Participation in athletics during childhood and adolescence has been associated with increased physical activity during adulthood.1 Youth sports involvement has a positive impact on current and future health. However, child and adolescent athletes have an increased risk of certain types of injuries and potentially harmful behaviors.
Children and adolescents may desire to gain or lose weight in an attempt to change their appearance. Young athletes may be more likely to pursue weight loss or gain to improve performance in their sports. The American Academy of Pediatrics (AAP) recently published an updated clinical report about weight change behaviors entitled “Promotion of Healthy Weight-Control Practices in Young Athletes.”2
There are many reasons why an athlete may attempt to lose weight to improve sports performance. Children involved in weight-class sports, such as wrestling, often attempt to lose weight rapidly to qualify for a lower weight class. Many athletes, as well as parents and coaches, believe that competing at the lowest possible weight class confers a competitive advantage. However, methods that allow for acute weight loss, especially those methods that lead to dehydration, can impair performance.
Some athletes who compete in the sports of cross-country running or cycling feel that losing weight will increase their ability to overcome resistance and the effects of gravity. In sports that are scored by judges, many athletes feel that they will have an edge if their body type fits with the aesthetic of the sport. For example, gymnasts, dancers, and figure skaters may want to lose weight to achieve a slimmer physique, whereas bodybuilders typically want to achieve a more muscular physique.
Football and weightlifting are examples of sports that emphasize strength and power. Children who participate in these sports frequently attempt to gain weight, generally by increasing lean body mass and decreasing body fat.
Children may seek to lose weight for a variety of reasons, including those related to health and appearance. For youth who are overweight or obese, there may be a benefit to weight loss or decreased rate of weight gain. The AAP recommends that pediatric primary care providers promote physical activity and healthy dietary practices for all children.3 Clinicians should consider “structured weight management” for patients who are overweight or obese with body mass index (BMI) measurements that are trending upward.3
Unhealthy Weight Loss Practices: Cyclic Weight Loss
Athletes may have additional motivation to lose weight. For weight-class sports, participants often believe that competing at a lower weight class will increase their chances of success. Wrestling, judo, lightweight crew, and boxing are examples of weight-class sports. Athletes who participate in these activities typically have fluctuations in weight throughout an athletic season. These athletes may employ a strategy of dropping weight quickly, usually with dehydration methods, for a weigh-in to qualify for a weight class. Engaging in excessive exercise to increase sweating, use of diuretics, and fluid restriction are examples of dehydration practices used by athletes.4 Participants subsequently try to regain weight after the weigh-in and prior to competition, generally by increasing intake of fluids.5
These cycles of weight gain and loss are unhealthy. Despite beliefs commonly held in the sports community, even mild dehydration leads to impaired athletic performance.6,7 Athletes who are dehydrated have a higher susceptibility to heat-related illness.8 The National Collegiate Athletic Association (NCAA) and National Federation of State High School Associations have enacted policies designed to discourage unhealthy weight control practices.9,10 At the NCAA level, these policies were a reaction to multiple deaths during a single season of college wrestling due to extreme dehydration.9,11,12 The current rules require athletes to compete at a minimum weight based on preseason weight and body fat percentage. The determination of minimum allowable weight includes checking urine specific gravity to ensure appropriate hydration at the time of the preseason weigh-in.
Unhealthy Weight Loss Practices: Long-Term Weight Loss
Children and adolescents who engage in sports that emphasize a thin build generally employ strategies aimed at long-term, rather than temporary, weight loss. The approach for weight loss in these athletes includes decreasing energy intake by consuming fewer calories and increasing metabolic rate. These weight loss practices of decreased caloric intake and increased expenditure may be reasonable for athletes who are overweight or obese but can be problematic in an athlete of healthy weight. Athletes require additional calories to compensate for expenditure due to physical activity. Inadequate caloric intake may be particularly harmful in athletes who are skeletally immature. Parents and children may not recognize the extent to which athletes have increased need for energy or the long-term effects of inadequate intake, such as suboptimal bone density. Additionally, some athletes employ unhealthy weight loss practices, such as using stimulant medications, with harmful side effects.
The American College of Sports Medicine publicized the term “female athlete triad” in a position statement in 1997.13 The phrase initially described the interplay between eating disorders, amenorrhea, and osteoporosis in female athletes.13 The female athlete triad definition has been revised to encapsulate the spectrum of features seen in female athletes and now includes decreased energy availability (inadequate caloric intake for energy expended), osteopenia, and oligomenorrhea.14
Athletes with features of the triad have increased risk of bone stress injuries during childhood and adolescence.15
Additionally, inadequate intake of calories and nutrients, such as vitamin D and calcium, can interfere with achieving and maintaining optimal bone density in adulthood and increases risk of future insufficiency fractures.15 Menstrual irregularities and prior history of stress fractures are most highly correlated with future bone stress injuries.15,16 Amenorrhea and oligomenorrhea may result from decreased energy availability. Female athletes have higher rates of primary and secondary amenorrhea.14 In some sports, a high percentage of athletes experience menstrual irregularity.17,18 Athletes, parents, and coaches may believe this is a normal finding for an athlete and fail to recognize amenorrhea and oligomenorrhea as indicators of inadequate energy availability. Young athletes are highly susceptible to comments about weight and body shape made by adults. Parents and coaches should be aware that exposure to comments suggesting athletes need to lose weight is correlated with disordered eating.19
Male athletes who compete in sports that emphasize leanness are also at risk for disordered eating:20 US Olympic figure skater Adam Rippon publicly discussed how he drastically restricted calories in an attempt to lose weight after a coach commented on his “heavy bottom.”21
Primary care physicians should incorporate screening for disordered eating and inadequate energy intake, particularly in athletes, and should counsel patients about the importance of sufficient caloric intake for performance and health.
The AAP's Preparticipation Physical Evaluation monograph has a standardized form for preparticipation assessment that includes screening questions for risk factors for bone stress injuries.22,23 Screening focuses on eating behaviors, weight loss, and menstrual dysfunction (for female athletes). The Female Athlete Triad Coalition survey includes additional screening questions.18
Healthy Weight Loss
Pediatricians spend a lot of time advocating healthy lifestyle practices such as eating a healthy diet, avoiding sedentary activities (including excessive screen time), and adhering to physical activity guidelines. The clinical report “The Role of the Pediatrician in the Prevention of Obesity”24 details developmentally appropriate methods of promoting a healthy weight in children and adolescents. For some children who exhibit increasing BMI, a structured obesity management program may be appropriate. Obesity management strategies should engage the entire household. Providing advice during routine visits has not been shown to be effective at changing exercise and diet patterns.3 There is a paucity of rigorous research to support approaches for promoting healthy behaviors. However, obesity management and prevention programs should employ techniques with some evidence to support them. Motivational interviewing is an example of a technique that has been employed successfully to promote healthy eating and exercise in several research protocols.24 Primary care providers should emphasize the importance of avoiding weight fluctuations as well as the importance of sustainable changes in behavior.
Children who are still growing should lose no more than 1 pound of weight per week. Skeletally mature adolescents can safely lose up to 2 pounds per week.25 Consultation with a registered dietary nutritionist may be especially helpful for young athletes given their increased caloric needs.26
Obesity is defined based on BMI. Children and adolescents at the 85th percentile up to the 95th percentile are classified as overweight; those who are at the 95th percentile or above are classified as obese.3 BMI is not a perfect measure for determining healthy body type. For example, muscular people may be categorized as overweight or obese based on BMI but have a high lean body mass and low body fat percentage; therefore, elevated BMI in certain people may not convey the health risks typically associated with obesity.24,27
It is not uncommon for children, especially adolescents, to have the desire to “bulk up” and achieve a more muscular physique. A muscular physique with low body fat and increased lean body mass may be perceived as particularly advantageous for some sports that are judged based on appearance, such as bodybuilding, and those that place an emphasis on strength and power, such as football.
Healthy Weight Gain
Children and adolescents who desire to increase weight in the form of increased lean body mass should discuss healthy means of achieving their objectives with their primary care providers. Consultation with a registered dietary nutritionist with expertise working with athletes may also be helpful.
Athletes should eat a balanced diet containing appropriate nutrients to achieve healthy weight gain. Supplements are generally not necessary as most adolescents get sufficient protein and other nutrients from diet alone.28
Athletes should be aware of the risks of taking supplements. These compounds are not regulated in the same way medications are and do not need to be proven safe before sale. Supplements are only removed from the market when adverse effects are documented, and they may contain substances not listed on the label.29
Athletes are at an increased at risk for using performance-enhancing substances.30 Creatine and protein powders are examples of commercially available supplements widely used by athletes. Although reports of adverse effects are rare, there is a scarcity of research demonstrating the safety of these supplements in children and adolescents. More concerning is the fact that athletes have higher rates of use of prescription medication for performance effects. Anabolic steroids, androstenedione, and human growth hormone (HGH) have a significant risk of adverse effects and are used by many young athletes as ergogenic aids. Whereas girls report higher use of stimulants to achieve weight loss, boys report using steroids, creatine, HGH, and protein supplements for weight gain at higher rates than girls.30
Young athletes who seek to increase lean body mass may incorporate weightlifting and other strength training into their training regimens. Historically, families and clinicians have been concerned that weightlifting could interfere with growth in skeletally immature children. However, children can benefit from a properly designed weight-training program. The risk of injuries from weight training is low. Most weightlifting injuries result from improper use of equipment.31 Therefore, a knowledgeable adult can supervise children who engage in strength training.31 Children must have the ability to follow instructions and handle weights properly. Adults should encourage children to practice proper form without weights before advancing in a strength-training program. Lower weights with high numbers of repetitions are more beneficial and carry a lower injury risk for skeletally immature children.31 Girls and prepubertal boys will not see significant gains in muscle bulk but can increase strength.
Sports and other physical activities are an important part of a healthy lifestyle for young people. Activity promotion is a critical part of health supervision visits in the primary care setting. However, participation in athletics may increase the risk of unhealthy behaviors related to weight loss and weight gain. Primary care providers can incorporate discussion of how athletes can maintain healthy weight into health supervision visits. Pediatric clinicians can also play a role in the education of families and community partners (eg, coaches) about adolescents' increased sensitivity to comments regarding weight and body shape and how these comments can lead to risky behaviors.
- Smith L, Gardner B, Aggio D, Hamer M. Association between participation in outdoor play and sport at 10 years old with physical activity in adulthood. Prev Med. 2015;74:31–35. doi:. doi:10.1016/j.ypmed.2015.02.004 [CrossRef]
- Carl RL, Johnson MD, Martin TJ. Promotion of healthy weight-control practices in young athletes. Pediatrics. 2017;140(3):e20171871. doi:. doi:10.1542/peds.2017-1871 [CrossRef]
- Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl 4):S254–S288. doi:. doi:10.1542/peds.2007-2329F [CrossRef]
- Brito CJ, Roas AF, Brito IS, Marins JC, Cordova C, Franchini E. Methods of body mass reduction by combat sport athletes. Int J Sport Nutr Exerc Metab. 2012;22(2):89–97. doi:10.1123/ijsnem.22.2.89 [CrossRef]
- Oppliger RA, Steen SA, Scott JR. Weight loss practices of college wrestlers. Int J Sport Nutr Exerc Metab. 2003;13(1):29–46. doi:10.1123/ijsnem.13.1.29 [CrossRef]
- Sawka MN. Physiological consequences of hypohydration: exercise performance and thermoregulation. Med Sci Sports Exerc. 1992;24(6):657–670. doi:. doi:10.1249/00005768-199206000-00008 [CrossRef]
- Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–390. doi:10.1249/mss.0b013e31802ca597 [CrossRef].
- Bergeron MF, Devore C, Rice SGCouncil on Sports Medicine and Fitness and Council on School HealthAmerican Academy of Pediatrics. Policy statement—climatic heat stress and exercising children and adolescents. Pediatrics. 2011;128(3):e741–e747. doi:10.1542/peds.2011-1664 [CrossRef].
- 2016 DI WRE Weight Management Program Information. http://www.ncaapublications.com/c-65-wrestling.aspx. Accessed June 20, 2019.
- Gardner RB. National Federation of State High School Associations Wrestling Rules Book. Indianapolis, IN: National Federation of State High School Associations; 2013.
- Oppliger RA, Utter AC, Scott JR, Dick RW, Klossner D. NCAA rule change improves weight loss among national championship wrestlers. Med Science Sports Exerc. 2006;38(5):963–970. doi:. doi:10.1249/01.mss.0000218143.69719.b4 [CrossRef]
- Hyperthermia and dehydration-related deaths associated with intentional rapid weight loss in three collegiate wrestlers—North Carolina, Wisconsin, and Michigan, November–December 1997. MMWR Morb Mortal Wkly Report. 1998;47(6):105–108.
- Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 1997;29(5):i–ix. doi:10.1097/00005768-199705000-00037 [CrossRef]
- Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867–1882. doi:10.1249/mss.0b013e318149f111 [CrossRef].
- Tenforde AS, Carlson JL, Chang A, et al. Association of the female athlete triad risk assessment stratification to the development of bone stress injuries in collegiate athletes. Am J Sports Med. 2017;45(2):302–310. doi:10.1177/0363546516676262 [CrossRef]
- Thein-Nissenbaum JM, Rauh MJ, Carr KE, Loud KJ, McGuine TA. Associations between disordered eating, menstrual dysfunction, and musculoskeletal injury among high school athletes. J Orthopaed Sports Phys Ther. 2011;41(2):60–69. doi:. doi:10.2519/jospt.2011.3312 [CrossRef]
- Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45(5):985–996. doi:. doi:10.1249/MSS.0b013e31827e1bdc [CrossRef]
- De Souza MJ, Nattiv A, Joy E, et al. Female Athlete Triad CoalitionAmerican College of Sports MedicineAmerican Medical Society for Sports MedicineAmerican Bone Health Alliance. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. Clin J Sport Med. 2014;24(2):96–119. doi:10.1097/JSM.0000000000000085 [CrossRef].
- Rosen LW, McKeag DB, Hough DO, Curley V. Pathogenic weight-control behavior in female athletes. Phys Sportsmed. 1986;14(1):79–86. doi:. doi:10.1080/00913847.1986.11708966 [CrossRef]
- Tenforde AS, Barrack MT, Nattiv A, Fredericson M. Parallels with the female athlete triad in male athletes. Sports Med. 2016;46(2):171–182. doi:. doi:10.1007/s40279-015-0411-y [CrossRef]
- Crouse K. Adam Rippon on Quiet Starvation in Men's Figure Skating. The New York Times. February13, 2018. https://www.nytimes.com/2018/02/13/sports/olympics/figure-skating-adam-rippon.html. Accessed June 17, 2019.
- American Academy of Pediatrics. Preparticipation physical evaluation. https://www.aap.org/en-us/Documents/PPE-4-forms.pdf. Accessed June 20, 2019.
- Bernhardt D, Roberts W, eds. Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
- Daniels SR, Hassink SG. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275–e292. doi:. doi:10.1542/peds.2015-1558 [CrossRef]
- Kleinman RAmerican Academy of Pediatrics.Committee on Nutrition. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2013:xlix.
- Academy of Nutrition and Dietetics. Find an expert. https://www.eatright.org/find-an-expert. Accessed June 20, 2019.
- Golden NH, Yang W, Jacobson MS, Robinson TN, Shaw GM. Expected body weight in adolescents: comparison between weight-for-stature and BMI methods. Pediatrics. 2012;130(6):e1607–e1613. doi:. doi:10.1542/peds.2012-0897 [CrossRef]
- Grandjean A. Nutritional requirements to increase lean mass. Clin Sports Med. 1999;18(3):623–632. doi:10.1016/S0278-5919(05)70172-1 [CrossRef]
- O'Connor A. New York attorney general targets supplements at major retailers. The New York Times. February3, 2015. https://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/. Accessed June 17, 2019.
- LaBotz M, Griesemer BACouncil on Sports Medicine and Fitness. Use of performance-enhancing substances. Pediatrics. 2016;138(1). pii: e20161300. doi:. doi:10.1542/peds.2016-1300 [CrossRef]
- McCambridge TM, Stricker PR. Strength training by children and adolescents. Pediatrics. 2008;121(4):835–840. doi:. doi:10.1542/peds.2007-3790 [CrossRef]