Search

Objective: This cross-sectional retrospective and prospective study implemented the 2023 International Olympic Committee Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool version 2 (CAT2) to determine the current severity of REDs (primary outcome) and future risk of bone stress injuries (BSI, exploratory outcome) in elite athletes., Methods: Female (n=143; 23.3±4.3 years) and male (n=70; 23.1±3.7 years) athletes (performance tier 3 (52%), tier 4 (36%), tier 5 (12%)) participated in a baseline CAT2 (with minor modifications) assessment, including a self-report questionnaire (menstrual function (females), BSI, Eating Disorder Examination Questionnaire (EDE-Q)), bone mineral density (BMD via DXA) and fasted blood analysis (triiodothyronine (T3), testosterone, cholesterol). Athletes were assigned a green, yellow, orange or red light via CAT2. The prospective risk of new self-report of physician-diagnosed BSI was assessed over a subsequent 6-24 months., Results: REDs prevalence was 55% green, 36% yellow, 5% orange and 4% red light. The CAT2 identified a greater prevalence of amenorrhoea and BSI and lower T3, testosterone and BMD (p<0.01) in red, orange and yellow (those with REDs) versus green light. ORs for a prospective self-reported BSI (majority physician diagnosed) were greater in orange vs green (OR 7.71, 95% CI (1.26 to 39.83)), in females with severe amenorrhoea (OR 4.6 (95% CI 0.98 to 17.85)), in males with low sex drive (OR 16.0 (95% CI 4.79 to 1038.87)), and athletes with elevated EDE-Q global scores (OR 1.45 (95% CI 0.97 to 1.97))., Conclusion: The CAT2 has high validity in demonstrating current severity of REDs, with increased future risk of self-reported BSI in athletes with a more severe REDs traffic light category., Competing Interests: Competing interests: MM and KEA are deputy editors of the BJSM., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: A paucity of studies assesses the intersection of physical health (injury and illness), mental health and experiences of interpersonal violence (IV, also known as harassment and abuse) in sport. The objectives of this study were to examine the (a) frequency of self-reported physical and mental health problems of elite athletes in the 12 months prior to the survey, (b) differences in physical and mental health between male and female athletes and (c) relationship of athlete health with experiences of IV., Methods: Elite adult athletes from four sports were approached at eight international events to answer an online questionnaire on their physical and mental health, as well as experiences of IV in sport within the past 12 months., Results: A total of 562 athletes completed the questionnaire. Overall, 75% reported at least one physical symptom, most commonly headache and fatigue (n=188; 33.5% each), followed by musculoskeletal symptoms (n=169; 29.4%). 65.1% reported at least one mental health symptom, mostly of anxiety or depression. More female than male athletes reported physical (F:81.9%; M:68.3%; p<0.001) and mental (F:71.9%; M:58.4%; p<0.001) health problems, while addiction problems were more frequent in male athletes (F:1.8%; M:6.4%; p=0.006. 53.0% of the female and 42.3% of the male participants reported having experienced at least one form of IV. Linear regression analysis demonstrated that all forms of IV, except physical IV (all p's<0.001), were associated with an increasing number of physical and mental health symptoms. In addition, the analysis showed that female athletes had a higher increase in symptoms in response to IV than male athletes., Conclusions: This study demonstrates the relationship of elite athlete physical and mental health with IV. Injury and illness prevention programmes in international sport should include strategies to reduce IV., Competing Interests: Competing interests: MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Our aim was to define the priorities for future research in safeguarding athletes from interpersonal violence (IV) in sport through a Delphi consensus study of researchers in the field., Methods: An internet-based three-round Delphi method was used as a multistage facilitation technique to arrive at a group consensus (set at ≥75% agreement). A targeted literature search was conducted to develop a list of potential research priorities that were presented as short statements in the first round., Results: A total of 52 participants (researchers in IV in sport) took part in the first round, 52 completed the second round and 44 completed the third round. Respectively, 47 items, 83 items and 60 items were included in each round. The participants achieved consensus on 11 statements in the first round, seven in the second round and 31 in the third round, for a total of 49 consensus research priorities. The first four priorities that reached consensus (78.8-80.8% agreement) directly following the first Delphi round were scored with high importance (between 6.2 and 6.3 on a scale of 7). Those four priorities included: (1) documenting the experiences of children athletes and minors, (2) studying the disclosure or reporting of violence, (3) developing, evaluating and advising on interventions targeting education and training and (4) documenting the experiences of violence of para athletes., Conclusion: This study defines research priorities for IV in sport that may elucidate further gaps in current policies and practices., Competing Interests: Competing interests: MM is a Deputy Editor of the British Journal of Sports Medicine., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess the clinical competence of sports medicine physicians to recognise and report harassment and abuse in sports, and to identify barriers to reporting and the need for safeguarding education., Methods: We implemented a cross-sectional cohort study design recruiting through social media and international sports medicine networks in 2023. The survey captured participant perceptions related to the harmfulness of harassment and abuse. The survey incorporated the reasoned action approach as a theoretical framework to design survey questions to identify attitudes and self-efficacy to detect and report suspicions of harassment and abuse and to identify barriers to reporting., Results: Sports medicine physicians (n=406) from 115 countries completed the survey. The situations of harassment and abuse presented in the survey were described by sports medicine physicians as having occurred in the 12 months before participating in the survey. Despite recognising the situations as harmful, sports medicine physicians were somewhat uncomfortable being vigilant for the signs and symptoms and reporting suspicions and disclosures of harassment and abuse (M=2.13, SD=0.67). In addition, just over one-quarter (n = 101, 26.9%) was unaware of where to report harassment and abuse, and over half did not know (n = 114, 28.1%), or were uncertain (n = 95, 23.4%) of who the safeguarding officer was in their sports organisation. Participants identified many barriers to reporting harassment and abuse, including concerns regarding confidentiality, misdiagnosis, fear of reprisals, time constraints and lack of knowledge. Over half felt insufficiently trained (n = 223, 57.6%), and most respondents (n=324, 84.6%) desired more education in the field., Conclusions: Educational programmes to better recognise and report harassment and abuse in sports are needed for sports medicine trainees and practising clinicians. An international safeguarding code for sports medicine physicians should be developed., Competing Interests: Competing interests: MM is a deputy editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an associate editor of the BJSM, an associate editor of the BJSM IPHP and editor in chief of BMJ Open Sports and Exercise Medicine. JTF is the training, prevention and rehabilitation section editor for Current Sports Medicine Reports. AM is an associate editor of the BJSM., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: MM is a deputy editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an associate editor of the BJSM, an associate editor of the BJSM IPHP and editor in chief of BMJ Open Sports and Exercise Medicine. JTF is the training, prevention and rehabilitation section editor for Current Sports Medicine Reports. AM is an associate editor of the BJSM,

In 2019, the International Olympic Committee (IOC) published a consensus statement outlining the principles for recording and reporting injury and illness in elite sport. The authors encouraged sport federations to adapt the framework to their sport-specific context. Since this publication, several sports have published extensions to the IOC consensus statement.In response to a paucity of epidemiological data on athlete mental health, the IOC mental health working group adapted the IOC consensus statement on injury and illness surveillance to improve the capturing of athlete mental health data. In addition to the members of the working group, other experts and athlete representatives joined the project team to address gaps in expertise, and to add stakeholder perspective, respectively. Following an in-person meeting, the authors worked remotely, applying the scientific literature on athlete mental health to the IOC injury and illness surveillance framework. A virtual meeting was held to reach consensus on final recommendations.Practical outcomes based on the analysis of the scientific literature are provided with respect to surveillance design, data collection and storage, data analysis and reporting of athlete mental health data. Mental health-specific report forms for athlete and health professional utilisation are included for both longitudinal and event-specific surveillance.Ultimately, this publication should encourage the standardisation of surveillance methodology for mental health symptoms and disorders among athletes, which will improve consistency in study designs, thus facilitating the pooling of data and comparison across studies. The goal is to encourage systematic surveillance of athlete mental health., Competing Interests: Competing interests: MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. VG is Chair of the IOC Mental Health Working Group and MM, AB, CB, AC, DM, RP and MP are members. CLR and BH are co-Chairs of the IOC Consensus Group on Mental Health in Elite Athletes. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities. TS is the IOC Scientific Manager. CB is an Associate Editor of the BJSM and a member of the BJSM IPHP Editorial Board. She is a member of the IOC Medical & Scientific Commission and the IPC Medical Committee. LE is an IPHP Editor of the BJSM., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies., Competing Interests: Competing interests: ISM and HPD are an Associate Editor of BJSM. JST and NSM are Editors of BJSM. KEA, PCZ and MM are Deputy Editors of BJSM. EV is the Editor in Chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred , Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care., Competing Interests: Competing interests: KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps., Competing Interests: Competing interests: MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities and an Editor of BJSM IPHP. UE is an IOC member and the Chair of the IOC Medical and Scientific Commission., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. KEA is a Deputy Editor of the BJSM and an Associate Editor of the BJSM IPHP. EV is an Associate Editor of the BJSM, an Associate Editor of the BJSM IPHP and Editor in Chief of BMJ Open Sports and Exercise Medicine. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities and an Editor of BJSM IPHP. UE is an IOC member and the Chair of the IOC Medical and Scientific Commission.

Sport, as a microcosm of society, is not immune to the abuse of its stakeholders. Attention to abuse in sport has recently become a priority for sport organisations following several high-profile cases of athlete abuse from different sports around the world. Resulting from this increased awareness, many sport organisations have commenced work in the field of athlete safeguarding including the development of policy, educational programmes, reporting pathways, investigation mechanisms and research initiatives. One mechanism adopted by many sport organisations to support their safeguarding efforts is the engagement of survivors of abuse in sport: typically, as guest speakers at conferences or educational events. Unfortunately, many sport organisations do not have the knowledge or trauma-informed expertise to engage survivors safely and effectively; and in doing so, may unintentionally retraumatise the survivor if erroneous methods of engagement are employed. For some survivors, this experience may compound the original harms, and thus it also represents an area of vulnerability for the organising entity. The purpose of this paper is to explore the rationale for partnering with survivors of abuse in sport in safeguarding initiatives and to propose a living conceptual framework to support effective and safe survivor engagement in safeguarding initiatives. We will explore the underpinning scientific background, as well as the 'why', and 'how' of survivor engagement to inform sport organisations, research scientists, policy-makers, conference organisers, safeguarding officers, sport medicine clinicians and survivors themselves., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

All sport events have inherent injury and illness risks for participants. Healthcare services for sport events should be planned and delivered to mitigate these risks which is the ethical responsibility of all sport event organisers. The objective of this paper was to develop consensus-driven guidelines describing the basic standards of services necessary to protect athlete health and safety during large sporting events. By using the Knowledge Translation Scheme Framework, a gap in International Federation healthcare programming for sport events was identified. Event healthcare content areas were determined through a narrative review of the scientific literature. Content experts were systematically identified. Following a literature search, an iterative consensus process was undertaken. The outcome document was written by the knowledge translation expert writing group, with the assistance of a focus group consisting of a cohort of International Federation Medical Chairpersons. Athletes were recruited to review and provide comment. The Healthcare Guidelines for International Federation Events document was developed including content-related to (i) pre-event planning (eg, sport medical risk assessment, public health requirements, environmental considerations), (ii) event safety (eg, venue medical services, emergency action plan, emergency transport, safety and security) and (iii) additional considerations (eg, event health research, spectator medical services). We developed a generic standardised template guide to facilitate the planning and delivery of medical services at international sport events. The organisers of medical services should adapt, evaluate and modify this guide to meet the sport-specific local context., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the Task Force used an iterative process and expert consensus to finalise the Position Statement. The objective of this Position Statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Training in the medical specialty of sport and exercise medicine (SEM) is available in many, but not all countries. In 2015, an independent Delphi group, the International Syllabus in Sport and Exercise Medicine Group (ISSEMG), was formed to create a basic syllabus for this medical specialty. The group provided the first part of this syllabus, by identifying 11 domains and a total of 80 general learning areas for the specialty, in December 2017. The next step in this process, and the aim of this paper was to determine the specific learning areas for each of the 80 general learning areas. A group of 26 physicians with a range of primary medical specialty qualifications including, Sport and Exercise Medicine, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. SEM, Family Medicine, Internal Medicine, Cardiology, Rheumatology and Anaesthetics were invited to participate in a multiple round online Delphi study to develop specific learning areas for each of the previously published general learning areas. All invitees have extensive clinical experience in the broader sports medicine field, and in one or more components of sports medicine governance at national and/or international level. The hierarchical syllabus developed by the ISSEMG provides a useful resource in the planning, development and delivery of specialist training programmes in the medical specialty of SEM., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe injuries and illnesses across traditional and new sports among the participating athletes of the Buenos Aires 2018 Youth Olympic Summer Games (BA YOG) (6-18 October 2018)., Methods: We recorded the daily number of athlete injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues manned by the BA YOG 2018 medical staff., Results: In total, 3.984 athletes from 206 NOCs were observed. NOCs and BA YOG 2018 medical staff reported 619 injuries and 334 illnesses, equalling 15.5 injuries and 8.4 illnesses per 100 athletes over the 13-day period. The eight new sports on the Youth Olympic programme (futsal, beach handball, karate, roller speed skating, kitesurfing, BMX freestyle, climbing and break dancing) fell in between the other sports with respect to injury and illness risk. Injury incidence was highest in rugby (43% of all rugby players), followed by boxing (33%) and badminton (24%), and lowest in swimming, archery, roller speed skating, equestrian, climbing and rowing (<5%). The highest incidences of illness were recorded in golf (20%), followed by triathlon (16%), beach volleyball and diving (both 14%). Of the illnesses, 50% affected the respiratory system and 15% the gastrointestinal system. Injury and illness incidences varied between continents with athletes representing Europe having significantly fewer injuries and illnesses compared with other continents, apart from a similar illness incidence to Asian athletes., Conclusion: The overall injury incidence of 15.5 injuries per 100 athletes was higher, while the overall illness incidence of 8.4 illnesses per 100 athletes was similar to previous youth and Olympic Games. The new sports did not differ significantly compared with the other sports with respect to injury and illness risk., Competing Interests: Competing interests: KS is the coeditor the British Journal of Sports Medicine–Injury Prevention and Health Protection and has a consultant position at the IOC. TS works as scientific manager in the Medical and Scientific Department of the IOC. LE is head of Scientific Activities in the Medical and Scientific Department of the IOC, and editor of the British Journal of Sports Medicine and Journal of Bone and Joint Surgery., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: Little is known about athletes' understanding of safe sport and occurrence of harassment and abuse in elite youth sport., Objective: To evaluate the IOC Safe Sport educational experience at the Youth Olympic Games 2018 in Buenos Aires and to ascertain the athletes' (1) understanding of what constitutes harassment and abuse, (2) perception of the occurrence in their sport, and (3) knowledge of where to report., Methods: Athletes visiting the IOC Safe Sport Booth answered a survey related to athletes' (1) understanding of harassment and abuse in sport, (2) perception of the occurrence of harassment and abuse in their sport, and (3) knowledge of where to report. Experts and volunteers answered an email survey on their experience., Results: The response rate was 71.8%. When asked to define 'safe sport', the athletes mainly relate the concept to general physical and environmental safety, fair play and clean sport, rather than sport free from harassment and abuse. Almost half (46%) of the athletes expressed surprise by the definition of behaviours of harassment and abuse within sport. When asked if harassment and/or abuse occur in their sport, 47.5% reported 'no' or 'not likely', while 34% stated 'likely' or 'very likely'; 19% were 'unsure'. The majority (63%) of athletes knew where to seek help. Three quarters (71%) of the athletes rated the educational materials as 'good' to 'excellent'. The experts and volunteers believed the intervention would result in change in athletes' awareness, knowledge and behaviour., Conclusions: This multinational cohort of elite youth athletes is not knowledgeable of the concept of harassment and abuse in sport, despite there being a significant perception of occurrence of harassment and abuse in their sports., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Objective: To identify changes in International Federations' priorities and the barriers to implementing athlete and global health initiatives. Results should influence the work of the International Federation medical committees, the IOC and the Association of Summer Olympic International Federation., Methods: The 28 Summer and 7 Winter International Federations participating in the most recent Olympic Games (2016; 2018) were surveyed to (i) identify the importance of 27 health topics, (ii) assess their progress on implementation health-related programmes and (iii) the barriers to implementation of these programmes. We compared International Federations' activities in 2016 and 2017., Results: The response rate was 83%. Health topics which most International Federations regarded as important and in which the International Federations felt insufficiently active were ' team physician certification ', ' prevention of harassment and abuse ', ' eating disorders/disordered eating ', ' mental health ' and ' injury surveillance '. Compared with 2016, there was a decrease in International Federations' activities in ' injury surveillance ', ' nutritional supplements ' and ' hyperandrogenism '. The main barrier to implementing health-related programmes was ' International Federation political support/willingness ', followed by ' knowledge '. ' Time ' and ' coach support ' were more often reported than ' finances ', or ' IOC or Association of Summer Olympic International Federations partnership '., Conclusion: If International Federations are going to promote health of athletes and global health promotion through physical activity (sport), International Federation leadership must change their focus and provide greater political support for related initiatives. Improving coach and athlete knowledge of the health issues could also facilitate health programme delivery. Time constraints could be mitigated by sharing experiences among the International Federations, Association of Summer Olympic International Federations and the IOC. International Federations should focus on those health-related topics that they identified as being important, yet rate as having insufficient activity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Objective: To identify areas of priority and activity for international sportsfederations (IFs) with respect to athlete health and safety, and global health. Results serve to direct the work of the Association of Summer Olympic IF Medical and Scientific Consultative Group, the International Olympic Committee and to influence IFs' planning and priorities., Methods: The 28 IFs participating in the Summer Olympic Games (2016) were asked to rank the relative importance of 11 health-related topics and to report their activities or research initiatives on 27 identified topics using an electronic survey. A comparison with a similar survey (2012) was made., Results: The response rate was 100%. In general, the ' fight against doping ' had the highest priority followed by 'image as a safe sport '. The topics with the lowest importance ratings were ' increasing the number of elite athletes ', and ' health of the general population '. Despite ranking ' health of your athletes ,' as a top priority, IFs are not addressing all aspects of athlete health. In comparison with 2012, there was a significant decrease in priority for IFs is ' health of the general population '., Conclusion: Despite the widespread knowledge of the importance of the promotion of physical activity (sport) on global health, the decreasing priority and programming of the IFs on physical activity promotion is concerning. Although IFs have prioritised the protection of the health of elite athletes, there are gaps in programming demonstrating that IFs are missing important areas of athlete health. Improving recreational athlete health programming could also benefit population health as well as improve IF fan base and sport participation., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Epidemiological information on injury/illness is required to develop effective injury prevention strategies., Aim: To assess the frequency and characteristics of injuries/illnesses (1) in the 4 weeks prior to and (2) during the Fédération Internationale de Natation (FINA) World Championships 2015 compared with 2013 and 2009., Method: (1) Athletes answered a retrospective questionnaire, and (2) the medical staff reported injuries/illnesses prospectively during the championships., Results: (1) A quarter of responding athletes reported symptoms in the 4 weeks prior to the championships. More than half of all affected athletes presented with substantial severity, 80% took medication, 70% had overuse injuries and 30% did not modify their training regime despite symptoms. At the start of the championships, 70% of affected participants were still symptomatic. (2) During the championships, injury and illness incidence was 12.9 per 100 athletes. The most common injuries were shoulder sprains (5.7%) and muscle cramps of the lower back (5.7%). The most common illnesses were infections of the respiratory (33.9%) and gastrointestinal tract (23.5%). Risk factors included discipline and age, but not gender. Incidence was highest in athletes competing in high diving (HD), water polo (WP) and diving (DIV) for injuries, and WP and swimming (SW) for illnesses. The significantly higher incidence of injuries and illnesses at the FINA World Championships 2015 compared with 2013 and 2009 was most probably due to a similarly improved response rate of the medical staff., Conclusions: In aquatic sports, surveillance and health promotion should focus on prevention of out-of-competition overuse injuries and athlete education., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Despite the well-recognised benefits of sport, there are also negative influences on athlete health, well-being and integrity caused by non-accidental violence through harassment and abuse. All athletes have a right to engage in 'safe sport', defined as an athletic environment that is respectful, equitable and free from all forms of non-accidental violence to athletes. Yet, these issues represent a blind spot for many sport organisations through fear of reputational damage, ignorance, silence or collusion. This consensus statement extends the 2007 IOC Consensus Statement on Sexual Harassment and Abuse in Sport, presenting additional evidence of several other types of harassment and abuse-psychological, physical and neglect. All ages and types of athletes are susceptible to these problems but science confirms that elite, disabled, child and lesbian/gay/bisexual/trans-sexual (LGBT) athletes are at highest risk, that psychological abuse is at the core of all other forms and that athletes can also be perpetrators. Harassment and abuse arise from prejudices expressed through power differences. Perpetrators use a range of interpersonal mechanisms including contact, non-contact/verbal, cyber-based, negligence, bullying and hazing. Attention is paid to the particular risks facing child athletes, athletes with a disability and LGBT athletes. Impacts on the individual athlete and the organisation are discussed. Sport stakeholders are encouraged to consider the wider social parameters of these issues, including cultures of secrecy and deference that too often facilitate abuse, rather than focusing simply on psychopathological causes. The promotion of safe sport is an urgent task and part of the broader international imperative for good governance in sport. A systematic multiagency approach to prevention is most effective, involving athletes, entourage members, sport managers, medical and therapeutic practitioners, educators and criminal justice agencies. Structural and cultural remedies, as well as practical recommendations, are suggested for sport organisations, athletes, sports medicine and allied disciplines, sport scientists and researchers. The successful prevention and eradication of abuse and harassment against athletes rests on the effectiveness of leadership by the major international and national sport organisations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: One of the primary roles of Fédération Internationale de Natation (FINA) is to promote athlete health. The planning and delivery of major international event medical services is carried out in collaboration with the Local Organizing Committee Medical Commission (LOCMC). Aspetar Orthopaedic and Sports Medicine Hospital provided the medical services to the 12th FINA World Swimming Championships (25 m) creating a unique opportunity for collaboration with FINA., Aim: The purpose of this paper is to review the planning and delivery of medical services and athlete health promotion projects during the 12th FINA World Swimming Championships (25 m) to facilitate the planning of future sporting events of this size and scope., Methods: The 12th FINA World Swimming Championships (25 m) hosted 974 athletes from 166 countries. The LOC medical team recorded all medical encounters-newly incurred (or acute exacerbations of chronic) injuries and illnesses as well as follow-up consultations., Results: More than 90% of teams did not travel with a team physician and relied on the LOCMC for diagnosis and treatment of injuries and illnesses in athletes and accredited team officials. The LOC medical team had a total of 554 medical encounters: 385 therapy, 34 athlete injury, 65 athlete illness and 70 non-athlete encounters., Conclusions: The LOCMC in collaboration with FINA delivered comprehensive medical services to athletes, officials and spectators attending the 12th FINA World Swimming Championships (25 m). This review paper provides information relevant to the planning and delivery of LOCMC medical services for future international swimming events contributing to the FINA objective of promoting athlete health., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Injury and illness surveillance in the aquatic disciplines has been conducted during the FINA World Championships and Olympic Games. The development of an aquatic-specific injury and illness surveillance system will improve the quality of the data collected and the development of preventive measures. Our ultimate objective is to enhance aquatic athlete health and performance., Objective: The objective was to refine the injury and illness surveillance protocols to develop aquatic-specific definitions of injury and illness; define aquatic-specific injury location and causation; better describe overuse injuries; regard pre-existing and recurrent injuries; more accurately define aquatic athlete exposures and develop a protocol to capture out-of-competition aquatic athlete health parameters., Methods: FINA compiled an Injury and Illness Surveillance Expert Working Group comprised of international experts to review the scientific literature in the field. A consensus meeting was convened to provide an opportunity for debate, following which recommendations were collated., Results: Aquatic-specific injury and illness surveillance protocols covering both the in-competition and out-of-competition time periods were developed. Definitions for all relevant variables were outlined, and documentation forms for athletes and for clinicians were proposed. Recommendations for the implementation of an injury and illness surveillance system for FINA are presented., Conclusion: The FINA consensus authors recommend ongoing in-competition and out-of-competition surveillance to determine injury and illness trends over time. The implementation of the definitions and methodology outlined in this paper will improve the accuracy and value of injury and illness surveillance, and provide important information for injury prevention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Antidoping and medical care delivery programmes are required at all large international multisport events., Objective: To document and critique the novel antidoping and medical care delivery models implemented at the 2nd Summer Youth Olympic Games, Nanjing 2014., Methods: The International Olympic Committee implemented two new models of delivery of antidoping and medical care at the YOG. A review of these models as well as the public health programme and two health educational initiatives in the Cultural and Educational Program was undertaken by the International Olympic Committee., Results: The implementation of the new antidoping model was feasible in the setting of the YOG. The antidoping rules and regulations of the International Olympic Committee were respected. This model enhanced the educational initiative and provided financial as well as human resource savings. The execution of the hospital-based venue model of medical care delivery at the YOG was also feasible in this setting. This model provided a practical infrastructure for the delivery of medical care at multisport events with the goal of providing optimum athlete healthcare. A public health prevention programme was implemented and no public health risks were encountered by the participants or the Nanjing citizens during the YOG. Finally, the implementation of the athlete health educational programmes within the Cultural and Educational Program provided athletes with an opportunity to improve their health and performance., Conclusions: To achieve the goal of protecting athlete health, and of employing effective doping control and education, new alternate models of antidoping and medical care delivery can be implemented., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The health, fitness and other advantages of youth sports participation are well recognised. However, there are considerable challenges for all stakeholders involved-especially youth athletes-in trying to maintain inclusive, sustainable and enjoyable participation and success for all levels of individual athletic achievement. In an effort to advance a more unified, evidence-informed approach to youth athlete development, the IOC critically evaluated the current state of science and practice of youth athlete development and presented recommendations for developing healthy, resilient and capable youth athletes, while providing opportunities for all levels of sport participation and success. The IOC further challenges all youth and other sport governing bodies to embrace and implement these recommended guiding principles., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Participation in sport has many physical, psychological and social benefits for the child athlete. A growing body of evidence indicates, however, that sport participation may have inherent threats for the child's well-being. The subject of safeguarding children in sport has seen an increase in scientific study in recent years. In particular, there is increasing emphasis on identifying who is involved in abuse, the context of where it occurs and the identification of the various forms of abuse that take place in the sporting domain. Safeguarding principles developed by the International Safeguarding Children in Sport Founders Group are presented along with 8 underlying pillars which underpin the successful adoption and implementation of safeguarding strategies. This safeguarding model is designed to assist sport organisations in the creation of a safe sporting environment to ensure that the child athlete can flourish and reach their athletic potential through an enjoyable experience. The aim of this narrative review is to (1) present a summary of the scientific literature on the threats to children in sport; (2) introduce a framework to categorise these threats; (3) identify research gaps in the field and (4) provide safeguarding recommendations for sport organisations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Injury and illness surveillance is the foundation for the development of prevention strategies., Objective: To examine injuries among the aquatic disciplines in the 4 weeks prior to and during the 2013 FINA World Championships., Methods: The study was comprised of two components: (1) a retrospective athlete survey recording injuries in the 4 weeks prior to the Championships and (2) a prospective recording of injuries and illnesses by the medical teams of the participating countries and the local host medical team., Results: One-third of the 1116 responding athletes reported an injury/physical complaint in the 4 weeks prior to the Championships. Significantly more women (36.7%) than men (28.6%) reported injuries. Divers reported the highest rate of injury/physical complaints (55.7%). At the start of the Championships, 70% of injured respondents (n=258) were still symptomatic; however, full participation was expected by 76%. During the Championships, 186 new injuries were reported (8.3/100 registered athletes) with the highest injury incidence rate in water polo (15.3/100 registered athletes). The most common injured body part was the shoulder (21%). A total of 199 illnesses were reported during the Championships (9.0/100 registered athletes) with the most common diagnosis of illness being gastrointestinal infection. Environmental exposure (allergy, otitis and jellyfish stings) was responsible for 27% of all illnesses in open water swimming., Conclusions: Injuries pose a significant health risk for elite aquatic athletes. A prospective study would improve understanding of out-of-competition injuries. Future injury and illness surveillance at FINA World Championships is required to direct and measure the impact of prevention strategies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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.

Objective: To determine the priorities and activities of International Sport Federations (IFs) with respect to the promotion of health in their sport and for the general population., Methods: All 35 IFs participating in Olympic Games in 2014 or in 2016 were asked to rate the importance of 10 indicated topics, and to report their programmes, guidelines or research activities on 16 health-related topics using an online questionnaire (response rate 97%)., Results: On average, the 'fight against doping' had the highest priority followed by 'health of their elite athlete' and 'image as a safe sport'. The topics with the lowest importance ratings were 'health of their recreational athlete', 'increasing the number of recreational athletes' and 'health of the general population'. All except one IF reported to have health-related programmes/guidelines/research activities; most IFs had 7 or 8 of the listed activities. Eight IFs (23.5%) stated to have activities for 'prevention of chronic diseases in the general population' but only FIFA and FINA reported related projects., Conclusions: IFs aimed to protect the health of their elite athletes through a variety of activities, however the health and number of their recreational athletes was of low importance for them. Thus, IFs are missing an important opportunity to increase the popularity of their sport, and to contribute to the health of the general population by encouraging physical activity through their sport. FIFA's 'Football for Health' and FINA's 'Swim for All' projects could serve as role models.

Although many elite sporting events occur in climate-controlled venues, some athletes train and compete in environments that can potentially pose a risk to the athlete's health. In particular, athletes in aquatics, track and field, tennis, football and triathlon can be exposed to extreme heat during competition or while training. The International Federations responsible for these sports are aware of these health risks and have implemented measures to help protect the health of their athletes. This review paper outlines the sport-specific environmental health risks and the safety standards implemented to safeguard athlete health.