2021 was a tragic year for the bodybuilding world. Over two dozen professional athletes died suddenly in a 12-month period, making headlines worldwide.

The youngest was 27 years old.

Today, a wealth of research suggests that elite athletes tend to live longer than the general population, but a spate of premature deaths among bodybuilders in recent years has raised questions about the safety of this sport.

A recent study, led by researchers at the University of Padova in Italy, is the first to investigate the risk of sudden death among a large sample of male bodybuilders.

The findings highlight an alarming phenomenon that the authors say can no longer be ignored by athletes, medical associations, or sports organisations.

The analysis tracked more than 20,000 bodybuilders over an average of 8 years, during which time 73 sudden deaths were registered at a mean age of 42.

Some of these deaths were due to steroids or performance-enhancing drugs. Others resulted from vehicle accidents, murder, or suicide. But by far the most common cause of death was sudden heart failure, including 46 cases.

That represents a low absolute risk for bodybuilders in general; however, the risk of sudden heart failure was found to be more than 14 times higher among the most elite professionals compared to amateur athletes, suggesting that as the sport becomes more serious, it may also become exponentially more dangerous.

When examining only the bodybuilders WHO participated in the highest-ranked international bodybuilding competition—the Mr. Olympia "open" category—researchers found an "alarmingly high" death rate.

Out of the 100 elite competitors WHO took part in the competition over the years, 7 died from sudden causes.

Five of those deaths were presumed or confirmed cases of sudden cardiac death at a mean age of just 36.

"Current data are alarming," the international team of authors concludes, "and sufficient to call for the development of specific recommendations for the prevention of sudden death/sudden cardiac death among bodybuilders, including the systematic implementation of bystander automated external defibrillators."

The analysis is limited by a lack of comprehensive data, as autopsies were only available for about 10 per cent of sudden cardiac deaths. This means there are few specifics on how and why many of these athletes died.

However, the authors of the study, led by sports medicine researcher Marco Vecchiato from the University of Padova, suspect that extreme training, strict dietary regimes, and frequent performance-enhancing drug abuse are risking the heart health of very high-level professional bodybuilders.

"These approaches can place significant strain on the cardiovascular system, increase the risk of irregular heart rhythm, and may lead to structural heart changes over time," explains Vecchiato.

Available autopsies included in the study consistently showed left ventricle thickening and enlarged hearts among bodybuilders.

This aligns with a previous autopsy study, which found that the mean heart mass of bodybuilders was nearly 74 per cent heavier than normal reference values, and that on average, their left ventricles were 125 per cent thicker than those of the average man.

Further research into the specific cardiovascular effects of bodybuilding is needed, including among female athletes, but Vecchiato emphasises that the message is clear.

"While striving for physical excellence is admirable, the pursuit of extreme body transformation at any cost can carry significant health risks, particularly for the heart," he explains.

"Based on this data, medical associations cannot ignore this health issue any longer and should collaborate with relevant federations and policymakers to promote safer participation."