In November 2021, a 29-year-old professional bodybuilder collapsed onstage during a regional competition in Europe. He died a few hours later. His autopsy would reveal a massively enlarged heart and thickened ventricles. These are classic signs of a cardiovascular system pushed past its limits. Another bodybuilder died after collapsing on a competition stage in Brazil earlier this month.
Now, in a new study, researchers have quantified what many in the bodybuilding world had long feared: the discipline carries an unusually high risk of death — particularly sudden cardiac death (SCD). And the danger appears most acute among professionals.
Researchers tracked over 20,000 male bodybuilders who competed in official events of the International Fitness and Bodybuilding Federation (IFBB) between 2005 and 2020. Their findings are grim.
Over an average follow-up of eight years, 121 of the athletes died.
Nearly 40% of those deaths were sudden and cardiac-related. Professional bodybuilders were more than five times as likely to die suddenly from heart-related causes than amateurs.
“These tragic events, often affecting young and apparently healthy athletes, highlight a gap in our understanding of the long-term health risks associated with competitive bodybuilding,” said Dr. Marco Vecchiato, the study’s lead author and a sports physician at the University of Padova.
Perfect Bodies, Crumbling Hearts
At first glance, bodybuilding might seem like the epitome of health. Chiseled physiques, disciplined regimens, and an emphasis on physical strength.
The problem is that this image is often built by heavy drug use.
Bodybuilding, especially at the professional level, often involves extreme training, caloric restriction, dehydration, and — most controversially — performance-enhancing drugs (PEDs), especially anabolic steroids. These substances help athletes grow muscle beyond their natural genetic ceiling, but the long-term health effects are proving catastrophic for some.
In the few autopsies available to Vecchiato’s team, the signs were consistent: cardiomegaly (an enlarged heart), thickened heart walls, and in some cases, fibrosis — scarring of the heart tissue. Several of the athletes tested positive for anabolic steroids. Others had well-documented histories of using PEDs.
“This is not a condemnation of strength training,” said Vecchiato. “On the contrary, regular physical activity and strength training can be extremely beneficial. But the pursuit of extreme body transformation at any cost can carry significant health risks, particularly for the heart.”
The numbers tell a chilling story. Among currently competing athletes — those who had entered an event within the past year — the incidence of sudden cardiac death was roughly 33 per 100,000 athlete-years. For professionals, the rate soared to 130 per 100,000.
And in the sport’s most elite circle, the “Mr. Olympia Open” category, the numbers become even more staggering. Of the 100 competitors identified, 7 died during the study period, 5 of them from sudden cardiac causes. That’s a 5% SCD rate — in a population of highly trained athletes in their 30s.
A Culture of Extremes
Why are these deaths happening? Experts say the answer lies in the very culture of modern bodybuilding. It rewards not strength, but appearance — it’s all about getting as huge and lean as physically possible.
“Arnold Schwarzenegger would not win today,” said Brad Schoenfeld, a professor of exercise science at Lehman College. “He would not even get a pro card.”
Modern top-tier bodybuilders don’t just train hard. They subject themselves to a cocktail of substances aimed at achieving hyper-muscular physiques that judges — and fans — have come to expect. These include anabolic steroids, human growth hormone, diuretics, insulin, and fat-burning drugs like clenbuterol and DNP. Many are not approved for human use. Some are explicitly banned, but enforcement is lax.
“The quantities and the doses and the regimes that they’re doing are insane compared to what people were able to get their hands on 10, 20, 30, let alone 40 years ago,” Stuart Phillips, a physiologist at McMaster University, told The Washington Post.
The impact on the cardiovascular system is profound. High doses of anabolic steroids enlarge the heart. Diuretics, used to “dry out” the physique before competition so athletes can achieve that paper-thin skin look, can trigger fatal electrolyte imbalances. Stimulants strain the heart and central nervous system. And while one drug might not kill, the combination — unregulated, unstandardized, and often self-prescribed — is a dangerous experiment conducted on living bodies.
The Heart Isn’t the Only Organ at Risk
Sudden cardiac death was the most common cause of death in the study, but it was far from the only one. Around 15% of cases were sudden traumatic deaths, including suicides, overdoses, car crashes, and homicides. Mental health, researchers say, is another under-addressed aspect of bodybuilding’s toll.
“The pursuit to reach an extreme physique via scrupulous training and lifestyle regimens . . . may contribute to psychological distress, body dissatisfaction, and athletes may develop or worsen body dysmorphic disorders,” the study notes.
Known colloquially as “bigorexia,” this condition leads men to view themselves as too small — even when they are objectively large and muscular. The pressure to perform and maintain an idealized image can drive substance abuse and mental illness.
Additionally, some athletes died of kidney failure — a consequence possibly tied to dehydration, excessive protein intake, or the toxic effects of certain drugs.
Considering Solutions
While sudden cardiac death remains rare in absolute terms, the researchers argue that it’s alarmingly frequent in bodybuilding compared to other athletic disciplines. In other elite sports, athletes typically outlive the general population. In bodybuilding, the opposite may be true — especially at the professional level.
So, what’s the solution?
Vecchiato and his colleagues suggest a multi-pronged approach: mandatory cardiovascular screening, regular medical check-ups, educational campaigns, and — most crucially — a cultural shift.
The IFBB does claim to follow the World Anti-Doping Agency’s guidelines. But WADA’s most recent data showed just 80 doping samples collected from over 6,000 IFBB events. Thirteen percent of those tested positive — a rate far higher than in any other sport. For comparison, FIFA’s rate is less than one percent.
“This positivity rate is over fifty times higher than that reported by FIFA,” Vecchiato’s team wrote in their study. “Such high rates should urge the respective federation to increase the number of tests.”
Yet change may also have to come from within the community itself. Several bodybuilders have begun to speak out publicly about their own experiences with steroids and the consequences of chasing mass over health.
Behind the Curtain
Mike Israetel, a sports scientist and national-level competitor, described steroids as making him feel like a “pincushion of emotions,” with constant rage simmering just below the surface. “It gets to be pretty exhausting,” he said.
Others have tried to warn younger athletes, even the female bodybuilders who take drugs. “Yes, you can still be feminine, you can still be strong and jacked,” said Brianny Terry, a professional female bodybuilder who said she uses drugs cautiously. “But you need to make an informed decision, because once you take an exogenous hormone, you are changing your body forever.”
When a person stops using steroids, the body’s machinery takes a while to rev up again. So, for a while, that person is producing no natural hormones and is not taking outside hormones. Sex drive plummets along with erectile function. It might take a year or more for sperm production to return to normal, and recent research has shown that about five percent of men never fully recover. Women can also become infertile due to steroid use.
This study — the largest of its kind — is a first step toward understanding the true cost of competitive bodybuilding. But the researchers are quick to point out its limitations. Many deaths likely went unreported. Autopsy data were scarce. Drug use, when known, was often self-reported or inferred. It could be much worse than these estimates imply. Still, the signal is clear.
“The research challenges the idea that appearance alone is an indicator of health,” said Vecchiato.
For now, the shimmering surface of professional bodybuilding — the oil-slicked, sculpted torsos, the dramatic stage lights, the triumphant poses — conceals a troubling reality.
The findings appeared in the European Heart Journal.
