What about emotional well-being for restricted athletes?

Middlebury College considers the emotional well-being of all its students to be important. It would be natural for athletes who are restricted from participation due to low energy availability to experience frustration and brief sadness. This is true of almost any athlete faced with an injury or illness, but in the case of low energy availability, the effect can be magnified due to a lack of visible injury or significantly palpable symptoms.

Hopefully, increased awareness regarding the devastating long term risks of participating in a low energy available state will help temper feelings of frustration. In cases where those feelings persist, referral to the Center for Counseling and Human relations may be appropriate.

How will Middlebury College screen athletes for low energy availability?

Sports Medicine certified athletic trainers (ATC) will obtain heights and weights of female athletes at the beginning of each season, and randomly throughout their season. Female athletes who are below 90% expected weight for height will enter a more regular monitoring program, be offered educational information, and offered visits with the Team Physician and Nutritionist for further assessment.

Female athletes who are below 85% expected weight for height will enter a more regular monitoring program and be asked to see the Team Physician and/ or Nutritionist for a more thorough assessment.

ATC’s will also encourage female athletes with stress fractures or greater than 3 consecutive months of amenorrhea to meet with the Team Physician to determine if more comprehensive assessment is needed.

Resources for athletes with low energy availability.

· Head Team Physician –x 5135

· Department of Sports Medicine – x 2315

· Center for Counseling and Human Relations – x 5141

· Kim Evans (Nutritionist) – 802-578-6975

In most cases, the resources above will be able to help the athlete recover from low-energy availability. However, in some cases, medical withdrawal for more intensive treatment may be recommended.


  1. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007 Oct;39(10):1867-82.
  2. Frisch RE, The right weight: body fat, menarche and fertility. Proceedings of the Nutrition Soc. 1994; (53):113-129.
  3. Robinson E, Bachrach LK, Katzman DK.Use of hormone replacement therapy to reduce the risk of osteopenia in adolescent girls with anorexia nervosa. J Adolesc Health. 2000 May;26(5):343-8.
  4. Bachrach LK. Consensus and controversy regarding osteoporosis in the pediatric population. Endocr Pract. 2007 Sep;13(5):513-20
  5. Keen AD, Drinkwater BL. Irreversible bone loss in former amenorrheic athletes Osteoporos Int. 1997;7(4):311-5.
  6. Cumming DC Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy. Arch Intern Med. 1996 Oct 28;156(19):2193-5.
  7. Williams, N. I., D. L. Helmreich, D. B. Parfitt, A. Caston-Balderrama, and J. L. Cameron. Evidence for a causal role of low energy availability in the induction of menstrual cycle disturbances during strenuous exercise training. J. Clin. Endocrinol. Metab. 86:5184-5193, 2001.
  8. Zanker, C. L., C. B. Cooke, J. G. Truscott, B. Oldroyd, and H. S. Jacobs. Annual changes of BMD over 12 years in an amenorrheic athlete. Med. Sci. Sports Exerc. 36:137-142, 2004.
  9. De Souza MJ, Williams NI, Beyond Hypoestrogenism in Amenorrheic Athletes: Energy Deficiency As a Contributing Factor for Bone Loss Current Sports Medicine Reports:Volume 4(1)February 2005p 38-44
  10. Johnson C, Powers PS, Dick R, Athletes and Eating Disorders: the NCAA Study. Int J Eat Disord 1999; 26: 79-88.
  11. Zanker CL.; Cooke CB. Energy Balance, Bone Turnover, and Skeletal Health in Physically Active Individuals. Medicine & Science in Sports & Exercise. 36(8):1372-1381, August 2004.
  12. Baum, Antonia Eating Disorders in the Male Athlete. Sports Medicine. 36(1):1-6, 2006.
  13. Bachrach LK, Guido D, Katzman D, Litt IF, Marcus R. Decreased bone density in adolescent girls with anorexia nervosa. Pediatrics. 1990 Sep;86(3):440-7.
  14. Braam LA, Knapen MH, Geusens P, Brouns F, Vermeer C, Factors Affecting Bone Loss in Female Endurance Athletes The American Journal of Sports Medicine 31:889-895 (2003)
  15. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement. 2000 Mar 27-29;17(1):1-45.
  16. Rencken ML, Chesnut CH 3rd, Drinkwater BL. Bone density at multiple skeletal sites in amenorrheic athletes. JAMA. 1996 Jul 17;276(3):238-40.
  17. Drinkwater BL. Exercise and bones. Lessons learned from female athletes Am J Sports Med. 1996;24(6 Suppl):S33-5.
  18. Lai K, Rencken M, Drinkwater BL, Chesnut CH 3rd. Site of bone density measurement may affect therapy decision. Calcif Tissue Int.1993 Oct;53(4):225-8.
  19. Gibson JH, Mitchell A, Harries MG, Reeve J. Nutritional and exercise-related determinants of bone density in elite female runners. Osteoporos Int. 2004 Aug;15(8):611-8. Epub 2004 Mar 26.
  20. Drinkwater BL, Nilson K, Chesnut CH, Bremner WJ, Shainholtz S, Southworth MB (1984) Bone mineral content of amenorrhoeic and eumenorrhoeic athletes. N Engl J Med 311:277–281
  21. Cobb KL, Bachrach LK, Sowers M, Nieves J, Greendale GA, Kent KK, Brown BW Jr, Pettit K, Harper DM, Kelsey JL. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc. 2007 Sep;39(9):1464-73.
  22. Fenichel RM, Warren MP Anorexia, bulimia, and the athletic triad: evaluation and management. Curr Osteoporos Rep. 2007 Dec;5(4):160-4.
  23. Fredericson M, Kent K. Normalization of bone density in a previously amenorrheic runner with osteoporosis. Med Sci Sports Exerc. 2005 Sep;37(9):1481-6.
  24. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Oral contraceptives improve endothelial function in amenorrheic athletes. J Clin Endocrinol Metab. 2005 Jun;90(6):3162-7. Epub 2005 Mar 15.
  25. Heckbert SR, Li G, Cummings SR, Smith NL, Psaty BM. Use of alendronate and risk of incident atrial fibrillation in women Arch Intern Med. 2008 Apr 28;168(8):826-31
  26. Sørensen HT, Christensen S, Mehnert F, Pedersen L, Chapurlat RD, Cummings SR, Baron JA.Use of bisphosphonates among women and risk of atrial fibrillation and flutter: population based case-control study. BMJ. 2008 Apr 12;336(7648):813-6. Epub 2008 Mar 11.
  27. Cobb, K. L., L. K. Bachrach, G. Greendale, et al. Disordered eating, menstrual irregularity, and BMD in female runners. Med. Sci. Sports Exerc. 35:711-719, 2003.
  28. De Souza, M. J., and N. I. Williams. Beyond hypoestrogenism in amenorrheic athletes: energy deficiency as a contributing factor for bone loss. Curr. Sports Med. Rep. 4:38-44, 2005.
  29. Golden, N. H., L. Lanzkowsky, J. Schebendach, C. J. Palestro, M. S. Jacobson, and I. R. Shenker. The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa. J. Pediatr. Adolesc. Gynecol. 15: 135-143, 2002.
  30. Grinspoon, S., L. Thomas, K. Miller, D. Herzog, and A. Klibanski. Effects of recombinant human IGF-1 and oral contraceptive administration on bone density in anorexia nervosa. J. Clin. Endocrinol. Metab. 87: 2883-2891, 2002.
  31. Hergenroeder, A. C., E. O. Smith, B. Shypailo, R. L. A. Jones, W. J. Klish, and K. Ellis. Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medoxyprogesterone, or placebo over 12 months. Am. J. Obstet. Gynecol. 176: 1017-1025, 1997.
  32. Klibanski, A., B. M. K. Biller, D. A. Schoenfeld, D. B. Herzog, and V. C. Saxe. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J. Clin. Endocrinol. Metab. 80: 898-904, 1995
  33. Munoz, M. T., G. Morande, J. A. Garcia-Centenera, F. Hervas, J. Pozo, and J. Argente. The effects of estrogen administration on bone mineral density in adolescents with anorexia nervosa. European Journal of Endocrinology 146: 45-50, 2002.
  34. Laughlin GA; Dominguez CE; Yen SS Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 1998 Jan;83(1):25-32.
  35. Loucks AB; Verdun M; Heath EM, Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol 1998 Jan;84(1):37-46.
  36. Grinspoon S, Miller K, Coyle C, Krempin J, Armstrong C, Pitts S, Herzog D, Klibanski A. Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea. J Clin Endocrinol Metab. 1999 Jun;84(6):2049-55
  37. Abernathy RP, Black DR. Healthy body weight standards. Nutrition. 1997 May;13(5):480-2.
  38. Pai MP, Paloucek FP, The origin of the "ideal" body weight equations. Ann Pharmacother. 2000 Sep;34(9):1066-9.
  39. Robinson JD, Lupkiewicz SM, Palenik L, Lopez LM, Ariet M, Determination of ideal body weight for drug dosage calculations. Am J Hosp Parm 1983 40:1016-9.
  40. Shah B, Sucher K, Hollenbeck CB. Comparison of ideal body weight equations and published height-weight tables with body mass index tables for healthy adults in the United States. Nutr Clin Pract. 2006 Jun;21(3):312-9.
Are male athletes being screened for low energy availability?

While there are also concerns about male athletes participating with low energy availability, there is currently insufficient medical evidence and outcomes data on which to make a similar screening recommendation for men.10 However, expansion of the screening program for male teams is being considered for the fall of 2009, depending on availability of resources, and all campus resources are available to male students who may have concerns. This issue will continue to be explored, and changes made if new information becomes available.

How is expected weight for height determined?

There are multiple formulas and actuarial tables for determining an expected weight for height. Unfortunately these methods, including determination of Body Mass Index (BMI), cannot account for differences in genetics and prior health status, and are therefore used for screening purposes only.

Middlebury College uses a screening formula which is commonly used by eating disorder specialists in both diagnosis and recovery.

Expected weight = 100 lbs + 5 lbs / inch over 60 inches.

For example, a 5’5” (65 inch) woman would have an expected weight of 125 lbs. Female athletes below 85-90% of this expected weight may be at significant risk for low energy availability.

Why is Middlebury College screening female athletes for low energy availability?

Middlebury College is committed to supporting the health and well-being of it’s student-athletes and strongly favors the student-athlete’s health over improved performance or competition. Current medical reports state that female athletes who participate in sports in a state of low energy availability can sustain significant and potentially irreversible adverse medical consequences which will impact them later in life. Athletes may not be able to recognize that they are participating in a state of low energy availability and are at risk for significant health consequences.

What is the right weight for me?

Body weight is affected by many factors. Some we have control over while others we do not. Some of these factors include: genetics, quality of food choices, percentage of lean body mass, bone density, and hydration.
Generally speaking the right body weight is the weight that you have most easily maintained during your adult life, with healthy eating practices. For women this assumes, as well, that weight at which you have a regular menstrual cycle while not taking hormones (i.e. “the pill”).
There are many different ways of calculating an estimation of “ideal body weight”. The formula used by Middlebury College is:

Female: 100 pounds for the first 5 feet and then 5 pounds for every Inch over 5 feet

Male: 106 pounds for the first 5 feet and then 6 pounds for every Inch over 5 feet.

In most cases, keeping your weight close to this range should ensure long-term health, sound eating habits, successful physical fitness and performance, and a healthy body image. Keep in mind that many athletes will weigh slightly greater than the estimated ideal weight because they have a significantly greater percentage of lean body mass.
The guidelines outlined in the LEAP program, namely that athletes must maintain a weight that is 90% of their ideal to participate, is a minimum recommendation. Most athletes will fare much better in terms of competitiveness and overall general health if they maintain a higher weight. Dieting or restricting calories to maintain a low weight can lead to serious medical and mental health illness. Brain chemistry is adversely affected by dieting and is not recommended for athletes. Lowering your caloric intake even minimally can cause mood changes (you may find yourself feeling blue and down or more anxious and compulsive than usual) and make workouts and training less enjoyable and successful. If you have questions about your weight, how to eat for maximize health and enjoyment or other questions related to nutrition, please contact Kim Evan, RD and make an appointment.

What if I weigh more than my expected weight for height?

Your risk for low energy availability is low; however, sudden drops in weight could indicate that an athlete is entering a state of low energy availability with similar consequences for low weight female athletes. Athletes concerned about weighing more than the expected weight for height are encouraged to discuss their concerns with the Team Physician and/or Nutritionist.

What is low energy availability?

Energy availability (EA) is the amount of dietary energy remaining for bodily functions after exercise.1

EA = dietary energy input - exercise energy output.

Energy availability is different than energy balance. When energy availability is too low, physiological mechanisms reduce the amount of energy used for cellular maintenance, thermoregulation, growth, and reproduction. This compensation tends to restore energy balance and promote survival, but impairs health. Stable body weight in amenorrheic athletes suggests that energy balance can be restored while energy availability is low.1 Therefore, energy balance can occur during the low energy available state, but this is considered to be an overall state of impaired health.

Why should I weigh a weight close to my ideal range?

Our experience has shown us that athletes who weight close to their ideal body weight have improved performance, decreased risk of injury, shorter recovery times, and when injured they recover more quickly.
Our focus is on energy availability. One way of understanding this concept is to assume that in order to have energy available for daily living and physical fitness you need to sustain your body weight in a healthy range. Not doing so means that the energy you consume (in the foods that you eat) will be going to meet your body’s fuel needs for basic functioning and will not be available to you to use in purposeful activity.

How is low energy availability treated?

“The first aim of therapy to restore menstrual cycling and increase bone mineral density (BMD) is to modify the diet and exercise behavior to increase energy availability by increasing energy intake and reducing energy expenditure, or a combination. Menstrual cycles may be restored by increasing energy availability to more than 30 kcal.kg -1FFM.d -1, but the strong association between increases in BMD and increases in body weight implies that increasing BMD may require more than 45 kcal.kg -1FFM.d -1. This value corresponds to energy balance in healthy young women. Increased energy availability should continue until menses resume and be maintained while training and competing.” 1

Female athletes who screen positive for low energy availability will be referred to the Team Physician and a Nutritionist for more detailed assessment. When the assessment indicates low energy availability, the athlete may need complete or partial restriction from participation until normal or positive energy availability can be restored and maintained. In this situation, the athlete will be given specific goals with a timeframe for return. If goals cannot be reasonably met within the specified timeframe, a recommendation for full restriction may be made. Some athletes may be referred to the Center for Counseling and Human Relations for assessment of mental health and/or eating disorders. Athletes with exercise related compulsive disorders or eating disorders may need further assessment and possible restriction from athletic participation for reasons other than low-energy availability. Medical leaves will be recommended in severe or life threatening situations.

What are some health risks associated with low energy availability?

The following list represents several conditions that can be difficult to recognize, are interrelated (also known as the Female Athlete Triad), and if untreated can lead to devastating long-term health problems, such as:

a. Failure to attain peak bone mass

b. Low bone mineral density (osteopenia & osteoporosis)

c. Stress fractures

d. Problems with menstrual periods (oligomenorrhea & amenorrhea)

e. Infertility

f. Mental health issues:

1. Depression

2. Anxiety

3. Low self-esteem

4. Disordered eating

Energy Balance vs. Energy Availability

Energy Balance is a concept that looks at weight maintenance in terms energy (in the form of calories) going into the body being balanced with energy leaving the body (in the form of physical activity). In theory, these should be equal in order to maintain body weight. However, in the case of under-eating the body will compromise metabolic functions in order to preserve body composition. This significantly skews energy balance making it appear that the body requires less energy than it actually does.
Energy Availability looks at maintaining energy balance at the highest level of functioning. This model ensures that energy is available for optimal metabolic functioning, maintaining thermal regulation of the body, maximizing the digestive process, maintaining all blood constituents, daily activity, and purposeful exercise. It also provides an energy reserve so that energy is available to be transferred when the need arises (such as during extended physical activity or when the body is in repair and maintenance mode).

Can I protect my bones by going on “the pill” to get a menstrual period?

The use of hormone replacement therapy was suggested many years ago to increase bone density in exercising women with amenorrhea and low bone density. Though an occasional small study might support this practice 6, many amenorrheic patients are still prescribed oral contraceptives despite emerging evidence that exogenous hormones do not restore bone mass in amenorrheic women. 3

“It must be emphasized that pharmacological restoration of regular menstrual cycles with oral contraceptives will not normalize metabolic factors that impair bone formation, health and performance. Thus, it is unlikely to fully reverse the low BMD in this population.” 1

“Sex steroid replacement has not proven effective in restoring bone mass in patients with anorexia nervosa or exercise-associated amenorrhea.” 4

“Despite several years of normal menses or use of oral contraceptives, the mean vertebral BMD of former oligo-amenorrheic athletes remained low. Our results suggest early intervention is necessary to prevent irreversible vertebral bone loss in oligo/amenorrheic athletes.” 5

“Exogenous estrogens may be ineffective at improving BMD in the absence of improved nutrition and weight gain.” 7

“There have been few controlled trials that have investigated the efficacy of combined estrogen and progesterone treatment for the protection of bone mass in young, active women with a low body mass and amenorrhea and the majority have shown no beneficial effect.” 8

“If BMD declines in an athlete greater than 16 years of age with persistent hypothalamic amenorrhea despite adequate nutritional intake and weight, then OCP may be considered with the hope of minimizing further bone loss.” 1

What are the physical symptoms and signs of low energy availability?

The symptoms and signs of low energy availability can be subtle and difficult to recognize. Some female athletes may not realize that they are in a low energy state. Stress fractures and not getting a period (amenorrhea) are concerning signs; however, some females take medications such as oral contraceptives for other medical reasons, and may not be able to rely on amenorrhea as an effective sign.

A low body weight compared to what is expected for height and age can be another sign. Researchers suggest that a body weight of at least 85-90% of expected weight is one of the requirements for normal menstrual function. 2

Preoccupation with weight or food, dieting and specific food avoidance can also suggest disordered eating behavior that could lead to low energy availability. However, it is important to realize that “low energy availability may occur inadvertently without clinical eating disorders, disordered eating behaviors or even dietary restriction.” 1

How do I calculate my needs for energy availability?

There are many factors that get considered in making recommendations for ideal energy availability. A registered dietitian, ideally who specializes in sports nutrition, can help you calculate caloric requirements and look at macro and micro nutrient distribution.

Health Services
Centeno House
1st & 2nd Floor
Phone: 802.443.5135
Fax: 802.443.2066

Centeno House
3rd Floor
Phone: 802.443.5141
Fax: 802.443.3407

Sports Medicine
Field House
Phone: 802-443-2315
Fax:  802-443-2094