Contact: Rich Killingsworth, MPH, CHES Physical Activity Interventionist Centers for Disease Control 770-488-5481Hyperthermia and Dehydration-Related Deaths Associated with Intentional Rapid Weight-Loss in Three Collegiate Wrestlers North Carolina, Wisconsin, and Michigan
During November 7 - December 9, 1997, three previously healthy collegiate wrestlers in different states died while each was engaged in a program of rapid weight-loss to qualify for competition. In the hours preceding the official weigh-in, all three wrestlers engaged in a similar rapid weight-loss regimen that promoted dehydration through perspiration and resulted in hyperthermia. The wrestlers restricted food and fluid intake and attempted to maximize sweat losses by wearing vapor-impermeable suits under cotton warm-up suits, and doing vigorous exercise in hot environments. This report summarizes the investigation of these three cases.
Case Reports
Case 1. During November 6 - 7, over a 12-hour period a 19-year-old man in North Carolina attempted to lose 15 pounds to compete in the 195-pound weight class of a wrestling tournament scheduled for November 8. His preseason weight on August 27 was 233 pounds and during the next ten weeks he lost 23 pounds. From 3:00 p.m. to 11:30 p.m. on November 6, using the weight-loss regimen described above, he lost an additional 9 pounds. After a 2-hour rest, he resumed his weight-loss regimen on November 7 at 1:45 a.m. At approximately 2:45 a.m., he stopped exercising, but began to experience extreme fatigue and became incommunicative, and in the following hour, he developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained seven hours after death were sodium, 152 [normal postmortem: 135-151] mmol/L; urea nitrogen, 40 [normal postmortem: < 40] mg/dL; urine myoglobin was <20 [normal antemortem: 0-40] ng/mL; creatinine results were unavailable. Anatomic findings from the autopsy were insufficient to determine the cause of death.
Case 2. On November 21, over a 4-hour period, a 22-year-old man in Wisconsin was trying to lose 4 pounds to compete in the 153-pound weight class of a wrestling tournament scheduled for November 22. His preseason weight on September 6 was 178 pounds and during the next 10 weeks he lost 21 pounds, of which 8 pounds were lost during November 17-20. At 5:30 a.m. on November 21, he initiated the same weight-loss regimen as in case 1. An hour later, he complained of shortness of breath but continued exercising. By 8:50 a.m., he had lost 3.5 pounds. He drank approximately 8 ounces of water, rested for 30 minutes, and resumed exercise. At 9:30 a.m. he stopped exercising and indicated he was not feeling well. Efforts were made to cool him, and his clothing was removed. He soon became unresponsive and developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in antemortem blood were serum sodium, 161 [normal: 136-145] mmol/L; urea nitrogen, 34 [normal: 7-18] mg/dL; and creatinine, 5.0 [normal: 0.8-1.3] mg/dL. Serum myoglobin was >5000 [normal: 0-110] ng/mL. Rectal temperature was 108 F (42 C) at the time of death. The autopsy report cited the cause of death as hyperthermia.
Case 3. On December 9, over a 3-hour period a 21-year-old man in Michigan was attempting to lose six pounds to compete in the 153-pound weight class of a wrestling meet scheduled for December 10. His preseason weight on September 4 was 180 pounds. During the next 13 weeks he lost 21 pounds, of which 11 pounds were lost during December 6-8. On December 9, between 3:30 p.m. and 5:00 p.m., he lost 2.3 pounds and weighed 156.7 pounds. After wrestling practice, he initiated the weight-loss regimen as in case 1; after 75 minutes, he lost an additional 2 pounds. After a 15 minute rest, he resumed exercise. Approximately 1 hour later, he stopped exercising to weigh himself and demonstrated fatigue. A few minutes later, his legs became unsteady, he became incommunicative, and breathing difficulty was observed. Attempts to administer fluid orally were unsuccessful, and he soon developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained 4 hours after death were sodium, 159 [normal: 136-146] mmol/L; urea nitrogen, 31 [normal: 8-20] mg/dL; and creatinine, 0.7 [normal: 0.9-1.3] mg/dL. Urine myoglobin was 4280 [normal: 0-45] ng/mL. The autopsy report cited cause of death as rhabdomyolysis.
Reported by: Daniel Remick, M.D., University of Michigan, Ann Arbor, MI. Karen Chancellor, M.D., North Carolina Department of Health and Human Services, Raleigh, NC. John Pederson, M.D., Franciscan Skemp Healthcare, LaCrosse, WI. Edward J. Zambraski Ph.D., Rutgers University, Piscataway, NJ; Michael N. Sawka, Ph.D., and C. Bruce Wenger, M.D., Ph.D., U.S. Army Research Institute of Environmental Medicine, Natick, MA. Office of Regulatory Affairs; Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration. Division of Environmental Hazards and Health Effects, National Center for Environmental Health; Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Editorial Note:
This report presents the first identified deaths in collegiate wrestling, and the first deaths associated with intentional rapid weight-loss in interscholastic or collegiate wrestling since national record keeping began in 1982 (1). Many coaches and wrestlers believe that wrestlers should compete at a weight category lower than their preseason weight to maximize their competitive advantage (2,3). To reach their competition weight, many wrestlers achieve rapid weight-loss by dehydration through such practices as vigorous exercise, fluid restriction, wearing vapor-impermeable suits, using hot environments (saunas, hot rooms, steam rooms). More extreme but less common measures include consuming diuretics, emetics, laxatives, and self-induced vomiting (2,3). A combination of these practices are often used during the days that precede each competition (4). Alone or in combination, these practices may adversely affect cardiovascular function, electrical activity, thermal regulation, renal function, electrolyte balance, body composition, muscular endurance and muscular strength (3,5,6).
Vigorous exercise and dehydration increase body temperature, which is further increased by use of vapor-impermeable suits that decrease evaporative and convective heat loss. In the three cases presented in this report, all three wrestlers used vapor-impermeable suits and exercised vigorously in hot environments. These conditions promoted dehydration and heat illness (3,5,6). In all three cases, elevated sodium and urea in antemortem blood or postmortem vitreous fluid showed clear evidence of dehydration. The exercise regimen, the elevated rectal temperature in case 2, and the findings of rhabdomyolysis and myoglobinuria in case 3 indicate that hyperthermia contributed to these deaths (6,7).
Among the three wrestlers, the difference between their pre-season weight and their goal weight for competition was 30 lbs. (range 25-37 lbs.), or approximately 15% of total body weight. Among collegiate wrestlers, the difference between pre-season and competitive weight averages approximately 16 pounds (5), or approximately 10% of total body weight (4). These cases highlight the extreme extent of absolute and relative weight loss. Under such conditions, particularly when dehydration is involved, there are no established limits for safe weight loss.
To ensure fair and safe competition, wrestlers compete within defined weight categories. At the time of these deaths, existing NCAA guidelines recommended that the rapid weight-loss behaviors associated with these deaths be prohibited (8). Using practices contrary to the guidelines, all three wrestlers, while under the supervision of athletic staff, attempted to lose unsafe amounts of weight in a short period of time. The findings in the three c