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Pearls and Pitfalls

News and Views on Russian Doping, Spin Rhabdo, and Renal Stones

Eichner, E. Randy MD, FACSM

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doi: 10.1249/JSR.0000000000000228
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Introduction

Doping in sports is back in the news. This time, it is the Russians. I cover selected aspects of the new blockbuster report on state-sponsored doping. I also update the fast-moving field of “spin rhabdo” and answer a question I got on a football player with renal stones. Let me begin.

Russian Doping

In November 2015, the World Anti-Doping Agency (WADA) released a 323-page report that detailed a state-sponsored sport-doping program in Russia (12). WADA implicated Russian athletes, coaches, trainers, doctors, laboratory directors, and sport officials in “a deeply rooted culture of cheating” and “a systemic culture of doping.” The Russian cheating has been so long-enduring and all-encompassing as to make even Lance Armstrong envious.

Four days after the WADA report was released, Sebastian Coe, president of the International Association of Athletics Federations (IAAF), called it a “shameful wake-up call.” The IAAF voted to ban Russia from all international track and field events, including the 2016 Olympics in Rio, until Russia has fixed its problems and fallen in line with global antidoping rules.

In recent years, top Russian endurance athletes have been caught doping, as have endurance athletes in other countries, notably including Kenya, Turkey, and the United States. Russia’s Liliya Shobukhova, the second fastest female marathoner of all time, who won the Chicago Marathon three times and the London Marathon once, was banned in 2014, when her athlete biological passport (ABP) indicated the use of erythropoietin (Epo) and blood transfusion. In race walking, 22 Russian athletes have been banned in the past decade, including 15 for Epo and/or anomalies in their ABP (1). But this new WADA report is staggering in its view of epic Russian cheating in sport.

WADA urged lifetime bans for five female middle-distance runners, including the 800-m gold and bronze medalists in the 2012 London Olympics, Mariya Savinova and Ekaterina Poistogova. Both women used Epo and admitted (on a secret tape) using oxandrolone, an anabolic androgenic steroid. The irony is that all three medalists likely had high testosterone, but only the silver medalist, Caster Semenya of South Africa, came by it naturally. In 2009, after winning a world 800-m championship, Semenya was forced to undergo gender verification, which showed that she is intersex, with internal testes. In 2010, Semenya was allowed to return to racing.

Oxandrolone, with an anabolic-to-androgenic ratio of 10/1, has been used clinically to preserve lean mass in catabolic conditions. In a recent study in elderly women with mild frailty, oxandrolone for 12 wk augmented body adaptations (gain in lean mass, loss in fat mass) to resistance training. But it failed to improve strength, power, or function, and it caused unfavorable changes in cholesterol profile and hepatic enzymes (8). Using oxandrolone in this setting seems to me a bad idea.

Oxandrolone is also “blood doping” for female athletes. Why? Because testosterone increases hemoglobin in two ways: It increases Epo and it suppresses hepcidin, which increases iron supply for red cell production (2). That is why hemoglobin level is higher in men than women. When female athletes use Epo with oxandrolone, they combine two forms of doping. Let us never forget that Epo doping has killed up to 25 or 30 competitive cyclists (5).

Spin Rhabdo

Recently, a 25-year-old woman reported on her first class of spinning — where she was encouraged to go all out — and on her 6-d hospitalization for major acute rhabdomyolysis (peak creatine kinase, 400,000 U·L−1) that followed. She got a refund for the spin class, but the owner and his lawyer said they did not think spinning could cause exertional rhabdomyolysis (ER), and they had never heard of it (11).

Contrary to the misinformation from the owner, there are more than 50 cases of “spin rhabdo” in the medical literature and about 15 self-reports on the Internet; I covered some in a prior column (6). In 2005 to 2006, the spinning industry published three warnings (at www.spinning.com) to instructors about risks for first timers and about practical precautions to keep them safe. It seems these precautions were ignored in the new case of spin rhabdo (11).

Most cases of ER in healthy persons are from novel overexertion, but the type of overexertion changes with the settings and the times. In a report of 30 soldiers hospitalized for ER (excluding heat stroke) in Honolulu from 2010 to 2012, only a few were from military training per se, including four cases from ruck marches, and these four had the highest serum creatinine levels, as if dehydrated. Only one case was from the Army Physical Fitness Test, and this was the mildest case of all. Nearly 75% of these ER cases were from novel resistance training, e.g., weight-lifting workouts, CrossFit, or P90X workouts. None was from spinning (10).

In contrast, reports of spin rhabdo are now appearing frequently. In a new case series (in press) from NYC, reporting 29 persons hospitalized for ER, nearly half the ER cases (14 cases) were spin rhabdo, and almost all the spin rhabdo cases (13 cases) were in 2013 to 2014. Spin rhabdo may be the latest fad cause of ER in the community. Commonsense precautions can prevent it, e.g.: 1) classes for beginners only — easier and briefer; 2) tell participants to go at their own pace; 3) avoid standing movements and keep intensity low to moderate; 4) show participants how to lower the resistance of the flywheel; and 5) watch participants closely to make sure they do not overexert.

Renal Stones

I am asked about a college football player with recurrent renal stones, which were assumed to be calcium oxalate, because in 80% of adults, such stones are calcium oxalate, calcium phosphate, or both. About 13% of men and 7% of women will have a renal stone in their lifetime; without treatment, the 5-year recurrence rate is 35% to 50% (9).

I am asked: Should he go on a low-calcium diet? The answer is no. This reverses the long-standing advice. In a 5-year randomized trial in Italian men with recurrent renal stones and hypercalciuria, a normal-calcium diet (but low in animal protein and salt) was more effective in preventing recurrent renal stones than the traditional low-calcium diet (3). Calcium in dairy food binds oxalate in the gut and sweeps it out in the stool, thereby keeping it out of the urine, where it could contribute to stones.

I have covered other dietary and lifestyle measures to ward off stones (4). First, drink more water. Increase fluid intake through the day to achieve at least 2 L of urine per day (9). Also, cut salt, limit meat, consume citrus and phytate (as in plant fiber), limit oxalate (as in tea, chocolate, peanuts, beets, spinach, strawberries), and reduce intake of colas containing phosphoric acid (4).

Believe it or not, two studies find that in up to 80% of cases, the side you sleep on is the side the stone forms on. So you may want to toss and turn at night (4). Finally, the advice on caffeine has been reversed, so coffee lovers can rejoice. Caffeine can increase urinary calcium, and so was once thought to contribute to stones. But caffeine also decreases urinary oxalate and increases urine volume, so its net effect is to prevent stones. In a new study that followed more than 200,000 health professionals for over 8 years, caffeine intake was independently associated with a 25% to 30% lower risk of renal stones (7). I’ll drink to that!

References

1. Associated press. List of Russia race walkers caught for doping in last decade. [Cited 2015 November 15]. Available from: http://news.yahoo.com/list-russia-race-walkers-caught-doping-last-decade-155828822.html.
2. Bachman E, Travison TG, Basaria S, et al. Testosterone induces erythrocytosis via increased erythropoietin and suppressed hepcidin: evidence for a new erythropoietin/hemoglobin set point. J. Gerontol. A Biol. Sci. Med. Sci. 2014; 69: 725–35.
3. Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N. Engl. J. Med. 2002; 346: 77–84.
4. Eichner ER. Throw no stones. How to prevent calcium oxalate renal stones. Curr. Sports Med. Rep. 2010; 9: 260–1.
5. Eichner ER. Dying to win: memories of doping and duping. Curr. Sports Med. Rep. 2013; 12: 2–3.
6. Eichner ER. Pelvic pain from running, rhabdomyolysis from spinning, and leukopenia in athletes. Curr. Sports Med. Rep. 2015; 14: 73–4.
7. Ferraro PM, Taylor EN, Gambaro G, Curhan GC. Caffeine intake and the risk of kidney stones. Am. J. Clin. Nutr. 2014; 100: 1596–603.
8. Mavros Y, O’Neill E, Connerty M, et al. Oxandrolone augmentation of resistance training in older women: a randomized trial. Med. Sci. Sports Exerc. 2015; 47: 2257–67.
9. Qaseem A, Dallas P, Forceia MA, et al. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians. Ann. Intern. Med. 2014; 161: 659–67.
10. Oh RC, Arter JL, Tiglao SM, Larson SL. Exertional rhabdomyolysis: a case series of 30 hospitalized patients. Mil. Med. 2015; 180: 201–7.
11. Shea L. Spin class: a cautionary tale. [cited 2015 November 15]. Available from: http://dragonflyeye.net/blog/2015/09/28/spin-class-rhabdomyolysis/.
12. WADA. Independent Commission — Report 1, November 9, 2015. [cited 2015 November 15]. Available from: https://www.wada-ama.org/en/resources/world-anti-doping-program/independent-commission-report-1.
Copyright © 2016 by the American College of Sports Medicine.