Uncoupling exposure from disease: improving epidemiological rigour in the study of low energy availability and its translation to practice in elite female athletes

  • Margot Rogers

Student thesis: Professional Doctorate


Optimal health is critical for an athlete’s success throughout and beyond their sporting career.Adequate energy intake is a key component in the prevention of negative health outcomes. Lowenergy availability (LEA) is a physiological state whereby an individual’s energy intake isinsufficient for normal physiological functioning in addition to their exercise energy expenditure.Chronic exposure to this state results in marked impairments to multiple body systems in males andfemales. The outcomes of LEA in females have been well-documented and are described by twomodels: The Female Athlete Triad (“Triad”) and Relative Energy Deficiency in Sport (REDs). TheTriad model describes the causal role of LEA in impaired bone health and reproductive function.The REDs model expands on this and describes detrimental health and performance consequencesassociated with LEA exposure, occurring in almost all body systems in both male and femaleathletes. Consequences of chronic exposure to LEA are prevalent in athletes, resulting in time loss,impeded success and the potential for lifelong health complications.Much of the research on the outcomes included in the Triad and REDs models has focussed onendurance athletes. The first study of this thesis established the prevalence of outcomes included inthe REDs model, within a mixed-sport cohort including team sports and sports that require weightcategories for competition. Most participants (80%) demonstrated physiological impairments, witha high prevalence of impaired function of the immunological, gastrointestinal, and haematologicalsystems. Practitioners should be aware that symptoms included in the REDs model are prevalent,despite athletes continuing to undertake training and competition with these impairments.The second study of this thesis explored the utility of a commonly used tool – the Low EnergyAvailability in Females Questionnaire (LEAF-Q) – in a mixed-sport cohort. Despite its originalvalidation in endurance athletes for the assessment of risk of the Triad, it is used widely in researchand clinical practice to assess risk of LEA exposure and/or outcomes included in the Triad andREDs models, in varying athletic populations. Diagnostic statistics demonstrated that the LEAF-Qiitool was able to rule out risk of LEA-related conditions in mixed-sport athletes, however it wasunable to identify “high-risk” athletes, nor could it be used as a surrogate diagnostic tool to detectoutcomes associated with LEA exposure in its current form.The LEAF-Q is one of many methods utilised within the literature. A critical analysis of themethodologies for the assessment of energy availability (EA) and the outcomes included in theTriad and REDs models is presented. Marked inconsistencies in these methods exist and there is aneed for consensus on direct methods of assessment of EA and indirect markers of LEA exposure.Recommendations for optimising field- and/or laboratory-based methodologies are proposed toimprove transferability of study findings and understanding of disease/outcome progression.The methodology review highlighted the limited inclusion of epidemiological concepts withinmuch of the literature within this field, as well as the Triad and REDs models. Key terminology isdefined and translated to clinical practice to encourage the use of precise and correct terminologyto promote scientific rigour. Adopting these key fundamentals will enhance understanding of therole of LEA exposure in the development of the impairments included in the Triad and REDsmodels and inform prevention and intervention strategies.The aim of this thesis was to explore LEA and its associated outcomes in elite female athletes. LEAexposure is a likely contributor to impaired health and performance in Australian female athletes.Understanding risk factors and the necessary cause(s) will assist in determining the exact nature ofthis relationship. Consensus on methodologies for assessment of EA and the outcomes included inthe Triad and REDs models will support high-quality research which can then inform improvedclinical practice.
Date of AwardJul 2023
Original languageEnglish
SupervisorGordon Waddington (Supervisor)

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