a demographic survey, Pittsburgh Sleep Quality Scale, a 7-day online dietary and exercise log. Participants were measured for height, weight, DXA scan (BMD), and RMR through indirect calorimetry (MedGem). ANOVAs examined differences between gender and energy needs, and Chi-squared analysis examined differences between gender and risk for LEA and Poor Sleep. RESULTS: Significant differences were found between gender and RMR (males: 2296.7±400.3 kg; females: 1761.7±341.6 kg; P=0.001), EI (males: 2027.5±694.5 kg; females: 1568.9±461.1 kg; P=0.038) and EEE (males: 357.8±60.3 kg; females: 279.3±44.4 kg; P≤0.01). No significant differences were found between gender and LEA (males: 24.8.7±12.2 kg; females: 25.0±8.9 kg). Overall risk for LEA was 66.7% (n = 20); however independently LEA was 50% (n=6) for males and 77.8% (n=14) for females. Overall, 63.3% (n=19) recreational athletes report poor sleep. No significant differences were found across gender and poor sleep, independently poor sleep for males was 50% (n=6) and females 72.2% (n=13). No significant differences were found between gender, poor sleep, and LEA. Of those at risk for LEA (n=20), 60% (n=12) also had reported poor sleep. CONCLUSIONS: Recreational athletes were at risk for both LEA and poor sleep, with a majority at risk for both. A combination of LEA and poor sleep can lead to poor performance and recovery from high-intensity exercises. Therefore, education to recreational athletes on the importance of dietary intake to match energy needs and encouragement for positive sleeping habits is imperative to optimize physiological recovery.

BackgroundA 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.MethodsA 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.ResultsThirty-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.ConclusionThese questionnaires may be effective in identifying intentional energy restriction but less valuable in identifying inadvertently failure to increase energy intake with increased EEE.

There have been several published studies on the prevalence of low energy availability (LEA) risk amongst North American and European endurance athletes. Yet the prevalence and risk factors amongst rugby league players are less well understood. This study assessed the prevalence of low energy availability risk, eating disorder risk, and food security amongst players from a female National Rugby League squad in Australia. Players from one Australian professional rugby league club volunteered to participate in the study. An online questionnaire was conducted to determine the prevalence of low energy availability (Low Energy Availability in Females Questionnaire [LEAF-Q]), eating disorder risk (Eating Disorders Inventory [EDI-3]), and food security. Differences between those "at risk" and "not at risk" based on their total LEAF-Q score were determined. Of the 28 players, 64% (N.=18) were at risk of LEA. Raw scores for the EDI-3 subscales, body dissatisfaction (P=0.043), bulimia (P=0.002), composite score (P=0.038), were significantly higher for those at risk and not at risk of LEA. Forty percent of players had some level of food insecurity. The results suggest LEA risk is similar to other populations and those at risk of LEA are more likely to have an elevated clinical risk of eating disorders. Food security is also an issue in this population and could contribute to LEA risk for some. Future research is needed amongst team sports athletes to understand interplay between eating disorder risk and food insecurity with LEA risk.

Collegiate female distance runners may be at risk for low energy availability (LEA) due to increased exercise energy expenditure with or without decreased energy intake. Furthermore, this population has an increased risk of disordered eating (DE), which can lead to LEA and negative health consequences, such as menstrual dysfunction (MD). To (1) investigate risk of LEA, DE, and MD; (2) compare DE, training volume, and weight dissatisfaction between female collegiate runners at risk and those not at risk for LEA; and (3) compare the risk for LEA between National Collegiate Athletic Association Division I, II, and III female collegiate runners. Cross-sectional study. Free-living conditions. A total of 287 female runners who competed on a National Collegiate Athletic Association Division I, II, or III cross-country team, track team, or both. Participants completed a 45-item questionnaire that included the Low Energy Availability in Females Questionnaire (LEAF-Q) and the Disordered Eating Screen for Athletes (DESA-6). We observed that 54.4% (n = 156) of runners were at risk for LEA (LEAF-Q score ≥ 8), 40.8% (n = 117) were at risk for DE (DESA-6 score ≥ 3), and 56.5% (n = 162) reported MD (LEAF-Q menstrual function subsection score ≥ 4). Athletes at risk for LEA had higher DESA-6 scores than athletes not at risk for LEA (P < .001). Athletes at risk for LEA had greater weight dissatisfaction than those not at risk for LEA ( = 15.92, P = .001). Higher weekly training volume was not associated with risk for LEA ( = 4.20, P = .11). A substantial percentage of collegiate female runners were found to be at risk for LEA and DE and to report MD. These findings demonstrate that the risks for DE, MD, and weight dissatisfaction are associated with risk for LEA.

Background: Nutrition in sport is a priority; it is the basis for maintaining optimal health and a prerequisite for the high performance necessary for competitions. The aim of this study was to assess low energy availability and its possible consequences among female triathletes by using the Low Energy Availability in Females Questionnaire (LEAF-Q). Methods: The study involved 30 female triathetes. The LEAF-Q was used in the study. An analysis of the body composition was carried out with the seca device mBCA 515 medical Body Composition Analyzer. Results: Of the 30 female triathletes studied, 23.3% had a monthly cycle disorder, defined as an amenorrhea state for more than 90 days. No differences were found in injury rates or training days lost to injury due to menstrual disturbances. Menstruation changes were significantly greater due to increases in exercise intensity, frequency, and duration in the group experiencing menstrual disturbances (85.7 [95% CIs: 42.1–99.6] vs. 8.7 [95% CIs: 1.1–28.0]). The menstrual disorder group had a greater incidence of their periods stopping for more than 3 months than the group without menstrual disturbances. Conclusions: The female triathletes did not show abnormalities in body weight or composition, and these were not related to the incidence of menstrual disturbances. However, 20% of the triathletes either had, at the time of the study, or had had in the past monthly cycle disorders that could indicate an immediate risk of low energy availability. The LEAF-Q identified 10% of the triathletes as at risk (score > 8) of low energy availability and the physiological and performance consequences related to relative energy deficiency in sports (RED-S).

BackgroundEating disorders and low energy availability independently and negatively impact eating behaviors and attitudes and overall health. Screening provides early identification of athletes suffering from these conditions, yet few studies have evaluated both simultaneously, and none have investigated eating disorder and low energy availability in the context of sex or sport type. This study determined the prevalence of eating disorder and low energy availability risk in collegiate athletes at a large National Collegiate Athletic Association (NCAA) Division 1 university and the variation of prevalence by sport, sport type, and sex.MethodsThis cross-sectional study of NCAA Division 1 athletes used a self-administered survey to collect demographic data and assessed risk using the Eating Disorder Screen for Athletes, Low Energy Availability in Females Questionnaire, and Low Energy Availability in Males Questionnaire. Variations in prevalence were assessed using chi-square tests and variations in mean screening tool scores were assessed using t-tests and ANOVA. Significance was set at p < 0.05.ResultsOut of 220 athletes (76 males, 144 females) across 19 sports, 38.18% were at risk for an eating disorder and 47.17% were at risk for low energy availability, while 22.73% were at risk for both conditions. Females had a higher distribution of positive screens for an eating disorder (p = 0.002) and low energy availability (p < 0.001) than males. Aesthetic sport athletes had the highest proportion of eating disorder risk (p = 0.016)—but low energy availability (p = 0.871) did not vary by sport type. Dance team athletes had the highest prevalence of eating disorder risk by sport (p < 0.001), while women’s gymnasts had the highest prevalence of low energy availability risk (p < 0.001) by sport.ConclusionsA high percentage of athletes were at risk for an eating disorder and low energy availability. Screening protocols can identify eating disorders and low energy availability earlier, leading to quicker treatment and prevention of severe consequences.

This study investigated the association between the risk of low energy availability, disordered eating, and anxiety in collegiate female athletes. Female athletes (n = 115) completed questionnaires that assessed disordered eating (Disordered Eating Screen for Athletes, DESA-6; and the Eating Disorder Examination Questionnaire Short, EDE-QS), anxiety (Generalized Anxiety Disorder-7) and the risk of low energy availability (Low Energy Availability in Females Questionnaire; LEAF-Q). The athletes were 19.9 ± 0.1 years old and presented with no anxiety (14.8%), mild (33.0%), moderate (24.3%), and severe (27.8%) anxiety. The EDE-QS scores revealed that 22.6% of the participants had a high risk of an eating disorder, while the DESA-6 scores revealed that 31.3% of the participants scored positive for a risk of disordered eating. The LEAF-Q total scores revealed that 68.7% of the participants were at risk of low energy availability. Increased GAD-7 scores were associated (p < 0.001) with measures of disordered eating (EDE-QS and DESA-6) and the risk of low energy availability (LEAF-Q total score). Non-parametric partial correlations demonstrated that anxiety (increased GAD-7 scores) correlated with the risk of low energy availability (increased LEAF-Q total scores) while controlling for eating disorder scores (EDE-QS) (r (112) = 0.353, p < 0.001), or while controlling for the risk of disordered eating (DESA-6 scores) (r (112) = 0.349, p < 0.001). In female collegiate athletes, both disordered eating and the risk of low energy availability were positively associated with increased anxiety.

ABSTRACTIntroduction: Low energy availability (LEA) results in physiological adaptations, which can contribute to unfavourable health outcomes. Little information exists on risk of LEA in active individuals competing in different sports or levels of competition. The aims of this study were to (1) identify risk of LEA in females competing at different levels of competition and (2) investigate associations between risk of LEA, illness and dietary habits. Methods: The validated questionnaire, ‘Low Energy Availability in Females Questionnaire’ was distributed online (November 2016–February 2017) to assess risk of LEA. Twenty-nine additional questions collected information on demographics, illness history and dietary habits. Participants were considered at risk of LEA if they attained a score of ≥ 8 and were grouped into: (i) international; (ii) provincial/inter-county; (iii) competitive; and (iv) recreationally active. Chi-square and logistic regression analyses were used to explore differences between those at risk or not at risk of LEA. Results: Risk of LEA was identified in 40% (n = 331) of 833 participants and was 1.7 and 1.8 times more likely in international and provincial/inter-county athletes compared to those who were recreationally active (International: odds ratios (OR) 1.68, 95% confidence intervals (95%CI) 1.12–2.54; Provincial/inter-county: OR 1.83, 95%CI 1.20–2.77). In participants at risk of LEA, missing >22 days of training during the previous year due to illness occurred 3 times more frequently (OR 3.01, 95%CI 1.81–5.02). Conclusion: Risk of LEA was widespread in this heterogeneous sample. Awareness of LEA and the development of appropriate energy management strategies to ensure athlete health across levels of competition are required.

Introduction: Running is characterized by high physiological demands with an emphasis on body weight, which may lead to a greater risk of developing low energy availability (LEA) and/or disordered eating (DE). The prevalence of LEA among recreational runners has not been well defined, and this population may lack the ability to distinguish between nutrition resources that are evidence-based or not. Purpose: This study investigated (a) the prevalence of those at risk for LEA, menstrual dysfunction (MD), and risk of DE and (b) compared the risk of DE, training volume, and body weight dissatisfaction between female recreational runners at risk for LEA versus not at risk for LEA. Methods: Female recreational endurance runners (n = 1,923) completed an online questionnaire that included the Low Energy Availability in Females Questionnaire to evaluate LEA risk and MD, and the Disordered Eating Screening Assessment to evaluate DE risk and body weight dissatisfaction. Results: 53.04% of participants are at risk for LEA, 42.5% are at risk for DE, and 61.7% reported MD. Conclusions: The current study suggests that recreational runners are at an increased risk for LEA and DE. Furthermore, DE, MD, training volume, and weight dissatisfaction may be associated with LEA in recreational runners. These findings highlight the need for education and preventative measures around LEA, MD, and DE among recreational female runners.

Trail running is an endurance sport growing in popularity. It is characterised by long event durations and extreme environments that are likely to result in high exercise energy expenditure. Energy availability is defined as the amount of energy available to support normal physiological functions after subtracting the energy cost of exercise from energy intake. Insufficient energy intake, increased exercise, or a combination of both can result in a state of low energy availability (LEA). While research shows a weak positive association between nutrition knowledge and diet quality, results are conflicting regarding associations between nutrition knowledge and LEA. Research has demonstrated a high prevalence of risk of LEA (~33%-85%) among both elite and recreational athletes, across both sexes and in endurance sports such as running. However, little is known about risk of LEA and nutrition knowledge in trail runners. The aim of this study was to determine the risk of LEA prevalence in recreational trail runners and investigate associations with nutrition knowledge. Risk of LEA was assessed using the ‘Low Energy Availability in Females Questionnaire’ (LEAF-Q)(1), and the ‘Low Energy Availability in Males Questionnaire’ (LEAM-Q)(2). Nutrition knowledge was measured via the ‘Platform for Evaluating Athlete Knowledge in Sports – Nutrition Questionnaire’ (PEAKS-NQ)(3). Demographics and trail-running experience questions were integrated into the survey. Data was analysed in SPSS version 29 (IBM Corporation). Comparisons between groups (e.g. ‘low risk’ vs ‘not low risk’) were performed using a chi-square test for categorical variables, and an independent samples t-test for continuous variables. The final survey sample was 217 (140 females, 42.01 ± 10.72 years; 77 males, 47.86 ± 12.05 years) for the LEAF-Q, LEAM-Q, and trail running questions; and 152 for the PEAKS-NQ. Thirty-one percent of females (n = 43) were classified as ‘not low risk’ of LEA based on the LEAF-Q cut-off of ≥8. Twenty-three percent of males (n = 18) were identified as having low sex drive, a marker of LEA risk. The LEAF-Q/sex drive score was higher in those ‘not at low risk’ (10.72 ± 2.28/4.50 ± 1.95) compared to those at low risk (3.94 ± 2.34/1.53 ± 1.12, p&lt;0.001). Three quarters of general nutrition knowledge responses were correct (females, 78.60 ± 10.09%; males, 75.78 ± 10.67%). However, sports nutrition scores were lower (females, 66.31 ± 13.44%; males, 63.18 ± 15.53%) with the lowest mean scores observed for ‘fuel for during events’. There was no significant association between nutrition knowledge and risk of LEA in both sexes. The findings suggest that recreational trail runners are a group of active individuals who are at risk of LEA and that they might benefit from more sports-specific nutrition education.

ABSTRACTBackgroundCollegiate women athletes face unique challenges regarding nutrition, body image, and athletic performance, which increase their risk for low energy availability (LEA). This risk may be further compounded if there are underlying disordered eating (DE) and body dissatisfaction (BID) behaviors. Therefore, the objective was to examine the prevalence of and relationships between LEA, ED risk and behaviors, and BID among women collegiate athletes from a variety of sports.MethodsNational Collegiate Athletic Association women athletes (n = 115) participated from the following sports: basketball (n = 11), cross country (n = 23), lacrosse (n = 33), soccer (n = 18), volleyball (n = 8), and wrestling (n = 22). Athletes completed the low energy availability for females questionnaire (LEAF-Q), eating attitudes test (EAT-26), muscularity-oriented eating test (MOET), and body dissatisfaction items from the eating disorder examination questionnaire (EDE-Q) to assess LEA risk, DE behaviors, and BID, respectively. A Kruskal–Wallis H test assessed differences in LEAF-Q and EAT-26 scores by sport, and a Mann–Whitney U test determined differences in EAT-26, MOET, BID, and BMI by LEA status. Pearson correlation coefficients and linear regression analysis were used to examine relationships between LEA risk, ED risk, DE behaviors, and BID (p < 0.05).ResultsA total of 64% athletes were considered at risk for LEA with the highest prevalence observed in volleyball (100%) followed by wrestling (68%), cross country (57%), and soccer (56%). There was no difference in LEA risk across sport (p = 0.067), but risk of ED was highest in volleyball (12.5%) and wrestling (23%). Further, 81% and 84% athletes reported dissatisfaction with their body weight and shape, respectively. No differences were observed in EAT-26 (p = 0.131), MOET (p = 0.051), BID (p = 0.077), or BMI (p = 0.332) according to LEA risk. Very strong positive relationships existed between MOET and EAT-26 (p < 0.001, r = 0.760), MOET and BID (p < 0.001, r = 0.723), and EAT-26 and BID (p < 0.001, r = 0.707). Moderate positive relationships existed between MOET and BMI (p < 0.001, r = 0.329), EAT-26 and BMI (p < 0.05, r = 0.318), and BID and BMI (p < 0.001, r = 0.414). BID positively predicted EAT-26 (p < 0.001, R2 = 0.49) and MOET (p < 0.001, R2 = 0.50) scores.ConclusionA high prevalence of LEA and BID was observed across collegiate women’s sports, with DE behaviors strongly linked to body image concerns. Despite a high LEA risk among athletes, clinical eating disorder risk remained low, suggesting that undereating may often be unintentional. It is recommended educational interventions directed at proper nutritional practices be developed and improvements in physical and psychological well-being be focused on to enhance athletic performance and optimize health-related quality of life.

This study examined the risk of low energy availability (LEA) and eating disorders among elite adolescent female athletes from a mixed-sport cohort and ballet dancers in Singapore, where the accelerated biological needs of adolescent growth and maturation overlap with the pursuit of sport/ballet excellence and high-stakes academic testing. All of these are competing demands for adequate fuelling and seeking timely treatment, which consequently affect the risk of LEA. Eighty-nine participants (41 athletes, 48 dancers; age 16.00 [3.00] years old) were screened for the risk of LEA and eating disorders using the Low Energy Availability in Females Questionnaire (LEAF-Q) and Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), respectively. The main effects of athlete/ballet status and age (≤15 years old versus 15.1 years–18 years old) on LEAF-Q and BEDA-Q scores was be determined via Spearman’s correlation coefficient and linear regression analyses. The Mann–Whitney U test and Fisher’s exact test were used to compare the groups for the risk of LEA and ED. We observed that adolescent athletes and ballet dancers had a similar prevalence of being at risk of LEA (61.98% versus 54.17%, respectively, p = 0.529), with the risk of eating disorders absent in most of them. It appeared that the risk of LEA is likely of an unintentional nature in this study as the risk of ED was absent in 90.2% of the adolescent athletes/ballet dancers that were at risk of LEA. The age of the participants was significantly correlated with the risk of LEA, while the number of training hours was negatively correlated with the same factor. Age was also found to be negatively correlated with the number of training hours. The findings suggest that the risk of LEA in Singapore youth athletes and dancers are multifaceted, involving factors such as type of activity, age, and training hours. Targeted and tailored interventions and programmes are thus needed to promote adequate energy availability for optimal physical and psychological growth in sport and dance.

Data on menstrual health, energy availability, and injury risk in women undertaking extreme ultra-endurance expeditions remain limited. We conducted a prospective cohort study of the first all-female UK military team competing in a 3000-mile transatlantic rowing race, aiming to characterize menstrual function, low energy availability (LEA) risk, eating disorder (ED) risk, and injury profiles. Four female British Army personnel completed the 46-day race. Menstrual symptoms, injuries, and illnesses were recorded daily, while reproductive, inflammatory, biochemical, and hematological markers were assessed before and after the race. LEA and ED risk were evaluated using the Low Energy Availability in Females Questionnaire and Brief Eating Disorder in Athletes Questionnaire, respectively. Analyses were primarily descriptive. Three athletes experienced amenorrhea during the expedition, including one with previously regular cycles. The fourth reported intermittent abnormal bleeding associated with injury and illness and screened positive for LEA risk before and after the race. Another athlete screened positive for ED risk at both time points. Most biomarkers remained stable post-race, whereas reproductive hormones showed consistent reductions in follicle-stimulating hormone and luteinizing hormone in all four participants, alongside increased oestradiol. These findings, based on a sample of four athletes, suggest that menstrual function may be sensitive to sustained physiological stress in extreme ultra-endurance settings, and support prospective monitoring in female ultra-endurance, military, and expeditionary populations.