Androgenic-anabolic steroid-induced body changes in strength athletes

Androgenic-anabolic steroid-induced body changes in strength athletes Citation for published version (APA): Hartgens, L. M. G., van Marken Lichtenbelt, W. D., Ebbing, S., Vollard, N., Rietjens, G. J. W. M., & Kuipers, H. (2001). Androgenic-anabolic steroid-induced body changes in strength athletes. Physician and Sportsmedicine, 29, 49-66. https://doi.org/10.3810/psm.2001.01.316 Document status and date: Published: 01/01/2001 DOI: 10.3810/psm.2001.01.316 Document Version: Publisher's PDF, also known as Version of record Document license: Taverne Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: repository@maastrichtuniversity.nl providing details and we will investigate your claim. Download date: 19 Feb. 2024 The Physician and Sportsmedicine ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: https://www.tandfonline.com/loi/ipsm20 Androgenic-Anabolic Steroid—Induced Body Changes in Strength Athletes Fred Hartgens, Wouter D. Van Marken Lichtenbelt, Spike Ebbing, Niels Vollaard, Gerard Rietjens & Harm Kuipers To cite this article: Fred Hartgens, Wouter D. Van Marken Lichtenbelt, Spike Ebbing, Niels Vollaard, Gerard Rietjens & Harm Kuipers (2001) Androgenic-Anabolic Steroid—Induced Body Changes in Strength Athletes, The Physician and Sportsmedicine, 29:1, 49-66, DOI: 10.3810/ psm.2001.01.316 To link to this article: https://doi.org/10.3810/psm.2001.01.316 Published online: 19 Jun 2015. Submit your article to this journal Article views: 75 View related articles Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ipsm20 ORIGINAL RESEARCH Androgenic-Anabolic Steroid-Induced Body Changes in Strength Athletes Fred Hartgens, MD; Wouter D. Van Marken Lichtenbelt, PhD; Spike Ebbing, MSc; Niels Vollaard, MSc; Gerard Rietjens, MSc; Harm Kuipers, MD, PhD BACKGROUND: Some strength athletes use androgenic-anabolic steroids (AAS) to improve body dimensions, though the drugs' long- and short-term effects have not been definitively established. OBJECTIVE: This study sought to investigate the short- and long-term effects of AAS self-administration on body dimensions and total and regional body composition. DESIGN: This prospective, unblinded study involved 35 experienced male strength athletes: 19 AAS users (drugs were self-administered) and 16 non user controls engaged in their usual training regimens. At baseline, 8 weeks, and 6 weeks after AAS withdrawal (for AAS users) circumferences were measured at 10 sites, and skinfolds measured at 8 sites. To assess differences in AAS regimens, 9 subjects took AAS for 8 weeks (short-AAS) and 10 athletes took PAS for 12 to 16 weeks (long-AAS). Body composition and anthropometry were assessed at baseline, at the end of AAS use, and 6 weeks later. Lean body mass (LBM) was calculated from body weight and percentage fat. Total and regional body composition was measured by dual-energy x-ray absorptiometry. RESULTS: AAS use increased users' body weight by 4.4 kg and LBM by 4.5 kg, and produced increases in several circumferences. Percentage of fat decreased (17 .0% to 16.0% ), but fat mass remained unchanged. Changes persisted 6 weeks after drug withdrawal but were not less than those taken at 8 weeks. Bone-free lean mass of all regional body parts increased in subjects taking AAS, but fat mass was unaffected. Short- and long-term AAS users did not differ in any parameter measured at 8 weeks or after drug withdrawal. CONCLUSION: In AAS users, 8 weeks of self-administered AAS increased body weight, lean body mass, and limb circumferences, but decreased percentage fat compared with controls. Changes remained 6 weeks after drug withdrawal, though for some measurements only partially. AAS stimulated the bone-free lean mass of all body parts, but it did not affect fat mass. Short-term and long-term AAS administration produced comparable effects. T he use of androgenic-anabolic steroids (MS) in athletes seems to be widespread. As reported by laboratories accredited by the International Olympic Committee,' these drugs have been the most frequently detected substances in urine samples of athletes. MS use by elite athletes is of great concern for national and international sports federations because the drugs give users an unfair advantage and produce potentially dele terious health effects.2 • 3 MS use is not limited to elite For CME, see www.physsportsmed.com/cme.htm beginning in February 2001 athletes, however, and may be more extensive among recreational and amateur strength athletes, even though the media devote less attention to use in these groups. Strength athletes often progress to self-administra tion of AAS to increase muscle mass and strength. Weight lifters and power lifters strive primarily for strength, whereas bodybuilders train for optimal muscle mass and body dimensions.' Consequently, in all strength athletes increased muscle mass is desir able. Only a few studies have investigated the effects of MS on muscle mass and body dimensions. Unfor tunately, data are equivocal, and many questions re main to be answered. continued 49 THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 11@@i@j continued Our study sought answers to three questions: (1) Which body measure ments and composition are altered in strength athletes when they use sev eral AAS simultaneously? (2) Does self-administration of AAS exert dis tinct effects on the separate compo nents of regional body composition? and (3) What impact does the dura tion of AAS use have on anthropome try and body composition? Methods TABLE 1. Baseline Physical and Training Status of Strength Athletes Characteristic AAS (n = 19) Controls (n = 16) 32.8 ± 5.3 177 ± 7 88.5 ± 11.2 19.4 ± 3.6 Age (yr) Height (cm) Weight (kg) Body fat(%) Training history (yr) Training regimen (hr/wk) 31.3 ± 7.0 176 ± 9 84.0 ± 9.9 17.0 ± 5.7 10.0 ± 7.3 8.8 ± 2.5 8.8 ± 3.6 8.2 ± 2.3 Values are expressed as the mean± standard deviation; AAS =androgenic-anabolic steroid Subjects and their AAS use. Strength athletes were recruited with advertisements at local gyms. Inclusion criteria were: male, at least 3 years of strength training experience, and age between 20 and 45 years. Candi dates excluded were those who smoked or had hyper tension, diabetes mellitus, liver disease or abnormal liv er enzyme levels, hereditary hypercholesterolemia, elevated serum cholesterol levels (>6.5 mrnol/L), or in fertility. Before participating, all subjects completed a questionnaire containing questions about medical his tory, health status, training experience and status, nu trition, nutritional supplement use, and AAS use. After the initial screening, each strength athlete under went a full medical examination by a physician for evalu ation of health status and to screen for possible missed exclusion criteria During the examination, we provided extensive oral and written information about the study to each subject. All subjects signed an informed consent form approved by the Ethical Committee of Maastricht Dr Hartgens is research and science coordinator at The Netherlands' Center for Doping Affairs in Capelle aan den IJssel, The Netherlands. Or Van Marken Lichtenbelt is assistant professor in the department of human biology at Maas tricht University, Mr Ebbing and Mr Vollaard were Masters students at The Netherlands Center for Doping Affairs in Capelle aan den IJssel. Mr Rietjens is assistant research and science coordinator at The Netherlands Center for Doping Affairs in Capelle aan den IJssel and a doctoral candidate in the department of movement sciences at Maastricht University, Maastricht, The Netherlands. Dr Kuipers is head of the department of movement sciences at Maastricht University. Address correspondence to Fred Hartgens, MD, The Netherlands Centre for Doping Affairs, PO Box 5014, 2900 EA Capelle aan den IJssel, The Netherlands; e-mail to fred.hartgens@necedo.ni. University (Maastricht, The Netherlands). Thirty-five strength athletes participated in this study. Most athletes (28) performed strength training mainly for esthetic purposes and characterized their training regimen as bodybuilding training; only 7 of these subjects participated in bodybuilding contests. Seven participants were competitors: 3 engaged in strength training as a part of their boxing training in addition to using AAS for esthetic reasons, and 4 ath letes were principally involved in resistance training for powerlifting competition. Among the subjects, 19 had decided to begin using AAS to supplement their regular strength training regi men (AAS group). The remaining 16 volunteers who had not used nor were willing to take AAS served as con trols (CO group). The physical and training characteris tics of both groups are presented in table 1. Assessing AAS status. Before entering the study, AAS group members were expected not to have used AAS for at least the previous 3 months. This was veri fied from information that each subject provided and was corroborated by urinalysis before the start of the study. Interviews revealed that AAS subjects had been drug-free for 8.1 ± 6.4 months (range, 3 to 30 months). All but l of the AAS group had previously used AAS. The average participant had started using AAS 4.8 years (range, l to 14 years) before the study, and the mean number of AAS cycles self-administered was 7.1 (range, l to 30 cycles). Study disclaimer. Although several subjects had re ceived a prescription for steroids from a physician, most AAS users bought the drugs on the black market. Users devised MS regimens based on information provided by other strength athletes and on their own THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 53 (i!Ji@i@j continued TABLE 2. Subjects and Duration, Route, and Total of Androgenic-Anabolic Steroids Used ID Number AAS Duration (wk) Drug (route) Total Used* 1. BC101 16 2.SS102 16 3. MB108 8 4. JD111 12 5.ES112 16 stanozolol (im) nandrolone decanoate (im) metenolone ~po l metenolone im drostanolone (po) mesterolone (po) stanozolol (im) nandrolone decanoate (im) metenolone f~oj mefenoione 1m drostanolone (po) mesterolone (po) --·-·----~------··· --.... -~----~,_ ___ ' -·--~ ------·-.. ~--~-~ nandrolone decanoate (im) trenbolone acetate (im) methandrostenolone (po) chorionic gonadotropin (im) ---------------------------------- testosterone enanthate (im) stanozolol (im) nandrolone decanoate (im) -· -·-··--··' -------·----~ 500 mg 350mg 375 mg 1,400 mg 14 mg 350 mg 500 mg 350 mg 375 mg 1,400 mg 14 mg 350mg ~---~-·~~---~·--·· --~ 1,600 mg 228mg 940mg 9,000 IU ------ 1,250 mg 700mg 100 mg stanozolol (im) 750 mg stanozolol (po) 450 mg testosterone propionate (im) 375 mg nandrolone decanoate (im) 875 mg metenolone (im) 300 mg ----·------·-----·------········· -........................ ______ ..... , .. _______ .. __ 6. JN113 8 7.GS115 16 8.FB121 8 9.RT122 16 methandrostenolone (po) nandrolone decanoate (im) drostanolone (im) ~---·-,---~ _,.-..... ··~·-·"-··-----~ .. ---· clenbuterol (po) stanozolol (po) nandrolone decanoate (im) stanozolol (po) stanozolol (im) trenbolone acetate (im) chorionic gonadotropin (im) testosterone undecanoate (1m) tamoxifen (po) nandrolone decanoate (im) stanozolol (im) chorionic gonadotropin (im) stanozolol (po) methandrostenolone (po) testosterone heptilate (im) AAS = androgenic-anabolic steroid; im = intramuscular; po = oral 960mg 300mg 300 mg Subject began stacked use of these but did not know exact doses Subject said dosages were "high" for each drug ----·-·------·------ 2,000 mg 750mg 13,500 IU 1,080 mg 1,240 mg 3,000 mg I ID Number AAS Duration (wk) 10. GR124 8 11. PW125 8 -·----------- 12. MD139 12 13. CL148 8 ~---~--------- 14.FL151 12 15. RD161 8 16.HK401 8 17.GT402 16 18.DV403 8 19.EK404 12 insights and beliefs. Table 2 presents the details of MS use in participants. Readers should note that the inves tigators did not provide MS, that researchers did not at tempt to influence which MS was used, and the re searchers did not have any role in MS administration. that was divided in three experiments to investigate the objectives set (figure 1). Study design. We conducted a nonblinded study 54 Experiment 1: Total body composition and anthro pometry. Experiment 1 was designed to investigate changes of body composition and anthropometric measurements in strength athletes induced by self-ad Vol 29 • No. 1 • January 2001 e THE PHYSICIAN AND SPORTSMEDICINE Drug (route) Total Used* methandrostenolone (po) mesterolone (po) metenolone Jim) nandrolone ecanoate (im) testosterone (phenyl-) propionate isohexanoate (im) trenbolone acetate (im) stanozolol (im) boldenone (im) stanozolol (po) mesterolone (po) metenolone (im) oxymetholone (po) nandrolone decanoate (im) nandrolone decanoate (im) stanozolol ~po l stanozolol im testosterone enanthate (im) testosterone cypionate (im) chorionic gonadotropin (im) methandrostenolone (po) testosterone cypionate (im) trenbolone acetate (im) chorionic gonadotropin (im) methandrostenolone (po) metenolone (po) mesterolone (po) 560mg 1,400 mg 800mg 400mg 1,750 mg 602 mg 250mg 300mg 420mg 5,600 mg 1,600 mg 3,500 mg 1,625 mg 2,600 mg 1,036 mg 850 mg 3,750 mg 5,000 mg 4,500 IU 980mg 750 mg 880 mg 4,500 IU 1,115 mg 1,850 mg 675mg stanozolol (po) oxymetholone (po) nandrolone decanoate (im) clenbuterol (po) testosterone enanthate (im) testosterone cypionate (im) drostanolone (im) tanozolol (im) stanozolol (im) testosterone (im) l clenbuterol {po oxymetholone po) chorionic gonadotropin (im) tamoxifen (po) 2,170 mg 1,225 mg 4,400 mg 1.68 mg 2,500 mg 1,000 mg 300 mg 1,200 mg 1,150 mg 5,500 mg 1 mg 1,900 mg 1,500 IU 440mg ministered MS. Body composition and dimensions were assessed by taking skinfold thicknesses and cir cumferences, respectively. Measurements were taken before the start of MS use {baseline) and after 8 weeks of MS use. In all MS users, measurements were also tak~n 6 weeks after drug cessation, regardless of the length of MS self-administration. In controls, the same measurements were done at the start of the study and after 8 weeks of strength training. Experiment 2: Regional alterations of body compo sition. Eleven strength athletes (6 MS, 5 CO) from ex periment 1 were randomly selected to participate in experiment 2. Subjects' body composition was deter mined with dual-energy x-ray absorptiometry (DEXA), in addition to the regular body composition and anthropometric measurements taken in experi ment 1. In 6 strength athletes, we performed DEXA measurements at baseline and after 8 weeks of MS self-administration. In 5 controls, body composition measurements by DEXA were carried out only at the start of the study. Experiment 3: Impact of duration of MS self-admin istration. Before the start of the study we divided the MS users from experiment 1 into two subgroups based on their intended MS course duration. Nine subjects had decided to take these drugs for 8 weeks (short MS), while the remaining 10 athletes intended to use MS for 12 to 16 weeks {long-MS). Anthropometric measurements and determination of body composi tion were carried out at baseline, at the end of the drug administration, and 6 weeks after MS withdrawal. Measurements. Height was measured with an an thropometer. Body weight was determined to the nearest 0.1 kg using a bascule. Skinfolds were measured with a Holtain caliper at eight sites: biceps, triceps, subscapular, pectoral, suprailiac, umbilicus, thigh, and calf. All measurements were taken twice by an experienced investigator. The mean of both measurements was recorded. To avoid interobserver error, a single investigator took measure Wormersley.4 ments in the same subject throughout the study. The percentage of fat was estimated from skinfold mea surements according to the method of Dumin and Lean body mass and fat mass were calcu lated using body weight and percentage fat. Eleven circumference measurements at 10 sites were taken with a tape measure: neck, thorax, waist, but tacks, upper arm (relaxed), upper arm (contracted), forearm, wrist, thigh Uust below the buttocks), thigh (two-thirds the distance from the major trochanter and lateral site of the knee joint), and calf. An experi enced investigator took all measurements twice, and the mean of both measurements was recorded. continued THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 55 @!Ji.jijlltJj continued Experiment 1: Total body composition and anthropometry. Subjects: 19 AAS users (9 subjects administered 8 weeks AAS and 10 subjects used for 12-16 weeks) and 16 nonusers. AAS use for 8 weeks AAS use for 12-16 weeks Controls + Baseline + Baseline + Baseline + End of AAS use (= 8 weeks) // + 8 weeks AAS use + 8 weeks end of AAS use + 6 weeks after withdrawal (= 14 weeks) Experiment 2: Regional alterations of body composition (DEXA measurements). Subjects: 6 AAS users and 5 non users. (DEXA measurements done in controls at baseline only.) AAS users + Baseline Experiment 3: Impact duration AAS sell-administration. Subjects were 19 AAS users: 9 short course and 10 long course Short-AAS Long-AAS + + 6 weeks after withdrawal 8 weeks AAS use + Baseline + Baseline + End of AAS use after 8 weeks + 6 weeks after withdrawal + End of AAS use after 12-16 weeks + 6 weeks after withdrawal FIGURE 1. Overview of the experiments of AAS use and body changes. ~ = indicates measurement; 11= indicates that the duration of AAS sell-administration varied between subjects from 12 to 16 weeks; AAS =androgenic-anabolic steroids; DEXA =dual energy x-ray absorptiometry Total and regional body composition measurements were performed using DEXA apparatus (DPX-L, Lunar Carp, Madison, Wisconsin) at a fast scan speed with a whole-body resolution of 4.8 x 9.6 mm. To determine the composition of regional body segments and limbs, DEXA measurements were divided in discrete values 56 for arms, legs, and trunk on the basis of anatomic land marks. As determined by Mazess et al,S the precision of these measurements is 1.5% for the arms, 0.8% for the legs, and 1.1% for the trunk. Total mass, fat mass, and bone-free lean mass were determined using Lunar software (version 1.3 z) for each body region (arms, continued Vol 29 • No. 1 • January 2001 e THE PHYSICIAN AND SPORTSMEDICINE @!Ji.jiji@j continued trunk, and legs). Monitoring and compli ance. Information about the subjects' training and nutri tional habits was collected before the start of the study and in week 8. Subjects' nu tritional intake was deter mined with a 3-day diary. Training data were obtained by a 1-week log. For long MS strength athletes, nutri tional and training data were also obtained at the end of the MS administration. In all MS users, these data were collected 6 weeks after drug cessation. To gauge subjects' compli ance with drug administra tion or abstinence before the start of the study and after 8 weeks, urine samples from all athletes were obtained for drug evaluation purposes (Netherlands Institute for Drug and Doping Research, Utrecht, The Netherlands). For the long-MS group, urine samples were taken at the end of the drug-use period. All MS-using strength ath letes submitted urine sam ples 6 weeks after drug with drawal. From all samples taken, about one-third were randomly chosen for analysis. Statistical analysis. De scriptive statistics were calcu lated for all measurements TABLE 3. Changes in Limb and Trunk Circumferences in AAS and Control Groups 6Wk Segment Group Baseline Neck Thorax Waist Buttocks Upper arm (relaxed) Upper arm (contracted) Forearm Wrist Thigh (upper) Thigh (lower) Call AAS Control AAS Control AAS Control AAS Control AAS Control AAS Control AAS Control AAS Control AAS Control AAS Control 39.2 ± 1.9 39.6 ± 2.2 95.8 ± 6.5 98.5 ± 7.3 84.8±7.1 86.8 ± 5.4 98.7 ± 5.6 99.3 ± 4.8 36.6 ± 3.0 38.9 ± 3.7 40.1 ± 3.3 42.0 ± 3.6 31.3 ± 1.9 32.8 ± 2.8 18.2 ± 1.0 18.3 ± 0.8 61.5 ± 5.5 63.4 ± 4.6 50.0 ± 3.4 51.8±3.3 8Wk Postwithdrawal 40.5 ± 2.1 ### 40.2 ± 1.9 * * 39.6 ± 2.2 na 98.4 ± 6.4 99.9 ± 7.2 86.3±7.1 87.1 ± 6.4 100.6 ± 5.5 100.0 ± 4.9 98.1 ± 6.5 * * na 85.1 ± 7.2 na 100.0±5.5** na 38.5 ± 3.3 ### 37.8 ± 3.4 ** 39.0 ± 3.8 na 41.6±3.1## 41.5 ± 3.5 *** 42.4 ± 3.7 na 32.4 ± 2.1 ### 32.6 ± 2.8 ** 32.7 ± 2.2 na 18.5±1.1# 18.3 ± 0.9 63.7 ± 5.1 ## 63.4 ± 4.8 52.2 ± 4.4 ## 51.6 ± 2.9 18.3 ± 1.0 na 62.7 ± 5.1 * na 50.8 ± 3.6* na AAS Control 38.7 ± 2.2 40.2 ± 2.6 39.6 ± 2.2 ### 39.1 ± 2.2* 40.2 ± 2.7 na All values are expressed in grams as the mean ±standard deviation. Mann Whitney test for interaction was used to test interaction, the difference between change in control group and AAS group;#= P< 0.05; ## = P< 0.01; ### = P< 0.001. Wilcoxon test was used to compare differences between postwithdrawal and baseline; * = P< 0.05; * * = P< 0.01; *** = P< 0.001. AAS =androgenic-anabolic steroid; na =data not available using Stat-View software (Abacus Concepts, Berkeley, California, 1994). Data are presented as mean plus or minus standard deviation (SD). The Mann-Whitney U-test was used to compare differences in the ob served changes between groups. The Wilcoxon signed rank test was used for analysis of intragroup changes after drug withdrawal (experiment 1) and for DEXA measurements of subjects taking MS (experiment 2). The level of significance was set at 0.05 for all analyses. Results Total body composition and anthropometry. After 8 weeks, the MS group had a significant increase of approximately 4.5 kg in body weight and lean body continued THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 59 (1W@ii(ij continued TABLE 4. Analysis of the Effects of AAS Use on Regional Body Mass Region and Segment Control AAS Group, AAS Group, Difference, Group (g) Baseline (g) 8 Wk (g) Baseline vs 8 Wk (g) Arms: Total mass Fat mass Bone-free lean mass 10,013 ±1 ,993 1,370 ±838 8,642 ±1 ,296 10,470 ±1 ,723 1,721 ±1 ,240 8,750 ±1 ,066 11,320 ± 1,910 1,317 ±828 10,004 ± 1 '129 0.028 ns 0.03 Legs: Total mass 25,699 24,228 25,390 ±4,866 Fat mass 4,649 ± 1,755 Bone-free lean mass 21,050 ±3,443 ±3,390 3,785 ±1 ,600 20,443 ±2,436 ±2,768 3,605 ± 1 '1 01 21,785 ±2,134 ns ns 0.03 Trunk: Total mass Fat mass 35,762 ±4,269 6,824 ±1,778 Bone-free lean mass 28,938 ±3,257 37,798 ±4,845 7,073 ±3, 119 30,725 ±2,602 39,375 ±4,372 6,490 ±2,670 32,885 ±1 ,936 ns ns 0.046 All values are expressed in grams as the mean ± standard deviation. Paired AAS group data were analyzed using the Wilcoxon signed rank test at 0.05 significance. AAS =androgenic-anabolic steroid; ns = not significant mass, whereas the controls exhibited no significant change. Mean body weight increased from 84.0 ± 9.9 to 88.4 ± 10.7 kg, and lean body mass rose from 69.6 kg to 7 4.1 kg. The percentage of fat during MS use was sig nificantly reduced from 17.0% to 16.0%, but this was not reflected in a loss of fat mass. Gains in body weight and lean body mass were still partly present 6 weeks after drug withdrawal (table 3). In both groups, no sig nificant increase in sk.infold measurements or their sums were observed during the study. In the MS group, increases in the circumferences of neck, upper arm, forearm, wrist, thigh, and lower leg were significantly larger than in the control group. Cir cumference changes of the thorax, waist, and buttocks did not reach significance compared with those of controls. Although the circumferences were slightly re duced after drug withdrawal, they were still increased compared with baseline levels (see table 3). Regional body composition changes. Baseline DEXA measurements of body segment composition were not significantly differ ent between the MS users and control athletes. After 8 weeks of AAS use, the weight of the arm was sig nificantly increased, but the weight of the trunk and legs remained unchanged. Bone-free lean masses of the arms, trunk, and legs were significantly greater during AAS use than at baseline (table 4). MS use did not affect the fat mass of the arms, legs, and trunk. Total bone mineral density and bone mineral content did not change significantly. Length of AAS regimen. No significant differences were observed in body weight, percentage of fat, fat mass, lean body mass, and circumferences be tween short-MS and long MS users. Similarly, these parameters were not sig nificantly different between groups 6 weeks after drug withdrawal . Training, nutrition, and compliance. Throughout the entire study, weekly training hours and regimens be tween groups in the three experiments remained com parable. The same was true for nutritional intake. Uri nalysis revealed compliance within the groups: Urine samples from the MS users contained steroid metabo lites, and samples of the CO group did not. Discussion AAS-induced changes. Experienced strength ath letes who use a self-composed course of MS for 8 weeks exhibited increased total body weight and to tal lean body mass compared with those who did strength training alone; total fat mass remained unaf fected. Among regional body segments (arms, legs, and trunk) in these athletes, only arm weight in creased significantly. However, lean mass was signifi cantly increased in all regional body parts, and these 60 Vol 29 • No. 1 • January 2001 • THE PHYSICIAN AND SPORTSMEDICINE em.m•IBJ continued findings are reflected in the increased arm and leg cir cumferences. Increases were for the most part still present 6 weeks after drug cessation. These findings are relevant because until now scientific data con cerning AAS effects on anthropometry and body composition were equivocal. From cross-sectional studies, one might infer that AAS-using strength athletes differ in body composition from nonusing athletes."·' These observations have been supported by longitudinal studies. The most pro nounced effects on body weight and lean body mass were found in athletes who self-administered several AAS simultaneously in high doses.•·• Such regimens may increase body weight by an average of about 5.2 kg (ll.4lb). Lean body mass increases may be even larger, especially after long-term administration."·10 The present study indicates that the use of a single AAS seems to induce less remarkable effects than mul tiple-drug regimens."-11-13 This is in line with an observa tion of Forbes, 1 ' who had previously described a posi tive relationship between the total dose of AAS used and the increase oflean body mass. On the other hand, research9,11Is.Ifi that compared the effects of different doses of a single AAS indicates that such a relationship might be less ambiguous than that proposed by Forbes. Previous methods and DEXA. One factor that may have contributed to the consistent results is the method used to determine body composition. No al terations were seen in studies17-20 that investigated body composition with underwater weighing. In these stud ies, the effect of a single drug was analyzed, but, unfortunately, no reports are available on underwater weighing assessment of body composition in multiple drug-using athletes. Although previous studies as sessed the traditional two-compartment model either with skinfold measurements or with underwater weighing, our study employed DEXA to assess a three compartment model for body composition alterations. DEXA was designed primarily to estimate bone mineral content and density in humans.21 Determina tion of body composition by DEXA is based on the dif ference in attenuation ofx-rays between soft and bone tissue as well as the difference in attenuation between fat and lean tissue. This method provides a three-com partment model that divides the body into total bone mineral content, bone-free lean mass, and fat mass. An advantage of DEXA over hydrodensitometry is that DEXA appears to be less affected by hydration sta tus.21.'' This may be an important advantage in esti mating body composition in athletes since hydration status may be affected by training. Assessing regional body changes. Because of the documented DEXA accuracy for total and regional body dimension measurement5 · 23 and the AAS poten tial for inducing regional changes in body composi tion, strength athletes may have particular interest in both DEXA and AAS. DEXA measurements in this study reveal an increase in bone-free lean mass of all body parts measured in bodybuilders using AAS. One interesting finding was that the increase in the bone free mass of the arms was approximately twice that in the leg or trunk (14% versus about 7%). This finding could not be attributed to differences in training regi mens because the training diaries revealed compara ble regimens in both groups. On the other hand, in an other study16 the administration a single anabolic steroid (nandrolone decanoate) induced the largest gain of bone-free lean mass in the legs and trunk. Since both studies are complementary, one possibility might be that different AAS regimens may affect spe cific areas more than others. Although evidence has shown that AAS increases lean body mass,24-26 no one has determined what con stitutes the change in lean mass. Previous research as sociated AAS-induced lean body mass alterations with increments of blood volume and water retention.1w.zs In a recent study (W Van Marken Lichtenbelt etal, manuscript submitted for publication), we were able to investigate the effects of AAS on body composition with a four-compartment model. That study revealed that total body water increased from AAS use but that the ratio between extracellular and intracellular water remained unaffected. In addition, lean mass hydration status was not influenced by AAS. Thus, the most likely explanation for the gain oflean mass can be explained by muscle increase rather than from water retention. Dispelling steroid-use myths. Among strength ath letes, long-term AAS administration is generally be lieved to produce better results than short-term use. Additionally, these athletes claim that after long-term AAS use the gains in body composition parameters will persist longer than after short-term administra tion. These beliefs are not supported by the present study. The effects on body composition and anthropo continued THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 61 em.m•IBJ continued metric variables after short- and long-term MS use were comparable. The same applied for residual changes seen after drug withdrawal. Therefore, we conclude that duration of MS administration in itself is not the key factor for optimal and longstanding ef fects on body composition. Health hazards. From a medical point of view, long-term MS administration is of great concern.'• Several investigators•·30• 31 have reported that MS use in duces an unfavorable lipoprotein profile and thus in creases the risk for cardiovascular diseases. Recent re search has demonstrated that duration of MS use has a strong impact on the lipoprotein profile changes.33 Extended MS administration provokes more dramatic side effects on the lipoprotein profile compared with short-term MS use, and the time required for full re versal of these side effects was prolonged after long term use (E Hartgens et al, manuscript submitted for publication). Consequently, long-term users are more prone to have cardiovascular events. Most strength athletes are convinced that after drug abstinence the effects on body composition will persist for some time. Our results show that 6 weeks after drug withdrawal the changes of circumferences were still significantly increased over baseline values, though slight decreases were seen compared with values at the REFERENCES l. International Olympic Committee: 1997 Statistics of the In ternational Olympic Committee accredited laboratories. International Olympic Committee, Lausanne, Switzerland, 1998 2. Vogels T, Brugman E, Coumans B, et al: Lijf, sport en mid delen. Nederlands Instituut voor Praeventieve Gezondhei dszorg. Leiden, The Netherlands, TNO, 1994 3. 4. 5. 6. 7. Yesalis CE: Anabolic Steroids in Sport and Exercise, ed 2. Champaign, IL, Human Kinetics, 2000 Durnin JVGA, Wormersley J: Body fat assessed from total density and its estimation from skinfold thickness: mea surements on 481 men and women aged from 16 to 72 years. BrJ Nutr 1974;32:77-97 Mazess RB, Bard en HS, Bisek JP, et al: Dual-energy x-ray ab sorptiometry for total body and regional bone mineral and soft tissue composition. Am J Clin Nutr 1990;51:1106-1112 Hartgens F. Kuipers H, Wijnen J. et al: Body composition, cardiovascular risk factors and liver function in long-term androgenic-anabolic steroids using bodybuilders three months after drug withdrawal. Int J Sports Med 1996; 17(6)429-433 Kouri EM, Pope HJ Jr. Katz DL, et al: Fat-free mass index in users and nonusers of anabolic-androgenic steroids. Clin J Sports Med 1995;5(4):223-228 end of MS use. Many MS users take, on average, two to three courses in l year."~' Their approach is to start a new MS course when they assume that the side effects have disappeared but the desired effects on body com position and strength are still present to some extent. There are indications that such procedures may be ef fective," but the effects of such procedures on health status are unknown and remain of great concern. Summary This study has demonstrated that in athletes the administration of a self-composed, 8-week course of MS combined with strength training increased body weight, lean body mass, and limb circumferences more than did strength training alone. Arm mass, but not trunk and leg mass, was increased by MS use. DEXA analysis showed that MS stimulated the bone free lean mass of all body parts, but the effects on the arms were the most pronounced. Fat mass was not af fected by AAS use. The increments in total body weight, lean body mass, and girths were still largely ev ident 6 weeks after drug withdrawal. There was no re lationship between the duration of MS use and the extent of changes in body composition and anthropo metric variables. RN 8. 9. Alen M, Hakkinen K, Korni PV: Changes in neuromuscular performance and muscle fiber characteristics of elite pow er athletes self-administering androgenic and anabolic steroids. Acta Physiol Scand 1984;122(4):535-544 Kuipers H, Wijnen JA, Hartgens F. et al: Influence of anabol ic steroids on body composition, blood pressure, lipid pro file and liver function in bodybuilders. Int J Sports Med 1991;12(4):413-418 10. Alen M, Hakkinen K: Physical health and fitness of an elite bodybuilder during 1 year of self-administration of testos terone and anabolic steroids: a case study. Int J Sports Med 1985;6(1):24-29 11. Fried! KE, Dettori JR, Hannan CJ, et al: Comparison of the effects of high dose testosterone and 19-nortestosterone to a replacement dose of testosterone on strength and body composition in normal men. J Steroid Biochem Mol Bioi 1991;40(4-6):607 -612 12. Hervey GR, Hutchinson I, Knibbs AV, et al: i\nabolic' effects of methandienone in men undergoing athletic training. Lancet 1976;2(7988):699-702 13. Win-May M, Mya-Tu M: The effect of anabolic steroids on physical fitness. J Sports Med Phys Fitness 1975;15(3):266-271 14. Forbes GB: The effect of anabolic steroids on lean body mass: the dose response curve. Metabolism 1985;35(6):571-573 continued THE PHYSICIAN AND SPORTSMEDICINE e Vol 29 • No. 1 • January 2001 65 J1iJi@i@j continued 15. Bhasin S, Starer TW, Berrnan N, et al: The effects of supra physiologic doses of testosterone on muscle size and strength in normal men. N Eng!J Med 1996;335(1):1-7 16. Hartgens F, Van Marken Lichtenbelt W, Ebbing S, et al: body composition and anthropometry in bodybuilders: regional changes due to nandrolone decanoate administration. Int J Sports Med, to be published 17. Casner SJ, Early RG, Carlson BR: Anabolic steroid effects on body composition in normal young men. J Sports Med Phys Fitness 1971;11:98-103 18. Crist OM, Stackpole PJ, Peake GT: Effects of androgenic-an abolic steroids on neuromuscular power and body compo sition. J Appl Physiol1983;54(2):366-370 19. Fahey TO, Brown CH: The effects of an anabolic steroid on the strength, body composition, and endurance of college males when accompanied by a weight training program. Med Sci Sports 1973;5(4):272-276 20. Golding LA, Freydinger JE. Fishel SS: Weight, size, and strength unchanged with steroids. Phys Sportsmed 1974; 2(6):39-43 21. Lohman T: Advances in Body Composition Assessment. Champaign, IL, Human Kinetics, 1992 22. Heyward VH: Evaluation of body composition: current is sues. Sports Med 1996;22(3): 146-156 23. Fuller NJ, Laskey MA, Elia M: Assessment of the composi tion of major body regions by dual-energy x-ray absorp tiometry (DEXA), with special reference to limb muscle mass. Clin Physiol1992;12(3):253-266 24. Lovejoy JC, Bray GA, Bourgeois MO, et al: Exogenous an drogens influence body composition and regional body fat distribution in obese postmenopausal women: a clinical research center study. J Clin Endocrinol Metab 1996;81 (6): 2198-2203 25. Lovejoy JC, Bray GA, Greeson CS, et al: Oral anabolic ste roid treatment, but not parenteral androgen treatment, de creases abdominal fat in obese, older men. Int J Obes Relat Metab Disord 1995;19(9):614-624 26. Marin P, Holmang S, Jonsson L, et al: The effects of testos terone treatment on body composition and metabolism in middle-aged obese men. Int J Obes Relat Metab Disord 1992; 16(12):991-997 27. Hervey GR, Knibbs AV, Burkinshaw L, et al: Effects of methandienone on the performance and body composi tion of men undergoing athletic training. Clin Sci 1981; 60(4):467 -461 28. Holma P: Effect of an anabolic steroid (methandienone) on central and peripheral blood flow in well-trained male ath letes. Ann Clin Res 1977;9:215-221 29. Wtlson JD: Androgen abuse by athletes. Endocr Rev 1988; 9(2)181-199 30. Alen M, Rahkila P, Marniemi J: Serum lipids in power ath letes self-administering testosterone and anabolic steroids. lnt J Sports Med 1985;6(3):139-144 31. Lenders JW. Demacker PN, V os JA. et al: Deleterious effects of anabolic steroids on serum lipoproteins, blood pressure, and liver function in amateur body builders. Int J Sports Med 1988;9(1):19-23 32. DeBoer A, van Haren SF, Hartgens F, et al: Onderzoek naar het gebruik van prestatieverhongende middelen bij body builders in Nederland. Nederlands Centrum voor Dop ingvraagstukken, Universiteit Utrecht, Rotterdam, The Netherlands, 1996 CASE REPORT transplant fractures continued from page 40 The level of performance is also affected by the par ticular kind of grafting. Most kidney and liver trans plant recipients are able to regain their former physical condition, but this is not true for heart and lung trans plant subjects. The latter continue to be affected by heart denervation and altered lung function, which of ten keeps them out of competition. Recommendations Preventive medical therapy and follow-up measures as well as sport -specific recommendations are needed to allow transplant patients safe athletic participation. Until reliable clinical and epidemiologic studies are performed, low-impact, recreational, noncontact sports are recommended, and high-level competition by transplant patients should be discouraged. AN REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Markey KL: Stress fractures. Clin Sports Med 1987;6(2): 405-425 Nixon JE. Hughes SP, Castro JE: Orthopaedic complications of renal transplantation. J Bone Joint Surg (Br) 1980; 62(4):526 Ramsey-Goldman R. Dunn JE. Dunlop DD, et al: Increased risk of fracture in patients receiving solid organ transplants. J Bone Miner Res 1999;14(3):456-463 Torg JS. Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. J Bone Joint Surg (Am) 1984;66(2):209-214 Lukert BP, Raisz LG: Glucocorticoid-induced osteoporosis: pathogenesis and management. Ann Intern Med 1990; 112(5):352-364 Grotz WH, Mundinger FA, Gugel B. et al: Bone mineral den sity after kidney transplantation: a cross-sectional study in 190 graft recipients up to 20 years after transplantation. Transplantation 1995;59(7):982-986 Horber FF, Casez JP. Steiger U, et al: Changes in bone mass early after kidney transplantation. J Bone Miner Res 1994; 9(1):1-9 Adachi JD. Olszynski WP, Hanley DA, et al: Man!lgement of corticosteroid-induced osteoporosis. Semin Arthritis Rheum 2000;29(4):228-251 Takeo Y, Tominaga K, Tsuji H, et al: Spontaneous fracture and osteoporosis following renal transplantation, abstract ed (in Japanese). Nippon Seikeigeka Gakkai Zasshi 1989; 63(5):507-513 10. Smets YF, van der Pijl JW. de Fijter JW. et al: Low bone mass and high incidence of fractures after successful simultane ous pancreas-kidney transplantation. Nephrol Dial Trans plant 1998;13(5):1250-1255 11. Kalker AJ. Pirsch JD. Heisey 0, et al: Foot problems in the diabetic transplant recipient. Clin Transplant 1996;10(6 pt 1):503-510 12. Brukner PO, Khan KM: Clinical Sports Medicine. Sydney, Australia, McGraw-Hill, 1993, p 17 66 Vol 29 • No. 1 • January 2001 e THE PHYSICIAN AND SPORTSMEDICINE