Researchrepository.ucd.ie



TITLE PAGETitle of Article: Low energy availability in athletes: a review of prevalence, dietary patterns, physiological health and sports performance Author:Danielle Logue, Woodview House, University College Dublin, Belfield, Dublin 4, Ireland. Email: Danielle.logue@ucdconnect.ieTelephone: 00 353 86 730 6607Co-authors: Dr. Sharon M. Madigan, Sport Ireland Institute, Sports Campus Ireland, Abbotstown, Dublin, Ireland.Associate Professor Eamonn Delahunt, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.Assistant Professor Mirjam Heinen, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.Sarah-Jane Mc Donnell MSc, Sport Ireland Institute, Sports Campus Ireland, Abbotstown, Dublin, Ireland.Associate Professor Clare Corish, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland. Word count: 6519 words (excluding title page, abstract, references, figures and tables)ABSTRACTIn a high performance sports environment, athletes can present with low energy availability for a variety of reasons; these range from not consuming enough food for their specific energy requirements to disordered eating behaviors. Both male and female high performance athletes are at risk of low energy availability. Longstanding low energy availability can cause unfavourable physiological and psychological outcomes which have the potential to impair an athlete’s health and sports performance. This narrative review summarizes the prevalence of low energy availability and its associations with athlete health and sports performance. It is evident in the published scientific literature that the methods used to determine low energy availability and its associated health outcomes vary. This contributes to poor recognition of the condition and its sequelae. This review also identifies interventions designed to improve health outcomes in athletes with low energy availability and indicates areas which warrant further investigation. While return-to-play guidelines have been developed for healthcare professionals to manage low energy availability in athletes, behavioral interventions to prevent the condition and manage its associated negative health and performance outcomes are required.(Word count: 180)KEY POINTSAdvancements in research have revealed low energy availability as an unfavourable factor involved in the disruption of physiological processes that may affect health and sports performance.Research is required to establish a standardised method to measure energy availability and the identification of low energy availability cut-offs is warranted for both male and females athletes.Investigations into health outcomes, injury and illness in athletes with relative energy deficiency/low energy availability are needed to define potential negative effects and ensure optimal health and sports performance. IntroductionOver the last thirty years, considerable research has been undertaken to understand the cause(s) of menstrual dysfunction and low bone mineral density (BMD), both of which are frequently observed amongst high performance female athletes. It is widely acknowledged that low energy availability (LEA) is the main factor underpinning these unfavourable health outcomes. LEA occurs when an individual has insufficient energy to support normal physiological function, after the cost of energy expended during exercise has been removed. This may occur with/without an eating disorder (ED) or disordered eating (DE) behavior and can have a negative effect on an athlete’s health PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb3Vja3M8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [1, 2]. The female athlete triad (TRIAD) ADDIN EN.CITE <EndNote><Cite><Author>Nattiv</Author><Year>2007</Year><IDText>American College of Sports Medicine position stand. The female athlete triad</IDText><DisplayText>[3]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2007</year></dates><keywords><keyword>Amenorrhea/epidemiology/etiology</keyword><keyword>*Consensus</keyword><keyword>Energy Intake</keyword><keyword>Feeding and Eating Disorders/epidemiology/etiology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/complications/diagnosis/pathology/prevention &amp;</keyword><keyword>control/therapy</keyword><keyword>Humans</keyword><keyword>Osteoporosis/epidemiology/etiology</keyword><keyword>Risk Factors</keyword><keyword>*Societies</keyword><keyword>*Sports Medicine</keyword><keyword>United States/epidemiology</keyword></keywords><isbn>0195-9131 (Print)&#xD;0195-9131</isbn><titles><title>American College of Sports Medicine position stand. The female athlete triad</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>1867-82</pages><number>10</number><contributors><authors><author>Nattiv, A.</author><author>Loucks, A. B.</author><author>Manore, M. M.</author><author>Sanborn, C. F.</author><author>Sundgot-Borgen, J.</author><author>Warren, M. P.</author></authors></contributors><edition>2007/10/03</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><remote-database-provider>NLM</remote-database-provider><rec-number>126</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>17909417</accession-num><electronic-resource-num>10.1249/mss.0b013e318149f111</electronic-resource-num><volume>39</volume></record></Cite></EndNote>[3] demonstrates the interrelationship between LEA (with/without ED), menstrual dysfunction and poor bone health; it is characterised by a continuum, whereby an individual can move from optimal health to disease, with clinical EDs, functional hypothalamic amenorrhea (FHA) and impaired bone health considered the most harmful characteristics PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXR0aXY8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [3, 4].Little is known about the physiological effects of LEA in male athletes although it is widely acknowledged that investigation of the physiological issues associated with LEA in this sex group is necessary PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PdGlzPC9BdXRob3I+PFllYXI+MTk5NzwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [1, 3, 4, 6, 7]. This concept has recently been referred to as relative energy deficiency in sport (RED-S). For example, an energy deficient athlete may maintain normal body mass due to physiological adaptations such as decreased resting metabolic rate (RMR); thus, an athlete can be weight stable yet energy deficient. Irrespective of the terminology used, TRIAD or RED-S, both depict LEA as the primary causative factor PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TbGF0ZXI8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [8, 9]. Previous research highlights the need to identify the prevalence of LEA, particularly among male athletes, and understand the consequences of LEA on physiological function ADDIN EN.CITE <EndNote><Cite><Author>Tenforde</Author><Year>2016</Year><IDText>Parallels with the Female Athlete Triad in Male Athletes</IDText><DisplayText>[7]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2016</year></dates><isbn>0112-1642</isbn><titles><title>Parallels with the female athlete triad in male athletes</title><secondary-title>Sports Med</secondary-title><alt-title>Sports medicine (Auckland, N.Z.)</alt-title></titles><pages>171-82</pages><number>2</number><contributors><authors><author>Tenforde, A. S.</author><author>Barrack, M. T.</author><author>Nattiv, A.</author><author>Fredericson, M.</author></authors></contributors><edition>2015/10/27</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><remote-database-provider>NLM</remote-database-provider><rec-number>28</rec-number><last-updated-date format="utc">1499189417</last-updated-date><accession-num>26497148</accession-num><electronic-resource-num>10.1007/s40279-015-0411-y</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[7]. LEA may promote susceptibility to respiratory tract infections and adversely affect blood lipid levels. This review discusses what LEA is, how it is currently measured and the lack of research on potential biomarkers of energy deficiency. Furthermore, the physiological and health issues, dietary patterns and potential impact on sports performance associated with LEA are examined, and interventions to minimise the deleterious effects of LEA on athletes’ health are critically evaluated.MethodologyThis is a narrative review which was conducted using targeted internet searches, for example, PubMed, Google Scholar and Web of Science. Combinations of the following key search terms were included: athlete, bone, energy availability (EA), energy intake (EI), immune, injury, low energy availability, nutrition education/diet intervention, relative energy deficiency in sport and weight loss. Articles were considered if they were available in full text, were written in English, and were conducted among trained or exercising human subjects. Only studies that quantified EA by assessing EI, exercise energy expenditure (EEE) and body composition within the text of the manuscript were included in this review. Reference lists of articles retrieved were also reviewed. No time limit on retrieval of articles was set. Animal studies were not included. The quality and strength of the supporting evidence was graded according to the criteria of the Scottish Intercollegiate Guidelines Network (SIGN) ADDIN EN.CITE <EndNote><Cite><Author>Harbour</Author><Year>2001</Year><IDText>A new system for grading recommendations in evidence based guidelines</IDText><DisplayText>[10]</DisplayText><record><dates><pub-dates><date>Aug 11</date></pub-dates><year>2001</year></dates><keywords><keyword>Evidence-Based Medicine/*methods</keyword><keyword>Meta-Analysis as Topic</keyword><keyword>Practice Guidelines as Topic/*standards</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Review Literature as Topic</keyword></keywords><isbn>0959-8138 (Print)&#xD;0959-535x</isbn><custom2>PMC1120936</custom2><titles><title>A new system for grading recommendations in evidence based guidelines</title><secondary-title>BMJ</secondary-title><alt-title>BMJ (Clinical research ed.)</alt-title></titles><pages>334-6</pages><number>7308</number><contributors><authors><author>Harbour, R.</author><author>Miller, J.</author></authors></contributors><edition>2001/08/11</edition><language>eng</language><added-date format="utc">1498918532</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Scottish Intercollegiate Guidelines Network, Royal College of Physicians of Edinburgh, Edinburgh EH2 1JQ. r.harbour@rcpe.ac.uk</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>394</rec-number><last-updated-date format="utc">1499277651</last-updated-date><accession-num>11498496</accession-num><volume>323</volume></record></Cite></EndNote>[10]. Energy availabilityEA has been defined as the amount of ingested energy remaining for bodily function and physiological processes such as growth, immune function, locomotion and thermoregulation after the energy required for exercise/training has been removed ADDIN EN.CITE <EndNote><Cite><Author>Nattiv</Author><Year>2007</Year><IDText>American College of Sports Medicine position stand. The female athlete triad</IDText><DisplayText>[3]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2007</year></dates><keywords><keyword>Amenorrhea/epidemiology/etiology</keyword><keyword>*Consensus</keyword><keyword>Energy Intake</keyword><keyword>Feeding and Eating Disorders/epidemiology/etiology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/complications/diagnosis/pathology/prevention &amp;</keyword><keyword>control/therapy</keyword><keyword>Humans</keyword><keyword>Osteoporosis/epidemiology/etiology</keyword><keyword>Risk Factors</keyword><keyword>*Societies</keyword><keyword>*Sports Medicine</keyword><keyword>United States/epidemiology</keyword></keywords><isbn>0195-9131 (Print)&#xD;0195-9131</isbn><titles><title>American College of Sports Medicine position stand. The female athlete triad</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>1867-82</pages><number>10</number><contributors><authors><author>Nattiv, A.</author><author>Loucks, A. B.</author><author>Manore, M. M.</author><author>Sanborn, C. F.</author><author>Sundgot-Borgen, J.</author><author>Warren, M. P.</author></authors></contributors><edition>2007/10/03</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><remote-database-provider>NLM</remote-database-provider><rec-number>126</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>17909417</accession-num><electronic-resource-num>10.1249/mss.0b013e318149f111</electronic-resource-num><volume>39</volume></record></Cite></EndNote>[3]. Figure 2 outlines how energy availability is calculated and the recommended EA thresholds for physically active females. These thresholds originated from experiments in small groups of untrained females that determined the effects of exercise stress and EA on luteinizing hormone (LH) pulsatility and markers of bone turnover PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb3Vja3M8L0F1dGhvcj48WWVhcj4xOTk4PC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [12, 15, 16], a randomised controlled trial highlights that varying levels of energy deficiency predict frequency, but not severity, of menstrual disturbances PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaWxsaWFtczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

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ADDIN EN.CITE.DATA [17]. Further research is warranted to accurately determine LEA cut-offs, particularly for the athletic population. Studies conducted outside the laboratory setting highlight the complexity in determining EA, which requires measures of EI, EEE and body composition PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWVkPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [11, 12]. Furthermore, non-purposeful physical activity expenditure needs to be accounted for to accurately reflect changes in the energy available for physiological processes. Moreover, current recommendations are only pertinent to females and, to our knowledge, no EA recommendations have been proposed for male athletes. Low Energy Availability, Eating Disorders and Disordered Eating behaviorsThere are many detrimental effects of decreased EA; those most widely acknowledged are the perturbation of reproductive function and bone metabolism when EA falls below 30 kcal/kg FFM/day PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JaGxlPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [12, 14]. LEA may be intentional, due to a clinical ED and/or DE behavior. It can also occur unintentionally, due to poor awareness of appropriate sport-specific fuelling or re-fuelling requirements PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXR0aXY8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [19, 20]. Those doing so report similar prevalence in both sexes ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2013</Year><IDText>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</IDText><DisplayText>[20]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2013</year></dates><keywords><keyword>*Athletes</keyword><keyword>Body Composition</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Humans</keyword><keyword>*Self Report</keyword></keywords><isbn>1715-5312</isbn><titles><title>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</title><secondary-title>Appl Physiol Nutr Metab</secondary-title><alt-title>Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme</alt-title></titles><pages>725-33</pages><number>7</number><contributors><authors><author>Koehler, K.</author><author>Achtzehn, S.</author><author>Braun, H.</author><author>Mester, J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2013/08/29</edition><language>eng</language><added-date format="utc">1469027227</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Institute of Biochemistry, German Sport University, Am Sportpark Muengersdorf 6, D-50933 Cologne, Germany. k.koehler@biochem.dshs-koeln.de</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>12</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23980730</accession-num><electronic-resource-num>10.1139/apnm-2012-0373</electronic-resource-num><volume>38</volume></record></Cite></EndNote>[20]. Indeed, the existence of widespread energy deficiency is evident across an array of sports, not just in those that specifically emphasize leanness PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWVkPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [18, 20-22]. Nonetheless, accurate estimates of prevalence are problematic due to variability in the sports and groups of athletes (e.g. performance level and age) investigated, as well as small study sample sizes (range: 10-352). On the basis of the best available evidence (Grade B: consistent, low quality evidence), further research is needed to establish a better understanding of the prevalence of LEA in both sexes across all sports. To date, no gold standard assessment of EA has been agreed. Different methods have been used to assess EI and EEE as part of an EA assessment and to investigate the links with DE, reproductive function, BMD, body composition and biochemical variables. Some examples are outlined in Table 2. Unfortunately, many methodological issues prevail. Self-reported food and exercise logs lack accuracy, yet are widely used to measure EA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WaW5lcjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [19, 20, 23-30]. Reduced compliance with self-reported dietary intake has been documented after 4 days ADDIN EN.CITE <EndNote><Cite><Author>Magkos</Author><Year>2003</Year><IDText>Methodology of dietary assessment in athletes: concepts and pitfalls</IDText><DisplayText>[31]</DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2003</year></dates><keywords><keyword>*Diet</keyword><keyword>Diet Records</keyword><keyword>Drinking</keyword><keyword>Energy Intake</keyword><keyword>Female</keyword><keyword>Guidelines as Topic</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Recall</keyword><keyword>*Nutrition Assessment</keyword><keyword>Nutritional Requirements</keyword><keyword>Seasons</keyword><keyword>Sports/*physiology</keyword></keywords><isbn>1363-1950 (Print)&#xD;1363-1950</isbn><titles><title>Methodology of dietary assessment in athletes: concepts and pitfalls</title><secondary-title>Curr Opin Clin Nutr Metab Care</secondary-title><alt-title>Current opinion in clinical nutrition and metabolic care</alt-title></titles><pages>539-49</pages><number>5</number><contributors><authors><author>Magkos, F.</author><author>Yannakoulia, M.</author></authors></contributors><edition>2003/08/13</edition><language>eng</language><added-date format="utc">1482489636</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Laboratory of Nutrition and Clinical Dietetics, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>348</rec-number><last-updated-date format="utc">1482489636</last-updated-date><accession-num>12913671</accession-num><electronic-resource-num>10.1097/01.mco.0000087969.83880.97</electronic-resource-num><volume>6</volume></record></Cite></EndNote>[31]. Some researchers have tried to overcome this difficulty by educating athletes on the importance of keeping accurate dietary logs and regularly checking these PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWVkPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [18, 32]. Furthermore, the definition of “exercise” varies, highlighting the need for a standardised definition. Few studies use adjusted EEE (i.e. subtracting the energy cost of sedentary behaviors during the exercise period from EEE) to avoid over/under-estimating EEE and, thereby, over/under-estimating EA ADDIN EN.CITE <EndNote><Cite><Author>Burke</Author><Year>2015</Year><IDText>Clinical sports nutrition</IDText><DisplayText>[33]</DisplayText><record><keywords><keyword>Sports Nutritional Physiological Phenomena</keyword><keyword>Physiological aspects</keyword><keyword>Nutritional aspects</keyword><keyword>Physical fitness</keyword><keyword>Exercise</keyword><keyword>Nutrition</keyword><keyword>Athletes</keyword></keywords><urls><related-urls><url> sports nutrition</title></titles><number>Book, Whole</number><contributors><authors><author>Burke, Louise</author><author>Deakin, Vicki</author></authors></contributors><added-date format="utc">1470214707</added-date><pub-location>North Ryde, N.S.W</pub-location><ref-type name="Book">6</ref-type><dates><year>2015</year></dates><rec-number>182</rec-number><publisher>McGraw-Hill Education</publisher><last-updated-date format="utc">1470214707</last-updated-date><volume>5th</volume></record></Cite></EndNote>[33]. Moreover, the majority of studies lack a non-athlete control group. This variability in study design makes it difficult to interpret study results and accurately estimate the extent of the problem. Only one study has assessed dietary information in situ ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2016</Year><IDText>Elite synchronized swimmers display decreased energy availability during intensified training</IDText><DisplayText>[34]</DisplayText><record><dates><pub-dates><date>Jul 1</date></pub-dates><year>2016</year></dates><keywords><keyword>Esthetic sports</keyword><keyword>competition preparation</keyword><keyword>energy deficiency</keyword><keyword>training camp</keyword></keywords><isbn>0905-7188</isbn><titles><title>Elite synchronized swimmers display decreased energy availability during intensified training</title><secondary-title>Scand J Med Sci Sports</secondary-title><alt-title>Scandinavian journal of medicine &amp;amp; science in sports</alt-title></titles><contributors><authors><author>Schaal, K.</author><author>Tiollier, E.</author><author>Le Meur, Y.</author><author>Casazza, G.</author><author>Hausswirth, C.</author></authors></contributors><edition>2016/07/02</edition><language>Eng</language><added-date format="utc">1469027377</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Laboratory of Sport, Expertise and Performance (EA 7370), Research Department, French National Institute of Sport, Expertise and Performance, Paris, France.&#xD;Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, CA, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>16</rec-number><last-updated-date format="utc">1504274508</last-updated-date><accession-num>27367601</accession-num><electronic-resource-num>10.1111/sms.12716</electronic-resource-num><pages>925-934</pages><volume>27</volume></record></Cite></EndNote>[34]. In this study, all athletes were resident at the training centre for the study duration and ate at the same food station each day. Innovative technologies may prove useful to reduce the burden of recording dietary intake and increase the accuracy of EI estimation within an EA assessment ADDIN EN.CITE <EndNote><Cite><Author>Burke</Author><Year>2015</Year><IDText>Clinical sports nutrition</IDText><DisplayText>[33]</DisplayText><record><keywords><keyword>Sports Nutritional Physiological Phenomena</keyword><keyword>Physiological aspects</keyword><keyword>Nutritional aspects</keyword><keyword>Physical fitness</keyword><keyword>Exercise</keyword><keyword>Nutrition</keyword><keyword>Athletes</keyword></keywords><urls><related-urls><url> sports nutrition</title></titles><number>Book, Whole</number><contributors><authors><author>Burke, Louise</author><author>Deakin, Vicki</author></authors></contributors><added-date format="utc">1470214707</added-date><pub-location>North Ryde, N.S.W</pub-location><ref-type name="Book">6</ref-type><dates><year>2015</year></dates><rec-number>182</rec-number><publisher>McGraw-Hill Education</publisher><last-updated-date format="utc">1470214707</last-updated-date><volume>5th</volume></record></Cite></EndNote>[33]. Few studies assessing EA included male athletes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PElE

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ADDIN EN.CITE.DATA [19, 20, 26, 35]. One study, which did not assess EA but instead analyzed biomarkers of nutritional status and serum hormone levels, concluded that males competing in sports that emphasise leanness are characterised by a different body composition and endocrine status than those competing in non-lean sports ADDIN EN.CITE <EndNote><Cite><Author>Hagmar</Author><Year>2013</Year><IDText>Body composition and endocrine profile of male Olympic athletes striving for leanness</IDText><DisplayText>[36]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2013</year></dates><keywords><keyword>Absorptiometry, Photon</keyword><keyword>Adult</keyword><keyword>Anthropometry</keyword><keyword>Athletes/*psychology</keyword><keyword>Body Composition/*physiology</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Endocrine System/*physiology</keyword><keyword>Hospitals, University</keyword><keyword>Humans</keyword><keyword>Leptin/blood</keyword><keyword>Male</keyword><keyword>Sweden</keyword><keyword>Testosterone/blood</keyword><keyword>Thinness/blood/*psychology</keyword><keyword>Young Adult</keyword></keywords><isbn>1050-642x</isbn><titles><title>Body composition and endocrine profile of male Olympic athletes striving for leanness</title><secondary-title>Clin J Sport Med</secondary-title><alt-title>Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine</alt-title></titles><pages>197-201</pages><number>3</number><contributors><authors><author>Hagmar, M.</author><author>Berglund, B.</author><author>Brismar, K.</author><author>Hirschberg, A. L.</author></authors></contributors><edition>2013/01/01</edition><language>Eng</language><added-date format="utc">1478532520</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Women&apos;s and Children&apos;s Health, Karolinska Institutet and University Hospital, Stockholm, Sweden. magnus.hagmar@karolinska.se</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>347</rec-number><last-updated-date format="utc">1478532520</last-updated-date><accession-num>23275346</accession-num><electronic-resource-num>10.1097/JSM.0b013e31827a8809</electronic-resource-num><volume>23</volume></record></Cite></EndNote>[36]. In direct contrast to the study conclusion, biomarkers of nutritional status and serum hormone levels were within the normal range (i.e. showed no indication of hypothalamic suppression), thus, providing no evidence for LEA in leanness sports. These findings indicate that physiological adaptations to LEA occur within males but they do not manifest as measureable, clinically recognizable changes. The use of different methodologies to determine EA, for example, EI and EEE vs. biomarkers of nutritional status, makes it difficult to compare study results, thus reinforcing the need for appropriate sex-specific tools/biomarkers to clearly identify the extent of LEA among athletes. Over the last two decades, assessment of individual TRIAD components using questionnaires has occurred (Table 2). In 2014, a screening tool for female athletes, the LEA in Females Questionnaire (LEAF-Q), was devised and validated ADDIN EN.CITE <EndNote><Cite><Author>Melin</Author><Year>2014</Year><IDText>The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad</IDText><DisplayText>[37]</DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>2014</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Female</keyword><keyword>Female Athlete Triad Syndrome/*diagnosis</keyword><keyword>Humans</keyword><keyword>Risk Assessment/methods</keyword><keyword>Self Report</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Surveys and Questionnaires/*standards</keyword><keyword>Young Adult</keyword><keyword>Assessing Validity and Reliability of Test of Physiological Parameters</keyword><keyword>Bone Density/Endocrine Status</keyword><keyword>Nutrition</keyword><keyword>Women in Sport</keyword></keywords><isbn>0306-3674</isbn><titles><title>The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad</title><secondary-title>Br J Sports Med</secondary-title><alt-title>British journal of sports medicine</alt-title></titles><pages>540-5</pages><number>7</number><contributors><authors><author>Melin, A.</author><author>Tornberg, A. B.</author><author>Skouby, S.</author><author>Faber, J.</author><author>Ritz, C.</author><author>Sjodin, A.</author><author>Sundgot-Borgen, J.</author></authors></contributors><edition>2014/02/25</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>63</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>24563388</accession-num><electronic-resource-num>10.1136/bjsports-2013-093240</electronic-resource-num><volume>48</volume></record></Cite></EndNote>[37]. With a 78% sensitivity and 90% specificity, this tool can be used to detect female athletes “at risk” of the physiological symptoms associated with LEA. Although it can be used alone, its recommended use is in combination with a validated DE screening tool, for example, the Female Athlete Screening Tool (FAST) ADDIN EN.CITE <EndNote><Cite><Author>McNulty</Author><Year>2001</Year><IDText>Development and validation of a screening tool to identify eating disorders in female athletes</IDText><DisplayText>[38]</DisplayText><record><dates><pub-dates><date>Aug</date></pub-dates><year>2001</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Anthropometry</keyword><keyword>Body Image</keyword><keyword>Body Weight</keyword><keyword>Connecticut</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Feeding and Eating Disorders/*diagnosis/*psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Internal-External Control</keyword><keyword>Mass Screening/*methods</keyword><keyword>Personality Inventory</keyword><keyword>*Psychometrics</keyword><keyword>Reproducibility of Results</keyword><keyword>Sensitivity and Specificity</keyword><keyword>*Sports</keyword><keyword>Surveys and Questionnaires</keyword></keywords><isbn>0002-8223 (Print)&#xD;0002-8223</isbn><titles><title>Development and validation of a screening tool to identify eating disorders in female athletes</title><secondary-title>J Am Diet Assoc</secondary-title><alt-title>Journal of the American Dietetic Association</alt-title></titles><pages>886-92; quiz 893-4</pages><number>8</number><contributors><authors><author>McNulty, K. Y.</author><author>Adams, C. H.</author><author>Anderson, J. M.</author><author>Affenito, S. G.</author></authors></contributors><edition>2001/08/15</edition><language>eng</language><added-date format="utc">1472203657</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Baptist Medical Center, Food and Nutrition Services, Jacksonville, Fla 32204, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>276</rec-number><last-updated-date format="utc">1472203657</last-updated-date><accession-num>11501862</accession-num><electronic-resource-num>10.1016/s0002-8223(01)00218-8</electronic-resource-num><volume>101</volume></record></Cite></EndNote>[38]. Only one study has been published using the LEAF-Q in combination with the FAST in an athlete population ADDIN EN.CITE <EndNote><Cite><Author>Folscher</Author><Year>2015</Year><IDText>Ultra-Marathon Athletes at Risk for the Female Athlete Triad</IDText><DisplayText>[39]</DisplayText><record><keywords><keyword>Female athlete triad</keyword><keyword>Knowledge of female athlete triad</keyword><keyword>Risk of female athlete triad</keyword><keyword>Ultra-marathon runners</keyword></keywords><isbn>2198-9761 (Print)&#xD;2198-9761</isbn><custom2>PMC4564455</custom2><titles><title>Ultra-marathon athletes at risk for the female athlete triad</title><secondary-title>Sports Med Open</secondary-title><alt-title>Sports medicine - open</alt-title></titles><pages>29</pages><number>1</number><contributors><authors><author>Folscher, L. L.</author><author>Grant, C. C.</author><author>Fletcher, L.</author><author>Janse van Rensberg, D. C.</author></authors></contributors><edition>2015/09/19</edition><language>Eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.&#xD;Department of Statistics, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.</auth-address><dates><year>2015</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>30</rec-number><last-updated-date format="utc">1499189609</last-updated-date><accession-num>26380807</accession-num><electronic-resource-num>10.1186/s40798-015-0027-7</electronic-resource-num><volume>1</volume></record></Cite></EndNote>[39]; over 40% (44.1%) of female ultra-marathon athletes were found to be “at risk”, with 32% demonstrating DE behaviors. Furthermore, it was demonstrated using six additional questions that 92.5% of the athletes lacked awareness of the TRIAD. 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ADDIN EN.CITE.DATA [41, 42]. EDs also occur more frequently among male athletes compared to non-athletic male controls ADDIN EN.CITE <EndNote><Cite><Author>Sundgot-Borgen</Author><Year>2004</Year><IDText>Prevalence of eating disorders in elite athletes is higher than in the general population</IDText><DisplayText>[42]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2004</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Body Mass Index</keyword><keyword>Case-Control Studies</keyword><keyword>Confidence Intervals</keyword><keyword>Feeding and Eating Disorders/diagnosis/*epidemiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Norway/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Risk Assessment</keyword><keyword>Sex Distribution</keyword><keyword>Sex Factors</keyword><keyword>Sports/*statistics &amp; numerical data</keyword></keywords><isbn>1050-642X (Print)&#xD;1050-642x</isbn><titles><title>Prevalence of eating disorders in elite athletes is higher than in the general population</title><secondary-title>Clin J Sport Med</secondary-title><alt-title>Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine</alt-title></titles><pages>25-32</pages><number>1</number><contributors><authors><author>Sundgot-Borgen, J.</author><author>Torstveit, M. K.</author></authors></contributors><edition>2004/01/09</edition><language>eng</language><added-date format="utc">1471856509</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Norwegian University of Sport and Physical Education, Oslo, Norway. Jorunn.Sundgot-borgen@nih.no</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>255</rec-number><last-updated-date format="utc">1471856509</last-updated-date><accession-num>14712163</accession-num><volume>14</volume></record></Cite></EndNote>[42]. Athletes most susceptible to developing DE are those who experience pressure to improve performance, to maintain a specific sporting appearance or to have an “ideal” physique PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdW5kZ290LUJvcmdlbjwvQXV0aG9yPjxZZWFyPjIwMTA8

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ADDIN EN.CITE.DATA [43]. Nearly one-quarter of male athletes competing in ED high-risk sports (weight-class sports; sports where leanness improves performance; aesthetic sports) displayed DE behaviors associated with body image dissatisfaction PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2x0ejwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PElE

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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2x0ejwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PElE

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ADDIN EN.CITE.DATA [44]. Similarly, a higher percentage of female athletes in ED high-risk sports (46.7%) had clinical EDs compared with athletes in other sports (19.8%) and non-athletic controls (21.4%) respectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3JzdHZlaXQ8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFy

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ADDIN EN.CITE.DATA [45]. Few studies have investigated DE behaviors in combination with an assessment of EA (Table 2). Again, interpretation of study findings is difficult due to variability in the methods used to assess EDs/DE behaviors. It has been reported that male athletes demonstrating dietary restraint practices consciously restricted EI as a method of weight control ADDIN EN.CITE <EndNote><Cite><Author>Viner</Author><Year>2015</Year><IDText>Energy Availability and Dietary Patterns of Adult Male and Female Competitive Cyclists With Lower Than Expected Bone Mineral Density</IDText><DisplayText>[19]</DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2015</year></dates><isbn>1526-484x</isbn><titles><title>Energy availability and dietary patterns of adult male and female competitive cyclists with lower than expected bone mineral density</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>594-602</pages><number>6</number><contributors><authors><author>Viner, R. T.</author><author>Harris, M.</author><author>Berning, J. R.</author><author>Meyer, N. L.</author></authors></contributors><edition>2015/07/02</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Beth-El College of Nursing and Health Sciences, Sport Nutrition, University of Colorado Colorado Springs, Colorado Springs, CO.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>35</rec-number><last-updated-date format="utc">1499189525</last-updated-date><accession-num>26131616</accession-num><electronic-resource-num>10.1123/ijsnem.2015-0073</electronic-resource-num><volume>25</volume></record></Cite></EndNote>[19]. Extreme weight-loss methods such as use of saunas (86%), excessive exercising to the point of sweating (81%) and dieting (71%) ADDIN EN.CITE <EndNote><Cite><Author>Dolan</Author><Year>2011</Year><IDText>Nutritional, lifestyle, and weight control practices of professional jockeys</IDText><DisplayText>[26]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>*Athletes</keyword><keyword>Health Surveys</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Male</keyword><keyword>*Nutrition Assessment</keyword><keyword>*Sports</keyword><keyword>Weight Loss/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Nutritional, lifestyle, and weight control practices of professional jockeys</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>791-9</pages><number>8</number><contributors><authors><author>Dolan, E.</author><author>O&apos;Connor, H.</author><author>McGoldrick, A.</author><author>O&apos;Loughlin, G.</author><author>Lyons, D.</author><author>Warrington, G.</author></authors></contributors><edition>2011/04/21</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Health and Human Performance, Dublin City University, Dublin, Ireland.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>104</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21506039</accession-num><electronic-resource-num>10.1080/02640414.2011.560173</electronic-resource-num><volume>29</volume></record></Cite></EndNote>[26] were the most commonly reported behaviors practised by male jockeys. Lower EA among exercising females and professional dancers with high dietary restraint compared to those with normal dietary restraint is apparent PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb3lsZS1MdWNhczwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll

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ADDIN EN.CITE.DATA [27, 46]. Greater body dissatisfaction in female soccer players with LEA ADDIN EN.CITE <EndNote><Cite><Author>Reed</Author><Year>2013</Year><IDText>Changes in energy availability across the season in Division I female soccer players</IDText><DisplayText>[18]</DisplayText><record><keywords><keyword>Adult</keyword><keyword>*Attitude to Health</keyword><keyword>Body Fluid Compartments</keyword><keyword>Body Image</keyword><keyword>*Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>*Exercise/psychology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/psychology</keyword><keyword>Humans</keyword><keyword>Meals</keyword><keyword>Motivation</keyword><keyword>Personal Satisfaction</keyword><keyword>*Seasons</keyword><keyword>*Soccer/psychology</keyword><keyword>Thinness</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Changes in energy availability across the season in Division I female soccer players</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>314-24</pages><number>3</number><contributors><authors><author>Reed, J. L.</author><author>De Souza, M. J.</author><author>Williams, N. I.</author></authors></contributors><edition>2012/10/19</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Kinesiology, The Pennsylvania State University, University Park, Pennsylvania 16802, USA.</auth-address><dates><year>2013</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>87</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23075047</accession-num><electronic-resource-num>10.1080/02640414.2012.733019</electronic-resource-num><volume>31</volume></record></Cite></EndNote>[18] and in amenorrheic compared to eumenorrheic endurance athletes has been reported ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2011</Year><IDText>Reduced catecholamine response to exercise in amenorrheic athletes</IDText><DisplayText>[47]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/blood/etiology/*metabolism/psychology</keyword><keyword>*Athletes</keyword><keyword>Blood Glucose/analysis</keyword><keyword>Blood Pressure</keyword><keyword>Case-Control Studies</keyword><keyword>Energy Metabolism</keyword><keyword>Epinephrine/*blood</keyword><keyword>Exercise/*physiology</keyword><keyword>Exercise Test</keyword><keyword>Female</keyword><keyword>Heart Rate</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/blood</keyword><keyword>Lactic Acid/blood</keyword><keyword>Norepinephrine/*blood</keyword><keyword>Oxygen Consumption</keyword><keyword>Physical Exertion</keyword></keywords><isbn>0195-9131</isbn><titles><title>Reduced catecholamine response to exercise in amenorrheic athletes</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>34-43</pages><number>1</number><contributors><authors><author>Schaal, K.</author><author>Van Loan, M. D.</author><author>Casazza, G. A.</author></authors></contributors><edition>2010/05/29</edition><language>eng</language><added-date format="utc">1469693273</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, 95816, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>175</rec-number><last-updated-date format="utc">1469693273</last-updated-date><accession-num>20508538</accession-num><electronic-resource-num>10.1249/MSS.0b013e3181e91ece</electronic-resource-num><volume>43</volume></record></Cite></EndNote>[47]. Furthermore, more than 75% of endurance runners were identified with DE behaviors ADDIN EN.CITE <EndNote><Cite><Author>Muia</Author><Year>2016</Year><IDText>Adolescent elite Kenyan runners are at risk for energy deficiency, menstrual dysfunction and disordered eating</IDText><DisplayText>[24]</DisplayText><record><keywords><keyword>bone mineral density</keyword><keyword>energy availability</keyword><keyword>menstrual function</keyword><keyword>young athlete</keyword></keywords><isbn>0264-0414</isbn><titles><title>Adolescent elite Kenyan runners are at risk for energy deficiency, menstrual dysfunction and disordered eating</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>598-606</pages><number>7</number><contributors><authors><author>Muia, E. N.</author><author>Wright, H. H.</author><author>Onywera, V. O.</author><author>Kuria, E. N.</author></authors></contributors><edition>2015/07/15</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Department of Food, Nutrition and Dietetics, School of Applied Human Sciences , Kenyatta University , Nairobi , Kenya.&#xD;b Centre of Excellence in Nutrition , North-west University , Potchefstroom , South Africa.&#xD;c School of Health and Sport Sciences, Faculty of Health Science , University of the Sunshine Coast , Sippy Downs , Queensland , Australia.&#xD;d Department of Recreation Management and Exercise Science , School of Applied Human Sciences, Kenyatta University , Nairobi , Kenya.</auth-address><dates><year>2016</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>33</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>26153433</accession-num><electronic-resource-num>10.1080/02640414.2015.1065340</electronic-resource-num><volume>34</volume></record></Cite></EndNote>[24].In contrast, one study reported that adolescent athletes and sedentary students with LEA had satisfactory eating-attitude test scores, suggesting that those with LEA do not necessarily display ED characteristics PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2NoPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [2]. Identifying athletes with EDs and/or DE behaviors does not appear to be sufficiently sensitive to indicate LEA. This emphasizes the need to investigate excessive exercise as an indicator of LEA. Validated screening tools such as the EDE-16 are available to screen for DE in the general population, some of which have been used with athletes (Table 2). Recent emphasis has been on the development of athlete-specific DE screening tools. Along with the validated DE screening tool (FAST) previously mentioned, the latest screening tool developed for female athletes, the Brief ED in Athletes Questionnaire (BEDA-Q), complements the LEAF-Q and can be used to identify female athletes with or without an ED ADDIN EN.CITE <EndNote><Cite><Author>Martinsen</Author><Year>2014</Year><IDText>The development of the brief eating disorder in athletes questionnaire</IDText><DisplayText>[48]</DisplayText><record><dates><pub-dates><date>Aug</date></pub-dates><year>2014</year></dates><keywords><keyword>Adolescent</keyword><keyword>Feeding and Eating Disorders/*diagnosis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Psychometrics</keyword><keyword>Self Concept</keyword><keyword>*Surveys and Questionnaires</keyword></keywords><isbn>0195-9131</isbn><titles><title>The development of the brief eating disorder in athletes questionnaire</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>1666-75</pages><number>8</number><contributors><authors><author>Martinsen, M.</author><author>Holme, I.</author><author>Pensgaard, A. M.</author><author>Torstveit, M. K.</author><author>Sundgot-Borgen, J.</author></authors></contributors><edition>2014/02/08</edition><language>eng</language><added-date format="utc">1472406507</added-date><ref-type name="Journal Article">17</ref-type><auth-address>1Oslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, NORWAY&#xD;2Department of Coaching and Psychology, Norwegian School of Sport Sciences, Oslo, NORWAY&#xD;3Faculty of Health and Sport Sciences, University of Agder, Kristiansand, NORWAY&#xD;and 4Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, NORWAY.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>286</rec-number><last-updated-date format="utc">1472406507</last-updated-date><accession-num>24504432</accession-num><electronic-resource-num>10.1249/mss.0000000000000276</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[48]. No athlete specific screening tool has yet been developed to assess EDs/DE behaviors or the physiological symptoms of LEA in the athletic male population.Biomarkers of Energy DeficiencyIdentifying unintentional LEA can be problematic as the signs and symptoms are difficult to detect. The use of validated biomarkers associated with LEA could provide a quick method of monitoring energy status and identifying athletes potentially “at risk” of energy deficiency. Biomarkers suggested include leptin, triiodothyronine (T3) and cortisol ADDIN EN.CITE <EndNote><Cite><Author>Warren</Author><Year>2011</Year><IDText>Endocrine manifestations of eating disorders</IDText><DisplayText>[49]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2011</year></dates><keywords><keyword>Adipose Tissue/physiopathology</keyword><keyword>Adrenal Glands/physiopathology</keyword><keyword>Anorexia Nervosa/complications/physiopathology/therapy</keyword><keyword>Bone and Bones/physiopathology</keyword><keyword>Endocrine System/*physiopathology</keyword><keyword>Endocrine System Diseases/*etiology/therapy</keyword><keyword>Feeding and Eating Disorders/*complications/*physiopathology/therapy</keyword><keyword>Gastrointestinal Hormones/physiology</keyword><keyword>Gonads/physiopathology</keyword><keyword>Hormones/blood</keyword><keyword>Human Growth Hormone/physiology</keyword><keyword>Humans</keyword><keyword>Neuropeptides/blood</keyword><keyword>Thyroid Gland/physiopathology</keyword></keywords><isbn>0021-972x</isbn><titles><title>Endocrine manifestations of eating disorders</title><secondary-title>J Clin Endocrinol Metab</secondary-title><alt-title>The Journal of clinical endocrinology and metabolism</alt-title></titles><pages>333-43</pages><number>2</number><contributors><authors><author>Warren, M. P.</author></authors></contributors><edition>2010/12/17</edition><language>eng</language><added-date format="utc">1475239896</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. mpw1@columbia.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>338</rec-number><last-updated-date format="utc">1475239896</last-updated-date><accession-num>21159848</accession-num><electronic-resource-num>10.1210/jc.2009-2304</electronic-resource-num><volume>96</volume></record></Cite></EndNote>[49]. Table 3 outlines the small number of studies that have investigated metabolic substrates and hormone levels in athletes who exhibited LEA. Evidence for an association between LEA (< 30 kcal/kg FFM/day) and metabolic substrates/hormones is not particularly strong, with weak or conflicting data reported in studies in athletic populations. 5.1 Appetite hormones-leptin and ghrelinLeptin (appetite-suppressing hormone), a marker of low body fat and restricted food intake ADDIN EN.CITE <EndNote><Cite><Author>Warren</Author><Year>2011</Year><IDText>Endocrine manifestations of eating disorders</IDText><DisplayText>[49]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2011</year></dates><keywords><keyword>Adipose Tissue/physiopathology</keyword><keyword>Adrenal Glands/physiopathology</keyword><keyword>Anorexia Nervosa/complications/physiopathology/therapy</keyword><keyword>Bone and Bones/physiopathology</keyword><keyword>Endocrine System/*physiopathology</keyword><keyword>Endocrine System Diseases/*etiology/therapy</keyword><keyword>Feeding and Eating Disorders/*complications/*physiopathology/therapy</keyword><keyword>Gastrointestinal Hormones/physiology</keyword><keyword>Gonads/physiopathology</keyword><keyword>Hormones/blood</keyword><keyword>Human Growth Hormone/physiology</keyword><keyword>Humans</keyword><keyword>Neuropeptides/blood</keyword><keyword>Thyroid Gland/physiopathology</keyword></keywords><isbn>0021-972x</isbn><titles><title>Endocrine manifestations of eating disorders</title><secondary-title>J Clin Endocrinol Metab</secondary-title><alt-title>The Journal of clinical endocrinology and metabolism</alt-title></titles><pages>333-43</pages><number>2</number><contributors><authors><author>Warren, M. P.</author></authors></contributors><edition>2010/12/17</edition><language>eng</language><added-date format="utc">1475239896</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. mpw1@columbia.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>338</rec-number><last-updated-date format="utc">1475239896</last-updated-date><accession-num>21159848</accession-num><electronic-resource-num>10.1210/jc.2009-2304</electronic-resource-num><volume>96</volume></record></Cite></EndNote>[49], appears to be reduced when EA is low, perhaps indicating inadequate recovery from exercise and relative energy deficiency. A study of healthy exercising females demonstrated that the pulsatility of leptin is dependent on EA and not exercise-induced stress; exercise had no suppressive effect on the diurnal rhythm of leptin when EI was adequate ADDIN EN.CITE <EndNote><Cite><Author>Hilton</Author><Year>2000</Year><IDText>Low energy availability, not exercise stress, suppresses the diurnal rhythm of leptin in healthy young women</IDText><DisplayText>[50]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2000</year></dates><keywords><keyword>Adult</keyword><keyword>Circadian Rhythm/*physiology</keyword><keyword>*Energy Intake</keyword><keyword>Energy Metabolism/*physiology</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Leptin/*blood</keyword><keyword>Reference Values</keyword></keywords><isbn>0193-1849 (Print)&#xD;0193-1849</isbn><titles><title>Low energy availability, not exercise stress, suppresses the diurnal rhythm of leptin in healthy young women</title><secondary-title>Am J Physiol Endocrinol Metab</secondary-title><alt-title>American journal of physiology. Endocrinology and metabolism</alt-title></titles><pages>E43-9</pages><number>1</number><contributors><authors><author>Hilton, L. K.</author><author>Loucks, A. B.</author></authors></contributors><edition>2000/01/25</edition><language>Eng</language><added-date format="utc">1478513176</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Biological Sciences, Ohio University, Athens, Ohio 45701-2979, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>345</rec-number><last-updated-date format="utc">1478513176</last-updated-date><accession-num>10644535</accession-num><volume>278</volume></record></Cite></EndNote>[50]. In contrast, another study showed no difference in leptin level between endurance female athletes, regardless of their EA status PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2]. Studies investigating ghrelin (appetite-stimulating hormone) levels have also reported mixed findings with both lower EA ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2016</Year><IDText>Elite synchronized swimmers display decreased energy availability during intensified training</IDText><DisplayText>[34]</DisplayText><record><dates><pub-dates><date>Jul 1</date></pub-dates><year>2016</year></dates><keywords><keyword>Esthetic sports</keyword><keyword>competition preparation</keyword><keyword>energy deficiency</keyword><keyword>training camp</keyword></keywords><isbn>0905-7188</isbn><titles><title>Elite synchronized swimmers display decreased energy availability during intensified training</title><secondary-title>Scand J Med Sci Sports</secondary-title><alt-title>Scandinavian journal of medicine &amp;amp; science in sports</alt-title></titles><contributors><authors><author>Schaal, K.</author><author>Tiollier, E.</author><author>Le Meur, Y.</author><author>Casazza, G.</author><author>Hausswirth, C.</author></authors></contributors><edition>2016/07/02</edition><language>Eng</language><added-date format="utc">1469027377</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Laboratory of Sport, Expertise and Performance (EA 7370), Research Department, French National Institute of Sport, Expertise and Performance, Paris, France.&#xD;Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, CA, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>16</rec-number><last-updated-date format="utc">1504274508</last-updated-date><accession-num>27367601</accession-num><electronic-resource-num>10.1111/sms.12716</electronic-resource-num><pages>925-934</pages><volume>27</volume></record></Cite></EndNote>[34] and normal EA ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2016</Year><IDText>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</IDText><DisplayText>[35]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2016</year></dates><keywords><keyword>Energy deficiency</keyword><keyword>caloric restriction</keyword><keyword>exercise</keyword><keyword>leptin</keyword><keyword>testosterone</keyword></keywords><isbn>0264-0414</isbn><titles><title>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>1921-9</pages><number>20</number><contributors><authors><author>Koehler, K.</author><author>Hoerner, N. R.</author><author>Gibbs, J. C.</author><author>Zinner, C.</author><author>Braun, H.</author><author>De Souza, M. J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2016/02/09</edition><language>eng</language><added-date format="utc">1469697296</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Biochemistry , German Sport University , Cologne , Germany.&#xD;b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.&#xD;c Department of Nutrition and Health Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA.&#xD;d Department of Kinesiology , University of Waterloo , Waterloo , Canada.&#xD;e Department of Sport Science , University of Wurzburg , Wurzburg , Germany.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>178</rec-number><last-updated-date format="utc">1469697296</last-updated-date><accession-num>26852783</accession-num><electronic-resource-num>10.1080/02640414.2016.1142109</electronic-resource-num><volume>34</volume></record></Cite></EndNote>[35] associated with higher ghrelin level. One study of healthy females reported a significant increase in fasting ghrelin concentrations following a decrease in EA during a 3-month diet and exercise intervention ADDIN EN.CITE <EndNote><Cite><Author>Scheid</Author><Year>2011</Year><IDText>Ghrelin but not peptide YY is related to change in body weight and energy availability</IDText><DisplayText>[51]</DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>2011</year></dates><keywords><keyword>Adipose Tissue/metabolism</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Body Weight/*physiology</keyword><keyword>*Diet</keyword><keyword>Energy Metabolism/physiology</keyword><keyword>Exercise</keyword><keyword>Female</keyword><keyword>Ghrelin/*blood</keyword><keyword>Humans</keyword><keyword>Peptide YY/*blood</keyword><keyword>Weight Loss/physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0195-9131</isbn><titles><title>Ghrelin but not peptide YY is related to change in body weight and energy availability</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>2063-71</pages><number>11</number><contributors><authors><author>Scheid, J. L.</author><author>De Souza, M. J.</author><author>Leidy, H. J.</author><author>Williams, N. I.</author></authors></contributors><edition>2011/04/20</edition><language>Eng</language><added-date format="utc">1478521045</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Women&apos;s Health and Exercise Laboratory, Noll Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>346</rec-number><last-updated-date format="utc">1478521045</last-updated-date><accession-num>21502892</accession-num><electronic-resource-num>10.1249/MSS.0b013e31821e52ab</electronic-resource-num><volume>43</volume></record></Cite></EndNote>[51]. Furthermore, 3-month diet and exercise interventions in healthy females that elicited a significant decrease in body weight were associated with increases in fasting ghrelin PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaWxsPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [52-54]. Further research to determine if changes in leptin and ghrelin levels are sensitive enough to identify changes in EA are required. 5.2 TriiodothyronineTriiodothyronine (T3) [involved in the hypothalamic-pituitary-thyroid axis and responsible for regulation of metabolism] levels have been explored as a biomarker of EA, with studies collectively presenting mixed results. Lower T3 levels were observed in ovarian hormone-suppressed athletes ADDIN EN.CITE <EndNote><Cite><Author>Vanheest</Author><Year>2014</Year><IDText>Ovarian suppression impairs sport performance in junior elite female swimmers</IDText><DisplayText>[23]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2014</year></dates><keywords><keyword>Adolescent</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Energy Intake/physiology</keyword><keyword>Energy Metabolism/physiology</keyword><keyword>Estradiol/blood</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Insulin-Like Growth Factor I/metabolism</keyword><keyword>Menstrual Cycle/blood/physiology</keyword><keyword>Primary Ovarian Insufficiency/blood/*physiopathology</keyword><keyword>Progesterone/blood</keyword><keyword>Swimming/*physiology</keyword><keyword>Triiodothyronine/blood</keyword></keywords><isbn>0195-9131</isbn><titles><title>Ovarian suppression impairs sport performance in junior elite female swimmers</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>156-66</pages><number>1</number><contributors><authors><author>Vanheest, J. L.</author><author>Rodgers, C. D.</author><author>Mahoney, C. E.</author><author>De Souza, M. J.</author></authors></contributors><edition>2013/07/13</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>1Departments of Educational Psychology and Kinesiology, University of Connecticut, Storrs, CT&#xD;2College of Kinesiology, University of Saskatchewan, Saskatchewan, CANADA&#xD;and 3Department of Kinesiology, Pennsylvania State University, University Park, PA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>76</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23846160</accession-num><electronic-resource-num>10.1249/MSS.0b013e3182a32b72</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[23] and among female athletes who had lost weight ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2013</Year><IDText>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</IDText><DisplayText>[20]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2013</year></dates><keywords><keyword>*Athletes</keyword><keyword>Body Composition</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Humans</keyword><keyword>*Self Report</keyword></keywords><isbn>1715-5312</isbn><titles><title>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</title><secondary-title>Appl Physiol Nutr Metab</secondary-title><alt-title>Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme</alt-title></titles><pages>725-33</pages><number>7</number><contributors><authors><author>Koehler, K.</author><author>Achtzehn, S.</author><author>Braun, H.</author><author>Mester, J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2013/08/29</edition><language>eng</language><added-date format="utc">1469027227</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Institute of Biochemistry, German Sport University, Am Sportpark Muengersdorf 6, D-50933 Cologne, Germany. k.koehler@biochem.dshs-koeln.de</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>12</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23980730</accession-num><electronic-resource-num>10.1139/apnm-2012-0373</electronic-resource-num><volume>38</volume></record></Cite></EndNote>[20]. Although T3 levels did not differ between endurance trained females with different EA status (optimal, sub-optimal and LEA respectively), lower T3 levels were reported among athletes with menstrual dysfunction when compared to eumenorrhoeic athletes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2]. These study results indicate that T3 levels decrease in female athletes with menstrual irregularities. LEA did not significantly influence T3 levels in exercising men ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2016</Year><IDText>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</IDText><DisplayText>[35]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2016</year></dates><keywords><keyword>Energy deficiency</keyword><keyword>caloric restriction</keyword><keyword>exercise</keyword><keyword>leptin</keyword><keyword>testosterone</keyword></keywords><isbn>0264-0414</isbn><titles><title>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>1921-9</pages><number>20</number><contributors><authors><author>Koehler, K.</author><author>Hoerner, N. R.</author><author>Gibbs, J. C.</author><author>Zinner, C.</author><author>Braun, H.</author><author>De Souza, M. J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2016/02/09</edition><language>eng</language><added-date format="utc">1469697296</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Biochemistry , German Sport University , Cologne , Germany.&#xD;b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.&#xD;c Department of Nutrition and Health Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA.&#xD;d Department of Kinesiology , University of Waterloo , Waterloo , Canada.&#xD;e Department of Sport Science , University of Wurzburg , Wurzburg , Germany.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>178</rec-number><last-updated-date format="utc">1469697296</last-updated-date><accession-num>26852783</accession-num><electronic-resource-num>10.1080/02640414.2016.1142109</electronic-resource-num><volume>34</volume></record></Cite></EndNote>[35] or in female soccer players ADDIN EN.CITE <EndNote><Cite><Author>Reed</Author><Year>2013</Year><IDText>Changes in energy availability across the season in Division I female soccer players</IDText><DisplayText>[18]</DisplayText><record><keywords><keyword>Adult</keyword><keyword>*Attitude to Health</keyword><keyword>Body Fluid Compartments</keyword><keyword>Body Image</keyword><keyword>*Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>*Exercise/psychology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/psychology</keyword><keyword>Humans</keyword><keyword>Meals</keyword><keyword>Motivation</keyword><keyword>Personal Satisfaction</keyword><keyword>*Seasons</keyword><keyword>*Soccer/psychology</keyword><keyword>Thinness</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Changes in energy availability across the season in Division I female soccer players</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>314-24</pages><number>3</number><contributors><authors><author>Reed, J. L.</author><author>De Souza, M. J.</author><author>Williams, N. I.</author></authors></contributors><edition>2012/10/19</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Kinesiology, The Pennsylvania State University, University Park, Pennsylvania 16802, USA.</auth-address><dates><year>2013</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>87</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23075047</accession-num><electronic-resource-num>10.1080/02640414.2012.733019</electronic-resource-num><volume>31</volume></record></Cite></EndNote>[18]. Further research is necessary to investigate whether T3 levels can be used to reflect changes in EA.5.3 CortisolAlthough cortisol (a steroid hormone released in response to stress) levels were similar among elite female endurance athletes regardless of EA status (optimal, sub-optimal and LEA respectively) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2, 47]. Moreover, exercising at different exercise intensities appears to influence cortisol levels ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2011</Year><IDText>Reduced catecholamine response to exercise in amenorrheic athletes</IDText><DisplayText>[47]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/blood/etiology/*metabolism/psychology</keyword><keyword>*Athletes</keyword><keyword>Blood Glucose/analysis</keyword><keyword>Blood Pressure</keyword><keyword>Case-Control Studies</keyword><keyword>Energy Metabolism</keyword><keyword>Epinephrine/*blood</keyword><keyword>Exercise/*physiology</keyword><keyword>Exercise Test</keyword><keyword>Female</keyword><keyword>Heart Rate</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/blood</keyword><keyword>Lactic Acid/blood</keyword><keyword>Norepinephrine/*blood</keyword><keyword>Oxygen Consumption</keyword><keyword>Physical Exertion</keyword></keywords><isbn>0195-9131</isbn><titles><title>Reduced catecholamine response to exercise in amenorrheic athletes</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>34-43</pages><number>1</number><contributors><authors><author>Schaal, K.</author><author>Van Loan, M. D.</author><author>Casazza, G. A.</author></authors></contributors><edition>2010/05/29</edition><language>eng</language><added-date format="utc">1469693273</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, 95816, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>175</rec-number><last-updated-date format="utc">1469693273</last-updated-date><accession-num>20508538</accession-num><electronic-resource-num>10.1249/MSS.0b013e3181e91ece</electronic-resource-num><volume>43</volume></record></Cite></EndNote>[47]. Although no significant changes in cortisol levels were observed in a group of elite synchronized swimmers across a 4-week intensive training period, direct correlations between cortisol levels and perceived fatigue suggest greater physiological stress among energy deficient swimmers ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2016</Year><IDText>Elite synchronized swimmers display decreased energy availability during intensified training</IDText><DisplayText>[34]</DisplayText><record><dates><pub-dates><date>Jul 1</date></pub-dates><year>2016</year></dates><keywords><keyword>Esthetic sports</keyword><keyword>competition preparation</keyword><keyword>energy deficiency</keyword><keyword>training camp</keyword></keywords><isbn>0905-7188</isbn><titles><title>Elite synchronized swimmers display decreased energy availability during intensified training</title><secondary-title>Scand J Med Sci Sports</secondary-title><alt-title>Scandinavian journal of medicine &amp;amp; science in sports</alt-title></titles><contributors><authors><author>Schaal, K.</author><author>Tiollier, E.</author><author>Le Meur, Y.</author><author>Casazza, G.</author><author>Hausswirth, C.</author></authors></contributors><edition>2016/07/02</edition><language>Eng</language><added-date format="utc">1469027377</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Laboratory of Sport, Expertise and Performance (EA 7370), Research Department, French National Institute of Sport, Expertise and Performance, Paris, France.&#xD;Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, CA, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>16</rec-number><last-updated-date format="utc">1504274508</last-updated-date><accession-num>27367601</accession-num><electronic-resource-num>10.1111/sms.12716</electronic-resource-num><pages>925-934</pages><volume>27</volume></record></Cite></EndNote>[34]. In summary, elevated cortisol levels suggest greater physiological stress during intensive training, with this being more pronounced in females with menstrual irregularities. 5.4 Insulin-like growth factor 1A marked decline in insulin-like growth factor 1 (IGF-1) [supports cell division and growth] was apparent in ovarian-hormone suppressed female swimmers compared to eumenorrheic swimmers. However, even in those with normal menstrual function, IGF-1 significantly declined over a 12-week season ADDIN EN.CITE <EndNote><Cite><Author>Vanheest</Author><Year>2014</Year><IDText>Ovarian suppression impairs sport performance in junior elite female swimmers</IDText><DisplayText>[23]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2014</year></dates><keywords><keyword>Adolescent</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Energy Intake/physiology</keyword><keyword>Energy Metabolism/physiology</keyword><keyword>Estradiol/blood</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Insulin-Like Growth Factor I/metabolism</keyword><keyword>Menstrual Cycle/blood/physiology</keyword><keyword>Primary Ovarian Insufficiency/blood/*physiopathology</keyword><keyword>Progesterone/blood</keyword><keyword>Swimming/*physiology</keyword><keyword>Triiodothyronine/blood</keyword></keywords><isbn>0195-9131</isbn><titles><title>Ovarian suppression impairs sport performance in junior elite female swimmers</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>156-66</pages><number>1</number><contributors><authors><author>Vanheest, J. L.</author><author>Rodgers, C. D.</author><author>Mahoney, C. E.</author><author>De Souza, M. J.</author></authors></contributors><edition>2013/07/13</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>1Departments of Educational Psychology and Kinesiology, University of Connecticut, Storrs, CT&#xD;2College of Kinesiology, University of Saskatchewan, Saskatchewan, CANADA&#xD;and 3Department of Kinesiology, Pennsylvania State University, University Park, PA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>76</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23846160</accession-num><electronic-resource-num>10.1249/MSS.0b013e3182a32b72</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[23]. Furthermore, IGF-1 decreased in untrained females when EI was restricted to 10, 20 or 30 kcal/kg FFM/day respectively ADDIN EN.CITE <EndNote><Cite><Author>Loucks</Author><Year>2003</Year><IDText>Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women</IDText><DisplayText>[12]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2003</year></dates><keywords><keyword>Adult</keyword><keyword>Body Weight</keyword><keyword>Carbohydrate Metabolism</keyword><keyword>Circadian Rhythm</keyword><keyword>Energy Metabolism/*physiology</keyword><keyword>Estradiol/blood</keyword><keyword>Female</keyword><keyword>Follicle Stimulating Hormone/blood</keyword><keyword>Hormones/blood</keyword><keyword>Humans</keyword><keyword>Luteinizing Hormone/*secretion</keyword><keyword>Menstrual Cycle/*physiology</keyword><keyword>Pulsatile Flow</keyword><keyword>Sleep/physiology</keyword><keyword>Wakefulness/physiology</keyword></keywords><isbn>0021-972X (Print)&#xD;0021-972x</isbn><titles><title>Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women</title><secondary-title>J Clin Endocrinol Metab</secondary-title><alt-title>The Journal of clinical endocrinology and metabolism</alt-title></titles><pages>297-311</pages><number>1</number><contributors><authors><author>Loucks, A. B.</author><author>Thuma, J. R.</author></authors></contributors><edition>2003/01/10</edition><language>eng</language><added-date format="utc">1475148860</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Biological Sciences, Ohio University, Athens, Ohio 45701, USA. loucks@ohiou.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>337</rec-number><last-updated-date format="utc">1475148860</last-updated-date><accession-num>12519869</accession-num><electronic-resource-num>10.1210/jc.2002-020369</electronic-resource-num><volume>88</volume></record></Cite></EndNote>[12]. This suggests that lower IGF-1 concentrations could indicate inadequate EA and excessive training in females. In contrast, no relationship between IGF-1 and EA has been established in males. Similar IGF-1 levels were reported in young elite male and female athletes with normal or LEA ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2013</Year><IDText>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</IDText><DisplayText>[20]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2013</year></dates><keywords><keyword>*Athletes</keyword><keyword>Body Composition</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Humans</keyword><keyword>*Self Report</keyword></keywords><isbn>1715-5312</isbn><titles><title>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</title><secondary-title>Appl Physiol Nutr Metab</secondary-title><alt-title>Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme</alt-title></titles><pages>725-33</pages><number>7</number><contributors><authors><author>Koehler, K.</author><author>Achtzehn, S.</author><author>Braun, H.</author><author>Mester, J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2013/08/29</edition><language>eng</language><added-date format="utc">1469027227</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Institute of Biochemistry, German Sport University, Am Sportpark Muengersdorf 6, D-50933 Cologne, Germany. k.koehler@biochem.dshs-koeln.de</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>12</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23980730</accession-num><electronic-resource-num>10.1139/apnm-2012-0373</electronic-resource-num><volume>38</volume></record></Cite></EndNote>[20]. In summary, although there may be suggestive evidence for an association between IGF-1 and LEA, this needs to be investigated in highly trained male and female athletes before promotion of IGF-1 as a biomarker of LEA. 5.5 Insulin and glucoseSimilar insulin levels were reported in male and female athletes with low or normal EA ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2013</Year><IDText>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</IDText><DisplayText>[20]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2013</year></dates><keywords><keyword>*Athletes</keyword><keyword>Body Composition</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Humans</keyword><keyword>*Self Report</keyword></keywords><isbn>1715-5312</isbn><titles><title>Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes</title><secondary-title>Appl Physiol Nutr Metab</secondary-title><alt-title>Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme</alt-title></titles><pages>725-33</pages><number>7</number><contributors><authors><author>Koehler, K.</author><author>Achtzehn, S.</author><author>Braun, H.</author><author>Mester, J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2013/08/29</edition><language>eng</language><added-date format="utc">1469027227</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Institute of Biochemistry, German Sport University, Am Sportpark Muengersdorf 6, D-50933 Cologne, Germany. k.koehler@biochem.dshs-koeln.de</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>12</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23980730</accession-num><electronic-resource-num>10.1139/apnm-2012-0373</electronic-resource-num><volume>38</volume></record></Cite></EndNote>[20], whilst insulin and fasting glucose levels were equivalent in female endurance athletes with low (≤ 30 kcal/kg FFM/day), reduced (30–45 kcal/kg FFM/day) or optimal (≥ 45 kcal/kg FFM/day) EA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2]. Following four days of LEA (15 kcal/kg FFM/day) in exercising men, reduced insulin levels were observed ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2016</Year><IDText>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</IDText><DisplayText>[35]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2016</year></dates><keywords><keyword>Energy deficiency</keyword><keyword>caloric restriction</keyword><keyword>exercise</keyword><keyword>leptin</keyword><keyword>testosterone</keyword></keywords><isbn>0264-0414</isbn><titles><title>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>1921-9</pages><number>20</number><contributors><authors><author>Koehler, K.</author><author>Hoerner, N. R.</author><author>Gibbs, J. C.</author><author>Zinner, C.</author><author>Braun, H.</author><author>De Souza, M. J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2016/02/09</edition><language>eng</language><added-date format="utc">1469697296</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Biochemistry , German Sport University , Cologne , Germany.&#xD;b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.&#xD;c Department of Nutrition and Health Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA.&#xD;d Department of Kinesiology , University of Waterloo , Waterloo , Canada.&#xD;e Department of Sport Science , University of Wurzburg , Wurzburg , Germany.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>178</rec-number><last-updated-date format="utc">1469697296</last-updated-date><accession-num>26852783</accession-num><electronic-resource-num>10.1080/02640414.2016.1142109</electronic-resource-num><volume>34</volume></record></Cite></EndNote>[35]. Increases in glycerol and free fatty acid concentrations and reductions in fasting glucose were also observed in this state of LEA (15 kcal/kg FFM/day). These findings suggest that insulin has increased sensitivity when EA is chronically low. Lower fasting glucose levels were also reported among those with menstrual dysfunction when compared to eumenorrhoeic athletes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2]. However, resting blood glucose levels were similar in athletes with amenorrhoea and those who were eumenorrheic ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2011</Year><IDText>Reduced catecholamine response to exercise in amenorrheic athletes</IDText><DisplayText>[47]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/blood/etiology/*metabolism/psychology</keyword><keyword>*Athletes</keyword><keyword>Blood Glucose/analysis</keyword><keyword>Blood Pressure</keyword><keyword>Case-Control Studies</keyword><keyword>Energy Metabolism</keyword><keyword>Epinephrine/*blood</keyword><keyword>Exercise/*physiology</keyword><keyword>Exercise Test</keyword><keyword>Female</keyword><keyword>Heart Rate</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/blood</keyword><keyword>Lactic Acid/blood</keyword><keyword>Norepinephrine/*blood</keyword><keyword>Oxygen Consumption</keyword><keyword>Physical Exertion</keyword></keywords><isbn>0195-9131</isbn><titles><title>Reduced catecholamine response to exercise in amenorrheic athletes</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>34-43</pages><number>1</number><contributors><authors><author>Schaal, K.</author><author>Van Loan, M. D.</author><author>Casazza, G. A.</author></authors></contributors><edition>2010/05/29</edition><language>eng</language><added-date format="utc">1469693273</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, 95816, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>175</rec-number><last-updated-date format="utc">1469693273</last-updated-date><accession-num>20508538</accession-num><electronic-resource-num>10.1249/MSS.0b013e3181e91ece</electronic-resource-num><volume>43</volume></record></Cite></EndNote>[47]. Currently, it can only be deduced that female athletes with menstrual irregularities appear to have lower blood glucose levels, which could be suggestive of greater overall physiological stress; further work is necessary to achieve consensus. 5.6 Summary The viability of biomarkers of energy deficiency is unclear, with questions around appropriate assessment of EA, defined EA cut-offs and standardised techniques impeding the quality of research in this area. These need to be considered in order to accurately determine the viability of biomarkers of energy deficiency. Although further research, especially with respect to the appetite hormones, is required, this represents an interesting area of investigation. Low Energy Availability and Dietary Intake in AthletesAthletes should be encouraged to consume a wide variety of foods on a regular basis. Athletes with LEA reported lower energy density and lower percentage energy from fat (28%) compared to those with optimal EA (31%) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [55]. Female soccer players who exhibited LEA consumed a lower EI at lunch during competition, pre- and mid-season and at dinner mid-season when compared to those with optimal EA ADDIN EN.CITE <EndNote><Cite><Author>Reed</Author><Year>2013</Year><IDText>Changes in energy availability across the season in Division I female soccer players</IDText><DisplayText>[18]</DisplayText><record><keywords><keyword>Adult</keyword><keyword>*Attitude to Health</keyword><keyword>Body Fluid Compartments</keyword><keyword>Body Image</keyword><keyword>*Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>*Exercise/psychology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/psychology</keyword><keyword>Humans</keyword><keyword>Meals</keyword><keyword>Motivation</keyword><keyword>Personal Satisfaction</keyword><keyword>*Seasons</keyword><keyword>*Soccer/psychology</keyword><keyword>Thinness</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Changes in energy availability across the season in Division I female soccer players</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>314-24</pages><number>3</number><contributors><authors><author>Reed, J. L.</author><author>De Souza, M. J.</author><author>Williams, N. I.</author></authors></contributors><edition>2012/10/19</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Kinesiology, The Pennsylvania State University, University Park, Pennsylvania 16802, USA.</auth-address><dates><year>2013</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>87</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23075047</accession-num><electronic-resource-num>10.1080/02640414.2012.733019</electronic-resource-num><volume>31</volume></record></Cite></EndNote>[18]. Methodological issues, such as reliance on self-reported food diaries, failure to compare dietary intakes with non-athletic controls who have optimal EA, and small sample sizes, make comparison between studies difficult PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WaW5lcjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [19, 25, 26, 32, 55]. 6.1 Low Energy Availability and Macronutrient Intakes In individuals with LEA, total EI is reduced which, subsequently, negatively influences diet quality. As low carbohydrate intake (≤ 6-10 g/kg/day for athletes exercising at moderate to high intensity ADDIN EN.CITE <EndNote><Cite><Author>Burke</Author><Year>2011</Year><IDText>Carbohydrates for training and competition</IDText><DisplayText>[56]</DisplayText><record><keywords><keyword>*Adaptation, Physiological</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Central Nervous System/drug effects</keyword><keyword>*Diet</keyword><keyword>Dietary Carbohydrates/*administration &amp; dosage/pharmacology</keyword><keyword>Drug Administration Schedule</keyword><keyword>*Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Exercise/*physiology</keyword><keyword>Humans</keyword><keyword>Intestinal Absorption</keyword><keyword>Nutritional Requirements</keyword><keyword>Physical Education and Training</keyword><keyword>Physical Endurance/physiology</keyword><keyword>Rest/physiology</keyword><keyword>Sports/*physiology</keyword></keywords><isbn>0264-0414</isbn><titles><title>Carbohydrates for training and competition</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>S17-27</pages><contributors><authors><author>Burke, L. M.</author><author>Hawley, J. A.</author><author>Wong, S. H.</author><author>Jeukendrup, A. E.</author></authors></contributors><edition>2011/06/11</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Sports Medicine, Australian Institute of Sport, Belconnen, ACT, Australia. louise.burke@.au</auth-address><dates><year>2011</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>103</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21660838</accession-num><electronic-resource-num>10.1080/02640414.2011.585473</electronic-resource-num><volume>29 Suppl 1</volume></record></Cite></EndNote>[56]) is commonly reported in athletes, it is not surprising that it has been observed in athletes identified with LEA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PElE

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Pn==

ADDIN EN.CITE.DATA [19, 26, 32, 55, 57]. A low carbohydrate, high fibre diet was reported among female endurance athletes with FHA when compared to eumenorrheic athletes; thus, a diet which exceeds the upper limit for dietary fibre may indicate risk of LEA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [55]. The erratic restriction of carbohydrate observed among athletes may be influenced by media-driven fad diet trends such as the “gluten-free” and “paleo” diets that promote the elimination of carbohydrate-rich foods ADDIN EN.CITE <EndNote><Cite><Author>Viner</Author><Year>2015</Year><IDText>Energy Availability and Dietary Patterns of Adult Male and Female Competitive Cyclists With Lower Than Expected Bone Mineral Density</IDText><DisplayText>[19]</DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2015</year></dates><isbn>1526-484x</isbn><titles><title>Energy availability and dietary patterns of adult male and female competitive cyclists with lower than expected bone mineral density</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>594-602</pages><number>6</number><contributors><authors><author>Viner, R. T.</author><author>Harris, M.</author><author>Berning, J. R.</author><author>Meyer, N. L.</author></authors></contributors><edition>2015/07/02</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Beth-El College of Nursing and Health Sciences, Sport Nutrition, University of Colorado Colorado Springs, Colorado Springs, CO.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>35</rec-number><last-updated-date format="utc">1499189525</last-updated-date><accession-num>26131616</accession-num><electronic-resource-num>10.1123/ijsnem.2015-0073</electronic-resource-num><volume>25</volume></record></Cite></EndNote>[19].Although inadequate intake of all macronutrients has been observed in female gymnasts ADDIN EN.CITE <EndNote><Cite><Author>Silva</Author><Year>2015</Year><IDText>Low energy availability and low body fat of female gymnasts before an international competition</IDText><DisplayText>[25]</DisplayText><record><keywords><keyword>Energy availability</keyword><keyword>body composition</keyword><keyword>energy intake</keyword><keyword>female athletes</keyword><keyword>macronutrients</keyword><keyword>micronutrients</keyword></keywords><isbn>1536-7290</isbn><titles><title>Low energy availability and low body fat of female gymnasts before an international competition</title><secondary-title>Eur J Sport Sci</secondary-title><alt-title>European journal of sport science</alt-title></titles><pages>591-9</pages><number>7</number><contributors><authors><author>Silva, M. R.</author><author>Paiva, T.</author></authors></contributors><edition>2014/10/17</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Molecular Medicine , Medical Faculty of Lisbon , Lisbon , Portugal.&#xD;b Faculty of Health Sciences , University Fernando Pessoa , Oporto , Portugal.&#xD;c Scientific Commission of the National School of Gymnastics , Gymnastics Federation of Portugal , Lisbon , Portugal.&#xD;d Research Centre for Anthropology and Health , University of Coimbra , Coimbra , Portugal.&#xD;e CENC , Sleep Medicine Center , Lisbon , Portugal.</auth-address><dates><year>2015</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>45</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>25318582</accession-num><electronic-resource-num>10.1080/17461391.2014.969323</electronic-resource-num><volume>15</volume></record></Cite></EndNote>[25], the evidence for low protein intakes in athletes with LEA is not consistent. Jockeys were shown to meet their protein requirements (1.3 g/kg/day) ADDIN EN.CITE <EndNote><Cite><Author>Dolan</Author><Year>2011</Year><IDText>Nutritional, lifestyle, and weight control practices of professional jockeys</IDText><DisplayText>[26]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>*Athletes</keyword><keyword>Health Surveys</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Male</keyword><keyword>*Nutrition Assessment</keyword><keyword>*Sports</keyword><keyword>Weight Loss/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Nutritional, lifestyle, and weight control practices of professional jockeys</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>791-9</pages><number>8</number><contributors><authors><author>Dolan, E.</author><author>O&apos;Connor, H.</author><author>McGoldrick, A.</author><author>O&apos;Loughlin, G.</author><author>Lyons, D.</author><author>Warrington, G.</author></authors></contributors><edition>2011/04/21</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Health and Human Performance, Dublin City University, Dublin, Ireland.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>104</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21506039</accession-num><electronic-resource-num>10.1080/02640414.2011.560173</electronic-resource-num><volume>29</volume></record></Cite></EndNote>[26] and all but one female endurance athlete met or exceeded the recommended protein intake for endurance-trained athletes PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [55]. 6.2 Low Energy Availability and Micronutrient IntakesInadequate intake of several essential micronutrients, such as vitamins A and C, riboflavin, folate, calcium and zinc have been documented in male jockeys and endurance trained females PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PElE

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ADDIN EN.CITE.DATA [26, 55]. A mean consumption of 0.9 servings of fruit and vegetables per day was reported in male jockeys ADDIN EN.CITE <EndNote><Cite><Author>Dolan</Author><Year>2011</Year><IDText>Nutritional, lifestyle, and weight control practices of professional jockeys</IDText><DisplayText>[26]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>*Athletes</keyword><keyword>Health Surveys</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Male</keyword><keyword>*Nutrition Assessment</keyword><keyword>*Sports</keyword><keyword>Weight Loss/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Nutritional, lifestyle, and weight control practices of professional jockeys</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>791-9</pages><number>8</number><contributors><authors><author>Dolan, E.</author><author>O&apos;Connor, H.</author><author>McGoldrick, A.</author><author>O&apos;Loughlin, G.</author><author>Lyons, D.</author><author>Warrington, G.</author></authors></contributors><edition>2011/04/21</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Health and Human Performance, Dublin City University, Dublin, Ireland.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>104</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21506039</accession-num><electronic-resource-num>10.1080/02640414.2011.560173</electronic-resource-num><volume>29</volume></record></Cite></EndNote>[26], indicating the need to educate athletes on appropriate nutritional strategies and the importance of meal timing and re-fuelling following exercise. Micronutrient inadequacies are also common among female gymnasts, with low intakes of folate, pantothenic acid, vitamins D, E and K, calcium, iron and magnesium reported ADDIN EN.CITE <EndNote><Cite><Author>Silva</Author><Year>2015</Year><IDText>Low energy availability and low body fat of female gymnasts before an international competition</IDText><DisplayText>[25]</DisplayText><record><keywords><keyword>Energy availability</keyword><keyword>body composition</keyword><keyword>energy intake</keyword><keyword>female athletes</keyword><keyword>macronutrients</keyword><keyword>micronutrients</keyword></keywords><isbn>1536-7290</isbn><titles><title>Low energy availability and low body fat of female gymnasts before an international competition</title><secondary-title>Eur J Sport Sci</secondary-title><alt-title>European journal of sport science</alt-title></titles><pages>591-9</pages><number>7</number><contributors><authors><author>Silva, M. R.</author><author>Paiva, T.</author></authors></contributors><edition>2014/10/17</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Molecular Medicine , Medical Faculty of Lisbon , Lisbon , Portugal.&#xD;b Faculty of Health Sciences , University Fernando Pessoa , Oporto , Portugal.&#xD;c Scientific Commission of the National School of Gymnastics , Gymnastics Federation of Portugal , Lisbon , Portugal.&#xD;d Research Centre for Anthropology and Health , University of Coimbra , Coimbra , Portugal.&#xD;e CENC , Sleep Medicine Center , Lisbon , Portugal.</auth-address><dates><year>2015</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>45</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>25318582</accession-num><electronic-resource-num>10.1080/17461391.2014.969323</electronic-resource-num><volume>15</volume></record></Cite></EndNote>[25]. Similar deficiencies were reported among cyclists ADDIN EN.CITE <EndNote><Cite><Author>Viner</Author><Year>2015</Year><IDText>Energy Availability and Dietary Patterns of Adult Male and Female Competitive Cyclists With Lower Than Expected Bone Mineral Density</IDText><DisplayText>[19]</DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2015</year></dates><isbn>1526-484x</isbn><titles><title>Energy availability and dietary patterns of adult male and female competitive cyclists with lower than expected bone mineral density</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>594-602</pages><number>6</number><contributors><authors><author>Viner, R. T.</author><author>Harris, M.</author><author>Berning, J. R.</author><author>Meyer, N. L.</author></authors></contributors><edition>2015/07/02</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Beth-El College of Nursing and Health Sciences, Sport Nutrition, University of Colorado Colorado Springs, Colorado Springs, CO.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>35</rec-number><last-updated-date format="utc">1499189525</last-updated-date><accession-num>26131616</accession-num><electronic-resource-num>10.1123/ijsnem.2015-0073</electronic-resource-num><volume>25</volume></record></Cite></EndNote>[19]. Methodological problems, such as misreporting ADDIN EN.CITE <EndNote><Cite><Author>Poslusna</Author><Year>2009</Year><IDText>Misreporting of energy and micronutrient intake estimated by food records and 24 hour recalls, control and adjustment methods in practice</IDText><DisplayText>[58]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2009</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Biomarkers/metabolism</keyword><keyword>*Diet Records</keyword><keyword>Diet Surveys</keyword><keyword>Eating</keyword><keyword>*Energy Intake</keyword><keyword>Feeding Behavior</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Recall</keyword><keyword>Micronutrients/*administration &amp; dosage</keyword><keyword>Middle Aged</keyword><keyword>Nutrition Assessment</keyword><keyword>Young Adult</keyword></keywords><isbn>0007-1145</isbn><titles><title>Misreporting of energy and micronutrient intake estimated by food records and 24 hour recalls, control and adjustment methods in practice</title><secondary-title>Br J Nutr</secondary-title><alt-title>The British journal of nutrition</alt-title></titles><pages>S73-85</pages><contributors><authors><author>Poslusna, K.</author><author>Ruprich, J.</author><author>de Vries, J. H.</author><author>Jakubikova, M.</author><author>van&apos;t Veer, P.</author></authors></contributors><edition>2009/07/15</edition><language>eng</language><added-date format="utc">1498913192</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Food Safety and Nutrition, NIPH - National Institute of Public Health in Prague, Palackeho 3a, Brno 61242, Czech Republic.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>390</rec-number><last-updated-date format="utc">1498913192</last-updated-date><accession-num>19594967</accession-num><electronic-resource-num>10.1017/s0007114509990602</electronic-resource-num><volume>101 Suppl 2</volume></record></Cite></EndNote>[58], make accurate measurement of dietary intake extremely difficult, particularly among athletes involved in weight or lean-dependent sports who are more susceptible to misreport energy intake ADDIN EN.CITE <EndNote><Cite><Author>Dwyer</Author><Year>2012</Year><IDText>Eating attitudes and food intakes of elite adolescent female figure skaters: a cross sectional study</IDText><DisplayText>[59]</DisplayText><record><dates><pub-dates><date>Dec 13</date></pub-dates><year>2012</year></dates><isbn>1550-2783</isbn><custom2>PMC3529676</custom2><titles><title>Eating attitudes and food intakes of elite adolescent female figure skaters: a cross sectional study</title><secondary-title>J Int Soc Sports Nutr</secondary-title><alt-title>Journal of the International Society of Sports Nutrition</alt-title></titles><pages>53</pages><number>1</number><contributors><authors><author>Dwyer, J.</author><author>Eisenberg, A.</author><author>Prelack, K.</author><author>Song, W. O.</author><author>Sonneville, K.</author><author>Ziegler, P.</author></authors></contributors><edition>2012/12/15</edition><language>eng</language><added-date format="utc">1498914013</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Frances Stern Nutrition Center, Tufts Medical Center, 800 Washington Street, Box #783, Boston, MA 02111, USA. Alanna.Eisenberg@.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>392</rec-number><last-updated-date format="utc">1498914013</last-updated-date><accession-num>23237333</accession-num><electronic-resource-num>10.1186/1550-2783-9-53</electronic-resource-num><volume>9</volume></record></Cite></EndNote>[59]. Nevertheless, it is essential to monitor EI and EEE to avoid a state of LEA, to allow for optimisation of diet quality and to ensure athletes are meeting nutrient recommendations relative to their sport. Encouraging carbohydrate consumption for performance and recovery to ensure muscle glycogen stores are replenished is important ADDIN EN.CITE <EndNote><Cite><Author>Burke</Author><Year>2011</Year><IDText>Carbohydrates for training and competition</IDText><DisplayText>[56]</DisplayText><record><keywords><keyword>*Adaptation, Physiological</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Central Nervous System/drug effects</keyword><keyword>*Diet</keyword><keyword>Dietary Carbohydrates/*administration &amp; dosage/pharmacology</keyword><keyword>Drug Administration Schedule</keyword><keyword>*Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Exercise/*physiology</keyword><keyword>Humans</keyword><keyword>Intestinal Absorption</keyword><keyword>Nutritional Requirements</keyword><keyword>Physical Education and Training</keyword><keyword>Physical Endurance/physiology</keyword><keyword>Rest/physiology</keyword><keyword>Sports/*physiology</keyword></keywords><isbn>0264-0414</isbn><titles><title>Carbohydrates for training and competition</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>S17-27</pages><contributors><authors><author>Burke, L. M.</author><author>Hawley, J. A.</author><author>Wong, S. H.</author><author>Jeukendrup, A. E.</author></authors></contributors><edition>2011/06/11</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Sports Medicine, Australian Institute of Sport, Belconnen, ACT, Australia. louise.burke@.au</auth-address><dates><year>2011</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>103</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21660838</accession-num><electronic-resource-num>10.1080/02640414.2011.585473</electronic-resource-num><volume>29 Suppl 1</volume></record></Cite></EndNote>[56]. Furthermore, personalised nutrition education is vital; for example, the low EI observed amongst jockeys is consistent with their need to maintain a low body mass for competition ADDIN EN.CITE <EndNote><Cite><Author>Dolan</Author><Year>2011</Year><IDText>Nutritional, lifestyle, and weight control practices of professional jockeys</IDText><DisplayText>[26]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>*Athletes</keyword><keyword>Health Surveys</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Male</keyword><keyword>*Nutrition Assessment</keyword><keyword>*Sports</keyword><keyword>Weight Loss/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Nutritional, lifestyle, and weight control practices of professional jockeys</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>791-9</pages><number>8</number><contributors><authors><author>Dolan, E.</author><author>O&apos;Connor, H.</author><author>McGoldrick, A.</author><author>O&apos;Loughlin, G.</author><author>Lyons, D.</author><author>Warrington, G.</author></authors></contributors><edition>2011/04/21</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Health and Human Performance, Dublin City University, Dublin, Ireland.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>104</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21506039</accession-num><electronic-resource-num>10.1080/02640414.2011.560173</electronic-resource-num><volume>29</volume></record></Cite></EndNote>[26]. Physiological and Health Issues Associated with Low Energy Availability7.1 Reproductive functionThe frequency at which the pituitary gland secretes luteinizing hormone into the circulatory system is a proxy indicator of the central modulation of the reproductive axis ADDIN EN.CITE <EndNote><Cite><Author>Martin</Author><Year>2008</Year><IDText>Caloric restriction: impact upon pituitary function and reproduction</IDText><DisplayText>[60]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2008</year></dates><keywords><keyword>Animals</keyword><keyword>*Caloric Restriction</keyword><keyword>Hormones/physiology</keyword><keyword>Humans</keyword><keyword>Pituitary Gland, Anterior/*physiology</keyword><keyword>*Reproduction</keyword></keywords><isbn>1568-1637</isbn><custom2>PMC2634963</custom2><titles><title>Caloric restriction: impact upon pituitary function and reproduction</title><secondary-title>Ageing Res Rev</secondary-title><alt-title>Ageing research reviews</alt-title></titles><pages>209-24</pages><number>3</number><contributors><authors><author>Martin, B.</author><author>Golden, E.</author><author>Carlson, O. D.</author><author>Egan, J. M.</author><author>Mattson, M. P.</author><author>Maudsley, S.</author></authors></contributors><edition>2008/03/11</edition><language>eng</language><added-date format="utc">1497381828</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Laboratory of Neurosciences, National Institute on Aging Intramural Research Program, 5600 Nathan Shock Drive, Baltimore, MD 21224, USA. martinbro@grc.nia.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>381</rec-number><last-updated-date format="utc">1497381828</last-updated-date><accession-num>18329344</accession-num><custom6>NIHMS83459</custom6><electronic-resource-num>10.1016/j.arr.2008.01.002</electronic-resource-num><volume>7</volume></record></Cite></EndNote>[60]. Luteinizing pulsatility in an exercising woman is solely dependent on EA and is not affected by the stress of exercise itself. Prolonged LEA (10 kcal/kg FFM/day) reduces luteinizing pulsatility ADDIN EN.CITE <EndNote><Cite><Author>Loucks</Author><Year>1998</Year><IDText>Low energy availability, not stress of exercise, alters LH pulsatility in exercising women</IDText><DisplayText>[11]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>1998</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Blood Glucose/metabolism</keyword><keyword>Energy Metabolism/*physiology</keyword><keyword>Exercise/*physiology</keyword><keyword>Follicle Stimulating Hormone/blood</keyword><keyword>Growth Hormone/blood</keyword><keyword>Humans</keyword><keyword>Luteinizing Hormone/*blood</keyword><keyword>Male</keyword><keyword>Stress, Physiological/*physiopathology</keyword></keywords><isbn>8750-7587 (Print)&#xD;0161-7567</isbn><titles><title>Low energy availability, not stress of exercise, alters LH pulsatility in exercising women</title><secondary-title>J Appl Physiol (1985)</secondary-title><alt-title>Journal of applied physiology (Bethesda, Md. : 1985)</alt-title></titles><pages>37-46</pages><number>1</number><contributors><authors><author>Loucks, A. B.</author><author>Verdun, M.</author><author>Heath, E. M.</author></authors></contributors><edition>1998/02/06</edition><language>eng</language><added-date format="utc">1472224046</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Biological Sciences and College of Osteopathic Medicine, Ohio University, Athens 45701-2979, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>278</rec-number><last-updated-date format="utc">1472224046</last-updated-date><accession-num>9451615</accession-num><volume>84</volume></record></Cite></EndNote>[11] and studies in athletes consistently report negative effects of LEA such as perturbed reproductive function PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2NoPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [2, 23, 24, 57, 61, 62]. Such athletes have lower RMR compared to athletes with good EA and normal menstrual function PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [63]. Self-reported menstrual history is the most commonly used technique to diagnose a clinical menstrual disorder (Table 2). This can be used in combination with a single measurement of sex hormones PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2NoPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48SURU

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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2NoPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [28, 61]. More recently, a number of studies have included a gynaecological ultrasound examination in the diagnostic assessment PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYWdtYXI8L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxJ

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b3RlPn==

ADDIN EN.CITE.DATA [2, 47, 57, 62, 64]. The recent 2014 TRIAD Coalition Consensus Statement outlines an amenorrhea algorithm that recommends a diagnosis of exclusion, whereby a history and physical examination, a series of clinical and endocrine tests and diagnosis by a physician are required to rule out pregnancy and endocrinopathies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZSBTb3V6YTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA [4]. However, given the cost of gynaecological function assessment, a standardised method to assess EA would be both clinically and economically advantageous. 7.2 Bone healthThe evidence supporting the benefits of vitamin D and calcium for bone health are widely accepted ADDIN EN.CITE <EndNote><Cite><Author>Cashman</Author><Year>2007</Year><IDText>Diet, nutrition, and bone health</IDText><DisplayText>[65]</DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>2007</year></dates><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Bone and Bones/drug effects/metabolism/physiology</keyword><keyword>Calcium, Dietary/metabolism/*therapeutic use</keyword><keyword>*Diet</keyword><keyword>Female</keyword><keyword>Hip Fractures/etiology</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>*Nutritional Physiological Phenomena</keyword><keyword>*Osteoporosis/complications/etiology/prevention &amp; control</keyword><keyword>Risk Factors</keyword></keywords><isbn>0022-3166 (Print)&#xD;0022-3166</isbn><titles><title>Diet, nutrition, and bone health</title><secondary-title>J Nutr</secondary-title><alt-title>The Journal of nutrition</alt-title></titles><pages>2507s-2512s</pages><number>11 Suppl</number><contributors><authors><author>Cashman, K. D.</author></authors></contributors><edition>2007/10/24</edition><language>Eng</language><added-date format="utc">1477917183</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Food and Nutritional Sciences and Department of Medicine, University College Cork, Cork, Ireland. k.cashman@ucc.ie</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>342</rec-number><last-updated-date format="utc">1477917183</last-updated-date><accession-num>17951494</accession-num><volume>137</volume></record></Cite></EndNote>[65]; thus, it is critical that appropriate nutritional practices are adopted to ensure BMD is maintained. Bone formation is suppressed once EA decreases below 30 kcal/kg FFM/day PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JaGxlPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [14]; thus, both contribute independently and synergistically to bone loss. For females competing in weight-bearing sports, the American College of Sports Medicine (ACSM) has defined low BMD as a z-score of less than -1.0; however, a defined criterion has not been established in male athletes ADDIN EN.CITE <EndNote><Cite><Author>Nattiv</Author><Year>2007</Year><IDText>American College of Sports Medicine position stand. The female athlete triad</IDText><DisplayText>[3]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2007</year></dates><keywords><keyword>Amenorrhea/epidemiology/etiology</keyword><keyword>*Consensus</keyword><keyword>Energy Intake</keyword><keyword>Feeding and Eating Disorders/epidemiology/etiology</keyword><keyword>Female</keyword><keyword>*Female Athlete Triad Syndrome/complications/diagnosis/pathology/prevention &amp;</keyword><keyword>control/therapy</keyword><keyword>Humans</keyword><keyword>Osteoporosis/epidemiology/etiology</keyword><keyword>Risk Factors</keyword><keyword>*Societies</keyword><keyword>*Sports Medicine</keyword><keyword>United States/epidemiology</keyword></keywords><isbn>0195-9131 (Print)&#xD;0195-9131</isbn><titles><title>American College of Sports Medicine position stand. The female athlete triad</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>1867-82</pages><number>10</number><contributors><authors><author>Nattiv, A.</author><author>Loucks, A. B.</author><author>Manore, M. M.</author><author>Sanborn, C. F.</author><author>Sundgot-Borgen, J.</author><author>Warren, M. P.</author></authors></contributors><edition>2007/10/03</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><remote-database-provider>NLM</remote-database-provider><rec-number>126</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>17909417</accession-num><electronic-resource-num>10.1249/mss.0b013e318149f111</electronic-resource-num><volume>39</volume></record></Cite></EndNote>[3]. Prevalence of low BMD among female athletes ranges from 0 to 15.4% using a z-score of ≤ -2.0. This increases to 39.8% when z-scores are defined as between -1.0 and -2.0 ADDIN EN.CITE <EndNote><Cite><Author>Gibbs</Author><Year>2013</Year><IDText>Prevalence of individual and combined components of the female athlete triad</IDText><DisplayText>[21]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2013</year></dates><keywords><keyword>Bone Density</keyword><keyword>Feeding and Eating Disorders/epidemiology</keyword><keyword>Female</keyword><keyword>Female Athlete Triad Syndrome/*epidemiology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Menstruation Disturbances/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Young Adult</keyword></keywords><isbn>0195-9131</isbn><titles><title>Prevalence of individual and combined components of the female athlete triad</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>985-96</pages><number>5</number><contributors><authors><author>Gibbs, J. C.</author><author>Williams, N. I.</author><author>De Souza, M. J.</author></authors></contributors><edition>2012/12/19</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Women&apos;s Health and Exercise Laboratory, Noll Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>86</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23247706</accession-num><electronic-resource-num>10.1249/MSS.0b013e31827e1bdc</electronic-resource-num><volume>45</volume></record></Cite></EndNote>[21]. Studies in athletes have rarely assessed BMD using dual-energy x-ray absorptiometry (DEXA) in combination with EA assessment (Table 4). Although DEXA is expensive, it is acknowledged as the gold standard assessment of BMD, is used to determine the extent and severity of osteoporosis and osteopenia and can predict fracture risk. A best-practice DEXA protocol should be followed to accurately assess bone changes in athletes ADDIN EN.CITE <EndNote><Cite><Author>Nana</Author><Year>2016</Year><IDText>Importance of Standardized DXA Protocol for Assessing Physique Changes in Athletes</IDText><DisplayText>[66]</DisplayText><record><dates><pub-dates><date>Jun</date></pub-dates><year>2016</year></dates><isbn>1526-484x</isbn><titles><title>Importance of standardized DXA protocol for assessing physique changes in athletes</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>259-67</pages><number>3</number><contributors><authors><author>Nana, A.</author><author>Slater, G. J.</author><author>Hopkins, W. G.</author><author>Halson, S. L.</author><author>Martin, D. T.</author><author>West, N. P.</author><author>Burke, L. M.</author></authors></contributors><edition>2014/01/25</edition><language>eng</language><added-date format="utc">1482491257</added-date><ref-type name="Journal Article">17</ref-type><auth-address>AIS Sports Nutrition, Australian Institute of Sport, Canberra, ACT, Australia.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>349</rec-number><last-updated-date format="utc">1499189664</last-updated-date><accession-num>24458265</accession-num><electronic-resource-num>10.1123/ijsnem.2013-0111</electronic-resource-num><volume>26</volume></record></Cite></EndNote>[66]. Male and female athletes competing in endurance sports and those sports that emphasise leanness appear to have low BMD. However, despite the persistence of LEA and presence of low BMD among a group of cyclists, BMD did not further reduce over a 10-month cycling season ADDIN EN.CITE <EndNote><Cite><Author>Viner</Author><Year>2015</Year><IDText>Energy Availability and Dietary Patterns of Adult Male and Female Competitive Cyclists With Lower Than Expected Bone Mineral Density</IDText><DisplayText>[19]</DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2015</year></dates><isbn>1526-484x</isbn><titles><title>Energy availability and dietary patterns of adult male and female competitive cyclists with lower than expected bone mineral density</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>594-602</pages><number>6</number><contributors><authors><author>Viner, R. T.</author><author>Harris, M.</author><author>Berning, J. R.</author><author>Meyer, N. L.</author></authors></contributors><edition>2015/07/02</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Beth-El College of Nursing and Health Sciences, Sport Nutrition, University of Colorado Colorado Springs, Colorado Springs, CO.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>35</rec-number><last-updated-date format="utc">1499189525</last-updated-date><accession-num>26131616</accession-num><electronic-resource-num>10.1123/ijsnem.2015-0073</electronic-resource-num><volume>25</volume></record></Cite></EndNote>[19]. Although non-weight bearing sports, such as cycling, can influence BMD, these findings highlight that poor bone health develops over a long period, suggesting that changes in BMD may not be detectable over a short timeframe and that previous exercise (jumping) and dietary (vitamin D and calcium supplements) interventions may stimulate bone mineralisation sufficiently to maintain BMD over the period of LEA. Although the positive impact that the mechanical loading from high impact exercise has on bone health is irrefutable, irregular menstruation, running in five or more seasons, intentionally restricting dietary intake and belief that thinness leads to improved performance were associated with low BMD in adolescent endurance runners PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJyYWNrPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48

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ADDIN EN.CITE.DATA [71]. Although the impact of LEA on reproductive function and BMD is not well documented among male athletes ADDIN EN.CITE <EndNote><Cite><Author>Tenforde</Author><Year>2016</Year><IDText>Parallels with the Female Athlete Triad in Male Athletes</IDText><DisplayText>[7]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2016</year></dates><isbn>0112-1642</isbn><titles><title>Parallels with the female athlete triad in male athletes</title><secondary-title>Sports Med</secondary-title><alt-title>Sports medicine (Auckland, N.Z.)</alt-title></titles><pages>171-82</pages><number>2</number><contributors><authors><author>Tenforde, A. S.</author><author>Barrack, M. T.</author><author>Nattiv, A.</author><author>Fredericson, M.</author></authors></contributors><edition>2015/10/27</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><remote-database-provider>NLM</remote-database-provider><rec-number>28</rec-number><last-updated-date format="utc">1499189417</last-updated-date><accession-num>26497148</accession-num><electronic-resource-num>10.1007/s40279-015-0411-y</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[7], indicators such as low testosterone and estradiol levels were found to be associated with low BMD and indicative of stress fractures PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WYW5kZXJzY2h1ZXJlbjwvQXV0aG9yPjxZZWFyPjIwMTQ8

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ZT4A

ADDIN EN.CITE.DATA [72, 73]. Jockeys who engaged in extreme weight loss practices had an elevated rate of bone loss and reduced BMD, which appeared to be associated with disrupted hormonal activity, for example, elevated sex hormone-binding globulin; this causes a decrease in the availability of biologically active testosterone PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PElE

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ADDIN EN.CITE.DATA [74]. Evidence of LEA ADDIN EN.CITE <EndNote><Cite><Author>Dolan</Author><Year>2011</Year><IDText>Nutritional, lifestyle, and weight control practices of professional jockeys</IDText><DisplayText>[26]</DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>*Athletes</keyword><keyword>Health Surveys</keyword><keyword>Horses</keyword><keyword>Humans</keyword><keyword>*Life Style</keyword><keyword>Male</keyword><keyword>*Nutrition Assessment</keyword><keyword>*Sports</keyword><keyword>Weight Loss/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>0264-0414</isbn><titles><title>Nutritional, lifestyle, and weight control practices of professional jockeys</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>791-9</pages><number>8</number><contributors><authors><author>Dolan, E.</author><author>O&apos;Connor, H.</author><author>McGoldrick, A.</author><author>O&apos;Loughlin, G.</author><author>Lyons, D.</author><author>Warrington, G.</author></authors></contributors><edition>2011/04/21</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Health and Human Performance, Dublin City University, Dublin, Ireland.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>104</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>21506039</accession-num><electronic-resource-num>10.1080/02640414.2011.560173</electronic-resource-num><volume>29</volume></record></Cite></EndNote>[26], together with disrupted hormonal activity and low BMD PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PElE

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AG==

ADDIN EN.CITE.DATA [3, 6].The potential for low BMD to increase the incidence of injury needs consideration. As stress fractures develop from recurring excessive strain caused by repetitive micro-trauma to bone at a rate greater than repair PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZXBwZXI8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxJ

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ADDIN EN.CITE.DATA [76-78], particularly among younger athletes. In contrast, one study investigating overuse injuries found no associations between these, menstrual irregularity and/or DE ADDIN EN.CITE <EndNote><Cite><Author>Tenforde</Author><Year>2011</Year><IDText>Overuse injuries in high school runners: lifetime prevalence and prevention strategies</IDText><DisplayText>[79]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2011</year></dates><keywords><keyword>Adolescent</keyword><keyword>Cumulative Trauma Disorders/*epidemiology/*prevention &amp;amp; control</keyword><keyword>Fasciitis, Plantar/epidemiology</keyword><keyword>Female</keyword><keyword>Health Surveys</keyword><keyword>Humans</keyword><keyword>Iliotibial Band Syndrome/epidemiology</keyword><keyword>Male</keyword><keyword>Patellofemoral Pain Syndrome/epidemiology</keyword><keyword>Prevalence</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Running/*injuries</keyword><keyword>San Francisco/epidemiology</keyword></keywords><isbn>1934-1482 (Print)&#xD;1934-1482</isbn><titles><title>Overuse injuries in high school runners: lifetime prevalence and prevention strategies</title><secondary-title>PM R.</secondary-title><alt-title>PM &amp;amp; R : the journal of injury, function, and rehabilitation</alt-title></titles><pages>125-31; quiz 131</pages><number>2</number><contributors><authors><author>Tenforde, A. S.</author><author>Sayres, L. C.</author><author>McCurdy, M. L.</author><author>Collado, H.</author><author>Sainani, K. L.</author><author>Fredericson, M.</author></authors></contributors><edition>2011/02/22</edition><language>eng</language><added-date format="utc">1471340271</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, CA 94063, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>229</rec-number><last-updated-date format="utc">1499188864</last-updated-date><accession-num>21333951</accession-num><electronic-resource-num>10.1016/j.pmrj.2010.09.009</electronic-resource-num><volume>3</volume></record></Cite></EndNote>[79]. This study only observed associations between higher training load (higher mileage) and injury in males. These discordant results may be due to the methods used to assess DE and injury, the athlete type investigated and sample size. In studies on this topic, “musculoskeletal injury” has either not been defined ADDIN EN.CITE <EndNote><Cite><Author>Beals</Author><Year>2002</Year><IDText>Disorders of the female athlete triad among collegiate athletes</IDText><DisplayText>[80]</DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2002</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/epidemiology</keyword><keyword>Body Image</keyword><keyword>Feeding and Eating Disorders/complications/*epidemiology/psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Menstruation Disturbances/complications/*epidemiology</keyword><keyword>Musculoskeletal System/*injuries</keyword><keyword>Prevalence</keyword><keyword>Psychiatric Status Rating Scales</keyword><keyword>Risk Factors</keyword><keyword>Self Concept</keyword><keyword>*Sports</keyword><keyword>Students</keyword><keyword>Surveys and Questionnaires</keyword><keyword>United States/epidemiology</keyword><keyword>Universities</keyword></keywords><isbn>1526-484X (Print)&#xD;1526-484x</isbn><titles><title>Disorders of the female athlete triad among collegiate athletes</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>281-93</pages><number>3</number><contributors><authors><author>Beals, K. A.</author><author>Manore, M. M.</author></authors></contributors><edition>2002/11/15</edition><language>eng</language><added-date format="utc">1471337543</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Family and Consumer Sciences at Ball State University, Muncie, IN 47304, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>227</rec-number><last-updated-date format="utc">1471337543</last-updated-date><accession-num>12432173</accession-num><volume>12</volume></record></Cite></EndNote>[80] or has been defined as “an injury from either overuse or direct trauma that occurred during participation in the current sport season” ADDIN EN.CITE <EndNote><Cite><Author>Thein-Nissenbaum</Author><Year>2012</Year><IDText>Menstrual irregularity and musculoskeletal injury in female high school athletes</IDText><DisplayText>[78]</DisplayText><record><dates><pub-dates><date>Jan-Feb</date></pub-dates><year>2012</year></dates><keywords><keyword>Adolescent</keyword><keyword>Athletes</keyword><keyword>Athletic Injuries/*epidemiology</keyword><keyword>Bone Density</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Female</keyword><keyword>Female Athlete Triad Syndrome/epidemiology</keyword><keyword>Humans</keyword><keyword>Menstrual Cycle</keyword><keyword>Menstruation Disturbances/*epidemiology</keyword><keyword>Musculoskeletal System/*injuries</keyword><keyword>Schools</keyword><keyword>Students</keyword></keywords><isbn>1062-6050</isbn><custom2>PMC3418118</custom2><titles><title>Menstrual irregularity and musculoskeletal injury in female high school athletes</title><secondary-title>J Athl Train</secondary-title><alt-title>Journal of athletic training</alt-title></titles><pages>74-82</pages><number>1</number><contributors><authors><author>Thein-Nissenbaum, J. M.</author><author>Rauh, M. J.</author><author>Carr, K. E.</author><author>Loud, K. J.</author><author>McGuine, T. A.</author></authors></contributors><edition>2012/04/11</edition><language>eng</language><added-date format="utc">1469027379</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Graduate Program in Orthopaedic and Sports Science, Rocky Mountain University of Health Professions, Provo, UT, USA. thein@pt.wisc.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>93</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>22488233</accession-num><volume>47</volume></record></Cite></EndNote>[78]. A standardised definition of “injury” is required to enable accurate interpretation of future research studies and will permit work that can determine if links between LEA and injury exist. Furthermore, the recording of epidemiological data on injuries warrants attention; the majority of previous surveillance studies have focused on the aetiology of “medical-attention” and/or “time-loss” injury/ illness. Few studies have related these to athletes’ subsequent training limitations; this has resulted in the underreporting of “performance-restriction” type injuries, whereby athletes continue training yet incur performance detriments ADDIN EN.CITE <EndNote><Cite><Author>Palmer-Green</Author><Year>2013</Year><IDText>The Injury/Illness Performance Project (IIPP): A Novel Epidemiological Approach for Recording the Consequences of Sports Injuries and Illnesses</IDText><DisplayText>[81]</DisplayText><record><isbn>2356-7651 (Print)&#xD;2314-6176</isbn><custom2>PMC4590896</custom2><titles><title>The Injury/Illness Performance Project (IIPP): a novel epidemiological approach for recording the consequences of sports injuries and illnesses.</title><secondary-title>J Sports Med (Hindawi Publ Corp)</secondary-title><alt-title>Journal of sports medicine (Hindawi Publishing Corporation)</alt-title></titles><pages>523974</pages><contributors><authors><author>Palmer-Green, D.</author><author>Fuller, C.</author><author>Jaques, R.</author><author>Hunter, G.</author></authors></contributors><edition>2013/01/01</edition><language>eng</language><added-date format="utc">1488042565</added-date><ref-type name="Journal Article">17</ref-type><auth-address>University of Nottingham, Nottingham, UK.&#xD;F-MARC, Zurich, Switzerland.&#xD;English Institute of Sport, Bath, UK.&#xD;UK Sport, London, UK.</auth-address><dates><year>2013</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>365</rec-number><last-updated-date format="utc">1499188963</last-updated-date><accession-num>26464883</accession-num><electronic-resource-num>10.1155/2013/523974</electronic-resource-num><volume>2013</volume></record></Cite></EndNote>[81]. Further research is needed to accurately quantify injury incidence; this will help to determine associations between LEA and injury and inform injury/illness prevention initiatives in sport. 7.3 Immune functionEating a varied diet that meets athletes’ energy needs can help maintain an effective immune system ADDIN EN.CITE <EndNote><Cite><Author>Walsh</Author><Year>2011</Year><IDText>Position statement. Part two: Maintaining immune health</IDText><DisplayText>[82]</DisplayText><record><keywords><keyword>Circadian Rhythm</keyword><keyword>*Exercise</keyword><keyword>Humans</keyword><keyword>Immune System/*physiology</keyword><keyword>Infection Control</keyword><keyword>Nutritional Physiological Phenomena</keyword><keyword>Sleep Wake Disorders/immunology</keyword><keyword>Stress, Psychological/immunology</keyword></keywords><isbn>1077-5552 (Print)&#xD;1077-5552</isbn><titles><title>Position statement. Part two: maintaining immune health</title><secondary-title>Exerc Immunol Rev</secondary-title><alt-title>Exercise immunology review</alt-title></titles><pages>64-103</pages><contributors><authors><author>Walsh, N. P.</author><author>Gleeson, M.</author><author>Pyne, D. B.</author><author>Nieman, D. C.</author><author>Dhabhar, F. S.</author><author>Shephard, R. J.</author><author>Oliver, S. J.</author><author>Bermon, S.</author><author>Kajeniene, A.</author></authors></contributors><edition>2011/03/31</edition><language>eng</language><added-date format="utc">1471449121</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Sport, Health and Exercise Sciences, Bangor University, UK. n.walsh@bangor.ac.uk</auth-address><dates><year>2011</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>241</rec-number><last-updated-date format="utc">1499190083</last-updated-date><accession-num>21446353</accession-num><volume>17</volume></record></Cite></EndNote>[82]. 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ADDIN EN.CITE.DATA [82-84]. Particularly when EEE is high, athletes are more susceptible to infectious agents ADDIN EN.CITE <EndNote><Cite><Author>Gleeson</Author><Year>2016</Year><IDText>Immunological aspects of sport nutrition</IDText><DisplayText>[84]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2016</year></dates><isbn>0818-9641</isbn><titles><title>Immunological aspects of sport nutrition</title><secondary-title>Immunol Cell Biol</secondary-title><alt-title>Immunology and cell biology</alt-title></titles><pages>117-23</pages><number>2</number><contributors><authors><author>Gleeson, M.</author></authors></contributors><edition>2015/12/05</edition><language>eng</language><added-date format="utc">1471426075</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>231</rec-number><last-updated-date format="utc">1471426075</last-updated-date><accession-num>26634839</accession-num><electronic-resource-num>10.1038/icb.2015.109</electronic-resource-num><volume>94</volume></record></Cite></EndNote>[84]. From a health perspective, and as sports performance is influenced by days and weeks lost to injury and illness ADDIN EN.CITE <EndNote><Cite><Author>Raysmith</Author><Year>2016</Year><IDText>Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study</IDText><DisplayText>[85]</DisplayText><record><dates><pub-dates><date>Jan 7</date></pub-dates><year>2016</year></dates><keywords><keyword>Athletics</keyword><keyword>Epidemiology</keyword><keyword>Performance analysis</keyword><keyword>Sporting injury</keyword><keyword>Success</keyword></keywords><titles><title>Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study</title><secondary-title>J Sci Med Sport</secondary-title><alt-title>Journal of science and medicine in sport / Sports Medicine Australia</alt-title></titles><contributors><authors><author>Raysmith, B. P.</author><author>Drew, M. K.</author></authors></contributors><edition>2016/02/04</edition><language>Eng</language><added-date format="utc">1470929399</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Physical Therapies, Australian Institute of Sport, Australia. Electronic address: ben.raysmith@.au.&#xD;Department of Physical Therapies, Australian Institute of Sport, Australia|Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University, Australia.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>223</rec-number><last-updated-date format="utc">1504275090</last-updated-date><accession-num>26839047</accession-num><electronic-resource-num>10.1016/j.jsams.2015.12.515</electronic-resource-num><pages>778-83</pages><number>10</number><volume>19</volume></record></Cite></EndNote>[85], preventative measures need to be implemented to ensure adequate energy to minimize these adverse health events in an elite performance environment. Catecholamines regulate immune and inflammatory responses and are released by the sympathetic nervous system and the adrenal medulla. They cause an increase in the contraction and conduction velocity of cardiomyocytes, resulting in increased cardiac output and a rise in blood pressure, ultimately increasing vascular tone and resistance ADDIN EN.CITE <EndNote><Cite><Author>Flierl</Author><Year>2008</Year><IDText>Catecholamines-crafty weapons in the inflammatory arsenal of immune/inflammatory cells or opening pandora&apos;s box?</IDText><DisplayText>[86]</DisplayText><record><dates><pub-dates><date>Mar-Apr</date></pub-dates><year>2008</year></dates><keywords><keyword>Animals</keyword><keyword>Catecholamines/chemistry/*metabolism</keyword><keyword>Humans</keyword><keyword>Immune System/physiology</keyword><keyword>Inflammation/*immunology</keyword><keyword>Molecular Structure</keyword><keyword>Phagocytes/metabolism</keyword><keyword>T-Lymphocytes/metabolism</keyword></keywords><isbn>1076-1551 (Print)&#xD;1076-1551</isbn><custom2>PMC2136428</custom2><titles><title>Catecholamines-crafty weapons in the inflammatory arsenal of immune/inflammatory cells or opening pandora&apos;s box?</title><secondary-title>Mol Med</secondary-title><alt-title>Molecular medicine (Cambridge, Mass.)</alt-title></titles><pages>195-204</pages><number>3-4</number><contributors><authors><author>Flierl, M. A.</author><author>Rittirsch, D.</author><author>Huber-Lang, M.</author><author>Sarma, J. V.</author><author>Ward, P. A.</author></authors></contributors><edition>2007/12/15</edition><language>eng</language><added-date format="utc">1473779190</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109-0602, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>319</rec-number><last-updated-date format="utc">1473779190</last-updated-date><accession-num>18079995</accession-num><electronic-resource-num>10.2119/2007-00105.Flierl</electronic-resource-num><volume>14</volume></record></Cite></EndNote>[86]. It has been speculated that the reduced catecholamine (epinephrine and norepinephrine) response, observed in amenorrheic athletes, could be an adaptive mechanism that preserves energy in order to promote survival by suppressing non-essential physiological processes in a state of LEA ADDIN EN.CITE <EndNote><Cite><Author>Schaal</Author><Year>2011</Year><IDText>Reduced catecholamine response to exercise in amenorrheic athletes</IDText><DisplayText>[47]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/blood/etiology/*metabolism/psychology</keyword><keyword>*Athletes</keyword><keyword>Blood Glucose/analysis</keyword><keyword>Blood Pressure</keyword><keyword>Case-Control Studies</keyword><keyword>Energy Metabolism</keyword><keyword>Epinephrine/*blood</keyword><keyword>Exercise/*physiology</keyword><keyword>Exercise Test</keyword><keyword>Female</keyword><keyword>Heart Rate</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/blood</keyword><keyword>Lactic Acid/blood</keyword><keyword>Norepinephrine/*blood</keyword><keyword>Oxygen Consumption</keyword><keyword>Physical Exertion</keyword></keywords><isbn>0195-9131</isbn><titles><title>Reduced catecholamine response to exercise in amenorrheic athletes</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>34-43</pages><number>1</number><contributors><authors><author>Schaal, K.</author><author>Van Loan, M. D.</author><author>Casazza, G. A.</author></authors></contributors><edition>2010/05/29</edition><language>eng</language><added-date format="utc">1469693273</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Sports Performance Laboratory, Sports Medicine Program, University of California, Davis, Sacramento, 95816, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>175</rec-number><last-updated-date format="utc">1469693273</last-updated-date><accession-num>20508538</accession-num><electronic-resource-num>10.1249/MSS.0b013e3181e91ece</electronic-resource-num><volume>43</volume></record></Cite></EndNote>[47]. Norepinephrine and epinephrine are key hormones that prepare the body for one of its most primeval reactions: the “fight or flight” response ADDIN EN.CITE <EndNote><Cite><Author>Flierl</Author><Year>2008</Year><IDText>Catecholamines-crafty weapons in the inflammatory arsenal of immune/inflammatory cells or opening pandora&apos;s box?</IDText><DisplayText>[86]</DisplayText><record><dates><pub-dates><date>Mar-Apr</date></pub-dates><year>2008</year></dates><keywords><keyword>Animals</keyword><keyword>Catecholamines/chemistry/*metabolism</keyword><keyword>Humans</keyword><keyword>Immune System/physiology</keyword><keyword>Inflammation/*immunology</keyword><keyword>Molecular Structure</keyword><keyword>Phagocytes/metabolism</keyword><keyword>T-Lymphocytes/metabolism</keyword></keywords><isbn>1076-1551 (Print)&#xD;1076-1551</isbn><custom2>PMC2136428</custom2><titles><title>Catecholamines-crafty weapons in the inflammatory arsenal of immune/inflammatory cells or opening pandora&apos;s box?</title><secondary-title>Mol Med</secondary-title><alt-title>Molecular medicine (Cambridge, Mass.)</alt-title></titles><pages>195-204</pages><number>3-4</number><contributors><authors><author>Flierl, M. A.</author><author>Rittirsch, D.</author><author>Huber-Lang, M.</author><author>Sarma, J. V.</author><author>Ward, P. A.</author></authors></contributors><edition>2007/12/15</edition><language>eng</language><added-date format="utc">1473779190</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109-0602, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>319</rec-number><last-updated-date format="utc">1473779190</last-updated-date><accession-num>18079995</accession-num><electronic-resource-num>10.2119/2007-00105.Flierl</electronic-resource-num><volume>14</volume></record></Cite></EndNote>[86]. As reductions in catecholamine responses also correlate with lower peak blood lactate, fewer menstrual cycles and higher EEE, reduced lactate and catecholamine responses to maximal exercise may be suitable as biomarkers of inadequate EI ADDIN EN.CITE <EndNote><Cite><Author>Zouhal</Author><Year>2008</Year><IDText>Catecholamines and the effects of exercise, training and gender</IDText><DisplayText>[87]</DisplayText><record><keywords><keyword>Catecholamines/*metabolism</keyword><keyword>Exercise/*physiology</keyword><keyword>Humans</keyword><keyword>Muscle, Skeletal/*metabolism</keyword><keyword>Physical Fitness/physiology</keyword><keyword>Sex Factors</keyword></keywords><isbn>0112-1642 (Print)&#xD;0112-1642</isbn><titles><title>Catecholamines and the effects of exercise, training and gender</title><secondary-title>Sports Med</secondary-title><alt-title>Sports medicine (Auckland, N.Z.)</alt-title></titles><pages>401-23</pages><number>5</number><contributors><authors><author>Zouhal, H.</author><author>Jacob, C.</author><author>Delamarche, P.</author><author>Gratas-Delamarche, A.</author></authors></contributors><edition>2008/04/18</edition><language>eng</language><added-date format="utc">1497540700</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Movement, Sport and Health Laboratory, Universite de Rennes 2-ENS Cachan, Rennes, France. hassane.zouhal@univ-rennes2.fr</auth-address><dates><year>2008</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>388</rec-number><last-updated-date format="utc">1497540700</last-updated-date><accession-num>18416594</accession-num><volume>38</volume></record></Cite></EndNote>[87]. Table 5 summarises the studies that examined the effects of short-term dieting/rapid weight loss and exercise training on immunological parameters. Despite the lack of conclusive evidence of the effects of LEA on immune function, mucosal immunity appears to be is altered in weight class sports, in which athletes intermittently use rapid weight loss methods in combination with intensive training PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYmVkZWxtYWxlazwvQXV0aG9yPjxZZWFyPjIwMTU8L1ll

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ADDIN EN.CITE.DATA [88-90]. The alterations in immunoglobulins, in combination with rapid weight loss, suggest that these athletes are more susceptible to infectious illnesses. Disrupted neutrophil function, reactive oxygen species production and increased phagocytic activity are observed, demonstrating compensatory mechanisms in order to maintain immunological homoeostasis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb3dhdGFyaTwvQXV0aG9yPjxZZWFyPjIwMDE8L1llYXI+

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ADDIN EN.CITE.DATA [91-93]. Furthermore, repetitive weight cycling appears to alter levels of salivary immunoglobulin A (IgA) during training, competition and recovery periods ADDIN EN.CITE <EndNote><Cite><Author>Tsai</Author><Year>2011</Year><IDText>Changes of mucosal immunity and antioxidation activity in elite male Taiwanese taekwondo athletes associated with intensive training and rapid weight loss</IDText><DisplayText>[94]</DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2011</year></dates><keywords><keyword>Adipose Tissue/immunology</keyword><keyword>Antioxidants/metabolism</keyword><keyword>Body Mass Index</keyword><keyword>Exercise/*physiology</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/metabolism</keyword><keyword>Immunity, Mucosal/*physiology</keyword><keyword>Immunoglobulin A/metabolism</keyword><keyword>Lactoferrin/metabolism</keyword><keyword>Male</keyword><keyword>Martial Arts/*physiology</keyword><keyword>Saliva/chemistry</keyword><keyword>Taiwan</keyword><keyword>Urinary Tract Infections/immunology</keyword><keyword>Weight Loss/*immunology</keyword><keyword>Young Adult</keyword></keywords><isbn>0306-3674</isbn><titles><title>Changes of mucosal immunity and antioxidation activity in elite male Taiwanese taekwondo athletes associated with intensive training and rapid weight loss</title><secondary-title>Br J Sports Med</secondary-title><alt-title>British journal of sports medicine</alt-title></titles><pages>729-34</pages><number>9</number><contributors><authors><author>Tsai, M. L.</author><author>Chou, K. M.</author><author>Chang, C. K.</author><author>Fang, S. H.</author></authors></contributors><edition>2009/10/23</edition><language>eng</language><added-date format="utc">1471528422</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Institute of Athletics, National Taiwan Sport University, Taichung, Taiwan.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>249</rec-number><last-updated-date format="utc">1471528422</last-updated-date><accession-num>19846424</accession-num><electronic-resource-num>10.1136/bjsm.2009.062497</electronic-resource-num><volume>45</volume></record></Cite></EndNote>[94]. Salivary IgA prevents attachment of external pathogens and toxic molecules to mucosal surfaces and, thus, plays a key role in mucosal immunity ADDIN EN.CITE <EndNote><Cite><Author>Marcotte</Author><Year>1998</Year><IDText>Oral microbial ecology and the role of salivary immunoglobulin A</IDText><DisplayText>[95]</DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>1998</year></dates><keywords><keyword>Animals</keyword><keyword>Bacteria/*immunology</keyword><keyword>Ecosystem</keyword><keyword>Humans</keyword><keyword>Immunoglobulin A, Secretory/*immunology</keyword><keyword>Mouth/*microbiology</keyword><keyword>Mouth Diseases</keyword><keyword>Saliva</keyword></keywords><isbn>1092-2172 (Print)&#xD;1092-2172</isbn><custom2>PMC98907</custom2><titles><title>Oral microbial ecology and the role of salivary immunoglobulin A</title><secondary-title>Microbiol Mol Biol Rev</secondary-title><alt-title>Microbiology and molecular biology reviews : MMBR</alt-title></titles><pages>71-109</pages><number>1</number><contributors><authors><author>Marcotte, H.</author><author>Lavoie, M. C.</author></authors></contributors><edition>1998/04/08</edition><language>eng</language><added-date format="utc">1471528882</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Departement de Microbiologie-Immunologie, Faculte de Medecine, Universite Laval, Quebec, Canada.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>251</rec-number><last-updated-date format="utc">1471528882</last-updated-date><accession-num>9529888</accession-num><volume>62</volume></record></Cite></EndNote>[95]. It is not surprising that the incidence of upper respiratory tract infection was significantly increased after competition in taekwondo athletes with low salivary IgA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Uc2FpPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48SURU

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ADDIN EN.CITE.DATA [94, 96]. Recently, it has been suggested that monitoring salivary IgA secretion can identify athletes at risk of upper respiratory symptoms ADDIN EN.CITE <EndNote><Cite><Author>Gleeson</Author><Year>2016</Year><IDText>Respiratory inflammation and infections in high-performance athletes</IDText><DisplayText>[83]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2016</year></dates><isbn>0818-9641</isbn><titles><title>Respiratory inflammation and infections in high-performance athletes</title><secondary-title>Immunol Cell Biol</secondary-title><alt-title>Immunology and cell biology</alt-title></titles><pages>124-31</pages><number>2</number><contributors><authors><author>Gleeson, M.</author><author>Pyne, D. B.</author></authors></contributors><edition>2015/11/17</edition><language>eng</language><added-date format="utc">1471601180</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Hunter Medical Research Institute and School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.&#xD;Department of Physiology, Sports Science and Medicine, Australian Institute of Sport, Belconnen, Australian Capital Territory, Australia.&#xD;Research Institute for Sports and Exercise, University of Canberra, Canberra, Australian Capital Territory, Australia.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>254</rec-number><last-updated-date format="utc">1471601180</last-updated-date><accession-num>26568028</accession-num><electronic-resource-num>10.1038/icb.2015.100</electronic-resource-num><volume>94</volume></record></Cite></EndNote>[83]. Further research is recommended to more precisely identify the relationship between LEA, IgA and other immunological markers. 7.4 Cardiovascular healthEndothelial dysfunction can be classed as the earliest detectable stage of cardiovascular disease (CVD) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hhY2hpbmdlcjwvQXV0aG9yPjxZZWFyPjIwMDA8L1ll

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ADDIN EN.CITE.DATA [97]. Normal vascular endothelium is essential for the production of nitric oxide (NO). Cardiovascular health is influenced by NO which acts as a vascular protector by playing a key role in preventing platelet aggregation, leukocyte adhesion and vascular smooth muscle proliferation and migration ADDIN EN.CITE <EndNote><Cite><Author>Dusting</Author><Year>1998</Year><IDText>Nitric oxide in atherosclerosis: vascular protector or villain?</IDText><DisplayText>[98]</DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>1998</year></dates><keywords><keyword>Animals</keyword><keyword>Arteriosclerosis/*etiology</keyword><keyword>Endothelium/physiology</keyword><keyword>Humans</keyword><keyword>Hyperlipidemias/etiology</keyword><keyword>Leukocytes/*physiology</keyword><keyword>Nitric Oxide/*physiology</keyword><keyword>Nitric Oxide Synthase/metabolism</keyword><keyword>Nitric Oxide Synthase Type II</keyword><keyword>Platelet Aggregation/*physiology</keyword><keyword>Vascular Diseases/etiology</keyword></keywords><isbn>0143-9294 (Print)&#xD;0143-9294</isbn><titles><title>Nitric oxide in atherosclerosis: vascular protector or villain?</title><secondary-title>Clin Exp Pharmacol Physiol Suppl</secondary-title><alt-title>Clinical and experimental pharmacology &amp; physiology. Supplement</alt-title></titles><pages>S34-41</pages><contributors><authors><author>Dusting, G. J.</author><author>Fennessy, P.</author><author>Yin, Z. L.</author><author>Gurevich, V.</author></authors></contributors><edition>1998/11/11</edition><language>eng</language><added-date format="utc">1472479670</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Howard Florey Institute, University of Melbourne, Parkville, Victoria, Australia. gjd@hfi.unimelb.edu.au</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>296</rec-number><last-updated-date format="utc">1472479670</last-updated-date><accession-num>9809190</accession-num><volume>25</volume></record></Cite></EndNote>[98]. Oestrogen also plays a key role in the vascular endothelial NO signalling system. Associations between reduced flow-mediated dilation (FMD) and amenorrhoea PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aZW5pIEhvY2g8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFy

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ADDIN EN.CITE.DATA [99, 100] have been observed. However, investigations carried out in dancers suggest that FMD is not simply a function of circulating oestrogen concentrations as reduced FMD was observed in amenorrheic dancers as well as in some eumenorrheic and hormonal contraceptive-using dancers ADDIN EN.CITE <EndNote><Cite><Author>Hoch</Author><Year>2011</Year><IDText>Association between the female athlete triad and endothelial dysfunction in dancers</IDText><DisplayText>[61]</DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Brachial Artery/*physiopathology</keyword><keyword>Dancing/*physiology</keyword><keyword>Dilatation, Pathologic</keyword><keyword>Endothelium, Vascular/*physiopathology</keyword><keyword>Female</keyword><keyword>Female Athlete Triad Syndrome/*epidemiology/physiopathology</keyword><keyword>Humans</keyword><keyword>Prevalence</keyword><keyword>Prospective Studies</keyword><keyword>Young Adult</keyword></keywords><isbn>1050-642x</isbn><custom2>PMC3570811</custom2><titles><title>Association between the female athlete triad and endothelial dysfunction in dancers</title><secondary-title>Clin J Sport Med</secondary-title><alt-title>Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine</alt-title></titles><pages>119-25</pages><number>2</number><contributors><authors><author>Hoch, A. Z.</author><author>Papanek, P.</author><author>Szabo, A.</author><author>Widlansky, M. E.</author><author>Schimke, J. E.</author><author>Gutterman, D. D.</author></authors></contributors><edition>2011/03/02</edition><language>eng</language><added-date format="utc">1469693346</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Orthopaedic Surgery, Medical College of Wisconsin, 9200 West Wisconsin Ave., Milwaukee, WI 43226, USA. azeni@mcw.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>176</rec-number><last-updated-date format="utc">1469693346</last-updated-date><accession-num>21358502</accession-num><custom6>NIHMS396391</custom6><electronic-resource-num>10.1097/JSM.0b013e3182042a9a</electronic-resource-num><volume>21</volume></record></Cite></EndNote>[61]. Of those dancers identified with LEA, 71% had reduced FMD. These findings suggest that in a state of LEA, regardless of oestrogen levels, endothelial dysfunction can occur PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aZW5pIEhvY2g8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFy

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ADDIN EN.CITE.DATA [101]. Other researchers speculate that starvation results in an increased synthesis of lipoproteins, contributing to an unfavourable lipid pattern in patients with anorexia nervosa ADDIN EN.CITE <EndNote><Cite><Author>Ohwada</Author><Year>2006</Year><IDText>Etiology of hypercholesterolemia in patients with anorexia nervosa</IDText><DisplayText>[102]</DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>2006</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Anorexia Nervosa/*epidemiology</keyword><keyword>Apolipoproteins/blood</keyword><keyword>Cholesterol Ester Transfer Proteins/blood</keyword><keyword>Cholesterol, HDL/blood</keyword><keyword>Cholesterol, LDL/blood</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypercholesterolemia/blood/*epidemiology/*etiology</keyword><keyword>Incidence</keyword><keyword>Ketone Bodies/blood</keyword><keyword>Triglycerides/blood</keyword></keywords><isbn>0276-3478 (Print)&#xD;0276-3478</isbn><titles><title>Etiology of hypercholesterolemia in patients with anorexia nervosa</title><secondary-title>Int J Eat Disord</secondary-title><alt-title>The International journal of eating disorders</alt-title></titles><pages>598-601</pages><number>7</number><contributors><authors><author>Ohwada, R.</author><author>Hotta, M.</author><author>Oikawa, S.</author><author>Takano, K.</author></authors></contributors><edition>2006/06/23</edition><language>eng</language><added-date format="utc">1472555037</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Medicine, Institute of Clinical Endocrinology, Tokyo Women&apos;s Medical University, School of Medicine, Shinjuku-ku, Tokyo, Japan. rinaowad@endm.twmu.ac.jp</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>300</rec-number><last-updated-date format="utc">1472555037</last-updated-date><accession-num>16791856</accession-num><electronic-resource-num>10.1002/eat.20298</electronic-resource-num><volume>39</volume></record></Cite></EndNote>[102]. Increases in Apo-A1, Apo-C2, Apo-E and cholesterol ester transfer protein (CETP) activity have been observed, suggesting accelerated cholesterol synthesis, indicating a metabolic basis leading to hypercholesterolemia, among anorexic patients compared to age-matched controls. In amenorrheic athletes compared to other athlete groups ADDIN EN.CITE <EndNote><Cite><Author>Rickenlund</Author><Year>2005</Year><IDText>Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile</IDText><DisplayText>[100]</DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>2005</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Amenorrhea/*metabolism/*physiopathology</keyword><keyword>Apolipoproteins B/blood</keyword><keyword>Biomarkers</keyword><keyword>Brachial Artery/physiology</keyword><keyword>Cholesterol, LDL/*blood</keyword><keyword>Endothelium, Vascular/metabolism/*physiopathology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Lipoprotein(a)/blood</keyword><keyword>Physical Endurance</keyword><keyword>Sports</keyword></keywords><isbn>0021-972X (Print)&#xD;0021-972x</isbn><titles><title>Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile</title><secondary-title>J Clin Endocrinol Metab</secondary-title><alt-title>The Journal of clinical endocrinology and metabolism</alt-title></titles><pages>1354-9</pages><number>3</number><contributors><authors><author>Rickenlund, A.</author><author>Eriksson, M. J.</author><author>Schenck-Gustafsson, K.</author><author>Hirschberg, A. L.</author></authors></contributors><edition>2004/12/02</edition><language>eng</language><added-date format="utc">1472477021</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Clinical Physiology, N101, Karolinska University Hospital, Box 140, SE-17176 Stockholm, Sweden. anette.rickenlund@karolinska.se</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>292</rec-number><last-updated-date format="utc">1472477021</last-updated-date><accession-num>15572426</accession-num><electronic-resource-num>10.1210/jc.2004-1286</electronic-resource-num><volume>90</volume></record></Cite></EndNote>[100], unfavourable lipid profiles (higher total cholesterol and low-density lipoprotein [LDL] cholesterol) have been reported. This supports the premise of a relationship between LEA and development of CVD risk factors.Furthermore, energy deficiency may accelerate changes in cholesterol synthesis. High total cholesterol levels were recently observed among endurance athletes with LEA and/or EDs/DE behavior (73%) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxpbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [2]. Although a 7-day dietary restriction in male judo players did not influence changes in total, LDL or high-density lipoprotein [HDL] cholesterols, it negatively influenced triglyceride and free fatty acid levels ADDIN EN.CITE <EndNote><Cite><Author>Filaire</Author><Year>2001</Year><IDText>Food restriction, performance, psychological state and lipid values in judo athletes</IDText><DisplayText>[103]</DisplayText><record><dates><pub-dates><date>Aug</date></pub-dates><year>2001</year></dates><keywords><keyword>Adult</keyword><keyword>Affect/physiology</keyword><keyword>Apolipoproteins/blood</keyword><keyword>Energy Intake/*physiology</keyword><keyword>Exercise/*physiology</keyword><keyword>Hand Strength</keyword><keyword>Humans</keyword><keyword>Lipids/*blood</keyword><keyword>Lipoproteins/blood</keyword><keyword>Male</keyword><keyword>Martial Arts/*physiology/*psychology</keyword><keyword>Psychomotor Performance/physiology</keyword><keyword>*Task Performance and Analysis</keyword><keyword>Weight Loss/physiology</keyword></keywords><isbn>0172-4622 (Print)&#xD;0172-4622</isbn><titles><title>Food restriction, performance, psychological state and lipid values in judo athletes</title><secondary-title>Int J Sports Med</secondary-title><alt-title>International journal of sports medicine</alt-title></titles><pages>454-9</pages><number>6</number><contributors><authors><author>Filaire, E.</author><author>Maso, F.</author><author>Degoutte, F.</author><author>Jouanel, P.</author><author>Lac, G.</author></authors></contributors><edition>2001/09/04</edition><language>eng</language><added-date format="utc">1471467435</added-date><ref-type name="Journal Article">17</ref-type><auth-address>CRIS, Laboratoire de la Performance, UFRSTAPS Lyon I, Villeurbanne, France. filaire@nat.fr</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>245</rec-number><last-updated-date format="utc">1471467435</last-updated-date><accession-num>11531040</accession-num><electronic-resource-num>10.1055/s-2001-16244</electronic-resource-num><volume>22</volume></record></Cite></EndNote>[103]. Similarly, higher free fatty acid concentrations were reported in exercising males when subjected to 15 kcal/kg FFM/day for 4 days ADDIN EN.CITE <EndNote><Cite><Author>Koehler</Author><Year>2016</Year><IDText>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</IDText><DisplayText>[35]</DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2016</year></dates><keywords><keyword>Energy deficiency</keyword><keyword>caloric restriction</keyword><keyword>exercise</keyword><keyword>leptin</keyword><keyword>testosterone</keyword></keywords><isbn>0264-0414</isbn><titles><title>Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones</title><secondary-title>J Sports Sci</secondary-title><alt-title>Journal of sports sciences</alt-title></titles><pages>1921-9</pages><number>20</number><contributors><authors><author>Koehler, K.</author><author>Hoerner, N. R.</author><author>Gibbs, J. C.</author><author>Zinner, C.</author><author>Braun, H.</author><author>De Souza, M. J.</author><author>Schaenzer, W.</author></authors></contributors><edition>2016/02/09</edition><language>eng</language><added-date format="utc">1469697296</added-date><ref-type name="Journal Article">17</ref-type><auth-address>a Institute of Biochemistry , German Sport University , Cologne , Germany.&#xD;b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.&#xD;c Department of Nutrition and Health Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA.&#xD;d Department of Kinesiology , University of Waterloo , Waterloo , Canada.&#xD;e Department of Sport Science , University of Wurzburg , Wurzburg , Germany.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>178</rec-number><last-updated-date format="utc">1469697296</last-updated-date><accession-num>26852783</accession-num><electronic-resource-num>10.1080/02640414.2016.1142109</electronic-resource-num><volume>34</volume></record></Cite></EndNote>[35]. From the evidence reviewed, it is probable that the type of sport (endurance vs. weight class) and the length of time spent in an energy deficient state may influence lipid levels. Potential Impact of Low Energy Availability on Sports Performance The maintenance of dietary restriction for a long period appears to detrimentally affect sports performance through the depletion of glycogen stores. This, in turn, causes a premature reduction in physical, psychological and mental capacity, including increased risk of dehydration and higher circulatory lactate, both of which can produce muscular pain, cramps and/or a reduction in FFM, leading to a reduction in muscular strength and aerobic performance PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gb2dlbGhvbG08L0F1dGhvcj48WWVhcj4xOTk0PC9ZZWFy

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ADDIN EN.CITE.DATA [104, 105]. Thus, LEA can contribute to poor sports performance due to the loss of fat and lean body mass, electrolyte abnormalities and dehydration ADDIN EN.CITE <EndNote><Cite><Author>El Ghoch</Author><Year>2013</Year><IDText>Eating disorders, physical fitness and sport performance: a systematic review</IDText><DisplayText>[105]</DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2013</year></dates><keywords><keyword>Athletic Performance/*physiology</keyword><keyword>Databases, Factual</keyword><keyword>Feeding and Eating Disorders/*therapy</keyword><keyword>Humans</keyword><keyword>Physical Fitness/*physiology</keyword><keyword>Risk Factors</keyword></keywords><isbn>2072-6643</isbn><custom2>PMC3875919</custom2><titles><title>Eating disorders, physical fitness and sport performance: a systematic review</title><secondary-title>Nutrients</secondary-title><alt-title>Nutrients</alt-title></titles><pages>5140-60</pages><number>12</number><contributors><authors><author>El Ghoch, M.</author><author>Soave, F.</author><author>Calugi, S.</author><author>Dalle Grave, R.</author></authors></contributors><edition>2013/12/20</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo, Garda (VR) 89I-37016, Italy. marwan1979@.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>65</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>24352092</accession-num><electronic-resource-num>10.3390/nu5125140</electronic-resource-num><volume>5</volume></record></Cite></EndNote>[105]. A decrease in performance by 9.8% was observed in swimmers with LEA in contrast to an 8.2% increase in performance in those with adequate EA ADDIN EN.CITE <EndNote><Cite><Author>Vanheest</Author><Year>2014</Year><IDText>Ovarian suppression impairs sport performance in junior elite female swimmers</IDText><DisplayText>[23]</DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2014</year></dates><keywords><keyword>Adolescent</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Energy Intake/physiology</keyword><keyword>Energy Metabolism/physiology</keyword><keyword>Estradiol/blood</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Insulin-Like Growth Factor I/metabolism</keyword><keyword>Menstrual Cycle/blood/physiology</keyword><keyword>Primary Ovarian Insufficiency/blood/*physiopathology</keyword><keyword>Progesterone/blood</keyword><keyword>Swimming/*physiology</keyword><keyword>Triiodothyronine/blood</keyword></keywords><isbn>0195-9131</isbn><titles><title>Ovarian suppression impairs sport performance in junior elite female swimmers</title><secondary-title>Med Sci Sports Exerc</secondary-title><alt-title>Medicine and science in sports and exercise</alt-title></titles><pages>156-66</pages><number>1</number><contributors><authors><author>Vanheest, J. L.</author><author>Rodgers, C. D.</author><author>Mahoney, C. E.</author><author>De Souza, M. J.</author></authors></contributors><edition>2013/07/13</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>1Departments of Educational Psychology and Kinesiology, University of Connecticut, Storrs, CT&#xD;2College of Kinesiology, University of Saskatchewan, Saskatchewan, CANADA&#xD;and 3Department of Kinesiology, Pennsylvania State University, University Park, PA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>76</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>23846160</accession-num><electronic-resource-num>10.1249/MSS.0b013e3182a32b72</electronic-resource-num><volume>46</volume></record></Cite></EndNote>[23]. These results support previous literature that indicates that long-term energy restriction in athletes increases their risk of compromised sporting performance PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWNleTwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PElE

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ADDIN EN.CITE.DATA [106-108]. Nutrition interventions to Improve Health Issues Associated with Low Energy AvailabilityAs consensus statements have previously addressed the treatment and return to play of athletes with health issues associated with LEA in great depth PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZSBTb3V6YTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA [4, 6], Table 6 goes beyond this by exploring specific interventions conducted to help minimise the deleterious effects of LEA on athletes’ health and performance PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWdvd3NrYTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA [62, 109-113]. Current data on the nutritional practices of athletes highlight the need to educate them about the suppressive effects of acute exercise on food intake and its relationship with wellbeing. The evidence for the effectiveness of interventions on dietary pattern in athletes presents a mixed picture (Table 6). Some studies have reported improvements PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWdvd3NrYTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA [62, 110, 111, 113, 114] and others, none ADDIN EN.CITE <EndNote><Cite><Author>Day</Author><Year>2015</Year><IDText>Prevalence of Low Energy Availability in Collegiate Female Runners and Implementation of Nutrition Education Intervention.</IDText><DisplayText>[115]</DisplayText><record><titles><title>Prevalence of low energy availability in collegiate female runners and implementation of nutrition education intervention.</title><secondary-title>Sports Nutr Ther.</secondary-title></titles><number>101</number><contributors><authors><author>Day, Jennifer.</author><author>Wengreen, Heidi.</author><author>Heath, Edward.</author><author>Brown, Katie.</author></authors></contributors><edition>November, 05, 2015</edition><added-date format="utc">1474882859</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2015</year></dates><rec-number>332</rec-number><last-updated-date format="utc">1499189085</last-updated-date><electronic-resource-num>10.4172/snt.1000101</electronic-resource-num><volume>1</volume></record></Cite></EndNote>[115] in EI. Furthermore, increased EI did not always translate into improved EA ADDIN EN.CITE <EndNote><Cite><Author>Guebels</Author><Year>2014</Year><IDText>Active women before/after an intervention designed to restore menstrual function: resting metabolic rate and comparison of four methods to quantify energy expenditure and energy availability</IDText><DisplayText>[111]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2014</year></dates><keywords><keyword>Adult</keyword><keyword>*Basal Metabolism</keyword><keyword>Body Weight</keyword><keyword>Diet Records</keyword><keyword>*Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Menstruation</keyword><keyword>*Menstruation Disturbances/diet therapy/etiology</keyword><keyword>Young Adult</keyword></keywords><isbn>1526-484x</isbn><titles><title>Active women before/after an intervention designed to restore menstrual function: resting metabolic rate and comparison of four methods to quantify energy expenditure and energy availability</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>37-46</pages><number>1</number><contributors><authors><author>Guebels, C. P.</author><author>Kam, L. C.</author><author>Maddalozzo, G. F.</author><author>Manore, M. M.</author></authors></contributors><edition>2013/08/07</edition><language>eng</language><added-date format="utc">1474533070</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>323</rec-number><last-updated-date format="utc">1474533070</last-updated-date><accession-num>23918617</accession-num><electronic-resource-num>10.1123/ijsnem.2012-0165</electronic-resource-num><volume>24</volume></record></Cite></EndNote>[111]. The methods used to measure and calculate EEE and hence, to determine EA, may, at least in part, contribute to the equivocal results reported ADDIN EN.CITE <EndNote><Cite><Author>Guebels</Author><Year>2014</Year><IDText>Active women before/after an intervention designed to restore menstrual function: resting metabolic rate and comparison of four methods to quantify energy expenditure and energy availability</IDText><DisplayText>[111]</DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2014</year></dates><keywords><keyword>Adult</keyword><keyword>*Basal Metabolism</keyword><keyword>Body Weight</keyword><keyword>Diet Records</keyword><keyword>*Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Menstruation</keyword><keyword>*Menstruation Disturbances/diet therapy/etiology</keyword><keyword>Young Adult</keyword></keywords><isbn>1526-484x</isbn><titles><title>Active women before/after an intervention designed to restore menstrual function: resting metabolic rate and comparison of four methods to quantify energy expenditure and energy availability</title><secondary-title>Int J Sport Nutr Exerc Metab</secondary-title><alt-title>International journal of sport nutrition and exercise metabolism</alt-title></titles><pages>37-46</pages><number>1</number><contributors><authors><author>Guebels, C. P.</author><author>Kam, L. C.</author><author>Maddalozzo, G. F.</author><author>Manore, M. M.</author></authors></contributors><edition>2013/08/07</edition><language>eng</language><added-date format="utc">1474533070</added-date><ref-type name="Journal Article">17</ref-type><auth-address>School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>323</rec-number><last-updated-date format="utc">1474533070</last-updated-date><accession-num>23918617</accession-num><electronic-resource-num>10.1123/ijsnem.2012-0165</electronic-resource-num><volume>24</volume></record></Cite></EndNote>[111]. It is worth noting that solely educating athletes on nutrition may not always translate into behavioral changes that optimise EI. Although improvements in nutritional knowledge were observed in athletes with low and sub-optimal EA following six interactive nutritional education group sessions which focused on the TRIAD and healthy body image, this did not translate into increased caloric intake ADDIN EN.CITE <EndNote><Cite><Author>Day</Author><Year>2015</Year><IDText>Prevalence of Low Energy Availability in Collegiate Female Runners and Implementation of Nutrition Education Intervention.</IDText><DisplayText>[115]</DisplayText><record><titles><title>Prevalence of low energy availability in collegiate female runners and implementation of nutrition education intervention.</title><secondary-title>Sports Nutr Ther.</secondary-title></titles><number>101</number><contributors><authors><author>Day, Jennifer.</author><author>Wengreen, Heidi.</author><author>Heath, Edward.</author><author>Brown, Katie.</author></authors></contributors><edition>November, 05, 2015</edition><added-date format="utc">1474882859</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2015</year></dates><rec-number>332</rec-number><last-updated-date format="utc">1499189085</last-updated-date><electronic-resource-num>10.4172/snt.1000101</electronic-resource-num><volume>1</volume></record></Cite></EndNote>[115]. In contrast, significant improvements in EI were reported following individualised nutrition intervention ADDIN EN.CITE <EndNote><Cite><Author>Valliant</Author><Year>2012</Year><IDText>Nutrition education by a registered dietitian improves dietary intake and nutrition knowledge of a NCAA female volleyball team</IDText><DisplayText>[114]</DisplayText><record><dates><pub-dates><date>Jun</date></pub-dates><year>2012</year></dates><keywords><keyword>*Athletes</keyword><keyword>Energy Intake/*physiology</keyword><keyword>Female</keyword><keyword>Food</keyword><keyword>Health Education/*methods</keyword><keyword>Health Knowledge, Attitudes, Practice</keyword><keyword>Humans</keyword><keyword>Nutrition Assessment</keyword><keyword>Nutrition Therapy/*methods</keyword><keyword>*Nutritional Requirements</keyword><keyword>Volleyball/physiology</keyword><keyword>Young Adult</keyword><keyword>athletes</keyword><keyword>carbohydrate</keyword><keyword>energy</keyword><keyword>female</keyword><keyword>knowledge</keyword><keyword>nutrition</keyword></keywords><isbn>2072-6643</isbn><custom2>PMC3397349</custom2><titles><title>Nutrition education by a registered dietitian improves dietary intake and nutrition knowledge of a NCAA female volleyball team</title><secondary-title>Nutrients</secondary-title><alt-title>Nutrients</alt-title></titles><pages>506-16</pages><number>6</number><contributors><authors><author>Valliant, M. W.</author><author>Emplaincourt, H. P.</author><author>Wenzel, R. K.</author><author>Garner, B. H.</author></authors></contributors><edition>2012/07/24</edition><language>eng</language><added-date format="utc">1475098248</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Nutrition and Hospitality Management, University of Mississippi, University, MS 38677, USA. valliant@olemiss.edu</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>334</rec-number><last-updated-date format="utc">1475098248</last-updated-date><accession-num>22822449</accession-num><electronic-resource-num>10.3390/nu4060506</electronic-resource-num><volume>4</volume></record></Cite></EndNote>[114]. The educational strategies employed in these studies may also contribute to the conflicting results reported. 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ADDIN EN.CITE.DATA [109, 116]. Thus, EI as part of a weight gain plan should be carefully considered to increase lean body mass ADDIN EN.CITE <EndNote><Cite><Author>Garthe</Author><Year>2013</Year><IDText>Effect of nutritional intervention on body composition and performance in elite athletes</IDText><DisplayText>[109]</DisplayText><record><keywords><keyword>Absorptiometry, Photon</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Anthropometry</keyword><keyword>Athletic Performance/*physiology</keyword><keyword>Body Composition/*physiology</keyword><keyword>Body Weight/physiology</keyword><keyword>Energy Intake/*physiology</keyword><keyword>Energy Metabolism</keyword><keyword>Female</keyword><keyword>Food Habits/physiology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Muscle Strength/physiology</keyword><keyword>Norway</keyword><keyword>Nutritional Requirements/*physiology</keyword><keyword>Sports/*physiology</keyword><keyword>Young Adult</keyword></keywords><isbn>1536-7290</isbn><titles><title>Effect of nutritional intervention on body composition and performance in elite athletes</title><secondary-title>Eur J Sport Sci</secondary-title><alt-title>European journal of sport science</alt-title></titles><pages>295-303</pages><number>3</number><contributors><authors><author>Garthe, I.</author><author>Raastad, T.</author><author>Refsnes, P. E.</author><author>Sundgot-Borgen, J.</author></authors></contributors><edition>2013/05/18</edition><language>eng</language><added-date format="utc">1475094436</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway. ina.garthe@olympiatoppen.no</auth-address><dates><year>2013</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>333</rec-number><last-updated-date format="utc">1475094436</last-updated-date><accession-num>23679146</accession-num><electronic-resource-num>10.1080/17461391.2011.643923</electronic-resource-num><volume>13</volume></record></Cite></EndNote>[109]. A three-month dietary intervention did not achieve resumption of menses in female athletes with menstrual dysfunction ADDIN EN.CITE <EndNote><Cite><Author>Lagowska</Author><Year>2014</Year><IDText>Effects of dietary intervention in young female athletes with menstrual disorders</IDText><DisplayText>[62]</DisplayText><record><keywords><keyword>Dietary intervention</keyword><keyword>Female athletes</keyword><keyword>Menstrual disorders</keyword><keyword>Nutritional habits</keyword><keyword>Nutritional status</keyword></keywords><isbn>1550-2783</isbn><custom2>PMC4038365</custom2><titles><title>Effects of dietary intervention in young female athletes with menstrual disorders</title><secondary-title>J Int Soc Sports Nutr</secondary-title><alt-title>Journal of the International Society of Sports Nutrition</alt-title></titles><pages>21</pages><contributors><authors><author>Lagowska, K.</author><author>Kapczuk, K.</author><author>Friebe, Z.</author><author>Bajerska, J.</author></authors></contributors><edition>2014/05/31</edition><language>eng</language><added-date format="utc">1469027378</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Human Nutrition and Hygiene, Dietetic Division, University of Life Sciences, Wojska Polskiego 28 str, 60-637 Poznan, Poland.&#xD;Department of Perinatology and Gynecology, Division of Gynecology, Karol Marcinkowski University of Medical Sciences in Poznan, Polna 33 str, 60-535 Poznan, Poland.</auth-address><dates><year>2014</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>55</rec-number><last-updated-date format="utc">1469027546</last-updated-date><accession-num>24876828</accession-num><electronic-resource-num>10.1186/1550-2783-11-21</electronic-resource-num><volume>11</volume></record></Cite></EndNote>[62], although resumption of menses was attained in a six-month intervention PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaWFsZGVsbGEtS2FtPC9BdXRob3I+PFllYXI+MjAxNDwv

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ADDIN EN.CITE.DATA [110]. A continuous, controlled dietary intervention, potentially greater than six months, may be necessary to allow for favourable menstrual changes. This supports previous research that showed non-pharmacological treatment (a sports nutrition beverage providing an additional 360 kcal/day), in combination with a reduced amount of exercise training, can contribute to re-establishing the hormonal profile necessary for resumption of menses ADDIN EN.CITE <EndNote><Cite><Author>Dueck</Author><Year>1996</Year><IDText>Treatment of athletic amenorrhea with a diet and training intervention program</IDText><DisplayText>[112]</DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>1996</year></dates><keywords><keyword>Adult</keyword><keyword>Amenorrhea/blood/*diet therapy/etiology</keyword><keyword>Body Composition</keyword><keyword>Diet</keyword><keyword>*Energy Intake</keyword><keyword>Energy Metabolism</keyword><keyword>Estradiol/blood</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Luteinizing Hormone/*blood</keyword><keyword>Progesterone/blood</keyword><keyword>*Running/physiology</keyword></keywords><isbn>1050-1606 (Print)&#xD;1050-1606</isbn><titles><title>Treatment of athletic amenorrhea with a diet and training intervention program</title><secondary-title>Int J Sport Nutr</secondary-title><alt-title>International journal of sport nutrition</alt-title></titles><pages>24-40</pages><number>1</number><contributors><authors><author>Dueck, C. A.</author><author>Matt, K. S.</author><author>Manore, M. M.</author><author>Skinner, J. S.</author></authors></contributors><edition>1996/03/01</edition><language>Eng</language><added-date format="utc">1478174904</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Exercise Science &amp; Physical Education, Arizona State University, Tempe 85287-0404, USA.</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>343</rec-number><last-updated-date format="utc">1478174904</last-updated-date><accession-num>8653102</accession-num><volume>6</volume></record></Cite></EndNote>[112]. Despite the lack of conclusive evidence, partially due to the small sample size and variation in the type of interventions used, there appears to be sufficient support for implementation of individualised dietary interventions, in conjunction with appropriate exercise training. Such interventions should increase awareness of the nutritional practices necessary to meet energy needs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb3BwLVdvb2Ryb2ZmZTwvQXV0aG9yPjxZZWFyPjE5OTk8

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ADDIN EN.CITE.DATA [117]. Further opportunities to improve athletic health and performance, such as screening for symptoms associated with LEA, may also be beneficial for the athletic population. Two research groups have shown that screening active females for symptoms of LEA effectively identified those at increased risk who would benefit from diet and exercise interventions PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gb2xzY2hlcjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

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ADDIN EN.CITE.DATA [39, 118]. The benefits of regular screening among female athletes needs further exploration as does the development of screening tools that can be used with male athletes. ConclusionThis review highlights the impact of LEA on a range of physiological functions that can potentially negatively affect athlete health and sports performance. Athletes need to be screened and educated individually by an appropriate healthcare professional about EA and potential health consequences associated with LEA. A recurrent theme in the literature is the lack of standardised methods for assessing EA in athletes. Small sample size in research studies is compounded by “exercise” and athlete groups (e.g. performance level) being poorly defined, creating difficulty and confusion when making comparisons between studies and impairing clear demonstration of the prevalence and consequences of the problem. Furthermore, consideration of study design is vital as much of the current research provides low quality evidence. Nonetheless, an association between LEA and unfavourable health and sports performance outcomes is apparent. A standardised method for measuring EA is a priority. The lack of information on injury, illness and CVD risk factors in a state of relative energy deficiency, and on effective diet and exercise interventions for use within this group, imply the need for further research to ensure that athletes achieve optimal health and sports performance. Compliance with Ethical Standards Funding This research is funded by the Irish Research Council (IRC) and Sport Ireland (grant number: EPS-PG-2015-99). Conflicts of Interest Danielle Logue, Sharon Madigan, Eamonn Delahunt, Mirjam Heinen, Sarah-Jane McDonnell and Clare Corish declare that they have no conflicts of interest relevant to the content of this review.References ADDIN EN.REFLIST 1.Loucks AB, Kiens B, Wright HH. 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