Chapter 11: Muscle-Building Agents Used in Sports

As athletic trainers, we work with many athletes who are enticed to use muscle-building agents in order to become more competitive in their sport. Being more competitive can mean better scholarship opportunities to better schools where the athlete might have a chance to make it to professional sports and possibly make millions of dollars. Typically, in sports such as football and baseball, athletes are more willing to use muscle-building agents to become bigger, stronger, and faster. However, athletes competing in other sports, such as tennis, volleyball, or track and field, are becoming more willing to use drugs for ergogenic purposes. An ergogenic aid is something an athlete might take to increase work output or, more specifically, increase the potential for work output during the athlete's sport or activity.

The disqualification of many Olympic and non- Olympic athletes for the use of steroids has been headline news since the 1960s, when medical personnel from the Soviet-bloc countries were promoting steroid use to all types of athletes.⁵⁶ The June 3, 2002 issue of Sports Illustrated contained a number of articles discussing the use of steroids in major-league baseball by what is estimated to be over 50 percent of the players. Interestingly, USA Today (April 25, 2002) reported that a table-tennis player had been suspended for using steroids. The use of muscle-building agents by both male and female athletes, from baseball players to table-tennis players, continues to grow as the rewards of fame generated by sports performance continue to soar.

Muscle-building agents are abused not only by college and professional athletes; high-school athletes have also been using anabolic steroids for years. In 1988, Buckley et al.⁹ published what was then an eye-opening article indicating that approximately 6.6 percent of high-school seniors nationwide had used anabolic steroids starting at an average age of 16. In the years following, other authors have confirmed that high-school athletes continue to use anabolic steroids. Specifically, Whitehead reported that 5.3 percent of the athletes in a rural state were using steroids,63 and Johnson reported that 11.1 percent of high-school seniors in Arkansas were using steroids.²⁷ Stigler reported steroid use among Indiana high-school students at an estimated 6.3 percent; he further reported that an estimated 4.6 percent of the student-athletes in Ohio were using steroids.⁶⁶ In the southwestern states, the estimate was approximately 3 percent.⁶⁵ Nebraska high school students were the lowest, with 2.5 percent reported to be using steroids.⁴⁹ Use among the secondary school population is an issue not only in the United States. One report found that 2.7 percent of high–school-age students in Sweden are using anabolic steroids for a variety of reasons other than as muscle-building agents.³¹ Thus, the problem of anabolicandrogenic steroid abuse is growing in many different countries.

In this chapter we discuss the various types of musclebuilding agents and miscellaneous sports supplements commonly used today by high school, collegiate, and professional athletes. Some of these ergogenic aids are considered nutritional supplements and are sold in a variety of different stores frequented by athletes. Others are sold via the Internet. Nutritional supplements are not regulated or subjected to Food and Drug Administration (FDA) rules and regulations because they are marketed as food products, unlike prescription medications. (For more information on supplement use, please see Chapter 13). We begin this chapter by discussing one of the most popular ergogenic aids for muscle building in athletes: steroids.

Many different hormones are naturally synthesized in the human body. Males produces testosterone in the testes and females produce estrogen and progestin in the ovaries. These hormones are used by the body for the development of secondary sexual characteristics. Females also produce a small amount of testosterone via the adrenal gland and ovaries. These hormones have both androgenic and anabolic properties. The androgenic part of the compound promotes the male sex characteristics, such as body hair growth, deepening of the voice, and increased muscle mass. The anabolic compounds enhance tissue metabolism. Many times these drugs are referred to as anabolic/androgenic steroids (AAS) by the athlete or public when they are being discussed for their ergogenic properties.

In males, as previously discussed, testosterone is produced in the testes. In females, endogenous testosterone begins in the form of androstenedione and is converted to testosterone as needed. Testosterone is carried in the blood by one of three methods: via sex hormone-binding globulin (SHBG); bound to albumin; or if not bound, in what is called a "freeform" or unbound state. When carried by SHBG, testosterone is tightly bound and is not readily available for use by the tissues in the body. About 30 percent of male-available and 58 percent of female-available testosterone is carried by SHBG. A second method of testosterone movement in the body is via a loose bond to albumin. In males 67 percent of testosterone is carried in this manner, and in females 40 percent of testosterone is loosely bound to albumin. The remaining 3 percent for males and 2 percent for females is free and available to the system. The loosely bound and free testosterones are the most readily available forms for utilization by the body. As can be observed through outward secondary sex characteristics, males have much more testosterone readily available for utilization.

Both sexes naturally produce androgenic and anabolic compounds. Male and female hormones can also be synthetically produced and used for many different types of medical disorders, which will be discussed later. There has yet to be a synthetic steroid that does not produce both androgenic and anabolic properties in the person abusing them. Therefore both genders can experience the development of secondary sex characteristics of the opposite gender if these hormones are "out of sync" in the body or the person is abusing these drugs. Steroid abuse will be discussed in more detail further on in this chapter.

History

Throughout recent history, AAS have been used by some to gain an advantage over their competitors or enemies. The illicit use of AAS has been documented in war and athletic competition by numerous authors. It is reported that steroids were used to increase the size and aggressiveness of the German soldiers in World War II.⁴² As mentioned, the use of steroids for performance enhancement in athletes can be documented back to the 1970s in East Germany. In the 1960s and 1970s, the sports medicine teams for some Eastern- Bloc countries (East Germany, Poland, and others) were providing steroids to young athletes to increase size and improve performance in all types of sports. Ungerleider⁵⁶ reported that steroids were given to these Eastern-Bloc athletes unknowingly. They were told that the pills and shots they were receiving were vitamins that would help their athletic performance. When these athletes found out that they were receiving large doses of steroids, it was usually too late. Many of the female athletes had experienced the masculinizing effects of the steroids. Athletes were also experiencing the physical and mental problems associated with steroid abuse that will be discussed in the adverse effects section.

Because excessive use of steroids is illegal, it is virtually impossible to do scientific testing on athletes using steroids that accurately accounts for the true amounts they use on a daily, weekly, or monthly basis. Most of the information athletes receive about using steroids to generate muscle size and strength comes from people trying to sell steroids, such as teammates or friends who are also using steroids illegally. It is not reasonable to expect persons who are using drugs illegally to maintain accurate and reliable records over many years and then share that information with persons who may oppose the illegal use of these drugs. Essentially, we are aware that AAS will generate muscle mass, but we do not know how much a person needs to take in order to achieve significant gains. To prescribe steroids in the amounts typically used by athletes to build strength and increase body mass would be unethical and illegal in a legitimate scientific research project.

Therefore, in this chapter, we will discuss the prescription of steroids for medicinal purposes and the amounts reportedly abused by some athletes who were willing to divulge information regarding their steroid use. The major difficulty in analyzing self-reported data from illegal drug users is that there is no way to determine if the self reported amounts are correct. This makes it difficult to get objective information for the athletic trainer. The authors of this chapter find it very difficult to believe that information gathered from athletes using drugs is accurate and without bias. We do know that athletes who abuse steroids are taking more than the prescribed therapeutic dosages recommended for the treatment of diagnosed disease processes or other problems that can be treated by medicinal steroid use. The most common types of AAS are outlined in Table 11–1.

Methods of Use

Individuals who use excessive dosages of steroids as part of their weight-training activities follow what is called a stacking protocol or cycling. A stacking protocol consists of simultaneously using multiple types of steroid drugs in high doses. The cycling of drugs means that the athlete follows a timed cycle that begins with small doses and increases to very high doses, then tapers off to a drug-free period. Examples are given in Tables 11–2 and 11–3. The concepts of stacking and cycling drugs have been around for many years. These practices are believed to enhance the effectiveness of the total combination of steroids taken during the cycle. Some users believe that the stacking protocol can reduce some of the adverse effects produced by one or more of the more potent steroids being taken. Again, the recommended length of cycle, combination of steroids used, and daily dosing procedures vary depending on whom you talk to and what they have experienced or learned secondhand about these techniques. According to "experts," cycles range from 8 weeks to a year in length. Users may not take steroids every day, but instead may have weeks "on" and weeks "off" that correspond to the type of steroids being taken and the perceived reason for taking each drug.

The propagation of steroid abuse via Internet resources is astonishing. One has only to look for a matter of minutes on the Internet to find dozens of Websites promoting steroid use for a variety of objectives. Many Websites have steroids for sale and contain stacking regimens and question- and-answer pages. The use of commercial Websites as a source of information for athletes using steroids is unconscionable. These Websites can be very convincing, and a novice athlete could be easily persuaded to use steroids to gain muscle strength and body mass.

Physiological Effects of Steroids

It is difficult to document all of the physiological effects of steroids through scientific research, but many athletes can provide testimonials regarding the increase in body mass associated with steroid abuse. Usually, individuals use AAS to increase muscle strength by increasing muscle protein synthesis, inhibiting the catabolic effects of glucocorticoids, and increasing the aggressive behavior tendencies of the individual, thereby inclining him or her to train harder. Kadi et. al.³⁰ reported that taking steroids and participating in strength training increases the size of the muscle (hypertrophy) and the number of muscle fibers (hyperplasia). One must recognize that this study was conducted using subjects (weightlifters) who claimed that they had abused steroids for an average of almost 10 years. The investigators did not make any comparisons of the genetic makeup of the subjects. Some researchers would like to link steroid users' increase in strength to the increase in resistance training that is often associated with the abuse of AAS. Other researchers believe that the increase in strength correlates directly with the use of excessive doses of AAS. They posit that the steroids increase muscle mass; after an athlete has gained muscle mass, he or she is able to lift more weight.

Published clinical studies demonstrate that an increase in the size of a person occurs after the medicinal use of steroids, such as by a physician for growth delay in an adolescent. It is well documented that a person will get bigger when he or she uses supraphysiologic doses of AAS.^7,30,35 However, it is not well documented that the person will generate more strength. In published research, it has been demonstrated that when a person is abusing AAS, typically he or she is also performing a great deal of resistance training on a very regular schedule. This was demonstrated by Bhasin et al.,⁷ who demonstrated that either steroid use alone or resistance training alone will individually increase strength in some athletes. However, when steroids and resistance training were combined, the strength gains were greater than those achieved with either of the individual treatments.

It is also suggested that steroids may provide a decrease in reflex latency. A study conducted by Ariel and Saville3 indicated that there is a quicker patellar reflex response by the muscle from a stimulus in the athlete using AAS. This would indicate that athletes requiring quick reflex movements might benefit from the use of steroids. Almost any athlete would benefit from being quicker in his or her reflex activity; obvious examples include baseball players, hockey goalies, and volleyball players.

The effect of supraphysiologic doses of AAS on aerobic performance is not clear. Over the years, research studies have indicated that there does not appear to be a positive effect on aerobic performance.^4,17,52 However, athletes will explain that steroids give them a psychological advantage that assists them through the aerobic work and that they feel more vigor, energy, and aggressiveness as they exercise. The psychological aspect of the use of AAS is difficult to measure objectively. The use of AAS by endurance athletes has not been documented to improve their performance because the effects of steroids appear to be more generalized to the strength-training athlete.

Adverse Effects of Steroids

General

The adverse effects of steroid abuse can be similar in males and females. However, in some athletes, AAS can produce adverse effects that are very specific to the individual. Many times the adverse effects common to both male and female athletes can have long-term consequences on the internal organs of the body. Other types of adverse effects are specific to the male or the female steroid abuser and have signs and symptoms that are more outwardly observable.

In studies conducted on mice, it was demonstrated that testosterone propionate impairs the capillary function in cardiac tissue, which can lead to blood flow difficulties, especially during physical activity.⁵⁴ This decrease in blood flow may be one of the factors contributing to sudden death from cardiac failure in steroid abusers. Additionally, an athlete with a compromised cardiovascular system may be subject to a cerebrovascular accident. In addition to vascular and cardiac problems, the athlete can experience damage or drastic changes to other organs and systems.

Another problem that appears to cause difficulty for both genders is the damage to the liver by steroids from first-pass metabolism. Oral steroids are much more toxic and damaging to the liver than injectable steroids as a result of first-pass metabolism. Oral steroids are broken down in the gastrointestinal tract and delivered to the liver via the vascular network. The liver has the job of cleaning the impurities from the blood before it is circulated throughout the body, providing nutrients and oxygen to the rest of the body. The AAS are recognized as impurities, and the liver tries to metabolize these foreign substances and remove them from the blood. However, the liver cannot take all the impurities out of the blood, so some of the oral steroids get through to the other parts of the body. The steroids that are removed for processing are hard on the liver, and can ultimately cause severe and irreparable damage. Over time, the liver becomes chronically damaged and ceases to function properly. Continuing steroid use may cause such conditions as jaundice, peliosis hepatis (bloodfilled cysts), and tumors.

Injected steroids appear to be much more effective in building muscle. Steroids taken via intramuscular injection are not subjected to first-pass metabolism, but directly enter the blood and site of action. Therefore they are available to the muscle tissues in much greater amounts. The liver eventually does process some of the injected steroids that remain in the vascular system as blood is returned to the liver to be cleaned. In The Underground Steroid Handbook it is mentioned that injectable steroids are much more effective in making the athlete bigger faster. Of course, information provided by this and other nonscientific resources may contain misunderstandings and half-truths. It is easy to understand how a naïve athlete can be led to believe that the authors of these resources are telling the truth in all respects regarding the illegal use of steroids for performance enhancement.

The kidneys also play a role similar to that of the liver in cleansing impurities from the blood. When excessive levels of steroids are passed through the kidneys, this too can result in chronic dysfunction. Conditions such as hyperinsulinism, decreased high-density lipoprotein concentrations, and increased blood pressure are not uncommon in an individual with an AAS abuse problem.

Many, if not all, of the studies of problems associated with the abuse of AAS have focused on male athletes. However, when a female abuses AAS, the physical changes that can occur are typically irreversible. This does not mean that the physical adverse effects are always reversible in males who abuse AAS. Males must realize that when they abuse steroids, their body will go through changes that may not reverse on discontinuation of steroid abuse. For this reason, it is better to discuss the adverse effects of AAS abuse on males and females in separate subsections.

Adverse Effects in Males

One of the most talked-about adverse effects of steroids is their effect on the endocrine system. If exogenous testosterone is being taken into the body, there is no need for the endocrine system to produce testosterone. Therefore, the testicles may cease to produce sperm in the AAS abuser. Alternatively, AAS abuse can cause oligospermia (small number of sperm), azoospermia (lack of sperm in the semen), decrease in testicular size, and decreased production of testosterone. It is suggested that these effects will reverse when the exogenous testosterone is withdrawn, but there are no guarantees. Another well-documented side effect in the male AAS abuser is gynecomastia, female-type breast enlargement. Gynecomastia is not reversible, and some AAS abusers have their mammary glands surgically removed so that they do not continue to enlarge. Other steroid users augment their cycle or stacking with the drug Clomid, which is intended to counteract the actions of steroids that result in female-type breast growth.

The AAS abuser should also be prepared for premature balding; severe acne problems on the face, chest, or back; premature closure of growth plates in adolescents; enlargement of the prostate; impotence and decrease in libido; glucose intolerance, insulin resistance; ataxia; and tendon rupture in addition to the previously mentioned hepatotoxicity, increased risk of cardiovascular disease, and gynecomastia.^15,33,38 These are the adverse effects documented in the scientific literature. The undocumented adverse effects are just as significant but have not been reported in reputable scientific journals because of the inherent restrictions on how this type of research would have to be conducted (i.e., excessive amounts of the drug would have to be taken by human subjects to produce reproducible and credible results).

Adverse Effects in Females

Females also experience significant adverse effects from AAS abuse. The most common effect is masculinization. When a female takes large doses of the male hormone testosterone, over time she will begin to exhibit many male characteristics. Women may develop facial hair (hirsutism), male-pattern baldness, and a deepened voice tone. They may also develop an enlarged clitoris, along with a decrease in breast size, menstrual cycle changes, and amenorrhea. ³³ These changes are typically irreversible. Many of the problems males experience (described in the previous subsection) are also common in female AAS abusers. These can include acne problems, reduction in libido, and mood swings.

Adverse Effects in Adolescents

Adolescent athletes who abuse steroids have a significantly greater problem because AAS abuse can lead to premature closure of epiphyseal growth zones. This is a long-term side effect that can result in smaller adult stature. Obviously, this is the opposite effect that is desired: the athlete will not be bigger; he or she will be shorter.

Human growth hormone (HGH) is produced and released on a regular basis to aid in homeostasis of the body. It is also released as part of the regular hormonal changes that occur during exercise in both competitive and recreational athletes. Exactly how and when HGH is released during or after exercise is being studied on an ongoing basis. It appears that numerous variables influence the increase and decrease of HGH as related to exercise. However, some athletes have promoted the use of exogenous HGH as an ergogenic aid and to give them a competitive edge in their sport.

History

Before the mass production of synthetic growth hormone in 1986, HGH was cultivated from the pituitary glands of cadavers, which was costly and could introduce contaminants that could be passed along to the receiver of the drug. Animal GH could not be used because the growth hormone receptors in humans have affinity only for HGH. When HGH was bioengineered, it was developed to assist young people who were short in stature and not producing enough growth hormone to increase their height to normal levels for their age group. Athlete use of HGH has increased dramatically since the introduction of bioengineered or otherwise known as synthetic growth hormone.

In 1996, the Atlanta Olympic games were give the nickname "Growth Hormone Games" because of the impression that fewer athletes were using steroids and more were using HGH. The synthetic version of HGH is now much more affordable for many athletes and is much harder to detect in routine urine samples. Many athletes now use HGH to increase muscle mass, train with increased intensity and frequency, and facilitate quicker training recovery. ⁴⁸ When these factors are combined with claims of increased size and strength, the unscrupulous athlete has a nearly perfect drug.

Mechanism of Action

HGH is an endogenous substance produced by the pituitary glands in normal people. It facilitates the transport of amino acids across membranes, which increases the RNA in a cell and thereby enhances the protein synthesis of the cell. With enhanced protein synthesis, the cell can function at a higher capacity. HGH also maintains blood glucose levels, facilitates glucose and amino acid uptake into muscle cells, and assists in releasing fatty acids from adipose (fat) cells.

Effects on the Body

HGH has been shown to increase lean body mass and decrease fat tissue in individuals who were deficient in growth hormone.⁴⁵ Conversely, when GH-deficient individuals ceased using the supplement, they exhibited a decrease in muscular strength and fiber size and an increase in body fat.⁴⁴ When HGH is studied under scientific conditions, the results indicate that neither speed nor strength is enhanced in the athlete who is not deficient in growth hormone.^12,13,16

Although its ergogenic effects have not been proven, HGH continues to be used by many different types of athletes.

Adverse Effects of HGH

Many athletes are getting their information about the use of HGH on the Internet. These athletes typically do not receive the entire list of adverse effects, many of which are life threatening when using high doses of HGH. Fisher¹⁹ reported that the adverse effects of excessive use of HGH include, but are not limited to, the following: acromegaly, hypertension, cardiomyopathy, respiratory disease, diabetes, abnormal lipid metabolism, osteoarthritis, increased risk of breast and colorectal cancers, development of a "cone-shaped body," and excessive sweating. These are all adverse effects documented in individuals who used HGH for relatively short time periods.

During childhood, excessive secretion of HGH can cause gigantism or, after puberty, acromegaly. Other adverse effects include fluid retention and joint swelling, skeletal deformities, arthritis, and possible visual impairments.^21,62

Two other types of supplements have been reported to provide strength and muscle mass for athletes taking these drugs. They are described here.

Dehydroepiandrosterone

History

Dehydroepiandrosterone (DHEA) is a prohormone (a precursor to a hormone) that circulates in the blood. It is converted to androstenedione, a precursor to both the male and female sex hormones. DHEA was not commercially available from the mid-1980s until the mid 1990s because the FDA determined that it could cause liver damage if taken in excessive amounts. However, it is currently available commercially under a law that allows it to be marketed as a food supplement. See Chapter 13 for more details on the marketing of this substance.

Mechanism of Action

Blood-borne DHEA, produced in the adrenal gland, is typically converted to androstenedione, then to testosterone. The specific action of DHEA is very complex and depends on several factors, including gender and concentration. Many athletes believe that if they augment their diet with DHEA, they will increase testosterone production. As more testosterone is produced, the body is able to generate more muscle mass and repair damaged tissues. However, the ability of DHEA to increase an athlete's muscular strength, body composition, or other metabolic activities has not been proven.^8,62 DHEA became popular in 1993 as a cure for aging because DHEA levels appear to decrease as we age. However, these claims have been under scrutiny and are not proven. DHEA is used medically for various disorders including cardiovascular disease, obesity, and cancer.¹¹

Effects on the Body

In athletes, DHEA may act like a prohormone, increasing levels of androstendiol and eventually testosterone on a short-term basis. DHEA also acts as an antiglucocorticosteroid agent that alleviates the stresses from exercise and training, thus increasing recovery rates. However, evidence-based research in trained human subjects is inconclusive regarding the alleviation of these stresses. Athletes also consume DHEA because of its ability to disguise steroid levels in the body.

Many athletes appear to be spending money on DHEA. However, it has not been scientifically proven to have any effect on their strength or lean tissue mass. The use of DHEA as a supplement may be helpful only to older athletes in reducing cardiovascular problems and lipid levels.^5,18

In general, DHEA used as a supplement may have more benefit as an anti-aging product.

Adverse Effects of DHEA

DHEA is on the IOC and NCAA lists of banned substances. Long-term adverse effects are unknown, especially in the hormonal and endocrine systems.

Beta-hydroxy-beta-methylbutyrate

Mechanism of Action

Beta-hydroxy-beta-methylbutyrate (HMB) is an amino acid used in the body for cholesterol synthesis. HMB is produced from the amino acid leucine and is believed to have anticatabolic effects in humans. When HMB is taken into the body, it is broken down and used in cholesterol synthesis. Cholesterol is important to the body in cell building or membrane repair situations. HMB is thought to decrease muscle damage during activity and promote a faster recovery after stressful physical exertion.²⁰ In addition, HMB may decrease low-density lipoprotein concentrations, increase lean body mass, and increase strength. Thus, it is suggested that the use of exogenous HMB will provide the building mechanism or repair process to continue when the body is running low on the reserves it maintains from normal nutritional consumption habits.

Effects on the Body

HMB has been used for years by athletes wanting to increase strength and lean body mass.²⁰ Interestingly, there has not been a great deal of scientific research published on HMB. The scientific evidence published recently indicates that HMB does not appear to have much of an effect on improving strength or muscle mass.^40,51,59

HMB has also been analyzed for its ability to reduce the damage to muscle during eccentric (muscle-lengthening) exercise. However, HMB did not prove to be any different from other agents in curtailing damage to the muscle tissue.^40,34 It appears that short-term supplementation does not negatively affect the liver functioning, blood lipids, renal function, or immune system.²⁰ In summary, there is very little evidence that the consumption of high doses of HMB will enhance strength or increase lean body mass in athletes.

History

Creatine was first discovered in 1832 by the French scientist Michel-Eugène Chevreul. German scientist Karl Lohmann discovered adenosine triphosphate (ATP) in 1927. Only many years later was the connection between creatine and ATP made, and not until the 1980s did athletes start using creatine as an ergogenic aid.⁵⁰ Although there are reports of creatine use in the 1920s, not much research was reported between 1928 and the 1980s.

Mechanism of Action

Creatine is a substance that appears to be helpful to the muscle cell in producing energy for muscular activity. It assists in the process of rephosphorylation of adenosine diphosphate (ADP) to ATP and is taken into the system through ordinary dietary intake of meats and fish. Thus, an athlete participating in an exercise that requires short bursts of anaerobic power may benefit from creatine use, if indeed any benefit can be derived from this supplement.

When creatine is taken into the body, it is broken down in the liver and transported to the skeletal muscles, where it is stored mainly as phosphocreatine (PCr). When it is needed, it serves multiple functions. Phosphocreatine is important in energy production because it becomes a phosphate donor to convert ADP into ATP, which can then be used for energy. It is also thought that the PCr works as an energy shuttle to connect sites of energy production with energy utilization sites. The other uses for creatine or PCr are to act as a buffer to maintain normal pH in areas where a great deal of hydrogen is being released from the ATP hydrolysis. Some suggest that creatine is a modulator for glycolysis. When a great deal of energy is being used by a specific muscle or site, the decrease in PCr signals the need for increased glycolysis to that area.

Effects on the Body

In reviewing published research, there is debate as to whether creatine increases both muscle mass and strength in the athlete. Much of the published research indicates that creatine increases total body weight and fat-free mass.^6,41,58 The proponents of creatine postulate a couple of different theories as to why creatine will increase muscle mass and strength in the human body.^14,46,47,58 Dangott et al.¹⁴ reported that, in rats, creatine will increase satellite cell mitotic activity. Satellite cells can donate their nuclei to an enlarging myofibril, which will allow the new tissue to obtain the appropriate DNA to function on its own. Schedel et al⁴⁷ explained there is an increase in growth hormone secretion after creatine intake. Growth hormone will provide the environment for tissue growth and development to make the muscle bigger and consequently, stronger. Either of these physiological effects can be linked to an increase in muscle mass and, ultimately, strength.

The opposite argument regarding creatine supplementation is that it does not increase muscle mass or strength in athletes.^1,22,64 Most research indicates that muscle strength is not affected by creatine supplementation. However, the ability of the athlete to recover faster during resistance training episodes leads one to believe that the athlete is able to lift more weight. The maximum isometric contractions of the subjects in most studies has not shown improvement; therefore it would seem that maximal strength is not affected. It should be pointed out that the majority of studies published on creatine supplementation have been completed on males aged 18 to 35 years with little regard to its effects on females or the aging population.

After creatine supplementation, an increase in the athlete's total body weight has been documented and accepted by most researchers. The reason for this body weight increase is a point of contentious debate. Many researchers indicate that the increase in body weight is a result of water retention.^1,26,28,29

Creatine supplementation techniques are fairly standardized. First, it is generally recommended that creatine powder be mixed with a fruit juice (preferably grape juice) to increase the availability and transportability of the creatine in the body. Many sellers encourage the athlete to begin the creatine cycle with a "loading phase." During the first week, the athlete is told to ingest 20 g daily for 7 days and then take 5 g daily for the remainder of the time they will be taking the supplement. The idea behind the loading phase is to get as much creatine as possible into the system quickly and then maintain the increased levels with a smaller daily dosage. However, recent information suggests that there is no need to go through the loading phase of 20 g daily for the first week as promoted by most companies.^1,64 With the use of 3 to 5 g of supplemental creatine daily, the body will gain the extra levels over time.

The long-term benefits of creatine loading do not appear to make any difference in the 1 repetition maximum (RM) squat after 10 weeks of supplementation.⁶⁴ The total effect of creatine long-term supplementation is questionable when groups of users are compared to nonsupplementing groups in performing resistance exercise. Essentially, there does not appear to be any advantage to a loading phase in a long-term creatine supplementation plan.

An interesting note regarding creatine supplementation are the reports that up to 30 percent of people who use creatine fail to retain adequate storage levels in the body.⁵⁰ This indicates that about one-third of all creatine users will not gain any benefit from its use because their bodies are incapable of retaining the supplement. Thus, creatine supplementation cannot produce any type of enhancement effects in these athletes. To date there is no mechanism or technique that can easily and quickly determine who will benefit from creatine and who will not.

Who Uses It

Most creatine users would argue that the greatest benefit from its use is in activities that require rapid muscle recovery throughout the exercise period. The population using creatine includes athletes, individuals with muscle diseases, and aging persons. In the athletic population, the largest users of creatine are football players, specifically high-school juniors, seniors, and collegiate-level players.^23,28,36,39 The use of creatine by football players is obviously to make them bigger and stronger. Athletes in other sports use creatine to generate strength.³⁹ Other reasons why athletes may use creatine are to generate increases in total power, weight, and speed and to decrease body fat content.

When an activity requires the use of two different energy systems (anaerobic and aerobic), the replacement of glucose is critical to the athlete's performance. In a study that presents a new outlook on the types of athletes using creatine, it is argued that creatine could be helpful to athletes participating in sports that alternate between the anaerobic and aerobic systems (soccer, basketball, hockey, etc.) but utilize more aerobic metabolism for the majority of the activity.⁴³ The idea that creatine supplementation may be helpful to the athlete in a nonsteady-state exercise or when the anaerobic energy supply is diminished and the athlete is performing repeated high-intensity exercise with rest periods in between exercise bouts has some value. Multiple scientific studies replicating these findings in various sports have yet to approve or contradict this latest theory. The advantage of creatine supplementation in assisting with the aerobic power of a muscle is not proven, and there is no evidence of an anabolic effect from creatine supplementation at any dosage.

Adverse Effects of Creatine

When athletes were surveyed regarding their perception of the adverse effects of creatine use and the actual documented adverse effects, the athletes demonstrated a good knowledge of the actual reported adverse effects.^39,50 These are kidney damage, fluid retention, muscle cramps, upset stomach, and diarrhea.^1,29,50 Muscle cramping is reported to be more severe during the initial loading phase and is not as problematic during the continuation phase of creatine use.

Although athletes perceive that there are risks to using creatine, they continue to use it as a supplement because they do not believe the risks are long term or cause any physiological changes in their body. Most of the athletes using creatine think their coach is not aware of their creatine use; however, when asked where the most encouragement came from to use creatine, the most common response was "from friends," followed closely by "from coaches."^28,39 The largest source of discouragement for creatine use was parents, followed by friends and then coaches.³⁹

Androstenedione

Androstenedione, known as andro, is a testosterone or estrogen precursor. It is an androgen produced in the body by either the adrenal gland or the ovaries and is mostly converted into either testosterone in the male or estrogen in the female.

It is suggested that exogenous androstenedione taken by a male has the effect of supplementing the endogenous androstenedione supplies and providing more testosterone. This result is controversial at this time, and different researchers have come to varying conclusions about the ergogenic effect of androstenedione.

The real question is: Does oral androstenedione supplementation provide more of the necessary androgen to build muscle in the athlete? Leder et al³⁷ concluded that oral ingestion of high doses of androstenedione (300 mg/day) did increase the levels of testosterone in healthy males. Short-term supplementation (1 week) of androstenedione does not increase serum testosterone and does not increase skeletal muscle.³² Conversely, Earnst¹⁷ concluded that as much as 300 mg/day of oral androstenedione will not produce a positive outcome in young, healthy males. When lower dosages of androstenedione (200 mg/day) were consumed by athletes, plasma testosterone was not elevated.⁴ New research following the breakdown of substances in the body via different metabolic pathways suggests that androstenedione may not convert to testosterone in the body. DHEA will convert to androstenedione after ingestion, but after this change still does not increase the serum testosterone levels in the athlete.¹⁷

Although an athlete may think that supplementing with androstenedione will benefit his or her resistance training, the scientific research does not support that theory. In fact, significant damage can be done by abusing androstenedione, including an increase in estrogen production and an impairment of the body's ability to metabolize lipids in healthy young males.¹⁷ Androstenedione has not been proven to increase muscle size, and has no effect on protein synthesis or muscle mass.

Androstenedione has been marketed as a dietary supplement and can be purchased at many nutritional supplement stores by anyone wanting to take the drug. The International Olympic Committee and the National Football League have banned the use of androstenedione, but other sporting governing bodies continue to allow athletes to use this supplement.

The adverse effects of high doses of androstenedione are similar to those of AAS in both male and female athletes.³⁷ Damage to the liver and cardiovascular system are in all probability connected with high doses of androstenedione. Long-term masculinizing effects in women are also likely with the abuse of androstenedione.

19-norandrostendione

Some athletes are starting to use 19-norandrostendione, a water-soluble supplement, under the impression that it will convert to nandrolone in the body. Many athletes using 19- norandrostendione have a marked increase in nandrolone in their urine samples. Thus the athlete makes the supposition that 19-norandrostendione is converting to nandrolone in the body and is available for use to generate muscle mass. This supplement has not been studied in detail at this time, but the results currently available from scientifically based research do not indicate that there is any improvement in muscle size or strength with 19-norandrostendione. One adverse effect recognized at this time is that, after just a single dose of 19- norandrostenedione, the athlete may test positive for illegal steroid use up to 10 days after the original dose.

Chromium Picolinate

Mechanism of Action

In the 1990s there was some suggestion that the use of chromium picolinate supplementation would enhance the strength capabilities of the young athlete, increase muscle size, and decrease the percentage of body fat. In older individuals, chromium may slow down the changes in body composition associated with aging. Chromium is a trace element that works in the body with other compounds to assist with the regulation of nutrient metabolism (fat, carbohydrate, and lipid) through insulin activity. The action of chromium on the metabolic pathways may be beneficial for individuals who have blood glucose irregularities (such as diabetes) by improving impaired glucose tolerance and decreasing blood lipid concentrations.^2,25 Exactly how chromium works with insulin in the body is an ongoing debate among many researchers, but it is thought to be connected to the binding of insulin to its specific receptors.

Effect on the Body

Chromium supplementation has been studied and does not appear to have an ergogenic effect on athletes or the aging population in terms of body composition, energy metabolism, or muscular strength or power.^10,24,55,60

Adverse Effects of Chromium Picolinate

Chromium picolinate supplementation may cause headaches or sleep disturbances, although these adverse effects are based on anecdotal evidence.

1. An ergogenic substance is something that has:

   1. A genetic beginning

   2. Eggs in the supplement

   3. The ability to increase exercise output

   4. To be injected into the body

2. Steroid use has been traced to which of the following athletic populations?

   1. High school

   2. College

   3. Professional

   4. All of the above

3. Only males produce testosterone.

   True  False

4. The term endogenous means:

   1. Originating within the organism

   2. Contains eggs in the supplement

   3. Will increase work output

   4. Has a genetic ending

5. Irreversible adverse effects of steroids in females include:

   1. Increased foot size

   2. Increased acne

   3. Masculinizing effects

   4. Sterility

6. When an athlete is simultaneously using multiple types of steroids in high doses, the athlete is said to be:

   1. Injecting

   2. Stacking

   3. Maximizing

   4. Producing

7. By using high doses of AAS, an athlete will definitely experience:

   1. Adverse side effects

   2. Faster running speeds

   3. More wins in their sport

   4. Stronger muscles

8. Which of the following AAS are least affected by first-pass metabolism?

   1. Androgenic

   2. Oral

   3. Anabolic

   4. Injected

9. HGH is now mainly available from what source?

   1. Human cadavers

   2. Monkeys

   3. Synthetic production

   4. Pig pituitary glands

10. DHEA is a precursor to:

    1. Androstenedione

    2. Human growth hormone

    3. HMB

    4. Creatine

11. Creatine is reported to result in an increase in weight mainly because of an increase in:

    1. Calories consumed

    2. Strength

    3. Bone size

    4. Water retention

12. The physiological argument for creatine use is that it provides an increase in:

    1. Strength

    2. Energy production

    3. Anaerobic capacity

    4. Aerobic capacity