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Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport
  1. Kathryn E Ackerman1,2,
  2. Bryan Holtzman1,
  3. Katherine M Cooper1,
  4. Erin F Flynn1,
  5. Georgie Bruinvels3,4,
  6. Adam S Tenforde5,
  7. Kristin L Popp6,
  8. Andrew J Simpkin4,7,
  9. Allyson L Parziale1
  1. 1 Female Athlete Program, Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
  2. 2 Neuroendocrine Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3 UCL Division of Surgery and Interventional Science, University College London, London, UK
  4. 4 Orreco Ltd, National University of Ireland Business Innovation Centre, Galway, Ireland
  5. 5 Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
  6. 6 Division of Endocrinology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
  7. 7 Insight Centre for Data Analytics, National University of Ireland, Galway, Ireland
  1. Correspondence to Dr Kathryn E Ackerman, Female Athlete Program, Division of Sports Medicine, Boston Children’s Hospital, Boston MA 02115, USA; kathryn.ackerman{at}


Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC.

Objective The purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes.

Methods One thousand female athletes (15–30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05).

Results Athletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance.

Conclusion These findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.

  • relative energy deficiency
  • female athlete triad

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  • Contributors KEA: Conceptualisation of project, survey development, drafting and revision of manuscript, confirmation of final version to be published. BH: Contributions to data analysis, drafting and revision of manuscript. KMC and EFF: Contributions to data collection, revision of manuscript. GB: Contributions to advanced statistical analysis, drafting and revision of manuscript. AST: Contributions to survey development and revision of manuscript. KLP: Contributions to survey development, statistical consultation, drafting and revision of manuscript. AJS: Statistical consultation, drafting and revision of manuscript. ALP: Survey development and implementation, directed data collection, drafting and revision of manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval This study was approved by the Boston Children’s Hospital Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No unpublished data were used in the preparation of this manuscript.