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=== '''<u>Introduction</u>''' ===
'''<u>Introduction</u>'''
Relative Energy Deficiency in Sport (RED-S) (the updated model of the female athlete triad) was defined by the International Olympic Committee in 2014 as: ‘impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health’<ref name=":0">Mountjoy, M., Sundgot-Borgen, J., Burke, L. M., Carter, S., Constantini, N., Lebrun, C., ... Ljungqvist, A. (2014). The IOC consensus statement: beyond the female athlete triad--relative energy deficiency in sport (red-s). British Journal of Sports Medicine, 48(7), 491–497. <nowiki>https://doi.org/10.1136/bjsports-2014-093502</nowiki></ref>


Low energy availability is the instance in which there is a chronic mismatch between nutritional intake and energy expenditure, thus leaving insufficient energy available for essential physiological functions<ref name=":0" />. As a result, physiological functions are down-regulated in order to preserve energy for more essential functions and for movement.
Relative Energy Deficiency in Sport (RED-S) (the updated model of the female athlete triad) was defined by the International Olympic Committee in 2014 as: ‘impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health’<ref name=":0">Mountjoy, M., Sundgot-Borgen, J., Burke, L. M., Carter, S., Constantini, N., Lebrun, C., ... Ljungqvist, A. (2014). The IOC consensus statement: beyond the female athlete triad--relative energy deficiency in sport (red-s). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502</ref>


This term has replaced the female athlete triad as we are now aware that this syndrome impacts both female and male individuals experiencing low energy availability.
Low energy availability is the instance in which there is a chronic mismatch between nutritional intake and energy expenditure, thus leaving insufficient energy available for essential physiological functions. <ref name=":0" /> As a result, physiological functions are down-regulated in order to preserve energy for more essential functions and for movement.  


=== '''<u>Definitions</u>''' ===
This term has replaced the female athlete triad as we are now aware that this syndrome impacts both female and male individuals experiencing low energy availability.  
* Amenorrhea - An abnormal absence of menstruation<ref name=":1">Ferin, M., Jewelewicz, R., Warren, M. (1993) The Menstrual cycle. Oxford: Oxford University Press (pp. 186-187)</ref>
* Dysmenorrhea - Painful menstruation, typically involving abdominal cramps<ref name=":1" />
* The Female Athlete Triad – The interrelationship of menstrual cycle dysfunction, reduced energy availability and reduced bone mineral density<ref name=":3">Nazem and Ackerman, 2012. The Female Athlete Triad. Sports Health. 4(4). [Online].</ref>
* Hypomenorrhea – Abnormally light menstrual bleeding <ref>Yaffe, H., Ron, M., Polishuk, W. Amenorrhea, Hypomenorrhea, and Uterine Fibrosis. American Journal of Obstetrics and Grynaecology. 130(5): 599-601</ref>
* Menarche – ‘The occurrence of the first menstrual period in the female adolescent’<ref>Lacroix, A., Gondal, H., Langaker, M., 2020. Physiology, Menarche. StatPearls Publishing. Treasure Island (FL)</ref>
* Menorrhagia – Heavy menstrual blood loss <ref>National Institute for Health and Care Excellence 2018. Menorrhagia: What is it? Clinical Knowledge Summaries
</ref>
* Menstrual cycle - The process of ovulation and menstruation <ref name=":1" />
* Menstruation - The process of discharging blood and other material from the lining of the uterus at intervals of about one lunar month from puberty to the menopause, except during pregnancy<ref name=":1" />
* Oligomenorrhea - Menstrual cycle length of greater than 45 days <ref>Riaz Y, Parekh U. Oligomenorrhea. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK560575/</nowiki></ref>
* Osteopenia - A medical condition in which the protein and mineral content of bone is reduced, but less severely than in osteoporosis <ref name=":1" />
* Relative Energy Deficiency in Sport (RED-S) - This is impaired physiological function including, but not limited to impairment of: metabolic rate; menstrual function; bone health; immunity; protein synthesis; and cardiovascular health, caused by energy deficiency <ref name=":0" />


=== '''<u>Menstrual Dysfunction Relating to RED-S</u>''' ===
'''Functional Hypothalamic Amenorrhea'''


Amenorrhea occurs as a result of this energy imbalance, in which energy availability (nutritional intake) is lower than required<ref>Manore, M. 2002. Dietary Recommendations and Athletic Menstrual Dysfunction. Sports Med 32, 887–901. </ref>. This occurs as the body does not have enough energy available for essential physiological functions, and therefore is unable to maintain normal reproductive function<ref>Gordon, C. 2010. Functional Hypothalamic Amenorrhea. The New England Journal of Medicine. 363: pp. 365 – 371.</ref>.
'''<u>Relevant Definitions</u>'''


This manifestation of energy-deficient amenorrhea occurs when the hypothalamus receives information indicating that the body is not receiving sufficient energy, and therefore suppresses the hypothalamic-pituitary- gonadal (HPG) axis, altering circulating GnRH, LH and FSH levels<ref>Caronia, L., Martin, C., Welt, C., Sykotis, G, Quinton, R., Thambundit, A., Avbelj, M., Dhruvakumar, S., Plummer, L., Hughes, V., Seminara, S., Boepple, P et al., 2011. A Genetic Basis for Functional Hypothalamic Amenorrhea. The New England Journal of Medicine. 364 pp. 215 – 225.</ref>.
* Amenorrhea - An abnormal absence of menstruation<ref name=":1">Ferin, M., Jewelewicz, R., Warren, M. (1993) The Menstrual cycle. Oxford: Oxford University Press (pp. 186-187)</ref>
* Dysmenorrhea - Painful menstruation, typically involving abdominal cramps<ref name=":1" />
* The Female Athlete Triad – The interrelationship of menstrual cycle dysfunction, reduced energy availability and reduced bone mineral density<ref>Nazem and Ackerman, 2012. The Female Athlete Triad. Sports Health. 4(4). [Online]. </ref>
* Hypomenorrhea – Abnormally light menstrual bleeding<ref>Yaffe, H., Ron, M., Polishuk, W. Amenorrhea, Hypomenorrhea, and Uterine Fibrosis. American Journal of Obstetrics and Grynaecology. 130(5): 599-601 </ref>
* Menarche – ‘The occurrence of the first menstrual period in the female adolescent’ <ref>Lacroix, A., Gondal, H., Langaker, M., 2020. Physiology, Menarche. StatPearls Publishing. Treasure Island (FL) </ref>
* Menorrhagia – Heavy menstrual blood loss<ref>National Institute for Health and Care Excellence 2018. Menorrhagia: What is it? Clinical Knowledge Summaries</ref>
* Menstrual cycle - The process of ovulation and menstruation<ref name=":1" />
* Menstruation - The process of discharging blood and other material from the lining of the uterus at intervals of about one lunar month from puberty to the menopause, except during pregnancy<ref name=":1" />
* Oligomenorrhea - Menstrual cycle length of greater than 45 days<ref>Riaz Y, Parekh U. Oligomenorrhea. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK560575/</nowiki></ref>
* Osteopenia - A medical condition in which the protein and mineral content of bone is reduced, but less severely than in osteoporosis<ref name=":1" />
* Relative Energy Deficiency in Sport (RED-S) - This is impaired physiological function including, but not limited to impairment of: metabolic rate; menstrual function; bone health; immunity; protein synthesis; and cardiovascular health, caused by energy deficiency<ref name=":0" />  


FHA has been categorised into three groups: ‘stress- related amenorrhea; weight-loss related amenorrhea; and exercise related amenorrhea’<ref>Meczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Genazzani A. 2008. Functional Hypothalamic Amenorrhea and its Influence on Women’s Health. Journal of Endocrinological Investigation. 24(1):4-11. </ref>


In cases of weight-loss related, and exercise-related amenorrhea, GnRH levels may be reduced by psychological/emotional ill-health in the form of eating disorders, or by excessive exercise<ref>Utiger, R 2009. "Oligomenorrhea." Britannica Academic, Encyclopædia Britannica.</ref>. It has also been identified that inadequate nutritional intake, insufficient intake of key macronutrients and micronutrients, as well as binge-eating; are contributing factors to amenorrhea and oligomenorrhea<ref name=":4">Algars, M, Huang, L., Holle, A., Peat, C., Thornton, L., Lichtenstein, P., Bulik, C. 2014. Binge Eating and Menstrual Dysfunction. Journal of Psychosomatic Research. 76(1) pp. 19 – 22 </ref>.
'''<u>Prevalence of RED-S</u>'''


This correlation between FHA and eating disorders has significant implications for psychological well-being, by potentially exacerbating low self-esteem, anxiety and depression<ref name=":3" />. The combination of deteriorating mental health and intentional weight-loss further disrupts the normal volumes of circulating hormones<ref name=":4" />.
The prevalence of RED-S is not well documented due to the inherent methodological difficulties in diagnosing true low energy availability.


Hypothalamic amenorrhea was consistent with physical stressors, and sub-clinical eating disorders, and yet not consistent with low BMI<ref name=":4" />. FHA was present in normal-weight, premenopausal women with sub-clinical eating disorders, even in ‘the absence of significant weight- loss’<ref>Lewis, M., Thomas, B., 1996. Menstrual Cycle Dysfunction and Weight Loss Practices among College-age Women. Journal of the American Dietetic Association. 96(9). Pp.31</ref>.  
The understanding of RED-S and its symptoms are poorly known by athletes and coaches, and therefore it is also not commonly recognised<ref name=":2">Logue DM, Madigan SM, Melin A, Delahunt E, Heinen M, Donnell SM, Corish CA. Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients. 2020 Mar 20;12(3):835. doi: 10.3390/nu12030835. PMID: 32245088; PMCID: PMC7146210.</ref>. Fewer than 50% of physicians, coaches, physiotherapists and athletic trainers could identify the triad components (Low energy availability +/- disordered eating, menstrual dysfunction, low bone mineral density (IOC update RED-S0.


The degree to which the HPG axis is affected dictates the severity of MCD, as oligomenorrhea may develop into amenorrhea with further reductions to GnRH, LH and FSH levels <ref>Koltun, K., Williams, N., Scheid, J., De Souza, M. 2020. Discriminating Hypothalamic Oligomenorrhea/Amenorrhea from Hyperandrogenic Oligomenorrhea/Amenorrhea in Exercising Women. Applied physiology, Nutrition, and Metabolism. 45(7) </ref>
Prevalence varies between sports and ranges in the literature between 22-58%<ref name=":2" />.


=== '''<u>Prevalence of RED-S</u>''' ===
'''<u>Health Implications of RED-S</u>'''
The prevalence of RED-S is not well documented due to the inherent methodological difficulties in diagnosing true low energy availability.


The understanding of RED-S and its symptoms are poorly known by athletes and coaches, and therefore it is also not commonly recognised<ref name=":2">Logue DM, Madigan SM, Melin A, Delahunt E, Heinen M, Donnell SM, Corish CA. Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients. 2020 Mar 20;12(3):835. doi: 10.3390/nu12030835. PMID: 32245088; PMCID: PMC7146210.</ref>. Fewer than 50% of physicians, coaches, physiotherapists and athletic trainers could identify the triad components (Low energy availability +/- disordered eating, menstrual dysfunction, low bone mineral density (IOC update RED-S).
Health implications are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.


Prevalence varies between sports and ranges in the literature between 22-58%<ref name=":2" />.
'''<u>Performance Implications of RED-S</u>'''
[[File:Health and Performance Implications of RED-S.png|thumb|Health and Performance Implications of RED-S]]
Performance implications are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.


=== '''<u>Health and Performance Implications of RED-S</u>''' ===
'''<u>Red Flags</u>'''
[[File:Health and Performance Implications of RED-S.png|thumb|<ref>Mountjoy M, Sundgot-Borgen J, Burke L et al. The IOC Consensus Statement: Beyond the Female Athlete Triad – Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014;48(7)</ref><ref>Keay N, Rankin A. Infographic. Relative Energy Deficiency in Sport: An Infographic Guide. British Journal of Sport Medicine. 2019;50(20).</ref>]]'''Health implications''' are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.


'''Performance implications''' are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.
=== '''<u>Red Flags</u>''' ===
The health and performance implications – cardiac abnormalities, recent weight loss, stress fractures, overuse injuries, anxiety/depression, oligomenorrhea/amenorrhea, poor concentration, restrictive eating, worsened performance, and body dysmorphia – are the red flags for RED-S.
The health and performance implications – cardiac abnormalities, recent weight loss, stress fractures, overuse injuries, anxiety/depression, oligomenorrhea/amenorrhea, poor concentration, restrictive eating, worsened performance, and body dysmorphia – are the red flags for RED-S.


=== '''<u>Screening tools</u>''' ===
'''<u>Screening tools</u>'''
# RED-S CAT - Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT) https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf <ref>Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. doi: 10.1136/bjsports-2015-094873. PMID: 25896450.</ref>
 
#* Can assess males and females]
RED-S CAT - Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT)
#* Assesses risk and return to play
https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf <ref>Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. doi: 10.1136/bjsports-2015-094873. PMID: 25896450.</ref>
#* Is a more functional model using a traffic light system  
 
# LEAF-Q – Low Energy Availability in Females Questionnaire http://www.diva-portal.org/smash/get/diva2:1303041/FULLTEXT02.pdf <ref>Melin A, Tornberg ÅB, Skouby S'', et al.'' The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. ''British Journal of Sports Medicine'' 2014;'''48:'''540-545.</ref>
* Can assess males and females]
#* High Sensitivity (78%) and specificity (90%)
* Assesses risk and return to play
#* For female athletes only
* Is a more functional model using a traffic light system
 
 
LEAF-Q – Low Energy Availability in Females Questionnaire http://www.diva-portal.org/smash/get/diva2:1303041/FULLTEXT02.pdf <ref>Melin A, Tornberg ÅB, Skouby S'', et al.'' The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. ''British Journal of Sports Medicine'' 2014;'''48:'''540-545.</ref>
 
* High Sensitivity (78%) and specificity (90%)


* For female athletes only




=== '''<u>Management</u>''' ===
'''<u>Management</u>'''
'''Non-pharmacologic''' – When a patient is diagnosed with RED-S, the following management strategies should be implemented: education; optimising energy availability; modification of exercise and nutrition; supplementation of vitamin D and calcium; and CBT <ref name=":0" />. An MDT approach should be adopted, including mental health support. Sport participation may be used as leverage.


'''Pharmacologic''' – oral contraceptive is not recommended as it creates false menstruation or a ‘pseudo-period’. They are currently reviewing the use of recombinant parathyroid hormones and its role in improving bone mineral density <ref name=":0" />
Non-pharmacologic – When a patient is diagnosed with RED-S, the following management strategies should be implemented: education; optimising energy availability; modification of exercise and nutrition; supplementation of vitamin D and calcium; and CBT<ref name=":0" />. An MDT approach should be adopted, including mental health support. Sport participation may be used as leverage.


== References ==
Pharmacologic – oral contraceptive is not recommended as it creates false menstruation or a ‘pseudo-period’. They are currently reviewing the use of recombinant parathyroid hormones and its role in improving bone mineral density <ref name=":0" />
<references />

Revision as of 12:37, 15 February 2023

Introduction

Relative Energy Deficiency in Sport (RED-S) (the updated model of the female athlete triad) was defined by the International Olympic Committee in 2014 as: ‘impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health’[1]

Low energy availability is the instance in which there is a chronic mismatch between nutritional intake and energy expenditure, thus leaving insufficient energy available for essential physiological functions. [1] As a result, physiological functions are down-regulated in order to preserve energy for more essential functions and for movement.

This term has replaced the female athlete triad as we are now aware that this syndrome impacts both female and male individuals experiencing low energy availability.


Relevant Definitions

  • Amenorrhea - An abnormal absence of menstruation[2]
  • Dysmenorrhea - Painful menstruation, typically involving abdominal cramps[2]
  • The Female Athlete Triad – The interrelationship of menstrual cycle dysfunction, reduced energy availability and reduced bone mineral density[3]
  • Hypomenorrhea – Abnormally light menstrual bleeding[4]
  • Menarche – ‘The occurrence of the first menstrual period in the female adolescent’ [5]
  • Menorrhagia – Heavy menstrual blood loss[6]
  • Menstrual cycle - The process of ovulation and menstruation[2]
  • Menstruation - The process of discharging blood and other material from the lining of the uterus at intervals of about one lunar month from puberty to the menopause, except during pregnancy[2]
  • Oligomenorrhea - Menstrual cycle length of greater than 45 days[7]
  • Osteopenia - A medical condition in which the protein and mineral content of bone is reduced, but less severely than in osteoporosis[2]
  • Relative Energy Deficiency in Sport (RED-S) - This is impaired physiological function including, but not limited to impairment of: metabolic rate; menstrual function; bone health; immunity; protein synthesis; and cardiovascular health, caused by energy deficiency[1]


Prevalence of RED-S

The prevalence of RED-S is not well documented due to the inherent methodological difficulties in diagnosing true low energy availability.

The understanding of RED-S and its symptoms are poorly known by athletes and coaches, and therefore it is also not commonly recognised[8]. Fewer than 50% of physicians, coaches, physiotherapists and athletic trainers could identify the triad components (Low energy availability +/- disordered eating, menstrual dysfunction, low bone mineral density (IOC update RED-S0.

Prevalence varies between sports and ranges in the literature between 22-58%[8].

Health Implications of RED-S

Health implications are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.

Performance Implications of RED-S

Health and Performance Implications of RED-S

Performance implications are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.

Red Flags

The health and performance implications – cardiac abnormalities, recent weight loss, stress fractures, overuse injuries, anxiety/depression, oligomenorrhea/amenorrhea, poor concentration, restrictive eating, worsened performance, and body dysmorphia – are the red flags for RED-S.

Screening tools

RED-S CAT - Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT) https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf [9]

  • Can assess males and females]
  • Assesses risk and return to play
  • Is a more functional model using a traffic light system


LEAF-Q – Low Energy Availability in Females Questionnaire http://www.diva-portal.org/smash/get/diva2:1303041/FULLTEXT02.pdf [10]

  • High Sensitivity (78%) and specificity (90%)
  • For female athletes only


Management

Non-pharmacologic – When a patient is diagnosed with RED-S, the following management strategies should be implemented: education; optimising energy availability; modification of exercise and nutrition; supplementation of vitamin D and calcium; and CBT[1]. An MDT approach should be adopted, including mental health support. Sport participation may be used as leverage.

Pharmacologic – oral contraceptive is not recommended as it creates false menstruation or a ‘pseudo-period’. They are currently reviewing the use of recombinant parathyroid hormones and its role in improving bone mineral density [1]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Mountjoy, M., Sundgot-Borgen, J., Burke, L. M., Carter, S., Constantini, N., Lebrun, C., ... Ljungqvist, A. (2014). The IOC consensus statement: beyond the female athlete triad--relative energy deficiency in sport (red-s). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Ferin, M., Jewelewicz, R., Warren, M. (1993) The Menstrual cycle. Oxford: Oxford University Press (pp. 186-187)
  3. ↑ Nazem and Ackerman, 2012. The Female Athlete Triad. Sports Health. 4(4). [Online].
  4. ↑ Yaffe, H., Ron, M., Polishuk, W. Amenorrhea, Hypomenorrhea, and Uterine Fibrosis. American Journal of Obstetrics and Grynaecology. 130(5): 599-601
  5. ↑ Lacroix, A., Gondal, H., Langaker, M., 2020. Physiology, Menarche. StatPearls Publishing. Treasure Island (FL)
  6. ↑ National Institute for Health and Care Excellence 2018. Menorrhagia: What is it? Clinical Knowledge Summaries
  7. ↑ Riaz Y, Parekh U. Oligomenorrhea. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560575/
  8. ↑ 8.0 8.1 Logue DM, Madigan SM, Melin A, Delahunt E, Heinen M, Donnell SM, Corish CA. Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients. 2020 Mar 20;12(3):835. doi: 10.3390/nu12030835. PMID: 32245088; PMCID: PMC7146210.
  9. ↑ Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. doi: 10.1136/bjsports-2015-094873. PMID: 25896450.
  10. ↑ Melin A, Tornberg ÅB, Skouby S, et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. British Journal of Sports Medicine 2014;48:540-545.
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