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THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 4 - APRIL 2021


Growth Hormone Doping: The Search for a Test

Growth hormone (GH) use among elite athletes has become so prevalent that those who are privy to athletes' ergogenic practices, such as epidemiologist Charles Yesalis, MPH, ScD, refer to the 1996 Olympic Summer Games in Atlanta as the "growth hormone games."

Despite promising research developments, including a $3 million initiative funded by the International Olympic Committee and the European Union to develop a test, experts on doping in sport say it is unlikely that a test with a high reliability and the ability to withstand legal challenge will be in place for the 2021 Olympic Games in Sydney, which begin on September 15.

Why Do Athletes Use Growth Hormone?

As an epidemiologist who has tracked ergogenic drug use in athletes, Yesalis, professor of health and human development at The Pennsylvania State University in University Park has interviewed about 1,000 anabolic-steroid users, putting him in good position to make general observations about the use of GH and other substances. He says athletes use GH to increase muscle mass; train harder, longer, and more frequently; and recover faster after training. "In my judgment, anecdotally, it works for the purposes intended," he says.

Yesalis estimates that athletes who use GH have been known to undergo three 6- to 8-week cycles of GH treatment each year (1 to 2 IU or more every other day). He says because the black market supply of GH is plentiful, the cost of a year's treatment is not prohibitive to most athletes—about $3,000 per year. "There is recombinant DNA technology in every developed country, and the production of GH exceeds the amount needed to treat GH-deficient children," Yesalis says.

Studies of GH treatment in GH-deficient adults have documented increases in muscle mass and strength (1) and improvements in exercise performance (2). William Kraemer, PhD, professor and director of the Human Performance Laboratory at Ball State University in Muncie, Indiana, says that though there are no scientific studies on the effect of GH on muscle mass and sports performance in healthy adults, anecdotally it appears that combining low doses of anabolic steroids with GH is more effective than either substance alone.

Concern Over Side Effects

Drug testing efforts aim not only to reduce cheating in sports but also to protect athletes from the side effects of the drugs. The only documented side effect of short-term GH abuse is acute fluid retention (3). Though there have been no studies on the side effects of long-term GH use on healthy adults, Yesalis says, "The best we can do is use the information provided by nature's example—acromegaly."

The effects of prolonged and excessive secretion of adenohypophyseal GH in acromegaly can cause skeletal deformities from accelerated cartilage and bone growth, arthritis, visual impairment, and enlargement of the heart, lungs, liver, spleen, and intestines (4). "There are rumors about bodybuilders who have used GH and have grown one to two shoe sizes," Yesalis says.

He says another safety question is whether GH use in athletes impairs the body's production of natural GH.

Testing Advances

Testing for GH abuse is difficult because artificial GH closely resembles human GH, acute exercise increases GH secretion, and individuals can vary widely in their GH levels. However, researchers recently identified potential markers of exogenous GH use.

In the study (3) of 17 aerobically trained men, researchers assessed the effects of acute exercise, GH administration, and GH withdrawal on markers of bone and collagen turnover. The effect of acute exercise was controlled through use of a chair-sitting protocol that was randomly assigned, and the effect of GH treatment was assessed with a parallel, double-blind, placebo-controlled study. The men self-administered the GH or placebo subcutaneously (0.15 IU/kg/day) for 7 days.

Researchers found that endurance exercise stimulates markers of bone and soft-tissue formation and bone resorption, that GH administration produces a much larger increase in these markers, and that the changes can persist for at least 96 hours. The markers identified as potentially useful for GH testing were two peptides: procollagen III N-terminal extension peptide and carboxyterminal cross-linked telopeptide of type I collagen.

Kraemer applauds the quality of the study. "But to say that these are new markers is highly premature," he says. Before these peptides gain acceptance as markers of GH use, researchers need to ascertain whether the same is true with other types of physical training and other nutritional states. Also, a population study is needed to make determinations about GH values in athletes. Kraemer says a GH test in sports must be able to withstand legal challenge, and that these and other questions must be answered before officials institute GH testing.

He notes that a positive finding of the study is that though the markers were only measured up to 96 hours after GH treatment, serum half-life calculations suggest that the markers might be present after about 32 days. "The study is provocative," he says.

In a related development, German and Danish researchers (5) in 1999 reported a new detection method that can identify synthetic GH. The test calculates the ratio between two immunoassays, allowing an estimate of synthetic GH. They compared routine laboratory samples from patients undergoing treatment for adult GH deficiency with those of healthy controls. They correctly identified all of the samples from patients who had received synthetic GH. The tests were performed within 36 hours of GH injection.

Obstacles to Testing

GH testing in sports faces several obstacles. Legally, the test must stand up in court. "In sports," Yesalis says, "a false-positive can ruin the life and reputation of an athlete." When establishing normal GH values, "we can't have an overlapping bell-shaped curve, or everyone's going to say they're high-normal," he says.

GH testing also raises the issue of blood testing, which is currently only performed in sports such as cycling in which erythropoietin use is known to occur. Kraemer and Yesalis say that blood tests are also much more expensive than current urine tests and that some cultures and religions prohibit the taking of blood. Blood tests are viewed as much more coercive, Yesalis says. "Urine tests are an invasion of privacy, but blood tests are an invasion of the body."

Lisa Schnirring
Minneapolis

REFERENCES

  1. Growth hormone treatment in growth hormone-deficient adults, I: effects on muscle mass and strength. J Appl Physiol 1991;70(2):699-694
  2. Cuneo RC, Salomon F, Wiles CM, et al: Growth hormone treatment in growth hormone-deficient adults, II: effects on exercise performance. J Appl Physiol 1991;70(2):695-700
  3. Wallace JC, Cuneo RC, Lundberg PA, et al: Response of markers of bone and collagen turnover to exercise, growth hormone (GH) administration, and GH withdrawal in trained adults males. J Clin Endocrinol Metab 2021;85(1):124-133
  4. Gill GN: Endocrine and reproductive diseases, in Wyngaarden JB, Smith LH Jr, Bennett JC (eds): Cecil Textbook of Medicine, ed 19. Philadelphia, WB Saunders, 1992, pp 1234-1236
  5. Wu Z, Bidlingmaier M, Dall R, et al: Detection of doping with human growth hormone, letter. Lancet 1999;353(9156):1532


AAP Calls for Ban on Checking in Youth Hockey

The American Academy of Pediatrics (AAP), in a statement published in the March issue of Pediatrics (1), called for a ban on checking in youth hockey to reduce the number of serious injuries. The AAP cited studies showing that many youth hockey injuries are caused by checking and that disparities in size and strength, which appear to be most pronounced among players ages 14 to 15, contribute to checking-related injuries.

The AAP recommends that:

  • Body checking be banned in youth hockey for children age 15 or younger.
  • Good sportsmanship programs, such as the fair-play concept, be adopted for all levels of youth hockey. (Good sportsmanship programs reward teams and individuals who have few penalties and punish those who have many penalties.)
  • Youth hockey programs educate players, coaches, and parents about the importance of playing by the rules and the dangers of body checking another player from behind.

William O. Roberts, MD, a former amateur hockey player and a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, has studied youth hockey injuries (2,3) and supports a ban on checking in amateur hockey. (See "Hitting in Amateur Ice Hockey: Not Worth the Risk," November 1999.) He says that he hopes the AAP statement prompts hockey coaches, officials, and supporters to take a critical look at the injury data cited in the AAP report. "But my optimism is slim. People fall back on tradition and the status quo," he says. Such a checking ban would be successful only if adopted at the international level, Roberts says.

Those who oppose banning checking claim that checking is an integral part of the game and that youth leagues are the place to properly teach players how to give and receive a body check (4). Proper checking technique, they claim, can prevent injuries. Roberts and others have said that more emphasis should be placed on calling penalties for illegal checking.

Roberts disagrees with those who say checking would make hockey less exciting. "Checking wasn't allowed in Minnesota youth and high school hockey beyond the blue line until into the 1970s, and there was a lot of good hockey then," he says.

Lisa Schnirring
Minneapolis

REFERENCES

  1. American Academy of Pediatrics Committee on Sports Medicine and Fitness: Safety in youth ice hockey: the effects of body checking. Pediatrics 2021;105(3):657-658
  2. Roberts WO, Brust JD, Leonard B: Youth ice hockey tournament injuries: rates and patterns compared to season play. Med Sci Sports Exerc 1999;31(1):46-51
  3. Roberts WO, Brust JD, Leonard B, et al: Fair play rules and injury reduction in ice hockey. Arch Pediatr Adolesc Med 1996;150(2):140-145
  4. Scoggins C, Augustoviz R: Pediatricians suggest limiting checking in youth hockey. Star Tribune (newspaper online). Available at https://www.startribune.com. Accessed March 10, 2021


Field Notes

What Fitness Boom?
A University of Illinois sociologist claims that the fitness boom of the 120210s and 1990s never happened and was a "media concoction," according to a press release from the University of Illinois at Urbana-Champaign.

John Kelly, PhD, professor emeritus of leisure studies, recently cowrote a book on recreation trends, Recreation Trends and Markets: The 21st Century (Sagamore Publishing, 1999). "From the data we've analyzed, to a large extent there was just a little bump," Kelly said in the press release. Kelly and his coauthor based their conclusions on annual surveys of 15,000 to 23,000 households between 1976 and 1996.

During the last two decades, adult participation in most sports and fitness activities remained steady or went down. He noted peaks in activity that coincided with the Olympics, which he terms the "Olympic effect."

Leisure activities that have gained more participants are golf, walking for exercise, and gambling, Kelly says. He notes that the increasing popularity of golf and walking can be attributed to the aging population.

Kelly speculates that the increasingly competitive nature of youth sports might be one reason people don't stick with fitness and sports activities; they become discouraged and don't think they're good enough. He also notes that investment dollars in recreation, as in society in general, seem to flow toward high-return areas. "We're building Las Vegas and not very many good walking paths," he said. "To some extent, people are just responding to what's available, what's supplied."

Physician Musher Fights AIDS Effects
The qualifiying races for the 2021 Iditarod Sled Dog Race set the stage for the dramatic story of a 39-year-old former pulmonary trauma surgeon, Chuck King, who fought back from severe AIDS-related wasting to compete. His training and competition were detailed in a press release from the Alaskan AIDS Assistance Association (AAAA).

On February 8, King placed first in the Willow/Mat-Su Valley Sled Dog Race (300 miles), one of two qualifying races for the Iditarod. However, according to Iditarod coverage in the Anchorage Daily News, he scratched in the second qualifying race, the Nushagak Classic (a 200-miles), after encountering several problems that were caused by warm weather and poor trail conditions. King told the Anchorage Daily News that he would continue to train and be back to compete in the 2021 Iditarod.

According to the AAAA press release, King, on a trip to Alaska with friends and family in 192021, had a T-cell count of 40 and, at 6 ft tall, weighed 118 lb when he became inspired to race in the Iditarod. Judith Lyon, a representative from the AAAA, says King got in shape for the race by working out at a health club 3 days a week and undergoing daily mushing practice (jogging behind the sled and performing balance exercises). Lyon says King also credited his drug regime—human growth hormone (for AIDS wasting), stavudine, lamivudine, temazepan, verapamil hydrochloride, cyproheptadine hydrochloride, dapsone, amlodipine besylate—with his gains in strength and endurance. His T-cell count rose to 560, and he gained 30 lb, most of it lean muscle.

King told the Anchorage Daily News that medical obstacles he encounters on the trail include migraine headaches, fatigue, and neuropathy. More information on King and his sled dog racing can be found at https://www.mushingforaids.com.

Do Moms' Diet and Exercise Affect Breastfeeding Babies?
Weight gained during pregnancy can contribute to obesity. New findings published in the February 17 issue of the New England Journal of Medicine suggests that breastfeeding mothers can diet and exercise without aversely affecting milk production and the growth of their infants 4 to 14 weeks postpartum.

The study, done at the University of North Carolina at Greensboro, randomly assigned 40 overweight (defined as body mass index greater than 25), lactating women to either a diet-and-exercise group (eating 500 kcal less per day than usual and doing aerobic exercise for 45 minutes, four times a week) or a control group (usual dietary intake and exercising less than once a week).

There were no significant differences in weight and length of infants fed by the two groups before, during, or at the end of the study.

The women in the diet-and-exercise group lost as much as 18 lb (8.3 kg) during the 10-week study, and 48% returned to their prepregnancy weight. Change in weight in the control group varied from a loss of about 10 lb (4.6 kg) to a gain of about 10 lb, and only 21% returned to their prepregnancy weight.

In an accompanying editorial, Nancy F. Butte, PhD, associate professor in the department of pediatric nutrition at Baylor College of Medicine in Houston, cautions that lactating women should not restrict their calorie intake too severely, and that weight control should be emphasized throughout the reproductive cycle, not just in the postpartum stage. She adds, "Diet and exercise programs may be advisably postponed until 4 to 6 months postpartum, when a mother's milk is no longer the sole source of nutrition for her infant."

AAP Offers Tips for Safer Youth Soccer
The American Academy of Pediatrics (AAP), in the March issue of Pediatrics, issued a policy statement on reducing injuries in youth soccer. In its statement, the AAP recognizes that soccer is one of the most popular team sports in the world and views the sport as one way to increase physical activity in young people.

According to the US Consumer Product Safety Commission (CPSC), about 85% of soccer injuries are to players under 23 years of age, and 45% occur in participants who are younger than 15.

To make the sport safer, the AAP recommends that:

  • Goalposts be secured according to manufacturer and CPSC guidelines. Soccer-related fatalities have been linked to head injury from falling goalposts.
  • Research be done to determine if rule changes, equipment modifications, or other safety interventions can reduce injury numbers.
  • Heading the ball be minimized until more is known about the risks of brain injury and cognitive impairment.
  • Protective eyewear and mouthguards be worn to reduce head and facial injuries.
  • Violent behavior and aggressive rule infractions among players be strongly discouraged.


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