Asthma in United States Olympic athletes who participated in the 1996 Summer Games☆☆☆★

Article Outline

• Abstract
• METHODS
• RESULTS
• DISCUSSION
• References
• Copyright

Abstract 

Background: Asthma prevalence appears to be increasing in the general population. We sought to determine whether asthma prevalence has also increased in highly competitive athletes. Objective: Our aim was to determine how many United States Olympic athletes who were chosen to participate in the 1996 Summer Olympic Games had a past history of asthma or symptoms that suggested asthma or took asthma medications. Methods: We analyzed responses to questions that asked about allergic and respiratory diseases on the United States Olympic Committee (USOC) Medical History Questionnaire that was completed by all athletes who were chosen to represent the US at the 1996 Summer Olympic Games in Atlanta. Results: Of the 699 athletes who completed the questionnaire, 107 (15.3%) had a previous diagnosis of asthma, and 97 (13.9%) recorded use of an asthma medication at some time in the past. One hundred seventeen (16.7%) reported use of an asthma medication, a diagnosis of asthma, or both (which was our basis for the diagnosis of asthma). Seventy-three (10.4%) of the athletes were currently taking an asthma medication at the time that they were processed in Atlanta or noted that they took asthma medications on a permanent or semipermanent basis and were considered to have active asthma. Athletes who participated in cycling and mountain biking had the highest prevalence of having been told that they had asthma or had taken an asthma medication in the past (50%). Frequency of active asthma varied from 45% of cyclists and emountain bikers to none of the divers and weight lifters. Only about 11% of the athletes who participated in the 1984 Summer Olympic Games were reported to have had exercise-induced asthma on the basis of other criteria that may have been less restrictive. On the basis of these less restrictive criteria, more than 20% of the athletes who participated in the 1996 Olympic Games might have been considered to have had asthma. Conclusions: Asthma appeared to have been more prevalent in athletes who participated in the 1996 Summer Games than in the general population or in those who participated in the 1984 Summer Games. This study also suggests that asthma may influence the sport that an athlete chooses. (J Allergy Clin Immunol 1998;102:722-6.)

Keywords:  Asthma, exercise-induced asthma, sports medicine

Abbreviations:  USOC: , United States Olympic Committee

More than 11% of the athletes who represented the US at the 1984 Los Angeles Summer Olympic Games were reported as having exercise-induced asthma.¹ Since those Games, other publications have also suggested that more than 1 of every 10 competitive athletes may have asthma.², ³, ⁴, ⁵, ⁶ Published data indicate a very high prevalence of asthma in athletes in contrast to the suggestion by many authors that the prevalence of asthma in the general population is only about 4% to 7%.⁷, ⁸ No study has been performed since 1984 to determine whether the number of Olympic athletes who participated in the Los Angeles Games and who met the criteria for exercise-induced asthma was abnormally high or was representative of athletes from other Summer Olympic Games.

We sought to determine the number of US athletes at the 1996 Atlanta Summer Olympic Games who recorded a history of asthma. Our goal was to compare the data obtained from athletes who participated in the 1984 Games with data from those who participated in the 1996 Games. A secondary goal was to determine whether the prevalence of asthma varied among sports and whether a history of asthma had any impact on performance (as measured by those who won medals) at this high level of competition.

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METHODS 

All athletes who represented the US at the 1996 Summer Olympic Games in Atlanta were required to complete a medical history questionnaire that was designed by the United States Olympic Committee (USOC) Sports Medicine Division. Questionnaires were given to the athletes by USOC medical staff at team processing in Atlanta, Ga, within 2 weeks before participation in the Games. All US athletes completed and signed the questionnaire. USOC medical staff then reviewed all of the questions on each form and conferred with each athlete to complete missing entries and to clarify concerns. There were 60 questions, most allowing for a yes or no response. When appropriate, the athletes were asked to list drugs that they were taking or to give dates or details about injuries and illnesses. Sixteen of the 60 questions asked were about allergic and respiratory disease (Table I) and were similar to questions asked of athletes who participated in the 1984 Summer Olympic Games¹ and to questions asked of those who participated in previous studies sponsored by the American Academy of Allergy, Asthma and Immunology.⁹

Table I. Questions asked on the USOC Medical History Questionnaire

At the completion of the 1996 Summer Olympic Games, all medical history questionnaires were sent to the US Olympic Training Center in Colorado Springs, Colo, where the information related to allergic and respiratory disease was transcribed onto SymptomScoreCardII diary cards (CompleWare Corporation, Iowa City, Iowa). These cards were returned to Iowa City, Iowa, where they were scanned into a database, transformed into a Microsoft Access data file, and analyzed.

Table II indicates the basis to determine that an athlete had asthma (a history of having been told that he or she had asthma, the indication that he or she had taken an asthma medication, or both). This project was approved by the University of Iowa Institutional Review Board.

Table II. Response to question 5 and indication that athletes had taken an asthma medication on the USOC Medical History Questionnaire

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RESULTS 

Six hundred ninety-nine athletes completed a medical history questionnaire; 662 were on the US Olympic Team, and 37 were alternates. Responses to the 16 allergic and respiratory disease questions are tabulated in Table I. About 11% indicated an allergy to some medication (question 1), and almost 8% reported an allergy to insects or foods (question 2). More than 15% of the athletes had been told that they had asthma (question 5). A history of chest tightness, wheezing, itchy eyes, and itching (of nose or throat) or sneezing spells (questions 6 to 9) was present in about 8%, 10%, 18%, and 17% of the athletes, respectively. Running caused chest symptoms (question 10) in almost 8%. Only 3% responded that chest symptoms had caused them to miss school, work, or practice (question 12). Athletes were more likely to give an affirmative response to question 11 (10.2%), which asked whether chest tightness, cough, wheezing, asthma, or other chest or lung problems impaired performance, than they did to question 14 (6.6%), which only asked about trouble breathing or cough during or after exercise.

More than half of the athletes indicated taking “any” medications, including over-the-counter medications (question 3), and about one third recorded that prescription medications were taken on a “permanent or semipermanent basis” (question 4). Eighty-four athletes listed having taken a medication specifically for asthma at some time (question 13). When we combined all questions on the questionnaire that asked athletes to list medications, we found that 97 (13.9%) had listed an asthma medication somewhere on the form or provided this information to USOC medical staff who recorded it on the questionnaire. Thus 13 did not list an asthma medication as a response to question 13 but did so elsewhere on the questionnaire.

Of the 699 athletes who completed medical history questionnaires (Table II), 107 (15.3%) answered yes to question 5 (Table I), the question that asked about a diagnosis of asthma, and 97 (13.9%) recorded having taken an asthma medication.

One hundred seventeen (16.7%) either had been told that they had asthma (question 5) or had taken an asthma medication. Of the 10 athletes who answered no to question 5 but recorded an asthma medication (or a response to question 13), 3 listed albuterol as a response to question 4, 2 listed albuterol as a response to question 13, 2 reported having had asthma as a child for which they had taken medicine, 2 listed albuterol as a response to question 16, and 1 listed triamcinolone acetate, albuterol, and cromolyn in response to question 16. At the time of team processing, 69 of 699 (9.9%) of the athletes recorded that they were currently taking an asthma medication (Table I), and 4 additional athletes indicated taking an asthma medication on a permanent or semipermanent basis in response to question 4. Therefore 73 of 699 (10.4%) athletes were considered to have active asthma; Table III lists the medications they were taking.

Table III. Medications taken for asthma and allergy by athletes with active asthma

We also evaluated the responses to questions that asked about asthma symptoms in athletes who had not been told that they had asthma and had not recorded asthma medications. These additional questions asked about a history of chest tightness (question 6); a history of wheezing (question 7); symptoms with running (question 10); performance impairment from respiratory symptoms (question 11); missed school, work, or practice because of respiratory symptoms (question 12); and respiratory symptoms after exercise (question 14). Responses of yes were recorded by 11, 6, 8, 8, 2, and 7 athletes, respectively, who had not been told that they had asthma and had not recorded taking any asthma medications. Twenty-four athletes answered yes to at least 1 of these questions but were not included in the 117 who we concluded had asthma. Unfortunately, we have no basis to determine whether these additional athletes did indeed have asthma, particularly exercise-induced asthma. Thus 141 athletes (20%) recorded that they had been told that they had asthma or had taken an asthma medication at some time or indicated symptoms suggestive of asthma. These criteria were similar to those used for the 1984 Summer Olympic Games,¹ suggesting that there may have been an increase in asthma in the 12 intervening years. Unfortunately, because the 2 studies were so different, we cannot say more about the comparability of asthma in these 2 populations of Olympic athletes.

We examined whether there were differences among sports in the numbers of athletes who recorded a history of asthma or listed asthma medications (Table IV). For this evaluation, we combined sports with similar characteristics for 2 reasons: (1) to provide as much confidentiality for the athletes as possible and (2) to provide sufficient numbers of athletes so that a difference in small numbers would tend to have less influence on the results. There were substantial differences among sports. In some sports no individuals had a history of asthma or had taken an asthma medication, whereas in other sports almost half of the athletes either had a history of asthma or had taken an asthma medication in the past. For example, half of the cyclists and mountain bikers, more than a quarter of synchronized swimmers and swimmers (29.6%), and about a quarter of those who participated in canoe/kayak, rowing, and sailing/yachting (25.3%) recorded a history of asthma or had taken asthma medication. Athletes who participated in track and field and modern pentathlon (18.2%) and in boxing, wrestling, and judo (15.6%) comprised the next group. The remainder of the athletic groups had an asthma prevalence ranging from 7.5% to 13.5%. Active asthma, as defined here, was present in similar proportions among sports (Table IV); 45% of the cyclists and mountain bikers had active asthma.

Table IV. Number of athletes who met criteria for asthma by sports

Next we considered whether the sex of the athlete had any influence on whether the athlete reported asthma. We found that a significantly higher percentage of female athletes (60 of 301, 19.9%) met our criteria for asthma than did male participants (57 of 398, 14.3%) (P < .05, chi-square test). Similarly, 35 female (11.6%) and 38 male (9.5%) athletes had active asthma.

Finally, we determined whether those with asthma won a similar proportion of medals as compared with their nonasthmatic teammates. Of the 117 athletes having been told they had asthma or who had taken an asthma medication, 35 athletes (29.9%) won medals, including both individual and team medals. Of the 73 athletes with active asthma, 24 (32.9%) won 31 medals. In contrast, of the 582 who did not have asthma, 167 athletes (28.7%) won medals, again including both team and individuals awards.

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DISCUSSION 

We found that 117 (16.7%) of the 699 US athletes who participated in the Atlanta Summer Olympic Games had a history of asthma, took asthma medications, or both. Of these athletes, 107 (15.3%) answered yes to the question “Have you ever been told that you have (had) asthma or exercise-induced asthma?” on the medical history questionnaire, and 97 (13.9%) recorded taking asthma medications. We scored as positive for asthma any athlete who recorded having been told that he or she had asthma, listed an asthma medication, or both. These were easily determined objective criteria on which to make a presumptive diagnosis of asthma. Likewise, 10.4% of the athletes had active asthma on the basis of their need for asthma medications at the time of completion of the questionnaire or the need for medication on a permanent or semipermanent basis.

Certain sports had a substantially greater number of athletes who met these criteria for asthma. For example, among cyclists, swimmers, and those who participated in canoe/kayak and sailing/yachting, 48 of 161 (29.8%) had a history of asthma or had taken an asthma medication in the past. In contrast, only 16 of 188 (8.5%) athletes who participated in basketball, field hockey, soccer, team handball, water polo, badminton, volleyball, table tennis, and tennis met these criteria. Frequency of active asthma varied from 45% of cyclists and mountain bikers to none of the divers and weight lifters.

The proportion of athletes who had a history of asthma or had taken an asthma medication was higher for female (19.9%) than for male (14.3%) athletes; active asthma was seen in 11.6% of female and 9.5% of male athletes. It did not appear that athletes who had been told that they had asthma or had taken asthma medications were less skilled; 29.9% won team and individual medals, whereas 28.7% of athletes who did not meet these criteria won team and individual medals. Clearly, the athletes with active asthma fared as well, with 32.9% winning medals.

Only limited data have previously been reported regarding the prevalence of asthma in comparable populations of highly competitive athletes. Fitch, in 1984,¹⁰ reported that 9.7% and 8.5% of Australian Olympic athletes who participated in the 1976 and 1980 Olympics had asthma, respectively. In 1986, Voy¹ reported experience with the 1984 US team at the Summer Olympic Games in Los Angeles. Five hundred ninety-seven athletes represented the US in those Games, of which 67 (11.2%) were described as having exercise-induced bronchospasm. Twenty-eight of the 67 (42%) were female. The diagnosis was made on the basis of a history of asthma (in 26 athletes), use of a bronchodilator (in 41 athletes), request to the International Olympic Committee for approval of medications (in 13 athletes), and a history of chest tightness, wheezing, or cough related to strenuous exercise (in 42 athletes). About 90% of the 67 athletes diagnosed as having exercise-induced asthma were identified by their responses to an extensive questionnaire that was given to the athletes to be completed at the time of the Olympic Trials. A few of the athletes were also subjected to exercise challenges. The key questions from the 1984 questionnaire were also included in the 1996 USOC Medical History Questionnaire.

Of the 67 athletes identified in the Voy study, 41 won medals¹ ; 15 were awarded gold, 21 silver and 5 bronze medals. It is not clear how many nonasthmatic athletes won medals nor was it clear how many asthmatic athletes won more than 1 medal. We do know from this study that only 35 of the 67 athletes identified as having exercise-induced asthma were diagnosed before the Games as having asthma. Voy’s study differed from ours in the following ways: (1) the major focus in his study was on exercise-induced asthma; (2) the criteria to make the diagnosis of exercise-induced asthma were less specific (a history of asthma, use of a bronchodilator, request to the International Olympic Committee for approval of medications, and history of chest tightness, wheezing, or cough related to strenuous exercise) than were the criteria to make the diagnosis in this study (a history of asthma or use of an asthma medication); (3) Voy’s criteria depended on a self report of symptoms rather than a self report of a diagnosis as we required; and (4) although an extensive questionnaire was used in 1984, that instrument was not the official medical history questionnaire that athletes were required to complete as was the case in 1996. Therefore we cannot directly compare data from 1984 with data obtained by us in 1996. In our study athletes who recorded positive responses to questions 6, 7, 10, 11, 12, or 14 were not identified as having asthma unless they also listed an asthma medication or responded that they had been told that they had asthma. If we also included these questions and allowed a positive response to make the diagnosis of asthma, then we might have been able to conclude that more than 20% of the athletes who participated in the 1996 Summer Olympic Games had asthma.

Past reports suggest that about 90% of patients with chronic asthma will be triggered to have an exacerbation of symptoms associated with exercise.⁹ An additional group, of perhaps 7% of an unselected population, would also be expected to have asthma associated with exercise but not chronic asthma.⁹, ¹¹ Taken together, these observations suggest that an even higher percentage of the athletes who participated in the 1996 Summer Olympic Games would have had exercise-induced asthma than we identified as having asthma .

With this report we now have data from US athletes who participated in 2 Summer Games in 1984 and 1996. These studies suggest that at least 1 of every 6 US Olympic athletes has a history of asthma, a history of taking asthma medications, or both, and about 1 in 10 has active disease. Some high-profile Olympic athletes who have asthma have received extensive publicity as a result of their achievements, including Amy Van Dyken, Tom Dolan, and Jackie Joyner-Kersee, who are 3 of the 117 asthmatic athletes who participated in the 1996 Summer Olympic Games.¹²

Studies should be undertaken to examine the prevalence of asthma in athletes who participate in future Olympiads, especially Winter Olympic Games. For now, it remains important for young asthmatic athletes to recognize that asthma need not prevent them from achieving success even at the highest levels of competition.

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References 

1. Voy RO, The US. Olympic Committee experience with exercise-induced bronchospasm, 1984. Med Sci Sports Exerc. 1986;18:328–330
   • View In Article
   • MEDLINE
   • CrossRef
2. Weiler JM, Metzger WJ, Donnelly AL, Crowley ET, Sharath MD. Prevalence of bronchial hyperresponsiveness in highly trained athletes. Chest. 1986;90:23–28
   • View In Article
   • MEDLINE
   • CrossRef
3. Huftel MA, Gaddy JN, Busse WW. Finding and managing asthma in competitive athletes. J Respir Dis. 1991;12:1110–1122
   • View In Article
4. Rupp NT, Guill MF, Brudno DS. Unrecognized exercise-induced bronchospasm in adolescent athletes. Am J Dis Child. 1992;146:941–944
   • View In Article
   • MEDLINE
5. Larsson K, Ohlsén P, Larsson L, Malmberg P, Rydström P-O, Ulriksen H. High prevalence of asthma in cross country skiers. Br Med J. 1993;307:1326–1329
   • View In Article
6. Mannix ET, Farber MO, Palange P, Galassetti P, Manfredi F. Exercise-induced asthma in figure skaters. Chest. 1996;109:312–315
   • View In Article
   • MEDLINE
   • CrossRef
7. Guidelines for the Diagnosis and Management of Asthma. National Asthma Education Program, Expert Panel Report. Bethesda (MD): National Asthma Education Program, Office of Prevention, Education and Control, National Heart, Lung, and Blood Institute, National Institutes of Health; 1991 Aug; Publication no.: 91-3042
   • View In Article
8. Evans R. Epidemiology and natural history of asthma, allergic rhinitis and atopic dermatitis. In: 4th ed.  Middleton E,  Reed CE,  Ellis EF,  Adkinson NF,  Yunginger JW,  Busse WW editor. Allergy: principles and practice. St. Louis: Mosby; 1993;p. 1116–1118
   • View In Article
9. Weiler JM. Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence, and treatment. Allergy Asthma Proc. 1996;17:315–325
   • View In Article
   • MEDLINE
   • CrossRef
10. Fitch KD. Management of allergic athletes: management of allergic Olympic athletes. J Allergy Clin Immunol. 1984;73:722–727
    • View In Article
    • MEDLINE
    • CrossRef
11. Bierman CW, Kawabori I, Pierson WE. Incidence of exercise-induced asthma in children. Pediatrics. 1975;56(suppl):847–850
    • View In Article
    • MEDLINE
12. Peter MM, Thompson FL, Silvers WS, Weiler JM. Case studies of asthma in elite and world-class athletes: the roles of the athletic trainer and physician. In:  Weiler JM editors. Allergic and respiratory disease in sports medicine. New York: Marcel Dekker; 1997;
    • View In Article