Safe Weight Loss and Maintenance Practices in Sport and Exercise

National Athletic Trainers’Association Position Statement:Safe Weight Loss and MaintenancePractices in Sport and ExerciseKathleen M. Laquale, PhD, ATC, LAT, LDNProfessor and Licensed Dietary NutritionistBridgewater State Universityklaquale@bridgew.edu

National Athletic Trainers’ AssociationPosition Statement: Safe Weight Loss andMaintenance Practices in Sport andExerciseAUTHORS:Paula Sammarone Turocy, EdD, ATC (Chair)Craig Horswill, PhDKathleen M. Laquale, PhD,ATC, LDNThomas J. Martin, MDArlette C. Perry, PhDMarla J. Somova, PhDAlan C. Utter, PhD, MPH, FACSM)

PURPOSEProvide athletic trainers withrecommendations for safe weight loss andweight maintenance practices for athletesand active clients and to provide athletes,clients, coaches and parents with safeguidelines that will allow athletes andclients to achieve and maintain weight andbody composition goals.

This position statement by NATA giveshealth care professionals scientifically basedrecommendations to implement safe weightloss and weight maintenance programs fortheir physically active clients and athletes.

DR. CRAIG HORSWILL“Athletic trainers and otherhealth professionals arepivotal in the health ofathletes in their programsproviding hands-on guidancein the prevention andtreatment of injuries as wellas advising them onstrategies for peakperformance.This includes weightmanagement and dietaryguidelines.”

Basis of Recommendations• These recommendations are built on thepremise that– scientific evidence supports safe and effectiveweight loss and weight management practicesand techniques, regardless of the activity orperformance goals.

MAIN POINTS OF THEPOSITION STATEMENT1. The process of using assessment results to change bodyweight safely, wisely modifying the diet and using dailyexercise to do so.2. The role of education of all shareholders in weight-classsports- the athletes, coaches and parents-and the utilizationof experts in nutrition to support these athletes.3. The health-hazardous techniques used to rapidly changebody weight in very lean athletes, and the added caution onusing unsubstantiated methods for weight reduction,including devices, clothing or dietary supplements as aprimary means.

WEIGHT CLASSIFICATIONSWhy was the concept of weight classificationsin sports such as wrestling, boxing, etc.established?To ensure healthy, safe and equitableparticipationHOWEVER,Not all sports or activities in which weightmight play a role in performance use aweight classification system.

1997 THREE WRESTLERSDIE ATTEMPTINGWEIGHT LOSSThe first of the deaths occurred onNov. 9, when Billy Saylor, a freshmanat Campbell University in Buies Creek,N.C., died of cardiac arrest after ridingan exercise bike and refusing liquids ashe tried to lose six pounds. He was 19years old.Two weeks later, on Nov. 21, JosephLaRosa, a senior at the University ofWisconsin-La Crosse, died of heatstroke after dressing in a rubber suitand riding a stationary bike in anattempt to lose four and a half pounds.He was 22.And on Dec. 9, Jeff Reese, a junior atMichigan, died of kidney failure andheart malfunction while wearing arubber suit and working out in a roomheated to 92 degrees. He was 21.

SINCE 1997-Specific rules andguidelines havebeen implementedto ensure thatweight controlpractices inwrestling are:SAFEAPPLIED EARLY IN THECOMPETITIVE SEASONCONDUCTED ON AREGULAR AND PLANNEDSCHEDULE AROUNDCOMPETITIONSDOES NOT INCLUDEDEHYDRATION AS AMEANS OF WEIGHT LOSS

• Diet and exercise have always affectedsports and physical activity, but with theintensity of competition increasing at alllevels has come a renewed interest incontrolling the factors that influenceperformance and health.• Diet, exercise, body composition, andweight management now play larger roles inan active person's life and performance.

Guidelines for objective assessment of body compositionas the basis for determining a competitive body weight.• Remind athletes: a lowered bodycomposition does not necessarily equateto improved performance.• Most aesthetic performance activitiesrequire fit body types for success andthese requirements may trigger anunhealthy preoccupation with weight.

CHRISTY HENRICHA few days before ChristyHenrich died in 1994, her 4-foot-11, 95-pound frame hadshrunk to 47 pounds.Henrich died from multiple organfailure stemming from her eightyearbattle with eating disorders, abattle that her family said beganshortly after she joined the U.S.national gymnastics team in 1986.Unsafe weight managementpractices can compromiseathletic performance andnegatively affect an individual'shealth.Athletes and physically activeindividuals often attempt to loseweight by not eating, engaging inunhealthy weight controlbehaviors and restricting fluids.

What Is Disordered Eating vs. EatingDisorders ? How Can You Identify It?Disordered eating: abnormal and potentiallyharmful eating behaviors that do not meetspecific criteria for eating disorders.Eating disorders: psychological illnesses thatinvolve specific abnormal eating behaviorsand other factors

Salivary gland enlargement

Dental Enamel Erosionwww.maxillofacialcenter.com/bulimia.html- Dentin (yellow) visible beneatheroded enamel (white)- Worse on lingual than buccalsurfaceswww.thejcdp.com/issue001/gandara/nitrogan.htmA: Less enamel loss on buccalsurfacesB: Enamel sparing in gingivalcrevices

Erosion of enamel (white) and dentin (yellow)from persistent vomiting, resulting in toothdecay, fracture, and loss

Malnutrition and HypometabolismMusclewastingLanugo• ⇓ Energy intake results in wasting of lean (muscle)Metabolism occurs in the lean body mass• Energy conservation: ⇓ BMR; ⇓ Temp.; ⇓ HR; ⇓ Peripheralblood flow; ⇓ Physical activity

Edema

Slow Capillary RefillAcrocyanosis –Decrease inoxygenCarotenemia – pseudo jaundice

Livedo Reticulariswww.pediatrics.wisc.edu/education/derm/tutc/69.html• Bluish discoloration ofskin• Reticular (“lacy”)pattern• Asymptomatic, but oftenassociated with low coretemperature andmetabolism

DISORDERED EATING ANDEATING DISORDERS• Disordered eating can lead to eatingdisorders• Treating eating disorders is a “three-prong”approach• Athletes who suddenly want to become avegetarian could be masking an eatingdisorderThe NATA’s position statement on preventing, detecting and managingdisordered eating in athletes delves into these issues in great detail.

DEHYDRATION AND FOOD RESTRICTIONThe most common unsafe methods for achieving weightlossgoals include mixing dehydration with food restrictionand improper dieting to reduce body fat.The use of laxatives and diuretics, and excessive exerciseare inappropriate methods of weight loss.The physiologic effects of dehydration are discussed indepth in 2 NATA position statements and will not bediscussed in this lecture.

HYDRATION STATUS: Duration of workout, fluidsconsumed and weight difference pre/post workout1)Pre-workout body weight (pounds)(2)Post-workout body weight (pounds)(3)Weight loss (pounds)(3) = (2) – (1) = sweat weight not replaced(4) Fluids consumed during workout (pints)1 pint = i.e. 2 cups = 16 fl. oz(5) Total sweat loss (pints)(5) = (3) + (4)% body weight loss(6) = [ (3) / (1) ] x 100Hydration StatusIf weight gain = over hydratedIf (6) = 0 - 1.9% = adequateIf (6) =2 – 3.9% = dehydrated, performance impairedIf (6) = 4 –5.9 % = significant dehydration, potential dangerIf (6) > 6% = severe dehydration, danger likelyMinimal fluid replacement rate ( oz / min)(7) = {(5) – [ 2% x (1) ]} x 16 / workout time(min)Minimal fluid replacement rate ( oz/15 min )(8) = (7) x 15Maximum fluid replacement rate ( oz/min )(9) = (5) x 16 / workout time (min)Maximum fluid replacement rate ( oz/15 min )(10) = (9) x 15Recommended fluid replacement (oz every15 minutes)(8) to (10)*assumes that no urine production during workoutDunford and Doyle, 2010

• Thirst is NOT the best indicator of adequate hydration-WHY???• High protein diets can lead to excessive fluid loss whichmay be dehydrating- WHY??• Medications with sulfur and excess vitamin B2• Teach athletes Turgor and how to classify urine color• Put bottles on display

WHAT IS THE COLOR OF• Fill three clear coveredbottles:– One with clear water andtinted with yellow foodcolor– One with clear water andvanilla flavoring to createa darker color– One with apple juice• Place a sign “What isthe color of your “pee”YOUR “PEE”

TAKE HOME MESSAGEREGARDING PROTEIN• Individuals don’trealize how muchprotein they areactually ingesting– 2 slices of bread (6 gms)– 2 tablespoons ofpeanut butter (8 gms)– 2 cups of milk (16 gms)• Recommendation.8 g/kg/bw per day– 130#s/2.2 = 59 kg– 59kg x .8 = 47 grams• Total - 30 gms

Identify the role of the Athletic Trainer inhelping weight-classification athletes.• Body composition assessments should beused to determine safe body weight andbody composition goals however thereliability of the trained assessor is crucial.• Common to all methods is hydration.Athletes must be fully hydrated duringtesting.

• Monitoring of athlete’s body compositionto determine goal weight is completedtwice annually with no less than 3 monthsbetween measurements.• Results of assessment must be must bemanaged as personal and confidentialmedical information.

• Athletic trainers and allied healthprofessionals should be aware of the highand low ranges for a healthy bodycomposition.• (The highest safe weights should not exceedthe body fat ranges considered satisfactory forhealth: 10%-22% for males and 20%-32% forfemales.• Conversely, low reference body fatcomposition is 5% in males and 12% infemales.)

SKINFOLD CALIPERSBOD PODHYDROSTATIC TANKBIADEXA

How Do You Know If You are at aHealthy Weight? Body mass index (BMI) = weight (lbs) x 703 /Measure your BMI:–Healthy Weight = 18.5 – 24.9Underweight = < 18.5(can also be unhealthy)height squared (in 2 )►BMI of 25-29.9 is overweight: modestincrease in risk of dying from diseases►30 is obese: 50 – 100% higher risk of dyingprematurely compared to healthy weight• Class I = 30.0-34.9• Class II = 35.0-39.9• Class III = > 40.0

BMI AND MUSCULARINDIVIDUALS• DO YOU THINK THISCOMPETITIVEATHLETE ISOVERWEIGHT?• HER BMI AT 32WOULD INDICATE AHEALTH RISK.• SHE MAY BEOVERWEIGHT BUTNOT OVERFAT!

TARGET WEIGHT• A healthy body weight or target weight can bedetermined using the body-fat percentage asthe guide to weight loss.• Once the athlete’s percent body fat and leanbody mass has been determined, a target bodyweight formula can be utilized:• Target body weight= lean body mass inpounds/ 1.00 – desired body-fat percentage.

For example, an athlete weighs 154 pounds with a 24percent body fat and they wish to compete between20 and 21 percent body fat.Fat Mass = Body Weight (Mass) x Percent Body FatFat Mass (37 pounds) = 154 pounds x .24 (percent body fat)Lean Body Mass = Body Weight – Fat MassLean Body Mass (117 pounds)= Body Weight (154 pounds) – Fat Mass (37 pounds)Target Body Weight = Lean Body Mass/ 1.0 – desired body fat percentageAt 20% Body Fat PercentageTarget Body Weight (146 pounds) = Lean Body Mass (117 pounds)/ 1.0 - .20At 21% Body Fat PercentageTarget Body Weight (148 pounds) = Lean Body Mass (117 pounds)/ 1.0-.21Thus, the athlete’s target body weight would range from 146 pounds to 148 pounds.

The process of using assessment results to change bodyweight safely, wisely modifying the diet and using dailyexercise to do so.• Management of body composition shouldinclude both diet and exercise.• The dietary plan should be developed toaddress the athlete’s or client’s specificbody composition, body weight andactivity goals.

A healthy diet or meal plan is considereda balance of energy producingmacronutrients (carbohydrates, fats andprotein) and non-energy producingmicronutrients (vitamins, minerals andwater) which provides adequate caloriesto achieve body weight goals, supplyessential (from food) nutrients andmaintain hydration.

• However, someone might want to decrease bodyfat BUTif energy intake is low andif energy expended in exercise too high• End result may be a decrease in musclemass in addition to body fat, which mayresult in a decrease instrengthendurancespeedA dietary intake less than 1500 calories/day is required to prevent avitamin or mineral deficiency.

Dietary Restrictions Over Time Can AdverselyAffect Endocrine and Immune SystemsImpairs thyroid functionLowers metabolism (decreasing energy levels)Impairs hormone productionLowering of estrogen levels (increasing therisk of osteoporosis and menstrualdysfunction)Suppresses the immune systemCan lead to an increased number ofinfections.

.DIETING…I’VE BEENDIETING FOR AMONTH ANDALL I’VE LOSTIS 31 DAYS!

PITFALLS OF DIETING• Feelings of deprivation• Binge eating on favorite foods• Overeating and weight regain• Guilt• Too few calories• Metabolism lowers• Increased fat storage• Could lead to disordered eating• MOOD CHANGES

Three Pieces of the Long-TermWeight Loss Puzzle

Caloric intake should be based on the body weight goal• Just as athletes know they must acclimatize to environmental conditionsduring training, we must encourage athletes to “get in shape”nutritionally. Persuade athletes and clients to adjust their weight andbody composition during the “pre-season”. “Get in shape to do the sportnot use the sport to get in shape” (Laquale, 1985).• Combining weight management and body composition goals with physicalconditioning periodization goals will assist athletes and clients in reachingweight goals.• There are metabolic estimation equations (to determine how manycalories per day the athlete should consume) which take into considerationbody size, fat mass and FFM (muscle), age and the expenditure of energyfor activity.• (Table 4 in the position statement refers to two formulas (Harris-Benedictand the Mifflin-St.Jeor) which calculate total caloric need.)

1. Convert weight to kg (divide weight in pounds by 2.2)2. Convert height to cm (multiply your height in inchesby 2.54 cm)Example: 5’3” = 63 inches5’ x 12” = 60 inches + 3” = 63”6’4” = 76 inches6” x 12” = 72 inches + 4” = 76”

BEE ____________ x Activity Factor =Total Energy Intake/dayACTIVITY FACTOR:1.2 SEDENTARY (little or no exercise)1.375 LIGHTLY ACTIVE (light exercise 1-3 times per week)1.55 MODERATELY ACTIVE (3-5 days/week)1.725 VERY ACTIVE (hard exercise or sports 6-7 days/week)

• Count caloriesor• Use the MyPlate• or• Use the ExchangeSystem

Foods in an exchange contain similar nutrient andcaloric valueThere are six food exchanges:1. Milk exchange2. Meat and meat substitutes exchange3. Starch exchange4. Fruit exchange5. Vegetable exchange6. Fat exchange

FOOD EXCHANGEEXCHANGESSTARCH 12FRUIT 7VEGETABLES 4MILK/DAIRY 3MEAT/PROTEIN 8FAT 6

SAMPLE BREAKFAST• ½ cup cereal ½ starch• ½ cup skim milk ½ milk• 1 slice of toast 1 starch• 1 tsp of butter1 fat• ½ cup orange juice 1 fruit• ½ banana 1 fruit

What Is a ReasonableRate of Weight Loss?To lose 1 lb of body fat, need3,500 calorie deficit:1# of fat = 3,500 caloriesOnce the metabolic estimation is calculated for theindividual, increases or decreases in calories to the levelneeded for weight gain or weight loss can be adjusted.• Weight loss of 1 lb/week, need to decrease daily calories by 500calories• 3,500 calories/7 day in a week =500 calories/d• Deduct 500 calories/d from total calories2,500 kcal • To safely lose 1# of fat/week-500 kcal2,000 kcal per day– 2,500 calories/day – 500 calories/day =new energy intake of 2,000 calories/day

Additional Protein to GainOne Pound of Muscle• One pound of muscle tissue = 454 grams– 70% water, 7% lipids, 22% muscle tissue• One pound of muscle tissue– 454 grams x .22 = 14 grams• If the goal is to increase muscle mass byone pound per week - a person wouldneed to consume an additional 14 gramsof protein per day» Melvin Williams, 2010

The role of education of all shareholders in weight-classsports- the athletes, coaches and parents-and theutilization of experts in nutrition to support these athletes.• Education on safe dietary and weightmanagement practices should be conductedon a regular and planned basis.• The initial team meeting or client interviewis an opportune time to communicateinformation on healthy eating habits and theeffect of proper nutrition and hydration onperformance.• Maybe add a section on sports nutrition toyour policy and procedure handbook.

• The key to communication with your athletes is toeducate them on the dietary practices of athletes.• Learn what is being said and discussed aboutnutrition by your athletes first.• What they think they know about nutrition may beinaccurate or even harmful.• Encourage them to inquire about nutritionalconcepts with you.

• THERE ARE NOBAD FOODS,JUST BADEATING HABITSIMPRESSUPON YOURATHLETESTO MAKEHEALTHIERFOODCHOICES• Bodiescannotperform wellwithout avariety offoodsCOMMON MISTAKESMaking food choices that hamper performanceHigh fat and high protein beforecompetitionWaiting too long to refuel after exercise“The golden hour”Relying on supplements as meal replacementSkipping breakfast or lunchIf you restrict one or more nutrients, you are not goingto be fueling your body optimally, AND your eatingplan will be very boring!

We eat FOOD,NOT nutrientsAthletes need carbohydrate, protein and fatcontainingfoods daily– An athlete’s diet cannot omit a whole food groupi.e. low carbohydrates-high protein diet– A bowl of cereal and milk can provide B-vitamins, proteinand dairy and grains. Add a banana and we can add fruitto the list.FACT: Cereal is composed of carbohydrates and some protein.Milk is a combo of carbohydrate, protein and some fat (%varies). Fruit provides vitamins and minerals.

THE ROLE OF THEATHLETIC TRAINER• It is up to the athletic trainer or healthcareprovider to be– honest with their athletes– be sure their advice is current– be familiar with the nutritional and physiologicaldemands of an athlete’s sport (plus the rulesgoverning weigh-in procedures)– know when to refer the athlete to anotherprofessional, regarding topics which they are notproficient

Consultation with a board certified Sports Dietitian(CSSD) who is a registered dietitian credentialed by theAmerican Dietetic Association is the ideal.However, a registered (RD)or licensed dietarynutritionist (LDN) can provide nutritional informationto athletes and clients.A qualified nutritionist whose specialty is sports nutritioncould provide a lecture to a specific team or all varsitysports.Nutrition information which is common publicknowledge can be provided by athletic trainers andother health professionals.

Coaches, peers and family members shouldnot provide information on diet, bodycomposition, weight, or weightmanagementpractices and should refrainfrom making comments on participating inthe monitoring of body composition andweight(Bonci et al, 2008)

The health-hazardous techniques used to rapidly change bodyweight in very lean athletes, and the added caution on usingunsubstantiated methods for weight reduction, includingdevices, clothing or dietary supplements as a primary means.• Ergogenic (performance enhancing) anddietary aids should be ingested cautiouslyand under the advisement of thoseknowledgeable of the requirements ofsports and other governing organizations.

• Athlete needs to know what they are putting intheir body• “Hidden ingredients” – “tests positive”– Symbols on the label– GMP

DIETARY SUPPLEMENTSFOR WEIGHT LOSS

Dietary Supplements for Weight Loss• Power Thin:• Contains folic acid, vitamin B12, mg,chromium, potassium citrate, and proprietaryblend of ma huang(ephedrine), kola nut(caffeine), fo-ti root, licorice, spirulina algea,guarana seed, gotu kola, ginseng (2 types),gingko biloba, and much more• Dose: 1 capsule 3-4x/day

POWER THIN• Ma Huang helps to suppress craving and burns body fat more efficiently. Furthermore, also knownto increase the basal metabolic rate, thereby increasing the energy level.• Magnesium Salicylate assists in enzyme reactions, energy release assistance in neuro-muscularcontraction, absorption of calcium, vitamins C, E, B complex, protein synthesis, and regulation ofbody temperature.• Chromium facilitates insulin to metabolize fat, turn protein into muscle and convert sugar intoenergy.• Ginseng stimulates hormonal activities, increases energy and is a known food for the heart andnerves.• Bladderwrack assists in overcoming fatness and normalizing the thyroid gland.•• Kola Nut is helpful in reducing mental fatigue and high blood pressure.• White Willow Bark contains Salicylic Acid, which helps to generate thermogenesis.• Ginger Root stimulates circulation and aids in digestion.

POWER THIN• Gotu Kola is known to be a brain food and is good for memory.• Licorice Root is beneficial in treating adrenal insufficiency and other glandular deficiencies.• Hawthorne Berries regulates heart rate and blood pressure.• Saw Palmetto helps the body to eliminate excess water, improves digestion, and increasesstrength.• Ginkgo Biloba improves mental alertness and helps stimulate blood flow to the brain.• Boron helps in preventing calcium loss.•• Spirulina contains essential amino acids, Beta Carotene, B vitamins and trace minerals.• Vitamin B-12 assists in the metabolism of protein, carbohydrates and fats.• Folic Acid helps in synthesis of DNA and RNA

AN ATHLETE ASKS MEABOUT A SUPPLEMENTWHAT IS THE NEXT STEP?SUPPLEMENTWEB SITE OF COMPANYCONSUMERLAB.COMPRODUCTINFORMATION

WHAT TO LOOK UP?HYDROXYCUT• ACTIVE INGREDIENTS:– CLAIMS– RECOMMENDED AMOUNT– SIDE EFFECTS

WHAT TO LOOK UP?HYDROXYCUT• ACTIVE INGREDIENTS:– GARCINIA CAMBOGIA REDUCES BODY FAT– GLUCOMANNAN (FIBER) APPETITE CONTROL– L CARNITINE BURNS FAT FOR ENERGY– GREEN TEA THERMOGENIC RAISES BODYTEMPERATURE

WHAT TO LOOK UP?HYDROXYCUT– CLAIMS: WEIGHT LOSS– RECOMMENDED AMOUNT: NINE PILLS/DAY– SIDE EFFECTS:» CARDIAC COMPLICATIONS» DEHYDRATION – HEAT SYNCOPE» IRRITABILITY AND INSOMNIA» APPETITE SUPPRESSANT» IMPAIRS FAT UTILIZATION AS ENERGYPRIOR TO RECALL: CONTAINED EPHEDRINESIDE EFFECTS:LIVER INJURY can cause jaundice, excessive fatigue, nausea, vomiting andbrown urineCan also cause users to develop seizures, cardiovascular disorders and rhabdomyolysis -- a type ofmuscle damage that is linked to kidney failure.

WHAT TO LOOK UP?• WHAT DOES IT DO?– CLAIMS:– BENEFITS:– ADMINISTRATION:

WHAT TO LOOK UP?• WHAT DOES IT DO?– CLAIMS: CUTTING EDGE WEIGHT LOSSSUPPLEMENT WITH UNIQUE INGREDIENTS– BENEFITS: INCREASE ENERGY LEVELS, BOOSTMETABOLISM AND CALORIE-BURNING– ADMINISTRATION: ORALLY

WHAT TO LOOK UP?• SUPPLY/CONTAINER– # MG OR GM PER DAY:– PILL OR POWDER:– COST:– TOTAL SUPPY PER CONTAINER:

WHAT TO LOOK UP?• SUPPLY/CONTAINER– # MG OR GM: 1.6 gm/3 capsules– PILL OR POWDER: PILL– COST: $19.00-$21.00– TOTAL SUPPY PER CONTAINER: 46

WHAT TO LOOK UP?• SUGGESTED USE– DOSAGE:– AM OR PM:– EMPTY OR FULL STOMACH:– HYDRATION:– RELATIONSHIP TO WORKOUT:

WHAT TO LOOK UP?• SUGGESTED USE– DOSAGE : THREE CAPSULES 3X/D– AM OR PM: DO NOT TAKE WITHIN 5 HOURS OF SLEEP– EMPTY OR FULL STOMACH: EMPTY– HYDRATION: 12 OUNCES OF WATER/10XS/DAY– RELATIONSHIP TO WORKOUT: NA

• NCAA• Center for FoodSafety and AppliedNutrition (CFSAN)• NIH Office of DietarySupplements• U.S. Pharmacopoeia• Food and NutritionInformation Council• MedWatch• Supplement Watch• WADA & USADA

• MyPlate– www.MyPlate.gov • Australian Sports Institute– www. Australiansportsinstitute.org• NCAA Nutrition and Performancewebsite– www.ncaa.org/nutritionandperformance.html

• Sports, Cardiovascular and WellnessNutritionists (SCAN) practice group ofAmerican Dietetic Association:• http://www.scandpg.org/ , factsheets athttp://www.scandpg.org/sports-nutrition/sports-nutritionfact-sheets/

IF I TREAT YOU, I CAN HELP YOU TODAY.IF I TEACH YOU, I CAN HELP YOU FOR ALIFETIME.Kathleen M. Laquale 2012