Cardiometabolic Abnormalities in Current National Football League Players
Media reports suggested an increased prevalence of cardiovascular disease and premature death in former National Football League (NFL) players. The prevalence of cardiometabolic syndrome was determined in current active NFL players. The presence of cardiometabolic syndrome was defined as > or =3 of (1) blood pressure > or =130/85 mm Hg, (2) fasting glucose > or =100 mg/dl, (3) triglycerides > or =150 mg/dl, (4) waist circumference > or =100 cm, and (5) high-density lipoprotein cholesterol < or =40 mg/dl. Sixty-nine of 91 players (76%) from 1 NFL team were studied before the 2008 preseason training camp. Cardiometabolic syndrome markers, body mass index (BMI), waist-height ratio, and triglycerides/high-density lipoprotein cholesterol ratio were compared between 69 players and an age- and gender-matched reference population from NHANES (1999 to 2002) and by player position of linemen versus nonlinemen. Blood pressure > or =130/85 mm Hg, glucose > or =100 mg/dl, and BMI > or =30 kg/m(2) were significantly more prevalent in the 69 players than the NHANES cohort (28% vs 17%, p = 0.032; 19% vs 7%, p = 0.002; and 51% vs 21%, p <0.001, respectively), although cardiometabolic syndrome prevalence was similar in both groups. However, cardiometabolic syndrome prevalence, BMI > or =30 kg/m(2), and waist-height ratio >0.5 were significantly more common in the linemen versus the nonlinemen subgroup (22% vs 0%, p = 0.004; 100% vs 32%, p <0.001, and 95% vs 36%, p <0.001 respectively). In conclusion, cardiometabolic syndrome and its individual components were noted in current NFL players, particularly linemen.
Cardiometabolic Abnormalities in Current National Football
Michael A. Selden, MD
, John H. Helzberg, MD
*, Joseph F. Waeckerle, MD
Jon E. Browne, MD
, Joseph H. Brewer, MD
, Michael E. Monaco, MD
Fengming Tang, MS
, and James H. O’keefe, MD
Media reports suggested an increased prevalence of cardiovascular disease and premature
death in former National Football League (NFL) players. The prevalence of cardiometa-
bolic syndrome was determined in current active NFL players. The presence of cardiom-
etabolic syndrome was deﬁned as >3 of (1) blood pressure >130/85 mm Hg, (2) fasting
glucose >100 mg/dl, (3) triglycerides >150 mg/dl, (4) waist circumference >100 cm, and
(5) high-density lipoprotein cholesterol <40 mg/dl. Sixty-nine of 91 players (76%) from 1
NFL team were studied before the 2008 preseason training camp. Cardiometabolic syn-
drome markers, body mass index (BMI), waist-height ratio, and triglycerides/high-density
lipoprotein cholesterol ratio were compared between 69 players and an age- and gender-
matched reference population from NHANES (1999 to 2002) and by player position of linemen
versus nonlinemen. Blood pressure >130/85 mm Hg, glucose >100 mg/dl, and BMI >30 kg/m
were signiﬁcantly more prevalent in the 69 players than the NHANES cohort (28% vs 17%,
p ⴝ 0.032; 19% vs 7%, p ⴝ 0.002; and 51% vs 21%, p <0.001, respectively), although
cardiometabolic syndrome prevalence was similar in both groups. However, cardiometabolic
syndrome prevalence, BMI >30 kg/m
, and waist-height ratio >0.5 were signiﬁcantly more
common in the linemen versus the nonlinemen subgroup (22% vs 0%, p ⴝ 0.004; 100% vs 32%,
p <0.001, and 95% vs 36%, p <0.001 respectively). In conclusion, cardiometabolic syndrome
and its individual components were noted in current NFL players, particularly
linemen. © 2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;103:969 –971)
Previous reports suggested increased prevalences of meta-
bolic syndrome and cardiovascular mortality in former retired
National Football League (NFL) players.
A news report
comparing mortality rates for 3,850 professional football play-
ers with 2,403 professional baseball players who have died
during the last century found football players were more than
twice as likely to die before the age of 50 years.
28% of obese NFL players died before their 50th birthday
compared with 13% of players who were not obese. Twenty-
two percent of deaths in NFL players were caused by cardio-
vascular disease. As a result of these concerns, the National
Institute for Occupational Safety and Health evaluated the
health status of 6,848 retired NFL players who played from
1972 to 1988.
The National Institute for Occupational Safety
and Health study showed that linemen had a 52% higher risk
of dying of heart disease than the general population. Cardio-
vascular mortality of linemen was 3 times that of nonlinemen.
The higher rate of heart disease in former linemen was con-
cerning because the average weight of NFL players has in-
creased by 10% since 1985 to an average of 248 lbs in 2006.
Previous studies have evaluated metabolic syndrome abnor-
malities in retired NFL players, but none have analyzed current
We hypothesized that markers of cardiometabolic
syndrome may be present in current NFL players.
We prospectively collected data for 69 of 91 players
(76%) aged 21 to 35 years (mean age 25) from 1 NFL team
who consented to participate. Each player’s body mass
index (BMI), height, and cardiometabolic syndrome mark-
ers were obtained. Cardiometabolic syndrome was deﬁned
as ⱖ3 of the markers of (1) blood pressure ⱖ130/85 mm
Hg, (2) fasting glucose ⱖ100 mg/dl, (3) triglycerides ⱖ150
mg/dl, (4) waist circumference ⱖ100 cm, and (5) high-
density lipoprotein (HDL) cholesterol ⱕ40 mg/dl.
Laboratory values were measured in the fasting state.
Waist circumference was measured using true-ﬁtting pants
sizes. Players were compared with men aged 20 to 29 years
from the National Health and Nutrition Examination Survey
(NHANES). Linemen and nonlinemen were also each com-
pared with this reference population. Finally, linemen were
compared with nonlinemen. Linemen were deﬁned as de-
fensive tackles and ends and offensive guards, tackles, and
centers. Nonlinemen were all other players.
SAS, version 9.1 (SAS Institute, Cary, North Carolina), was
used for statistical analysis. Chi-square or Fisher’s exact test
was used, with p ⬍0.05 considered statistically signiﬁcant.
Institutional review board approval was obtained through St.
Luke’s Hospital of Kansas City (institutional review board no.
07-134; JHH, principal investigator).
University of Missouri-Kansas City School of Medicine, Kansas City,
Saint Luke’s Hospital of Kansas City, Kansas City, Missouri;
Orthopaedic and Sports Medicine Clinic of Kansas City, Leawood, Kan-
Mid-America Heart Institute, Kansas City, Missouri. Manuscript
received October 26, 2008; revised manuscript received and accepted
December 12, 2008.
*Corresponding author: Tel: 816-561-2000; fax: 816-931-7559.
E-mail address: email@example.com (J.H. Helzberg).
0002-9149/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved. www.AJConline.org
Waist-height ratio of players by position is shown in
Figure 1. Comparisons of cardiometabolic syndrome mark-
ers, waist-height ratio ⬎0.5, and triglycerides/HDL choles-
terol ratio ⬎3.5 were shown for the team versus NHANES,
linemen versus NHANES, nonlinemen versus NHANES,
and linemen versus nonlinemen in Tables 1 through 4,
respectively. Cardiometabolic syndrome prevalence did not
differ between the team and NHANES. The presence of
cardiometabolic syndrome was more common in linemen
than in the NHANES population, although this difference
did not reach statistical signiﬁcance. Nonlinemen had a
lower prevalence of cardiometabolic syndrome compared
with the NHANES population. The prevalence of cardiom-
etabolic syndrome was signiﬁcantly higher in linemen com-
pared with nonlinemen.
Increased BMI and hypertension were signiﬁcantly more
common in the team compared with the reference popula-
tion. These ﬁndings were particularly notable in linemen.
0 0.1 0.2 0.3 0.4 0.5 0.6 0
Offensive Line men
Figure 1. Waist-height ratio by position in NFL players.
The team compared with the National Health and Nutrition Examination
Survey (NHANES) population
Team NHANES p
Blood pressure ⱖ130/85 mm Hg 19 (28%) 17% 0.032
Glucose ⱖ100 mg/dl 13 (19%) 7% 0.002
Triglycerides ⱖ150 mg/dl 8 (12%) 24% 0.041
HDL cholesterol ⱕ40 mg/dl 6 (10%) 34% ⬍0.001
Triglycerides/HDL cholesterol ratio ⬎3.5 7 (12%) 22% 0.085
Waist circumference ⱖ100 cm 26 (38%) 26% 0.057
Waist-height ratio ⬎0.5 36 (52%) 55% 0.726
Cardiometabolic syndrome 4 (6%) 10% 0.355
Linemen compared with the National Health and Nutrition Examination
Survey (NHANES) population
Linemen NHANES p
Waist-height ratio ⬎0.5 18 (95%) 55% ⬍0.001
Waist circumference ⱖ100 cm 18 (95%) 26% ⬍0.001
Blood pressure ⱖ130/85 mm Hg 9 (47%) 17% 0.003
Glucose ⱖ100 mg/dl 5 (26%) 7% 0.012
Triglycerides ⱖ150 mg/dl 3 (16%) 24% 0.568
HDL cholesterol ⱕ40 mg/dl 3 (19%) 34% 0.216
Triglycerides/HDL cholesterol ratio ⬎3.5 3 (19%) 22% 1.000
Cardiometabolic syndrome 4 (22%) 10% 0.104
Nonlinemen compared with the National Health and Nutrition
Examination Survey (NHANES) population
Nonlinemen NHANES p Value
HDL cholesterol ⱕ40 mg/dl 3 (7%) 34% ⬍0.001
Trigylcerides ⱖ150 mg/dl 5 (10%) 24% 0.042
Waist-height ratio ⬎0.5 18 (36%) 55% 0.015
Glucose ⱖ100 mg/dl 8 (16%) 7% 0.047
Cardiometabolic syndrome 0 (0%) 10% 0.02
4 (9%) 22% 0.057
Blood pressure ⱖ130/85 mm Hg 10 (20%) 17% 0.541
Waist circumference ⱖ100 cm 8 (16%) 26% 0.117
Linemen compared with nonlinemen
Linemen Nonlinemen p
Waist-height ratio ⬎0.5 18 (95%) 18 (36%) ⬍0.001
Waist circumference ⱖ100 cm 18 (95%) 8 (16%) ⬍0.001
Blood pressure ⱖ130/85 mm Hg 9 (47%) 10 (20%) 0.023
Cardiometabolic syndrome 4 (22%) 0 (0%) 0.004
Glucose ⱖ100 mg/dl 5 (26%) 8 (16%) 0.326
Triglycerides ⱖ150 mg/dl 3 (16%) 5 (10%) 0.677
HDL cholesterol ⱕ40 mg/dl 3 (19%) 3 (7%) 0.330
3 (19%) 4 (9%) 0.375
970 The American Journal of Cardiology (www.AJConline.org)
However, legitimate concerns have been raised that BMI
may not be an accurate measure of obesity in muscular
athletes. Therefore, waist circumference and waist-height
ratio for each player were also determined. Waist circum-
ference and waist-height ratio were better measures of vis-
ceral obesity than BMI and more accurately predicted risk
of cardiovascular disease.
Linemen were found to have
a bigger waist circumference and higher waist-height ratio
compared wih the NHANES population.
The team had a similar prevalence of cardiometabolic
syndrome compared with the NHANES population. Glu-
cose was signiﬁcantly increased in players, both linemen
and nonlinemen, compared with the NHANES population.
High fasting glucose suggested the possibility of insulin
resistance in players, particularly linemen, and may be an
early marker of cardiometabolic syndrome. Triglycerides
ⱖ150 mg/dl and HDL cholesterol ⱕ40 mg/dl were more
common in the NHANES population than the team. Players
likely had higher HDL cholesterol because of their in-
creased physical activity. The higher prevalence of in-
creased HDL cholesterol in players made the association of
an increased prevalence of cardiometabolic syndrome in
linemen versus nonlinemen more striking. Exercise in this
subgroup, although beneﬁcial, may not prevent heavier
players from developing future cardiovascular events.
Linemen had a higher prevalence of cardiometabolic syn-
drome compared with NHANES, although this difference did
not reach statistical signiﬁcance. The small sample size of this
subgroup may have prevented the detection of a statistical
difference. The prevalence of hypertension was signiﬁcantly
higher in linemen compared with the NHANES population and
nonlinemen. These results supported a previous study that
suggested an increase in blood pressure in heavier players.
The lower prevalence of cardiometabolic syndrome in non-
linemen compared with NHANES suggested that nonlinemen
were more physically ﬁt than the NHANES population. It was
unclear why a higher percentage of nonlinemen had glucose
ⱖ100 mg/dl compared with the reference population. There-
fore, the triglycerides/HDL cholesterol ratio was also calcu-
lated. This ratio has been shown to have high sensitivity for
There was no signiﬁcant difference
between nonlineman and the NHANES population in triglyc-
erides/HDL cholesterol ratio. Although nonlineman had a
higher BMI than the NHANES population, the waist-height
ratio of nonlineman was lower than for the NHANES popu-
lation, suggesting that nonlineman had less visceral fat than the
reference population. Because all players were routinely
screened for performance-enhancing drugs that could alter
glucose and HDL cholesterol, we presumed they were not
used. This therefore suggested that increased sympathetic ac-
tivity may account for the dysglycemia, although it was pos-
sible that some players were not totally compliant with the
request of fasting before laboratory test collections.
Linemen had a signiﬁcantly higher prevalence of cardiom-
etabolic syndrome compared with nonlinemen. This ﬁnding
was not surprising given the increased BMI, waist circumfer-
ence, waist-height ratio, and presumed visceral obesity in line-
men relative to nonlinemen.
There were several limitations of this study. First, several
players from the team did not consent to participate in the
study. It was unclear whether results would have differed if
these players had enrolled. Second, as noted, it was not
possible to conﬁrm that all players were compliant with
fasting before the collection of laboratory samples. Third,
use of pants size may not be a completely accurate mea-
surement of waist circumference. Finally, the sample size
was small because only 1 team was analyzed.
Because heavier NFL players showed cardiovascular risk
factors and evidence of cardiometabolic syndrome, careful
medical evaluation of active players is warranted. Present
retirees who exercised reported lower body weight, lower
BMI, and lower prevalence of hypertension.
ers found to be at risk of future cardiovascular complica-
tions can undergo interventions to reduce their risk. These
interventions may include both behavioral and medical ther-
apy, particularly after their playing careers have concluded.
Acknowledgment: We thank David Price, BS, Jimmy
Ntelekos, BS, MS, and Mike Davidson for contributions.
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971Preventive Cardiology/Cardiometabolic Abnormalities in Current NFL Players