lafe.iefd.uerj@gmail.com

gabrielboaventura@gmail.com

*Graduado em Educação Física

pela Universidade do Estado do Rio de Janeiro

Mestre em Biologia - Biociências Nucleares

e doutorado em Ciências pela UERJ

Realizou estágio de pós-doutorado no Instituto de Bioquímica Médica

na Universidade Federal do Rio de Janeiro

Professor Associado da UERJ

junto ao Instituto de Educação Física e Desportos

**Graduado em Educação Física pela UERJ

Mestre em Biologia (Biociências Nucleares) pela UERJ

Doutor em Ciências (Fisiopatologia Clínica e Experimental) pela UERJ

(Brasil)

Reception: 11/02/2020 - Acceptance: 04/28/2022

1st Review: 04/15/2022 - 2nd Review: 04/23/2022

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Casimiro-Lopes, G., & Cunha, G.B. da (2022). Anabolic Androgenic Steroids Persistently Modify the User's Lipid Profile: a Case Report. Lecturas: Educación Física y Deportes, 27(290), 134-145. https://doi.org/10.46642/efd.v27i290.2672

 

Abstract

    The aim of the study was to show a lasting modification of the lipid profile and atherogenic indices by the abuse of anabolic androgenic steroids (AAS) by a amateur bodybuilder. This study reports a case of a 27-year-old non-competitive bodybuilder with severe abnormalities in lipid profile and atherogenic indices. He used anabolic androgenic steroids and had no other risk factors for heart disease or associated risk factors. After some educational lectures, he decided to continue his training without using anabolic androgenic steroids or any illegal ergogenic drugs. Lipid profile and atherogenic indices returned to normal values ​​in the third laboratory test performed five years after her last cycle of AAS. Abusing anabolic androgenic steroids can promote increased risk of cardiovascular disease, a trait that can persist for many years after even after discontinuing anabolic androgenic steroid use.

    Keywords: Anabolic androgenic steroids. Bodybuilder. Heart diseases. Cardiovascular abnormalities. Arteriosclerosis. HDL.

 

Resumo

    O objetivo do estudo foi mostrar uma modificação duradoura do perfil lipídico e dos índices aterogênicos pelo uso abusivo de esteróides anabólicos androgênicos (EAA) por um fisiculturista amador. Este estudo relata um caso de fisiculturista não-competitivo de 27 anos com graves anormalidades no perfil lipídico e nos índices aterogênicos. Ele usava esteróides anabólicos androgênicos e não tinha nenhum outro fator de risco para doença cardíaca ou fatores de risco associados. Após algumas palestras educacionais, ele decidiu continuar seu treinamento sem o uso de esteróides anabólicos androgênicos ou quaisquer drogas ergogênicas ilegais. O perfil lipídico e os índices aterogênicos voltaram aos valores normais no terceiro teste laboratorial feito cinco anos após seu último ciclo de EAA. O abuso de esteróides anabólicos androgênicos pode promover aumento do risco de doenças cardiovasculares, uma característica que pode persistir por muitos anos depois mesmo após a interrupção do uso de esteróides anabólicos androgênicos.

    Unitermos: Esteróides anabólicos androgênicos. Fisiculturista. Doenças cardíacas. Anormalidades cardiovasculares. Arteriosclerose. HDL.

 

Resumen

    El objetivo del estudio fue mostrar una modificación duradera del perfil lipídico y los índices aterogénicos por el uso abusivo de esteroides anabólicos androgénicos (EAA) por parte de un fisicoculturista aficionado. Este estudio reporta un caso de un fisicoculturista no competitivo de 27 años con anormalidades severas en el perfil lipídico e índices aterogénicos. Hacía uso de esteroides anabólicos androgénicos y no tenía otros factores de riesgo de enfermedad cardíaca o factores de riesgo asociados. Después de algunas conferencias educativas, decidió continuar su entrenamiento sin usar esteroides anabólicos androgénicos ni drogas ergogénicas ilegales. El perfil lipídico y los índices aterogénicos volvieron a valores normales en la tercera prueba de laboratorio realizada cinco años después de su último ciclo de EAA. Abusar de los esteroides androgénicos anabólicos puede promover un mayor riesgo de enfermedad cardiovascular, un rasgo que puede persistir durante muchos años incluso después de suspender el uso de esteroides anabólicos androgénicos.

    Palabras clave: Esteroides anabólicos androgénicos. Fisicoculturista. Enfermedades cardíacas. Anomalías cardiovasculares. Arteriosclerosis. HDL.

 

Lecturas: Educación Física y Deportes, Vol. 27, Núm. 290, Jul. (2022)

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Introduction 

 

    Anabolic androgenic steroids (AAS) are a class of substances that include different types of synthetic derivatives of testosterone, the hormone responsible for the acquisition of male sexual characteristics. These substances were originally synthesized for the purpose of treatment in different pathological conditions, such as: dysfunction of the reproductive system, breast cancer and anemia (Sagoe et al., 2014). Currently, around 80% of non-competitive bodybuilders use these substances to keep their muscles growing, showing that the pattern of male bodies is increasingly determined by images of muscular bodies, whether in the form of action toys, cartoons, advertisements in magazines or movies, showing masculine figures with astonishing muscle hypertrophy. Advertising for nutritional supplements has been one of the drivers of the non-competitive bodybuilders consumer market. This market seeks to profit from the insecurity of physical appearance and AAS can become an irresistible option to reach more muscular bodies and with less fat. (Irwig et al., 2020; Kanayama, & Pope, 2018; Leit et al., 2001; Pope et al., 1999)

 

    With the spread of the use of AASs, the rules by the surveillance and control agencies have been increasing. However, despite the rules of the World Anti-Doping Agency (WADA) apply to all athletes, regardless of the competitive level (professional or amateur), there is a lack in the control of doping of amateur athletes when compared to professional athletes (Veras et al., 2015). This can be easily noticed in mass sports, such as triathlon, running and cycling, where amateur athletes do not undergo a routine doping control test, in the same way as professional athletes (Henning, 2017; Mann et al., 2014). Some studies indicate the use of prohibited substances by amateur athletes in some sports; however the knowledge of what is prohibited may vary according to the sport modality, concentrating its use on fitness categories, such as enthusiasts and amateur bodybuilders. (Kanayama, & Pope, 2018)

 

    Although several studies on the use of AAS on the lipid profile have been conducted, their results are controversial, a fact that makes it difficult to understand the effects of these drugs on LDL and HDL concentrations. Most present the results grouped without considering the individual values ​​related to their respective clinical references (Hislop et al., 1999; Pope et al., 2000). Other studies do not present the description of the substances used (Karila et al., 1996), as well as the dosages (Gårevik et al., 2014; Schwingel et al., 2011) or in some cases the totality of the research data is not presented. (Gårevik et al., 2011)

 

    The aim of the study was to evaluate potential lasting effects of anabolic androgenic steroids abuse in lipid profile and atherogenic indexes during a 5-year follow-up in anon-competitive bodybuilder.

 

Method 

 

    Case Study: A 27-year-old male non-competitive bodybuilder, 189 cm tall, with a total body mass of 124.3 kg, with a history of self-administered anabolic androgenic steroids (AAS) in constant cycles, requested the services of a personal trainer at the gym where he trained. Interestingly, the bodybuilder reportedly stated poor knowledge of AAS and other ergogenic drugs. His cycle consisted of weekly amounts of two oral drugs continuously on a daily basis with the following dosages: Oxymetholone (250 mg/day) and Stanozolol (25 mg/days) in cycles of 12 weeks of duration. The first substance also known as Anadrol-50 was widely available in drugstores at the time and the latter was chosen based on the sudden fame gained after the Ben Johnson doping scandal at the Seoul Olympics in 1988. The bodybuilder displayed a morphological trait similar to seen in most professional bodybuilders, but refused to frequent the competitive field, declaring that the sport was just a hobby. The results presented in blood tests as described by Test 1 represents the last time he used such drugs after years on consistent abuse.

 

    After some educational lectures given by his personal trainer on AAS covering its history, therapeutic applications, side effects and emphasizing the health risks, the bodybuilder decided to continue his physical training without the use of AAS or any other illegal ergogenic drugs. So, in a period of five years of follow-up, the bodybuilder had his blood collected for the analysis of his lipid profile and atherogenic indices in three moments: (Test 1) immediately after the last cycle of androgenic anabolic use; (Test 2) after two years of physical training without the use of androgenic anabolic steroids and; (Test 3) after five years of physical training without the use of anabolic androgenic steroids.

 

Results 

 

    The bodybuilder anthropometric measures are described in Table 1.

 

Bodyweight	Stature	BMI	% Body fat	Lean body mass	Fat mass
124.3 Kg	189 cm	34.4 Kg/m²	12.6%	108.6 Kg	15.6 Kg

Source: Own elaboration. Note: BMI (Body mass index)

 

    Most of the bodybuilder initial biochemical values (Test 1) were inside reference values including hepatic function, protein profile, glucose levels and blood count. We observed a mildly increased hemoglobin (+10%) and red blood width levels (RDW, +12%) above reference values. Creatine kinase levels were above reference (≤90 UI/L) values at Tests 1 (4,000 UI/L), Test 2 (3,096 UI/L) and Test 3 (307 UI/L). Hepatic function was normal, but aspartate aminotransferase (AST) was increased (77 UI/L; +71%) when compared with reference levels (≤45 UI/L. These parameters remained in this range two years after at Test 2 (79 UI/L; +75%), reaching normal values only at Test 3 (five years later).

 

    Cardiovascular risk was assessed by lipid profile, which was constituted by high density lipoprotein (HDL-c), low density lipoprotein (LDL-c), very low density lipoprotein (VLDL-c), Total cholesterol (TC) and Triglycerides (TG). HDL-c was the most affected parameter with the lowest values at Test 1 (8 mg/dL), increasing slightly at Test 2 (14 mg/dL) and finally reaching physiological values at Test 3, five years after the last cycle of AAS (39 mg/dL). LDL-c levels were increased only after Test 1 (144 mg/dL) with normal values in the other tests. C-reactive protein (CRP) levels showed strikingly increased values at Test 1 (3.80 md/dL) and Test 2 (3.73 md/dL) reaching normal values (<0,3 md/dL) at Test 3. Additionally was evaluated CRP levels, specific cardiovascular risk factors (TG/HDL-c ratio, Castelli index I and II) and atherogenic index of plasma (AIP) based on the formula log10 (TG/HDL) as shown in Table 2. We present a case based in several laboratory exams showing persistent elevated cardiovascular risk factors in a amateur bodybuilder that lasted for many years after discontinuing his AAS regimen.

 

	CRP	Castelli I	Castelli II	TG/HDL	AIP
Test 1	3.80 mg/dL*	21.0*	18.0*	10.0*	1.0
Test 2	3.73 mg/dL *	8.9*	7.1*	4.1*	0.6
Test 3	<0.07 mg/dL	3.6	2.3	1.4	0.1
Reference	<0.3 mg/dL	5.4	3.3	3.8	N/D

Note: *Parameter outside the reference normal range. CRP normal range; Castelli I normal range; 

Castelli II normal range; TG/HDL normal range; AIP normal range. Source: Own elaboration

 

Discussion 

 

    Based on World Health Organization (WHO, 1995), BMI values of the patient is moderately obese (class I), a feature that does not apply since BMI only consider body mass and stature, which by the way does not reflect muscle mass. Additionally, body fat levels showed a value of 12.6% that is quite low.

 

    The isolation and chemical classification of testosterone occurred in 1935, soon was discovered that anabolic-androgenic steroids (AAS) therapy was a valuable therapeutic strategy in many chronic conditions like HIV, cancer, malnutrition, anemia, renal disease and hepatic failure (Basaria et al., 2001). However in supraphysiologic doses AAS may cause many clinical side effects that can be potentially life threatening in some cases, just like many others pharmacological agents. Unfortunately, drug abuse coming from these substances is frequently observed in non-competitive and professional athletes in search for aesthetics and physical performance improvements. In fact, following the use of AAS among professional and amateur athletes has been growing; earlier data from Blue & Lombardo (Blue, & Lombardo, 1999) shows that the annual market of AAS around the world is estimated in $1 billion.

 

    The increased AST levels presented by the subject seem to be related with muscle tissue damage induced by exercise training (Pettersson et al., 2008). Gamma glutamyl-transpeptidase levels were within normal range in all tests, which together with other tests excludes hepatic disease. Creatine kinase levels were also elevated, which reinforces the hypotheses of muscle damage induced by high-intensity exercise. Alternatively, some studies shows that AAS use can potentiate CK and AST levels in response to resistance training (Pertusi et al., 2001). The most prominent result observed in this case study remains under cardiac risk factors abnormalities. Our results show that even after two years of AAS withdrawal, still exists an increased risk for cardiac events. While hematocrit levels remained within normal limits, the values observed in all tests was above 50%, which according to International Cycling Federation is indicative of erythropoietin (EPO) doping (Schmidt et al., 2000). The subjected did not even know anything about this substance, beyond that in bodybuilding circles EPO use is not beneficial. However, the hematopoietic properties of AAS are well described in scientific literature (Palacios et al., 1983; Shahidi, 1973), and could also play a role since hemoglobin and RDW showed increased values, which in turn could promote higher blood viscosity leading to cardiac overload.

 

    Extensive research clearly shows that AAS abuse can cause acne, gynecomastia and male pattern baldness, which pose minimal health risks. However the scientific community has increasingly raised the interest by this subject in response to many published papers associating AAS use and sudden death in high level and amateur athletes (Montisci et al., 2012; Far et al., 2012; Nieminen et al., 1996). Baggish et al. (2010) showed that long-term AAS use is associated with left ventricular (LV) dysfunction, where 83% of the study sample showed LV ejection fractions below the accepted normal limit (≥55%). Ahlgrim, & Guglin (2009) described a case study of cardiomyopathy, with severe systolic dysfunction and Class IV heart failure despite maximal medical therapy due to AAS use. Cardiovascular alterations due to AAS use can be caused by multiple mechanisms. Increased blood viscosity, alterations in cardiac structure, abnormalities in blood lipid profile and inflammatory markers like C-reactive protein (CRP) are normally reported as relevant parameters to access heart disease (REF). Generally, many of the side effects above described subsides with discontinuation of AAS use, however some studies points to irreversible side effects like infertility or male-pattern baldness. (Hengevoss et al., 2015; Maravelias et al., 2005)

 

    Testosterone injections could induce cardiovascular disease through multiple mechanisms like structural cardiac alteration through matrix metalloprotease MMPs (Marqueti et al., 2012) or via thrombogenic pathways by increasing human platelet thromboxane A2 receptor density and aggregation responses (Ajayi et al., 1995). Additionally, AAS use can also disrupt the normal pattern blood lipid profile, which could affect other atherogenic indexes like Castelli index, TG/HDL ratio and AIP levels (Santora et al., 2006; Glazer, 1991). These parameters have been elaborated to optimize lipid profile analysis and could have a better predictive capacity to evaluate the intricacies of metabolic and clinical interactions between lipid fractions (Millán et al., 2009). Indeed, HDL-C/LDL-C is of special interest to cardiovascular risk assessment, especially when the absolute values of individual lipoproteins remain in the normal range (Nwagha et al., 2010). Elevation in Castelli index (I and II) is related with high risk for coronary heart disease (Castelli et al., 1986; Fernandez & Webb, 2008), besides both Castelli I and AIP are negatively associated with LDL-c particle size, since small dense LDL-c have a higher atherogenic profile (Dobiasova et al., 2005). In this study all the atherogenic indexes evaluated showed values within the normal range five years after the last AAS cycle only at Test 3.

 

    Urhausen et al. (2004) observed a slight concentric left ventricular hypertrophy in strength athletes who previously used AAS several years after discontinuation, suggesting that other functional and structural cardiac abnormalities could be even more persistent. Further research must be conducted to evaluate cardiac effects in these individuals in later life, since the number of AAS abusers has been increasing worldwide at an astounding rate (Angell et al., 2012). Years after Test 3, the athlete studied in this case was admitted to emergency room after two consecutive episodes of non-fatal ischemic stroke that could be related at least in part to his previous heavy AAS use (Santamarina et al., 2008). Data from recent studies shows that most AAS users are recreational exercisers or non-athletes, which in most cases studies weekly doses in excess of 1000 mg. (Ip et al., 2011; Parkinson, & Evans, 2006)

 

Conclusion 

 

    This case study shows a persistent increased cardiovascular risk that lasted for two years after discontinuation of AAS use and showed normal values five years later. Biochemical parameters related with lipid profile was by far the most affected by AAS utilization, a fact that could be related with cardiac disease and could potentially lead to sudden death. Data from the evaluated subject related with cardiac structural alterations was unavailable and should be a focus of attention since these effects are irreversible. Due to the ethical limitations related with data collection, experimental studies are limited to some specific conditions (clinical therapies and animal research).So, attention should be given to continuous education effort of the danger associated with the abuse of this drugs.

 

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Lecturas: Educación Física y Deportes, Vol. 27, Núm. 290, Jul. (2022)