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Medical Report: Just Say “No”

Rush, Shelby M.D., FACSM

ACSM'S Health & Fitness Journal: March/April 2004 - Volume 8 - Issue 2 - pp 22-24

With the advent of anti-aging medicine, more people will be using performance-enhancing drugs. Are they safe and should they be recommended?

Shelby Rush, M.D., FACSM, is a full-time faculty member at Natividad Family Medicine Residency Program in Salinas, CA, and is assistant clinical professor at the University of California, San Francisco Department of Family and Community Medicine. She coordinates the orthopedic and sports medicine curricula at Natividad Medical Center where she has a sports medicine clinic. Dr. Rush completed a fellowship in sports medicine at The Orthopedic Specialty Hospital in Salt Lake City, UT. She is board certified in Sports Medicine and Family Practice. Dr. Rush is a physician for the U.S. Ski & Snowboard Association and a team physician for Hartnell College and North Salinas High School. She was also a member of the medical team for skating events at the 2002 Olympic Games.

The catch phrase made famous by Nancy Reagan in the 1980s is gaining new relevance. High school, amateur, professional, and recreational athletes alike are now using performance-enhancing drugs. More professional athletes are using “natural” products to boost their performance, and are communicating this to the public. Health supplement stores boast of the energy-enhancing supplements they sell. Many of the substances used by people are legal, but some are not. Truth of the matter is, legal or not, there are a fair number of people taking these supplements to enhance their performance, and they will at some point approach their trainers and coaches and other sports professionals and surreptitiously ask about the supplements they are using. Other than echoing Mrs. Reagan, what do you say to a client who asks about the effects of EPO, testosterone, or anabolic steroids? How do you answer clients who ask about anti-aging physicians: doctors who use a combination of nutrition and drugs to counter the effects of aging? The drugs commonly involved are human growth hormone (HGH), anabolic steroids, and testosterone.

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Some health care professionals offer drugs to athletes to enhance their performance and speed their recovery; many of the drugs are legal. Erythropoietin (EPO) enhances performance by increasing red blood cell production increasing the supply of oxygen to exercising muscles. It commonly is used in patients with bone marrow suppression, such as patients with leukemia or receiving chemotherapy, or in patients with renal failure. In these instances, the injections are mandated to keep up the body’s production of red blood cells. In athletes, the injections are abused for EPO’s endurance-enhancing effects. EPO injections lead to an increase in hematocrit and the oxygen-carrying capacity of blood, in turn enhancing V̇O2max and endurance. One study on male athletes showed an increase of 8% in V̇O2max. EPO has traditionally been difficult to detect, because it is a hormone produced by the kidneys. Newer blood tests are available now to detect EPO use and deter its abuse among athletes. Typically, athletes with an elevated hematocrit have been banned from endurance sports for suspected misuse of EPO or other blood doping measures. But pharmaceutical manufacturers constantly are developing new drugs, and therefore, ways around the latest drug testing. Despite being banned by the International Olympic Committee (IOC), EPO is still abused widely. Its abuse has been implicated in the deaths of cyclists in Belgium and Holland. Drastically high hematocrits combined with exercise-induced dehydration can lead to overly thick, or viscous blood. Viscous blood can lead to coronary or cerebral vascular occlusions—heart attack or stroke, respectively. EPO also can cause elevated blood pressure, flu-like symptoms, and elevated potassium levels.

Another popular drug used by the anti-aging physicians, and those boosting athletes’ performances, is human growth hormone (HGH). It is new on the banned substances list. HGH has many functions in the body, and is produced naturally throughout life. It stimulates protein synthesis; enhances carbohydrate and fat metabolism; helps maintain sodium balance; and stimulates bone and connective tissue turnover. Levels of HGH produced throughout the day decrease with age, after peak growth years. The amount of HGH secreted is affected by diet, exercise, nutrition, stress, and medications. The largest release of the hormone is one to two hours into sleep. Exercise also increases HGH levels. HGH has been shown to be important for recovery in athletes.

Again, the IOC has banned HGH use among athletes, and again the athletes continue to abuse the drug. The 1996 Atlanta Olympic games were dubbed the “Growth Hormone Games.” Five percent of high school boys reported using the drug in one survey. Its abuse is not limited to male athletes. There are no androgenic, or masculizing effects, therefore, many women are using the drug. HGH users tout increased lean muscle mass, shorter recovery times, and performance enhancements, although these claims have not been supported in studies on normal subjects. HGH has been shown to increase muscle size and strength in HGH-deficient people. Normal subjects experience acromegaly, muscle hypertrophy, and increased collagen without increased contractile ability.

Potential side effects from the use of HGH are not mentioned in the underground ergogenic guides or the pamphlets from the anti-aging physicians. HGH changes skin texture and can stimulate dark moles, or nevi, to grow. It has an adverse effect on lipid profile and glucose metabolism. Users who develop acromegaly can have growth of the skull bones, leading to a protruding jaw and a boxy forehead. Connective tissue growth leads to thickened fingers and coarse facial features. Acromegaly is associated with diabetes, high blood pressure, diseased blood vessels in the heart, heart failure, nerve problems, sexual dysfunction, and menstrual dysfunction. There is a high death rate associated with acromegaly, usually from heart failure.

Another commonly used performance-enhancing agent is androgenic steroids, such as testosterone. Usually the androgenic anabolic steroids (AAS) are used in combination with the above products to enhance performance. The performance-enhancing effects of AAS have been known for a long time. AAS use was reported in the 1950 Olympics, and was banned in 1976. Use among high school athletes also dates back to the 1950s. Currently, 5% to 10% of high school males (not just athletes) have used AAS. For every 10 male students using AAS, 1 female student used the drug. The rates are slightly higher among college athletes.

The AAS are based on testosterone and androstenedione, which are produced naturally in both men and women. Anabolic effects include increased muscle mass; increased bone mineral density; increased heart, liver, and kidney size; increased red blood cell production; decreased body fat; vocal cord changes; and increased libido. Androgenic effects are the development of secondary sexual characteristics in men: changes in genital size and function, growth of axillary, pubic and facial hair. AAS also have an anticatabolic effect, reducing the effect of cortisol. This reduces recovery time allowing more intense training.

It is difficult to find double-blind controlled studies evaluating the effect of AAS on untrained individuals. In trained athletes, strength, endurance and performance were improved. Despite increasing the hematocrit, AAS has not been shown to increase V̇O2max. Regardless, many athletes continue to use AAS alone or in combination with other ergogenic aids. Most athletic organizations forbid the use of steroids, but until this year, Major League baseball did not forbid their use. Mark McGwire, Sammy Sosa, and Barry Bonds all admit to using some form of ergogenic aid. This sends a message that it is OK to use AAS for the end goal of improving performance.

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The side effects of AAS have been greatly exaggerated by the medical profession for some time. Most of the effects are reversible and minor. AAS use can lead to decreased testicle size in men and an enlarged clitoris in women. Both sexes can experience enlarged breasts, hair loss, and acne. In kids, AAS use can lead to premature closure of the growth plates. Its use has been associated with tendon ruptures from collagen dysplasia. Other effects include mania, aggression, mood swings, addiction, low thyroid hormone levels, altered glucose metabolism and lipid profiles, suppression of the immune system, increased liver enzymes, jaundice (yellow skin and eyes), and elevated blood pressure.

Ergogenic aids raise many questions in the athletic community. Should they be legal so that everyone can use them equally—level the playing field, so to speak? Should we continue to monitor athletes, with random, unannounced testing of professional, collegiate, and Olympic athletes in the off-season? Should testing begin in high school? Is it appropriate for professional athletes to admit using ergogenic aids? Whatever your answer or philosophy regarding use of performance-enhancing drugs, they are available and popular with athletes. Now with the advent of anti-aging medicine, even more people will be using these drugs. Besides the obvious risks of blood-borne diseases for those sharing needles for the injections, the long-term health risks are not known. We will never be able to perform controlled studies, and with the use of these substances being illegal, we may never know which athletes die or have adverse health effects from the use of performance-enhancing drugs. Lyle Alzedo was an exception, publicly announcing that his cancer was linked to his AAS use.

Given that there may be no side effects, and even a small edge over the competition can mean the difference between first and 15th place in a finish, it is no wonder that athletes are attracted to ergogenic aids. In a society that longs for youth and beauty and human perfection, again it is no wonder that the population is seeking out anti-aging doctors for the anti-aging aids. Short-term use of any of the above drugs is probably safe, within reason. However, many people become addicted to the effects and continue their use long term. Remember to mention this to any new or would-be users, along with the adverse effects above. The same benefits can be enjoyed through a healthy diet and regular exercise. Although the “natural” way may be slower and more difficult, it also is safer and has been shown to have a beneficial effect on V̇O2max, blood pressure, lipid profiles, glucose and fat metabolism, and mood.

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Recommended Readings

Bamberger, M., and D. Yeager. Over the edge. Sports Illustrated April 14, 62-70, 1997.
Stevens, S. Drug test. Outside November 58-68, 136-137, 2003.
Sturmi, J.E., and D.J. Diorio. Anabolic agents. Cl Sports Med 17:261-297, 1998.
Whitehead, R., S. Chillag, and D. Elliott. Anabolic steroid use among adolescents in a rural state. J Fam Prac 35:401-406, 1992.
© 2004 American College of Sports Medicine