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Performance Enhancing Drugs

Who's taking them, and what are the benefits and risks?

Let’s face the facts: The use of performance-enhancing drugs is becoming relatively mainstream. Approximately 1&ndash 3 million people in the United States have used anabolic steroids (Silver 2001), with usage rates as high as 12% among young men and 2% among young women (Bahrke, Yesalis & Brower 1998). Not only are newscasts filled with reports of steroid use by both Olympic and professional athletes, but studies indicate that even teen athletes are using these performance enhancing drugs. In a 1999 survey of high&ndashschool football players, more than 6& reported using anabolic steroids&ndashand the use began at a mean age of about 14 years (stilger & Yesalis 1999). Many steroid users simply refuse to believe that the performance enhancing drugs are a great risk to their health. In fact a study by Pope and colleagues (2004) found that 56% of users never discussed their steroid use with a medical professional.

Steroid use among nonathletes is also increasing, especially among men, who are bombarded by media images of the lean, muscular “alpha male.” The search for this “ideal” body type has lead to a new body image issue known as muscle dysmorphia, or reverse anorexia, a condition in which males never feel big enough. (See “Muscle Dysmorphia” on page 63.)

The use of anabolic agents is becoming commonplace even among older adults, who are looking to this “fountain of youth” to fight off the effects of aging (Haber 2004).

In light of these facts, it seems clear that you have a responsibility as a fitness professional to become informed so you can recognize the symptoms of steroid use and inform users and potential users of the deleterious side effects.

Anabolic steroids are synthetic drugs that mimic the effects of testosterone, the male sex hormone. Over the last 50–60 years, testosterone derivatives (e.g., oxymetholone [Anadrol®], nandrolone [Deca Durabolin®], norbolethone, gestrinone and trenbolone) have been developed, formulated and chemically enhanced to provide the desirable effects of testosterone—namely muscle growth and strength development—while attempting to limit the negative side effects (Pope et al. 2004). By mimicking testosterone, these synthetic derivatives diffuse across the muscle cell membrane and bind to a natural testosterone receptor inside the cell. The hormone-receptor complex then enters the cell’s nucleus, where it binds to DNA. Once the steroid hormone is bound to DNA, it stimulates mRNA synthesis and subsequently activates the synthesis of proteins used for muscle growth (Tokish, Kocher & Hawkins 2004). In addition, anabolic steroids are thought to slow the catabolic (breakdown) actions of hormones such as cortisol. In other words, anabolic steroids help increase muscle size and limit muscle breakdown.

Anabolic steroids are currently banned by the International Olympic Committee, National Football League, National Basketball Association, National Collegiate Athletic Association (NCAA) and, very recently, Major League Baseball. Technically, only physicians can prescribe anabolic steroids—for medical conditions like growth deficiencies, muscle-wasting diseases and a natural lack of certain hormones such as testosterone.

How, then, are steroids getting into the hands of so many people, including adolescents? Black-market sales, which exceed $100 million every year (Tokish, Kocher & Hawkins 2004), are a big source. But other providers include unethical healthcare professionals and team physicians looking to make some cash. A 2001 survey of NCAA substance abuse rates found that 1.1% of 13,914 student-athletes used anabolic steroids, and almost 40% of the users said that they obtained their steroids from physicians (Green et al. 2001). What is most striking regarding this survey is that only 0.7% of respondents said that they did not use steroids because they were “hard to get.”

In a laboratory setting, testosterone use has equivocal results for a number of possible reasons. Most athletes who use steroids self-administer the drugs and use polydrug infusions, a practice often called “stacking.” Users may also inject or ingest doses five to 20 times larger than most research studies can provide, owing to ethical concerns (Hartgens & Kuipers 2004). In addition, because most steroids used by athletes are obtained on the black market, their quality and content cannot be guaranteed. Finally, many studies do not control for activity level, macronutrient intake or motivation for subjects’ participation (Bhasin et al. 1996).

Nevertheless, research demonstrates that injecting anabolic steroids in normal men in supraphysiological doses of 600 milligrams a week—six times the dose normally given to hypogonadal men (men with low testosterone levels)—will boost muscle size, strength and fat-free mass, especially when combined with strength training. In one study (Bhasin et al. 1996), subjects taking large doses of testosterone over a 10-week treatment period gained 7 pounds of muscle, and those who combined testosterone with strength training gained 13.5 pounds of muscle. In addition, taking testosterone alone improved leg and chest strength by 19% and 10%, respectively, while combining testosterone with strength training increased leg and chest strength by 38% and 22%, respectively. Of note is the fact that subjects in the placebo group who strength trained were able to increase their muscle mass by more than 4 pounds and their leg and chest strength by 21% and 11%, respectively, in the same amount of time.

Other studies (Giorgi, Weatherby & Murphy 1999; Forbes et al. 1992) also indicate an increase in body weight, fat-free mass, muscle size and libido with anabolic steroid use. However, the improvement in some of these physiological variables, although impressive, is counterbalanced by negative and possibly life-threatening side effects.

Due to the illegal status of anabolic steroids and the variability in the amount that real-life users take, well-controlled research regarding the health risks is hard to come by. But available research suggests that the health consequences are alarming and may include the following:

  • psychological disturbances
  • muscle dysmorphia
  • cardiovascular problems
  • testicular atrophy
  • enlarged prostate
  • infertility
  • increased risk of cancer, especially of the prostate
  • hair loss
  • breast development
  • rage
  • severe acne

While not every study supports all these health consequences, the promise of large muscles and a strong libido should not blind potential users to the obvious and inherent psychological, physiological and ethical problems associated with steroid use.

The Studies. Bhasin and colleagues (1996) reported acne development in three men and breast tenderness in two men among subjects receiving testosterone treatment for 10 weeks. No irregularities were found in serum liver enzyme concentrations, hemoglobin concentrations or red blood cell counts; and no changes were found in plasma lipid concentrations. However, many animal studies support a negative effect on liver enzymes from large doses of anabolic androgenic steroids (Hartgens & Kuipers 2004).

In a 1999 study, Giorgi and coworkers found increased systolic blood pressure, frontal alopecia, acne and psychological problems, including increased aggression and irritability—commonly called “’roid rage.”

Some researchers have found cardiovascular complications with steroid use. Kuipers and colleagues (1991) noted a 25% decrease in HDL (good) cholesterol and an increase in diastolic blood pressure after 8 weeks of steroid use. Hartgens and coworkers (2004) reported that steroid use was associated not only with decreased HDL but also with increased LDL (bad) cholesterol. Other possible cardiovascular complications include cardiomyopathies, atrial fibrillation, embolism development and acute heart failure (Hartgens & Kuipers 2004). Some research has shown increased left ventricular mass and larger posterior wall and interventricular septum thickness. Steroid use also reduces natural production of testosterone, which can lead to the onset of testicular atrophy and decreased spermatogenesis (Hartgens & Kuipers 2004).

Excess anabolic steroids in the body are converted to estrogens, causing an increase in breast tissue development, as well as breast tenderness, even among men (Hartgens & Kuipers 2004).

In addition to all these factors, athletes who abuse steroids may have a heightened risk of injury, since their tendons and ligaments may not keep pace with the sudden and dramatic increase in muscle strength (Stannard & Bucknell 1993; Battista, Combs & Warme 2003). Even more frightening is the fact that power lifters who use anabolic steroids and other performance enhancing drugs have an increased incidence of premature mortality (Parssinen et al. 2000).

Less well recognized health consequences—including HIV, hepatitis B and C, and abscesses—have been reported among steroid users who share injection needles (Rich et al. 1999). And a 1996 Canadian study that surveyed more than 1,600 students found that, of the 2.8% using steroids, 29% reported injecting them, and 29% of those students shared needles (Melia, Pipe & Greenberg 1996).

Growth hormone (GH), which is secreted by the anterior pituitary gland, has both anabolic and metabolic effects. It promotes amino acid uptake and protein synthesis, bone growth and lipolysis. GH is secreted in bursts in response to exercise and stress, and secretion also increases during sleep. A decline in endogenous GH levels is associated with aging, and some older adults may experience symptoms of growth hormone deficiency, sometimes referred to as “somatopause” or “andropause” (Toogood, O’Neill & Shalet 1996). (See “Aging and Anabolics” on page 64.)

GH diverts energy toward protein synthesis rather than lipogenesis (fat storage). The lay literature, anti-aging quacks and “life extensionists” have picked up on this fact and promoted GH’s supposed ability to trigger muscle growth, enhance energy and vigor, and reduce wrinkles. However, scientific research doesn’t necessarily support these conclusions. A number of researchers who have administered GH to healthy young athletic males have not reported an increase in muscle strength or mass in these subjects compared to age- and activity-matched controls (Yarasheski et al. 1993; Deyssig et al. 1993). In the general population with normal GH levels, researchers have concluded, GH supplementation will not provide any benefit.

Side Effects. Clinical experience in working with individuals who have an overabundance of endogenous GH has provided evidence that high concentrations over long periods can lead to muscle weakness. Other side effects include water retention, carpal tunnel syndrome, insulin resistance and diabetes. With extended use, down regulation of receptors also appears to occur. Lange and colleagues (2002) reported the following side effects: pitting leg edema, carpal tunnel syndrome, so-called “trigger finger” and transient atrial fibrillation.

Among diabetics, insulin treatment increases lean body mass, improves glucose transporter translocation to the muscle membrane, promotes amino acid uptake and reduces proteolysis (the breakdown of muscle protein). Because of this metabolic action, insulin use by bodybuilders has increased. In many states individuals can obtain insulin from a pharmacy simply by stating that they are diabetic.

Side Effects. No studies have specifically investigated the effect of insulin use by nondiabetics for the purpose of increasing muscle mass. However, bodybuilders have used short-acting insulin with high-carbohydrate and high-protein diets to promote muscle growth, and a few case studies have reported negative consequences (Evans & Lynch 2003; Konrad et al. 1998; Dawson & Harrison 1997; Reverter et al. 1994). The primary side effect of insulin use by nondiabetics is hypoglycemia. While this condition is preventable and treatable, most individuals use insulin in secrecy and are discovered only when they are found by friends or family in a state of unconsciousness induced by hypoglycemia. Coma, convulsions and death have been reported in some cases (Evans & Lynch 2003; Konrad et al. 1998; Dawson & Harrison 1997; Reverter et al. 1994).

While the use of hormones to promote muscle growth is popular among several populations, the risk-to-benefit ratio really needs to be considered. Many athletes think that winning the gold medal or the championship is worth the risk. In fact Bamberger and Yaeger (1997) asked a number of elite athletes the following question: If you were offered a performance-enhancing drugs that came with the guarantees that (1) you would not get caught, (2) you would win every competition you entered for the next 6 years and (3) you would then die from the side effects of the substance, would you take it? Over 50% of the athletes responded yes! While this wasn’t a true scientific survey, it does illustrate that many young, athletic adults are more concerned with the present than the future.

Older individuals are no different. Some believe plastic surgery will help reverse the aging process, while others flock to anti-aging clinics to try any so-called therapy available to reduce wrinkles, increase energy and preserve muscle—all to no avail, since aging is inevitable.

As fitness professionals, we can’t be sure of all the side effects of performance enhancing drugs, but we do know one thing: Leading a lifestyle that includes exercise and sound nutrition helps to keep people strong in body and mind—with no associated risks. This is the best way to live a long and healthy life.

Muscle Dysmorphia

Everywhere we turn we see images of hard-bodied men with the “Abercrombie look”—strong, muscular, athletic and chiseled. This is the look most recreational steroid users are after. Pope and colleagues (2000) surveyed men from three different countries and found that they all chose ideal body types that were almost 30 pounds more muscular than they were. The same subjects also believed that women preferred a male body with 30 pounds more muscle than the subjects had, when in fact women said that they preferred a normal male body.

Individuals with muscle dysmorphia, or reverse anorexia, perceive themselves as small and disproportionate despite being highly muscular, and they are pathologically preoccupied with acquiring bigger muscles. Olivardia and colleagues (2000) found that men with muscle dysmorphia felt shame, embarrassment and impairment of their social and occupational functioning. In fact these authors report that most men with this condition avoid public places that involve minimal clothing, such as beaches, pools and locker rooms. Bodybuilders and weightlifters are perhaps most prone to developing this complex, since they are regularly evaluated for their strength and level of muscularity.

Muscle dysmorphic tendencies are relatively easy to spot. They include narcissism, avoidance of public places where minimal attire is worn, and an overabundance of time spent in the weight room.


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