• Jeffrey S. Markowitz
Part of the SpringerBriefs in Public Health book series (BRIEFSPUBLIC)


Improving knowledge regarding mortality and its determinants is essential to public health. A better understanding of mortality risk and protective factors can help to extend life and enhance its quality. Mortality research has evolved over centuries of time from casual observations focused on individuals to sophisticated studies of groups conducted by social scientists and epidemiologists. Social and demographic risk factors, including socioeconomic status (SES) and factors that occur early in life, are now routinely studied with an emphasis on reducing health disparities that may be linked to mortality risk.

This study will examine all-cause mortality and its determinants among a cohort of professional basketball and football players. Internal comparisons will be made based on a large cohort of former NBA and NFL players. The potential risk factor variables to be studied include race, body mass index (BMI), US birthplace region, number of career years of professional playing experience and player position. Mortality risk will be compared within and between former players in the two leagues. External comparisons of mortality rates will also be conducted between the two groups of professional athletes and the US male general population.

Mortality comparisons between professional basketball (NBA) and football players (NFL) have never been studied before. There have been several separate prior studies that have compared mortality rates between NBA and NFL players versus the general population. However, this previous research has limitations and is largely outdated. The current study seeks to advance knowledge in this important area and provide direction for future research efforts.


Mortality and public health Social and demographic risk factors for mortality Health disparities and mortality Mortality comparisons between NBA and NFL players Mortality comparisons between NBA/NFL players and the general population Early life experiences and mortality risk 


This chapter begins with a brief general history of the study of mortality and its risk factors. This public health interest has evolved over centuries of time from casual observations of individuals, made by chroniclers with minimal research knowledge, to sophisticated studies conducted by highly trained epidemiologists, social scientists, and others with the ability to meld science, medicine and public health.

The second part of the Introduction shifts to a description of the purpose and background of the study detailed in this book. Only a few prior studies have examined the question of mortality among professional basketball and football players, and none of these have compared the two groups of athletes. There have also been separate attempts to study how mortality within former NBA and NFL players compares to the general population . These prior research efforts, however, have limitations and need to be brought up to date.

Brief History of Public Health and Mortality Research

The study of mortality is indispensable to public health research. While morbid-sounding and possibly upsetting for some, the study of death and its risk factors can instead be viewed as potentially health-promoting and life-extending for current and future generations. It would be unfortunate, short-sighted, and naïve to avoid studying mortality simply because it’s thought to be a grim topic. This is because, so much can be learned from mortality research, like which groups live longer and why? If this is accomplished, it may also be possible to propose preventative measures. Mortality research can be conceptualized as the study of life itself and factors that could help to improve and extend it.

In fact, the study of mortality and its risk factors is nothing new to public health and public health research. Centuries before the field of public health existed, Hippocrates wrote about the relationship between the environment and health including the outbreak of deadly diseases: “…in summer dysenteries, diarrheas, and protracted quartan fevers frequently seize them, and these diseases when prolonged dispose such constitutions to dropsies, and thus prove fatal.” (Hippocrates 400 B.C.E.). While hard to fathom now, this work was far ahead of its time since it offered natural, rather than supernatural explanations of disease and death.

It took about 2500 more years before epidemiology was said to be born and it was the work of John Graunt, an English statistician, that led the way in 1662 (Morabia 2013). King Charles II of England issued an order to monitor the large numbers of deaths being caused by repeated bubonic plague outbreaks and Graunt was selected to lead this effort. He began his work by determining the size of the population within London and then conducted rudimentary counts, locations, and causes of deaths. County parish clerks were tasked with collecting cause of death data, but with little or no medical training, they reported things like griping, grief, stopping of the stomach, fright, itch, and consumption. Nevertheless, Graunt was able to conclude that it was healthier to live in the country rather than the city and attributed this to things like air quality and topography.

During this same period, the concepts of disease and exposure were developing. The seminal work of Francis Bacon, specifically directed at prolonging life, included the examination of demographic and social risk factors like age, weight, height, diet, housing, exercise and other variables (Bacon 2010). Of course, these variables continue to be frequently used today in public health and epidemiological research and several of these serve as the focus of this book.

By the 1800s, Louis-Rene Villerme of France began looking at the relationship between socioeconomic status (SES)) and health. Such inquiries lay the foundation for the research area now known as social epidemiology (Berkman et al. 2014). Statistical techniques had not yet been developed enough to conclude with confidence that certain variables were related to one another. Nonetheless, Villerme collected data on three income indicators including a taxation index, average rent, and a trade taxation index, and believed that these variables would be negatively associated with mortality. In a re-analysis of Villerme’s data that was published in an epidemiology journal in 2011, correlation coefficients ranged from −0.67 to −0.83, confirming Villerme’s beliefs that income and mortality were inversely related (Julia and Valleron 2011).

Rudolf Virchow, a German physician, scientist and public health activist, was well-known for his critical work in cellular pathology. When he served on a commission to investigate an outbreak of typhus in a Prussian province in 1848, however, Virchow focused on social causes of disease and its spread (Schultz 2008), and became known as one of the creators of social medicine. Virchow blamed the government for the uncontrolled spread of typhus, and in his recommendations, called for “…more freedom, prosperity, and improvements in education.” (Trostle 1986).

Through the nineteenth century , the public health movement progressed in the US and Great Britain with an emphasis on how social conditions impacted on health. Efforts to reduce poverty, improve education, acquire better and safer jobs, enhance nutrition, improve sanitation, ensure cleaner water and air, … etc. became integral parts of this movement.

The emphasis on reducing social inequalities linked to poor health, disease and mortality has gained momentum since the nineteenth century . While so many infectious and other diseases have been conquered in the last 100 years, social inequalities and resulting health disparities between certain groups persist. In fact, it is believed that tens of thousands of minority Americans die each year because of health care disparities (Satcher et al. 2005). According to some health and social science researchers, discrepancies like these are linked, at least in part, to things like socioeconomic status (Howard et al. 2000; Hayward and Gorman 2004).

Epidemiologists and social scientists have also raised the possibility that conditions early in life can impact on future health and even mortality. Research findings on this topic remain uncertain since questions persist about the mechanisms whereby childhood experiences influence later-life health. Nevertheless, evidence establishing a link between social conditions experienced early in life and adult mortality continue to infuse the public health and social science literature (Signorello et al. 2014; Pudrovska and Anikputa 2014).

Current Study Purpose and Background

The purpose of this book is to examine all-cause mortality and its risk factors among former professional basketball and football players. Comparisons will be made within and between former NBA and NFL players . Analyses of mortality risk among the two groups of professional athletes and the US general population will also be undertaken. Every former NBA and NFL player who played in their respective leagues anytime between 1960 and 1986 will be studied.

NBA and NFL players must be considered members of two special occupational groups and there are at least three common factors that can impact on morbidity and mortality among worker groups. First, there are toxic environmental exposures like asbestos or coal dust that can lead to specific types of disease. Second, there are on the job dangers that may result in injuries or accidents. In the case of both toxic environmental exposures and injuries or accidents, immediate and/or delayed deleterious health effects can follow. Finally, there are selection factors related to certain occupations like body size, educational level, and lifestyle that may be linked to morbidity and even mortality.

There does not appear to be any issues in professional basketball or football with respect to exposure to toxic environmental hazards.

Leisure time physical activity is thought to have health benefits for participants. However, when these activities become competitive and significant physical contact is a major part of the scenario, the health benefits can become tainted by short- and even long-term injury and illness. In addition, body sizes required to play some basketball and football positions can be extreme, but only limited research is available that addresses the role of position, body size and mortality among former players. Surprisingly, there has not been any prior research of any kind that has examined mortality differences between former professional basketball and football players.

The empirical part of this book is divided into internal and external analyses. The former includes all within- and between-group risk factor analyses of NBA and NFL players except for the comparisons with the general population . These latter comparisons are referred to as external analyses.

Internal Analysis

Within-league analyses of mortality risk represents a major focus of this book. This is because several sources of variation can be better controlled when a single player group is studied. There are certainly going to be differences within NBA and within NFL players on demographic, social and other variables of interest. However, there is likely to be some common grounds as well among players participating in the same professional sport. Potential confounding variables like physical size, education, income, and professional career interests are likely to be more similar within a group of athletes playing the same sport than they are compared to the general population . To some extent, and assuming data are available, differences that do exist between former players from the same sport, and even between sports, can be statistically controlled, or stratified, to help “level the playing field” when investigating mortality risk .

Between-league differences or similarities in the risk factors associated with mortality are also very important. Uncovering similar risk factor results between two professional groups of athletes may indicate general effects that could be evident in other groups of athletes, or even more broadly in the general population. Different mortality risk factor profiles between players in the two leagues may have something to do with the sports themselves, or variation in player backgrounds.

A primary goal of public health is prevention of disease and extension of quality living, and a better understanding of mortality and its risk factors may lead to the introduction of useful interventions. Some potential risk factors, like race and where a player was born, are immutable. However, identifying risk factors like these can help get to the root of these problems, whether they be inequalities in health care associated with discrimination, poor childhood education, or a host of other things.

This book will examine how several early-life and playing-related factors are associated with mortality risk in former NBA and NFL players . The critical potential risk factor variables of interest are: race, body mass index (BMI), US birthplace region, and number of career years of professional basketball or football playing experience. Professional league, i.e., NBA versus NFL, and player position will also be studied as potential risk factors. Here are several facts that pique interest in studying these variables:
  • African-Americans live fewer years than whites and/or have increased mortality risk: within the general population (Arias 2015; Satcher et al. 2005), within NBA players (Lawler et al. 2012), and within NFL players (Baron et al. 2012; Lehman et al. 2012).

  • Obese BMI increases the risk of mortality in the general population (Flegal et al. 2005) as well as within NFL players (Baron et al. 2012; Markowitz 2016).

  • People born in the Southern part of the US have shorter life expectancies than individuals born in other US regions (Xu et al. 2016). Mortality risk has also been reported to be elevated within former NFL players born in the South (Markowitz 2016).

  • Socioeconomic conditions experienced during childhood impact adult mortality risk (Hayward and Gorman 2004).

  • Mortality risk is generally elevated in the lowest SES groups relative to the highest (Steenland et al. 2004).

External Analysis

External analyses will examine whether mortality rates differ between NBA and NFL players versus the general population . There is a substantial body of scientific literature on mortality and life expectancy among elite athletes. In fact, several mortality studies of former NBA (Lawler et al. 2012) and NFL players (Baron and Rinsky 1994; Baron et al. 2012; Lehman et al. 2012) versus the general population have appeared in the scientific literature. This literature, however is somewhat limited and largely obsolete.

This study focuses on a research area that’s really in its scientific infancy with few hard and proven facts. The intent of this book is to add to existing knowledge in this important area. Future studies can use the information gained in this book to expand knowledge further. Ultimately, the goal is to extend life and improve its quality, not just among professional athletes, but within other groups and populations as well .


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© The Author(s) 2018

Authors and Affiliations

  • Jeffrey S. Markowitz
    • 1
  1. 1.Health Data AnalyticsPrinceton JunctionUSA

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