POPULAR ERGOGENIC DRUGS AND SUPPLEMENTS IN ATHLETES Ramsey

POPULAR ERGOGENIC DRUGS AND SUPPLEMENTS IN ATHLETES Ramsey Shehab MD Dept. of Orthopaedics Henry Ford Health System

Disclosure n I have no relevant relationships to disclose or conflicts of interest to declare

INTRODUCTION n n Substances used to enhance athletic performance marketed nutritional supplements Illicit substances For years widely used by ‘older’ professional athletes Available and used by teenagers Anabolic steroids Steroid precursors Growth Hormone Creatine Ephedra Caffeine HMB Glutamine EPO Bicarbonate Protein

STATISTICS n n n 50 -60% of high school kids play on teams ~50% of those who play on teams admit to using supplements 1/3 of high school users are non-athletes who use to improve body image and appearance n 1 -2 million US athletes taking steroids n 4 -12 % lifetime steroid use for males

HISTORY n n n n 776 BC: Greek Olympians 1889: Dr. Brown-Sequard: elixir 1935: Dr. Laqueuer: Testosterone 1950 s: Russian weightlifters 1960 s: Steroids banned and testing started 1988: Ben Johnson gold medal stripped 1994: 2 Question Olympic survey

(1) ANABOLIC STEROIDS n n n n synthetic derivative of testosterone T = primary male hormone anabolic & anti-catabolic effects binds androgen receptors in cells a) inc protein production b) inhibit muscle breakdown oral/ injectable / transdermal injectable form has longest effects used in the offseason bc less likely detected

n n n 4 12 week cycles pyramid dosing schedules 50 -100 x normal physiologic steroid levels gains in muscle strength and fat-free mass muscle hypertrophy new muscle fiber production n most gains with weight-lifters n n 1/3 of users experience side effects

n n n n n Acne Increased blood pressure Worsening of lipid profiles Left ventricular hypertrophy Increased liver enzymes Premature arrest of bone growth Sharing needles HIV, Hepatits Depression, agression Tendon injury MALES: testicular atrophy, gynecomastia, balding FEMALES: deepened voice, loss of breast tissue

n n High school steroid use: 2010 Monitoring of the future study: 8 th : 1. 2% 10 th : 2. 4% 12 th : 3. 3% 2/3 of are noncompetitive users n n 4 -11% boys 3% girls polypharmacy: 80%

• Durabolin/Nandrolone: - injectable with long metabolic breakdown - highly anabolic, moderate androgenic - water retention • Drostanolone: - fast-acting injectable derived from DHT - uses in breast CA patients to inhibit estrogen - hair loss common • Dianabol: - oral - around since 1960 s in the US - made to help US olympians keep pace • Winstrol/Stanozolol: - oral - females low androgenic potency - males cutting cycle - daily - significant hepatoxicity - Ben Johnson

Tetrahydrogestrinone: - THG or ‘the clear’ - synthetic developed by BALCO - cream on arms/droplet under tongue

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: -Athletic Performance: ? no controlled studies

(2) STEROID PRECURSORS n n DHEA, Androstenedione DHEA- weak androgen produced in adrenals Androstenedione- more potent produced in gonads DHEA Andro Testosterone n Effects hypothetical No changes in testosterone levels with supplementation No changes in athletic measures Increased estrone and estradiol n Same side effect profile as steroids n n n

n n n n n Acne Increased blood pressure Worsening of lipid profiles Left ventricular hypertrophy Increased liver enzymes Premature arrest of bone growth Sharing needles HIV, Hepatits Depression, aggression Tendon injury MALES: testicular atrophy, gynecomastia, balding FEMALES: deepened voice, loss of breast tissue

n BOTTOM LINE: -Efficacy: -Side Effect Profile: -Athletic Performance: - (limited studies)

(3) GROWTH HORMONE n n n Protein secreted by pituitary Secretion gradually decreases after adolescence 3 functions increases protein production breaks down lipids stimulates bone growth Injectable form only One month supply = $3000 -5000

n n n Risks >> Benefits No evidence that it benefits healthy young athletes with normal growth hormone levels Decreases fat tissue giving more toned appearance which makes it aesthetically apealing Risks: -injection risks: HIV/Hepatitis -premature growth plate closure -jaw enlargement -inc IC pressure Banned by all major sports NCAA survey 2011: 3. 5% athletes have used GH in last 12 m

n BOTTOM LINE: -Efficacy: + (in GH deficient patients) -Side Effect Profile: -Athletic Performance: mixed (limited studies)

(4) CREATINE n n n n Formed by natural AA found in body (G/M/A) Naturally produced by liver, kidneys, pancreas Transported into muscle/heart/brain In muscle converted to phosohocreatine which provides energy to muscle Daily requirement is 2 grams Most useful in short, high intensity activities (10 s) Delays muscle fatigue

n n n Loading phase: 5 grams 4 x/day x 5 days Maintenance: 2 grams/ day x 3 months Anything over excreted by kidneys 1 month abstinence after 3 months 6 -8 glasses of H 2 O to avoid dehydration 1/3 athletes non-responder Improvements is short duration anaerobic events Weight gain ~ 5 lbs GI discomfort and muscle cramps Rare cases of acute renal failure Legal Trainers/coaches not allowed to supply it anymore

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: + -Athletic Performance: + (sport dependant)

(5) EPHEDRINE n n n Stimulant related to amphetamine Derived from herb ma huang Enhances release of NE and stimulates sympathetic Provides quick energy Aids in fat loss No change in athletic performance Inc BP, HR, anxiety, tremors, insomnia Seizures, heart attack, death Banned in 2004 Overturned in 2005: 10 mg dose wan not dangerous 2006: sales banned again 10 -20% of high school athletes (F>M)

n BOTTOM LINE: -Efficacy: ? -Side Effect Profile: -Athletic Performance: -

(5) CAFFFEINE n n n Mostly widely used stimulant in world Inc: mental alertness/concentration/use FFA by muscles Enhances release of NE Decreases fatigue Studies: Improves sprint + strength performance n Nervousness, insomnia, tremors Diuresis dehydration n >4 cups in 30 minutes: + urine test for disqualification n

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: + -Athletic Performance: +

(7) HMB n n n n Leucine metabolite: anti-catabolic effects? marketed to suppress protein breakdown exact mechanism unknown Most studies Improved muscle mass Mixed results athletic performance SAFE No Ban

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: + -Athletic Performance: mixed

(8) Glutamine n n n n most abundant AA found in body fish, red meat, beans aids in recovery after long bouts of exercise/stress Past: used in hospital after surgery 5 -10 grams/ day no good studies no ban no side effects

n BOTTOM LINE: -Efficacy: +/-Side Effect Profile: + -Athletic Performance: ?

(9) EPO n hormone naturally produced in kidneys stimulates increase in hemoglobin Inc hgb Inc O 2 in blood Inc VO 2 max n endurance athletes n increased blood viscosity stroke and MI n n available by Rx only screened at an Olympic level

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: -Athletic Performance: mixed

(10) BICARBONATE n n n Maintains normal p. H in body Loading increases body alkalinity more lactic acid buffering which leads to delays fatigue 300 mg/kg body weight inc performance anaerobic exercise bouts up to 7 mins n SI: GI bloating/diarrhea/cramping n No current bans!

n BOTTOM LINE: -Efficacy: + -Side Effect Profile: + -Athletic Performance: ?

(11) Protein n n n Endurance 1. 2 g/kg Resistance 1. 7 g/kg Doses 20 -25 gm/serving Immediately after exercise Whey vs Casein Leucine

Whey Casein Complete protein Yes High in leucine Yes No High in glutamine No Yes Absorption rate Fast Slow Duration of elev blood AA Short Long

ADDRESSING PROBLEM TESTING *1995 supreme court authorized testing *national data: 13% high schools test athletes *only 29% of those test for anabolic steroids *majority of testing on marijuana/opiates/alcohol EDUCATION *Adolescents Training and Learning to Avoid Steroids *classroom and exercises training sessions * Tested on a group >3000 kids decrease suppl use

References n Tokish, John M. , Mininder S. Kocher, and Richard J. Hawkins. "Ergogenic aids: a review of basic science, performance, side effects, and status in sports. " The American journal of sports medicine 32. 6 (2004): 1543 -1553. n American College of Sports Medicine, and American Dietetic Association. "Joint Position Statement: nutrition and athletic performance. American College of Sports Medicine, American Dietetic Association, and Dietitians of Canada. " Medicine and Science in Sports and Exercise 32. 12 (2000): 2130. n Maughan, R. J. , P. L. Greenhaff, and P. Hespel. "Dietary supplements for athletes: emerging trends and recurring themes. " Journal of sports sciences 29. sup 1 (2011): S 57 -S 66. n Harmer, Peter A. "Anabolic-androgenic steroid use among young male and female athletes: is the game to blame? . " British journal of sports medicine 44. 1 (2010): 26 - 31. n n Kanayama, Gen, James I. Hudson, and Harrison G. Pope. "Illicit anabolic–androgenic steroid use. " Hormones and behavior 58. 1 (2010): 111 -121. Meinhardt, Udo, et al. "The effects of growth hormone on body composition and physical performance in recreational athletes: a randomized trial. " Annals of internal medicine 152. 9 (2010): 568 -577.

n Cooper, Robert, et al. "Creatine supplementation with specific view to exercise/sports performance: an update. " Journal of the International Society of Sports Nutrition 9. 1 (2012): 1. n Koo, Ga Hee, et al. "Effects of Supplementation with BCAA and L-glutamine on Blood Fatigue Factors and Cytokines in Juvenile Athletes Submitted to Maximal Intensity Rowing Performance. " Journal of physical therapy science 26. 8 (2014): 1241. n n n Adamson, John W. , and Daniel Vapnek. "Recombinant erythropoietin to improve athletic performance. " N Engl J Med 324. 10 (1991): 698 -9. Shelton, Jose, and Gideon V. Praveen Kumar. "Sodium Bicarbonate-A Potent Ergogenic Aid? . " Food and Nutrition Sciences 1. 1 (2010): 1. Zanchi, Nelo Eidy, et al. "HMB supplementation: clinical and athletic performance-related effects and mechanisms of action. " Amino acids 40. 4 (2011): 1015 -1025.