Date of Award
2026
Degree Type
Dissertation
Degree Name
Doctor of Philosophy in Health Sciences
Specialization
Kinesiology
Department
Kinesiology
First Advisor
Christie L. Ward-Ritacco
Abstract
Female athletes are frequently exposed to harmful messaging and pressures - such as body shaming, encouragement to engage in unhealthy eating patterns, and exposure to excessive training loads - that may contribute to their adoption of poor nutrition and exercise behaviors. In response, athletes may engage in under-fueling and/or overexercising, increasing their risk for low energy availability (LEA). LEA is characterized by a mismatch between energy intake (EI) and exercise energy expenditure (EEE) that leaves the body’s total energy needs unmet. LEA can lead to Relative Energy Deficiency in Sport (REDs), where insufficient energy prevents the body from maintaining essential physiological and/or psychological functions, such as reproduction, bone health, metabolism, and immunity. REDs can result in negative signs and symptoms, including, but not limited to, bone stress injuries, low bone mineral density, menstrual cycle irregularities, suppressed metabolism, sleep disturbances, body dissatisfaction, and mental health issues. The short- and long-term consequences of LEA and REDs can have harmful effects on the health, well-being, and performance of athletes.
The prevalence of LEA/REDs in female athletes ranges from 23-79.5% across a variety of sport types and is particularly common in collegiate athletes. As such, there is a critical need to address the causes of LEA/REDs and provide actionable interventions to reduce risk in female athletes. Experts in the field have suggested that achieving this will require comprehensive sports nutrition and REDs education for at risk populations. Other prevention recommendations, such as establishing REDs screening protocols and knowledgeable referral networks, have also been suggested. Primary and secondary prevention strategies aim to prevent REDs and reduce the risk of REDs-related health and performance consequences; however, if these strategies fail, tertiary prevention focuses on the treatment and management of diagnosed cases of REDs. Treatment of REDs includes reversing problematic LEA and addressing REDs outcomes, as well as referral to a REDs-informed multidisciplinary team, appropriate return-to-play protocols, and policy changes to support REDs prevention.
The primary recommendation for REDs prevention from the International Olympic Committee (IOC) includes sports nutrition and REDs education. Despite this, only ~12% of REDs-related research is interventional and there is minimal data on education-based interventions to improve REDs outcomes specifically. Existing preliminary research has failed to establish a consensus on the association between nutrition knowledge and REDs risk, with studies illustrating positive, negative, or no associations. Previous education interventions have shown promise in improving awareness and knowledge related to sports nutrition; however, incorporating behavior change theory into their design may further enhance their impact and long-term effectiveness on fueling and exercise behaviors. Therefore, there is a clear need to continue exploring the development of effective interventions to reduce LEA/REDs risk in female athletes.
Nonetheless, education is necessary for the prevention of REDs because it can empower athletes with the knowledge necessary to recognize and address early warning signs. Athletes may unknowingly engage in behaviors that lead to LEA due to misconceptions about nutrition, body composition, and training demands. Without proper education, harmful patterns can persist, increasing the risk of serious health consequences, such as impaired bone health, hormonal disruptions, compromised cardiovascular and hematological function. Furthermore, targeted education promotes a culture of awareness and support, facilitating early identification and intervention to prevent the progression of LEA/REDs to more severe conditions, like DE/ED. Prioritizing comprehensive and accessible education programs protects the long-term health and well-being of female athletes, ultimately leading to enhanced sports performance. Therefore, the primary aim of this project is to examine the effectiveness of an online education intervention, the Female Energy Deficiency (FED) Project, on energy availability (EA) status, REDs risk, and LEA knowledge in collegiate female athletes.
Beyond education, REDs health and performance outcomes require prompt attention, but screening and diagnosis of LEA/REDs is challenging, as it is time-consuming and is difficult to calculate accurately in the real-world settings. Nevertheless, identifying the underlying causes of LEA/REDs is essential for implementing appropriate treatment strategies that are effective in reversing LEA and REDs outcomes. The IOC REDs Clinical Assessment Tool Version 2 (IOC REDs CAT2) was updated in 2023 to enhance REDs identification. The IOC REDs CAT2 recommends a three-step process that includes: (1) REDs screening, (2) REDs severity/risk assessment, and (3) REDs clinical diagnosis and treatment. Available low-cost, easy-to-administer questionnaires provide a useful initial screening tool for LEA/REDs in athletic populations. However, screening should be followed by further risk assessment using objective REDs indicators, in athletes screening at risk for REDs. The IOC REDs CAT2 currently recommends thirteen population-specific questionnaires/clinical interviews, such as the Low Energy Availability in Females Questionnaire (LEAF-Q) and Eating Disorder Examination Questionnaire (EDE-Q). Given the scientific advancements in REDs research and clinical assessment in recent years, the effectiveness of previously validated screening questionnaires needs to be reevaluated. As such, the secondary aim of this project is to investigate the individual and combined use of the LEAF-Q and EDE-Q to detect LEA and REDs in collegiate female athletes.
The two studies in this dissertation included data from a sample of NCAA Division I female collegiate athletes (18-23 years, performance tier 4) who completed baseline (n = 30) and follow-up visits (n = 27) as part of a two-arm randomized controlled trial.
The first study used a longitudinal design to assess the efficacy of the FED Project intervention on primary outcomes (EA status and REDs risk) and secondary outcomes (LEA knowledge and athlete self-efficacy for nutrition behavior change) in NCAA Division I female collegiate athletes. Participants were matched for age and sport type and randomized into the FED Project (FED, n = 14) or waitlist control (CON, n = 13). The FED group participated in a 10-week, self-paced, online education intervention that included five 30-minute modules. To determine interactions between intervention groups (FED vs. CON) and time (baseline vs. follow-up), 2x2 mixed ANOVAs were conducted. No group-by-time interactions for EA, EI, or REDs risk were observed, suggesting that EA status and REDs risk did not change over time for either group. There was a significant group-by-time interaction for EEE, demonstrating no difference in EEE between groups at either time point, despite a significant decrease in EEE from baseline to follow-up for the CON group. Additionally, there was a significant group-by-time interaction for LEA knowledge, indicating that there were no differences in LEA knowledge between groups at baseline or follow-up, despite a significant increase in LEA knowledge over time for the FED group. Nonetheless, both groups illustrated a significant increase in athlete self-efficacy over time. Findings suggest that REDs education is an effective means of improving LEA knowledge and athlete self-efficacy, but not necessarily EA status or REDs risk. As such, additional work is needed to understand the aspects of education programs that may lead to meaningful behavior changes for REDs prevention.
The second study used a cross-sectional design to determine the utility of the individual and combined use of the LEAF-Q and EDE-Q in identifying REDs risk in a mixed sport cohort of collegiate female athletes (n = 30) at baseline. LEA risk was determined using the previously validated LEAF-Q, and ED risk was determined using previously validated EDE-Q. Diagnostic performance of the LEAF-Q and EDE-Q was based on the ability to detect differences in EA components (EI, EEE, EA) and objectively measured REDs indicators (REDs risk). EA was calculated based on EI (via diet records), EEE (via accelerometry), and fat-free mass (FFM; via dual x-ray absorptiometry (DXA)). REDs indicators were scored in accordance with the IOC REDs CAT2, adapted for the research setting. Diagnostic properties of the LEAF-Q and EDE-Q were assessed using area under the curve and contingency tables. Independent samples t-tests and Pearson’s χ2 evaluated differences in low and high risk for LEA (via LEAF-Q) and ED (via EDE-Q) and EA status and REDs risk, respectively. The LEAF-Q was able to determine LEA, classified based on EA status, but not REDs cases. The EDE-Q had an ability to distinguish REDs cases, but not LEA. With a few exceptions, neither questionnaire was able to differentiate individual EA components or REDs indicators. The combined use of the LEAF-Q and EDE-Q allowed for more accurate detection of REDs in female athletes.
Overall, the current findings have implications for the screening, diagnosis, prevention, treatment, and monitoring of LEA/REDs in research and clinical settings, particularly for female collegiate athletes who may be vulnerable to poor health, well-being, and performance. Results from this dissertation suggest education improves knowledge related to LEA/REDs, but does not reduce LEA/REDs risk, in collegiate female athletes. Other prevention strategies, such as individual nutrition counseling, targeted education related to individualized risk factors, sport rule changes, reduced emphasis on body composition, screening and return-to-sport protocols, ought to be considered and addressed. Early identification and management of REDs signs and symptoms is vital to timely diagnosis and treatment, preventing the development of more severe or long-term REDs outcomes. As such, the current screening questionnaires available may be able to successfully detect LEA/REDs risk, especially when used in combination, but more comprehensive screening protocols that reduce the risk of false negatives are needed. Further efforts are needed to address broader aspects of REDs prevention - efforts that extend beyond the individual athlete and include systemic changes involving coaches, support staff, and leadership at both departmental and organizational levels. These efforts must encompass not only education and screening, but also policy development, protocol implementation, cultural change, and structural support to effectively prevent REDs and safeguard the long-term health, well-being, and performance of female athletes.
Recommended Citation
Lodge, Melissa, "THE FEMALE ENERGY DEFICIENCY (FED) PROJECT: EDUCATION AND SCREENING STRATEGIES TO PREVENT RELATIVE ENERGY DEFICIENCY IN SPORT (REDs) IN COLLEGIATE FEMALE ATHLETES" (2026). Open Access Dissertations. Paper 4532.
https://digitalcommons.uri.edu/oa_diss/4532