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Alarming weight cutting behaviours in mixed martial arts: a cause for concern and a call for action

Authors:
Ben Crighton at Liverpool John Moores University
Ben Crighton
Graeme Close at Liverpool John Moores University
Graeme Close
James P Morton at Liverpool John Moores University
James P Morton
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Abstract

Some nutritional practices in mixed martial arts (MMA) are dangerous to health, may contribute to death, and are largely unsupervised. MMA is a full contact combat sport (often referred to as cage fighting) that emerged to western audiences in 1993 via the Ultimate Fighting Championship (UFC). MMA is one of the world's fastest growing sports and now broadcasts to over 129 countries and 800 million households worldwide. Underpinning the focus on weight controlling practices, lies MMA's competition structure of 11 weight classes (atomweight, 47.6 kg; strawweight 52.2 kg; flyweight, 56.7 kg; bantamweight, 61.2 kg; featherweight, 65.8 kg; lightweight, 70.3 kg; welterweight, 77.1 kg; middleweight, 83.9 kg; light-heavyweight, 93 kg; heavyweight, 120.2 kg; super-heavyweight, no limit) that are intended to promote fair competition by matching opponents of equal body mass. Athletes aim to compete at the lowest possible weight, usually achieved by rapid weight loss methods reliant on acute/chronic dehydration (eg, saunas, sweat suits, diuretics, hot baths, etc). Weigh-in occurs on the day before (24–36 h prior) competition therefore …
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Alarming weight cutting behaviours in
mixed martial arts: a cause for concern
and a call for action
Ben Crighton,
1
Graeme Close,
2
James Morton
3
Some nutritional practices in mixed
martial arts (MMA) are dangerous to
health, may contribute to death, and are
largely unsupervised. MMA is a full
contact combat sport (often referred to as
cage fighting) that emerged to western
audiences in 1993 via the Ultimate
Fighting Championship (UFC). MMA is
one of the world’s fastest growing sports
and now broadcasts to over 129 countries
and 800 million households worldwide.
Underpinning the focus on weight con-
trolling practices, lies MMA’s competition
structure of 11 weight classes (atomweight,
47.6 kg; strawweight 52.2 kg; flyweight,
56.7 kg; bantamweight, 61.2 kg; feather-
weight, 65.8 kg; lightweight, 70.3 kg;
welterweight, 77.1 kg; middleweight,
83.9 kg; light-heavyweight, 93 kg; heavy-
weight, 120.2 kg; super-heavyweight, no
limit) that are intended to promote fair
competition by matching opponents of
equal body mass. Athletes aim to compete
at the lowest possible weight, usually
achieved by rapid weight loss methods
reliant on acute/chronic dehydration (eg,
saunas, sweat suits, diuretics, hot baths,
etc). Weigh-in occurs on the day before
(24–36 h prior) competition therefore per-
mitting athletes what is ‘perceived’as suffi-
cient time to rehydrate and refuel.
Although limited accounts exist of
weight-making practices in MMA,
1
ath-
letes have tested positive for diuretics,
failed to make weight, and have with-
drawn from contests due to adverse
effects of weight cutting for example,
nausea, vomiting, headaches, cramping,
seizures, feinting, flu-like symptoms.
2
In
September 2013, Brazilian MMA athlete
Leandro Souza died in a sauna after
attempting to lose 20% of body mass
(approximately 15 kg) in 7 days. Such
extreme dehydration and chronic use of
non-steroidal anti-inflammatory drugs
(NSAIDs) also resulted in high-profile
fighters hospitalised (and forced to retire)
with kidney disease.
2
WHAT IS THE EXTENT OF RAPID
WEIGHT LOSS?
We recently surveyed UK MMA athletes
(n=30), spanning five weight classes from
flyweight to welterweight, and discovered
an alarming culture of weight making.
These athletes lost 9±2% of body mass in
the week before competition and a further
5±2% in the final 24 h before weigh-in.
Such losses are greater than in other
combat sports,
3
likely due to the require-
ment to possess higher lean mass for
‘grappling’and the significant time
between weigh-in and competition.
PREVALENCE OF RAPID WEIGHT LOSS
METHODS AND NOVEL DEHYDRATION
METHODS
In total, 67% of athletes engaged in a pre-
viously unreported practice of ‘water-
loading’, whereby athletes reduce sodium
intake and overdrink water (eg, 20–23 L
over 3 days), in the belief it will trigger a
‘flushing mode’to induce excessive urine
production. Several athletes (17%)
reported the use of solutions to increase
sweating by increasing circulation
(eg, Sweet sweat) or by blocking the pores
(eg, Albolene). Athletes (37%) consumed
prescription and over-the-counter diure-
tics and 13% utilised intravenous lines (1
self-administered, 3 administered by a
physician) and glycerol to encourage rehy-
dration post-weigh-in. In total, 73% of
athletes consumed nutritional supple-
ments during weight-cutting, though 61%
did not know whether supplements were
tested for banned substances. Since 1 July
2015, all UFC fighters have been subject
to random drug testing procedures and
from 1 October, use of intravenous drugs
following weigh-ins will not be permitted
(both overseen by USADA). One hundred
per cent of the MMA athletes engaged in
complete fasting or low carbohydrate
diets in the final 3–5 days prior to
weigh-in thereby promoting ‘relative
energy deficiency’.
4
Only 20% of athletes
obtained dietary advice from qualified
sports dietitians/nutritionists, with the
majority of advice provided from coaches,
peers and internet sources.
BRAIN TRAUMA RISK IN MMA
The effects of dehydration on brain
trauma risk
5
is especially concerning for
MMA given that, unlike boxing, head
trauma can occur after an athlete has lost
consciousness. On average, 2.6 head
strikes are delivered after an opponent has
lost consciousness which could potentially
increase the risk of traumatic brain injury.
6
Perhaps most concerning, UK MMA
has no regulatory body that ensures the
health, safety and well-being of athletes.
UK MMA events are not covered by
formal antidoping procedures. Similar to
recent calls from the IOC
78
and the
Association of Ringside Physicians,
9
we
suggest MMA regulations need changing
and recommend the following:
▸Introduction of more weight classes
and restructuring of current weight cat-
egories to reduce differences in abso-
lute weight, especially between lower
weight categories, for example, <3 kg
as opposed to typical >4 kg.
▸Policies focusing on ‘check’weigh-ins
and maximal weight regain allowances
following weigh-in). In August 2015,
the Arkansas State Athletic Commission
has commissioned a maximal weight
regain allowance of 7.5% following
weigh-in.
▸Scheduling weigh-ins 24 h or less
before competition alongside minimal
hydration acceptable limits.
▸Antidoping procedures for domestic
championship bouts in accordance
with WADA policy.
▸Implementation of educational
packages to support MMA athletes in
making weight safely.
We encourage the MMA community to
embrace quality research, injury surveil-
lance
10
and health monitoring. This will
provide the basis for appropriate policy to
ensure the safety of MMA athletes.
Competing interests None declared.
Ethics approval Liverpool John Moores University.
Provenance and peer review Not commissioned;
externally peer reviewed.
To cite Crighton B, Close G, Morton J. Br J Sports
Med Published Online First: [please include Day Month
Year] doi:10.1136/bjsports-2015-094732
Accepted 1 September 2015
1
Centre for Public Health, Liverpool, UK;
2
Sports
Nutrition and Exercise Metabolism, Research Institute
for Sport and Exercise Sciences, Liverpool John Moores
University, Liverpool, UK;
3
Exercise Metabolism and
Nutrition, Research Institute for Sport and Exercise
Sciences, Liverpool John Moores University, Liverpool,
UK
Correspondence to Dr James Morton, Exercise
Metabolism and Nutrition, Research Institute for Sport
and Exercise Sciences, Liverpool John Moores
University, Room 1.37, Tom Reilly Building, Byrom St
Campus, Liverpool L3 3AF, UK; J.P.Morton@ljmu.ac.uk
Crighton B, et al.Br J Sports Med Month 2015 Vol 0 No 0 1
Editorial
Br J Sports Med 2015;0:1–2.
doi:10.1136/bjsports-2015-094732
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Editorial
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Full-text available
  • Mar 2014
Background: Mixed martial arts (MMA) is a full combative sport with a recent global increase in popularity despite significant scrutiny from medical associations. To date, the empirical research of the risk of head injuries associated with this sport is limited. Youth and amateur participation is growing, warranting investigation into the burden and mechanism of injuries associated with this sport. Purpose: (1) To determine the incidence, risk factors, and characteristics of knockouts (KOs) and technical knockouts (TKOs) from repetitive strikes in professional MMA; and (2) to identify the mechanisms of head trauma and the situational factors that lead to KOs and TKOs secondary to repetitive strikes through video analysis. Study design: Descriptive epidemiology study. Methods: Competition data and video records for all KOs and TKOs from numbered Ultimate Fighting Championship MMA events (n = 844) between 2006 to 2012. Analyses included (1) multivariate logistic regression to investigate factors associated with an increased risk of sustaining a KO or TKO secondary to repetitive strikes and (2) video analysis of all KOs and TKOs secondary to repetitive strikes with descriptive statistics. Results: During the study period, the KO rate was 6.4 per 100 athlete-exposures (AEs) (12.7% of matches), and the rate of TKOs secondary to repetitive strikes was 9.5 per 100 AEs (19.1% of matches), for a combined incidence of match-ending head trauma of 15.9 per 100 AEs (31.9% of matches). Logistic regression identified that weight class, earlier time in a round, earlier round in a match, and older age were risk factors for both KOs and TKOs secondary to repetitive strikes. Match significance and previously sustained KOs or TKOs were also risk factors for KOs. Video analysis identified that all KOs were the result of direct impact to the head, most frequently a strike to the mandibular region (53.9%). The average time between the KO-strike and match stoppage was 3.5 seconds (range, 0-20 seconds), with losers sustaining an average of 2.6 additional strikes (range, 0-20 strikes) to the head. For TKOs secondary to strikes, in the 30-second interval immediately preceding match stoppage, losers sustained, on average, 18.5 strikes (range, 5-46 strikes), with 92.3% of these being strikes to the head. Conclusion: Rates of KOs and TKOs in MMA are higher than previously reported rates in other combative and contact sports. Public health authorities and physicians should be cognizant of the rates and mechanisms of head trauma. Preventive measures to lessen the risks of head trauma for those who elect to participate in MMA are described.
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The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED- S)
Article
Full-text available
  • Apr 2014
  • BRIT J SPORT MED
Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as 'Female Athlete Triad'. The term 'Relative Energy Deficiency in Sport' (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a 'triad' of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The 'Sport Risk Assessment and Return to Play Model' categorises the syndrome into three groups and translates these classifications into clinical recommendations.
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How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, under the auspices of the IOC Medical Commission
Article
Full-text available
  • Nov 2013
  • BRIT J SPORT MED
A focus on low body weight and body fat content, combined with regulations in some weight-sensitive sports, are considered risk factors for extreme dieting, eating disorders (EDs) and related health consequences among athletes. At present there are, from a health perspective, no generally accepted optimum values for body weight or percentage of fat mass in different sports and there is no 'gold standard' method for body composition assessment in athletes. On the basis of health considerations as well as performance, medical support teams should know how to approach elite athletes who seek to achieve an unrealistic body composition and how to prevent restrictive eating practices from developing into an ED. In addition, these teams must know when to raise the alarm and how to advice athletes who are affected by extreme dieting or clinical EDs. However, there is no consensus on when athletes struggling with extreme dieting or EDs should be referred for specialist medical treatment or removed from competition. Based on the present review, we conclude that there is a need for (1) sport-specific and gender-specific preventive programmes, (2) criteria for raising alarm and 'does not start' (DNS) for athletes with EDs and (3) modifications to the regulations in some sports. Further, the key areas for research identified include the development of standard methods for body composition assessment in elite athletes; screening measures for EDs among athletes; development and testing of prevention programmes; investigating the short and long-term effects of extreme dieting; and EDs on health and performance.
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The Oslo Sports Trauma Research Center Questionnaire on Health Problems: a new approach to prospective monitoring of illness and injury in elite athletes
Article
Full-text available
  • Feb 2013
  • BRIT J SPORT MED
Background Little information exists on the illness and injury patterns of athletes preparing for the Olympic and Paralympic Games. Among the possible explanations for the current lack of knowledge are the methodological challenges faced in conducting prospective studies of large, heterogeneous groups of athletes, particularly when overuse injuries and illnesses are of concern. Objective To describe a new surveillance method that is capable of recording all types of health problems and to use it to study the illness and injury patterns of Norwegian athletes preparing for the 2012 Olympic and Paralympic Games. Methods A total of 142 athletes were monitored over a 40-week period using a weekly online questionnaire on health problems. Team medical personnel were used to classify and diagnose all reported complaints. Results A total of 617 health problems were registered during the project, including 329 illnesses and 288 injuries. At any given time, 36% of athletes had health problems (95% CI 34% to 38%) and 15% of athletes (95% CI 14% to 16%) had substantial problems, defined as those leading to moderate or severe reductions in sports performance or participation, or time loss. Overuse injuries represented 49% of the total burden of health problems, measured as the cumulative severity score, compared to illness (36%) and acute injuries (13%). Conclusions The new method was sensitive and valid in documenting the pattern of acute injuries, overuse injuries and illnesses in a large, heterogeneous group of athletes preparing for the Olympic and Paralympic Games.
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Weight loss in combat sports: Physiological, psychological and performance effects
Article
Full-text available
Background The present article briefly reviews the weight loss processes in combat sports. We aimed to discuss the most relevant aspects of rapid weight loss (RWL) in combat sports. Methods This review was performed in the databases MedLine, Lilacs, PubMed and SciELO, and organized into sub-topics: (1) prevalence, magnitude and procedures, (2) psychological, physiological and performance effects, (3) possible strategies to avoid decreased performance (4) organizational strategies to avoid such practices. Results There was a high prevalence (50%) of RWL, regardless the specific combat discipline. Methods used are harmful to performance and health, such as laxatives, diuretics, use of plastic or rubber suits, and sauna. RWL affects physical and cognitive capacities, and may increase the risk of death. Conclusion Recommendations during different training phases, educational and organizational approaches are presented to deal with or to avoid RWL.
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Dehydration and Acute Weight Gain in Mixed Martial Arts Fighters Prior to Competition.
Article
  • Feb 2013
  • J STRENGTH COND RES
The purpose of this study was to characterize the magnitude of acute weight gain (AWG) and dehydration in mixed martial arts (MMA) fighters prior to competition. Urinary measures of hydration status and body mass were determined ∼24 h prior and then again ∼2 h prior to competition in 40 MMA fighters (Mean ± SE, age: 25.2 ± 0.65 yr, height: 1.77 ± 0.01 m, body mass: 75.8 ± 1.5 kg). AWG was defined as the amount of body weight the fighters gained in the ∼22 h period between the official weigh-in and the actual competition. On average, the MMA fighters gained 3.40 ± 2.2 kg or 4.4% of their body weight in the ∼22 h period prior to competition. Urine specific gravity significantly decreased (P < 0.001) from 1.028 ± 0.001 to 1.020 ± 0.001 during the ∼22 h rehydration period. Results demonstrated that 39% of the MMA fighters presented with a Usg of greater than 1.021 immediately prior to competition indicating significant or serious dehydration. MMA fighters undergo significant dehydration and fluctuations in body mass (4.4% avg.) in the 24 h period prior to competition. Urinary measures of hydration status indicate that a significant proportion of MMA fighters are not successfully rehydrating prior to competition and subsequently are competing in a dehydrated state. Weight management guidelines to prevent acute dehydration in MMA fighters are warranted to prevent unnecessary adverse health events secondary to dehydration.
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Effects of Acute Dehydration on Brain Morphology in Healthy Humans
Article
Dehydration can affect brain structure which has important implications for human health. In this study, we measured regional changes in brain structure following acute dehydration. Healthy volunteers received a structural MRI scan before and after an intensive 90-min thermal-exercise dehydration protocol. We used two techniques to determine changes in brain structure: a manual point counting technique using MEASURE, and a fully automated voxelwise analysis using SIENA. After the exercise regime, participants lost (2.2% +/- 0.5%) of their body mass. Using SIENA, we detected expansion of the ventricular system with the largest change occurring in the left lateral ventricle (P = 0.001 corrected for multiple comparisons) but no change in total brain volume (P = 0.13). Using manual point counting, we could not detect any change in ventricular or brain volume, but there was a significant correlation between loss in body mass and third ventricular volume increase (r = 0.79, P = 0.03). These results show ventricular expansion occurs following acute dehydration, and suggest that automated longitudinal voxelwise analysis methods such as SIENA are more sensitive to regional changes in brain volume over time compared with a manual point counting technique.
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Dehydration and acute weight gain in mixed martial arts fighters before competition
  • Jan 2013
  • J STRENGTH COND RES
  • 1322-1326
  • A M Jetton
  • M M Larence
  • M Meucci
Jetton AM, Larence MM, Meucci M, et al. Dehydration and acute weight gain in mixed martial arts fighters before competition. J Strength Cond Res 2013;27:1322-6.
Documenting the toll of rapid extreme weight cuts in MMA
  • E Magraken
Magraken E. Documenting the toll of rapid extreme weight cuts in MMA. 2014. http://combatsportslaw. com/2014/09/03/yes-athletes-have-been-hurt-fromweight-cutting-in-mma/ (accessed 10 Apr 2015)