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)
Yes, this applies to you!
Your patients will be using them and will be asking you about them Athletes are looking for an edge “Role models” are using them Billion dollar industry
Prevalence
In 1995, 198 Olympiclevel 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!
Prevalence
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
Ergogenic Aid # 1
Anabolic Steroids
Analogs of testosterone More than 100 types Forms:
–Oral –Injection –Topical (gels, creams)
Anabolic Steroids
Claims:
–Increase mass –Increase –Increase –Increase lean body muscle mass strength endurance
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 - Side Effects
Hepatocellular damage Cardiovascular disease Psychological disturbance
Effects can sometimes be permanent!
More side effects„
Men
–Acne –Premature baldness –Prostatic hypertrophy –Prostatitis –*Injection complications –Testicular atrophy –*Impotence –*Gynecomastia
More side effects…
Adolescents
–Acne –Premature closure of physes –Decreased libido –Depression –*Steroid rage
More side effects…
Women
–Clitoral enlargement –Acne –Menstrual dysfunction –Male-pattern baldness –*Masculinization –Deepening of voice –*Hirsutism
Anabolic Steroid regulation
Illegal except by prescription Banned by the USADA, NCAA, NFL, NBA, and MLB
Ergogenic Aid # 2
Prohormones
Precursors of testosterone
–Androstenedione –Dehydroepiandrosterone –Androstenediol
Prohormones – proven effects
No improvement in strength or lean body mass *Causes positive urine test for steroids
Prohormones - Side Effects
• Similar to anabolic steroids
Prohormone regulation
Anabolic Steroid Control Act of 2004
–Added certain prohormones to list of anabolic steroids classified as controlled substances
Banned
–USADA, NCAA, NFL, NHL, NBA, MLS
Ergogenic Aid # 3
Stimulants
Caffeine Amphetamines Cocaine Sympathomimetics
–Ephedrine –Pseudoephedrine –Phenylephrine –Phenylpropanolamine (PPA)
Stimulants
Claims
–Boost metabolism
Burns fat Promotes weight loss
–Increase alertness
Stimulants – proven effects
Increases Endurance
–Increases use of free fatty acids and triglycerides –Spares muscle glycogen early in exercise
Enhances Anaerobic Exercise
–Decreases time to exhaustion –Decreases perception of exertion –Hypoanalgesic effect
Small amount of weight loss
Caffeine’s Proven Effects
– Increased time to fatigue in prolonged, moderate intensity exercise – Approx 3% improvement
25 seconds off a 15-minute 2-mile run
– Dose 5-9 mg/kg
250-500 mg
– No effect on repeated sprints/heavy exercise
Examples of Caffeine Content
Cola: 40 mg Coffee: 100 mg Tea: 20-100 mg Red Bull: 115 mg Vivarin: 200 mg
Stimulants - Side Effects
Anxiety* Dysrhythmias* Hypertension* Hallucinations Addiction Death
Stimulant regulation
Most banned by the USADA Ephedra
–Banned in the US
Caffeine
–USADA < 12 mcg/ml in urine –NCAA < 15 mcg/ml –1 cup coffee = 100mg = 1.5 mcg/ml in urine
Ergogenic Aid # 4
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 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 banned by USADA Blood tested for antigens Ceiling on allowable Hct level at 50
Creatine
Introduced in 1992 Olympics in Barcelona Most popular nutritional supplement In 2000, >$300 million in sales in the US No federal assessment of quality, performance, or safety
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:
– Increased performance in some labbased anaerobic tasks – No significant difference in field-based athletic performance (e.g. running, swimming)
X
Branch JD. Int J Sports Nutr Exerc Metab June 2003
X X
Creatine – proven effects
2003 meta-analysis of strength efx:
– Proven 8% increase in 1RM strength vs placebo (20% vs 12%) – Proven 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 - Side Effects
Studies of 2-10 weeks: no side efx Long term: 40% non-responders
Creatine - regulation
Not banned anywhere NCAA allows use but prohibits colleges from providing product to players
Surveys suggest ~ 50% of male college athletes and 1/3 of all NFL players are on creatine
β-Hydroxy- β -Methylbutyrate
(HMB)
Physiology
– A metabolite of the essential amino acid leucine – Regulates protein metabolism – Produced in small amounts endogenously
HMB – proven effects
Meta-analysis 2003:
– Small increase in lean mass and 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
Nitric Oxide-releasing agents
Physiology
– Arginine is a precursor of N.O. – NO2 regulates BP and blood flow to organs – Most supplements: Arginine αketoglutarate
Claims
– Improves “pump” and blood flow to muscles – Increases strength and size – Speeds recovery
Nitric Oxide-releasing agents: proven effects
Several studies in performance
– Endurance exercise:
Limited evidence of benefit in debilitated pts No benefit in endurance athletes
– Strength exercise: mixed results, no benefit proven, more studies needed
Nitric Oxide-releasing agents
Side effects
– Diarrhea, nausea, migraines
Regulation: none
Beta-2-Agonists
Physiology
– Bronchodilation, tachycardia – Examples: albuterol, terbutaline, salmeterol
Beta-2-Agonists – proven effects
No increase in ventilation of performance in studies of NONasthmatic athletes Clear benefit in asthma and EIB Clenbuterol: anabolic (25% as effective as anabolic steroids) Side effects: tremor, tachycardia Regulation
– Prohibited by USADA
Beta blockers
Physiology
– Decreased heart rate, reduced tremor, lower BP
Efficacy in sports
– Proven improved scores in shooting sports
Beta blockers
Side effects
– Hypotension, bronchospasm, bradycardia
Regulation
– Banned by USADA, NCAA in certain sports
Archery, billiards, bobsled, bridge, chess, curling, gymnastics, motorcycling, modern pentathlon, bowling, sailing, shooting, skiing, swimming, diving, wrestling Alcohol banned for same reason
Other Ergogenic Aids
Branched chain amino acids
–Inconsistent effects in Overtraining Syndrome
Human growth hormone
–No proven benefit; huge side-effects
Vitamin E
–No proven benefits in athletic performance
Chromium
–Enhances insulin uptake; no decrease in fat or increase in muscle mass in good studies
Protein
–Increased amounts needed in heavy strength
Anti Doping in Elite Athletic Competition
USADA and WADA rules apply
– Testing will be done in accordance with WADA/USADA
Permitted/Prohibited? http://www.usantidoping.org.dro 1-800-233-0393
Anti Doping
Commonly utilized Prohibited Substances:
– – – – – Glucocorticosteroids (asthma, joint injections) Beta 2 Agonists (asthma) Methylphenidate (ADHD) HCTZ (HTN) Insulin (diabetes)
Medical uses require a Therapeutic Use Exemption (TUE)
Therapeutic Use Exemptions
Abbreviated TUE
– – – – Doc fills out; athlete faxes to USADA Effective immediately, up to 1 year IM/IJ/inhaled corticosteroids Inhaled beta-agonists
Regular TUE
– All other substances – Doc fills out, send to USADA, along with supporting documents – Process takes 1-2 months to approve – Variable duration
Supplements, Herbals, Energy Drinks
„TAKE AT YOUR OWN RISK’ Not tested by the FDA
– Be VERY cautious to recommend any – 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/
Testing During Competition
Commonly tested substances: • Stimulants • Narcotics • Cannabinoids • Glucocorticosteroids • Anabolic Agents • Hormones and Related Substances • Diuretics and other Masking Agents • Beta-2 Agonists • Anti-Estrogenics • Prohibited methods, such as blood doping
If a prohibited substance or method is detected in your sample – even if it was unintentional – it will result in a doping violation.
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!