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• Cardiorespiratory fitness is a strong and consistent predictor of morbidity and mortality among adults: an overview of meta-analyses representing over 20.9 million observations from 199 unique cohort studies
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• http://orcid.org/0000-0002-1768-319X Justin J Lang 1 , 2 , 3 ,
• http://orcid.org/0000-0001-6729-5649 Stephanie A Prince 1 , 2 ,
• Katherine Merucci 4 ,
• http://orcid.org/0000-0002-4513-9108 Cristina Cadenas-Sanchez 5 , 6 ,
• http://orcid.org/0000-0002-5607-5736 Jean-Philippe Chaput 2 , 7 , 8 ,
• http://orcid.org/0000-0002-1752-5431 Brooklyn J Fraser 3 , 9 ,
• http://orcid.org/0000-0001-5461-5981 Taru Manyanga 10 ,
• Ryan McGrath 3 , 11 , 12 , 13 ,
• http://orcid.org/0000-0003-2001-1121 Francisco B Ortega 5 , 14 ,
• http://orcid.org/0000-0002-7227-2406 Ben Singh 3 ,
• http://orcid.org/0000-0001-7601-9670 Grant R Tomkinson 3
• 1 Centre for Surveillance and Applied Research , Public Health Agency of Canada , Ottawa , Ontario , Canada
• 2 School of Epidemiology and Public Health, Faculty of Medicine , University of Ottawa , Ottawa , Ontario , Canada
• 3 Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance , University of South Australia , Adelaide , South Australia , Australia
• 4 Health Library , Health Canada , Ottawa , Ontario , Canada
• 5 Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS) , University of Granada; CIBEROBN, ISCIII , Granada , Andalucía , Spain
• 6 Stanford University, Department of Cardiology; and Veterans Affair Palo Alto Health Care System , Palo Alto , California , USA
• 7 Children’s Hospital of Eastern Ontario Research Institute , Ottawa , Ontario , Canada
• 8 Department of Pediatrics, Faculty of Medicine , University of Ottawa , Ottawa , Ontario , Canada
• 9 Menzies Institute for Medical Research , University of Tasmania , Hobart , Tasmania , Australia
• 10 Division of Medical Sciences , University of Northern British Columbia , Prince George , British Columbia , Canada
• 11 Fargo VA Healthcare System , Fargo , North Dakota , USA
• 12 Department of Health, Nutrition, and Exercise Sciences , North Dakota State University , Fargo , North Dakota , USA
• 13 Department of Geriatrics , University of North Dakota , Grand Forks , North Dakota , USA
• 14 Faculty of Sport and Health Sciences , University of Jyväskylä , Jyväskylä , Finland
• Correspondence to Dr Justin J Lang, Public Health Agency of Canada, Ottawa, Canada; justin.lang{at}phac-aspc.gc.ca

Objective To examine and summarise evidence from meta-analyses of cohort studies that evaluated the predictive associations between baseline cardiorespiratory fitness (CRF) and health outcomes among adults.

Design Overview of systematic reviews.

Data source Five bibliographic databases were searched from January 2002 to March 2024.

Results From the 9062 papers identified, we included 26 systematic reviews. We found eight meta-analyses that described five unique mortality outcomes among general populations. CRF had the largest risk reduction for all-cause mortality when comparing high versus low CRF (HR=0.47; 95% CI 0.39 to 0.56). A dose–response relationship for every 1-metabolic equivalent of task (MET) higher level of CRF was associated with a 11%–17% reduction in all-cause mortality (HR=0.89; 95% CI 0.86 to 0.92, and HR=0.83; 95% CI 0.78 to 0.88). For incident outcomes, nine meta-analyses described 12 unique outcomes. CRF was associated with the largest risk reduction in incident heart failure when comparing high versus low CRF (HR=0.31; 95% CI 0.19 to 0.49). A dose–response relationship for every 1-MET higher level of CRF was associated with a 18% reduction in heart failure (HR=0.82; 95% CI 0.79 to 0.84). Among those living with chronic conditions, nine meta-analyses described four unique outcomes in nine patient groups. CRF was associated with the largest risk reduction for cardiovascular mortality among those living with cardiovascular disease when comparing high versus low CRF (HR=0.27; 95% CI 0.16 to 0.48). The certainty of the evidence across all studies ranged from very low-to-moderate according to Grading of Recommendations, Assessment, Development and Evaluations.

Conclusion We found consistent evidence that high CRF is strongly associated with lower risk for a variety of mortality and incident chronic conditions in general and clinical populations.

• Cardiovascular Diseases
• Cohort Studies
• Physical fitness

Data availability statement

Data are available on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bjsports-2023-107849

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Many systematic reviews have examined the prospective link between baseline cardiorespiratory fitness and health outcomes, but no study has compiled all the evidence to help identify important gaps in the literature.

WHAT THIS STUDY ADDS

This study identified 26 systematic reviews with meta-analysis representing over 20.9 million observations from 199 unique cohort studies. Cardiorespiratory fitness was strongly and consistently protective of a variety of incident chronic conditions and mortality-related outcomes.

Gaps in the literature continue to exist, with limited evidence available among women, and certain clinical populations. Several health outcomes could benefit from future meta-analyses, including specific cancer types, especially among women (eg, breast cancer) and mental health conditions beyond depression.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Given the strength of the predictive utility of cardiorespiratory fitness across many health outcomes, cardiorespiratory fitness would be a valuable risk stratification tool in clinical practice.

Introduction

Cardiorespiratory fitness (CRF) is a physical trait that reflects the integrated function of numerous bodily systems to deliver and use oxygen to support muscle activity during sustained, rhythmic, whole-body, large muscle physical activity. 1 CRF can be objectively measured using direct (usually by maximal exercise testing with concomitant gas exchange analysis) 2 or indirect (exercise predicted equations) 3 4 methods with a variety of maximal or submaximal protocols using different modalities (eg, stationary cycling, treadmill running/walking, bench stepping, field-based running/walking). Non-exercise prediction equations with reasonable validity are also available when direct CRF measurement is not feasible. 5 6 CRF is commonly expressed as the maximum or peak rate of oxygen consumption per kilogram of body mass (common units: mL/kg/min) or metabolic equivalents of task (METs). Nearly half of the variance in CRF is attributable to genetics, with the remainder modified primarily through habitual physical activity. 7 For example, brisk walking for approximately 150 min per week can result in large relative improvements in CRF among sedentary and unfit individuals. 8 9 Even those with severe chronic disease can improve CRF through well-planned aerobic physical activity programmes. 10

Low CRF is considered a strong chronic disease risk factor that is not routinely assessed in clinical practice. 11 Evidence suggests that the inclusion of CRF as a clinical vital sign would enhance patient management by improving the classification of those at high risk of adverse outcomes. 11 The evidence supporting CRF as an important risk factor has accumulated since the 1980s through large cohort studies that investigated the prospective risk of all-cause mortality and cardiovascular events associated with CRF. 12–14 Research has linked CRF to the incidence of some cancers (eg, colon/rectum, lung), 15 type 2 diabetes, 16 metabolic syndrome, 17 stroke 18 and depression. 19 Higher CRF may even improve the prognosis in those with chronic conditions such as cancer, 20 peripheral artery disease, 21 heart failure 22 and chronic kidney disease. 23

Given the mounting evidence supporting CRF as an important risk factor, numerous systematic reviews with meta-analyses summarising results of primary studies for various health outcomes have been published. Kodama et al 24 published the first meta-analysis on the health-related predictive validity of CRF and found that a 1-MET (3.5 mL/kg/min) higher level of CRF was associated with a 13% and 15% reduction in the risk of all-cause mortality and cardiovascular disease (CVD) events, respectively. This study helped to establish the meaningful clinically important difference (MCID) of 1-MET for exercise trials. Since Kodama’s study, there have been several systematic reviews with meta-analyses, with several published in recent years (ie, 2020+). Most systematic reviews have focused on a single health outcome. To date, there has not been a systematic synthesis of the relationships between CRF and a broad range of health outcomes. To help summarise the breadth of evidence, an overview of reviews provides a systematic method to examine evidence across a range of outcomes for a specific exposure. 25 Thus, the objective of this study was to conduct an overview of systematic reviews with meta-analyses from cohort studies that investigated relationships between CRF and prospective health-related outcomes among adults. We also aimed to assess the certainty of the evidence for each identified health outcome.

This overview followed the methods outlined in the Cochrane handbook, 25 and additional methods that were published elsewhere. 26 We adhered to both the Preferred Reporting Items for Overviews of Reviews statement 27 and the Meta-analyses of Observational Studies in Epidemiology reporting standards. 28 The overview was prospectively registered with the PROSPERO international prospective register of systematic reviews (#CRD42022370149). Here, we present a condensed methods section with the full methods available in online supplemental methods .

Supplemental material

Eligibility criteria.

Adult populations (≥18 years) including apparently healthy and clinical populations with diagnosed chronic conditions. Studies that focused on certain special populations were excluded (ie, those recovering from surgery, athletes, disease at birth, pregnant individuals).

The primary exposure was CRF measured using the following approaches: (1) maximal exercise testing with gas analysis (ie, directly measured V̇O 2max/peak ), (2) maximal or submaximal exercise testing without gas analysis, which used either exercise prediction equations to estimate CRF or the measured exercise performance (ie, indirect measures) or (3) non-exercise prediction equations for estimating CRF.

Any health-related outcome such as all-cause or cause-specific mortality, incident conditions related to physical risk factors, chronic conditions or mental health issues were included. Among populations with diagnosed chronic conditions, we included evidence on outcomes such as mortality or disease severity.

Study design

Only systematic reviews with meta-analyses that searched a minimum of two bibliographic databases and provided a sample search strategy were included. We also included meta-analyses that pooled data from primary prospective/retrospective cohort or case-control studies. These studies were the focus because of their ability to assess causality for observational research.

Publication status and language restriction

Only systematic reviews published in peer-reviewed journals in English, French or Spanish (based on authors’ language capacity) were eligible. Conference abstracts or papers, commentaries, editorials, dissertations or grey literature were ineligible.

Systematic reviews published during the past 20 years for the initial search.

Information sources

Five bibliographic databases, including OVID Medline, OVID Embase, Scopus, CINAHL and EBSCOhost SPORTDiscus, were searched from 1 January 2002 to 21 November 2022. The search was later updated from 1 November 2022 to 8 March 2024.

Search strategy

A research librarian (KM) created the search strategy in collaboration with the authorship team, and the final search was peer-reviewed by an independent research librarian using the Peer Review of Electronic Search Strategies guidelines. 29 The search strategies for each database are available in online supplemental appendix 1 . The reference lists of included papers were also searched for additional relevant systematic reviews.

Selection process

All records were imported into RefWorks where duplicates were removed using automated and manual methods. Records were imported into Covidence for further deduplication and record screening. Reviewers were not blinded to the study metadata when screening. The title and abstract from each record were screened by two of the following independent reviewers (JJL, SAP, CC-S, J-PC, BJF, TM, BS and GRT) against the inclusion criteria. Full-text papers were obtained for each record that met the inclusion criteria or provided insufficient evidence to make a conclusive decision at the title and abstract stage. Conflicts during title and abstract screening automatically advanced to full-text screening. Each full-text record was screened by two of the following independent reviewers (JJL, SAP, CC-S, J-PC, BJF, TM, BS and GRT) against the inclusion criteria. Conflicts at the full-text stage were resolved through discussion by two reviewers (JJL and SAP), with a third reviewer resolving disagreements (GRT).

Data collection process

Data extraction was completed in Covidence using a form that was piloted by the authorship group for accuracy. Data from the included studies were extracted by two of the following independent reviewers (JJL, SAP, CC-S, J-PC, BJF, TM, FBO, BS and GRT). Conflicts were resolved by one reviewer (JJL), who contacted the reviewers who extracted the data when necessary to resolve conflicts.

The data extraction form included several items related to the demographic characteristics of the primary studies, the meta-analyses effect estimates and related statistics, and details for risk of bias and subgroup analyses.

Review quality

We extracted the original risk of bias assessment for each primary study, as reported by the study authors. Most of the included studies used the Newcastle-Ottawa Scale (NOS) to assess risk of bias for cohort studies. 30 In the event that risk of bias was not assessed, a new assessment was conducted and verified by two reviewers using the NOS. We also assessed quality of the systematic reviews using the second edition of A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR2) checklist. 31 Two of the following independent reviewers (JJL, SAP, CC-S, J-PC, BJF, TM, FBO, BS and GRT) assessed review quality. Conflicts were resolved by one reviewer (JJL), with the reviewers who extracted the data contacted to resolve outstanding conflicts.

Effect measures

We presented pooled hazard ratios (HRs) or relative risks (RRs) for an incident event (ie, mortality or morbidity) across the included systematic reviews. We extracted data from models that compared high versus low CRF and those that examined the impact of a 1-MET higher level of CRF.

Synthesis of data

We followed an outcome-centric approach, as outlined by Kho et al . 26 Our goal was to identify systematic reviews with non-overlapping primary studies for each outcome to avoid double counting evidence. When more than one eligible systematic review was identified for a single outcome, we calculated the corrected covered area (CCA) to assess the degree of overlap in the primary studies. 32

Where, N is the total number of times a primary study appeared across reviews (inclusive of double counting), r is the number of unique primary studies and c is the number of systematic reviews included for the outcome.

The CCA was interpreted as slight (0%–5%), moderate (6%–10%), high (11%–15%) or very high (>15%). If the CCA was slight or moderate, we included multiple systematic reviews per outcome. If the CCA was high or very high, we selected the highest quality systematic review according to the AMSTAR2 assessment. We included the most recent systematic review when reviews of the same outcome were rated as equal in quality.

Synthesis of results

For each health outcome, we reported evidence for apparently healthy and clinical populations separately. We summarised results using a narrative synthesis approach using summary of findings tables. Results were reported as described by the systematic review authors. Meta-analytical results, including the effect, confidence limits, number of studies and number of participants, were presented by outcome using a forest plot to allow for easy comparison between studies. RR values were taken to approximate the HR. When comparing high versus low CRF, we inverted the scale when studies compared low versus high by taking the reciprocal (ie, HR=2.00 was changed to HR=0.50). Dose−response values were rescaled to a 1-MET higher level of CRF when more than 1-MET was used or if the unit increase was in VO 2 . We rescaled by taking the natural log of the HR, dividing or multiplying it to correspond with 1-MET, and exponentiating the result. Subgroup analyses for sex were described when available.

Certainty of the evidence assessment

For each outcome, the certainty of the evidence was assessed using a modified Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. 33 Observational cohort evidence began at ‘high’ certainty because randomised controlled trials were deemed not feasible for our research question. 34 The certainty of the evidence could be rated down based on five domains (ie, risk of bias, imprecision, inconsistency, indirectness and publication bias). See online supplemental table 1 for a GRADE decision rules table.

Equity, diversity and inclusion statement

Our research team included diversity across genders with representation from researchers at all career stages. We stratified our results by sex which allowed use to identify the potential need for more diversity in this area of the literature. This stratification allowed us to discuss the overall generalisability of our results. The GRADE evaluation carried out in this study assessed the indirectness of the results. We downgraded evidence that did not demonstrate good global representation or did not provide a gender-balanced sample. Reducing indirectness is important for ensuring the results are representative of the target population.

We identified 9062 records after removing duplicates, assessed 199 full-text papers, and excluded 165 papers during full-text screening, and 8 papers because of high or very high overlap based on the CCA calculation (see figure 1 and online supplemental appendix 2 for full texts with reasons for exclusion). The proportion of agreement between reviewers for title and abstract screening ranged from 95% to 100% while the agreement for full-text screening ranged from 75% to 100%. We included 26 systematic reviews with meta-analyses representing over 20.9 million observations from 199 unique cohort studies, including 21 mortality or incident chronic disease outcomes. We identified CCA values in the high or very high range for sudden cardiac mortality (CCA=33%; n=2), incident heart failure (33%; n=2), incident depression (50%; n=2), incident type 2 diabetes (25%; n=4) and all-cause mortality among those living with heart failure (14%; n=3; see online supplemental appendix 2 for more details). We included multiple systematic reviews for all-cause mortality because the CCA was moderate (10%; n=3).

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PRISMA flow chart depicting the number of papers identified, screened and included in the overview. *A list of excluded studies with reasons are provided in online supplemental appendix 2 .

Tables 1–3 describe the study characteristics. We identified 8 systematic reviews that investigated mortality outcomes, with pooled data from 95 unique primary cohort studies. Nine systematic reviews investigated incident outcomes, pooling data from 63 unique primary cohort studies. The remaining 9 systematic reviews investigated health-related outcomes among populations living with chronic conditions, which represented data from 51 unique primary cohort studies. 11 reviews were of critically low quality, 4 were low, 8 were moderate and 3 were of high quality as assessed using the AMSTAR2 (see online supplemental table 2 ). See online supplemental table 3 for a detailed summary of findings with the certainty of the evidence for each outcome.

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Study characteristics for general populations without known disease at baseline and mortality outcomes

Study characteristics for general populations without known disease at baseline and incident outcomes

Study characteristics for clinical populations with diagnosed chronic disease at baseline and mortality outcomes

Figure 2 illustrates results for CRF as a predictor of mortality outcomes, which included all-cause, CVD, sudden cardiac, all cancer and lung cancer mortality. When comparing high versus low CRF across all outcomes, there was a 41% (HR for all-cause mortality 24 =0.59; 95% CI 0.52 to 0.66) to 53% (HR for all-cause mortality 35 =0.47; 95% CI 0.39 to 0.56) reduction in the risk of premature mortality. The certainty of the evidence was assessed as very low-to-moderate, mainly due to serious indirectness (ie, most studies only included male participants). In assessing the dose–response relationship, a 1-MET higher level of CRF was associated with a 7% (HR for all cancer mortality 35 =0.93; 95% CI 0.91 to 0.96) to 51% (HR for sudden cardiac mortality 36 =0.49; 95% CI 0.33 to 0.73) reduction in the risk of premature mortality. The certainty of the evidence ranged from very low-to-moderate, largely due to serious indirectness from a large proportion of male-only studies. Sex differences were similar between outcomes with larger CIs for females because of smaller samples (see online supplemental figure 1 ). For example, there were 1 858 274 male participants compared with 180 202 female participants for all-cause mortality.

HRs for each mortality outcome in apparently healthy populations at baseline for high versus low CRF and per 1-MET increase in CRF. Estimates from Laukkanen (2022), Han (2022), Kodama (2009) and Aune (2020) were reported as RR, the remaining studies were reported as HR. Qui (2021) reported estimates from self-reported CRF. Kodama (2009) reported low versus high CRF which were inverted for this study. CRF, cardiorespiratory fitness; CVD, cardiovascular disease; eCRF, estimated non-exercise cardiorespiratory fitness; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; MET, metabolic equivalent of task; NA, not applicable; NR, not reported; RR, relative risk.

Figure 3 describes results for CRF as a predictor of newly diagnosed chronic conditions, including: hypertension, heart failure, stroke, atrial fibrillation, dementia, chronic kidney disease, depression and type 2 diabetes. Online supplemental figure 2 describes results for all cancer (male only), lung cancer (male only), colon/rectum cancer (male only) and prostate cancer. When comparing high versus low CRF, there was a 37% (HR for incident hypertension 37 =0.63; 95% CI 0.56 to 0.70) to 69% (HR for incident heart failure 38 =0.31; 95% CI 0.19 to 0.49) reduction in the risk of incident conditions. The certainty of this evidence was rated as very low-to-low largely due to inconsistency and indirectness (ie, high heterogeneity that could not be described by subgroup analysis and largely male populations). The dose–response relationship per 1-MET higher level of CRF was associated with a 3% (HR for incident stroke 39 =0.97; 95% CI 0.96 to 0.98) to 18% (HR for incident heart failure 38 =0.82; 95% CI 0.79 to 0.84) reduction in the risk of incident conditions. The certainty of the evidence ranged from very low-to-low due to inconsistency and indirectness. Only two studies reported results for females separately. High versus low CRF was more protective for incident stroke and type 2 diabetes among females compared with males ( online supplemental figure 2 ). Among men, there was a null association between high versus low CRF for prostate cancer (HR=1.15; 95% CI 1.00 to 1.30). 40

HRs for each incident outcome in apparently healthy populations at baseline for high versus low CRF and per 1-MET increase in CRF. Note: Estimates from Cheng (2022), Aune (2021), Wang (2020), Xue (2020), Tarp (2019) and Kunutsor (2023) were reported as RR, the remaining studies were reported as HR. Kandola (2019) reported estimates for low versus high which were inverted for this study. The estimates from Tarp (2019) are fully adjusted for adiposity. Aune (2021) was reported per 5-MET increase which we converted to 1-MET increase for this study. CRF, cardiorespiratory fitness; CVD, cardiovascular disease; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; MET, metabolic equivalent of task; NA, not applicable; NR, not reported; RR, relative risk.

Figure 4 highlights results comparing high versus low CRF among individuals living with chronic conditions. There was a 19% (HR for adverse events among those living with pulmonary hypertension 41 =0.81; 95% CI 0.78 to 0.85) to 73% (HR for cardiovascular mortality among those living with CVD 42 =0.27; 95% CI 0.16 to 0.48) reduction in the risk of all-cause and type-specific mortality. Comparing delayed versus not delayed heart rate recovery was associated with an 83% reduced risk of adverse events among those living with coronary artery disease. The certainty of the evidence for mortality in those living with a chronic condition was rated as very low-to-low largely due to risk of bias, indirectness and imprecision (ie, low-quality studies, mainly male participants and small sample sizes). No evidence examining sex differences were available. See online supplemental table 3 for a detailed summary of findings.

HRs for health outcomes in patients living with chronic conditions at baseline for high versus low CRF and delayed versus not delayed HRR. Estimates from Morris (2014) were reported as RR, the remaining estimates were reported as HR. Yang (2023), Fuentes-Abolafio (2020), Morris (2014), Rocha (2022) and Lachman (2018) reported estimates as low versus high which were inverted for this study. Cantone (2023) was reported per 1-unit VO 2 increase which we converted to 1-MET increase for this study. Adverse events for Lachman (2018) were all-cause mortality, cardiovascular mortality and hospitalisations for congestive heart failure. CRF, cardiorespiratory fitness; CVD, cardiovascular disease; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; HRR, heart rate recovery; MET, metabolic equivalent of task; NA, not applicable; NR, not reported; RR, relative risk.

This overview of systematic reviews demonstrated that CRF is a strong and consistent predictor of risk across many mortality outcomes in the adult general population. Among populations living with chronic conditions such as cancer, heart failure and CVD, this study showed better prognosis for those with higher CRF. We also demonstrated that low CRF is an important risk factor for developing future chronic conditions such as hypertension, heart failure, stoke, atrial fibrillation, dementia and depression. Given that we summarised evidence from cohort studies, and randomised controlled trials cannot be used in our investigation, the results of this study may signal a causal relationship between CRF and future health outcomes. We also found a significant dose–response effect showing protection for every 1-MET higher level of CRF. This evidence further supports 1-MET as an MCID for CRF and could be considered as a target for interventions. The strength and consistency of the evidence across a wide range of outcomes supports the importance of CRF for clinical assessment and public health surveillance.

Several studies have identified the need for the routine measurement of CRF in clinical and public health practice. 11 43 For instance, a scientific statement from the American Heart Association concluded that healthcare providers should assess CRF during annual routine clinical visits using submaximal tests (eg, treadmill, cycling or bench stepping tests) or self-report estimates and that patients living with chronic conditions should have CRF measured regularly using a symptom-limited direct measure. 11 There are several benefits to regular measurement of CRF in clinical practice. First, CRF is an important risk factor that provides additional information beyond traditional risk factors such as blood pressure, total cholesterol and smoking status. 44 Second, given the strong link with habitual physical activity, CRF could be a valuable tool to help guide exercise prescription. In those with low CRF (defined based on age, sex and health status), large relative improvements can be attained through additional moderate physical activity (ie, brisk walking at a heart rate of 50% of peakO 2 ). 45 The largest health benefits have been observed when individuals move from being unfit to fit. 46 Lastly, CRF measured using field-based tests are easy to implement with a variety of tests that could be adapted to suit space and time limitations.

Areas of future work

Applying the GRADE approach to evaluate the certainty of the evidence helped identify several important gaps in the literature. Nearly all the outcomes identified in this study were downgraded due to the evidence being generated largely from samples comprising males. Although an increase in female samples would help improve the certainty of the evidence, it likely would not impact the magnitude of the observed effects because the benefits of CRF were similar for males and females in our study (see online supplemental figures 1,2 ) and other large cohort studies. 47 There is also a need for higher-quality studies with larger samples sizes in clinical populations, as many of the outcomes were downgraded due to primary studies with high risk of bias, low sample sizes (<4000 participants), and inconsistencies in the measurement of CRF across studies. Improving the evidence for CRF in clinical populations remains an important research gap. For instance, outcomes in clinical populations with a serious or very serious risk of bias were often rated this way due to a lack of adequate control for confounding, including a lack of adjustment for age, sex, and body mass.

In addition to the need for higher-quality studies with greater samples in more diverse populations including females, we did not identify any systematic reviews that explored the association between CRF and breast cancer 48 or mental health outcomes beyond incident depression and dementia, as an example. These outcomes present important areas for future work. Finally, future studies would benefit from repeated longitudinal measures of CRF to further establish causality.

Implications for clinical practice

This study further demonstrates the importance of including CRF measurement in regular clinical practice. For every 1-MET (3.5 mL/kg/min) higher level of CRF, we identified substantial reductions in the risk of all-cause, CVD and cancer mortality. We also identified significant reductions in the risk of incident hypertension, heart failure, stroke, atrial fibrillation and type 2 diabetes per higher MET. For most, a 1-MET higher level of CRF is attainable through a regular aerobic exercise programme. For example, in a large population-based observational study of over 90 000 participants, nearly 30% were able to increase their CRF by 1-MET (median follow-up was 6.3 years) without intervention. 49 However, for some, improvements as small as 0.5-METs may substantially benefit health. 50 51

Given the strength of the predictive utility of CRF across many health outcomes, CRF would be a valuable risk stratification tool in clinical practice. Furthermore, the predictive strength of CRF is maintained regardless of age, sex and race. 47 Through regular CRF measurement, clinicians could better identify patients at greater risk of premature mortality, initiating the need for targeted exercise prescription. Improvements in CRF through regular physical activity results in a proportional reduction in mortality risk, regardless of the presence of other major risk factors such as higher body mass index, hypertension, type 2 diabetes, dyslipidaemia, or smoking. 49 There is an important need for clinical and public health guidelines around the assessment, interpretation of results and MCID of CRF across age, sex and clinical populations.

Strengths and limitations

Our paper has several strengths, including a focus on pooled meta-analyses from cohort studies, assessment of the certainty of the evidence using a modified GRADE, and an evaluation of the systematic review quality using AMSTAR2. Our study identifies gaps where new evidence is needed across a broad range of health outcomes. However, this study is not without limitations. As in any overview, the quality of the data is restricted to the included papers. In our case, heterogeneity was high for many of the included meta-analyses and was often not explained by subgroup analyses. We also identified low-to-very low certainty of the evidence for most outcomes, suggesting the need for higher-quality studies in this research area including adequate adjustment for confounding and greater representation of females. The evidence was also limited to studies examining associations between a single measure of CRF and prospective health outcomes.

Our findings showed that high CRF is strongly associated with lower risk of premature mortality, incident chronic conditions (ie, hypertension, heart failure, stroke, atrial fibrillation, dementia and depression), and poor prognosis in those with existing chronic conditions. The consistency of the evidence across a variety of health outcomes demonstrates the importance of CRF and the need to incorporate this measure in routine clinical and public health practice. Future studies should focus on outcomes with limited evidence and where the certainty of the evidence was rated as very low by improving study quality.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

We would like to acknowledge the support of Valentine Ly, MLIS, Research Librarian at the University of Ottawa for her help with translating and conducting the search strategy in CINAHL and SPORTDiscus. We would also like to acknowledge the Health Library at Health Canada and the Public Health Agency of Canada for their support in constructing and carrying out the search strategy for MEDLINE, Embase and Scopus. The PRESS peer-review of the search strategy was carried out by Shannon Hayes, MLIS, research librarian, from the Health Library at Health Canada and the Public Health Agency of Canada. We would also like to thank Joses Robinson and Iryna Demchenko for their help with the paper.

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Contributors JJL, GRT and SAP conceptualised and planned the study design. JJL and SAP led the study. JJL accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. All coauthors contributed to article screening. JJL and SAP wrote the first draft of the article. All coauthors reviewed, revised and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Dr. Ortega is supported by the Grant PID2020-120249RB-I00 funded by MCIN/AEI/10.13039/501100011033 and by the Andalusian Government (Junta de Andalucía, Plan Andaluz de Investigación, ref. P20_00124). Dr. Cadenas-Sanchez is supported by a grant from the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska Curie grant agreement No 101028929. Dr. Fraser is supported by a National Heart Foundation of Australia Postdoctoral Fellowship (106588).

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• Current Opinion
• Open access
• Published: 28 November 2019

Mental Health In Elite Athletes: Increased Awareness Requires An Early Intervention Framework to Respond to Athlete Needs

• Rosemary Purcell 1 , 2 ,
• Kate Gwyther 1 , 2 &
• Simon M. Rice   ORCID: orcid.org/0000-0003-4045-8553 1 , 2  

Sports Medicine - Open volume  5 , Article number:  46 ( 2019 ) Cite this article

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The current ‘state of play’ in supporting elite athlete mental health and wellbeing has centred mostly on building mental health literacy or awareness of the signs of mental ill-health amongst athletes. Such awareness is necessary, but not sufficient to address the varied mental health needs of elite athletes. We call for a new model of intervention and outline the backbone of a comprehensive mental health framework to promote athlete mental health and wellbeing, and respond to the needs of athletes who are at-risk of developing, or already experiencing mental health symptoms or disorders. Early detection of, and intervention for, mental health symptoms is essential in the elite sporting context. Such approaches help build cultures that acknowledge that an athlete’s mental health needs are as important as their physical health needs, and that both are likely to contribute to optimising the athlete’s overall wellbeing in conjunction with performance excellence. The proposed framework aims at (i) helping athletes develop a range of self-management skills that they can utilise to manage psychological distress, (ii) equipping key stakeholders in the elite sporting environment (such as coaches, sports medicine and high-performance support staff) to better recognise and respond to concerns regarding an athlete’s mental health and (iii) highlighting the need for specialist multi-disciplinary teams or skilled mental health professionals to manage athletes with severe or complex mental disorders. Combined, these components ensure that elite athletes receive the intervention and support that they need at the right time, in the right place, with the right person.

Currently, there is no comprehensive framework or model of care to support and respond to the mental health needs of elite athletes.

We propose a framework that recognises the impact of general and athlete-specific risk factors, and engages key individuals that may identify and promote athlete mental health.

The framework is adaptable and responsive to varied career stages and mental health states.

There has been a rapid increase in research examining the mental health of elite athletes culminating with the International Olympic Committee’s (IOC’s) recent Expert Consensus Statement on mental health in elite athletes [ 1 ]. This statement provides a comprehensive analysis of, and recommendations for, the treatment of both high prevalence (e.g. anxiety and mood symptoms) and more complex mental health disorders (e.g. eating and bipolar disorders) in the elite sporting context. This is a timely resource which will help guide and ultimately improve the clinical management of athletes by sports medicine, mental health, and allied health professionals. The primary focus of the consensus statement, along with much of the extant literature, is on managing the individual athlete affected by mental ill-health. There has been little scholarly and service-level attention to more comprehensive frameworks that (a) recognise the role of the broader elite sports ecology as both a contributor to athlete mental health difficulties and a facilitator of their remediation, and (b) approaches that emphasise the prevention of mental health symptoms, along with early detection and intervention to restore athlete wellbeing (and ideally optimise performance).

Risk Factors for Mental Ill-health in Elite Athletes

Meta-analytic reviews indicate that elite athletes experience broadly comparable rates of mental ill-health relative to the general population in relation to anxiety, depression, post-traumatic stress and sleep disorders [ 2 , 3 ]. This should not be unexpected given the considerable overlap in the years of active elite competition and the primary ages of onset for most mental disorders [ 4 , 5 , 6 ].

Increasing evidence points to a range of both athlete-specific and general risk factors associated with mental ill-health in elite athletes. Athlete-specific risk indicators include sports-related injury and concussion [ 3 , 7 , 8 , 9 ], performance failure [ 10 ], overtraining (and overtraining syndrome) [ 11 ] and sport type (e.g. individual sports conferring a higher risk that team sports) [ 12 ]. General risk indicators include major negative life events [ 13 , 14 ], low social support [ 15 , 16 ] and impaired sleep [ 17 , 18 ]. These risk factors may impact the severity and onset of particular mental health symptoms, but can also guide appropriate response strategies.

The salience of particular risk factors may vary across career phases. For example, in junior development years, supportive relationships with parents and coaches are imperative to athlete wellbeing [ 19 , 20 ]. During the high performance and elite phase, in addition to the coaching relationship, environmental and training demands become more relevant to mental health and wellbeing [ 21 ], including extended travel away from home and exposure to unfamiliar (training) environments [ 22 ]. Environmental conditions and travel may be especially salient for the mental health of para-athletes, who often encounter disruptive logistical issues associated with travel, such as a lack of adaptive sport facilities and sleeping conditions [ 23 ]. Prominent risk factors during the transition out of sport include involuntary or unplanned retirement and lack of a non-athletic identity, both of which are associated with a range of psychological challenges [ 24 ]. For para-athletes, involuntary retirement due to declassification (i.e. no longer meeting the required criteria to be classified as a para-athlete) is a unique burden [ 25 ].

Optimising the Mental Health and Wellbeing of Elite Athletes: Barriers and Facilitators

A comprehensive framework for mental health in elite athletes needs to consider the range of relevant risk factors across key career phases, as well as factors that inhibit or facilitate the ability to effectively respond to athletes’ needs. Key barriers include more negative attitudes towards help-seeking amongst athletes than the general population [ 26 ], as well as greater stigma and poorer mental health literacy. Fear of the consequences of seeking help (e.g. loss of selection) and lack of time are also influential [ 26 , 27 , 28 ]. Facilitative factors include support and acknowledgment from coaches [ 27 ] who can help to create a non-stigmatised environment where help-seeking can be normalised [ 28 ]. Approaches that seek to optimise athletic performance while simultaneously providing intervention for mental health symptoms may also facilitate engagement [ 29 , 30 ]. Brief anti-stigma interventions and mental health literacy programs that seek to increase knowledge of mental health symptoms have been shown to improve help-seeking intentions in elite athletes [ 31 , 32 , 33 ], although the impact of such programs on help-seeking behaviours is not known.

Are there Existing Frameworks or Models of Care for Mental Health in Elite Sport?

To date there are no published frameworks regarding how best to support the mental health needs of elite athletes. In addition to the IOC Consensus Statement, recent position statements have emphasised the need to build awareness of mental health problems and increase help-seeking behaviours [ 34 , 35 , 36 ]. These initiatives are unquestionably warranted; however, improving awareness and help-seeking behaviours are at best pointless, and at worst unsafe, if systems of care to respond to athlete’s need are not available. A whole of system approach needs to be developed simultaneously.

Beyond the peer-reviewed literature, useful guidelines exist within selected sporting associations regarding supporting athlete wellbeing [ 37 , 38 , 39 ]. These resources highlight a number of critical factors in managing athlete mental health in the sporting context including (i) the sports’ responsibility for managing the athlete’s care and support (e.g. duty of care issues); (ii) the need for regular screening or monitoring of athletes to detect changes in mental state or behaviour; (iii) privacy and confidentiality regarding mental health as key ethical issues and challenges; (iv) athlete preferences for help-seeking (how and from whom); (v) the need to refer out to or engage external mental health professionals where expertise does not exist within the sporting environment; and (vi) the value of trained peer workers (former athletes/players) to provide support and guidance to athletes and to coordinate activities related to professional development needs (such as public speaking or financial planning) and individual goal-setting (e.g. around educational or post-sport vocational interests). However, no single framework incorporates all of these factors nor is there a framework that focuses on the spectrum of athlete/player mental health needs, from symptom prevention to specialist mental health care. There has been some progress in developing mental health guidelines in collegiate-level athletes [ 40 , 41 , 42 ], which highlight the need to provide specific and targeted support, while noting that few comprehensive or targeted models of care for mental health have been developed for this population.

Developing a Comprehensive Mental Health Framework to Support Elite Athletes

Many of the general and athlete-specific risk factors for mental ill-health are potentially modifiable (e.g. coping strategies, coaching style, training demands) and require intervention at the individual athlete, the sporting or environmental and/or organisational levels. A comprehensive framework for athlete mental health that is conceptualised within the broader ‘ecology’ of elite sporting environments will be best able to respond to the range of risk indicators in this context (see Fig. 1 ). Ecological systems help to explain the relationship between the aspects or experiences of an individual (termed ‘ontogenetic’ factors, such as coping or substance use) and the broader social and cultural contexts in which they exist [ 43 ]. In the case of elite athletes, this includes the ‘microsystem’ of coach(es), teammates (where appropriate) and family/loved ones. The wider sporting environment (e.g. the athlete’s sport, its rules and governing body) forms the exosystem, while the role of national and international sporting bodies and the media and broader society form the macrosystem.

An ecological systems model for elite athlete mental health

Any mental health framework that ignores wider ecological factors runs the risk of focusing exclusively on, and potentially pathologising the individual athlete, when other factors may be more influential in contributing to, or perpetuating poor mental health. Such factors may include maladaptive relationships with coaches or parents, social media abuse and/or financial pressures.

In addition to ecological factors, a comprehensive framework for mental health should encompass both prevention and early intervention, consistent with established models that are influential in public health and social policy (e.g. Haggerty and Mrazek’s mental health promotion spectrum [ 44 ]; see Fig. 2 ). An early intervention framework can optimise athlete mental wellbeing and respond rapidly to mental health symptoms and disorders as they emerge to best maintain the athlete’s overall function.

The mental health promotion spectrum

Within this framework, the prevention stages aim to reduce the risk of mental health symptoms developing or to minimise their potential impact and severity; the treatment and early intervention stages seek to identify and halt the progression of emerging mental health difficulties; and the continuing care stages help an individual to recover and prevent relapse, typically through ongoing clinical care with a mental health professional [ 44 ].

Based on the extant literature regarding risk factors for mental ill-health in elite athletes, along with existing sporting guidelines or statements regarding athlete wellbeing, and our experience developing and implementing early intervention services and system reform for young people’s mental health [ 45 , 46 , 47 ], we propose the following framework to respond to the mental health of elite athletes (see Fig. 3 ).

Elite athlete mental health and wellbeing framework

Preventative or ‘Foundational’ Components

Core foundational components should include (i) mental health literacy to improve understanding, reduce stigma and promote early help-seeking; (ii) a focus on athlete development (both career and personal development goals) and skill acquisition to help attain these goals; and (iii) mental health screening of, and feedback to, athletes. The purpose of these foundational components is to enhance awareness of the importance of athlete wellbeing across the elite sport ‘ecology’. This in turn addresses workplace duty of care and occupational health and safety responsibilities towards athletes’ overall wellbeing in the context of sport-related stressors.

Mental Health Literacy

Mental health literacy programs should be provided to athletes, coaches and high-performance support staff to help to create a culture that values enhancing the mental health and wellbeing of all stakeholders. Programs should also be offered to the athlete’s family or friends to build their capacity to identify symptoms and encourage help-seeking, particularly as these are the individuals from whom athletes will initially seek help and support [ 48 , 49 ]. Engaging an array of individuals, including organisational staff, in these programs broadens the reach of mental health literacy within an athlete’s (or sport’s) ecology (see Fig. 1 ). Gulliver and colleagues effectively trialled the delivery of a mental health literacy program to elite athletes via team-based workshops facilitated by mental health professionals [ 26 ]. This delivery method is preferred given the opportunity for qualified facilitators to discuss and explore athlete questions or concerns (especially regarding confidentiality and the implications of help-seeking for selection) and to potentially problem-solve together. The content of such training should be customised to address the specific aspects of the sport (e.g. team-based versus individual sport) and developmental stages (e.g. junior versus retiring athletes). Basic program content should cover (i) athlete-specific and general risk factors that can increase susceptibility to mental ill-health; (ii) key signs or symptoms of impaired wellbeing; (iii) how and from whom to seek help, both within and outside the sport; and (iv) basic techniques for athletes to self-manage transient mood states or psychological distress, such as relaxation techniques, adaptive coping strategies, self-compassion and mindfulness.

Individually Focused Development Programs

Individually focused development programs can assist athletes to identify personal/vocational goals and acquire the skills necessary to achieve them. This is necessary to help develop a parallel non-athletic identity, the skills to manage life-sport balance and to prepare for the eventual end of competitive sport. The latter may be challenging in younger athletes who often lack the longer-term perspective or life experience to perceive the need for such planning. However, a focus on developing a non-athletic identity must occur at all phases of the sporting career and not be confined to the transition out of sport phase, since building such skills takes time (and athletes are prone to unplanned retirement due to injury). These activities are ideally facilitated by a skilled, well-trained ‘peer workforce’. These are individuals who have a lived experience of mental ill-health and sufficient training to share their knowledge to help support others in similar situations [ 50 ]. In the sporting context, a peer workforce could include former athletes or coaches who work with current athletes to discuss and normalise experiences of mental health symptoms or their risk factors. Former athletes can assist with athlete development programs and mobilise athletes to the importance of actively participating with such programs, based on their own experiences [ 39 ].

Mental Health Screening

Mental health screening should be included alongside routine physical health checks by medical staff as part of a comprehensive framework. Screening items should be sensitive to the elite context [ 50 , 51 ] and should be designed to provide feedback to athletes to help promote improved self-awareness, such as their mental state and triggers for symptoms. Critical times to screen are following severe injury (including concussion) and during the transition into, and out of sport [ 1 ], and the lead-up to and post major competitions may also be periods of higher risk. It is important to note that there is currently a lack of widely validated athlete-specific screening tools, though one elite athlete sensitised screening measure—the Athlete Psychological Strain Questionnaire—has been validated in a large sample of male elite athletes reporting strong psychometric properties [ 52 ], and is under further validation with female and junior athletes. Research potential exists to not only develop further athlete-specific measures, but to determine who is best suited to conduct screening, and what credentials or training may be required to ensure safety and integrity in this process (e.g. that appropriate help or referral is provided to athletes who screen positive).

Indicated (‘at-risk’) Prevention Programs

The second phase is indicated prevention programs for those considered or assessed as being ‘at-risk’ of impaired mental health and wellbeing. This phase aims to mitigate the likelihood of deterioration in mental health by detecting symptoms as early as possible and facilitating referral to appropriate health professionals. Key staff within the sports system can be assisted to develop skills in early symptom identification and to promote professional help-seeking. This includes coaches, athletic trainers and teammates (where appropriate) who are in a position to notice ‘micro’ changes in an athlete over days or weeks, and sports medicine staff, such as physiotherapists who may detect other non-observable signs, such as changes in energy or body tension. We term these individuals ‘navigators’ in the mental health framework, as they have a crucial role in observing the athlete’s behaviour or mental state and being able to link them to professional care. These navigators can be provided with additional training (adjunctive to mental health literacy) to better recognise and interpret the athlete’s behaviour in relation to their overall wellbeing, understand athlete privacy concerns that inhibit the disclosure of mental health symptoms and build self-efficacy to be able to raise their concerns safely with the affected athlete or medical/mental health staff.

Sport administrators should also consider developing guides on ‘what to do if concerned about an athlete’s mental wellbeing’ and make these available to all relevant staff. These should include information regarding appropriate referral sources, responses (e.g. prevention program vs. early intervention) and facilitators to engage athletes, such as support and encouragement [ 27 , 28 ] and/or linking mental wellbeing with athletic performance [ 29 , 30 ]. Protocols or guides for responding to mental health concerns become less stigmatised when wellbeing needs are already routinely promoted via foundational programs.

Early Intervention

Early intervention is necessary in instances where the performance and life demands placed on an athlete exceed their ability to cope (i.e. major career-threatening injury or significant life stress). Structured clinical interventions for mild to moderate mental ill-health are typically indicated at this phase and should ideally be provided ‘in-house’ by mental health clinicians, such as sports or clinical psychologists or psychiatrists, or medical staff where appropriate (e.g. pharmacotherapy). The use of in-house professionals helps to counter the low levels of service use associated with referring athletes out to external service providers and the stigma that is associated with the athlete needing expert ‘outside help’ [ 53 ]. Where requisite in-house expertise does not exist, this can be managed by the use of qualified consultants, but ideally these professionals should be ‘embedded’ to some extent within the sporting environment to ensure that athletes and other staff understand ‘who they are and what their role is’, even if their presence is infrequent [ 54 ]. When referral out is necessary, or preferred by the athlete, ideally this should be to a mental health professional with appropriate sport sensitised training, knowledge and experience assisting elite athletes.

Early interventions need not always be face-to-face, but can be augmented by telephone or web-enabled consultations, the latter particularly relevant given the frequency with which elite athletes travel unaccompanied by the sporting entourage. All interventions, regardless of the mode of delivery, should use an individualised care approach that is based on assessment and conceptualisation of the individual athlete’s presenting problem(s). The intervention should target the psychological processes of the athlete that are impeding mental health [ 55 ] and take account of the specific familial, sporting and organisational issues that may be impacting on the athlete’s wellbeing.

An example of an early intervention model of care is the Australian Institute of Sport (AIS) mental health referral network [ 56 ]. Athletes are assessed by an AIS mental health advisor, who can make a referral, if necessary, to a qualified mental health practitioner who has been credentialed to work within the network. This practitioner then works individually with the athlete to address their needs and ideally restore their mental health and functioning [ 57 ].

Specialist Mental Health Care

Despite best efforts to prevent or intervene early, some athletes will nonetheless experience severe or complex psychopathology requiring specialist mental health care, particularly where there is a risk of harm to self or others. In some cases, this may include hospitalisation or specialist inpatient or day programs. The IOC Expert Consensus Statement provides a summary of recommended clinical interventions for a range of mental disorders, including bipolar, psychotic, eating and depressive disorders, and suicidality [ 1 ]. Developing and implementing a mental health emergency plan may also be required, particularly in cases where an athlete presents with an acute disturbance in their mental state, for instance agitation/paranoia, or suicidal ideation [ 58 ]. The IOC Expert Consensus Statement recommends that structured plans should acknowledge and define what constitutes a mental health emergency, identify which personnel (or local emergency services) are contacted and when, and consider relevant mental health legislation [ 1 ].

There is also arguably a need for ‘return to sport or training’ guidance for athletes who have been unable to compete or train for their sport due to mental illness, akin to guidelines for managing concussion [ 59 ]. Such guidance could potentially provide a graduated, step-by-step protocol that prepares not only the athlete for a successful return to sport, but also the microsystem that supports them.

Conclusions

We have proposed a comprehensive framework for elite athlete mental health. More research is needed to bolster the efficacy of the approaches discussed here in the elite sports context, as well as other factors that are under-researched in the literature, such as gender-specific considerations in mental health [ 60 ] and considerations for para-athletes [ 23 ]. We are mindful that coaches and other high-performance staff are vulnerable to mental health problems [ 61 ] and the needs of these individuals need to be incorporated into a more inclusive model of care. Further, we recognise the scope of this framework does not cover the needs of non-elite athletes. Elements of this framework may be tailored in the future to be applicable and contextualised for non-elite environments where there may be limited resources, less professional staffing and greater limitations in athlete schedules.

Despite the exponential increase in research interest related to athlete mental wellbeing, major service delivery and treatment gaps remain. Evaluating the efficacy of mental health prevention and intervention programs via controlled trials or other high-quality designs is urgently needed. Program evaluation should ideally adopt an ecological systems approach to account for competition-related, individual-vulnerability and organisational factors on mental health outcomes, for example by seeking to measure system-level variables (e.g. the degree of perceived psychological safety within the sporting organisation [ 62 , 63 ]) and individual athlete-level variables (e.g. coping skills, relationship with coach, injury history). As initiatives are evaluated and enhanced or adapted, developers should consult with elite sport organisations and individuals to ensure the relevance and sport sensitivity of their programs. Increased resources and research funding to support the evaluation and implementation of athlete mental health programs is needed, such as currently exists for managing athletes’ physical health (e.g. musculoskeletal injuries, concussion).

Finally, we are acutely aware that a framework such as that articulated here requires substantial investment and that such funding is scant even in high income settings. The foundational and at-risk components lend themselves, we believe, to be adaptable to low resource settings, given the emphasis on athlete self-management and a trained peer workforce. Adaptations to providing early intervention in low resource settings will be needed, and innovations in general mental health can act as a blueprint [ 64 ]. Regardless of settings or resources, investment in a comprehensive response to athlete mental health needs attention if it is to ever gain parity with physical health.

Availability of Data and Materials

Not applicable.

Abbreviations

International Olympic Committee

Australian Institute of Sport

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Acknowledgements

Simon M Rice was supported by a Career Development Fellowship (APP115888) from the National Health and Medical Research Council.

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Purcell, R., Gwyther, K. & Rice, S.M. Mental Health In Elite Athletes: Increased Awareness Requires An Early Intervention Framework to Respond to Athlete Needs. Sports Med - Open 5 , 46 (2019). https://doi.org/10.1186/s40798-019-0220-1

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DOI : https://doi.org/10.1186/s40798-019-0220-1

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Grubbs JB , Kraus SW. Binge Drinking Among Sports Gamblers. JAMA Netw Open. 2024;7(4):e245473. doi:10.1001/jamanetworkopen.2024.5473

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Binge Drinking Among Sports Gamblers

• 1 Department of Psychology, Center on Alcohol, Substance use, And Addictions, University of New Mexico, Albuquerque
• 2 Department of Psychology, University of Nevada, Las Vegas

Over the past 6 years, sports wagering has become accessible to most individuals in the US via mobile applications or websites. 1 Increasing evidence suggests that sports wagering is associated with greater substance use and misuse, particularly alcohol, and symptoms of alcohol use disorder. 2 - 4 Alcohol consumption is higher among sports gamblers, 3 and sports gamblers often use substances while gambling. 5 Sports gamblers tend to be more inclined toward risk taking, suggesting that sports gambling may be associated with more risky alcohol use behaviors. 4 - 6 Accordingly, we examined whether individuals who wager on sports in the US are at greater risk of binge use of alcohol.

This survey study was approved by the Bowling Green State University Institutional Review Board; informed consent was obtained from all participants. The study followed the AAPOR reporting guideline.

From March 17 to April 6, 2022, we collected a census-matched sample of US adults with an oversample of adults who wager on sports. Full information about this survey is available elsewhere. 1 Race and ethnicity data were collected because they are potential factors in sports gambling likelihood and binge drinking habits. Among those reporting any past year alcohol use, binge drinking was assessed via the National Institute on Drug Abuse Quick Screen, version 1.0, which asks how often respondents consumed an excess of alcohol at a single time (≥5 drinks for men; ≥4 for women). Participants responded on a scale of 1 (never) to 5 (daily or more). Sports betting status was assessed by asking participants whether they had placed bets on sporting events or esports or participated in daily fantasy sports over the past 12 months.

Statistical analyses were conducted in SPSS, version 28. We conducted 2-tailed χ 2 analyses for distributions of past year binge drinking frequency, followed by multinomial logistic regressions estimating binge drinking frequency; P  < .05 was considered statistically significant.

A total of 4363 respondents were included (51.4% men, 46.4% women, and 2.2% nonbinary or other; mean [SD] age, 49.6 [16.2] years) ( Table 1 ). The national census-matched survey consisted of 2806 participants (mean [SD] age, 48.9 [17.2] years; 1365 [48.6%] men and 1441 [51.4%] women; response rate, 2806 of 3203 [87.6%]). The oversample of sports gamblers consisted of 1557 participants (mean [SD] age, 41.7 [15.3] years; 1043 [67.0%] men and 514 [33.0%] women; response rate, 1557 of 1978 [78.7%]), of whom 1474 reported past year sports betting. Additionally, in the national sample, 338 respondents (12.0%) indicated they had gambled on sports in the past 12 months, resulting in a total of 1812 sports gamblers ( Table 1 ). Sports gamblers were disproportionally likely to be men and younger. In these combined samples, 3267 respondents (74.9%) reported past year alcohol use.

Sports wagerers were disproportionately more likely to report binge drinking at monthly or greater frequency over the past 12 months and were also disproportionately less likely to report no binge drinking episodes in the past 12 months ( Table 1 ). Multinomial logistic regressions adjusted for age and race and ethnicity showed that sports gamblers were substantially more likely to report higher levels of binge drinking ( Table 2 ), suggesting that elevated risky drinking episodes among sports gamblers are not due to demographic differences.

In this survey study, binge drinking in both men and women was reported at greater frequency among sports wagering individuals compared with nongamblers and non–sports gamblers. This study is limited by its cross-sectional design and use of nonprobability polling methods. Regardless, with past research showing that sports gamblers are more likely to report symptoms of alcohol use disorder, our results suggest that individuals who wager on sports use alcohol in particularly risky ways. Given the rapid spread of sports wagering in the US over recent years, this finding highlights an immense need for ongoing research, particularly to examine how novel gambling technologies influence the prevalence, presentation, and prevention of alcohol use disorders and related harms.

Accepted for Publication: February 9, 2024.

Published: April 1, 2024. doi:10.1001/jamanetworkopen.2024.5473

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Grubbs JB et al. JAMA Network Open .

Corresponding Author: Joshua B. Grubbs, PhD, Center for Alcohol, Substance Use, and Addiction, University of New Mexico, 2650 Yale Blvd SE, Albuquerque, NM 87106 ( [email protected] ).

Author Contributions: Drs Grubbs and Kraus had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical review of the manuscript for important intellectual content: Both authors.

Statistical analysis: Both authors.

Obtained funding: Both authors.

Administrative, technical, or material support: Grubbs.

Conflict of Interest Disclosures: Dr Grubbs reported receiving research grant funding from the Problem Gambling Network of Ohio outside the submitted work. Dr Kraus reported receiving personal fees from New York Council on Problem Gambling, the International Center for Responsible Gaming, the California Council on Problem Gambling, and Massachusetts General Hospital Psychiatry Academy, serving as editor-in-chief for Taylor & Francis journals, and receiving Summer research support from the Nevada Project on Problem Gambling during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by grants from the International Center for Responsible Gaming, the Kindbridge Research Institute, and the Problem Gambling Network of Ohio.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement .

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The Cass review: an opportunity to unite behind evidence informed care in gender medicine

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At the heart of Hilary Cass’s review of gender identity services in the NHS is a concern for the welfare of “children and young people” (doi: 10.1136/bmj.q820 ). 1 Her stated ambition is to ensure that those experiencing gender dysphoria receive a high standard of care. This will be disputed, of course, by people and lobbying groups angered by her recommendations, but it is a theme running through the review. Cass, a past president of the UK’s Royal College of Paediatrics and Child Health, seeks to provide better care for children and adolescents on one of the defining issues of our age. Her conclusion is alarming for anybody who genuinely cares for child welfare: gender medicine is “built on shaky foundations” (doi: 10.1136/bmj.q814 ). 2

That verdict is supported by a series of review papers published in Archives of Disease in Childhood , a journal published by BMJ and the Royal College of Paediatrics and Child Health (doi: 10.1136/archdischild-2023-326669 doi: 10.1136/archdischild-2023-326670 doi: 10.1136/archdischild-2023-326499 doi: 10.1136/archdischild-2023-326500 ). 3 4 5 6 The evidence base for interventions in gender medicine is threadbare, whichever research question you wish to consider—from social transition to hormone treatment.

For example, of more than 100 studies examining the role of puberty blockers and hormone treatment for gender transition only two were of passable quality. To be clear, intervention studies—particularly of drug and surgical interventions—should include an appropriate control group, ideally be randomised, ensure concealment of treatment allocation (although open label studies are sometimes acceptable), and be designed to evaluate relevant outcomes with adequate follow-up.

One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally (doi: 10.1136/bmj.q794 ). 7

The Cass review attempted to work with the Gender Identity Development Service (GIDS) and the NHS adult gender services to “fill some of the gaps in follow-up data for the approximately 9000 young people who have been through GIDS to develop a stronger evidence base.” However, despite encouragement from NHS England, “the necessary cooperation was not forthcoming.” Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.

A spiralling interventionist approach, in the context of an evidence void, amounted to overmedicalising care for vulnerable young people. A too narrow focus on gender dysphoria, says Cass, neglected other presenting features and failed to provide a holistic model of care. Gender care became superspecialised when a more general, multidisciplinary approach was required. In a broader sense, this failure is indicative of a societal failure in child and adolescent health (doi: 10.1136/bmj.q802 doi: 10.1136/bmj-2022-073448 ). 8 9 The review’s recommendations, which include confining prescription of puberty blockers and hormonal treatments to a research setting (doi: 10.1136/bmj.q660 ), now place the NHS firmly in line with emerging practice internationally, such as in Scandinavia (doi: 10.1136/bmj.p553 ). 10 11

Cass proposes a future model of regional multidisciplinary centres that provide better access and, importantly, standardised care for gender dysphoria, including a smoother transition between adolescent and adult services. Staff will need training. All children and young people embarking on a care pathway will be included in research to begin to rectify the problems with the evidence base, with long term outcomes being an important area of focus. An already stretched workforce will need to extend itself further (doi: 10.1136/bmj.q795 doi: 10.1136/bmj-2024-079474 ). 12 13 In the meantime, some children and young people will turn to the private sector or online providers to meet their needs. The dangers in this moment of service transition are apparent.

But it’s also a moment of opportunity. Families, carers, advocates, and clinicians—acting in the best interests of children and adolescents—face a clear choice whether to allow the Cass review to deepen division or use it as a driver of better care. The message from the evidence reviews in Archives of Disease in Childhood is as unequivocal as it could be. Cass’s review is independent and listened to people with lived experience. Without doubt, the advocacy and clinical practice for medical treatment of gender dysphoria had moved ahead of the evidence—a recipe for harm.

People who are gender non-conforming experience stigmatisation, marginalisation, and harassment in every society. They are vulnerable, particularly during childhood and adolescence. The best way to support them, however, is not with advocacy and activism based on substandard evidence. The Cass review is an opportunity to pause, recalibrate, and place evidence informed care at the heart of gender medicine. It is an opportunity not to be missed for the sake of the health of children and young people. It is an opportunity for unity.

• Mitchell A ,
• Langton T ,
• Heathcote C ,
• Hewitt CE ,
• Hardiman L ,
• Wilkinson E
• Dixon-Woods M ,
• Summers C ,

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Application of Particle Physics Detector in Medical Science

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Initially, the growth of particle detectors was focused on the identification of particles, but new detector designs have made it possible to build new diagnostic techniques. Clinical settings and medical research facilities utilize cutting-edge methods developed from particle accelerators, detectors, and physics computers, including imaging technologies, accelerators specifically designed for cancer therapy, simulations, data analysis, and nuclear medicine. It is still obvious that research in nuclear and basic particle physics is what motivates and propels the development of particle detectors for medical applications. The applications of the particle physics detector in medical science will be the main topic of this paper.

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Verma, M., Kumar, P., Kumari, B. et al. Application of Particle Physics Detector in Medical Science. J. Electron. Mater. (2024). https://doi.org/10.1007/s11664-024-11062-4

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Gender medicine ‘built on shaky foundations’, Cass review finds

Analysis finds most research underpinning clinical guidelines, hormone treatments and puberty blockers to be low quality

• Review of gender services has major implications for mental health services

The head of the world’s largest review into children’s care has said that gender medicine is “built on shaky foundations”.

Dr Hilary Cass, the paediatrician commissioned to conduct a review of the services provided by the NHS to children and young people questioning their gender identity, said that while doctors tended to be cautious in implementing new findings in emerging areas of medicine, “quite the reverse happened in the field of gender care for children”.

Cass commissioned the University of York to conduct a series of analyses as part of her review.

Two papers examined the quality and development of current guidelines and recommendations for managing gender dysphoria in children and young people. Most of the 23 clinical guidelines reviewed were not independent or evidence based, the researchers found.

A third paper on puberty blockers found that of 50 studies, only one was of high quality.

Similarly, of 53 studies included in a fourth paper on the use of hormone treatment, only one was of sufficiently high quality, with little or only inconsistent evidence on key outcomes.

Here are the main findings of the reviews:

Clinical guidelines

Increasing numbers of children and young people experiencing gender dysphoria are being referred to specialist gender services. There are various guidelines outlining approaches to the clinical care of these children and adolescents.

In the first two papers, the York researchers examined the quality and development of published guidelines or clinical guidance containing recommendations for managing gender dysphoria in children and young people up to the age of 18.

They studied a total of 23 guidelines published in different countries between 1998 and 2022. All but two were published after 2010.

Most of them lacked “an independent and evidence-based approach and information about how recommendations were developed”, the researchers said.

Few guidelines were informed by a systematic review of empirical evidence and they lack transparency about how their recommendations were developed. Only two reported consulting directly with children and young people during their development, the York academics found.

“Healthcare services and professionals should take into account the poor quality and interrelated nature of published guidance to support the management of children and adolescents experiencing gender dysphoria/incongruence,” the researchers wrote.

Writing in the British Medical Journal (BMJ) , Cass said that while medicine was usually based on the pillars of integrating the best available research evidence with clinical expertise, and patient values and preferences, she “found that in gender medicine those pillars are built on shaky foundations”.

She said the World Professional Association of Transgender Healthcare (WPATH) had been “highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency”.

In the foreword to her report, Cass said while doctors tended to be cautious in implementing new findings “quite the reverse happened in the field of gender care for children”.

In one example, she said a single Dutch medical study, “suggesting puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence”, had formed the basis for their use to “spread at pace to other countries”. Subsequently, there was a “greater readiness to start masculinising/feminising hormones in mid-teens”.

She added: “Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better.”

Both papers repeatedly pointed to a key problem in this area of medicine: a dearth of good data.

She said: “Filling this knowledge gap would be of great help to the young people wanting to make informed choices about their treatment.”

Cass said the NHS should put in place a “full programme of research” looking at the characteristics, interventions and outcomes of every young person presenting to gender services, with consent routinely sought for enrolment in a research study that followed them into adulthood.

Gender medicine was “an area of remarkably weak evidence”, her review found, with study results also “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint”.

Alongside a puberty blocker trial, which could be in place by December, there should be research into psychosocial interventions and the use of the masculinising and feminising hormones testosterone and oestrogen, the review found.

Hormone treatment

Many trans people who seek medical intervention in their transition opt to take hormones to masculinise or feminise their body, an approach that has been used in transgender adults for decades.

“It is a well-established practice that has transformed the lives of many transgender people,” the Cass review notes, adding that while these drugs are not without long-term problems and side-effects, for many they are dramatically outweighed by the benefits.

For birth-registered females, the approach means taking testosterone, which brings about changes including the growth of facial hair and a deepening of the voice, while for birth-registered males, it involves taking hormones including oestrogen to promote changes including the growth of breasts and an increase in body fat. Some of these changes may be irreversible.

However, in recent years a growing proportion of adolescents have begun taking these cross-sex, or gender-affirming, hormones, with the vast majority who are prescribed puberty blockers subsequently moving on to such medication.

This growing take-up among young people has led to questions over the impact of these hormones in areas ranging from mental health to sexual functioning and fertility.

Now researchers at the University of York have carried out a review of the evidence, comprising an analysis of 53 previously published studies, in an attempt to set out what is known – and what is not – about the risks, benefits and possible side-effects of such hormones on young people.

All but one study, which looked at side-effects, were rated of moderate or low quality, with the researchers finding limited evidence for the impact of such hormones on trans adolescents with respect to outcomes, including gender dysphoria and body satisfaction.

The researchers noted inconsistent findings around the impact of such hormones on growth, height, bone health and cardiometabolic effects, such as BMI and cholesterol markers. In addition, they found no study assessed fertility in birth-registered females, and only one looked at fertility in birth-registered males.

“These findings add to other systematic reviews in concluding there is insufficient and/or inconsistent evidence about the risks and benefits of hormone interventions in this population,” the authors write.

However, the review did find some evidence that masculinising or feminising hormones might help with psychological health in young trans people. An analysis of five studies in the area suggested hormone treatment may improve depression, anxiety and other aspects of mental health in adolescents after 12 months of treatment, with three of four studies reporting an improvement around suicidality and/or self-harm (one reported no change).

But unpicking the precise role of such hormones is difficult. “Most studies included adolescents who received puberty suppression, making it difficult to determine the effects of hormones alone,” the authors write, adding that robust research on psychological health with long-term follow-up was needed.

The Cass review has recommended NHS England should review the current policy on masculinising or feminising hormones, advising that while there should be the option to provide such drugs from age 16, extreme caution was recommended, and there should be a clear clinical rationale for not waiting until an individual reached 18.

Puberty blockers

Treatments to suppress puberty in adolescents became available through routine clinical practice in the UK a decade ago.

While the drugs have long been used to treat precocious puberty – when children start puberty at an extremely young age – they have only been used off-label in children with gender dysphoria or incongruence since the late 1990s. The rationale for giving puberty blockers, which originated in the Netherlands, was to buy thinking time for young people and improve their ability to smooth their transition in later life.

Data from gender clinics reported in the Cass review showed the vast majority of people who started puberty suppression went on to have masculinising or feminising hormones, suggesting that puberty blockers did not buy people time to think.

To understand the broader effects of puberty blockers, researchers at the University of York identified 50 papers that reported on the effects of the drugs in adolescents with gender dysphoria or incongruence. According to their systematic review, only one of these studies was high quality, with a further 25 papers regarded as moderate quality. The remaining 24 were deemed too weak to be included in the analysis.

Many of the reports looked at how well puberty was suppressed and the treatment’s side-effects, but fewer looked at whether the drugs had their intended benefits.

Of two studies that investigated gender dysphoria and body satisfaction, neither found a change after receiving puberty blockers. The York team found “very limited” evidence that puberty blockers improved mental health.

Overall, the researchers said “no conclusions” could be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development, though there was some evidence bone health and height may be compromised during treatment.

Based on the York work, the Cass review finds that puberty blockers offer no obvious benefit in helping transgender males to help their transition in later life, particularly if the drugs do not lead to an increase in height in adult life. For transgender females, the benefits of stopping irreversible changes such as a deeper voice and facial hair have to be weighed up against the need for penile growth should the person opt for vaginoplasty, the creation of a vagina and vulva.

In March, NHS England announced that children with gender dysphoria would no longer receive puberty blockers as routine practice. Instead, their use will be confined to a trial that the Cass review says should form part of a broader research programme into the effects of masculinising and feminising hormones.

• Transgender
• Young people

More on this story

No case for closing Scotland’s only NHS gender services clinic, says first minister

Veteran trans campaigner: ‘Cass review has potential for positive change’

Cass review must be used as ‘watershed moment’ for NHS gender services, says Streeting

‘This isn’t how good scientific debate happens’: academics on culture of fear in gender medicine research

Five thousand children with gender-related distress awaiting NHS care in England

Ban on children’s puberty blockers to be enforced in private sector in England

What Cass review says about surge in children seeking gender services

Adult transgender clinics in England face inquiry into patient care

‘Children are being used as a football’: Hilary Cass on her review of gender identity services

Thousands of children unsure of gender identity ‘let down by NHS’, report finds

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Posted by duthip1 on Wednesday, April 17, 2024 in News .

PhD candidate Shengxin Tu has been named a recipient of Vanderbilt’s Provost Pathbreaking Discovery Award , which “recognizes doctoral students who exhibit exceptional academic excellence in publications, awards, patents, and other forms of national or international distinction” with $2,500 in supplemental funding. Tu is first author of a recent paper in the prestigious Statistics in Medicine journal, as well as second author of a retrospective cohort study discussed in last month’s  Journal of the International AIDS Society.  Tu currently serves as secretary of the Biostatistics Graduate Student Association and has completed internships at Genetech and Amazon; she is also presently a research assistant with CCASAnet , the Caribbean, Central and South America network for HIV epidemiology.

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Athletic Training and Population Health Science

Justin beaupre.

Main Line Health System, Wynnewood, PA

Sam W. Meske

Meghan buckley.

To define and discuss the role of population health as a framework to improve care and clinical decision making in athletic training practice.

Athletic trainers (ATs) are allied health professionals who are uniquely suited to provide preventive and educational health and wellness programs to improve health outcomes across a physically active population. Athletic trainers are often the first contacts for high school athletes seeking health and wellness education, which may allow ATs to be the first intervention or prevention point for reducing or eliminating negative health behaviors and outcomes among their patients.

Conclusions

Integrating a population-health framework into the athletic training setting prepares ATs to address complex health concerns in communities that result from factors that influence determinants of health. The field of athletic training could benefit from a population-health approach to care by broadening consideration of the factors that affect the health of homogeneous populations that are served by ATs.

The Commission for Accreditation of Athletic Training Education implemented new core competency standards in 2020. 1 These revisions include education about public health and the value of population-health tools, such as data-driven research and outcomes, electronic health record utilization, health informatics, and value-based care decisions. 1 Curricular changes to athletic training programs include foundational knowledge in population health, epidemiology, health care delivery systems, and payer systems. 1 Athletic training students will be required to receive educational and clinical experiences that address factors that influence the health of a population, such as behavioral health and substance abuse. Incorporating this knowledge will create a new paradigm that pushes the field of athletic training forward by widening the lens to focus on the external influences that shape health behaviors and create potential health risks for patients.

Athletic trainers (ATs) are well educated in the prevention and management of injuries and regularly collaborate with other health care providers to treat and manage patients with acute and chronic health conditions. However, what if ATs could use data and surveillance methods to predict health risks and potential illnesses in their population and to develop the appropriate interventions earlier? This is the focus of population health. Population health is defined as a cohesive, integrated, and comprehensive approach to health care that considers the distribution of health outcomes within a population, the health determinants that influence the distribution of care, and the policies and interventions that affect and are affected by the determinants. 2 A population-health framework allows health professionals to think critically about how to manage and treat health conditions by focusing specifically on the factors that drive health and disease within groups of people (populations). These factors include biological, social, psychological, geographic, and economic conditions that shape health over the life course. 3 Athletic trainers who adopt a population-health–based approach to injury and illness prevention will be better suited to take leading roles in policy development and assessment and be able to develop and implement large-scale translations to practice initiatives that are informed by public health approaches. 4 Beyond the policy boundaries, ATs have a set of clinical responsibilities and skills that have prepared them to provide high-quality preventive care that can reduce risk and injury to the patients they serve. From a population-health perspective, with its focus on prevention and risk reduction, ATs should consider the characteristics and factors that make a subset of the population more vulnerable.

Athletic trainers are well positioned to provide effective and efficient health care to student-athletes at the secondary school level. 5 They focus on improving the health of their patients under the direction of or in collaboration with physicians and may serve as a liaison to the greater medical community. Because ATs are allied health care professionals with extensive knowledge of disease and illness prevention, they are often capable of working with patients and health professionals to find appropriate solutions to address a wide variety of health-related concerns. 4 As the number of US student-athletes has risen to nearly 8 million, 6 the responsibility of caring for them has increased not only the volume of patients seen by ATs but also the roles that ATs play in health maintenance and care. In 2015, researchers 7 found that nearly 70% of US public schools had access to some athletic training services; however, only 30% of those schools had full-time services. The focus of this paper is on the role high school ATs can play in addressing health determinants that affect the health of their patients. In the high school setting, the AT is often the first contact for care outside of an athlete or patient's primary care physician. Because health behaviors and attitudes are often shaped during these early adolescent years, providing ATs with a population-health framework to recognize and identify the factors that affect health determinants may reduce the risk of worse health outcomes later in the athlete's career.

POPULATION HEALTH

Population-health programs assess the distribution of health outcomes and policies surrounding health determinants. Programs use this evidence to strategize improvements in how determinants of health are affecting large homogeneous groups of individuals throughout a system, which improves health outcomes. Population health seeks to provide a conceptual framework to organize thinking and approaches to the study of wellbeing and variability among populations. 2 In a population-health framework, clinical practice standards shift from care that is individual to care that considers population-level perspectives. This can be achieved by using primary and secondary prevention strategies, improved screening and surveillance, and broadening our focus beyond acute and episodic health care events.

The framework for population health has 4 pillars: chronic care management, quality and safety, health policy, and public health ( Figure ). 2 Athletic trainers are part of an interprofessional health care model that works closely with patients, providers, school officials, and others to improve the health and wellbeing of the population they treat. Although the pillars of population health are all-encompassing for allied health professionals, this does not imply that providers should be responsible for activities in each category. For example, ATs will not often be working in public health settings or actively engaged in policy making at the state or national level. However, it is important that ATs begin to think about the tasks in their daily practice that fit into each of these pillars. In the following paragraphs, ATs' engagement in the pillars of population health are highlighted with examples.

Four pillars of population health.

Chronic Care Management

Care management is a vital role in athletic training practice. Athletic trainers use a variety of health promotion and preventive measures that focus on health behavior modification. Athletic trainers work with patients who have a variety of existing health conditions and help to facilitate and manage both acute and chronic care needs. Because of this relationship, it is imperative that they establish partnerships with a variety of health care providers and resources. Using this care management model, ATs gain information about the patients they serve and are able to share information with those patients by becoming part of a broader community of interprofessional health care teams. For instance, an athlete who was diagnosed with type 1 diabetes and is using an insulin pump will require care coordinated among the AT, primary care provider, and endocrinologist to manage insulin levels that fluctuate due to physical activity. This potentially improves the way in which patients use their health care, both to prevent the misuse of health services and to promote effective and efficient use of health services over the course of their care with ATs.

Quality and Safety

Participating in athletics is associated with an inherent risk of injury. Athletic trainers often use injury surveillance to track and make inferences about the causes and risks of illness and injury among the populations they serve. With the current focus on value-based care models, many ATs collect patient-reported outcomes data to evaluate the quality of interventions and treatments. These tools and practices have advanced the development of evidence-based treatment protocols, as well as the creation and implementation of prevention and screening tools, and informed epidemiologic studies that lead to reductions in the risk of injury or illness.

Health Policy

Health policy in athletic training is likely to occur on the state and national levels. The National Athletic Trainers' Association has developed practice policies and guidelines that keep ATs and athletes safe and protected. Athletic trainers may be part of the policy development process for injury prevention, risk management, behavioral health policy, return-to-play guidelines, and referral guides at the school and district levels. In nearly all 50 states, the athletic training profession is managed by a regulatory body that outlines policies, practice guidelines, and rules and regulations. Athletic trainers have been involved in developing many of these laws and regulations.

Public Health

Public health is a relatively new field for athletic training. The National Athletic Trainers' Association has created a task force to examine the role of ATs in public health and collaborate with the American Public Health Association to bring awareness of public health initiatives to ATs. Collaborating with health departments and community-facing organizations may create opportunities for developing innovative strategies to address the social determinants of health, reducing health disparities and preventing disease transmission. Athletic trainers also regularly engage in injury prevention, health screenings, health education, and injury and disease surveillance within populations. Given ATs' unique skill set and the overlap between the medical and public health models, they are well positioned to lead responses to public health emergencies. For example, the global COVID-19 pandemic has created an opportunity for ATs to begin interpreting and implementing public health policy and data from organizations such as the Centers for Disease Control and Prevention. As a result of the pandemic, ATs are consulting with organizational leadership to implement new policies and procedures that protect the health of the populations they serve.

Characteristics of Population-Health Professionals

An interdisciplinary population-health model suggests that clinicians adopt certain attributes or characteristics that will lead to successful health outcomes. These include taking personalized, patient-centered approaches to health, such as shared decision making about health promotion and case management; calling on interdisciplinary care teams to address complex health needs; gaining knowledge about determinants of health and their effect on population health and individual health outcomes; and using evidence-based care strategies that provide high-quality, value-based, effective care. 2 These attributes of population health align well with ATs' current practices. Athletic trainers use evidence-based treatment guidelines to manage a variety of conditions such as concussions, mental health disorders and addictions, and musculoskeletal injuries.

Translating Population Health Into Athletic Training Practice

Three athletic training competencies can be used to improve health of populations:

• Assess the health status of populations using available data (eg, public health surveillance data, vital statistics, registries, surveys, electronic health records, and health plan claims data).
• Discuss the role of socioeconomic, environmental, cultural, and other population-level determinants of health on the health status and health care of individuals and populations.
• Identify community assets and resources to improve the health of individuals and populations. 8

Population-level data alert us to trends in populations. The field of athletic training should be informed by data that surveil risks and trends to inform assessments, treatments, and health outcomes. Athletic trainers know how to care for individuals and their health needs but may not be attuned to the larger group needs within the populations they serve. Athletic trainers spend numerous hours with patients developing treatment plans, assessing and monitoring their health status, and building relationships that foster trust and engagement. Because population health focuses on homogeneous groups of people and identifying and understanding factors that affect health outcomes in these groups, incorporating these competencies can serve as an additional protective factor for reducing injury, illness, and worse health outcomes. The causes of population health are multilevel (institutions, socioeconomic policies, communities, social relationships, and individual behaviors) and accumulate throughout the life course. 9 This population-health lens of increasingly vigilant surveillance to identify the factors and conditions that put populations at greater risk than others for health disparities, injuries, and risk is critical for the field of athletic training.

Athletic trainers are often in positions where they observe disparities that are caused by health inequity. In a pilot focus group we conducted, ATs discussed health concerns related to poverty, food scarcity, substance abuse, mental health, housing insecurity, crime, and violence. Surveillance and detection of these problems may help ATs develop preventive initiatives that connect patients with the appropriate professionals and resources to prevent worse health outcomes.

CONCLUSIONS

A population-health framework can benefit the field of athletic training by positioning ATs to consider a broader perspective in understanding the factors that affect the health of the populations they serve through interprofessional collaborations and community support. Early detection and prevention of illness and injury has long been the primary role of the AT. The profession can continue to expand on this by shifting toward a population-health framework and recognizing how the distribution of health determinants may place the populations they serve at risk for worse health outcomes. Athletic trainers should take proactive steps to recognize these population-health concerns and implement new preventive health-education opportunities. As ATs become more knowledgeable about population health and begin thinking critically about the conditions affecting the health of their communities and patients, they will be able to implement transformative policies, interventions, and practices that raise the health status of the populations they serve.