NFL Players Tackling Heart Disease
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Many football players are essentially paid to be big—really big—especially those whose job is to block or stop the big guys on the other team. There is a good chance that these players weigh in at sizes that are classified as obese as defined by body mass index (BMI). In the general population, high BMI generally correlates with high body fat, and we know that high body fat is a risk factor for death (mortality) and heart disease. Is the same true for elite athletes, for whom high BMI may relate to increased muscularity rather than increased body fat? What if the athlete plays a position where size simply matters, regardless of whether size is related to muscle or to body fat? And what happens when former athletes are no longer conditioning at their playing-day levels? Do professional football players die earlier than or more often from heart disease or cancer than the average American male? New research from the National Institute for Occupational Safety and Health (NIOSH) helps answer these and other questions.
In 1994, NIOSH published research examining death rates and risk factors for former National Football League (NFL) players.1 At that time the research was based on all deaths that had occurred through 1991. After following these players for an additional 16 years, NIOSH has just published new research on the topic in the American Journal of Cardiology.
The study included 3,439 retired NFL players from the 1959 through 1988 seasons. The study found that:
- Players had a much lower overall rate of death compared to men in the general U.S. population of similar age and racial mix. On average, NFL players are actually living longer than the average American male. Out of the 3,439 players in the study, 334 were deceased. Based on estimates from the general population, we anticipated roughly 625 deaths.
- Players also had a much lower rate of cancer-related deaths compared to the general U.S. population. A total of 85 players died from cancer when we anticipated 146 cancer-related deaths based on estimates from the general population.
- Players who had a playing-time BMI of 30 or more had twice the risk of death from heart disease compared to other players. Similar findings have been noted in other studies. Offensive and defensive linemen were more likely to have a BMI greater than 30. A BMI of 30 or more is considered obese in the general population whereas a healthy BMI is between 18.5-24.9.
- African American players had a 69% higher risk of death from heart disease compared to Caucasian players. The study controlled for player size and position and determined that those factors are not the reason for this difference.
- Defensive linemen had a 42% higher risk of death from heart disease compared to men in the general population. A total of 41 defensive linemen died of heart disease, when we anticipated 29 deaths based on estimates from the general population. Among the 41 defensive linemen who died of heart disease, 8 deaths were due to cardiomyopathy (a specific kind of heart disease that causes the heart to enlarge and can lead to heart failure). We anticipated fewer than two deaths from cardiomyopathy. We saw this increased risk only among the defensive linemen.
What Does This Mean?
The fact that players live longer than the average American male is likely explained by several factors including previously documented low levels of cigarette smoking which is an important contributor to decreased mortality.2,3 Players’ body composition (more muscle mass) and high fitness levels likely also contribute to their longer life span compared to the general U.S. population, especially given their increased size. The study did not attempt to contact retired players so we do not have information about whether players smoked or if they have a family history of heart disease, cholesterol, or diabetes. We also lack information on changes in players’ fitness and weight after retirement.
Different access to or compliance with improved medical therapies and prevention methods could be one explanation for the differences in cardiovascular-related deaths between offensive and defensive linemen and deserves further evaluation. Since 2000, cardiovascular disease deaths for defensive linemen, after accounting for differences in size, have been similar to other players. This may indicate a positive impact from the increased media attention and expanded health promotion campaigns by the NFL and the NFL Players Association since the initial NIOSH report in 1994.2,3
Racial disparities in heart disease risk factors, illness and death are well documented in the general population4 and are partly explained by racial differences in socioeconomic status (see HHS Office of Minority Health ).5 The racial disparity in heart disease deaths in NFL players is notable given players’ more similar socioeconomic status during their playing career and the absence of racial differences in hypertension or prehypertension (indicators of heart disease) in active NFL players. 3
Anabolic androgenic steroid use in athletes has been associated with various adverse cardiovascular outcomes including altered lipid profiles, atherosclerosis, and increased left ventricular dimensions and could contribute to CVD mortality in NFL players.6 A survey of 3,683 retired players found 9% reported anabolic steroid use while playing but offensive and defensive linemen were most likely to report use (16.3% and 14.8%, respectively). Reported usage for all players peaked in the 1980s at 20%.7
What Next?
The study found an association between weight (as expressed in BMI) and risk for heart disease. Further research is needed to determine whether or to what degree the specific characteristics of a defensive lineman’s playing position, training regimen or post-playing lifestyle might contribute to risk for heart disease.
The decrease in risk for cardiovascular disease deaths for defensive linemen since 2000 would seem to indicate that attention to this issue can reduce risk for death. We realize that professional athletes are physically unique compared to the general population. When players retire or stop playing due to injury, activity levels may decrease. This lack of activity may result in an increase in percentage of body fat, which places strain on the heart. Though football-related injuries may make it difficult to exercise regularly, it is important that players continue to be active to achieve or maintain a healthy weight. As with the general population, it is also important that players take steps to protect themselves from cardiovascular disease (see CDC guidelines) such as not smoking, eating right and receiving appropriate treatment for medical conditions like high blood pressure and diabetes.
After the 1994 study, the NFL started the NFL Retired Player Cardiovascular Screening Program which provides testing and monitoring for heart health at various locations across the country. Screenings like this as well as regular consultations with their doctors can help players monitor their health and take the necessary step to prevent illness and death.
Dr. Baron is the Coordinator for Occupational Health Disparities at NIOSH
References
- Baron S, Rinsky R. Health Hazard Evaluation Report, National Football League Players Mortality Study. Report No. HETA 88-085. Atlanta, GA: Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 1994.
- Miller MA, Croft LB, Belanger AR, Romero-Corral A, Somers VK, Roberts AJ, Goldman ME. Prevalence of metabolic syndrome in retired National Football League players. Am J Cardiol 2008;101:1281– 1284.
- Tucker AM, Vogel RA, Lincoln AE, Dunn RE, Ahrensfield DC, Allen TW, Castle LW, Heyer RA, Pellman EJ, Strollo PJ Jr, Wilson PW, Yates AP. Prevalence of cardiovascular disease risk factors among National Football League players. JAMA 2009;301:2111–2119.
- Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation 2005;111:1233–1241.
- Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci 2010;1186:69 –101.
- Achar S, Rostamian A, Narayan SM. Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. Am J Cardiol 2010;106:893–901.
- Horn S, Gregory P, Guskiewicz KM. Self-reported anabolic-androgenic steroids use and musculoskeletal injuries: findings from the Center for the Study of Retired Athletes Health Survey of Retired NFL Players. Am J Phys Med Rehabil 2009;88:192–200.
31 comments on “NFL Players Tackling Heart Disease”
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This is very interesting study and findings. It will be even more interesting if you clarify this. On the average, NFL players have higher earnings than the national average. Did the study compare NFL mortality rates to those of men with similar earnings? If they were compared to average people – the findings would be flawed because people with higher incomes tend to have lower mortality than those with lower incomes.
Thank you for your comment. You raise an important issue. Unfortunately we did not have any data related to the income level of the players. Many of the members of the cohort played many years ago. On average players had retired more than 26 years before our last year of follow up, which would mean that they played prior to 1980. The average salary of players in that era was not as high as it is today and over the years there was likely to be substantial variability in their post playing earnings. Therefore, while this may contribute to players better than average mortality we were unable to further explore this issue. This might be something to explore in future studies.
This is very interesting and timely study. I applaud the authors. However, I’m a little bit concerned about a potential ‘selection bias’ problem. These athletes were not randomly selected from the general male population of the U.S. I suspect that these individuals would be in a very good health condition even before they were recruited. Directly comparing the health status of these individuals to ‘the general U.S. population of similar age and racial mix’ might give biased results. Have you tried to address this sample selection issue?
In our study we used both an external and internal comparison population. For the external comparison we compared players to the general US population. The issues you raise, that professional athletes are a select healthy population, are addressed in the paper’s discussion. We suggest that players better than expected mortality risk results from being a select population with high fitness levels, low smoking rates and other protective factors. We also used an internal comparison population and compared the different player positions categories to each other. It was through that analysis that we determined that players with higher BMIs, African Americans and the defensive linemen were at higher risk for CVD mortality compared to similarly “select” individuals.
Clearly the income levels of post 1980 players would allow them to afford better access to the healthcare they need. However, not all income increases necessarily cause their beneficiaries to take better care of themselves. Some might continue their unhealthy ways despite having engrossed bottom lines (and I don’t mean their backsides, but rather their greenbacks).
What I wonder is how many of the former players have switched careers, to more banal jobs, like being Wall Street traders or accountants, and what effect that would have on their health given the more sedentary nature of those jobs. And also, which of those is actively investing their assets back in to the US Dollar, which after all, is the currency which padded their wallets to begin with, even as they were wrecking their health with oversized BMI ratings.
I look forward to reading any follow-up on this important topic.
The tranistion to a less active life style is a risk factor discussed in the blog. This study is a records-based study. We did not interview the subjects so we do not have information about post-NFL careers.
Thank you for this post- it is quite timely for the week of the Super Bowl! What is your perception regarding the NFL’s commitment to cardiovascular health among its players? I ask because there has been such a strong focus on player concussions that I’ve heard little else regarding other health issues. Just this week I reviewed the NFL’s “Evolution” campaign on my blog [http://pop-health.blogspot.com/2012/02/nfl-super-bowl-commercial-has.html] which serves to present the NFL’s commitment to player safety and how it has evolved over the past 100 years. Again, this campaign focuses primarily on equipment innovation, policy changes and education aimed at reducing injury. We don’t tend to hear as much about diet, exercise, and cardiovascular health.
Thanks!
The NFL responded to the 1994 study by starting the NFL Retired Player Cardiovascular Screening Program which provides testing and monitoring for heart health at various locations across the country.
Very good study of cardiovascular problems in elite players, this is very worrying when a study of sedentary people. Regards. Rocio.
What were the smr’s for whites and non-whites separately?
Did the pmr’s for cancer, which would clearly be elevated, achieve statistical significance?
Does the case series for cardiomyopathy, which was one of the few causes with SMR excess although not achieving statistical significance, suggest any hypotheses regarding cause. I would expect this cause to be significantly elevated in pmr. Would Marfan’s syndrome be considered a cardiomyopathy?
Also, was the original HHE filed by the NFLPA?
Thanks for your comment-
We did not report separate SMRs for whites and nonwhites. The Cox modeling included in the paper provides internal comparisons between different player groups. These internal comparisons allow us to assess differences between player groups- such as the difference in heart disease mortality risk for white versus nonwhite players, linemen versus other positions and higher BMI players versus others. Comparing players to each other rather than to the general population helps to account for any potential selection bias associated with being an elite athlete at the time they entered the NFL. We found that the increased heart disease mortality risk comparing white players to nonwhite players was of a similar magnitude to other studies that make such comparisons within the general US population.
Our study used standardized mortality ratios (SMRs) rather than proportionate mortality ratios (PMRs). For the benefit of all readers, proportionate mortality ratios are used when researchers only have data on deceased individuals and therefore they can only examine whether the proportion of deaths attributed to specific causes, such as cancer, is higher than the expected proportion in the general population. SMRs on the other hand are calculated when a researcher has access to data on the entire population under study (both deceased and living). SMRs are the better way of examining the mortality experience of a population because it allows us to examine whether the rate and not just the proportion of deaths are increased. In this case we found no increase in cancer risk for players, including when looking across the different position categories.
We did find a statistically significant increase in risk for cardiomyopathy among the defensive linemen. In our paper we discuss potential explanations for this elevation including obesity, players’ isometric training regimen and potential anabolic steroid use. We also noted that further study that provides autopsy or medical record confirmation of the diagnosis would be important.
The cardiovascular complications associated with Marfan’s Syndrome involve aortic aneurysms or dissections rather than cardiomyopathies. It has been noted as one rare but potential cause of sudden cardiac death among young athletes.
Yes, the original study in 1994 was initiated following a request from the NFL Players Association.
Would the size of a player have anything to do with type of training they were subjected to? For example the smaller/faster players might have been subjected to more cardio training while the focus with the large players (higher BMI) would be to build muscle mass through strength and weight training.
Thank you for your comment-
You raise an interesting point. We do not have any information related to specific training regimens for the players in our cohort. Since we have players who were active players as far back as the late 1950’s and early 1960’s this may also have changed somewhat over time. We also do not have any data related to the aerobic capacity of the players in our cohort including how this might vary across playing positions. The issues you raise might be interesting questions for future research.
Loved the article. very interesting. The whole BMI thing is a trip.
Moral of the story: Excerise and no smoking = longer life.
Is there any effort underway (or data available for other researchers) to resolve some of the confounding factors by comparing NFL retirees to that of other professional sports (e.g., MLB, NBA, NHL)? While the comparison may not be perfect, given higher body mass among football players than other sports, many of the other factors discussed above (e.g., high fitness levels, above average incomes) might be somewhat more controlled for in a sports-focused comparison set.
This would be an interesting comparison, however NIOSH has no efforts underway at this time to examine the mortality experience of other types of professional athletes.
You would think that these NFL Players are in great shape and have no need to worry about heart disease. Steroid use has to be a part of this. Interesting article.
Joe
Interesting study, dispels some of the common myths associated with retired NFL players.
Although in my opinion the reported steroid use is on the low side, that’s one statistic that we’ll never know for sure.
Very interesting article. Thank you for sharing the study results. I came across this today as some of my colleagues and I at the ACLS Certification Institute were discussing the death of the former USC Trojan offensive linemen. The larger body frames seem to endure more long term stress, but these statistics you are reporting are very promising. I will pass this article along to my fellow docs. Thanks again.
Best,
Dr. Baker
I concur with Jakub in that the reported steroid use in on the low side.
Especially w.r.t. 17-AA drugs which have a very short hal-life enabling athletes to play around with drug detection times much better.
Diana Sabrain
It’s interesting. There are probably a myriad of factors for this, ranging from the benefits of vigorous exercise and diet, access to healthcare, the latent tendencies of violent sports to show up many years later, being rich, and etc. Also, the fact that smoking and obesity are the primary behaviors of the average American that cause death, and most athletes do not have those issues.
Cassy Villard
Interesting study, dispels some of the common myths associated with retired NFL players.
Yeah, I knew this myth was going to dissapear… anyways, what can you do.. get some extra testosterone?
In my opinion the reported steroid use is on the low side… or testo-boosters.
I truly believe that the players should be given something extra, something that can rely on. Players can wear a heart rate monitor on their wrists or arms, which will track all the cardiac activities in an accurate manner. The data will be automatically transfer to the computers and physio of the team can have a look at it.
Moral of the story look after your bodies you only get one. Fitness is key
Would the size of a player have anything to do with type of training they were subjected to? For example the smaller/faster players might have been subjected to more cardio training while the focus with the large players would be to build muscle mass through strength and weight training.
Thank you for your comment. What you suggest has been examined in other studies, but the study results have been inconsistent so far. One of the analysis that we conducted suggests that overall weight (as measured by body mass index or BMI) was associated with higher cardiovascular mortality. Clearly, linemen are the heaviest among football positions and would be at higher risk of cardiovascular mortality. Differences in weight training may also contribute to differences in risk, but we believe BMI is a more significant factor.
great post. thanks
worked collaboratively with homecare nurses and residents of public housing to modify a diabetes prevention program to meet the needs of the community
Would the type of training a player received depend in any way on their size? The objective with the huge players would be to gain muscular mass through strength and weight training, whereas the smaller/faster players may have been subjected to more aerobic training.
Thank you for your comment. We received a similar comment in 2015 and this is the response we provided:
“What you suggest has been examined in other studies, but the study results have been inconsistent so far. One of the analysis that we conducted suggests that overall weight (as measured by body mass index or BMI) was associated with higher cardiovascular mortality. Clearly, linemen are the heaviest among football positions and would be at higher risk of cardiovascular mortality. Differences in weight training may also contribute to differences in risk, but we believe BMI is a more significant factor.”
NIOSH is not currently conducting research in this area. You may be interested in this study and commentary published in 2019 from other researchers that address the topic of NFL players, heart disease, and other causes of death.