Риск относительной недостаточности энергии в спорте из-за низкой доступности энергии: масштаб проблемы среди подростков, занимающихся командными видами спорта

Туласи Раман Дипак Рам; Чандрасекара Пандиян Рамеш; Шанмугам Арвинд; Нараянан Хариш; Сабапати Шива Прасант; Санил Ушакумари Сурав; Шридхар Мутху Кумар; Раджеш Кумар Вигнеш Кумар; Джозеф Эдвин; Мутхьяпвар Винайяк

Резюме

Подростковый возраст - это критический период для роста, развития костной ткани и гормональной регуляции, который в значительной степени зависит от пищевого статуса и энергетического баланса. В соревновательных видах спорта юные спортсменки сталкиваются с растущим давлением, связанным с необходимостью достижения результатов, часто в условиях ограничений в питании или высоких тренировочных нагрузок, что может негативно сказаться на их здоровье. Низкая доступность энергии (LEA), являющаяся предшественником относительного энергетического дефицита в спорте (REDs), остается скрытой, но серьезной угрозой для этой группы. Несмотря на глобальную значимость данной проблемы, исследования по LEA и REDs среди юниоров, особенно в развивающихся странах, таких как Индия, крайне ограничены. Настоящее исследование восполняет этот пробел, изучая данные состояния у подростков, занимающихся командными видами спорта.

Цель исследования - оценка распространенности LEA и REDs среди девочек-подростков, занимающихся командными видами спорта.

Материал и методы. Проведено поперечное (кросс-секционное) исследование, включавшее 203 спортсменок в возрасте от 12 до 17 лет (средний возраст 14,9±1,6 года), в период подготовки к Молодежным играм KHELO India. Критерии включения: ≥5 лет тренировочного стажа (в среднем 5,91±0,87 года), ≥10 ч физической активности в неделю (в среднем 15,14±4,31 ч) и постменархеальный период. В качестве инструментов оценки использовали опросник по низкой доступности энергии у женщин (LEAF-Q), комплексную оценку риска (CRA), расчет доступности энергии (EA) и двухэнергетическую рентгеновскую абсорбциометрию (DEXA). EA рассчитывали на основе потребления пищи и энергозатрат при физической нагрузке. Минеральную плотность костной ткани (BMD) и тощую массу тела (FFM) оценивали с помощью DEXA с использованием Z-скора.

Результаты. Согласно опроснику LEAF-Q, 79,3% спортсменок находились в группе риска по LEA, при этом среди баскетболисток доля лиц с глубоким риском была наибольшей - 8,2% против 0-6,9% среди представительниц других видов спорта (волейбол, хоккей, футбол, кабадди, кхо-кхо) (p=0,050). CRA показала, что 35,0% участниц были ограничены в занятиях спортом, в то время как 37,4% получили полное разрешение на участие (p=0,718). Средняя доступность энергии составила 23,46±7,23 ккал/кг FFM, что отражает выраженный дефицит энергии. Низкий уровень BMD (Z-скор <-2,0) был выявлен у 34,5% спортсменок (p=0,926).

Заключение. Исследование выявило высокую распространенность LEA и риска REDs у девочек-подростков, занимающихся командными видами спорта. Полученные данные подчеркивают необходимость переосмысления подхода тренеров, диетологов, родителей и спортивных организаций к благополучию юных спортсменок. Приоритет должен отдаваться здоровью, гармоничному развитию и долгосрочной результативности, а не краткосрочным достижениям. Данное исследование акцентирует внимание на важности соблюдения энергетического баланса и образовательных мер как основы устойчивого спортивного успеха.

Ключевые слова: низкая доступность энергии; относительный дефицит энергии в спорте; юные спортсменки; минеральная плотность костной ткани; питание; командные виды спорта

The participation of women in sports is progressively increasing in India. Women have seen a substantial rise in their participation in sports, from school-level competitions to Olympic competitions. Globally, physical activity rates of women are disproportionately lower than those of men, a phenomenon amplified among countries with overall lower amounts of activity [1]. In India, only 38% of young adolescents and 17% of children get the recommended 60-minutes/day of moderate-to-vigorous intensity physical activity [2]. This is also important in developing countries like India, where female involvement in sports is insignificant to the participation of males. Many factors (economic, educational background, cultural impact, and domestic roles) influence women’s sports participation [3]. Various sports organizations and academies persistently aim to promote sports, especially those that engage female participants. Girls experienced social censure for physical activity participation and felt that the stereotypical gender roles that they were expected to adopt in Indian society were at odds with them being active [4]. Adolescence is an important developmental period of transition from childhood to adulthood, and empowering adolescents through social programs can be an important means of fostering opportunities for growth and positive engagement and preventing delinquency and harmful health behaviors [5]. Illnesses and injuries tend to increase with the raising of athletic competition levels. The increasing participation of females in sports has corresponded with a notable rise in injury incidence, particularly among youth athletes [6]. Sports-related injuries are an on-going public health concern in several countries, with approximately 30% of injuries among children and adolescents stemming from sports-related incidents and regular sports participation [7]. Strength deficits, musculoskeletal problems, and time loss in sports all impair an athlete’s performance capability. The significance of low energy availability (LEA) and relative energy deficiency in sport (REDs) received considerable attention during the past decade. The updated 2023 definition of REDs according to The IOC consensus statement states that REDs is a “syndrome of impaired physiological and/or psychological functioning experienced by female and male athletes that is caused by exposure to problematic (prolonged and/or severe) LEA. The detrimental outcomes include but are not limited to, decreases in energy metabolism, reproductive function, musculoskeletal health, immunity, glycogen synthesis, and cardiovascular and haematological health, which can all individually and synergistically lead to impaired well-being, increased injury risk, and decreased sports performance” [8]. A multitude of female athletes participate in daily tournament preparation, leading to a greater energy expenditure than their calorie intake.

Consequently, they experience an overall reduction in energy availability. LEA is any mismatch between dietary energy intake and energy expended in exercise that leaves the body’s total energy needs unmet, that is, there is inadequate energy to support the functions required by the body to maintain optimal health and performance [8].

This study examines the prevalence of LEA and REDs among Indian adolescent athletes. Adolescence in girls has been recognized as a special period which signifies the transition from girlhood to womanhood. This transitional period is marked with the onset of menarche, an important milestone. Menstruation is a natural physiological milestone in adolescent development, often accompanied by a spectrum of symptoms including pain, mood fluctuations, and fatigue, which can significantly impact daily functioning and quality of life [9]. In India, the average age at menarche has been reported to be around 13.5 years, with regional variations observed across the country [10]. There are many tools to identify females at risk for REDs. In this study, the low energy availability in females questionnaire (LEAF-Q), cumulative risk assessment (CRA) and energy availability were applied. As both these questionnaires rely on menstrual status of the athlete. We included only athletes who attained menarche and premenarcheal females were excluded in this study. The 25-item LEAF-Q questionnaire identifies athletes at risk for LEA by utilizing subsets of gastrointestinal symptoms, injury frequency, and menstrual dysfunction. The LEAF-Q score ≥8 indicates that an individual is at risk for LEA and female athlete triad [11]. The LEAF-Q has 78% sensitivity and 90% specificity [12]. The CRA is an assessment tool initiated by the Female Athlete Triad Coalition that examines the following components: LEA with or without Eating Disorder, low body mass index (BMI), delayed menarche, oligomenorrhea and/or amenorrhea, low BMD, and stress reaction/fracture [13]. Final scores were associated with recommendations on return to play (RTP) or performance and were identified as either “fully cleared (0-1 point)”, “provisionally cleared (2-5 points)”, or “restricted from play” (≥6 points). Energy availability (EA) is defined as:

EA = Energy intake (EI) (kcal) - Exercise energy expenditure (EEE) (kcal)/ Fat-free mass (FFM) (kg),

where EEE is calculated as the additional energy expended above that of daily living during the exercise bout, and the overall result is expressed relative to FF), reflecting the body’s most metabolically active tissues [14]. This study has multiple methods to assess the severity of risk score assessment of both LEA and REDs like LEAF-Q, Cumulative risk assessment, and energy availability.

Energy deficits are often observed in athletes, especially in female athletes, due to the high expenditure of sport and strict diets. LEA can cause serious health problems and affect sport performance [15]. This study focuses on female adolescent athletes under 17, training for the KHELO India Youth Games in team sports like football, basketball, kho-kho, hockey, kabaddi, and volleyball. The primary objective was to assess the prevalence of LEA and the risk of REDs among female adolescent athletes participating in team sports, with athletes at risk showing symptoms such as menstrual dysfunction, low bone mass, fatigue, injuries, and poor performance.

Material and methods

Ethical approval

All methods and procedures were reviewed and approved by the Institutional Human Ethics Committee of Chettinad Hospital and Research Institute (IHEC-II/0771/24) prior to any data collection at the respective site. All components of the research process at the research locations adhered to the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from each subject prior to their participation in the study.

Study design and participants

This study is a retrospective cross-sectional study. Initial recruitment was done among female participants training for KHELO India youth games (KIYG). It is the annual national-level multidisciplinary grassroots game in India. It encompasses the U-17 adolescent athlete category and U-21 category. In this study, 203 female participants of age between 12-17 years training for KHELO India youth games were recruited. The first round of recruiting was conducted through schools that prioritize athletics and place a high value on participation in sports. At first, we identified a total of twenty schools that prioritize sports participation and prepare athletes for national competitions. Data was gathered from five schools that specialize in female sports that we were able to locate. Each school had a medical allied collaboration team of sports nutritionists and team coaches.

Inclusion criteria: Athletes with at least five years of training experience in sports including basketball, football, kabaddi, volleyball, hockey, and Kho-Kho have been recruited for this study. For this study, athletes who trained for at least 10 hours a week were included. Exclusion criteria: Female athletes who has not attained menarche were excluded from this study. Athletes with a recent past surgical history within 6 months and Athletes with metabolic and neurological disorders were excluded from the study.

Measurement of energy availability

Data collection was conducted between June and September 2024 under the supervision of certified sports nutritionists. Energy intake (EI) and exercise energy expenditure (EEE) were recorded for each female athlete to calculate energy availability (EA). Athletes maintained a comprehensive daily food log for a continuous period of 30 days, documenting all meals, snacks, beverages, portion sizes (in grams), preparation methods, and meal timings. Prior to data collection, participants received structured training from nutritionists to ensure accuracy and were monitored weekly for compliance. Nutritional analysis was performed using HealthifyMe and MyFitnessPal applications, both tailored for Indian dietary patterns, and cross-referenced with the Indian Food Composition Tables (IFCT). Total daily caloric intake (kcal/day) was determined, along with a complete macronutrient profile - quantifying daily intake (in grams) and energy contribution (%) from carbohydrates, proteins, and fats. Carbohydrate consumption was sub-categorized into simple and complex forms; proteins were classified by source (plant-based vs. animal-based); and fats were analyzed as saturated, unsaturated, or trans-fats to assess overall dietary quality.

Micronutrient intake focused on critical nutrients for adolescent female athletes, particularly calcium and vitamin D. Daily intakes (mg/day for calcium and IU/day for vitamin D) were computed from food logs and nutritional labels, and compared to the Indian Council of Medical Research (ICMR) recommended dietary allowances. These micronutrient data were critically reviewed in relation to individual bone health status, allowing preliminary interpretation of whether observed intakes aligned with bone mineral demands during adolescence.

EEE was estimated using sport-specific MET values (Football: 9 METs, Basketball: 8 METs, Hockey: 8 METs, Volleyball: 7 METs, Kabaddi: 7 METs, Kho-Kho: 8 METs. EA values were categorized as either optimal (≥ 45 kcal/kg FFM/day) or clinically low (<30 kcal/kg FFM/day), providing a physiological context for assessing risk of LEA among athletes.

Screening tools

This study used the LEAF-Q and CRA questionnaires to assess female adolescent athletes. The players were evaluated at the department of sports medicine on slot basis. The LEAF-Q evaluated injury history, gastrointestinal issues, and menstrual health, with scores ≥8 indicating LEA, categorized as mild (8-12), moderate (13-24), and severe (25-33). Data was collected and compiled in Excel.

Body composition and bone mineral density

The bone mineral density and the fat-free mass of the athletes was scored using the dual-energy X-ray absorptiometry (DEXA) scan. DEXA scans were taken on a slot basis, during the visit to the sports medicine department, in collaboration with the radiology department. Z-scores were calculated in accordance with International Society for Clinical Densitometry (ISCD). According to International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions, Z-scores, not T-scores, are preferred. This is particularly important in children. A Z-score of -2.0 or lower is defined as “below the expected range for age” and a Z-score above -2.0 is “within the expected range for age”. All the data were compiled in the excel sheet and statistical analysis was done.

Statical analysis

All statistical analyses were conducted using SPSS Version 21 (IBM, USA). Descriptive statistics were used to summarize the demographic, anthropometric, and training-related characteristics of participants, including age, height, weight, BMI, type of sport, years of training experience, and average weekly training duration. Continuous variables were presented as means ± standard deviations (σ), and categorical variables as frequencies and percentages. The prevalence of RED-S risk was determined using the LEAF-Q questionnaire (score ≥8) and RED-S risk assessment criteria. Chi-square (χ²) tests were used to examine associations between RED-S risk and categorical variables (e.g., type of sport, age category, LEA classification). Independent samples t-tests and one-way ANOVA were applied to compare means of continuous variables (e.g., BMI, training duration) across EA categories. Post-hoc Bonferroni correction was applied for multiple comparisons. Binary logistic regression was performed to evaluate predictors of RED-S risk (dependent variable: at-risk vs. not-at-risk), adjusting for potential confounders including age, training hours per week, and BMI. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Multicollinearity among predictors was checked using Variance Inflation Factors (VIFs). Effect sizes (Cohen’s d or eta squared, as appropriate) were reported for key comparisons to assess the magnitude of associations. Statistical significance was set at p<0.05. Missing data were minimal (<5%) and were handled using listwise deletion. As this was a cross-sectional study, follow-up was not applicable.

Results

Participant characteristics and sports-wise distribution

A total of 203 adolescent female team-sport athletes (mean age: 14.9±1.6 years) participated in this study. The mean BMI was 20.4±1.8 kg/m², with 88.2% falling within the normal range (18.6-24.99 kg/m²) and 11.8% classified as underweight (≤18.5 kg/m²). Average fat-free mass was 33.17±4.82 kg. In our study, football was the most represented sport (27.6%), followed by basketball (24.1%), kho-kho (15.3%), hockey (14.3%), kabaddi (11.3%), and volleyball (7.4%). Athletes trained an average of 15.14±4.31 hours per week and had a mean training experience of 5.91±0.87 years (table 1).

Energy availability, intake, and expenditure

The mean energy availability was 23.46 kcal/kg FFM - well below the optimal threshold of 30 kcal/kg - highlighting widespread LEA. Athletes averaged 1,941 kcal/day intake and 1,157 kcal/day expenditure, reflecting a significant energy mismatch consistent with LEAF-Q findings (table 2).

Low energy availability assessment using LEAF-Q

The LEAF-Q was used to assess LEA, with risk categorized as Mild (8-12), Moderate (13-24), and Severe (25-33). Among 203 athletes, 20.7% had minimal risk (≤7), 48.3% had mild risk, 26.1% moderate, and 4.9% severe risk - highlighting a substantial prevalence of LEA. Most footballers (55.4%) and basketball players (51.0%) fell into the moderate LEAF-Q risk category (8-12), with 36.7% of basketball players in the higher risk range (13-24). Volleyball and kho-kho athletes showed a more balanced distribution, with no volleyball players in the highest-risk group (≥25). A borderline significant association was observed between sport type and LEA risk (p=0.050) (fig. 1).

Cumulative risk assessment score

The CRA classified 37.4% of athletes as low risk (fully cleared), 27.6% as moderate risk (provisionally cleared), and 35.0% as high risk (restricted from play). Over one-third were at elevated REDs risk, highlighting the need for targeted monitoring and intervention (fig. 2).

High CRA scores (≥6) were most common in basketball (38.8%) and football (37.5%), with kho-kho and volleyball also showing notable high-risk rates (>29% and 33%, respectively). No significant difference was found across sports (p=0.718), suggesting REDs risk is widespread among all team sports assessed.

Bone mineral density of the athletes

Bone mineral density (BMD) assessment via DEXA revealed that 34.5% of athletes had Z-scores ≤-2.0, indicating low bone mass, while 65.5% fell within the expected range. This highlights a notable prevalence of compromised bone health, which may impact long-term skeletal development and injury risk (fig. 3).

Kho-kho athletes showed the highest proportion of normal bone mass (74.2%), while football (37.5%) and basketball (36.7%) athletes had the highest rates of low BMD. However, these differences were not statistically significant (p=0.926).

Discussion

To our knowledge, this is the first study to report the prevalence of REDs risk among Indian female adolescent athletes. We focused on adolescent athletes, a key transitional stage between childhood and adult sports. All participants had at least six years of training and trained an average of 15 hours per week across commonly played sports such as football, basketball, hockey, kabaddi, kho-kho, and volleyball. Female athletes face greater challenges than males in sustaining long-term physical activity, affecting both their physical and psychological performance.

Screening tools and abnormal score risk categorization

We used the LEAF-Q and CRA tools to assess REDs risk. While the standard LEAF-Q cut-off for high risk is ≥8, we applied a refined classification: mild (8-12), moderate (13-24), and severe (25-33) to better capture varying physiological impacts of LEA. This three-tiered approach enabled more precise differentiation among at-risk athletes. Among 203 female adolescent athletes, 48.3% were at mild risk, 26.1% at moderate risk, and 4.9% at severe risk. This was supported by E. Luszczki et al., in their study 64.7% of participants were classified as being at-risk for REDs according to their LEAF-Q scores [16]. To complement LEAF-Q findings and guide return-to-play (RTP) decisions, we used the CRA, which incorporates variables like menstrual status, BMD, and disordered eating. Among the athletes, 37.4% were fully cleared (CRA ≤1), 27.6% provisionally cleared (CRA 2-5), and 35% were restricted (CRA ≥6), indicating substantial REDs risk. While LEAF-Q identifies early physiological disturbances, CRA offers a broader risk profile. Our study’s tiered LEAF-Q classification (mild, moderate, severe) enhances clinical utility by tailoring interventions to risk severity, offering a novel stratification method.

LEAF-Q in female athletes

This study presents a novel Indian perspective by using LEAF-Q to categorize female adolescent team-sport athletes into LEA risk levels. Kabaddi showed the highest mild risk (60.9%), followed by football (55.4%) and basketball (51%), suggesting many train with unrecognized energy deficits. Our findings also supported by M.S. Dasa et al., in their study a high prevalence of LEA has been reported in female football players, and they also states us to focus on nutritional periodization to secure sufficient energy availability, mitigating the risk of problematic LEA and REDs should be addressed [17]. Basketball players showed the highest intermediate LEA risk (36.7%), followed by volleyball (33.3%) and hockey (31.0%). This may reflect fluctuating training loads, inconsistent nutrition, and recovery practices. Basketball had the highest severe LEA risk (8.2%), followed by kho-kho (6.5%), kabaddi (4.3%), and football (3.6%). Though numbers were small, clinical risks are high. Significant findings (p=0.050) stress the need for sport-specific screening and education. Kho-kho and kabaddi also showed notable mild and moderate LEA risks, despite limited global research. Our findings were supported by K. Kalpana et al., their study revealed that there was a higher prevalence of REDs risk outcomes among Kho-Kho players, with or without LEA [18]. These data highlight the LEAF-Q’s effectiveness in screening and risk classification, detecting early LEA signs like menstrual irregularities, gastrointestinal issues, and injuries. The findings emphasize the need for LEA screening in sports health evaluations for adolescent female athletes.

Energy availability among female athletes

Our study reveals a concerning pattern of LEA in female adolescent athletes, with an average of 23.46 kcal/kg of fat-free mass (FFM), well below the clinically recommended threshold of 30 kcal/kg FFM/day. A.B. Loucks et al., in their Research investigating changes in endocrine parameters over a short period of time suggested that an EA of  ≥45 kcal/kg FFM·day⁻¹ is considered ‘optimal’, with <30 kcal·kg FFM·day⁻¹ and between 30-45 kcal/kg FFM·day⁻¹ classified as ‘clinically low EA’ and ‘subclinical/reduced EA’, respectively [14]. H.E. Cabre et al., stated that if athletes develop LEA, it can lead to a REDs which has severe health consequences if not treated [19]. These clinically low energy levels are concerning, especially for growing adolescents with higher energy demands. Despite training over 15 hours weekly, athletes averaged only 1,940.89 kcal/day, revealing a major intake-expenditure mismatch. This low energy intake among athletes was also supported by M. Renard et al., in their study majority reported that the dietary intake of female field-based team sport athletes was insufficient in overall energy (2064±309 kcal/day) when compared to recommendations [20]. The average energy expenditure during exercise (EEE) for these athletes was 1,156.9 kcal, reflecting the high physical demands of their intense training regimens, which exceed 15 hours per week. J. Heydenreich et al., in their study in female endurance athletes, a negative energy balance was also observed during the preparation phase (-1145 kcal/day, 95% CI -1404, -887, p<0.0001) and the competition phase (-1252 kcal/day, 95% CI -1778, -727, p<0.0001) [21]. Despite participating in team sports, the athletes’ high EEE levels could lead to hormonal and metabolic abnormalities associated with LEA and REDs if not supported by proper nutrition.

Cumulative risk assessment and risk for REDs

This study used the CRA tool to assess multidimensional risks of REDs in female adolescent athletes. Approximately 35% of participants had scores ≥6, indicating increased REDs risk. CRA scores were linked to return-to-play (RTP) recommendations: “fully cleared (0-1 point)”, “provisionally cleared (2-5 points)”, and “restricted from play (≥6 points)”. M.J. De Souza et al., states that the Cumulative Risk Assessment Tool is an evidenced-based tool and provides well-defined criteria for consistent utilization of the tool [22]. The CRA provides a holistic view of athlete health, especially valuable in adolescents where early REDs signs may be missed. In our study, over one-third had high-risk scores (≥6), notably in basketball (38.8%), football (37.5%), and kabaddi (34.8%). These findings highlight the need for proactive monitoring in adolescent sports. Our findings are further supported by recent literature emphasizing the importance of developmental stage considerations in risk assessment among youth athletes. G.N. Parry et al., in their scoping review, highlighted that individual variability in biological maturation significantly influenced both performance and injury risk in adolescent athletes, necessitating age- and developmentally-appropriate screening tools [23].

Bone mineral density of the athletes

During the course of our research, we observed that a significant number of female athletes had a low bone mass. For the purpose of our research, Z-scores were utilized rather than T-scores because the participants in our study were adolescents. According to the International Society for Clinical Densitometry (2019), Z-scores are recommended for children and adolescents still gaining peak bone mass. Among 203 athletes, 34.5% had Z-scores below -2.0, indicating low bone mass and potential REDs risk. Low BMD was most common in football (37.5%), basketball (36.7%), and kabaddi (34.8%), with no significant sport-wise differences (p=0.926), underscoring a broad risk of poor bone health in female adolescent athletes. Studies have highlighted the critical role of vitamin D intake in maintaining bone health among adolescents. K. Song et al., demonstrated a positive association between serum vitamin D levels and bone mineral density in adolescents, emphasizing the importance of adequate vitamin D status for skeletal development [24]. Similarly, A. Armento et al., reviewed recent literature indicating that adolescent athletes, particularly those with limited sun exposure, are at increased risk for vitamin D deficiency, which can adversely affect bone mineral density [25]. These findings underscore the necessity of ensuring sufficient dietary vitamin D intake to support optimal bone health during adolescence. Recent studies have demonstrated that LEA-resulting from increased energy expenditure, decreased energy intake, or the presence of eating disorders-is associated with reduced BMD in both adolescents and adults. For instance, A.C. Sella et al., in their study found that low-weight female youth with avoidant/restrictive food intake disorder exhibited significantly lower BMD, highlighting the impact of disordered eating on bone health [26]. Low BMD may signal early REDs, especially in weight-bearing sports with inadequate nutrition. This highlights the need for targeted screening and integrated assessments to address health gaps in adolescent athletes.

Importance of screening female athletes at adolescent stage

Adolescent screening provides a unique opportunity for early, effective interventions. A multidisciplinary, athlete-centered approach is crucial to address REDs risk in female adolescent athletes. Our findings emphasize the need for continuous, collaborative screening involving sports medicine professionals, dietitians, psychologists, coaches, educators, and families. This holistic approach promotes physical wellness and long-term performance. Our research highlights the importance of risk-based stratification, especially in countries like India, where early recognition and intervention are vital for female athletes’ health and future in sports.

Strengths, limitations and future scope

This study offers key insights into LEA, REDs risk, and bone health in Indian adolescent female athletes-an under-researched area. It is among the first to assess these factors across six team sports, enabling sport-specific comparisons for targeted interventions. Limitations include the LEAF-Q’s reduced accuracy in adolescents and reliance on self-reported energy intake. Future research should develop age- and sport-specific tools, integrate REDs monitoring into athlete care, and use longitudinal data to track long-term health and performance outcomes.

Conclusion

As adolescent girls’ participation in competitive sports rises in India, our study highlights a concerning prevalence of LEA and risk for RED-S among female athletes in team sports. Many athletes with LEA, exhibiting signs such as irregular menstrual cycles, low bone mass, fatigue, injuries, and mental health challenges, continue training despite these risks, compromising their long-term health and performance. The lack of awareness and preventive strategies threatens their sports careers. Our research underscores the need for proactive screening, education, and collaboration among coaches, parents, nutritionists, and sports physicians to safeguard their well-being and future success.

To enhance the nutritional status of female athletes, we advocate for personalized dietary strategies that address their specific energy requirements and sport-specific demands, ensuring sufficient intake of macronutrients and critical micronutrients such as calcium and vitamin D. Ongoing evaluation through comprehensive food tracking and nutritional assessments, alongside targeted education for athletes and their support networks, is essential to maintain optimal energy availability, promote bone health, and support peak athletic performance and recovery.

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