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Journal of Athletic Training 201146(3)322-336copy by the National Athletic Trainers Association Incwwwnataorgjat

position statement

National Athletic Trainers Association PositionStatement Safe Weight Loss and MaintenancePractices in Sport and ExercisePaula Sammarone Turocy EdD ATC (Chair) Bernard F DePalmaMEd PT ATCt Craig A Horswill PhDtKathleen M Laquale PhDATC LDNsect Thomas J Martin MDII Arlette C Perry PhD~ Marla JSomova PhD Alan C Utter PhD MPH FACSMDuquesne University Pittsburgh PA tCornell University Ithaca NY tUniversity of Illinois at Chicagoand Trinity International University Deerfield IL sectBridgewater State University MA IIHershey MedicalCenter PA ~University of Miami FL Carlow University Pittsburgh PA Appalachian State UniversityBoone NC

Objective To present athletic trainers with recommenda-tions for safe weight loss and weight maintenance practicesfor athletes and active clients and to provide athletes clientscoaches and parents with safe guidelines that will allow ath-letes and clients to achieve and maintain weight and bodycomposition goals

Background Unsafe weight management practices cancompromise athletic performance and negatively affect healthAthletes and clients often attempt to lose weight by not eat-ing limiting caloric or specific nutrients from the diet engagingin pathogenic weight control behaviors and restricting fluidsThese people often respond to pressures of the sport or ac-tivity coaches peers or parents by adopting negative bodyimages and unsafe practices to maintain an ideal body com-position for the activity We provide athletic trainers with rec-ommendations for safe weight loss and weight maintenance insport and exercise Although safe weight gain is also a concernfor athletic trainers and their athletes and clients that topic isoutside the scope of this position statement

Recommendations Athletic trainers are often the sourceof nutrition information for athletes and clients therefore theymust have knowledge of proper nutrition weight management

Weight classifications in sport (eg youth footballwrestling rowing boxing) were designed to ensurehealthy safe and equitable participationl however

not all sports or activities in which weight might playa rolein performance use a weight classification system In activi-ties such as dance distance running gymnastics and cyclingweight and body composition are believed to influence physicalperformance and the aesthetics of performance Yet the govern-ing organizations of these activities have no mandated weightcontrol practices In 2005 the American Academy of Pediat-rics2 published a general weight control practice guide for chil-dren and adolescents involved in all sports

In addition to the potential performance benefits of leanbody mass and lower levels of body fat long-term health bene-fits include decreased cardiovascular risk factors reduced trig-lyceride concentration possible increases in cardioprotective

322 Volume 46 bull Number 3 bull June 2011

practices and methods to change body composition Bodycomposition assessments should be done in the most scientifi-cally appropriate manner possible Reasonable and individual-ized weight and body composition goals should be identified byappropriately trained health care personnel (eg athletic trainersregistered dietitians physicians) In keeping with the AmericanDietetics Association (ADA) preferred nomenclature this docu-ment uses the terms registered dietitian or dietician when refer-ring to a food and nutrition expert who has met the academicand professional requirements specified by the ADAs Commis-sion on Accreditation for Dietetics Education In some cases aregistered nutritionist may have equivalent credentials and bethe commonly used term All weight management and exer-cise protocols used to achieve these goals should be safe andbased on the most current evidence Athletes clients parentsand coaches should be educated on how to determine safeweight and body composition so that athletes and clients moresafely achieve competitive weights that will meet sport and ac-tivity requirements while also allowing them to meet their energyand nutritional needs for optimal health and performance

Key Words body composition body fat diet hydrationmetabolism sport performance

high-density lipoprotein cholesterol concentration increasedfibrinolysis reduced resting blood pressure reduced restingglucose and insulin and increased insulin sensitivity In fe-males lower body fat may also protect against breast and otherreproductive cancers4 Although lean body mass has been as-sociated with positive health benefits negative health outcomesare associated with excessive loss or gain of body masss

RECOMMENDATIONS

Based on the current research and literature the NationalAthletic Trainers Association (NATA) suggests the followingsafe weight loss and weight maintenance strategies for partici-pants in all sports and physical activities These recommenda-tions are built on the premise that scientific evidence supportssafe and effective weight loss and weight management practices

Assessing Body Composition and Weight

Table 3 Determining Goal Weight from Body Composition

Current body fat - Desired body fat = Nonessential body fat

Current body weight x Nonessential body fat = Nonessential fat Ib(in decimal format)

7 When hydration is a concern regular or more frequent (orboth) assessments of body weight are indicated EvidenceCategory C

8 Active clients and athletes in weight classification sportsshould not gain or lose excessive amounts of body weightat any point in their training cycles Evidence Category C

9 Management of body composition should include both dietand exercise Evidence Category B

10 Total caloric intake should be determined by calculatingthe basal metabolic rate (BMR) and the energy needs foractivity Evidence Category B

11 Caloric intake should be based on the body weight goal(Table 4) Evidence Category C

12 A safe and healthy dietary plan that supplies sufficient en-ergy and nutrients should be maintained throughout theyear (Table 5) Evidence Category B

13 The US Department of Agricultures Food Pyramid Guideis one of the methods that can be used to ensure adequatenutrient intake Evidence Category C

14 The metabolic qualities of the activity should be consideredwhen calculating the need for each energy-producing nutri-ent in the diet (Tables 6-8) Evidence Category B

15 Safe and appropriate aerobic exercise will facilitate weightand body fat loss Evidence Category C

16 Body composition adjustments should be gradual with noexcessive restrictions or use of unsafe behaviors or prod-ucts Evidence Category C

17 Combining weight management and body compositiongoals with physical conditioning periodization goals willassist athletes or clients in reaching weight goals EvidenceCategory C

18 Education on safe dietary and weight management prac-tices should be communicated on a regular and plannedbasis Evidence Category C

19 Individual body composition or dietary needs should bediscussed privately with appropriately trained nutrition andweight management experts Evidence Category C

20 Ergogenic and dietary aids should be ingested cautiouslyand under the advisement of those knowledgeable of therequirements of sports and other governing organizationsEvidence Category C

Current body weight - Nonessential fat Ib = Ideal body weight Ib

x

plusmn25

plusmn22-37a

plusmn35b

plusmn5b

plusmn35-5b

plusmn18a

Not fully developeda

Assessment Technique

HydrodensitometryAir displacement

plethysmographySkinfold measurementsNear-infrared interactanceBioelectric impedanceDual-energy x-ray

absorptiometryComputed tomography or

magnetic resonanceimaging

Model

2 Compartment

1 Body composition assessments should be used to determinesafe body weight and body composition goals EvidenceCategory B

2 Body composition data should be collected managed andused in the same manner as other personal and confidentialmedical information Evidence Category C

3 The body composition assessor should be appropriatelytrained and should use a valid and reliable body composi-tion assessment technique (Table 1) Evidence Category C

4 Body weight should be determined in a hydrated state Evi-dence Category B

5 When determining goal weight body weight should beassessed relative to body composition This assessmentshould occur twice annually for most people with no lessthan 2 to 3 months between measurements (Tables 2 3)Evidence Category C

6 To track a persons progress toward a weight or body com-position goal private weigh-ins and body compositionassessments should be scheduled at intervals that provideinformation to guide and refine progress as well as to es-tablish reinforcement and reassessment periods EvidenceCategory C

Multiplecompartment

3 Compartment

and techniques regardless of the activity or performance goalsThe recommendations are categorized using the Strength of Rec-ommendation Taxonomy criterion scale proposed by the Ameri-can Academy of Family Physicians6 on the basis of the level ofscientific data found in the literature Each recommendation isfollowed by a letter describing the level of evidence found inthe literature supporting the recommendation A means there arewell-designed experimental clinical or epidemiologic studies tosupport the recommendation B means there are experimentalclinical or epidemiologic studies that provide a strong theoreti-cal rationale for the recommendation and C means the recom-mendation is based largely on anecdotal evidence at this time

Table 1 Body Composition Assessment Techniques7

Standard Errorof Estimate

Table 2 Body Fat Standards () by Sex and Age

a More research is neededb Differs with each equation

Body Fat Standard

Lowest reference body fat (adults)58-11Lowest reference body fat (adolescents)12Healthy body fat ranges13

Males

57

10-22

Females

1214

20-32

Background and Literature Review

Weight management and nutrition is a multibillion-dollarindustry that has become pervasive in almost every aspect ofmodern life Diet and exercise have always affected sports andphysical activity but with the intensity of competition increas-ing at all levels has come a renewed interest in controlling thefactors that influence performance and health Diet exercisebody composition and weight management now play largerroles in an active persons life and performance Because ath-

Journal of Athletic Training 323

Table 4 Determining Total Caloric Needs

Harris-Benedict14

Female basal metabolic rate = 6551 + (96xweight [kg]) + (19xheight [cm])-(47xage [y]) + Activity needsMale basal metabolic rate = 665 + (138xwt [kg]) + (5xht [cm])-(68x age [y]) + Activity needs

Activity needsSedentary (mostly sitting) add 20-40 of basal metabolic rateLight activity (sitting standing some walking) add 55--65 of basal metabolic rateModerate activity (standing and some exercise) add 70-75 of basal metabolic rateHeavy activity add 80-100 of basal metabolic rate

Mifflin-St Jeor5Female basal metabolic rate=(10xwt [kg]) + (625xht [cm])-(5xage [y])-161Male basal metabolic rate=(10xwt [kg])+(625xht [cm])-(5xage [y])+5

Abbreviations BW body weight CHO carbohydrate

Table 6 Energy-Producing Nutrients

b Convert the 9 of CHO into kcal needed__ 9 CHOx4 = kcal from CHO

b Total caloric need - value A = fat needed kcal__ =(B)_

Many safe and effective methods are available to achieveand maintain goal weight and body composition However al-though published and widely accepted weight and body com-position standards exist9 there are few published or mandatedweight or body composition management requirements Evenwithin sports with weight-class systems (eg boxing light-weight crew sprint football wrestling) only wrestling andsprint football consider the components of an athletes weightand body composition as well as the safety considerations forachieving and maintaining that body size192o

Since 1997 specific rules and guidelines have been imple-mented to ensure that weight control practices in wrestling aresafe applied early in the competitive season and conducted ona regular and planned schedule around competitions and do notinclude dehydration as a means of weight loss 1These weightmanagement and dehydration prevention regulations are effec-tive in reducing unhealthy weight-cutting behaviors and pro-moting equitable competition21

In 2006 the National Federation of State High School As-sociations adopted similar standards (ie body compositionweigh-in procedures and hydration status) for determiningminimum body weights in high school wrestlers but the bodyfat minimums were higher (-7 in males -12 in females)than the levels for collegiate athletes determined by the NationalCollegiate Athletic Association (NCAA)21 These differenceswere implemented to address growth needs in adolescents andsex differences The National Federation of State High School

letic trainers (ATs) and other members of the health care teamhave regular contact and ongoing relationships with athletesand clients engaged in active lifestyles they are frequentlyasked for assistance in achieving personal and performancegoals These goals often include diet exercise and weightmanagement Some AT-client relationships and their sharedbody composition goals are formalized as with weight-classsport athletes others are not

Weight Management in Weight-Class Sports

General Population Requirement

5-7 gkg of body weight per d08-1 gkg of body weight per d15-35 of total caloric intake per d

CarbohydratesProteinsFats

Nutrient

c Convert kcal into actual number of calories__ kcal from CHO divided by __ total kcal = __

Fat intakea Based on the remaining number of calories needed calculate

the fat intake neededCHO kcal + protein kcal = kcal from CHO and protein___ + = (A) __

c Value B +9 = fat 9___ +9= _

b Convert the 9 of protein into kcal needed__ 9 protein x 4 = kcal from protein

c Protein needed of total caloric intake__ kcal from protein + __ total kcal = __

Carbohydrate intakea Calculation of CHO needs based on activity levels

BW in kg x gramskg BW = 9 of CHOkg BW_____ x _

Table 5 Determining Energy-Producing Nutrient Intake

Protein intakea Calculation of protein needs based on activity levels

BW kg x gkg BW = 9 of proteinkg BW_____ x _

Table 7 Carbohydrate Intake516

Activity Type

Optimal glycogen storage for single term or single eventCarbohydrate for moderate-intensity or intermittent exercise gt1 hDaily recovery and fuel for aerobic athlete

(1-3 h moderate-intensity to high-intensity exercise)Daily recovery and fuel for extreme exercise program

(gt4-5 h moderate-intensity to high-intensity exercise)

Recommendation

7-10 gkg of body weight per d05-1 gkg of body weight per h (30-60 gh)

7-10 gkg of body weight per d

10-12 + gkg of body weig ht per d


Sport Performance and Aesthetics

Practices of weight manipulation and body fat control arenot exclusive to sports with weight-class requirements Partici-pants in other activities requiring speed and aesthetics also useweight manipulation to improve performance Leaner athletesin sports such as middle-distance and long-distance runningcycling and speed skating are often perceived by coaches andpeers to perform better 10

Although body fat contributes to weight it does not alwayscontribute to energy in the muscular contractions needed for ex-ercise and sport A disproportionately greater amount of musclemass and smaller amount of body fat are needed by participantsin activities that may be influenced by body size In sports suchas the broad jump or vertical jump in which the body must bepropelled through space generating power is essential Morepower can be achieved by a body with a higher ratio of muscleto fat than one of the same mass with a lower ratio of muscleto fat In swimming although body fat allows for greater buoy-ancy in water which reduces drag athletes with a greater pro-portion of muscle mass to fat can produce more speed

Similarly in sports such as ski jumping a lean slight buildwas once thought desirable to reduce air resistance and to al-

Associations standards have not been accepted or enforced uni-versally in the United States Therefore universally safe or ef-fective weight management practices in high school wrestlingare not assured

Sprint football is a collegiate sport sponsored by 6 teamsin the Collegiate Sprint Football League Cornell UniversityMansfield University Princeton University University of Penn-sylvania US Military Academy at West Point (Army) andUS Naval Academy (Navy) Sprint football has the same rulesas NCAA football but also has a weight limit for players of1720 Ib (78 kg) which is far lower than the weights typicallyseen in NCAA football players2o To the previously requiredminimum body composition of 5 body fat sprint football in2008 added compulsory assessment of body composition andplaying weight in a hydrated state with a urine specific gravityof lt102020

In 1997 collegiate lightweight crew and rowing athletes be-gan using US Rowing weight classifications and a 5 min-imum body fat guideline to determine a safe rowing weightUnlike wrestling the revised 2007 crew weight requirementsdid not take into account the athletes body composition or hy-dration status in determining minimum body weight Althoughsome institutions have adopted weight certification guidelinessimilar to those in wrestling no formal rules are in place To-days standards stipulate that male lightweight rowers must notexceed 160 Ib (73 kg) and female lightweight rowers must notexceed 130 Ib (59 kg) Minimum weights are in place only forcoxswains All crew members must be weighed once a day be-tween 1 and 2 hours before the scheduled time of the first raceeach day that the athlete competes22

Table 8 Protein Intake58141718

Athlete Type

low the athlete to stay airborne as long as possible and to covera greater distance before landing1OThis performance standardalso holds true for activities such as dance figure skating gym-nastics and diving The aesthetic aspect of performance is alsoa consideration for weight management practices in these ac-tivities Leaner participants are viewed as more attractive andsuccessfuF324 and perceived to demonstrate better body sym-metry position and fluidity of motion

Because no scientific or health principles support weightmanagement for the purpose of aesthetics in performance wewill address this topic only in its association with body com-position and weight management Many considerations foraesthetic performance activities are related to the body com-position of female participants but research2526also recognizesthe effect of similar social pressures on male body images

Pressures on participants to control weight stem from varioussources including society family2527-29peers3 and coaches3deg-33as well as the judging criteria used in some activities34 Thesepressures may place participants at higher risk for developingunrealistic weight goals and problematic weight control be-haviors Most aesthetic performance activities require fit bodytypes for success and these requirements may trigger an un-healthy preoccupation with weight 35Generally participants incompetitive activities that emphasize leanness for the sake ofperformance or aesthetic enhancement are at the highest riskfor developing dysmorphia eating disorders and disorderedeating 36-4D

Because of the need to control all factors that may affectperformance perfectionism is a common psychological traitamong athletes Along with the desire to look thin and the be-lief that decreased weight enhances performance perfection-ism increases the risk of developing an eating disorder41-43Perfectionism is typically associated with setting high goalsand working hard to attain them which enables athletes to suc-ceed4044People who are aware of concerns about their weightfrom coaches parents teammates friends or significant othersare more likely to develop subclinical eating disorders45

In general women in non-weight-class activities identifytheir ideal body sizes and shapes as smaller than their actualbodies whereas men tend to want to be larger (ie more mus-cular) and are more concerned with shape than with weight46-49The demands of a males activity determine whether desirablebody size or weight (or both) is smaller (eg gymnastics) orlarger (eg football) Because the topic of dysmorphia has beenaddressed more comprehensively in the NATAs position state-ment on preventing detecting and managing disordered eatingin athletes50 it is addressed here only in the context of weightmanagement practices

Regardless of the rationale to support weight managementpractices goal weights and body compositions for athletes andactive clients must be determined and maintained in a safe andeffective manner The purposes of this position statement are toidentify safe methods by which goal weight can be determinedand maintained and to discuss unsafe weight managementpractices and the effects of those practices on performance andoverall health

Body Composition

To fully understand the topic of body composition it is es-sential to understand how body composition is assessed Us-ing the most common description of body composition the2-compartment (2-C) model is a quantifiable measure that can

Recommendation

17-18 gkg of body weight (maximum=2 g)12-1 4 gkg of body weight08-1 gkg of body weight09-1 gkg of body weight

Strength athletesEndurance athletesGeneral populationVegetarians


Body Weight Fat and FFM

Table 9 Body Mass Index (BMI) Classifications7

8MI Classification

Fat mass can be categorized as essential fat sex-specific fatand storage fat9 Essential fat which averages 3 of total fatmakes up the bone marrow heart lungs liver spleen kidneysintestines muscles and lipid-rich tissues of the central nervoussystem9 In women essential fat also may include sex-specificfat (eg breasts hips pelvis) and averages 1258-11Storage fatwhich averages 12 in men and 12 to 15 in women is lay-ered subcutaneously it is stored by the body to provide an en-ergy substrate for metabolism9 When essential fat is added tostorage fat men average 15 total body fat whereas women av-erage 20 to 27 total body fat Low-reference body fat com-position is 5 in men and 12 in women58-11Low-referencebody fat composition which is necessary to maintain normalreproductive health and hormone function is 7 in adolescentmales and 14 in adolescent females212Lower levels of fathave been associated with good health and normal body func-tion58-11Although no maximum body fat requirements exist thehighest safe weights should not exceed the body fat ranges con-sidered satisfactory for health 10 to 22 and 20 to 32 inphysically mature adolescent males and females respectively13

Body fat is distributed in sex-specific patterns Typically

be divided into 2 structural components fat and fat-free mass(FFM) Fat-free mass consists primarily of muscle bone wa-ter and remainder elements9 In the general population excessbody fat is associated with adverse health consequences whichinclude cardiovascular disease51 diabetes52 gallstones53 ortho-paedic problems54 and certain types of cancer 55Although ac-tive people have a lower incidence of these conditions excessbody fat combined with a family history of cardiovascular ormetabolic diseases and inactivity can reverse the benefits of ac-quired health associated with an active healthy lifestyle

To develop a method for determining the risks associatedwith excess body fat the body mass index (BMI) assessmentwas created The original purpose of the BMI assessment wasto predict the potential for developing the chronic diseases as-sociated with obesity9 Body mass index may be an appropriatemethod for determining body size in the general population butthis technique does not assess fat mass and FFM ThereforeBMI assessment is less accurate for athletes and active clientswho have higher levels of FFM14Even though a sedentary per-son and an active person may have the same height and weighttheir fat to FFM ratios may be very different When applied tothe BMI formula the active persons additional FFM skews theassessment of body composition resulting in a BMI evaluationthat is inaccurate as a predictor of increased risk for chronicdiseases More individualized body weight and body composi-tion assessments are needed for active people with high lev-els of lean body mass to accurately evaluate the effect of bodyweight on the risk of developing chronic diseases (Table 9)

Assessment of Body Composition

Clinical Methods Used to Assess Body Composition

Skinfold thickness which has been validated with hydro-static weighing is the most frequently used and easily acces-sible clinical method to estimate body composition Although

Several methods are available to measure body composi-tion but most research on assessment in athletes has focusedon densitometry indirect measurement of body density using a2-C model consisting of fat mass and FFM Body density is theratio of body weight to body volume (Table 1)

Total body volume is typically measured by hydrostatic(underwater) weighing59 with a correction for pulmonary re-siduallung volume60 Most other body composition techniqueshave been validated in comparison with hydrostatic weighingbecause of its lower standard error of the estimate Similar tohydrostatic weighing air displacement plethysmography is anewer densitometric method that measures mass and volume tocalculate body density61

Multicompartment models in which FFM is divided into2 or more components have been validated with hydrostaticweighing methods in athletes59-65Some authors66-68suggestedthat these multicompartment models may be more appropri-ate for the athletic population however these findings are notwidely accepted Two-compartment models demonstrated asignificant overestimation for air displacement plethysmogra-phy in collegiate football players69 but close agreement betweenhydrostatic weighing and air displacement plethysmography incollegiate wrestlers70

Some concerns have been raised about selecting the appro-priate conversion formula when using the 2-C model to assessbody composition in active people The Schutte equation71 iscommonly used to estimate fat and FFM from body densityin black males but with multicompartment models recent re-searchers72-74found that using race-specific equations to esti-mate percentage of fat from bone density was inappropriateFor adolescent and high school athletes the adult conversionformulas of SirF5 and Brozek et aF6 are generally accepted

Dual-energy x-ray absorptiometry (DXA) has been re-ported6364to slightly underestimate body fat in some athleticpopulations when compared with multicompartment modelsOther authors5456have noted strong agreement between DXAand multicompartment models in various athletic groups Ath-letes generally have greater bone mineral content bone min-eral density and FFM and a lower percentage of body fat thannonathletes77 Considering that DXA also measures bone min-eral composition and density it may be preferable to either hy-drostatic or air displacement plethysmography 2-C models asa reference method for assessing body composition in athletesand active people78

women distribute more body fat in the gluteofemoral region ina gynoid fat distribution pattern sometimes referred to as pearshaped Women also store more fat in the extremities than menIn contrast men distribute more fat in the abdominal region inan android or apple pattern and have greater subscapular to tri-ceps skinfold thickness than do women56 The android fat distri-bution has been related to more significant health consequencesassociated with cardiovascular disease including diabetes hy-pertension and hyperlipidemia757 and may contribute more toincreased disease risk than does obesity alone 58

UnderweightAverage (normal)OverweightGrade I obesityGrade II obesityGrade III extreme obesity

lt185185-2499250-299300-349350-399~40a 8M I=weight kgheight2 m


skinfold measures are easy to obtain the importance of de-veloping a skillful measuring technique cannot be overstatedStandardized skinfold sites and measurement techniques aredescribed in the Anthropometric Standardization ReferenceManual79 An extensive number of prediction equations areavailable for estimating bone density from skinfold measuresin different athletic populations (Durnin and Womersley Katchand McArdle Jackson-Pollock) but selected equations havebeen recognized for broad applicability to both male and fe-male athletic populations In addition to these equations thegeneralized Lohman equation80 is recommended for both highschool and collegiate wrestlers78 Based on the referenced va-lidity studies ready availability of equipment and ease of useskinfold prediction is highly recommended as a body composi-tion assessment technique for athletes and active clients

The accuracy of bioelectric impedance analysis (BIA) an-other method used to assess body composition is highly depen-dent on testing under controlled conditions Skin temperaturestrenuous exercise dehydration and glycogen depletion sig-nificantly affect impedance values8182Population-specific andgeneralized BIA equations developed for the average popula-tion do not accurately estimate the FFM of athletic men andwomen83-86Some researchers658788reported that the skinfoldmethod is a better predictor of body fat percentage in athletesthan the BIA method which is a more effective tool for obtain-ing group data on athletes than for detecting small changes inindividual athletes body fat89

Another body fat measuring technique near-infrared inter-actance (NIR) provides optical density values for estimatingbody fat The manufacturers prediction equation systemati-cally underestimated body fat in both active men and collegiatefootball players839091Limited research is available on the va-lidity of NIR among female athletes in various sports A fewauthors9293used optical density values to develop predictionequations in athletic populations The NIR prediction equationswere slightly better than the skinfold method in estimating bodycomposition and minimal wrestling weight in high school-agedwrestlers94

Fat and FFM should be assessed by an AT or other trainedbody-composition assessor using one of the validated meth-ods available (eg hydrostatic weighing air displacement ple-thysmography skinfold measures) All manual measurementtechniques (eg skinfold calipers) should follow standardizedprotocols and be performed at least 3 times by the same as-sessor to ensure reliability79 The body size needs of the activ-ity and the typical body composition of the participants in thatactivity should be considered as well as the minimum bodycomposition standards when available

Body Composition and Hydration Assessment

Body composition and weight assessments should always beconducted on hydrated people Criterion (ie total body waterand plasma markers) and field methods (ie acute body masschange urine and saliva markers bioelectric impedance) canbe used to assess hydration status The gold standard for de-termining hydration status is measurement of total body waterRepeated measurements of water content before and after rapidweight reduction reflect the absolute change in fluid contentThe FFM of adult bodies contains approximately 72 water94a value slightly less than in children (75) and adolescents(73)9495

Plasma markers or a comparison of blood indices of hydra-

tion status with laboratory standards also may be used to deter-mine hydration status Plasma osmolality of the blood sodiumcontent and hemoglobin and hematocrit levels are typicallyelevated when the plasma volume is reduced because of dehy-dration The plasma osmolality of a hydrated person ranges be-tween 260 and 280 mOsmkg A plasma osmolality above 290mOsmkg indicates dehydration96 Hemoglobin and hematocritlevels can also be used to assess relative changes in plasma vol-ume based on loss of fluid from the vascular space Howeverthis technique has many limitations and does not always reflectchanges in hydration9798

The acute body-mass change field method is one of thesimplest ways to assess changes in hydration Assessing bodyweight before and after a period of exercise or heat exposurecan provide data reflecting hydration Immediate weight lossafter exercise results from dehydration and should be addressedusing the guidelines described in the NATA position statementon hydration99 Using weight-tracking charts to evaluate thesechanges during exercise can help to determine the hydrationstatus of an active person

Urine markers are another noninvasive method to determinethe hydration status of the bloodlOo-104When the body has afluid deficit urine production decreases and the urine becomesmore concentrated The total volume of urine produced duringa specified period is lower than expected (normal is approxi-mately 100 mLlh)96 Simultaneously urine specific gravity os-molality and conductivity increase due to a greater number ofsolids in the urine and the conservation of body fluid Urinecolor also may serve as a gross predictor of hydration state102

Urine specific gravity and osmolality respond to acutechanges in hydration status However changes in these markersmay be delayed or insensitive to low levels of acute dehydration(1 to 3 of body weight)lOo In addition these markers maybe no more effective in detecting dehydration than assessingurine protein content via the dipstick method105 Ease of col-lection and measurement at least for urine specific gravity andcolor make the dipstick method practical for self-assessment ofhydration status in most settings99

Similar to those of urine characteristics of saliva change asthe hydration level changes106Because the salivary glands pro-duce saliva using plasma a decrease in plasma volume due todehydration affects the concentration of substances found in sa-liva Although a saliva sample is easy to obtain the analysis forosmolality and total protein content requires instrumentationbeyond the scope of most practice settings Saliva flow rate iscollected with a dental swab but requires an analytical balancefor precise measurement of the change in swab weight aftersaliva collection

Recently BIA and bioelectric impedance spectroscopy havebeen proposed104107for measuring total body water and thecompartments within the total body water respectively Thesemethods provide reasonable measurements of body composi-tion and total body water for groups of individuals but whetherthey can track changes in hydration status and an individualshydration level is unknown Several investigators108109foundthat bioelectric impedance analysis and bioelectric impedancespectroscopy failed to accurately predict reductions in totalbody water after rapid dehydration Some of this inaccuracymay result from other factors (eg increased core temperatureand skin blood flow) that may influence the reactance and resis-tance measurements on which these techniques rely

To ensure adequate hydration an average adults wa-ter intake should be 37 Lid for men and 27 Lid for women


Athletes active clients and those who are exposed to hot en-vironments need higher intakes of total water110To maintainadequate hydration a person should drink 200 to 300 mL offluid every 10 to 20 minutes during exercise Pre-exercise andpostexercise fluid intake should be consistent with the recom-mendations provided in the NATA position statement on fluidreplacement99

As noted previously body weight and body compositionshould be assessed with the person in a hydrated state Thosewho fail to meet the minimum hydration levels (urine specificgravity of less than 1020 or urine color less than or equal to4)1ll should not be assessed until hydration standards are metand no sooner than 24 hours after the first hydration statusfailure

Body Composition and Determining Body Weight

No single source offers normative body composition datafor athletes Therefore ATs and other health care personnelinvolved in body composition assessment should become fa-miliar with data sources specific to their athlete or client popu-lations They should take into consideration the safe ranges andthe body composition needs of the sport and then individualizeweight and body composition goals

The lowest safe weight should be calculated at no lowerthan the weight determined by the low-reference body fat com-position delineated by sex and age The lowest safe weight canbe defined operationally as the lowest weight sanctioned bythe governing body at which a competitor may compete Whenno standard exists participants should be required to remainabove a certain minimum body fat Highest safe weight shouldbe calculated using a value no higher than the highest end ofthe range considered satisfactory for health 10 to 22 bodyfat in males and 20 to 32 in females (Table 2)13

The AT should work closely with the team physician ormedical supervisor to develop a plan for the collection andmanagement of body composition data and related informa-tionll2 This information should be restricted to those who needit to provide care for the athlete or client The AT should fullydisclose to the athlete or client who will have access to personalbody composition informationll3 If the body composition orother nutritional and weight management findings indicate apotentially harmful or high-risk behavior the AT is responsiblefor informing the athlete or client of the risk113and the teamphysician or medical supervisor of the medical concern 114

Body composition measurements to determine goal weightsshould be assessed twice annually115with no less than 2 to 3months between measurements50 for most people These regu-lar measurements will allow ATs and other health profession-als to alter weight goals based on decreases in body fat andincreases in lean muscle mass Caution should always be takento ensure that an athletes or clients body composition neverfalls below the lowest or rises above the highest safe weight orbody fat level To track an athletes or clients progress towarda weight or body composition goal private weight and bodycomposition assessments should be scheduled at more frequentintervals to guide and refine progress and to establish reinforce-ment and reassessment periods

Measurement intervals should be identified in consultationwith the physician and other members of the health care teaminvolved in the athletes or clients care This team should in-clude an AT licensed mental health care provider physicianand registered dietitian116If weight control practices are a con-


cern collaboration and education should occur early and fre-quently in the process

Monitoring Body Weight

During preseason activities that involve equipment that couldincrease sweat loss or prevent adequate cooling in warmer andmore humid climates body weight should be reassessed at leastdaily because of the increased risk of dehydration and heat-related illness Daily weigh-ins before and after exercise canhelp identify excessive weight loss due to dehydration

Active clients and athletes in weight classification sportsshould not gain or lose excessive amounts of body weight atany point in their training cycles Athletes and clients should at-tempt to maintain levels that are close to their weight and bodycomposition goal when not competing and maintain their goalweight and body composition during competition Excessivefluctuations in body weight or body composition (or both) cannegatively affect the body including but not limited to changesin metabolic activity fluctuations in blood glucose levels andmuscle wasting14Athletes in weight classification sports shouldhave individual monitoring plans such as assessments at leastonce per month in the off-season and at regular intervals not toexceed once per week to monitor for weight fluctuationsY5

Body Composition and Dietary Intake

Caloric and nutrient intake should be based on lean bodymass desired body composition goal weight and sport or ac-tivity requirements Intake that is too high or too low to supportthe desired lean body mass will negatively affect metabolicfunction and body composition Metabolic function is moreefficient in those with greater amounts of lean body massMetabolic function and oxygen utilization can be measuredor estimated with predictive equations that take into consider-ation body size fat mass FFM age sex and the expenditureof energy for activity12117The Harris- Benedict14 and Mifflin-StJeor15 estimation formulas which account for height weightage and sex to determine the BMR are commonly recom-mended methods for indirectly estimating total caloric needhowever other methods are also appropriate One drawback tothe use of estimation formulas is that muscular tissue uses moreenergy than does nonmuscular tissue Therefore estimationformulas may underestimate the daily caloric needs of athletesor clients who are very muscular (Table 4)

A healthy diet or meal plan should provide adequate caloriesto achieve body weight goals supply essential nutrients andmaintain hydration To ensure effective performance energyintake must come from an appropriate balance of the 3 essen-tial energy-producing nutrients (ie protein carbohydrates andfats) In addition appropriate intake of non-energy-producingessential nutrients (eg vitamins minerals water) is needed tofacilitate energy creation and maintain other body processes8Carbohydrates should provide 55 to 70 of the total caloricneed of athletes and active people and may be as high as 12 g ormore per kilogram of body weight 51016Muscle glycogen (storedglucose) and blood glucose derived from carbohydrates arethe primary energy substrates for working muscle 1718118There-fore the more aerobic the activity the greater the carbohydrateneed (Tables 6 7)

To determine needed protein intake it is important to iden-tify the type of exercise and the intensity level of that exer-cise5101718Protein assists with many bodily functions but

most athletes and clients are interested in building and repair-ing muscle contractile and connective tissue Protein provides8 to 10 of the bodys total energy needs In events lastinglonger than 60 to 70 minutes amino acid oxidation increasesthereby increasing the use of protein to support the greater en-ergy demands Strength athletes and those whose goals are tobuild FFM need the most protein in the diet For those who arenot interested in developing a great deal of FFM but want tomeet the needs of an aerobic activity more moderate amountsof protein are desirable Protein intake in excess of the bodysphysical requirements increases hydration needs overburdensthe liver and kidneys and interferes with calcium absorption inaddition excess protein can be broken down and used as com-ponents of other molecules including stored fat (Table 6)14

Finally dietary fats are essential to a healthy diet becausethey provide energy assist in the transport and use of fat-sol-uble vitamins and protect the essential elements of cells12 Fatmetabolism provides a portion of the energy needed for low- tomoderate-intensity exercise and the use of fat for energy me-tabolism increases as aerobic metabolism increases Fats can beused to spare both readily available glucose and stored muscleglycogen Although the average intake of fat in athletes is ap-proximately 30 of total caloric intakeIO14the commonly heldconsensus is that 20 to 25 of total caloric intake shouldcome from fats12 To maximize performance athletes shouldtake in no less than 15 of total caloric intake from dietaryfats 1217Fat intake should minimize partially hydrogenated un-saturated (trans) fats and saturated fats17 total fat intake shouldbe equally divided among polyunsaturated monounsaturatedand trans or saturated fats

Maintaining Body Composition and Weight withDiet and Exercise

Diet Management of body composition should include bothdiet and exercise To maintain good health and stave off dis-ease a regular exercise program should be combined with adietary plan The dietary plan should be developed to addressthe athletes or clients specific body composition body weightand activity goals Individual body composition and dietaryneeds should be discussed privately with appropriately trainednutrition and weight management experts Athletic trainers andother health professionals such as registered dietitians shouldprovide nutritional information to athletes and clients A Board-Certified Sports Dietitian (CSSD) is a registered dietitian whohas earned the premier professional sports nutrition credentialfrom the American Dietetic Association Coaches peers andfamily members should not provide information on diet bodycomposition weight or weight management practices andshould refrain from making comments on or participating in themonitoring of body composition and weight5o

Total caloric intake should be determined by calculatingBMR and the energy needs for activity Many methods are avail-able to determine total caloric need including assessments of met-abolic function and oxygen utilization but equations that estimatemetabolic function are more plausible options for clinicians Thesemetabolic estimation equations take into consideration body sizefat mass and FFM age sex and the expenditure of energy foractivity12117One drawback to the use of estimation formulas isthat muscular tissue uses more energy than does nonmusculartissue therefore estimation formulas that are not adjusted forlean muscle mass may underestimate the daily caloric needs forathletes or clients who are very muscular

Caloric intake should be based on the body weight goal Aperson should consume a total number of calories based on bodycomposition and weight goals Caloric intake that is too high ortoo low to support the desired lean body mass will negativelyaffect metabolic function and body composition Metabolicfunction is more efficient in those with greater amounts of leanbody mass When BMR is calculated based on the body com-position and weight goals this formula provides an importantestimate of the energy needed to meet activity requirements

A safe and healthy dietary plan that supplies sufficient en-ergy and nutrients should be maintained throughout the year Ahealthy diet or meal plan provides adequate calories to achievebody weight goals supply essential nutrients and maintain hy-dration The US Department of Agricultures Food PyramidGuide is one method that can be used to ensure adequate nutri-ent intake Athletes and clients should identify the appropriateFood Guide Pyramid (wwwmypyramidgov)1l9 that describesfood groups and the recommended number of daily servingsper group adults and children need to consume for essential nu-trients The AT or other trained health care professional can alsouse the appropriate Food Guide Pyramid to calculate the rec-ommended caloric intake level based on the individuals goalweight The guidelines at wwwmypyramidgov are consistentwith recommendations by organizations such as the AmericanHeart Association and the American Cancer Society to controldiabetes heart disease cancer and other chronic and debili-tating diseases12oEven though this method may underestimatethe protein and carbohydrate needs of athletes or clients it canbe used to correctly guide a persons eating needs for vitaminand mineral intake and overall caloric intake

The metabolic qualities of the activity should be used tocalculate the need for each energy-producing nutrient in thediet To determine specific dietary needs and adjustments ananalysis of the metabolic characteristics (eg anaerobic or aero-bic) with consideration for the performance body compositionweight and personal goals of the athlete or client (eg buildmuscle mass lose fat) must be performed

Ergogenic and dietary aids should be ingested with cautionand under the advice of those knowledgeable about the require-ments of sports and other governing organizations The NCAAUS Olympic Committee and International Olympic Commit-tee regulate supplements approved for use by athletes By-law1652 g of the NCAA states that an institution may provide onlynon-muscle-building nutritional supplements to a student-ath-lete at any time for the purpose of providing additional calo-ries and electrolytes as long as the supplements do not containany substances banned by the NCAA19 Athletes and clientsshould be educated against taking any dietary or other nutri-tional supplements without first checking with the AT or an-other health care provider who is familiar with the competitiveregulations

Exercise The exercise program should not only train theperson for his or her activity but should also help the personmaintain overall physical fitness and wellness Body weight andcomposition may be maintained by pursuing an exercise regimenthat matches a persons needs The American College of SportsMedicine recommends 30 minutes of exercise 5 days per weekto remain healthy7 however if the goals are to facilitate weightand body fat loss a safe and appropriate aerobic exercise pro-gram will facilitate that loss To maximize the metabolism ofexcess fat one must participate in continuous rhythmic aerobicexercise for a minimum of 30 minutes per exercise bout butno longer than 60 to 90 minutes for at least 150 minutes per


weekY8119IZIAlthough interval exercise for 30 minutes burnsthe same number of calories the metabolism of fat is less Ifthe person is unfit or has not exercised at this level previously agraded-progression approach should be used to achieve the ex-ercise goals 14Target heart rate for this aerobic activity must beabove 50 VOzmax to initiate lipolysis with the most efficientfat metabolism occurring between 60 and 70 VOzmax (ap-proximately 55 to 69 of maximum heart rate)5118Cautionshould be used in those with orthopaedic or other health con-ditions that may warrant changes in exercise protocols Non-weight-bearing or limited-weight-bearing aerobic exercises arerecommended for those with orthopaedic conditions

Body composition adjustments should be gradual with noexcessive restrictions or unsafe behaviors or products On aver-age weight loss goals should be approximately 1 to 2 Ib (05 to09 kg) per week but should not exceed 15 of body weightloss per week1IZZA higher rate of weight loss indicates dehy-dration or other restrictive or unsafe behaviors that will nega-tively affect performance and health One pound (05 kg) offat is equal to 3500 kilocalories of energy therefore increasesor decreases in calories to the level needed to maintain ideallean mass will help to achieve body fat goals Few authors havestudied plans for weight gain goals in active people but a pro-cess similar to that for weight loss may be used The AT shouldwork closely with the other members of the health care team toassist in this determination

Combining weight management and body compositiongoals with physical conditioning periodization goals will as-sist athletes and clients in reaching weight goals Periodizationinvolves manipulating training intensity and volume to yieldspecific performance outcomes The best time for adjustmentsin weight and body composition is during the preparatory pe-riod which occurs outside competition115 The main emphasisof the competitive period should be on performing the sportor activity with the body nearing its highest level of physicalfitness During the competitive period less time is availablefor physical conditioning and more time is spent on strengthpower and increased training intensity specifically related tosport performance During the different phases of the prepara-tory period physical conditioning goals can be used to achievebody composition goals During the hypertrophy or endurancephase the emphasis is on developing lean body mass aerobiccapacity and muscular endurance which can provide a physi-ologic environment to assist in decreasing body fat During thebasic strength and strength-power phases the emphasis is ondeveloping strength and speed and involves increasing levels ofanaerobic activitylz3 An AT or other trained health care profes-sional should be consulted for assistance in manipulating thesephases of the periodization plan to meet training goals

Education on safe dietary and weight management practicesshould be conducted on a regular and planned basis The ATand other health care professionals should be involved in edu-cating athletes or clients and monitoring their diets The initialteam meeting or client interview is an opportune time to com-municate information on healthy eating habits and the effect ofproper nutrition and hydration on performance

Common Unsafe Weight Management Practices

Athletes and active people regularly seek methods to maxi-mize performance and many of the common methods involvemanaging diet weight or body composition (or a combinationof these) Although many safe methods exist to achieve goal


weight or the lowest safe weight unsafe practices involve self-deprivation techniques that lead to dehydration self-starvationand disordered eating In field studies and experimental researchon weight-class athletes the most common unsafe methods area mixture of dehydration and other methods including food re-striction or improper dieting to reduce body fat Therefore theresults of studies examining the physiologic and performanceeffects of rapid weight reduction may not reflect only dehydra-tion Studies selected for this summary are those that focusedprimarily on dehydration techniques and involved short-termrapid weight reduction

Dehydration and Weight Management

Since the late 1930s and as recently as 2003 authors1Z4IZ5have reported that athletes used voluntary dehydration as amethod of rapid weight loss to reach a lower body weight forcompetition Several rapid weight loss methods involve rapidfluid loss these methods use active passive diet-inducedpharmacologic-induced and blood reinfusion techniques toachieve a desired weight The active method involves increas-ing metabolic rate through exercise to increase the rate of heatproduction in active skeletal muscle1Z6At least 1 L of fluid maybe lost through sweat evaporation during exercise1z7 when anactive person abstains from drinking fluid during activity Toensure continued sweating exercise is often combined with ex-cessive clothing which diminishes the evaporative effects ofsweating and increases insulation and core temperature1Z8IZ9At one time dehydration was a common method used bywrestlers130-132but a surveylZ7 indicated that this method hasbecome less popular because of changes in the weigh-in proce-dures (ie assessments of hydration status) of sport governingbodies These active methods may be enhanced by combiningthe active technique with environmental changes that increasethe passive sweat rate resulting in higher levels of dehydrationor the training facility may be artificially heated to ensure ahigher passive sweat rate with less physical effort 130-134Recentchanges in sport guidelines appear to have reduced the extent towhich collegiate wrestlers use passive dehydration1z5

Athletes who use passive dehydration methods also mayrestrict food intake for weight loss or may purposefully con-sume foods that promote diuresis for fluid loss A combinedhigh-protein low-carbohydrate diet may promote dehydra-tion through several mechanisms Meals high in protein anddevoid of carbohydrate may modestly stimulate urine produc-tion As the body is deprived of carbohydrates fat oxidationis increased promoting additional fluid loss in the urine Witha high protein intake the person may further induce diuresisfrom the increased nitrogen metabolism and urea excreted viathe kidneys14

Some researchers135 suggested that total body water is el-evated with the consumption of a high-carbohydrate diet forc-ing muscle glycogen to be stored along with water which canincrease body weight As dietary carbohydrate intake is re-stricted glycogen resynthesis may be limited thereby avoid-ing the increase in body weight caused by water storage 135However this dietary strategy does not provide optimal energystores for a competitive athlete136137and performance maysuffer98138139

Ingesting medications that stimulate urine production (egdiuretics) may have a greater influence on body weight thandoes altering the diet Diuretics appropriately prescribed forhypertensive therapy or to reduce edema have been misused by

athletes seeking rapid weight loss for competition Fortunatelythe misapplication of pharmacologic agents was uncommonin weight-class athletes who were surveyed23132however thispractice has not been fully eradicated

Finally one reportl4D and other anecdotal stories from ath-letes indicate that some athletes at international competitionshave had blood removed intravenously before the requiredweigh-in The blood is then reinfused after the athlete makesweight for competition Other than the lone report no for-mal information is available about this method or the extent towhich it has been practiced or is currently used

Effects of Dehydration on Performance

Dehydration results in suboptimal performance when thedehydration is ~l in children and ~2 in adults14D141Inchildren 1 dehydration causes a reduction in aerobic perfor-mance142and an increase in core temperature143 In adults 2to 3 dehydration causes decreased reflex activity maximumoxygen consumption physical work capacity muscle strengthand muscle endurance and impairs temperature regulation 144145At 4 to 6 dehydration further deterioration occurs in maxi-mum oxygen consumption physical work capacity musclestrength and endurance time temperature regulation is se-verely impaired III These physiologic effects of dehydration arediscussed in depth in 2 NATA position statements991ll and willnot be discussed further here

Most athletes who participate in weight-class sports needshort-duration high-intensity efforts that demand rates of en-ergy production at or above the peak oxygen uptake For singleefforts whether performance is affected by dehydration be-fore performance is unclear Dehydration does not appear toreduce phosphagen energy stores (adenosine triphosphatecreatine phosphate)137 although some of the weight reductionfound in this study occurred with diet manipulation and not de-hydration alone People involved in activities that use weightmanipulation to improve performance appear to be more pro-foundly affected by hydration status Efforts that are sustainedat intensities below peak oxygen uptake are notably affected byprior dehydration Dehydration induced with the use of phar-macologic diuretics increases frequency of muscle twitches apotential risk factor for muscle cramps more so than does exer-cise- or sauna-induced dehydration 132

Dietary Caloric Restriction and WeightManagement

Dietary restriction is another common method used to main-tain weight Very low-calorie diets affect the cardiovascularsystem and can produce myofibrillar damage orthostatic hy-potension bradycardia low QRS voltage QT-interval prolon-gation ventricular arrhythmias and sudden cardiac death146-149Sudden death may be caused by the ventricular arrhythmias orhypokalemia associated with caloric restriction14 Very low-calorie diets can also result in a marked blunting of the normalheart rate increase and blood pressure response to exercise149Inaddition to these physiologic changes dietary restrictions causedeficits in recall understanding visuospatial information 150working-memory capacity recall on the phonologic loop taskand simple reaction time 151They also affect planning time1s2

Low-calorie diets also affect the endocrine system Levelsof growth hormone and insulin-like growth factor (IGF) bind-ing protein 2 are increased The growth hormone response to

growth hormone-releasing hormone is increased however lev-els of IGF I and IGF binding protein 3 are decreased1s3-155Thedecrease in IGF I an anabolic factor limits growth and muscledevelopment 153With improved nutrition growth catchup oc-curs but is inadequate children in particular will never achievetheir potential genetic height1s6ls7Also lower levels of IGF Iare associated with poor muscle development and thus poten-tial maximum strength is never realized1s3 Lower levels of IGFI are associated with lower bone mineral densities1s3 Urinaryexcretion of cross-links a marker of bone absorption is in-creased and serum osteocalcin a marker for bone formation islower than normal in patients with low BMls1s4 These findingsindicate that more bone is being absorbed and less bone is be-ing produced than normal potentially leading to osteoporosis 154and stress fractures

Changes in thyroid function also occur as a result of low-calorie diets Total thyroxine (T4) and triiodothyronine (free T3)decrease and reverse triiodothyronine (rT3) increases155 Theresponse of thyroid-stimulating hormone (TSH) to thyrotro-pin-releasing hormone (TRH) is diminished 155and the BMRis lowered The adrenal glands produce an increased amountof free cortisol and serum cortisol levels are elevated withoutassociated changes in adrenocorticotropic hormone 155Gonad-otropin-releasing hormone (GnRH) from the hypothalamus isreduced1s8 leading to decreased levels of luteinizing hormone(LH) and follicle-stimulating hormone (FSH) from the anteriorpituitary1s9 Estrogen production is low contributing signifi-cantly to osteoporosis1S9 and menstrual dysfunction 15

Dietary restrictions affect the immune system by signifi-cantly impairing cell-mediated immunity phagocyte functionthe complement system secretory immunoglobulin A levelscytokinase production160-163haptoglobin production orosomu-coid production164 T-lymphocyte response and production ofTh2 cytokine Th1 cytokinase production increases 162These im-munologic abnormalities may lead to an increased number ofinfections during the period of inadequate dietary intake16s

Eating Disorders Disordered Eating andWeight Management

Disordered eating behaviors have been identified in bothmale and female athletes131166A total of 10 to 15 of boyswho participate in weight-sensitive sports practice unhealthyweight loss behaviors131166Eleven percent of wrestlers havebeen found to have eating disorders or disordered eating166andup to 45 of wrestlers were at risk of developing an eating dis-order129167168Several studies169-171revealed a high prevalence ofeating disorders in female athletes involved in weight-sensitivesports Sixty percent of average-weight girls and 18 of un-derweight girls involved in swimming were attempting to loseweight172Thus both males and females may develop dysmor-phia disordered eating and eating disorders as a consequenceof their efforts to lose weight for their activities The femaleathlete triad is a relationship among disordered eating alteredmenstrual function and abnormal bone mineralization160173174Amenorrhea occurs as a result of decreased pulsatile releaseof GnRH from the hypothalamusls7 which leads to fewer LHand FSH pulses from the anterior pituitary17s Osteoporosis canresult from decreased estrogen or IGF PS3lS4and from excesscortisol production 155

Athletes competing in aesthetic sports had the highest indi-cators of eating disorders176Those who participated in weight-matched sports also showed higher levels of disordered eating


than did athletes in non-weight-restricted sports175-177 Athleteswhose bodies differ from the ideal physique of the sportmay also be at higher risk for developing disordered eating20Some experts have surmised that the demands of the athleticsubculture may involve inherent risk for the development ofunhealthy weight control behaviors Subclinical eating disor-ders in athletes have been associated with dieting to enhanceappearance or improve health or dieting because someone (egcoach peer) recommended it45

The spectrum of disordered eating behaviors ranges from thevery benign and mild to the very severe 50 In athletes disorderedeating may affect up to 62 of the population and is reportedlyhighest in weight-class events such as boxing and wrestlingand aesthetic activities such as dance and gymnastics in whichlow body weight and leanness are emphasized 178 179

Disordered eating in the mild and earliest stages may startsimply as a dietary plan to achieve a better aesthetic appearanceor better performance A common diet involves caloric re-strictions but when these restrictions are taken to the extremethere is reason for concern Often athletes seek weight loss ordieting advice from friends or teammates or simply follow thesuggestions of others without fully understanding the impor-tance of maintaining an adequate energy balance Other timesathletes may adhere to the recommendations made by coacheswithout understanding the nutritional requirements of thesport 50 The health care team should be in place to help athletesand active clients address disordered eating behaviors and toassist in providing accurate and appropriate advice The topicsof disordered eating eating disorders and dysmorphia are ad-dressed more comprehensively in the NATAposition statementon disordered eating 50

ACKNOWLEDGMENTS

We gratefully acknowledge the efforts of Leslie J BonciMPH RD LDN Matthew Doyle ATC Dan Foster PhD ATCGregory L Landry MD Margot Putukian MD James Thorn-ton MS ATC and the Pronouncements Committee in the prep-aration of this document

DISCLAIMER

The NATA publishes its position statements as a service topromote the awareness of certain issues to its members The in-formation contained in the position statement is neither exhaus-tive not exclusive to all circumstances or individuals Variablessuch as institutional human resource guidelines state or federalstatutes rules or regulations as well as regional environmen-tal conditions may impact the relevance and implementationof these recommendations The NATA advises its membersand others to carefully and independently consider each of therecommendations (including the applicability of same to anyparticular circumstance or individual) The position statementshould not be relied upon as an independent basis for care butrather as a resource available to NATA members or othersMoreover no opinion is expressed herein regarding the qualityof care that adheres to or differs from NATAs position state-ments The NATA reserves the right to rescind or modify itsposition statements at any time

REFERENCES1 National Collegiate Athletic Association Wrestling Rules Committee

Rule 8 weight management In Bubb RG ed 2008-2009 Wrestling


Rules Indianapolis IN National Collegiate Athletic Association Publi-cations 2008 WR81- WR92

2 American Academy of Pediatrics Committee on Sports Medicine andFitness Policy statement promotion of healthy weight control practicesin young athletes Pediatrics 20051l6(6)1557-1564

3 Fletcher GF Blair SN Blumenthal J et al Statement on exercise benefitsand recommendations for physical activity programs for all Americansa statement for health professionals by the Committee on Exercise andCardiac Rehabilitation of the Council on Clinical Cardiology AmericanHeart Association Circulation 199286(1)340-344

4 Frisch RE Hubinont PO Adipose Tissue and Reproduction Progress inReproductive Biology and Medicine Basel Switzerland S Karger AG199014

5 Berning JR Steen SN Nutrition for Sport and Exercise GaithersburgMD Aspen Publishers Inc 199823-2549505465 163

6 Ebell MH Siwek J Weiss BD et al Strength of recommendation tax-onomy (SORT) a patient-centered approach to grading evidence in themedical literature Am Fam Physician 200469(3)548-556

7 Ehrman JK ed ACSMs Resource Manual for Guidelines for ExerciseTesting and Prescription 6th ed Philadelphia PA Lippincott Williamsamp Wilkins 2010266 277

8 Clark N Nancy Clarks Sport Nutrition Guidebook 3rd ed ChampaignIL Human Kinetics 200322 163 164 182

9 McArdle WD Katch Fl Katch VL Exercise Physiology Energy Nutri-tion and Human Performance 6th ed Baltimore MD Lippincott Wil-liams amp Wilkins 2007776 779 783-785 793-796 812-813

10 McArdle WD Katch Fl Katch VL Sports and Exercise Nutrition 3rded Baltimore MD Lippincott Williams amp Wilkins 2009247 402 403429430 462

11 Behnke AR Wilmore JH Evaluation and Regulation of Body Build andComposition Englewood Cliffs NJ Prentice Hall 1974

12 American College of Sports Medicine American Dietetic AssociationDietitians of Canada Joint position statement nutrition and athletic per-formance Med Sci Sports Exerc 200032(12)2130-2145

13 Thompson WR ed ACSMs Guidelinesfor Exercise Testing and Prescrip-tion 8th ed Philadelphia PA Lippincott Williams amp Wilkins 201071

14 Byrd-Bredbenner C Beshgetoor D Moe G Berning J Wardlaws Per-spectives in Nutrition 8th ed New York NY McGraw Hill 2009247-248302320378-383

15 Seagle HM Strain GW Makris A Reeves RS American Dietetic Asso-ciation Position of the American Dietetic Association weight manage-ment J Am Diet Assoc 2009109(2)330-346

16 Burke LM Cox GR Culmmings NK Desbrow B Guidelines for dailycarbohydrate intake do athletes achieve them Sports Med 200131(4)267-299

17 Rosenbloom C Fueling athletes facts versus fiction on feeding athletesfor peak performance Nutr Today 200641(5)227-232

18 Lambert EV Goedecke JH The role of dietary macronutrients in optimiz-ing endurance performance Curr Sports Med Rep 20032(4)194-201

19 National Collegiate Athletic Association Bylaw 1652g In NCAA By-laws and Regulations Division I Handbook Indianapolis IN NationalCollegiate Athletic Association 2008199

20 Collegiate Spring Football League CSFL weight certification proce-dures httpwwwsprintfootballcomp4_league_informationjspAc-cessed March 12009

21 Oppliger RA Utter AC Scott JR Dick RW Klossner D NCAA rulechange improves weight loss among national championship wrestlersMed Sci Sports Exerc 200638(5)963-970

22 US Rowing Rules of Rowing Article IV rules 4-106 4-110 httpwwwrcirutgersedu~ronchenruleindxhtm Accessed June 7 2004

23 Eating body weight and performance in athletes an introduction InBrownell KD Rodin J Wilmore JH eds Eating Body Weight and Per-formance in Athletes Disorders of Modern Society Philadelphia PA Leaamp Febiger 19921-16

24 Johnson A Steinberg R Lewis W Bulimia In Clark K Parr R Cas-telli W eds Evaluation and Management of Eating Disorders AnorexiaBulimia and Obesity Champaign IL Life Enhancement Publications1988187-227

25 McCabe MP Ricciardelli LA Sociocultural influences on body image

and body changes among adolescent boys and girls J Soc Psychol2003143(1)5-26

26 Cohane GH Pope HG Jr Body image in boys a review of the literaturelnt J Eat Disord 200129(4)373-379

27 Benedikt R Wertheim EH Love A Eating attitudes and weight-lossattempts in female adolescents and their mothers J Youth Adolesc199827(1)43-57

28 Paxton SJ Wertheim EH Gibbons K Szmukler GL Hillier I PetrovichJL Body image satisfaction dieting beliefs and weight loss behaviorsin adolescent girls and boys J Youth Adolesc 1991 20(3) 361-379

29 Dixon R Adair V OConnor S Parental influences on the dieting beliefsand behaviors of adolescent females in New Zealand J Adolesc Health199619(4)303-307

30 Berry TR Howe BL Risk factors for disordered eating in female univer-sity athletes J Sport Behav 200023(3)207-218

31 Rosen LW Hough DO Pathogenic weight control behaviors of femalecollege gymnasts Phys Sportsmed 198816(9)141-146

32 Neumark-Sztanier D Beutler R Palti H Personal and socioenvironmen-tal predictors of disordered eating among adolescent females J NutrEduc 199628(4)195-201

33 Griffin J Harris ME Coaches attitudes knowledge experiences and recom-mendations regarding weight controL Sport Psycho 199610(2)180-194

34 Beals KA Manore MM The prevalence and consequences of subclinicaleating disorders in female athletes lnt J Sports Nutr 19944(2)175-195

35 Gill KS OverdorfVG Body image weight and eating concerns and useof weight control methods among high school female athletes WomenSport Phys Act J 19943(2)69

36 Brooks-Gunn J Burrow C Warren MP Attitudes toward eating andbody weight in different groups of female adolescents lnt J Eat Disord19887(6)749-757

37 Davis C Cowles M A comparison of weight and diet factors among fe-male athletes and non-athletes J Psychosom Res 198933(5)527-536

38 Fulkerson JA Keel PK Leon GR Dorr T Eating-disordered behaviorsand personality characteristics of high school athletes and nonathletes lntJ Eat Disord 199926(1)73-79

39 Garner DM Garfinkel PE Rochert W Olmsted MP A prospective studyof eating disturbances in the ballet Psychother Psychosom 1987 48(1-4)170-175

40 Sundgot-Borgen J Prevalence of eating disorders in elite female athleteslnt J Sport Nutr 19933(1)29-40

41 Johnson MD Disordered eating in active and athletic women Clin SportsMed 199413(2)355-369

42 Leichner P Anorexia nervosa bulimia and exercise Coach MarchApril198666-68

43 Taub D Blinde EM Eating disorders among adolescent female athletesinfluence of athletic participation and sport team membership Adoles-cence 199227(108)833-848

44 Hewitt PI Flett GL Perfectionism in the self and social contexts con-ceptualization assessment and association with psychopathology J PersSoc Psychol 199160(3)456-470

45 Williams PI Sargent RG Durstine LJ Prevalence of subclinical eat-ing disorders in collegiate female athletes Women Sport Phys Act J2003 12(2) 127

46 Andersen AE DiDomenico L Diet vs shape content of popular male andfemale magazines a dose-response relationship to the incidence of eatingdisorders lnt J Eat Disord 19921l(3)283-287

47 Furnham A Badmin N Sneade 1 Body-image dissatisfaction genderdifferences in eating attitudes self-esteem and reasons for exercise JPsychol 2002136(6)581-596

48 Raudenbush B Meyer B Muscular dissatisfaction and supple-ment use among male intercollegiate athletes J Sport Exerc Psychol200325(2)161-170

49 Silberstein LR Striegel-Moore RH Timko C Rodin J Behavioral andpsychological implications of body dissatisfaction do men and womendiffer Sex Roles 198819(3-4)219-232

50 Bonci CM Bonci LJ Granger LR et aL National Athletic Trainers As-sociation position statement preventing detecting and managing disor-dered eating in athletes J Athl Train 200843(1)80-108

51 Health implications of obesity National Institutes of Health consensus

development conference statement Ann Intern Med 1985103(6 pt2)1073-1077

52 Mokdad AH Ford ES Bowman BA et aL Prevalence of obesity diabetesand obesity-related health risk factors 2001 JAMA 2003289(1)76-79

53 Maclure KM Hayes KC Colditz GA Stampfer MJ Speizer FE WillettWC Weight diet and the risk of symptomatic gallstones in middle-agedwomen N Engl J Med 1989321(9)563-569

54 Manninen P Riihimaki H Heliovaara M Makela P Overweight genderand knee osteoarthritis lnt JObes Relat Metab Disord 199620(6)595-597

55 Calle EE Rodriguez C Walker-Thurmond K Thun MJ Overweightobesity and mortality from cancer in a prospectively studied cohort ofUS adults N Engl J Med 2003348(17)1625-1638

56 Baumgartner RN Roche AF Guo S Lohman T Boileau RA SlaughterMH Adipose tissue distribution the stability of principal components bysex ethnicity and maturation stage Hum Bioi 198658(5)719-735

57 Brown CD Higgins M Donato KA et aL Body mass index and the prev-alence of hypertension and dyslipidemia Obes Res 20008(9)605-619

58 Durstine JL Moore GE Painter PI Roberts SO eds ACSMs ExerciseManagementfor Persons with Chronic Diseases and Disabilities 3rd edChampaign IL Human Kinetics 2009194

59 Akers R Busrkirk ER An underwater weighing system utilizing forcecube transducers J Appl Physiol 196926(5)649-652

60 Wilmore JH A simplified method for determination of residual lung vol-ume J Appl Physiol 196927(1)96-100

61 Dempster P Aitkens S A new air displacement method for the determi-nation of human body composition Med Sci Sports Exerc 199527(12)1692-1697

62 Penn IW Wang ZM Buhl KM Allison DB Burastero SE HeymsfeldSB Body composition and two-compartment model assumptions in malelong distance runners Med Sci Sports Exerc 199426(3)392-397

63 van der Ploeg GE Brooks AG Withers RT Dollman J Leaney F Chat-terton BE Body composition changes in female bodybuilders duringpreparation for competition Eur J Clin Nutr 200155(4)268-277

64 Arngrimsson SA Evans EM Saunders MJ Ogburn CL III Lewis RDCureton KJ Validation of body composition estimates in male and femaledistance runners using estimates from a four-component model Am JHum Bioi 200012(3)301-314

65 Clark RR Bartok C Sullivan JC Schoeller DA Minimum weight pre-diction methods cross-validated by the four-component model Med SciSports Exerc 200436(4)639-647

66 Modlesky CM Cureton KJ Lewis RD Prior BM Sioniger MA RoweDA Density of the fat-free mass and estimates of body composition inmale weight trainers J Appl Physiol 199680(6)2085-2096

67 Prior BM Cureton KJ Modlesky CM et al In vivo validation of wholebody composition estimates from dual-energy x-ray absorptiometry JAppl Physiol 199783(2)623-630

68 Bunt JC Going SB Lohman TG Heinrich CH Perry CD Pamenter RWVariation in bone mineral content and estimated body fat in young adultfemales Med Sci Sports Exerc 199022(5)564-569

69 Collins MA Millard-Stafford ML Sparling PB et al Evaluation of theBOD POD for assessing body fat in collegiate football players Med SciSports Exerc 199931(9)1350-1356

70 Utter AC Goss FL Swan PD Harris GS Robertson RJ Trone GA Eval-uation of air displacement for assessing body composition of collegiatewrestlers Med Sci Sports Exerc 200335(3)500-505

71 Schutte JE Townsend EJ Hugg J Shoup RF Malina RM BlomqvistCG Density of lean body mass is greater in blacks than in whites J ApplPhysiol 198456(6)1647-1649

72 Millard-Stafford ML Collins MA Modlesky CM Snow TK RosskopfLB Effect of race and resistance training status on the density of fat-freemass and percent fat estimates J Appl Physiol 200191(3)1259-1268

73 Visser M Gallagher D Deuenberg P Wang J Pierson RN Jr HeymsfieldSB Density of fat-free mass relationship with race age and level ofbody fatness Am J Physiol 1997272(5 pt 1)E781-E787

74 Collins MA Millard-Stafford ML Evans EM Snow TK Cureton KJRosskopf LB Effect of race and musculoskeletal development on the ac-curacy of air plethysmography Med Sci Sports Exerc 200436(6) 1070-1077


75 Siri WE Body compositiOn from fluid spaces and density analysisof methods In Brozek J Henschel A eds Techniques for MeasuringBody Composition Washington DC National Academy of Sciences1961223-244

76 Brozek J Grande F Anderson JT Keys A Densitometric analysis ofbody composition revision of some quantitative assumptions Ann N YAcad Sci 19631l0 113-140

77 Evans EM Prior BM Arngrimsson SA Modlesky CM Cureton KJ Re-lation of bone mineral density and content to mineral content and densityof the fat-free mass J Appl Physiol 200191(5)2166-2172

78 Heyward VH Wagner DR Applied Body Composition Assessment 2nded Champaign IL Human Kinetics 2004

79 Lohman TG Roche AF Martorell R ed Anthropometric StandardizationReference Manual Champaign IL Human Kinetics 1988

80 Lohman TG Skinfolds and body density and their relation to body fat-ness a review Hum Bioi 198153(2)181-225

81 Caton JR Mole PA Adams WC Heustis DS Body composition analysisby bioelectrical impedance effect of skin temperature Med Sci SportsExerc 198820(5)489-491

82 Deurenberg P West strate JA Paymans I van der Kooy K Factors affect-ing bioelectrical impedance measurements in humans Eur J Clin Nutr198842(12)1017-1022

83 Hortobagyi T Israel RG Houmard JA OBrien KF Johns RA WellsJM Comparison of four methods to assess body composition in blackand white athletes Int J Sport Nutr 19922(1)60-74

84 Oppliger RA Nielsen DH Shetler AC Crowley ET Albright JP Bodycomposition of collegiate football players bioelectrical impedance andskinfolds compared to hydrostatic weighing J Orthop Sports Phys Ther199215(4)187-192

85 Williams CA Bale P Bias and limits of agreement between hydrodensi-tometry bioelectrical impedance and skinfold calipers measures of percent-age body fat Eur J Appl Physiol Occup Physiol 199877(3)271-277

86 Colville BC Heyward VH Sandoval WM Comparison of two methodsfor estimating body composition of bodybuilders J Appl Sport Sci Res19893(3)57-61

87 Houtkoopr LB Mullins VA Going SB Brown CH Lohman TG Bodycomposition profiles of elite American heptathletes Int J Sport Nutr Ex-erc Metab 20011l(2)162-173

88 Stewart AD Hannan WJ Prediction of fat and fat-free mass in male ath-letes using dual X-ray absorptiometry as the reference method J SportsSci 200018(4)263-274

89 Segal KR Use of bioelectrical impedance analysis measurements as anevaluation for participating in sports Am J Clin Nutr 199664(suppl3)469S-47IS

90 Israel RG Houmard JA OBrien KF McCammon MR Zamora BS EatonAW Validity of a near-infrared spectrophotometry device for estimatinghuman body composition Res Q Exerc Sport 198960(4)379-383

91 Houmard JA Israel RG McCammon MR OBrien KF Orner J ZamoraBS Validity of near-infrared device for estimating body composition ina collegiate football team J Appl Sport Sci Res 19915(2)53-59

92 Fornetti WC Pivarnik JM Foley JM Fiechtner JJ Reliability and valid-ity of body composition measures in female athletes J Appl Physiol199987(3)11l4-1122

93 Oppliger RA Clark RR Nielsen DH New equations improve NIR pre-diction of body fat among high school wrestlers J Orthop Sports PhysTher 200030(9)536-543

94 Boileau RA Lohman TG Slaughter MH Ball TE Going SB HendrixMK Hydration of the fat-free body in children during maturation HumBioi 198456(4)651-666

95 Boileau RA Lohman TG Slaughter MH Exercise and body compositionof children and youth Scand J Sports Sci 1985717-27

96 Girandola RN Wisewell RA Romero G Body composition changesresulting from fluid ingestion and dehydration Res Q 197748(2)299-303

97 Hayes PM Lucas JC Shi X Importance of post-exercise hypotension inplasma volume restoration Acta Physiol Scand 2000169(2)1l5-124

98 Horswill CA Hickner RC Scott JR Costill DL Gould D Weight lossdietary carbohydrate modifications and high intensity physical perfor-mance Med Sci Sports Exerc 199022(4)470-476


99 Casa DJ Armstrong LE Hillman SK et al National Athletic TrainersAssociation position statement fluid replacement for athletes J AthlTrain 200035(2)212-224

100 Popowski LA Oppliger RA Lambert GP Johnson RF Johnson AK Gi-solf Cv Blood and urinary measures of hydration status during progres-sive acute dehydration Med Sci Sports Exerc 200133(5)747-753

101 Armstrong LE Soto JA Hacker FT Jr Casa DJ Kavouras SA MareshCM Urinary indices during dehydration exercise and rehydration Int JSport Nutr 19988(4)345-355

102 Armstrong LE Maresh CM Castellani JW et al Urinary indices of hy-dration status Int J Sport Nutr 19944(3)265-279

103 Francesconi RP Hubbard RW Szlyk PC et al Urinary and hematologicindexes of hypo hydration J Appl Physiol 198762(3)1271-1276

104 Kavouras SA Assessing hydration status Curr Opin Clin Nutr MetabCare 20025(5)519-524

105 Bartok C Schoeller DA Sullivan JC Clark RR Landry GL Hydrationtesting in collegiate wrestlers undergoing hypertonic dehydration MedSci Sports Exerc 200436(3)510-517

106 Walsh NP Montague JC Callow N Rowlands AV Saliva flow rate totalprotein concentration and osmolality as potential markers of whole bodyhydration status during progressive acute dehydration in humans ArchOral Bioi 200449(2)149-154

107 Armstrong LE Kenefick RW Castellani JW et al Bioimpedance spec-troscopy technique intra- extracellular and total body water Med SciSports Exerc 199729(12)1657-1663

108 Bartok C Schoeller DA Clark RR Sullivan JC Landry GL The effectof dehydration on wrestling minimum weight assessment Med Sci SportsExerc200436(1)160-167

109 Petrie H Osterberg KL Horswill CA Murray R Reliability of bio-electrical impedance spectroscopy (BIS) use in athletes after exercise-induced dehydration Med Sci Sports Exerc 200436(suppl 5)S239

110 Institute of Medicine of the National Academies of Science Dietary Ref-erence Intakes Water Potassium Sodium Chloride and Sulfate Wash-ington DC Institute of Medicine 2004

Ill Binkley HM Beckett J Casa DJ Kleiner DM Plummer PE NationalAthletic Trainers Association position statement exertional heat ill-nesses J Athl Train 200237(3)329-343

112 Rankin JM Ingersoll CD Athletic Training Management Concepts andApplications 3rd ed Boston MA McGraw-Hill 2006118

113 Ray R Management Strategies in Athletic Training 2nd ed ChampaignIL Human Kinetics 2000247 250

114 Schlabach GA Peer KS Professional Ethics in Athletic Training StLouis MO Mosby-Elsevier 2008169

115 National Collegiate Athletic Association Guideline 2e assessment ofbody composition In NCAA Sports Medicine Handbook 2008-09 In-dianapolis IN National Collegiate Athletic Association 200834-38

116 Johnson M The female athlete triad 1994 update (disordered eating amen-orrhea and osteoporosis) Paper presented at 41 st Annual Meeting of theAmerican College of Sports Medicine June I 1994 Indianapolis IN

117 Manore MM Dietary recommendations and athletic menstrual dysfunc-tion Sports Med 200232(14)887-901

118 Jakicic JM Clark K Coleman E et al American College of SportsMedicine position stand appropriate intervention strategies for weightloss and prevention of weight regain for adults Med Sci Sports Exerc200 I 33(12)2145-2156

119 United States Department of Agriculture Food pyramid httpwwwmypyramidgovpyramid Accessed March 12009

120 Krebs-Smith SM Kris-Etherton P How does MyPyramid compare toother population-based recommendations for controlling chronic diseaseJ Am Diet Assoc 2007107(5)830-837

121 Carey DG Quantifying differences in the fat burning zone and theaerobic zone implications for training J Strength Cond Res 200923(7)2090-2095

122 Horswill CA The 15-per-week rule part I fat loss httpwwwnwcaonlinecomarticlespercentage_partlpdf Accessed March 15 2009

123 Baechle TR Earle RW eds Essentials of Strength Training and Condi-tioning 3rd ed Champaign IL Human Kinetics 2008509-514

124 Kenney HE The problem of weight making for wrestling meets J HealthPhys Educ 19301(24)24-2549

125 Oppliger RA Steen SA Scott JR Weight loss practices of college wres-tlers lnt J Sport Nutr Exerc Metab 200313(1)29-46

126 Nadel ER Temperature regulation and prolonged exercise In Lamb DRCarmel MR eds Perspectives in Exercise Science and Sports MedicineProlonged Exercise Indianapolis IN Benchmark Press Inc 1988125-151

127 Astrand PO Rodah1 K Textbook of Work Physiology New York NYMcGraw-Hill Book Co 1977

128 Kenny GP Reardon PD Thoden JS Giesbrecht GG Changes in exerciseand post-exercise core temperature under different clothing conditionslnt J Biometeorol 199943(1)8-13

129 Shapiro Y Pando1f KB Goldman RF Predicting sweat loss response toexercise environment and clothing Eur J Appl Physiol Occup Physiol198248(1 )83-96

130 Steen SN Brownell KD Patterns of weight loss and regain in wrestlershas tradition changed Med Sci Sports Exerc 199022(6)762-768

131 Weissenger E Housh TJ Johnson GO Evans SA Weight loss behaviorin high school wrestling wrestler and parent perceptions Ped Exerc Sci1991 3(1)64-73

132 Tipton CM Tcheng TK Iowa Wrestling Study weight loss in high schoolstudents JAMA 1970214(7)1269-1274

133 Caldwell JE Ahonen E Nousiainen U Diuretic therapy physical per-formance and neuromuscular function Phys Sportsmed 1984(6)1273-85

134 Fogelho1m M Effects of bodyweight reduction on sports performanceSports Med 199418(4)249-267

135 Olsson KE Saltin B Variation in total body water with muscle glycogenchanges in man Acta Physiol Scand 197080(1)11-18

136 Tarnopo1sky M Cipriano N Woodcroft C et al The effects of rapidweight loss and wrestling on muscle glycogen concentration Clin J ApplPhysiol 19946(2)78-84

137 Houston ME Marrin DA Green HJ Thomson JA The effect of rapidweight loss on physiological functions in wrestlers Phys Sportsmed1981 9(11)73-78

138 Walberg JL Leidy MK Sturgill DJ Hinkle DE Ritchey SJ Sebo1t DRMacronutrient content of a hypoenergy diet affects nitrogen retention andmuscle function in weight 1ifterslnt J Sports Med 19889(4)261-266

139 Buschsch1uter S Games blood-letting Swim Tech 19771399140 Nagii MR The significance of water in sport and weight control Nutr

Health 200014(2)127-132141 Cheuvront SN Carter R III Sawka MN Fluid balance and endurance

exercise performance Curr Sports Med Rep 20032(4)202-208142 Wilks B Yuxiu H Bar-Or O Effect of body hypohydration on aerobic

performance of boys who exercise in the heat Med Sci Sports Exerc200234(supp1 5)S48

143 Bar-Or 0 Blimkie CJR Hay JA MacDougall JD Ward DS WilsonWM Voluntary dehydration and heat intolerance in cystic fibrosis Lan-cet 1992339(8795)696-699

144 Montain SJ Coyle EF Influence of graded dehydration on hyperthermiaand cardiovascular drift during exercise J Appl Physiol 199273(4) 1340-1350

145 Sawka MN Pando1f KB Effects of body water loss in physiologicalfunction and exercise performance In Lamb DR Giso1fi CV eds Per-spectives in Exercise Science and Sports Medicine Fluid HomeostasisDuring Exercise Indianapolis IN Benchmark Press 19901-38

146 Ahmed W Flynn MA Alpert MA Cardiovascular complications ofweight reduction diets Am J Med Sci 2001321(4)280-284

147 Stevens A Robinson DP Turpin J Groshong T Tobias JD Sudden cardi-ac death of an adolescent during dieting South Med J 200295(9) 1047-1049

148 Swenne I Larsson PT Heart risk associated with weight loss in anorexianervosa and eating disorders risk factors for QTc interval prolongationand dispersion Acta Paediatr 199988(3)304-309

149 Schocken DD Holloway JD Powers PS Weight loss and the heart effectsof anorexia nervosa and starvation Arch Intern Med 1989149(4)877-881

150 Mathias JL Kent PS Neuropsychological consequences of extremeweight loss and dietary restriction in patients with anorexia nervosa JClin Exp Neuropsychol 199820(4)548-564

151 Kretsch MJ Green MW Fong AK Elliman NA Johnson HL Cogni-tive effects of a long-term weight reducing diet lnt JObes Relat MetabDisord 199721(1)14-21

152 Green MW Rogers PJ Impairments in working memory associated withspontaneous dieting behavior Psychol Med 199828(5)1063-1070

153 Snow CM Rosen CJ Robinson TL Serum IGF-1 is higher in gymnaststhan runners and predicts bone and lean mass Med Sci Sports Exerc200032(11)1902-1907

154 Hotta M Fukuda I Sato K Hizuka N Shibasaki T Takano K The re-lationship between bone turnover and body weight serum insulin-likegrowth factor (IGF) I and serum IGF binding protein in patients withanorexia nervosa J Clin Endocrinol Metab 200085(1)200-205

155 Douyon 1 Schteingart DE Effect of obesity and starvation on thyroidhormone growth hormone and cortisol secretion Endocrinol Metab ClinNorth Am 200231(1)173-189

156 Lantzouni E Frank GR Golden NH Shenker RI Reversibility of growthstunting in early onset anorexia nervosa a prospective study J AdolescHealth 200231(2)162-165

157 Lanes R Soros A Decreased final height of children with growth decel-eration secondary to poor weight gain during late childhood J Pediatr2004145(1)128-130

158 Joy EA MacIntyre JG Women in sports In Mellion ME Walsh WMMadden C Putukian M Shelton GL eds The Team PhysicianS Hand-book 3rd ed Philadelphia PA Hanley and Be1fus Inc 200277-83

159 Nattiv A Loucks AB Manore MM Sanborn CF Sundgot-Borgen J War-ren MP American College of Sports Medicine position stand the femaleathlete triad Med Sci Sport Exerc 200739(10)1867-1882

160 Chandra RK Nutrition and the immune system from birth to old age EurJ Clin Nutr 200256(supp13)S73-S76

161 Vaisman N Hahn T Dayan Y Schattner A The effect of different nutri-tional states on cell-mediated cytotoxicitylmmunol Lett 199024(1)37-41

162 Marcus A Va1ela P Toro 0 et al Interaction between nutrition andimmunity in anorexia nervosa a 1-y follow-up study Am J Clin Nutr1997 66(2) 485S-490S

163 Lord GM Matares G Howard JK Baker RJ Bloom SR Lechler RILeptin modulates the T-cell immune response and reverses starvation-induced immunosuppression Nature 1998394(6696)897-901

164 Palmb1ad J Cantell K Holm G Norberg R Strander H Sunb1ad LAcute energy deprivation in man effect on serum immunoglobulins an-tibody response complement factors 3 and 4 acute phase reactants andinterferon-producing capacity of blood lymphocytes Clin Exp lmmunol197730(1)50-55

165 Bishop NC B1annin AK Walsh NP Robson PJ Gleeson M Nutritional as-pects of immunosuppression in athletes Sports Med 199928(3)151-176

166 Garner DM Rosen LW Barry D Eating disorders among athletesresearch and recommendations Child Adolesc Psychiatr Clin N Am19987(4)839-857

167 Perriello VA Jr Aiming for healthy weight in wrestlers and other athletesContemp Pediatr September 120011855-74

168 Perriello VA Jr Almquist J Conkwright D Jr et al Health and weightcontrol management among wrestlers a proposed program for highschool athletes Va Med Q 1995122(3)179-185

169 Brownell KD Rodin J Prevalence of eating disorders in athletes InBrownell KD Rodin J Wilmore JH eds Eating Body Weight and Per-formance in Athletes Disorders of Modern Society Philadelphia PALea amp Febiger 1992

170 Rosen LW McKeag DB Hough DO Curley V Pathogenic weight-con-trol behavior in female athletes Phys Sportsmed 198614(1)79-86


172 Dummer GM Rosen LW Heusner WW Roberts PJ Counsi1man JEPathogenic weight control behaviors of young competitive swimmersPhys Sportsmed 198715(5)75-86

173 Kazis K Iglesias E The female athlete triad Adolesc Med 2003 14(1) 87-95

174 Otis CL The female athlete triad In Sallis RE Massimino F eds Es-sentials of Sports Medicine 1997 St Louis MO Mosby-Year Book1997202-205


175 Hausenblas HA Carron AV Eating disorder indices and athletes an in-tegration J SportExeu PSyChol199921(3)230-258

176 Stoutjesdyk D Jevne R Eating disorders among high performance ath-letes JYouthAdoJes 199322(3)271-282

177 Sundgot-Borgen J Prevalence of eating disorders in elite female athletesJhtJ SpgtrtNutr 19933(1)29-40

178 Sundgot-Borgen J Risk and trigger factors for the development of eatingdisorders in female elite athletes MeiSciSportsExeu 199426(4)414-419

179 Steen SN Bernadot D Englebert-Fenton K Freeman K Hartsough CRoundtable 18 eating disorders in athletes the dieticians perspectiveGatJnadeSports sci Jillt19945( 4)2

Address mrrepondence to NationalAthJetic Trainers AffDdation Canmunications DEpartment 2952 StEmmons FJB2WayD aJJasTX 75247


Assessing Body Composition and Weight

Table 3 Determining Goal Weight from Body Composition

Current body fat - Desired body fat = Nonessential body fat

Current body weight x Nonessential body fat = Nonessential fat Ib(in decimal format)

7 When hydration is a concern regular or more frequent (orboth) assessments of body weight are indicated EvidenceCategory C

8 Active clients and athletes in weight classification sportsshould not gain or lose excessive amounts of body weightat any point in their training cycles Evidence Category C

9 Management of body composition should include both dietand exercise Evidence Category B

10 Total caloric intake should be determined by calculatingthe basal metabolic rate (BMR) and the energy needs foractivity Evidence Category B

11 Caloric intake should be based on the body weight goal(Table 4) Evidence Category C

12 A safe and healthy dietary plan that supplies sufficient en-ergy and nutrients should be maintained throughout theyear (Table 5) Evidence Category B

13 The US Department of Agricultures Food Pyramid Guideis one of the methods that can be used to ensure adequatenutrient intake Evidence Category C

14 The metabolic qualities of the activity should be consideredwhen calculating the need for each energy-producing nutri-ent in the diet (Tables 6-8) Evidence Category B

15 Safe and appropriate aerobic exercise will facilitate weightand body fat loss Evidence Category C

16 Body composition adjustments should be gradual with noexcessive restrictions or use of unsafe behaviors or prod-ucts Evidence Category C

17 Combining weight management and body compositiongoals with physical conditioning periodization goals willassist athletes or clients in reaching weight goals EvidenceCategory C

18 Education on safe dietary and weight management prac-tices should be communicated on a regular and plannedbasis Evidence Category C

19 Individual body composition or dietary needs should bediscussed privately with appropriately trained nutrition andweight management experts Evidence Category C

20 Ergogenic and dietary aids should be ingested cautiouslyand under the advisement of those knowledgeable of therequirements of sports and other governing organizationsEvidence Category C

Current body weight - Nonessential fat Ib = Ideal body weight Ib

x

plusmn25

plusmn22-37a

plusmn35b

plusmn5b

plusmn35-5b

plusmn18a

Not fully developeda

Assessment Technique

HydrodensitometryAir displacement

plethysmographySkinfold measurementsNear-infrared interactanceBioelectric impedanceDual-energy x-ray

absorptiometryComputed tomography or

magnetic resonanceimaging

Model

2 Compartment

1 Body composition assessments should be used to determinesafe body weight and body composition goals EvidenceCategory B

2 Body composition data should be collected managed andused in the same manner as other personal and confidentialmedical information Evidence Category C

3 The body composition assessor should be appropriatelytrained and should use a valid and reliable body composi-tion assessment technique (Table 1) Evidence Category C

4 Body weight should be determined in a hydrated state Evi-dence Category B

5 When determining goal weight body weight should beassessed relative to body composition This assessmentshould occur twice annually for most people with no lessthan 2 to 3 months between measurements (Tables 2 3)Evidence Category C

6 To track a persons progress toward a weight or body com-position goal private weigh-ins and body compositionassessments should be scheduled at intervals that provideinformation to guide and refine progress as well as to es-tablish reinforcement and reassessment periods EvidenceCategory C

Multiplecompartment

3 Compartment

and techniques regardless of the activity or performance goalsThe recommendations are categorized using the Strength of Rec-ommendation Taxonomy criterion scale proposed by the Ameri-can Academy of Family Physicians6 on the basis of the level ofscientific data found in the literature Each recommendation isfollowed by a letter describing the level of evidence found inthe literature supporting the recommendation A means there arewell-designed experimental clinical or epidemiologic studies tosupport the recommendation B means there are experimentalclinical or epidemiologic studies that provide a strong theoreti-cal rationale for the recommendation and C means the recom-mendation is based largely on anecdotal evidence at this time

Table 1 Body Composition Assessment Techniques7

Standard Errorof Estimate

Table 2 Body Fat Standards () by Sex and Age

a More research is neededb Differs with each equation

Body Fat Standard

Lowest reference body fat (adults)58-11Lowest reference body fat (adolescents)12Healthy body fat ranges13

Males

57

10-22

Females

1214

20-32

Background and Literature Review

Weight management and nutrition is a multibillion-dollarindustry that has become pervasive in almost every aspect ofmodern life Diet and exercise have always affected sports andphysical activity but with the intensity of competition increas-ing at all levels has come a renewed interest in controlling thefactors that influence performance and health Diet exercisebody composition and weight management now play largerroles in an active persons life and performance Because ath-



Harris-Benedict14
















Nutrient




c Value B +9 = fat 9___ +9= _









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Body Composition


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ACKNOWLEDGMENTS


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Nutrient




c Value B +9 = fat 9___ +9= _









Activity Type




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Athlete Type







Body Composition


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8MI Classification



























































































ACKNOWLEDGMENTS


DISCLAIMER







































































































































































































Athlete Type







Body Composition


Recommendation






8MI Classification



























































































ACKNOWLEDGMENTS


DISCLAIMER

































































































































































































8MI Classification



























































































ACKNOWLEDGMENTS


DISCLAIMER









































































































































































































































































ACKNOWLEDGMENTS


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ACKNOWLEDGMENTS


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ACKNOWLEDGMENTS


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ACKNOWLEDGMENTS


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ACKNOWLEDGMENTS


DISCLAIMER


































































































































































































ACKNOWLEDGMENTS


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Documents

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