Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes

Abstract

Background A 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. Methods A 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. Results Thirty-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. Conclusion These questionnaires may be effective in identifying intentional energy restriction but less valuable in identifying inadvertently failure to increase energy intake with increased EEE.

Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes

“…The EDE-Q 6.0 was used to measure behavioral and cognitive symptoms of eating disorders the past 28 days (Fairburn and Beglin, 1994 ). The EDE-Q is based on the Eating Disorder Examination Interview which is considered as the gold standard in eating disorder assessment (Guest, 2000 ) and is one of the most used instruments to screen for eating disorder symptoms and risk of LEA/RED-S (Sim and Burns, 2021 ). It consists of 28 items which were divided into four subscales (restraint, eating concern, shape concern, and weight concern) and a global score averaging the subscales, used as cut-off for eating disorder pathology.…”

“…In female endurance athletes, the reported prevalence of LEA ranges between 8 and 56% when defined as energy availability <30 kcal/kg fat-free mass/day assessed with food and training records (Monyeki et al, 2014 ; Melin et al, 2015 ; Day et al, 2016 ; Muia et al, 2016 ; Heikura et al, 2017 ; Mccormack et al, 2019 ; Beermann et al, 2020 ). It has been suggested that assessing self-reported physiological symptoms of LEA using questionnaires, such as the Low Energy Availability in Females Questionnaire (LEAF-Q), provides a better assessment of the overall health status of an athlete than a snapshot of current energy availability using error-prone assessments of dietary energy intake and exercise energy expenditure (Heikura et al, 2017 ; Burke et al, 2018 ; Sim and Burns, 2021 ). When assessed as a LEAF-Q score ≥ 8, the LEA risk rate ranges from 31 to 80% in female endurance athletes (Melin et al, 2014 ; Folscher et al, 2015 ; Heikura et al, 2017 ; Carr et al, 2019 ; Ihalainen et al, 2021 ; Jesus et al, 2021 ).…”

Rehabilitation of the Postpartum Runner: A 4-Phase Approach

“…In addition to the normal physical therapy review of systems, the first step in determining readiness to run after childbirth should include a thorough physical therapy evaluation (review of systems, 16 musculoskeletal examination, [17][18][19] and questions on pelvic health 20,21 ) as well as screening for impact readiness (musculoskeletal tolerance to impact), pelvic health symptoms, physiological variables (sleep, fatigue, nutrition, and systems review [22][23][24][25][26] ), and performing a running gait analysis (see Supplemental Digital Content Appendix A, available at: http://links.lww. com/JWHPT/A76, and Supplemental Digital Content Figure 1, available at: http://links.lww.com/JWHPT/ A77).…”

Clinical application of monitoring indicators of female dancer health, including application of artificial intelligence in female hormone networks

“…Using this dance specific questionnaire as part of the onboarding process for dancers joining a dance company would be helpful and also as a yearly quantitative monitoring tool to support dancer health. Nevertheless, a recent review of questionnaires for low energy availability found that these were not so effective in assessing unintentional low energy availability with increased energy expenditure [8].…”