- Bodybuilders are warning about the health hazards of extreme physiques, often involving steroid use.
- Too much mass, combined with performing-enhancing drugs, can devastate the heart, liver, and kidneys.
- Experts say educating athletes can reduce harm, but the risk remains unless competitions change.
On January 29, Ashley Gearhart died in her sleep at just 37 years old. Having dominated world-class bikini competitions for almost a decade, Gearhart had reached star status in the sport before her death, most recently landing second place in her division at the International Federation of Bodybuilding and Fitness Baltimore Classic Master's pro in November and December 2020.
Gearhart's is the latest in a string of deaths that have rocked the bodybuilding community, driving Arnold Schwarzenegger, one of the most recognizable bodybuilders in history, to call out the sport as "the most dangerous" in the world.
Well-known athletes and legends of bodybuilding, many in their 40s or younger, have died in recent years, some under mysterious circumstances.
Experts say parts of the sport taken to the extreme — like weight gain, weight loss, exercise, and diets — can strain the heart and prove taxing on the body.
But in 2017, two high-profile deaths shed light on another factor: performance-enhancing drugs, or PEDs.
Rich Piana — a legendary bodybuilder who had quit competing to focus on growing his nutrition company — collapsed in his home on August 7, 2017, after experiencing symptoms of impending cardiac arrest. After his collapse, Piana was hospitalized and put in a medically induced coma before he died on August 25. An autopsy later revealed his heart and liver were enlarged, twice the size of typical organs.
Three days before Piana's death, 26-year-old Dallas McCarver died suddenly — after choking on his food, TMZ reported.
McCarver was considered a prodigy in the bodybuilding world, earning his pro card at age 21. An autopsy found the cause of death was an acute cardiac episode. His heart was severely enlarged, nearly three times the normal size. The coroner said the condition of his heart indicated that steroid use played a contributing role in his death.
Carver's and Piana's deaths prompted experts to warn that bodybuilding, particularly with the assistance of performance-enhancing steroids, might have life-threatening consequences long term.
Some athletes say nothing will change as long as competitions keep cashing in on larger-than-life physiques for top-level titles. But experts say harm-reduction strategies could prevent the new generation of athletes from trading their health to become the next big name in the sport.
Building massive physiques is an 'extreme' sport, whether drugs are involved or not
Bodybuilding has never been risk-free. Longtime coaches, medical consultants, and competitors told Insider that athletes who push their bodies to achieve high levels of muscle mass face some inherent side effects.
Lowering body fat to competition levels can be excruciating, Brandon Wadas, a natural bodybuilder who has spoken out about the risks of enhanced competition, told Insider. The severe dieting involved in the process lowers testosterone levels, leading to symptoms like fatigue, loss of sex drive, and moodiness.
At the same time, gaining weight to add massive amounts of muscle also has health consequences.
"Weight is weight when it comes to strain on your heart, whether it's fat or muscle," Wadas said.
Putting on extra weight also requires athletes to eat a massive number of calories (averaging 3,800 a day) and risk overuse injuries from extreme commitment to the gym.
Bodybuilders strive for size at the cost of their health, George Farah, a former bodybuilder who has coached award-winning clients like Kai Green and Big Ramy, told Insider.
To preserve as much mass as possible, many avoid regular aerobic exercise, which research shows has a wealth of benefits. Some competitors also steer clear of doctor-recommended diets full of produce and whole grains in favor of "dirty bulking" with calorie-dense, nutrient-poor foods.
"It's like they're scared of vegetables and fruit because they only want to gain weight. What's going to happen if you eat a strawberry?" Farah said.
Steroid use, long an open secret in bodybuilding, can be devastating on the body, expert says
Loading up on donuts and cheeseburgers is far from the riskiest technique for building muscle.
Piana was outspoken about his 27 years of steroid use and its effects on his body in the years leading up to his death.
"I am totally 100 percent aware that damage is being done to my body in the choices I am making," he said in a 2014 YouTube video. "For every positive I'm getting from these steroids, there's a negative that's going to come along with it."
On the day Piana collapsed, police found 20 bottles of steroids in his home, TMZ reported.
Performance-enhancing drugs, though illegal, have permeated nearly all levels of the sport, from aspirational to elite, according to experts who spoke with Insider.
"To be a professional bodybuilder, you have to be taking steroids. It's a given," said Tom O'Connor, a doctor who specializes in educating people on steroids.
It's not clear how much more dangerous bodybuilding has become over time, but certain potent PEDs have become more widely available in recent years online, according to research.
One drug in particular, trenbolone, which O'Connor calls a "monster" steroid, was initially developed to help cattle gain huge amounts of mass before slaughter. A longer-lasting version of the drug was developed in the 1980s and gained traction among bodybuilders, though it was never approved for human use, O'Connor said.
Despite being banned in 1997, the drug quickly found its way onto the black market, sometimes in the form of cattle implants sold online for illegal human use, researchers have found.
Performance-enhancing drugs can help athletes build muscle faster but carry risks like high blood pressure, erectile dysfunction, and heart attacks
There are two major functions of performance-enhancing substances in bodybuilding — building lean mass and cutting weight, from both body fat and water, to improve muscle definition. Drugs can help competitors build mass and pack on pounds of muscle. These include human growth hormone and steroids, a broad category referring to synthetic versions of human hormones, including testosterone.
Steroids can strain the cardiovascular system by packing on mass, forcing the heart to work harder to support a bigger body, O'Connor told Insider. Adding a layer of risk is the fact that muscle-building drugs can also enlarge the heart muscle itself, further stressing the organ.
"Medical research has proven that steroids can significantly accelerate heart disease. Blood pressure goes through the roof," he said.
Other chemicals aid in reducing body fat and water weight, helping competitors attain the coveted lean, "cut" look for the stage. Some steroids also fall into this category, along with diuretics.
PEDs have increasingly severe health costs as competitors age
The trail of deaths in bodybuilding might also be related to health consequences of previous decades catching up to competitors.
A 2014 study suggested that about 80% of steroid users start before age 30, often after a year or more of trying to build lean muscle naturally.
"At 23 years old, your body can tolerate this stuff. At 33 you can still tolerate it, but at 43 maybe you're dead," O'Connor said.
Fakhri Mubarak, an IFBB pro competitor and coach, told Muscle and Fitness he started cycling steroids at age 26 and has had blood work done every six months.
"If my liver enzymes are too high, if my kidneys are off, I know I've got to come down. Every five months, I'll take 40 days off," he said. "But I know 10 people who have had kidney failure and seen a lot of people die."
The concerns aren't new: T-Nation, a leading publication in the sport, sounded the alarm in 2016 with a list of prominent athletes' deaths titled "Big Dead Bodybuilders."
"I've been talking about it for 10 years. More people are starting to pay attention because they're starting to agree," Wadas said.
Natural bodybuilding is still not risk-free, Wadas said. But natural bodybuilders also avoid many of the long-term, possibly fatal conditions related to illicit drugs in the sport. Athletes in natural divisions test frequently enough that cheating the system with careful drug cycling is less likely.
In more mainstream divisions, PEDs are technically banned as well, since the substances are largely illegal. But the rules are rarely enforced, experts say.
Despite the risks, persuading athletes to abstain from drugs in competition is a formidable task.
The increasingly competitive atmosphere of the sport means a career in bodybuilding, as well as lucrative sponsorships and opportunities, often hinges on competing on the biggest stages.
"Where the problem lies is that organizations give an incentive to be extreme," Wadas said.
Some of those incentives are financial. In 2021, Mr. Olympia, the world's most prestigious bodybuilding competition, paid its top three competitors $400,000, $150,000, and $100,000 for first, second, and third, respectively, Barbend reported. The first-place winner, Mamdouh "Big Ramy" Elssbiay, weighed in at just short of 300 pounds, followed by Brandon Curry at 255.
In contrast, the newer classic-physique division, in which competitors more closely resemble a proportional, tapered aesthetic, prize money for the top three winners were $50,000, $15,000, and $10,000, according to Barbend. The first-place finisher in the division, Chris Bumstead, weighed in at 235 pounds, and Terrence Ruffin, in second place, weighed 165 pounds.
To make it in the upper echelons in the sport, it's virtually required to have some form of chemical assistance to achieve a competitive physique in the biggest contests, Wadas said.
"There is no perfect way of bodybuilding. Guys combat the side effects with drugs but go to the extreme," Wadas said. "They're trying to push the upper limits of the human body, which is the nature of the sport, but at what cost?"
Fully natural athletes simply aren't capable of putting on the mass required to win bodybuilding's highest honors, according to pros and experts who spoke with Insider.
"It's like competing in a Hot Wheels car versus a race car," Wadas said.
The 'bigger the better' mentality fuels steroid use and bigorexia
Some of the top physiques of yesteryear would seem almost small compared with current champions. Schwarzenegger himself commented in 2015 that today's judging criteria seem to prioritize mass over everything else. He said winning seems based on the "thickest necks" rather than overall athleticism and muscular proportions.
The "mass monster" era of bodybuilding, in which size became a priority, exploded in the 1990s. Previously, aesthetic preferences included muscular size but also proportionality and the classic V-shape taper.
Some of the largest bodybuilders of the '70s, including Schwarzenegger, weighed in around 250 pounds. By the mid-'90s to late 2000s, winning weights had crept up to about 270 pounds.
These days, stars like Kai Greene, Big Ramy, and Ronnie Coleman are hitting the stage at well over 250 pounds to nearly 300.
Today's aesthetic, which is characterized by a blockier physique with protruding abs and prominent lats and shoulders, dominates the competition circuit and social media.
The most successful competitors have millions of followers, many of whom are young athletes aspiring to look like the pros and internalize unrealistic standards.
Evidence suggests that social media contributes to body dysmorphia, or a compulsion around fixing perceived flaws in one's appearance.
Among young men in particular, psychiatrists are seeing a rise in a subset of body dysmorphia sometimes called "bigorexia" — frequently feeling too small or skinny and wanting to gain mass by any means possible.
Drugs to help make muscles bulge and fat melt are widely available on social media, according to O'Connor, in spite of the risks.
"People think it's not going to happen to them, they're just going to do a little bit but it's a slippery slope," O'Connor said. "They all have body dysmorphia, including me."
'Somebody is literally going to have to die on stage' for change to happen, critics say
Creating more realistic expectations for what most athletes can achieve, even with chemical enhancement, could prompt the next generation to avoid the mistakes of their predecessors, O'Connor said.
More accountability for coaches and trainers, who often encourage use with little to no medical supervision or expertise, could also offset risk.
"It's not shameful to say you don't know that much. The problem is coaches think they know everything," Farah said. "And they just want results."
Both Farah and O'Connor have used steroids in the past and drawn from personal experiences as well as their expertise to inform others about the potential dangers.
Farah advocates for a harm-reduction approach, recognizing that athletes are going to do what they want but urging them to do it as carefully as possible with medical support.
If success comes at the cost of long-term health, aspiring athletes should step back from pursuing a career rather than risk years of suffering, O'Connor told Generation Iron.
But even knowing the risks, young, invincible-feeling athletes might still opt for the immediate gratification promised by PEDs, experts say. O'Connor says this is why the problem is unlikely to resolve anytime soon.
"It's not going to end. Fear doesn't work for people because young people don't have fear," he said.
Wadas and others have suggested removing certain categories of bodybuilding that are most prone to steroid abuse, including heavyweight classes.
Another strategy could be to change the culture of judging, shifting preferences away from size and more toward balance, similar to the "classic" physique categories, O'Connor suggested.
"The judges are the ones that are picking the winners. Changing the criteria, that might help. What else are you going to do?" he said.
Wadas posted on Instagram in October that he believes a famous, lucratively sponsored athlete will have to die mid-competition to attract enough notice for things to change.
"Someone is literally going to have to die on stage before something changes in bodybuilding," he wrote.
Previously, deaths have caused only a ripple in the bodybuilding world, and only briefly, before business resumes as usual.
"It's sad to see when someone who's a big part of the community dies, it doesn't have an effect beyond a week. We go back to the same thing, which is the definition of insanity," he said.
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