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BMJ Open Sport Exerc Med. 2018 Oct 4;4(1):e000424. doi: 10.1136/bmjsem-2018-000424. eCollection 2018.

Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists.

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Department of Sport and Exercise Sciences, Durham University, Durham, UK.
Science4performance, London, UK.



To evaluate the efficacy of a sport-specific energy availability (EA) questionnaire, combined with clinical interview, for identifying male athletes at risk of developing bone health, endocrine and performance consequences of relative energy deficiency in sports (RED-S).


Fifty competitive male road cyclists, recruited through links of participants in a pilot study, were assessed by a newly developed sport-specific questionnaire and clinical interview (SEAQ-I) and received dual energy X-ray absorptiometry (DXA) bone mineral density (BMD) and body composition scans and blood tests for endocrine markers.


Low EA as assessed using the SEAQ-I, was observed in 28% of cyclists. Low lumbar spine BMD (Z-score<-1.0) was found in 44% of cyclists. EA was the most significant determinant of lumbar spine BMD Z-score (p<0.001). Among low EA cyclists, lack of previous load-bearing sport was associated with the lowest BMD (p=0.013). Low EA was associated with reduced total percentage fat (p<0.019). The 10 cyclists with chronic low EA had lower levels of testosterone compared with those having adequate EA (p=0.024). Mean vitamin D concentration was below the level recommended for athletes (90  nmol/L). Training loads were positively associated with power-to-weight ratios, assessed as 60  min functional threshold power (FTP) per kg (p<0.001). Percentage body fat was not significantly linked to cycling performance.


This study demonstrates that a SEAQ-I is effective for identifying male road cyclists with acute intermittent and chronic sustained low EA. Cyclists with low EA, particularly in the long-term, displayed adverse quantifiable measures of bone, endocrinology and performance consequences of RED-S.


bone health; energy availability; male athletes; relative energy deficiency in sport

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