The tipping point was blood.
When your talents for hand-to-hand combat put food on the table and shelter overhead, the sight of your own blood usually isn’t enough to make a memory. Jim Miller remembers this particular sighting, though, because he hadn’t fought in months. And the blood was in his urine stream.
“I was peeing blood,” Miller said. “And my kidneys hurt.”
Soon after, Miller, a professional mixed martial artist in the UFC, learned he had kidney stones. On top of that, about a year earlier, he had suffered a full-blown kidney infection. The cause of these problems? Damage inflicted on the organs by the process of cutting weight.
“I think it has definitely had an effect on my body,” Miller said of weight cutting. “It’s something I don’t feel today, but I wouldn’t be surprised if it took a couple years off my life.”
In combat sports like MMA, wrestling and boxing, weight cutting is as common as heavy bags and ankle tape. The practice entails losing large amounts of weight, mostly through deliberately and aggressively dehydrating oneself, over the course of about a week. The goal is to meet the threshold of a certain weight class and then massively rehydrate between the official weigh-in and the fight in order to gain a maximum size advantage over an opponent.
Because weight cutting shares a risk-impact chart with brain injuries and performance-enhancing drugs, it usually assumes a backseat in the safety discourse. After all, its cause-and-effect cycle doesn’t play out under bright lights or in highlight reels or summer-movie physiques. It happens in the world’s grayer areas: the hotel bathroom, the low-lit sauna, the early-morning fitness room, before the conventioneers arrive, a hooded figure hunched over the wheels of a rapid-firing stationary bike.
But weight cutting is every bit as dangerous as the better-documented risks that combat sports present. In fact, the day-to-day familiarity of the practice may have spawned a counterproductive sense of complacence. In the two sports for which cutting weight is the largest problem—amateur wrestling and MMA—it may be the most insidious danger of all. And according to doctors, regulators and fighters, it’s only getting worse.
Fortunately, there are solutions. The key is finding the right ones—and the will to put them into motion.
“This is the biggest problem in combat sports,” said Andy Foster, executive officer of the California State Athletic Commission. “Five or 10 percent of people are doping. The number of people dehydrating is much, much higher… [Weight cutting is] a traumatic event. Then the very next day, you combine that with another traumatic event, and that’s called a fight. Combine these two things, and you’re just asking for trouble.”
According to a 2013 study published in the Journal of Strength and Conditioning Research, 39 percent of MMA fighters compete while significantly or seriously dehydrated. (Although it’s impossible to determine the percentage of MMA fighters using PEDs, it stands to reason that the number is declining in light of the UFC’s aggressive new drug-testing policies.)
Specific formulas vary from person to person or team to team, handed down from teacher to pupil like old family recipes. In general, though, a cut can include days of total fasting or severely restricted food intake, refusing all liquids for 12 hours or more, hours-long stints in a sauna or steam room to promote perspiration, Epsom salt baths, protracted cardio workouts that are sometimes performed in a heated room or while wearing sweats or special insulating suits, diuretics and even laxatives or induced vomiting.
“The methods are not necessarily healthy,” wrote Dr. Sherry Wulkan, medical chair for the Association of Boxing Commissions and lead MMA and muay thai ringside physician for the New Jersey State Athletic Control Board (NJSACB), in an emailed response to questions. “And some, especially if modified by the athlete, can be dangerous and may even result in permanent organ damage or death.”
Many in the combat sports community seem desensitized to weight cutting. As a typical fight week unfolds, observers tend to offer vague expressions of solidarity with a weight-cutting fighter, as if he or she was serving some undemocratic spate of after-school detention.
It’s different in the medical community.
Doctors who follow combat sports seem, to a person, gravely concerned (if not alarmed) over the practice and its growing intensity.
“No medical professional would be in favor of allowing that procedure,” said Dr. Robert Cantu, director of sports medicine at Emerson Hospital in Massachusetts and a clinical professor of neurosurgery at Boston University School of Medicine. “There are definite dangers of dehydration. There is electrolyte imbalance, low blood sugar, the danger of overhydration.”
What really illustrates the problem from a physiological standpoint is not so much the number of pounds but the amount of water that weight-cutting fighters wring out of their bodies. On average, water comprises 60 percent of total body weight. So, if a 144-pound MMA fighter loses eight pounds of water weight (along with weight lost in the form of body fat or other things) as part of an effort to reach the 135-pound bantamweight maximum, the fighter has drained 8.6 percent of the body’s water weight.
“I wasn’t aware of what an issue this was,” said Jeff Novitzky, who in April was named the UFC’s vice president of athlete health and performance. “Some athletes drain 10-15 percent of their water in two or three days. After that point, [medical professionals] I’ve spoken to recommend immediate hospitalization.”
Groups including the American College of Sports Medicine and the Association of Ringside Physicians have issued recommendations to end excessive dehydration and its related mechanisms as a weight-loss tool.
As the body dehydrates, blood thickens, forcing the kidneys to work harder to filter it. The organs can’t produce enough urine to flush themselves out, laying the groundwork for kidney stones and infection. Once a person has experienced these conditions, the likelihood of a future incident increases. In a worst-case scenario, severely dehydrated individuals can experience kidney failure, shock, seizures and coma, at which point death is possible.
And the kidneys are far from the only vulnerability.
According to Dr. Wulkan, dehydration on this scale strains the heart and thyroid, increases the chance of muscle and tendon injury and weakens the immune system. It also turns out that the endpoints of an opponent’s limbs are not the only factor in brain injury. Excessive rehydration after a cut can spur the body to channel massive amounts of water back into cells, which can sometimes cause them to expand and burst. If this occurs inside the brain, the result, called cerebral edema, can be fatal.
Then there’s that little thing called a fight. A definitive study would be inhumane, but it’s widely accepted that dehydrated fighters run a higher risk of concussion.
“When you’re dehydrated, the brain is smaller because there is less cerebrospinal fluid,” Cantu said. “So you can think of the brain having more room to bounce around the skull.”
Female fighters take more risks than their male counterparts by cutting weight. Estrogen, a crucial ingredient for proper bone health in women, is stored in fat cells. As such, a significant body-fat shortage potentially compromises bone density. What’s more, big drops in water weight can interfere with menstrual cycles.
Ronda Rousey, the UFC women’s bantamweight champion and the most famous MMA fighter in the world, has been fairly open about the sizable cut she makes (about 17 pounds) to reach her division’s 135-pound limit. She has been almost as open about the role that the pressure of making weight played in her developing bulimia, a condition that affects about 1.5 million Americans, 95 percent of whom are women.
“When I started MMA, I walked around at 145 pounds, so I fought there, but I thought I could capitalize more fighting at 135 pounds and get more attention because it’s a deeper division,” Rousey said of her weight-cutting rationale in a 2012 article on UFC.com. “But I hadn’t been that light since I was like 15 years old, so I went and got help for that. It’s been one of the easiest weight cuts I’ve ever done.”
When the Cut Goes Wrong
The perception of weight cutting as little more than an inconvenience is countered by relatively recent history. Tragedies are not uncommon.
Weight cutting’s largest casualties to date occurred in grim succession over a six-week period in the late autumn of 1997, when three collegiate wrestlers, competing for different schools in different parts of the country, died from weight-cut-related complications.
The amateur wrestling community responded on several fronts, and no deaths have occurred since. But leaders with USA Wrestling, one of the sport’s top regulators as well as its Olympics coordinating body, are quick to acknowledge that challenges persist two decades after those wrenching six weeks.
The most prominent illustration comes from 2008, when Daniel Cormier, who happens to be the UFC's reigning light heavyweight champion, suffered kidney failure and was hospitalized while cutting weight for the Beijing Olympics. He was unable to compete in the games as a result.
It doesn’t account for the many thousands who have competed without incident, but it does indicate that more work remains.
“It’s definitely less of a problem than it was in the '90s and prior. But there’s still problems and things we need to face,” said Mike Clayton, manager of USA Wrestling's national coaches education program. “Wrestlers are a strong reactive group. If there’s a problem, we fix it. But we can be better at being proactive so we don’t have to be reactive in the first place.”
As MMA has continued its ascendance toward the mainstream, tragedies and problems around weight cutting have grown proportionately.
In September 2013, MMA fighter Leandro Souza, 26, a member of Brazil’s prominent Nova Uniao training camp, was offered a fight with the Shooto Brazil promotion. There was a catch: The fight was in the 125-pound flyweight division. Normally, Souza was a bantamweight. He had one week to cut 33 pounds. He had not competed professionally since 2011.
Did he want the fight or not?
Souza accepted. He shed many pounds, evidently taking diuretic pills to help him along. As he waited his turn to step on the scales, Souza collapsed. He was later pronounced dead, with the cause of death determined as a stroke.
Shooto Brazil President Andre Pederneiras claimed the death was not related to his weight cut.
Two months after Souza’s death, UFC welterweight Brian Melancon retired from competition after learning his kidneys were functioning at 47 percent of their capacity, thanks to a condition exacerbated by cutting weight.
Jose Aldo, the lineal UFC featherweight champion and one of the greatest fighters in the world, was hospitalized in 2013 for kidney stones.
In late 2012 and early 2013, UFC middleweight Alessio Sakara was forced to withdraw from a bout and stop training for several months because of “renal stress.”
The list goes on.
'You Feel Like You're Gonna Die'
On fight-week Monday, Miller (25-6-1, 14-5-1 UFC) clocks in at about 170 pounds. On Friday morning, he’s down to 155.
“It’s kind of miserable,” Miller said. “You get kind of foggy. It’s hard to make decisions. I get a headache, a little bit of weakness.”
The night before weigh-ins might be the toughest stretch. The kinetic life of a fighter grinds to a halt when Miller settles into a near-scalding salt bath that draws every bit of moisture from his pores. He emerges periodically to scrape away the sweat, clearing the way for more. In this manner, he sheds the final pounds.
Despite prolonged fasting, when Miller wakes up on weigh-in day, his appetite is gone. By that point, his body is unable to muster saliva. Forcing down a side salad or spinach omelet keeps the machine running, one final shovelful of coal for the metabolic fires.
Miller makes weight; he always does. That consistency speaks to his professional diligence over the long term, as well as the experience gained by cutting weight approximately 75 times, dating back to his scholastic wrestling days.
But part of it stems from another fact, plain to fighters and observers but perhaps surprising to the uninitiated.
“My cut,” Miller observed, “is not on the extreme end.”
For the extreme end, you have to look to someone like James Vick.
Like Miller, the 28-year-old Vick (8-0, 4-0 UFC) competes at 155 pounds. But the 6’3” Vick’s “walking-around” weight hovers near 185. That means he cuts as much as 30 pounds during fight week.
Also like Miller, Vick has yet to miss his mark. But it comes at a brutal cost.
“You feel like you’re gonna die,” Vick said. “It’s hard to explain how painful it is. You have the attention span of a two-year-old. You can’t focus on anything. If I fought on the day I weighed in, I’d lose to anyone.”
Vick’s relative youth renders him resilient, able to handle and recover reasonably well from the process. But, he says, he still gets the question: Why would someone do that?
“People look at me like I’m nuts when I tell them [how much weight I cut],” Vick said. “But I do it because of the size advantage it gives me.”
After rehydrating, Vick enters the cage more or less back to his original size, which is technically equivalent to that of a middleweight, two weight classes up. That is, quite literally, a big advantage, and it illustrates the nature of the arms race happening in MMA and other combat sports, where ever-steeper weight cuts keep athletes ahead of the pack.
“There are a ton of risks when you cut that kind of weight,” said George Lockhart, a nutritionist and former fighter who, with his company, Fitness VT, works with Vick and some 60 other fighters. “Everyone’s trying to push that envelope and get that edge. Cuts keep getting bigger and bigger.”
The Bottom Line and the UFC
In the past, UFC officials have attempted to distance themselves from incidents like Souza's. Days after Souza’s death in Brazil, UFC President Dana White drew a sharp distinction between a typical UFC fighter’s weight cut and Souza’s. In a 2013 news conference, White told reporters, according to MMA Weekly:
Where you see the dangerous situations are the guys that take last-minute fights and have to lose a ton of weight. It's never good. In the UFC, these guys have plenty of time. They know when they have to fight. They know the time they have. They diet and do the proper nutrition to get down the right way. When they get closer (to weigh-ins), they cut a few pounds. That's the healthy, normal way to do it.
It’s a nice bit of talk, but it doesn’t sync with the UFC’s walk. Souza’s case was undoubtedly extreme (and most diuretics are prohibited by most state athletic commissions in the U.S.), but White’s sound bite conflicts with UFC reality, where injuries and other circumstances routinely set off mad scrambles to keep a fight afloat.
An unscientific review of UFC events between January and August shows 15 instances of a replacement fighter filling in on 15 days’ notice or less. In 12 of these cases, it was the replacement fighter’s UFC debut—not exactly the strongest of negotiating positions. In two instances, the replacement fighter missed weight or was ultimately unable to compete because of complications that arose during weight cuts.
One of those instances was the case of Andrew Todhunter. Nine days before UFC 188 on June 13, the UFC tapped the welterweight to replace the injured Hector Urbina. It was to be Todhunter’s UFC debut. During his weight cut, he passed out, and medical professionals subsequently deemed him medically unfit to compete. His bout with Albert Tumenov was cancelled.
About a month later, the UFC released Todhunter.
UFC fighter cuts also frequently surpass “a few pounds.” Vick's case is extreme, but it's not a total outlier. Middleweight champion Chris Weidman, for example, said he once cut 32 pounds in 10 days to take a UFC bout with Demian Maia as an injury replacement. Anthony Johnson, currently on the UFC roster as a 205-pound light heavyweight, first entered the promotion as a 170-pound welterweight. According to Brett Okamoto of ESPN.com, Johnson has said he “knocked on death’s door” while cutting to welterweight, which he did on 10 occasions while fighting for the UFC.
Though one might hope that health and safety dwarf any other concern, the truth is nothing motivates like the bottom line. And weight-cutting mishaps have the power to hit promotions squarely in the wallet.
An unscientific review of every UFC event from 2012 through August 25, 2015, shows what appears to be an upward trend line in matchups that have been disrupted either by a fighter missing weight or because what appear to be cut-related issues forced a matchup change or cancellation. In 2012 and 2013, the UFC held 31 and 33 events, respectively, with 12 fights altered in each of those two years. In 2014, a total of 20 fights were altered in 35 UFC events. As of August 25, 2015 has seen 19 fights altered in 29 events.
The most famous example came in August 2014, when a scheduled rematch at UFC 177 between bantamweight champion T.J. Dillashaw and Renan Barao was scuttled the day before the event after Barao was hospitalized near the end of his weight cut. UFC announced newcomer Joe Soto as Barao's last-minute replacement; Soto fought gamely before losing by knockout in the final round.
UFC 177, a pay-per-view event, drew an estimated 125,000 buys, tied for the UFC’s second-lowest total of the past nine years.
Culture Change and the Role of Wrestling
The solutions to weight cutting are as multivariate as the problems but a good deal more nebulous. But they are out there. For simplicity’s sake, they can be grouped under two conceptual umbrellas: culture change and regulatory actions.
The former begins with perhaps the biggest—and truest—cliche in the entire health world: diet and exercise.
“In general, more accomplished professional athletes tend to have fewer large weight swings in the ‘off season,’ and have the ability to hire sports nutritionists and other…‘experts’ to assist with healthier forms of weight reduction,” Wulkan wrote.
In other words, maintaining consistent fitness and nutrition habits keeps an athlete closer to his or her “fighting weight,” which mitigates the need for bigger cuts. That’s where nutritionists like Lockhart come in. But when it comes time to make the cut, Lockhart and others like him are honing bodily tendencies down to the cellular level, where modulating weight becomes a matter of what switches to flip and when, in order to eliminate the “negative feedback,” as Lockhart puts it, that interferes with the body’s ability to shed fats and fluids.
The hormone aldosterone, for example, helps instruct the body on whether to hold sodium. Vasopressin, secreted by the pituitary gland, influences water retention.
“Your body doesn’t have a brain,” Lockhart said. “What your body knows and what your brain thinks are different. Your body doesn’t know that if you’re not eating, you can just go to the grocery store. So it slows down your metabolism.”
Vick started working with Lockhart about a year ago and says the approach is making his gargantuan cut more tolerable and efficient. Vick now eats six times per day during his cut. If only it could narrow the gap between his normal weight and the weight at which he technically competes.
“Even with the science, it’s horrible,” Vick said. “It’s extremely grueling. When you can’t drink water and you’re stuck in the sauna for two or three sessions a day, that’s just hard, man. You suck on a piece of ice to give you the feeling of drinking something.”
Vick does it to gain a size advantage. Backstopping and motivating this assertion is an easy assumption: that heavier is always better. But that’s not necessarily so.
“While some in the media make great comment about the actual fight time weight of the contestant and the advantage therein, statistics in New Jersey for mixed martial arts do not support that viewpoint,” NJSACB Counsel Nick Lembo wrote in an emailed response to questions. “Frequently, the lighter contestant or the contestant who had an easier time at the weigh-in proves to be the victor. …[The other fighter’s] lack of cardio and strength becomes apparent.”
State athletic commissions bear responsibility, Lembo wrote. The New Jersey commission, long considered a leader in combat sports regulation, can serve as a role model and partner for less-active governing bodies. Every state athletic commission is freestanding, with no consistent policy-making or information-sharing among them.
“The sport should have the same or similar weigh-in rules regardless of the location of the contest,” Lembo wrote. “A weigh-in change should be discussed by and among the various commissions and their medical staffs…There needs to be cooperative efforts between commissions, physicians, athletes and trainers to educate proper weight-loss techniques, dangers of dehydration and improper cutting, and selecting a proper weight class.”
Many professional MMA fighters (especially Americans) start their careers on the wrestling mat, so that sport’s culture has a wide ripple effect on the landscape. According to some, that effect is not healthy.
“While more recent methods of weight cutting heavily rely on ‘science,’ the basic tenet, based predominantly in wrestling culture, has remained the same,” Dr. Wulkan stated.
A wrestler’s mindset is one of will and determination. Anything other than gritting one’s teeth and powering through your weight cut is often interpreted as weakness.
“MMA has evolved; wrestling really hasn’t,” said Lockhart. “It’s tradition. ... They’ve done it the same way for so long. There’s almost a quiet understanding that they all kind of agreed to.”
To its credit, USA Wrestling has since 1997 worked hard to turn wrestling culture around, implementing several concrete measures like prohibiting the use of saunas, self-induced vomiting and diuretics.
If only people were as easily changed as rule books. Rank-and-file wrestling coaches have proven more than once that old-school habits die hard.
“One of the common sayings is that we can’t change everybody,” Clayton said. “Some coaches say ‘this is the way I was coached and it made me tough, and this is what I’ll do.’ You can’t change that. ... [But] if I affect one coach and the coach has 20 kids a year for 20 years, that’s 400 people I’ve directly affected. ... We have coaches that are willing to learn.”
Culture change is always a long game. In the nearer term, with the cuts and awareness of their consequences both growing, promotions and commissioners are looking hard at tests and regulations that safeguard athletes and the competition.
The UFC is a part of this contingent, with Novitzky at the helm. In June, the promotion, as part of its new partnership with the U.S. Anti-Doping Agency, announced a ban on intravenous rehydration—long considered an effective tool for quick fluid replacement after a cut—following weigh-ins, barring a medical exemption.
Never known for nuance or half-measures, UFC officials recently added that violators could face two-year suspensions.
Several fighters have publicly lamented the new policy, calling it unwieldy, unhelpful and even dangerous. Perhaps in response, the USADA pushed back the effective date to October 1 but doesn’t appear willing to bend any further, stating the ban will ultimately help mitigate weight cuts.
“[Fighters are] using IVs as a crutch to do these severe and unsafe cuts,” Novitzky said. “I think they really need to educate [themselves]. [Rehydration] can be done smoothly with salts and electrolytes.”
Novitzky said he and the UFC are still researching the issue, with more changes potentially “on the table,” though nothing is imminent.
The UFC is far from the only MMA promotion struggling to address weight-cutting problems. At least one organization is putting its mouth where its (and its fighters') money is. Great Britain's Cage Warriors, which has spawned big names like current UFC interim featherweight champ Conor McGregor, stripped Brett Johns of his bantamweight title after Johns came in heavy for what would have been a title defense. In May 2014, after seven athletes missed weight for a single event, the promotion announced it would begin docking fighters 60 percent of their purse.
One oft-visited idea for new regulation on this topic is that of same-day weigh-ins, either instead of or in addition to regular weigh-ins the day before an event. The move worked well for NCAA wrestling, proponents say, and could work elsewhere, as it shortens rehydration periods, thus curtailing steep cuts.
“Our sport and our boxers suffer from ill-advised weight loss and weight-loss practices,” Greg Sirb, executive director of the Pennsylvania State Athletic Commission, wrote in a letter to the Association of Boxing Commissions that called for a ban on day-before weigh-ins in boxing, according to a 2014 article on ESPN.com. “By granting them the privilege to weigh in well before the event we are only encouraging boxers to starve so that they can regain, sometime[s] large amounts of weight, so that by the time the actual competition takes place, the true weight class of the boxer becomes a farce.”
According to Lembo, however, same-day weigh-ins may not be as strong a deterrent in practice as they sound in theory.
“I am not certain that ‘double weigh-ins’ or same-day weigh-ins are improvements, at the current time,” Lembo stated. “In theory, the concept that contestants will properly cut weight because of the added weigh-in or same-day weigh-in is a nice concept. In practice, I fear that a high enough percentage of contestants will not change their weight-cutting habits. Thus, we will have even less hydrated contestants in the ring or cage at greater health risks.”
As far as MMA drawing lessons from boxing, increasing the number of weight divisions—the UFC currently has nine, the World Boxing Council has 18—could also encourage more fighters to compete closer to their “normal” weight.
Another measure implemented for wrestling by the NCAA is the so-called “1.5%-Per-Week Rule,” which stipulates that amateur wrestlers can only lose 1.5 percent of their total body weight each week, based on body fat and hydration benchmarks. The issue here, however, is one of enforcement.
“[The rules] do help a lot by reducing the impact of severe cuts,” Clayton said. “But they don’t guarantee that [wrestlers] are descending by 1.5 percent, that they’re following it.”
Foster said CSAC is set to begin certifying amateur MMA fighters at a specific weight class in January 2016, based on a physical assessment that will include a body-composition test. Fighters will not be able to compete at a lower weight class than the one at which they are certified. Fighters are re-assessed once per year under the program.
“We use a body-composition scale or body-caliber test and calculate the lowest weight the fighters should be fighting at, while maintaining 5-7 percent body fat,” Foster said. “We assign that for one year, and you can amend it later.”
CSAC also is performing hydration testing in a pro setting—as they did Saturday at the Bellator 141 event in Temecula, California—but so far are doing so only for informational purposes.
The athletic state comission monitors the water in our body. To make sure dehydration is not too extreme. Great! pic.twitter.com/RwwbtTObPT— MarloesCoenen (@MarloesCoenen) August 28, 2015
There is one hydration test that appears to be effective, simple and inexpensive. It's also a well-established tool for assessing not only dehydration, but the degree of dehydration in individuals, and without extensive measurements or regulation.
It’s called urine specific gravity testing, or gravity-strip testing, and it’s done with a simple urine test that measures the specific gravity of urine. The specific gravity of water is 1.000. If a urine sample’s specific gravity clocks in at over 1.020, the person is dehydrated. The higher the specific gravity, the greater the degree of dehydration. Already in use in the NCAA and elsewhere, these tests can be administered at or before weigh-ins, before fights or any other time.
“Urine has a specific gravity that can be measured,” said Dr. Cantu. “There are safe gravity ranges and unsafe gravity ranges. You just look at the urine to see how concentrated it is.”
On several different medical supply sites, a pack of 10 gravity-strip tests sells for less than $30. Reusable refractometer devices—shown in at least one study to be the most effective means of specific gravity testing—range in price from $90 to $2,000.
It might be difficult. Still, the answers are out there, right alongside the problems. It’s all about lining them up.
“Let’s take things one step at a time,” Novitsky said. “Throwing a ton of rules out there is not a good thing. ... We’re furiously reaching out to the medical community, nutritionists, [to] put the tools, research and science together.”
Combat sports are as old as sport itself, but MMA is still fairly new to the landscape, as are scientific findings that can evolve weight cutting beyond a test of wills with oneself. As the sport and the science mature, new measures will continue to do the same and reduce the risk of long-term health problems and worse.
“The way so many people do weight cuts is so primitive, and we’re so far past that nowadays,” Lockhart said. “But people don’t know what they don't know."
Scott Harris is a freelance writer covering MMA for Bleacher Report. He is available on Twitter. All quotes obtained firsthand unless otherwise noted.