Transform your infant into a mini version of the lovable Chewbacca! WARNING: This Chewbacca infant onesie might cause your infant to grow unwanted body hair at an early age.
Become Chewbacca with this amazing sweatshirt. WARNING: Wearing this for extended periods of time could cause your speech to become intelligible.
I mean, how could we not include this? This will turn your little one into an adorable Jedi Master. However, we can't make any promises as to the powers of the force that your young one will gain. It all depends on their midi-chlorian count, duh.
Show the world you support the empire with these Stormtrooper & Darth Vader Crew Socks. We promise everyone around you will be jealous when they get a peek of these bad boys.
Sometimes after a 10 hour day at the office filled with force-choking people during webinars, blowing up the planets of competing companies, and growing a new workforce in test tubes, you just need to take a load off in your meditation sphere with these Darth Vader Slippers.
Again, it's Star Wars and Beer. The copy pretty much writes itself. Need we say more? This Star Wars Drinking Buddies Tank Top will be sure to impress anyone at a social drinking gathering.
Transport yourself to a galaxy, far away with this amazing Star Wars Rebel Classic Tee!
Show off your Star Wars artistry with this Star Wars starry night tee!
Just because a ship looks like a hunk of junk doesn't mean it doesn't have it where it counts. Every ship is good for something. Sometimes that something is blowing up a Death Star, and sometimes it's blowing up a power generator. What we're trying to say is that they are good at blowing things up.
Own the battle for the Death Star with this Official Star Wars Tie Fighter Vs. X-Wing Christmas Ugly Sweater. It doesn't matter whether you're fighting in the skies over Yavin, Hoth or even Coruscant, with this knitted Christmas Ugly Sweater you can show your ardour for the Alliance or your enthusiasm for the Empire with style.
This backpack is Rebel Fighter theme and It features two large zippered compartments, two side mesh pockets, 2 small front zippered pockets, and 2 small front button pockets. Inside the main compartment it has a padded laptop compartment with a velcro closure.
Hopefully you can put on these boxers as quickly as the Millennium Falcon can make the Kessel Run. Speed is of the essence in the morning. Especially when you hit the snooze button about five times. Put on a fresh pair as you pay homage to a ship that has it where it counts. By association, these boxer briefs also have it where it counts. We're pretty sure that's how it works, right?
Choose between The Empire or The Rebellion with these Star Wars themed hats. Both caps are black and feature their iconic logos front and center. Hook and loop patch on the back and be adjusted for Sith or Jedi comfort.


text:
Infosys BPO Wins 7 Awards at the World HRD Congress 2012
Bangalore – March 14, 2012
Infosys BPO Ltd., today announced that it has won 7 Awards at the World HRD Congress 2012, held in Mumbai. The three day congress was attended by senior HR leaders from across key industries and prominent sectors. The World HRD Congress Awards aim to celebrate leading organizations' impactful HR practices that have achieved overall effectiveness in their HR functions.
The awards won by Infosys BPO included the Global HR Excellence Award, Fun at Work Award, RASBIC Award which recognizes exemplary practices in innovative acquisition of talent, Employer Branding Award for innovation in retention strategy, Employer Branding Award for innovation in career management, STAR News Talent Leadership & HR Award for best overall talent management organization of the year and Top 10 Best Employers of the Year Award.
The World HRD Congress recognizes the efforts of organizations which have demonstrated excellence through their innovative programs, showing clear and measurable business results to drive organizational excellence.
Speaking about the awards, Raghavendra K., VP and Head, Human Resources Development, Infosys BPO, said, "Winning seven awards in a prestigious forum like the World HRD Congress 2012, is a true testimony to the talent centric and industry leading HR practices implemented by Infosys BPO. We will continue to strive towards introducing new and relevant HR practices in the company and retaining our position as an employer of choice in the ITeS industry."
Infosys BPO Ltd. ( www.infosysbpo.com), the Business Process Outsourcing subsidiary of Infosys Limited, was set up in April 2002. Infosys BPO focuses on integrated end-to-end outsourcing and delivers transformational benefits to its clients through reduced costs, ongoing productivity improvements, and process reengineering. Infosys BPO operates in India, the Czech Republic, Poland, Mexico, Brazil, USA, China, the Philippines and Australia, and as on December 31, 2011, employed 20,251 people. It closed FY 2010-11 with revenues of $426.8 million.
Many of the world's most successful organizations rely on the 145,000 people of Infosys to deliver measurable business value. Infosys provides business consulting, technology, engineering and outsourcing services to help clients in over 30 countries build tomorrow's enterprise. For more information about Infosys (NASDAQ: INFY), visit www.infosys.com
Certain statements in this release concerning our future growth prospects are forward-looking statements, which involve a number of risks and uncertainties that could cause actual results to differ materially from those in such forward-looking statements. The risks and uncertainties relating to these statements include, but are not limited to, risks and uncertainties regarding fluctuations in earnings, fluctuations in foreign exchange rates, our ability to manage growth, intense competition in IT services including those factors which may affect our cost advantage, wage increases in India, our ability to attract and retain highly skilled professionals, time and cost overruns on fixed-price, fixed-time frame contracts, client concentration, restrictions on immigration, industry segment concentration, our ability to manage our international operations, reduced demand for technology in our key focus areas, disruptions in telecommunication networks or system failures, our ability to successfully complete and integrate potential acquisitions, liability for damages on our service contracts, the success of the companies in which Infosys has made strategic investments, withdrawal or expiration of governmental fiscal incentives, political instability and regional conflicts, legal restrictions on raising capital or acquiring companies outside India, and unauthorized use of our intellectual property and general economic conditions affecting our industry. Additional risks that could affect our future operating results are more fully described in our United States Securities and Exchange Commission filings including our Annual Report on Form 20-F for the fiscal year ended March 31, 2011 and on Form 6-K for the quarters ended June 30, 2011, September 30, 2011 and December 31, 2011.These filings are available at www.sec.gov. Infosys may, from time to time, make additional written and oral forward-looking statements, including statements contained in the company's filings with the Securities and Exchange Commission and our reports to shareholders. The company does not undertake to update any forward-looking statements that may be made from time to time by or on behalf of the company.
Lakshmi Naidu

redpajama_set_name: RedPajamaCommonCrawl


Editing the SiteWhere global configuration and tenant configurations currently requires manipulating the Spring-based XML files by hand. User experience would be much improved if the configuration could be managed via a visual (form-based + possibly drag-and-drop) interface available in the administrative application. This would also make it easier to configure instances remotely since accessing the file system would not be required.


This mold blown pitcher is another example of the precision of Ennion's glass formulas, processes and techniques.
The piece was produced in the early 1st Century AD and in spite of being 2000 years old, it has all the characteristics of a modern design.
The detail and symmetry of the lines Ennion carved into his master molds produced finished pieces that were centuries ahead of their time.
An Ennion signed cup found at Corinth in Greece in a sealed deposit together with a coin of AD 37-41 has provided a firm date for the early range of his career.
Ennion's signature is clearly visible in relief just beneath the handle in this image.


Though arguably one of the more famous 3D printed objects, the 3DBenchy 'jolly torture-test' boat used to test the capabilities of a 3D printer is not particulary seaworthy. 3D printing for actual maritime purposes is still a relatively unexplored territory for many additive manufacturers. That's not to say that the shipbuilding industry hasn't been listening.
Earlier this week the National Institute for Shipping and Shipbuilding (NISS) in the Netherlands set out their blueprint for construction in the maritime sector for the next 30+ years, expecting 3D printing to turn shipbuilding on its head.
The combination 3D printing, digitalization and robotization is developing very fast. Other sectors are moving ahead quite fast already, so I expect some trendsetters to stand up in the maritime sector soon too. These trendsetters will completely renew the maritime sector. Real innovators, maritime game changers.
The first digital ship builders will conquer the maritime world quicker than people think. They will leverage digitalization, robotization and 3D printing successfully.
Aerospace is, of course, a leader in the adoption and industrialization of additive manufacturing. Both GE in the U.S. and the French aerospace manufacturer Airbus are well known examples. Airbus have an ongoing partnership with Stratasys and standardized the ULTEM™ 9085 3D printing material for use in its A350 XWB aircraft mid-October 2016. Additionally, Oak Ridge National Laboratory (ORNL) earned the Guinness World Record for largest 3D printed part with a trim-and-drill tool for Boeing airplanes. That record was then superseded by SHoP architects' 3D printed pavilion Flotsam and Jetsam this year.
3D printing is also making inroads into car manufacturing, with Divergent3D printing the Blade supercar in 2015 and subsequently entering into partnership with PSA Groupe who manufacture Peugeot and Citroën cars in September of this year. Larger automakers have used 3D printing as a rapid prototyping tool for many years.
Since we can print houses, cars and airplane parts, does the technology make sense in the ship building world? While large format metal 3D printing systems do exist these are typically for high value components, for example Sciaky or Norsk Titanium working with aerospace manufacturers. Making the vast hull of a ship is a project we have not seen.
However, at a smaller level and as innovation starts to take hold of maritime manufacturing, it may be worth looking to HanseYachts who developed a 20-meter-long 3D printer and successfully 3D printed the hull of a yacht earlier in 2016.
With maritime industry experts looking at the 3D printing market to see where value can be added more news is expected.


text:
Q: Socket.io emit an event with data will disconnect the client with "parse error" I built a Socket.io server which handle connection and event :
import { createServer } from "http";
import { Server } from "socket.io";

const httpServer = createServer();
const io = new Server(httpServer);

io.on("connection", (socket) => {
    console.log('New connection');

    socket.on('join', data => {
        console.log(data);
    });
   ...
});

I'm trying to built a Socker.io client using npm module socket.io-client
import { io } from 'socket.io-client';
const socket = io(servHost);

socket.on('connect', () => {
    console.log(`Connected : ${socket.id}`);

    socket.emit('join', "Some data");
    socket.emit('otherEvent');

  });

 socket.on('disconnect', (err) => {
    console.log(err);
    console.log("Disconnected");
});

Server log :
New connection
New connection
...

Client log :
Connected : IyR4Gr0Gvao16UD6AAAD
parse error
Disconnected
Connected : m8aSe6HI67i6VIBNAAAF
parse error
Disconnected
...

Note : If I comment socket.emit('join', "Some data"); everything works fine, even the otherEvent is emited and client can handle the expected event in return (not shown on the code). So I guess the error comes from the data inside join event.
some data can be string / array or object (I tried everything) I have the same error.
I'm using :
"socket.io": "^4.5.2",
"socket.io-client": "^4.5.2"

A: Looks like .emit() expects object as 2nd argument.
I had exactly the same issue, fixed by passing an object:
socket.emit('join', {text: "Some data"});

redpajama_set_name: RedPajamaStackExchange


Stephen Dudley collapsed after being punched. He later died and a Coroner has made a number of findings in his report released Thursday.
A West Auckland high school has been cleared of blame in a student's death, as the Coroner releases his official findings.
The report will likely bring little closure for the parents of Stephen Eruwera Dudley, after they slammed the school for having a "culture of violence".
They are now calling for police to reopen an investigation into the death of their 15-year-old son and charge his two attackers with manslaughter, according to lawyer Nikki Pender, who represented the Dudley family at the inquest.
"What the family would like is for a review with a view to laying a manslaughter charge. I think there's a very strong argument," she said.
"You can't argue there's double jeopardy, because neither boy has ever faced trial for manslaughter."
Stephen died on June 6, 2013, following a brawl on school grounds after rugby practice.
Father Brent Dudley said at the Coroner's inquest he was "gutted" by the way the family had been treated, and claimed he and his wife had been kept in the dark by the school and police.
"We lost our son while he was in your care, and I think you guys could have put a bit more bloody effort into it," he said.
However in his report, released on Thursday, Coroner Gordon Matenga acknowledged the school already had a zero-tolerance policy on violence, and rejected any suggestion the school may be to blame.
"The evidence does not support this allegation from Mr Dudley," he wrote.
The Coroner found Stephen died of cardiac arrest and suffered from previously undiagnosed heart conditions.
He said the cause of death "was cardiac arrhythmia due to stress associated with a physical assault in the context of cardiac sarcoid involving the cardiac conduction system".
The Coroner said the school had already introduced additional anti-violence, anti-bullying and personal development programmes, and further recommendations were unnecessary.
"There is no evidence to support the suggestion that further programmes are likely to reduce the chances of further deaths occurring in similar circumstances," he said.
The Coroner did recommend that the school in question develop a programme for Year 9 students to learn how to perform CPR and use an automated external defibrillator (AED) as part of their basic first aid training.
He also recommended that the Ministry of Education develop guidelines for schools around purchasing AEDs, including appropriate training for staff and students.
The Coroner rejected a request that the parents of Stephen's attackers be forced to make a donation to the school, and said he had "no power to make such a recommendation".
Stephen Dudley collapsed and died after brawling with two brothers after rugby practice.
Earlier that afternoon he'd scuffled with a fellow student, and he was called back to fight with him after their coach had left the grounds.
The 17-year-old brother of the other student also began attacking Stephen in what he claimed was defence of his sibling.
"I was worried about my brother because he doesn't know how to fight and I was scared he would get hurt," he said at the inquest. "I wanted to defend my little brother."
The elder teen punched Stephen in the neck, after which he fell to the ground.
"I have never thrown a punch in anger before and didn't realise how hard I hit Stephen," he said.
"I thought I had knocked him out and I got scared."
Another student recalled how Stephen had "froth coming out of his mouth" and "veins bulging out on his neck".
An ambulance was eventually called, and students began performing CPR under direction of the emergency operator.
The Coroner heard there was delay of seven minutes and 30 seconds before CPR was commenced, which likely reduced the chances of survival.
Stephen was resuscitated several times, but was ultimately declared dead after arrival at Auckland Hospital.
Stephen's cause of death was officially listed as cardiac arrhythmia - an irregular heartbeat which occurs when electrical impulses in the heart aren't working properly.
"Stress associated with physical assault" was identified as a contributing factor in his death.
However an autopsy identified that Stephen also had "underlying vulnerability" due to lesions and inflammation around his heart.
Several medical professionals disagreed over the extent to which the physical altercation could be blamed for his death.
Police initially charged his two attackers with manslaughter, but withdrew the charges after receiving medical opinions.
The two brothers later pleaded guilty to assault and were both discharged without conviction.
The name of the West Auckland high school Dudley attended is suppressed, and on Thursday its principal was unable to answer questions because he was overseas.
A communications adviser issued a statement in which the school acknowledged the Coroner's recommendations and said it had already sought to implement them.
"The...school again extends its sincere sympathy to the Dudley family," the statement said.
"In relation to the Coroner's findings, the principal is grateful that the school's strict policy of zero tolerance for violence at the school has been acknowledged.
"The school plans to implement the Coroner's suggestion that it add CPR and the use of AED (automated external defibrillator) training to its existing Year 9 first aid course."
Stephen Dudley's parents, Mona and Brent Dudley, declined to comment directly.


text:
Family worries SDUSD layoffs will hurt son's development
Family worries SDUSD layoffs will hurt son
By: Grecia Aguilar
SAN DIEGO (KGTV) - A parent is refusing to be silent about the pink slip his son's teacher received.
That layoff is among the hundreds happening within the San Diego Unified School District.
Six-year-old Elias Corado loves his fruit snacks. Selecting what he wants is something he learned at school. His dad, Margarito, said he's thankful for the work of his son's teacher.
"For us it's been significant. It's something we didn't see before," he said.
Elias has tuberous sclerosis. He gets tumors throughout his body and oftentimes he has seizures. Elias attends a special needs class at Rowan Elementary. There, his teacher sets high standards for her kids.
"We appreciated that she was putting all that effort into the kids, that she was trying to teach them stuff that people may not think those kids can achieve," said Corado.
Recently, SDUSD announced budget cuts. A couple of weeks ago, Corado found out Elias' teacher had received one of nearly 1,000 pink slips.
"We were caught by surprise and to be honest I was really upset," he said.
Corado worries a change in routine could have a negative impact on his son.
"It'll be real difficult for him to even do well in school and at home."
Now, he is asking the District to reconsider their decision.
"It's definitely upsetting that they're doing all these decisions without consideration of the kids," he said.
In a statement, district representatives tell 10news:
"The deadline for teachers eligible to accept the district's early retirement package is on April 21st. After that, the district will have a better idea as to how many pink slips can be rescinded. It will be sometime after in May when teachers know whether their employment with SDUSD will continue. If not, they will be employed through the end of the school year (June 30)."
They also said there is a formula they have, relying heavily on seniority. There are also other variables that factor into which teacher gets laid off.


Learning in a well-known game studio is a dream I always wanted in life. Therefore I started to enroll related course in brush up my 3d modeling and drawing skills .I understanding that an industry require these solid fundamental skills and these are the reasons I enrolled.
Spending a year in college realized that learning course is not good enough to support me so I desired to skip my course and apply a position in a Brand-new game company called Ares game limited because it allows me to update me knowledge and learn from an expert.


Welcome to the website of Treadstone Resource Partners Pty Ltd ACN 161 140 183 (Treadstone Resource Partners, we, our). By accessing this website, you acknowledge and agree that you have read, understand and accept without modification the terms, conditions and notices set out below (Terms).
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This Website is intended only as source of general information about us. No part of the Website or any of the content or material available through the Website (Website Content) constitutes financial advice and you acknowledge and agree that Treadstone Resource Partners has not provided you with any financial advice. You must not rely on any of the Website Content (including any updates or newsletters) as financial advice.
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This is a huge steep North face that exits through a choice of gullies. The skier's right exit contains cliffs so you may want to take the skier's left exit. Be careful on the approach as you come up the ridge above the cornice. You don't want to break that off. There may also be a cornice at the drop-in point. This is definitely not a winter line. Save it for a safe, solid snowpack. You can get a good look at your line from down below in Mayflower Gulch.


text:
Stacy T. Sims
SPRINZ, Auckland University of Technology, New Zealand
Claire Badenhorst
College of Health, Massey University, New Zealand
Dane Baker
University of Otago, New Zealand
José Miguel Martínez Sanz
University of Alicante, Spain
Open supplemental data
Front. Sports Act. Living, 03 May 2022
Sec. Sport and Exercise Nutrition
Volume 4 - 2022 | https://doi.org/10.3389/fspor.2022.869594
Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes
Ida Lysdahl Fahrenholtz1*, Anna Katarina Melin2, Paulina Wasserfurth3, Andreas Stenling1,4, Danielle Logue5, Ina Garthe6, Karsten Koehler3, Maria Gräfnings7, Mia Beck Lichtenstein8, Sharon Madigan5 and Monica Klungland Torstveit1
1Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
2Department of Sport Science, Linnaeus University, Kalmar, Växjö, Sweden
3Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
4Department of Psychology, Umeå University, Umeå, Sweden
5Sport Ireland Institute, National Sports Campus, Dublin, Ireland
6The Norwegian Olympic and Paralympic Committee and Confederation of Sport, Oslo, Norway
7Department of Medical Science, Dalarna University, Falun, Sweden
8Centre for Telepsychiatry, Mental Health Services in the Region of Southern Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18–35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of RED-S among female endurance athletes.
The syndrome Relative Energy Deficiency in Sport (RED-S) describes impairments of multiple physiological functions including energy metabolism, reproductive function, bone health, immune function, protein synthesis, and cardiovascular health (Mountjoy et al., 2014, 2018). The etiology behind this syndrome is low energy availability (LEA), which can occur with or without disordered eating behavior or eating disorders (Mountjoy et al., 2014, 2018). Psychological factors can therefore precede RED-S, but LEA may also result in significant psychological distress (Mountjoy et al., 2014; Ackerman et al., 2019; Langbein et al., 2021; Rogers et al., 2021). LEA seems to affect both males and females, elite athletes and recreational exercisers (Torstveit and Sundgot-Borgen, 2005; Mountjoy et al., 2014, 2018), able-bodied athletes and para-athletes (Brook et al., 2019) and across all age groups (Sharps et al., 2021).
Although any athlete can suffer from RED-S, athletes participating in weight-sensitive sports (i.e., endurance sports, combat sports, and aesthetic sports) seem to be particularly at risk. Endurance athletes also have high exercise energy expenditure (Sjödin et al., 1994) as an additional risk factor for LEA (Burke et al., 2018). Furthermore, some studies report gender differences in the sensitivity of LEA as well as the endocrine and metabolic responses, indicating a vulnerability of LEA related to females compared to males (Koehler et al., 2016). Therefore, female endurance athletes seem to be a high-risk group for RED-S.
In female endurance athletes, the reported prevalence of LEA ranges between 8 and 56% when defined as energy availability <30 kcal/kg fat-free mass/day assessed with food and training records (Monyeki et al., 2014; Melin et al., 2015; Day et al., 2016; Muia et al., 2016; Heikura et al., 2017; Mccormack et al., 2019; Beermann et al., 2020). It has been suggested that assessing self-reported physiological symptoms of LEA using questionnaires, such as the Low Energy Availability in Females Questionnaire (LEAF-Q), provides a better assessment of the overall health status of an athlete than a snapshot of current energy availability using error-prone assessments of dietary energy intake and exercise energy expenditure (Heikura et al., 2017; Burke et al., 2018; Sim and Burns, 2021). When assessed as a LEAF-Q score ≥ 8, the LEA risk rate ranges from 31 to 80% in female endurance athletes (Melin et al., 2014; Folscher et al., 2015; Heikura et al., 2017; Carr et al., 2019; Ihalainen et al., 2021; Jesus et al., 2021).
Sustained research on factors associated with LEA is important for practitioners and other health professionals for early detection and aid in the nutrition interventions to prevent potential decrements in health and performance (Melin et al., 2019; Ackerman et al., 2020). The association between disordered eating behavior and health consequences as a result of LEA in female athletes is well-researched and suggest that particular athletes from weight-sensitive sports, including endurance sports, may be at higher risk (Gibbs et al., 2013). While the prevalence of disordered eating behavior, which may lead to LEA, is reported to be higher among athletes competing in weight-sensitive sports compared with controls (Torstveit et al., 2008; Wasserfurth et al., 2020), LEA without disordered eating behavior is also common among female endurance athletes (Melin et al., 2016).
Another potential reason for LEA might be the exclusion or avoidance of different foods due to food allergies or intolerances. Although self-reported incidences of food intolerances and adherence to special diets are commonly reported in athletes (Lis et al., 2015, 2019; Logue et al., 2019), associations with LEA and RED-S among female endurance athletes have not been examined yet.
High levels of exercise energy expenditure without a corresponding increase in energy intake can result in LEA (Burke et al., 2018). It has been proposed that athletes with propensity to exercise addiction, characterized as excessive exercise behavior with potential negative consequences such as injuries and mental health problems (Griffiths et al., 2005; Lichtenstein et al., 2017), could increase the vulnerability for RED-S (Turton et al., 2017). We have previously reported an association between symptoms of exercise addiction and markers of RED-S in male endurance athletes (Torstveit et al., 2019). However, research investigating the association between exercise addiction and symptoms of RED-S among female endurance athletes is scarce with only one study investigating this association in a group representing 63% female endurance athletes (Kuikman et al., 2021). This study reported an exacerbated risk of LEA when disordered eating is accompanied with exercise addiction compared to disordered eating in isolation (Kuikman et al., 2021).
Therefore, the aim of the present cross-sectional study was to identify the risk of LEA and associated risk factors in a multi-country cohort of competitive female endurance athletes. Specifically, we aimed to compare disordered eating behavior, exercise addiction, and food intolerances in athletes at risk of LEA vs. low risk of LEA. Finally, we aimed to assess explanatory variables for the risk of LEA in this cohort. We hypothesized that athletes with risk of LEA would report more disordered eating behavior, exercise addiction, and food intolerances, have lower BMI and higher training volume compared to athletes with low risk of LEA.
The present analysis is based on cross-sectional data collected during the screening and inclusion phase of an international multicenter intervention study aiming to induce health behavior change and improve nutritional status in female endurance athletes with symptoms of RED-S.
Recruitment and data collection took place during the COVID-19 pandemic. Participants were recruited via Norwegian, Swedish, Irish, and German endurance competitive clubs, the Norwegian Olympic Sport Centre, Sport Ireland Institute, Swedish Olympic Committee, German Ski Federation, German Olympic Sport Confederation, and social media with a link to the project website and an online survey. Participants had to be 18–35 years of age, competitive female endurance athletes from cycling, long-distance running, orienteering, triathlon, biathlon, or cross-country skiing, training ≥5 times a week. The study was approved by the regional ethics committee in Norway (31640), Sweden (2019-04809), and Norwegian Centre for Research Data (968634). Because data collection occurred remotely and included no medical procedures, the study was considered exempt from additional approval at the other study sites. Regardless, the study was conducted in full accordance with the Declaration of Helsinki at all sites. All data were stored and analyzed in Services for Sensitive Data (University of Oslo, 2022).
All participants provided written consent to their participation before they were given access to the survey. The survey questions concerned the participants' background information, including current and past sports participation, level of competition, best competition results, education attainment, occupation, training volume, age, height, body weight, menstrual dysfunction diagnosis, and food intolerances. This was followed by the validated instruments LEAF-Q (Melin et al., 2014), Exercise Addiction Inventory (EAI) (Terry et al., 2004), Eating Disorder Evaluation Questionnaire (EDE-Q) (Fairburn and Beglin, 1994), two self-constructed questions regarding history of eating disorders, and concluded with a comment section.
Low Energy Availability in Females Questionnaire
By assessing injury frequency, the past year, current gastrointestinal function, and current and past reproductive function the LEAF-Q was used to consider LEA related symptoms. The LEAF-Q has been validated in female endurance athletes with Cronbach's Alpha = 0.61–0.79 (Melin et al., 2014). A total score ≥8 was used to classify athletes at risk of LEA (Melin et al., 2014). Minor clarifications from the original LEAF-Q were added to question A2:1 ["Specify how old you were when you started taking oral contraceptives and for how long? (Months or years in total)"], C6 [added answer option: "0-4 weeks" (scoring 0 points), to the answer option "I am pregnant…," "…/I am breastfeeding…" was added] and D ["…/breastfeeding" following pregnancy]. These additions do not affect the scoring key and were approved by the first author (AKM) of the development and validation of the LEAF-Q.
Eating Disorder Evaluation Questionnaire
The EDE-Q 6.0 was used to measure behavioral and cognitive symptoms of eating disorders the past 28 days (Fairburn and Beglin, 1994). The EDE-Q is based on the Eating Disorder Examination Interview which is considered as the gold standard in eating disorder assessment (Guest, 2000) and is one of the most used instruments to screen for eating disorder symptoms and risk of LEA/RED-S (Sim and Burns, 2021). It consists of 28 items which were divided into four subscales (restraint, eating concern, shape concern, and weight concern) and a global score averaging the subscales, used as cut-off for eating disorder pathology. A global EDE-Q score ≥ 2.5 was used to classify athletes with disordered eating behavior (Rø et al., 2015; Kuikman et al., 2021). The EDE-Q has been validated in an athletic population with Cronbach's Alpha coefficients ranging from 0.81 to 0.91 in the subscales (Lichtenstein et al., 2021a).
Self-Constructed Questions About Eating Disorders
Based on previous studies investigating disordered eating behavior in female athletes (Sundgot-Borgen and Torstveit, 2004), the EDE-Q was followed by two self-constructed questions regarding eating disorder history: "Have you ever been diagnosed with an eating disorder?" If the participants answered "yes," the following question was "What eating disorder(s) have you been diagnosed with?" with the answer options "Anorexia Nervosa," Bulimia Nervosa" "Binge Eating Disorder," or "Eating Disorder Not Otherwise Specified/Other Specified Feeding or Eating Disorders (e.g., atypical Anorexia or Bulimia Nervosa)" (multiple answers allowed). If the participants' answered "no" to the first question, the following question was "Do you think you have had an eating disorder even though you have not been diagnosed?" with the following answer option: "yes," "no," or "I do not know."
Exercise Addiction Inventory
The EAI was used to assess the risk of exercise addiction (Terry et al., 2004), since this tool is suggested to be more appropriate to screen the risk of exercise addiction in specific populations of exercisers compared to the other frequently used screening instrument, i.e., the Exercise Dependence Scale (Di Lodovico et al., 2019). It consists of six general components describing the degree of addiction rated on a five-point Likert scale: salience (exercise is the most important thing in life) conflicts (e.g., interpersonal conflicts due to the exercise behavior), mood modification (a coping strategy to regulate emotions), tolerance (increasing amounts of exercise is needed to achieve effect), withdrawal symptoms (e.g., irritability when a exercise session is missed), relapse (reversions to earlier patterns). Risk of addiction was defined as an EAI score ≥24 (Griffiths et al., 2005). The EAI was originally validated in recreational exercisers and has later been validated in elite athletes with a Cronbach's Alpha = 0.72 (Lichtenstein et al., 2021b). Athletes were classified with primary exercise addiction (EAI score ≥24 and EDE-Q global score <2.5) and secondary exercise addiction (EAI score ≥24 and EDE-Q global score ≥2.5).
Menstrual Dysfunction Diagnosis
Participants were asked: "Do you have any diagnosis related to menstruation? [For example, polycystic ovary syndrome (PCO/PCOS)]? With the possibility to answer "yes" or "no."
Food Intolerances
To measure food intolerances or allergies, participants were asked: "Do you have any food intolerance or allergy?." If the participants answered "yes" they were asked to answer the following question: "Please specify your food intolerance(s)/allergy." To ease the readability in the paper reported food intolerances and/or allergies are here collectively termed food intolerances.
The online survey was pilot tested in a group of ten females who were current or former endurance athletes and subsequently adjusted where needed (minor clarifications). The survey took ~15 mins to complete. A total of 208 athletes answered the survey. After exclusion based on non-endurance sport (badminton, n = 1), age (n = 2 <18 years, n = 1 > 35 years), and sex (n = 2), a total of 202 responses were eligible for analysis.
Body mass index (BMI) was calculated as weight (kg) divided by height squared (m2). Low BMI was defined as BMI <18.5 kg/m2 as recommended when screening athletes for risk of LEA (Joy and Nattiv, 2017).
Statistical analysis was undertaken using STATA software version 16.0 (StataCorp, College Station, TX 77845, USA) with a two-tailed significance level of <0.05. Histograms were used to verify normality of distribution of continuous variables. Data are presented as mean ± standard deviation (SD) for normally distributed data and as median and interquartile range (IQ 25 and IQ 75 percentiles) for non-normally distributed values. For normally distributed data, comparisons between two independent groups were made using unpaired Student's t-test. To test for equality of variances, Levene's Test was applied. For non-normally distributed data, the Wilcoxon rank-sum test was used to compare two independent groups. The chi-square test for independence was used to test for differences between categorical outcomes between two independent groups. Pearson's correlation coefficient was calculated to explore associations between continuous variables for normal distributed data, while Spearman's correlation coefficient was calculated for non-normally distributed data. Finally, logistic regression models using Firth's bias reduction method (Firth, 1993; Heinze and Schemper, 2002) was used to explore possible risk factors of LEA defined as a LEAF-Q score ≥ or <8 as the dependent variable. Odds ratios and confidence intervals were used to examine associations in the logistic regression model. The Wald χ2 test and its accompanying P-value were used to examine model fit.
Subject Characteristics and Risk of Low Energy Availability
Subject characteristics are presented in Table 1. Endurance athletes from Norway (n = 57), Sweden (n = 83), Ireland (n = 17), and Germany (n = 45) were included from the following endurance disciplines: running (n = 54), orienteering (n = 18), triathlon (n = 50), cycling (n = 45), cross country skiing (n = 15), and biathlon (n = 20). In total 65.0% of the participants were categorized as being at risk of LEA (running: 85.2%, orienteering: 77.8%, triathlon: 50.0%, cycling: 57.8%, cross country skiing: 53.8%, biathlon: 65.0%). Athletes at risk of LEA had a lower body weight and BMI compared to athletes with low risk of LEA (Table 1). There were no differences in age, height, training volume, level of competition or education comparing athletes with risk of LEA and low risk of LEA. Nor was there a difference in the risk rate of LEA between the countries (Norway: 73.7%, Sweden: 67.5%, Ireland: 64.7%, Germany: 51.1%, P = 0.114).
Table 1. Description of subjects characterized by energy availability status.
All correlations with LEA and potential risk factors for LEA are offered in Supplementary Table S1.
Twenty-five percent of the participants reported menarche at 15 years of age or older and two had never menstruated (current age 19 and 25 years). Twenty-nine percent (n = 58) reported using hormonal contraceptives of which 9.1% reported using hormonal contraceptives to avoid amenorrhea. After excluding all hormonal contraceptive users, 62% were at risk of LEA. Among non-hormonal contraceptive users, 25.7% reported not having normal menstruation, while 11.8%% answered that they did not know whether their menstruation was normal or not. Of the 62.5% who reported normal menstruation among non-hormonal contraceptive users, 18.7% reported irregular periods. Thirty-three percent of the non-hormonal contraceptive users reported menstruation stoppage when exercise intensity, frequency, or duration increased. There was no difference in LEAF-Q score when comparing hormonal contraceptive users with non-users (10.2 ± 5.2 vs. 9.4 ± 4.9, P = 0.309), and therefore hormonal contraceptive users were included in the same manor when categorization of being at risk of LEA vs. low risk. Among all participants, two reported having a diagnosed menstrual dysfunction (polycystic ovary syndrome and unspecified secondary amenorrhea).
Disordered Eating Behavior
As presented in Table 2, a total of 43 athletes (21.3%) had disordered eating behavior with a higher frequency among those at risk of LEA compared with those with low LEA risk (26.5 vs. 11.4%, P = 0.013). Athletes with disordered eating behavior had higher LEAF-Q total score compared to athletes without disordered eating behavior (12.6 ± 5.8 vs. 8.9 ± 4.4, P < 0.001), due to a higher gastrointestinal function score (4.0 ± 2.4 vs. 1.9 ± 1.3, P < 0.001). There was a positive correlation between EDE-Q score and BMI (r = 0.22, P = 0.002) and LEAF-Q score (r = 0.37, P < 0.001). All EDE-Q subscales correlated with total LEAF-Q score (restraint: r = 0.287, P < 0.001, eating concern: r = 0.297, P < 0.001, shape concern: r = 0.280, P < 0.001, weight concern: r = 0.284, P < 0.001).
Table 2. Symptoms of disordered eating behavior characterized by energy availability status.
Of the 43 athletes with disordered eating behavior, 41.9% of participants reported a previous eating disorder diagnosis (Anorexia Nervosa: 20.9%, Bulimia Nervosa: 16.3%, Binge Eating Disorder: 4.7%, and Other EDs: 14.0%). Among the 159 athletes with low EDE-Q score, 12.0% responded they had been diagnosed with an eating disorder in the past (Anorexia Nervosa: 5.7%, Bulimia Nervosa: 2.5%, Binge Eating Disorder: 0.6%, and Other EDs: 5.7%).
Risk of Exercise Addiction
Athletes at risk of LEA had higher EAI score compared to athletes with low risk (Table 3). In total, 23.3% of the athletes were at risk of exercise addiction with a higher LEAF-Q total score compared to athletes with low risk of exercise addiction (12.1 ± 5.6 vs. 8.9 ± 4.5, P < 0.001), due to a higher injury (3.1 ± 2.2 vs. 2.2 ± 2.2, P = 0.013) and gastrointestinal function score (3.5 ± 2.3 vs. 2.1 ± 1.8, P < 0.001). Among athletes with disordered eating behavior, 60.5% (n = 26) were at risk of exercise addiction compared to 13.2% (n = 21) among athletes without disordered eating behavior (P < 0.001). That is, 10.4% (n = 21) were classified with primary exercise addiction, 12.9% (n = 26) with secondary exercise addiction, and 8.4% (n = 17) had disordered without exercise addiction. The higher EAI score in athletes with risk of LEA compared to athletes with low risk remained however after excluding athletes with disordered eating behavior (20.6 ± 3.0 vs. 19.4 ± 3.1, P = 0.017). After the exclusion of athletes with disordered eating behavior, 71.4% with risk of exercise addiction were also at risk of LEA compared to 59.4% without risk of exercise addiction (P = 0.293).
Table 3. Symptoms of exercise addiction characterized by energy availability status.
Total EAI score was positively correlated with the EDE-Q global score (r = 0.47, P < 0.001). Further, the EAI score was positively correlated with the LEAF-Q score (r = 0.32, P < 0.001), even after excluding athletes with disordered eating behavior (r = 0.21, P = 0.007). There was no association between training volume and EAI score.
Distribution of scores on the EAI is offered in Supplementary Table S2.
Food-Intolerances
In total, 14.4% of the athletes responded having one or more food intolerances, with gluten and lactose intolerance being the most common, and a higher total LEAF-Q score compared to athletes not reporting food intolerances (11.3 ± 4.9 vs. 9.4 ± 4.9, P = 0.048) due to a higher gastrointestinal function score (3.8 ± 1.9 vs. 2.1 ± 1.9, P < 0.001). There was no difference in the prevalence of food intolerance between athletes at risk of LEA compared to those with low risk (16.7% vs. 10.0%, P = 0.198). Food intolerances were more frequent among athletes with disordered eating behavior compared to athletes without disordered eating behavior (27.9% vs. 10.7%, P = 0.004), and among athletes at risk of exercise addiction compared to athletes with low risk of exercise addiction (29.8 vs. 9.7%, P = 0.001). Food intolerances were, however, not more frequent among athletes with exercise addiction compared to athletes with low risk of exercise addiction after excluding athletes with disordered eating behavior (19.0 vs. 9.4%, P = 0.183). Among the 29 athletes who reported food intolerances, 38.0% (n = 11) had simultaneously both disordered eating behavior and were at risk of exercise addiction.
Explanatory Variables for the Risk of LEA
Results from the logistic regression analysis are presented in Table 4. The statistically significant Wald χ2 test indicated a better model fit when including the predictors in the model. The logistic regression analysis showed that lower BMI (OR = 0.69, P < 0.001) and higher EDE-Q score (OR = 1.72, P = 0.001) were associated with risk of LEA. None of the other predictors had a statistically significant association with LEA.
Table 4. Risk factors for low energy availability.
The main purpose of the study was to identify the risk of LEA and associated risk factors in this group of athletes, including exercise addiction and food intolerances where research has been lacking. Specifically, we aimed to compare disordered eating behavior, exercise addiction, and food intolerances in athletes at risk of LEA and low risk of LEA. A key novel finding of the study was that athletes at risk of LEA were more likely to exhibit symptoms of exercise addiction related to salience, conflicts, and withdrawal symptoms.
By using the LEAF-Q we found that 65.0% of the athletes were at risk of LEA, which is similar to the 62.2% clinically verified LEA in female endurance athletes by Melin et al. (2014). When compared to other studies which used the LEAF-Q in female endurance athletes, Carr et al. (2019), reported a lower number (31.0%) than the present study and Jesus et al. (2021) a higher number (79.5%.) In contrast to the present study, the study by Jesus et al. (2021) recruited only female athletes from cross-county running (n = 83) and when comparing their reported risk rate of LEA, it is similar to the risk rate among runners (85.2%) and orienteers (77.8%) in the present study. Carr et al. (2019) also had a lower number of participants (n = 13) only from cross-country skiing, which may partly explain the lower reported risk rate of LEA. Of note, the current cross-sectional study served as a screening phase for an intervention study aiming to improve dietary habits in athletes at risk of RED-S. Therefore, the recruitment may have attracted athletes who were interested in improving knowledge related to sports nutrition. Conversely, others may have not participated due to fears or anxiety coming from their LEA, disordered eating behavior and/or exercise addiction.
In this study we did not directly assess energy availability, which requires assessments of body composition, energy intake, and exercise energy expenditure. Although it is well-recognized that LEA is the etiological factor underpinning the syndrome of RED-S (Mountjoy et al., 2014), several barriers prohibit the direct measurement of energy availability from being a practical and reliable option (Heikura et al., 2017; Burke et al., 2018; Fahrenholtz et al., 2018; Mountjoy et al., 2018). Questionnaires can therefore be a convenient method for screening, with the LEAF-Q (Melin et al., 2014) and the EDE-Q (Fairburn and Beglin, 1994) being the most widely used and validated questionnaires in the research of RED-S (Sim and Burns, 2021).
We emphasize that although the LEAF-Q is useful for screening purposes it cannot be used as a diagnostic tool and additional individual evaluation is necessary in intervention contexts (Melin et al., 2014; Mountjoy et al., 2018). Despite acceptable sensitivity (78%) and specificity (90%) (Melin et al., 2014), there are risks of either false positive or false negative classifications. For instance, false positive cases may be due to injuries, gastrointestinal problems, and menstrual dysfunctions not related to LEA, including acute injuries, irritable bowel syndrome, or polycystic ovary syndrome, although features of polycystic ovary syndrome have been found to be prevalent in women with functional hypothalamic amenorrhea (Carmina et al., 2018). False negative cases may occur if participants use oral contraceptives, that may mask an underlying menstrual dysfunction. Other forms of hormonal contraceptives may, on the other hand, result in absence of bleeding, which accordingly can falsely be interpreted as a menstrual dysfunction.
Of note, 12.0% answered that they did not know whether they had a normal cycle and 18.7% of those who reported normal menstruation answered that they had irregular periods. This controversy indicates that a relatively high frequency of adult female endurance athletes lacks basic knowledge of female reproduction. In addition, only two athletes reported a diagnosed menstrual dysfunction, despite a high occurrence of amenorrhea and oligomenorrhea, which may relate to a perception that menstrual dysfunction often is accepted as a natural consequence of intense training programs (Beals and Meyer, 2007) or lack of awareness about the consequences of LEA among medical professionals (Curry et al., 2015). This is concerning since the menstrual cycle is an important health marker and calls for educational interventions on menstrual cycle function for female endurance athletes but also awareness among medical professionals.
In the present study, athletes at risk of LEA had lower BMI compared to athletes with a low risk of LEA and lower BMI was identified as a risk factor in the logistic regression analysis. Similar to our findings Christo et al. (2008) reported lower BMI in female endurance athletes with amenorrhea compared to their eumenorrheic counterparts. In contrast, Vanheest et al. (2014) reported higher BMI in amenorrhoeic swimmers compared to eumenorrheic swimmers, while Melin et al. (2014, 2015) found no difference in BMI comparing female endurance athletes at risk of LEA with those with a low risk of LEA. Thus, research seems conflicting when it comes to the relationship between BMI and LEA. In addition, it is important to notice, that the vast majority of athletes at risk of LEA in the current study had a BMI within the normal range, supporting that BMI alone should not be used for screening of RED-S due to potential metabolic compensatory mechanisms as a result of LEA (Mountjoy et al., 2014).
In this study, athletes at risk of LEA had higher EAI scores compared to athletes with low risk of LEA. Our results indicate that female endurance athletes with LEA are more likely to have symptoms of exercise addiction. However, in approximately half of the cases of athletes exceeding the cut-off point, exercise addiction was accompanied with disordered eating behavior. Therefore, both dietary patterns and exercise behavior should be addressed when treatment interventions for athletes with RED-S are developed. Although exercise addiction is often associated with excessive exercise (Lichtenstein et al., 2017) that may result in LEA, we found no association between training volume and EAI score, which is consistent with previous research in athletes (Lichtenstein et al., 2021b). Nor did we find a difference in the EAI item concerning increasing exercise amount when comparing athletes at high vs. low risk of LEA. One explanation for this can be that all participants in the current study had a high training volume and frequency, since this was a part of the inclusion criteria (being a competitive endurance athletes and training at least five times per week). For competitive endurance athletes it is a natural part of their training protocol to increase exercise amount to improve performance. However, we found an association between LEA and the EAI items concerning the importance exercise is attributed in life, conflicts with family and friends, and negative feelings if an exercise session is missed. The findings suggest that these exercise addiction related behaviors are more pronounced in athletes at risk of LEA, and therefore practitioners should pay attention to these personality characteristics when screening for LEA and RED-S.
Injuries are a potential consequence of both exercise addiction (Lichtenstein et al., 2017) and LEA (Mountjoy et al., 2014) and questions related to injuries are a part of the LEAF-Q due to its association to low bone mineral density (Melin et al., 2014). We found a higher injury score in athletes at risk of exercise addiction compared to athletes with low risk of exercise addiction, which may be a part of the explanation for the association between risk of LEA and exercise addiction in this group.
As reviewed by Di Lodovico et al. (2019) endurance sports are characterized with the highest risk of exercise addiction with a weighted average of 14.2% compared to 10.2% in mixed disciplines and 3.0% in the general population, although the reported risk rate spans from 0.5 to 43.0%. The risk rate of 23.3% reported in the present study is therefore considerably higher compared to previous research. The review did not distinguish between male and female responders, although female triathletes have been found to be at higher risk of exercise addiction compared to males (Griffiths et al., 2015). Hence, one potential reason for the differences in the results may be that our studied population is at high risk of disordered eating behavior. Exercise addiction is a frequent comorbid condition in female patients with eating disorders, often termed secondary exercise addiction, and therefore, eating disorder symptoms should be considered separately in the assessment of exercise addiction (Cook and Luke, 2017). Among athletes without disordered eating behavior (n = 159), 13.2% (n = 21) were at risk of exercise addiction, suggesting a risk rate of 10.4% for primary exercise addiction for the total sample. This is higher than the 4% among female athletes reported by Kuikman et al. (2021). Beyond recruiting athletes from different sports with no upper age limit, the study by Kuikman et al. (2021) differs from the present study by using the Exercise Dependence Scale, which generally identifies a lower proportion of individuals at risk of exercise addiction compared to the EAI (Di Lodovico et al., 2019). However, the occurrence of secondary exercise addiction in the present study (13%, n = 26) is similar to the 13% reported by Kuikman et al. (2021).
Since the EAI was originally validated in habitual exercisers, the interpretation of the questions by athletes may differ and researchers have suggested that exercise addiction is not the same phenomenon in competitive athletes as in non-competitive athletes (de la Vega et al., 2016). However, a recent study reported adequate psychometric properties of the EAI in a sample of elite athletes, suggesting that the EAI is useful for assessing symptoms of exercise addiction in competitive athletes (Lichtenstein et al., 2021b).
Disordered eating behavior and eating disorders are a well-known risk factors for LEA (Wasserfurth et al., 2020) supported by the findings in the present study. Nevertheless, the reasons for LEA are manifold (Wasserfurth et al., 2020) and in the present study, only 26.5% of the athletes at risk of LEA had disordered eating behavior, supporting the findings of Melin et al. (2014) where 28.6% of the female endurance athletes with a total LEAF-Q ≥8 had a clinically verified eating disorder or disordered eating behavior. Our results suggests that for the majority of the athletes, LEA is due to unintentional origins such as suppression of appetite post exercise (Larson-Meyer et al., 2012; Howe et al., 2016), low energy-dense diets (Melin et al., 2015), lack of knowledge regarding optimal sports nutrition (Benardot, 2013; Trakman et al., 2016; Heikkilä et al., 2018; Sim and Burns, 2021), lack of knowledge about the consequences of LEA (Folscher et al., 2015; Condo et al., 2019; Tosi et al., 2019; Logue et al., 2020) or a busy lifestyle with frequent traveling where lack of time and access to food become important barriers to adequately fueling (Benardot, 2013; Burke et al., 2018; Logue et al., 2021). Nevertheless, disordered eating behavior was common among this group of female endurance athletes with a risk rate of 21.3% using a EDE-Q global score 2.5 as cut-off compared to 24-25% earlier reported in elite female endurance athletes (Sundgot-Borgen and Torstveit, 2004; Melin et al., 2015) using the gold standard EDE Interview (Fairburn and Beglin, 1994). Collectively, these results suggest a concerning and persistently high prevalence of disordered eating among female endurance athletes.
Another potential origin to LEA could be food intolerances, since the risk of energy deficiency increases when food groups are removed from the diet, if proper replacements are not made (Lis et al., 2019). However, in contrast to our hypothesis, we did not find any differences of the frequency of reported food intolerances when comparing athletes at risk of LEA with athletes at low risk. This may indicate that athletes who report food intolerances are already familiar with finding dietary alternatives to compensate for potential deficiencies. We did, however, find a higher LEAF-Q total score among athletes reporting food intolerances, which was due to a higher gastrointestinal score. Since the study is based on self-reported data, we can only speculate whether the gastrointestinal problems are due to food intolerances or due to the gastrointestinal alterations as a result of LEA, where the symptoms may have been misinterpreted by some athletes.
Food intolerances were, however, more frequently reported by athletes with disordered eating behavior compared to athletes with low EDE-Q score, and also among athletes with risk of exercise addiction compared to athletes with low risk of exercise addiction. While there is evidence to suggest that a diagnosed food allergy increases the likelihood of developing a subsequent eating disorder (Jafri et al., 2021), it is also possible that the fear and anxiety regarding food and eating in a pre-existing eating disorder may lead to self-diagnosis to gain social acceptance for food exclusion. Likewise, the association in the present study between exercise addiction and food intolerances can potentially be explained by increased attention to the body and its reactions in athletes at risk of exercise addiction, since exercise addiction may develop as a way of dealing with difficult emotions and low self-esteem where one tries to get better mentally by finding simple physical explanations (Wågan et al., 2021). Therefore, some athletes, specifically those with secondary exercise addiction, may use food elimination as a part of their coping strategy.
Strength and Limitations
The present study was conducted in female endurance athletes, which is the population in which the LEAF-Q was initially validated. In addition, inclusion of athletes from four different European countries increases the generalizability of the findings. To our knowledge, it is the first study to investigate the association between food intolerances and risk of LEA in female endurance athletes and one of few (Kuikman et al., 2021) to investigate the association between exercise addiction and LEA in female endurance athletes.
Studies based on self-reported data are vulnerable to response bias, denial, and inaccurate reporting, for instance when it comes to anthropometric data. However, evidence suggests that endurance athletes may more accurately self-perceive and/or report their anthropometric characteristics compared to the general population (Nikolaidis and Knechtle, 2020) and a systematic review and meta-analysis concluded that the magnitude of which self-reported data over- or underestimated the real value by women of reproductive age is negligible regarding clinical and research use (Seijo et al., 2018). Concerning the data of food intolerances, previous studies have reported a high adherence to special diets by athletes (Lis et al., 2016, 2019; Logue et al., 2019) despite lack of medical rationale (Lis et al., 2015) and it is a limitation that we did not ask whether participants who reported food intolerances had a medical verification or not. Additionally, although the EDE-Q is frequently used for screening in larger samples, it was originally developed for clinical use. The validity of the EDE-Q in athletes needs to be investigated in future studies.
We acknowledge that analysis of biomarkers of RED-S from blood samples, e.g., cortisol and triiodothyronine (Elliott-Sale et al., 2018) and measurements of bone health and resting metabolic rate (Mountjoy et al., 2018) would have strengthened the validity of the study. Unfortunately, this was not possible due to the COVID-19 pandemic. On the other hand, the self-reported data assessment enabled recruitment of athletes from all over Norway, Sweden, Ireland, and Germany, which often is problematic if participants have to meet in the laboratory.
Finally, the recruitment during the COVID-19 pandemic, may somewhat have affected the athletes' training and eating habits (Roberts et al., 2020; Shaw et al., 2021; Washif et al., 2021). The long period of isolation could potentially result in a more restricted eating behavior and/or excessive training habits for some athletes, but it is also possible that the pandemic for others have resulted in reduced training and/or increased food intake.
This study confirms that female endurance athletes are at high risk of LEA (65%) and disordered eating behavior (21%), and that an association between the two exist. However, athletes with risk of LEA were also more likely to exhibit symptoms of exercise addiction and a high risk of both primary (10.4%) and secondary (13%) exercise addiction was found. In a multivariate analysis, however, symptoms of exercise addiction were not identified as predictor of LEA, nor were food intolerances, whereas lower BMI and symptoms of disordered eating behavior were. More studies are needed to investigate food intolerances and the role of exercise addiction with and without disordered eating behavior and associations with LEA among female endurance athletes.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The study was approved by the Regional Ethics Committee in Norway (31640), Sweden (2019-04809), and Norwegian Centre for Research Data (968634). Because data collection occurred remotely and included no medical procedures, the study was considered exempt from additional approval at the other study sites. Regardless, the study was conducted in full accordance with the Declaration of Helsinki at all sites. All data were stored and analyzed in Services for Sensitive Data. The patients/participants provided their written informed consent to participate in this study.
ILF, AKM, IG, and MKT were responsible for study design and conceptualization. AKM and MG were responsible for the Swedish cohort. ILF, MKT, and IG the Norwegian cohort. DL and SM for the Irish cohort. PW and KK for the German cohort. ILF was responsible for coordination and overall data collection, for data analyzation under the supervision of AS, and for constructing the article where everyone reviewed and gave feedback for improvements. All authors reviewed and approved the final version of the article.
This work was supported by Grants from the University of Agder and the Norwegian Olympic Sports Center.
We would like to thank master student Ingvild Brattekleiv for assisting with the recruitment and data collection.
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fspor.2022.869594/full#supplementary-material
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Keywords: Low Energy Availability in Females Questionnaire, compulsive exercise, endurance training, Relative Energy Deficiency in Sport (RED-S), eating disorder, restrictive eating behavior
Citation: Fahrenholtz IL, Melin AK, Wasserfurth P, Stenling A, Logue D, Garthe I, Koehler K, Gräfnings M, Lichtenstein MB, Madigan S and Torstveit MK (2022) Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes. Front. Sports Act. Living 4:869594. doi: 10.3389/fspor.2022.869594
Received: 04 February 2022; Accepted: 04 April 2022;
Published: 03 May 2022.
Stacy T. Sims, Auckland University of Technology, New Zealand
José Miguel Martínez Sanz, University of Alicante, Spain
Claire Badenhorst, Massey University, New Zealand
Dane Baker, University of Otago, New Zealand
Copyright © 2022 Fahrenholtz, Melin, Wasserfurth, Stenling, Logue, Garthe, Koehler, Gräfnings, Lichtenstein, Madigan and Torstveit. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ida Lysdahl Fahrenholtz, ida.fahrenholtz@uia.no
This article is part of the Research Topic
Women in Sport and Exercise Nutrition: 2021
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Christmas Day Arrest Lands Washington Parish Man in Jail on Numerous Charges
On December 25, 2021, a Washington Parish Sheriff's Office deputy arrested Phillip Fowler, age 52 and a resident of Bateman Drive. Fowler was booked into the parish jail on several charges, including attempted home invasion, battery, criminal trespass, resisting an officer, disturbing the peace and two counts of contempt of court. His bond was set at $7,500.
When the deputy responded to a complaint on Harvey Road, he encountered Fowler who was screaming and waving his arms back and forth while in the front yard of a residence. He advanced towards the deputy and then began to advance towards another male who was nearby, all the time screaming and behaving in a threatening manner. Once Fowler was restrained, the homeowner stated Fowler had attempted to force himself into the residence, at which time she called 911 for assistance. She also called a neighbor who arrived on the scene and attempted to calm Fowler as the deputy arrived and took Fowler into custody.
Fowler has at least six previous arrests in Washington Parish on charges that include two counts of unauthorized entry of an inhabited dwelling, three counts of failure to appear in court, resisting arrest, attempted criminal trespass, resisting a police officer with force or violence, possession of illegal drugs, two counts of contempt of court, and being a fugitive from Minehaha County, South Dakota.
"Uncontrolled anger always ends up hurting the angry person," stated Sheriff Randy Seal. "In this situation, Mr. Fowler's anger earned him a trip to the parish jail while other involved persons were able to sleep in their own homes. His criminal history indicates he has never learned self-control, a weakness that has resulted in numerous arrests and spoiled Christmas day for others.