0 Pregnancy and Postpartum Nutritional Wants and Needs in Athletes: A Cross-Sectional Survey in the United Kingdom and Republic of Ireland OriginalPaper 1 1 2018 44410 IrelandCatherine V. George Zoë Bell Michèle Renard Elizabeth Brown Paulina Kloskowska Laura Edwards Alexandra Newman Andri Rauber Angela C. Flynn Dr Fiona Lavelle Fiona.lavelle@kcl.ac.uk Department of Nutritional Sciences, School of Life Course & Population Sciences King’s College London London United Kingdom School of Population Health Royal College of Surgeons Ireland Dublin Ireland SHE Research Centre, Department of Sport and Health Sciences Technological University of the Shannon Athlone Ireland Physiotherapy Department, School of Life Course and Population Sciences King’s College London London United Kingdom King’s Sport & Wellness King’s College London London United Kingdom UK Sport London United Kingdom Department of Nutritional Sciences King’s College London 150 Stamford Street SE1 9NH London United Kingdom Catherine V. George 1,2 , Zoë Bell1, Michèle Renard1,3, Elizabeth Brown1, Paulina Kloskowska4, Laura Edwards5, Alexandra Newman6, Andri Rauber6, Angela C. Flynn2, and Fiona Lavelle1* 1Department of Nutritional Sciences, School of Life Course & Population Sciences, King’s College London, London, United Kingdom 2School of Population Health, Royal College of Surgeons Ireland, Dublin, Ireland 3SHE Research Centre, Department of Sport and Health Sciences, Technological University of the Shannon, Athlone, Ireland 4Physiotherapy Department, School of Life Course and Population Sciences, King’s College London, London, United Kingdom 5King’s Sport & Wellness, King’s College London, London, United Kingdom 6UK Sport, London, United Kingdom *Corresponding author; Dr Fiona Lavelle, King’s College London, Department of Nutritional Sciences, 150 Stamford Street, London, SE1 9NH, United Kingdom; Fiona.lavelle@kcl.ac.uk Abstract Background There is a need to continue to understand, nutrition, and overall health and wellbeing of athletes during pregnancy and postpartum. This study aimed to explore nutritional perceptions, needs, preferences, and concerns of female athletes in the United Kingdom (UK) and Republic of Ireland (ROI) during pregnancy and postpartum. An exploratory cross-sectional online survey was conducted between April and May 2024 among athletes ≥ 18 years who had experienced a pregnancy while competing (or retiring due to pregnancy) within the last eight years. Descriptive analyses were conducted for the full sample and stratified by pregnancy status and athlete level. Group differences were assessed using chi-square and McNemar’s test. Results 287 athletes (34.7 ± 3.8years) from 48 different primary sporting types and activities completed the survey. 44% were elite and 56% active non-elite. Only 21.6% of athletes received nutrition advice during pregnancy and 10.8% during postpartum, with no significant differences between levels (pregnancy: p = 0.61; postpartum: p = 0.81). Most advice focused on general healthy eating and supplementation, while athletes expressed a strong preference for specific nutrition for athletes during pregnancy or postpartum, supplement use, and return-to-sport nutrition, ideally delivered by registered dietitians/nutritionists or sporting organisations in addition to general and sport healthcare providers. Conclusion Pregnant and postpartum athletes in the UK and ROI receive limited nutrition support that did not meet the demands of training, recovery or return to sport. There is a clear need for athlete-specific nutrition education and coordinated care pathways between maternity and sport performance systems. Key words: Pregnancy Postpartum Athlete Nutrition Sports Nutrition Physical Activity Supplementation Performance Training Guidance Health Background An increasing number of females are engaging in physical activity, including structured exercise and competitive sport, during pregnancy and postpartum (1, 2), leading to a growing body of research, rising media visibility, and the ongoing professionalisation of women’s sport. As a result, many female athletes are choosing to pursue pregnancy and parenthood while maintaining exercise and training loads, competitive careers, return-to-play timelines, and childcare arrangements that were not previously considered feasible, particularly within high-performance sporting environments (3). This evolving landscape highlights the need to continue to understand how pregnancy and postpartum intersect with training, nutrition, and the health and wellbeing of athletes of all abilities. Nutrition during pregnancy and postpartum is a well-established determinant of maternal and infant health. Key micronutrients, including iron, zinc, iodine, long-chain polyunsaturated fatty acids, and vitamins A, B6, B12 and folate, play essential roles in early pregnancy by influencing oxidative stress, immune function, methylation, and cellular differentiation during critical developmental periods such as implantation, placenta function and organ formation (4). Nutrition guidance during pregnancy and postpartum generally promotes a balanced dietary pattern in line with national healthy eating recommendations, adequate folic acid and vitamin D intake, moderation of foods high in sugar and saturated fat, and avoidance of alcohol and specific high-risk foods (5, 6). Suboptimal maternal nutrition has implications on both short- and long-term outcomes including, 1) neonatal: increased risk of preterm birth and low birthweight; 2) metabolic: increased risk of gestational diabetes and gestational hypertension, cardiovascular disease and type 2 diabetes; and 3) developmental: impaired cognitive development and altered growth trajectories in infancy and childhood (4). Female athletes have unique physiological, training and performance demands that require tailored nutritional strategies (7). During pregnancy, basal metabolic rate and micronutrient requirements increase to support maternal tissue expansion and fetal development, while the energy expenditure associated with ongoing training is often maintained (8, 9). This can exacerbate the risk of inadequate energy and nutrition intake and low energy availability, concerns already well recognised in female athletes (10). Such that, insufficient energy or nutrient intake during this period has the potential to adversely affect maternal metabolic regulation, fetal growth trajectories, and training adaptation or performance capacity. Exercise during pregnancy is associated with numerous health benefits and growing evidence indicates that high volume and/or long duration exercise, common features of high calibre athletic training, during pregnancy are not associated with adverse maternal or neonatal outcomes (11). This could suggest that the primary consideration is whether energy intake adequately matches elevated physiological demands rather than exercise participation itself. In the postpartum period, additional factors, including recovery from childbirth, breastfeeding-related energy requirements, sleep disruption and return-to-sport timelines may further influence nutritional status and behaviours (12). Despite this, there remains a lack of empirical data specific to pregnant and postpartum athletes related to nutrition (13). While some elite sport organisations have introduced pregnancy and maternity policies for athletes (14–20), these efforts have focused on physical training adaptations and return-to-play timelines rather than comprehensive dietary guidance. Qualitative data from elite female athletes in the United Kingdom (UK) shows that nutrition and supplementation guidance during pregnancy and postpartum was limited across sporting disciplines, organisations, governing bodies and medical providers (13, 21). For example, several athletes reported difficulty identifying Informed-Sport certified folic acid supplements, despite clear public health recommendations advising 400 µg of folic acid daily before conception and through the first trimester to reduce neural tube defects (5). Addressing this gap necessitates the provision of evidence-based nutritional guidance specifically tailored to the unique requirements of females in elite sport. It is still unclear when nutrition guidance should be delivered, what it should consist of, and who is best placed to provide it. Importantly, there is limited understanding of what information athletes themselves consider most relevant or valuable during pregnancy and postpartum. Ensuring that athletes’ priorities inform future guidance is critical to developing support that is both acceptable and effective (22). This cross-sectional study therefore aimed to explore female athletes’ nutritional perceptions, needs, preferences and concerns in the UK and Republic of Ireland (ROI) during pregnancy and postpartum, and investigate how these differed by pregnancy status and athlete level. Methods This study was approved by King’s College London’s ethics committee (Ref No: LRU/DP-23/24-41676) and was conducted in line with the guidance given in the Declaration of Helsinki. Methodological information is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (23) (see Additional file 1). The protocol was registered on the Open Science Framework (24). Study Design and Sample An exploratory cross-sectional online survey was conducted and hosted on Qualtrics XM software (Provo, UT). Between April and May 2024, a convenience sample of athletes was recruited using multiple strategies including dissemination through researcher networks, UK Sport and King’s Sport networks and social media (e.g., X, Instagram, Facebook and LinkedIn). Participants were eligible if they were > 18 years, had experienced a pregnancy while competing (or retiring due to pregnancy) within the last eight years, willing and able to give informed consent and a resident of the UK or ROI. Athlete level was assessed in the survey using a training and performance calibre framework (25). Following the consensus set by the International Olympic Committee (26) and previous research (3, 27), elite athletes were defined as individuals who are part of any national team or other high-level representative teams in any sport, as organised by a National Sports Federation. Such that, “Elite Athletes” defined in this study, encompass Tiers 3 (Highly Trained/National Level), 4 (Elite/International Level) and 5 (World Class) from the performance calibre framework (25) and “Active Non-Elite” encompass Tiers 1 (Recreationally Active) and 2 (Trained/Developmental). Survey Development and Design A research team with expertise in behavioural nutrition, sports and exercise science, maternal and child health, sport standards and operations, and survey development and validation, developed and tested the questionnaire. Key topics of importance for investigation were identified in previous qualitative research (13, 21) and reviewed by two members of UK Sport (AN, AR), representing the female athletes. Where possible existing reliable and validated instruments were used for the survey (25, 28–30), otherwise researcher developed measures were used. The survey included a combination of dichotomous, multiple choice, matrix and open-ended questions on sociodemographic, athlete and sporting characteristics, pregnancy and postpartum nutritional support and preferences, experienced pregnancy and postpartum symptoms, performance changes and supplementation behaviours. An overview of these measures is provided in Table 1. Dimension assessed Main variable Response categories Reference Demographic characteristics Sex/gender, age, country/region, marital status, education, occupation status Demographic questions, multiple choice Pregnancy and Postpartum Characteristics Currently pregnant, pregnancy week, number of months postpartum, number of children, retired from athletic career, reason for retirement, year of retirement, pregnancy symptoms experienced. Multiple choice, dichotomous, open-ended questions, matrix questions 25, 30 Exercise/Sport Characteristics Type of primary sport, number of years participating in primary sport, highest level played/competed at in primary sport, current frequency of exercise (hours/week), timing of and types of changes made to training or competition schedule during pregnancy, perceived performance changes due to experiencing a pregnancy, experience of pregnancy symptoms during each trimester, time to return to same or similar performance calibre postpartum, retired from athletic career, reason for retirement, year of retirement. Multiple choice, dichotomous, open-ended questions 25, 28–30 Support Access and Nutritional Concerns in Pregnancy Participants were asked if they had access to sporting organisation or National Governing Body pregnancy and/or maternity guidelines, access to nutrition advice during pregnancy, changes made during pregnancy as a result of the advice, from whom/where the advice received came from, and in what format was the advice provided. Participants were then asked if all their questions and/or concerns during pregnancy were addressed, what nutrition advice during pregnancy they wanted to receive, from whom/where and in what format they wanted to receive it. Multiple choice, dichotomous, open-ended questions 24 Support Access and Nutritional Concerns in Postpartum Participants were asked if they had access to nutrition advice during postpartum and/or returning to sport, changes made during postpartum and/or returning to sport as a result of the advice, from whom/where the advice received came from, and in what format was the advice provided. Participants were then asked if all their questions and/or concerns during postpartum were addressed, what nutrition advice during postpartum they wanted to receive, from whom/where and in what format they wanted to receive it. Participants were then asked to identify perceived challenges during postpartum Multiple choice, dichotomous, open-ended questions 24 Supplementation Behaviours Reason for using sport or pregnancy dietary supplements Multiple choice 29

Table 1 Dimensions assessed, and main variables recorded to answer the research questions

Face Validity, Review and Piloting Face validity was obtained by research team members not involved in initial development, reviewing the questionnaire using their knowledge and experience in the relevant areas. The questionnaire had a two-stage face validity process. Stage one included the presentation of the questionnaire contents to two experts in the field: one with a background in exercise research and one with a background in maternal health and nutrition. Both experts were provided with a document containing a template to complete with a column added for them to conclude if they ‘Agree’ or ‘Disagree’ with each survey question and a column for additional comments. They were asked to consider if each question was appropriate to gather the information needed for the intended outcomes of the survey. A second round of face validity was then conducted after the initial round of feedback was received and relevant amendments made. This face validity review gathered feedback using the same template from a further five experts with a background in either exercise research or maternal health. Two female postpartum athletes based in the United States and two recreationally active women (one pregnant and one postpartum) based in the ROI piloted the survey to ensure clarity of questions, usability, and length of time of completion. Data Collection Prior to starting the survey, participants were provided with a participation information leaflet and to confirm consent. Participants were also made aware that they could leave the survey at any time. After confirming consent, the initial screening questions confirmed participant's eligibility. All participants were informed that by participating in the survey they consented for their data to be used. Forced responses was enforced to ensure no missing data. The target sample size was 300, informed by previous cross-sectional research in 112 UK female athletes (31) and women’s health cross-sectional research in 252 athletes internationally (32). Data analysis Data were analysed using STATA/SE Version 18 (STATA Corp, 2023). Descriptive and inferential analyses were conducted for the full sample and stratified by pregnancy status (pregnant and postpartum) and athlete level (“Elite” and “Active Non-Elite"). Continuous variables such as age, months postpartum were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were reported as means ± standard deviations (SD) and skewed variables were reported as medians with interquartile ranges (IQR). Categorical variables such as type of nutrition advice were summarised as counts and percentages, with 95% confidence intervals where appropriate. Forced responses were used to ensure no missing data. Chi-square tests were used to assess group differences by athlete level (elite vs. active non-elite) for two outcomes: receiving nutrition advice and whether all nutritional questions and concerns were addressed in pregnancy and postpartum. For these categorical outcomes, chi-square tests were used. McNemar’s tests were then used to evaluate within-participant differences between these two outcomes. Open-ended Data Analysis Conventional content analysis (33) was used to analyse the open ended responses. First, all open responses were read. Upon re-reading, each response was assigned a code. These codes were then grouped into clusters of related meaning to form categories. Non-coherent or irrelevant responses to the question were not coded during analysis. This was repeated for each open-response question. Frequencies of prominent codes were reported alongside narrative descriptions. Results Participants The survey was accessed by 604 participants. 317 respondents were not included due to either not completing the survey (n = 295) or not matching the inclusion criteria: identifying sex as male (n = 1), under the age of 18 (n = 1), not currently pregnant or experienced a pregnancy within the last 8 years (n = 9) or residents of countries outside the UK and ROI (n = 11). The final sample consisted of 287 eligible participants. 286 (99.7%) participants identified as a woman and 1 (0.04%) as non-binary. Of these, 126 (44%) classified themselves as elite athletes and 161 (56%) as active non-elite. The mean age of participants was 34.7 years (SD 3.8). Most participants were based in England (77%), with smaller representations from the Republic of Ireland (12%), Wales (4%), Scotland (4%), and Northern Ireland (4%). At the time of survey completion, 30% of participants (n = 87) were pregnant and 70% (n = 200) were postpartum, with a median postpartum duration of 9 months (IQR = 17). Among those pregnant (n = 87; 30%), 19 (22%) were in their first trimester, 29 (29%) in the second, and 43 (49%) in the third. Over half of the participants (n = 161; 56%) had one child, while 55 (19%) were nulliparous, 52 (18%) had two children and 19 (7%) had three or more children (see Table 2). Overall (n = 287) Tier 3–5: Elite (n = 126) Tier 1–2: Active Non-Elite (n = 161) Age (years), mean (SD) 34.7 (3.83) 34.8 (4.16) 34.5 (3.56) Country/Region, n (%) England 222 (77.35) 91 (72.22) 131 (81.37) Scotland 10 (3.48) 6 (3.97) 5 (3.11) Wales 11 (3.83) 7 (5.56) 4 (2.48) Northern Ireland 10 (3.48) 6 (4.76) 4 (2.48) Republic of Ireland 34 (11.85) 17 (13.49) 17 (10.56) Education Level, n (%) Secondary school 5 (1.74) 1 (0.79) 4 (2.48) Leaving Certificate 9 (3.14) 4 (3.17) 5 (3.11) Undergraduate 116 (40.42) 48 (38.10) 69 (42.24) Postgraduate 157 (54.70) 73 (57.94) 84 (52.17) Ethnicity, n (%) White (e.g. English, Scottish, Welsh, Irish) 260 (90.59) 119 (94.44) 142 (87.58) Asian/Asian British/Asian Irish etc.) 6 (2.09) 1 (0.79) 5 (3.11) Black/African/Caribbean/Black British etc.) 5 (1.74) 1 (0.79) 4 (2.48) Mixed/Multiple ethnic groups 12 (4.18) 4 (3.17) 8 (4.97) Any other ethnic group 4 (1.39) 1 (0.79) 3 (1.86) Employment Status, n (%) Full-time paid work 139 (48.43) 58 (46.03) 81 (50.31) Part-time paid work 43 (14.98) 18 (14.29) 24 (15.53) In full-time higher education (college/university) 4 (1.39) 2 (1.59) 2 (0.62) Unemployed 1 (0.35) 0 (0) 1 (0.62) Full-time parent 10 (3.48) 7 (5.56) 3 (1.86) Full-time paid athlete 6 (2.09) 6 (4.67) 0 (0) Pregnancy/Maternity Leave 84 (29.27) 35 (27.78) 49 (30.43) Pregnancy Status Pregnant, n (%) 87 (30.31) 38 (30.16) 49 (30.43) First Trimester 19 (21.84) 6 (15.79) 13 (26.53) Second Trimester 29 (28.74) 12 (31.58) 13 (26.53) Third Trimester 43 (49.43) 20 (52.63) 23 (46.94) Postpartum, n (%) 200 (69.69) 88 (69.84) 112 (69.57) Time postpartum (months), median, IQR 9 (17) 9.5 (18) 9 (15) Number of children n (%) 0 55 (19.16) 18 (14.29) 37 (22.98) 1 161 (56.10) 69 (54.76) 92 (57.14) 2 52 (18.12) 28 (22.22) 24 (14.91) 3+ 19 (6.62) 11 (8.73) 8 (4.97)

Table 2 Participant Characteristics

Sport Participation and Training Behaviours during Pregnancy and Postpartum Participants reported engaging in 48 different primary sporting types and activities, including endurance, strength and power-based, and individual and team sports. The majority of participants (n = 243; 85%) reported currently participating in their reported primary sport or activity, while 44 (15%) identified as retired or stopping their primary sport or activity. Among those who had retired, the most cited reasons for retirement were pregnancy (n = 12; 27%), and a desire to pursue other passions (n = 12; 27%) (see Table 3). Overall Tier 3–5: Elite Tier 1–2: Active Non-Elite Primary Sport, n(%) (n = 287) (n = 126) (n = 161) Athletics 12 (4.18) 8 (6.35) 4 (2.48) Ballet 2 (0.70) 1 (0.79) 1 (0.62) Basketball 1 (0.35) 1 (0.79) 0 (0) Beach Volleyball 1 (0.35) 1 (0.79) 0 (0) Bouldering 4 (1.39) 0 (0) 4 (1.24) Boxing 1 (0.35) 1 (0.79) 0 (0) Brazilian Jiu Jitsu 2 (0.70) 1 (0.79) 1 (0.62) Camogie 1 (0.35) 1 (0.79) 0 (0) Canoe Slalom 1 (0.35) 1 (0.79) 0 (0) Cheerleading 1 (0.35) 1 (0.79) 0 (0) Climbing 4 (1.39) 2 (1.59) 2 (1.24) CrossFit 30 (10.45) 6 (4.76) 24 (14.91) Cycling 13 (4.53) 6 (4.76) 7 (4.35) Dance 1 (0.35) 0 (0) 1 (0.62) Dragonboat 1 (0.35) 1 (0.79) 0 (0) Football 5 (1.74) 2 (1.59) 3 (1.86) Gaelic football 14 (4.88) 5 (3.97) 9 (5.59) Gymnastics 1 (0.35) 1 (0.79) 0 (0) HIIT 1 (0.35) 0 (0) 1 (0.62) Hockey 9 (3.14) 7 (5.56) 2 (1.24) Hyrox 2 (0.70) 1 (0.79) 1 (0.62) Lacrosse 1 (0.35) 1 (0.79) 0 (0) Mixed Martial Arts 2 (0.70) 1 (0.79) 1 (0.62) Marathon 20 (6.97) 7 (5.56) 13 (8.07) Motorcycle Trials 1 (0.35) 1 (0.79) 0 (0) Mountain biking 1 (0.35) 0 (0) 1 (0.62) Muay Thai 2 (0.70) 2 (1.59) 0 (0) Netball 8 (2.79) 4 (3.17) 4 (2.48) Olympic Weightlifting 3 (1.05) 1 (0.79) 2 (1.24) Para cycling 1 (0.35) 1 (0.79) 0 (0) Powerlifting 2 (0.70) 1 (0.79) 1 (0.62) Roller Derby 1 (0.35) 0 (0) 1 (0.62) Rowing 2 (0.70) 2 (1.59) 0 (0) Rugby 8 (3.14) 5 (3.97) 3 (1.86) Running 79 (27.53) 24 (19.05) 55 (34.16) Strength Training 3 (1.05) 1 (0.79) 2 (1.24) Swimming 9 (3.14) 6 (4.76) 3 (1.86) Taekwondo 1 (0.35) 1 (0.79) 0 (0) Tennis 1 (0.35) 1 (0.79) 0 (0) Triathlon 23 (8.01) 13 (10.32) 10 (6.21) Ultimate frisbee 1 (0.35) 1 (0.79) 0 (0) Ultra Marathon 2 (0.70) 2 (1.59) 0 (0) Volleyball 1 (0.35) 1 (0.79) 0 (0) Walking 1 (0.35) 0 (0) 1 (0.62) Weightlifting 5 (1.74) 2 (1.59) 3 (1.86) Yoga 1 (0.35) 0 (0) 1 (0.62) Activity Status, n (%) Active 243 (84.67) 93 (73.81) 148 (93.08) Retired 44 (15.33) 33 (26.19) 11 (6.92) Retirement Reason, n (%) Pregnancy 12 (27.27) 10 (30.30) 2 (18.18) COVID 2 (4.54) 2 (6.06) 0 (0) Decline in Physical Ability 4 (9.09) 3 (9.09) 1 (9.09) Financial Security 2 (4.54) 1 (3.03) 1 (9.09) Injury 7 (15.90) 6 (18.18) 1 (9.09) Mental or Emotional Burnout 2 (4.54) 2 (6.06) 0 (0) Pursue a different passion 12 (27.27) 9 (27.27) 3 (27.27) Prefer Not to Say 2 (4.54) 0 (0) 2 (18.18) Other 1 (2.27) 0 (0) 1 (9.09)

Table 3 Sporting Characteristics

Athletes reported a variety of training modifications during pregnancy, with reported training behaviours decreasing with each successive trimester (see Additional file 2). Qualitative responses revealed that the type of training most altered was cardiovascular or endurance-based (n = 91) activity such as running and cycling, with most reporting reducing intensity (n = 17) and duration (n = 9) of sessions. When reductions in intensity were reported, most athletes avoided high-intensity intervals or activities that elevated heart rate or caused excessive fatigue due to guidance provided by a healthcare professional, anatomical changes in the body or perceived social perception. Additional reasons for reported modifications of training or exercise duration or frequency were to accommodate symptoms such as fatigue or nausea (n = 27). Some described shifting toward strength training with reduced loads or lower-impact movements (n = 47). In addition, athletes reported ceasing or substantially reducing participation in specific activities including contact sports, climbing, and other impact-based exercise (n = 18). Additionally, athletes described additions or adjustments to exercise such as incorporating pelvic floor rehabilitation exercises (n = 32) or avoiding supine movements (n = 9). Among those who were postpartum (n = 200; 70%), 136 (68%) reported resuming training after childbirth, and 76 (87%) of currently pregnant individuals intended to return to training postpartum. The median return-to-sport time was 6 months (IQR = 9), though 54 (30%) had reported that they had not yet returned at the time of the survey. In open-ended responses, athletes reported struggling to return to their previous performance levels postpartum, citing musculoskeletal injury, issues or discomforts (n = 38), fatigue or changes in energy levels (n = 27), reduced fitness and performance capacity (n = 24), or strength or muscle loss (n = 24). Overall, participants highlighted these and other factors as perceived barriers to returning to sport postpartum (See Table 4). Additional responses revealed that many athletes self-managed return to sport performance changes (n = 58), while few reported seeking specialist support (n = 6). Overall Tier 3–5: Elite Tier 1–2: Active Non-Elite Perceived Barriers, n (%) (n = 287) (n = 126) (n = 161) Body Image 162 (56.45) 73 (57.94) 89 (55.28) Childcare (i.e. provisions, costs) 249 (86.76) 114 (90.48) 135 (83.85) Drop in Funding 47 (16.38) 21 (16.67) 26 (16.15) Drop in Ranking 38 (13.24) 21 (16.67) 17 (10.56) Family Support 132 (45.99) 63 (50.00) 69 (42.86) Finances 112 (39.02) 57 (45.24) 55 (34.16) Infant Feeding Practices 205 (71.43) 94 (74.60) 111 (68.94) Injury Concerns 127 (44.25) 58 (46.03) 69 (42.86) Lack of Energy 195 (67.94) 84 (66.67) 111 (68.94) Pelvic Floor Health 192 (66.90) 86 (68.25) 106 (65.85) Sleep 224 (78.05) 99 (78.57) 125 (77.64) Sporting Contracts 24 (8.36) 14 (11.11) 10 (6.21) Travel 97 (33.80) 55 (43.65) 42 (26.09)

Table 4 Reported Perceived Barriers to Returning to Sport Postpartum

Pregnancy and Postpartum Symptoms & current dietary and supplementation adaptations Participants reported a range of physical and emotional symptoms during pregnancy. Fatigue was the most common, especially in the first trimester (81%), followed by nausea/vomiting (70%), and anxiety about the baby’s health (64%). Other prevalent symptoms included anxiety about delivery, back pain, pelvic discomfort, constipation, mood swings, and heartburn (See Additional file 3). Primary reasons for supplement use were to improve health (n = 115), preconception/pregnancy health (n = 112), postpartum health (n = 101), recovery (n = 69), and performance (n = 44). When asked about the specific changes participants made to their nutrition during pregnancy, participants (n = 52, 18%) reported in open-ended responses primarily on taking pregnancy-safe supplements (n = 29) with some specifying nutrients such as iron, folic acid and omega-3s, increasing caloric intake (n = 18), avoiding high-risk foods such as unpasteurised cheese and deli meats (n = 11), and reducing or eliminating caffeine (n = 10). These changes were guided by either healthcare professionals or self-directed research. Further changes were often reported as symptom-driven, especially in response to nausea (n = 7), or gastrointestinal issues (n = 3). During the postpartum period, participants who made changes (n = 21) mainly reported improving overall diet to support breastfeeding (n = 9), increasing calories (n = 8) and keeping hydrated (n = 7), and including supplements (n = 8), specifically highlighting iron (n = 2), vitamin D (n = 2) and calcium (n = 1). When reporting changes specific to returning to sport (n = 5), athletes either reported that they took their energy needs for breastfeeding into account in addition to training (n = 2) and ensuring they fueled properly before and after each training session to support performance and recovery (n = 3). Pregnancy and Postpartum Nutrition current support and athlete wants Only 21.6% (n = 62) of participants reported receiving any nutrition advice during pregnancy. This was consistent across athlete tiers, with slightly higher proportions among elite athletes (n = 29; 23%) than active non-elite athletes (n = 33; 21%), though this difference was not significant (χ²(1, n = 287) = 0.26, p = 0.61). Based on the proportion that did receive advice, most advice received related to pregnancy supplement intake (n = 55; 89%) and general healthy eating (n = 54; 87%). However, athletes expressed a preference for more specific guidance tailored to their dual needs as pregnant individuals and as athletes. Specifically, many wanted advice on athlete-specific nutrition during pregnancy (n = 228; 79%) or sport supplements to take during pregnancy (n = 151; 53%). These patterns were consistent across elite and non-elite subgroups. Of those that did receive advice, sources and formats of advice varied NHS or public healthcare professionals (including Midwife, Obstetrician and GP) (n = 44; 77%) and the internet (n = 32; 52%) were cited as the most common sources in the format of private consultations (n = 37; 60%), information sheets (n = 28; 45%) and online searches (n = 30; 49%). Athletes reported preferring more information from either sporting/team registered nutritionists and dietitians (n = 134; 47%), any registered nutritionists and dietitians (n = 100; 35%) or sporting organisations (n = 102; 36%) and (See Table 5). Participants who reported receiving nutrition advice were significantly less likely to indicate that all their nutrition information needs were met during pregnancy (McNemar’s χ²(1, N = 287) = 9.24, p = 0.002; OR = 0.68, 95% CI [0.53, 0.87]). Overall Tier 3–5: Elite Tier 1–2: Active Non-Elite Received nutrition support, n (%) 62 (21.60) 29 (23.02) 33 (20.49) Type of Nutrition advice, n (%) Received (n = 62) Preferred (n = 287) Received (n = 29) Preferred (n = 126) Received (n = 33) Preferred (n = 161) General Healthy Eating Advice 54 (87.10) 196 (68.29) 24 (82.76) 40 (31.75) 30 (90.91) 56 (34.8) Specific Nutrition Advice for Athletes during Pregnancy 11 (17.74) 228 (79.44) 4 (13.79) 104 (82.54) 7 (21.21) 124 (77.02) Symptom Management 21 (33.87) 131 (46.64) 7 (24.14) 62 (49.21) 14 (42.42) 69 (42.86) Pregnancy Supplement Intake 55 (88.71) 155 (54.01) 26 (89.66) 68 (53.97) 29 (87.88) 87 (54.04) Sport Supplement Intake 8 (12.90) 151 (52.61) 3 (10.34) 64 (50.79) 5 (15.15) 87 (54.04) Specific Meal Composition/Quantities 4 (6.45) 89 (31.01) 1 (3.45) 37 (29.37) 3 (9.09) 52 (32.30) Fluid Intake and Hydration 28 (45.16) 103 (35.89) 12 (41.38) 41 (32.54) 16 (48.48) 62 (38.51) Body Image 6 (19.68) 100 (34.84) 1 (3.45) 41 (32.54) 5 (15.15) 59 (36.65) Relationship with Food 3 (4.84) 79 (27.53) 1 (3.45) 32 (25.40) 2 (6.06) 47 (29.19) Source of Nutrition advice, n (%) Sporting Organisation/National Governing Body 1 (1.61) 102 (35.54) 1 (3.45) 45 (35.71) 0 (0) 57 (35.40) Sports or Team Nutritionist/Registered Dietitian 7 (11.29) 134 (46.69) 5 (17.24) 59 (46.83) 2 (6.06) 75 (46.58) Any other Nutritionist/Registered Dietitian 9 (14.52) 100 (34.84) 3 (10.34) 40 (31.75) 6 (18.18) 60 (37.27) Sports or Team Coach, Trainer, Physician, Physiotherapist or Performance Lifestyle Advisors 6 (9.68) 98 (34.14) 1 (3.45) 40 (31.75) 5 (15.15) 58 (36.02) Any other Coach, Trainer, Physician, Physiotherapist or Performance Lifestyle Advisors 6 (9.68) 50 (17.42) 3 (10.34) 14 (11.11) 3 (9.09) 36 (22.36) Private Midwife, Obstetrician or GP 10 (16.13) 51 (17.77) 6 (20.69) 24 (19.05) 4 (12.12) 27 (16.77) NHS or Public Midwife, Obstetrician or GP 48 (77.42) 178 (62.02) 22 (75.86) 65 (51.59) 26 (78.79) 113 (70.19) Fellow athlete who has experienced a pregnancy 21 (33.87) 147 (51.22) 10 (34.48) 63 (50.00) 11 (33.33) 84 (52.17) Fellow athlete who hasn’t experienced a pregnancy 0 (0) 2 (0.70) 0 (0) 0 (0) 0 (0) 2 (1.24) Family/Spouse/Partner/Friends 17 (27.42) 37 (12.89) 9 (31.03) 13 (10.32) 8 (24.24) 24 (14.91) Internet (e.g. search engines, websites, blogs, news articles, webinar etc.) 32 (51.61) 94 (32.75) 12 (41.38) 36 (28.57) 20 (60.61) 58 (36.02) Social Media (e.g. Instagram, Twitter, Facebook etc.) 9 (14.52) 43 (14.98) 4 (13.79) 18 (14.29) 5 (15.15) 25 (15.53) Format of Nutrition advice, n (%) Private Consultation 37 (59.68) 165 (57.49) 21 (72.41) 75 (69.52) 16 (48.48) 90 (55.90) Information Sheet/Brochure 28 (45.16) 169 (58.89) 13 (44.83) 74 (58.73) 15 (45.45) 95 (59.01) Lesson/Class/Webinar 3 (4.84) 104 (36.24) 3 (10.34) 48 (38.10) 1 (3.03) 56 (34.78) Presentation/Workshop 4 (6.45) 36 (12.54) 2 (6.90) 17 (13.49) 2 (6.06) 19 (11.80) Team Meeting/Briefing 8 (12.90) 135 (47.04) 2 (6.90) 53 (42.06) 5 (15.15) 82 (50.93) Online/Internet (e.g. search engines, websites, blogs, news articles, webinars, social media posts etc.) 30 (48.39) 149 (51.92) 12 (41.38) 54 (42.86) 18 (55.55) 95 (59.01) No Alternative Preference 10 (3.48) 2 (1.59) 8 (4.97) All Questions/Concerns Answered, n (%) 91 (31.70) 41 (32.54) 50 (31.06) There were no significant differences between athlete levels in participants who received nutrition advice (p = 0.61) or difference between athlete levels in participants with all questions and concerns answered (p = 0.80).

Table 5 Types, Sources, and Formats of Nutrition Advice Received and Preferred During Pregnancy

During postpartum, 10.8% (n = 25) received nutrition advice, with no significant difference between athlete levels (χ²(1, n = 231) = 0.11, p = 0.81). Most advice focused on breastfeeding and mixed feeding (n = 20; 80%) and general healthy eating (n = 13; 52%). However, in addition to these, athletes reported that they wanted specific nutrition advice for athletes during postpartum (n = 146; 63%), return to sport (n = 182; 79%), postpartum (n = 146; 65%), sport supplement intake (n = 117; 51%), injury prevention (n = 131; 57%) and body image support (n = 96, 42%). These preferences were consistent across athlete tiers. Similar to the findings in pregnancy, most participants reported receiving information from an NHS or public healthcare professional (including Midwife, Obstetrician and GP) (n = 10; 40%) or from the internet (n = 10; 40%) in the format of private consultations (n = 15; 60%), information sheets (n = 8; 32%) and online searches (n = 13; 52%). Preferences again indicated a desire for more support from sporting/team registered nutritionists and dietitians (n = 116; 50%) or any registered nutritionists and dietitians (n = 120; 52%) (see Table 6). Participants who reported receiving postpartum nutrition advice were not significantly likely to indicate that all their postpartum nutrition information needs were met (McNemar’s χ²(1, N = 199) = 0.04, p = 0.84; OR = 0.92, 95% CI [0.38, 2.19]), indicating alignment between receiving advice and perceived adequacy of information during the postpartum period. Overall Tier 3–5: Elite Tier 1–2: Active Non-Elite Received nutrition support, n (%) 25 (10.8) 11 (10.28) 14 (11.3) Type of Nutrition advice, n (%) Received (n = 25) Preferred (n = 231) Received (n = 11) Preferred (n = 107) Received (n = 14) Preferred (n = 124) General Healthy Eating Advice 13 (52.00) 105 (45.45) 6 (54.55) 44 (41.12) 7 (50.00) 61 (49.49) Specific Nutrition Advice for Athletes during Postpartum 3 (12.00) 146 (63.20) 3 (27.27) 65 (60.75) 0 (0) 81 (65.32) Specific Nutrition Advice for Athletes during Returning to Sport 5 (20.00) 182 (78.79) 3 (27.27) 90 (84.11) 2 (14.29) 92 (74.19) Sport Supplement Intake 2 (8.00) 117 (50.65) 1 (9.09) 63 (58.88) 1 (7.14) 54 (43.55) Postpartum Supplement Intake 9 (36.00) 149 (64.50) 3 (27.27) 74 (69.16) 6 (42.86) 75 (60.48) Specific Meal Composition/Quantities 4 (16.00) 71 (30.74) 2 (18.18) 30 (28.04) 2 (14.29) 41 (33.06) Breastfeeding/Mixed Feeding 20 (80.00) 170 (73.59) 7 (64.64) 79 (73.83) 13 (92.86) 91 (73.39) Injury Prevention 2 (8.00) 131 (56.71) 0 (0) 64 (659.81) 2 (14.29) 67 (54.03) Fluid Intake and Hydration 8 (32.00) 77 (33.33) 4 (36.36) 27 (25.23) 4 (28.57) 50 (40.32) Body Image 3 (12.00) 96 (41.56) 1 (9.09) 44 (41.12) 2 (14.29) 52 (41.94) Relationship with Food 2 (8.00) 65 (28.14) 1 (9.09) 36 (33.64) 1 (7.14) 29 (23.39) Source of Nutrition advice, n (%) Sporting Organisation/National Governing Body 2 (8.00) 102 (44.16) 2 (18.18) 54 (50.47) 0 (0) 48 (38.71) Sports or Team Nutritionist/Registered Dietitian 6 (24.00) 116 (50.22) 5 (45.45) 60 (56.07) 1 (7.14) 56 (45.16) Any other Nutritionist/Registered Dietitian 4 (16.00) 120 (51.95) 1 (9.09) 52 (48.60) 3 (21.43) 68 (54.84) Sports or Team Coach, Trainer, Physician, Physiotherapist or Performance Lifestyle Advisors 4 (16.00) 84 (36.36) 2 (18.18) 40 (37.38) 2 (14.29) 44 (35.48) Any other Coach, Trainer, Physician, Physiotherapist or Performance Lifestyle Advisors 3 (12.00) 66 (298.57) 0 (0) 26 (24.30) 3 (21.43) 40 (32.26) Private Midwife, Obstetrician or GP 2 (8.00) 66 (28.57) 1 (9.09) 34 (31.78) 1 (7.14) 32 (25.81) NHS or Public Midwife, Obstetrician or GP 10 (40.00) 147 (63.64) 4 (36.36) 63 (58.88) 6 (42.86) 84 (67.76) Fellow athlete who has experienced a pregnancy 6 (24.00) 107 (46.32) 3 (27.27) 49 (45.79) 3 (21.43) 58 (46.77) Fellow athlete who hasn’t experienced a pregnancy 1 (4.00) 7 (3.03) 1 (9.09) 3 (2.80) 0 (0) 4 (3.23) Family/Spouse/Partner/Friends 3 (12.00) 23 (9.96) 1 (9.09) 7 (6.54) 2 (14.29) 16 (12.90) Internet (e.g. search engines, websites, blogs, news articles, webinar etc.) 10 (40.00) 96 (41.56) 2 (18.18) 35 (32.71) 8 (57.14) 61 (49.19) Social Media (e.g. Instagram, Twitter, Facebook etc.) 4 (16.00) 48 (20.78) 0 (0) 21 (219.63) 4 (28.57) 27 (21.77) Format of Nutrition advice, n (%) Private Consultation 15 (60.00) 32 (13.85) 7 (63.64) 21 (19.63) 6 (42.86) 11 (8.87) Information Sheet/Brochure 8 (32.00) 18 (7.79) 4 (36.36) 9 (8.41) 5 (35.71) 9 (7.26) Lesson/Class/Webinar 6 (24.00) 154 (66.67) 2 (18.18) 73 (68.22) 1 (7.14) 81 (65.32) Presentation/Workshop 1 (4.00) 18 (7.79) 1 (9.09) 11 (10.28) 2 (14.29) 7 (5.65) Team Meeting/Briefing 1 (4.00) 136 (58.87) 1 (9.09) 66 (61.68) 5 (35.71) 70 (56.45) Online/Internet (e.g. search engines, websites, blogs, news articles, webinars, social media posts etc.) 13 (52.00) 102 (44.16) 5 (45.45) 47 (43.93) 8 (57.14) 55 (44.35) No Alternative Preference, n (%) 0 (0) 0 (0) 0 (0) All Questions or Concerns Answered, n (%) 26 (11.26) 11 (10.28) 15 (12.10) There were no significant difference between athlete levels in participants who received nutrition advice (p = 0.81) or difference between athlete levels in participants with all questions and concerns answered (p = 0.83).

Table 6 Types, Sources, and Formats of Nutrition Advice Received and Preferred During Postpartum.

Discussion This study highlights significant gaps in existing nutritional support for elite and non-elite female athletes in the UK and ROI. Fewer than one in four athletes received advice during pregnancy and only approximately one in ten postpartum. When advice was provided, it centred primarily on general population guidance such as general healthy eating and routine supplementation. While this information is necessary, it does not meet the needs of athletes who continue to train during pregnancy or plan to return to exercise and sport postpartum. Athletes in this study consistently expressed a desire for advice that acknowledged the dual demands of pregnancy and sport, including fuelling strategies to maintain training where appropriate, managing breastfeeding-related energy requirements and making informed sport-supplement decisions. The absence of such tailored guidance is particularly notable in elite environments, where broader pregnancy and maternity policies now exist in several national governing bodies, yet nutrition-specific direction remains limited (14–20). A recent narrative review (15) on return-to-play protocols for postpartum female footballers highlighted that while breastfeeding is highly energy-demanding, it is not negatively affected by moderate to vigorous exercise when caloric needs are met and appropriate nutritional support is in place, further underscoring the need to understand and integrate sport-specific postpartum nutrition pathways. This gap is clinically relevant given the well-established risks associated with low energy availability and Relative Energy Deficiency in Sport (REDs) among female athletes, which may be heightened during pregnancy and postpartum when energy demands fluctuate significantly. Emerging evidence also suggests that a history of low energy availability and REDs may be linked to adverse perinatal outcomes, underscoring the need for proactive, continuity of support for athletes as they move through pregnancy, postpartum recovery, and into subsequent pregnancies (34). Success in sport, as well as transition out of it, rely on a holistic approach to athlete development that integrates lifestyle practices, performance strategies, psychological skills, education and supportive social relationships (35). Female athletes are particularly vulnerable to low energy availability, micronutrient deficiencies, body image expectations and psychological stress, due in part to performance pressures and limited access to female-specific coaching and medical expertise (36). These vulnerabilities can become more pronounced during major life transitions such as pregnancy and postpartum, when physiological, sociocultural and identity-related demands increase (3, 12). Our findings show that the low level of nutrition support observed was similar among elite and non-elite athletes, indicating that inadequate provision is systemic rather than resource dependent. This suggests that the issue is not solely a matter of access to performance environments but instead reflects broader infrastructure and knowledge gaps across both sport and healthcare systems. Existing evidence shows that nutrition education in medical, midwifery and allied health training is often minimal, variable and insufficient to equip practitioners to provide personalised nutrition care (37). Similarly, sport and exercise science and coaching qualifications have historically lacked structured content on the female athlete (38), especially pregnancy, postpartum recovery or breastfeeding-related fuelling (39). Although specialised courses and initiatives are beginning to emerge in some sport systems, particularly in response to concerns around REDs and women’s health in high-performance contexts, their integration into routine training pathways remains limited (40). As a result, healthcare and sport practitioners may be uncertain in supporting athletes during pregnancy and early postpartum, leaving athletes to seek advice independently or self-manage their nutrition needs. In this study, athletes most often received guidance from general healthcare providers such as midwives, GPs and obstetricians, professionals who play essential roles in pregnancy care but may not be equipped to offer sport-specific nutrition advice. In contrast, athletes expressed a clear preference for receiving support from registered sport nutritionist and dietitians or sport organisations, reflecting a belief that these sources hold the contextual knowledge required to address the demands of training and competition. Supplement use is widespread in elite sport to help maintain micronutrient status and support performance (41, 42). In this study, many participants continued to use supplements during and after pregnancy, but highlighted the need for clearer, pregnancy-safe, sport-specific guidance to ensure appropriate and compliant use. Strengthening collaboration between maternity services, primary care and sport performance systems may therefore be critical to improving support, especially within the elite context where demands are increased. Further research into specific referral pathways and knowledge translation of fueling among both practitioners and athletes in each context is warranted. Implications for performance and return to sport are notable. Most athletes in this study reported modifying their training during pregnancy, often reducing intensity or shifting toward lower-impact or strength-based activities. While these adjustments are appropriate in response to physiological changes, symptoms or personal comfort, they alter energy requirements and recovery needs. Nutrition is a modifiable factor that can influence energy restoration, tissue recovery and training adaptation (43). Yet, without guidance that accounts for varying metabolic demands, breastfeeding status, sleep disruption and staged return-to-play progression, athletes are left to navigate these challenges alone. Improving access to dynamic athlete-specific nutrition support may therefore not only benefit maternal health but also contribute to a safer return to exercise and sport. These findings underscore the consideration to embed pregnancy and postpartum-specific nutrition content into medical, sport science and performance nutrition education, alongside the development of practical, evidence-based guidelines and resources tailored to athletic populations. Embedding this knowledge within existing education and continuing professional development offers feasible opportunities to improve support, while reducing reliance on athletes to self-manage nutritional demands. Strengths and Limitations This study has several strengths. Notably, it is the first large-scale investigation in the UK, ROI and globally to examine the supports, wants and needs as it relates to nutrition for elite and recreational athletes during pregnancy and/or postpartum. It targeted elite and recreational athletes, a group often overlooked in pregnancy and exercise research (7). As our study explored both pregnancy and postpartum, it offers a more complete picture of the athletes’ experiences. As with all retrospective designs, this study has limitations that must be acknowledged. First is recall bias, participants' experiences of pregnancy and postpartum may be inaccurate or incomplete. Due to the exploratory nature of the study, a sample size calculation is not applicable. Generalisability may be limited by the non-probability sampling, therefore the representativeness of all female athletes cannot be assumed (31, 32). Furthermore, while a broad range of athletes across calibres, representing a large number of sports was achieved, it is worth noting that the sample was highly educated and of a white ethnic background. Although support and advice was extremely limited within this sample, future research should include those from diverse ethnic and educational backgrounds to assess whether there were further gaps or barriers for this group. Conclusion This research highlights the lack of nutrition advice being provided to athletes during pregnancy and postpartum. Elite and non-elite athletes reported similar experiences, suggesting that the absence of tailored nutrition support reflects broader system-level gaps in practitioner training, resource availability and care pathways, rather than differences in individual athletic ability or organisation-level provision. Despite this, athletes expressed a need for guidance that addresses the demands of both pregnancy and athletic participation, including fuelling for modified training demands, managing breastfeeding-related energy requirements and making informed supplementation decisions. Additional research is needed to understand if and how pregnancy and postpartum-specific nutrition education can be effectively integrated into medical, midwifery, sport science and performance nutrition curriculum, and how clear referral pathways between maternity care and sport performance environments can be established, especially at the elite level. Developing evidence-based, athlete-centred guidelines has the potential to enhance health, facilitate safer and more sustainable return to exercise and sport and help retain females in sport during and after pregnancy. Abbreviations UK United Kingdom ROI Republic of Ireland STROBE Strengthening the Reporting of Observational Studies in Epidemiology AN Alexandra Newman AR Andri Rauber IQR Interquartile Range REDs Relatively Energy Deficiency in Sport Declarations Ethics approval This study was approved by King’s College London’s ethics committee {Ref No: LRU/DP-23/24-41676} and conducted in line with the guidance given in the Declaration of Helsinki. Consent Informed consent was obtained from all individual participants included in the study. Data AvailabilityThe participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. Competing interests The authors have no financial or non-financial interests to declare. Funding This work was supported by the King’s Together Fund (King’s College London) Author ContributionConceptualisation: FL ACF, CVG, ZB, MR; Funding Acquisition: FL, ACF, ZB, MR, PK, LE, AN, AR; Data curation: FL, CVG, ZB; Methodology: FL, ACF, ZB, MR, CVG, AN, AR, PK, LE; Investigation: FL, CVG, ZB, MR, EB; Project Administration: FL; Supervision: FL, ZB, ACF; Formal Analysis: CVG, FL, ACF; Writing – Original Draft preparation: CVG; Writing – Review & Editing: All authors. Authors Information Catherine V. George: 0009-0006-5306-8414 Zoë Bell: 0000-0003-2416-4184 Michèle Renard: 0000-0003-4517-1316 Paulina Kloskowska: 0000-0002-2975-993X Angela C. Flynn: 0000-0001-8438-1506 Fiona Lavelle: 0000-0002-1211-0261 Electronic Supplementary Material Below is the link to the electronic supplementary material Supplementary Material 1 Supplementary Material 2 Supplementary Material 3 References 1. McGannon KR, Busanich R. Athletes and motherhood. Routledge international handbook of sport psychology: Routledge; 2016. p. 286 − 95. 2. McGannon KR, McMahon J, Gonsalves CA. Juggling motherhood and sport: A qualitative study of the negotiation of competitive recreational athlete mother identities. Psychology of Sport and Exercise. 2018;36:41 − 9. 3. Titova J, Davenport MH, Humphrys A, Hayman M. Barriers and enablers encountered by elite athletes during preconception and pregnancy: a mixed-methods systematic review. British Journal of Sports Medicine. 2024:bjsports-2024-108380. 4. Marshall NE, Abrams B, Barbour LA, Catalano P, Christian P, Friedman JE, et al. The importance of nutrition in pregnancy and lactation: lifelong consequences. Am J Obstet Gynecol. 2022;226(5):607 − 32. 5. Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years National Institute for Health and Care Excellence2025 [NG247:[Available from: https://www.nice.org.uk/guidance/ng247. 6. Healthy eating during pregnancy Health Service Executive2025 [Available from: https://www2.hse.ie/pregnancy-birth/keeping-well/food-drink/healthy-eating/. 7. Holtzman B, Ackerman KE. Recommendations and Nutritional Considerations for Female Athletes: Health and Performance. Sports Medicine. 2021;51(1):43–57. 8. King JC. Physiology of pregnancy and nutrient metabolism. The American Journal of Clinical Nutrition. 2000;71(5):1218S-25S. 9. Butte NF, Wong WW, Treuth MS, Ellis KJ, O'Brian Smith E. Energy requirements during pregnancy based on total energy expenditure and energy deposition. Am J Clin Nutr. 2004;79(6):1078-87. 10. Jagim AR, Fields J, Magee MK, Kerksick CM, Jones MT. Contributing Factors to Low Energy Availability in Female Athletes: A Narrative Review of Energy Availability, Training Demands, Nutrition Barriers, Body Image, and Disordered Eating. Nutrients. 2022;14(5). 11. Davenport MH, Meah VL, Ruchat SM, Davies GA, Skow RJ, Barrowman N, et al. Impact of prenatal exercise on neonatal and childhood outcomes: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1386-96. 12. Tighe BJ, Williams SL, Porter C, Hayman M. Barriers and enablers influencing female athlete return-to-sport postpartum: a scoping review. Br J Sports Med. 2023;57(22):1450-6. 13. Caro CV, Trow S, Bell Z, Flynn AC, Lavelle F. The Translation of Policy to Person: A Qualitative Analysis of Elite Athletes’ Perceptions of Pregnancy in the United Kingdom. Sports Medicine. 2025. 14. Davenport MH, Bains G, Hayman M, Cai C, Mkumbuzi NS, McHugh T-L. Advancing gender equity in sport: a scoping review of international sport federation policies for pregnant, postpartum and parenting elite athletes. British Journal of Sports Medicine. 2025:bjsports-2024-109135. 15. Hassan A, Brockwell E, Dufour S, Dohi M, Davenport MH. Kicking Off Motherhood: Considering Return to Play Postpartum in the Footballer. Sports Med. 2025. 16. Hassan A, Dufour S, Brockwell E, Dohi M, Davenport MH. Pregnant Pitches: Navigating Football Before and During Pregnancy. Sports Med. 2025. 17. Pregnancy Guidance and Support for UK Sport Funded Athletes. UK Sport; 2021. 18. Kari B, Raul A, Ruben B, Wendy JB, Gregory ALD, Michael D, et al. Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. Recommendations for health professionals and active women. British Journal of Sports Medicine. 2018;52(17):1080. 19. McHugh T-LF, Davenport MH. Development of sport policy and practice recommendations for pregnant, postpartum and parenting Canadian high-performance athletes. BMJ Open Sport & Exercise Medicine. 2024;10(3):e001888. 20. The Parenthood Recommendations2025. Available from: https://www.ausport.gov.au/ais/fphi/parenthood-recommendations. 21. O'Leary N, Caro C, Trow S, Bell Z, Payne E, Silverio SA, et al. Returning to sport after pregnancy: A qualitative study of elite female athletes in the UK. 2024. 22. Holden J, Wagstaff CRD, Wadey R, Brown P. Navigating athlete development in elite sport: Understanding the barriers to the provision of performance lifestyle service in England. Psychology of Sport and Exercise. 2025;77:102779. 23. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9. 24. George CV, Bell Z, Renard M, Brown E, Edwards L, Kloskowska P, et al. An investigation of the wants and needs for Pregnancy in Athletes and their postpartum return to sport in relation to Nutrition (The PAN project). 2024. 25. McKay AKA, Stellingwerff T, Smith ES, Martin DT, Mujika I, Goosey-Tolfrey VL, et al. Defining Training and Performance Caliber: A Participant Classification Framework. Int J Sports Physiol Perform. 2022;17(2):317 − 31. 26. Bø K, Artal R, Barakat R, Brown W, Davies GA, Dooley M, et al. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant. British Journal of Sports Medicine. 2016;50(10):571 − 89. 27. Dalhaug EM, Sanda B, Bø K, Brown WJ, Sundgot-Borgen J, Haakstad LAH. Exceeding the guidelines: A descriptive study of exercise, pregnancy, maternal and neonatal health outcomes in elite and recreational athletes. BMC Pregnancy and Childbirth. 2025;25(1):475. 28. Forsdick VK, Harris R, Saw R, Hayman M, Buckling H, Sundgot-Borgen J, et al. Exploring Australian high-performance athletes’ perceptions and experiences of sport participation during pregnancy and post-pregnancy: Development and test-retest reliability of the Mum-Alete Survey. Physical Therapy in Sport. 2022;58:80 − 6. 29. Renard M, Kelly DT, N NC, Lavelle F, C ÓC. Cooking and food skills confidence of team sport athletes in Ireland. Nutr Bull. 2023;48(3):329 − 42. 30. Taim BC, Lye J, Suppiah HT, Chan TW, Chia M, Clarke A. Menstrual cycle characteristics, perceived impact on performance, and barriers to communication: Perspectives of high-performance adolescent athletes in Singapore. Scandinavian Journal of Medicine & Science in Sports. 2024;34(1):e14488. 31. Sharps FRJ, Wilson LJ, Graham CA, Curtis C. Prevalence of disordered eating, eating disorders and risk of low energy availability in professional, competitive and recreational female athletes based in the United Kingdom. Eur J Sport Sci. 2022;22(9):1445-51. 32. Kamemoto K, Yamada M, Matsuda T, Ogata H, Tanaka N, Sakamaki-Sunaga M. Relationship between weight management and menstrual status in female athletes: a cross-sectional survey. Women Health. 2021;61(8):819 − 27. 33. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-88. 34. Jones PAT, Brockwell E, Dufour S, Hassan A, Matenchuk BA, Davenport MH. The lasting impacts of relative energy deficiency in sport imposed on pregnancy health outcomes: A survey-based investigation. J Sport Health Sci. 2025;14:101072. 35. Burns L, Weissensteiner JR, Cohen M, Bird SR. A survey of elite and pre-elite athletes’ perceptions of key support, lifestyle and performance factors. BMC Sports Science, Medicine and Rehabilitation. 2022;14(1):2. 36. Wasserfurth P, Palmowski J, Hahn A, Krüger K. Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. Sports Medicine - Open. 2020;6(1):44. 37. Khiri N, Howells K. Nutritional Education in Medical Curricula and Clinical Practice: A Scoping Review on the Knowledge Deficit Amongst Medical Students and Doctors. J Hum Nutr Diet. 2025;38(2):e70031. 38. Stone ME, Chapman P, Khasnis U, Collins D. Addressing the Shortage of Women in High-Performance Sport: What Is Known and What We Need to Know. Psychology International. 2025;7(3):74. 39. Santos-Rocha R, Szumilewicz A. Fostering the social and physical challenges of female recreational or professional athletes in pregnancy and postpartum. BMC Pregnancy and Childbirth. 2024;24(1):128. 40. McNulty K, Taim BC, Freemas J, Hassan A, Brantner C, Oleka C, et al. Research Across the Female Life Cycle: Reframing the Narrative for Health and Performance in Athletic Females and Showcasing Solutions to Drive Advancements in Research and Translation. Women in Sport and Physical Activity Journal. 2024;32. 41. Maughan RJ, Burke LM, Dvorak J, Larson-Meyer DE, Peeling P, Phillips SM, et al. IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete. International Journal of Sport Nutrition and Exercise Metabolism. 2018;28(2):104 − 25. 42. Close GL, Kasper AM, Walsh NP, Maughan RJ. "Food First but Not Always Food Only": Recommendations for Using Dietary Supplements in Sport. Int J Sport Nutr Exerc Metab. 2022;32(5):371 − 86. 43. Smith-Ryan AE, Hirsch KR, Saylor HE, Gould LM, Blue MNM. Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. J Athl Train. 2020;55(9):918 − 30. YesPregnancy and Postpartum Nutritional Wants and Needs in Athletes: A Cross-Sectional Survey in the United Kingdom and Republic of