DISCUSSION PAPER - Canadian Academy of Sport Medicine

CANADIAN ACADEMY OF SPORT MEDICINE
ACADÉMIE CANADIENNE DE MÉDECINE DU
SPORT
“Committed to Excellence • L’excellence dans la pratique”
DISCUSSION PAPER
Abandoning Routine Body Composition Assessment
A Strategy to Reduce Disordered Eating among
Female Athletes and Dancers
James D. Carson, MD, CCFP, Dip Sport Med and
Eileen Bridges, MD, CCFP, Dip Sport Med
This discussion paper was prepared by the Canadian Academy of Sport
Medicine (CASM) Women’s Issues in Sport Medicine Committee (WIISM). This
discussion paper was approved by the CASM Board of Directors as a CASM
CASM discussion paper in June, 2003.
Please see the accompanying position statement published in Clin J Sport Med.
2001,11(4):280 and available for viewing on the CASM Web site under CASM
Position Statements.
1.0 INTRODUCTION
The Canadian Academy of Sport Medicine (CASM) believes that daily or group weighins
and body composition assessments are negative stressors for female athletes and
dancers and may trigger the disordered eating that can lead to amenorrhea and
osteoporosis (a syndrome called the Female Athlete Triad). There is a significant
mortality risk associated with both eating disorders and the Female Athlete Triad. 1,2 The
severity of these disorders demand that intervention be instituted and monitored.
CASM is interested in preventing the Female Athlete Triad and must act to protect
athletes’ health and best interests, based on the best information available. For more
information on the Female Athlete Triad, please see definitions (page 13) and
recommended reading (page 14).
2.0 METHODS
A comprehensive review of the literature was performed using a Medline search with the
MeSH headings “body composition,” “disordered eating,” “athlete,” and “performance.”
Focus groups were conducted with sport medicine physicians, athletes, coaches and
trainers. The information compiled was used to validate concerns about mandatory body
composition assessment.

3.0 CONTEXT FOR BODY COMPOSITION ASSESSMENT
CONCERNS
3.1 Improving Performance?
There are conflicting arguments when discussing body composition assessment and
athletic performance. According to Barr et. al., “It is assumed that the knowledge gained
from body composition assessment will be useful in either directly or indirectly
enhancing athletic performance.” 3 Body composition is an estimate of adiposity or
muscularity. Theoretically it is used to ensure that athletes are not compromising lean
tissue, health or performance in an effort to arrive at a weight established arbitrarily by
the coach or by the sport. 3 Almost 20 years ago, before the Female Athlete Triad was
fully recognized, Wilmore advised that experienced personnel, using accurate equipment
and the correct regression equation, should be able to identify an ideal body fat range for
a given athlete. 4 Thus, in theory, optimum competitive body composition may be thought
to influence an athlete’s speed, endurance and power.
It is unlikely, however, that a change in body composition leads to improved
performance. There is a large inter-individual variation within athletes of similar standard
and consequently an overlap in body composition between elite and above average
performing athletes. While average values for body composition clearly differ among
sports, there is rarely a close relationship between body composition and performance in
elite athletes in a particular sport. 3 There are currently no published studies examining if
interventions designed only to decrease body weight or body fat are effective in
improving an individual’s performance. The known reasons for athletic success are
genetic endowment, proper nutrition, good coaching, and strenuous training. 3
3.2 Consequences
Although the testing procedure is rarely harmful, it is the consequences of testing and
conferring results to the athlete that may cause harm. When young athletes view
themselves as anything other than a well-proportioned, confident winner, they are
psychologically at risk . 5 The true incidence of Female Athlete Triad, whether caused
directly or indirectly by daily or group weigh-in or body composition assessment, will
never be known because disordered eating is well hidden. Since a review of the literature
reveals that no one has properly studied a link to performance and there is an absence of
recognizable benefits attributed to these assessments, coaches should justify how the
assessments will affect training changes.

4.0 CONSIDERING SOLUTIONS
4.1 Culture and Attitude Change
Would a recommendation for abandoning daily or group weigh-ins and body composition
assessment have any impact on decreasing the incidence of the Female Athlete Triad?
Any effective approach to prevention must include a major shift in attitude which
addresses the practices of coaches, physicians, trainers, parents, dietitians, media, and
athletes. Awareness of the problem is not enough to stop it.
4.2 Actions to date
The 1992 Task Force and the 1997 American College of Sports Medicine (ACSM)
position stand on The Female Athlete Triad have heralded a new era . 6 Abandoning daily
or group weigh-ins and body composition assessment of female athletes and dancers can
signal a further change in attitude. An example of progress is the 1997 Penn State
“Athletics Student-Athlete Handbook” which states, “weighing athletes, punishment for
lack of weight control, and linking weight to performance can lead to pathogenic weight
control behaviors, and ultimately eating disorders.” Their weight control and eating
disorder policy takes much of the responsibility for monitoring weight control of athletes
away from coaches and gives it to the nutrition and sport medicine staff. 7
In 1999, the University of Florida finalized and approved the "UAA policy regarding
weighing / body composition measurement of female athletes,” which contains guidelines
regarding weight and body composition issues. It prohibits measurements of weight or
body composition by any head coach, assistant coach, strength coach or volunteer and
provides action guidelines for coach and trainer concerns about athlete weight issues.
Final approval of this very specific policy took major work to complete but is a huge
accomplishment. (Personal communication A. Grooms).
4.3 Abandon Body Composition Testing as a Routine Assessment
Body composition assessment may do harm by promoting anxiety that could lead to
disordered eating. As firm evidence of a causal relationship has not been established,
CASM advocates the option which potentially does less harm. CASM believes that risks
outweigh benefits, as outlined in the previously published position statement, and as
outlined in this discussion paper and its appendices. Appendix C contains a brief synopsis
for athletes, dancers, teachers and coaches and Appendix D includes a practical strategy
for sport medicine physicians.

5.0 APPENDICES
APPENDIX A – BODY COMPOSITION ASSESSMENT METHODS
The most commonly used body composition methods are listed below. The method most
frequently used by clinicians is low cost hand-held devices.
Common
Research
Tests
Hydrostatic
weighing
Total Body
Electrical
Conductivity
(TOBEC)
Dual Electron Xray
Absorptiometry
(DEXA)
Underlying
Principle
Two-component
model divides the
body’s constituents
into fat mass (FM)
and fat-free mass
(FFM) and uses
classic underwater
(displacement)
measurement
techniques to
estimate body
composition. 8
Measures total body
electrical
conductivity via the
electrolytes present in
lean body mass.
Dual Electron X-ray
Absorptiometry
utilizing the same
machine now
commonly used to
measure bone density
in many community
and teaching
hospitals.
Uses Pros Cons
Long considered
the “gold standard”
method against
which the accuracy
of other methods
are compared.
Currently no
advantages over other
newer methods
(DEXA).
Shows some promise
as a clinical tool
largely due to
improvements in
software. 13
Provides reasonably
accurate results in
weight-stable
individuals whose
FFM composition is
similar to established
reference values. 8
Acceptable validity
in comparison with
other commonly used
methods. 8
No radiation
shielding is required.
Other methods based
on the 2-component
model may have
limitations when used
on individuals who
have changes in bone
mineralization. 14
Limited by the size of
the tank and the time,
expense and
equipment required.
9,10,11
They are not
sufficiently precise to
detect small changes
in FM (

Common
Clinical Tests
Skinfold
thicknesses
Near Infrared
Interactance
(NIR)
Bioelectric
Impedance
Assessment
(BIA)
Underlying
Principle
Numerous regression
equations have been
developed to
determine percent
body fat from the
sum of a number of
selected skinfold
thickness
measurements.
Applying principles
of light absorption
and reflection
measures the optical
density of the
underlying tissues
and extrapolates this
measurement to body
fat percentage.
Measures the
resistance of the
body’s tissues to a
weak electrical
current.
Impedance is greater
in adipose tissue
while lean body mass
is hydrous compared
to fat and is a good
conductor. 8
Uses Pros Cons
Used more often with
athletes than other
anthropometry
techniques.
Calipers to measure
skinfold thicknesses
come in a variety of
designs, degree of
accuracy and
therefore cost.
This electronic
device uses a light
wand applied to the
midline of the biceps
brachii muscle.
Though there are
newer variations
including one that
looks like a bathroom
scale, the typical BIA
device has wires that
connect electrodes
from the ankle and
wrist to a portable
central unit.
This technique has
been used for
decades and remains
the most popular
method for the
assessment of
athletes due to
affordability of the
equipment.
Very quick and easy
to set up and use.
Little training
required. Few
operational or
computational skills
demanded of the
user. 9,18
Fairly reliable, quick,
safe and easy to use.
This makes BIA
popular with
dietitians, fitness
clubs and health spas
that have a higher
volume of clients and
can justify the
expense. 12,18
For the performance
of an accurate test
with skinfold
thickness
measurement, perfect
technique is crucial.
12,16,17
Error can occur
unless you use the
same calipers for
measurements over
time. 18
It is of questionable
accuracy and offers
no advantage over
skinfolds except ease
of use. 3,18
More expensive than
calipers.
Not an appropriate
measurement tool for
tracking body
composition changes
over time. 19
Weaknesses of BIA
are assumptions of a
fixed level of
hydration and a
relatively cylindrical
body configuration.
18
Current regression
equations are less
precise at extremes of
adiposity because
impedance
overestimated
percent body fat in
thin subjects and
underestimated body
fat in fatter subjects.
12

APPENDIX B – BODY COMPOSITION ASSESSMENT VALIDITY CONCERNS
COMMON TO THE ABOVE METHODS
The dangers inherent in depending on invalid and/or unreliable measures of body
composition include misdiagnosis of excess adiposity, inappropriate prescription of
weight or fat loss and the inability to measure changes that may occur over time. 3,20
Assessment of body composition is indirectly measured with one of the methods
described in Appendix A and a calculated mathematical regression equation.
Assumptions for the equation used account for some of the error. 21 Along with skin fold
thickness measurements, BIA and NIR yield doubly indirect estimates of body
composition, as the assumptions upon which each is based are added to those
assumptions relied upon by hydrostatic (underwater) weighing. 3,22 This model assumes
that the constituents of the FM and FFM compartments have constant densities and that
the relative amounts of the three major components of the FFM (aqueous, mineral, and
protein) are known, additive, and constant in all individuals. 14 These assumptions have
been challenged, particularly the theoretical constancy of the fat-free compartment which
is problematic in women, athletes, non-whites, children, adolescents, and elderly who
may have different levels of tissue hydration and/or a significantly different range of
bone density. Many equations assume a constant body density which may be incorrect,
particularly in female athletes and dancers. Amenorrhea may initiate osteopenic changes,
decreasing bone mineral content and density. Lohman estimated differences as great as
8% in relative fatness with only a 2% difference in the body’s bone mineral content. 16,23
Thus, generalizing these equations among a diverse population can lead to significant
errors. Depending on the selected subjects, the resultant equation may be useful for only
one type of athlete or dancer of a particular gender, race, age and body shape. 16,18,24,25

APPENDIX C - BODY COMPOSITION ASSESSMENT- FACT AND FICTION
A BRIEF SYNOPSIS FOR ATHLETES, DANCERS, TEACHERS AND
COACHES
Is there a correlation between body composition assessment and
athletic performance?
For elite athletes in a particular sport, there is rarely a close relationship between body
composition and performance. There is no support for the myth that changing body
composition, independent of other factors, leads to changes in performance. There are
currently no published studies examining whether interventions designed only to decrease
body weight or body fat are effective in improving an individual’s performance. So what
are the reasons for low body fat levels and athletic success? Most successful athletes and
dancers have good genes, proper nutrition, good coaching and strenuous, appropriate
training.
How accurate is body composition assessment?
Skin fold thickness testing with calipers, bioelectric impedance assessment (BIA) and
near infrared interactance (NIR) are techniques to assess body composition. They all
produce some errors that reduce the accuracy of measurement. Certain tests are only
good for specific race, gender, age, and body type. Level of hydration also affect results.
What are the downfalls of body composition assessment?
There may be a link between body composition assessment and eating disorders. Some
athletes may be at risk of developing an eating disorder such as anorexia nervosa,
especially in sports where body appearance is perceived to be more important for success.
The result of mandatory daily or group weigh-ins and body composition assessment may
be mishandled or misinterpreted and may trigger the emergence of an eating disorder.
Body composition assessment may also trigger comments from coaches and precipitate
worry about weight and performance.
Is there an appropriate time to use body composition assessment?
In general, body composition assessment should not be done routinely. However, in
certain individual circumstances, it may be appropriate. For example, to ensure that an
athlete does not lose too much lean body mass with an increase in training volume and
intensity, or to ensure sufficient dietary intake, it may be appropriate to monitor lean
body mass over time. Assessments should only be done by a trained professional and the
information should be shared only with those who will be directly affected by the results.
So what should be done for optimal performance?
A qualified team of specialists can provide an athlete or dancer with all the components
for a successful career. A good coach or teacher can implement a successful training
plan, a physician can ensure optimal health, a nutritionist can perform a nutritional
assessment and design a nutritious diet, and a sports psychologist can ensure optimal
mental health.

APPENDIX D – A PRACTICAL STRATEGY FOR SPORT MEDICINE
PHYSICIANS
THE ROLE OF THE SPORT MEDICINE PHYSICIAN
1. Encourage and coordinate teamwork
All athletes, dancers, teachers and coaches should have the opportunity to work with a
team of qualified professionals who can provide education, support, assistance and
remedial programming. The team can include physicians, psychologists, dieticians,
athletic trainers and exercise physiologists. The athlete’s health is the first priority of all
sport personnel. Weight and thinness should be de-emphasized. This will be reflected in
the athlete’s thoughts, attitudes, discussions and behaviors. 26
2. Provide information to coaches
There are many things athletic departments, coaches and other sport-related personnel
can do to decrease the risk of development of eating disorders in the sport environment. 26
Coaches should focus less on body weight and body composition, and more on
information specifically related to sports, such as nutrition and psychology. Most
enlightened coaches and instructors follow nutritional guidelines and emphasize better
nutrition and healthy eating rather than weight standards. 27 Coaches and other sport
personnel need basic information about eating disorders and can play an essential role in
denouncing unhelpful and unhealthy behaviors and supporting programs designed to
assist in the primary and secondary prevention of eating disorders in athletes. 28
Coaches are in a unique position because they are trusted and respected by athletes. 28,29
They can play an important role in changing unhealthy “subcultural” aspects of their
sport. The attitudes and behaviours that have more to do with tradition, myth and
subculture than with factual information relating to sport performance can be changed by
a firm but gentle communication of the behaviours that are unhelpful and unhealthy and
therefore unacceptable. 26
3. Encourage access to qualified nutritionists for all athletes and
dancers
Athletes and dancers should be presented with information about what the body needs to
be healthy and to perform at its best. A nutritionist is an integral part of the sports team
and should be available to all coaches as well as athletes identified as being at risk for
eating disorders or requesting nutritional counselling. 30,31 Ideally, every athlete should
have at least one session each season with a nutritionist to obtain accurate and complete
information about his or her nutritional needs. More realistically, a sports nutritionist can
make a team presentation to provide accurate information on healthy eating behaviors for
optimal performance and dispel myths about eating and weight. Notwithstanding the
CASM opposition to body composition assessment recommendations, CASM believes
that the remainder of the recent “Dietitians’ Position Statement” encompasses excellent
guidance. 32

4. Provide knowledge about eating disorders
The team physician who is knowledgeable about eating disorders is encouraged to talk to
the team once each season to inform athletes, trainers and coaches about the early
warning signs of eating disorders and to convey information about the risks of having an
eating disorder. This can augment the message of a nutritionist or dietitian but is essential
in the absence of an available nutritionist or dietitian. The myth that amenorrhea is a
normal part of being an athlete should be dispelled and it should be clearly stated that
amenorrhea can lead to skeletal system injuries and difficulties that may interfere with
sport performance. 6,29,30,33,34,35,36 Written or audiovisual information is helpful in
educating athletes and dancers and physicians should encourage its availability. The
message given should ensure that the focus is on the athlete or dancer’s health and
performance rather than on his or her weight.
5. Screen for eating disorders
The pre-participation physical evaluation can include a module to assess eating habits,
weight changes, methods of weight control, excessive exercise and, for females, an
evaluation of menstrual function. If an athlete with an eating disorder or considered at
risk for an eating disorder is discovered, they are referred to the professionals familiar
with the treatment of the disorder. The team should include a dietician, psychologist and
physician familiar with the management of this difficult entity. 37
6. Raise awareness of weight-related health issues
Coaches and other sport personnel need to understand why weight is such a sensitive and
personal issue for many women. Weighing athletes indiscriminately or group weigh-ins
can cause psychological discomfort and can contribute to pathological means of weight
control. 30 Derogatory comments or behaviours about weight should be eliminated.
Athletes or dancers can perceive even innocuous comments as rude and embarrassing.
The athletes most affected by these comments or behaviors are more likely to be those
with low self-esteem and those predisposed to developing an eating disorder. 27
7. Encourage physical and emotional well-being
Sport performance is affected by many factors. Physical and emotional factors play a
significant role. The purported relationship between body fat and performance should
not be emphasized. The focus should be on physical conditioning, balance, dexterity,
flexibility, endurance and strength development as well as commitment and self-control.
26,38
.

APPENDIX E - DEFINITIONS
The Female Athlete Triad is a syndrome of disordered eating, amenorrhea and
osteoporosis. It usually occurs in women who are training very hard and are not eating in
proportion to their needs.
Eating disorders are characterized by gross disturbances in eating behaviour. They
include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified.
Milder disturbances in eating behaviour have been termed disordered eating. Subclinical
eating disorders have been used to describe individuals whose behaviour does
not meet the specific DSM-IV criteria for eating disorders. 39 Pugliese et al. described
certain athletes with such a sub-clinical eating disorder as having anorexia athletica. 40
Osteoporosis is a medical disorder in which the normal replenishment of old bone tissue
is disrupted, resulting in weakened bones and increased risk of fracture. It is most
common in white women after menopause, although it can also occur in younger women
and men. 41 A decrease in bone density of greater than 2.5 standard deviations compared
to an average young adult reflects osteoporosis. 42
Primary amenorrhea is a delay in or a failure to start menstruation; secondary
amenorrhea is a cessation in the menstrual cycle. It can be caused by dysfunction of the
pituitary gland, ovaries, uterus, or hypothalamus, surgical removal of the ovaries or
uterus, stress and/or other emotional factors, or inadequate nutrition. Women with
anorexia and female athletes have an increased incidence of amenorrhea. 41

6.0 THE 2003 WOMEN'S ISSUES IN SPORT MEDICINE
COMMITTEE (WIISM) OF THE CANADIAN ACADEMY OF SPORT
MEDICINE (CASM)
James D. Carson (Chair), Julia Alleyne, Eileen Bridges, Nina Gow, Janice
Harvey, Roger Hobden, Maureen Kennedy, Connie Lebrun (ACSM Liaison), and
Margo Mountjoy.
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