• Anabolic-androgenic steroids

• Steroid precursors
   (androstenedione and
   dehydroepiandrosterone)
   growth hormone

• Creatine

• Protein/amino acids

• Ephedra alkaloids

• Nitric oxide producers

• Energy drinks (especially high
   caffeine products)

Ergogenic use by athletes to improve athletic performance is not a new practice. As early as 776 BC, the Greek Olympians used substances, such as mushrooms, dried figs, and strychnine, to

enhance performance. In 1889, Dr. Brown-Sequard hypothesized that testicles secreted substances that acted as physiologic regulators. Attempting to confirm his assumption, he injected himself with the extract of dog and guinea pig testicles and perceived that he had reversed his 72-year-old body’s ailments.

This experiment helped lead to the discovery of hormones in 1905 and the isolation of testosterone in 1935. The use of various hormones and steroid precursors has dramatically increased since the early 1960s, when commercial anabolic androgenic steroids first became available.

Today, athletes go to great lengths to increase athletic ability. Many young athletes admit that the competitive drive to win can be very intense. For a growing number of athletes, winning at all costs includes taking ergogenic aids. Some athletes appear to benefit from these products, but at what cost and risk? The short and long-term benefits of taking these products have not been rigorously studied, nor have the potential side effects.

No Food and Drug Administration (FDA) Oversight

The Food and Drug Administration (FDA) classifies sports supplements as dietary supplements, and does not require them to meet any standards or regulations. Supplement manufacturers are supposed to follow Good Manufacturing Practices (GMP), but these are essentially self-regulated and self-reported guidelines. There are no regulations that guarantee the safety or purity of products sold as a supplement.

Additionally, the FDA is prohibited from removing a product from the market unless the product has caused proven medical harm. Most heath risks from supplements are discovered only after the product is on the market. It is usually only after a supplement has been linked to multiple serious health risks or death that the FDA can remove it from the market. Therefore, supplements are:

• Not guaranteed to meet product potency or purity

• Not required to meet the same safety requirements as prescription or over-the-counter drug or food requirements

• Not held to specific manufacturing Standards

• Not required to meet safety or efficacy thresholds before
  going on the market

• Not required to be proven effective for any claimed health benefit

Ergogenic Use

390,000 10- to 14-year-olds admitted to using sports supplements.

1 million 12- to 17-year-olds admitted to using potentially dangerous sports supplements.

Only 57% of 12th graders perceived anabolic steroid use as harmful.

70% of young people & 50% of their parents could not identify any specific negative side effects from using sports supplements.

80% of young people have never discussed sports supplements with their parents.

What Has Been Found in Supplements on the U.S. Market?

An International Olympic Committee study, conducted from 2000 to 2002, showed that 18.8% of the 240 supplements purchased in the USA surreptitiously contained steroids.

A study overseen by Informed Choice, a non-profit coalition of dietary supplements, found that 13 of the 52 supplements (25%) purchased at various U.S. retailers surreptitiously contained steroids and that six (11.5%) contained banned stimulants. Numerous studies have found that ~25% of dietary supplements are contaminated with heavy metals, steroids, and/or medications not listed on the labels.

It is important to check supplement labels for a seal of approval from a legitimate, independent (third-party) company. These independent companies contract with supplement manufacturers to assess and verify the purity and content of their products. If supplements do not have a seal of approval, then they either have not been analyzed by an independent company or they have not met an independent company’s standards.

Many supplements have labels that falsely appear to contain seals of approval, e.g., “GNC Approved.” However, in many cases, these seals are not from independent testing companies. ï At left are three seals of approval from legitimate, independent companies.

Energy Drinks
Energy drinks are increasing in popularity among athletes of all ages. Caffeine is the main “energy” ingredient in energy drinks, but they also frequently contain other ingredients, such as, vitamins, glucuronolactone, ginseng, guarana, and taurine. Familiar brand names include Jolt, Red Bull, Rock Star, and even some VitaWater products. It is claimed that these products improve alertness, stamina and reaction time. Caffeine has been used for its stimulant effects by endurance athletes as a way to stay alert and improve endurance. Its ability to enhance performance, under certain conditions, has been well documented. However, consuming too much caffeine often has negative effects on overall performance, and has even led to the deaths of athletes.

In the United States, manufacturers are not required to list the ingredients of energy drinks. Therefore, it is difficult for consumers to appreciate how much caffeine they ingest with an energy drink. In addition to acting as a stimulant, caffeine is also a diuretic. Thus, it can contribute to dehydration in athletes. Ginseng and guarana also have stimulant effects in the body and add to the danger of these products. Considerable concern remains regarding the negative effects of energy drinks. Emergency room visits arising from energy drink consumption are becoming commonplace.

Current trends among students include mixing energy drinks with alcohol at parties and bars. Side effects of energy drinks include dehydration, nausea, nosebleeds, heart arrhythmias, and death.

Creatine
Creatine is a natural substance that the body uses to produce energy. The daily requirement of creatine is 2g per day. Humans produce half the daily requirement, while the other half comes from a balanced diet. Creatine supplements are commonly used by athletes in the hope that they will provide quick bursts of energy. Creatine supplementation can have some athletic benefits, as it increases strength and improves outcomes in short duration, anaerobic events (such as weightlifting or short sprints). It does not improve endurance, since prolonged muscle activity depends on aerobic glycolysis.

Despite the wide-spread use of creatine by young athletes, little information exists regarding its safety or efficacy in children and teens. Creatine side effects include dehydration, muscle cramps, diarrhea, and renal function compromise. Additionally, there is no data to judge the effects of creatine supplementation on the other tissues that store creatine (such as the heart and brain), and the effects of chronic use are unknown.

The amount of protein that should be ingested per day:

0.8g/kg per day for normal activity levels

1.0-1.2g/kg per day for light-moderate athletic training

1.4-1.7g/kg per day for moderate-heavy athletic training

(Limited data suggests up to)2g/kg per day may be used for heavy athletic training

Protein/Amino Acids
Proteins provide critical amino acids that serve as building blocks for new muscle. Fortunately, the higher intakes recommended for athletes are easily achieved in a well-balanced diet without the use of supplements.

Common sources of dietary protein include meat (5-7g protein/ounce) and milk (8g protein/cup). Milk consists primarily of two proteins: 80% casein and 20% whey. Both of these proteins are excellent sources of all essential amino acids, but they differ in one important aspect.

Whey is a quickly-digested protein that provides an immediate increase in the blood’s amino acid content. However, its effects are short-lived. Casein is a slowly-digested protein that provides a slower increase of blood amino acids, and its effects last much longer (7 hours). Drinking 16 to 32 ounces of chocolate milk within  20  to  30  minutes  after  weightlifting  or  other strenuous

exercise is the safest way to efficiently build muscles. Chocolate milk specifically is most helpful because chocolate reduces lactic acid that builds up during strenuous exercise, while milk provides an immediate source of both protein and carbohydrates.

Protein supplements available on the market consist primarily of casein, whey, or both proteins. If an athlete is set on using a protein supplement, it is best to use a product that has both whey and casein to maximize the benefit. Side effects of protein supplements include constipation, gas, diarrhea, dehydration (especially intravascular), and high prolactin levels (if tainted with steroids). Rare side effects have included liver, renal, and heart disease.

Nitric Oxide Producers
Considerable interest has been shown by athletes in nitric oxide and associated vasodilators to enhance athletic performance. Nitric oxide is a gas that is produced when an enzyme, nitric oxide synthase (NOS), breaks down L-arginine into L-citruline. The most common way to increase nitric oxide in the body is through exercise. As the heart pumps with more pressure to supply the muscles with blood, arterial walls release nitric oxide into blood. Nitric oxide dilates vessel walls, allowing greater blood flow. Athletes and youth have the most optimal nitric oxide systems, affecting their energy and resilience.

The supplement market is now flooded with products that contain L-arginine for athletes. The theory is that the athlete taking these products right before working out will provide maximal blood flow to the muscles. In reality, this shunts blood away from other vital organs, such as the brain, heart, and kidneys.

Athletes also theorize that by consuming these products in combination with creatine or protein supplements, these supplements are delivered more effectively to the muscles since the vessels are dilated. Common side effects of these products include hypotension, fainting, dizziness, nausea, diarrhea, changes in electrolytes, and increased bleeding. The long-term consequences of using these products are unknown and may be serious, particularly if they lead to cardiac hypertrophy and heart failure.

Ephedra Alkaloids
Similar to amphetamine, ephedra is a stimulant. Athletes use ephedra to improve mental alertness, limit fatigue, and reduce weight. In 2004, the FDA banned the sale of ephedra after it was linked to the sudden deaths of three college and pro athletes. However, some sports drinks and energy foods still contain ephedra or ephedra-like substances. It can also be found in cold products, such as pseudoephedrine (i.e., Sudafed). Athletes are increasingly using these products for their stimulant effects to enhance performance. Side effects include insomnia, tachycardia, hypertension, heart attacks, seizures, and death.

Growth Hormone
Growth hormone is a polypeptide secreted by the anterior pituitary. The liver converts growth hormone to insulin-like growth factor 1, which has several effects throughout the body. Its main role is to increase protein synthesis, lipid catabolism, and bone growth.

Although growth hormone has many benefits for those who are congenitally deficient, it does not hold similar promise for healthy young athletes. There is no conclusive evidence that growth hormone enhances athletic performance. Use of exogenous growth hormone requires a prescription, but athletes are easily able to obtain it over the internet. Growth hormone is banned by all major sporting leagues.

However, no reliable test to detect use by athletes has been developed. Nearly 5% of 10th graders have used growth hormone for enhanced athletic performance purposes. It is typically injected several times per month, and the cost of a 1-month supply can approach $5000. Athletes who take growth hormone often combine it with anabolic steroids. Side effects of exogenous growth hormone include acromegaly, myopathy, hypertension, papilledema with intracranial hypertension, and premature closure of growth plates.

Anabolic Steroids and Steroid Precursors
Most anabolic steroids are synthetic versions of testosterone or testosterone precursors. This male sex hormone is responsible for sex characteristics and the growth of skeletal muscle. More than 100 anabolic steroids or steroid precursors are on the market.

Trade names for these steroids include Anadrol, Anavar, Winstrol, and Oxadrin. Examples of steroid precursors are androstenedione and DHEA. Slang terms commonly used for these products are roids, hype, andro, pump, and juice.

These products are available legally, by prescription only, to treat certain medical conditions such as delayed puberty, muscle wasting, and some breast cancers. Unfortunately, these products are easily available over the internet without legitimate, legal prescriptions. Athletes engaged in endurance and strength-focused sports are the most likely to use steroids. Steroids are used to increase muscle mass, to train faster and longer, and to reduce recovery time.

Anabolic steroids have very dangerous side effects that include bone growth arrest; heart, kidney, and liver damage; high cholesterol; testicular atrophy; diabetes, mood swings; aggressive behavior; depression; fluid retention and acne. The use of anabolic steroids, and of the steroid precursor androstenedione, are banned by all athletic associations. DHEA remains an over-the-counter nutritional supplement. Although DHEA is a legal supplement, impurities during production can place athletes at risk for testing positive for a banned substance.

Advice to Parents and Athletes
Health care professionals play an important role in reducing the use of ergogenic aids in athletes. The best sports performance enhancers are adequate water, carbohydrates, and electrolytes.

For kids, adequate water intake is the most important exercise supplement. For vigorous or long-lasting exercise, sports drinks with electrolytes and snacks with sufficient carbohydrates should be used.

Encourage parents of athletes to educate themselves about the risks of products that children are buying in stores or over the internet.

Teach parents and athletes to be extremely cautious of supplement information on the internet. Most websites are trying to sell a product and provide very biased, unscientific information.

Discuss the health risks associated with products and encourage parents to do the same.

Advise parents to ask their child’s coach what rules are in place to reduce the use of these products, and what the school is doing to help educate athletes about ergogenic use.

Sources of information for parents and families:

• National Center for Drug Free Sports

• National Collegiate Athletic Association (NCAA)