As we were writing ACSM’s consensus statement on  “Anabolic-Androgenic Steroid Use in Sports, Health and Society,” one piece of information that stood out to me was that users of anabolic-androgenic steroids (AAS) spent an average of 268 hours researching AAS before initiating use! That is a LOT of homework, and there is no way that the vast majority of us in sports medicine can match this degree of knowledge and research in an ongoing fashion. It can be intimidating when a patient or client knows more than we do on matters related to sport and performance. So, how do we keep up with all of this information?  

Our understanding of the physiology and epidemiology of AAS use has undergone significant evolution over the past few years, and this recently published ACSM consensus statement provides a solid update on the issues at hand regarding AAS use and abuse. I encourage you to give this document a look, but some basic patterns to understand include:

1. Contrary to popular perception of AAS use as primarily for performance enhancement, the majority of AAS users are male recreational athletes focused on increasing muscle size, rather than improving athletic performance per se. Muscle dysmorphia (aka “megarexia”) is a dominant risk factor for AAS misuse.
2. Regarding patterns of use: over 99% of AAS users are injecting these drugs; 80% are “stacking” different AAS compounds; and 40% are using ancillary drugs to minimize side effects.
3. AAS are Schedule III drugs with risk for physical and psychological dependence. With the increased use of testosterone as replacement therapy for aging men, or as part of gender affirming treatment for transgender males, more households will have ready access to AAS with greater risk for diversion of these drugs for non-medical use (similar to that seen with opiates and stimulants).
4. Data on the long-term muscle-related effects of AAS exposure is somewhat nuanced with many variables, and it is a “hot button” topic with large implications for transgender females in competitive sport. Controlled studies with short-term AAS use in exercising adults seem to show transient increases in strength and muscle size that dissipate within several months. However, these studies probably don’t reflect “real life” dose and patterns of non-medical AAS use. Longer-term use appears to increase muscle cell numbers and myonuculei, which would seem to create the potential for permanent advantage regarding building strength and muscle hypertrophy. This is an area that will spark much additional work and ongoing debate.

The medical profession has little credibility among AAS users, with less than 10% perceiving physicians or pharmacists as knowledgeable on the topic. Unfortunately, this may be accurate, and has a historical foundation. The first ACSM position stand on AAS in 1977 stated that there was no conclusive evidence that large doses of AAS “either aid or hinder athletic performance.” However, anyone who was paying attention to the performance of Eastern Bloc athletes at the 1976 Olympics may have come to a different conclusion, and the medical profession has had a difficult time regaining an authoritative voice on this topic since then. The publication of ACSM’s pronouncement is an important step in that direction. 

Our knowledge regarding the effects of AAS use will be increasingly tested as growing numbers of men are prescribed testosterone replacement therapy, and as legislation pertaining to sport participation by transgender athletes continues to proliferate. ACSM and the scientific rigor of our sports medicine community are helping us to reclaim credibility regarding use of AAS and other appearance and performance enhancing substances. Our consensus statement reflects the “state of the art” on the basic and applied science regarding the use of AAS in sport and beyond, and I would encourage you to take a few minutes to “up your game” on the subject and give it a read. Your patients, your athletes, and your community will be better for your effort.

Michele LaBotz, M.D., is a sports medicine physician who has been caring for athletes at all levels of participation since 1997. She is currently in private practice at InterMed’s sports medicine clinic in Maine.

Sports Supplements & Performance EXPLAINED

Courtesy of Nancy Clark's The Athlete's Kitchen

     In their effort to enhance energy and optimize performance, many athletes purchase vitamins, herbs, amino acids, and other sports supplements that are reputed to offer a competitive advantage. While a few supplements (beta-alanine, creatine, caffeine, nitrates) might play a small role when added to a well-thought-out fueling plan, no amount of supplements will compensate for a lousy diet.

     Fundamental to every high-performance athlete is an effective sports diet. All athletes should be taught from an early age how to optimize their performance using the food-first approach so they know how to best fuel-up, fuel during, and refuel after challenging exercise sessions. Once an athlete has finished growing and maturing and has fine-tuned his or her fitness and performance skills, some sports supplements might be appropriately introduced with guidance from a knowledgeable professional.

     That said, to the detriment of their wallets, many athletic people look for a glimmer of hope from the multibillion-dollar supplement industry. Consulting with a registered dietitian (RD) who is board certified as a specialist in sports dietetics (CSSD) could easily be a better use of money.

Supplements are popular

     A survey of Division-1 college students (89 females, 49 males) at Arizona State University indicated 77% consumed at least one “claimed to be” ergogenic aid (1). Another survey of U.S. Army personnel reports 75% used some type of dietary supplement at least once a week. Protein/amino acids were the most popular, taken by 52% of subjects (2).

      Why are so many athletes willing to spend (or is that waste?) a great deal of money to buy sports supplements? The glimmer-of-hope reasons include: to improve physical appearance or physique, increase muscle mass, optimize general health, and help meet physical demands on their bodies. Unfortunately, most supplements don’t work. Before you spend your money, please educate yourself about each supplement you plan to buy.

Where to learn more

    For information about (supposedly) performance-enhancing supplements, the U.S. Dept. of Defense website Operation Supplement Safety offers abundant information for anyone who is curious to learn more.  The website includes:

• a list of at least 28 unsafe sports supplements to avoid.

• a list of questions to help determine if a supplement is safe. (Does the label have a “certified safe” seal from Informed Sport or NSF? Is the label free of the words blend, matrix, proprietary, or complex? Does it make questionable claims?)

• an A-Z index with info about specific supplements, with all you need to know about Adderall, apple cider vinegar, caffeine, creatine, energy drinks, ephedra, ketone supplements, nitric oxide, omega-3 fats, pre-workouts, pro-hormones, proprietary blends, plus many more.

• information on unusual reactions and adverse effects (nausea, headaches, shakiness, elevated heat rate, mood change, etc.) and how to report an adverse event to the FDA and the National Institutes of Health (NIH).

       Another helpful source of information is the Australian Institute for Sport’s ABCD Classification System. The system ranks sports foods and supplements into four groups according to scientific evidence and practical considerations that determine whether a product is safe and if it effectively improves sports performance.

• Group A includes specialized products with strong evidence for benefits in specific events, including sports drinks, gels, iron, caffeine, beta-alanine, bicarbonate, beet root/nitrate, and creatine, among others.

• Group B deserves further research. It includes food compounds with anti-oxidant and anti-inflammatory properties (i.e., tart cherry juice, curcumin), vitamin C, and collagen, to name just a few.

• Group C lacks scientific evidence to support use. These include (and are not limited to) magnesium, alpha lipoic acid, HMB, BCAAs, leucine, vitamin E, plus more.

•Group D includes products with a high risk of leading to a positive doping test: ephedrine, DMAA, herbal stimulants, pro-hormones, hormone boosters (such as DHEA, androstenedione, Tribulus terrestris), and others.

What supplements do “work”?

Sports supplements that do “work” actually improve performance by just a small (but potentially valuable) amount (3), despite carefully crafted advertisements that can lead you to believe otherwise. Case in point, the popular branch-chain amino acids (BCAAs), specifically the BCAA leucine, which is known to activate the muscle-building process. Unfortunately, simply activating the process is not enough to promote muscle growth.

     BCAA research indicates they do not provide any benefits above and beyond the amino acids athletes normally consume when eating protein-rich food at meals and snacks. To see any meaningful muscle-building effect, you actually need to have many other amino acids present (as happens when you eat real food, as opposed to an isolated amino acid), as well as enough calories—and of course, a good strength training program plus adequate sleep.

Varied responses

     Even among supplements that “work,” the response varies greatly from person to person. Case in point, beta-alanine, a supplement used by athletes such as sprinters, rowers, and wrestlers to reduce muscular fatigue and improve endurance during high-intensity exercise that lasts for one to four minutes. The varied responses can be related to not only genetics and biological factors, but also to the power of the mind, the placebo effect, adequate fuel, and enough sleep. Hence, when a supplement does “work” for some athletes, the response may be due not to the supplement, but rather to the athletes getting serious about taking better care of their bodies, eating wisely and getting enough sleep (4).

     Enhancing sports performance may not require rocket science after all.

Author:

Sports Nutritionist Nancy Clark, MS, RD, counsels both casual and competitive athletes in the Boston area (Newton; 617-795-1875). Her best-selling Sports Nutrition Guidebook and her online workshop can help you eat a winning sports diet. Visit NancyClarkRD.com for more information.

References

1. Vento KA, Wardenaar FC. Third-party testing nutritional supplement knowledge, attitudes, and use among an NCAA I collegiate student-athlete population. Front Sports Act Living. 2020 Sep 15;2:115. doi: 10.3389/fspor.2020.00115

2. Bukhari A, DiChiara A, Merrill E, et al. Dietary supplement use in US Army personnel: A mixed-methods, survey and focus-group study examining decision making and factors associated with use. J Acad Nutr Diet. 2021; 121(6):1049-1063.

3. Maughan R, Burke L, Dvorak J, et al. IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete. Int J Sport Nutr Exerc Metab. 2018;28:104-125.

4. Esteves G, Swinton P, Dale C, et al. Individual participant date meta-analysis provides no evidence of intervention response variation in individuals supplementing with beat-alanine. Int J Sport Nutr Exerc Metab. 2021;31(4):305-313.

Impact of COVID-19 on Clinical Exercise Physiology: Performance, Practice, & Patients

The Clinical Exercise Physiology Association (CEPA) online conference

Saturday, October 2, 2021, 10 am to 5 pm EST

Approved for five (5) CECs from ACSM

Reduced registration fees:

Professional & Associate members only $25

Non-members $105 (Join CEPA today and SAVE)

Student members FREE

Learn more about conference speakers and register

View More Popular Content

Should Clinical Exercise Physiologists be Doctors? Explained

ACSM Guidelines Resources and Downloads

The YMCA Bench Press Test | An Alliance of Health and Fitness Member Feature

Health and Fitness Alliance Members save up to $70 on Certification exams and up to 50% on courses.

Join today and save!

Access More Exclusive Member Content

Exercise Physiologist Salaries and More | Member Article

Each year the U.S. spends over eight billion dollars treating skin disorders and cancers. Skin cancer is the most common cancer in the US, affecting around one in five Americans.¹ Melanoma, the deadliest form of skin cancer has been on the rise for the last forty years even though we know one of the major causes is excessive ultraviolet radiation (UV) exposure.^{2, 3} Our best method for measuring excessive UV exposure is sunburns.

Sunburns are preventable and there are some effective treatments to limit your UV exposure. You can use sun-protective behaviors such as wearing protective clothing (rash guards, long sleeves), use sunscreen, and seek out or create shade to avoid peak UV times during the day.²  These protective measures are important for active people because physical activity is related to a 28% increased risk of melanoma, primarily through sunburns rather than exercise directly.⁴

Tips to stay safe:

• Wear sun protective clothing and hats like rash guards, long sleeves and sun glasses with UV protective lens
• Use Sunscreen
• Seek out or create shade to avoid peak UV time with a shade umbrella or sunrise and sunset photo

How are sport and physical activity related to skin cancer?

You may be aware that skin cancer risk is increased from indoor tanning (which is unfortunately far too common in popular gym chains).⁵ However, you may not know that skin cancer risk from sunburns is similar to the cancer risk from indoor tanning. Unlike indoor tanning, sunburns are far more common among teens (57%) and adults (35%) and strongly related to participation in physical activity.^{2, 3, 6} Many physical activities take place outside during peak UV exposure times.

We hadn’t known if sunburns were more common for people who participate physical activity, but in a recent survey among adults sunburned in the last 12 months, 33% reported engaging in swimming or spending time near the water and 14% were sunburned while participating in leisure time physical activity.⁷ Other national data show that approximately half of adults (52%) reporting sunburn in the last year were sunburned specifically while swimming or while participating in non-swimming sports.⁸ More than half of adult golfers (58%) who play golf reported a painful sunburn in the past year.⁹ In addition, 12% reported being sunburned while watching a sporting event. Moreover, only a small percentage of those sunburned were seeking a tan.⁷ Unfortunately, among those sunburned while swimming, about 13% reported not using any sun protection, and among those sunburned doing non-swimming physical activity, almost 25% reported no sun protection or sun avoidance (e.g., seeking shade).⁷ Estimates from adult golfers are similar.⁹

Research suggests that sunburns are highly tied to physical activity and the large majority of people sunburned unintentionally were participating in sports or physical activity. A large majority of people sunburned were using sun-protection measures ineffectively and a small number of people sunburned reported using no protection while participating in physical activity.

Can sunburn and sun protection play a role in sports and athletic performance?

Sunburn and sun protection are important considerations for exercise performance and sports occurring in the sun, especially in hot and humid environments. Sunburn affects thermoregulation and the dissipation of excessive heat that can profoundly affect performance. It is a risk factor for heat related illness in athletes. Sweating, while vital for thermoregulation, also increases photosensitivity to sun i.e., reduces the amount of UV exposure (ultraviolet radiation) before sunburn will occur.¹⁰

Yet, sometimes, athletes must train under hot, humid and frequently high-UV (ultraviolet radiation) conditions to acclimate for competition, or they simply can’t control the schedules and locations for events and practices. So, what can athletes and recreational exercisers due when they can’t avoid the sun?

Applying sunscreen significantly reduces UV dose and can prevent sunburn.^{10, 11} Sunscreen may also improve microvascular blood flow to the skin, which normally is impeded with UV exposure, and plays an important role in thermoregulation and overall skin health and aging.^{11, 12}  While athletes report some barriers with sunscreen use (e.g., makes hands slippery or gets in eyes), these can be avoided when applied before going outside so it can be absorbed into the skin, choosing a sunscreen with the “feel” you like, and combining sunscreen use with clothing, hat/visor and sun glasses. Many sunglasses designed for sports are UV-rated and completely block UV radiation. Exercise apparel is also increasingly incorporating use of breathable but tightly woven materials with other sun protective features (e.g., UPF rating) that lessen the body surface area requiring sunscreen, which saves time and improves ease of application and reapplication. Some dermatologists recommend higher SPF sunscreen for athletes because of sweat effects on photosensitivity and the common finding that most people only apply about half the recommended amount of sunscreen. The CDC currently recommends broadband sunscreen with SPF of 15 or greater with reapplication every 80 minutes. Athletes may need to apply more frequently if toweling off.

Considering that sun protection can impact sports performance, overall health and skin cancer rates, there are strategies to use in sports and recreational physical activity. As ACSM members, we can engage as parents, coaches, advisors, sports/recreational governing bodies, and organizations in promoting sun protection. Given the limited number of sun protection programs for different physical activity contexts, we also need to understand what physically active children and adults will accept in the way of supports for sun protection if we hope to maximize uptake of these behaviors.

Exercise Science and Skin Cancer Prevention Research was a topic at the National Cancer Institute (NCI) meeting to engage exercise science and physical activity investigators into the conversation about individual and organizational demands and the ethos of the sports and physical activity context.¹³ We have an opportunity to play an important research role, particularly for youth who are especially sensitive to excess sun exposure.


Frank Perna, Ed.D., Ph.D.

David Conroy, Ph.D., FACSM, is a Professor the The Pennsylvania State University and an Adjunct Professor at Northwestern University Feinberg School of Medicine

References

1. Guy, G.P., Jr., et al., Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med, 2015. 48(2): p. 183-187.

2. Holman, D.M., et al., Sunburn prevalence among US adults, National Health Interview Survey 2005, 2010, and 2015. J Am Acad Dermatol, 2019. 80(3): p. 817-820.

3. National Cancer Institute, N., DHHS, Cancer Trends Progress Report Bethesda, MD, July 2021, https://progressreport.cancer.gov. July 2021.

4. Moore, S.C., et al., Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med, 2016. 176(6): p. 816-25.

5. Pagoto, S.L., et al., Assessment of Tanning Beds in 3 Popular Gym Chains. JAMA Netw Open, 2019. 2(12): p. e1918058.

6. Siegel, R.L., et al., Cancer Statistics, 2021. CA Cancer J Clin, 2021. 71(1): p. 7-33.

7. Holman, D.M., et al., The Context of Sunburn Among U.S. Adults: Common Activities and Sun Protection Behaviors. Am J Prev Med, 2021. 60(5): p. e213-e220.

8. National Cancer Institute, NIH., DHHS, HINTS 5, Cycle 3 (2019) dataset, updated April 2021. 2021. https://hints.cancer.gov/data/download-data.aspx

9. Weikert, A.E., et al., Golfers’ Interest in Multilevel Sun-Protection Strategies. International Journal of Environmental Research and Public Health, 2021. 18(14): p. 7253.

10. Wendt, D., L.J. van Loon, and W.D. Lichtenbelt, Thermoregulation during exercise in the heat: strategies for maintaining health and performance. Sports Med, 2007. 37(8): p. 669-82.

11. Kenney, W.L., et al., Temperature regulation during exercise in the heat: Insights for the aging athlete. J Sci Med Sport, 2020.

12. Wolf, S.T., et al., Sunscreen or simulated sweat minimizes the impact of acute ultraviolet radiation on cutaneous microvascular function in healthy humans. Exp Physiol, 2019. 104(7): p. 1136-1146.

13. Perna, F.M., Sun Safety in the Physical Activity Context: Opportunities and Challenges, in Dispatches from Implementation Science at NCI NCI, Editor. 2018 https://cancercontrol.cancer.gov/is/blog/dispatches-from-is-at-nci-blog-november-2018