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Table 6

Methods (preferred, used and recommended, and potential) for studying various health and performance outcomes of REDs

Health outcome	Methods and notes
Impaired reproductive function	Preferred Overnight sampling of LH and FSH324 Menstruating females: phase-based hormonal approach using urinary ovulation kits (testing mid-cycle LH surge) and blood sampling287 Postpubertal males: morning total and free testosterone level325 326 Used and recommended Females: self-reported menstrual history, urinary ovulation testing,287 327 LEAF-Q¹⁷¹ Males: self-reported libido/morning erection (eg, LEAM-Q328 or ADAM-Q111 329)
Impaired bone health	Preferred DXA123 330 Using age-appropriate and medically appropriate body-site scanning330 Using age-appropriate, sex-appropriate and activity-appropriate interpretation (eg, Z-score vs T-score) Used and recommended Bone stress injury and fracture history Potential HRpQCT
Impaired gastrointestinal function	Preferred Oesophageal motility: oesophageal manometry, barium swallow GERD: upper endoscopy Gastric motility: electrogastrography331 332 Gastroparesis: gastric emptying study Pancreatitis: ≥2 of: (a) lipase >3× upper limit of normal; (b) imaging findings consistent with pancreatitis; (c) characteristic epigastric pain Intestinal transit: radiopaque marker study,333 orocaecal transit time test334 335 SMA syndrome: upper GI oral contrasted study, MRI or CT336–338 Used and recommended GERD: many questionnaires,339 including GerdQ340 Constipation: Wexner Constipation Score,341 Bristol Stool Scale342 Diarrhoea: Bristol Stool Scale342 Irritable bowel syndrome: Rome IV Criteria343 Elevated transaminases344 345 Defecatory disorders, faecal incontinence346: Faecal Incontinence Questionnaire,8 347 Faecal Incontinence Severity Index (FISI),348 Altomare’s Obstructed Defecation Scale (ODS) score349 Multiple GI symptoms: Rome II questionnaire350 GI symptoms during exercise351 352 LEAF-Q GI subsection score ≥2 indicative of LEA214 353 Athlete-specific GI symptom inventory354 Feeding challenge during exercise334 355 Potential Intestinal transit: wireless motility capsule Gut bacterial profile Faecal or plasma short-chain fatty acid concentration
Impaired energy metabolism/regulation	Preferred Thyroid function tests: TSH, free T4, total and free T3165 Leptin: overnight sampling356 Cortisol: overnight sampling,179 24-hour urinary free cortisol357 Laboratory/expert-controlled measurements/estimates of all compartmentalised energetic intakes and total daily expenditures (exercise, non-exercise activity, basal metabolic rate, thermic effect of food)358 Used and recommended Cortisol: morning serum cortisol, late-night salivary cortisol357 RMR: indirect calorimetry,359 room calorimetry311
Impaired haematological status	Preferred CBC with differential Iron studies (iron, ferritin, transferrin, total iron binding capacity) with age-appropriate, sex-appropriate and laboratory-appropriate cut-offs Carbon monoxide haemoglobin mass measurement360 361 Used and recommended Self-reported history of iron deficiency or anaemia Potential App-based self-assessment362
Urinary incontinence	Preferred Stress urinary incontinence: bladder stress test363 International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI-SF)230 231 3 Incontinence Questionnaire (3IQ)364 Potential Pelvic Floor Dysfunction-ScrEeNing Tool IN fEmale athLetes (PFD-SENTINEL)365
Impaired glucose and lipid metabolism	Preferred Fasting blood glucose (serial measures)366 Fasting insulin366 Lipid panel: HDL, LDL, total cholesterol, triglycerides299 Used and recommended Continuous glucose monitor367
Mental health issues	Preferred Clinical interview with psychiatrist or psychologist, DSM-5-TR368 Used and recommended Depression: PHQ,369 Centre for Epidemiological Studies Depression Scale,370 Beck Depression Inventory371 Generalised anxiety: GAD-7,164 372 DASS-2178 269 373 374 Stress: Perceived Stress Scale375 Brunel Mood Scale376 Profile of Mood States377 378 Eating disorders: EDE-Q,379–381 BEDA-Q,382 Eating Disorder Inventory,383 self-report
Impaired neurocognitive function	Preferred Clinical neuropsychological assessment Used and recommended Multiple domains: CogState assessment battery384 Planning/cognitive flexibility: Wisconsin Card Sorting Test242 Attention: Stroop Colour and Word Test385–387 Decision making: Iowa Gambling Test388 389 Verbal memory: California Verbal Learning Test-II390 Executive function: Delis-Kaplan Executive Function System Color-Word Interference Test,238 BRIEF-A391
Sleep disturbances	Preferred Polysomnography392 Used and recommended 392 Research-grade actigraphy Sleep diaries Numerous questionnaires, including Athlete Sleep Screening Questionnaire (ASSQ),393 Athlete Sleep Behaviour Questionnaire (ASBQ),394 Epworth Sleepiness Scale,395 Pittsburgh Sleep Quality Index,10 396 Insomnia Severity Index164 397 Potential Sport wearables398
Impaired cardiovascular function	Preferred Conduction, rhythm abnormalities: ECG313 Rate abnormalities: cardiac telemetry, Holter monitor Haemodynamics: sphygmomanometery, orthostatic sphygmomanometery (≥20 mm Hg drop in systolic pressure, ≥10 mm Hg drop in diastolic pressure on standing from supine)313 399 Autonomic function: heart rate variability by Holter monitor,400 401 baroreflex sensitivity testing,402 bedside tests (eg, Valsalva, tilt testing) Structural abnormalities: transthoracic echocardiogram313 Endothelial dysfunction: brachial artery flow-mediated dilatation235 403 Used and recommended Heart rate: chest-mounted electrode-containing heart rate strap404 405 Haemodynamics: self-reported episodes of orthostatic (pre-) syncope Potential Sport wearables398 406
Reduced skeletal muscle function	Preferred Muscle protein synthesis: isotopic amino acid labelling,407 deuterated water ingestion408 409 Muscle glycogen content: histochemical analysis of biopsy-derived muscle samples,410 ¹³C-magnetic resonance spectroscopy48 411 Used and recommended None–exclude assessment if unable to directly measure as above
Impaired growth and development	Preferred Paediatric patients: clinical assessment with growth charts Deviation from baseline growth trajectory, defined as a dynamic change with time (vs a single measurement) Decrease in growth Z-score by >1294 412 Growth hormone: overnight sampling413 IGF-1: serum levels, IGFBP-3 levels414 Used and recommended Paediatric patients: delayed markers of puberty (thelarche, menarche, spermarche)
Reduced immunity	Preferred To be determined Used and recommended Self-reported illness frequency10 271 415 Potential CBC, with differential, immunoglobulin G glycome, leucocyte transcriptome and cytokine profile272

Performance outcome	Methods and notes
Decreased athlete availability	Preferred Self-reported days of training/competition lost or modified due to illness or injury10 274 416
Decreased training response	Preferred Longitudinal tracking of valid performance-related metric specific to athlete/sport (eg, sport-related time trial)168 417 418 Used and recommended Self-reported plateauing of ability/performance despite training progression419 Exercise lactate profile420 421 Lactate: RPE ratio422 423 Catecholamine concentrations424
Decreased recovery	Preferred To be determined Used and recommended Lab-based studies: Creatine phosphate system: ³¹P magnetic resonance spectroscopy425 Exercise-induced muscle damage: muscle biopsy426 Field-based studies: Questionnaires: Recovery-Stress Questionnaire (REST-Q),10 427 self-reported perceptions of recovery, Profile of Moods State (POMS),377 Hooper MacKinnon Questionnaire428 Creatine kinase (total, muscle)429 Athlete’s subjective report of readiness430 Potential Wearable/commercialised recovery/readiness algorithms431
Decreased cognitive performance/skill	Preferred Skill: sport-specific measures (eg, Loughborough Soccer Passing Test)432 433 Used and recommended Reaction time: consider sport-specific tests434 Spatial awareness: mental rotation test241
Decreased drive/motivation	Preferred To be determined Used and recommended Motivation: Behavioural Regulation in Sport Questionnaire (BRSQ),435 Psychological Need States in Sport-Scale (PNSS-S)436 Athlete Burnout Questionnaire (ABQ)437 Maslach Burnout Inventory438
Decreased muscle strength	Preferred Longitudinal tracking of valid performance-related metric specific to athlete/sport (eg, sport-related strength test, such as snatch or clean and jerk for weightlifting, or throw distance for shot put)439 Used and recommended Isokinetic dynamometry440 441 One repetition maximum, specific movement (eg, bench press)442 443
Decreased endurance performance	Preferred Longitudinal tracking of valid performance-related metric specific to athlete/sport (eg, sport-related time-trial)168 417 418 Used and recommended Laboratory-based VO₂ max testing (via indirect calorimetry)444 Laboratory-based lactate threshold testing445 Multistage shuttle run446 447 Cycling ramp test448
Decreased power performance	Preferred Wingate test449 Used and recommended Counter-movement jump73 Standing broad jump450 451 Bosco test452 453

*While various methods have been used clinically and in research settings, many have not been validated or used in athletes or specifically used to assess the effects of REDs. Therefore, this table proposes methods that have been used for outcomes of interest and that the authors recommend to date.
ADAM-Q, Androgen Deficiency in Ageing Males Questionnaire; BEDA-Q, Brief Eating Disorder in Athletes Questionnaire; BRIEF-A, Behaviour Rating Inventory of Executive Function–Adult Version; CBC, complete blood count; DASS-21, Depression Anxiety Stress Scale-21; DSM-5 TR, Diagnostic and Statistical Manual of Mental Disorders– fifth edition, text revision; DXA, dual-energy X-ray absorptiometry; EDE-Q, Eating Disorder Examination Questionnaire; FSH, follicle stimulating hormone; GAD-7, General Anxiety Disorder-7; GERD, Gastro-oesophageal reflux disease; GerdQ, Gastro-oesophageal Reflux Disease Questionnaire; GI, gastrointestinal; HDL, high-density lipoprotein; HRpQCT, high-resolution peripheral quantitative computed tomography; IGF-1, Insulin-like growth factor 1; IGFBP-3, Insulin-like growth binding protein-3; LDL, low-density lipoprotein; LEA, low energy availability; LEAF-Q, Low Energy Availability in Females Questionnaire; LH, luteinising hormone; PHQ, Patient Health Questionnaire; RMR, Resting Metabolic Rate; RPE, rating of perceived exertion; SMA, superior mesenteric artery; T3, triiodothyronine; T4, thyroxine; TSH, thyroid stimulating hormone; VO₂ max, Maximal oxygen consumption.