Bone Mineral Density in Physique-Focused and Non-Physique-Focused Female Collegiate Athletes: Associations With Relative Energy Deficiency in Sport Risk Factors

ABSTRACT: Kolb, DE, Cipriano, NL, Moody, RA, Stephens, JA, Caldwell, LK, Lindley, MR, Ware, ME, and Deemer, SE. Bone mineral density in physique-focused and non-physique-focused female collegiate athletes: Associations with relative energy deficiency in sport risk factors. J Strength Cond Res XX(X): 000-000, 2026-Bone mineral density (BMD) is a critical indicator of skeletal health and long-term injury risk in athletic populations. Female athletes are susceptible to changes in BMD because of sport-specific training demands, hormonal dysregulation, and energy availability. The present study aimed to compare BMD between physique-focused (PF; endurance, aesthetic, and weight-dependent sports) and non-physique-focused (NPF; ball, power, and skill-based sports) female collegiate athletes and assess risk factors associated with relative energy deficiency in sport (REDs) across both groups. Thirty-three female athletes were evaluated for BMD by dual-energy X-ray absorptiometry (DXA), REDs risk using the Clinical Assessment Tool 2 (CAT2), anthropometric measurements, blood biomarkers, the Eating Disorder Examination Questionnaire (EDE-Q), and the Low Energy Availability in Females Questionnaire (LEAF-Q). Group differences were assessed using independent t-tests with significance set at p < 0.05. Physique-focused athletes demonstrated significantly lower DXA-derived z-scores at anteroposterior spine, right and left femur, and total body sites than NPF athletes (p < 0.001). There were no differences in leptin (p = 0.35), cortisol (p = 0.16), vitamin D (p = 0.29), LEAF-Q total score (p = 0.72), or global EDE-Q score (p = 0.10). No group differences in CAT2 REDs risk were observed; thus, subjects were combined: 19 athletes were classified as "green;" 12 were "yellow;" and 2 were "orange." Lower BMD in PF athletes supports the importance of early screening and targeted interventions to support bone health. These findings suggest sport type may influence skeletal outcomes independent of traditional REDs indicators, emphasizing the need for sport-specific assessment strategies.