Sport is good for you, but be careful not to exaggerate. Above all, beware of substances that are all too common in the sports world and make it far less sporting than it should be. Does that sound strange? Well, it is true! ‘Reckless’ bodybuilding is bad for your heart. According to an international survey coordinated by researchers at the University of Padua, including Stefano Palermi, a lecturer at UniCamillus, male bodybuilders are at risk of health problems. The study revealed concerning findings about the health of male bodybuilders, especially top professionals.
The research, published in the European Heart Journal, is the result of a collaboration between Italian, American and Austrian researchers. They analysed a large sample of over 20,000 athletes who took part in International Fitness and Bodybuilding Federation (IFBB) competitions between 2005 and 2020. The researchers followed the athletes’ health data for an average of over eight years.
During this period, 121 deaths were recorded, 38% of which were attributed to sudden cardiac death. In several cases, these deaths were associated with structural changes to the heart and frequently with doping. The study’s key finding is that professional bodybuilders are more than five times more likely to die suddenly of cardiac causes than amateur athletes.
To gain a better understanding of this study and its subject matter, we interviewed Stefano Palermi, who was directly involved in the international team that conducted the research. Stefano Palermi is a lecturer in Diseases of the Musculoskeletal System at UniCamillus University.
Could you please outline your role in the study and the specific contribution you made?
“The study was conceived and coordinated by my friend and colleague Dr Marco Vecchiato, who is a sports physician and researcher at the University of Padua. He knows the world of bodybuilding very well and has been studying the potential risks associated with it for some time. He designed the study and initiated the large-scale data collection that has produced impressive results. The study has been published in the European Heart Journal, one of the world’s most authoritative scientific journals, and has had an extraordinary international impact, receiving wide coverage in scientific and general media outlets around the world. Marco has already given numerous interviews, demonstrating the interest and relevance that this work has generated beyond the medical community.
My contribution focused mainly on the methodological and organisational aspects. The dataset was complex, based on a thorough review of over 20 thousand athletes. Cross-checking, categorisation and clinical interpretation required cross-skills, and it was a pleasure to collaborate. We were joined by other internationally renowned colleagues, including Andrea Ermolao, Marco Da Col, Andrea Aghi, Giampaolo Berton, Francesca Battista, Sandro Savino, Jonathan Drezner, Alessandro Zorzi, Josef Niebauer and Daniel Neunhaeuserer”.
The study reveals that professional bodybuilders are at significantly higher risk of sudden cardiac death, partly due to structural changes in the heart and partly because of the use of doping substances. What is the most frequent cause?
“It is difficult to identify a single cause because several factors can often coexist. However, some hypotheses are viable: intense training regimes combined with extreme high-protein diets involving large weight fluctuations between off-season and on-season training, often with drastic hydrosaline depletion before competitions, place the cardiovascular system under great stress. Added to this is the use, and often abuse, of performance-enhancing substances, many of which are doping substances—in particular, anabolic steroids.
In the few cases where autopsy or toxicological reports were available, clear abuse of anabolic-androgenic steroids (AAS) was evident, associated with thickening and enlargement of the heart, fibrosis, and coronary artery disease. These changes are known to significantly increase the risk of fatal arrhythmias”.
Does the structural change to the heart only occur with bodybuilding, or does it occur with other sports too? And is it due to intense physical effort or substance use?
“Structural changes to the heart can also occur in other endurance or power sports and are known as ‘athlete’s heart’ or ‘athletic heart syndrome (AHS)’. Generally, however, these changes are physiological and benign. In cases identified in deceased athletes, however, these changes exceeded physiological limits and became pathological. Cardiomegaly and severe ventricular hypertrophy are conditions that are difficult to detect in healthy athletes, even at a high level”.
Autopsies have often revealed cardiomegaly and ventricular hypertrophy. What are they and how dangerous are they?
“Clinically, cardiomegaly indicates an abnormal enlargement of the heart, while ventricular hypertrophy—particularly left ventricular hypertrophy—is a thickening of the ventricular walls that can impair the heart’s electrical and mechanical function.
While these conditions are not always dangerous, they can become critical when associated with myocardial fibrosis or reduced cardiac muscle compliance. In athletes, they can lead to malignant ventricular tachyarrhythmias, which are the most common cause of sudden cardiac death”.
Is structural change to the heart an inevitable event, or does it only affect certain predisposed individuals? Can it be prevented? Are there medical checks for competitive athletes?
“It is not inevitable, but it depends on factors such as genetics, the intensity and duration of the stimulus, and the use of doping substances. Some individuals can develop damage early on, whereas others can tolerate stress better. In any case, prevention is possible and involves raising awareness and medical monitoring.
In Italy, compulsory competitive sports medical check-ups are one of the most advanced cardiovascular screening tools in the world. Despite this, only a few bodybuilding federations require the medical check-up for membership, while the rest make no mention of it. Consequently, some individuals undergo an in-depth assessment involving cardiovascular stress testing, while others undergo an assessment involving a resting electrocardiogram aimed at determining non-competitive fitness aptitude. Many individuals, however, escape the screening system altogether. Internationally, of course, it depends on the individual country, but generally speaking, these rules are often disregarded or inapplicable. It is crucial to strengthen the culture of prevention in these contexts as well”.
Is there anything you would recommend to competitive bodybuilders?
“The message is clear: bodybuilding can be an extraordinary form of physical and mental discipline. However, the quest for extreme performance at any cost must never compromise your health. Intense training is legitimate, but it must be done without taking pharmacological shortcuts and by respecting the body’s physiological timing. Regular medical check-ups are also important.
We need a cultural change that emphasises strength and fitness without idealising unsustainable and potentially dangerous models. Appearance should not be synonymous with health”.
Are there any further studies in this area that you are about to conduct with UniCamillus?
“Yes, absolutely. Together with other colleagues, I am concluding a similar study on female bodybuilders which is just about to be published. This is an even less explored area, but just as sensitive because it involves specific psychological and hormonal dynamics.
UniCamillus pays close attention to health issues in sport and prevention, and we are already planning further longitudinal studies on athletes’ hearts from a sports medicine perspective, among other things. This area of research is still at an early stage, but it is of great social relevance”.