1. Performance Enhancing Modalities MechanicalPsychologicalPhysiologicNutritionalPharmacologic

3. Stimulants

4. Stimulants CaffeineAmphetaminesCocaineSympathomimetics –Ephedrine –Pseudoephedrine –Phenylephrine –Phenylpropanolamine (PPA) Modafinil

5. Stimulants – proven effects Increases Endurance –Increases use of free fatty acids and triglycerides –Spares muscle glycogen early in exercise –Decreased perceived exhaustion Enhances Anaerobic Exercise –Decreases time to exhaustion –Decreases perception of exertion –Hypoanalgesic effect Small amount of weight loss

6. Stimulant Use Prevalence Ephedrine: –3.5% in NCAA athletes Clin J Sports Med 2001 –12% of HS boys/26% of girls have tried Med Sci Sports Exer 2002 Caffeine –33% of British club track/field athletes –60% of British club cyclists Chester N, Int J Sports Med 2008

7. Caffeine’s Proven Effects Increased time to fatigue in prolonged, moderate intensity exercise No effect on repeated sprints/heavy exercise

8. Caffeine in Endurance Running 4.2-sec faster 1.5-km 1-3% faster 5-km 24-sec faster 8-km 50-sec faster 10-km military pack march No change in 21-km race Improved treadmill time-to- exhaustion in marathoners

9. Caffeine in Other Sports Rowing: 1-3% faster 2000m race Swimming: 24-sec faster 1500m race –About 21 min Cycling: 3.5% higher mean power in 40km race

10. Caffeine Dosing Doses 2-9 mg/kg in studies 2-5 mg/kg usually effective 250-500 mg –Cola: 40 mg –Coffee: 100 mg –Tea: 20-100 mg –Red Bull: 115 mg –Vivarin: 200 mg

11. Caffeinated Sports Drinks No proven performance benefit –18-km run times –Pl vs carb drink vs carb+150mg caffeine –consumed 4x in race –Int J Sports Med 2005

12. Ephedrine 78-sec faster 10-km run (with backpack & helmet) vs placebo –30-sec faster than caffeine -0.8 mg/kg –No benefit when added to caffeine

13. Modafinil Cycling at 85% VO2max –22% longer time to exhaustion vs Placebo 18.3 min vs 15.6 –Central mechanism: decreased RPE –Dose 4 mg/kg –No side-efx seen

14. Stimulants - Side Effects Anxiety*Dysrhythmias*Hypertension*HallucinationsAddictionDeath

15. Stimulant regulation Most banned by USADA & NCAA –Ephedrine –PPA –Most ADHD meds Some still allowed (cold meds) –Pseudephedrine –Phenylephrine Caffeine –USADA: no longer monitored –NCAA < 15 mcg/ml –1 cup coffee = 100mg = 1.5 mcg/ml in urine

16. Blood Doping Increasing the number of red blood cells in the body to increase the oxygen carried to muscle –Administration of blood, red blood cells, or related blood products –Erythropoietin Stimulates bone marrow to produce red blood cells

17. Blood Doping – proven effects 7% increase in Hgb 5% increase in VO2 max 34% increase in time to exhaustion at 95% VO2 max 44 second improvement in 5 mile treadmill run time (Williams and Branch summarized study findings)

18. Blood Doping - Side Effects Transfusion reactions Infections Increased viscosity of blood –Stroke, MI, PE

19. Blood Doping - regulation Erythropoietin only by prescription Doping banned by USADA, NCAA Blood tested for antigens Ceiling on allowable Hct level at 50

20. Beta-2-Agonists Physiology –Bronchodilation, increased ventilation –Examples: albuterol, terbutaline, salmeterol

21. Beta-2-Agonists – proven effects Clear benefit in asthma and EIB –Increased ventilation No increase in performance in NON- asthmatic athletes Side effects: tremor, tachycardia Regulation –USADA: prohibited –NCAA: inhalation permitted

22. Creatine Replenishes ATP in anaerobic exercise No federal assessment of quality, performance, or safety Proven to increase lean body mass, strength

23. Creatine – disproven effects Meta-analysis 2003: –No significant difference in field-based athletic performance (e.g. running, swimming) Branch JD. Int J Sports Nutr Exerc Metab June 2003 XX X XX X XX

24. Creatine - Side Effects Studies of 2-10 weeks: no side efx Long term: 40% non-responders

25. Anabolic Steroids Analogs of testosterone More than 100 types Forms: –Oral –Injection –Topical (gels, creams) Prevalence of use –2001: 1% in US college athletes –2006: 13% of German fitness center attendees had used in past

26. Anabolic Steroids – Proven Effects Increase in fat-free massIncrease in fat-free mass Increase in body weightIncrease in body weight Increase in arm girthIncrease in arm girth Increase in leg girthIncrease in leg girth Increase in bench press and squat scoresIncrease in bench press and squat scores

27. Anabolic Steroids—Disproven Effects No effect on endurance exercise –Males on treadmill Eur J Appl Physiol 2006 –VO2max in rats Med Sci Sports Exer 2004

28. Anabolic Steroids - Side Effects Hepatocellular damage Cardiovascular disease Psychological disturbance Effects can sometimes be permanent!

29. More side effects… Men –Acne –Premature baldness –Prostatic hypertrophy –Female masculinization –Injection complications* –Testicular atrophy –Impotence* –Gynecomastia* (some may be permanent)

30. Nitric Oxide-releasing agents Physiology –Arginine is a precursor of NO –NO regulates BP and blood flow to organs –Most supplements: Arginine α- ketoglutarate Claims –Improves “pump” and blood flow to muscles –Increases strength and size –Speeds recovery

31. Nitric Oxide-releasing agents Endurance exercise studies No benefit in endurance athletes Limited evidence of benefit in debilitated pts Strength exercise: mixed results, no proven benefit More studies needed

32. Sodium Bicarbonate Mechanism: buffers metabolic acidosis after strenuous exercise Proven ergogenic efx in high-intensity exercise –1–1–1–100m & 200m swim –R–R–R–Repeated sprints –R–R–R–Repeated judo throws

33. Bicarbonate Limited & conflicting evidence of benefit in aerobic exercise –High-intensity running: 17% better time-to-exhaustion (30 vs 26 min) –60-min max-effort cycle ergometry: 14% higher power vs Placebo –60-min high-intensity cycling: no difference vs Placebo

34. Bicarbonate Dose: 0.2 - 0.3 mg/kg GI side effects common

35. Carbs Sports drink consumption Carbohydrate loading

36. Sports Drink Consumption Evidence supports enhanced endurance performance vs water in events >60 min No benefit from added protein

37. Carbohydrate Loading Known to increase muscle glycogen levels 13% - 100% Prolongs time to exhaustion 2-3% in endurance events >90 minutes Higher effect in Untrained persons –25-km treadmill

38. Methods of Carbo Loading Classic 6-day regimen –3 days intense glycogen-depleting exercise –3 days high-CH diet, no exercise Modified 6-day regimen –3-day exercise taper, normal diet –High-CH (70%) & light exercise 3d prior Single-day regimen –10 gm/kg/day CH 1-day prior –Normal exercise regimen

39. Carbohydrate Loading ‘s Little standardization of methods –Athletes need to try methods prior to competition to see what works Exact roles of glycogen-depleting exercise, type of CH, and timing are unclear

40. Miscellaneous Losers in endurance exercise performance Vitamin E and other vitamins Minerals: Cr, Mg, Zn, Se L-CarnitineAntioxidantsPyruvateArginine Hydroxy-methyl-butyrate (HMB)

41. Anti Doping in Elite Athletic Competition Permitted/Prohibited? http://www.usantidoping.org.dro 1-800-233-0393

42. Therapeutic Use Exemptions- “TUE” Abbreviated TUE –Doc fills out; athlete faxes to USADA –Effective immediately, up to 1 year –IM/IJ/inhaled corticosteroids –Inhaled beta-agonists Regular TUE –All other substances –Doc fills out, send to USADA, along with supporting documents –Process takes 1-2 months to approve –Variable duration

43. No substitute for hard work… Questions?

44. Thank You!