November 16, 2020
Online Journal Club November 2020
Jason L Zaremski, MD
Introduction: As we turn the corner on a unique fall sports season in the United States and around the world, we as a sports medicine community continue to find ourselves facing innumerable COVID-19 related challenges which must be overcome as we promote safe participation in sport. There is a substantial body of research which demonstrates that participation in sport improves confidence, lowers rates of depression, and improves sense of self and self-confidence. During this pandemic, we are more than ever in need of all these sports-related quality of life outcomes.
In this original research from the Micheli Center for Sports Injury Prevention and other centers (including four colleges), the authors do a deep dive into long-term quality of life measures in female athletes. As the authors highlight, female athletes who participate in sports are less likely to join gangs or use drugs, and are less likely to have unprotected sex or an unintended pregnancy than non-athletes. Nearly fifty years after the passage of Title IX in 1972, in the midst of a global pandemic none of us have ever faced, the November CJSM Journal Club has chosen to highlight this wonderful manuscript on how participation in sport by females in college can potentially impact long term health quality of life measures.
Purpose: Due to the substantial growth in female participation in sport in the past 40+ years, the authors investigated the association between sports participation and (1) later-life health outcomes and (2) later-life quality-of-life (QoL) measures among female college alumni.
Setting: A cross-sectional study comparing former athletes and non-athletes of alumni from 4 NCAA New England Division III institutions [Colby, Middlebury, Wesleyan, Williams]. The questionnaire was sent out in a staggered fashion over a 5-month period. The study protocol was approved by the IRB of Boston Children’s Hospital and all participating academic institutions. Each individual participant in the study consented electronically.
Methods/Design: The survey included QoL measures that include executive function, general concerns regarding cognition, anxiety, depression, emotional and behavioral dyscontrol, fatigue, positive effect, sleep disturbance, and negative consequences of alcohol use. Each participating institution sent their alumni one (and only one) introductory email, and no other forms of communication, containing a link to an online questionnaire.
This survey was designed and used via the Assessment Center, an online research program that enables researchers to design research . The studies use a variety of secure, customized, and well-validated measures. This study used the Neuro-QoL as well as the PROMIS Global 03 questionnaire. For further details of the study design and description, please refer to page 527 (page 2 out of 7) in the manuscript.
Participants: Questionnaire were sent to 47,836 alumni. A total of 3702 (8%) responded and were included in the study. Of the 3702, only female respondents were used, with a resulting total n = 1597. 44% of the respondents participated in collegiate sports. Participants were female collegiate alumni between the ages of 40 and 70 years of age.
Demographics: 43.6% (697) participated in sports, 56.7% (900) did not participate in sports. When based on income, 401 of 649 (61.8%) former athletes made more than $100,000; 502 out of 830 (60.5%) former athletes made more than $100,000; 656 out of 696 (94.3%) athletes were white; 833 out of 897 (92.9%) non-athletes were white.
- Self-reported medical diagnoses and scores on health-related QoL measures
- The main predictor variable was collegiate sports participation
- **Covariates included age, race, annual income, highest educational degree, college grades, exercise frequency, and the presence of common medical conditions that include:
- heart disease, hypercholesterolemia, obesity, diabetes, hypertension, and a family history of dementia.
**Of note, covariates were self-reported.
Statistical Measures/Analysis: As the authors described (and summarized from their manuscript), descriptive statistics were used to report the number and percentage of respondents in each variable category. Temporal trends were assessed using tests for linear trends and rates. Multivariable linear regression adjusted for the effect of covariates in separate models for each patient-reported outcome measure. Significance was set at P ≤ 0.05.
Results: Those who participated in collegiate sports versus non-athletes were more likely to exercise >3×/week (61.8% vs 50.2%; P ≤ 0.001), view themselves in good/great health (91% vs 85%; P < 0.001), and less likely to have ever smoked (13.6% vs 25.3%; P ≤ 0.001) or used recreational drugs (7.5% vs 9.5%; P = 0.018). Furthermore, athletes were less likely to have ever used recreational drugs compared to non-athletes (7.5%vs 9.5%; P≤ 0.018).
In addition, athletes reported hypertension (5.4% vs 13.5%; P≤0.001), high cholesterol (9.9% vs 17.0%; P≤0.001), and obesity (3.1% vs 6.8%; P≤0.001) compared to non-athlete respondents.
Former collegiate athletic participation was associated with decreased mobility (R2 = 0.18; P = 0.002) and increased anxiety (R2 = 0.04; P = 0.016) QoL scores. There were no significant differences for QoL between athletes and non-athletes of executive functioning, general concerns about cognition, anxiety, depression, emotional and behavioral dyscontrol, fatigue, or sleep.
It should be noted that a smaller proportion of female athletes than non-athletes had hypertension (5.5% vs 13.5%; P ≤ 0.001), hypercholesterolemia (9.9% vs 17.0%; P < 0.001), and obesity (3.1% vs 6.8%; P = 0.001).
- Fills a niche in the literature about long term (life-long) effects of participation in sport
- There is a deserved focus on research investigating the female athlete, given the explosive growth in sports participation among women since the 1970s (see Figure 1, Page 530). More research on female athletes as a whole is warranted
- While a survey study, study tools are well validated
- Large sample size (though there was a poor response rate)
- The study cohort was homogenous with regard to race, income, and education level, hence making applicability of the data difficult to generalize to the population as whole.
- Low response rate, but (as the authors indicate) this is in part due to the inability to send reminders or contact alumni using forms of communication in addition to email.
- As the authors state, the staggered roll out of the questionnaire may have impacted the response rate
- The sample is likely not representative of the larger population of all female collegiate alumni
- Data was dependent on self-reporting and not formal medical and psychiatric evaluations
Conclusion: Sports participation for female collegiate athletes was associated with primarily positive health outcomes.
Clinical Relevance: Providing more opportunities for females with respect to collegiate sport participation has the potential to lead to greater health outcomes long term. Physicians who care for females who also participate in sports when they are younger should advocate for continued participation in sport and exercise (should their patients want to) given the positive long-term positive health associations.
Though it is speculative at this point, it is noteworthy that American college sports are being heavily and negatively impacted by the COVID-19 pandemic. For instance, the Ivy League just announced that it is cancelling all winter sports as of November 12th, 2020, as it had already done with fall sports prior to the start of the academic year. It would be of clinical interest to follow a cohort of these athletes out over the next four or five decades to see if there are persistent QOL effects noted on female (and male) athletes whose collegiate careers are circumscribed by the pandemic.