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Cardiometabolic Abnormalities in Current National Football League Players

2009; Elsevier BV; Volume: 103; Issue: 7 Linguagem: Inglês

10.1016/j.amjcard.2008.12.046

1879-1913

Michael Selden, John H. Helzberg, Joseph F. Waeckerle, Jon E. Browne, Joseph Brewer, Michael E. Monaco, Fengming Tang, James H. O’Keefe,

Muscle metabolism and nutrition

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 ≥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 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 ≥130/85 mm Hg, glucose ≥100 mg/dl, and BMI ≥30 kg/m2 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 0.5 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. 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 ≥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 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 ≥130/85 mm Hg, glucose ≥100 mg/dl, and BMI ≥30 kg/m2 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 0.5 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. Previous reports suggested increased prevalences of metabolic syndrome and cardiovascular mortality in former retired National Football League (NFL) players.1Hargrove T. Supersized in the NFL: many ex-players dying young. Scripps Howard News Service Online, 2006.http://www.shns.com/shns/g_index2.cfm?action=detail&pk=SUPERSIZE-NFL-01-31-06Google Scholar, 2National Institute for Occupational Safety and Health NFL Mortality Study.http://www.cdc.gov/niosh/pdfs/nflfactsheet.pdfGoogle Scholar, 3Miller M.A. Croft L.B. Belanger A.R. Romero-Corral A. Somers V.K. Roberts A.J. Goldman M.E. Prevalence of metabolic syndrome in retired National Football League players.Am J Cardiol. 2008; 101: 1281-1284Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Science Daily Retired NFL Players at Increased Risk for Heart Problems.http://www.sciencedaily.com/releases/2008/03/080327171014.htmGoogle Scholar, 5Croft L.B. Belanger A. Miller M.A. Roberts A. Goldman M.E. Comparison of National Football League linemen versus nonlinemen of left ventricular mass and left atrial size.Am J Cardiol. 2008; 102: 343-347Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 6Nicholas S.J. Nicholas J.A. Nicholas C. Diecchio J.R. McHugh M.P. The health status of retired American football players.Am J Sports Med. 2007; 35: 1674-1679Crossref PubMed Scopus (27) Google Scholar A news report comparing mortality rates for 3,850 professional football players 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.1Hargrove T. Supersized in the NFL: many ex-players dying young. Scripps Howard News Service Online, 2006.http://www.shns.com/shns/g_index2.cfm?action=detail&pk=SUPERSIZE-NFL-01-31-06Google Scholar Furthermore, 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 cardiovascular 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 1988.2National Institute for Occupational Safety and Health NFL Mortality Study.http://www.cdc.gov/niosh/pdfs/nflfactsheet.pdfGoogle Scholar 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. Cardiovascular mortality of linemen was 3 times that of nonlinemen. The higher rate of heart disease in former linemen was concerning because the average weight of NFL players has increased by 10% since 1985 to an average of 248 lbs in 2006.1Hargrove T. Supersized in the NFL: many ex-players dying young. Scripps Howard News Service Online, 2006.http://www.shns.com/shns/g_index2.cfm?action=detail&pk=SUPERSIZE-NFL-01-31-06Google Scholar Previous studies have evaluated metabolic syndrome abnormalities in retired NFL players, but none have analyzed current players.3Miller M.A. Croft L.B. Belanger A.R. Romero-Corral A. Somers V.K. Roberts A.J. Goldman M.E. Prevalence of metabolic syndrome in retired National Football League players.Am J Cardiol. 2008; 101: 1281-1284Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar We hypothesized that markers of cardiometabolic syndrome may be present in current NFL players.7Harp J.B. Hecht L. Obesity in the National Football League.JAMA. 2005; 293: 1061-1062Crossref PubMed Google Scholar, 8Laurson K.R. Eisenmann J.C. Prevalence of overweight among high school football linemen.JAMA. 2007; 297: 363-364Crossref PubMed Scopus (37) Google Scholar, 9Gomez J.E. Ross S.K. Calmbach W.L. Kimmel R.B. Schmidt D.R. Dhanda R. Body fatness and increased injury rates in high school football linemen.Clin J Sports Med. 1998; 8: 115-120Crossref PubMed Scopus (62) Google Scholar 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 markers were obtained. Cardiometabolic syndrome was defined as ≥3 of the markers 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 (HDL) cholesterol ≤40 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 compared with this reference population. Finally, linemen were compared with nonlinemen. Linemen were defined as defensive 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 0.5, and triglycerides/HDL cholesterol ratio >3.5 were shown for the team versus NHANES, linemen versus NHANES, nonlinemen versus NHANES, and linemen versus nonlinemen in Table 1, Table 2, Table 3, Table 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 cardiometabolic syndrome was significantly higher in linemen compared with nonlinemen.Table 1The team compared with the National Health and Nutrition Examination Survey (NHANES) populationTeamNHANESp ValueBlood pressure ≥130/85 mm Hg19 (28%)17%0.032Glucose ≥100 mg/dl13 (19%)7%0.002Triglycerides ≥150 mg/dl8 (12%)24%0.041HDL cholesterol ≤40 mg/dl6 (10%)34% 3.57 (12%)22%0.085Waist circumference ≥100 cm26 (38%)26%0.057Waist-height ratio >0.536 (52%)55%0.726Cardiometabolic syndrome4 (6%)10%0.355 Open table in a new tab Table 2Linemen compared with the National Health and Nutrition Examination Survey (NHANES) populationLinemenNHANESp ValueWaist-height ratio >0.518 (95%)55%<0.001Waist circumference ≥100 cm18 (95%)26% 3.53 (19%)22%1.000Cardiometabolic syndrome4 (22%)10%0.104 Open table in a new tab Table 3Nonlinemen compared with the National Health and Nutrition Examination Survey (NHANES) populationNonlinemenNHANESp ValueHDL cholesterol ≤40 mg/dl3 (7%)34% 0.518 (36%)55%0.015Glucose ≥100 mg/dl8 (16%)7%0.047Cardiometabolic syndrome0 (0%)10%0.02Triglycerides/HDL cholesterol ratio >3.54 (9%)22%0.057Blood pressure ≥130/85 mm Hg10 (20%)17%0.541Waist circumference ≥100 cm8 (16%)26%0.117 Open table in a new tab Table 4Linemen compared with nonlinemenLinemenNonlinemenp ValueWaist-height ratio >0.518 (95%)18 (36%)<0.001Waist circumference ≥100 cm18 (95%)8 (16%) 3.53 (19%)4 (9%)0.375 Open table in a new tab Increased BMI and hypertension were significantly more common in the team compared with the reference population. These findings were particularly notable in linemen. 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 circumference and waist-height ratio were better measures of visceral obesity than BMI and more accurately predicted risk of cardiovascular disease.10Vega G.L. Adams-Huet B. Peshock R. Willett D. Shah B. Grundy S.M. Influence of body fat content and distribution on variation in metabolic risk.J Clin Endocrinol Metab. 2006; 91: 4459-4466Crossref PubMed Scopus (253) Google Scholar, 11Gelber R.P. Gaziano J.M. Orav E.J. Manson J.E. Buring J.E. Kurth T. Measures of obesity and cardiovascular risk among men and women.J Am Coll Cardiol. 2008; 52: 605-615Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar 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. Glucose 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 ≥150 mg/dl and HDL cholesterol ≤40 mg/dl were more common in the NHANES population than the team. Players likely had higher HDL cholesterol because of their increased physical activity. The higher prevalence of increased 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 syndrome 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.12George C.F. Kab V. Levy A.M. Increased prevalence of sleep-disordered breathing among professional football players.N Engl J Med. 2003; 348: 367-368Crossref PubMed Scopus (36) Google Scholar The lower prevalence of cardiometabolic syndrome in nonlinemen 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 ≥100 mg/dl compared with the reference population. Therefore, the triglycerides/HDL cholesterol ratio was also calculated. This ratio has been shown to have high sensitivity for insulin resistance.13Kannel W.B. Vasan R.S. Keyes M.J. Sullivan L.M. Robins S.J. Usefulness of the triglyceride-high-density lipoprotein versus the cholesterol-high-density lipoprotein ratio for predicting insulin resistance and cardiometabolic risk (from the Framingham Offspring Cohort).Am J Cardiol. 2008; 101: 497-501Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 14Cordero A. Laciaustra M. Leon M. Casasnovas J.A. Grima A. Luengo E. Ordonez B. Bergua C. Bes M. Pascual I. Alegria E. Comparison of serum lipid values in subjects with and without the metabolic syndrome.Am J Cardiol. 2008; 102: 424-428Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 15McLaughlin T. Abbasi F. Cheal K. Chu J. Lamendola C. Reaven G. Use of metabolic markers to identify overweight individuals who are insulin resistant.Ann Intern Med. 2003; 139: 802-809Crossref PubMed Scopus (795) Google Scholar There was no significant difference between nonlineman and the NHANES population in triglycerides/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 population, 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 activity may account for the dysglycemia, although it was possible that some players were not totally compliant with the request of fasting before laboratory test collections. Linemen had a significantly higher prevalence of cardiometabolic syndrome compared with nonlinemen. This finding was not surprising given the increased BMI, waist circumference, waist-height ratio, and presumed visceral obesity in linemen 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 measurement 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.16Center for the Study of Retired Athletes. News.www.csra.unc.edu/statistics.htmGoogle Scholar Current players found to be at risk of future cardiovascular complications can undergo interventions to reduce their risk. These interventions may include both behavioral and medical therapy, particularly after their playing careers have concluded. We thank David Price, BS, Jimmy Ntelekos, BS, MS, and Mike Davidson for contributions.