Mortality in male bodybuilding athletes

Abstract

Background and Aims

Premature deaths of bodybuilders have raised questions about the safety and associated risks of this discipline. The main objective of this study was to analyse mortality risk in a large international population of bodybuilders.

Methods

Male athletes who performed International Federation of Bodybuilding and Fitness (IFBB) competitions between 2005 and 2020 were identified and classified according to age, division and level. A standardized web-search, tailored to detect deaths, was performed for each athlete using specific keywords, with follow-up through July 2023. Mortality rates have been calculated both as the overall incidence rate during the monitored period as well as the annual incidence rate of those who participated in at least one competition within the previous year, i.e. currently competing athletes.

Results

A total of 20 286 athletes competing in 730 IFBB events were identified with an average follow-up of 8.1 ± 3.8 years (i.e. 190 211 athlete-years of surveillance). During the study period, 121 deaths were identified: 73 were considered sudden deaths, of which 46 were classified as sudden cardiac deaths (SCD), including 11 currently competing athletes (mean age 34.7 ± 6.1 years). The incidence of SCD in currently competing athletes was 32.83 cases per 100 000 athlete-years. Available autopsies of SCD cases consistently showed cardiomegaly and ventricular hypertrophy. Professional bodybuilders had a higher risk of SCD than amateurs (HR 5.23 [3.58-7.64]).

Conclusions

The results of this study should alert the bodybuilding and medical communities to the need for improved preventive measures to promote safer sports participation.

Structured Graphical Abstract

Graphical Abstract.

See the editorial comment for this article ‘High-stakes hypertrophy: implications of elevated sudden cardiac death rates in competitive bodybuilders’, by J.M. Smoliga, https://doi.org/10.1093/eurheartj/ehaf353.

Introduction

The practice of intense exercise training and extreme muscle development has become increasingly popular in recent decades, with a growing number of individuals engaging in bodybuilding. Despite the benefits of physical activity and the promotion of a healthy lifestyle, some concerns arise regarding risks associated with excessive muscle building.^1,2 Particularly alarming is the occurrence of sudden death (SD) and sudden cardiac death (SCD) in some famous bodybuilders and fitness influencers in recent years,³ which have gained significant attention in this community, but not in the medical field.

SCD in athletes is a dramatic event, often caused by masked cardiovascular conditions.⁴ The underlying causes include structural and/or functional cardiac disorders as well as complex arrhythmias but have also been attributed to exogenous substance abuse.^5,6

While the risks and causes of SCD in bodybuilders have been a subject of debate, scientific evidence only stems from case reports or small case series.^3,6–8 Therefore, this study aimed to analyse the overall mortality risk and incidence of SCD in a large sample of male bodybuilding athletes over a long follow-up period.

Methods

Case selection: Who is a bodybuilder?

The International Fitness and Bodybuilding Federation (IFBB) is the governing body of sports related to bodybuilding and fitness, and oversees the major international championships, including “Mr. Olympia”.⁹ There are three main age categories, i.e. junior (<24 years), master (>40 years), and open (no age restriction).⁹ Athletes were categorized as junior only if they exclusively competed in junior events, master if they participated in at least one master competition, and open otherwise. Further, male bodybuilders can compete in the “men’s bodybuilding” (no weight over height limit) or “classic physique” (weight-height limits) division; athletes were considered “men’s bodybuilding” competitors if they had participated in at least one event within this division. Other recently introduced divisions not primarily focused on muscle mass increase were not included in the analysis. Finally, an athlete is classified as a professional or amateur based on his participation in a professional event; athletes were classified as professional if they had competed in at least one professional event. This is granted by obtaining a professional card through high rankings at regional/national events.

Athletes who participated in at least one official IFBB competition between 2005 and 2020 were identified by the following sources:

• IFBB website,¹⁰ which contains all available 2013–2020 IFBB event results. No events prior to 2013 are reported in the official website.

• MuscleMemory,¹¹ an unofficial database of bodybuilding contest results, containing >270 000 entries.

Case detection: athlete’s death

All identified athletes were catalogued, and duplicates were removed, i.e. those athletes having performed multiple competitions in the selected period. For this purpose, a software was specifically developed in PHP to match the names including non-standard ASCII characters (e.g. accented letters); the software first normalized each name by transliteration and removing special characters and then performed a case-insensitive automatic text matching in order to avoid doubling of cases and ensure the identification of unique athletes. Subsequently, each athlete's name (first and last name) was entered into a standardized web-based Google search string with specific keywords and Boolean operators related to “death” in the English, French, German, Italian, and Spanish language (Supplementary data online, Table S1). Official media reports, major social media including Facebook, Instagram, Twitter/X and YouTube, as well as specific forums/blogs were searched, also using automatic translators (last update 16 July 2023).

Each identified case was verified and analysed by two independent physicians (M.V. and M.D.C.), cross-referencing multiple sources to confirm the identity and details of each death. Deaths were divided into SD or non-SD depending on whether a pre-existing condition could be identified as the underlying cause. SD was classified as traumatic sudden death (TSD) or non-traumatic sudden death (non-TSD), the latter including SCD, defined as death of a cardiac cause that was clearly identifiable by autopsy or description of the event, i.e. if cardiac death occurred suddenly and unexpectedly either within 1 h of symptom onset when witnessed or within 24 h of having been observed alive and symptom-free when unwitnessed.¹²

Analyses

Mortality was investigated as overall incidence rates, analysing bodybuilders from their first registered competition until the end of the follow-up period. Furthermore, an annual incidence rate was calculated focusing only on bodybuilders participating in at least one IFBB event during the respective year, i.e. currently competing athletes. Incidence rates were calculated with exact 95% confidence intervals derived from the Poisson distribution, reporting events per 100 000 athlete-years (AY). The exact Poisson method was used to calculate the 95% confidence interval for the incidence rate ratio, without any adjustment for other covariates. The Kaplan-Meier observation period starts for each athlete from the date of the first IFBB competition. The log-rank test was used to compare the survival curves of professional and amateur athletes.

Results

Over a 16-year period, a total of 44 194 athletes participated in 730 IFBB events (Supplementary data online, Table S2); after removal of duplicates, the final uniquely identified athletes were 20 286. The average follow-up was 8.1 ± 3.8 years for a total of 190 211 AY. During this period, 121 deaths were registered at a mean athlete age of 45.3 ± 11.8 (range 22–77) years. Most deceased athletes were from North America (40.5%; mostly from the USA), followed by Europe (38.8%), Asia (7.4%), Africa (6.6%), South America (5.0%), and Oceania (1.7%).

Causes of death

A specific cause of death was documented in 78.5% of the cases, with 22 being non-SDs and 73 SDs, of which 18 were TSD and 55 non-TSD, the latter including 46 SCDs (38% of total deaths) at an average age of 42.2 ± 10.9 years (Figure 1; Supplementary data online, Table S3). Among non-SCD, the most frequently reported causes were traumatic events such as vehicle accidents (9.1%) and murder/suicide (3.3%); non-traumatic causes were due to cancer (6.6%), COVID-19 complications (5.8%) and kidney/multi-organ failure (4.1%).

Figure 1.

Causes of death. All identified deaths (n = 121) grouped by causes of death. The outer and inner rings represent causes of death for each group and different sub-classifications, respectively. COVID-19, coronavirus disease 2019; MOF, multi-organ failure; NTSD, non-traumatic sudden death; SCD, sudden cardiac death; SD, sudden death; TSD, traumatic sudden death

Autopsy reports were available for only five professional athletes; four subjects presented with left ventricular hypertrophy and cardiomegaly, while two of them also had coronary artery disease and one showed a non-ischemic left ventricular scar. A fifth incomplete autopsy report provided only the presence of coronary artery disease as the cause of death. Three out of five available toxicological analyses demonstrated anabolic-androgenic steroids (AAS) intake. At least 16 further athletes had reported direct testimony or personal history of performance enhancing drug (PED) abuse.

Mortality rate during follow-up

The overall incidence of death and SCD was 63.61 (52.78–76.01) and 24.18 (17.71–32.26) per 100 000 AY, respectively (Table 1).

Table 1.

Overall mortality rate of all athletes and subgroups over the monitored period

		Age classification				Division			Competition level
All athletes	Total (n = 20286; 190211 AY)	Junior (n = 1229; 13943AY)	Open (n = 15799; 141422 AY)	Masters (n = 3258; 34846 AY)	Incidence rate ratio	Men’s Bodybuilding (n = 15787; 155905 AY)	Classic Physique (n = 4499; 34306 AY)	Incidence rate ratio	Professional (n = 1454; 12911 AY)	Amateur (n = 18832; 177300 AY)	Incidence rate ratio
Deaths (%)	121 (100%)	2 (2%)	74 (61%)	45 (37%)		117 (97%)	4 (3%)		41 (34%)	80 (66%)
Incidence rate of death (95% CI)	63.61 (52.78 -76.01)	14.34 (1.74–51.82)	52.33 (41.09–65.69)	129.14 (94.2–172.8)	0.41 (0.28–0.60)	75.05 (62.06–89.94)	11.66 (3.18–29.85)	6.44 (2.45–24.02)	317.56 (227.89–430.8)	45.12 (35.78–56.16)	7.04 (4.71–10.38)
SD (%)	73 (100%)	2 (3%)	51 (70%)	20 (27%)		70 (96%)	3 (4%)		31 (42%)	42 (58%)
Incidence rate of SD (95% CI)	38.38 (30.08–48.26	14.34 (1.74–51.82)	36.06 (26.85–47.42)	57.4 (35.06–88.64)	0.63 (0.37–1.11)	44.9 (35.00–56.73)	8.74 (1.8–25.56)	5.13 (1.69–25.50)	240.11 (163.14–340.81)	23.69 (17.07–32.02)	10.14 (6.16–16.51)
SCD (%)	46 (100%)	0 (0%)	35 (76%)	11 (24%)		44 (96%)	2 (4%)		25 (54%)	21 (46%)
Incidence rate of SCD (95% CI)	24.18 (17.71–32.26)	/	24.75 (17.24–34.42)	31.57 (15.76–56.48)	0.78 (0.39–1.71)	28.22 (20.51–37.89)	5.83 (0.71–21.06)	4.84 (1.26–41.22)	193.63 (125.31–285.84)	11.84 (7.33–18.11)	16.35 (8.78–30.71)

Incidence rates are shown as events per year per 100 000 athletes. Incidence rate ratio with corresponding 95% confidence intervals between subgroups were reported as follows: open vs. master athletes; men’s bodybuilding vs. classic physique athletes; professionals vs. amateur athletes.

CI, confidence interval; SD, sudden death; SCD, sudden cardiac death.

There were 45 deaths among master athletes with an average age of 55.1 ± 10.1 years, of which 11 were classified as SCD. Only two junior athletes died in the monitored period, and none of SCD. Although master athletes presented a twofold overall risk of all-cause death compared with open athletes, the risk of SCD appeared comparable.

Only four deaths were reported among athletes in the “classic physique” division with a risk of SCD five times lower than in the “men's bodybuilding” division.

During follow-up, 41 out of 1 454 professional athletes died (2.8%), compared with 80 among 18 832 amateur athletes (0.4%), resulting in an HR of 5.23 (3.58–7.64; P < 0.001) (Figure 2). Twenty-five professional athletes died of SCD with an incidence of 193.63 (125.31–285.84) per 100 000 AY, more than 14 times higher than in amateur athletes. Restricting the analysis only to bodybuilders who participated in the Mr. Olympia “open” category, the highest-ranked international bodybuilding competition, deaths recorded during the study period were 7 out of 100 athletes, including five presumed or confirmed SCD at a mean age of 36.0 ± 10.3 years and an average incidence of 386.10 (125.37–901.03) per 100 000 AY.

Figure 2.

Time to death for professional and amateur athletes. Kaplan-Maier survival curves for deceased professional and amateur athletes. Mortality was significantly higher among professional athletes by log-rank test (P < 0.0001)

Mortality rate in currently competing athletes

Twenty-seven athletes died within 1 year after the last participation in an official IFBB competition, registering 11 SCD (mean age 34.7 ± 6.1 years). One athlete collapsed onstage during competition, two athletes had a SCD during training, and four athletes soon after an official event (one a few hours later while the remaining three within a week). The incidence of death and SCD in currently competing athletes was 80.58 (53.10–117.24) and 32.83 (16.39–58.74) per 100 000 AY, respectively (Table 2).

Table 2.

Mortality rate of currently competing athletes and subgroups

		Age classification				Division			Competition level
Currently competing athletes	Total (n = 20 286; 33 506 AY)	Junior (n = 1229; 2006 AY)	Open (n = 15 799; 25434 AY)	Masters (n = 3258; 6066 AY)	Incidence rate ratio	Men’s Bodybuilding (n = 15 787; 27563 AY)	Classic, Physique (n = 4499; 5943 AY)	Incidence rate ratio	Professional (n = 1454; 3845 AY)	Amateur (n = 18 832; 29661 AY)	Incidence rate ratio
Deaths (%)	27 (100%)	2 (7%)	17 (63%)	8 (30%)		25 (93%)	2 (7%)		8 (30%)	19 (70%)
Incidence rate of death (95% CI)	80.58 (53.10–117.24)	99.7 (12.07–360.15)	66.84 (38.94–107.02)	131.88 (56.94–259.86)	0.51 (0.21–1.36)	90.7 (58.70–133.89)	33.65 (4.08–121.57)	2.70 (0.67–23.45)	208.06 (89.83–409.97)	64.06 (38.57–100.03)	3.25 (1.23–7.77)
SD (%)	23 (100%)	2 (9%)	17 (74%)	4 (27%)		21 (91%)	2 (9%)		8 (35%)	15 (65%)
Incidence rate of SD (95% CI)	68.64 (43.51–103.00)	99.7 (12.07–360.15)	66.84 (38.94–107.02)	65.94 (17.97–168.84)	1.01 (0.33–4.14)	76.19 (47.16–116.46)	33.65 (4.08–121.57)	2.26 (0.55–19.92)	208.06 (89.83–409.97)	50.57 (28.30–83.41)	4.11 (1.51–10.34)
SCD (%)	11 (100%)	0 (0%)	10 (91%)	1 (9%)		10 (91%)	1 (8%)		5 (45%)	6 (55%)
Incidence rate of SCD (95% CI)	32.83 (16.39–58.74)	/	39.32 (18.85–72.31)	16.49 (0.42–91.85)	2.39 (0.34–103.50)	36.28 (17.4–66.72)	16.83 (0.43–93.75)	2.16 (0.31–93.57)	130.04 (42.22–303.47)	20.23 (7.42–44.03)	6.43 (1.55–25.28)

Incidence rates are shown as events per year per 100 000 athletes. Incidence rate ratio with corresponding 95% confidence intervals between subgroups were reported as follows: open vs. master athletes; men’s bodybuilding vs. classic physique athletes; professionals vs. amateur athletes.

CI, confidence interval; SD, sudden death; SCD, sudden cardiac death.

No difference was found between open and master athletes regarding the incidence of SCD. Only one athlete in the “classic physique” division died from SCD compared with 10 in the “men's bodybuilding” division. Currently competing professional athletes have an incidence rate of SCD of 130.04 (42.22–303.47) per 100 000 AY, about six times higher than amateur athletes.

Discussion

This is the first study to report the incidence of all-cause death, SD and SCD in a large sample of bodybuilding athletes and to assess the mortality rate in this specific population over a long follow-up period (Structured Graphical Abstract). The aim of this research project was not to defame bodybuilding or the IFBB but rather to contribute to the understanding of a complex phenomenon and provide insights for future policy intervention strategies in order to promote safer sports participation. This study emphasizes an important health problem related to a specific sport discipline, which also affects many non-professional athletes practising strength training in territorial gyms. The ultimate goal is to ensure good health and well-being of all these athletes, allowing them to pursue their passion safely and effectively. The influence of famous bodybuilders on the general fitness community could lead to a concerning public health issue or become an opportunity for specific initiatives, working together on a new cultural approach and perspective.

Causes of deaths

Case reports on SCD in bodybuilders have been reported before,^3,7,8,13 but there has never been any research study using a standardized and systematic methodology that directly examines mortality rates in bodybuilders. In this worldwide retrospective observational study, 121 deaths were registered among more than 20 000 athletes, with ∼38% SCDs as the most common cause of death. It is reasonable to assume that many of the unknown causes of death were also SCDs. Furthermore, it was possible to identify several athletes with cardiovascular conditions including heart failure, stroke, pulmonary embolism, vasculitis, and myocardial infarction (Supplementary data online, Table S3). However, since autopsy findings were available in only 10% of SCDs, this limited medical data precludes strong inferences about underlying diseases and pathophysiological mechanisms. Nevertheless, severe left ventricular hypertrophy and cardiomegaly were common findings, associated with fibrosis and necrosis of myocardial tissue. Moreover, in a study analysing specifically autopsies of bodybuilders, it was shown that the mean heart mass was 73.7% heavier than normal reference values with left ventricular myocardium thickness 125% thicker than predicted.¹³ Intense strength training may cause mild concentric or eccentric left ventricular hypertrophy.^14,15 Instead, severe concentric hypertrophy is rarely found in healthy athletes and suggests an impact of anabolic substance abuse, coinciding with an increased risk of ventricular dysfunction and SCD.^16,17

Unnatural causes of death, including suicide, homicides, vehicle accidents, overdoses and intoxication, have also been observed in our cohort. Indeed, it is crucial to acknowledge the potential impact of bodybuilding on mental health and psychosocial factors leading to a propensity for risk-taking behaviour and these tragic events. The pursuit to reach an extreme physique via scrupulous training and lifestyle regimens, associated with the pressure to achieve social ideals of muscularity may contribute to psychological distress, body dissatisfaction, and athletes may develop or worsen body dysmorphic disorders.^18,19 These psychological conditions, coupled with potential substance abuse, can increase the risk for different mental health disorders and the susceptibility to impulsive or self-destructive behaviours.²⁰ It is thus essential to prioritize mental well-being in the bodybuilding community, by offering support and education to promote a balanced and sustainable approach to the sport.

A significant number of athletes died from kidney-related causes. Moreover, at least three of the athletes who died of SCD had a known history of kidney disease/transplantation; one autopsy finding reported nephrosclerosis and kidney hypertrophy. The high protein intake in combination with vigorous training and aesthetically motivated weight loss and dehydration, frequently via diuretic drug intake, can place a significant strain on the kidneys.^21–23 Furthermore, the use of AAS has been linked to the development of acute and chronic kidney diseases.^24,25

Mortality risk

Bodybuilding transcends the conventional definition of a competitive sport since the purpose is an aesthetic modification of the body by maximising muscle mass, and the exhibition is not the athlete's moment of maximal muscular effort. However, the period of competition should be considered as psychophysically very demanding and still at risk, because of the preparation protocols regarding drastic weight loss procedures in the proximity of the event, obtained through caloric restriction and hydro-saline depletion. This is confirmed by the high mortality rate found in currently competing athletes and the fact that five athletes died of SCD during or shortly after an official event. These intense pre-competition practices impose significant haemodynamic and metabolic demands, which may exacerbate underlying cardiovascular diseases. Additionally, even after stopping competitive events, bodybuilders frequently maintain a lifestyle that closely aligns with the ideals of the sport with the associated risks remaining high. For this reason, our analyses do not solely focus on deaths occurring among currently competing athletes but also include overall mortality rates within the monitored period, which appeared rather high, especially in certain subgroups. This is in contrast with other elite athletes who have a longer life expectancy than the general population with lower risks of cardiovascular diseases and cancer.^26,27

Although SCD can still be described as a rare event even among bodybuilders, studies conducted over the past 30 years in healthy young athletes and the military have shown very variable incidence rates of SCD but all far lower than what was observed in our cohort.⁴ Nevertheless, it should be considered that the bodybuilding athlete is generally older compared with other sport disciplines, with an average age of Mr. Olympia winners exceeding 35 years of age, usually representing the end of a high-level competitive career for many sports. Interestingly, the risk of SCD in currently competing bodybuilders appears higher compared with overall risk of SCD in the whole monitored period.

It has already been shown how pre-participation screening can lead to a significant risk reduction in competing athletes of other sports.²⁸ Resting electrocardiogram, exercise testing and echocardiogram could also help to identify cardiac maladaptation in bodybuilders such as increased wall thickness, cardiomegaly and potentially associated arrhythmias, but evidence on the potential impact and implications of such screening in bodybuilding is currently not available.^17,29–31 However, bodybuilding does currently not involve any specific medical risk assessment, and in many countries it is not even considered a sport discipline, thus precluding specific evaluations and medical checks for professionals. In most of the deceased athletes, it was not possible to find information about the subject's personal or family history. Furthermore, potentially pathological substrates favouring SCD such as structural or primary electrical cardiac disorders cannot be excluded. Nevertheless, the absence of SCD among junior athletes suggests predisposing substrates as unlikely reasons. Moreover, the similar risk of SCDs between open and master athletes conflicts with what is known in other sports and the general population, leading to the assumption that there are additional factors to be considered. Regular medical checks for athletes engaged in this discipline may allow early detection of pathological cardiovascular conditions and potentially reduce the burden of SCD.³² Indeed, preventive strategies could mitigate the risk of such major adverse events,^30,33 particularly given the well-documented association between PED abuse and increased cardiovascular risk.^34,35

Moreover, our findings indicate that mental health-related deaths imply further significant medical concerns, particularly among younger and professional athletes. The prevalence of body dysmorphic disorders, combined with substance abuse, creates a toxic environment that amplifies the risks of impulsive or self-destructive behaviours. These observations highlight the need for psychological screening and the implementation of mental health support programmes within the bodybuilding community.

Performance enhancing drugs

Bodybuilders often engage in PED abuse to attain and maintain their highly muscular and defined physiques.⁶ AAS are certainly the most widely used PEDs for these purposes, reaching a prevalence of more than 75% among male competitive bodybuilders.^36,37 AAS exert various adverse effects on the entire organism and specifically on the cardiovascular system that contribute to an increased SCD risk.³⁸ Alterations in lipid profiles as well as higher homocysteine and haematocrit levels have been associated with increased atherosclerotic plaque formation and elevated risk of coronary artery disease in this population.^34,35,39,40 The use of AAS may also lead to hypertension and has been associated with ventricular hypertrophy, cardiomegaly and systolic dysfunction, which could be further influenced by other diseases irrespective of AAS abuse such as coronary artery disease.^{17,29,30,41–44} Furthermore, AAS may modify cardiac remodelling processes, leading to abnormal fibrosis and impaired contractility, potentially predisposing individuals to life-threatening arrhythmias and SCD.^6,13 Moreover, the psychiatric side effects of AAS abuse, including mood swings, aggression, depression, and anxiety, may also contribute to the observed risk of suicides and overdoses in this population.⁴⁵ The pursuit of extreme physique ideals and the psychological pressure to succeed in competitions can also exacerbate existing mental health vulnerabilities. This emphasizes the importance of educational initiatives targeting substance abuse and its broader health consequences, not only on the cardiovascular system but also on mental well-being.

Despite not having systematic information on the whole study sample, toxicological findings or a history of PED abuse were identified in ∼16% of deceased athletes. This is in line with previous reports and an increasing number of professional bodybuilders that have declared the use of PEDs and talked openly about their doping routines.^46,47 Our results showed huge differences between professional and amateur athletes, with an incidence of SCD that can no longer be considered a rare occurrence in professional bodybuilding. A recent research letter investigating mortality and cause of death among a smaller cohort of AAS users during a follow-up period like ours, found similar mortality rates in professional athletes.⁴⁸ Analysing the most extreme elite of the “open” Mr. Olympians, the 7% incidence of deaths, including 5% of SCD, are alarmingly high. These very high-level professional athletes, when compared with amateur athletes, show an increased risk of health complications indirectly contributing to morbidity and mortality because of extreme training, a more stringent dietary regime and frequent PED abuse.

Although this direct and indirect evidence of PED abuse, the competitive bodybuilding community seems to lack robust anti-doping test protocols, which has created an environment where athletes openly expose the use of PEDs despite the known adverse effects.⁴⁹ The IFBB has drug testing policies aligned with the World Anti-Doping Agency (WADA) Code.⁹ However, there have been concerns about these anti-doping measures in recent decades. Indeed, the IFBB annually holds more than 6 000 competitions⁹ but the most recent available WADA report shows that only 80 samples were submitted for doping analyses, resulting in 13% positive findings.⁵⁰ This positivity rate is over fifty times higher than that reported by FIFA and about five times higher than that of the International Powerlifting Federation, where ten times as many samples have been tested.⁵⁰ Positivity rates this high should urge the respective federation to increase the number of tests; therefore, WADA itself approached the IFBB for not engaging in the implementation of an adequate testing programme and not devoting enough resources to doping control.⁵¹ The bodybuilding federations must become responsible for initiating a cultural shift in this sport discipline, while WADA and the medical associations are needed to provide the scientific background and guide them to change their approach for promoting safer sports participation. Implementing systematic screening and programmes could significantly contribute to athletes’ safety and align bodybuilding with other sports that have established health surveillance frameworks.

However, distinguishing the specific impact of PEDs from the broader context of substance abuse and all remaining bodybuilding practices, including extreme strength exercise loads and restrictive dietary requirements, is challenging. Yet, there is not enough quality data available to attribute the increased SCD risk solely to PED abuse and it is important to not overlook the mentioned confounders to health issues and mortality within the bodybuilding community.

Limitations and future perspectives

It is important to clarify that this is not a complete list of bodybuilders who died during the selected period but it only includes those who participated in at least one verified IFBB event. Many other bodybuilders registered with other federations may have died during the investigated period, but they are not included in the current analysis. Although this research project is the first to offer an extensive overview of the mortality risk in bodybuilding, several limitations should be disclosed. First, the web-search method, although systematically conducted on participants from all over the world drawing from the most extensive available sources, cannot be as precise as prospective death registries and institutional recordings. The reliance on publicly available sources introduces a possible ascertainment bias, where certain causes of death may be underreported due to stigma, while SD in young athletes may receive disproportionate attention. Additionally, the notoriety of an athlete may influence the level of available details, leading to potential selection bias and misclassification of underlying causes of death. While this study focused on mortality, only few data on chronic cardiovascular diseases are available, which represents a limitation imposed by the applied web-based search methodology. These facts underscore the need for future research to include also non-fatal outcomes, which could provide a more comprehensive understanding of the cardiovascular burden in bodybuilding. Second, the number of autopsy findings is low; consequently, many SCD diagnoses have been derived from a clinical interpretation of available online reports. In order to be as restrictive as possible, deaths reported as sudden but lacking autopsy findings or a description of circumstances, were defined as unknown. Moreover, the absence of consistent autopsy protocols for deceased athletes in many regions contributed to this limitation. This highlights the critical need for a systematic approach to accurately determine the causes of SDs, pathophysiological mechanisms and improve the robustness of future research findings. Third, the conducted analysis was time-limited by research methodology (restricted web-data before 2005). Furthermore, the limited notoriety of amateur and master athletes may underestimate mortality rates with inaccurate identification of the causes of death. Fourth, athletes were considered as competing only if they took part in an IFBB competition within the previous year, while potential participation in other competitions could not be excluded. Fifth, resuscitation cases when not subsequently leading to death could not be considered for methodological issues; thus, it is possible that the number of total cardiac arrests was even higher. Future research studies and a prospective and systematic registry should incorporate survived SCD as well as other chronic cardiovascular conditions to provide a more comprehensive understanding of this phenomenon. Sixth, the web-based search was conducted using limited keywords in five languages; therefore, some information reported exclusively in other languages may have been lost. This language issue might have affected the representation of athletes from some countries with known high prevalence of AAS abuse.⁵² Moreover, media coverage and the accessibility of reliable online information vary widely across such regions and are higher in North America and Europe. The use of the automatic translator for idioms with a different phonetic structure may have further affected the outcomes. Therefore, future studies should include other languages to improve global representation. Finally, database entries reporting athletes with similar but not identical names have been considered as distinctive athletes.

However, all these approximations lead to a further underestimation of the real number of deaths and SCDs.

This study demonstrates a necessity for an independent prospective registry. Irrespective of that, current data are alarming and sufficient to call for the development of specific recommendations for the prevention of SD/SCD among bodybuilders, including the systematic implementation of bystander automated external defibrillators. Upcoming studies could extend this research further into the past to analyse how the modernisation of practices and pharmacology influenced mortality rates over time. It would also be interesting to investigate these mortality rates in female bodybuilders, evaluating sex differences.

The influence of professional bodybuilders and fitness influencers extends beyond the competitive arena, potentially affecting many non-professional athletes and fitness enthusiasts. Addressing these risks could therefore have widespread public health implications, increasing the potential clinical impact of these findings and subsequent related policy strategies.

Conclusion

Bodybuilding is a sport discipline that exposes the athlete to several health risks, and this study showed an elevated risk of death and SCD, especially for those competing at a high-level. These data demonstrate the need for a collaborative partnership involving the bodybuilding community, federations and medical associations to better understand this alarming phenomenon, in order to subsequently implement all necessary preventive measures to reduce the risk of SD among these athletes. It is thereby aimed to promote safer sports participation in the short and long term, also considering the significant impact these athletes can have on the general population engaging in strength training in territorial gyms. Besides a required intensification of doping control, our study emphasizes the need for further research and the systematic collection of prospective data to explore the implications of PED-induced cardiac toxicity in bodybuilders and its differentiation from adaptive remodelling in athletes. Finally, safety should be improved by specific preventive measures, also with educational initiatives possibly leading to a cultural shift in the athletic approach.

Supplementary data

Supplementary data are available at European Heart Journal online.

Declarations

Disclosure of Interest

All authors declare no conflict of interest for this contribution.

Data Availability

See Supplementary data online, Table S3. Complete dataset can be shared after reasonable request to corresponding author.

Funding

All authors declare no funding for this contribution.

Ethical Approval

Ethical approval was not required.

Pre-registered Clinical Trial Number

None supplied.