Low Energy Availability (LEA) - Not Just a Young Athlete Problem

The most missed diagnosis among active mid-life women

As a menopause hormonal specialist who focuses on active and high-performing women, I am amazed (and saddened, quite frankly) by how so many women are being misdiagnosed or worse yet, completely blown off by their providers when they seek care for often debilitating symptoms during mid-life.

A typical situation is a menopausal woman in her mid-fifties sees her provider for symptoms of fatigue, poor mental and physical performance, sleep disturbance, mood changes, and a 10 lb weight gain despite “doing nothing differently”. Her provider may or may not do an evaluation and ultimately tells this woman either “You need hormone therapy” or “You’re just getting older”. She then, understandably, gets frustrated because she’s really suffering and doesn’t feel like pills are the answer. She schedules a visit with me and shares that she is a lifelong recreational runner training for the Boston Marathon - on 1200 calories per day. I ask if she shared this information with her provider and she responds “They never asked”.

Scenarios similar to this are apparent in at least half of the active women whom I see for menopausal care. A major player leading to this problem is that the hormonal changes of menopause result in sometimes dramatic changes in body composition, which elicits the “knee-jerk” reaction to train more and eat less, try fad interventions such as “keto” or “intermittent fasting” - all of which further exacerbate the energy imbalance causing her symptoms. There is also not a lot of guidance on how to adjust nutrition to changing activity levels, activity types, injuries, or evolving health issues in the midlife female population.

What is Low Energy Availability (LEA)?

Simply defined, LEA occurs when there is an inadequate amount of energy available (EA) to support vital bodily functions after supplying physical activity/exercise. For the math geeks in the audience, the equation looks like this:

When LEA is prolonged and or severe (Relative Energy Deficiency in Sport: REDs), this can cause metabolic disturbance, injury, bone fractures, loss of or irregular menstrual cycles, sleep disturbance, brain fog, and poor performance among other long-term health issues.

This year, the International Olympic Committee (IOC) released its Consensus Statement on LEA and Relative Energy Deficiency in Sport (REDs). This statement includes an outstanding review of the latest research done on LEA and REDs as it relates to causes, short and long-term impact on the athlete, and describes a very useful tool (IOC REDs CAT2 three-step protocol) for trainers and providers to assess the degree of risk of LEA / REDs and plan interventions.

Below are two (among many) important points from the IOC 2023 Consensus statement:

1. Inadequate carbohydrate intake is a major contributor to LEA / REDs. The statement cites multiple studies in male and female endurance athletes that show that <3g carbohydrate/kg of body mass was associated with a deleterious impact on bone, immunity, and iron biomarkers and can accelerate the progression of LEA to REDs.

2. Seminal research in sedentary females identified 30 kcal/kg of fat-free body mass/day as a threshold below which perturbations in sex hormones and changes in bone turn-over markers were seen and that >/= 45 kcal/ kg of fat-free body mass is optimal for maintenance and growth.

   It’s important to note that these thresholds were determined in studies of sedentary females, which underscores the even greater caloric needs of active women and competitive/elite athletes.

Symptoms of LEA Look Just Like Symptoms of Perimenopause and Menopause

The overlap between the symptoms of the menopause transition and LEA can be challenging for providers - especially if they don’t ask about the patient’s training and fueling. If they do ask, they may not understand what “adequate” and “inadequate” fueling look like, as this is also a challenge for experts in the fitness industry. For this reason, publications like the IOC Consensus Statement above are critically important for healthcare providers and trainers alike.

Symptoms common to LEA, Perimenopause, and Menopause:

• Brain fog

• Irregular menstrual cycles

• Sleep disturbance

• Mood disturbance and irritability

• Poor mental and physical performance

• Lack of motivation

Impact of LEA on the Perimenopausal and Menopausal Woman

LEA has a unique impact on females as compared to males due to the evolutionary design of female hormone physiology to achieve and support pregnancy. This is evidenced by the need for adequate energy and fat composition for the initiation of puberty (reproductive competence) and the loss of menstrual cycles that often occurs when females are in a persistent state of LEA.

During perimenopause and menopause, female physiology is still “wired” to depend heavily on energy availability. However, as menstrual cycles become irregular and ultimately absent, the reproductive hormonal “buffer” wanes and the impact of LEA weighs more heavily on the stress response (Cortisol) system.

When LEA is persistent, activation of the stress response is persistent, which leads to inflammation, potential for injury, poor recovery, possible thyroid disturbance, and fat retention to preserve energy when energy intake is inadequate. This is why fasting > 12 hours shows no greater benefit than sound nutrition strategies that do not involve prolonged fasting and CAN EVEN BE HARMFUL in the non-obese, active, mid-life female population.

Unfortunately, there is little to no study of LEA and REDs specifically in the perimenopausal and menopausal populations, however, the published guidelines noted above can provide a starting point.

Approach to the Mid-life Female Experiencing Symptoms

• STEP 1 of the approach to symptoms in perimenopausal and menopausal women is to assess their energy balance! If you are a trainer, coach, or healthcare provider, the first thing to address is her training, physical activity, participation in sport, and her nutrition. The most “average appearing” individual could be a competitive athlete, so ask EVERYONE! A week or 2 of training and food logs can be very helpful for gaining an objective perspective of the client’s energy state.

• Carbohydrate management is challenging in midlife women because as hormones change, relative insulin resistance becomes apparent, in part, due to declines in muscle mass and function rendering glucose utilization by skeletal muscle less efficient. As we have learned above, adequate carbohydrate intake is critical to optimal energy balance however, should focus on high-quality carbohydrate sources, minimizing refined sugars, nutrient timing strategies where carbohydrate is available pre-and post-training, and concentrating carbohydrate intake earlier in the day.

• Adequate total energy is critical for energy balance, however, adequate macronutrients are also important. For mid-life women, protein intake needs priority as the changing hormones result in catabolism of muscle and bone, particularly in the first few years of menopause. Ensuring that there are sufficient “building blocks” to rebuild muscle following training or physical activity is essential for recovery.

• Lastly, the importance of effective recovery cannot be overstated. Because females are particularly sensitive to energy balance and stress response system activation, a comprehensive recovery regimen will help prepare the athlete for subsequent training sessions and avoid injury. Greater attention to warm-up and cool-down, tissue care with massage, foam rolling, mobility work, cold plunges, sauna, sleep, sound nutrition, and mindset work should be part of every training program.

My Training and Nutrition are Optimized, but I’m Still Having Symptoms

There is no doubt that optimal training and nutrition do not solve every symptom of menopause, however, it does lay the foundation for vitality, and longevity and for helping therapeutics work more effectively!

For those symptoms such as hot flashes, vaginal dryness, painful sex, urinary symptoms of menopause - and so many more - many hormonal and non-hormonal treatments are safe and effective. However, when the basic foundations of health are not addressed, the therapeutics alone may not provide the same efficacy of symptom relief.

The key to optimal health, vitality, and longevity requires a “team” approach with coordinated input from experienced fitness and nutrition experts and informed healthcare professionals. This model of women’s healthcare is finally emerging and is certain to be the next revolution in women’s health. Stay tuned!