To an Athlete Dying Young by A.E. Houseman
"…Smart lad, to slip betimes away
From fields where glory does not stay,
And early though the laurel grows
It withers quicker than the rose.
Eyes the shady night has shut
Cannot see the record cut,
And silence sounds no worse than cheers
After earth has stopped the ears:
Now you will not swell the rout
Of lads that wore their honours out,
Runners whom renown outran
And the name died before the man.
So set, before its echoes fade,
The fleet foot on the sill of shade,
And hold to the low lintel up
The still-defended challenge-cup…" (1)
There is an attitude of invincibility that accompanies youth. It is this quality that often fosters the daring challenges to the unknown, taunting the previously impossible, that defines many of the great achievements of our time. Defeat, injury, and death are vague sentiments to the young. This bonhomie allows them to leap into the fray and risk all while their elders watch from the sidelines with apprehension. Sometimes they succeed, and sometimes they fail. But we would not have progress without risk.
Yet the perception of risk varies significantly. Unnecessary or preventable risk is something that we sometimes struggle to consistently define. One person's foolhardy behavior is another's everyday venture. Athletes are by definition, but by no means exclusively, individuals who engage in activities that others may consider risky. Much of this is relative. Surfing is risky to the non-swimmer. Downhill skiing or race car driving are crazy to those who fear speed. Mountaineering or sky diving is anathema to those with a fear of heights. Yet among most individuals, there is a general sense of reason and motivation to lessen the unnecessary risks of everyday life. This review looks at some of those risks as they apply to high school and college athletes.
What Is Risky Behavior?
Ford describes "risky behavior" as "any behavior that increases negative health-related outcomes for the participant" (2). For the purposes of this review, risk behaviors in high school and college athletes may include (but are not limited to) reckless motor vehicle use, alcohol and illicit drug use, unsafe sexual practices, failure to use helmets or seatbelts, obesity and its co-morbidities, sensation seeking, carrying weapons or guns, gambling, poor nutrition, and inappropriate medication or supplement use.
Literature in the Past Decade
Numerous articles in decades past have discussed the lifestyles and health risks of high school and college athletes (3). Most of these studies suggested a significantly higher level of risk-taking behavior in athletes when compared with their nonathlete peers. Typically, they showed an association between contact sports and maladaptive lifestyle behaviors. Alcohol was often citied as a concomitant risk factor in injury and was the most prevalent drug (other than caffeine) used by athletes and nonathletes. Cigarette use has declined significantly from 65% in nonathletes and 27% in athletes in the late 1980s to currently less than 23% overall in society (4). Contrary to other researchers, Kokotailo et al. suggested that many athletes do not, in fact, engage in high-risk behaviors more frequently than nonathletes (5).
Gender and Risk: A Drug-Drug Interaction
Most studies indicate that males are greater risk takers than females. Younger athletes (mean age of 15 yr) report fewer risk behaviors, while older athletes 18-21 yr of age report greater risk behaviors. Findings suggest that during the last 3 months of the senior year in high school, male athletes consume more alcohol and drink more frequently, engage in more sex, more unsafe sex, and have more partners than nonathletes (6). Many of the injuries and fatalities that occur in males and male athletes are the result of a drug-drug interaction between testosterone and alcohol.
Does Sports Participation Benefit Women More Than Men?
Other studies indicate that sports participation actually lessens the likelihood that female athletes (compared with nonathlete women) will partake in risky behaviors, whereas male athletes (when compared to nonathlete males), to the contrary, seem more inclined to participate in dangerous or risky activities (7). Involvement in sports by the adolescent female is correlated with later first sexual experience, fewer sexual partners, and a lower pregnancy rate (8). Female athletes in general note greater societal scrutiny of their behavior: there is always the risk of pregnancy that does not exist for males and a higher risk of sexually transmitted disease. That sports participation may be protective for women and a liability for males is a somewhat provocative notion. It certainly validates the Title IX initiative.
According to U.S. Census Bureau statistics for "School Enrollment - Social and Economic Characteristics of Students: October 2006," the population of the United States was 282 million (9). There were a total of 75 million individuals enrolled in preschool, primary, secondary, and collegiate programs. Of these, there were roughly 17 million high school students (grades 9-12 and ages 14-18) with 8,777,000 male and 8,372,000 female students. At the college level, there were nearly 14 million students enrolled in undergraduate programs (potential candidates for varsity sport), of whom 6,134,000 were men and 7,719,000 were women. The percentage of individuals enrolled in school or college was 98% for ages 14-15, 94% for 16-17, 65% for 18-19, 47% for 20-21, 26% for 22-24, and 11% for 25-29.
As might be expected, the number and percentage of high school students participating in sports is significantly higher than at the college level (10). Recent numbers show 4,206,549 male (47.9% participation rate) and 2,953,355 female (35.3%) high school athletes. At the intercollegiate level (not including intramural or recreational), there were 291,797 male (4.7% participation rate) and 205,492 female (2.6%) athletes. Since the enactment of Title IX in 1972, women's sports funding and participation has increased significantly, but it continues to lag behind their male counterparts (11).
Youth Risk Behavior Surveillance System
In the general population, the definitive study that addresses the issue of high school risk taking is the Youth Risk Behavior Surveillance System (YRBSS) prepared by the U.S. Centers for Disease Control and Prevention (CDC) annually and published in the Morbidity and Mortality Weekly Report (MMWR) (12). This compendium summarizes the information collected on more than 14,000 students, grades 9-12, in both public and private schools in the United States. These data include all youth, athletes and nonathletes. Although 56.3% of students played on at least one sport team in the previous year, 62.1% of males participated compared with 50.4% of female students. In addition, sports participation declined from 59.2% in grade 9 to 49.0% in grade 12.
The most recent edition of the YRBSS (2007) monitors six categories of health risk behavior in these young adults:
- Behaviors that contribute to unintentional injury and violence
- Tobacco use
- Alcohol and other drug use
- Sexual behaviors that contribute to unintended pregnancy and STD including HIV
- Unhealthy dietary behaviors
- Physical inactivity and obesity
In 2007, 11.1% of students had never or rarely worn a seatbelt when riding in a car driven by someone else. In the month preceding the study, 29.1% had ridden in a car or vehicle driven by someone who had been drinking alcohol, and 10.5% had themselves driven after using alcohol. Lifetime alcohol use was 75%, with 26% having had more than five drinks in a row in the previous month. Current cigarette, smokeless tobacco, or cigar use was 25.7%. Lifetime use (vs. current use in the last month in parentheses) of other drugs was marijuana 38.1% (19.7%), cocaine 7.2% (3.3%), anabolic steroids 3.9%, heroin 2.3%, methamphetamine 4.4%, ecstasy 5.8%, and hallucinogenic (e.g., LSD, mushrooms) 7.8%. On an average school day, 35.4% of students watched more than 3 h of television, and 24.9% used the computer more than 3 h per day for nonschool-related video or games. Nationwide, 47.8% were sexually experienced, and 35% were currently sexually active; while 61.5% of those who were sexually active reported condom use during last sexual intercourse, only 16% used oral birth control. In Holland, where the rates of teen pregnancy are much lower than in the United States, concomitant use of condoms and oral contraceptive pills is known as "double Dutch&"- a belt and suspenders, as it were.
In the United States in 2007, 72% of all deaths among persons aged 10-24 yr resulted from four causes: motor vehicle crashes (30%), other unintentional injuries (15%), homicide (15%), and suicide (12%). By comparison in the United States among adults: 59% of all deaths are from either cardiovascular disease (36%) or cancer (23%).
Risk Behaviors that Contribute to Injury and Violence
Suicide resulted in approximately 32,439 deaths in the United States in 2004; 4316 were in the 15-24 yr old age group (13). Athletes are not spared this great tragedy. The "do or die" aspect of sport is intimated in the terms "suicide play" (baseball), "suicide squad" (football), and "suicide knot" (rodeo). Depending upon the study, 1%-10% of all persons have attempted suicide. Baum reported on 71 cases of suicide in athletes (8). The average age was 22.3 yr, with 61 males and 10 females. Although depression is lower in athletes, suicide rates appear unrelated to physical activity. The loss of mastery or control after injury or loss of a major championship is often associated with the onset of suicidal ideation. The harsh notion of being "winners" or "losers" seems particularly difficult for some to process. Use of steroids increases the risk. Homosexuality infers a two to three times increased risk of suicide in the 15-24 yr age group compared with heterosexual peers. The rate of suicide is 3:1 male:female in the general population and 5.5:1 in sport; this may be caused by greater numbers of males in athletics. Self-esteem is a central value.
Nicotine has a long history in America. Since the 1965 Surgeon General's report, Americans have been aware of the dangers of smoking in terms of lung disease (emphysema and lung cancer) and heart disease. Major litigation and removal of cigarette ads from television have sullied the once glamorous image of smoking for many. While most athletes are not smokers, the use of smokeless tobacco, that is, snuff or chew, has a history of use particularly in baseball. Smokeless tobacco significantly increases the risk of developing oral cancers and other mouth disorders (14). Groups such as the National Cancer Institute and the National Institute for Dental Research have partnered to try to reduce the use of oral tobacco. Despite the fact that this is the age of information, tobacco abuse remains a major health problem in the United States.
Alcohol and Other Drug Use
Studies reveal that approximately 66% of college students reported alcohol use in the past month, and 39% of college students engage in heavy alcohol binge-use (15). In comparison, drinking by non-college-age-peers was significantly lower: 58% reported past month use, and 34% reported binge drinking. Binge drinking is considered five or more drinks in a row by men and four or more drinks in a row by women. Female college students have shown a rising prevalence of alcohol use in recent years. "Positive drinking expectancies" were predictive of an increased likelihood of hazardous alcohol use despite known concerns. Negative consequences include hangovers, academic difficulty, relationship problems, accidents, injury, criminal behavior, and sexual victimization. A setting that promotes or condones alcohol use and other risk behaviors may confound avoidance attempts. Martens et al. have proposed an athlete drinking scale (ADS) to help screen for alcohol-related problems (16). They suggest that athletes commonly use alcohol as a coping mechanism or for negatively reinforcing reasons that require expanded assessment and interventions to achieve successful clinical outcomes.
Ford performed a comparative analysis of alcohol and substance use in 2316 athletes among eight collegiate sports (football, volleyball, soccer, swimming/diving, basketball, ice hockey, baseball/softball, and running) using data from the 1999 Harvard School of Public Health College Alcohol Study (17). He found significant differences based upon sport/team affiliation in the percentage of male and female athletes, and also nonathletes, with regard to binge drinking, marijuana use, and other illicit drug use (Tables 1 and 2). Among men, the hockey players had the greatest percentage of use for all three substances, alcohol (75.2%), marijuana (38.5%), and other drug use (18.8%), with running athletes near the bottom (40.9%, 16.3%, and 10.1% respectively). Among women, the soccer players had the highest percentage of alcohol (46.9%), marijuana (37.8%), and other drug use (23%). It was of interest that the male nonathletes showed relatively low levels of binge alcohol use (49%) just above runners, but a level of marijuana (31%) and other illicit drug use (16%) exceeded only by the male hockey players. Similarly female nonathletes had low levels of binge alcohol use (29%) but were third behind the women soccer and softball players for marijuana (25%) and other illicit drug use (12%). This review suggests that there is a wide range of variation in risk behavior based upon sporting activity, and certainly a wide margin of within-sport variation as well that is probably not appreciated here. It does not, therefore, seem appropriate to lump all athletes into the same category in terms of risk behavior labeling or to compare them ipso facto against nonathletes.
A growing concern is the mixing of alcohol with new concoctions called "energy drinks," which contain hodgepodge doses of caffeine, refined sugars, amino aids, herbs, and vitamins. The marketing of these drinks has been highly aggressive in the youth culture. In 2006 Americans spent more than $3.2 billion dollars on energy drinks (18). There are over 1000 different energy drinks now on the market, each trying to out-sensationalize the other. Approximately 34% of 18-24 yr olds are regular energy drink users. Drinking games involving energy drinks offer an additional incentive to consume these substances; doing so constitutes "high risk" drinking according to the Society for Academic Emergency Medicine. Associated risks of heavy episodic drinking include serious injury, sexual assault, drunk driving, and death; these risks are roughly doubled when alcohol is mixed with energy drinks (Table 3). Laboratory studies have shown that while caffeine lessens the subjective symptoms of intoxication and the appreciation of intoxication in others, it does not lessen the impaired motor or visual skills, that is, the physical drunkenness. Ireland, Australia, Sweden, Finland, and France have issued warnings about the combined use of alcohol and energy drinks. The U.S. Food and Drug Administration (FDA) has not.
Sexual Behaviors that Contribute to Unintended Pregnancy and Disease, Including HIV
The likelihood of transmission of sexual transmitted diseases (STDs) or human immunodeficiency virus (HIV) during sport is negligible. However, athletes must be educated regarding the nature of HIV and STD sexual transmission, as well as the high-risk behaviors including drug and alcohol use that may increase the risk of exposure. There are now over 1 million people in the U.S. living with HIV/AIDS, with roughly 25% unaware of their infection. An increasing proportion of cases (15%-27%) are now being reported in women, with the case proportion of high-risk heterosexual contact having risen to 34%, second only to male-male sexual contact at 44% (19).
Most college students (72%) have never been tested for HIV, despite the fact that 10% have been diagnosed with an STD, many participate in unprotected sex, and nearly 40% have had 2-5 partners in the previous 6 months (20). It may be that the visibility of Magic Johnson and Greg Louganis have taken some of the fear away from this diagnosis, and perhaps rightly so, yet some 16,000 others annually in the U.S. from this often unnecessary, communicable illness. Some 19 million STDs are treated annually in the U.S. at a cost of approximately $15.5 billion. Human papilloma virus (HPV) is the most widespread STD in the world. Approximately 20% of the U.S. adult population is infected with herpes simplex virus (HSV). Student motivation to take such risk remains poorly understood.
Unhealthy Dietary Behaviors
Disordered eating patterns, including anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) remain a significant concern primarily for female athletes in the aesthetic, leanness, and endurance sports (21). Anorexia athletica is a term sometimes used for athletes. Issues regarding the female triad and potential complications such as metabolic disturbance, skeletal injury and stress fractures, reproductive disorders, fatigue, and psychological concerns have been discussed in great detail (22). The mortality rate associated with AN is between 9% and 12%, with upwards of a third of deaths from suicide (8). The exact incidence among femaleathletes is highly variable, depending upon sport and ethnicity. White female athletes have the greatest mean body dissatisfaction scores and drive for thinness (23) (Fig. 1). Awareness and dialogue remains crucial to any effective treatment or intervention.
Diet and Disuse = Disability
At the other end of the spectrum, dietary excess and inertia have emerged as perhaps the greatest threats to the overall health of Americans in this century. Athletes are not spared this threat, and a significant percentage of youth in football, baseball, basketball, and other sports carry more weight than is healthy. Athletes who do not remain physically active after years of sports participation often become overweight and thus become "at risk" for the co-morbidities of metabolic syndrome, type II diabetes, heart disease, hypertension, hypercholesterolemia, blindness, renal failure, and amputation. It is estimated that more than 50% of all high school and college football linemen may be clinically obese. Many have BMIs of 35 or more. Professional football player Corrie Stringer, 6'4' and >335 lbs, who died in training camp in 2001, had a BMI of 41, qualifying for class III morbid obesity by the National Heart Lung and Blood Institute system.
Unfortunately, many of these players gain further weight when they quit playing football and become relatively inactive. In 1985, there were approximately 10 professional football players weighing over 300 lbs. Now there are well over 300 players weighing over 300 lbs (28). Football players in secondary schools and college subsequently show increasing numbers of markedly overweight "athletes." While it would seem contrary to our definition of sport that anathlete could be physically unfit, a significant number of power sport athletes, while strong, lack significant cardiovascular fitness. The "athlete's heart" of left ventricular hypertrophy is a phenomenon of aerobic exercise; it rarely is seen in those who weigh 300 lbs and lumber short distances on the field of play. The contrast in fitness levels of soccer, lacrosse, or rugby players and American gridiron linemen is revealing and potentially instructive.
Supplements: Caveat Emptor (Let the Buyer Beware!)
Although the FDA has been able to tighten the controls on labeling and control of dietary supplements, this process has been hampered by the 1994 Dietary Supplement Health and Education Act that kept them outside of FDA restrictions. Gurly et al. showed that some 19% of ephedra products had either contaminants or failed to contain the stated ingredients (25). For athletes, the potential contamination of a supplement with any banned substance has significant implications. Over the last decade the FDA has received more than 1000 adverse event reports involving ephedrine-type alkaloid-containing dietary supplements prompting recent action. Much remains unknown about the interactions between naturopathic substances and supplements when used in combination with prescription medications. The widespread use of supplements and other non-FDA controlled substances continues to frustrate caregivers.
Steroids and Illicit Drug Use
Recent media disclosures of the rampant illicit use of steroids by athletes have led at least one parent to openly express the hope that her child would become a rock musician rather than a professional baseball player. A review of studies over the past 20 yrs has shown that 2%-12% of high school seniors have used steroids, many starting before the age of 16. Use did not seem to be exclusively for performance enhancement but often was to improve body appearance or for "anti-aging" reasons (26). A longitudinal review of four national surveys on the non-medical use of anabolic steroids (NMAS) was associated with being male, participation in intercollegiate athletics, and demonstrated a prevalence of less than 1% (with little change from 1993 to 2001) (27). Among intercollegiate student-athletes, the lifetime prevalence was 3.3% and past-year prevalence was 1.5%. NMAS use was associated with additional health risk behaviors, including cigarette smoking, illicit drug use, drinking and driving, and DSM-IV alcohol use disorders (28).
In a notable 1997 Sports Illustrated interview, a group of elite Olympic athletes were asked the question, "If you were given a performance enhancing substance and you would not be caught and win, would you take it?" An alarming 98% responded, "yes." To the follow-up question, "If you were given a performance enhancing substance and you would not be caught, win all competitions for 5 years, then die, would you take it?" surprisingly, 50% said yes. This is a sobering commentary on our current emphasis on win at all cost sports and the financial gain to be made from such domination (29).
Concerns over adolescent substance abuse have inevitably led to drug testing programs. World Anti-Doping Agency and the United Stated Anti-Doping Agency have made significant progress in this campaign as long as governing bodies have provided appropriate penalties. In certain instances, local organizations or schools have contested the testing as an infringement of rights, yet the 1995 U.S. Supreme Court ruling affirmed the legality of drug testing of adolescent athletes involved in school-sponsored sport and later extended that right in 2002 to all students in extra-curricular school-based activities. However, as has been shown with persistent cigarette use rates of 23%-25% in the general population, education alone is incompletely effective in changing behaviors. The 2007 Student Athlete Testing Using Random Notification (SATURN) study was a 2-yr prospective randomized controlled study of a single cohort of five intervention high schools with drug and alcohol testing (DAT) programs, and six high schools with a no-test, deferred policy. Confidential questionnaire surveys failed to show a significant deterrent effect in reducing drug and alcohol use among high school students (30).
The Role of the Media
Marshall McLuhan, the brilliant Canadian social philosopher, observed in his classic text The Medium is the Massage that market forces have great influence upon the behaviors of individuals in society (31). Advertising via television, the Web, music, magazines, newspapers, and word of mouth significantly influences the adoption of behaviors by young adults and young athletes. For better or worse, the film media have influenced the attitudes and risk taking of our youth (and we were once them) for years with such films as North Dallas Forty, Breaking Away, Chariots of Fire, Slapshot, Animal House, Miracle on Ice, Blades of Glory, and the recent gambling film 21. We need to borrow the marketing and advertising skills of our cinematic, music, and Web professionals as a platform for our own cultural change and role modeling. We need to send a creative and healthful message to our youth.
Schools are a Protective Setting
A Canadian study of nearly 6000 youth looked at multiple risk behaviors (MRBs) on physical activity-related injuries in adolescents and found that organized sport in the school setting was a protective influence (32). MRBs in this study included smoking and drug use, sensation seeking, failure to take safety precautions (helmets and seatbelts), and failure to use condoms or engage in safe sex. It consistently is reported that youth who engage in MRBs face a higher injury risk than those who do not engage in such behaviors. The ability to modify environmental factors, equipment, or setting (contextual risks) offers a significant way to minimize injury and accidents, even if the MRBs themselves cannot be eliminated. The U.S. Surgeon General has called for expansion of school-based extracurricular sports to help address the obesity epidemic and work to reduce high-risk behaviors. Schools with greater numbers of sports programs had lower levels of teen birth rates and juvenile arrest rates (33).
Limitations of these Studies: Just What and Who is an "Athlete"?
How accurate is it to say "athletes" do this, more or less, than "nonathletes"? Some reviews define an athlete as any student or individual who spends more than 10 h·wk−1 in competitive athletics (6). The distinction between the sedentary individual and an intercollegiate or elite athlete seems fairly obvious. What about the gifted recreational, intramural, or masters athlete who trains 5-9 h·wk−1 and works 50? Do we differentiate level of competition or number of hours of annual training base? Should we do categorical V˙O2max tests on everybody? It should surprise no one that spectators and recreational athletes often consume prodigious quantities of alcohol and may participate in far more risky activities than the elite athlete (34) (Fig. 2). This clouds the notion of athletes as risk takers to any extent greater than the average "wannabe" on the playground or in the stands.
Central to this discussion is the classification of athlete status and the nature of the sport involved. There are great differences in the physical, socioeconomic, psychological, and disciplinary demands among various sporting activities. Are we to lump football linemen in the same category with ballerinas or golfers? Sumo wrestlers with tennis players? Rugby players with swimmers? Race-car drivers with gymnasts, or soccer players with shot putters? How do the characteristics of these participants affect their behavior? Whether risk perception is a mediator of causation or an "exogenous variable" cannot be inferred without further distinction among sports and further differentiation of athlete status. Ford's review helps dissuade us from simple categorical assumptions.
Deaths in Sport
"Death thou comest when I had thee least in mind" (35).
The greatest risks to young athletes (and young athletes on the way to becoming older athletes) are, by and large, those things that are the greatest risk to the majority of all Americans: tobacco use, heart disease, obesity and its co-morbidities, motor vehicle accidents, and cancers. While we worry greatly about catastrophic injury or sudden death in sport, the reality is that such events are fortunately quite uncommon. More people are killed in car crashes with deer than die on the fields of sport in the United States in a given year. There are on average 10-20 episodes of sudden cardiac death due to HCM annually in the U.S., 1-3 cases of commodo cordis, and 10 catastrophic head or neck injuries. This does not lessen in any way the diligence of researchers and caregivers to improve safety records and further minimize the incidence of these traumatic events. Rather, it speaks exceptionally well to the preparations, coverage, and response of athletic trainers, physicians, coaches, and other medical caregivers in the sporting venue. Conscientious pre-participation evaluations continue to provide the opportunity to screen athletes by history and physical exam for anatomic abnormalities and risk behaviors.
While it is important and interesting to look at the incidence/prevalence of "risk behaviors in sport," our message on these behaviors needs to be delivered at a broad population level. Addressing the issues of sub-set groups, in youth and early adulthood, can help clarify special concerns in high-risk populations. Yet the prescription should be applied equally to all youth, whatever their athletic disposition. Kept in the perspective of sheer numbers of morbidity and mortality, it is clear that the greatest risks to high school and college youth, athletes and nonathletes alike, are much the same.
- Don't smoke or use illicit drugs.
- Don't drink and drive or get in a car with someone who has been drinking.
- Always wear your seatbelt and a helmet as indicated.
- Make daily physical activity a habitual part of your life.
- Consume a balanced diet of appropriate caloric volume.
- Limit refined sugars, soft drinks, and "sports" drinks.
- Get at least 50-60 h of sleep per week.
- If sexually active, be responsible and safe.
- Keep your weight in normal range.
- Get routine physical exams, preventive vaccines, and screening tests.
- Brush and floss your teeth daily.
Preserving a habit of lifelong physical activity and minimizing preventable risks remain cornerstones of ahealthy existence. The Exercise is Medicine™ (EIM) initiative champions this cause (36). Minimizing "risky behaviors" is sometimes a no-brainer (not smoking, legal and sensible use of alcohol, safe sex, maintaining a normal weight) and sometimes a matter of choice (scuba-diving, hang-gliding, or mountaineering). Sport can improve both quality of life and one's appreciation of life. Many would argue that compressing the "period of morbidity" at the end of life is more important than having a prolonged but insensate existence in a care facility. Life has bookends; there is a birth and a death awaiting us all. What matters is living well and nurturing what mythologist Joseph Campbell calls the "rapture of being alive."
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