Ergogenic aids: a review of basic science, performance, side effects, and status in sports

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses

CONTEXT

Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health.

OBJECTIVE

To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes.

DATA SOURCES

PubMed and Scopus databases were searched on April 8, 2022.

STUDY SELECTION

Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis.

STUDY DESIGN

Umbrella review of SRs and MAs.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted.

RESULTS

A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance.

CONCLUSION

In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Prevalence of supplement usage and related attitudes and reasons among fitness athletes in the gyms of Kashan and its relationship with feeding behavior: a cross-sectional study

BACKGROUND

The overuse of supplements among athletes is a widespread issue affecting the health of both male and female athletes. However, research on supplements usage among female fitness athletes is limited, and there is little information on the feeding behavior of fitness athletes who use supplements. This study aimed to fill the gap in knowledge by examining the prevalence of supplement usage and its related attitudes and reasons among fitness athletes in the gyms of Kashan. It further aimed to investigate the correlation between supplements usage and the feeding behavior of fitness athletes.

METHODS

For these purposes, in this cross-sectional study, 433 fitness athletes (15‒46 years old) in 28 gyms in the city of Kashan were surveyed using a researcher-made questionnaire in 2023. Five experts confirmed the validity of the questionnaire. The present study considered the supplements based on the Australian Institute of Sport position statement. A Chi-square analysis was conducted to examine the relationship between the study variables and supplement usage.

RESULTS

Overall, 272 male and 161 female fitness athletes participated in this study. The results revealed that 57.9% of participants used supplements, most commonly vitamin C, vitamin D, omega-3 fatty acids, and whey protein. The main reason for using supplements was to speed up body repair after exercise (69.5%). Additionally, 41.8% of these athletes believed that using supplements improves their overall performance, and 21.9% thought that supplements do not harm the body. Moreover, a correlation was observed between feeding behavior and the consumption of supplements. It was found that athletes who use supplements tend to eat more white meat, seeds, and nuts and fewer high-fat dairy products than those who do not consume them.

CONCLUSION

Using supplements among fitness athletes in the gyms of Kashan is common. The main reason for using these substances was to speed up body repair after exercise, and nearly half of the athletes believed that supplements improved their performance. In addition, it was revealed that athletes who take supplements have healthier feeding behaviors than those who do not. Thus, these findings confirm the necessity of informing fitness athletes about using supplements.

Placebo and Nocebo Effects on Sports and Exercise Performance: A Systematic Literature Review Update

Sports performance could be affected by placebo and nocebo effects. The last literature review on placebo and nocebo effects on sports and exercise performance was published in 2019. In the past five years, several new studies have been published. This review aimed to update the previous synthesis and evaluate the results of new studies focusing on placebo or nocebo interventions in sports and exercise by determining the form and magnitude of their effect. Hence, we searched for empirical studies published from 2019 until the end of May 2024 indexed in PubMed, Medline, Web of Science, EBSCO, and Google Scholar databases. The search yielded 20 eligible studies with control or baseline-control conditions, focusing on nutritional, mechanical, and other mixed ergogenic aids. They yielded small to large placebo effects (Cohen's d) for nutritional (d = 0.86), mechanical (d = 0.38), cream and gel (d = 0.05), and open-label placebo (d = 0.16) interventions. The pooled effect size for placebo effects was moderate to large (d = 0.67), larger than in the earlier review, suggesting that placebo effects can improve motor performance even more than previously reported. However, based on five measures from three studies, the nocebo effects were almost twice as large (d = 1.20). Accordingly, the current findings support and expand the last review in the field by yielding additional support for placebo and nocebo effects in sports and exercise.

Performance-enhancing substances in sport: A scientometric review of 75 years of research

The use of performance-enhancing substances not only undermines the core values of sports but also poses significant health risks to athletes. In a fast-evolving doping environment, where sport professionals are constantly seeking novel and illegal means to bypass doping tests, and new substances are regularly detected on the drug market, it is crucial to inform authorities with updated evidence emerging from scientific research. The current study aims to (i) outline the structure of knowledge in the literature on performance enhancers in sports (i.e., most active countries, main sources, most productive authors, and most frequently used keywords); (ii) identify the most impactful documents in the field; and (iii) uncover the main domains of research in the literature. To do so, we conducted a comprehensive scientometric analysis of the literature on doping, sourcing our data from Scopus. Our research involved a document co-citation analysis of 193,076 references, leading to the identification of the 51 most influential documents and seven key thematic areas within the doping literature. Our results indicate that the scientific community has extensively studied the most prevalent doping classes, such as anabolic agents and peptide hormones, and little is still known about the use of contaminated supplements or other types of enhancers identified as emergent trends. Concurrently, technological advancements contributed to the development of more sophisticated doping detection techniques, using blood or urine samples. More recently, the focus has shifted towards the athlete biological passport, with research efforts aimed at identifying biomarkers indicative of doping. The dynamic nature of doping methods underlines the necessity for more robust educational campaigns, aiming at raising awareness among sports professionals and their entourage about the dangers of doping and the intricacies of its control mechanisms.

Online information and availability of three doping substances (anabolic agents) in sports: role of pharmacies

Background: The Internet has become an important source for easy access to doping substances, where people and athletes may acquire, outside pharmacies and without a (medical) prescription. These online websites do not always offer quality-assured products, and are outside the regular distribution channels of medicines. The aim of this study was to estimate the availability and accessible information on the Internet about the sale of three doping substances (oxandrolone, DHEA, androstenedione). Methods: Cross-sectional exploratory study, being an observation at a point in time of the online availability of these three doping substances (WADA S1 category: anabolic agents), purchased from Spain, Puerto Rico, Canada, United States, Ukraine and Russia. The characteristics of the websites, the countries the webs sold to, the pharmaceutical forms offered and the recommendations for its use were analyzed by using a computer tool designed ad hoc. Results: There were significant differences between countries in the number of webpages that sold the products (Chi-square test, p < 0.05). Oxandrolone was available for purchase mainly when buying from Spain (27.12%) and Ukraine (26.58%), in websites dedicated to sports (77.26%). For DHEA, most of the pages offered it if the search was done from Canada (23.34%) and Russia (21.44%). Products containing androstenedione or DHEA are claimed to enhance sports performance or for sports use without providing details. Compared to the total number of websites checked, the proportion of pharmacies offering these products was low, ranging from 4.86% for DHEA to 15.79% for androstenedione. Conclusion: The three substances selected are easily available without control through the Internet. Only a small number of websites offering them were online pharmacies, and requested a prescription. Most of the doping substances are purchased from the country where they are requested. Product information described benefits for sports performance, but did not do the same with their side effects. It would be advisable for these products to be sold through pharmacies, to guarantee their quality and provide evidence-based information on their safe use, benefits and risks, and only with a prescription. Athletes should be encouraged to consult health professionals about those supplements suitable for their type of training and sports objectives.

Psychosocial aspects of sports medicine in pediatric athletes: Current concepts in the 21st century

Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.

Effects of Sodium Bicarbonate Supplementation in Martial Arts

The aim of this systematic review was to evaluate the effects of consuming sodium bicarbonate (NaHCO3) and to gain insight into the nature of any changes in performance following NaHCO3 supplementation among combat sport athletes. The analysis of the results provides compelling evidence in favor of acute or chronic NaHCO3 supplementation as an ergogenic substance which could have an impact on several aspects of performance in judo [23, 31, 32], taekwondo [17, 20], karate [17, 33] [28, 29], wrestling [18, 19], jiu-jitsu [32] and boxing [16].

Acute or chronic NaHCO3 supplementation is effective in the improvement of several variables of physical performance in combat sports during testing and simulated matches. Enhanced performance resulted in the increased capacity of the glycolytic system. However, the positive effects of its use are most often visible following the onset of fatigue. In addition, the use of NaHCO3 is associated with an increased concentration of lactate in the blood. This systematic review provides data relevant for sports professionals and athletes alike regarding the use of NaHCO3 as a supplement, prior or during training and matches.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Bodybuilding, dietary supplements and hormones use: behaviour and determinant analysis in young bodybuilders

BACKGROUND

Among athletes, bodybuilders are more predisposed to the use of dietary supplements (DS) and hormones (H) to increase in adaptations to physical training and performance. The purpose of the study was to identify social, psychological, and organisational factors that are associated with the use of food supplements and hormones in young bodybuilders of the metropolitan area of Naples.

METHODS

107 athletes, practicing bodybuilding, were consecutively recruited in 30 gyms, randomly selected in the metropolitan area of Naples. Athletes were administered an anonymous questionnaire. The questionnaire consists of 5 sections (socio-demographic, frequency and reasons for bodybuilding, knowledge, attitudes and behaviours). Descriptive statistics were performed using T-test and Chi-square statistics. A score was created for knowledge, attitudes, behaviours. Multivariable logistic regression models were employed to assess association between each score and the use of DS and H. Statistical analyses were carried out using STATA 15.

RESULTS

81.31% of the subjects reported to use DS while 35.51% H. Females are less likely to practise bodybuilding frequently than males (OR 0.18 (95% CI 0.05-0.69), p = 0.01). Subjects who have attended high school or university have a lower probability of taking DS (OR 0.17 (95% CI 0.04-0.65), p = 0.01). H users also use supplements more frequently (OR 61.21 (95% CI 3.99-939.31), p < 0.001). Those who scored higher on knowledge scores are more likely to take DS (OR 1.53 (95% CI 1.11-2.12), p < 0.001). Attitudes are correlated with the use of DS; those who scored higher were less likely to use DS (OR 0.77 (95% CI 0.30-0.98), p = 0.03). People who use DS are 30 times more likely to use H at the same time (OR 30.25 (95% CI 2.51-365.24), p < 0.001). Subjects who have a higher score for knowledge and attitudes are less likely to use H (OR 0.68 (95% CI 0.54-0.87), p < 0.001, OR 0.75 (95% CI 0.62-0.90), p < 0.001).

CONCLUSIONS

Prevalence of H and DS' use, although lower than reported in the literature, is a worrying public health problem. Better knowledge can lead to an informed use. Gym instructors should be trained to provide accurate and scientifically sound information. Health professionals should combine their expertise to provide more comprehensive guidance to the exercisers.

Androstenedione (a Natural Steroid and a Drug Supplement): A Comprehensive Review of Its Consumption, Metabolism, Health Effects, and Toxicity with Sex Differences

Androstenedione is a steroidal hormone produced in male and female gonads, as well as in the adrenal glands, and it is known for its key role in the production of estrogen and testosterone. Androstenedione is also sold as an oral supplement, that is being utilized to increase testosterone levels. Simply known as "andro" by athletes, it is commonly touted as a natural alternative to anabolic steroids. By boosting testosterone levels, it is thought to be an enhancer for athletic performance, build body muscles, reduce fats, increase energy, maintain healthy RBCs, and increase sexual performance. Nevertheless, several of these effects are not yet scientifically proven. Though commonly used as a supplement for body building, it is listed among performance-enhancing drugs (PEDs) which is banned by the World Anti-Doping Agency, as well as the International Olympic Committee. This review focuses on the action mechanism behind androstenedione's health effects, and further side effects including clinical features, populations at risk, pharmacokinetics, metabolism, and toxicokinetics. A review of androstenedione regulation in drug doping is also presented.

Elevated arousal following acute ammonia inhalation is not associated with increased neuromuscular performance

Many athletes seek to enhance their performance using legal ergogenic aids, including ammonia inhalants (AIs). AIs trigger the inhalation reflex and increase blood pressure, respiration and heart rate; but, despite their widespread use, there is little evidence for the benefits of AI on exercise performance. We aimed to determine the psychological and neuromuscular impact of acute ammonia inhalation. Fourteen non-resistance trained males completed three trials: control, experimental (AI), and sham. The order of the sham and experimental trials was randomised. Participants completed handgrip and knee extension maximal voluntary contractions (MVC), and countermovement jump (CMJ). Heart rate and alertness were recorded at rest and immediately following control, experimental or sham treatment, followed by functional performance measurements. Reaction time, electromechanical delay, rate of force development and peak force were calculated from MVCs, and peak power from CMJ. On completion of trials, perceived performance was recorded. Statistical significance was accepted at P < .05. Heart rate (P < .001), alertness (P = .009) and perceived performance (P = .036) were elevated by AIs. Markers of functional performance were unaltered by AIs. Alertness was moderately correlated with perceived performance in control (r = 0.61) and sham conditions (r = 0.54), and very-highly correlated in the experimental condition (r = 0.90). AI elevates alertness and perceived physical performance, but not peak strength, power, or neuromuscular drive. AIs may be a useful psychological stimulant to increase focus and mental preparation, however it is unlikely that this will improve functional performance in an untrained population. Our data suggest however, that ammonia inhalants may improve the perception of an individual's performance.

Amplified detection of phosphocreatine and creatine after supplementation using CEST MRI at high and ultrahigh magnetic fields

Creatine is an important metabolite involved in muscle contraction. Administration of exogenous creatine (Cr) or phosphocreatine (PCr) has been used for improving exercise performance and protecting the heart during surgery including during valve replacements, coronary artery bypass grafting and repair of congenital heart defects. In this work we investigate whether it is possible to use chemical exchange saturation transfer (CEST) MRI to monitor uptake and clearance of exogenous creatine and phosphocreatine following supplementation. We were furthermore interested in determining the limiting conditions for distinguishing between creatine (1.9 ppm) and phosphocreatine (2.6 ppm) signals at ultra-high fields (21 T) and determine their concentrations could be reliably obtained using Bloch equation fits of the experimental CEST spectra. We have tested these items by performing CEST MRI of hind limb muscle and kidneys at 11.7 T and 21.1 T both before and after intravenous administration of PCr. We observed up to 4% increase in contrast in the kidneys at 2.6 ppm which peaked ~30 min after administration and a relative ratio of 1.3 in PCr:Cr signal. Overall, these results demonstrate the feasibility of independent monitoring of PCr and Cr concentration changes using CEST MRI.

Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

Red blood cells: the forgotten player in hemostasis and thrombosis

New evidence has stirred up a long-standing but undeservedly forgotten interest in the role of erythrocytes, or red blood cells (RBCs), in blood clotting and its disorders. This review summarizes the most recent research that describes the involvement of RBCs in hemostasis and thrombosis. There are both quantitative and qualitative changes in RBCs that affect bleeding and thrombosis, as well as interactions of RBCs with cellular and molecular components of the hemostatic system. The changes in RBCs that affect hemostasis and thrombosis include RBC counts or hematocrit (modulating blood rheology through viscosity) and qualitative changes, such as deformability, aggregation, expression of adhesive proteins and phosphatidylserine, release of extracellular microvesicles, and hemolysis. The pathogenic mechanisms implicated in thrombotic and hemorrhagic risk include variable adherence of RBCs to the vessel wall, which depends on the functional state of RBCs and/or endothelium, modulation of platelet reactivity and platelet margination, alterations of fibrin structure and reduced susceptibility to fibrinolysis, modulation of nitric oxide availability, and the levels of von Willebrand factor and factor VIII in blood related to the ABO blood group system. RBCs are involved in platelet-driven contraction of clots and thrombi that results in formation of a tightly packed array of polyhedral erythrocytes, or polyhedrocytes, which comprises a nearly impermeable barrier that is important for hemostasis and wound healing. The revisited notion of the importance of RBCs is largely based on clinical and experimental associations between RBCs and thrombosis or bleeding, implying that RBCs are a prospective therapeutic target in hemostatic and thrombotic disorders.

Extreme blood boosting capacity of an Antarctic fish represents an adaptation to life in a sub-zero environment

Blood doping, the practice of boosting the oxygen carrying capacity of blood, is an illegal strategy used by human athletes to enhance aerobic capacity and athletic performance. Interestingly, the practice of boosting blood oxygen carrying capacity is also naturally prevalent in the animal kingdom via the splenic release of stored erythrocytes. Here we demonstrate that an Antarctic notothenioid fish, the bald notothen (Pagothenia borchgrevinki), is a master of this practice. Due to the sub-zero environment these fish inhabit, they sequester a large proportion of erythrocytes in the spleen during times of inactivity to reduce the energetic and physiological costs associated with continuously pumping highly viscous blood around the body. However, in response to metabolically demanding situations (i.e. exercise and feeding), these fish contract the spleen to eject stored erythrocytes into circulation, which boosts blood oxygen carrying capacity by up to 207% (c.f. exercise-induced increases of ∼40-60% in a range of other vertebrates and ∼5-25% in blood-doping athletes). By evaluating cardiorespiratory differences between splenectomized (unable to release erythrocytes from the spleen) and sham-operated individuals, we demonstrate the metabolic benefits (i.e. aerobic scope increased 103%) and the cardiovascular trade-offs (i.e. ventral aortic blood pressure and cardiac workload increased 12% and 30%, respectively) associated with the splenic blood boosting strategy. In conclusion, this strategy provides bald notothens with an extraordinary facultative aerobic scope that enables an active lifestyle in the extreme Antarctic marine environment, while minimizing the energetic and physiological costs of transporting highly viscous blood during times of reduced energetic demand.

Instructional design and assessment of an elective course on the use of drugs in sport

BACKGROUND AND PURPOSE

The use and misuse of drugs in sport is becoming increasingly important globally, and the role of pharmacists is evolving in this regard. This paper describes the design and implementation of an elective course "Drugs in Sport" in an undergraduate pharmacy curriculum.

EDUCATIONAL ACTIVITY AND SETTING

The elective course was designed to introduce BSc pharmacy students to an evidence-based approach to safe, effective, and legal use of drugs in sport. The course covered why athletes take drugs, evolution of doping in sport, the international regulations regarding doping and anti-doping in sport including the World Anti-doping Agency Prohibited List, as well as testing and monitoring for drug use in sport. It also included the role of athlete support personnel (ASP) in preventing the use of prohibited substances by athletes. A web-based survey was conducted at the end of the course to assess the students' perspectives of the course.

FINDINGS

Students provided an evaluation of the course in terms of its content, methods of delivery, and assessment. Overall, the students demonstrated competence. They gained insight into international and national regulations regarding doping and anti-doping in sport and the potential role of pharmacists as ASP in providing support and advice for athletes and the public.

SUMMARY

Designing and implementing an evidence-based course on the use of drugs in sport customized for pharmacy students was achieved successfully. Such courses could provide an opportunity to advance the scope of pharmacy practice and possibly provide a new career path for future pharmacists.

Recombinant erythropoietin acutely decreases renal perfusion and decouples the renin-angiotensin-aldosterone system

The effect of recombinant erythropoietin (rhEPO) on renal and systemic hemodynamics was evaluated in a randomized double-blinded, cross-over study. Sixteen healthy subjects were tested with placebo, or low-dose rhEPO for 2 weeks, or high-dose rhEPO for 3 days. Subjects refrained from excessive salt intake, according to instructions from a dietitian. Renal clearance studies were done for measurements of renal plasma flow, glomerular filtration rate (GFR) and the segmentel tubular handling of sodium and water (lithium clearance). rhEPO increased arterial blood pressure, total peripheral resistance, and renal vascular resistance, and decreased renal plasma flow in the high-dose rhEPO intervention and tended to decrease GFR. In spite of the decrease in renal perfusion, rhEPO tended to decrease reabsorption of sodium and water in the proximal tubule and induced a prompt decrease in circulating levels of renin and aldosterone, independent of changes in red blood cell mass, blood volumes, and blood pressure. We also found changes in biomarkers showing evidence that rhEPO induced a prothrombotic state. Our results suggest that rhEPO causes a direct downregulation in proximal tubular reabsorption that seems to decouple the activity of the renin-angiotensin-aldosterone system from changes in renal hemodynamics. This may serve as a negative feed-back mechanism on endogenous synthesis of EPO when circulating levels of EPO are high. These results demonstrates for the first time in humans a direct effect of rhEPO on renal hemodynamics and a decoupling of the renin-angiotensin-aldosterone system.

Cardiovascular Effects of Performance-Enhancing Drugs

Exercise and competitive sports should be associated with a wide range of health benefits with the potential to inspire a positive community health legacy. However, the reputation of sports is being threatened by an ever-expanding armamentarium of agents with real or perceived benefits in performance enhancement. In addition to the injustice of unfair advantage for dishonest athletes, significant potential health risks are associated with performance-enhancing drugs. Performance-enhancing drugs may have an effect on the cardiovascular system by means of directly altering the myocardium, vasculature, and metabolism. However, less frequently considered is the potential for indirect effects caused through enabling athletes to push beyond normal physiological limits with the potential consequence of exercise-induced arrhythmias. This review will summarize the known health effects of PEDs but will also focus on the potentially greater health threat posed by the covert search for performance-enhancing agents that have yet to be recognized by the World Anti-Doping Agency. History has taught us that athletes are subjected to unmonitored trials with experimental drugs that have little or no established efficacy or safety data. One approach to decrease drug abuse in sports would be to accept that there is a delay from when athletes start experimenting with novel agents to the time when authorities become aware of these drugs. This provides a window of opportunity for athletes to exploit with relative immunity. It could be argued that all off-label use of any agent should be deemed illegal.

Illicit drugs and cardiac arrhythmias in athletes

The current management of athletes with cardiac arrhythmias has become complicated by the widespread use of illicit drugs, which can be arrhythmogenic.

The World Anti-Doping Agency annually updates a list of prohibited substances and methods banned by the International Olympic Committee that includes different classes of substances namely, anabolic androgenic steroids, hormones and related substances, β2-agonists, diuretics, stimulants, narcotics, cannabinoids, glucocorticosteroids, alcohol, β-blockers and others. Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular) that can even be lethal and which are frequently sport activity related.

A large use of illicit drugs has been documented in competitive athletes, but the arrhythmogenic effect of specific substances is not precisely known. Precipitation of cardiac arrhythmias, particularly in the presence of a latent electrophysiologic substrate including some inherited cardiomyopathies, at risk of sudden death or due to long-term consumption of the substances, should raise the suspicion that illicit drugs may be a possible cause and lead cardiologists to investigate carefully this relationship and appropriately prevent the clinical consequences.

Challenges to promoting health for amateur athletes through anti-doping policy

Anti-doping regulations are intended, at least in part, to promote the health of athletes. While most anti-doping efforts target elite and professional competitors, there have been recent moves by sport governing bodies to expand anti-doping testing to include amateur athletes. Drawing on previous critiques of anti-doping policies and illustrating cases, this article outlines five of the challenges to health promotion of applying the current detect and ban model to the amateur level of sport. I argue that the current approach is not effective and, in some ways, may undermine the goal of health promotion at the amateur level. In order to address these challenges, I propose alternative, health-centred strategies that focus on athlete empowerment and choice through critical awareness of a variety of substances, associated risks and rewards, and the role of expertise in decision-making.

Preparticipation Evaluation of the Young Athlete: What an Orthopaedic Surgeon Needs to Know

The preparticipation evaluation (PPE) is a widely used tool for detecting health conditions that may delay or disqualify athletic participation. The medical interview is the most valuable tool for identifying athletes who may be at increased risk for injury. Physical examination is tailored to identifying cardiac abnormalities or factors that may place an athlete at increased risk for injury. Although practiced in Europe, universal cardiac screening with electrocardiography is not currently recommended in the United States largely due to the high rate of false-positive results. Neuropsychological testing for management of concussion and laboratory testing for sickle cell trait may be indicated in select groups of athletes. Health care providers should view the PPE as a chance for anticipatory guidance and athlete-directed health counseling. Despite widespread acceptance of the PPE, the quality of such examinations varies significantly, which is an area for possible improvement and further research.

Synthetic androgens as designer supplements

Anabolic androgenic steroids (AAS) are some of the most common performance enhancing drugs (PED) among society. Despite the broad spectrum of adverse effects and legal consequences, AAS are illicitly marketed and distributed in many countries. To circumvent existing laws, the chemical structure of AAS is modified and these designer steroids are sold as nutritional supplements mainly over the Internet. Several side effects are linked with AAS abuse. Only little is known about the pharmacological effects and metabolism of unapproved steroids due to the absence of clinical studies. The large number of designer steroid findings in dietary supplements and the detection of new compounds combined with legal loopholes for their distribution in many countries show that stricter regulations and better information policy are needed.

Effect of pseudoephedrine in sport: a systematic review

OBJECTIVE

Pseudoephedrine is a stimulant that can be purchased over-the-counter to relieve symptoms of nasal and sinus congestion. Owing to its similar composition to ephedrine and other amphetamines, pseudoephedrine mirrors some of its ergogenic effects. This study investigates its possible ergogenic effect through a systematic review. Our primary aim was to determine the effects of pseudoephedrine in sport and its potential for performance enhancement.

DESIGN

We searched EMBASE, MEDLINE, PsychINFO and The Cochrane Library for trials conducted from their beginning to March 2015. Any published trial that used randomised assignment to the intervention and control groups in full text and measured pseudoephedrine as an independent variable were included.

RESULTS

Overall, the review showed that the ergogenic effect of pseudoephedrine is dose-dependent. None of the reviewed studies showed an ergogenic effect at the therapeutic dose of the drug (60-120 mg); however, supratherapeutic doses (≥180 mg) yielded clinically significant results.

CONCLUSIONS

Owing to the limitations of the published studies in this field, we were unable to make any firm conclusions with respect to the overall effect of pseudoephedrine and its ergogenic effect. It is evident that there is a correlation between the dose administered and its ergogenic effects, but it is also evident that the side effects of using above the therapeutic dose outweigh the possible benefits of using pseudoephedrine in sport. Further research with larger sample sizes is required to determine the relationship between doses (≥180 mg) and concentrations in urine that cause an ergogenic effect.

Ten weeks of branched-chain amino acid supplementation improves select performance and immunological variables in trained cyclists

We examined if supplementing trained cyclists (32 ± 2 year, 77.8 ± 2.6 kg, and 7.4 ± 1.2 year training) with 12 g/day (6 g/day L-Leucine, 2 g/day L-Isoleucine and 4 g/day L-Valine) of either branched-chain amino acids (BCAAs, n = 9) or a maltodextrin placebo (PLA, n = 9) over a 10-week training season affected select body composition, performance, and/or immune variables. Before and after the 10-week study, the following was assessed: (1) 4-h fasting blood draws; (2) dual X-ray absorptiometry body composition; (3) Wingate peak power tests; and (4) 4 km time-trials. No group × time interactions existed for total lean mass (P = 0.27) or dual-leg lean mass (P = 0.96). A significant interaction existed for body mass-normalized relative peak power (19 % increase in the BCAA group pre- to post-study, P = 0.01), and relative mean power (4 % increase in the BCAA group pre- to post-study, P = 0.01). 4 km time-trial time to completion approached a significant interaction (P = 0.08), as the BCAA group improved in this measure by 11 % pre- to post-study, though this was not significant (P = 0.15). There was a tendency for the BCAA group to present a greater post-study serum BCAA: L-Tryptophan ratio compared to the PLA group (P = 0.08). A significant interaction for neutrophil number existed (P = 0.04), as there was a significant 18 % increase within the PLA group from the pre- to post-study time point (P = 0.01). Chronic BCAA supplementation improves sprint performance variables in endurance cyclists. Additionally, given that BCAA supplementation blunted the neutrophil response to intense cycling training, BCAAs may benefit immune function during a prolonged cycling season.

Knowledge and Perceptions of Pharmacy Students in Qatar on Anti-Doping in Sports and on Sports Pharmacy in Undergraduate Curricula

Objective. To assess pharmacy students' knowledge and perceptions of doping and anti-doping in sports and to explore the curricular needs for undergraduate pharmacy in the field of sports pharmacy. Methods. A cross-sectional, descriptive, web-based survey of pharmacy students was conducted at Qatar University College of Pharmacy from March to May 2014. Data were analyzed using descriptive and inferential statistics. Results. Eighty respondents completed the online survey (80% response rate). Sixty percent were unaware of the World Anti-Doping Agency, and 85% were unaware of the International Pharmaceutical Federation's statement on the pharmacist's role in anti-doping. Students' knowledge score regarding the prohibited status of drugs that may be used by athletes was around 50%. Fourth-year pharmacy students had significantly higher knowledge scores than the other groups of students. Respondents acknowledged the important role of health care professionals, including pharmacists, as advisors on the safe and effective use of drugs in sports. Ninety percent of the students supported the inclusion of sports pharmacy in the curriculum. Conclusion. Pharmacy students indicated a strong desire to play a role in doping prevention and ensure safe and rational use of drugs among athletes. They suggested requiring an education and training strategy for sports pharmacy in undergraduate pharmacy curricula.

Doping in sport and exercise: anabolic, ergogenic, health and clinical issues

The use of doping agents is evident within competitive sport in senior and junior age groups, where they are taken by non-elite as well as elite participants. They are also taken in non-sporting contexts by individuals seeking to ‘improve’ their physique through an increase in muscle and/or decrease in fat mass. While attaining accurate data on the prevalence of their use has limitations, studies suggest the illicit use of doping agents by athletes and non-athletes may be 1–5% in the population and greater than 50% in some groups; with the prevalence being higher in males. There is conclusive evidence that some doping agents are anabolic and ergogenic. There is also evidence that the use of doping agents such as anabolic androgenic steroids, growth hormone and other anabolic agents, erythropoietin and stimulants conveys considerable health risks that include, but are not limited to: cardiovascular disease, diabetes, cancer, mental health issues, virilisation in females and the suppression of naturally produced androgens in males. This review will outline the anabolic, ergogenic and health impacts of selected doping agents and methods that may be used in both the sporting and physique development contexts. It also provides a brief tabulated overview of the history of doping and how doping agents may impact upon the analyses of clinical samples.

Speed trends in male distance running

The major cycling "Grand Tours" have shown an attenuation of performance over the last decade. This has been interpreted as circumstantial evidence that newer anti-doping strategies have reduced the use of performance-enhancing drugs. To examine this idea under more controlled conditions, speed trends for world class 5000 m, 10000 m, and marathon performances by men from 1980 to 2013 were analyzed. We obtained comprehensive records from the International Association of Athletics Federations, Association of Road Racing Statisticians, and the Track and Field All-time Performances database webpages. The top 40 performances for each event and year were selected for regression analysis. For the three distances, we noted cumulative performance improvements in the 1990s thru the mid-2000s. After the peak speed years of the mid 2000 s, there has been limited improvement in the 5000 m and 10,000 m and world records set during that time remain in place today, marking the longest period of time between new records since the early 1940s. By contrast marathon speed continues to increase and the world record has been lowered four times since 2007, including in 2013. While the speed trends for 5000 m and 10000 m track results parallel those seen in elite cycling, the marathon trends do not. We discuss a number of explanations other than improved anti-doping strategies that might account for these divergent findings.

Silk peptide treatment can improve the exercise performance of mice

BACKGROUND

We previously reported that silk peptide (SP) treatment led to increased resting fat oxidation in exercised mice. However, it was not known whether SP treatment could effectively increase exercise capacity. Accordingly, this study aimed to examine whether SP treatment affected energy metabolism during exercise in addition to exercise performance.

METHODS

We randomized 36 7-week-old male ICR mice into 2 groups: the control (n = 18) and SP (n = 18) groups. All mice were trained by treadmill running 5 times per week for 2 weeks. SP was dissolved in distilled water and daily 800-mg/kg body weight doses before the running exercise were oral administered intraperitoneally to the SP group for 2 weeks. [Formula: see text] was measured before and after the 2 weeks training period. We also assessed energy metabolism during exercise for 1 h after the 2 week training period. In addition to blood samples, liver glycogen and gastrocnemius-white and gastrocnemius-red muscle was obtained at the following 3 time points: at rest, immediately after exercise, and 1-hour post exercise.

RESULTS

The [Formula: see text] max after 2 weeks of training was significantly increased (8%) in the SP group compared to the baseline; a similar result was not observed in the CON group. The sum of fat oxidation during a 1-h period tended to be 13% higher in the SP group than in the CON group (P < 0.077). In particular, the sum of fat oxidation was significantly higher in the SP group during the initial 20-min phase than that in the CON group (P < 0.05). The glycogen concentration in the white gastrocnemius muscle did not differ between the groups either rest or after 1 h of exercise but was significantly higher in the SP group than in the CON group during the recovery period (1 h post-exercise completion).

CONCLUSIONS

These results suggest that SP treatment can improve the exercise performance. Therefore, SP is considered to confer beneficial effects upon athletes, in whom exercise abilities are required.

Stimulant doping agents used in Brazil: prevalence, detectability, analytical implications, and challenges

This article presents the prevalence of stimulant doping among Brazilian athletes, the analytical approaches used, as well as a general evolution of the detectability of the stimulants being used. Results from the Brazilian accredited doping control laboratory are compared with the global statistics disclosed by the World Anti-Doping Agency. The high prevalence of stimulant doping in Brazil can be attributed to several reasons, including "self-administration," a "body-shaping" culture, and the use of nutritional supplements.

Pre-exercise ingestion of pickle juice, hypertonic saline, or water and aerobic performance and thermoregulation

CONTEXT

Ingesting high-sodium drinks pre-exercise can improve thermoregulation and performance. Athletic trainers (19%) give athletes pickle juice (PJ) prophylactically for cramping. No data exist on whether this practice affects aerobic performance or thermoregulation.

OBJECTIVE

To determine if drinking 2 mL/kg body mass of PJ, hypertonic saline, or deionized water (DIW) pre-exercise affects aerobic performance or thermoregulation.

DESIGN

Crossover study.

SETTING

Controlled laboratory study.

PATIENTS OR OTHER PARTICIPANTS

Nine euhydrated men (age = 22 ± 3 years, height = 184.0 ± 8.2 cm, mass = 82.6 ± 16.0 kg) completed testing.

INTERVENTION(S)

Participants rested for 65 minutes. During this period, they ingested 2 mL/kg of PJ, hypertonic saline, or DIW. Next, they drank 5 mL/kg of DIW. Blood was collected before and after ingestion of all fluids. Participants were weighed and ran in the heat (temperature = 38.3°C ± 1°C, relative humidity = 21.1% ± 4.7%) at increasing increments of maximal heart rate (50%, 60%, 70%, 80%, 90%, 95%) until exhaustion or until rectal temperature exceeded 39.5°C. Participants were weighed postexercise so we could calculate sweat volume.

MAIN OUTCOME MEASURE(S)

Time to exhaustion, rectal temperature, changes in plasma volume, and sweat volume.

RESULTS

Time to exhaustion did not differ among drinks (PJ = 77.4 ± 5.9 minutes, hypertonic saline = 77.4 ± 4.0 minutes, DIW = 75.7 ± 3.2 minutes; F2,16 = 1.1, P = .40). Core temperature of participants was similar among drinks (PJ = 38.7°C ± 0.3°C, hypertonic saline = 38.7°C ± 0.4°C, DIW = 38.8°C ± 0.4°C; P = .74) but increased from pre-exercise (36.7°C ± 0.2°C) to postexercise (38.7°C ± 0.4°C) (P < .05). No differences were observed for changes in plasma volume or sweat volume among drinks (P > .05).

CONCLUSIONS

Ingesting small amounts of PJ or hypertonic saline with water did not affect performance or select thermoregulatory measures. Drinking larger volumes of PJ and water may be more effective at expanding the extracellular space.

Effects of combined creatine and sodium bicarbonate supplementation on repeated sprint performance in trained men

Creatine and sodium bicarbonate supplementation independently increase exercise performance, but it remains unclear whether combining these 2 supplements is more beneficial on exercise performance. The purpose of this study was to evaluate the impact of combining creatine monohydrate and sodium bicarbonate supplementation on exercise performance. Thirteen healthy, trained men (21.1 ± 0.6 years, 23.5 ± 0.5 kg·m(-2), 66.7 ± 5.7 ml·(kg·m)(-1) completed 3 conditions in a double-blinded, crossover fashion: (a) Placebo (Pl; 20 g maltodextrin + 0.5 g·kg(-1) maltodextrin), (b) Creatine (Cr; 20 g + 0.5 g·kg(-1) maltodextrin), and (c) Creatine plus sodium bicarbonate (Cr + Sb; 20 g + 0.5 g·kg(-1) sodium bicarbonate). Each condition consisted of supplementation for 2 days followed by a 3-week washout. Peak power, mean power, relative peak power, and bicarbonate concentrations were assessed during six 10-second repeated Wingate sprint tests on a cycle ergometer with a 60-second rest period between each sprint. Compared with Pl, relative peak power was significantly higher in Cr (4%) and Cr + Sb (7%). Relative peak power was significantly lower in sprints 4-6, compared with that in sprint 1, in both Pl and Cr. However, in Cr + Sb, sprint 6 was the only sprint significantly lower compared with sprint 1. Pre-Wingate bicarbonate concentrations were significantly higher in Cr + Sb (10%), compared with in Pl and Cr, and mean concentrations remained higher after sprint 6, although not significantly. Combining creatine and sodium bicarbonate supplementation increased peak and mean power and had the greatest attenuation of decline in relative peak power over the 6 repeated sprints. These data suggest that combining these 2 supplements may be advantageous for athletes participating in high-intensity, intermittent exercise.

Nutritional supplements and ergogenic AIDS

Performance enhancing drugs, ergogenic aids, and supplements come in many forms. The financial, personal, social, and health-related impact of these substances has wide and varied consequences. This article reviews common substances and practices used by athletes. It discusses the history, use, effects, and adverse effects of androgenic anabolic steroids, peptide hormones, growth factors, masking agents, diuretics, volume expanders, β-blockers, amphetamines, caffeine, other stimulants, and creatine. The evidence base behind the use, safety, and efficacy of these items as well as testing for these substances is discussed.

Sarcopenia: pharmacology of today and tomorrow

Sarcopenia remains largely undiagnosed and undertreated because of the lack of a universally accepted definition, effective ways to measure it, and identification of the outcomes that should guide treatment efficacy. An ever-growing number of clinicians and researchers along with funding and regulatory agencies have gradually recognized that sarcopenia is a human condition that requires both prevention and treatment. In this article, we review sarcopenia and its common and less known pharmacological treatments, attempt to define sarcopenia in its broader context, and present some new ideas for potential future treatment for this devastating condition.

Anabolic androgenic steroids in police cases in Sweden 1999-2009

Anabolic Androgenic Steroids (AAS) are considered drugs of abuse and are controlled substances in Sweden since 1999. Traditionally AAS have been used by elite athletes to enhance performance, but in recent years it has become an increasing problem outside elite sport among athletes, bodybuilders and criminals. Use of AAS is associated with psychiatric side effects such as aggression, depression and violent behavior. Supraphysiological doses and long term use can cause serious physical harm such as cardiovascular toxicity and even premature death. We investigated and evaluated the drug analytical findings in forensic cases from suspected perpetrators in cases from the police where a screening for AAS was requested to get information about the prevalence of AAS use and the occurrence of poly-drug abuse. The study was based on samples submitted from the police authorities to the Department of Forensic Toxicology in Sweden during the period 1999-2009. Urines were analyzed by methods based on GC-MS and LC-MS-MS. We also analyzed the prevalence of AAS use at the prison and probation services. A total number of 12,141 urine samples (6362 police cases and 5779 inmates) were analyzed and 33.5% of the cases from the police and 11.5% of the inmates were tested positive for AAS. The users of AAS were mainly in 99.2% men with a mean age of 26.2±6.2 years whereas the women were 29.5±6.5 years old. The most frequently used AAS was nandrolone followed by testosterone and methandienone. Other illicit and licit drugs were detected in 60% of the cases from the police, strongly indicating a frequent poly-drug abuse among users of AAS.

Drug use and sport--a commentary on: Injury, pain and prescription opioid use among former National Football League football players by Cottler et al

The accompanying paper by Cottler et al. reports on findings from a telephone survey study that examined opioid analgesic use and misuse by U.S. professional football players. The study shows high rates of misuse of these medications, and provides an opportunity to consider the intersection between sports and drug use. While in recent years there has been increasing focus upon the use of performance enhancing drugs (e.g., steroids) in athletes, the present report provides valuable information about a relatively unexplored but important topic: opioid analgesic misuse by athletes. The data provided show that misuse of opioids in this population is cause for concern, suggest that study of other groups of athletes should be undertaken, and that further assessment of opioid use in football players is also needed. The study also provides an opportunity to conceptualize drug (and non-drug) use in athletes, as a means to either return athletic functioning to a previous level of performance, or to enhance functioning. Discussions of drug use in sports need to appreciate the complexity of such use, which can be indicated and appropriate under certain circumstances, but which can also be inappropriate and problematic under others-for example, for drugs such as opioid analgesics.

Dietary supplements and team-sport performance

A well designed diet is the foundation upon which optimal training and performance can be developed. However, as long as competitive sports have existed, athletes have attempted to improve their performance by ingesting a variety of substances. This practice has given rise to a multi-billion-dollar industry that aggressively markets its products as performance enhancing, often without objective, scientific evidence to support such claims. While a number of excellent reviews have evaluated the performance-enhancing effects of most dietary supplements, less attention has been paid to the performance-enhancing claims of dietary supplements in the context of team-sport performance. Dietary supplements that enhance some types of athletic performance may not necessarily enhance team-sport performance (and vice versa). Thus, the first aim of this review is to critically evaluate the ergogenic value of the most common dietary supplements used by team-sport athletes. The term dietary supplements will be used in this review and is defined as any product taken by the mouth, in addition to common foods, that has been proposed to have a performance-enhancing effect; this review will only discuss substances that are not currently banned by the World Anti-Doping Agency. Evidence is emerging to support the performance-enhancing claims of some, but not all, dietary supplements that have been proposed to improve team-sport-related performance. For example, there is good evidence that caffeine can improve single-sprint performance, while caffeine, creatine and sodium bicarbonate ingestion have all been demonstrated to improve multiple-sprint performance. The evidence is not so strong for the performance-enhancing benefits of β-alanine or colostrum. Current evidence does not support the ingestion of ribose, branched-chain amino acids or β-hydroxy-β-methylbutyrate, especially in well trained athletes. More research on the performance-enhancing effects of the dietary supplements highlighted in this review needs to be conducted using team-sport athletes and using team-sport-relevant testing (e.g. single- and multiple-sprint performance). It should also be considered that there is no guarantee that dietary supplements that improve isolated performance (i.e. single-sprint or jump performance) will remain effective in the context of a team-sport match. Thus, more research is also required to investigate the effects of dietary supplements on simulated or actual team-sport performance. A second aim of this review was to investigate any health issues associated with the ingestion of the more commonly promoted dietary supplements. While most of the supplements described in the review appear safe when using the recommended dose, the effects of higher doses (as often taken by athletes) on indices of health remain unknown, and further research is warranted. Finally, anecdotal reports suggest that team-sport athletes often ingest more than one dietary supplement and very little is known about the potential adverse effects of ingesting multiple supplements. Supplements that have been demonstrated to be safe and efficacious when ingested on their own may have adverse effects when combined with other supplements. More research is required to investigate the effects of ingesting multiple supplements (both on performance and health).

Anabolic steroid use in adolescents: identification of those at risk and strategies for prevention

Success in sports is often defined by winning, which drives athletes to use performance-enhancing drugs (PEDs) to gain an advantage over opponents. Over the past 20 years, use of PEDs by Olympic and professional athletes has led to public discussion regarding potential negative health effects and ethical implications of their use. Unfortunately, PEDs are not isolated to professional athletes, as PED use in adolescents has increased dramatically. Many professional organizations, including the American Academy of Orthopaedic Surgeons (AAOS), have taken a stance against PED use in sports. The AAOS believes neither anabolic steroids nor their precursors should be used to enhance performance or appearance, and that these substances should be banned in all sports programs. Pediatricians and orthopedists are often the first physicians to see these young athletes. It is critical for these physicians to recognize the significance of the problem, have the knowledge to inform adolescents, dissuade them from future use, and provide viable alternatives for meeting performance goals.