Monday, February 1, 2016

Triathletes and Doping

by Larry Creswell, M.D.

Recently, an interesting study caught my eye. In the November 13, 2013 issue of PLOS ONE, a group of investigators from Germany reported on the prevalence of physical and cognitive doping in a group of nearly 3,000 age-group triathletes who took part in the Ironman Frankfurt, Ironman Regensburg, or Ironman 70.3 Wiesbaden events last summer. The study was simple and the results were perhaps surprising.

Short questionnaires -- available either in German or English -- were distributed and collected during race registration for the three events; nearly 97% of athletes completed the anonymous surveys. In addition to some basic identifying information, athletes were asked to answer two primary questions:

  1. Have you used substances which can only be prescribed by a doctor, are available in a pharmacy, or can be bought on the black market (such as anabolic steroids, erythropoietin, stimulants, growth hormones) to enhance your physical performance during the last 12 months?

  2. Have you used substances which can only be prescribed by a doctor, are available in a pharmacy, or can be bought on the black market (such as caffeine tablets, stimulants, cocaine, methylphenidate, modafinil, beta-blockers) to enhance your cognitive performance during the last 12 months?

The investigators were interested in two types of doping:

  1. Physical doping, intended to have a beneficial physical effect on performance
  2. Cognitive doping, intended to improve cognitive performance during a race (memory, attention, mood).

According to the authors, 13% of athletes reported physical doping and 15.1% reported cognitive doping during the previous year. The questions weren’t designed to tease out recent versus remote use of doping agents.

For perspective, some general characteristics of the study population included: 87.3% male and 12.7% female; age 18-79 years with mean age 39.5 years; 65.6% were using a structured training plan for their race; and mean training time per week was 13.2 hours. Remember that professional athletes were excluded.

This study is useful because it provides a contemporary look at the use of performance enhancing drugs (PEDs) among recreational athletes. These data help to inform event organizers, event medical workers, coaches, governing bodies, and indeed the broader triathlon community about the reality of PEDs today. It’s a bit discouraging to learn that, among the three races studied, the doping rates were highest at the Ironman Frankfurt race, the European Championship, where additional Kona slots and prestige were at stake for the best performers.

Over the past couple years, I’ve been asked many times about the possibility that PEDs somehow played a role in the deaths of athletes at triathlon events. I truly don’t know the answer. In fact, we may never know. But I can understand why people ask, particularly since perhaps 15% of age-group triathletes are doping. I’m not aware of any abnormal toxicology reports among victims, but I’m also not sure that toxicology analysis is typically pursued when an amateur athlete death appears to be accidental.

Aside from the possibility of event-related fatalities, though, there are other health concerns -- including heart and cardiovascular risks -- with the use of many of the physical and cognitive doping agents, over both the short and the long term. Here's an overview of some of the doping agents I’m most commonly asked about.

  • Anabolic steroids have a variety of effects on the cardiovascular system. They elevate the blood pressure and have an unfavorable effect on the serum lipid levels, raising the “bad” LDL cholesterol level and lowering the “good” HDL cholesterol level. Anabolic steroids have also been linked to abnormal thickening, or hypertrophy, of the heart muscle as well as to sudden cardiac death. I’ve written more about anabolic steroids and the heart at my blog.

  • Erythropoeitin (EPO) is used to stimulate the production of red blood cells, in the hopes of increasing aerobic capacity and decreasing or delaying fatigue. The risks of EPO are not well studied in the athlete population because its use is banned, but there appears to be a small risk of increased blood pressure, formation of various blood clots and an increase in inflammation. Used in clinical settings for the treatment of patients with anemia, the drug has come under recent scrutiny because of the cardiovascular risks associated with its use. I’ve written more about EPO at my blog.

  • Stimulants as a group have the unwanted side effect of producing arrhythmias. This is true even for the most innocuous of these drugs, caffeine. These are the agents that are sometimes at the center of speculation when athletes have problems like syncope (blacking out) or even cardiac arrest. As just one example of the stimulant drugs, I’ve written about Adderall at my blog.

  • Growth hormone is thought to be relatively safe when used clinically to treat children and adults. There have been reports of increased mortality rates over the long term when the drug is used for extended periods of time. Its use has not been well studied in athletes, again because it’s a banned substance.

Larry Creswell, M.D., is a cardiac surgeon and Associate Professor of Surgery at the University of Mississippi Medical Center in Jackson, Mississippi. In addition to his regular column on Endurance Corner, he maintains The Athlete's Heart blog to offer information about athletes and heart disease in an informal way and to encourage exchange and discussion that will help athletes build a heart-healthier lifestyle. You can contact him at
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