Female Athlete Triad Research Articles

Knowledge of the Female Athlete Triad and Relative Energy Deficiency in Sport Among Female Cross-Country Athletes and Support Staff.

Female endurance athletes exhibit an increased risk of the female athlete triad (Triad) and relative energy deficiency in sport (RED-S). The triad and RED-S are conditions that involve the health and performance consequences of low energy availability. Few authors of studies to date have assessed the knowledge that athletes, coaches, and athletic trainers (ATs) have regarding the Triad or RED-S. Proper education has been shown to be effective in increasing knowledge of sports medicine concerns for athletes, yet no known continuing education programs for the Triad or RED-S exist at collegiate institutions. To assess the knowledge, confidence, and educational impact of identifying, screening, treating, and preventing the Triad or RED-S. Cross-sectional study. An evidence-based online survey was developed and administered via Qualtrics. Female collegiate cross-country athletes (n = 275, age = 20 ± 1 years), collegiate cross-country coaches (n = 55, age = 34 ± 9 years), and ATs working with cross-country teams (n = 30, age = 36 ± 11 years). Knowledge, confidence, and educational impact scores were assessed among groups using analysis of variance. Independent t tests were calculated to determine differences in impact scores between people who had or had not received education on the topic. Female cross-country athletes' total knowledge, confidence, and educational impact scores (mean scores = 25.00 ± 5.27, 95.42 ± 28.83, and 18.81 ± 7.05, respectively) were different from those of coaches (mean scores = 26.92 ± 5.02, 111.35 ± 24.14, and 22.41 ± 6.33, respectively) and ATs (mean scores = 28.66 ± 4.02, 117.67 ± 22.53, and 23.93 ± 5.69, respectively; P < .05). Knowledge, confidence, and educational impact scores regarding Triad or RED-S were lowest in female cross-country athletes and highest in ATs. These findings support the call for education, which should be regarded as the primary tool for increasing knowledge, to improve the prevention and treatment of the Triad or RED-S.

Analysis of female athlete triad in adolescent female Bharatanatyam dancer using low energy availability questionnaire

Background: The aim of this study was to assess adolescent Bharatanatyam female dancers for female athlete triad (FAT) which includes low energy availability (LEA), musculoskeletal injury profile, gastrointestinal function and menstrual dysfunction using in females LEAF questionnaire.Methods: The approval was taken from the institutional review board of K. J. Somaiya college of physiotherapy. A pre-designed, pre-validated, questionnaire was distributed in the google form layout, among population according to the inclusion and exclusion criteria; asking for consent to confirm their willingness to participate voluntarily. After confirmation, the participants were directed to complete the LEAF questionnaire, maintaining their confidentiality. Data collected was analyzed using descriptive statistics.Results: A total of 82 participants took part in this study. The cumulative incidence of musculoskeletal injuries is about 50%. 35.4% of population experienced gaseous or bloated abdomen apart from menstrual function and 32.9% experienced cramps or stomach ache which were not related to menses. 7.3% of population reported primary amenorrhea, 35.8% reported secondary amenorrhea and 18.6% reported oligomenorrhea. Thus, overall, 34.5% population reported all the components of FAT.Conclusions: Prevalence of LEA in Bharatanatyam female dancers was reported amongst which prevalence of musculoskeletal injuries was high amongst the participants followed by menstrual dysfunction. LEA might have been interpreted as a usual or needed procedure to achieve better performance in past, but now it is recognized that it may lead to several negative consequences. Therefore, timely screening of dancers along with adequate training protocol will help alleviate LEA.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis.

The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners.

To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD). Multiyear cross-sectional study. One hundred-mile ultramarathon. Competing runners were recruited in 2018 and 2019. Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only). A Triad Cumulative Risk Assessment Score was calculated for each participant. One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk. Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.

Commentaries on Viewpoint: Fragile bones of elite cyclists: to treat or not to treat?

Commentaries on Viewpoint: Fragile bones of elite cyclists: to treat or not to treat?

TIME LOSS INJURIES AMONG FORMER COLLEGIATE GYMNASTS: THE INFLUENCE OF FEMALE ATHLETE TRIAD SYMPTOMS

Background:Female college gymnasts have one of the highest injury rates in the NCAA and are at risk for female athlete triad syndrome. While female athlete triad syndrome leads to bone stress injuries, little research has been done on specific injury location and type.Purpose:Our objective was to compare injuries sustained during gymnastics between former collegiate gymnasts who did and did not report experiencing symptoms of Female Athlete Triad Syndrome during college, including disordered eating (DE) or menstrual irregularity (MI).Methods:465 former collegiate gymnasts completed an online survey distributed via social media. Participants were grouped based on mensural irregularity and whether they had a history of DE/ED of not. We compared injury outcomes (time-loss injuries and injuries resulting in surgery) and injury locations between groups using Chi-square analyses.Results:A significantly greater proportion of those who reported MI during college reported a time-loss wrist/hand and injury during gymnastics compared to eumenorrheic gymnasts (Table 1).A significantly greater proportion of those who reported MI during college sustained an injury that required surgery relative to those who reported regular periods during college (52% vs 65%, p=0.009). Specifically, they reported a greater proportion of hip/pelvis (2% vs. 7%, p=0.02) and leg/ankle/foot surgeries (23% vs. 33%, p=0.009).A significantly greater proportion of the group who reported DE during college reported a time-loss gymnastics injury during college that did not require surgery or retirement, relative to those who did not report DE (78% vs 66%, p= 0.005) (Table 2). Specifically, they reported a greater proportion of spine (25% vs. 14%, p=0.002), hip/pelvis (8% vs. 2%, p=0.001), and leg/ankle/foot injuries (53% vs. 41%, p=0.01).There was a significantly greater proportion of gymnasts who reported DE during college who sustained a hip/pelvis (7% vs. 3%, p=0.04) and leg/ankle/foot injury (34% vs. 23%, p=0.02) requiring surgery compared to those who did not report DE during college.onclusion:College gymnasts who experienced triad symptoms were more likely to experience a time-loss injury, or have an injury requiring surgery. Clinicians and providers should be aware of the association between injuries and DE and MI in gymnasts. Early intervention for athletes with triad symptoms should be undertaken to decrease the risk of musculoskeletal injury.

Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities.

The symptom similarities between training-overload (with or without an Overtraining Syndrome (OTS) diagnosis) and Relative Energy Deficiency in Sport (RED-S) are significant, with both initiating from a hypothalamic-pituitary origin, that can be influenced by low carbohydrate (CHO) and energy availability (EA). In this narrative review we wish to showcase that many of the negative outcomes of training-overload (with, or without an OTS diagnosis) may be primarily due to misdiagnosed under-fueling, or RED-S, via low EA and/or low CHO availability. Accordingly, we undertook an analysis of training-overload/OTS type studies that have also collected and analyzed for energy intake (EI), CHO, exercise energy expenditure (EEE) and/or EA. Eighteen of the 21 studies (86%) that met our criteria showed indications of an EA decrease or difference between two cohorts within a given study (n = 14 studies) or CHO availability decrease (n = 4 studies) during the training-overload/OTS period, resulting in both training-overload/OTS and RED-S symptom outcomes compared to control conditions. Furthermore, we demonstrate significantly similar symptom overlaps across much of the OTS (n = 57 studies) and RED-S/Female Athlete Triad (n = 88 studies) literature. It is important to note that the prevention of under-recovery is multi-factorial, but many aspects are based around EA and CHO availability. Herein we have demonstrated that OTS and RED-S have many shared pathways, symptoms, and diagnostic complexities. Substantial attention is required to increase the knowledge and awareness of RED-S, and to enhance the diagnostic accuracy of both OTS and RED-S, to allow clinicians to more accurately exclude LEA/RED-S from OTS diagnoses.

Nutritional Considerations for Female Athletes in Weight Category Sports

ABSTRACT Weight making can be described as the process of reducing body mass in events where aesthetics, propulsion or the requirement to meet a specific weight category limit, are considered to be of competitive importance. Cross sectional research specifically focussed on weight category sports, has highlighted behaviours and practices that are similar in athletes of both sexes. Regardless of this and despite parallel participation in weight category sporting events, females are drastically underrepresented in studies examining body mass loss interventions across both chronic and acute timeframes. However, it has been well characterised that these types of body mass loss strategies can be causative of low energy availability, leading to consequences of female athlete triad and relative energy deficiency in sports. Furthermore, female-specific body composition and physiological systems modulated by the anterior pituitary and ovarian hormones within the menstrual cycle or use of hormonal contraception, can lead to potential outcomes which need to be considered carefully, particularly when employing acute weight loss strategies that are often utilised by weight making athletes. Therefore, the aim of this article serves to review the aforementioned issues, whilst offering practical recommendations via initial assessment, chronic/acute interventions and refeeding/recovery plans to help support the implementation of body mass loss strategies in the context of weight making specifically with female athletes.

Translational Medicine and Exercise Prescription (TMEP): Advancing the Era of Exercise Medicine

Translational Medicine and Exercise Prescription (TMEP): Advancing the Era of Exercise Medicine

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play.

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

CULTURAL ADAPTATION AND VALIDATION OF THE LOW ENERGY AVAILABILITY IN FEMALES QUESTIONNAIRE (LEAF-Q)

ABSTRACT Introduction: Low energy availability, amenorrhea and osteoporosis make up the Female Athlete Triad observed in physically active females and athletes. The Low Energy Availability in Females Questionnaire (LEAF-Q) was created with the purpose of identifying female athletes at risk for the Female Athlete Triad. Objective: To translate and culturally adapt the LEAF-Q for Brazilian Portuguese and validate it in a group of Brazilian athletes. Methods: The first stage of the study consisted of translation, cultural adaptation and content validation of the questionnaire in 20 athletes. In the second stage, for the test-retest reliability analysis and the construct validation, the final adapted version was applied in a sample of 127 athletes from various sports disciplines, 54 of whom responded to the questionnaire on a second occasion. For the test-retest reliability analysis, the intraclass correlation coefficient (ICC) was calculated and the paired t-test, McNemar’s test and Bland-Altman plot were carried out. The construct validation modeled by known or contrasted groups was carried out by comparing the mean LEAF-Q scores of group 1 (athletes who practiced weight-sensitive sports) with those of group 2 (athletes who practiced team sports) using the Student’s t test. Results: The Brazilian version of the LEAF-Q showed excellent test-retest reliability, with an ICC of 0.92. The construct validity by known or contrasted groups was confirmed after demonstrating that athletes who practiced weight-sensitive sports had a higher LEAF-Q mean score than athletes who practiced team sports (p≤0.05). Conclusion: The Brazilian version of the LEAF-Q is an important tool, which presented textual and cultural adequacy, proved to be reliable in terms of test-retest reliability, and presents evidence of validity to investigate the risk of the triad. Level of evidence II; Diagnostic Studies – Investigating a diagnostic instrument .

BODY COMPOSITION AMONG UNIVERSITY FEMALE ATHLETES OF TEAM SPORTS

ABSTRACT Introduction: The assessment of body composition in female athletes of different sports is important for health monitoring. Objective: To compare body composition in university athletes of different team sports (indoor soccer, flag football and volleyball). Methods: A cross-sectional study carried out with 45 female athletes, aged 18 to 35 years (22.8 ± 3.55). The dependent variables were body fat mass (FM) and fat-free mass (FFM) measured by air displacement plethysmography. Bone mineral content, adjusted for height (BMC/height) and bone mineral density (BMD), were measured by dual energy X-ray absorptiometry. The independent variable was sport [flag football (n = 12); indoor soccer (n = 20); volleyball (n = 13)] and the covariates were age (complete years), training volume (minutes per week) and length of time playing the sport (complete years). Analysis of covariance was used. Results: Adjusting the model for covariates, volleyball athletes (19.27 kg ± 2.20) presented higher FM values compared to the flag football (16.00 kg ± 1.70) and indoor soccer players (12.20 kg ± 1.30). There was no significant difference in FFM, BMC/height and total BMD between sports, even after adjusting for covariates. Conclusion: Volleyball athletes presented higher FM compared to flag football and indoor soccer athletes. There were no differences in FFM, BMC/height and BMD among the players of the different team sports. This study can help coaches and other sports professionals to prevent injuries to athletes in sports such as higher FM (volleyball), or to prevent diseases such as menstrual irregularities, which are common in athletes who may have low levels of body fat (indoor soccer players), this being one of the risk factors for the female athlete triad (eating disorders, menstrual irregularities and low BMD). Level of evidence III; Retrospective comparative study .

Commentary in Response to “A Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in Sport”

Commentary in Response to “A Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in Sport”

Embracing Change: The Evolving Science of Relative Energy Deficiency in Sport.

Embracing Change: The Evolving Science of Relative Energy Deficiency in Sport.

Performance and Health Decrements Associated With Relative Energy Deficiency in Sport for Division I Women Athletes During a Collegiate Cross-Country Season: A Case Series.

The purpose of this case series was to evaluate the presence of low Energy Availability (EA) and its impact on components of Relative Energy Deficiency in Sport (RED-S) in a population of female collegiate runners. Seven female NCAA Division I athletes (age: 22.3 ± 1.5 yrs; height: 169.7 ± 5.7 cm; weight: 58.3 ± 4.1 kg) were tracked from August until February, covering the beginning (Pre XC), end (Post XC) of their competitive cross country season, and beginning of the following track season (Pre Track). The athletes were assessed for female athlete triad (Triad) risk, energy availability, body composition, resting metabolic rate (RMR), nutritional intake, and blood markers (including vitamin D, ferritin, and triiodothyronine (T3)). From Pre XC to Post XC there were no significant differences in body mass, fat free mass or body fat percentage. At Pre XC, mean EA was 31.6 ± 13.3 kcal/kg FFM∙d-1. From Post XC to Pre Track, there was a significant increase in body mass (59.1 ± 5.1 to 60.6 ± 5.7 kg, p<0.001,d=0.27). From Post XC to Pre Track, there was a significant increase in RMR (1466 ± 123.6 to 1614.6 ± 89.1 kcal·d-1, p<0.001,d=2.6). For 25(OH) vitamin D, there was a significant reduction from Pre XC to Post XC (44.1 ± 10.6 vs 39.5 ± 12.2 ng·mL-1, p=0.047,d=-0.4), and a significant increase from Post XC to Pre Track (39.5 ± 12.2 vs. 48.1 ± 10.4 ng·mL-1, p=0.014,d=0.75). For ferritin, there was a trend towards a decrease from Pre XC to Post XC (24.2 ± 13.2 vs. 15.7 ± 8.8 ng·mL-1, p=0.07, d=-0.75), as well as a trend toward an increase from Post XC to Pre Track (15.7 ± 8.8 vs. 34.1 ± 18.0 ng·mL-1, p=0.08, d=1.3). No differences in T3 were observed across time points. Average Triad risk score was 2.3 ± 1.4. Notably, 5 of 7 athletes met criteria for moderate risk. Despite many athletes meeting criteria for low EA and having elevated Triad risk assessment scores, most were able to maintain body mass and RMR. One athlete suffered severe performance decline and a reduced RMR. Surprisingly, she was the only athlete above the recommended value for ferritin. Following increased nutritional intake and reduced training volume, her performance and RMR recovered. Changes in body mass and body composition were not indicative of the presence of other concerns associated with RED-S. This exploratory work serves as a guide for future, larger studies for tracking athletes, using RMR and nutritional biomarkers to assess RED-S.

A Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in Sport.

Relative energy deficiency in sport (RED-S) can result in negative health and performance outcomes in both male and female athletes. The underlying etiology of RED-S is low energy availability (LEA), which occurs when there is insufficient dietary energy intake to meet exercise energy expenditure, corrected for fat-free mass, leaving inadequate energy available to ensure homeostasis and adequate energy turnover (optimize normal bodily functions to positively impact health), but also optimizing recovery, training adaptations, and performance. As such, treatment of RED-S involves increasing energy intake and/or decreasing exercise energy expenditure to address the underlying LEA. Clinically, however, the time burden and methodological errors associated with the quantification of energy intake, exercise energy expenditure, and fat-free mass to assess energy availability in free-living conditions make it difficult for the practitioner to implement in everyday practice. Furthermore, interpretation is complicated by the lack of validated energy availability thresholds, which can result in compromised health and performance outcomes in male and female athletes across various stages of maturation, ethnic races, and different types of sports. This narrative review focuses on pragmatic nonpharmacological strategies in the treatment of RED-S, featuring factors such as low carbohydrate availability, within-day prolonged periods of LEA, insufficient intake of bone-building nutrients, lack of mechanical bone stress, and/or psychogenic stress. This includes the implementation of strategies that address exacerbating factors of LEA, as well as novel treatment methods and underlying mechanisms of action, while highlighting areas of further research.

The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S).

In a healthy athlete, the caloric intake is sufficient for sports energy needs and body physiological functions, allowing a balance between energy availability, bone metabolism, and menstrual cycle. On the other hand, an imbalance caused by low energy availability due to a restrictive diet, eating disorders or long periods of energy expenditure leads to multisystemic deregulation favoring the essential functions of the body. This phenomenon, described as the female athlete triad, occurs in a considerable percentage of high-performance athletes, with harmful consequences for their future. The present review was carried out based on a critical analysis of the most recent publications available and aims to provide a global perception of the topic relative energy deficit in sport (RED-S). The objective is to promote the acquisition of more consolidated knowledge on an undervalued theme, enabling the acquisition of preventive strategies, early diagnosis and/or appropriate treatment.

Low energy availability in female athletes: From the lab to the field

ABSTRACT Decades of laboratory research have shown impairments to several body systems after only 4–5 days of strictly controlled consistent low energy availability (LEA); where energy availability (EA) = Energy Intake (EI) − Exercise Energy Expenditure (EEE)/Fat-Free Mass. Meanwhile, cross-sectional reports exist on the interrelatedness of LEA, menstrual dysfunction and impaired bone health in females (the Female Athlete Triad). These findings have demonstrated that LEA is the key underpinning factor behind a broader set of health and performance outcomes, recently termed as Relative Energy Deficiency in Sport (RED-S). There is utmost importance of early screening and diagnosis of RED-S to avoid the development of severe negative health and performance outcomes. However, a significant gap exists between short-term laboratory studies and cross-sectional reports, or clinically field-based situations, of long-term/chronic LEA and no definitive, validated diagnostic tests for RED-S exist. This review aims to highlight methodological challenges related to the assessment of the components of EA equation in the field (e.g. challenges with EI and EEE measures). Due to the uncertainty of these parameters, we propose the use of more chronic “objective” markers of LEA (i.e. blood markers). However, we note that direct extrapolations of laboratory-based outcomes into the field are likely to be problematic due to potentially poor ecological validity and the extreme variability in most athlete’s daily EI and EEE. Therefore, we provide a critical appraisal of the scientific literature, highlighting research gaps, and a potential set of leading objective RED-S markers while working in the field. Highlights Direct application of short-term laboratory-based findings in the field is problematic. Calculation of energy availability (EA) in the field is methodologically challenging and prone to errors. The use of several biomarkers may allow the detection of early exposure to low EA in the female athlete.

Energy deficiency, menstrual disorders, and low bone mineral density in female athletes: a systematic review.

Low energy availability (LEA) may lead to menstrual disorders and low bone mineral density, predisposing to the female athlete triad. The primary aim of the present review was to systematically investigate the impact of chronic strenuous exercise on the energy status of professional female athletes compared to sedentary, recreationally active controls as concerns their menstrual status and bone mineral density (BMD). A secondary aim was evaluation of the combined prevalence of the components of the female athlete triad in athletes as compared to non-athletes. A systematic review was conducted from 2007 to February 2018. The inclusion and exclusion criteria of the studies were established in advance of the literature search according to the clinical inquiry and the study design. Four studies were included in this systematic review. The female athlete triad was more prevalent in professional athletes compared to non-athletes. The same results were obtained for both LEA and menstrual disorders. However, BMD and Z-scores showed high heterogeneity among the studies. Both female athletes and non-athletes are prone to LEA and subsequent menstrual disorders and low BMD or osteoporosis. Future studies are needed to examine energy availability in elite female athletes as well as in non-athletes.

The relationship between the female athlete triad and injury rates in collegiate female athletes.

BackgroundThis study aimed to clarify the relationship between the triad risk assessment score and the sports injury rate in 116 female college athletes (average age, 19.8 ± 1.3 years) in seven sports at the national level of competition; 67 were teenagers, and 49 were in their 20s.MethodsThose with menstrual deficiency for >3 months or <6 menses in 12 months were classified as amenorrheic athletes. Low energy availability was defined as adolescent athletes having a body weight <85% of ideal body weight, and for adult athletes in their 20s, a body mass index ≤17.5 kg/m2. Bone mineral density (BMD) was measured on the heel of the right leg using an ultrasonic bone densitometer. Low BMD was defined as a BMD Z-score <−1.0. The total score for each athlete was calculated. The cumulative risk assessment was defined as follows: low risk (a total score of 0–1), moderate risk (2–5), and high risk (6). The injury survey recorded injuries referring to the injury survey items used by the International Olympic Committee.ResultsIn swimming, significantly more athletes were in the low-risk category than in the moderate and high-risk categories (p = 0.004). In long-distance athletics, significantly more athletes were in the moderate-risk category than in the low and high-risk categories (p = 0.004). In the moderate and high-risk categories, significantly more athletes were in the injury group, whereas significantly more athletes in the low-risk category were in the non-injury group (p = 0.01). Significantly more athletes at moderate and high-risk categories had bone stress fractures and bursitis than athletes at low risk (p = 0.023).DiscussionThese results suggest that athletes with relative energy deficiency may have an increased injury risk.