The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad

Correspondence to Anna Melin, Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1876 Frederiksberg, Denmark; [email protected]

Introduction

When energy intake is restricted or inadequate, the amount of energy available for basic physiological functions, such as reproductive function, becomes insufficient.^{1 2} Therefore, persistent low energy availability (EA), with or without an eating disorder (ED) present, may pose a significant health risk to female athletes. There are validated screening tools for the detection of disordered eating behaviour (DE) in athletes including the Athletic Milieu Direct Questionnaire (AMDQ),³ the Female Athlete Screening Tool (FAST)⁴ and the American Physiological Screening Test for eating disorders among Female College Athletes (PST).⁵ The prevalence of low EA is assumed to be high in female athletes,¹ but there are no screening tools based on self-reported physiological symptoms of low EA. It is, therefore, relevant to develop an instrument that can be routinely and widely used for screening female athletes to identify individuals at risk of the female athlete triad (Triad).

EA <125 kJ/kg fat-free mass (FFM) over more than 5 days has been shown to reduce blood glucose and leptin levels, to suppress the pulsatility of gonadotropin-releasing hormone and hypothalamic-pituitary axis hormones, like luteal hormone (LH) and triiodothyronine (T₃), and to elevate cortisol as well as to increase bone resorption markers in eumenorrheic sedentary women.^{6 7} If maintained for a longer period, low EA can cause functional hypothalamic amenorrhoea (FHA),^{2 8} and FHA has been shown to have a high predictive value when screening for ED among female athletes.⁹ Low levels of oestrogen increase the risk for stress fractures and osteoporosis,^{1 10} and results from a study on young female athletes indicate that restricted eating behaviour and FHA may also increase the risk for muscular and joint overload.¹¹ Orthostatic hypotension is common among patients with ED,^{5 10} and the sensation of dizziness when rising from a supine to a standing position could, therefore, be a symptom of low EA. Reduced T₃ and T₄ have been reported in athletes with FHA^{12 13} and in patients with ED.¹⁴ Hypothyroidism can result in an increased cold sensitivity and could, therefore, be a symptom of low...