Jan 29, 2015
Erasing the Deficit

Related to the female athlete triad, a new concern called Athletic Energy Deficit is causing sports medicine professionals to take a closer look at the needs of girls involved in competitive athletics.

By Kathleen Cody

Kathleen Cody is the Executive Director of American Bone Health and the Foundation for Osteoporosis Research and Education, a community-based health organization providing support and education to the public to promote lifelong bone health. She can be reached at: [email protected].

This article is dedicated to Tina Bonci, MS, ATC, LAT, who helped with its initial drafts. Associate Athletics Director and Co-Director of Sports Medicine at the University of Texas, Tina passed away on March 7. A pioneer and leader in athletic training, Tina served on T&C’s editorial board since 2001 and we will miss her deeply.

It starts innocently enough. A young female athlete sets high goals for her upcoming season and starts to push herself harder. Hoping to gain a competitive edge, she trains intensely and restricts her caloric intake even though her workouts place greater demands on her body than before. In the field of competitive athletics, such a regimen is often seen as normal and natural, if not downright healthy. Girls who reconfigure their diets to pursue excellence in sports are rewarded by coaches and admired by parents for their discipline and focus. The problem, however, is that the nutrition sacrificed along the way, particularly during puberty, can adversely affect a young female athlete in ways that are not immediately obvious. Most athletic trainers have heard of the female athlete triad. Initially identified as an association of eating disorders, amenorrhea, and osteoporosis in female athletes, it now includes broader definitions along spectrums of energy availability, menstrual function, and bone mineral density.

One particular syndrome along this spectrum more recently recognized is called Athletic Energy Deficit (AED). Though related to the female athlete triad, AED includes heavily exercising younger teens and preteens who are premenarchal and thus would not manifest the menstrual dysfunction that is a component of the female athlete triad. In addition, athletes with AED are not necessarily heading down a path toward an eating disorder. But it can have the same negative consequences as the triad. AED can lead to hormonal alterations that cause a decrease in bone formation and bone density and an increase in bone fractures. It can have lifelong consequences for the bone and reproductive health of a developing girl and the woman she will become.

In 2012, American Bone Health convened an interdisciplinary panel of sports medicine and health care professionals to take an in-depth look at AED. The consensus from the meeting was that athletic trainers, coaches, parents, and physicians must work together to increase the awareness and prevention of AED among young female athletes. An athlete suffering from AED may show no overt signs of this condition, and recognizing and treating it requires different tactics than those used in managing most injuries.


Whenever a person does not eat enough to meet their body’s requirements–whether as a result of dieting or not increasing their caloric intake to match what they expend–the body is weakened. If the deficit remains for an extended period of time, the body responds by suppressing physiological functions. Menstruation is one of the essential bodily functions that can be suppressed by AED. Getting insufficient or inappropriate nutrition causes hormonal imbalances that result in menstrual cycles that are delayed (primary amenorrhea), absent (primary or secondary amenorrhea), or irregular (oligomenorrhea). Growth hormone, IGF-1, and estrogen are important for stimulating bone-building cells and inhibiting bone-resorbing cells, and an imbalance in the secretion of these hormones during the preteen, teen, and young adult years can lead to suboptimal bone development, bone loss, and fractures. In severe cases, amenorrhea can lead to premature osteoporosis. Even after girls resume normal menstruation, the damage sustained from energy deficit may not be completely reversible. Experts now suspect that the United States may be developing a generation of young female athletes who will experience AED-related stress fractures and premature osteoporosis as early as their 20s. There are four factors that account for peak bone mass–hormones, physical activity, intake of calcium and vitamin D, and heredity. While no one can change the genes they are born with, there is a lot that young athletes can do to ensure the other three avenues to optimal bone growth are being taken care of.


In helping to diagnose AED, the first thing to understand is that the lack of nutritional intake is not always an eating disorder. Although eating disorders such as anorexia nervosa or bulimia can also lead to amenorrhea and severe energy deficit, they are most often caused by a significant psychological component unrelated to participation in competitive sports.

Athletes with AED limit consumption for various reasons. Sometimes it’s with the belief that being thinner will garner a competitive edge. Other times it’s to achieve a certain body type they believe will look more appealing, encouraged through peer pressure or media images. Another reason is time constraints and poor choices–with so many demands on both children and their parents these days, it is easy to settle for convenience foods that do not provide appropriate nutrition. Finally, it is sometimes the case that athletes simply do not understand how many calories they need to maintain peak performance. So what does AED look like in an athlete? A delay in menstrual onset or oligomenorrhea may be the only definitive symptom. Regardless of athletic performance, age-appropriate and regular menstrual periods are a vital indicator of a girl’s overall health. Occasional “missed” menstrual periods can occur normally in some young girls, but concern is appropriate if an athlete has not started menstruating by age 15 or has missed several consecutive menstrual periods. A stress fracture in a young female athlete should also be considered a red flag. Stress fractures are typically seen in athletes who are focused exclusively on one sport or activity, such as long-distance running, or those who aren’t getting sufficient rest or nutrition for their bodies to effectively recover. Further examination of both nutrition and activity is warranted in teens with stress fractures. In addition, athletic trainers should know that AED is more prevalent in certain sports in which a lean body type is seen as ideal for peak performance, such as swimming, gymnastics, skating, and ballet. The incidence of AED is also thought to be higher among young women participating in strenuous endurance sports such as cross country, track and field, and crew.

One of the best ways to become aware of a potential case of AED is through the preparticipation exam (PPE). The following questions can help tease out a potential problem that should be addressed:

– Have you ever had a menstrual period? – How old were you when you had your first menstrual period? – When was your most recent menstrual period? – How many periods have you had in the past 12 months? – Are you presently taking any female hormones (estrogen, progesterone, birth control pills)? – Do you worry about your weight? – Are you trying to or has anyone recommended that you gain or lose weight? – Are you on a special diet, or do you avoid certain types of foods or food groups? – Have you ever had an eating disorder? – Have you ever had a stress fracture? – Have you ever been told you have low bone density (osteopenia or osteoporosis)?

Beyond the PPE, watching for signs of AED is important. However, it can be complicated for a number of reasons. Girls who love athletic competition and feel a loyalty to their coach or team may be reluctant to reveal their symptoms, or they might have a male coach or athletic trainer who is uncomfortable talking about menstruation with adolescent females. In addition, even when the risks of AED are explained to them, young female athletes may have difficulty imagining the consequences of their behavior on their future health. Those who are sexually active may also be reluctant to discuss missing a menstrual period out of anxiety or denial about a possible pregnancy.

Athletic trainers who suspect a female athlete may be at risk for AED should contact their school nurse or the parents directly, suggesting they see a pediatrician. The doctor will screen the girl and may refer her to a nutritionist or other specialist in behavioral therapy to assess for an eating disorder. In cases not complicated by psychological factors, successful treatment may require no more than a relatively modest reduction in exercise, better nutrition, and a small increase in body weight. The best solutions usually entail athletes sitting down with their parents and mapping out a nutrition strategy. Once the adequate amount of calories is determined, meals and snacks can be planned around helping the athlete reach her nutritional goals. For busy athletes, snacks that travel well are critical and can include peanut butter and jelly sandwiches, bagels with cream cheese, and nutrition bars. In the past, amenorrhea in older teens was often treated by doctors with oral contraceptives. However, this remedy is slowly being discontinued because it does not fix the energy deficit at the root of the menstrual problem, nor has this method been shown to improve bone health. No drug treatment has been approved for the prevention of bone loss in this age group, although a recent study has shown that estrogen patches with cyclic oral progesterone may cause some improvement in bone density in teenage girls with restrictive eating disorders.


Awareness, education, and proper nutrition are key to preventing AED. This starts with making sure all coaches and administrators understand AED and its consequences, which can be accomplished through a department workshop and one-on-one discussions with coaches of girls’ sports. These coaches should be encouraged to introduce the subject to their entire team in a group setting, with assistance from sports dietitians, team doctors, or volunteer medical professionals familiar with AED.

Encourage parents to talk to their daughters about their level of sports activity, proper nutrition, healthy menstrual periods, and how these three elements relate to strong bone development. Parents are an important ally in preventing AED since they may be most in tune with their daughter’s menstrual cycle. Many parents mistakenly believe that irregular periods are a part of puberty, but irregular periods should not persist for more than two years after menstruation begins. Athletic trainers can send home information sheets or talk about the facts surrounding this topic during preseason parent meetings. Educating female athletes is the second vital component. Since young teens can be indifferent to their long-term health, it can work well to relay how AED can hurt their current competitive performance. For instance, energy deficit does not improve exercise tolerance and can lead to stress fractures and other injuries. Explain how stress fractures make it harder to compete, and that athletes can help prevent them by meeting their nutritional needs. Lastly, proper nutrition is critical. AED can be prevented when athletes maintain a positive energy balance by consuming enough calories to offset the energy expended during physical activity. Young, growing female athletes should consume a minimum of 2,000 calories per day and sometimes much more, depending on their training schedule. Athletic trainers can raise awareness about these facts by sharing slogans such as, “Eat… grow stronger… win!” or “Fuel your sport!”

A quick way to help girls understand their energy needs is to use a Resting Metabolic Rate calculator that can be found online, which shows them how many calories they’d burn if they stayed in bed all day. When they see how much they burn when at rest, they may recognize how much more they go through when active and the importance of fueling accordingly. It may also be helpful to consult a sports dietitian about nutrition education for your teams. In addition, research shows that consuming adequate carbohydrate and protein within 20 to 30 minutes of strenuous athletic activity will help replenish the body and prevent the development of AED. This practice is especially important if additional strenuous physical activity will occur again later in the day or the next day. The young female athlete’s diet needs to consist of an adequate intake of all the macronutrients (protein, carbohydrate, and fat). Also important are the essential micronutrients, including bone- and blood-building nutrients (calcium, magnesium, iron, folate, vitamin B12, and vitamin D) and B vitamins required for energy metabolism (vitamin B6, riboflavin, thiamin, niacin, biotin, and pantothenic acid).

Calcium and vitamins are especially critical. Girls nine to 18 need 1,300 mg of calcium a day. To get there, they should consume three to four servings of calcium-rich foods, such as dairy or fortified juices. Girls who are lactose intolerant can use lactase pills or they may need to take a calcium supplement. Vitamin D is important for the absorption of calcium and phosphorus from the stomach and the development of peak bone mass. Recent studies have shown that vitamin D helps reduce the incidence of stress fractures in physically active girls. All healthy adolescents require 600 IU of vitamin D daily, and those at risk for vitamin-D deficiency or insufficiency may need at least 1,000 IU daily.

While AED is a serious problem, adults should not discourage girls from participating in competitive athletics. For young girls, the health benefits associated with regular exercise and athletic competition can be gained without encountering AED as long as careful attention is paid to energy balance. Armed with an awareness of AED and its risks, athletic trainers and coaches can make sure their young female athletes continue to grow where it really counts–down deep in their bones.

Sidebar: Road to Recovery

Clara Peterson fell in love with running after completing the mile in her fourth-grade gym class, but she didn’t start equating skinny with fast until her teen years. By this time, she was competing on her high school’s cross country and track and field teams and noticed other girls’ times were dropping after they lost weight. Her reaction? To restrict her caloric intake in an extreme manner, which set off a multiyear battle with Athletic Energy Deficit (AED).

Part of her diet plan was to eliminate all fat. “I ate a lot of fat-free foods because I thought that meant they were healthy,” Peterson says. “As a young female athlete in a sport where lighter is better, I sometimes got carried away. I wasn’t consuming enough to support my training, let alone the systems in my body that were critical for my long-term health.”

Peterson developed amenorrhea, which tipped her mother off that something might be wrong. “My mom looked into it further and scheduled me for a bone scan,” Peterson says. “At that age, I should have been at the peak of my bone development, but the scan showed that my bone density was low.”

While the bone density test results indicated a clear link to AED, Peterson’s success in her spikes–she won three California state championships in cross country–made her brush aside any health concerns. She felt invincible and wasn’t aware of the consequences that could come later in life. Furthering her running career at Duke University, as well as her restrictive diet, her amenorrhea continued.

Peterson’s mother, however, remained concerned and eventually convinced her daughter to undergo a second bone scan as she reached the end of her teen years. The results were telling.

“My bone density got worse during my first few years at Duke,” Peterson says. “It was finally the red flag I needed. I realized that if I didn’t get my menstrual cycle back, my bones were going to continue to suffer, and I would eventually start getting stress fractures. It was also really scary to think about what could happen down the road with fertility problems and osteoporosis. I knew I needed to make a change.”

Peterson began taking steps to fix her energy deficit during her junior and senior years. “I added a lot more fat into my diet through avocadoes, olive oil, and coconut oil,” she says. “On long runs, I brought bottles of electrolyte-enhanced drinks and goos and had protein shakes after workouts. In high school, I was worried about gaining weight, but once I increased my body fat in a healthy way, I actually got stronger and faster.”

The positive effects showed up on the track. Peterson’s senior season at Duke was her best, as she took second in the 5,000 meters at the 2006 NCAA Division I Indoor Championships and second in the 10,000 meters at the 2006 Outdoor Championships. And they also showed up in her health. “I started getting my period again, and my bone density stopped declining,” Peterson says. “I’ll have permanent bone density damage from not menstruating for eight years, but I’ve been able to slowly build it back up.”

Since graduating from college in 2006, Peterson continues to run, with a goal of qualifying for the 2016 Olympic marathon. She pays careful attention to her fueling and menstruates more regularly. “My performance and energy are 100 percent better than they were when I was younger,” says Peterson. “I’m running almost twice the weekly mileage I ran in college, and I recover a lot quicker from workouts.”

In addition, Peterson now serves as an AED Ambassador for American Bone Health, speaking around the country to spread awareness among young female athletes. “AED is a silent disorder, so it can be hard to address,” she says. “Bone health and a regular menstrual cycle can feel unimportant to girls who haven’t had any injuries yet, but my message is they can’t ignore what’s going on with their bodies.”

Through her advocacy work, Peterson often encounters girls who are hesitant to tell anyone they have amenorrhea because they are uncomfortable broaching the subject with male coaches or athletic trainers. Therefore, she encourages sports medicine professionals and coaches to take proactive roles.

“Girls don’t usually want to talk about their periods, so coaches and athletic trainers can’t be afraid to ask,” Peterson says. “And if you know an athlete who is not menstruating has had stress fractures in the past, make the connection that she could have AED. It’s something that needs to be discussed a lot more.

— Mary Kate Murphy

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