Patient Presentation
A 13-year-old male came to clinic for his sports physical. During the interview he asked about using creatine to help him with his weight training for football.
He said that he didn’t know much about it, just that other boys were taking it and they said it would increase his size and he would be able play football better.
He denied taking any supplements or other performance enhancing substances or other complementary/alternative medicines.
He was otherwise healthy and the interview revealed no other concerns.
The pertinent physical exam showed a healthy male with weight at the 75% and a height at the 90% for age. He was tanner 3 for pubertal development.
The diagnosis of a healthy male was confirmed.
He was counseled that although creatine was not illegal to take, there was almost no information in adolescents if it actually worked and there were potential side effects such as nausea and vomiting and dehydration.
He was also reminded that if he had these side effects then he wouldn’t be able to train or participate. There was also the cost of the creatine.
He was reminded that he could be strong and beat his competitors without creatine or other supplements or performance enhancing drugs.
He was counseled that these supplements are of unknown purity and may or may not contain what is on the label.
He was reminded that proper strength, conditioning and a well-balanced diet including extra calories, extra carbohydrates during workouts, and extra protein after workouts are the best way to build his strength.
Discussion
Performance enhancing substances or ergogenic substances are supplements or drugs used to enhance athletic performance. They are widely used because of the desire to be strong, look better, improve overall performance and because of peer pressure.
They are commonly classified as metabolic stimulants (e.g. Ephedra) or anabolic agents (e.g. anabolic-androgenic steroids, prohormones, protein supplements and creatine).
Few if any medical research studies with these substances have been performed on children or adolescents. What little research is available was done almost exclusively in adult populations.
Nutritional supplements are not regulated, controlled, or have any oversight by the FDA or other government agencies.
Therefore, a supplement may or may not have the labeled substances in it and the amounts listed may or may not be accurate.
When counseling adolescents it helps to emphasize the current or near future effects. For example, for anabolic-androgenic steroids emphasize the decreased tendon strength (i.e. risk for rupture) and the irreversibility of gynecomastia and virilization rather than the malignant risk.
Emphasis on what adolescents can do, such as proper strengthening and conditioning along with eating a well-balanced diet including extra calories, extra carbohydrates during workouts, and extra protein after workouts may be helpful.
Learning Point
Some of the common performance enhancing substances are listed below.
Creatine
- Action: amino acid compound synthesized in skeletal muscle that facilitates regeneration of ATP needed for muscle contraction
- Proposed effects: delays workout fatigue, promotes weight gain, improves performance for sports needing short bursts of energy (e.g. weight lifting, sprinting, etc.)
- Medical research: increases workout capacity for certain short burst energy sports, increases weight mainly through water retention, improves physiologic response to resistance training, does not improve endurance
- Potential side effects: muscle and stomach cramps, nausea and diarrhea, dehydration, renal overload with rare case reports of renal failure
- Legal: Not banned by sports governing organizations, but the National Collegiate Athletic Association prohibits distribution at training facilities
Protein supplements
- Action: increases dietary protein intake
- Proposed effects: increase lean muscle mass, strength and power, promotes weight gain
- Medical research: does not build muscle strength or mass by itself, requires increased calorie and carbohydrate intake for strength and muscle mass increases, weight gain varies depending on the athlete’s routine diet
- Potential side effects: antedoctal reports of renal problems
- Legal: not banned by sports governing organizations
Prohormones
- Names: Androstenedione and DHEA
- Action: hormone precursors to testosterone
- Proposed effects: increases strength, improves performance and builds muscle
- Medical research: in moderate doses does not increase testosterone, in high doses may increase testosterone, not proven to increase strength, muscle mass or performance
- Potential side effects: same as anabolic-androgenic steroids, increased estrogen effect and therefore may increase hormone-sensitive malignancies
- Legal: Androstenedione is banned by sports governing organizations and is a controlled substance by the Federal Drug Administration (FDA). DHEA is available as a nutritional supplement and therefore is not regulated.
Anabolic-androgenic steroids
- Action: increases protein synthesis, enhanced development of male secondary sex characteristics. All anabolic steroids are also androgenic.
- Proposed effects: increases strength, improves performance and builds muscle
- Medicalresearch: increases muscle mass and strength at high doses, does not increase endurance, not proven to improve performance
- Potential side effects:
- Cardiovascular: cardiomyopathy, hypertension, lipid profile changes (decreased HDL, increased LDL)
- Endocrine/reproductive: gynecomastia in males (irreversible), precocious puberty, testicular atrophy, virilization in females (irreversible)
- Gastrointestinal: liver enzyme elevation, jaundice, possible malignancy
- Musculoskeletal: premature closure of growth plates, decreased tendon strength
- Psychological/behavioral – these problems can last up to one year after the steroids are stopped: mood swings, aggressive behavior (“roid rage”) depression and/or suicide, psychosis, addiction/dependence and strong correlation with other drug use
- Legal: banned by sports governing organizations, are controlled substances by the FDA
Ephedra
- Herbal name: ma huang
- Action: sympathomimetic which acts on alpha and beta adrenergic receptors
- Proposed effects: burns fat, increases energy, decreases appetite, delays workout fatigue and improves performance and concentration
- Medical research: burns fat when combined with high-doses of caffeine. It may delay fatigue but this is not proven.
- Potential side effects (which can be potentiated with caffeine): include heart attack, hypertension, stroke, seizure, sudden death and heat stroke
- Legal: banned by sports governing associations, and banned by the FDA
Questions for Further Discussion
1. What are the costs of common performance enhancing substances?
2. Where can common performance enhancing substances be obtained?
3. What performance enhancing substances are tested for by different sports governing organizations?
Related Cases
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MEDLINEplus for this topics: Anabolic Steroids and Herbal Medicine
and at Pediatric Common Questions, Quick Answers for this topic: Substance Abuse.
To view current news articles on this topic check Google News.
Kreider RB. Effects of creatine supplementation on performance and training adaptations. Mol Cell Biochem. 2003 Feb;244(1-2):89-94.
American Academy of Pediatrics. Committee on Sports Medicine and Fitness Policy
Statement. Use of Performance-Enhancing Substances. Pediatrics. 2005;115:1103-1106.
LaBella CR. Ergogenic Substances. Pediatric Academic Societies Meeting, San Francisco CA. April 30, 2006.
ACGME Competencies Highlighted by Case
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
May 22, 2006
Pediatric Education 