The recent exchange of promising young referees between the Spanish Federation and Northern California had impacts beyond those felt by the fortunate few young referees at the center of the program. Among the benefits to our referee community were reminders from the Spanish staff and our own Brian Hall that referees must regard themselves as athletes.

In Brian’s talk he described some of the training he went through in preparation for his participation in WC 2002. As with the other referees selected for the competition, his individual training was directed by FIFA, particularly Dr. Werner Helsen Director of the UEFA Top-Referees’ physical training program and Jean-Baptist Bultynck. In addition to maintaining written journals of their training, each referee used a heart monitor. This data was then downloaded to FIFA via the internet. Helsen and Bultynck then evaluated the data, so that they could individualize the referees training and determine which referees were in the best physical condition. Emphasizing the importance of his physical preparation, Brian commented that he had never before been as tired as he was from working as the center referee at the World Cup

As is increasingly the case among the European federations, the Spanish Federation is very serious about the physical training of its referees. Their delegation included both a physical trainer (Javier Navarro who was a sprinter at the Atlanta Olympics) and the sports medicine physician (José Casajús, MD, PhD) who is in charge of the medical aspects of the Spanish referee training program.

In my next article I will discuss physical training in much greater detail. This will include what we know about the physical demands placed on referees, differences between assistant and center referee and training regimens to meet those demands. Through contacts with referee training staff from the Spanish, Italian and English federations as well as UEFA and FIFA staff, I have been learning what these experts recommend to elite referees. While sharing some of that information with you, my hope is to provide you with recommendations that will adapt to your own level of fitness to help you achieve your best as a referee.

The remainder of this article will focus on more fundamental good health habits for referees. I strongly agreed with the advice offered by Dr. Casajús who told us that basic health habits are essential and must not be neglected. His expertise transends his professional medical experience. For 12 years he played for Zaragosa in La Liga.

Proper hydration is extremely important. Essentially every major sports medicine group and many nutritional, governmental and soccer organizations have issued guidelines about fluid intake and sporting events. Each of these strongly encourages fluid intake as fundamentally important to safe participation and optimal athletic performance. In addition, there is substantial evidence in the medical literature that chronically low water consumption is linked to increased rates of a variety of cancers and heart disease. In my medical practice I often see patients with chronic infections, fatigue and certain kinds of heart irregularities all helped or even cured by increasing their fluid intake so I believe this to be true.

Fluid loss during exercise can be considerable. Adult soccer players commonly lose 5-10 pounds playing one game. This is almost entirely fluid loss (roughly 5-10 quarts). Referees often work back to back games with limited time to rehydrate. Extensive research shows that physical and mental performance declines by 2% fluid loss (2 lbs or 2 quarts per 100lbs of body weight). At the same time, it appears that most people don’t feel thirsty until they pass 2% dehydration. We also have some evidence suggesting that the bodies of many people who have been athletic since childhood lose more fluid than others and are then less aware of the loss (or more accustomed to pushing on while ignoring their need?). Early in the season or when the first heat spell arrives, under-trained individuals will lose more body water and more electrolytes (sodium, potassium and possibly magnesium) adding to their physical stress.

In addition to the acute fluid losses, many Americans start out in a hole. Some claim that as many as 80% of Americans are chronically dehydrated. Again, my clinical experience supports that contention, although the dehydration is usually mild. In any case, starting out already dehydrated and then walking out onto a soccer field in hot weather when you are even a bit out of shape is a needlessly risky and unpleasant endeavor. Don’t do it.

As Shakespeare wrote in Romeo and Juliet, anything which can help, also carries the power to harm. While the preceding facts highlight the importance of attending to your fluid intake, just simply guzzling every liquid in sight is not a good idea. Too much water can kill. Around a dozen Americans die each year from slavishly drinking water to excess during prolonged athletic activity in hot climates. They lose a large amount of electrolytes in their perspiration and, by drinking large amounts of plain water, dilute these salts even further leading to hyponatremia and death. Despite these extremely unfortunate examples, we know well that proper hydration by habitually consuming adequate fluids and then working diligently to replace fluid loss with "sports type" drinks during activity is very important in preventing heat stress.

The first principle of managing your fluids is to avoid chronic dehydration. Don’t start out in a hole. Plain water is the best. Alcoholic beverages make you lose body water. The medical literature is divided over the dehydrating effects of caffeine containing drinks. The official Mayo Clinic recommendation (http://www.mayo.edu/comm/mcs/news/news_754.html) is to take your weight in pounds, divide by two and that equals the number of ounces of fluid to drink every day. This requirement is increased with exercise or hot weather.

We do know that drinking fluids during athletic events longer than 30 minutes improves performance. We also know that the type of fluid consumed during exercise makes a difference. This is because different fluids are absorbed at different speeds, certain nutrients make you want to drink more and some nutrients strengthen you by replenishing those you have lost.

During exercise you usually can’t absorb fluids anywhere near as rapidly as you lose them. So, what sort of fluids are most rapidly absorbed? Cool drinks and drinks that contain 5 – 9% carbohydrate by weight. Not juice or sodas. They are too sweet and while a certain amount of sweetness (carbohydrate content) helps your body absorb it, too much will slow it down.

The electrolyte you lose most when you sweat is sodium. Replenishing the bodies store of sodium is a good idea theoretically. In practice we are certain that drinking fluids with sodium is a good idea because people will drink nearly twice as much of a salted drink than an unsalted one. When you buy a sports drink look for sodium around 50 – 125 mg/8 oz. Some of us lose more, so if your sweat is salty and burns your eyes, look for drinks at the high end or even add a bit of salt (1/4 tsp/quart). Gatorade used to provide GatorLytes packets containing extra sodium, some potassium and magnesium to the teams they sponsored.

Some suspect that additional potassium and magnesium might be helpful. However, research to date does not support this theory. There is some early research evidence that a small amount of protein in the drink speeds absorption and helps performance. The only research I have seen thus far was conducted with funding from a company that holds a patent on adding protein to sports drinks though, so in my opinion, the jury is still out on this one.

Another bit of advice is that immediately after exercise your body sponges up nutrients extremely efficiently for the first 45 minutes to an hour. Especially in a stressful situation (tournament or recent illness or too much recent celebration) it is wise to use that window of opportunity to catch up quickly.

Bottom line advice:

1- Avoid dehydration before exertion

2- If you are thirsty you are way behind already

3- Drink 16 - 24 oz of water 2 - 3 hours before competition.

4- Drink 16 - 20 oz of water or a sports drink one hour before competition

5- Drink 8 oz of a sports drink every 15 minutes during competition

6- Drink right after the game

7- Adjust to the weather and how much you are sweating

8- To really do it right, drink 16-24 oz for every pound lost

Drink enough to keep your urine almost clear

 

In addition to its decorative function (BTW I do like blue more than black, yellow or red), clothing protects us from the elements. Wearing appropriate clothing can be a significant health consideration for referees. Growing up in Minnesota in the city reputed to be the coldest "big" city in the world, I (like all others who survived into adulthood) learned that you have to prepare for the weather.

The cold side of the equation is the simplest. It is much easier to stay warm than to re-warm, so bundle up. The newer moisture-wicking fabrics have a place in cold weather and may even be more important than in the heat. Those of us living in the SF Bay Area, or elsewhere in cool damp climates, are sympathetic to Hemmingway’s observation that the coolest winter he ever experienced was a San Francisco summertime. Hypothermia is most common in rainy weather with temperatures in the 30s and 40s. Keep dry and bundle up.

Problems with the heat seem to be the bigger complaint among referees. Certainly high temperatures force changes in game schedules more frequently than cold weather. Heat illness can take many shapes including heat cramps, heat syncope, heat exhaustion and heat stroke.

The name "heat cramps" is a bit misleading. It is misleading because the main problem actually appears to be fluid and electrolytes rather than heat. On the other hand, hot weather does contribute so the term persists. Fluids usually prevent and treat this problem. Some attribute heat cramps to inadequate calcium (fairly common in the USA) or to shifts of magnesium in the body due to perspiration losses. Potassium and sodium are the most important electrolytes in the treatment and prevention of this condition. One of my favorite sports medicine authorities, hematologist and University of Oklahoma team physician Randy Eichner recommends tomato juice for breakfast and pickle juice for acute treatment of heat related leg cramps.

Fainting in the heat, "heat syncope" usually happens when the weather has just turned hot to people with a tendency to faint. As we adjust to the heat the volume of our blood expands. It takes a while to drink enough water to increase the blood volume so, once again; the key is drinking more to prevent the problem. HOWEVER, very serious problems like heat stroke can look very similar. So, assume the worst and seek medical care immediately.

Heat exhaustion is the next step up the hierarchy of severity. Its symptoms of fatigue, mild confusion, headache and dizziness are far too familiar to too many. When you get to the point of experiencing chills on a hot day, the fact that you have exceeded your limits should be obvious. The key to treatment and prevention is getting out of the heat and lots of cool fluids.

Although heat stroke is very rare it kills hundreds of people every year in the USA. A significant number of those deaths are the result of exertion-induced heat stroke. Confusion is the hallmark symptom. These individuals often stop sweating despite the heat. Seizures, internal bleeding and death result. Immediate cooling and emergency medical care are essential.

The treatment of all of these conditions revolves around doing what should have been done before. Cooling the patient. Getting out of the sun. Cool towels. Cool fluids but not plain water.

Other treatments, including proper clothing, can help prevent these evils and certainly will prevent other sun-induced problems. Clothing varies in its ability to block damaging ultraviolet radiation. I have yet to see any SPF ratings on ref jerseys though. With all due humility and apologies to FIFA, allowing referees to wear hats would help reduce the very high risk we have for skin cancers and model sun protection to youth athletes.

Invisible sun protection includes sunscreens and certain vitamins. Ironically, we have data that most sun screening chemicals are themselves carcinogenic or allergenic and none of them protects entirely. Covering up is better. The best sunscreens contain micronized zinc oxide (clear) or titianium. Frequent reapplication is essential (something else to do at half time). There is evidence that oral vitamin C and E protect against sun damage. Also stabilized topical vitamin C appears to repair some cancer-causing skin damage created by the sun, so applying it after sun exposure is a good idea.

Some of the best research on heat illness and soccer has come from the medical staff at the USA Cup youth soccer tournament in Minnesota where they have maintain records on illness and injury correlated with weather conditions since 1988. Dr Elias, Medical Director of the tournament learned that the general injury rate increased over four fold when the weather was unusually hot and that females were more vulnerable to the heat.

I referee at this tournament regularly and, hoping to learn more about how this very busy clinic coped with heat illness, several years ago I dropped in the day before the tournament began. After asking a question about how they determined the risk from the weather conditions, the next thing I knew Dr. Elias was dragging me up three stories through the roof of the building to inspect his data collection devices. In 1957 the Marine Corps developed a measure called the Heat Index (or WBGT) which includes wet bulb, dry bulb and black globe temperatures thus accounting for temperature, humidity and reflected sunlight. At the USA Cup they have developed participation guidelines based upon WBGT military data and their own measurements and experience. With 55 fields in action, disseminating information to officials can take considerable time. To overcome this problem, they fly flags dictating the response to the weather conditions to make the tournament as safe as possible.

Although the low humidity in Northern California summers tempers conditions, heat stress is still a significant problem and one that is under-recognized by youth tournament officials. While adults complain more loudly about the heat, generally speaking, children are actually more vulnerable. If any of you want to learn of simple tools you can carry in your bag to approximate the heat index please contact me (michael@carlstonmd.com). You can also go to Thermal stress see http://www.zunis.org/chartroom.htm to find average heat stress for your area.

Unfortunately referees have the sterotype of being fat, old and poorly conditioned. More unfortunately the sterotype is too "widely" supported by reality. First impressions are important. You know that players are more likely to respect you if your shirt is tucked in and you don’t look like you just fell out of bed. In the same way, when players see a spare tire hanging around your middle, you are going to have to prove that you take your responsibility to their game seriously.

More important than impressions is the simple fact that you can’t do a good job as a referee if you are much fatter than the players in the games you officiate. As soccer is a sport demanding physical endurance, carrying even a few extra pounds around for mile after mile adds up to quite an unnecessary burden.

To be fair, everyone in America has been getting fatter, not just soccer referees. Obesity levels have soared in the past 20 years and in medicine it is considered a public health crisis. While players at the top levels are heavier than in the past, this appears more the result of weight training. They have improved their sprint speeds and thus made our job even tougher.

Ignoring soccer for a moment, weight control has "massive" impacts on your health. We use a number called the body mass index (BMI) to most accurately gauge your risk of disease. 24 and below is considered healthy. However, even at a BMI of 24 your risk of developing diabetes is 4 – 5 times higher than it is at a BMI of 21. Compared to the "healthy" BMI of 24, people with a BMI of 28 are 2-4 times as likely to develop gall stones, high blood pressure and other heart disease.

To calculate your BMI:

Weight(lbs) x 703/height(inches) x height(inches)

For example I am 5’10" and 170 lbs so:

170 x 703 = 119,510

70 x 70 = 4900

119510/4900 = 24.4

My BMI is a little bit higher than I would like so I am working on it.

Below are examples of weights that equal BMI of 24 at certain heights.

BMI 24 = 5’ 123 lbs

5’4" 140 lbs

5’ 8" 158 lbs

5’10" 167 lbs

6’ 177 lbs

6’2" 186 lbs

6’4" 197 lbs

You can also go to http://www.nhlbisupport.com/bmi/bmicalc.htm and enter your weight and height. There are slight refinements of this formula. One says that, due to hormone induced higher body fat, women should weigh around 3% less. Others take into account waist measurements advising greater attention for men with a waist measurement over 40 inches and women over 35 inches. People with a lot of muscle can have a higher BMI without increased risk. For example, many MLS players have a BMI of 24. Even Manny Lagos of San Jose, who looks thin to many, has a BMI of 22.

How to lose weight gets more complicated. Despite our governmental recommendations to cut dietary fat two decades ago, Americans have gotten fatter. Some believe that there is a cause and effect linkage between that recommendations and the subsequent weight gain. I admit that over the past 35 years of watching how people lose weight, the dietary change that seems to work the best for most people is focusing on healthy protein consumption. Please understand that I became a vegetarian in Minnesota in 1970 so I am not beholden to the beef lobby. I do not recommend any extreme diets. You should consult with your own physician if you have any significant health problems. Unfortunately most physicians have received little training in nutrition. Although this curricular deficiency is improving, I recommend that you either do some research on your own or seek out a physician who has more knowledgeable in the topic.

Some carbohydrates make the blood sugar rise rapidly and then fall just as quickly. These foods make the body less responsive to insulin leading to weight gain. This blood sugar change is measured by a number called the glycemic index. While high glycemic index foods are great for youth players in the midst of a tournament they are bad news for referees the day after the tournament. Go to http://www.glycemicindex.com/ or read any of the popular books by J Brand-Miller who has done much of the scientific research on the glycemic index. Proteins and fats carry many calories but as they don’t send the blood sugar bouncing up and down it is easier to control your calorie intake when you limit the carbohydrates.

Don’t let your weight be a drag!

Although I will save most of my comments on physical training for next time, I would like to give you some brief advice about stretching. Stretching is one of those topics which brings up the old saw about there being three kinds of lies – lies, damned lies and statistics. While almost "everyone knows" that stretching is good for you, medical research is all over the map. Some studies show a very positive effect and others show no benefit and still others show that stretching increases injury rates.

As I moved to the old men’s leagues I saw that the players who were older than me all carefully warmed up before the games and usually stretched before and/or afterwards. Over the years the old men that didn’t take of themselves had to quit playing. It was clear that warming up and stretching were helping keep the other guys on the field.

As I began to referee more and more I developed a heel problem which all of my sports medicine training told me should be treated with aggressive stretching. It didn’t help. After it progressed for a year or two, I traveled back to Minnesota for another USA Cup. While there, I visited with one of my closest friends, who was a volunteer physician at the tournament. He noticed my limp, asked about my symptoms, told me I really had to stretch, and explained how to do so. Not wanting to ignore advice from such a knowledgeable source, I did exactly what he told me and got much worse. In my nearly forgotten youth I was a yoga teacher. Unwilling to accept failure, I thought my problem through that yoga stretching experience as well as my decades in medicine. An idea came to light that worked for me and I have since confirmed many times with patients.

When you stretch it is very important how you go about it. Warming up is essential. Do not stretch too hard. Stretch so that you feel a pleasant tension and hold the stretch for at least 30 seconds (sometimes as long as 5 minutes might be necessary). My recognition was this – people tend to stretch so that they feel the pull at the place they feel the discomfort. That is usually a mistake. Muscles attach to bones by tendons. Inflammed tendons cause lots of problems and can be helped by stretching the muscle which then relaxes and reduces the pull on the tendon’s attachment to the bone. Inflamed tendons can be made much worse by pulling on them with stretching. As tendons attach muscles to bones at the joints, if you stretch so that you feel the tension in the body of the muscle and NOT AT THE JOINT stretching is much more effective and much less likely to make you worse.

My most important advice about stretching is to pay attention to how you feel. If you walk off the field, climb into your car, drive 45 minutes and then need help from the neighbors to climb back out of the car, you did something wrong. Learn from your experience.

My profession has a well-deserved reputation for conservatism. It isn’t wise to don’t onto every bandwagon. Unfortunately that sometimes means that we get left behind. Despite a mountain of research documenting vitamin and mineral deficiencies in this land of plenty, as well as considerable additional research showing that supplementation beyond the RDAs reduced disease, medicine has been slow to recognize the wisdom of taking vitamin and mineral supplements (we always said they just made for expensive urine). That age passed this past summer with the recommendation in the Journal of the American Medical Association that all adult Americans take a multiple vitamin supplement.

As we eat more highly processed foods and over use the soils the level of nutrients in the foods we consume declines. Additionally, the wild plants eaten by our ancestors were often much more nutrient rich than the cultivated and hybridized plants we eat today. One researcher recently analyzed the wild plants eaten by chimpanzees and learned that the average 12 pound chimp was getting over 600 mg of vitamin C from its daily food. Maybe Linus Pauling was right again.

It is always best to look to a diverse diet made up of good quality foods as the principle source of nutrition but taking a multiple vitamin with minerals is also an excellent idea. What should you look for? Look for nutrients that are as natural and close to food source as possible. The reason for this is that apparently there are differences between the effects of dietary consumption of vitamins and synthetic forms. For example high dietary consumption of beta carotene reduces risk of lung cancer but taking synthetic beta carotene instead increases the risk. It may be the synthetic form of the vitamin or some other missing nutrient explains this conundrum. So, looking for natural mixed carotenoids (there are alpha, beta, gamma, delta etc carotenoids) and natural E is important. Selenium reduces risk of several cancers quite significantly (eg 200 mcg of selenium lowered risk of prostate cancer by 40% in one study). Human beings assimilate minerals more rapidly when they are bound to proteins so this makes the good pills bigger than the little ones. Sorry, one pill a day won’t cover it. Because biotin is an expensive ingredient and most people don’t know what it is, manufacturers who are trying to cut corners don’t put much in. Low levels of biotin (under 200 mcg) is a tip off that the manufacturer might be cutting corners in other ways as well. Population studies tell us that many of you don’t get enough zinc in your diet and that around 10-20% of the women reading this have low body store of iron. That will significantly impair your athletic performance. Dietary requirements and typical intake of many nutrients change with age – for example, young women are usually quite deficient in calcium and the need for Vitamin D and B12 increases for "senior" referees.

While anything you do to take care of yourself should improve your performance, there is more controversy and uncertainty about "performance enhancing" supplements that step beyond an ill-defined line. Few adult Americans would willingly abstain from a performance-enhancing drug with perhaps the most substantial body of research evidence proving its effectiveness - coffee. Two performance-enhancing (ergogenic) supplements commonly used in soccer are L-carnitine and creatine.

L-carnitine is a simple substance, created by the body with functions essential to energy metabolism. Although many believe the body makes exactly as much as it needs, we also get L-carnitine in the diet in meat, fish and dairy products. L-carnitine deficiency is associated with heart failure, a common killer of elderly Americans. Although L-carnitine shifts around in the body during exercise misleading some to believe that exercise creates deficiencies, we know this is not true. Some think that taking more will help athletic performance however, at the present time, research findings do not support this idea.

This now leads to another discussion point. As we often, or even usually, lack definitive proof of efficacy, decisions must be made in relative ignorance. In such cases, I usually start by considering the ill effects of the proposed treatment and then the likelihood of effect based upon the experiences of users.

Studies of L-carnitine for up to one month in high doses have not disclosed any significant adverse effects. There is little reason to believe that it should have any significant adverse effects. It may be reasonable for those who eat little in the way of meat, fish and dairy products to consider experimenting with L-carnitine. The typical dose of L-carnitine is 2 grams/day. The other form, its optical isomer D-carnitine is biologically inactive.

The story on creatine monohydrate is similar only different. The similarities are that the body does make some, vegetarians get little or none in their diet and the adverse effects do not seem to be important. The biggest difference is the proof that it works. Creatine monohydrate enhances sprint performance (running, cycling, swimming) and weight lifting. It increases lean body mass (ie muscle mass). Back in the early days of the Soviet Gold Medal Machine, creatine was one of the secret supplements. A positive "side effect" was seen in some studies were creatine supplementation improved blood lipids (cholesterol family).

Suspected adverse effects of creatine from reports of users are abdominal distress, muscle cramping and dehydration. However, research to date does not support the contention that any of these are a result of creatine. There have been very rare reports of temporary adverse effects on kidney function but many more studies have shown no effect at all. An important issue might be the purity of the creatine. Due to the amounts taken, users can be exposed to relatively large amounts of impurities present at low concentrations. So users should look for claims of purity on the label like "100% pure," "99% pure," or "Dicyandiamide Free." Unfortunately such claims on the label might not be reliable. One of the most highly regarded testing organizations, ConsumerLab.com, found that one of the 13 creatine monohydrate samples submitted to them for testing was contaminated with dicyandiamide despite the otherwise labeled assurance.

My experiments with creatine over the years have been encouraging. The science indicates that it should work by building the user up to a certain threshold level of body creatine and also to replenish that supply. Anecdotally the best time to use it is during a time of increased explosive training (ie weight work or sprint training). It is most likely to help vegetarians. Until we know more, people with kidney disease should avoid it.

Traditional use of creatine monohydrate is 20 grams a day for 5 days for loading and then 2 grams daily for maintenance. Alternatively, the loading phase can take place over 6 weeks using 3 grams a day followed by the maintenance dosage.

Older referees, as well as younger ones who have sustained serious joint injuries, might want to consider using glucosamine sulfate (GS). Adding to the experience of many clinicians and patients, research is accumulating that shows GS reduces pain of osteoporosis. More impressively, research also shows that GS appears to help the body rebuild the damaged joint tissue. The pain relief from GS is much slower (weeks instead of hours) than that afforded by anti-inflammatory medications (Aspirin, ibuprofen, Motrin, etc, etc) or acetaminophen (Tylenol). On the other hand, some studies have shown that all of the others, except Tylenol, may further damage the joint tissue. At this point in time, it is reasonable to try GS first, especially because of the potential for healing not just pain relief. While I recommend the usual 1,500 mg dose of GS, after a few months many patients have been able to reduce the dosage and still do well. As chondroitin is digested into GS it is unlikely to add additional benefit, may add risk (derived from ground beef lung and joint tissue) and certainly adds significant expense.

One of my many favorite quotes about this game is from one of its greatest players Johann Cruyff who said "Football is a game you play with your brain". His truism is no less truthful for referees. You must be attentive, wise, physically exceptional with the equanimity of saint, while all others have lost their heads (and might be eager to remove yours as well). No easy task.

As none of us can achieve that perfection any more than can a player (or a coach), we must be philosophical about failure. At the same time, we cannot be complacent and must strive for that perfect game.

Too many referees try to do too many games. Yes, I know the argument "Well if I don’t do the game no one will". That may be true, but it may be that some bystander, a nascent Collina, may realize the need and step onto the pitch. If not, the players might be more appreciative of your fallible efforts next time. The additional rest might help you do a better job as you learn to perform within your abilities.

The point of this section is simply to remind you to be aware. Please recognize the need to develop yourself mentally and emotionally as well as physically to do the best job you can out there. Experience is undoubtedly the greatest teacher. Learn from your experience because no one knows more about you than you.