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. 2004 Apr-Jun;39(2):162–165.

Body-Weight Fluctuation in Collegiate Wrestlers: Implications of the National Collegiate Athletic Association Weight-Certification Program

Jack Ransone *,✉, Brian Hughes †
PMCID: PMC419511  PMID: 15173868

Abstract

Objective:

To determine fluctuations in total body weight of the elite collegiate wrestler during the competitive season.

Design and Setting:

The study period lasted 2 competitive seasons, beginning 1 month before the 1999–2000 and 2000– 2001 competitive seasons and ending 1 month after the National Championships.

Subjects:

Seventy-eight male subjects (age = 21.3 ± 1.5 years, height = 154.1 ± 0.5 cm) from 4 major universities whose teams finished in the top 5 at both the 2000 and 2001 National Collegiate Athletic Association Division I National Wrestling Championships.

Measurements:

Each subject was asked to report to the testing area 24 hours before, 1 hour before, and 24 hours after a competitive wrestling match, and weight was recorded to the nearest 0.1 lb (0.45 kg). Comparisons among the prematch weights, official weigh-ins, and postmatch weights were made using a randomized, 1-group, repeated-measures factorial analysis of covariance with an alpha level of .05.

Results:

A significant difference (F2,154 = 229.99, P < .0001) existed in subjects' weights 24 hours (73.93 ± 11.62 kg) and 1 hour (72.53 ± 11.66 kg) before a competitive match and 24 hours after (73.65 ± 13.58 kg) a competitive match. Additionally, we computed 2 t tests to determine the difference among weight changes 24 hours and 1 hour before and 24 hours after a competitive wrestling match. A significant difference was noted between body-weight changes 24 hours and 1 hour before the match (t77 = 56.21, P < .0001).

Conclusions:

Elite collegiate wrestlers, like novice wrestlers, significantly reduce weight immediately before and gain weight after the competition.

Keywords: dehydration, athletes, body composition

One month into the start of the 1997 collegiate wrestling season, 3 wrestlers died while attempting rapid weight loss. In the hours preceding the official weigh-in, all 3 wrestlers engaged in similar rapid weight-loss regimens that promoted dehydration through perspiration and resulted in hyperthermia. The wrestlers restricted food and fluid intake and exercised vigorously wearing vapor-impermeable suits under cotton warm-up suits in hot environments.1 The difference between their preseason and goal weights for competition was between 11.3 kg and 16.8 kg, or approximately 15% of total body weight. In collegiate wrestlers, the difference between their preseason and competitive weights averaged 7.3 kg, or approximately 10% of total body weight.1,2 These cases highlight the extreme extent of rapid weight loss undertaken by wrestlers striving to “make weight.”3,4 Under such conditions, particularly when dehydration is involved, no limits have been established for safe weight loss.5 In an attempt to curb unsafe practices in wrestling, the National Collegiate Athletic Association (NCAA) mandated a wrestling weight-certification program in 1998 to establish permanent weight classes for each wrestler and thus attempt to eliminate any incentive for detrimental weight loss.6 Additionally, the NCAA revised the guidelines governing weight-loss practices and weigh-in procedures and added penalties for noncompliance to promote a safer competitive environment in wrestling.7

Weight gains in 668 collegiate wrestlers, only 20 hours after the initial tournament weigh-ins, averaged 3.72 kg.1 Common practice in wrestling is for athletes to resort to extreme measures, such as binge eating or dehydration, in an attempt to make weight for an upcoming wrestling bout.8–12 One group found no relationship between acute weight gain after weigh-ins and success in a collegiate wrestling tournament.13 It has been suggested that novice wrestlers lose the greatest amounts of weight before competition and that elite athletes maintain a consistent body weight throughout the season. Our hypothesis was that acute weight gain after weigh-in is not related to success in a collegiate wrestling tournament. Our purpose was to determine fluctuations in total body weight of the elite competitive collegiate wrestler throughout an athletic season and to investigate how much weight a wrestler loses in the 24 hours before a competitive match and gains in the 24 hours after a match. Identifying body-weight changes during the competitive season may help us assess the influence of the NCAA wrestling weight-certification program and determine if the competitive wrestler is at risk for dehydration or related illnesses.

METHODS

Subjects

Seventy-eight male collegiate athletes (age = 21.3 ± 1.5 years, height = 154.1 ± 0.5 cm) from 4 major universities were studied over 2 years. The subjects were considered elite athletes based on each team's placement nationally (top 5 at the 2000 and 2001 NCAA Division I National Wrestling Championships) and the fact that 78% (n = 61) of the subjects qualified for the national tournament and 42.3% (n = 33) achieved All-American or National Champion status (Table 1). All members of each team were assessed throughout the competitive season, but only the individuals competing in each team's conference championship or participating in more than 50% of the season's competitive matches were included in the final data analyses. Subjects reported no previous history of dehydration or heat illness as determined by the injury-history questionnaire. Each subject was assigned a code number to protect confidentiality.

Table 1.

Subjects' Achievements

graphic file with name i1062-6050-039-02-0162-t01.jpg

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Procedures

The study period lasted 2 competitive seasons, beginning 1 month before the 1999–2000 and 2000–2001 competitive seasons and ending 1 month after the National Championships. The experimental protocol was approved by the university institutional review board before data collection, and all subjects gave written consent. Pretesting included a physical examination, health history, and body-composition measurements. All competitive weight classes (except for heavyweights) were represented in this sample. Each subject was asked to report to the testing area 24 hours before, 1 hour before, and 24 hours after each competitive wrestling match. A representative of each team's medical staff recorded total body weight to the nearest 0.1 lb (0.45 kg). In addition, body composition for percentage of body fat was determined, using skinfolds, 1 month before the start of the competitive season, every 2 months throughout the competitive season, and 1 month after the end of each subject's last competition. In order to obtain an accurate body composition, each athlete was tested in a hydrated state. Urine specific gravity was used to assess body hydration via a refractometer; all measurements were in the normal range at 1.020 or less.7 Each team's athletic trainer assessed body composition by skinfold measurements at 3 sites (triceps, subscapular, and abdomen).14 All measurements were coded to ensure confidentiality and sent to the investigators after data collection was completed.

Statistical Analyses

We used a pre-experimental, 1-group repeated-measures design. Demographic data (age and height) were evaluated using central tendency scores. Comparisons between the prematch weights, official weigh-ins, and postmatch weights were made using a randomized, 1-group repeated-measures factorial analysis of covariance. Additionally, we computed 2 t tests to determine the difference among body-weight changes 24 hours before, 1 hour before, and 24 hours after a competitive wrestling match. All analyses were performed using exact P values, and an alpha level of .05 was considered significant.

RESULTS

Each subject was asked to report to the testing area 24 hours before (73.93 ± 11.62 kg), 1 hour before (72.53 ± 11.66 kg) and 24 hours after (73.65 ± 13.58 kg) a competitive wrestling match. Total body weight was recorded at each time to the nearest 0.1 lb. In addition, body composition for percentage of body fat was determined every 2 months within normal urine specific gravity ranges to ensure hydration (13.1 ± 10.2, 10.0 ± 2.6, 9.7 ± 2.2, 9.6 ± 2.1, 10.6 ± 2.6, respectively) throughout the competitive season (Figure). A significant difference (F2,154 = 229.99, P < .0001) existed in subjects' weights 24 hours before (73.93 ± 11.62 kg), 1 hour before (72.53 ± 11.66 kg), and 24 hours after (73.65 ± 13.58 kg) a competitive wrestling match (Table 2). Additionally, 2 t tests were computed to determine the difference between weight changes 24 hours before, 1 hour before, and 24 hours after a competitive wrestling match. A significant difference existed between body weight 24 hours before and 1 hour before a match: t77 = 56.21, P < .0001. Additionally, a significant difference existed in body weight between 1 hour before and 24 hours after a competitive wrestling match (t77 = 54.93, P < .0001). The wrestlers in this investigation lost significant amounts of weight before and gained significant amounts of weight after competition.

graphic file with name i1062-6050-039-02-0162-f01.jpg

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Wrestlers' percentage of body fat and body weight during the athletic season.

Table 2.

Subjects' Mean Weights (kg) by Weight Category (Range)

graphic file with name i1062-6050-039-02-0162-t02.jpg

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DISCUSSION

Several investigators have noted that the weight-loss techniques used by wrestlers to make weight resemble the behavior of bulimics. Interviews with in-season wrestlers revealed that their concerns with weight were due entirely to the demands of wrestling and did not meet the severity level required for a diagnosis of bulimia nervosa.15 Weight loss by competitive wrestlers appears to be a perceived ergogenic aid contributing to improved performance.16,17 One underlying premise that leads to significant weight loss by wrestlers (>5% body weight) is the assumption that cutting weight does not ultimately affect performance, a belief that undermines systematic attempts to regulate body weight.13,17–19 The real danger from rapid loss of weight by competitive wrestlers is dehydration. The NCAA Wrestling Committee and Safeguards and Medical Aspects of Sports Committee adopted significant rule changes in 1998 to address weight-loss issues in wrestling.7 Six rule changes were enacted to address this issue: increase each existing weight by 3.18 kg; establish permanent weight classes for each wrestler the first week of December; have official weigh-ins 1 hour before the start of each match; establish weigh-ins for each day of a multiple-day tournament; eliminate the use of saunas, steam rooms, and impermeable suits; and require cardiopulmonary resuscitation and first-aid training for all wrestling coaches.

In 1989, the Wisconsin Interscholastic Athletic Association implemented new rules and educational programs, consistent with the American College of Sports Medicine and American Medical Association guidelines, to curtail weight cutting among high school wrestlers.18 The project included skinfold estimates of body fatness to determine a minimum competitive weight, a limit on weekly weight loss, and presentation of nutrition education information to help wrestlers diet effectively. Starting in the 1991–1992 school year, Wisconsin was the first state to have a mandatory minimum weight established for high school wrestlers, along with a comprehensive standardized nutrition education program.18 The Wisconsin wrestling minimal-weight program appeared to reduce unhealthy weight loss behaviors among high school wrestlers.16 The NCAA Wrestling Committee and Safeguards and Medical Aspects of Sports Committee adopted significant rule changes in 1998 to address weight-loss issues in wrestling.7 Six rule changes were enacted to address this issue: increase the weight of each existing weight class by 2.7 kg; establish permanent weight classes for each wrestler the first week of December; have official weigh-ins 1 hour before each match; establish weigh-ins for each day of a multiple-day tournament; eliminate the use of saunas, steam rooms, and impermeable suits; and require cardiopulmonary resuscitation and first-aid training for all wrestling coaches.

Our purpose was to determine daily fluctuation of total body weight of the competitive collegiate wrestler during the athletic season. Scott et al1 determined that wrestlers gained significant amounts of weight (3.7-kg average) during the 20 hours before the 1991 NCAA wrestling championships. We found that elite collegiate wrestlers, like novice wrestlers, lose a significant amount of body weight before competition and gain a significant amount after competition. Although these changes in body weight may be statistically significant, they are within the range observed as a result of normal water turnover.19–21 The NCAA wrestling weight-certification program appears to have influenced the volume of body-weight gains and losses by wrestlers as previously identified.22,23 Efforts must continue to change current trends of weight loss by competitive wrestlers. Review of high school and collegiate policies regarding weight loss needs to continue. To enhance the educational experience and reduce the health risks for the participants, the American College of Sports Medicine recommends measures to educate coaches and wrestlers about sound nutrition and weight-control behaviors, to curtail weight cutting, and to enact rules that limit weight loss.24 Most coaches (82%) considered themselves very knowledgeable about wrestling but less informed about sport nutrition, weight loss, and ergogenic supplements.25 The best preventive measure may be the education of wrestlers, parents, and coaches about the consequences of rapid and extreme weight loss and the significant role nutrition and fluid replacement play in successful training and competition. However, as long as wrestlers are allowed to compete in different weight categories, the popular practice of competing at the lowest possible weight will probably continue. In that situation, the best course of action for the certified athletic trainer is to become acutely aware of the unique nutritional concerns of these athletes in order to make this practice as safe as possible.26

CONCLUSIONS

The wrestlers in our investigation lost significant amounts of weight before and gained significant amounts of weight after competition. Although these changes in body weight may be statistically significant, they are within the range that has been observed as a result of normal water turnover.19,23

REFERENCES

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J Athl Train. 2004 Apr-Jun;39(2):165–167.

COMMENTARY

Danny T Foster

I appreciate the opportunity to comment on this article. The authors are to be commended for attempting to address a difficult problem that is in need of more study.

The authors proposed to follow periodic weight cycling of collegiate wrestling competitors over 2 seasons. The competitive seasons for this study came when collegiate wrestlers were required to follow a new wrestling weight-certification program and weigh-in rules instituted by the NCAA.1 Several other studies have added to our body of knowledge on measures of the effectiveness of the new program.2–4 We remain under very similar weight-certification rules, which prohibit methods of dehydration and force wrestlers to compete close to the weigh-in time. Studies like this provide clinical practice insights about short-term weight loss, dehydration, and associated effects. Wrestlers who lose weight rapidly, in less than 24 hours, give us a real-life model of repeated short-term weight loss as an independent variable. Whether by passive means or exercise induced, every athlete in our sports system could experience weight cycling. This study and others can benefit us all through the knowledge we gain about the effects resulting from rapid weight loss and regain.

The research questions from this study are not clear to me. As a reader, I assume the authors want to know the acute weight changes of collegiate wrestlers that occur close to competition weigh-in times throughout the season. The study design included pre– and post–weigh-in body weights at multiple time points, but these were not reported. Conclusions drawn from the averaging of weight loss and regain over multiple points during 2 seasons suffer from an interpretation of regression toward mean weight loss and regain. A wrestler who fluctuates largely at the beginning of the season will likely reduce that fluctuation toward or below a median value as the season progresses. Averaging the weight loss and regain scores eliminates these changes or fluctuations, yet the repeated acute bouts appear to be the losses and regains of interest.

Did these 4 teams of wrestlers lose and regain more weight in the spring, around NCAA tournament time, than in the fall at the start of the season? Body weight went down from September to November and then rose every 2 months to exceed the September body weight by May (Figure). During the same 2-month intervals, body fat dropped from September to March and then rose slightly in May. Previous studies have shown similar patterns of initial body-weight loss and then postseason rise. Wrestlers have less body fat at the beginning of the academic year than many athletes and substantially less than their age-group peers.5 From these data, I would ask the authors whether the wrestlers lost and then regained more weight for spring weigh-ins than they did in the fall? These wrestlers, in contrast with those in Utter's study,3 seem to have continued to lose body fat and still gained weight.

Including subjects who were All-Americans and champions biases the results against the actual fluctuations and effects of weight loss and regain experienced by most teams. Elite wrestlers and those who attain All-American status may have been so talented that they did not perceive a need to lose weight in order to win or they used a higher weight class and low weight-loss strategy to achieve success. Body-weight changes were statistically significant but not clinically relevant to dehydration effects because the average weight lost and regained was less than 2% of body weight. Wrestlers may skip a meal and work out before weigh-ins, so that, along with overnight insensible weight loss, they may easily lose 0.5 to 2.5 kg before weigh-ins. Airline travel and other dehydrating activities that are not contrary to weight certification and prohibited practices add substantially to this total.

These wrestlers lost a small proportion of their body weight some time within the 24 hours before weigh-in and did not quite regain it in the 24 hours after weigh-in. The data suggest that many nonelite athletes among the 78 may not have weighed in for each competition. Although 46 wrestlers were enrolled in 1999–2000 and 54 were enrolled in 2000–2001 (Table 1), the maximum number of participants each year should have been 36 (excluding heavy weights). Additional wrestlers beyond those who qualified for the National Championships appear to be included in the data, so there may have been many nonelite competitors who were not included in every weigh-in. Combined with the relatively high percentage of body fat for a wrestler in season in this group (10%), subject selection creates biases in the study that we are not able to interpret.

We do not know the stable weights of the wrestlers, nor the period of weight loss and subsequent regain to a stable weight, if one was achieved at all. We only know the weight from the 24 hours before and after weigh-ins. The assumption may be that the wrestler will return to his stable weight within the 24 hours post-weigh-in. Although not true for every wrestler, Steen and Brownell7 suggested that the resting metabolic rates of wrestlers who regularly cycle weight may be lower than those who have irregular weigh-in patterns (nonvarsity). Metabolic changes are a controversial issue.7–9 Reestablishing body-fluid homeostasis in wrestlers with dehydration may take hours.10 If we replace muscle glycogen, the period for complete recovery is longer.11 Lean tissue replacement, if any, may take longer still. A study design that uses the 48 hours surrounding a weigh-in may underestimate the weight loss and regain of a wrestler. Prior studies, when weigh-ins were permitted 24 hours before competition, have shown that longer periods of dehydration occur.7 If wrestlers going into the 24 hours precompetition are dehydrated, their weights will not reflect a short-term weight-loss strategy that is in the best interests of the competitor or wrestling community and will lead to biased results in effective weight management. Only in the Figure do we see some evidence the wrestlers may have been euhydrated 24 hours before competition.

This study shows a statistically significant difference in weight loss (mean = 1.4 kg) and subsequent regain (mean = 1.1 kg) within multiple 48-hour periods. Another question I assumed from the purpose was, “At what body-weight change is the wrestler at risk for dehydration or related illness?” The study design did not allow the authors to answer this question. Some measure of dehydration at weigh-in, as was apparently done monthly, would have been informative. If body-weight loss occurred within the 24 hours before weigh-in, we might assume minimal dehydration effects, as measured in previous studies.5 We cannot answer the question of whether these practices of weight cycling are detrimental to wrestlers and put them at risk of heat illness through dehydration. In fact, an indirect case may be made to consider the weight-cycling practices of these wrestlers as inconsequential to high-level performance (the antithesis of illness) and, therefore, acceptable.

The last question I assumed from the purpose statement, “What is the influence of the NCAA Wrestling Weight-Certification Program on body-weight changes?” This study follows the weight-certification changes instituted by the NCAA by 1 year.1 If we knew what data were collected in 1999–2000 and compared those with 2000–2001, some historical accounting might be inferred from the results. One and then 2 years after the institution of the new program and rule may have shown a consistent, or at least less extreme, pattern among upper classmen, but the inconsistencies found among freshmen constitute another study.2 As it is, other influences in wrestling circles may have affected the patterns seen in these wrestlers. Anecdotal evidence suggests that, without changing body weight, wrestlers can adjust their fluid-replacement strategy to affect hydration status as measured by urine specific gravity. Because we do not have data from these wrestlers in the years before the NCAA program, it is only speculation that extreme weight-cycling practices have been reduced for these wrestlers. Again, the study design did not allow the authors to answer this question.

No explanations of inclusion and exclusion criteria were given for this study, except that those who did not wrestle in the conference championships and heavy weights were excluded. How many were actually enrolled? If the data were confidential, how did the author find out which wrestlers competed in the conference championship and then subsequently earned All-American status? Were any data collected from the same wrestler over 2 years? If repeated measures were made on some wrestlers for each year but not others, the data are biased toward maturation influences and represent dependent samples.

In general, measurements were not described. We have to assume that data collectors were enlisted from at least 3 of the schools. When were the data points recorded and then reported to the investigators? We know that data were recorded by local staff, but did the staff have a manual or undergo training to consistently measure weight, skinfolds, and urine specific gravity? Did they all use the same instruments to measure these variables? Were the data reported to the investigators only after the season, when all time periods were completed? What methods were in place to ensure that the weights were actually measured by the staff? Wrestling teams travel. They have meets over weekends. Finding the scales to weigh in a wrestler 24 hours before and 24 hours after competition may conflict with another match or the availability of scales, and athletes in general may not be completely compliant subjects. How were these aspects of the study controlled, and what data were included or excluded related to these kinds of design issues?

The theme of this paper has focused on changes in body weight and body composition in wrestlers during 2 consecutive seasons. Descriptions of serial changes in body weight and composition have been shown in other studies.2,4,5 I could define no hypotheses that could be tested in this design. For the practitioner in me, I could find no treatment, diagnosis, screening, prognosis, or causation benefits from this study. There was no control or comparison group. I do not know who was actually included in the study or who was excluded other than in a general sense, nor whether data points were repeated for some wrestlers who returned the second year of study. So this paper appears to be a descriptive study of the practices of weight loss and regain among 4 NCAA wrestling teams who competed in their conference tournament. That description appears to show that the dramatic pre-weigh-in weight loss and post-weigh-in regain found in previous studies has changed, apparently for the better. It is only speculation that the reason is the 1-hour weigh-in rule, any other prohibited dehydration practice, or the weight-certification program.

What can be done with the data, given the procedures used for this study? I would recommend testing the following hypothesis: weight changes in the 24 hours before a dual-meet competition will remain the same throughout the wrestling season. We cannot randomly assign subjects to a weigh-in group and a control group, but we should be able to select matched controls from this sample who do not weigh in but who practice and undergo the same preparation as those who compete. Other control-group characteristics should match the competitors, especially body weight. If we can show that the competitors' weight changes are not substantially different from the control group (loss of less than 2% of body weight), then the short-term methods used for body-weight control before weighing in for competition do not alter the body weight of a wrestler, and the methods used to achieve the target body weight are consistent with the program goals. Consistency with the goals of the program is not the same as compliance with the program. We do not know what happens before the 24 hours before a competition, nor do we know what happens in the 24 hours after. We only know body-weight measures. The lack of knowledge of these important control features biases our interpretation of the results.

Once a comparison between groups is established, then the weight differences by weigh-in event can be compared across events or groups of events to determine if the same or different patterns of weight loss and regain emerge over the course of the season. I chose the null hypothesis to be a positive indicator of the success of the program. When no differences in weight loss and regain occur over the course of the season, then the wrestlers are more likely to have control of their weights, to be euhydrated, and to be in compliance with the program. However, for this example, using an alternative maximum mean weight loss of less than 2% as clinically acceptable, we would need a larger sample size because the power of the statistic from this group of wrestlers is low: about a .37 probability that the null hypothesis would be rejected.

It would be desirable to go back to the records to follow the competitor group as a cohort to see if they develop illnesses or other symptoms suggestive of dehydration effects that do not affect matched noncompetitors who are not required to weigh in. We know about single and short-term dramatic bouts of dehydration, but we do not have data on repeated acute weight cycling and the frequency of these same illnesses or deficits. Perhaps the low level of repeated dehydration that takes place with the current weight-certification program is sufficient to produce adverse effects in wrestlers over the course of a season. Using simple incidence rates and relative risk ratios would give us some answers about this group.

Both hypotheses have outcomes applicable to other sports and the daily dehydration that takes place among athletes who do not replenish fluids adequately. Are they more susceptible to immune-system dysfunction under these circumstances than the short-term dysfunction associated with vigorous physical activity? The implications for further study provide the impetus to look at outcomes and evidence in our clinical practice.

Editor's Note:

Danny T. Foster, PhD, ATC, is a lecturer in the Department of Exercise Science, University of Iowa, and a member of the JAT Editorial Board.

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J Athl Train. 2004 Apr-Jun;39(2):167–168.

AUTHORS' RESPONSE

We are responding to the reviewer's commentary on our manuscript, “Fluctuation of Body Weight in Collegiate Wrestlers: Implication of the National Collegiate Athletic Association Weight-Certification Program.” The comments of the reviewer are supportive of this manuscript and lend thoughtful suggestions, which have strengthened the study. We welcome the opportunity to respond to the commentary. With regard to the research questions, our focus was on changes in pre– weigh-in and post–weigh-in body weight and composition in wrestlers over 2 consecutive seasons. Body-fat losses and weight gain lend credence to the fact that these athletes were potentially improving physically throughout the entire season, in contrast with Utter's findings.1

As for the number of subjects included in the data pool, the experimental design remained consistent for all groups over the 2 competitive seasons. The medical personnel remained consistent over the 2 competitive seasons and complied with the NCAA weight-certification program2; subject confidentiality was maintained within each team's medical staff. The opportunity for a particular subject to be included in both competitive seasons certainly existed. As with any competitive season, unique circumstances exist that cannot be controlled and warrant the inclusions of these individuals.

The reviewer stated, “I could find no treatment, diagnosis, screening, prognosis, or causation benefits from this study” with a suggestion of discussing the implication of weight loss through dehydration. In the initial manuscript draft, a large portion of the discussion section was devoted to hydration and nutritional status compromised through weight-loss techniques in competitive wrestlers. This discussion was deleted from the present draft at the request of the initial reviewers.

Body-fat losses and weight gain lend credence to the fact that these athletes potentially were physically improving throughout the entire season in contrast with Utter's study.1 The theme of this paper focused on changes in pre–weigh-in and post–weigh-in body weight and composition in wrestlers over 2 consecutive seasons. The descriptions of serial changes in body weight and composition are discussed in the manuscript's final paragraph using 2 of the 3 papers the reviewer recommended.2,3 The wrestlers in this investigation lost significant amounts of weight before and gained significant amounts of weight after competition, suggesting that NCAA modifications in weight certification have not been effective. Although these changes in body weight may be statistically significant, they are within the range that has been observed as a result of normal water turnover.4,5

REFERENCES

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