Risk of relative energy deficiency in sport due to low energy availability: A nutritional concern among adolescent team sport athletes

Adolescence is a critical period for growth, bone development, and hormonal regulation which are profoundly influenced by nutritional status and energy balance. In the context of competitive sports, young female athletes face increasing pressure to perform, often under dietary restrictions or high training loads that compromise their health. Low Energy Availability (LEA), a precursor to Relative Energy Deficiency in Sport (REDs), remains a silent but significant threat in this population. Despite its global relevance, research on LEA and REDs in adolescent athletes, particularly in developing nations like India, is scarce. This study addresses a vital gap by exploring these conditions in adolescent team sports athletes. This study aimed to assess the prevalence of LEA and the risk of REDs among female adolescent athletes participating in team sports. A cross-sectional study was conducted among 203 female athletes aged 12-17 years (mean age 14.9±1.6 years) training for the KHELO India Youth Games. Inclusion criteria included ≥5 years of training (mean 5.91±0.87 years), ≥10 hours of physical activity per week (mean 15.14±4.31 h), and post-menarcheal status. Screening tools used were the low energy availability in females questionnaire (LEAF-Q), cumulative risk assessment (CRA), calculated energy availability (EA), and dual-energy X-ray absorptiometry (DEXA). EA was determined from dietary intake and exercise energy expenditure. Bone mineral density (BMD) and fat-free mass (FFM) were assessed via DEXA using Z-scores. LEAF-Q identified 79.3% of athletes at risk for LEA, with basketball players showing the highest proportion of severe risk - 8.2% versus 0-6.9% among representatives of other sports (volleyball, hockey, football, kabaddi, kho-kho) (p=0.050). CRA indicated that 35.0% of athletes were restricted from sport, while 37.4% received full clearance (p=0.718). Mean EA was 23.46±7.23 kcal/kg FFM, reflecting a significant energy deficit. Low BMD (Z-score <-2.0) was found in 34.5% of athletes (p=0.926). This study revealed that adolescent female team sports players had a high prevalence of LEA and REDs risk. Importantly, the findings suggest a new direction regarding the way coaches, nutritionists, parents, and governing bodies approach adolescent athlete welfare, prioritizing health, growth, and long-term performance over short-term success. This study serves as an important indication to prioritize energy balance and athlete education as the foundations of long-term sports performance.