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The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad
  1. Anna Melin1,
  2. Åsa B Tornberg2,3,
  3. Sven Skouby4,
  4. Jens Faber5,
  5. Christian Ritz1,
  6. Anders Sjödin1,
  7. Jorunn Sundgot-Borgen6
  1. 1Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
  2. 2Physiotherapy, Department of Health Sciences, Lund University, Sweden
  3. 3Genetic & Molecular Epidemiology (GAME) Unit, Lund University Diabetes Center (LUDC) Clinical Research Center, Skåne University Hospital, Malmö, Sweden
  4. 4Endocrinological and Reproductive Unit, Department of Ob/Gyn, Herlev Hospital, Faculty of Health and Medical Sciences University of Copenhagen, Denmark
  5. 5Medical and Endocrinological Unit, Herlev Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
  6. 6Norwegian School of Sport Sciences, Oslo, Norway
  1. Correspondence to Anna Melin, Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1876 Frederiksberg, Denmark; anna.katarina.melin{at}


Background Low energy availability (EA) in female athletes with or without an eating disorder (ED) increases the risk of oligomenorrhoea/functional hypothalamic amenorrhoea and impaired bone health, a syndrome called the female athlete triad (Triad). There are validated psychometric instruments developed to detect disordered eating behaviour (DE), but no validated screening tool to detect persistent low EA and Triad conditions, with or without DE/ED, is available.

Aim The aim of this observational study was to develop and test a screening tool designed to identify female athletes at risk for the Triad.

Methods Female athletes (n=84) with 18–39 years of age and training ≥5 times/week filled out the Low Energy Availability in Females Questionnaire (LEAF-Q), which comprised questions regarding injuries and gastrointestinal and reproductive function. Reliability and internal consistency were evaluated in a subsample of female dancers and endurance athletes (n=37). Discriminant as well as concurrent validity was evaluated by testing self-reported data against measured current EA, menstrual function and bone health in endurance athletes from sports such as long distance running and triathlon (n=45).

Results The 25-item LEAF-Q produced an acceptable sensitivity (78%) and specificity (90%) in order to correctly classify current EA and/or reproductive function and/or bone health.

Conclusions The LEAF-Q is brief and easy to administer, and relevant as a complement to existing validated DE screening instruments, when screening female athletes at risk for the Triad, in order to enable early detection and intervention.

  • Assessing Validity and Reliability of Test of Physiological Parameters
  • Bone Density/Endocrine Status
  • Women in Sport
  • Nutrition

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