WHEN THE BODY DOES NOT GET FUEL. EFFECTS OF EXCESSIVE FOOD INTAKE RESTRICTIONS IN ATHLETES - A REVIEW

Zuzanna Sawiec; Dominika Kondyjowska; Natalia Bukała; Dorota Maria Komuńska; Ewa Antonowicz; Sylwia Tomasiczek; Weronika Tomasiczek; Marta Rogozińska

doi:10.31435/ijitss.4(48).2025.4343

Authors

Zuzanna Sawiec Ludwik Rydygier Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0000-0002-3237-4029
Dominika Kondyjowska Ludwik Rydygier Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0006-1458-9284
Natalia Bukała University Clinical Hospital, Wrocław Medical University, Wrocław, Poland https://orcid.org/0009-0009-1617-3487
Dorota Maria Komuńska Stefan Żeromski Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0000-8919-0557
Ewa Antonowicz Independent Public Health Care Center of the Ministry of Internal Affairs and Administration in Kraków, Kraków, Poland https://orcid.org/0000-0002-6229-8389
Sylwia Tomasiczek Stefan Żeromski Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0005-4214-8454
Weronika Tomasiczek Gabriel Narutowicz Municipal Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0005-3466-0386
Marta Rogozińska Stefan Żeromski Specialist Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0000-7445-1128

DOI:

https://doi.org/10.31435/ijitss.4(48).2025.4343

Keywords:

Sports Nutrition, Relative Energy Deficiency in Sport, RED-S, Low Energy Availability, LEA, Female Athlete Triad, Eating Disorder, Athletes

Abstract

Background. With an increasing number of research, sports nutrition becomes an important topic both in professional and recreational athletes. In case of insufficient caloric supply, organism slowly shuts down expendable functions and that presents a health hazard. The first term trying to describe consequences of low energy availability (LEA) was Female Athlete Triad (eating disorder, menstrual disturbances and low bone density), later expanded to Relative Energy Deficiency in Sport (RED-S) which also includes fatigue, sleeping problems, hormonal imbalances, cardiovascular complications.

Aim. In this review we aimed to identify research of interest and sum up available information.

Material and methods. In order to identify research of interest, we used the following online databases: MEDLINE, CENTRAL and manually looked for applicable titles in references of identified publications.

Results. Identified researches showed that consequences of LEA are common which becomes a serious problem in sports medicine. The reasons for calorie restriction are connected to personal self-perception and discipline regulations. It is important to identify athletes at risk of complications and implement procedures aiming to improve their health while simultaneously understanding their motivation for sports success.

Conclusions. Although research on the topic is vast, it is still crucial to educate athletes and their ecosystem about risks and consequences of LEA.

References

Kris-Etherton, P. M., Petersen, K. S., Hibbeln, J. R., Hurley, D., Kolick, V., Peoples, S., Rodriguez, N., & Woodward-Lopez, G. (2021). Nutrition and behavioral health disorders: depression and anxiety. Nutrition reviews, 79(3), 247–260. https://doi.org/10.1093/nutrit/nuaa025

Wade, G. N., & Jones, J. E. (2004). Neuroendocrinology of nutritional infertility. AJP Regulatory Integrative and Comparative Physiology, 287(6), R1277–R1296. https://doi.org/10.1152/ajpregu.00475.2004

Thomas, D. T., Erdman, K. A., & Burke, L. M. (2016). Nutrition and athletic performance. Medicine & Science in Sports & Exercise, 48(3), 543–568. https://doi.org/10.1249/mss.0000000000000852

Lalonde M. A new perspective on the health of Canadians: a working document. Department of National Health and Welfare, 1974; Ottawa: 1981. Available at: http://www.phac-aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf (accessed 16 June 2025)

Ellouze, I., Sheffler, J., Nagpal, R., & Arjmandi, B. (2023). Dietary Patterns and Alzheimer's Disease: An Updated Review Linking Nutrition to Neuroscience. Nutrients, 15(14), 3204. https://doi.org/10.3390/nu15143204

Srour, B., Fezeu, L. K., Kesse-Guyot, E., Allès, B., Méjean, C., Andrianasolo, R. M., Chazelas, E., Deschasaux, M., Hercberg, S., Galan, P., Monteiro, C. A., Julia, C., & Touvier, M. (2019). Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé). BMJ (Clinical research ed.), 365, l1451. https://doi.org/10.1136/bmj.l1451

Loucks, A. B., Kiens, B., & Wright, H. H. (2011). Energy availability in athletes. Journal of Sports Sciences, 29(sup1), S7–S15. https://doi.org/10.1080/02640414.2011.588958

De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., Gibbs, J. C., Olmsted, M., Goolsby, M., & Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. British Journal of Sports Medicine, 48(4), 289. https://doi.org/10.1136/bjsports-2013-093218

Thomas, D. T., Erdman, K. A., & Burke, L. M. (2016b). Nutrition and athletic performance. Medicine & Science in Sports & Exercise, 48(3), 543–568. https://doi.org/10.1249/mss.0000000000000852

Mountjoy, M., Ackerman, K. E., Bailey, D. M., Burke, L. M., Constantini, N., Hackney, A. C., Heikura, I. A., Melin, A., Pensgaard, A. M., Stellingwerff, T., Sundgot-Borgen, J. K., Torstveit, M. K., Jacobsen, A. U., Verhagen, E., Budgett, R., Engebretsen, L., & Erdener, U. (2023). 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine, 57(17), 1073–1098. https://doi.org/10.1136/bjsports-2023-106994

Chapa, D. A. N., Johnson, S. N., Richson, B. N., Bjorlie, K., Won, Y. Q., Nelson, S. V., Ayres, J., Jun, D., Forbush, K. T., Christensen, K. A., & Perko, V. L. (2022). Eating-disorder psychopathology in female athletes and non-athletes: A meta-analysis. The International journal of eating disorders, 55(7), 861–885. https://doi.org/10.1002/eat.23748

Gillbanks, L., Mountjoy, M., & Filbay, S. R. (2022). Lightweight rowers’ perspectives of living with Relative Energy Deficiency in Sport (RED-S). PLoS ONE, 17(3), e0265268. https://doi.org/10.1371/journal.pone.0265268

Ficarra, G., Mannucci, C., Franco, A., Bitto, A., Trimarchi, F., & Di Mauro, D. (2024). A case report on dietary needs of the rowing athlete winner of the triple crown. Heliyon, 10(17), e36551. https://doi.org/10.1016/j.heliyon.2024.e36551

Slater, G., Rice, A., Jenkins, D., & Hahn, A. (2014). Body mass management of lightweight rowers: nutritional strategies and performance implications. British Journal of Sports Medicine, 48(21), 1529–1533. https://doi.org/10.1136/bjsports-2014-093918

Stenqvist, T. B., Melin, A. K., & Torstveit, M. K. (2023). Relative Energy Deficiency in Sport (REDs) Indicators in Male Adolescent Endurance Athletes: A 3-Year Longitudinal Study. Nutrients, 15(24), 5086. https://doi.org/10.3390/nu15245086

Norris, S. A., Frongillo, E. A., Black, M. M., Dong, Y., Fall, C., Lampl, M., Liese, A. D., Naguib, M., Prentice, A., Rochat, T., Stephensen, C. B., Tinago, C. B., Ward, K. A., Wrottesley, S. V., & Patton, G. C. (2022). Nutrition in adolescent growth and development. Lancet (London, England), 399(10320), 172–184. https://doi.org/10.1016/S0140-6736(21)01590-7

Karlson, K. A., Becker, C. B., & Merkur, A. (2001). Prevalence of eating disordered behavior in collegiate lightweight women rowers and distance runners. Clinical Journal of Sport Medicine, 11(1), 32–37. https://doi.org/10.1097/00042752-200101000-00006

Cabre, H. E., Moore, S. R., Smith-Ryan, A. E., & Hackney, A. C. (2022). Relative energy deficiency in sport (RED-S): scientific, clinical, andpractical implications for the female athlete. German Journal of Sports Medicine, 73(7), 225–234. https://doi.org/10.5960/dzsm.2022.546

Hoch, A. Z., Papanek, P., Szabo, A., Widlansky, M. E., Schimke, J. E., & Gutterman, D. D. (2011). Association between the female athlete triad and endothelial dysfunction in dancers. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 21(2), 119–125. https://doi.org/10.1097/JSM.0b013e3182042a9a

Coelho, A. R., Cardoso, G., Brito, M. E., Gomes, I. N., & Cascais, M. J. (2021). The Female Athlete Triad/Relative Energy Deficiency in Sports (RED-S). A tríade da atleta feminina/déficit energético relativo no esporte (RED-S). Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia, 43(5), 395–402. https://doi.org/10.1055/s-0041-1730289

Logue, D. M., Madigan, S. M., Heinen, M., McDonnell, S., Delahunt, E., & Corish, C. A. (2018). Screening for risk of low energy availability in athletic and recreationally active females in Ireland. European Journal of Sport Science, 19(1), 112–122. https://doi.org/10.1080/17461391.2018.1526973

Jurov, I., Keay, N., & Rauter, S. (2022). Reducing energy availability in male endurance athletes: a randomized trial with a three-step energy reduction. Journal of the International Society of Sports Nutrition, 19(1), 179–195. https://doi.org/10.1080/15502783.2022.2065111

Torstveit, M. K., Ackerman, K. E., Constantini, N., Holtzman, B., Koehler, K., Mountjoy, M. L., Sundgot-Borgen, J., & Melin, A. (2023). Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs. British journal of sports medicine, 57(17), 1119–1126. https://doi.org/10.1136/bjsports-2023-106932

Allen, N., Kelly, S., Lanfear, M., Reynolds, A., Clarke, R., Mountjoy, M. L., Wyon, M., & Wolman, R. (2024). Relative energy deficiency in dance (RED-D): a consensus method approach to REDs in dance. BMJ open sport & exercise medicine, 10(1), e001858. https://doi.org/10.1136/bmjsem-2023-001858

Cialdella-Kam, L., Guebels, C. P., Maddalozzo, G. F., & Manore, M. M. (2014). Dietary intervention restored menses in female athletes with exercise-associated menstrual dysfunction with limited impact on bone and muscle health. Nutrients, 6(8), 3018–3039. https://doi.org/10.3390/nu6083018