CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Rebecca L. Carl, MD, MS, FAAP,​a Miriam D. Johnson, MD, FAAP,b​ Thomas J. Martin, MD, FAAP,c,​ ​d,​e COUNCILPromotion ON SPORTS MEDICINE AND FITNESSof Healthy Weight- Control Practices in Young Athletes Children and adolescents may participate in sports that favor a particular abstract body type. Some sports, such as gymnastics, dance, and distance running, emphasize a slim or lean physique for aesthetic or performance reasons. Participants in weight-class sports, such as wrestling and martial arts, may attempt weight loss so they can compete at a lower weight class. Other sports, such as football and bodybuilding, highlight a muscular aInstitute for Sports Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; bDepartment of Pediatrics, physique; young athletes engaged in these sports may desire to gain weight University of Washington, Seattle, Washington; cDepartment of Pediatrics, Geisinger Commonwealth School of Medicine, Scranton, and muscle mass. This clinical report describes unhealthy methods of Pennsylvania; dDepartment of Pediatrics, Milton S. Hershey College of weight loss and gain as well as policies and approaches used to curb these Medicine, Pennsylvania State University, Hershey, Pennsylvania; and eCentral Pennsylvania Clinic for Special Children and Adults, Belleville, practices. The report also reviews healthy strategies for weight loss and Pennsylvania

weight gain and provides recommendations for pediatricians on how to Dr Martin drafted the report update proposal, conceptualized the promote healthy weight control in young athletes. initial manuscript, contributed to editing on the basis of comments from American Academy of Pediatrics (AAP) reviewers; Dr Johnson conceptualized and wrote the initial manuscript, contributed to editing on the basis of comments from AAP reviewers; Dr Carl revised the initial manuscript, contributed to editing on the basis of comments from AAP reviewers; and all authors approved the final manuscript.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have Young athletes who participate in sports that favor a particular body type filed conflict of interest statements with the American Academy “ ” of Pediatrics. Any conflicts have been resolved through a process may express a desire to lose or gain weight. Athletes who participate in approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial weight-sensitive sports, which emphasize a lean, slim physique, often involvement in the development of the content of this publication. seek to lose weight. In aesthetic sports, such as gymnastics, figure skating, Clinical reports from the American Academy of Pediatrics benefit from and diving, athletes may believe they will be judged more favorably if expertise and resources of liaisons and internal (AAP) and external they have a lean body build. With other sports, distance running and reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations cycling, for example, participants with a slim physique are perceived to or government agencies that they represent. have a greater ability to move the body against gravity if they weigh less. The guidance in this report does not indicate an exclusive course of ‍Table 1 lists examples of sports that typically favor a slim/lean build. For treatment or serve as a standard of medical care. Variations, taking weight-class sports, including wrestling and martial arts, athletes often into account individual circumstances, may be appropriate. desire to compete at the lowest possible weight in the belief that lighter All clinical reports from the American Academy of Pediatrics athletes have an increased strength-to-weight ratio (‍Table 2). automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Football and powerlifting are examples of sports that highlight a muscular physique (‍Table 3). Children and adolescents who participate in sports that emphasize strength and power often attempt to gain weight and lean To cite: Carl RL, Johnson MD, Martin TJ, AAP COUNCIL ON SPORTS MEDICINE AND FITNESS. Promotion of Healthy muscle mass to improve performance. Participants in bodybuilding may Weight-Control Practices in Young Athletes. Pediatrics. seek to increase muscle mass and definition for aesthetic reasons. 2017;140(3):e20171871 –

In their attempts to change body weight and composition,1 6 some athletes resort to unhealthy weight-control practices. ‍ ‍ These unhealthy Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 3, September 2017:e20171871 From the American Academy of Pediatrics

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 1 Sports That Emphasize a Thin/Lean Physique “ Dance The American Academy of Pediatrics inappropriate weight loss methods (‍AAP) policy statement Promotion can result in reduced muscle Cheerleading ” Cross country/distance running of Healthy Weight Control in Young strength, reduced performance in Cross-country skiing Athletes was published7,8​ in 1996 aerobic activities, decreased mental Cycling and updated in 2005. ‍ This clinical and cognitive performance, mood Diving Figure skating report replaces the 2005 statement changes, depression, compromised Gymnastics (artistic and rhythmic) and includes more recent evidence immune response, and changes Ski jump about the detrimental effects of in the cardiovascular, endocrine,– – Swimming dehydration and the benefits of gastrointestinal, renal, and 1 3,6,​ 9​ 16 Synchronized swimming gradual weight loss as compared with thermoregulatory systems. ‍ ‍ ‍ ‍ ‍ Weight Loss Attributable to Dehydration TABLE 2 Sports With Weight Classes/Weight acute weight loss. Data on the effects Limits of collegiate and high school rule Boxing changes are also included. Crew Weight Loss Up to 67% of athletes involved Horse racing—jockeys in weight-class sports, such as Martial arts wrestling, boxing, and weight-class Weight-class football crew, attempt to lose weight acutely Wrestling Athletes may attempt to lose weight 4 with dehydration techniques. High to enhance performance, to qualify school and college wrestlers report TABLE 3 Sports That Emphasize a Muscular for a particular weight class, or to high rates of fasting, restricting fluid Physique change their appearance for a sport intake, and engaging in practices Baseball that emphasizes a lean physique. that increase sweating for acute Basketball Weight loss becomes a problem when 17,18​“ ” weight loss. ‍ This process, Bodybuilding athletes are inadequately hydrated Football (especially linemen) referred to as weight cutting,​ and/or when nutritional needs are Powerlifting allows competitors to weigh in at the not met. Table 4 lists healthy and Rugby lowest possible weight; most athletes Track (eg, shot-put, discus) unhealthy weight loss methods. Unhealthy Weight Loss subsequently attempt to regain weight by rehydrating between the weigh-in and competition. The Some weight loss methods can lead term hypohydration refers to the weight-control approaches may to serious physical and psychological state of suboptimal hydration, adversely affect health and, in harm. Additionally, certain weight and dehydration describes the

some cases, can negatively affect loss practices impair athletic transition from a well-hydrated19 to performance. Pediatricians should performance and increase injury risk. a hypohydrated state. Examples have an awareness of safe and unsafe Weight loss may initially improve of dehydration techniques include weight-control practices so they can athletic performance because of an fluid restriction, spitting, vomiting, counsel young athletes and family increase in the strength-to-weight steam baths, saunas, using laxatives members appropriately. ratio. However, continued use of or diuretics, and wearing nonporous TABLE 4 Unhealthy and Healthy Weight Loss Methods Unhealthy Weight Loss Healthy Weight Loss Rapid weight loss Gradual weight loss Loss of >2 lb/wk Loss of no more than 1 lb/wk in growing athlete with excess body fat, 2 lb/ Muscle mass is lost wk in mature athlete Stimulant use to promote weight loss Weight lost is excess body fat, not muscle mass Exercise in excess of what is recommended for sport Exercise an appropriate amount for the sport Laxative use Diet is well-balanced and consists of ∼6–10 g/kg per d of carbohydrates, Diet pill use 0.85–1.7 g/kg per d of protein, and 1 g/kg per d of fat Vomiting Maintain euhydration Voluntary dehydration Preferable to lose weight in off-season Fluid restriction Caloric intake meets the energy costs of living, growth, and sport activities Diuretic use Spitting Enhanced sweat production Steam baths, saunas Exercise in nonpermeable clothing

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Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 5 Mental and Cognitive Changes Attribut­­ able to Hypohydration/Dehydration suits to increase sweat production. Decreased psychomotor function is measured by using 1 of 3 methods: Using these tactics over the course of Decreased reaction time skin fold caliper measurement by several days can lead to progressive– Decreased accuracy a trained evaluator, hydrostatic Decreased mental endurance dehydration because many athletes20 24 (‍underwater) weighing, or air fail to fully rehydrate each day. ‍‍ Decreased alertness displacement plethysmography Increased problem-solving time After 2 to 3 days of dehydration, Increased fatigue (‍commonly performed by using replacement of 25intracellular fluids Increased levels of perceived exertion a Bod Pod device). Body fat and takes 48 hours. Temporary learning deficits weight are entered into an online Mood swings optimal performance calculator Athletes and coaches in weight- Changes in cognitive state and are used to calculate the lowest class sports often harbor a belief Adapted from Weber AF, Mihalik JP, Register-Mihalik JK, Mays allowable weight (‍LAW) by using that weighing in at the lowest S, Prentice WE, Guskiewicz KM. Dehydration and performance 2 different methods. The LAW1 possible weight will maximize on clinical concussion measures in collegiate wrestlers. J ’ Athl Train. 2013;48(2):153 160, Petri NM, Dropulic N, Kardum formula incorporates the minimum strength-to-weight ratio and – G. Effects of voluntary fluid intake deprivation on mental body fat of 5% allowed by the increase an athlete s competitive and psychomotor performance. Croat Med J. 2006;47(6): 4,6​ NCAA. The LAW2 accounts for the advantage. ‍ However, inadequate 855–861, and Derave W, De Clercq D, Bouckaert J, Pannier JL. The influence of exercise and dehydration on postural 1.5% body weight loss per week hydration has been shown to stability. Ergonomics. 1998;41(6):782–789. permitted during the season. The decrease athletic performance; – highest of these calculated weights aerobic function is impaired more 26 32 is the lowest weight allowed for than anaerobic performance. ‍‍ competition during the wrestling Poor hydration status leads to 41,42​ season. ‍ Table 6 provides a list of decreased strength, power, and – these deaths, the National Collegiate the variables and the equations used endurance with high-intensity 30,32​ 34 Athletic Association (‍NCAA) in the calculation of LAW1 and LAW2 exercise. ‍ ‍‍ Dehydration results instituted new rules designed to for reference. in increased body temperature and curb the practice of acute weight raises susceptibility to heat illness. – loss; the rules were implemented in In the high school wrestling arena, The effects of hypohydration on – “ 1998 and updated in the 2003 2004 the Wisconsin Interscholastic thermoregulation is addressed in the 41 and 2013 2014 rule books. The Athletic Association was the first AAP policy statement Climactic Heat ” updated NCAA rules banned the use state high school athletic association Stress and Exercising Children and 20 of diuretics, impermeable suits, and to implement a plan to curtail Adolescents. ‍ saunas for weight loss and decreased weight cutting43 among high school Dehydrated athletes often the amount of time between weigh- wrestlers. The National Federation experience mental status and ins and competition. Additionally, of State High School Associations cognitive changes (‍Table 5). Poor the NCAA established a system adopted guidelines that apply to hydration status is also associated of setting a minimum weight for high schools in all states in 2006. with impaired performance on the competition during the wrestling High school wrestlers must have Sports Concussion Assessment season by using a calculation that a urinespecific gravity of 1.025 or Tool, an instrument– used to assess incorporates hydration status less for their preseason weigh-in.

mental status35 and37 symptoms after (‍based on urinespecific gravity), Minimum body fat during the concussion. ‍‍ Although most weight, and body composition. wrestling season is set at 7% for studies on the effects of hydration Before the competition season, boys and 12% for girls. As with on performance have included only athletes submit a urine sample from NCAA athletes, high school wrestlers adult participants, dehydration is also a witnessed collection for testing. If may lose no more than 1.5% of detrimental to aerobic performance the urinespecific gravity is 1.020 or body weight per week. Additionally,

and skill-based38,39​ activities in elite child less, the athlete is considered well there is a 2-lb growth allowance athletes. ‍ hydrated and can weigh in. Body fat for each weight class per season. National Sport Governing Bodies TABLE 6 LAW1 and LAW2 Calculations Address Rapid Weight Loss Attributable Variables Formulas to Dehydration and/or Hypohydration bf% LAW1 = FFW/0.95 wt LAW2 = wt − (1.5% × #wk × wt) FW = wt × bf% Fat-free weight (FFW) = wt − (wt × bf%) In 1997, over the course of 33 days, No. weeks in season (#wk) 3 college wrestlers died as a result bf%, body fat percentage; FFW, fat-free weight; FW, fat weight; #wk, number of weeks in season. of attempting drastic40 weight loss before competition. In response to Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 3, September 2017 3

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF High schools are permitted to use use bioelectrical impedance analysis growth, remodeling bone, building

bioelectrical impedance analysis as to measure body fat percentage; and repairing muscle tissue,9,57,​ 58​ and an alternative to skin fold caliper this technique is less accurate than participating in sports. ‍ ‍ and air displacement options to others, and hydration status can 44 52,55​ Unhealthy weight loss behaviors determine body fat percentage. affect the results. ‍ Dual-energy occur along a continuum. At one end Some individual states have adopted radiograph absorptiometry (‍DXA) is of the spectrum are individuals with stricter policies and require a accurate, nonintrusive, and easy to a mild energy imbalance: caloric urinespecific gravity of 1.020 or perform; but DXA scanning involves a ’ 45,46​ intake is not sufficient to cover the lower before weigh-ins. ‍ small amount of radiation exposure, body s energy requirements. At and athletes over 192 cm (‍73.5 in) The establishment of minimum 52 the other end of the spectrum are may not fit into standard scanners. competition weight rules has led to athletes engaging in dangerous The most precise way to determine a decrease in the practice of rapid weight loss practices that carry a 47,48​ body composition is by using several weight loss before competition. ‍ high risk of associated morbidity different methods (‍a multicomponent However, the urinespecific gravity and mortality; this extreme includes model), such as skinfold measurements of 1.020 and children and adolescents with frank measurements, DXA, and waist – 1.025 required by the NCAA and 27,56​ eating disorders, such as anorexia circumference measurements. 17,59​ 63 National Federation of State High nervosa and bulimia nervosa. ‍ ‍‍ However, the multicomponent School Associations for weigh-ins, In addition to fasting or restricting method is rarely feasible in the respectively, do not correspond with calories, risky weight loss practices clinical setting. Body composition is ideal hydration status. An optimally include vomiting after eating, ∼ most accurately calculated with serial hydrated athlete should have a performing excessive exercise, measurements that use the same urinespecific gravity of 1.010 and and the use of diuretic, laxative, or 49 assessment technique performed by a urine osmolality of 300 mOsm/L. stimulant medications. Persistent an experienced health care provider, Some athletes may use diuretics to weight loss via unhealthy behaviors such as an exercise physiologist, produce dilute urine. Additionally, may result in delayed physical athletic trainer, registered dietitian consuming a large quantity of plain maturation, growth impairment, nutritionist (‍RDN), or sports – water over a short period of time 52 and the development of eating medicine physician. 2,3,​ 11​ 16 leads to lower serum osmolality disorders“ . ‍ ‍ ‍ ‍ ” and increased50,51​ urine output and Changing the timing of dilution. This practice may result precompetition weigh-ins to The female athlete triad (‍triad) is a in a low urinespecific gravity test immediately before matches has been term that describes the combination of low energy availability, menstrual result in a dehydrated athlete. proposed as a means of decreasing4 the incentive to cut weight. Using dysfunction, and low bone mineral There is no agreed-on gold a random draw to determine density. When first described, standard for the assessment of body the order in which athletes of the 3 facets of the triad included composition. Skinfold measurement different weight classes compete disordered eating,64 amenorrhea, is an inexpensive, well-validated could also spur athletes to avoid and osteoporosis. The definition method that is commonly used in purposeful dehydration before sport was subsequently altered to the high school and collegiate setting 42 participation. reflect the spectrum of low energy to determine body composition. Unhealthy Weight Loss Attributable to Inadequate Energy (Caloric) Availability availability and its63, consequences65​ However, skinfold measurement in female athletes. ‍ Low energy requires trained personnel and may availability refers to an imbalance not be as accurate28,29,​ 52​ for individuals between caloric intake and energy with obesity. ‍ ‍ In addition, there Many athletes attempt to lose weight expenditure. A small body of research are racial and ethnic differences in by restricting energy (‍caloric) intake. supports the concept that male the location of body mass storage Athletes typically need a greater9, 27,​ 57​ athletes also appear to be susceptible and fat deposition that affect skin caloric intake than nonathletes. ‍ ‍ 53,54​ ’ to inadequate energy availability fold measurements. Hydrostatic The actual energy requirement and may experience adverse66,67​ health (‍underwater) weight and air depends on the athlete s body consequences as a result. displacement plethysmography composition, weight, height, age, are simple to perform but require stage of growth, and level of fitness, A survey of female high school

expensive equipment; both as well as the intensity, frequency,9,57​ athletes revealed that one third had methods may underestimate body and duration of exercise activity. disordered eating; disordered eating

fat percentage in extremely lean Athletes need to eat enough to cover was correlated with an increased68 athletes. High schools are allowed to the energy costs of daily living, risk of musculoskeletal injury. Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF 74,75​ “ Menstrual irregularities and low eating and menstrual irregularities. ‍ intake, when appropriate. The AAP bone mineral density, also features Weight, height, and BMI can also be clinical report, Identification and ” of the female athlete triad, have been plotted on a growth chart at each Management of Eating Disorders in “ 69 associated with higher injury risk. office visit, and abnormal trends Children and Adolescents,​ discusses ” The AAP statement The Female can be identified. BMI less than the the diagnosis and treatment of

Athlete Triad provides an in-depth fifth percentile, BMI less than 17.5 eating disorders16 in the pediatric review of energy deficiency and 70 in a skeletally mature adolescent, or population. Recommendations eating disorders in female athletes. weight less than 85% of expected have also been published on return- body weight would warrant further to-play criteria in female athletes Although female athletes have the evaluation for unhealthy weight loss with disordered eating, menstrual highest rates of eating disorders, 16,63​ behavior. ‍ dysfunction, and decreased bone male athletes are also at risk. In a 61,63​ mineral density. study of 677 elite adolescent athletes, Education of athletes, parents, and Healthy Weight Loss in the Athlete female athletes exhibited higher coaches about unhealthy weight loss Classified as Having Overweight or Obesity rates of eating disorders than male behaviors and their negative impact athletes (‍14% vs 3.2%), and both on health and athletic performance – groups had a greater risk than their is important to prevent adverse

nonathlete peers (‍5.1% of female 71 health effects. For non weight-class The AAP has published clinical controls and 0% of male controls). sports, coaches should promote reports that outline guidance for the Male elite athletes in weight-class healthy eating habits and be alert prevention and treatment of obesity78,79​ sports demonstrated higher rates to unhealthy eating habits in their for all children and adolescents. ‍ of subclinical and clinical eating athletes. Coaches of weight-class These AAP recommendations disorders than athletes participating sports should discourage unhealthy emphasize adherence to physical in endurance sports or ball game weight-control methods and activity recommendations, healthy sports, such as handball, soccer, and encourage athletes to compete at a diet, and limits on screen time. For volleyball (‍18% for weight-class weight that is appropriate for their most children and adolescents, the athletes vs 9% and 5% for endurance age, height, physique, and stage of goal of weight management should and ball game athletes, respectively). growth and development. Many be to keep BMI below the 85th In the same study, 42% of female coaches inappropriately focus on percentile. Recommendations for athletes involved in aesthetic sports, weight instead of performance. weight maintenance and weight loss78 such as gymnastics, met the criteria In addition, coaches generally do are based on the degree of obesity. for an eating disorder as compared not have an adequate nutritional ’ Excessive body fat may interfere with with 30% of females in weight-class background to counsel an athlete acclimation to heat and negatively sports and 16% involved in ball game about weight loss. Coaches 72 affect speed, endurance, and work sports. Male collegiate athletes in discussions of weight loss with 6,9,​ 27​ efficiency. ‍ ‍ Young athletes who weight-control sports have high rates athletes may increase the risk of 76,77​ are not classified as having obesity of subclinical eating disorders (‍16%) harmful weight loss practices. ‍ may strive to lose weight or increase and high rates of pathologic weight- Athletes should focus on optimizing lean body mass to improve sports control practices, including binge 73 energy availability for maximizing performance. Because weight is not eating, fasting, and strict dieting. Screening, Prevention, and Treatment performance and good health. Female an accurate indicator of body fat, lean of Unhealthy Weight Loss Attributable to athletes with menstrual dysfunction muscle mass, or performance, athletes Inadequate Energy Availability require an evaluation to determine should focus on27,57​ maintaining lean Preparticipation Physical the underlying etiology. If low energy muscle mass. Skeletally immature Examination availability is the cause, increasing athletes should not be encouraged The AAP energy intake will generally lead65, 70​to to lose weight to improve athletic monograph contains resumption of normal menses. ‍ performance. An imbalance between a history form for use during If an eating disorder is suspected, energy intake and energy expenditure preparticipation evaluation. This referral to a multidisciplinary team can result in the loss of lean muscle

form is available on the AAP Web of experts in this field, including a mass, which can9,27,​ negatively57​ affect site (‍https://​www.​aap.​org/​en-​ physician, RDN, and mental health performance. ‍ ‍ Changes in us/​about-​the-​aap/​Committees-​ provider, is appropriate. Referral to weight and body composition should Councils-​Sections/​Council-​on-​ an RDN may be of benefit to assist be achieved gradually, by using sports-medicine-​ and-​ ​fitness/Pages/​ ​ athletes with a well-designed, healthy sensible methods aimed at long-term PPE.​aspx) and includes questions weight loss program or to provide change. Athletes should avoid cyclic designed to screen for disordered guidance on increasing caloric weight fluctuations. Once desired Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 3, September 2017 5

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 7 Unhealthy and Healthy Methods of Weight Gain Unhealthy Weight Gain Healthy Weight Gain body composition and weight are achieved, dietary, exercise and Rapid weight gain Gradual weight gain Weight gain resulting in excess body fat Weight gain as muscle mass lifestyle behaviors should focus on Use of anabolic compounds Boys gain up to 0.5–1.0 lb/wk maintenance, with allowances for Use of supplements Girls gain up to 0.25–0.75 lb/wk growth. “Weight gainers,”​ which contain an Gain up to one’s genetic potential overabundance of calories and/or protein Gradual weight loss appears to If maintaining body weight and eating RDA of confer greater performance benefits protein: than rapid weight loss. A study of 1. Consume 300–500 kcal/d above baseline athletes engaged in strength training intake; 2. Consume extra 14 g of protein/d (or 1.5 1.8 g demonstrated that weight reduction of – protein/kg/d); 0.7% of body weight per week results 3. Strength train; and in increased lean body mass and 4. Get adequate sleep. strength when compared with rapid RDA, recommended daily allowance. weight reduction77 of 1.4% body weight per week. It has been recommended that growing athletes with excess body fat lose no more than 1 lb per week, and bodybuilding may desire to times more likely to use anabolic and athletes who are27, mature57​ can lose gain weight and lean muscle mass steroids to attempt to change body up to 2 lb per week. ‍ to improve power and strength or composition as compared with to achieve a muscular physique. those who perceive themselves as Adult athletes generally require a “ 84 Preadolescent and adolescent being at an appropriate weight. minimum of 2000 kcal per day, but ” this can vary widely depending80 on athletes who want to gain weight The AAP policy statement Use of sex and level of activity. Caloric may require guidance about Performance-Enhancing Substances requirements for active children appropriate, healthy strategies for reviews the risks of supplements and adolescents differ depending achieving their goals. Table 7 lists and drugs used for weight gain in on age and stage of growth; caloric healthy and unhealthy methods of detail; Table 8 provides a summary of requirements peak in adolescence Unhealthyweight gain. Weight Gain performance-enhancing substances and early adulthood. Type and and their effects85 adapted from this intensity of physical activity will statementHealthy Weight. Gain also influence caloric needs. The US Increasing caloric intake in the form Department of Agriculture provides of food consumption or use of dietary an online interactive tool for health ’ supplements may lead to excessive Young athletes in sports in which care providers to calculate an fat accumulation rather than the a muscular physique is valued for individual s caloric needs on the desired increase in lean muscle 57 aesthetic or performance reasons basis of sex, age, and activity level mass. Excess body fat can have may seek to gain weight and (‍https://​fnic.​nal.​usda.​gov/​fnic/​ a negative effect on overall health 27 increase lean body mass through interactiveDRI/​). and athletic performance. Often, a combination of increased caloric Approximately 55% to 65% of energy athletes use over-the-counter dietary ’ intake and strength training. An (‍calories), or 6 to 10 g/kg per day, supplements to increase lean body athlete s stage of development, should be from carbohydrates; 15% mass. Supplement manufacturers are genetic factors, type of training, diet, to 20%, or 0.85 to 1.7 g/kg per day, not required to prove safety before and motivation are all factors that should be from protein, and 20% to bringing their products to the market. influence weight gain and muscle 35%, or 1 g/kg per day, should be Many supplements, even those sold 57,83,​ 86,​ 87​ 9,27,​ 57​ development. ‍ ‍ ‍ from fat. ‍ ‍ The diet should be by national retailers, contain unlisted,82 well balanced and consist of a variety potentially harmful ingredients. In of foods. Young athletes attempting 1 analysis, 20% of drug-related liver Female athletes and prepubertal to lose weight may benefit from injuries resulting in hospitalization male athletes typically increase strength with a weight-training the guidance of a RDN81 with sports were associated83 with use of dietary nutrition experience. supplements. Young athletes program but generally do not have Weight Gain may use illegal and dangerous sufficient circulating androgens to 88 medications to gain weight and increase muscle bulk considerably. increase muscle mass. Adolescent Athletes with a slender body build Athletes involved in sports such males who perceive themselves as (‍ectomorphs) will have more as football, rugby, power lifting, under- or overweight are nearly 4 difficulty increasing muscle mass Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF

35 . 36 . Supplements contaminated with prohormones are a Potential Adverse Effects 37 . Increased availability of pure powdered caffeine is particular concern 42 . May impair performance in endurance activities. Causes water retention. Premature physeal closure with decreased final adult height. Acne. Gynecomastia (irreversible). Hair loss/male pattern baldness Hypogonadism. Dependence. Behavior change (hypomania, irritability, aggression). Cardiomyopathy. Increased low-density lipoproteins/decreased high-density lipoproteins. Cholestatic jaundice, liver tumors. evaluated specifically in the pediatric population. Most concern with impact on kidneys because of nephrotic metabolites (methylamine and formaldehyde), specific recommendation against use for athletes at risk kidney dysfunction testosterone as listed above Gastric irritation. blood pressure. Headaches, irritability, sleep disruption, tremor. Increased core temperature with exertion, particularly in hot environments. drinks, Significant toxicity has been associated with ingestion of multiple energy department visits in 2011 the 12- to 17-y age leading to almost 1500 emergency group and is responsible for at least 2 deaths in young people (1 teaspoon equivalent to 25 cups of coffee) (FDA warning). common cause of doping violations in organized sports common cause of doping violations in organized Possible long-term effects on brain remodeling with adolescent AAS exposure. Short-term use at usual doses appears safe in normal adults, but has not been Suppression of endogenous testosterone production, otherwise potentially same for Tolerance. Cardiac arrhythmias (premature ventricular contractions) increased 41 y No benefit 36 34 . h most studies is small and primarily seen in short-duration, maximum- intensity resistance training muscle mass repeated dosages do not appear to increase blood testosterone concentrations or increase muscle size strengt generally shown in aerobic activities or with “ on-field ” athletic performance improvements in strength of knee extensors (note: other muscle groups did not show strength improvements with caffeine); 14% in muscular endurance; and 10% – 20% improvements in time to exhaustion studies have examined 3 – 6 mg/ kg, but 1 – 3 mg/kg has been shown to have performance-enhancing effects, particularly in endurance activit Data on Performance Effects Performance benefit in Increased strength and lean Androstenedione and DHEA: This includes 4% Most studies with caffeine Performance Effect during high-intensity training by adenosine triphosphate production in high intensity activities that rely upon phosphocreatine shuttle by increasing transcription and decreasing catabolism testosterone concentrations after ingestion as well potential direct anabolic effects performance benefit primarily due to central nervous system stimulation and enhanced muscle activation Delays onset of muscle fatigue Enhances net protein synthesis Purported to enhance Currently believed that Usual Form of Intake Purported Mechanism of and fish. About 3 – 5 g/kg uncooked meat or fish. Cooking can degrade some creatine in food. Generally about 1 g/d found in omnivore diet monohydrate supplement derivatives. Schedule III drugs. Oral, injectable, buccal, and transdermal forms. Multiple forms often taken in “ stacks ” 6- to 12-wk cycles taken in combination ( “ stacks ” ) and in cyclical fashion are diverted from prescription use scheduled drugs as a result of the Anabolic Control Act of 2005 and Designer Anabolic Steroid Act of 2014 a variety of food and beverages, as well diet over-the-counter pills and “ stay awake ” medication Creatine is found in meat Orally ingested creatine Amphetamines often All except for DHEA are now Caffeine is ubiquitous in  Summary of Performance-Enhancing Substances Commonly Used by Athletes With Effects on Performance and Possible Adverse

8 E stimulants Creatine Anabolic agents Variety of testosterone Prohormones Variety of substances often Substance Caffeine/other TABL

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Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF 49 . 83 . 51 45 . Potential Adverse Effects . 47 . of HMB appears safe at 6 g/d arthralgia, benign intracranial hypertension, acromegaly, cardiovascular disease, gynecomastia forms of nitrate are associated with carcinogenesis, however, amino acids. Inorganic current data does not support restriction of vegetable source nitrates paresthesias at higher doses Contamination. Increased risk of liver disease Ingestion of single amino acids may result in imbalance others. Short-term ingestion Elevated plasma glucose/insulin resistance, sodium retention and edema, myalgia/ may create imbalance between other Supplementation with the amino acid arginine Sodium bicarbonate with significant gastric upset in about 10%. β -alanine ​

48, 37 . .

51 . 53 43 n s 50 s Meta-analysis 44 52 46 . o t Study on junior rowers protein supplement if diet provides adequate protein on young adults show untrained athletes with 6.6% gains in strength, but only trivial strength impacts in trained athlete appears minimal in arginine healthy young athletes who ingest sufficient protein endurance exercise support performance benefi 49 ‍ with 1.7% improvement in rowing time after repeat 500-m effort β -alanine with 2.85% median improvement in exercise lasting longer than 60 s No benefit to exercise of shorter duratio Studies in adolescent swimmers with sodium bicarbonate show some swimmers with ∼ 1-s improvement in 200-m efforts Results are mixed regarding potential benefit of high nitrate-containing foods on athletic performance volleyball players anaerobic power: HMB 11% improvement vs 4% with placeb Data on Performance Effects No performance benefit of HMB: meta-analysis of studies Any potential benefit of Data are variable regarding Most recent reviews do not Study on elite adolescent — , not applicable. 46 s Performance Effect for muscle and lean tissue growth increases in nitric oxide (see below for further discussion). β -alanine and carnosine buffer H+ accumulation (see buffer discussion below). HMB is believed to enhance repair of damaged muscle tissue IGF-1, resulting in increases in lean mass, decreases fat mas Synthesized vasodilator. via reduction from arginine to nitrate. Citrulline is an precursor arginine resulting from high-intensity physical activity. β -alanine is a precursor of carnosine Provides “ building blocks ” Arginine and citrulline produce Arginine hGH acts primarily through Nitric oxide is a potent Buffers the metabolic acidosis Usual Form of Intake Purported Mechanism of shakes amino acids or in combination or IGF-1 nitrate-containing foods (beets most commonly studied, but also found in lettuce, spinach, radish, celery) sodium citrate. Carnosine and β -alanine amounts of complete proteins are replete with essential amino acids. HMB is a leucine metabolite Oral supplements. Individual Injectable recombinant hGH Oral supplements and high Sodium bicarbonate or Diets with adequate Continued

8 E and related compounds hormone/insulin- like growth factor 1 (IGF-1) beetroot (arginine, juice, citrulline) Protein supplements Variety of powders/bars/ Substance Amino acids Human growth Nitric oxide boosters Buffers TABL Modified from LaBotz M, Griesemer BA; Council on Sports Medicine and Fitness. AAP Clinical Report: Use of Performance Enhancing Substances. Pediatrics . 2016;138(1):e20161300. AAS, anabolic-androgenic steroid; DHEA, dehydroepiandrosterone; hGH, human growth hormone; HMB, hydroxymethyl butyrate; IGF-1, insulin-like grow factor 1;

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Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF than athletes with27,87​ a solid body build as weight in kilograms divided2 male wrestlers and 12% for female (‍mesomorphs). ‍ by height in meters squared,​ is a wrestlers. These minimums are well commonly applied screening tool under the fifth percentile for body fat To increase muscle mass, athletes used as a measure to assess general observed in the general adolescent must consume sufficient calories health. BMI values between the population. Rather than suggesting a 5th and 85th percentile for age are specific percentage of body fat for an and include adequate proteins,57,86,​ 87​ carbohydrates, and fats. ‍ ‍ Weight considered normal. The Centers for individual athlete, a range of values gain needs to be gradual; gain in Disease Control and Prevention has that is realistic and appropriate94 published BMI charts that categorize should be recommended. excess of 2 lb per week may result in 89 27,57,​ 87​ BMIs on the basis of sex and age. increased body fat. ‍ Although BMI is easy to measure in Guidance for the Clinician A male athlete could expect to gain the clinical setting, abnormal values 0.5 lb to 1.0 lb of lean mass per should be interpreted with caution. week, and a female could expect Approximately one-third of adults to gain 0.25 lb to 0.75 lb of lean 1. Physicians who care for young classified as having obesity on the athletes are encouraged to have mass per week. Increased energy basis of BMI measurement have good an understanding of healthy intake should always be combined cardiac and metabolic health on the and unhealthy weight-control with strength training to induce basis of other variables, such as blood muscle growth. Children and methods; pressure, cholesterol concentrations,90 adolescents who wish to engage in and insulin resistance. BMI is 2. Health supervision visits for strength training should begin by a measure of weight relative to young athletes generally include learning proper technique without height but reveals 27nothing about history-taking to ascertain diet resistance. Weight loads should body composition. Athletes, and physical activity patterns. be increased gradually; programs particularly those with a muscular When discussing diet and exercise, should incorporate 2 to 3 sets of 8 build, are especially vulnerable to physicians can encourage to 15 repetitions with the athlete being misclassified as having obesity parents of young athletes to place maintaining proper technique. on the basis of BMI data because nutritional needs for growth Although weight-training programs increased lean body mass increases and development above athletic for children and adolescents have BMI values. An increased torso-to-leg considerations. Acute weight health and athletic performance ratio also results in increased BMI. In loss through dehydration and benefits, the AAP recommends that adolescents, increased weight gain the use of potentially harmful skeletally immature children and and increased height velocity during medications and supplements for puberty may not coincide, resulting weight control should be strongly adolescents avoid power lifting, 88 bodybuilding, and maximal lifts. in temporary91 elevation or depression discouraged; Referral to an RDN may be helpful of BMI. In addition, BMI values in 3. Physicians should counsel young for athletes attempting to gain adolescents with eating disorders (‍or underweight adolescents) can result athletes who express a desire weight and increase lean body to gain or lose weight to avoid mass, particularly for those who in an underestimation92 of the degree of malnutrition. weight-control methods that have not been successful despite may have adverse health effects, a seemingly appropriate strength- Although there are normative data such as acute weight loss through training program, adequate rest, and for body fat percentage, there are dehydration and the use of a nutritionally sound diet. no established recommendations potentially harmful medications Weight, BMI, and Body Composition and supplements. Many of these regarding body composition93 in Measurements children and adolescents. Body fat methods may have a negative percentage varies by age. The average effect on performance as well; ∼ body fat in healthy adolescents ∼ 4. Some states require a Optimal weight, BMI, and body without obesity ranges from 16% specific form for sports

composition measures for athletic to 18% for males57,94​ and 25% to 28% preparticipation examinations. performance have yet to be for females. ‍ The NCAA minimum For physiciansPreparticipation in states Physical without determined, and sports performance allowable body fat percentage is 5% a specific requirement, the ’ Examination measures may be the best indicator for male wrestlers. The minimum AAP for an athlete s optimal body body fat percentage recommended monograph contains composition and weight at his or her by the National Federation of State a standardized history-taking developmental stage. BMI, defined High School Associations is 7% for form that may be helpful for Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 3, September 2017 9

Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF Michele LaBotz, MD, FAAP Kelsey Logan, MD, FAAP screening athletes. This form is weight loss regimens should be Keith J. Loud, MDCM, MSc, FAAP also available on the AAP Web site initiated early enough to permit Kody A. Moffatt, MD, FAAP Blaise Nemeth, MD, FAAP and includes questions designed gradual weight change before a Brooke Pengel, MD, FAAP to screen for disordered eating75 sport season. Slow weight gain, Andrew Peterson, MD, FAAP and menstrual irregularities. in combination with strength When appropriate, pediatricians training, will decrease gain of body Past Executive Committee Members should advocate for the use of this fat. Slow weight loss in the athlete Joel S. Brenner, MD, MPH, FAAP form as the preferred tool for the with excess body fat will decrease Amanda K. Weiss Kelly, MD, FAAP preparticipation evaluation at the loss of muscle mass. A well- Liaisons state and local level; balanced diet is recommended for all athletes. Once the desired Mark E. Halstead, MD, FAAP – American Medical 5. Physicians are encouraged to Society for Sports Medicine weight is obtained, the athlete engage the services of RDNs should attempt to maintain a familiar with athletes to help with Consultant constant weight; and complex weight-control issues, if Gregory Landry, MD, FAAP these providers are available in 8. When opportunities for Neeru A. Jayanthi, MD community education arise, their communities. Monitoring Staff athletes with weight-control pediatricians should collaborate Anjie Emanuel, MPH issues every 1 to 3 months can with coaches and certified athletic aid the physician in detecting trainers to encourage healthy excessive weight loss; Leaeatingd Authors and exercise habits. Abbreviations 6. There are no established Rebecca L. Carl, MD, MS, FAAP recommendations for body Miriam D. Johnson, MD, FAAP Thomas J. Martin, MD, FAAP fat percentages in adolescent AAP: American Academy of athletes. Rather than suggesting Council on Sports Medicine and Pediatrics a specific percentage of body Fitness Executive Committee, DXA: dual-energy radiograph fat for an individual athlete, a 2015–2016 absorptiometry range of values that is realistic Cynthia R. LaBella, MD, FAAP, Chairperson LAW: lowest allowable weight and appropriate should be Margaret A. Brooks, MD, FAAP NCAA: National Collegiate recommended; Alex Diamond, DO, FAAP Athletic Association William Hennrikus, MD, FAAP RDN: registered dietitian 7. Physicians should counsel young nutritionist athletes that weight gain or DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1871

Address correspondence to Rebecca Carl, MD, MS, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Carl et al https://doi.org/10.1542/peds.2017-1871 September 2017 Promotion of Healthy Weight-Control Practices in Young Athletes 3 140 Pediatrics 2017 ROUGH GALLEY PROOF Promotion of Healthy Weight-Control Practices in Young Athletes Rebecca L. Carl, Miriam D. Johnson, Thomas J. Martin and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics originally published online August 21, 2017;

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Promotion of Healthy Weight-Control Practices in Young Athletes Rebecca L. Carl, Miriam D. Johnson, Thomas J. Martin and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics originally published online August 21, 2017;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2017/08/17/peds.2017-1871

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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