References

The purpose of this page is to provide justification and citations for our current version of the assessment.

Table of Contents

General Information

 

Question 1

What type of sport are you in?

  • The literature suggests that RED-S is most prevalent in endurance, aesthetic (judged sports), and weight-class sports, with lesser occurrence in team sports. That said, all high-performance athletes are at risk of RED-S and overreaching. 

  • See: Logue, D., Madigan, S.M., Delahunt, E., Heinen, M., McDonnell, S.J., Corish, C.A. (2018). Low energy availability in athletes: a review of prevalence, dietary patterns, physiological health and sports performance. Sports Medicine, 48, 73-96. 

  • See: Loucks, A. B. (2004). Energy balance and body composition in sports and exercise. Journal of Sports Sciences, 22(1), 1-14.

Question 2

What is your birth year?

  • We are using this data in order to determine, along with BMI, whether or not the athlete is at risk compared to age related normative values. BMI <17.5 or <85% of age related expected weight = high risk, BMI 17.5<18.5 or <90% of expected weight = moderate risk, BMI >18.5 or >90% expected weight = low risk. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232.

Question 4

What is your current height in cm?

  • With this question we can calculate BMI and determine whether or not the athlete is at risk compared to age relative norms. See: Joy, E., De Souza,

  • M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232.

Question 5

What is your biological sex?

  • This question is to determine whether or not the athlete goes on to menstrual cycle questions (females), or skips to training and life load questions (males and intersex). 

  • Elite female athletes experience more relative risk of stress fracture injuries than male athletes due to a higher occurrence of Relative Energy Deficiency in Sport Syndrome (RED-S). This can cause reduced calcium absorption and bone mineral density (BMD). However there needs to be more research done on male athletes to determine prevalence of RED-S. 

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . .Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28,

 

Female Specific

Question 6

How old were you when you had your first period?

  • This helps to develop a history and distinction between Primary Amenorrhea, Secondary Amenorrhea, and Oligomenorrhea, which determines your relative risk for stress fractures and other symptoms of RED-S. 

  • In the first three decades of life, optimal bone health is achieved by accumulating peak bone mass and preventing bone loss during this time (Nattiv et al., 2007). During adolescence, one should gain approximately half of their adult bone mineral content, since it may not be possible later in life to replicate the hormonal environment of an adolescent. One study of post menarche girls (age 11-18) found women have 95% of their total BMD by age 18. Starting in our early 30’s we lose ~1% of mineral bone content each year up to menopause. Amenorrheic athletes are thought to have similar rates with a loss of bone mass at a rate of ~2-3% per year (Abbott et al., 2019). Other factors that can negatively affect this bone mineral accumulation include a diet lacking in bone-building nutrients, extreme dietary restriction (anorexia nervosa), amenorrhea and delayed onset of menarche (Barrack et al., 2010). 

  • See: Abbott, A., Bird, M.L., Wild, E., Brown, S.M., Stewart, G., & Mulcahey, M.K. (2019). Part I: Epidemiology and risk factors for stress fractures in female athletes. The Physician and Sportsmedicine. 

  • Barrack, M.T., Rauh, M.J., Nichols, J.F. (2010). Cross-sectional evidence of suppressed bone mineral accrual among female adolescent runners. Journal of Bone and Mineral Research, 25(8), 1850-1857. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232. 

  • See: Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn C.F., Sundgot-Borgen, J & Warren, M.P. (2007). American college of sports medicine position stand. The female athlete triad. Medicine & Science in Sports & Exercise, 1867-1882. 

Question 7

Prior to hormonal contraception, did you have a regular menstrual cycle?

  • If an athlete answers that they had a healthy age of first menstruation, and then also answers that they are on hormonal contraceptives, we cannot know if they had RED-S related menstrual cycle disruption prior to the hormone useage. As such, this question should show whether or not athletes may have RED-S related menstrual disruption that is now being masked by hormonal contraception. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232. 

Question 8

Do you use any daily (pill) or consistent (IUD) contraceptive other than condoms? 

  • Hormonal contraceptives can change, mask, or replicate symptoms that are pertinent to detecting your risk level. Hormones from contraceptives will make it impossible to know if a woman would get her period naturally on her own.

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232. 

Question 9

What type of contraceptive do you use?

  • Certain contraceptives are hormone based and others are not. The non-hormonal contraceptives (copper IUD, and condoms) may allow for proper hormonal function. This sets up further lines of questioning based on your answer and removes women from which we can’t detect symptoms because of their contraceptive type. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232.

Question 10

In the last five weeks including this week, have you had a period?

  • This question assesses if an athlete is currently menstruating and their knowledge on menstrual tracking. Menstrual dysfunction is one of the earliest indicators of RED-S, and will indicate a heightened risk for other RED-S symptoms such as stress fractures. This also could highlight that the athlete may be at peak competition body composition and perhaps is currently missing their cycle. This question will be asked in regular follow-up questionnaires to help track whether normal menstruation is occuring. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232. 

Question 11

How many menstrual cycles do you typically have in 1 year?

  • RED-S associated diagnostic factors include oligomenorrhea (missing three or more menstrual cycles in 6 months), and amenorrhea (no periods). The increase in missed cycles means increased risk of RED-S. Menstrual Dysfunctions (MD) are common among female athletes but can be downplayed or considered a “normal part of training hard” or not treated in the serious manner they should be. The negative health consequences are well documented in the literature (Nattiv et al., 2007; Mountjoy et al., 2018). 

  • See: Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn C.F., Sundgot-Borgen, J & Warren, M.P. (2007). American college of sports medicine position stand. The female athlete triad. Medicine & Science in Sports & Exercise, 1867-1882. 

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . .Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. 

 

Training and Life Load

Question 12

What is your average hours of training per week in the last month (4 weeks)?

  • This question, in combination with the next few questions, allows us to determine what type of athlete is filling out the questionnaire, and what phase of training they are in. It has been suggested that athletes training over 11 hours/week are at risk of having an exercise dependence, which puts them at risk of RED-S (Logue et al., 2020). This question will inform whether athletes have a heightened risk of RED-S, where they stand in their season compared to peak cycles (from the following question), and is required for the scoring of question 14, which is assessing the acute:chronic workload ratio.

  • See: Logue, D., Madigan, S.M., Melin, A., Delahunt, E., Heinen, M., McDonnell, S., & Corish, C. A. (2020). Low energy availability in athletes 2020: An updated narrative review of prevalence, risk, within-day energy balance, knowledge, and impact on sports performance. Nutrients, 12(835), 1-19.

  • See: Murray, N. B., Gabbett, T. J., Townshend, A., & Blanch, P. (2017).Calculating acute: chronic workload ratios using exponentially weighted moving averages provides a more sensitive indicator of injury likelihood than rolling averages. BJSM, 51(9), 749-754.

  • See: Maupin, D., Schram, B., Canetti, E., & Orr, R. (2020). The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review. Open access journal of sports medicine, 11, 51.

  • https://www.scienceforsport.com/acutechronic-workload-ratio/#toggle-id-1

Question 13

What is your typical average hours of training per week when you are in a peak cycle (not including unique training camp blocks that are way above normal hours)?

  • This question will help us to determine what phase of a cycle the athlete may be in. If the athlete is in a peak training cycle, they are likely at a heightened risk of RED-S and overreaching. We will also know if the athlete is at a heightened risk of RED-S by virtue of their peak training hours, with athletes performing higher volumes of training (>11 hours/week), being at heightened risk of RED-S, injuries, illness, and overreaching. Finally, this question can be used in combination with other questions to determine the training load as a TRIMP score (duration x intensity).

  • See: Logue, D., Madigan, S.M., Melin, A., Delahunt, E., Heinen, M., McDonnell, S., & Corish, C. A. (2020). Low energy availability in athletes 2020: An updated narrative review of prevalence, risk, within-day energy balance, knowledge, and impact on sports performance. Nutrients, 12(835), 1-19.

  • See: Johnstona, R., Cahalanb, R., O’Keeffec, M., O’Sullivan, K.,Comyns, T. (2018). The associations between training load and baseline characteristics on musculoskeletal injury and pain in endurance sport populations: A systematic review. Journal of Science and Medicine in Sport, 21, 910-918.

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . .Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331

  • See: Maupin, D., Schram, B., Canetti, E., & Orr, R. (2020). The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review. Open access journal of sports medicine, 11, 51.

Question 14

How many more hours of training have you completed in the last 7 days in comparison to your typical weekly volume?

  • This question is used to calculate the acute:chronic workload from previous questions to determine if the athlete is at heightened risk of injury, illness, or RED-S. It has been suggested that an abrupt increase in training load puts an athlete at greater risk. We can also use this question to determine the athlete’s training load as duration x intensity. 

  • See: Murray, N. B., Gabbett, T. J., Townshend, A., & Blanch, P. (2017).Calculating acute: chronic workload ratios using exponentially weighted moving averages provides a more sensitive indicator of injury likelihood than rolling averages. BJSM, 51(9), 749-754.

  • See: Maupin, D., Schram, B., Canetti, E., & Orr, R. (2020). The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review. Open access journal of sports medicine, 11, 51.

  • https://www.scienceforsport.com/acutechronic-workload-ratio/#toggle-id-1

Question 15

How many hours per week do you currently spend in class, at work, and/or spend on deep work at home?

  • It is known that mental and emotional stress will negatively impact performance (Van Cutsem et al., 2017) with greater durations and intensities of mental stress relating to worse performances. Further, we know that mental stress will increase injury and illness risk. As such, this question will help to determine whether the athlete is at risk of injury/illness/ overreaching due to increased life stress. This question in combination with the “intensity” of the work will be used to calculate an overall mental stress score for the athlete. 

  • Van Cutsem, J., Marcora, S., De Pauw, K., Bailey, S., Meeusen, R., & Roelands, B. (2017). The effects of mental fatigue on physical performance: a systematic review. Sports medicine, 47(8), 1569-1588.

  • Andersen, M. B., & Williams, J. M. (1988). A model of stress and athletic injury: Prediction and prevention. Journal of sport and exercise psychology, 10(3), 294-306.

Question 16

On a scale of 1-6 how hard or intense would you rate your training on average during your most difficult training block?

  • This question, in combination with the duration of training in the peak season, will be used to calculate a “TRIMP” score for the athlete as duration x intensity (RPE). This allows us to assess how hard the athlete is training, and whether they have had an increase in training stress in the past week, which would put them at increased risk of overreaching, illness, and injury. 

  • See: Foster, C., Florhaug, J. A., Franklin, J., Gottschall, L., Hrovatin, L. A., Parker, S., ... & Dodge, C. (2001). A new approach to monitoring exercise training. The Journal of Strength & Conditioning Research, 15(1), 109-115.

  • Johnstona, R., Cahalanb, R., O’Keeffec, M., O’Sullivan, K.,Comyns, T. (2018). The associations between training load and baseline characteristics on musculoskeletal injury and pain in endurance sport populations: A systematic review. Journal of Science and Medicine in Sport, 21, 910-918.

  • Murray, N. B., Gabbett, T. J., Townshend, A., & Blanch, P. (2017).Calculating acute: chronic workload ratios using exponentially weighted moving averages provides a more sensitive indicator of injury likelihood than rolling averages. BJSM, 51(9), 749-754.

  • Maupin, D., Schram, B., Canetti, E., & Orr, R. (2020). The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review. Open access journal of sports medicine, 11, 51.

Question 17

On a scale of 1-6, how hard or intense would you rate your training on average for the past 7 days?

  • This question will be used to determine if the athlete has had a significant increase in training load (duration x intensity) in the past week, which would put them at an increased risk for injury, illness, and overreaching. 

  • Murray, N. B., Gabbett, T. J., Townshend, A., & Blanch, P. (2017).Calculating acute: chronic workload ratios using exponentially weighted moving averages provides a more sensitive indicator of injury likelihood than rolling averages. BJSM, 51(9), 749-754.

  • Maupin, D., Schram, B., Canetti, E., & Orr, R. (2020). The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review. Open access journal of sports medicine, 11, 51.

  • Foster, C., Florhaug, J. A., Franklin, J., Gottschall, L., Hrovatin, L. A., Parker, S., ... & Dodge, C. (2001). A new approach to monitoring exercise training. The Journal of Strength & Conditioning Research, 15(1), 109-115.

  • Johnstona, R., Cahalanb, R., O’Keeffec, M., O’Sullivan, K.,Comyns, T. (2018). The associations between training load and baseline characteristics on musculoskeletal injury and pain in endurance sport populations: A systematic review. Journal of Science and Medicine in Sport, 21, 910-918.

Question 18

On a scale of 1 to 6, how stressful do you find your work/ school currently?

  • In a similar fashion to training load, this question will be used to create a “TRIMP” score of work stress (duration x intensity). Those athletes experiencing the greatest amounts of work stress will be at heightened risk of injury, illness, and overreaching. 

  • See: Van Cutsem, J., Marcora, S., De Pauw, K., Bailey, S., Meeusen, R., & Roelands, B. (2017). The effects of mental fatigue on physical performance: a systematic review. Sports medicine, 47(8), 1569-1588.

  • See: Andersen, M. B., & Williams, J. M. (1988). A model of stress and athletic injury: Prediction and prevention. Journal of sport and exercise psychology, 10(3), 294-306.

 

Injury and Illness

Question 19

Do you have a history of low iron, anemia, low hemoglobin, and/or abnormal bruising?

  • Energy status can be affected by iron deficiency in several ways. Iron deficiency may potentiate the hypometabolic state associated with poor energy status, promote inadequate energy intake, and promote energy deficiency. Reproductive function may be compromised by iron deficiency, and vice versa. Iron deficiency may accelerate, or even initiate, declines in reproductive function and reproductive function may promote or prevent iron deficiency. Many of these potential interactions were constructed based on iron deficiency anemia research (Petkus et al., 2017).

  • See: Petkus, D. L., Murray-Kolb, L. E., & De Souza, M. J. (2017). The Unexplored Crossroads of the Female Athlete Triad and Iron Deficiency: A Narrative Review. Sports Medicine, 47(9), 1721–1737.

Question 20

In the past 4-weeks including today, approximately how many days have been spent sick? (Couldn’t train or had to seriously modify the training). 

  • As RED-S and overreaching are characterized by heightened incidence of illness and injuries, this question aims to determine if an athlete is already in a state of low energy availability or overreaching. 

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . .Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. 

  • See: Hausswirth, C., Louis, J., Aubry, A., Bonnet, G., Duffield, R., & Le Meur, Y. (2014). Evidence of disturbed sleep and increased illness in overreached endurance athletes. Medicine & Science in Sports & Exercise, 46(5), 1036-1045.

Question 21

In the past 4-weeks including today, approximately how many days have been spent injured? (Couldn’t train or had to seriously modify the training)

  • As RED-S and overreaching are characterized by heightened incidence of illness and injuries, this question aims to determine if an athlete is already in a state of low energy availability or overreaching. 

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . .Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. 

  • See: Hausswirth, C., Louis, J., Aubry, A., Bonnet, G., Duffield, R., & Le Meur, Y. (2014). Evidence of disturbed sleep and increased illness in overreached endurance athletes. Medicine & Science in Sports & Exercise, 46(5), 1036-1045.

Question 22

Have you ever been diagnosed as having a problem with your bones such as low bone density (osteopenia or osteoporosis)? 

  • One of the central symptoms of RED-S is low bone mineral density. RED-S-associated diagnostic factors may include: two or more career bone stress injuries and low bone mineral density for age (Z-score <-1.0) (Mountjoy et al., 2018).

  • See: The IOC Consensus Statement on Periodic Health Evaluation of Elite Athletes.  The Athlete Periodic Health Examination Questionnaire (2009): https://www.olympic.org/news/the-ioc-consensus-statement-on-periodic-health-evaluation-of-elite-athletes

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . . Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. 

Question 23

In your life, how many stress-fractures or stress reactions have you been diagnosed with?

  • The female athlete triad and RED-S are well-established risk factors for stress fractures and are common among athletes with low EA (Close et al., 2019). Low bone density (resulting in fractures) is a symptom of RED-S. The increase in frequency means the increase in risk, or likelihood. A history of a stress fracture or stress reaction can increase the risk of recurrent stress fractures, especially among female runners by 5-6 times (Abbott et al., 2019). 

  • Cross-sectional studies of physically active females with menstrual dysfunction or Low EA have shown decreased bone mineral density, altered bone turnover markers/microarchitecture, decreased bone strength estimates and increased risk for bone stress injuries compared to eumenorrheic athletes and those with adequate EA. 

  • See: Abbott, A., Bird, M.L., Wild, E., Brown, S.M., Stewart, G., & Mulcahey, M.K. (2019). Part I: Epidemiology and risk factors for stress fractures in female athletes. The Physician and Sportsmedicine.

  • See: Close, G.L., Baar, K., Sale, C., & Bermon, S. (2019). Nutrition for the prevention and treatment of injuries in track and field athletes. International Journal of Sport Nutrition and Exercise Metabolism, 29(2), 189-197. 

  • See: Mountjoy, M., Ackerman, K.A., Lebrun, C., Meyer, N., Torstveit, M.K., Sundgot-Borgen, J., . . . Tenforde, A.S. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. 

  • See: Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 749–765.

Question 24

If you previously had a stress fracture or compression fracture, please indicate if any occurred in one of the bones listed below

  • Certain locations of fractures have different implications for recovery times and carry different risk levels for the athlete. Most are treated with rest (low risk) and a gradual return to sport. Healing can take 6-12 weeks depending on the site and grade. 

  • Metabolic and hormonal changes and lower lumbar spine bone mass have been reported in studies in young-adult elite endurance runners. Lumbar vertebrae are largely trabecular bone that respond more to hormonal changes.

  • Periods of low EA suppresses metabolic processes and reduces many hormone levels that affect bone turnover and can cause Functional Hypothalamic Amenorrhea (FHA). FHA results from inadequate energy intake compared to expenditure and lowered estradiol levels. This negatively impacts bone mass by reducing absorption of calcium, suppressed bone formation and increasing bone resorption. This condition may lead to bone stress injuries of a higher MRI grade (particularly trabecular bone: femoral neck, sacral and pubic bone) and therefore a longer recovery period and time away from training and competing (Nattiv et al., 2013). 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232.

  • See: Barrack, M.T., Rauh, M.J., Nichols, J.F. (2010). Cross-sectional evidence of suppressed bone mineral accrual among female adolescent runners. Journal of Bone and Mineral Research, 25(8), 1850-1857.

  • See: Nattiv, A., Kennedy, G., Barrack, M.T. Abdelkerim, A., Goolsby, M.A., Arends, J.C., & Seger, L.L. (2013). Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: A 5-year prospective study in collegiate track and field athletes. American Journal of Sports Medicine, 41(8), 1930-1941. 

  • See: Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 749–765. 

Nutrition

 

Question 25

Have you ever been diagnosed with an eating disorder?

  • ED can cause serious and irreversible bone loss. Severe energy restriction will lead to fatigue and likely higher perception of effort. It is important to note that menstrual irregularities among endurance runners are associated with increased scores on the Eating Disorder Inventory. 

  • Low EA can occur with and without a diagnosed eating disorder or disordered eating. Restricting energy intake can be intentional and unintentional. Understanding all the components and etiology of what is causing inadequate energy intake is important to determine the correct treatment. 

  • Eating disorders, such as anorexia nervosa (AN), create the most common cause of infertility in underweight women. RED-S involves menstrual dysfunction due to low EA, which results in anovulation. Malnutrition and starvation can cause excessive weight loss. They may result in fertility problems due to the loss of adipose (fat) tissue and the resulting hormonal disturbances. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM -V) criteria, women with AN need to exhibit: a substantial decrease in body weight, due to restriction of caloric intake, fear of gaining weight, and a disturbed perception of body weight. Even though amenorrhea is not part of the updated diagnostic criteria, many women with AN have menstrual disturbance (oligomenorrhea or amenorrhea).

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  •  See: Barrack, M.T., Gibbs, J.C., De Souza, M.J., Williams, N.I., Nichols, J.F., Rauh, M.J., Nattiv, A. (2014). Higher incidence on bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women. American Journal of Sports Medicine, 42(4), 949-58. 

  • See: Berends T, et al. (2016) Rate, timing and predictors of relapse in patients with anorexia nervosa following a relapse prevention program: a cohort study. BMC Psychiatry, 16(1). 

  • See: Boutari, C., Pappas, P. D., Mintziori, G., Nigdelis, M. P., Athanasiadis, L., Goulis, D. G., & Mantzoros, C. S. (2020). The effect of underweight on female and male reproduction. Metabolism, 154229. 

  • See: Sundgot-Borgen, J & Garthe, I. (2011). Elite athletes in aesthetic and Olympic weight-class sports and the challenge of body weight and body compositions. Journal of Sports Sciences, 29(S1), S101-S114.

Question 26

Have you lost weight in the last month?

  • Initial weight loss could indicate the early signs of low energy availability and a consistent calorie deficit. It also highlights if an athlete is consciously trying to modify their body composition. This also highlights if an athlete is self monitoring their weight. 

  • See: Joy, E., De Souza, M.J., Nattiv, A., Misra, M., Williams, N., et al. (2014). 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Nutrition and Ergogenic Aids, 13(4), 219-232. 

  • See: Sundgot-Borgen, J & Garthe, I. (2011). Elite athletes in aesthetic and Olympic weight-class sports and the challenge of body weight and body compositions. Journal of Sports Sciences, 29(S1), S101-S114.

Question 27

Are you trying to lose weight right now?

  • If an athlete is trying to modify their body composition by intentionally eating less it puts them at risk for low energy availability, even if it is short term for an upcoming competition.

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Martinsen, M., Holme, I., Pensgaard, A.M., Torstveit, M.K., Klungland, M.K & Sundgot-Borgen, J. (2014). The Development of the Brief Eating Disorder in Athletes Questionnaire. Medicine & Science in Sports & Exercise, 46(8),1666-1675. 

  • See: Sundgot-Borgen, J & Garthe, I. (2011). Elite athletes in aesthetic and Olympic weight-class sports and the challenge of body weight and body compositions. Journal of Sports Sciences, 29(S1), S101-S114.

Question 28

Have you tried to lose weight Previously? If so, how many times have you tried?

  •  This question is similar to the previous question to determine if an athlete is trying to change body composition, which increases the risk of low energy availability and could impact hormone levels increasing the risk of developing RED-S.  

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: De Souza MJ, Hontscharuk R, Olmsted M, et al. Drive for thinness score is a proxy indicator of energy deficiency in exercising women. Appetite. 2007;48(3):359–67.

  •  Martinsen, M., Holme, I., Pensgaard, A.M., Torstveit, M.K., Klungland, M.K & Sundgot-Borgen, J. (2014). The Development of the Brief Eating Disorder in Athletes Questionnaire. Medicine & Science in Sports & Exercise, 46(8),1666-1675.

  • Sundgot-Borgen, J & Garthe, I. (2011). Elite athletes in aesthetic and Olympic weight-class sports and the challenge of body weight and body compositions. Journal of Sports Sciences, 29(S1), S101-S114.

Question 29

In the past month (4 weeks), how many days have you deliberately tried to limit food intake to influence your shape or weight?

  • This question is formulated based on questions from the Eating Disorder Examination Questionnaire, and aims to measure the frequency that an athlete is practicing cognitive dietary restraint due to concerns related to body composition. This is important to know for the initial questionnaire but also for follow up to monitor changes to see if an athlete is improving their relationship with food.

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

Question 30

In the past month (4 weeks), have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)?

  • Elite athletes who are lean focused for performance often exhibit Cognitive Dietary Restraint (CDR) which has been defined as a type of eating behaviour ruled by cognitive processes rather than hunger and satiety and can increase the stress hormone cortisol. Excess cortisol negatively affects bone formation, calcium absorption through the intestine and accelerates calcium excretion which may result in low bone mass (Barrack et al.,2008; Mclean et al., 2000). Guest & Barr 2005 completed the first study to measure the association between CDR and stress fractures in women runners. Subclinical menstrual cycle irregularities and increased cortisol levels have been related to high levels of CDR which both negatively affect bone mineral density. 

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Barrack, M.T., Rauh, M.J., Barkai, H.S., Nichols, J.F. (2008a). Dietary restraint and low bone mass in female adolescent endurance runners. The American Journal of Clinical Nutrition, 87(1), 36-43.

  • See: Mclean, J.A., Barr, S.I., & Prior, J.C. (2000). Dietary restraint, exercise, and bone density in young women: are they related? Medicine and Science in Sports and Exercise, 1292-1296. 

  • See: Guest, N. & Barr, S.J. (2005). Cognitive dietary restraint is associated with stress fractures in women runners. International Journal of Sport Nutrition and Exercise Metabolism. 15(2), 147-159

  • See: Torstveit, M.K., Fahrenholtz, I.L., Lichtenstein, M.B., Stenqvist, T.B., & Melin, A.K. (2019). Exercise dependence, eating disorder symptoms and biomarkers of Relative Energy Deficiency in Sport (RED-S) among male endurance athletes. British Medicine Journal Open Sport and Exercise Medicine, 5:e000439. 

Question 31

Over the past month (4 weeks) days, how many times have you made yourself sick (vomit), taken a laxative or diet pill, or exercised in a driven or obsessive way as a means of controlling your shape or weight OR getting ready for a competition?

  • This question is formulated based on questions from the Eating Disorder Examination Questionnaire, and aims to determine if an athlete is using unhealthy methods of losing weight. 

  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Torstveit, M.K., Fahrenholtz, I.L., Lichtenstein, M.B., Stenqvist, T.B., & Melin, A.K. (2019). Exercise dependence, eating disorder symptoms and biomarkers of Relative Energy Deficiency in Sport (RED-S) among male endurance athletes. British Medicine Journal Open Sport and Exercise Medicine, 5:e000439.

Question 32

Do you believe that you currently carry extra adipose tissue (fat) or swelling compared to what you normally have?

  • This question is related both to body and shape concerns, which are related to eating disorders according to the Eating Disorder Examination Questionnaire. Further, athletes in a state of low energy availability or overreaching tend to hold on to weight, even when they are training hard and can have a lowered resting metabolic rate. This question aims to identify athletes currently in a state of RED-S or overreaching. 

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Hackney, A. (2020). Hypogonadism in exercising males: Dysfunction or adaptive-regulatory adjustment? Frontiers in Endocrinology,11(11):1-16. https://doi.org/10.3389/fendo.2020.00011

  • See: Heikura, I., Stellingwerff, T., & Burke, L.M. (2018). Self-Reported Periodization of Nutrition in Elite Female and Male Runners and Race Walkers. Frontiers in Physiology, 9 (1732): 1-16. 

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835. 

Question 33

How true is this statement on a scale of 1 to 6: "as a child, you tried very hard to avoid disappointing your parents, teachers, and coaches"

  • This question is taken from the Brief Eating Disorder Questionnaire for Athletes, and aims to determine if athletes have a high “perfectionism” trait. Perfectionism is associated with eating disorders and exercise dependency in athletes. 

  • See: Martinsen, M., Holme, I., Pensgaard, A.M., Torstveit, M.K., Klungland, M.K & Sundgot-Borgen, J. (2014). The Development of the Brief Eating Disorder in Athletes Questionnaire. Medicine & Science in Sports & Exercise, 46(8),1666-1675. 

Question 34

 How true is this statement on a scale of 1 to 6? “I feel extremely guilty after overeating” hard to avoid disappointing your parents, teachers, and coaches"

  • This question is formulated based on questions from the Eating Disorder Examination Questionnaire, and aims to determine if athletes have an unhealthy relationship with food, and eating concerns. Eating concerns are associated with eating disorders and exercise dependency. 

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Torstveit, M.K., Fahrenholtz, I.L., Lichtenstein, M.B., Stenqvist, T.B., & Melin, A.K. (2019). Exercise dependence, eating disorder symptoms and biomarkers of Relative Energy Deficiency in Sport (RED-S) among male endurance athletes. British Medicine Journal Open Sport and Exercise Medicine, 5:e000439.

  • See: Martinsen, M., Holme, I., Pensgaard, A.M., Torstveit, M.K., Klungland, M.K & Sundgot-Borgen, J. (2014). The Development of the Brief Eating Disorder in Athletes Questionnaire. Medicine & Science in Sports & Exercise, 46(8),1666-1675.

Question 35

How true is this statement on a scale of 1 to 6: “I am preoccupied with a desire to be thinner.”

  • This question is formulated based on questions from the Eating Disorder Examination Questionnaire, and aims to determine if athletes have shape and weight concerns, which are associated with eating disorders or disordered eating. 

  • See: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Press Inc, 1994: 358.

  • See: Torstveit, M.K., Fahrenholtz, I.L., Lichtenstein, M.B., Stenqvist, T.B., & Melin, A.K. (2019). Exercise dependence, eating disorder symptoms and biomarkers of Relative Energy Deficiency in Sport (RED-S) among male endurance athletes. British Medicine Journal Open Sport and Exercise Medicine, 5:e000439.

  • See: Martinsen, M., Holme, I., Pensgaard, A.M., Torstveit, M.K., Klungland, M.K & Sundgot-Borgen, J. (2014). The Development of the Brief Eating Disorder in Athletes Questionnaire. Medicine & Science in Sports & Exercise, 46(8),1666-1675. 

Question 36

Do you eat more on days when you are training harder? Example: eating more carbohydrates on high volume/high intensity training days.

  • Athletes’ nutritional needs are principally determined by their training load (the intensity x frequency x duration of daily workouts) and body mass. Diets of track & field competitors and marathon runners reveal a macronutrient composition similar to that of weight-matched, inactive individuals. Male athletes generally ingest adequate dietary energy to meet their daily energy expenditure. Most female athletes’ energy intake is less than expected based on their training load. Compared to carbohydrate recommendations, most athletes consume a diet considered significantly deficient in carbohydrates. Increasing carbs to >5 g/kg/day would probably improve an athlete's training capacity, especially when rapid recovery from intense activity is required (Hawley et al., 1995). 

  • Some athletes report not significantly changing their eating habits from day to day which increases the risk of low EA on days with high training demands (volume/intensity). 

  • Intentional low EA might be related to a clinical eating disorder or disordered eating behaviour (Logue et al., 2018). Unintentional low EA can occur with an athlete who has a high training volume and exercise energy expenditure and is unaware of the resulting increased energy needs, therefore doesn’t eat enough consistently to meet their requirements. They might have poor awareness of fueling/recovery needs (carbohydrate requirements) due to lack of professional sport dietitian counselling. Appetite is not always a reliable indicator of needs and acute lowered appetite in response to heavy training and lack of strong drive to automatically match energy intake to exercise energy expenditure has been seen in athletes (Melin et al., 2016). The acute and chronic impact of appetite as a result of exercise needs to be studied more (Burke et al., 2018). 

  • See: Burke, L.M., Lundy, B., Fahrenholtz, I.L., & Melin, A.K. (2018). Pitfalls of conducting and interpreting estimates of energy availability in free-living athletes. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 350-363. 

  • See: Hawley, J. A., Dennis, S. C., Lindsay, F. H., & Noakes, T. D. (1995). Nutritional practices of athletes: Are they sub‐optimal? Journal of Sports Sciences, 13(sup1), S75–S81. 

  • See: Heikura, I., Stellingwerff, T., & Burke, L.M. (2018). Self-Reported Periodization of Nutrition in Elite Female and Male Runners and Race Walkers. Frontiers in Physiology, 9 (1732): 1-16. 

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835. 

  • See: Melin, A., Tornberg, A.B., Skouby, S., Moller, S.S., Faber, J., Sundgot-Borgen, J., & Sjodin, A. (2016). Low-energy density and high fiber intake are dietary concerns in female endurance runners. Scandinavian Journal of Medicine & Science in Sports, 26, 1060-1071. 

Question 37

Do you have longer than ~4 hour gaps in between meals/snacks during the day on days where you are exercising for over 75 minutes? This includes during endurance training (ex: no carbohydrates for sessions > 2 hours) 

  • The most important preventative nutritional strategy is to ensure adequate and appropriately timed total energy intake to avoid acute and chronic periods of low EA. Since adequate EA is one of the most important factors that may influence bone accrual, education for elite endurance athletes (especially young) should be included in their training program and discuss the importance of EA for athletic performance and optimal physiological function (McCormack et al., 2019). Since low EA can increase injury risk, illness and impair daily training capacity, performance can be negatively impacted (Close et al., 2019). Several issues related to the detection and practical management of low EA are challenging since there are no standardized protocols in place and accurately quantifying EA is difficult. 

  • Often athletes have workouts in the morning and might not meet their recovery needs, waiting until the evening to have a large meal. Most of the day they are in a calorie deficit (within-day energy deficiency). Overall calorie intake may be sufficient for the day but they spent most of the day in a deficit. Therefore, high meal frequency and attention to timing in relation to exercise to ensure adequate intake and improve within-day energy balance. Greater within-day energy deficiency is related to FHA and clinical markers of metabolic issues in female endurance athletes. Could also decrease bone mineral density for athletes (Benardot et al., 2013; Fahrenholtz et al., 2018). 

  • See: Benardot, D. (2013). Energy thermodynamics revisited: energy intake strategies for optimizing athlete body composition and performance. Pensar en movimiento: Revista de Ciencias del Ejercicio y la Salud, 11(2), 1-13.

  • See: Close, G.L., Baar, K., Sale, C., & Bermon, S. (2019). Nutrition for the prevention and treatment of injuries in track and field athletes. International Journal of Sport Nutrition and Exercise Metabolism, 29(2), 189-197.

  • See: Fahrenholtz, IL, Sjodin, A, Benardot, D., et al. (2018). Within-day energy deficiency and reproductive function in female endurance athletes. Scandinavian Journal of Medicine & Science in Sports. 28(3), 1139-1146.  

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835. 

  • See: McCormack, W.P., Shoepe, T.C., LaBrie, J., Almstedt, H.C. (2019). Bone mineral density, energy availability, and dietary restraint in collegiate cross-country runners and non-running controls. European Journal of Applied Physiology, 119(8), 1747-1756. 

  • See: Torstveit, M.K.; Fahrenholtz, I.; Stenqvist, T.B.; Sylta, Ø.; Melin, A (2018). Within-day energy deficiency and metabolic perturbation in male endurance athletes. Int. J. Sport Nutr. Exerc. Metab,28, 419–427. https://doi.org/10.1123/ijsnem.2017-

Current Training

 

Question 38

On a scale of 1-6, how would you rate your performance in training this week relative to what you were expecting, or have been doing recently?

  • The purpose of this question is to identify overreaching and overtraining. The main identifying feature of overreaching is a reduction in performance. 

  • See: Halson, S. L. (2014). Monitoring training load to understand fatigue in athletes. Sports medicine, 44(2), 139-147.

  • See: Le Meur, Y., Hausswirth, C., Natta, F., Couturier, A., Bignet, F., & Vidal, P. P. (2013). A multidisciplinary approach to overreaching detection in endurance trained athletes. Journal of applied physiology, 114(3), 411-420.

Question 39

On a scale of 1-6, how motivated did you feel to train this week?

  • Motivation to train is indicative of good recovery and low fatigue. If an athlete presents with low motivation, it is an early warning sign for overreaching, or burnout. As low mood states are one of the earliest indicators of overreaching, motivation can be an early predictor. 

  • See: Halson, S. L. (2014). Monitoring training load to understand fatigue in athletes. Sports medicine, 44(2), 139-147.

  • See: Li, C., Wang, C. J., & Kee, Y. H. (2013). Burnout and its relations with basic psychological needs and motivation among athletes: A systematic review and meta-analysis. Psychology of Sport and Exercise, 14(5), 692-700.

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 40

Were you able to hit your paces, times, or zones as prescribed (or as usual) this week?

  • The purpose of this question is to identify overreaching and overtraining. The main identifying feature of overreaching is a reduction in performance. 

  • See: Halson, S. L. (2014). Monitoring training load to understand fatigue in athletes. Sports medicine, 44(2), 139-147.

  • See: Le Meur, Y., Hausswirth, C., Natta, F., Couturier, A., Bignet, F., & Vidal, P. P. (2013). A multidisciplinary approach to overreaching detection in endurance trained athletes. Journal of applied physiology, 114(3), 411-420.

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 41

How many workouts this week did you feel as though you had no control over your effort? I.e. Couldn’t sprint if you needed to, or everything felt like the same effort.  

  • Overreaching is characterized by reductions to exercising heart rate and any intensity, and exercising lactic acid concentrations. As such, athletes may feel as though they cannot push in training, or cannot sprint. This question aims to identify athletes who are overreached. 

  • See: Le Meur, Y., Hausswirth, C., Natta, F., Couturier, A., Bignet, F., & Vidal, P. P. (2013). A multidisciplinary approach to overreaching detection in endurance trained athletes. Journal of applied physiology, 114(3), 411-420.

Question 42

How many workouts this week did you have an emotional outburst or internal emotional episode. This could present itself as crying, yelling at a teammate, quitting practice, being extremely self-critical, etc.

  • One of the earliest warning signs of overreaching is emotional dysregulation and negative mood states. Emotional outburst often occur during training, as it is a higher stress environment. This question aims to identify early signs of overreaching. 

  • See: Le Meur, Y., Hausswirth, C., Natta, F., Couturier, A., Bignet, F., & Vidal, P. P. (2013). A multidisciplinary approach to overreaching detection in endurance trained athletes. Journal of applied physiology, 114(3), 411-420.

  • See: Halson, S. L. (2014). Monitoring training load to understand fatigue in athletes. Sports medicine, 44(2), 139-147.

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Mood State

 

Question 43

Are there any biological reasons outside of training and life stress that might explain a change or reduction in mood state?

  • Certain underlying conditions may acutely or chronically shift your mood state independently of training or RED-S status. However, mental health changes have been considered as a symptom of RED-S or a result of RED-S. As such, this question will inform whether you do the next 6 questions on mood states, or not. 

Question 44

On a scale of 1-6, How friendly would you rate yourself today? Think about how considerate, sympathetic, and helpful you feel.

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835.

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

Question 45

On a scale of 1-6, How anxious or tense do you feel today? Think about how angry, stressed, shaky, on-edge, grouchy, and panicky you feel:

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835.

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

Question 46

On a scale of 1-6, How depressed or dejected do you feel today? Think about how unhappy, sad, hopeless, and unworthy you feel:

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 47

On a scale of 1-6, how fatigued do you feel today? Think about how worn-out, exhausted, sluggish, and weary you feel:

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • It was noted in the International Olympic Committee RED-S consensus statement that athletes experiencing chronic low EA would also experience chronic fatigue along with frequent infection/sickness.

  • See: Mountjoy M, Sundgot-Borgen J, Burke L, et al (2014). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)British Journal of Sports Medicine, 48:491-497.

  • See: Nattiv A,Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007;39:1867–82.

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 48

On a scale of 1-6, how much vigour do you have today? Think about how lively, active, energetic, and alert you feel:

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 49

On a scale of 1-6, how confused or bewildered do you feel? Think about how, uncertain, foggy, unable to concentrate, forgetful, and muddled you feel:

  • As the Profile of Mood States (POM-S) Questionnaire can be used as an early identifier of overreaching, this set of questions is intended to act as a reduced version of the POM-S questionnaire. Mood and psychological disturbances can be the result of, or contribute to, disordered eating and low energy availability in athletes. 

  • See: Saya Shacham (1983) A Shortened Version of the Profile of Mood States, Journal of Personality Assessment, 47:3, 305-306

  • See: Halson, S. L., & Jeukendrup, A. E. (2004). Does overtraining exist?. Sports medicine, 34(14), 967-981.

Question 50

How potent is your sex drive compared to usual on a scale of 1 to 6?

  • A recent cross-sectional study conducted on males participating in endurance training reported that regular exposure to high levels of chronic intense and greater durations of training on a regular basis is significantly associated with a decreased libido score (Hackney et al., 2017). Clinicians who treat male patients for sexual disorders and/or council couples on infertility issues should consider the degree of endurance exercise training a person is performing as a potential complicating factor.

  • The IOC and other researchers in the field advise that research should now focus on the energy demands and performance criteria of males engaged in a range of sports as the majority of research in the past has focused on women (Logue et al., 2020). 

  • See: Hackney, A., Lane, A., Register-Mihalik, J., and O’Leary, C.B. (2017). Endurance exercise training and male sexual libido. Med Sci Sports Exerc., 49(7), 1383-1388.

  • See: Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M., & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835. 

Sleep and Recovery

 

Question 51

How many hours of sleep do you get on average per night (without the use of sleeping pills)?

  • This sheds light on an athlete’s recovery protocols. Also, lack of sleep could be a result or a cause of overtraining, or low energy availability. 

  • See: Mountjoy M, Sundgot-Borgen J, Burke L, et al (2014). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) British Journal of Sports Medicine, 48:491-497.

  • See: Nattiv A,Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007;39:1867–82.

Question 52

Do you regularly experience any of the following (select all that apply)

  • Sleep disturbances are a common indicator of overreaching and low energy availability. This question aims to determine if an athlete is in a state of overreaching or low energy availability, or at risk of developing associated symptoms due to reduced recovery. 

  • See: Hausswirth, C., Louis, J., Aubry, A., Bonnet, G., Duffield, R., & Le Meur, Y. (2014). Evidence of disturbed sleep and increased illness in overreached endurance athletes. Medicine & Science in Sports & Exercise, 46(5), 1036-1045.

Question 53

How many times in the last month have you woken up because of night sweats? This would look like soaked pajamas or sheets from sweating.

  • Night sweats (hyperhidrosis) can be due to hormonal issues, thyroid issues and overtraining: Potential symptoms of RED-s. 

  • See: Hackney, A., Lane, A., Register-Mihalik, J., and O’Leary, C.B. (2017). Endurance exercise training and male sexual libido. Med Sci Sports Exerc., 49(7), 1383-1388.

  • See: Greenwood, M. (2008). Aspects of Overtraining. In Essentials of Sports Nutrition and Supplements (pp. 121-142). Humana Press.

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