Steroid and prescription medicine abuse in the health and fitness community: A regional study

The assessment of liver function test and fertility hormones in Saudi athletes using anabolic androgenic steroids

Background

A growing number of athletes are using synthetic anabolic-androgenic steroids (AAS), comprised of testosterone and other derivatives, to enhance athletic performance and muscle mass. Over the years, numerous reports elucidated the side effects of the illegal use of AAS, such as infertility, and liver disorders. The effect of AAS on the hepatic and reproductive systems in Saudi athletes has not yet been studied. Therefore, this study examined the liver function and sex hormone parameters of AAS users as compared to non-users.

Methods

Fasting blood samples were collected from 16 male Saudi athletes, 10 AAS-users (cases) and 6 non-users (controls) to measure liver function tests (ALT, AST, GGT, ALP, total protein, albumin, direct and total bilirubin) and muscle enzymes (CK, LDH), Fertility hormones (LH, FSH, total testosterone, estradiol, and prolactin) were included also. Furthermore, a self-reported questionnaire was obtained to identify the type of AAS used, the dosage, and the length of the course before sample collection.

Results

The results show a statistically significant increase in ALT (P < 0.001), AST (P < 0.001), CK (P < 0.05), and a significant decrease (P < 0.05) in albumin (P < 0.001) and total bilirubin levels (P < 0.01) in AAS-users. Total testosterone increased significantly among AAS (P < 0.05), along with a significant decrease in LH (P < 0.01), and FSH (P < 0.001) levels, while serum prolactin and estradiol levels were significantly increased (P < 0.05).

Conclusion

AAS can enhance physical performance and appearance, its potential adverse effects on the hepatic and reproductive systems necessitate careful consideration. Our research demonstrates an increase in the liver-specific enzyme ALT in AAS users relative to non-users and the possibility that short-term AAS usage increases the risk of liver injury.

The Uses of Anabolic Androgenic Steroids Among Athletes; Its Positive and Negative Aspects- A Literature Review

The use of anabolic androgenic steroids (AAS) for strength training and muscle building is a widespread practice among athletes and young individuals. Athletes and bodybuilders are using these substances for various purposes, such as enhancing muscle mass, strengthening their bodies, and enhancing their performances. AAS exert a wide range of physiological effects that result in the activation of central signaling, resulting in adverse effects. Moreover, excessive use of AAS which can be categorized as AAS abuse; is linked to biological and psychological pathologies, which can lead to mortality. Complications arising from steroid abuse involve both cellular and physiological complications. Cellular complications arise when activation of signaling proteins like mTOR, Akt, etc. leads to alteration in protein synthesis pathways, cell cycle, oxidative stress, and apoptosis, contributing to damage at the cellular level. Physiological complications are evident with cardiovascular pathologies, including an altered lipid profile, cardiac hypertrophy, hypogonadism after discontinuation of AAS, and modulation of GABA receptors in the brain, all contributed by the androgen receptor signaling. Clinical complications budding from these altered physiological processes lead to clinical effects like testicular dysfunction, acne, gynecomastia, and neuropsychiatric disorders. Despite potential therapeutic benefits, AAS use is prohibited by the World Anti-Doping Agency (WADA) due to concerns over adverse health effects. This review highlights the molecular mechanisms, physiological processes, and clinical complications arising from the excessive use of AAS among athletes.

Doping and sports endocrinology: growth hormone, IGF-1, insulin, and erythropoietin

Among the substances prohibited by the World Anti-Doping Agency, "peptide hormones, growth factors, related substances, and mimetics" are classified as prohibited both in- and out-of-competition in section S2. This work reviews growth hormone and its releasing peptides, insulin-like growth factor 1 as the main growth factor, insulin, and erythropoietin and other agents that affect erythropoiesis. This review analyzes the prevalence of use among professional athletes and gym clients, the forms of use, dosing, ergogenic effects and effects on physical performance, as well as side effects and anti-doping detection methods.

Antidiabetic Medication Utilisation before and during Pregnancy in Switzerland between 2012 and 2019: An Administrative Claim Database from the MAMA Cohort

Background

The incidence of diabetes mellitus (both pregestational and gestational) is increasing worldwide, and hyperglycemia during pregnancy is associated with adverse pregnancy outcomes. Evidence on the safety and efficacy of metformin during pregnancy has accumulated resulting in an increase in its prescription in many reports.

Aims

We aimed to determine the prevalence of antidiabetic drug use (insulins and blood glucose-lowering drugs) before and during pregnancy in Switzerland and the changes therein during pregnancy and over time.

Methods

We conducted a descriptive study using Swiss health insurance claims (2012-2019). We established the MAMA cohort by identifying deliveries and estimating the last menstrual period. We identified claims for any antidiabetic medication (ADM), insulins, blood glucose-lowering drugs, and individual substances within each class. We defined three groups of pattern use based on timing of dispensation: (1) dispensation of at least one ADM in the prepregnancy period and in or after trimester 2 (T2) (pregestational diabetes); (2) dispensation for the first time in or after T2 (GDM); and (3) dispensation in the prepregnancy period and no dispensation in or after T2 (discontinuers). Within the pregestational diabetes group, we further defined continuers (dispensation for the same group of ADM) and switchers (different ADM group dispensed in the prepregnancy period and in or after T2).

Results

MAMA included 104,098 deliveries with a mean maternal age at delivery of 31.7. Antidiabetic dispensations among pregnancies with pregestational and gestational diabetes increased over time. Insulin was the most dispensed medication for both diseases. Between 2017 and 2019, less than 10% of pregnancies treated for pregestational diabetes continued metformin rather than switching to insulin. Metformin was offered to less than 2% of pregnancies to treat gestational diabetes (2017-2019).

Conclusion

Despite its position in the guidelines and the attractive alternative that metformin represents to patients who may encounter barriers with insulin therapy, there was reluctance to prescribe it.

No association between psychiatric symptoms and doses of anabolic steroids in a cohort of male and female bodybuilders

The use of androgenic‐anabolic steroids (AAS) can be associated with psychiatric symptoms such as insomnia, anxiety and increased aggressiveness. Although dose‐dependent effects have been observed in some controlled studies, this association is not always seen in the ecological use of AAS. This study utilized WADA's steroid profile of suspicious use of AAS, urinary detection of AAS metabolites and measurement of sexual hormones to confirm recent use of AAS in a cohort of 103 bodybuilders (75 males, 28 females). The majority of participants (61.2%) presented symptoms of agitation, insomnia, increased aggressiveness or depression in the last 3 months. About one‐third of participants presented scores on the HAM‐A anxiety scale equivalent to moderate to severe symptoms of anxiety. A minority of participants (12.6%) presented high to moderate scores on the BPQ aggressiveness scale. The majority of participants (73.8%) presented hyperthymic temperament in the BRIEF‐TEMPS scale. There was no significant difference in the presence of psychiatric symptoms between males and females and no association between psychiatric symptoms and estimated weekly doses of AAS. A negative association was observed between scores on the BPQ scale (verbal aggression, anger and total score) and the time of AAS use. We discuss differences of AAS use between male and female bodybuilders and the screening of AAS use in the general population. Our findings highlight the importance of mental health awareness among people using AAS.

Anabolic androgenic steroids used as performance and image enhancing drugs in professional and amateur athletes: Toxicological and psychopathological findings

OBJECTIVE

The use of anabolic androgenic steroids (AASs) as performance and image enhancing drugs (PIEDs), once restricted to professional athletes, now includes amateurs and regular gym visitors. AAS use is associated with psychopathology, yet this relationship is complex and not fully understood. We aimed to assess the presence of AASs and other misused substances in athletes' biological samples and link toxicological to psychopathological findings.

METHODS

A multicentre, cross-sectional study in fitness centres in Italy recruited 122 professional and amateur athletes training in several sports (84 men; age range = 18-45 years). Athletes completed questionnaires, interviews, and toxicology testing for AASs, other PIEDs, illicit drugs, and non-prescribed psychotropics. Toxicology was conducted in blood, urine, and hair.

RESULTS

Self-reported and toxicologically detected use rates of AASs and other misused substances showed slight-to-fair agreement (Fleiss' κ = 0.104-0.375). There was slight-to-moderate agreement among the three biological samples used for AAS testing (κ = 0.112-0.436). Thirty-one athletes (25.4%) tested positive for AASs. More sport hours/week, narcissistic or antisocial personality disorders, and higher nonplanning impulsiveness scores predicted AAS use (pseudo-R²  = 0.665). AAS users did not differ significantly from non-users in major psychopathology, but their Hypomania Checklist-32 score, which also predicted AAS use, was significantly higher (p < 0.001), suggesting increased odds for cyclothymic disorder or subthreshold hypomania.

CONCLUSIONS

Our results have implications for studying AAS users, as they identify a cluster of variables that may be relevant in future understanding of AAS use risks (e.g., personality disorders). Possible disagreements between AAS assessment methods should be considered when implementing harm reduction interventions, such as needle and syringe distribution, health education, and counselling, as well as surveillance programmes.

Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review

Anabolic-androgenic steroids (AASs) are a large group of molecules including endogenously produced androgens, such as testosterone, as well as synthetically manufactured derivatives. AAS use is widespread due to their ability to improve muscle growth for aesthetic purposes and athletes’ performance, minimizing androgenic effects. AAS use is very popular and 1–3% of US inhabitants have been estimated to be AAS users. However, AASs have side effects, involving all organs, tissues and body functions, especially long-term toxicity involving the cardiovascular system and the reproductive system, thereby, their abuse is considered a public health issue. The aim of the proposed review is to highlight the most recent evidence regarding the mechanisms of action of AASs and their unwanted effects on organs and lifestyle, as well as suggesting that AAS misuse and abuse lead to adverse effects in all body tissues and organs. Oxidative stress, apoptosis, and protein synthesis alteration are common mechanisms involved in AAS-related damage in the whole body. The cardiovascular system and the reproductive system are the most frequently involved apparatuses. Epidemiology as well as the molecular and pathological mechanisms involved in the neuropsychiatric side-effects of AAS abuse are still unclear, further research is needed in this field. In addition, diagnostically reliable tests for AAS abuse should be standardized. In this regard, to prevent the use of AASs, public health measures in all settings are crucial. These measures consist of improved knowledge among healthcare workers, proper doping screening tests, educational interventions, and updated legislation.

An overview on performance and image enhancing drugs (PIEDs) confiscated in Italy in the period 2017-2019

CONTEXT

The illegal market of counterfeit and falsified medicines and supplements containing unlabeled pharmaceuticals is expanding worldwide. They are usually referred to by the term "performance and image enhancing drugs" (PIEDs) and are mainly steroids, stimulants, hormones, and drugs for erectile dysfunction. PIEDs are easily accessible through the online or black markets. We analyzed over 400 such medicines confiscated in Italy in the period 2017-2019, to determine their composition.

METHODS

Confiscated products were analyzed by gas chromatography/mass spectrometry and liquid chromatography/high-resolution mass spectrometry, in order to ascertain their composition and to evaluate the correspondence between what was declared on the label and the actual content, or to identify unknown products.

RESULTS

The most commonly found substance was anabolic steroids, found in 64% of products, with 11% containing hormone modulators, 6% stimulants, 6% sexual enhancers (mainly sildenafil) and other drugs, including thyroid hormones, melanin stimulators, and vitamins. These substances were often in mixtures. The products were often mislabeled, containing contaminants in addition to the drug declared, or consisted of a drug completely different from the one reported on the label. Fifteen percent of products had a qualitative composition completely different from that declared, while 10% of products showed cross-contamination with other drugs, mainly testosterone esters, probably due to the presence of residues of other drugs in the production line. In addition, 11% of products were not labeled, so their purported composition was unknown.

DISCUSSION

PIEDs pose a threat to public health. The main risks are related to the intrinsic toxicity of the substances found, especially when taken without a therapeutic indication. Another issue is related to the mislabeling of the fake medicines, and the poor-quality standard of counterfeit product preparation, with additional risks of the presence of other toxic ingredients or microbial contamination.

CONCLUSIONS

The use of counterfeit products is a public health concern, as it constitutes a high risk for consumer health. It is mainly caused by the uncontrolled use of steroids, stimulants, sexual enhancers, and other medicaments, without medical indication or supervision, with variable and unknown compositions and doses, as well as other contaminants as a result of the absence of good manufacturing practices.

Prevalence and Risk Factors Associated with Anabolic-androgenic Steroid Use: A Cross-sectional Study among Gym Users in Riyadh, Saudi Arabia

Objectives

Anabolic-androgenic steroids (AAS) have been used internationally for enhancing physical appearance and performance despite their significant side effects. We sought to identify the prevalence of AAS use and its different risk factors among gym users in Riyadh, Saudi Arabia.

Methods

A cross-sectional survey was distributed among gym users across 20 gyms in Riyadh. The cluster sampling technique was used to represent the four regions of Riyadh (North, South, East, and West). Univariate and multivariate analyses were performed to identify the factors associated with AAS.

Results

Out of 482 participants, 29.3% reported using AAS. The mean age of the study participants was 27.2±6.9 years, 61.0% were single, 67.1% were educated, 35.5% were government employees, and 31.1% were students. The use of AAS was more prevalent among gym members who practiced weightlifting (45.5%), were employed in the private sector (35.8%), and aged > 25 years old (53.3%). Multiple logistic regression showed that the most significant factors associated with the use of AAS among gym members were: weightlifting, using supplementary vitamins or minerals, following special diets, knowing individuals who used AAS, and being offered AAS.

Conclusions

Our study provides clear evidence that the lifetime prevalence of AAS use is high among male gym members in Riyadh with modifiable risk factors. The results could help public health policymakers to take the necessary measures to alleviate the potential negative implications of AAS use at the community level.

Prevalence of Performance-Enhancing Substance Use and Associated Factors among Portuguese Gym/Fitness Users

Background: Nowadays, doping is not confined to elite sport, it is also spread throughout gymnasia and fitness centers, and it is seen as a public health concern. Studies focusing on performance-enhancing substances (PES) use among gym users are few and mostly concern the practice of bodybuilding and the use of anabolic-androgenic steroids (AAS), without providing information about social indicators to further explore why this specific population use these substances. Objectives: To investigate the extent of PES use and examine the way social indicators, exercise profile and gym modalities influence the use of these substances among a sample of gym users. Methods: Cross-sectional descriptive study, among a convenience sample of 453 Portuguese gym users, recruited directly by five institutional gyms´ email and Facebook. Data were collected via a structured web-based survey, between October and November 2017. Multiple binary logistic regression, the Chi-Square test or Monte Carlo Simulation or Fisher's Exact test were used. The odds ratios and their respective 95% confidence intervals were calculated. Results: 11,1% of gym users reported the use of prohibited PES, which varies significantly according to gender, education, exercise profile and type of practice. Gender was associated with the class of PES used. Polypharmacy was a common practice among users, increasing the risk of side-effects. Peer effect and media appear to be strikingly important in the misuse of PES. Conclusion: Results provide precise insight into the specific factors associated with PES use, which could support prevention strategies in gym/fitness context.

Digit ratio (2D:4D) and testosterone supplementation

BACKGROUND

Testosterone (T) is taken or prescribed to enhance appearance, increase athletic performance and libido and to treat hypogonadism. Digit ratio (2D:4D) is thought to be a negative correlate of prenatal T. Here we consider the relationship between 2D:4D and T supplementation.

AIMS

Our sample was taken from the BBC internet study. Respondents were asked (y/n) if they were taking; (i) T, (ii) hormone replacement therapy with T (HRTwT). We removed extreme 2D:4D values and age and considered the most numerous ethnic group (i.e. "Whites"). Analyses were performed with a two-factor (sex*T) analysis of variance with covariate age and dependent variables 2D:4D or right-left 2D:4D (Dr-l).

RESULTS

Out of 197,589 respondents, 793 (598 males) reported taking T. There was a significant main effect for right 2D:4D such that T supplementing males had higher 2D:4D than those who did not. The sex*T interaction was significant, but the effect reversed in females. There were 22,576 (661 males) participants who reported taking HRTwT. We found a significant main effect for right 2D:4D, males taking HRTwT had higher 2D:4D than those who did not. This was reversed in females. The sex*HRTwT interaction was significant, a high Dr-l was also found in males reporting HRTwT.

CONCLUSION

Males who reported taking T or HRTwT had high right 2D:4D and/or Dr-l. The situation with females may be the reverse of that found in males but effect sizes are less. The health implications of an association between high (feminized) 2D:4D and T supplementation in males are discussed.

Hepatocellular carcinoma in body builders; an emerging rare but serious complication of androgenic anabolic steroid use

Illicit use of androgenic anabolic steroids (AAS) is a known problem amongst certain groups including body builders and other athletes. Use of these drugs is thought to be high in some areas of South Wales. A number of adverse effects have been associated with use of AAS including the development of hepatic adenomas. There have been a handful of rare cases of the development of hepatocellular carcinoma following AAS use. We report two such cases presenting to the same surgical centre in South Wales within six months. We do this with reference to data from Public Health Wales, including the Harm Reduction Wales Needle and Syringe provision report, which indicate a particularly high rate of use of AAS in the surrounding area. We believe these cases are important from the public health point of view. They demonstrate a rare and not widely known about, but potentially fatal adverse effect of AAS, now becoming prevalent with the high use of these drugs. This is important for doctors to be aware of, but also could form the focus of a public health campaign targeted at AAS users.

Pros and cons of insulin administration on liver glucose metabolism in strength-trained healthy mice

Non-diabetic individuals use hormones like insulin to improve muscle strength and performance. However, as insulin also leads the liver and the adipose tissue to an anabolic state, the purpose of this study was to investigate the effects of insulin on liver metabolism in trained non-diabetic Swiss mice. The mice were divided into four groups: sedentary treated with saline (SS) or insulin (SI) and trained treated with saline (TS) or insulin (TI). Training was made in a vertical stair, at 90% of the maximum load, three times per week. Insulin (0.3 U/kg body weight) or saline were given intraperitoneally five times per week. After eight weeks, tissue and blood were collected and in situ liver perfusion with glycerol+lactate or alanine+glutamine (4 mM each) was carried out. The trained animals increased their muscle strength (+100%) and decreased body weight gain (–11%), subcutaneous fat (–42%), mesenteric fat (–45%), and peritoneal adipocyte size (–33%) compared with the sedentary groups. Insulin prevented the adipose effects of training (TI). The gastrocnemius muscle had greater density of muscle fibers (+60%) and less connective tissue in the trained groups. Liver glycogen was increased by insulin (SI +40% and TI +117%), as well as liver basal glucose release (TI +40%). Lactate and pyruvate release were reduced to a half by training. The greater gluconeogenesis from alanine+glutamine induced by training (TS +50%) was reversed by insulin (TI). Insulin administration had no additional effect on muscle strength and reversed some of the lipolytic and gluconeogenic effects of the resistance training. Therefore, insulin administration does not complement training in improving liver glucose metabolism.

Knowledge of and Attitudes Toward the Use of Anabolic-Androgenic Steroids among the Population of Jeddah, Saudi Arabia

Purpose:

The aim of this study was to investigate the correlation between the use of anabolic-androgenic steroids (AASs) among the population of Jeddah, Saudi Arabia, and their knowledge and attitudes.

Methods:

This was a community-based, cross-sectional observational study. This study was conducted using a questionnaire that was distributed among the population during the period from February 3, 2018, to February 25, 2018. This questionnaire comprised 31 questions, designed to evaluate the knowledge and attitudes toward using AASs.

Results:

A total of 300 participants were enrolled in the study. The mean age of the population was 30.66 ± 9.2 years. Fourteen participants admitted using AASs, with a percentage of 4.7%, among whom 85.7% were male (P = 0.0005). Seventy-eight percent of AAS users believed that AASs do not cause tolerance when taken for a longtime (P = 0.023). However, the majority of both AAS users and nonusers did not agree on taking AASs for a longtime. Our results showed a strong correlation between not taking AASs and not consuming energy drinks (P = 0.0023). Half of our respondents exhibited poor knowledge regarding the side effects of AASs. The level of knowledge did not correlate with the use of AAS, gender, exercising, or consuming energy drinks.

Conclusion:

The results showed poor knowledge regarding using AASs among the population of Jeddah. Thus, we recommend having a national awareness program in order to prevent the possible side effects of misusing AASs.

The Use and Abuse of Human Growth Hormone in Sports

CONTEXT

Recombinant human growth hormone (rHGH) has become a target of abuse in the sporting world. Conversely, sports medicine clinicians may encounter athletes using rHGH to achieve normalcy in the context of growth hormone (GH) deficiency.

EVIDENCE ACQUISITION

Medline and PubMed databases were queried using the following keywords: GH, GH physiology, GH deficiency, acromegaly, GH athlete, GH sports, GH athletic performance, and GH deficiency concussion. Articles focusing on GH physiology, deficiency, excess, and its effects in both deficient and healthy patients were included.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

GH is a naturally occurring hormone with important roles in human physiology. Patients with GH deficiency (GHD) present variably, and GHD has numerous etiologies. rHGH treatment has substantial therapeutic benefits for patients with GHD. The benefits of rHGH treatment in otherwise-healthy adults are uncertain. GH excess may cause health problems such as acromegaly. Professional, collegiate, and international sports leagues and associations have banned rHGH use to maintain athlete health, safety, and fair play. Athletes misusing GH may face prolonged suspensions from competition. Implementing GH abuse testing is challenging, but new methods, such as the biomarker testing procedure, are being finalized.

CONCLUSION

rHGH is not only an important therapeutic agent for GH-deficient patients but also a target of abuse in competitive athletics. Its benefits in a healthy, adult population are uncertain. A safe exercise and competition plan, developed with a physician knowledgeable of GH use, physiology, and abuse potential, should be of benefit to a longitudinal clinician-patient relationship.

Anabolic androgenic steroids and carcinogenicity focusing on Leydig cell: a literature review

Anabolic androgenic steroids (AAS) are some of the most common drugs used among athletes, frequently in combination with resistance training, to improve physical performance or for aesthetic purpose. A great number of scientific reports showed the detrimental effects of anabolic androgenic steroids on different organs and tissues. In this literature review, we analyzed the AAS-mediated carcinogenicity, focusing on Leydig cell tumor.

AAS-induced carcinogenicity can affect DNA transcription through two pathways. It can act directly via the androgen receptor, by means of dihydrotestosterone (DHT) produced by the action of 5-a-reductase. It can also work through the estrogen receptor, by means of estradiol produced by CYP19 aromatase. In addition, nandrolone and stanazolol can activate the PI3K/AKT and PLC/PKC pathways via IGF-1. This would result in cell proliferation in Leydig cell cancer, or magnify cyclin D1 concentration inducing breast cell proliferation.

AAS abuse is becoming a serious public health concern in view of the severe health consequences secondary to AAS abuse. The negative role of AAS in supraphysiological dosage impairs the expression of enzymes involved in testosterone biosynthesis. Abnormal synthesis of testosterone plays has a negative effect on the hormonal changes/regulation, and might be involved in certain carcinogenic mechanisms. At the light of this review, it could become very interesting to perform an information campaign more strengthened in gyms and schools in order to prevent male fertility impairment and other tissues damage.

Identifying a typology of men who use anabolic androgenic steroids (AAS)

BACKGROUND

Despite recognition that the Anabolic Androgenic Steroid (AAS) using population is diverse, empirical studies to develop theories to conceptualise this variance in use have been limited.

METHODS

In this study, using cluster analysis and multinomial logistic regression, we identify typologies of people who use AAS and examine variations in motivations for AAS use across types in a sample of 611 men who use AAS.

RESULTS

The cluster analysis identified four groups in the data with different risk profiles. These groups largely reflect the ideal types of people who use AAS proposed by Christiansen et al. (2016): Cluster 1 (You Only Live Once (YOLO) type, n = 68, 11.1%) were younger and motivated by fat loss; Cluster 2 (Well-being type, n = 236, 38.6%) were concerned with getting fit; Cluster 3 (Athlete type, n = 155, 25.4%) were motivated by muscle and strength gains; Cluster 4 (Expert type, n = 152, 24.9%) were focused on specific goals (i.e. not 'getting fit').

CONCLUSION

The results of this study demonstrate the need to make information about AAS accessible to the general population and to inform health service providers about variations in motivations and associated risk behaviours. Attention should also be given to ensuring existing harm minimisation services are equipped to disseminate information about safe intra-muscular injecting and ensuring needle disposal sites are accessible to the different types.

History and epidemiology of anabolic androgens in athletes and non-athletes

The use of androgens, frequently referred to as anabolic-androgenic steroids (AAS), has grown into a worldwide substance abuse problem over the last several decades. Testosterone was isolated in the 1930s, and numerous synthetic androgens were quickly developed thereafter. Athletes soon discovered the dramatic anabolic effects of these hormones, and AAS spread rapidly through elite athletics and bodybuilding from the 1950s through the 1970s. However it was not until the 1980s that widespread AAS use emerged from the elite athletic world and into the general population. Today, the great majority of AAS users are not competitive athletes, but instead are typically young to middle-aged men who use these drugs primarily for personal appearance. AAS abuse has now become particularly prevalent in regions such as Scandinavia, the United States, Brazil, and British Commonwealth countries, but remains rare in countries such as China, Korea, and Japan - a pattern that reflects cultural differences in attitudes towards male muscularity.

Prevalence, Attitude, Knowledge, and Practice of Anabolic Androgenic Steroid (AAS) Use Among Gym Participants

Background:

Anabolic steroids (AS) are synthetic testosterone derivatives that last longer than physiological androgens in the body. Anabolic-androgenic steroid (AAS) abuse is spreading among athletes. The aim of this study is to assess the knowledge, attitudes, and practices of gym participants in Saudi Arabia.

Methods:

A cross-sectional survey was carried out among gym users from February 2017 to May 2017. The questionnaire included information on demographics related to the use of AAS and lifestyle habits. Any willing male gym participant could be included.

Results:

A total of 4860 male gym participants with a mean age of 28.6 ± 6.2 years were included. A majority were single, with a bachelor’s degree or higher. Moreover, 9.8% of the participants used AAS, of which 76.7% reported improved fitness. Friends were the main source of AAS-related information, but only 38.0% of AAS users sought medical consults. The oral route was most common, and testosterone enanthate was the AAS most used.

Conclusion:

Also, 9.8% of gym participants used AAS and were more likely to be involved in risky habits, such as smoking and growth hormone abuse. They were less aware of potential complications of AAS, with gym trainers being the predominant source of AAS substances.

Prevalence and awareness of Anabolic Androgenic Steroids (AAS) among gymnasts in the western province of Riyadh, Saudi Arabia

Background

Anabolic Androgenic Steroids (AAS) are synthetic derivatives of the male sex hormone (testosterone) that are increasingly used by athletes as performance enhancing drugs to increase muscle mass and strength. Multiple health adverse effects may be caused by its non-medical use. Several international and regional studies showed the high prevalence of AAS usage and low level of awareness of it among different populations.

Objective

To estimate the prevalence of AAS and to determine the level of awareness toward it among gymnasts in the western province of Riyadh.

Methods

This cross-sectional survey was conducted using a self-administered questionnaire distributed on 400 male gymnasts from 10 different fitness centers which have been chosen randomly from 23 centers in the western province of Riyadh city (Kingdom of Saudi Arabia) during 2016. Data analysis was performed by SPSS version 21, using descriptive statistics and Chi-square test.

Results

Among the 400 gymnasts who participated in the survey, a total of n=363 questionnaires were received completed. Of the responders, (n=89) were AAS users with a percentage 24.50%. The testosterone was the most commonly used type followed by Methandrostenolone then Stanozolol. The major sources for obtaining AAS were online shopping (45%) and gym-coach (22.5%). Regarding awareness, 74% of AAS users had an inadequate perception about AAS concept versus 55% of non-users with no significant difference (p=0.076). In addition, 82% of AAS users and 83% of non-users had inadequate knowledge of AAS adverse effects with no significant difference between the two categories (p=0.087).

Conclusion

The usage of AAS is high amongst gymnasts in the western province of Riyadh city considering they are prohibited. The level of awareness toward AAS is low among most gymnasts. We recommend for educational programs to be established in order to increase public awareness, in addition to a tightening of control by the responsible authorities over the sources of AAS procurement.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

Illicit Drug Use Among Gym-Goers: a Cross-sectional Study of Gym-Goers in Sweden

BACKGROUND

The use of anabolic-androgenic steroids has increased among gym-goers, and it has been proposed that this may be part of a polysubstance use pattern that includes the use of illicit drugs. Still, epidemiological data on illicit drug use among gym-goers of both genders are meager. The aim of the present study was thus to examine the use of illicit drugs and its correlates in a large sample of men and women who engaged in weight training at gyms across Sweden.

METHODS

In this cross-sectional study, a total of 1969 gym-goers who engaged in weight training in 54 gyms across Sweden were invited to fill in a questionnaire. The questionnaire included 25 items on background variables, weight training frequency, use of illicit drugs and doping substances, and non-medical use of benzodiazepines.

RESULTS

Of the gym-goers, 19.6% reported having ever used illicit drugs, 6.5% reported use during the past 12 months, and 2.1% during the past 30 days. The most commonly used drug was cannabis, followed by cocaine, amphetamine, and ecstasy. Almost 40% of those who reported drug use had used more than one drug. Male participants and participants between 20 and 39 years of age made up the majority of users. Furthermore, 5.1% of the reported drug users had ever used a doping substance. There was an almost threefold higher odds (OR = 2.99, 95% CI = 1.16-7.66, p < 0.023) of doping use among people who had reported drug use as compared to non-users.

CONCLUSIONS

Training at gyms is typically considered a health-promoting behavior. However, our results revealed a slightly higher prevalence of illicit drug use among gym attendees as compared to the general population. Our findings may have captured an underrecognized group of young adult males who engage in weightlifting and use illicit drugs recreationally and/or as training aids. Developing knowledge is imperative in orientating preventive efforts among at-risk gym-goers.

TRIAL REGISTRATION

ISRCTN11655041.

The prevalence of anabolic androgenic steroid use amongst athletes in Riyadh (Saudi Arabia)

Objective

The aim of this study was to determine the prevalence of anabolic androgenic steroid (AAS) use among athletes and examine the extent of their knowledge on the effects of AAS in Riyadh, Saudi Arabia.

Methods

This cross-sectional study was conducted at gyms in Riyadh, Saudi Arabia, during 2015. In total 600 athletes from three gyms participated in the study. The study included Saudi and non-Saudi athletes chosen by the simple random sampling method. A self-reported questionnaire was used for data collection. The questionnaire was designed to study the prevalence and assess the knowledge of athletes regarding AAS use. Frequency and percentage distributions were used to describe the data. Comparison between the subgroups was made with a chi-square test.

Results

The percentage of AAS users was 30.5%. The age of AAS users ranged from 15 to 49 years with the majority (52.5%) belonging to age group of 25–29 years. Approximately 20% of the users admitted using AAS due to body dysmorphia as their best motivational factor; in addition, they also believed that there are no side effects of the use. Among the nonusers, 40% had appropriate knowledge, while all the AAS-users had inadequate knowledge about the adverse effects of AAS. Moreover, 77% of the users would recommend AAS to their friends but none from the nonusers. A significant difference in age distribution (df = 5, p<0.001) and knowledge (df = 4, p< 0.001) between users and nonusers was observed.

Conclusion

Most athletes were ignorant of the harmful side effects of the drug but still continued to use and promote it to other athletes. These athletes should intensify their knowledge and awareness regarding the use of AAS and its effects on the body.

Smart coumarin-tagged imprinted polymers for the rapid detection of tamoxifen

A signalling molecularly imprinted polymer was synthesised for easy detection of tamoxifen and its metabolites. 6-Vinylcoumarin-4-carboxylic acid (VCC) was synthesised from 4-bromophenol to give a fluorescent monomer, designed to switch off upon binding of tamoxifen. Clomiphene, a chlorinated analogue, was used as the template for the imprinting, and its ability to quench the coumarin fluorescence when used in a 1:1 ratio was demonstrated. Tamoxifen and 4-hydroxytamoxifen were also shown to quench coumarin fluorescence. Imprinted and non-imprinted polymers were synthesised using VCC, methacrylic acid as a backbone monomer and ethylene glycol dimethacrylate as cross-linker, and were ground and sieved to particle sizes ranging between 45 and 25 μm. Rebinding experiments demonstrate that the imprinted polymer shows very strong affinity for both clomiphene and tamoxifen, while the non-imprinted polymer shows negligible rebinding. The fluorescence of the imprinted polymer is quenched by clomiphene, tamoxifen and 4-hydroxytamoxifen. The switch off in fluorescence of the imprinted polymer under these conditions could also be detected under a UV lamp with the naked eye, making this matrix suitable for applications when coupled with a sample preparation system.

Netnography of Female Use of the Synthetic Growth Hormone CJC-1295: Pulses and Potions

BACKGROUND

Communal online folk pharmacology fuels the drive for short cuts in attaining muscle enhancement, fat loss, and youthful skin.

OBJECTIVES

The study used "netnography" to explore female use of CJC-1295, a synthetic growth hormone analogue from the perspectives contained in Internet forum activity.

METHODS

A systematic Internet search was conducted using variation of the term "CJC-1295"; and combined with "forum." Ninety-six hits related to bodybuilding websites where CJC-1295 was mentioned. Following application of exclusion criteria to confine to female use and evidence of forum activity, 9 sites remained. These were searched internally for reference to CJC-1295. Twenty-three discussion threads relating to female use of CJC-1295 formed the end data set, and analyzed using the Empirical Phenomenological Psychological method.

RESULTS

Forum users appeared well versed and experienced in the poly use of performance and image drug supplementation. Choice to use CJC-1295 centered on weight loss, muscle enhancement, youthful skin, improved sleep, and injury healing. Concerns were described relating to female consequences of use given gender variations in growth hormone pulses affecting estimation of dosage, cycling, and long-term consequences.

CONCLUSIONS

Public health interventions should consider female self-medicating use of synthetic growth hormone within a repertoire of product supplementation, and related adverse health consequences.

Usage and perceptions of anabolic-androgenic steroids among male fitness centre attendees in Kuwait--a cross-sectional study

Background

Considering the recent popularity of bodybuilding and the apparent spread of anabolic androgenic steroid (AAS) use amongst bodybuilding enthusiasts in Kuwait, there is a relative lack of scientific investigation into the use, knowledge and attitudes towards AAS amongst the population at risk of abusing it. Therefore, this study aims to investigate the frequency, knowledge, attitudes and practice of AAS use amongst male fitness centre attendees in Kuwait.

Methods

A cross sectional survey utilizing a self-administered questionnaire was used. Information on demographics as well as knowledge and attitude about and towards the use of AAS was included in the questionnaire. Ten fitness centres in Kuwait were randomly selected and questionnaires were distributed to all individuals leaving each centre on randomly selected days and periods of time for each centre. Overall n = 400 questionnaires were distributed.

Results

A total of n = 194 questionnaires were returned completed (~49 %). Of the responders, 22.7 % used AAS. The 19–25 age group had the highest occurrence (46.8 %) of first-time AAS use. In contrast with non-users, most (70.5 %) of AAS users believed that having an optimally muscular body can only be achieved by using AAS, and a small minority (6.8 %) believed that AAS usage would have significant harms to health. Only 18.2 % of AAS users had appropriate knowledge regarding the side effects of AAS. Non-users were as much uninformed as AAS users regarding the side effects of AAS.

Conclusion

The usage of AAS is high amongst male gym users in Kuwait and is likely to present an additional burden to the health service. An effective initiative to minimize the burden of AAS abuse should focus on changing the attitudes towards AAS rather than spreading awareness of their side effects.

An exploratory study of image and performance enhancement drug use in a male British South Asian community

BACKGROUND

Consumerism of image and performance enhancement drugs (IPEDs) is a world-wide public health concern. Given anecdotal reporting of increased normalisation of IPED use and uptake of British South Asian male IPED users at UK needle and syringe exchange services, the study aimed to explore use of IPEDs among this under-researched ethnic group.

METHODS

20 in depth interviews were conducted with a purposive sample of British South Asian males attending harm reduction outreach in the North East of England. The interviews explored motives for use of IPEDs, sourcing routes, information seeking, injecting behaviours and cultural and community sensitivities around IPED use among this group. The data was collected and analysed using the Interpretative Phenomenological Analysis approach (IPA).

RESULTS

Motives for use centred on the achievement of enhanced definition and density of muscle, and improved recovery from training and injuries. All participants reported initial stimulation of interest and triggers to seek information on IPEDs due to social media, community and peer messages. Diverse forms of IPED use were described, with rational and moderated use common among older participants. In contrast younger participants adopted more excessive use in seeking short cuts to attaining muscle size. Sourcing of androgenic-anabolic steroids (AAS) and growth hormones from originating countries (Pakistan, India) was reported, along with diversification of entrepreneurial activity into IPED dealing networks. Sellers were generally reported to provide effective and reliable products and mentoring to inexperienced users. Group injecting practices were common. IPED use was observed by some as health promotion medium within religious contexts. Crime deterrence and drug abstinence occurred for some while involved in AAS cycles.

CONCLUSIONS

The study is intended to contribute to health policy and practice debate around the targeting of dedicated education, outreach and harm reduction for ethnic groups engaged in IPED use.

Anabolic-androgenic steroid use and psychopathology in athletes. A systematic review

The use of anabolic-androgenic steroids (AASs) by professional and recreational athletes is increasing worldwide. The underlying motivations are mainly performance enhancement and body image improvement. AAS abuse and dependence, which are specifically classified and coded by the DSM-5, are not uncommon. AAS-using athletes are frequently present with psychiatric symptoms and disorders, mainly somatoform and eating, but also mood, and schizophrenia-related disorders. Some psychiatric disorders are typical of athletes, like muscle dysmorphia. This raises the issue of whether AAS use causes these disorders in athletes, by determining neuroadaptive changes in the reward neural circuit or by exacerbating stress vulnerability, or rather these are athletes with premorbid abnormal personalities or a history of psychiatric disorders who are attracted to AAS use, prompted by the desire to improve their appearance and control their weights. This may predispose to eating disorders, but AASs also show mood destabilizing effects, with longterm use inducing depression and short-term hypomania; withdrawal/discontinuation may be accompanied by depression. The effects of AASs on anxiety behavior are unclear and studies are inconsistent. AASs are also linked to psychotic behavior. The psychological characteristics that could prompt athletes to use AASs have not been elucidated.

Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Because randomized trials cannot ethically duplicate the large doses of PEDs and the many factors associated with PED use, we need observational studies to collect valid outcome data on the health risks associated with PEDs. In addition, we need studies regarding the prevalence of PED use, the mechanisms by which PEDs exert their adverse health effects, and the interactive effects of PEDs with sports injuries and other high-risk behaviors. We also need randomized trials to assess therapeutic interventions for treating the adverse effects of PEDs, such as the anabolic-androgen steroid withdrawal syndrome. Finally, we need to raise public awareness of the serious health consequences of PEDs.

Cognitive deficits in long-term anabolic-androgenic steroid users

BACKGROUND

Millions of individuals worldwide have used anabolic-androgenic steroids (AAS) to gain muscle or improve athletic performance. Recently, in vitro investigations have suggested that supraphysiologic AAS doses cause apoptosis of neuronal cells. These findings raise the possibility, apparently still untested, that humans using high-dose AAS might eventually develop cognitive deficits.

METHODS

We administered five cognitive tests from the computerized CANTAB battery (Pattern Recognition Memory, Verbal Recognition Memory, Paired Associates Learning, Choice Reaction Time, and Rapid Visual Information Processing) to 31 male AAS users and 13 non-AAS-using weightlifters age 29-55, recruited and studied in May 2012 in Middlesbrough, UK. Testers were blinded to participants' AAS status and other historical data.

RESULTS

Long-term AAS users showed no significant differences from nonusers on measures of response speed, sustained attention, and verbal memory. On visuospatial memory, however, AAS users performed significantly more poorly than nonusers, and within the user group, visuospatial performance showed a significant negative correlation with total lifetime AAS dose. These were large effects: on Pattern Recognition Memory, long-term AAS users underperformed nonusers by almost one standard deviation, based on normative population scores (adjusted mean difference in z-scores=0.89; p=0.036), and performance on this test declined markedly with increasing lifetime AAS dose (adjusted change in z-score=-0.13 per 100g of lifetime AAS dose; p=0.002). These results remained stable in sensitivity analyses addressing potential confounding factors.

CONCLUSIONS

These preliminary findings raise the ominous possibility that long-term high-dose AAS exposure may cause cognitive deficits, notably in visuospatial memory.

National Athletic Trainers' Association position statement: anabolic-androgenic steroids

OBJECTIVE

This manuscript summarizes the best available scholarly evidence related to anabolic-androgenic steroids (AAS) as a reference for health care professionals, including athletic trainers, educators, and interested others.

BACKGROUND

Health care professionals associated with sports or exercise should understand and be prepared to educate others about AAS. These synthetic, testosterone-based derivatives are widely abused by athletes and nonathletes to gain athletic performance advantages, develop their physiques, and improve their body image. Although AAS can be ergogenic, their abuse may lead to numerous negative health effects.

RECOMMENDATIONS

Abusers of AAS often rely on questionable information sources. Sports medicine professionals can therefore serve an important role by providing accurate, reliable information. The recommendations provide health care professionals with a current and accurate synopsis of the AAS-related research.

Illicit use of androgens and other hormones: recent advances

PURPOSE OF REVIEW

To summarize recent advances in studies of illicit use of androgens and other hormones.

RECENT FINDINGS

Androgens and other appearance-enhancing and performance-enhancing substances are widely abused worldwide. Three notable clusters of findings have emerged in this field in recent years. First, studies almost unanimously find that androgen users engage in polypharmacy, often ingesting other hormones (e.g., human growth hormone, thyroid hormones, and insulin), ergo/thermogenic drugs (e.g., caffeine, ephedrine, and clenbuterol), and classical drugs of abuse (e.g., cannabis, opiates, and cocaine). Second, reports of long-term psychiatric and medical adverse effects of androgens continue to accumulate. In cardiovascular research particularly, controlled studies have begun to supersede anecdotal evidence, strengthening the case that androgens (possibly acting synergistically with other abused drugs) may cause significant morbidity and even mortality. Third, it is increasingly recognized that androgen use may lead to a dependence syndrome with both psychological and physiological origins. Androgen dependence likely affects some millions of individuals worldwide, and arguably represents the least studied major class of illicit drug dependence.

SUMMARY

Given mounting evidence of the adverse effects of androgens and associated polypharmacy, this topic will likely represent an expanding area of research and an issue of growing public health concern.

Vulnerability and the intention to anabolic steroids use among Iranian gym users: an application of the theory of planned behavior

This correlational study explored the psychological antecedents of 253 Iranian gym users' intentions to use the anabolic-androgenic steroids (AAS), based on the Theory of Planned Behavior (TPB). The three predictor variables of (1) attitude, (2) subjective norms, and (3) perceived behavioral control accounted for 63% of the variation in the outcome measure of the intention to use the AAS. There is some support to use the TPB to design and implement interventions to modify and/or improve individuals' beliefs that athletic goals are achievable without the use of the AAS.

The Anabolic 500 survey: characteristics of male users versus nonusers of anabolic-androgenic steroids for strength training

STUDY OBJECTIVE

To contrast the characteristics of two groups of men who participated in strength-training exercise-those who reported anabolicandrogenic steroid (AAS) use versus those who reported no AAS use.

DESIGN

Analysis of data from the Anabolic 500, a cross-sectional survey.

PARTICIPANTS

Five hundred six male self-reported AAS users (mean age 29.3 yrs) and 771 male self-reported nonusers of AAS (mean age 25.2 yrs) who completed an online survey between February 19 and June 30, 2009.

MEASUREMENTS AND MAIN RESULTS

Respondents were recruited from Internet discussion boards of 38 fitness, bodybuilding, weightlifting, and steroid Web sites. The respondents provided online informed consent and completed the Anabolic 500, a 99-item Web-based survey. Data were collected on demographics, use of AAS and other performance-enhancing agents, alcohol and illicit drug use, substance dependence disorder, other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnoses, and history of sexual and/or physical abuse. Most (70.4%) of the AAS users were recreational exercisers who reported using an average of 11.1 performance-enhancing agents in their routine. Compared with nonusers, the AAS users were more likely to meet criteria for substance dependence disorder (23.4% vs 11.2%, p<0.001), report a diagnosis of an anxiety disorder (10.1% vs 6.1%, p=0.010), use cocaine within the past 12 months (11.3% vs 4.7%, p<0.001), and report a history of sexual abuse (6.1% vs 2.7%, p=0.005).

CONCLUSION

Most of the AAS users in this study were recreational exercisers who practiced polypharmacy. The AAS users were more likely than nonusers to meet criteria for substance dependence disorder, report a diagnosis of an anxiety disorder, report recent cocaine use, and have a history of sexual abuse. The information uncovered in this study may help clinicians and researchers develop appropriate intervention strategies for AAS abuse.

Anabolic androgenic steroids in the general population: user characteristics and associations with substance use

AIMS

To analyse correlates of anabolic androgenic steroids (AAS) use in the general male population.

DESIGN

A national household survey.

PARTICIPANTS

Individuals aged 15-64 years in Sweden.

MEASUREMENTS

AAS use and potential correlates of AAS use, including demographic data, financial situation, physical training, and substance use. In hierarchical logistic regression analyses, lifetime users of AAS (n = 240) were compared to all nonusers (n = 13,920) and to nonusers who reported that they had been offered AAS (n = 487).

RESULTS

AAS use was most strongly associated with a lifetime history of illicit drug use and the misuse of prescription drugs. When controlling for substance use, AAS was associated with physical training and lower education. Illicit drug use and misuse of prescription drugs separated AAS users from nonusers who had been offered AAS. No associations were seen with AUDIT scores for risk alcohol drinking.

CONCLUSIONS

In this general population survey in men, lifetime use of AAS appears to share common characteristics with illicit substance use. Both substance use variables and physical training remained associated with AAS use when controlling for one another.

Anabolic androgenic steroids--use and correlates among gym users--an assessment study using questionnaires and observations at gyms in the Stockholm region

The purpose of this study was to estimate the prevalence of anabolic androgenic steroid (AAS) use and offers to use among gym users in Stockholm County (Sweden), and to conduct a comparison of concordance in estimates of AAS and supplements at gyms between two data collection methods. A questionnaire was distributed to members at 36 training facilities and 1,752 gym users participated in the study. An observation study was conducted as covert participant observations at 64 gyms. According to the questionnaire, 3.9% of men reported life time use of AAS, 1.4% use during the past 12 months and 0.4% AAS use during past 30 days. Not only were there similar patterns found in the two methods, i.e., similar age and gender distributions for AAS use, but analyses of concordance showed that gyms with a higher prevalence of self-reported AAS-use and supplement use (questionnaire) showed a significantly higher proportion of observer-assessed AAS users. Analyses of individual predictors showed that AAS users were almost always young men, regular weight trainers and more often users of drugs and nutritional supplements. The higher prevalence of AAS use among gym users than in the general population makes the former an appropriate target group for AAS prevention. The connection between supplements, drugs and AAS use suggests that effective AAS prevention need to focus on several risk factors for AAS use. The clear resemblance in estimates between the observation and questionnaire data strengthen the credibility of the two methods.