When it comes to football, size matters. Big players dominate the playing field, partly because they can tackle better and take hits more easily. According to former Green Bay Packer Jim Brown, being bigger helps “with strength and power — the ability to handle bigger guys across the line of scrimmage.”
But even beyond performance, football culture and American perceptions of masculinity are closely intertwined. According to Rusty Barrilleaux, the head football coach at Hammond High School in southeastern Louisiana, football culture “puts a premium on big boys the same way gymnastics put a premium on small, underweight girls.”
Consider the football uniform itself. Like a Barbie doll, it projects an unrealistic ideal of the human body — and of masculinity. Padding broadens the torso and shoulders, and capri tights expose the leg muscles, creating a silhouette that borders on superhuman. Or, as a study that looked at commentary during ABC’s Monday Night Football put it, “the phantasmic body of a titan.”
When masculinity is equated with strength, size, power, and domination, the line between identity and physique blurs. Unfortunately, one of the easiest ways for aspiring football players to achieve this ideal of masculinity is to ‘bulk up,’ regardless of the health consequences.
In a country where 70 percent of adults are overweight, the growing size of football players rarely comes under scrutiny. But as the United States faces rising rates of cardiovascular disease and stroke — both of which are linked to overweight and obesity — it may be time to take a deeper look at the intersection of culture, sports, and health. Recent studies of college football players seem to confirm this need, especially given the long-term consequences for aspiring middle and high school athletes.
Hypertension: The Silent Killer
Hypertension — high blood pressure — is a major risk factor for heart disease. It is measured with two numbers (i.e., 120/80), given in mmHg, a common unit of pressure. The first number is called systolic blood pressure, meaning the pressure in the arteries when the heart contracts. The second number is diastolic blood pressure and refers to the pressure in the arteries when the heart relaxes. Anything below 120/80 is considered healthy.
Being overweight, being sedentary, and eating a diet high in fat, cholesterol, alcohol, and sodium are the main risk factors associated with high blood pressure. Once you climb above the healthy range, there are often no symptoms for years.
But that is why hypertension is known as “the silent killer.”
Every 20 mmHg increase in SBP and 10 mmHg increase in DBP doubles the risk of cardiovascular disease and mortality. In any given year, as many as 410,000 Americans may die because of complications caused high blood pressure, including heart attack and stroke. In fact, CDC data cites heart disease as the leading cause of death in the United States, ahead of cancer by over 35,000 deaths per year.
This is what makes a 2013 study of the Harvard football team so alarming. In the study, a team of researchers from Harvard and the MGH Cardiovascular Performance Program found that participating in American-style football could put athletes at risk for increased blood pressure and subsequent hypertension.
Aaron Baggish, who co-authored the study, is the Harvard Athletics Team Physician Cardiologist, as well as the Associate Director of the MGH Cardiovascular Performance Program. Over six consecutive seasons, he and his colleagues followed 113 Harvard football players, tracking things like blood pressure and weight, and comparing them to a “control group” of 70 members of the Harvard Rowing team.
At the beginning of the study, none of the football players nor any of the rowers met the criteria for stage 1 hypertension. However, 39 percent of the football players were prehypertensive, meaning they were just under the SBP and DBP thresholds for hypertension.
By the end of the six seasons, 63 percent of all the football players now met the criteria for prehypertension or hypertension. That means only 44 of the 113 players had normal blood pressure. Among linemen, the results were even worse; at the end of the study, 83 percent of the team’s 64 linemen were either prehypertensive or hypertensive.
By contrast, none of the 70 rowers showed hypertension at the end of the study. In fact, they even showed a general downward trend in SBP and DBP after only 90 days of endurance training.
Could it be that aerobic versus anaerobic activity — cardio versus strength workouts — affects the incidence of hypertension? This is one possibility mentioned in the football study. But there are some other worthwhile considerations.
At the end of the study, a table listed a handful of predictors for postseason stage 1 hypertension in the group of football players. According to the data, there were three factors that most frequently predicted hypertension:
- Family history. Odds ~ 9 to 1.
- Black ethnicity. Odds ~ 3.5 to 1
- Intraseason BMI change. (change in BMI during the football season) Odds: 3.5 ~ 1
Family history and ethnicity often have a powerful ability to explain medical conditions, so it is perhaps unsurprising that they were such good predictors of hypertension. But BMI change is not necessarily as obvious. As football players gained weight over the course of the season, their chances of becoming hypertensive more than tripled.
This data has big implications. Family history and ethnicity are out of players’ personal control. Intraseason BMI change, on the other hand, is not.
In an interview with Barbara Natterson-Horowitz, professor of medicine at UCLA and visiting professor in human evolutionary biology at Harvard, she explained that in terms of heart health, “there is a pretty specific range of body weights for a given individual that are associated with low risk of cardiovascular health problems and morbidity.”
That is, heart health and weight are irrevocably linked, regardless of how you exercise.
Weight as Weapon
Tackling — one of football’s central features — is to blame for many of the sport’s health problems. In a 2015 drama called Concussion, based on a 2009 exposé published in GQ Magazine, Will Smith portrayed a forensic pathologists whose research found a long history of head trauma within the NFL, most of which was caused by collisions between players. More recently, tackling came under scrutiny in the wake of a research paper from the Boston University Chronic Traumatic Encephalopathy Center, which found neurological degeneration in the donated brains of 110 of 111 former NFL players. The study was covered in an interactive story from the New York Times.
Tackling may also be the culprit when it comes to elevated BMI; the best tacklers are often the heaviest.
But weight issues are far more contentious than brain issues. From fueling eating disorders to creating a stigma against being overweight, there is a special kind of sensitivity demanded by questions of food and weight. “Body weight has become a health issue, a political issue, and a cultural issue,” says Natterson-Horowitz. “It can be used in ways that are destructive.”
However, sensitivity should not stymie a real discussion about size and sport. Football per se might not be the smoking gun that causes chronic obesity, but it certainly prioritizes weight gain in the short run, perhaps against long-run health. This is reason enough to put the game under closer scrutiny.
In American football, most plays begin with a collision between the offensive and defensive lines, with one team trying to clear the way for runners on their own team. In such collisions, size is clearly an asset; imagine a wiry tennis player coming up against a 440-pound Aaron Gibson. This is why each team’s linemen — the main tacklers — tend to weigh the most.
In high school, players and coaches recognize the strategic benefit of hulking linemen, and the pressure to bulk up for the position has led to what some would call an “obesity epidemic” in youth football. A study of 3,600 high school linemen in Iowa, for example, found that 45 percent were overweight and 9 percent were severely obese. That is 36 percent higher than the state average for male adolescents.
These aspiring athletes may be mirroring the trends they see in their role models. A 2005 study across the NFL, for example, showed that nearly 100 percent of players were overweight, and almost 60 percent of those were obese. What is worse, a quarter of all players fell into a special category called “class 2 obesity” (meaning they’re just below the threshold of “morbid obesity”).
America is fat, but not that fat. At the time of the study, nationally about 60 percent of males of similar age were overweight, and 22 percent obese. Compared to the football players, the average Joe would be much closer to a healthy weight than these superstars, role models for thousands of middle and high school students.
Even if big linemen can win a play, or even the whole game, players pay a heavy toll for this win. One study found a 50 percent greater risk of cardiovascular disease in NFL retirees. Even worse, the Harvard football study concludes with a paragraph on its implications beyond the NFL, saying that nearly all former NFL players end up dying from hypertensive and ischemic heart disease (insufficient blood flow to vital organs). Are these consequences really justified by a more exciting spectator experience?
The Argument for Nutritional Optimization
Tim Haehl, class of 2017 and a proud Quincy House resident, played on the Harvard football team beginning in his sophomore year. As defensive back, he led a very successful college career, playing 29 games and ending his tenure as second leading tackler on the team.
Compared to a lineman, Haehl’s position involves fewer impacts, but he did suffer a handful of injuries. These included a bulging disc in his spine and a sprained ACL.
Haehl fell in love with the community he joined as part of Crimson football. Besides the bonding opportunities, he described a strong culture of health on the team, supported by a robust nutrition program.
“Most guys are pretty conscientious of what they eat,” said Haehl, who personally tried to include extra vegetables with every meal. In addition to an emphasis on fruits and veggies, his teammates follow advice from the team nutritionist, Meg Schrier, to eat lots of lean protein. “Chicken and eggs are your friends,” Haehl recalled Schrier saying. The sports nutrition program focuses on quality ingredients, whole foods, and optimal body fat percentages to maximize performance.
Even still, the athletes are getting hypertension. Why?
In an interview with the HPR, Katie Wicks, director of sports nutrition at Ohio State University, called the recent popularization of sports nutrition a revolution ripe for optimizing the modern athlete’s weight and health. Compared to twenty years ago, “we’re just as heavy, but we’re leaner,” she said. By optimizing the kinds of calories they take in, athletes can toy with the kind of weight they gain. In theory, Wicks explained, this could decouple weight with high blood pressure and cardiovascular disease.
It could also redefine the concept of obesity. In Wicks’s view, weight categories as defined by the BMI scale — which only measures height and weight — are insufficient to determine an athlete’s overall health. Body composition, or the percentages of muscle, fat, bone, etc, is a much better determinant of health and athletic prowess, Wicks explained.
This would explain why a muscular bodybuilder, for example, would be considered overweight or even obese under the BMI classification, but healthy in terms of body composition. Haehl himself confessed that the BMI scale would pin him as overweight.
“I don’t feel overweight,” he said. And he certainly is not fat — although he is big.
Optimizing nutrition for pure muscle growth is easier said than done. While players could stringently follow the nutrition program laid out by their coach, that is not the reality for most football teams. Ultimately, there is one goal that matters above all others. As Haehl put it, “most people are trying to get big because of the sport.”
A quick Google search for NFL players like Marcus Cannon, who weighs 358 lbs, sows doubt into the theory that football promotes pure and healthful muscle gain. According to the 2005 paper on obesity in the NFL, “it is unlikely that the high BMI in this group … is due to a healthy increase in muscle mass alone.”
In most schools — especially middle and high schools — there is no sports nutrition program. Without professional guidance, the onus of bulking up “healthily” falls on each player. It is uncertain how many aspiring athletes will understand on their own how to take preventative measures against elevated blood pressure and heart problems down the line, all while trying to achieve their goals of weight gain right now.
Wicks says sports nutrition “is going to trickle down into the high schools,” but if it is not even able to prevent hypertension at a Division I school like Harvard, it is doubtful how effective such nutrition programs could be at a high school level.
Slaughtering Sacred Cows
As a cardiologist who works in intensive and cardiac care units and sees so many people’s lives shortened by cardiovascular complications, Natterson-Horowitz stresses the importance of developing healthy habits early in life. The late teens and twenties, in particular, are times of significant plasticity and environmental sensitivity.
This raises a question about students and sports: should the long-term health and safety of college athletes be an important factor in decisions regarding school-sanctioned activities? This question is broader than just football — it applies to every college sport.
At the very least, the Harvard football study’s correlation between intraseasonal BMI rise and the risk of hypertension calls for some deep thought about the role an institution like Harvard can have in promoting a sports culture that is consistent with long-term health values. Maybe this means weight caps for football or — less likely — a restructuring of the game to de-incentivize indiscriminate weight gain. Regardless, it is clear that something must be done.
Does it really matter to have the phantasmatic body of a titan if your heart gives out years before it should have? For the health of Harvard athletes, and for football players around the country, re-evaluating cultural values around football has the potential to improve and even lengthen lives. As Natterson-Horowitz put it, this would be well worth it, “even if that means slaughtering some sacred cows.”
The cover art for this article was created by Dasha Bough, a student at Harvard College, for the exclusive use of the HPR’s Red Line.