Differences in Left Ventricular Hypertrophy in Black Football Athletes: Is it Race or Racism?

While it is well established that as a group Black American adults suffer disproportionately from cardiovascular disease (CVD) in this country, Black-White disparities in CVD among young athletes are rarely documented and poorly understood. Among athletes participating in the National Collegiate Athletic Association (NCAA), Black athletes have been shown to experience a higher incidence of sudden cardiac death as compared to other races.1 More broadly, Black race has been associated with higher rates of left ventricular hypertrophy (LVH) among hypertensive children, higher incidence of heart failure following transition to adulthood, and worse overall survival.2,3 While these associations are quite concerning, there remains a paucity of data regarding their etiology. There is a growing appreciation that the impact of race on health and disease may be strongly, if not solely, influenced by environmental and social determinants of health, discrimination in housing and neighborhood construction, educational opportunities, and access to quality healthcare.

In a recently published study in the British Journal of Sports Medicine, Tso et al. attempt to explore the relationship between social determinants of health and racial differences in acquired concentric LVH (C-LVH) among American-style football athletes.4 The authors recruited 249 freshman football players from two NCAA Division-I universities and compared Black versus White athletes over time. Further, the authors analyzed the athletes by two position groups: linemen (typically heavier with more fat mass, performing more strength-based activities) and non-linemen (typically smaller and leaner, performing more burst-of-speed activities). Additionally, they recorded the median neighborhood income for each athlete. The authors analyzed each athlete after every football season over a period of 3 years and reported two key findings: (1) among non-linemen, Black athletes developed C-LVH at a significantly higher rate than White athletes and (2) among White athletes, the lineman position was a risk factor for developing C-LVH (it is known that the lineman position, in general, increases the risk for C-LVH). Median neighborhood income did not predict acquired C-LVH, but this association did approach significance. These data suggest that Black race was independently associated with development of C-LVH among non-linemen. The development of C-LVH appeared to be maladaptive, as it was associated with impairments in diastolic function.

The study raises an intriguing question. Is Black race a risk factor for acquired C-LVH and potential diastolic dysfunction in young athletes? If so, is it mediated by social determinants like neighborhood and family income? This latter question has been largely ignored in studies of CVD in young athletes. As appropriately acknowledged by the authors, the interaction between race and health outcomes is historically complex and controversial.5,6

In this study, Black athletes had significantly lower household income than White athletes, which reflects national trends.7 Prior data have consistently shown a positive correlation between income and life expectancy, particularly with respect to CVD.8,9 Household income influences the ability to maintain a healthy lifestyle, access essential medical care, obtain health-related education, and ultimately avoid morbidity and mortality.

The authors are to be congratulated for understanding that their racial data should be interpreted within the context of socioeconomic status.10 For many Black families socioeconomic status is largely influenced by a legacy of racial discrimination. Scholars have issued a call to investigate and report the impact of racism on any observed racial disparities in health and disease, and the authors attempt to heed that call.11

The results of this study should be interpreted carefully, as multiple factors including depth chart position, workout intensity, weight gain, and specific playing positions (rather than broad categorization as "linemen/non-linemen") may also account for the observed results. The small sample size is another important limitation. It is possible that if more participants were enrolled in this study, the association between median neighborhood income and acquired C-LVH may have reached statistical significance. A subsequent larger study including multiple sports, geographic regions, and racial groups would help to elucidate the contribution of these factors.

Nevertheless, by exploring median neighborhood income as a potential contributor to the racial differences in C-LVH in football athletes, the authors have made a commendable effort to connect social determinants of health to racial outcomes. We hope this becomes a trend in studies of racial differences in the cardiac outcomes of athletes.


  1. Harmon HG,  Zigman M, Drezner JA. The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol 2015;48:329-38.
  2. Pruette CS, Fivush BA, Flynn JT, Brady TM. Effects of obesity and race on left ventricular geometry in hypertensive children. Pediatr Nephrol 2013;28:2015-22.
  3. Miller T, Carter SV, Smith BA. Disparities in acute decompensated heart failure. Curr Opin Cardiol 2021;36:335-39.
  4. Tso JV, Turner CG, Liu C, et al. Association between race and maladaptive concentric left ventricular hypertrophy in American-style football athletes. Br J Sports Med 2021;Aug 13:[Epub ahead of print].
  5. Burchard EG, Ziv E, Coyle N, et al. The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med 2003;348:1170-75.
  6. Loannidis JPA, Powe NR, Yancy C. Recalibrating the use of race in medical research. JAMA 2021;325:623-24.
  7. Annual Social and Economic Supplement (ASEC) of the Current Population Survey (CPS) (Census.gov). 2021. Available at: https://www.census.gov/programs-surveys/saipe/guidance/model-input-data/cpsasec.html. Accessed 09/20/2021.
  8. Chetty R, Stepner M, Abraham S, et al. The association between income and life expectancy in the United States, 2001-2014. JAMA 2016;315:1750-66.
  9. Schultz WM, Kelli HM, Lisko JC, et al. Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation 2018;137:2166-78.
  10. Borrell LN, Elhawary JR, Fuentes-Afflick E, et al. Race and genetic ancestry in medicine - a time for reckoning with racism. N Engl J Med 2021;384:474-80.
  11. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On Racism: A New Standard For Publishing on Racial Health Inequities (healthaffairs.org). 2020. Available at:  https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/. Accessed 09/20/2021.

Clinical Topics: Sports and Exercise Cardiology

Keywords: Sports, Athletes, African Americans, Racism, Social Determinants of Health, Hypertrophy, Left Ventricular, Universities, Football, Life Expectancy, Cardiovascular Diseases, Sample Size, Sample Size, Heart Failure, Social Class, Death, Sudden, Cardiac, Death, Sudden, Cardiac, Sports Medicine, Risk Factors, Healthy Lifestyle, Weight Gain, Outcome Assessment, Health Care, Delivery of Health Care

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