Objective To determine the priorities and activities of International Sport Federations (IFs) with respect to the promotion of health in their sport and for the general population.
Methods All 35 IFs participating in Olympic Games in 2014 or in 2016 were asked to rate the importance of 10 indicated topics, and to report their programmes, guidelines or research activities on 16 health-related topics using an online questionnaire (response rate 97%).
Results On average, the ‘fight against doping’ had the highest priority followed by ‘health of their elite athlete’ and ‘image as a safe sport’. The topics with the lowest importance ratings were ‘health of their recreational athlete’, ‘increasing the number of recreational athletes’ and ‘health of the general population’. All except one IF reported to have health-related programmes/guidelines/research activities; most IFs had 7 or 8 of the listed activities. Eight IFs (23.5%) stated to have activities for ‘prevention of chronic diseases in the general population’ but only FIFA and FINA reported related projects.
Conclusions IFs aimed to protect the health of their elite athletes through a variety of activities, however the health and number of their recreational athletes was of low importance for them. Thus, IFs are missing an important opportunity to increase the popularity of their sport, and to contribute to the health of the general population by encouraging physical activity through their sport. FIFA’s ‘Football for Health’ and FINA’s ‘Swim for All’ projects could serve as role models.
- Health Promotion Through Physical Activity
- Injury Prevention
- Sporting Injuries
- Elite Performance
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- Health Promotion Through Physical Activity
- Injury Prevention
- Sporting Injuries
- Elite Performance
The protection of the health of the athlete is embedded in the Olympic Movement Medical Code (OMMC) which governs the actions of the medical committees of the International Sports Federations (IFs): “The Olympic Movement, in accomplishing its mission, should encourage all stakeholders to take measures to ensure that sport is practised without danger to the health of the athletes … it encourages those measures necessary to protect the health of participants and to minimise the risks of physical injury and psychological harm.”1
According to the Olympic Charter, the International Olympic Committee (IOC) and the IFs have an obligation:
‘9 to encourage and support measures protecting the health of athletes.
12 to encourage and support the development of sport for all. ’2
In translating the Olympic Charter and the OMMC into action, the IOC and several IFs have developed activities for protecting the health of their athlete. Almost 10 years ago, Fuller and Drawer3 published a theoretical framework on the application of risk management in sport. Cognisant of the health risks of sport participation, IFs have the responsibility to identify the health risks inherent to participation in their specific sport, and to respond to these risks through the development and implementation of measures to decrease and manage the health risks so as to reach an acceptable level of risk for athlete participation.3
In 1998, FIFA (see table 1 for IFs’ acronyms) started as the first IF to systematically survey all injuries incurred in its competition.4 During the Olympic Games (OG) in 2004, injuries were recorded in all team sports.5 IAAF and FINA were the first IFs for individual sports to introduce injury surveillance in their World Championships 2007/2009.6 ,7 The IOC included all athletes in their injury surveillance project at the OG in 2008.8 The IOC injury surveillance protocol9 was expanded to also include illnesses in the Winter OG 201010 and Summer OG 2012.11 To standardise and encourage injury surveillance studies in their sports, several IFs have published consensus statements on injury definitions and data collection, such as football, rugby, tennis, horse racing, cricket and athletics.12–17
Sports injuries can be prevented by appropriate interventions, such as exercise-based programmes, rules and regulation as well as the promotion of Fair Play.18 ,19 Preparticipation/periodic medical examinations are another means aimed at protecting the health of the athlete. FIFA introduced a precompetition medical assessment (PCMA) to all players of its World Cup in 2006,20 and subsequently to women and youth players21 and referees.22 ,23 The PCMA is now mandatory for all players participating in FIFA World Cups. The IOC published a Consensus Statement on the periodic health evaluation of elite athletes in 2009.24 In addition, specific recommendations on the prevention of sudden cardiac death in sport have been published.25–27
Other important health-related topics in elite sport addressed by IFs and the IOC are nutrition/hydration,28–30 asthma,31 concussion,32–35 female athlete triad,36 hot environment,37 ,38 altitude,38 ,39 gender reassignment,40 age determination,41–43 prevention of sexual abuse and harassment44 and the fight against doping.45 Using the example of FIFA, Fuller et al18 demonstrated how an IF uses a risk management framework to identify, quantify, mitigate and communicate the risks of injury and illnesses in its sport.
Little is known about the postcareer life of top athletes and long-term consequences of elite sport. Retired football players, for example, have a higher rate of osteoarthritis in the lower extremity joints than the general population.46 Former male elite Finnish athletes in endurance, power and team sports had a greater risk of hospitalisation for the treatment of musculoskeletal disorders in comparison to an age-matched non-former elite athlete control group.47 This athlete cohort, however, had an improvement in life expectancy,48 and less hospitalisations for non-communicable diseases (NCDs) such as respiratory disease, heart disease and cancer than the control group.47
The WHO has classified insufficient physical activity (PA) as the fourth leading independent risk factor for the development of NCDs after hypertension, tobacco use and elevated blood glucose. Low levels of PA alone are responsible for 3.2 million or 5.5% of all deaths per year.49 Insufficient PA in children is associated with a higher incidence of hypertension, obesity and the metabolic syndrome.50 Participation in regular PA has well-established health benefits for the general population through the reduction in the risk of premature death from NCDs, such as diabetes mellitus, coronary artery disease, colon and breast cancer, obesity and hypertension.51 There is also evidence for prescribing PA in the treatment of types 1 and 2 diabetes, dyslipidaemia, hypertension, obesity, heart and pulmonary diseases, muscle, bone and joint diseases, cancer and depression.52
Sport as the gatekeeper to PA has the ability to participate in the prevention of the epidemic of NCDs. In their article entitled ‘Achieving the Millennium Development Goals’, the United Nations Inter-Agency Task Force on Sport for Development and Peace, reinforces the importance of sport in the prevention of NCDs: “Participation in sport has significant physical benefits, contributing to people's ability to lead long and healthy lives, improving well-being, extending life expectancy and reducing the likelihood of several major non-communicable diseases.”’53 Consequently, IFs should expand their mandate from protecting the health of their athletes to using their sport to improve the health of the general population.
In 2007, FIFA started to develop, test and implement a football-based health education programme ‘FIFA 11 for Health’ to reduce risk factors for communicable and NCDs.54–56 In 2010, the IOC signed a Memorandum of Understanding with the WHO agreeing “to join efforts and to co-operate ... to promote healthy lifestyles, PA and sport among the communities.”57 and published two related consensus statements: The Consensus Statement on the fitness and health of children through sport identifies the health risks of physical inactivity in the global youth population and outlines recommendations for the world of sport and governmental organisations to address the issue.50 The Consensus Statement on prevention and management of chronic disease focuses on the development of a strategy to prevent and treat NCDs by challenging and mobilising the sport and exercise medicine community to action.58
In summary, IFs have the responsibility to protect the health of their athletes and should promote PA via their sport to improve the health of the global population. The objective of the present study is, thus, to determine the current priorities and activities of IFs with respect to the promotion of health in their athletes and in the global population.
The Association for Summer Olympic International Federations and the Association of Olympic International Winter Federations contacted all IFs participating in the OG in 2014 or in 2016 (table 1) by email to the Secretary-General/Executive Director with a copy to the Chair of the IF Sports Medicine Committee. The IFs were requested to complete a survey on the protection of their athlete's health and promotion of their sport. The survey started with an introductory note and a request for contact information to ensure the validity of the respondent. The IF was then asked to rate the importance of a list of 11 topics (table 2) on a 5-point scale from ‘not important’ to ‘top priority’, and to report whether or not they have any programme(s)/guidelines(s)/research activities with regard to 16 health-related topics (table 3), and if so, to provide details about their particular programme or activity in writing. Both lists were developed by the authors (AJ and MM) based on the review of the literature outlined in the introduction. Both lists of topics provided the option to add ‘others’. Confidentiality of the data was maintained through password protection of the access to the results on the secure website. The IFs were given a 2-week time period to respond, following which email reminders were sent to encourage participation. Details on the characteristics of the 35 IFs (table 1) were gathered from the IOC website and the homepages of the IFs as well as from the publications of injury surveillance study during the OG in 2010 and 2012.10 ,11 Data were processed using Excel and SPSS. Statistical methods applied were frequencies, cross-tabulations and χ² test. Significance was accepted at p<0.05.
Characteristics of international sports federations
The characteristics of the 35 IFs are described in table 1. The oldest IFs were founded in 1892 (FIVB, ISU), the youngest (IGF) in 2010. The first modern OG in 1896 included athletics, cycling, gymnastics, fencing, shooting, swimming, weight lifting and wrestling. Rugby and golf will debut at the OG 2016 in Rio de Janeiro. The number of National Federations as an indicator of size and of popularity of the sport varied from 213 (FIBA) to 50 (WCF). The number of employees of the IFs ranged from 3 (IGF) to 400 employees (FIFA). Seven IFs represent team sports, 28 individual sports, and FINA includes both. The 35 IFs varied in the number of athletes participating in the OGs 2012/2010: five IFs (15%) were represented by more than 500 registered athletes, eight (24%) by 351–500 athletes, nine (27%) by 201–350 athletes and 11 (33%) by less than 201 athletes. All except one IF participated in the current study.
Importance of health and promotion of sport for IFs
The IFs’ rating of the perceived importance of the 10 indicated topics are presented in table 2. The ‘fight against doping’ had on average the highest priority, being ranked as ‘important’ or higher by all IFs and as a ‘top priority’ by 70%. The next two topics in order of ranked importance were ‘health of elite athletes’ and ‘image as a safe sport’; both classified as a ‘top priority’ by more than half (55.9%) of the IFs and ‘very important’ by further 38.2% and 35.3%, respectively. In descending order of importance ‘top performance of athletes in your sport’, ‘image as an enjoyable PA’, ‘increasing the number of spectators’ and ‘increasing the number of elite athletes’ followed. On average, the lowest importance for the IFs was the ‘health of the recreational athlete’, ‘increasing the number of recreational athletes’ and the ‘health of the general population’.
Five IFs (14.7%) rated none of the listed health topics as ‘top priority’ for their IF. Two IFs rated all topics ‘very important’, one IF all as ‘important’, one all either ‘important’ or ‘very important’, and one between ‘very’ and ‘less important’. Eight IFs rated five topics as ‘top priority’; the maximum number of top priorities was seven (by two IFs).
The importance of health topics did not differ between summer and winter sport IFs, nor between individual versus team sport IFs, except for ‘increasing the number of recreational athletes’ (being a higher priority for team sport IFs; p=0.018). Also no statistically significant relations were found between importance ratings and the numbers of participating athletes at the OG or the number of employees of the IFs. Seven IFs gave free text answers on ‘others’, mostly repetition of topics already mentioned; in addition ‘research’ and ‘prevention of drowning’ were listed each by one IF.
IF’s programmes/guidelines/research activities on health-related topics
Only one (2.9%) IF responded that they had no health-related programmes/guidelines/research activities. All, except this IF, stated to have activities regarding ‘first aid (eg, on pitch physician, AED) ’. The second most common health-related activities were ‘injury surveillance during championships’ and ‘prevention by regulation for equipment/venues’ (both 85.3%), followed by ‘nutrition/hydration’, ‘environmental conditions (eg, temperature, altitude)’, ‘injury prevention by exercise-based programmes’ and ‘pre-participation medical examination’. Eight (23.5%) IFs had activities related to ‘Prevention of chronic diseases in the general population’. The least common activities of the responding IFs were ‘mental health of their athletes’, ‘post elite career management’ and ‘training/competing during pregnancy’ (for further details see table 3)
Except the one IF with none of the listed health-related activities and the one with all of them, the number of activities ranged between 4 and 13. Most IFs stated to have either seven (20.6%) or eight (14.7%) activities. Eight IFs stated ‘yes’ to the question on other activities, but only seven specified them. Three referred to health of the population through sport and one each ‘Medical Guide’, ‘Instructors Formation Programmes’, ‘seminar and congress’, ‘Health Certificate’.
Significant differences were observed between team and individual sports IFs (FINA excluded) for ‘injury prevention by exercise-based programmes’ (p<0.05, all team sports vs 50% of individual sports), ‘injury prevention by Fair Play’ (p<0.05, 6 of 7 teams sports vs 34.6% of individual sports) and ‘Pre-participation medical examination’ (p<0.05, all team sports vs 42.3% of individual sports). No significant difference between winter and summer sport IFs or with regard to size of the IFs (based on number of athletes participating in the OG or on the numbers of employees) was found.
To the best of our knowledge this is the first study on the priorities and activities of IFs in the area of protection of the athlete's health and promotion of health in the general population. The survey cohort was intentionally addressed to the Olympic IFs, thus the results are limited to this cohort. Inherent in survey format are the potential for self-report bias and the missing evaluation of the quality of the activities/programmes. Differences between winter vs summer/individual vs team sports IFs should be interpreted with caution due to the small cohort size.
Protection of the health of elite athletes
Most IFs prioritised the protection of elite athlete health and had some activities in health-related areas. The ‘Fight against doping’ was a top priority for almost all IFs. This finding was expected as inclusion in the Olympic programme requires adherence to the WADA Anti-Doping Code that mandates antidoping programmes. Through the promotion of drug-free sport, in addition to preserving the integrity of sport, the IFs are indirectly protecting athletes from the adverse health consequences of doping. ‘Health of their elite athlete’ and ‘Image as a safe sport’ ranked second and third most important health-related topics for the IFs. Almost all IFs reported to have activities on ‘First Aid’, 85% ‘Injury surveillance during their championships’ and ‘Injury prevention by regulation for equipment/venues’. More than half of the IFs stated to have ‘Pre-participation medical examination’. Thus, the IFs included in this survey seem to have recognised their responsibility to ensure athlete health and safety. However, only few IFs have published their results from their injury surveillance projects (eg, IAAF,6 FINA,7 FIFA,4 IRB,59 IHF,60 FIS,61 FIVB62) in the scientific literature, and only FIFA has reported about its experience with the PCMA.20 ,21
Despite highly prioritising the ‘Health of the elite athlete’, IFs did not address all related aspects; especially ‘Training/competing during pregnancy’, ‘Mental health of athletes’ and ‘Post-elite career management’ which were addressed by very few IFs. Salmi et al63 reported the prevalence of mental health issues in elite multisport athletes. Malcolm and Scott64 addressed the issue of suicide among elite athletes in a recent editorial in the BJSM. The postelite athletic career time period was identified as one of the most vulnerable times for the emergence of mental health issues.63
Protection of the health of recreational athletes
The ‘Health of recreational athletes’ had a relatively low importance for IFs (ranking 8 of 10). Given the large numbers of recreational and amateur athletes globally, IFs are missing an ideal opportunity to promote health initiatives in this population. There exists a need to create policy and to support and motivate national federations and IFs to address the health and welfare of non-elite athletes. The largest sport participation in the world is football with a global participation of 265 million.65 FIFA has addressed the issue of protection of the health of the amateur and youth players by developing and implementing exercise-based prevention programmes66–68 and publishing information on different medical aspects for laymen (http://www.FIFA.com/Medical). FIFA is the only IF with a medical assessment and research centre (http://www.F-MARC.com) founded almost 20 years ago, and consequently has followed a risk-management framework to identify, quantify, mitigate and communicate the risks of injury and ill health in football players of different, gender, age and skill levels around the world.18
Promotion of sport for health of the general population
‘Health of the general population’ was of low importance for the IFs (ranking last of the 10 health-related topics of this survey), and few IFs had activities for the ‘Prevention of chronic diseases in the general population’. Furthermore, ‘increasing the number of recreational athletes’ was of low importance for the IFs (ranking second last). Attention to the recreational athlete would not only be advantageous for the IFs in terms of popularity of the sport but also indirectly for the health of the population.
Although influencing global health through the promotion of sport is a priority of the IOC, only two IFs (FIFA and FINA) had designed programmes in response to the public health crisis of NCDs caused by physical inactivity. These IFs are leveraging their reach and role in society to improve global health through the promotion of their sports. Their programmes serve as examples of the potential role for IFs in global health promotion.
FIFA’s Football for Health project
‘Football for Health’ encompasses FIFA’s philosophy that football is a health-enhancing activity for people of all ages. FIFA has initiated and supported a series of scientific studies demonstrating the value of football in the prevention of risk factors for NCDs by independent research groups.69 Furthermore, FIFA developed and evaluated the ‘FIFA 11 for Health’ programme which is a series of 11 football-based sessions aimed at encouraging PA and educating children about healthy behaviours related to communicable and NCDs.54–56 The ‘FIFA 11 for Health’ programme has been successfully implemented through the national Football Association in cooperation with the Ministries of Health, Education and Sport in currently 20 countries in Africa, Asia, Latin America and Oceania.
FINA’s Swim for All project
Swimming is the only sports skill which can directly prevent death. Drowning is a significant global public health issue; the leading cause of injury for all children and the leading cause of death of all children after infancy.70 FINA's ‘Swim for All’ programme focuses on drowning prevention as well as the promotion of PA in the sedentary population. The ‘IOC Sport for All’ provides promotion and support. Governmental influence to imbed learning to swim in the educational curricula worldwide is being sought in cooperation with UNESCO. UNICEF delivers in-depth FINA Learn to Swim programmes in targeted at-risk countries. Raising awareness and encouraging governments to prevent drowning will be accomplished in collaboration with the United Nations. Although still in the initial stages of implementation and analysis of the efficacy of this programme is pending, this initiative is another important example of the role an IF can contribute to health in the general population.
According to the Olympic Charter, the IOC and the IFs have an obligation among others to encourage and support measures to protect the health of athletes and to encourage and support the development of sport for all. Most IFs prioritised the health of their elite athlete as important and aimed to protect it through a variety of activities. However, increasing the number of recreational athletes and the health of their recreational athletes was of relatively low importance for them. IFs should reconsider this position as they are missing an important opportunity to contribute to increasing PA, and thus, the health of the population. Through the promotion of PA in their respective sports, IFs can play a central role in the fight of the global epidemic of NCDs. FIFA and FINA projects could serve as role models.
What is already known on this subject
According to the Olympic Charter, the International Olympic Committee (IOC) and the IFs have an obligation among others to encourage and support measures protecting the health of athletes, and to encourage and support the development of sport for all.
Some International Sport Federations (IFs) have implemented measures to protect the health of their elite athlete, such as standardised injury surveillance, preparticipation examinations, rules and regulations.
IFs and the IOC have published recommendations and consensus statements on various aspects of the athlete’s health.
Non-communicable diseases (NCDs) are reaching pandemic proportions worldwide, and physical inactivity is an independent risk factor for NCDs. Thus, IFs can play an important role in promoting their sport to combat NCDs.
How might it impact on clinical practice in the near future
IFs should systematically expand their activities with regard to protecting the health of their elite athletes following a risk management model.
IFs should aim to increase the number of recreational athletes and pay more attention to their health.
IFs should use the unique chance to contribute to the health of the general population by the promotion of physical activity through their sport.
FIFA’s ‘Football for Health’ and FINA’s ‘Swim for All’ projects can serve as role models for an IF’s contribution to global health.
The authors highly appreciate the co-operation of the International Federations and their medical staff who responded to the survey providing the data for this project. They would like to gratefully acknowledge the assistance of ASOIF (Association of Summer Olympic International Federations) and AOIWF (Association of Olympic International Winter Federations) in the implementation of the survey.
Contributors MM was involved in substantial contributions to conception and design, data collection, interpretation of results, drafting and revising the manuscript and final version to be published. AJ was involved in substantial contributions to conception and design, analysis and interpretation of the data, drafting and revising the manuscript and final approval of the version to be published.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
▸ References to this paper are available online at http://bjsm.bmj.com