Low Energy Availability and Its Impact on Bone Health and Metabolism in Athletes: A Narrative Review

Low energy availability (LEA) is a recognized risk factor that affects the health and performance of athletes. This narrative review summarizes current evidence on the relationship between LEA, resting metabolic rate (RMR), and bone mineral density (BMD). It focuses on the applicability of the RMR ratio as an indicator of metabolic adaptation to energy deficiency and analyzes the associations between energy availability and skeletal health outcomes. This narrative review demonstrates that reduced energy availability is related to a decrease in the RMR ratio and hormonal alterations characteristic of Relative Energy Deficiency in Sport (RED-S). Furthermore, prolonged LEA has been associated with impairments in bone metabolism and lower Z-scores, particularly among endurance and aesthetic athletes. However, the findings also suggest that the impact of LEA on BMD may be modulated by sport-specific loading patterns and additional individual factors. Considerable methodological heterogeneity between studies limits the direct comparability of the results, highlighting the need for standardization in the evaluation of EA, RMR, and BMD. This review emphasizes the importance of comprehensive screening strategies combining nutritional, metabolic, hormonal, and skeletal markers for early identification of the risk of RED-S. Future research should prioritize longitudinal designs to better understand the dynamics of metabolic and skeletal changes in response to fluctuations in energy availability. Key words Energy availability " Relative energy deficiency in sport " Resting metabolic rate " Bone mineral density " Sport.