January 17, 2023 – On January 2, the Buffalo Bills’ Damar Hamlin suffered cardiac arrest during a game. He’s now on the road to recovery, but the event put a spotlight on football’s inherent risks. Rachel Grashow, research scientist in Harvard Chan School’s Department of Environmental Health and director of epidemiological research initiatives with the Football Players Health Study at Harvard University, comments on Hamlin’s experience as well as other serious health issues players can face.
Q: The recent injury suffered by the Buffalo Bills’ Damar Hamlin seemed like a freak accident. Based on your work with the Football Players Health Study, do you see this accident that way? Is this the kind of injury that football teams should be more aware of?
A: Experts are still trying to determine the cause of Damar Hamlin’s cardiac arrest. Some media reports have prematurely implicated commotio cordis, in which the heart stops pumping due to blunt chest trauma. Should Hamlin’s evaluation result in a final diagnosis of commotio cordis, we want to emphasize that this is an incredibly rare event that has previously been seen primarily in sports that use balls and pucks, like lacrosse, baseball, and hockey. Our study team will continue to follow Hamlin’s case to determine if there are any actionable implications for the game of football. In the interim, we commend the emergency response to his collapse which included near immediate CPR and subsequent use of an external defibrillator. Regardless of why he collapsed, this response saved his life and should serve as an example of how emergency responses should be implemented at all levels of sport.
Taking a broader view, any adverse event during an NFL game—whether rare or common—underscores the need to better understand the risks and benefits of the game of football during active play and following career completion. Accordingly, the purpose of the Football Players Health Study is twofold. First, we aim to better understand the health hazards and benefits of a career in professional football. Next, we aim to identify and develop interventions that can be used improve health outcomes in active and former NFL players.
Q: Your team recently found that NFL players age significantly faster than the general population. Can you elaborate?
A: Our recent study on aging in former professional football players was motivated by anecdotal evidence from both players and their health providers. We learned that former players would often say they felt older than their chronological age, and providers observed that players appeared clinically older than their years. To study this in a systematic way, we selected four conditions generally associated with aging: hypertension, diabetes, arthritis, and Alzheimer’s disease/dementia. First, we defined the term “healthspan” for roughly 3000 former players under age 60 as freedom from any of these diseases. We saw that, compared to men in the general population—based on data derived from two large nationwide studies, the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS)—former players demonstrated healthspans that were approximately 10 years shorter than their non-football peers, even with adjustments for race and body mass index (BMI).
We then looked at each of the four conditions separately, and calculated race and BMI-adjusted prevalence estimates for former NFL players and for age-matched male controls. We saw two distinct patterns. The first was demonstrated in arthritis and Alzheimer’s disease/dementia. We found that prevalence estimates of these conditions were higher among former players ages 25-30, 31-40, 41-50, and 50-60, when compared to controls. We observed a different pattern for the cardiometabolic outcomes. Players in the youngest age group showed significantly more hypertension and diabetes than men in the general population, although in older age groups, prevalence estimates were equivalent among 31- to 40-year-olds and lower in the 41-60 age group.
These results are meaningful because, for relatively young players, even short-term exposures to hypertension and diabetes can lead to long-term cardiovascular and cognitive implications. If younger former players are screened and proactively treated for these conditions, it may be possible to mitigate long-term neurocognitive and cardiovascular outcomes that have been shown to affect quality and length of life.
Q: What would you say is the gravest long-term health risk that pro football players face and what does your team recommend for prevention?
A: Our data supports previous literature that continues to point to cardiovascular illness and deaths as the greatest health challenge for former NFL players. Research from our group and others has shown that these conditions may result from weight gain, training, dietary and nutritional factors, as well as potentially result from physiological dysfunction following traumatic orthopedic or brain injuries.
Degenerative neurological disease, which may result from repetitive head injury, is an additional concern for players. One possible risk is chronic traumatic encephalopathy (CTE), a trauma-related condition typified by neuroanatomical, cognitive, and mood-related changes, which currently has no established treatment or cure. However, questions continue to be raised about how best to identify conditions such as CTE in living former players since currently CTE can only be diagnosed after death. It is important to note that cognitive dysfunction (e.g., memory, attention and concentration issues) among players may not necessarily be due to head injury–related neurological disease. Cognitive impairment is commonly found with other conditions such as depression, hypertension, sleep apnea, diabetes, and high cholesterol. High proportions of players in our study are reporting diagnoses of such ailments, all of which have safe and effective treatment options.
As for how former players can protect their health, our study team recommends that they establish an ongoing relationship with a primary care doctor to take preventative steps to address health issues they may experience. Proactively treating hypertension and diabetes, sleep apnea, high cholesterol, chronic pain, mood disorders, weight gain, and other common chronic conditions can improve both lifespan and healthspan in former players. Lifestyle choices that include exercise, healthy diets, and a strong social network are also protective for long-term health.