Exploring the associations between low energy availability and mental health among university athletes: A systematic literature review.

Abstract

Low Energy Availability (LEA) and Relative Energy Deficiency in Sport (REDs) are associated with negative physical health outcomes, and growing evidence suggests connections with mental health problems. However, this relationship has not been systematically explored in university athletes. This review examined associations between LEA and adverse mental health symptoms in university athletes. The SPORTDiscus, Embase, PsychInfo, and Medline databases were searched from inception to May 2024, with an updated search in July 2025. Studies were included if they assessed relationships between validated mental health symptom measures and LEA in university athletes. LEA was measured either through direct calculation (<30 kcal/kg FFM/day) or through indicators recognised by the International Olympic Committee. Study quality was evaluated using modified Joanna Briggs Institute checklists. Eighteen studies were identified (17 cross-sectional, one prospective cohort). LEA prevalence was high (41.7%-100%). Consistent evidence showed co-occurring LEA and disordered eating, with cognitive dietary restraint and drive for thinness emerging as key correlates. Athletes with menstrual dysfunction had significantly higher disordered eating scores. Three studies examined anxiety and two examined depression, providing early evidence of increased prevalence with LEA. Integrated physical and mental health care, early intervention, and improved nutritional literacy may help reduce risks associated with LEA.