Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance

Abstract

Low energy availability (EA) underpins the female and male athlete triad and relative energy deficiency in sport (RED-S). The condition arises when insufficient calories are consumed to support exercise energy expenditure, resulting in compromised physiological processes, such as menstrual irregularities in active females. The health concerns associated with longstanding low EA include menstrual/libido, gastrointestinal and cardiovascular dysfunction and compromised bone health, all of which can contribute to impaired sporting performance. This narrative review provides an update of our previous review on the prevalence and risk of low EA, within-day energy deficiency, and the potential impact of low EA on performance. The methods to assess EA remain a challenge and contribute to the methodological difficulties in identifying "true" low EA. Screening female athletic groups using a validated screening tool such as the Low Energy Availability in Females Questionnaire (LEAF-Q) has shown promise in identifying endurance athletes at risk of low EA. Knowledge of RED-S and its potential implications for performance is low among coaches and athletes alike. Development of sport and gender-specific screening tools to identify adolescent and senior athletes in different sports at risk of RED-S is warranted. Education initiatives are required to raise awareness among coaches and athletes of the importance of appropriate dietary strategies to ensure that sufficient calories are consumed to support training.

Keywords: health and performance; low energy availability; relative energy deficiency in sport.

Figure 1

Adapted from the relative energy deficiency in sport health model [1,2] with the inclusion of the male and female athlete triad and the exercise-hypogonadal male condition [6]. Abbreviations: EHMC: exercise-hypogonadal male condition; RED-S: relative energy deficiency in sport *the exact physiological mechanism inducing the reduction of testosterone in men is currently unclear; it is postulated to be a dysfunction within the hypothalamic-pituitary-testicular regulatory axis.

Figure 2

Male and female hypothalamic-pituitary-gonadal axes. Reprinted with permission: Artoria2e5 [CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/) *the reproductive components of the neuroendocrine system in the body are extremely sensitive to Low Energy Availability (LEA) in females [1,2] and the stress of exercise in males [6].