Reported June 24, 2002

Dangers of Sports Supplements -- Full-Length Doctor&rsquos Interview

Ivanhoe Broadcast News Interview with
Susan Yussman, M.D., Pediatrician
University of Rochester, Minneapolis, Rochester, New York

Topic: Dangers of Sports Supplements

What are common sports supplements?

Dr. Yussman: The most common nutritional supplements we see right now are creatine and DHEA, which is dehydroepiandosterone and androstenedione, which is otherwise known as "andro" in the weight training world. Then there are specific anabolic steroids, which is even another class beyond that.

Which ones are legal and which ones are not?

Dr. Yussman: Technically, anabolic steroids are not legal, but things like DHEA and andro will actually turn a drug test positive, as if you had been on some kind of anabolic steroid.

But they&rsquore not drugs?

Dr. Yussman: Right.Â*DHEA and andro are actually hormones that are precursors to estrogen and testosterone. So, what will end up showing up is a drug test positive for that line of medications.

Explain what creatine is and how it works.

Dr. Yussman: Creatine is a naturally occurring substance that is actually in the pathway that helps ADP go to ATP, which is basically the unit of energy that we use. So, what creatine does is actually helps fester muscle recovery after short-burst, intense, repetitive kinds of exercise, like cycling or weight lifting or sprinting.

Is it building muscle mass? is it building weight?

Dr. Yussman: It&rsquos actually been shown to be effective as far as increasing strength and lean body mass, except there&rsquos some controversy because some people think that the actual increase in body mass is actually water retention in muscle cells. So, there are a lot of studies that are being done right now to try to delineate exactly how things are working.

How widely available is creatine?

Dr. Yussman: Well, it&rsquos available at any health food store or some grocery stores. So, may of our adolescents don&rsquot realize that its not FDA regulated under the DeShay or Dietary Health Education Act that. They think that just because it&rsquos sold in a health food store, or because it&rsquos natural, it&rsquos safe when it may or may not be.

Why do you think creatine gained popularity over the last few years? Why do you think it&rsquos growing so much among teens?

Dr. Yussman: That&rsquos a good question. Some of the theories involve specific sports, people who are very open about their use of these kinds of things like Mark McGwire, so we&rsquore not sure why, but I think that word of mouth among teenagers and also the popularity and the media.

Why are kids using them?

Dr. Yussman: They want to be strong and perform best. You know, it used to be that we would just see these kind of performance enhancing products in Olympic kinds of athletes, but now it&rsquos filtering down to college age, and now what we are seeing is actually in some of our patients that are high school students as well. That&rsquos the ones we&rsquore concerned about because very few studies have been done in the under-18 age group.

What are some of the health risks that have been studied and that have been actually documented?

Dr. Yussman: Specifically, with a DHEA or an androstenedione, there are specific health risks that have been studied and we know exist and therefore we don&rsquot recommend those products really to any age group. Basically, what happens is, because DHEA is a precursor to testosterone and estrogen, young boys can actually get breast enlargement and young girls can get increases in body hair and clitoris size. In both boys and girls you can potentially get what&rsquos called "precocious puberty," or puberty occurring in an earlier age than would be expected. What happens at that point the actual growth plate of a bone will fuse early, which means that potential adult height is actually stunted.

Potential side effects or things that have been associated with creatine use are anywhere from abdominal pain and diarrhea, headaches to dehydration, increased risk of muscle strains. But, the concern that most of us pediatricians worry about is there have been two case reports in the medical literature about kidney failure in adults.

There are studies being done right now where some scientists are trying to show that actually those kinds of side effects or associations actually are not occurring at any higher rate than a normal athlete would have them occur. So, it&rsquos a controversial area, but because a long-term potential adverse effects is not known specifically in the under-18 year-old age group, we don&rsquot recommend them.

How is it dangerous for kidneys?

Dr. Yussman: They basically say that is nephrotoxic, or it&rsquos toxic to kidneys and then causes kidney failure. And, the specific concerns with adolescents is that tissues, liver, bone, kidneys are all still developing. So we&rsquore not sure what the effect might potentially have on a still-developing body. Most of us say the word is still out. There are a few scientists that are saying its actually ok, but I think until we have really good placebo-controlled, randomized trials, we have to stick what the American College of Sports Medicine says, which is that the use of creatine is discouraged in the under-18 age group.

And the same for the DHEA?

Dr. Yussman: Yes, those definitely are discouraged.

Why do people take andro?

Dr. Yussman: Once again, to increase muscle mass. Instead of using an anabolic steroid, they would use something like that because it is herbal, it&rsquos natural -- it should be OK in some people&rsquos minds.

And for DHEA?

Dr. Yussman: The same, the same as andro. Because they both are on that pathway toward testosterone.

Do you think that any of this increase in use, other than the Mark McGwire&rsquos of the world are using it, how much of a role do you think the Adonis complex plays in it?

Dr. Yussman: I think that&rsquos a possibility as well. The Adonis complex is what some psychologists and physicians use as far as trying to explain that specifically males and some females want to look a perfect way. Eating disorders in young women, we see sort of that crossover now into men or adolescent boys trying to look a specific way as well. I think that is definitely a potential...

And you said the concern was because teens&rsquo bodies are still developing?

Dr. Yussman: Right. What we find is that certain medications or products affect a pediatric or adolescent population differently than they affect an adult population. Just if there are a few studies that show that things are safe in adults doesn&rsquot necessarily mean that they are safe at a younger age.

If you&rsquore a parent and you have a 15-year-old boy who is really into weight lifting, what are some signs you should watch for that he may be using just creatine or he may be using andro or DHEA as well?

Dr. Yussman: You know, it&rsquos difficult to specifically say, because some of things you see will happen automatically with increase in body mass from specifically weight training. Some of the gynecomastia or the increase in breast tissue size is actually normal in about 65 percent of young boys, but it can be increased with such things as andro and the DHEA. So, other potential things that might be related to increases in testosterone level, like increased aggression, just increased mood swings, its more of those kinds of effects, which some people say, &rsquoWell, my teenage is that way anyway.&rsquo So, it&rsquos really hard to know if your kid is taking one of those or not.

How many athletes do you think are using these?

Dr. Yussman: I hate to speculate without specific hard numbers, and there have been a handful of studies trying to quantify how many teenagers are actually taking performance-enhancing drugs. There was just a study a month ago published in Pediatrics August 2001 where some researchers at Cornell showed that 1.8 percent of 6th- to 12th-grade athletic girls are using creatine and 8.8 percent of 6th- to 12th-grade athletic boys are using creatine. And, then there is another study out of Wisconsin within the last couple of years too that showed 3.9 percent of female athletes are using creatine.

I think the only study I know of that has actually looked at sort of a random population of adolescents --Â* that&rsquos not just specifically looking at the athletic community -- is actually a study that some of my colleagues here at the University of Rochester in the Division of Adolescent Medicine did where they looked at 14- to 19-year-olds and did a random digit dial survey. What they found is that less than 1 percent of teenagers reported using some kind of natural performance enhancer. So, less than 1 percent of the girls, but almost 15 percent of boys. So, the numbers are varying and this is not even an athletic population.

This is a random sample in Monroe County, New York. One of the things that will be interesting is I&rsquom actually involved in a study with some of these same researchers, we want to quantify even further instead of just asking a question about natural performance enhancers. We want to try to figure out exactly which ones are being used, how they&rsquore first hearing about them, where they&rsquore or who they&rsquore getting them from, why they&rsquore using them, and any potential efficacy or side effects the teenagers believe they&rsquore having. I think in that way we will hopefully better understand which products teenagers are choosing and why.

Do you think teenagers are aware of the risk factors and ignore it, or do you think they&rsquore not even aware of it?

Dr. Yussman: That&rsquos a good question. There have been studies that have tried to figure out how many, what are the reasons, what did they know about it already. But, I&rsquom not sure. A lot of the teenagers I specifically see are know that there is some controversy but aren&rsquot quite sure what the controversy surrounds. So, we try to do a lot of education in the clinic. I think it is also appropriate for parents or athletic trainers to be educating teenagers as well.

Are there other long-term health complications people have seen studying adults with using these supplements?

Dr. Yussman: Not that I&rsquom aware of. It&rsquos mostly the kidney failure and then potential stunting of height. But, I didn&rsquot actually review much of the adult information. I saw some things about erectile dysfunction in adult men, but I haven&rsquot seen anything like that in kids.

So that is, I can&rsquot believe you said 15 percent, I was kind of assuming it would be lower.

Dr. Yussman: It will be interesting to see what this study that we&rsquore doing. Actually, that was a piece of a study on alternative medicine in adolescence. This study we are in the process of doing now will hopefully actually encompass a national sample, perhaps through the internet, we haven&rsquot decided yet, looking at all modalities of complementary and alternative medicines and one of the small subsections of that will be sort of herbal products and then natural performance enhancing drugs.

Do you teens could be taking creatine in secret?

Dr. Yussman: I&rsquom glad you actually asked me that because the study that my colleagues here did at the University of Rochester showed that, of that 14.9 percent of boys aged 14 to 19 in Monroe County, only 40.8 percent of them actually disclosed their use of natural performance enhancing products to their primary care physician. So, less than half are telling medical personnel. We haven&rsquot asked the question, &rsquoHow many of you are telling your parents or your coaches?&rsquo We&rsquore not sure where they&rsquore getting it from. Hopefully, they&rsquore not getting them from their parents of coaches. Some of it may be done surreptitiously.

Do you have anything else to add?

Dr. Yussman: One of the other points is: just that because the Food and Drug Administration does not regulate these products, or the FDA, then there&rsquos not assurance of quality, quantity, purity of any of substances that you sell or that you buy over the counter. So, we just have to be careful about making sure that adolescents know that these products are not regulated.