ORIGINAL RESEARCH Preparticipation Screening of Athletic Officials SEC Football Referees at Risk John L. Turner, Jr, MD; Rod Walters, ATC, DA; Mark J. Leski, MD; Robert M. Saywell, Jr, PhD, MPH; J. Scott Wooldridge, MHA THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 3 - MARCH 2003 BACKGROUND: Although preparticipation screening for athletes is commonplace, few studies have addressed the issue for those officiating at games. OBJECTIVES: To review current data on physiologic stress on sports officials, to obtain prevalence data on health parameters for football officials, and to determine the outcomes when screening criteria are applied in preseason exams. METHODS: A protocol was established using health history questionnaires and physical exams with laboratory screening to assess the health of all football officials working in the Southeastern Conference (SEC) from 1997 to 2000. The main outcome measure was the prevalence of cardiac risk factors as determined by American College of Sports Medicine guidelines. RESULTS: Initial screening of 102 football officials revealed that 10.1% of SEC referees had elevated systolic blood pressure, 13.9% had elevated diastolic blood pressure, and 3.8% had resting tachycardia. Average body mass index (BMI) was 28.6 kg/m2, with 87.3% having a BMI that exceeded 25 (overweight). About one-third (31.6%) had a BMI greater than 30 (obese). Total fasting cholesterol exceeded 200 mg/dL in 44.2%, HDL levels were below 35 mg/dL in 34.3%, and LDL levels were above 120 mg/dL in 62.3%. Compared with age-adjusted national data, there were more overweight and more obese officials, but they had lower systolic and diastolic blood pressures and lower mean total cholesterol levels. Using the Framingham Study prediction model to estimate coronary heart disease (CHD) risk, analysis revealed that referees had a lower risk than the national 10-year CHD risk but a higher risk compared with that of the low-risk population. CONCLUSIONS: These data reveal a greater need for graded exercise testing. The higher rates of obesity among officials will promote further screening for CHD risk factors. With the explosion of sports participation in the United States have come numerous efforts focused on the medical screening of athletes, especially for heart disease. Many officials who work at athletic events, however, do not undergo any formal medical screening program. Despite the physical exertion that referees and umpires often endure, no recognized recommendations exist for screening sports officials. Recent adverse events highlight the need to focus on the health of sports officials. In the past 7 years, there have been two on-field myocardial infarctions (MIs) in college football officials, an on-field death of a Major League Baseball umpire, and an on-field death of a referee during a British professional soccer match. Such examples reflect the need to ensure that officiating crews are in good health before asking them to participate in what is often strenuous work. Of the nine published studies found about sports officials, only six related to their physical health.1-6 None addressed screening sports officials for heart disease or other medical disorders but focused instead on physiologic stress. Officials' physiologic stress has been documented. Heart rates during games can exceed 135/min for baseball umpires2 and 165/min for soccer officials.4,5 In one study,4 soccer referees maintained a heart rate greater than 85% of predicted maximum for most of the time on the field. Ice hockey officials participated in what was considered low-intensity activities for 94% of the game, but their heart rates remained above 70% of predicted maximum throughout the contest. Elevated oral temperatures and weight losses were also documented in baseball umpires during a single event.6 In addition to the physiologic parameters, the studies on soccer referees4,5 showed that they logged an average of 9.4 km (5.8 miles) during a 90-minute match. Some research7-9 suggests that psychological stress in sports officials is an additive factor, above the physical demands of the occupation.3 Study Design and Methods Data collection. This study sought to obtain prevalence data on health parameters for football officials and to determine the outcomes when screening criteria are applied in preseason exams. Screening data were collected for all football officials working in the Southeastern Conference (SEC) from 1997 to 2000. A protocol was established using health history questionnaires and physical exams at a central location and adopting the guidelines for exercise testing of the American College of Sports Medicine (ACSM). Laboratory screening was also performed. Participants who had any two risk factors on the health history questionnaire or a single major sign or symptom (table 1) were required to undergo graded exercise testing (GXT) using a standard Bruce protocol. Any previous GXT did not necessitate a repeat test in subsequent years. American College of Cardiology criteria10 for abnormal exercise testing were used. Positive findings on the GXT were criteria for referring the participant to a personal physician for further medical review and clearance. The SEC paid for all costs, except for any additional workup required as the result of an abnormal stress test.

TABLE 1. Coronary Artery Disease Risk Factors and Warning Signs and Symptoms Risk Characteristic Age: men ≥40 yr, women ≥50 yr, or those with premature menopause not on HRT Family history: an MI or sudden death before age 55 in primary male relative or before age 65 in primary female relative Tobacco: current use Hypertension: BP ≥140/90 mm Hg confirmed by measurement on two separate occasions, or patients who are taking antihypertensive medication Hypercholesterolemia: serum cholesterol levels >200 mg/dL or HDL <35 mg/dL (HDL level >60 mg/dL is a negative risk factor) Sedentary lifestyle: the least active 25% of the general population (combination of having sedentary jobs and doing no exercise or recreational activity) Major Signs and Symptoms Pain or discomfort in the chest or surrounding areas that appears to be ischemic Shortness of breath at rest or with mild exertion Dizziness or syncope Orthopnea or paroxysmal nocturnal dyspnea Ankle edema Palpitations or tachycardia Claudication Known heart murmur Unusual fatigue or shortness of breath with usual activities HRT = hormone replacement therapy; MI = myocardial infarction; BP = blood pressure; HDL = high-density lipoprotein cholesterol

Statistics. Descriptive statistics were used to present the cumulative findings. Differences in risk factor prevalence rates and stress test results among years were analyzed for significance using Chi-square tests and the z-test of proportions. Statistical significance was tested at the 0.05 (P<0.05) level. Data are presented for all officials cumulatively for the 4 years and also for individual years. Results A total of 102 officials were initially screened by GXTs in the 4 years of the study, with 281 individual encounters. Complete data were available for 79 individuals (table 2). TABLE 2. Selected Cumulative Risk Factors and Stress Test Results for SEC Football Officials* Factor Number Percent Mean age (yr) 45.5 Blood Pressure (BP) Systolic BP >140 mmHg Diastolic BP >90 mm Hg 8 11 10.1 13.9 Body Mass Index Mean ≥25 ≥30 28.6 69 25 87.3 31.6 Resting Pulse ≥90 3 3.8 Total Cholesterol ≥200 mg/dL Missing 34 2 44.2 HDL <35 mg/dL Missing 24 9 34.3 LDL ≥120 Missing 43 10 62.3 Stress Test (96 tests) Normal Abnormal Total officials tested 34 36 70 48.6 51.4 72.9 *Missing figures are included where appropriate; others are complete. HDL = high-density lipoprotein; LDL = low-density lipoprotein Overall, the average age at the initial screening was 45.5 years. Physical exams revealed that 10.1% of officials had elevated systolic blood pressure, 13.9% had elevated diastolic blood pressure, and 3.8% had resting tachycardia. Calculation of body mass index (BMI) showed that the average BMI for the 79 officials was 28.6 kg/m2, with 87.3% having a BMI exceeding 25 kg/m2 (overweight). About one third (31.6%) of the 79 officials had a BMI greater than 30 kg/m2, which is considered obese. Total fasting cholesterol was greater than 200 mg/dL in 44.2% of the officials. A high-density lipoprotein (HDL) level less than 35 mg/dL was found in 34.3% of the officials. Low-density lipoprotein (LDL) levels of greater than 120 mg/dL were discovered in 62.3% of the officials. The remaining laboratory findings (hemoglobin, serum creatinine, fasting blood glucose, and urine protein levels [measured by dipstick]) were well within normal limits. There were 70 (72.9%) GXTs performed as a result of the screening criteria. Of these, 36 (51.4%) were abnormal, and those officials needed further workup. Officials who had a positive GXT result were required to be screened by their personal physicians. Discrete data from these tests were not available to the researchers, but each official was cleared for participation after undergoing a stress echocardiogram, technetium 99m scintigraphy, or cardiac catheterization. Physical and laboratory values. The annual prevalence rate varied for certain risk factors (table 3). The rate of systolic hypertension increased significantly throughout the 4 years; more than one third of the individuals in 2000 had elevated systolic blood pressure. The prevalence of diastolic hypertension was fairly constant, at approximately 20% during the years 1998 to 2000. BMI of officials remained relatively constant, with almost 90% of the participants each year being overweight. In a given year, approximately 30% were obese.

TABLE 3. Annual Demographic Data, Risk Factor Prevalence Rates, and Stress Test Results in SEC Officials, 1997-2000 1997 (n= 59) 1998 (n = 67) 1999 (n = 78) 2000 (n = 77) Demographics Age (yr) Mean 47.2 SD 5.71 Mean 47.55 SD 5.82 Mean 47.06 SD 6.69 Mean 48.01 SD 6.63 Risk Factor No. % No. % No. % No. % P-value Systolic BP ≥140 mm Hg Missing 5 0 8.5 12 0 17.9 20 6 27.8 28 0 36.4 <0.001* Diastolic BP ≥90 mm Hg Missing 8 0 13.6 16 0 23.9 16 6 22.2 17 6 22.1 0.487 BMI ≥30 kg/m2 ≥25 kg/m2 Missing Mean SD 51 18 0 28.51 3.46 86.4 30.5 62 24 0 29.51 3.94 92.5 35.8 65 26 6 28.88 3.26 90.3 36.1 69 23 1 28.86 3.30 90.8 30.3 0.710 0.808 Stress Test Result Abnormal Normal Total tested 8 13 21 38.1 61.9 27 7 34 79.4 20.6 20 11 31 64.5 35.5 17 6 23 73.9 26.1 0.014* Total Cholesterol ≥200 mg/dL Missing Mean SD 28 1 196.48 32.39 48.3 33 0 198.60 32.76 49.3 33 4 192.14 46.41 44.6 38 6 197.79 36.72 53.5 0.761 HDL ≤35 mg/dL Missing Mean SD 21 3 41.84 10.85 37.5 10 32 44.09 12.45 28.6 10 9 46.20 11.51 14.5 8 11 49.38 12.27 12.1 0.002* LDL ≥120 mg/dL Missing Mean SD 36 3 129.64 27.65 64.3 30 31 141.44 24.10 83.3 42 10 127.15 35.37 61.8 39 11 128.19 33.69 59.1 0.084 *Values are significant at the 0.05 level. SD = standard deviation; BP = blood pressure; BMI = body mass index; HDL = high-density lipoprotein cholesterol; LDL = low-density lipoprotein cholesterol

About half of the study participants in a particular year had elevated total cholesterol. The prevalence rate for low HDL decreased significantly, while the rate of elevated LDL remained nearly stable at about 60% in the study period. The HDL and LDL results for 1998 had a relatively large proportion of missing data, but the absence did not appear to affect overall trends. The prevalence of high-risk individuals who needed stress testing exceeded 30% annually, with a high of 50.1% in 1998. The BMI, HDL, LDL, and blood pressure risk factor levels were examined during each official's first year in the league and were classified into one of three age-groups: 30 to 39, 40 to 49, and 50 to 59 (table 4). A BMI exceeding 25 kg/m2 was observed in approximately 85% of first-year officials age 30 to 49, but more of the older ones (age 50 to 59) were overweight (92.6%). Of note is that obesity among officials was significantly lower for the older age-group and displayed a declining trend from the youngest age-group (42.9%) to the oldest (25.9%). The LDL levels showed a marked increase from the youngest age-group to the oldest. Both systolic and diastolic blood pressure decreased from the 30-to-39 age-group to the 50-to-59 age-group. TABLE 4. Risk Factor Prevalence Rates Among First-Year SEC Officials Age-Group 30 to 39 (n= 14) 40 to 49 (n = 38) 50 to 59 (n = 27)   No. %        No. %        No. %        BMI ≥25 kg/m2 ≥30 kg/m2 12 6 85.7 42.9 32 12 84.2 31.6 25 7 92.6 25.9 HDL Mean SD 41.25 14.72 - - 44.06 11.45 - - 39.42 7.89 - - LDL Mean SD 113.55 43.84 - - 122.50 28.69 - - 140.31 23.58 - - Systolic BP ≥140 mm Hg    2 14.3 5 13.2 1 3.7 SDiastolic BP ≥90 mm Hg 3 21.4 6 15.8 2 7.4 BMI = body mass index; HDL = high-density lipoprotein cholesterol; SD = standard deviation; LDL = low-density lipoprotein cholesterol; BP = blood pressure Comparisons were made between SEC data and national statistics for two age-groups. The most alarming differences were in the proportions of officials considered overweight and obese. Most (86.8%) of the first-year referees in the SEC were overweight, compared with nearly two thirds (63.7%) of the men in the national sample, age 25 to 44. The same held true for the 45-to-64 age-group with 87.8% of the older SEC referees being overweight, compared with 70.7% of the men nationwide. Obesity rates were also greater for the SEC referees, with more than one third (36.8%) of the SEC referees age 25 to 44 being obese, compared with 19.2% of the national sample. In the older age category, about one quarter of each group was obese (SEC sample, 26.8% versus national sample, 23.0%). On the other hand, for all age-groups, hypertension and total cholesterol levels were lower among the referees than in the nationwide sample. Coronary heart disease risk. The risk of coronary heart disease (CHD) among the SEC officials was calculated using the prediction score sheets of the Framingham Heart Study.11 The Framingham Heart Study reports an average 10-year CHD risk factor as well as a low 10-year average CHD risk factor. Adjusting for age reveals that the SEC officials had a lower 10-year CHD risk compared with the normal population. When compared with the low-risk population (men of the same age, with normal blood pressure, LDL levels between 100 mg/dL and 129 mg/dL, HDL of 45 mg/dL, nonsmoker, and no diabetes mellitus), however, the referees, with the exception of the 30-to-34 age-group, had a higher CHD risk. Discussing the Problem Both the National Football League and Major League Baseball have established formal screening programs for officials, but in some instances, officials did not receive medical clearance. Of the 21 NCAA Division 1 football conferences, only the SEC has a formal centralized referee-screening process. Most conferences rely on applicants to have a physical examination performed by a personal physician. This less structured process raises the question of whether each physician is applying standardized screening criteria and is performing a comprehensive physical exam and history. The SEC's pilot program of formal history taking and physical examination revealed that an average of 38.8% of applicants needed exercise testing annually, based on ACSM guidelines. This is a significant finding, particularly when extrapolated to the entire population of sports officials. All of the follow-up testing was negative for coronary artery disease that precluded participation, but positive GXTs necessitated further evaluation and testing from personal physicians and cardiologists. In our study, we had no participants who did not eventually obtain medical clearance, even after having a positive exercise treadmill test. The reason is unclear but may arise from ACSM guidelines and criteria being overly sensitive, which, in and of itself, is a topic of debate.12,13 Small study numbers or the inherent rate of false-positive exercise tests may also have affected the results. Of note, preliminary screening of SEC officials before this study did find significant heart disease, including one referee who underwent multivessel coronary artery bypass grafting. Officiating often requires significant physical stress and predisposes game officials to exacerbation of underlying health problems. The typical officiating population is older, with more cumulative disease burden, and is at higher risk for adverse events than typically well-screened athletes. We found that about 90% of screening encounters involved officials who were overweight by Quetelet Index parameters, which puts them at higher risk. There is clear documentation that officials in many sports undergo significant physical stress, even when it is not obvious to spectators. Given the tragic reports of referees dying on the field, a need exists for ensuring proper medical clearance for sports officials, particularly for those who have CHD. We do recognize that most officials at the collegiate level are independent contractors, and this creates logistical challenges for sports organizations. However, screening should be done, and we suggest that this is best accomplished with formal, structured programs established by governing bodies. Such a defined program avoids discrepancies in screening protocols by individual physicians and allows for easy tracking of test results and outcomes. Future Research We hope that the strong need for GXTs demonstrated by this study will prompt further investigation into how officials are medically approved for participation. Future studies need to compare the prevalence data for sports officials with matched population data. In addition, larger sets of data need to be examined to yield more generalizable results. Ideally, larger longitudinal studies are needed to measure the impact screening programs have on individual health outcomes. References Rontoyannis GP, Stalikas A, Sarros G, et al: Medical, morphological and functional aspects of Greek football referees. J Sports Med Phys Fitness 1998;38(3):208-214 Kurakake S, Nakaji S, Sugawara K, et al: A study of the effects of physical load on umpires during the national high school baseball games: the effects of physical load on umpires at the Koshien stadium in a summer-heat environment [in Japanese]. Nippon Eiseigaku Zasshi 1998;52(4):667-676 Wilkins HA, Petersen SR, Quinney HA: Time-motion analysis of and heart rate responses to amateur ice hockey officiating. Can J Sport Sci 1991;16(4):302-307 Johnston L, McNaughton L: The physiological requirements of soccer refereeing. Aust J Sci Med Sport 1994;26(3-4):67-72 Catterall C, Reilly T, Atkinson G, et al: Analysis of the work rates and heart rates of association football referees. Br J Sports Med 1993;27(3):193-196 Kurakake S, Sugawara K, Kumae T, et al: A study on the effect of physical load of baseball umpire, during a baseball game in the summer [in Japanese]. Nippon Eiseigaku Zasshi 1988;42(6):1013-1022 Rainey DW, Hardy L: Sources of stress, burnout, and intention to terminate among rugby union referees. J Sports Sci 1999;17(10):797-806 Stewart MJ, Ellery PJ: Amount of psychological stress reported by high school volleyball officials. Percept Mot Skills 1996;83(1):337-338 Rainey DW: Magnitude of stress experienced by baseball and softball umpires. Percept Mot Skills 1994;79(1 pt 1):255-258 Gibbons PJ, Balady GJ, Beasley JW, et al: ACC/AHA Guidelines for Exercise Testing: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30(1):260-311 Wilson PW, D'Agostino RB, Levy D, et al: Prediction of coronary heart disease using risk factor categories. Circulation 1998;97(18):1837-1847 Lowensteyn I, Joseph L, Grover S: Who needs an exercise stress test? evaluating the new American College of Sports Medicine risk stratification guidelines. J Cardiopulm Rehabil 1997;17(4):253-260 Norton K, Olds T, Bowes D, et al: Applying the Sports Medicine Australia pre-exercise screening procedures: who will be excluded? J Sci Med Sport 1998;1(1):38-51 Dr Turner is an assistant clinical professor in the Department of Family Medicine at Indiana University School of Medicine in Indianapolis. Mr Walters is an assistant athletic director for sports medicine at the University of South Carolina in Columbia, South Carolina. Dr Leski is an assistant professor of family medicine and director of the Sports Medicine Fellowship at Palmetto Richland Memorial Hospital at the University of South Carolina. Dr Saywell is a professor and director of research in the Department of Family Medicine, and Mr Wooldridge is a data analyst at the Bowen Research Center in the Department of Family Medicine, both at Indiana University School of Medicine. Address correspondence to John L. Turner, Jr, MD, Indiana University-Methodist Family Practice Residency, 1520 N Senate St, Indianapolis, IN 46202; e-mail to jlturner@clarian.org. Disclosure information: Drs Turner, Leski, and Saywell and Messrs Walters and Wooldridge disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use. RETURN TO MARCH 2003 TABLE OF CONTENTS HOME  |   JOURNAL  |   PERSONAL HEALTH  |   RESOURCE CENTER  |   CME  |   ADVERTISER SERVICES  |   ABOUT US  |   SEARCH