As a team physician for Tulane and co-director of the New Orleans school’s Center for Sport, Dr. Gregory Stewart is never far from the ravages of the coronavirus. Louisiana has one of the nation’s highest COVID-19 per-capita death rates, with over 4,100 total reported as of Sunday. All 64 parishes are considered hot spots for the virus.
The state also has one of the nation’s highest obesity rates. Experts say the two are related. Stewart doesn’t doubt it. He’s heard from enough doctors in coronavirus wards to be convinced.
“They tell you that they walk through and everyone was obese,” Stewart said in a telephone interview. “They would walk through and they would look at it and they’d be like, ‘Oh, my gosh.’ "
One month from the start of its regular season, the NFL is grappling with a set of coronavirus questions unique to the sports landscape. It’s not just a matter of how 32 teams can stay healthy amid a pandemic without a “bubble” environment. It’s what could become of a group of players that health officials consider at risk for severe infection.
According to the Centers for Disease Control and Prevention, people with a body mass index of 30 or higher are considered obese and more likely to become seriously ill because of COVID-19, the disease caused by the novel coronavirus. Under that definition, every Ravens lineman would be considered at risk. At a listed weight of 285 pounds, defensive end Derek Wolfe has a BMI of 33.8 — and he’s the lightest lineman on the team.
But while the team’s biggest cohort will play almost every snap in a Petri dish of sweat, saliva and whatever else gets swapped at the line of scrimmage, there is growing evidence that the NFL’s heavyweights might not be an especially vulnerable population.
Stewart, who has studied heart abnormalities in former NFL players and chairs the American Athletic Conference’s COVID-19 Medical Advisory Group, called the disease “very much a disease of sedentary people.” High blood pressure, obesity and diabetes are among the most common comorbidities found in coronavirus patients.
“Well, that’s your couch potato,” Stewart said. “That’s your person who never goes out and exercises, and overeats and underexercises. So is exercise somehow protective for the bad effects of COVID-19? Well, obviously, there’s a lot of people that have caught it and died and had bad outcomes when you go and look at the news, and here’s your triathlete who got it and had significant problems, or your marathoner. But I think that that’s more the exception than the rule.”
In a letter to player agents that addressed risk factors for the virus, the NFL Players Association noted that a BMI of over 30 was considered an underlying condition, echoing CDC guidelines. But BMI, which is derived from a simple formula (weight divided by height squared), does not account for the relative proportions of bone, muscle and fat in the body.
Dr. David Kass, a cardiologist who leads the Institute of CardioScience within the Johns Hopkins University School of Medicine, said BMI “warps weight.” When he lectures on heart failure, he shows his audience pictures of two types of beef. The first is a lean strip steak; the second is a Kobe steak. They’re the same size, Kass explains, but the fat content in Kobe beef is much higher.
“If that’s your leg, that’s bad,” he said in a phone interview. It’s not so much the size of a person’s skeletal muscle that concerns Kass but its composition. Visceral fat, he said, can trouble the immune system, promote inflammation and affect metabolism. “When it has that kind of fat in it, how much it weighs is another issue, but it’s not just the weight. That fat changes the ability of the skeletal muscle to extract the fuel, essentially, the sugar and oxygen from the blood, so it can actually do work when it’s called on to do something.”
The flaws of BMI are especially pronounced across football rosters. Under the CDC’s ranges, over half of the Ravens’ 80-man roster is considered obese, including rookie running back J.K. Dobbins (5 feet 10, 212 pounds) and inside linebacker Patrick Queen (6-0, 232 pounds).
Experts consider body fat percentage a more accurate metric for athletes, as it distinguishes fat from muscle. According to the American Council on Exercise, men with a body fat percentage over 25% are considered obese. Coach John Harbaugh said in a conference call Friday that some of the Ravens’ “heaviest guys” have body fat percentages in the low 20s, with none higher than 26%.
“I think that’s pretty darn good,” Harbaugh said. “If you could educate me on what the science is according to a certain percentage of muscle mass, I’d love to hear it. But that’s up to the guys. I think the guys do that. They look at their own situation. No two people are alike; they’re unique. … Just figure all that out, and that’s how we do it. That’s what we need to know. Everybody makes their own choices.”
Across the league, a disproportionate number of linemen chose to opt out of the season altogether. Of the 67 NFL players sitting out 2020 amid the pandemic, 20 are offensive linemen — including Ravens tackle Andre Smith — and 12 are defensive linemen. Linemen constitute nearly a third of NFL rosters, but they accounted for nearly half of all opt-outs.
“Obviously, being a bigger guy, [COVID-19] puts you at a higher risk, if you do catch it,” Ravens defensive end Calais Campbell said Friday, acknowledging that he, too, considered opting out of this season. The five-time Pro Bowl selection has played throughout his career with moderate asthma, and the virus can affect the respiratory tract and lead to an asthma attack.
Campbell, whose work on the NFLPA’s executive committee helped formulate new protocols amid the coronavirus outbreak, has faith in the league’s health and safety guidelines and his teammates’ off-field accountability. Players and coaches will be tested daily through at least the first two weeks of training camp, and NFL teams have modified their facilities to better accommodate social distancing.
“I feel like as long as I’m washing my hands regularly, not touching my face and wearing my mask, I should be OK,” Campbell said. But there will always be risk in playing, he acknowledged. Campbell is an asthmatic, 300-pound 33-year-old, after all. If the virus is not contained, football will be a risky proposition. If Campbell’s infected, what allows him to play — his physical conditioning — could also keep him healthy. Doctors just can’t say how protected he may be.
“It would still be guessing because we’ve never had this problem,” Kass said. “We’ve never had a virus like this. We’ve never had to make these decisions and we’ve not ever gotten this kind of data linking adverse outcomes of a virus with obesity or BMI in professional football players, so it’s all new territory. We’re guessing.”
“Does not having hypertension, not having diabetes, being in better metabolic shape somehow even out some of the other [risk factors of being overweight]?” said Stewart, the Tulane doctor. “I don’t think we know. And I don’t think we’re going to know for a while.”