Performance Enhancing Substances aka Ergogenic Substances by CX4gl9GV

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									    Performance Enhancing
          Substances
        aka Ergogenic Substances




    Kevin deWeber, MD, FAAFP
Director, Primary Care Sports Medicine Fellowship
                     USUHS
           Adapted from: Scott A. Playford MD, Garry Ho MD
              Objectives

Discuss what an ergogenic aid is
Discuss why this is important
Discuss specific examples
Stay awake…
       Ergogenic Aid - Defined

Substance or device that enhances
energy production, use, or recovery
and provides an athlete with a
competitive advantage.
                Ergogenic Aid - Examples
Mechanical (shoes)
Psychological (hypnosis)
Physiologic (blood doping)
Nutritional (creatine)
Pharmacologic (anabolic steroids)
     Why do athletes use
       supplements?
Provide more convenient form of
nutrient
Prevent a perceived deficiency
Provide direct ergogenic effect
Belief that every top athlete is taking
it; they can‟t afford to lag behind
   Many athletes will do whatever it
           takes to win…
In 1995, 198 Olympic-level
power athletes were given
this scenario:
– You are offered a banned
  substance with 2
  guarantees:
    You will not be caught
    By taking the substance you
    will win

              Only 3 declined!
                 …at any cost
The same 198 athletes
were offered a banned
substance with 2 additional
guarantees:
– You will win every event for
  the next 5 years
– You will die at the end of
  those 5 years

    50% still said they would use it!
             Prevalence

1996-1999 10,449 boys and girls age
12-18 surveyed:
  – 4.7% of boys and 1.6% of girls used
    protein powder or shake, creatine, amino
    acids/HMB, DHEA, growth hormone, or
    anabolic steroids at least weekly to
    improve appearance or strength
Placebo effect in athletes
Athletes are            “Expectancy Effect”
HIGHLY                  is significant
suggestible             – Belief in efficacy 
– 97% believe             performance
  placebo effect          improvement
  works                 Pill Colors
– 73% said they had     red/orange/yellow
  experienced it         stimulant
– Beedie CJ. J Sports
  Sci Med 2007
                        Injection > pill
                        Expensive > cheap
   Nocebo effect in athletes

Belief that a substance
negatively affects
performance
1.57% slower 3x30sec
sprints from nocebo
– Beedie et al.
Ergogenic Aid # 1
             Anabolic Steroids

Analogs of testosterone
More than 100 types
Forms:
– Oral
– Injection
– Topical (gels, creams)
Prevalence 2009
– Jr high: 2%
– 12th grade: 5% (males 7%,
  >females 2%)
    Anabolic Steroids – Proven Effects
• Increase in fat-free mass
• Increase in body weight
• Increase in arm girth
• Increase in leg girth
• Increase in bench press
  and squat scores
• Increase in libido
  Anabolic Steroids—Disproven
             Effects
No effect on endurance
exercise
– Males on treadmill
   Eur J Appl Physiol 2006
– VO2max in rats
   Med Sci Sports Exer 2004
Anabolic Steroids - Side Effects
                  Hepatocellular
                  damage
                  Cardiovascular
                  disease (stroke, MI)
                  Psychological
                  disturbance

                Effects can sometimes
                  be permanent!
    ―Side effects of anabolic
   androgenic steroids abuse‖
      Followed body builders for 2 years
Decr LH, FSH, SHBG
Decr sperm count and fertility index
Decr HDL (57  42)
No change liver/prostate US,
hematological indices
         More side effects…

Men
– Acne
– Premature baldness
– Prostatic hypertrophy
– Prostatitis
– *Injection complications
– Testicular atrophy
– *Impotence
– *Gynecomastia
       More side effects…
Adolescents
– Premature closure of physes
– Decreased libido
– Depression
       More side effects…
Women
– Clitoral enlargement
– Menstrual dysfunction
– Male-pattern baldness
– *Masculinization
– Deepening of voice
– *Hirsutism
    Side effects that can be
        PERMANENT
Premature growth plate closure
Testicular atrophy
Gynecomastia
Male pattern baldness
Female masculinization
Excessive hair growth
Deepening voice
Clitoral enlargement
Anabolic Steroid regulation
             Illegal except by
             prescription
             Banned by the
             USADA, NCAA, NFL,
             NBA, and MLB
             Prohormones
Precursors of testosterone
– Androstenedione
– Dehydroepiandrosterone
– Androstenediol
Prohormones – the evidence
              No improvement in
              strength or lean body
              mass
              *Causes positive urine
              test for steroids
     Prohormones - Side Effects
• May be similar to anabolic
  steroids, but probably less
  frequent.
Prohormone regulation
          Anabolic Steroid
          Control Act of 2004
           – prohormones classified
             as controlled substances
          Banned
           – USADA, NCAA, NFL,
             NHL, NBA, MLS
Stimulants
             Stimulants
Caffeine
Amphetamines
Cocaine
Sympathomimetics
– Ephedrine
– Pseudoephedrine
– Phenylephrine
– Phenylpropanolamine (PPA)
Modafinil (Provigil)
 Stimulant Use Prevalence

Ephedrine:
– 3.5% in NCAA athletes
    Clin J Sports Med 2001
– 12% of HS boys/26% of girls have tried
    Med Sci Sports Exer 2002
Caffeine
– 33% of British club track/field athletes
– 60% of British club cyclists
    Chester N, Int J Sports Med 2008
 Caffeine’s Proven Effects
– Increased time to fatigue (”capacity”)
  in wide range of lab protocols
   Prolonged submaximal (> 90 min)
   Sustained high-intensity (20-60 min)
   Short-duration supra-max (1-5 min)
– Likely beneficial in endurance and
  “stop-n-go” sports
– No clear benefit in strength/power
  events
Caffeine in Endurance Running

4.2-sec faster 1.5-km
1-3% faster 5-km
24-sec faster 8-km
50-sec faster 10-km military pack
   march
No change in 21-km race
Improved treadmill time-to-
exhaustion in marathoners
   Caffeine in Other Sports
Rowing: 1-3% faster
2000m race
Swimming: 24-sec
faster 1500m race
– About 21 min
Cycling: 3.5% higher
mean power in 40km
race
        Caffeine Dosing
Doses 2-9 mg/kg in studies
   2-5 mg/kg usually effective
   250-500 mg
– Cola: 40 mg
– Coffee: 100 mg
– Tea: 20-100 mg
– Red Bull: 115 mg
– Vivarin: 200 mg
No difference in fx between “users”
and “non-users”
  Caffeinated Sports Drinks
No proven performance
benefit
– 18-km run times
– Pl vs carb drink vs
  carb+150mg caffeine
– consumed 4x in race
– Int J Sports Med 2005
            Ephedrine

78-sec faster 10-km run (with
backpack & helmet) vs placebo
– 30-sec faster than caffeine
   -0.8 mg/kg
– No benefit when added to caffeine
             Modafinil
Cycling at 85% VO2max
– 22% longer time to exhaustion vs
  Placebo
   18.3 min vs 15.6
– Central mechanism: decreased RPE
– Dose 4 mg/kg
– No side-efx seen
Stimulant Mechanisms of Action
 Not conclusively known
 Likely: CNS-regulated decreased
 perceived exertion
                 Stimulants - Side Effects

Anxiety*
Dysrhythmias*
Hypertension*
Hallucinations
Addiction
Death
           Stimulant regulation
Many prohibited by WADA &
NCAA
– Most ADHD meds
Some still allowed (cold meds)
– Pseudephedrine, PPA
Caffeine
– WADA: no longer monitored
– NCAA < 15 mcg/ml
– 1 cup coffee = 100mg = 1.5
  mcg/ml in urine
               Blood Doping



Increasing the number of red blood
cells in the body to increase the
oxygen carried to muscle
– Administration of blood, red blood cells, or
  related blood products
– Erythropoietin
    Stimulates bone marrow to produce red blood
    cells
   Blood Doping – proven effects
Increased Endurance
– 7% increase in Hgb
– 5% increase in VO2 max
– 34% increase in time to
  exhaustion at 95% VO2 max
– 44 second improvement in 5 mile
  treadmill run time



     (Williams and Branch summarized study findings)
  Blood Doping - Side Effects

Infections with transfusions
Increased viscosity of blood
– Stroke, MI, PE
Blood Doping - regulation
Erythropoietin only by prescription
Doping prohibited by WADA, NCAA
Blood tested for antigens
Ceiling on allowable Hct level at 50
        Beta-2-Agonists
Physiology
– Bronchodilation, tachycardia
– Examples: albuterol, terbutaline,
  salmeterol
Beta-2-Agonists – proven effects
Clear benefit in asthma and EIB
– No increase in ventilation of performance in
  studies of NON-asthmatic athletes
Clenbuterol: anabolic (25% as effective
as anabolic steroids)
Side effects: tremor, tachycardia
Regulation
– WADA: most prohibited
– NCAA: inhalation permitted
           Beta blockers
Physiology
– Decreased heart rate, reduced tremor,
  lower BP
Examples
– Atenolol
– Metoprolol
– Propranolol
Efficacy in sports
– Proven improved scores in shooting
  sports
           Beta blockers
Side effects
– Hypotension, bronchospasm, bradycardia
Regulation
– NCAA: banned in Rifle sports
– WADA: banned in…
    Aeronautic, archery, autos, billiards, bobsled,
    boules, bridge, curling, golf, gymnastics,
    motorcycling, modern pentathlon,
    powerboating, bowling, sailing, shooting,
    skiing, snowboarding, wrestling
– Alcohol banned for same reason
              Creatine
Most popular nutritional
supplement
In 2000, >$300 million in
sales in the US
                 Creatine
Replenishes ATP in
anaerobic exercise
– Made in liver, kidneys,
  and pancreas
– Dietary sources: meat,
  fish
– Stored in skeletal
  muscle
– Excreted as creatinine
  in urine
Creatine – disproven effects
Meta-analysis 2002:
– NO overall benefit on anaerobic
  performance (weight lifting, sprint
  cycling, spring running, sprint
  swimming, kayaking, arm cranking, or
  jumping/kicking)
– 29 quality studies
   35% were statistically significant between
   Cr and Placebo
   65% NON statistically significant
Creatine – disproven effects
Meta-analysis 2003:
– No significant difference in field-based
  athletic performance (e.g. running,
  swimming)




X                       X X
    Branch JD. Int J Sports Nutr Exerc Metab June 2003
                Creatine –
              proven effects
2003 meta-analysis of strength efx:
– 8% increase in 1RM strength vs placebo (20%
  vs 12%)
– 14% increase in # of reps
– Highly variable response
Body Composition
– Increase in weight and lean body mass by 1-2 kg over
  short term


      Rawson, Volek. J Strength Cond Res 2003.
Creatine Mechanisms of Action
Increases PCr energy availability
 – ->Increased effort in resistance training
Increased satellite cell and myonuclei
Increased gene expression for
contractile proteins
– ? Due to more available energy
Increased contractile protein
synthesis
Creatine Mechanisms of Action
      Creatine - Side Effects
Studies of 2-10 weeks: no side efx
Long term:
       Creatine - regulation
Not banned anywhere
Surveys suggest ~ 50% of male college
athletes and 1/3 of all NFL players are
on creatine
β-Hydroxy-Methylbutyrate (HMB)

Physiology
– A metabolite of the essential
  amino acid leucine
– Produced in small amounts
  endogenously
– Regulates protein metabolism
   Less catabolism, more anabolism
    ? Increased muscle mass
   HMB – proven effects
Meta-analysis 2003:
– Small increase in lean mass and 25%
  greater strength vs placebo
Greater effect in untrained persons
– Less muscle breakdown
– Some utility in muscle wasting
Side-efx: none reported in 3 studies
Non-regulated

       Nissen, Sharp. J Appl Physiol 2003
     Buffering Agents: proven
Mitigate metabolic acidosis after strenuous
exercise
– Bicarbonate, citrate
NaHCO3: Proven ergogenic efx in high-intensity
exercise
–   100m & 200m swim
–   400 & 800 m run
–   Repeated sprints
–   Repeated judo throws
–   30 min high-intensity running
–   60 min max-effort cycle ergometry
Citrate less effective in studies
    Bicarbonate
Dose: 0.2 - 0.3 mg/kg
GI side effects common
             β-Alanine

Supplementation results in higher
skeletal muscle CARNOSINE, an
intracellular buffer
Proven effective in high-intensity
anaerobic performance
– >1 to <5 min duration
   Acidosis most prominent
– Delays onset of neuromusc fatigue
– Increased time to exhaustion
– (no change in VO2max or max strength)
            β-Alanine
Dose
– 3.2 – 6.4 gm/day
– Effective after 4 week supplementation
– 800 mg qid or 1600 mg slow-release qid
Side-efx: paresthesias at doses
higher than above
– No others reported
Not regulated or prohibited
Nitric Oxide-releasing agents
Physiology
– Arginine is a precursor of NO
– NO regulates BP and blood flow
  to organs
– Most supplements: Arginine α-
  ketoglutarate
Claims
– Improves “pump” and blood
  flow to muscles
– Increases strength and size
– Speeds recovery
Nitric Oxide-releasing agents: the
             evidence
Several studies in
performance
– Endurance exercise:
   No benefit in endurance athletes
   Limited evidence of benefit in
   debilitated pts
– Strength exercise: mixed
  results, no benefit proven,
  more studies needed
Nitric Oxide-releasing agents
Side effects
– Diarrhea, nausea, migraines
Regulation: none
Peptide Hormones & Analogues
 Adreno-corticotripon (ACTH)
 Growth hormone (hGH)
 Chorionic gonadotropin (hCG)
 Insulin-like growth factor (ILGF-1)
 Leutenizing hormine (LH)
 Erythropoietin (EPO) etc.
Diuretics & Urine Manipulators
Can be used to mask urine tests
Examples
– Acetazolamide (altitude sickness)
– Furosemide (Lasix)
– Spironolactone (acne, HF)
– Hctz (Htn)
          Anti-Estrogens
Often used to
counteract side-efx of
anabolic steroids
– Tamoxifen (breast
  cancer)
– clomiphene (infertility)
           Other Substances
NO proven ergogenic effects from:
–   Citrulline, Carnitine,
–   Coenzyme Q, Colostrum
–   Asparagine, Arginine, Pyruvate, Ribose
–   Choline, Chromium picolinate
–   Antioxidants, Bee pollen, Boron
–   Folate, Gamma-hydroxy-butyrate
–   Inosine, leucine
–   Yohimbine
–   Vitamins and Minerals
–   Branched chain amino acids
       Inconsistent effects in Overtraining Syndrome
      Supplements, Herbals,
         Energy Drinks
„TAKE AT YOUR OWN RISK’
– Be VERY cautious to recommend any
Not tested by the FDA
– Often contain traces of banned substances
– May not contain what label says
No such thing as “side-effect free!”
Some supplement ingredients are
discussed on USADA at
http://www.usantidoping.org.dro/
     Contamination facts
2001 IOC international study;
– 634 non-hormonal supplements,
– 15% contained undeclared steroids
2007 study of 58 USA supplements
– 25% contaminated w/ prohib steroids
– 11% contaminated w/ prohib stimulants
2008 UK study of 152 supplements
– 10% contaminated w/ steroids/stim
Drugs in Elite Athletes
                               2010-11
                                NCAA
                             Banned Drugs
The NCAA bans the following classes of drugs:
a. Stimulants
    a. Phenylephrine and pseudoephedrine OK
b. Anabolic Agents
c. Alcohol and Beta Blockers (banned for rifle only)
d. Diuretics and Other Masking Agents
e. Street Drugs
f. Peptide Hormones and Analogues
g. Anti-estrogens
h. Beta-2 Agonists
          Anti Doping in
   Elite Amateur Competition



WADA rules apply
– Testing will be done in accordance with
  WADA/USADA
Permitted/Prohibited?
http://www.usantidoping.org.dro
         1-800-233-0393
     2010 WADA
Prohibited Substances
 Anabolic androgenic steroids
 Other anabolic agents
 – Clenbuterol, selective androgen receptor
   modulators (SERM)
 Erythropoiesis-stimulating agents
 Growth hormone and growth factors
 Chorionic gonadotropins, LH
 Insulins
 Platelet-rich plasma (IM injection)
 – Other locations require Declaration
     2010 WADA
Prohibited Substances
 Hormone antagonists and
 modulators
 – DHT blockers (finasteride, dutasteride)
 – They mask anabolic steroid use
 Diuretics and masking agents
 – Acetazolamide, hctz, spironolactone
 – Plasma expanders; glycerol, IV albumin,
   etc.
    2010 WADA
Prohibited METHODS
Enhancement of Oxygen Transfer
 – Blood doping (transfusions, etc.)
Gene doping
 – Gene transfers
 – Substances than alter gene expression
Chemical or mechanical manipulation
 – IV infusions, except if hospitalized
 – Sample tampering
        2010 WADA
Prohibited in COMPETITION
  Stimulants, e.g. ADHD meds
   – Exceptions:
      Caffeine OK
      Phenylephrine and PPA OK
      Ephedrine < 10 mcg/ml
      Pseudoephedrine < 150 mcg/ml
  Narcotics
  Cannabinoids
        2010 WADA
Prohibited in COMPETITION
   Glucocorticoids by oral, IV, IM, rectal
   – Declaration required for inhalation and
     other injection sides
   – Topicals OK
        2010 WADA
Prohibited in PARTICULAR
         SPORTS
  Alcohol
   – Aeronautic, archery, auto, karate,
     shooting, motorcycle, bowling,
     powerboating
  Beta-blockers
   – Aeronautic, archery, autos, billiards,
     bobsled, boules, bridge, curling, golf,
     gymnastics, motorcycling, modern
     pentathlon, powerboating, bowling,
     sailing, shooting, skiing, snowboarding,
     wrestling
What if prohibited med is
required to treat illness or
          injury?
Declarations and Therapeutic Use
           Exemptions
Declaration required for:
– Non-systemic corticosteroid injections
– Inhaled albuterol, salmeterol, glucocorticoids
TUE required for
– All other prohibited substances
– Doc fills out, send to USADA, along with
  supporting documents
– Process takes 1-2 months to approve
– Variable duration
 Testing During Competition
Commonly tested
substances:
• Stimulants • Narcotics
• Cannabinoids               If a prohibited substance
                             or method is detected
• Glucocorticosteroids       in your sample – even
• Anabolic Agents            if it was unintentional –
• Hormones and Related       it will result in a
Substances                   doping violation.
• Diuretics and other
Masking Agents
• Beta-2 Agonists
• Anti-Estrogenics
• Prohibited methods, such
as blood doping
   Athletes’ Rights During Testing
  Having an Athlete Representative and/or
  Language Specialist present

  Doping Control Officer (DCO) explain any part of
  the testing process that you do not understand.

  A copy of all forms used to document the
processing of your sample.

  Providing feedback to improve testing policies or
procedures.

Note: If any portion of the test does not seem
 right to you, document that on the doping
 control paperwork.
     Athlete’s Responsibilities During
                 Testing
  Comply with the doping control procedures.

  Bringing a photo ID to the Doping Control Station.

  Report to the Doping Control Station within 60
minutes of being notified for testing.

  Stay within view of the DCO (or Chaperone) from the
time you are notified until the sample collection
  procedures
are complete.

  Ensure that all paperwork is completely accurate
No substitute for hard work…




           Questions?
Thank You!

								
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