High amounts of 17-methylated anabolic-androgenic steroids in effervescent tablets on the dietary supplement market

A Behaviourally Informed Approach to Reducing the Risk of Inadvertent Anti-doping Rule Violations from Supplement Use

For many reasons, athletes' use of supplements is highly prevalent across sports and competitive levels, despite the risk of these products containing a substance on the World Anti-Doping Agency Prohibited List. Contravening anti-doping rules through supplement use could have serious consequences for competitive athletes (e.g., ineligibility from major competitions, loss of medals and funding) due to the principle of strict liability. Indiscriminate supplement use also poses a risk to athlete health. To reduce the possibility of ingesting a supplement containing prohibited substances, independent quality assurance and certification programs have been established (e.g., Informed Sport). However, these programs do not completely eliminate risk, leading to some anti-doping organisations promoting a 'just say no' to supplements stance. Yet, this approach can be problematic as a small number of supplements may be necessary for athletes to consume, in certain situations. Recognising that athletes will continue to use these heavily marketed products, this narrative review describes a theoretically underpinned and systematic approach to preventing inadvertent doping by considering the barriers to and enablers of athlete adherence to risk minimisation supplement use guidelines (RMSUG). By outlining a conceptual shift towards a behaviourally informed approach, this review serves to stimulate the development of multifaceted interventions to prevent inadvertent doping through supplement use. Recognising that risk-minimised supplement use involves a myriad of behaviours, the problem of inadvertent doping through supplement use is framed, and research appraised, through the lens of the Behaviour Change Wheel.

Dietary Supplements as Source of Unintentional Doping

Background

The substances used in sport could be divided into two major groups: those banned by the World Anti-Doping Agency and those which are not. The prohibited list is extremely detailed and includes a wide variety of both medicinal and nonmedicinal substances. Professional athletes are exposed to intense physical overload every day. They follow a relevant food regime and take specific dietary supplements, which is essential for the better recovery between trainings and competitions. However, the use of “nonprohibited” dietary supplements (DS) is not always completely safe. One of the risks associated with the use of dietary supplements is the risk of unintended doping—originating from contaminated products. The presence of undeclared compounds in the composition of DS is a serious concern. The aim of this study is to evaluate the risk of unintentional doping.

Materials and Methods

Literature search was done through PubMed, Science Direct, Google Scholar, and Web of Science. Studies investigating the presence of undeclared compounds, in dietary supplements, banned by WADA met the inclusion criteria. The last search was conducted in June 2021. The present review is based on a total of 50 studies, which investigated the presence of undeclared compounds in DS.

Results

The total number of analyzed DS is 3132, 875 of which were found to contain undeclared substances. Most frequently found undeclared substances are sibutramine and anabolic-androgenic steroids.

Conclusion

More than 28% of the analyzed dietary supplements pose a potential risk of unintentional doping. Athletes and their teams need to be aware of the issues associated with the use of DS. They should take great care before inclusion of DS in the supplementation regime.

Undeclared Doping Substances are Highly Prevalent in Commercial Sports Nutrition Supplements

Sports nutrition supplements have previously been reported to contain undeclared doping substances. The use of such supplements can lead to general health risks and may give rise to unintentional doping violations in elite sports. To assess the prevalence of doping substances in a range of high-risk sports nutrition supplements available from Dutch web shops. A total of 66 sports nutrition supplements - identified as potentially high-risk products claiming to modulate hormone regulation, stimulate muscle mass gain, increase fat loss, and/or boost energy - were selected from 21 different brands and purchased from 17 web shops. All products were analyzed for doping substances by the UK life sciences testing company LGC, formerly known as the Laboratory of the Government Chemist, using an extended version of their ISO17025 accredited nutritional supplement screen. A total of 25 out of the 66 products (38%) contained undeclared doping substances, which included high levels of the stimulants oxilofrine, β-methylphenethylamine (BMPEA) and N,β-dimethylphenethylamine (NBDMPEA), the stimulant 4-methylhexan-2-amine (methylhexaneamine, 1,3-dimethylamylamine, DMAA), the anabolic steroids boldione (1,4-androstadiene-3,17-dione) and 5-androstene-3β,17α-diol (17α-AED), the beta-2 agonist higenamine and the beta-blocker bisoprolol. Based upon the recommended dose and the potential variability of analyte concentration, the ingestion of some products identified within this study could pose a significant risk of unintentional doping violations. In addition to inadvertent doping risks, the prescribed use of 3 products (4.5%) could likely impose general health risks.

Dutch Olympic and Non-Olympic Athletes Differ in Knowledge of and Attitudes Toward Third-party Supplement Testing

Knowledge of third-party testing is important for elite athletes using nutritional supplements to reduce the chances of a positive doping incident. Therefore, we compared the self-reported knowledge and attitudes of N = 601 Dutch Olympic status and non-Olympic status athletes toward an independent Dutch third-party tested system (NZVT) for purchasing nutritional supplements (NSs). Most of the athletes believed that contaminated NSs could lead to a positive doping test (68.0%), and found it unacceptable to use a contaminated NS as a result of incomplete labeling (87.8%). More Olympic status athletes were familiar with the NZVT system (71.1%) than non-Olympic status athletes (24.5%, p < 0.001). Of the athletes knowing about NZVT, Olympic status athletes reported more frequently using the NZVT than non-Olympic athletes (81.7% vs. 50.0%, p < 0.001). Apart from status, more females were familiar with and used the NZVT system for purchasing NSs than males, p < 0.01. In conclusion, many athletes were not familiar with nor used the preferred third-party testing supplement system in the Netherlands when purchasing NSs. While doping warnings and regulations have been in place, considering the risk of unintentional doping use for over two decades, the knowledge of Olympic status and non-Olympic status high-level athletes could still be improved, as many are not reporting the use of third-party testing systems.

Sports Foods and Dietary Supplements for Optimal Function and Performance Enhancement in Track-and-Field Athletes

Athletes are exposed to numerous nutritional products, attractively marketed with claims of optimizing health, function, and performance. However, there is limited evidence to support many of these claims, and the efficacy and safety of many products is questionable. The variety of nutritional aids considered for use by track-and-field athletes includes sports foods, performance supplements, and therapeutic nutritional aids. Support for sports foods and five evidence-based performance supplements (caffeine, creatine, nitrate/beetroot juice, β-alanine, and bicarbonate) varies according to the event, the specific scenario of use, and the individual athlete's goals and responsiveness. Specific challenges include developing protocols to manage repeated use of performance supplements in multievent or heat-final competitions or the interaction between several products which are used concurrently. Potential disadvantages of supplement use include expense, false expectancy, and the risk of ingesting banned substances sometimes present as contaminants. However, a pragmatic approach to the decision-making process for supplement use is recommended. The authors conclude that it is pertinent for sports foods and nutritional supplements to be considered only where a strong evidence base supports their use as safe, legal, and effective and that such supplements are trialed thoroughly by the individual before committing to use in a competition setting.

Intended or Unintended Doping? A Review of the Presence of Doping Substances in Dietary Supplements Used in Sports

Introduction: The use of dietary supplements is increasing among athletes, year after year. Related to the high rates of use, unintentional doping occurs. Unintentional doping refers to positive anti-doping tests due to the use of any supplement containing unlisted substances banned by anti-doping regulations and organizations, such as the World Anti-Doping Agency (WADA). The objective of this review is to summarize the presence of unlabeled doping substances in dietary supplements that are used in sports. Methodology: A review of substances/metabolites/markers banned by WADA in ergonutritional supplements was completed using PubMed. The inclusion criteria were studies published up until September 2017, which analyzed the content of substances, metabolites and markers banned by WADA. Results: 446 studies were identified, 23 of which fulfilled all the inclusion criteria. In most of the studies, the purpose was to identify doping substances in dietary supplements. Discussion: Substances prohibited by WADA were found in most of the supplements analyzed in this review. Some of them were prohormones and/or stimulants. With rates of contamination between 12 and 58%, non-intentional doping is a point to take into account before establishing a supplementation program. Athletes and coaches must be aware of the problems related to the use of any contaminated supplement and should pay special attention before choosing a supplement, informing themselves fully and confirming the guarantees offered by the supplement.

Doping Status of DHEA Treatment for Female Athletes with Adrenal Insufficiency

OBJECTIVE

To review the doping status of dehydroepiandrosterone (DHEA) for female athletes with adrenal insufficiency within the framework of Therapeutic Use Exemption (TUE) applications for this proandrogen, which is included on the World Anti-Doping Agency (WADA)'s Prohibited List.

DATA SOURCES AND MAIN RESULTS

Current knowledge of adrenal pathophysiology with a focus on the physiological role and pharmacological effects of DHEA in female athletes including placebo-controlled clinical trials of DHEA and consensus clinical practice and prescribing guidelines.

CONCLUSIONS

Because there is no convincing clinical evidence to support the use of DHEA replacement therapy in women with adrenal failure, a TUE for DHEA is not justified by definite health benefit for either secondary or primary adrenal failure. This is consistent with the 2014 update of the US Endocrine Society guidelines, meta-analyses of DHEA treatment in women with or without adrenal failure, current WADA TUE guidance document for adrenal insufficiency and recent case law of WADA's Court of Arbitration for Sport.

Anabolic steroid-induced hypogonadism: diagnosis and treatment

OBJECTIVE

To develop an understanding of hypogonadal men with a history of anabolic-androgenic steroid (AAS) use and to outline recommendations for management.

DESIGN

Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion criteria.

SETTING

Not applicable.

PATIENT(S)

Men seeking treatment for symptomatic hypogonadism who have used nonprescribed AAS.

INTERVENTION(S)

History and physical examination followed by medical intervention if necessary.

MAIN OUTCOME MEASURES(S)

Serum testosterone and gonadotropin levels, symptoms, and fertility restoration.

RESULT(S)

Symptomatic hypogonadism is a potential consequence of AAS use and may depend on dose, duration, and type of AAS used. Complete endocrine and metabolic assessment should be conducted. Management strategies for anabolic steroid-associated hypogonadism (ASIH) include judicious use of testosterone replacement therapy, hCG, and selective estrogen receptor modulators.

CONCLUSION(S)

Although complications of AAS use are variable and patient specific, they can be successfully managed. Treatment of ASIH depends on the type and duration of AAS use. Specific details regarding a patient's AAS cycle are important in medical management.

In vitro androgen bioassays as a detection method for designer androgens

Androgens are the class of sex steroids responsible for male sexual characteristics, including increased muscle mass and decreased fat mass. Illicit use of androgen doping can be an attractive option for those looking to enhance sporting performance and/or physical appearance. The use of in vitro bioassays to detect androgens, especially designer or proandrogens, is becoming increasingly important in combating androgen doping associated with nutritional supplements. The nutritional sports supplement market has grown rapidly throughout the past decade. Many of these supplements contain androgens, designer androgens or proandrogens. Many designer or proandrogens cannot be detected by the standard highly-sensitive screening methods such as gas chromatography-mass spectrometry because their chemical structure is unknown. However, in vitro androgen bioassays can detect designer and proandrogens as these assays are not reliant on knowing the chemical structure but instead are based on androgen receptor activation. For these reasons, it may be advantageous to use routine androgen bioassay screening of nutraceutical samples to help curb the increasing problem of androgen doping.

Prolonged intrahepatic cholestasis and renal failure secondary to anabolic androgenic steroid-enriched dietary supplements

The illegal enrichment of anabolic androgenic steroids in over-the-counter dietary supplements is well documented, but the health consequences have not been widely recognized. Three recent reports document cholestatic jaundice and nephropathy due to these compounds. We present 3 additional cases of anabolic androgenic steroid-enriched dietary supplement-induced hepatotoxicity and 1 case of renal failure, and we review the literature and the relevant features of this growing health concern. Recognition of this entity could obviate the need for invasive diagnostic testing and hospitalization and facilitate diagnosis and appropriate counseling.

The use of dietary supplements by athletes

Many athletes use dietary supplements as part of their regular training or competition routine, including about 85% of elite track and field athletes. Supplements commonly used include vitamins, minerals, protein, creatine, and various "ergogenic" compounds. These supplements are often used without a full understanding or evaluation of the potential benefits and risks associated with their use, and without consultation with a sports nutrition professional. A few supplements may be helpful to athletes in specific circumstances, especially where food intake or food choice is restricted. Vitamin and mineral supplements should be used only when a food-based solution is not available. Sports drinks, energy bars, and protein-carbohydrate shakes may all be useful and convenient at specific times. There are well-documented roles for creatine, caffeine, and alkalinizing agents in enhancing performance in high-intensity exercise, although much of the evidence does not relate to specific athletic events. There are potential costs associated with all dietary supplements, including the risk of a positive doping result as a consequence of the presence of prohibited substances that are not declared on the label.

Metabolism of androsta-1,4,6-triene-3,17-dione and detection by gas chromatography/mass spectrometry in doping control

The urinary metabolism of the irreversible aromatase inhibitor androsta-1,4,6-triene-3,17-dione was investigated. It is mainly excreted unchanged and as its 17beta-hydroxy analogue. For confirmation, 17beta-hydroxyandrosta-1,4,6-trien-3-one was synthesized and characterized by nuclear magnetic resonance (NMR) in addition to the parent compound. In addition, several reduced metabolites were detected in the post-administration urines, namely 17beta-hydroxyandrosta-1,4-dien-3-one (boldenone), 17beta-hydroxy-5beta-androst-1-en-3-one (boldenone metabolite), 17beta-hydroxyandrosta-4,6-dien-3-one, and androsta-4,6-diene-3,17-dione. The identification was performed by comparison of the metabolites with reference material utilizing gas chromatography/mass spectrometry (GC/MS) of the underivatized compounds and GC/MS and GC/tandem mass spectrometry (MS/MS) of their trimethylsilyl (TMS) derivatives. Alterations in the steroid profile were also observed, most obviously in the androsterone/testosterone ratio. Even if not explicitly listed, androsta-1,4,6-triene-3,17-dione is classified as a prohibited substance in sports by the World Anti-Doping Agency (WADA) due to its aromatase-inhibiting properties. In 2006 three samples from human routine sports doping control tested positive for metabolites of androsta-1,4,6-triene-3,17-dione. The samples were initially found suspicious for the boldenone metabolite 17beta-hydroxy-5beta-androst-1-en-3-one. Since metabolites of androst-4-ene-3,6,17-trione were also present in the urine samples, it is presumed that these findings were due to the administration of a product like 'Novedex Xtreme', which could be easily obtained from the sport supplement market.

Comprehensive two-dimensional gas chromatography with time-of-flight mass spectrometric detection for the determination of anabolic steroids and related compounds in nutritional supplements

A simple and effective analytical method for the determination of anabolic steroids and related compounds in nutritional supplements is reported. Target compounds are extracted with ethyl acetate, crude extract is purified using dispersive solid-phase extraction (SPE) with primary secondary amine (PSA) as sorbent, and finally they are identified and quantified as underivatized compounds using two-dimensional gas chromatography with time-of-flight mass spectrometric detection (GCxGC-TOF MS). This method was validated for 25 steroids in two types of commercially available solid nutritional supplements: protein concentrate and creatine monohydrate. Repeatability expressed as the relative standard deviation of analyte concentration ranged from 4.1 to 20.5%. Recoveries between 70.0 and 122.6% were obtained for the target compounds except for oxymetholone in protein concentrate where the recovery was low as a result of strong interactions with PSA. Excellent linearity was obtained for six-point calibration with regression coefficients of 0.997-1.000 for all compounds. The limits of quantification ranged from 0.007 to 0.114 mg kg(-1). For a monitoring programme of 48 samples of nutritional supplements, three were positive. Nandrolone, testosterone, dehydroepiandrosterone (DHEA), 5alpha-androstan-3,17-dione, 19-norandrostendione and progesterone were found in positive samples at concentrations between 0.022 and 0.398 mg kg(-1).

Nutritional supplements cross-contaminated and faked with doping substances

Since 1999 several groups have analyzed nutritional supplements with mass spectrometric methods (GC/MS, LC/MS/MS) for contaminations and adulterations with doping substances. These investigations showed that nutritional supplements contained prohibited stimulants as ephedrines, caffeine, methylenedioxymetamphetamie and sibutramine, which were not declared on the labels. An international study performed in 2001 and 2002 on 634 nutritional supplements that were purchased in 13 different countries showed that about 15% of the nonhormonal nutritional supplements were contaminated with anabolic-androgenic steroids (mainly prohormones). Since 2002, also products intentionally faked with high amounts of 'classic' anabolic steroids such as metandienone, stanozolol, boldenone, dehydrochloromethyl-testosterone, oxandrolone etc. have been detected on the nutritional supplement market. These anabolic steroids were not declared on the labels either. The sources of these anabolic steroids are probably Chinese pharmaceutical companies, which sell bulk material of anabolic steroids. In 2005 vitamin C, multivitamin and magnesium tablets were confiscated, which contained cross-contaminations of stanozolol and metandienone. Since 2002 new 'designer' steroids such as prostanozol, methasterone, androstatrienedione etc. have been offered on the nutritional supplement market. In the near future also cross-contaminations with these steroids are expected. Recently a nutritional supplement for weight loss was found to contain the beta2-agonist clenbuterol. The application of such nutritional supplements is connected with a high risk of inadvertent doping cases and a health risk. For the detection of new 'designer' steroids in nutritional supplements, mass spectrometric strategies (GC/MS, LC/MS/MS) are presented.

Clenbuterol marketed as dietary supplement

In several studies it has been demonstrated that products containing pharmaceutically active ingredients are marketed as dietary supplements. Most of these products contain anabolic steroids. Recently products for weight loss containing active drugs have also appeared on the market. In the present case a healthy male ordered the product 'Anabolic burner' via the Internet. The product was received from a German dispatcher and paid by bank transfer to a German bank account. After ingesting one tablet he reported tremor and delivered a urine sample. This urine was found to contain 2 ng/mL of clenbuterol utilizing LC-MS/MS analysis. Additionally the product itself was analyzed with GC-MS for clenbuterol, yielding a content of about 30 microg per tablet. The beta-2 agonist clenbuterol is only legally available on prescription and is classified as prohibited doping substance in sports. The present case for the first time confirms the presence of clenbuterol in a dietary supplement. It again demonstrates the common problem with products on the supplement market, where non-licensed pharmaceuticals and doping substances are easily available. The ingestion of these products containing additions of therapeutic drugs can lead to side effects and/or interactions with conventional medicines.

The continuing story of nutritional supplements and doping infractions

Nutritional supplements can be a source of positive doping cases as some supplements contain prohibited substances without showing this on their label. This problem has existed for some time and has been extensively studied in the past 8 years. The sport of tennis has played a particular role in this problem because of some peculiar doping cases within its community. This article focuses on this particular doping problem, explaining the background and reviewing the available literature. It presents the first 3 years of experience within the Netherlands Security System Nutritional Supplements Elite Sports ("Nederlands Zekerheidssysteem Voedingssupplementen Topsport" or NZVT) and explains the most extensive system established to combat this particular doping problem. The NZVT experience has shown that paper-based quality systems are still prone to possible contaminations, which leads to the conclusion that the best possible solution for athletes who wish to use nutritional supplements must include laboratory-based analysis for doping substances, preferably repeated for every new batch. The most important educational message, however, is to use a nutritional supplement only if it is deemed of benefit by a nutritional expert.

Hepatotoxicity associated with dietary supplements containing anabolic steroids

BACKGROUND & AIMS

The aim of this article was to re-emphasize the hepatotoxicity associated with the use of anabolic androgenic steroids and to highlight the marketing and sale of anabolic androgenic steroids as dietary supplements.

METHODS

This was a case series of 2 patients who developed a cholestatic liver panel after consumption of anabolic androgenic steroids. A detailed Pubmed/Medline search was performed to research this topic.

RESULTS

We present 2 young men who developed significant cholestatic liver injury after consumption of anabolic androgenic steroids. This was associated with considerable morbidity, although both patients recovered without the need for a liver transplant. Both of these anabolic androgenic steroids were being marketed as dietary supplements.

CONCLUSIONS

Despite being classified as class III controlled substances, anabolic androgenic steroids are still a cause for serious hepatotoxicity in the United States. Some of these anabolic androgenic steroids are being marketed as dietary supplements. Although the Food and Drug Administration is making concerted efforts to regulate this, increased vigilance also is required from the medical profession.

Steroidal isomers with uniform mass spectra of their per-TMS derivatives: synthesis of 17-hydroxyandrostan-3-ones, androst-1-, and -4-ene-3,17-diols

In human sports doping control analysis most of the steroids are analyzed after enzymatic hydrolysis of the glucuronides as per-trimethylsilyl (TMS) derivatives applying gas chromatography-mass spectrometry (GC-MS). According to the recommendations of the World Anti-Doping Agency the identification of analytes should be based on retention time and on mass spectrometric characterization. This study shows that the bis-TMS derivatives of 16 specific C19 steroids, namely the stereoisomers of 5xi-androst-1-ene-3xi,17xi-diol (8 isomers), androst-4-ene-3xi,17xi-diol (4 isomers), and 17xi-hydroxy-5xi-androstan-3-one (4 isomers), reveal very similar mass spectra. As a rule, when taking the retention times, which are provided as Kovac indices for all these isomers, into account, a restriction to two or three possible isomers is possible. Reliable identification should additionally include a comparison of the retention times of the analytes with the reference compounds measured concomitantly. In some cases standard addition may be appropriate. Due to the limited availability, the above mentioned isomers were synthesized by reduction of the corresponding alpha,beta-unsaturated oxo steroids either with K-Selectride or by catalytic hydrogenation (Pd/C as catalyst). The products of the reactions were identified by means of nuclear magnetic resonance (NMR) characterization and by further reduction to the corresponding 5xi-androstane-3xi,17xi-diols and GC-MS comparison with commercially available reference standards.