Substance Use & Misuse, 49:1138–1145, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.912062
ORIGINAL ARTICLE
Anabolic–Androgenic Steroid Use Among Brazilian Bodybuilders Fabiana Ranielle de Siqueira Nogueira1 , Aline de Freitas Brito2 , Caio Victor Coutinho de Oliveira3 , Thaiza Isidro Vieira1 and Rachel Linka Beniz Gouveia4
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1
Laboratory for the Study of Physical Training Applied to Performance and Health, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 2 Department of Physical Education, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 3 Institute for Educational Development Courses (IDE-Recife), Maur´ıcio of Nassau Faculty (FMN); and Laboratory for the Study of Physical Training Applied to Performance and Health – LETFADS, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 4 Center for Health Sciences for Health (CCS), Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil (Johnson, Jay, Shoup, & Rickert, 1989). However, the use of these ergogenic aids can cause severe pathologies, including cardiovascular, endocrine, and psychiatric disorders (Angell et al., 2012). The abuse1 of AAS inside and outside the world of sports has been a concern to society and to governments, as well as to the most important health and sports agencies including the World Health Organization (WHO) and the International Olympic Committee (IOC) (Silva, J´unior, Figueiredo, Cioffi, Prestes, & Czepielewski, 2007). Several studies have reported that adolescent populations, especially those that are physically active, are more vulnerable2 to the use of AAS (Dunn & White, 2011; Handelsman & Gupta, 1997; Nilsson, Spak, Marklund, Baigi, & Allebeck, 2005). Recently, it has been suggested that elite athletes are the smallest portion of AAS users (Bahrke & Yesalis, 2004); AAS’s higher prevalence use has been found among recreational athletes practicing bodybuilding (Larance, Degenhardt, & Copeland, 2005) and those concerned with aesthetics (Bahrke & Yesalis, 2004). According to a recent systematic review by Nogueira, Souza, and Brito (2013) including 18 studies, in Brazil, although there are only few studies on the prevalence of AAS, they are concentrated in regions with better
This cross-sectional, quantitative, exploratory study investigated the prevalence and profile of anabolic– androgenic steroids (AAS) users amongst a convenience sample of 510 bodybuilders from 52 gyms, in ˜ Pessoa, Brazil, with a structured questionnaire Joao containing selected questions about socioeconomic and training variables on the use of AAS. Data were analyzed using frequency and chi-square tests. AAS prevalence use was 20.6%; mostly young men (98.1%), of a low education level (46.7%), who trained for more than 4 years (49.5%). The use of AAS was related to the use of dietary supplements. About 81% of consumed AAS consisted of Deca-Durabolin, Winstrol, and Sustanon. Study’s limitations are noted. Keywords fitness centers, anabolic agents, resistance exercise, doping, risk-taking behaviors
INTRODUCTION
The use of anabolic–androgenic steroids (AAS) to improve sports performance among athletes has been observed since the early 1950s (Kanayama, Hudson, & Pope, 2008). Since the 1980s, young people have used AAS in order to increase lean body mass for aesthetic purposes
1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. 2 The reader is reminded that the concepts of “vulnerability,” “risk factors,” as well as “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development and decay; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level), which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith,” “doctrinaire positions,” “personal truths,” historical observation, precedents, and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion.” or what. This is necessary to consider and to clarify if these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith” and stakeholder objectives. Editor’s note. Address correspondence to Caio Victor Coutinho de Oliveira, Institute for Educational Development Courses (IDE-Recife), Maur´ıcio of Nassau Faculty (FMN); and Laboratory for the Study of Physical Training Applied to Performance and Health – LETFADS, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; E-mail: [email protected].
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economic conditions, including the south (Frizon, Macedo, & Yonamine, 2009; Silva et al., 2007; Silva, Danielski, & Czepielewski, 2002), the southeast (Silva & Moreau, 2003), and the Midwest regions (Ara´ujo, Andreolo, & Silva, 2002). In the northeast, fewer studies have been published (Iriart & Andrade, 2002; Santos, Rocha, & Silva, 2011; Schwingel et al., 2012). It was the increased demand and supply of AAS and the low number of studies in Northeast Brazil that led us to conduct the present study—aimed at investigating the prevalence of AAS use by bodybuilders in the city of Jo˜ao Pessoa, Para´ıba. Furthermore, we wanted to study selected socioeconomic parameters, training characteristics, body image perception, reasons for AAS use, and which steroids were consumed by these users.
METHODS Sample
This is a cross-sectional, quantitative, exploratory study. The selection of gyms took place through a survey at the Regional Council of Physical Education (CREF 10 PB/RN), which provided a list containing the records of the 122 registered gyms of Jo˜ao Pessoa city, Paraiba, as well as the owner’s name, address, and telephone number. The gyms were selected by area of the city, whose geographical criteria are determined by the Municipal Infrastructure of the city/SEINFRA, with 20 gyms in the north, 40 in the south, 49 in the east, and 13 in the west. Given the nonuniform distribution of the number of gyms per region (16.39% in the northern region, 32.79% in the southern region, 40.16% in the eastern region, and 10.66% in the west), the equivalent contribution of each region to the total number of gyms was conducted in order to ensure a proportional contribution by area of the city. A simple random probability sampling without replacement was used to select the fitness centers’ sampled. In case of refusal, a new selection in the same region was performed to replace the gym that had refused to participate. The sample size calculation was performed using the Epi Info program (version 6.04), where the parameters used to define the number of gyms were the expected frequency for AAS consumption of 50% (ratio that maximizes the sample size), accuracy of 10%, and confidence interval of 95%. The final representative sample included 9 gyms in the north region, 16 in the south, 21 in the east, and 6 in the west. Fifty-two gyms in total were visited, representing 42.62% of the 122 recorded gyms in CREF/PB. Among the gyms visited, only 2.45% refused to participate. 510 bodybuilders, representing both consumers and non-consumers of ergogenic substances, completed questionnaires. They included both genders (aged between 18 and 57 years). An experienced researcher was present for any questions. This study was approved by the Ethics Committee on Human Research of the Federal University of Para´ıba–UFPB under the Protocol 1223/2007.
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Instruments for Data Collection
Data were collected using a modified structured questionnaire (Ara´ujo et al., 2002; Silva et al., 2007) containing 48 objective and subjective questions related to selected socioeconomic status (gender, age, education level, family income, and marital status), physical activity level (time practicing bodybuilding, workout frequency, time spent during each exercise session), and type/name of the substance used, length of use, location of purchase, purpose for use, consumption guidance, and possible adverse effects. The questionnaire was structured to be answered voluntarily and anonymously. Individuals were encouraged to be at ease and completed the questionnaire within the weight room of the gym. Prior to the beginning of the study, the questionnaire was piloted in two randomly selected gyms, where it was completed by 80 participants. These data were not included in the total sample. Procedures for Data Collection
Following the pilot study and training of researchers, the 52 establishments visited were included in the study from October 2007 to March 2008. During the visit, a Free Informed Term of Consent (FITC), whose aim was to report on the procedures used during the research, was presented to the manager of the premises to obtain the consent of the owners to administer the questionnaires. The interviews were conducted using a convenience sample, with the collaboration of bodybuilding instructors, which indicated the students that should participate. Before the interviews, the participants were given a consent form regarding the scope of the study and, after reading it and consenting, the interviews were conducted. The importance of the reliability of data provided was stressed. Among the potential participants approached, 10.23% refused to participate. Processing and Data Analysis
Univariate analysis of the data provided frequencies, measures of central tendency, medium and dispersion, variance, and standard deviation. The dependent variable, use of AAS, was related to other variables to determine associations. We used chi-square (χ 2 ) analysis with a significance level set at 5% (p < .05). We adopted a probability of less than 5% to reject the null hypothesis or no association. Statistical analysis was performed using SPSS (Statistical Package for Social Science), version 15.0 for Windows. RESULTS
Of 510 individuals surveyed, 20.6% (n = 105) reported being users of AAS, being 98.1% male (n = 103). Concerning the demographic and socioeconomic profiles of AAS users (Table 1), there was a positive association (p < .05) with age of users between 23 and 27 years old (41%), with individuals who were in high school (46.7%), users who trained in gyms in the southern area of the city
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TABLE 1. Demographic and socioeconomic data of users of AAS in the city of Jo˜ao Pessoa (2007–2008) Users
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Variable Age groups (years) 18–22 23–27 28–32 33–37 38–42 43–48 >48 Total Education Elementary school Middle school High school Graduated Others Total Family income 1–3 3–5 5–7 >7 Total Marital status Single Married Divorced Total Academy area North South East West Total ∗
Not Users
N
%
N
%
N
%
36 43 15 8 1 2 0 105
34.2∗ 41.0∗ 14.3 7.6 1.0 1.9 0.0 100
179 105 64 28 16 5 2 399
44.9 26.3 16.0 7.0 4.0 1.0 0.5 100
215 148 79 47 26 7 3 505
42.6 29.3 15.6 9.3 5.1 1.4 0.6 100
12 49 42 1 1 105
11.4 46.7 40.0 1.0 1.0 100
23 194 161 20 7 405
5.7 47.9 39.8 4.9 1.7 100
35 243 203 21 8 510
6.9 28.0 29.8 4.3 1.6 100
47 19 13 25 104
45.2∗ 18.3 12.5 24 100
121 81 76 124 402
30.1 20.1 18.9 30.8 100
168 100 89 149 506
33.2 19.8 17.6 29.4 100
72 32 1 105
68.5∗ 30.5 1 100
317 80 7 404
78.5 19.8 1.7 100
389 112 8 509
76.4 22 1.6 100
29 41 19 15 104
27.9 39.4∗ 18.3 14.4 100
66 147 148 40 401
16.5 36.7 36.9 10.0 100
95 188 167 55 505
19.0 37.2 33.1 10.9 100
χ2 (p value) χ 2 = 11.861 ∗ (.0065)
χ 2 = 5.893 (.207)
χ 2 = 8.599 ∗ (.035)
χ 2 = 8.841 ∗ (.014)
χ 2 = 11.009 ∗ (.012)
means p < .05.
(39.4%), with family income between one and three minimum salary (45.2%), and those who were single (68.5%).3 Regarding data related to the time practicing bodybuilding, training frequency, and time spent during each workout, we observed the majority of AAS users trained for over 4 years (49.5%), usually attended the gym five times weekly (62.6%), and spend approximately 1 hour training (51.4%), while most nonusers trained for less than 6 months (26%), attended the gym five times per week (58%), and also spend 1 hour per training session (44.6%), as shown in Table 2. Among the AAS reported, 81.1% belonged to Group E1 (Deca-Durabolin, Winstrol, Anavar, Sustanon, Deposteron, Estandron-P, Primabolan, and Hemogenin), 11.3% to Group E2 (ADE–injectable oils, Glicopan) 4.1% to Group E3 (Mineral Oil, Clen3
Total
The reader is referred to Hills’s criteria for causation, which were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, A. B. (1965). The environment and disease: Associations or causation? Proceedings of the Royal Society of Medicine 58:295–300.). Editor’s note.
buterol, Lipobastil), 2.3% to Group E4 (Androgenol, Equifort, WinstrolVet), and 1.3% to the Group E5 (GH), as shown in Table 3. When users were asked whether they achieved improvement with the use of such substances, 87% (n = 94) reported and judged such an improvement. Regarding the knowledge of the adverse effects caused by the use of these substances, 80.8% (n = 84) of users reported knowing the effects caused by use/abuse. In the present study, physical appearance proved to be important, since 91.4% (n = 96) of AAS users were concerned about this. When asked if some aspect of their appearance made them depressed, angry, or anxious, 37.1% (n = 39) reported such feelings. According to the Protocol Stunkard, Sorenson, and Schlusinger (1983)4 (Figure 1), most AAS users reported their current body image was number 4 (36.2%, n = 38) and number 5 (32.4%, n = 4
This protocol, using pictograms which contain nine silhouettes that are on an ordinal scale, is self-reported judgments about past, current, or ideal body image of the respondents. Editor’s note.
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ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
TABLE 2. Time practicing bodybuilding, weekly training, and time spent per training session regarding the anabolic-androgenic steroid users and nonusers bodybuilders in the city of Jo˜ao Pessoa – PB (2007–2008) Users
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Variable Time practicing bodybuilding 3 hours Total ∗
N
Not Users %
N
Total %
N
%
12 7 7 13 14 52 105
11.4 6.7 6.7 12.4 13.3 49.5∗ 100
105 66 52 53 33 95 404
26.0 16.3 12.9 13.1 8.2 23.5 100
117 73 59 66 47 147 509
23.0 14.3 11.6 13.0 9.2 28.9 100
4 12 23 65 104
3.8 11.5 22.1 62.6 100
21 70 78 234 403
5.2 17.4 19.4 58.0 100
25 82 101 299 507
4.9 16.2 19.9 59.0 100
17 54 26 7 1 105
16.1 51.4∗ 24.8 6.7 1 100
28 179 176 13 5 401
7.1 44.6∗∗ 43.9 3.2 1.2 100
45 233 202 20 6 506
8.9 46.0 39.9 4.0 1.2 100
χ2 (p value) χ 2 = 32.299 ∗ (.000)
χ 2 = 892 (.827)
χ 2 = 14.512 ∗ (.006) ∗∗ (.045)
means p < .05.
34), already looking for who would like to match silhouettes with number 4 (32.4%, n = 34) and number 5 (40%, n = 42), (Figure 2). Recounting their appearance from the previous year, 29.5% (n = 31) of AAS users reported having the silhouette of number 3 and 26.7% (n = 28) of the number 2 (Figure 2). Among the 510 bodybuilders, 55.5% (n = 283) also reported using dietary supplements and 10.7% (n = 53) site injection of oil for appearance purposes. Regarding the association of the use of these substances and AAS, there was a significant statistical association (p < .005) (Table 1). DISCUSSION
This research aimed to document the prevalence of AAS use and the socioeconomic profile of bodybuilders freTABLE 3. Substances used by bodybuilders (n = 60) in gyms of Jo˜ao Pessoa city Groups E1 (AAS) E2 (ADE, Glicopan) E3 (Mineral oil, Clenbuterol, Lipobastil) E4 (ASS for veterinary use) E5 (GH) Total
N
%
180 25 9 5 3 225
81.1% 11.3% 4.1% 2.3% 1.4% 100
Note. E1(AAS): Deca-Durabolin, Winstrol, Anavar, Sustanon, Deposteron, Estandron-P, Primabolan, and Hemogenin; ADE: Injectable Oil; GH: Growth Hormone. Gave the sum of using one or more substances, as users concurrently used.
quenting gyms in the city of Jo˜ao Pessoa. It was observed that younger individuals (between 23 and 27 years of age), with a family income between one and three minimum salaries, unmarried, with at least 4 years of training experience and regular users of the gym (5× per week), constitute the typical user of this type of substance. These data can be of great importance to relevant policy makers in guiding projects and actions related to the prevention and treatment of the study population, exposed to substances that are illegal and especially deleterious to health. Considering that the lifestyle of the population changes as a function of the economic and structural conditions of each region, studies conducted in Brazil about the prevalence of AAS use have been concentrated in the south (Frizon, Macedo, & Yonamine, 2009; Silva et al., 2002; 2007), the southeast (Silva, & Moreau, 2003), and the Midwest (Ara´ujo et al., 2002) regions. In the northeast, few studies have been published (Iriart & Andrade, 2002; Santos et al., 2011; Schwingel et al., 2012). Given the above, this study fills a gap in the literature for information about the prevalence of AAS use and the profile of AAS users in these regions. Some discussion is warranted regarding the methodological aspects of the studies cited above. Unlike the others, the present study was designed, so that the sample size was representative of the entire population of bodybuilders in the city of Jo˜ao Pessoa, PB, allowing, in this way, inferences related to all bodybuilding practitioners within the city. Only Silva et al. (2007) have used a similar methodological design. In the study by Iriart & Andrade (2002), conducted in a poor neighborhood in the city of Salvador, Bahia (Brazil), young bodybuilders were
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FIGURE 1. Set of silhouettes proposed by Stunkard et al., 1983.
studied. In addition, the researchers used qualitative methodology with focus groups and semistructured interviews, which do not permit generalization of the findings to the population of the municipality. Additionally, in the study by Silva & Moreau (2003), just three gyms in S˜ao Paulo were evaluated, and only 3% of the questionnaires were completed by users, creating a serious bias in the findings and impossibility of extrapolating the data. Comparisons with other studies on this subject are complicated, especially given the wide variety with regard to the number of respondents, sample selection, methodology, and application of the protocol for data collection. Use of the questionnaire as an instrument of data collection in the present study is justified because of its easy application, low cost, security, anonymity, low rejection rate, and the fact that it is the most common method used by na-
tional and international institutions (Smart et al., 1980). Despite this, the questionnaire utilized was not previously validated, which is a limitation of the present study. The prevalence of use of AAS observed can be considered high (20.6%, n = 105). These data are similar to that reported by Ara´ujo et al. 2002 in Goiania, Brazil (24%, n = 183). On the other hand, Silva & Moreau (2003) in S˜ao Paulo, Brazil, found a prevalence rate of 8% (n = 16, of 209 interviewed). The wide variation in the prevalence estimates of use in these studies may be due to the potential methodological limitations already mentioned, in addition to the generation of false-positive data. The AAS user’s profile observed in this survey corresponds to young men (between 23 and 27 years), family income between one and three minimum salaries, unmarried, with at least 4 years of training experience, with
FIGURE 2. Distribution percentage of users of AAS according to which physical appearance they would like.
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ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
a low education level, regular gym use (5× a week), and an elevated concern with body image. Among users, 98.1% were men. This same trend of increased use by men was observed in studies by Kanayama, Boynes, Hudson, Field, and Pope (2007) and Tahtamouni et al. (2008). This finding is not surprising, since, as stated by Kanayama, Hudson, and Pope (2010), women rarely want to be extremely muscular, and that continued use of AAS is related to the development of masculine characteristics. The preoccupation with body image also seems to be a recurring theme in other studies, in terms of reasons reported for using AAS. The main reasons for use of AAS are based on the demands of increased sports performance, the admiration received from another person, obtaining the “perfectly toned” body, an increased libido, and an improved well-being (Cohen, Collins, Darkes, & Gwartney, 2007; Parkinson & Evans, 2006). Concerning the type of drugs used, we observed that substances such as Deca-Durabolin, Winstrol, and ADE are part of the group of substances, which are most commonly used. These findings are in agreement with Alberto, Iriart, and Chaves (2009), Silva et al. (2007), and Araujo et al. (2002). The fact that Deca-Durabolin and ADE are among the most widely used substances, probably lies in their relatively low cost, as discussed by Albert et al. (2009). This emphasizes the issue of sale of these drugs that require a prescription for purchase and are easily obtained in veterinary pharmacies or on the “black market” (Domingues & Marins, 2007; Silva et al., 2007). In spite of the efforts of the National Agency for Sanitary Surveillance (ANVISA), aiming to control and track the sales of controlled medicine with the launch of the National System of Management of Controlled Products—SNGPC, the sales of such substances without medical prescription are still high (Santos et al., 2011). A point of concern is the fact that 80.8% (n = 84) of AAS users know the adverse effects of using these substances. This finding complements that of Silva et al. (2007), where about half of the subjects (48.7%) who had used AAS would do it again. Similar findings were observed in the study of Santos et al. (2011): 34.9% of the participants knew that ASS were damaging drugs. Investigating the use of dietary supplements to improve the physical performance and aesthetic appearance is important since studies have demonstrated an association between the use of supplements and banned substances such as AAS (Dunn & White, 2011). The relationship found in the present study through a linear regression between the use of supplements and AAS (r = −0.7608, p < .000) shows this pattern of behavior. This can lead to the assumption that there may be an increased risk that consumers of food supplements also become consumers of AAS. In this regard, the “gateway theory,”5 developed 5
The reader is reminded that the concept of a “gateway drug” empowers specific “drugs,” while disempowering the novice user, in a linear cause and effect manner for a process, which is dynamic, complex, nonlinear, multidimensional, and bounded (time, place, culture, age, gender, ethnicity, etc.) among other relevant considerations. Editor’s note.
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some years ago, suggests a development trajectory or sequence of use of a substance, where the use of illicit substances is preceded by the use of legal ones (Degenhardt et al., 2011).
CONCLUSION
Data from this study confirm the trend found in other regions of Brazil, where there is a high prevalence of AAS use by practitioners of physical activity. Most important, we demonstrated the youth are the user profile of these substances and their use is motivated by aesthetic concerns. More studies in Brazil’s Northeast should be performed. A disturbing finding is that these bodybuilders use AAS even knowing its side effects. Moreover, the relationship found between consumption of dietary supplements and AAS, previously observed in other studies, suggests that there may be greater chances for consumers of dietary supplements becoming AAS users under yetto-be documented necessary endogenous as well as exogenous conditions. Thus, the results of this study identify and contribute to the understanding of an old problem, which appears to be growing, that requires relevant policy maker to implement a series of effective actions as well as new innovative ones, which open untried intervention pathways for their resolution. There is a need, for example, for evidence-based intervention campaigns aimed specifically at young bodybuilders to prevent the use of AAS, taking into account the context in which they are inserted. The role of health professionals working with this population (physical educator, nutritionist, endocrinologist) should be central.
Declaration of Interest
The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
THE AUTHORS Fabiana Ranielle de Siqueira Nogueira has received the degree in physical education from Federal University of Para´Iba (UFPB). She is also a specialist in bodybuilding and fitness from the University Gama Filho (UGF) and is a research member of Laboratory for the Study of Physical Training Applied to Performance and Health of the Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil. Her main interests include bodybuilding and fitness, sports nutrition, doping in sport and exercise, body image
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in sports and exercise, and anabolic-androgenic steroids in public health and health promotion.
Aline de Freitas Brito has received the degree in physical education from Federal University of Para´Iba (UFPB). Master’s in physical education. She is a PhD student in the Post Graduate Program in Natural Products and Synthetic Bioactive (UFPB). She is an acting professor in the Department of Physical Education (DEF), UFPB, of the disciplines: School and Health; Exercise Prescription, Bodybuilding, and Fitness Academy. Her main interests include hemodynamic responses to exercise cardiac autonomic modulation, and responses of smooth muscle in response to exercise.
Rachel Linka Beniz Gouveia has received the degree of bachelor of dentistry, bachelor of human anatomy and physiology, bacharelada legal sciences at the University Center of Jo˜ao Pessoa ˆ She is specialist in (UNIPE). public health education by UNAERP, expert Sanitary and Epidemiological Surveillance by UNAERP, law specialist Work by ESMAT13, and has the MS degree in biological sciences (Physiology) from the Federal University of Pernambuco (UFPE) and PhD in biomedical sciences (human physiology), University of S˜ao Paulo (USP). Currently, she holds the position of adjunct professor at the Federal University of Para´ıba (UFPB), the Center for Health Sciences for Health (CCS), Jo˜ao Pessoa, Brazil, and teaching in the discipline of human physiology, and an acting professor in the Department of Physical Education (DEF), UFPB.
GLOSSARY
Caio Victor Coutinho de Oliveira has received the degree in nutrition from Federal University of Para´ıba (UFPB), with expertise in nutritional bases of physical activity: sports nutrition from Gama Filho University (UGF). He has the master degree in nutrition sciences (UFPB). Currently, he is a professor at Maur´ıcio of Nassau Faculty (FMN) and Institute for Educational Development Courses (IDE-Recife) as well as researcher member of the Laboratory for the Study of Physical Training Applied to Performance and Health - LETFADS/UFPB. He has experience in clinical and sports nutrition, acting on the following topics: diets, athletes, dietary supplements, professional soccer, molecular biology, and markers of oxidative stress and muscle damage.
Thaiza Isidro Vieira has received the degree of full degree in physical education. She is physical education specialist, expert in foundations of education: interdisciplinary teaching practices. She is linked to the Laboratory for the Study of Physical Training Applied to Performance and Health of the Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil, and currently teaching in the Department of Education of the State of Para´ıba.
ADE (Injectable Oils): oils of local intramuscular application for immediate impact such as injections of vitamin complex for veterinary use formed by the fatsoluble vitamins A, D, and E (ADE) and mineral oil into smaller muscle groups considered, with the desire of many fans that will put tica. Despite being dangerous and without technical and scientific support, this practice is becoming increasingly common, producing serious harmful effects and physical deformations among users. Anabolic–Androgenic Steroids (AAS): Hormones are responsible for the harmony of the vital functions of organisms. AAS are synthetic forms of the main male hormone, testosterone, which mimics the anabolic effects of testosterone, with the aim of activating protein metabolism, retaining nitrogen, bringing the ribonucleic acid (RNA) activity, and promoting synthesis anabolic effect of growth. Body Image: has received great attention and appreciation in contemporary society, and has been associated with youth using and misusing a range of substances to achieve and to maintain “the ideal body.” It is an individual’s perception of their own body. Personal evaluation of the individual self is physical and biological. Body image is also the mindset of the individual self and his/her relationship to others. Collateral Effects: any variant or deviant condition from normal. A different effect from that considered for a main drug. This term should be distinguished from an adverse effect, which refers to an unwanted side effect, as a drug may cause other potentially beneficial effects in addition to the primary purpose. Ergogenic: Substances or devices are used with the goal of improving athletic performance and recovery from exercise. Thus, the purpose of the use of ergogenic
ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
is to increase performance through increased physical power, mental strength or mechanical threshold, and thus prevent or delay the onset of fatigue.
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REFERENCES Alberto, J., Iriart, B., & Chaves, J. C. (2009). Culto ao corpo e uso de anabolizantes entre praticantes de musculac¸a˜ o body cult and use of anabolic steroids bybodybuilders. Caderno de Sa´ude P´ublica, 25(4), 773–782. Angell, P., Chester, N., Green, D., Somauroo, J., Whyte, G., & George, K. (2012). Anabolic steroids and cardiovascular risk. Sports Medicine (Auckland, N.Z.), 42(2), 119–134. Ara´ujo, L., Andreolo, J., & Silva, M. (2002). Utilizac¸a˜ o de suplemento alimentar e anabolizante por praticantes de musculac¸a˜ o nas academias de Goiˆania-GO. Revista Brasileira de Ciˆencia e Movimento, 3(1), 13–18. Bahrke, M., & Yesalis, C. E. (2004). Abuse of anabolic–androgenic steroids and related substances in sport and exercise. Curr Opin Pharmacol, 4, 614–620. Cohen, J., Collins, R., Darkes, J., & Gwartney, D. A. (2007). A league of their own: Demographics,motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. J Int Soc Sports Nutr, 4, 12. Degenhardt, L., Dierker, L., Chiu, W. T., Medina-mora, M. E., Neumark, Y., Sampson, N., . . . Kessler, R. C. (2011). Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO. World Mental Health Surveys. Drug Alcohol Depend, 108(2), 84–97. Domingues, S., & Marins, J. (2007). Utilizac¸a˜ o de recursos ergogˆenicos e suplementos alimentares por praticantes de musculac¸a˜ o em Belo Horizonte - MG. Fitness & Performance, 6(4), 218–226. Dunn, M., & White, V. (2011). The epidemiology of anabolic–androgenic steroid use among Australian secondary school students. J Sci Med Sport/Sports Med Aust, Sports Medicine Australia, 14(1), 10–14. Frizon, F., Macedo, S., & Yonamine, M. (2009). Uso de ester´oides andr´ogenos anab´olicos por praticantes de atividade f´ısica das principais academias de Erechim e Passo Fundo/RS. Revista de Ciˆencias Farmacˆeuticas B´asica e Aplicada, 26(3), 227– 232. Handelsman, D. J., & Gupta, L. (1997). Prevalence and risk factors for anabolic-androgenic steroid abuse in Australian high school students. International Journal of Andrology, 2(3), 159–164. Iriart, J., & Andrade, T. (2002). Body-building, steroid use, and risk perception among young body-builders from a low-income neighborhood in the city of Salvador, Bahia State, Brazil. Cadernos de Sa´ude P´ublica, 18(5), 1379–1387. Johnson, M., Jay, M., Shoup, B., & Rickert, V. (1989). Anabolic steroid use by male adolescents. Pediatrics, 83, 921–924. Kanayama, G., Boynes, M., Hudson, J. I., Field, A. E., & Pope, H. G. (2007). Anabolic steroid abuse among teenage girls: An illusory problem? Drug Alcohol Depend, 88(2–3), 156–162.
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Kanayama, G., Hudson, J., & Pope, H. (2008). Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: A looming public health concern? Drug Alcohol Depend, 98, 1–12. Kanayama, G., Hudson, J., & Pope, H. (2010). Illicit anabolic–androgenic steroid use. Hormones and Behavior, 58(1), 111–121. Larance, B., Degenhardt, L., & Copeland, J. (2005). Rapid assessment of performance and image enhancing drugs (PIEDs) in New South Wales: Feasibility study. Techinal Reports, Sydney. Nilsson, S., Spak, F., Marklund, B., Baigi, A., & Allebeck, P. (2005). Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden. Substance Use Misuse, 40(1), 1–12. Nogueira, F. R. S., Sousa, A. A., & Brito, A. F. (2013). Prevalˆencia do uso e efeitos de recursos ergogˆenicos por praticantes de musculac¸a˜ o nas academias brasileiras: Uma revis˜ao sistematizada. Revista Brasileira de Ativividade F´ısica e Sa´ude, Pelotas/RS, 18(1), 16–30. Parkinson, A. B., & Evans, N. A. (2006). Anabolic androgenic steroids: A survey of 500 users. Med Sci Sports Exercise, 38(4), 644–651. Santos, A. M., Rocha, M. S. P. da, & Silva, M. F. da. (2011). Illicit use and abuse of anabolic-androgenic steroids among Brazilian bodybuilders. Substance Use & Misuse, 46, 742–748. Schwingel, P. A., Cotrim, H. P., Ribeiro, C., Cruz, B., Salles, R., Eduardo, C., & Zoppi, C. C. (2012). Non-medical anabolicandrogenic steroid consumption and hepatitis B and C virus infection in regular strength training practitioners. African Journal of Pharmacy and Pharmacology, 6(22), 1598–1605. Silva, I., & Moreau, R. (2003). Uso de ester´oides anab´olicos androgˆenicos por praticantes de musculac¸a˜ o de grandes academias da cidade de S˜ao Paulo. Revista Brasileira Ciˆencia Farmacˆeuticas, 39(3), 327–333. Silva, P., J´unior, L., Figueiredo, V., Cioffi, A., Prestes, M., & Czepielewski, M. (2007). Prevalˆencia do uso de agentes anab´olicos em praticantes de musculac¸a˜ o de PortoAlegre. Arquivos Brasileiros de Endocrinologia e Metabologia, 51(1), 104–110. Silva, P. D. A., Danielski, R., & Czepielewski, M. (2002). Ester´oides anabolizantes no esporte. Revista Brasileira de Medicina do Esporte, 8(51), 235–243. Smart, R., Hughes, P., Jonhston, L., Anumonye, A., Khant, U., & Medinamora, M. (1980). A methodology for students drug-use surveys. Geneva World Health Organization. Stunkard, A., Sorenson, T., & Schlusinger, F. (1983). Use of the Danish adoption register for the study of obesity and thinness. In S. S. Kety, L. P. Rowland, R. L. Sigman & S. Matthysse (Eds.), The genetics of neurological and psychiatric disorders (pp. 115–120). New York: Raven. Tahtamouni, L. H., Mustafa, N. H., Alfaouri, A. A, Hassan, I. M., Abdalla, M. Y., & Yasin, S. R. (2008). Prevalence and risk factors for anabolic–androgenic steroid abuse among Jordanian collegiate students and athletes. Eur J Public Health, 18(6), 661–665.
ORIGINAL ARTICLE
Anabolic–Androgenic Steroid Use Among Brazilian Bodybuilders Fabiana Ranielle de Siqueira Nogueira1 , Aline de Freitas Brito2 , Caio Victor Coutinho de Oliveira3 , Thaiza Isidro Vieira1 and Rachel Linka Beniz Gouveia4
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1
Laboratory for the Study of Physical Training Applied to Performance and Health, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 2 Department of Physical Education, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 3 Institute for Educational Development Courses (IDE-Recife), Maur´ıcio of Nassau Faculty (FMN); and Laboratory for the Study of Physical Training Applied to Performance and Health – LETFADS, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; 4 Center for Health Sciences for Health (CCS), Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil (Johnson, Jay, Shoup, & Rickert, 1989). However, the use of these ergogenic aids can cause severe pathologies, including cardiovascular, endocrine, and psychiatric disorders (Angell et al., 2012). The abuse1 of AAS inside and outside the world of sports has been a concern to society and to governments, as well as to the most important health and sports agencies including the World Health Organization (WHO) and the International Olympic Committee (IOC) (Silva, J´unior, Figueiredo, Cioffi, Prestes, & Czepielewski, 2007). Several studies have reported that adolescent populations, especially those that are physically active, are more vulnerable2 to the use of AAS (Dunn & White, 2011; Handelsman & Gupta, 1997; Nilsson, Spak, Marklund, Baigi, & Allebeck, 2005). Recently, it has been suggested that elite athletes are the smallest portion of AAS users (Bahrke & Yesalis, 2004); AAS’s higher prevalence use has been found among recreational athletes practicing bodybuilding (Larance, Degenhardt, & Copeland, 2005) and those concerned with aesthetics (Bahrke & Yesalis, 2004). According to a recent systematic review by Nogueira, Souza, and Brito (2013) including 18 studies, in Brazil, although there are only few studies on the prevalence of AAS, they are concentrated in regions with better
This cross-sectional, quantitative, exploratory study investigated the prevalence and profile of anabolic– androgenic steroids (AAS) users amongst a convenience sample of 510 bodybuilders from 52 gyms, in ˜ Pessoa, Brazil, with a structured questionnaire Joao containing selected questions about socioeconomic and training variables on the use of AAS. Data were analyzed using frequency and chi-square tests. AAS prevalence use was 20.6%; mostly young men (98.1%), of a low education level (46.7%), who trained for more than 4 years (49.5%). The use of AAS was related to the use of dietary supplements. About 81% of consumed AAS consisted of Deca-Durabolin, Winstrol, and Sustanon. Study’s limitations are noted. Keywords fitness centers, anabolic agents, resistance exercise, doping, risk-taking behaviors
INTRODUCTION
The use of anabolic–androgenic steroids (AAS) to improve sports performance among athletes has been observed since the early 1950s (Kanayama, Hudson, & Pope, 2008). Since the 1980s, young people have used AAS in order to increase lean body mass for aesthetic purposes
1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note. 2 The reader is reminded that the concepts of “vulnerability,” “risk factors,” as well as “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, nonlinear; rates of development and decay; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level), which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith,” “doctrinaire positions,” “personal truths,” historical observation, precedents, and traditions that accumulate over time, conventional wisdom, perceptual and judgmental constraints, “transient public opinion.” or what. This is necessary to consider and to clarify if these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith” and stakeholder objectives. Editor’s note. Address correspondence to Caio Victor Coutinho de Oliveira, Institute for Educational Development Courses (IDE-Recife), Maur´ıcio of Nassau Faculty (FMN); and Laboratory for the Study of Physical Training Applied to Performance and Health – LETFADS, Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil; E-mail: [email protected].
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ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
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economic conditions, including the south (Frizon, Macedo, & Yonamine, 2009; Silva et al., 2007; Silva, Danielski, & Czepielewski, 2002), the southeast (Silva & Moreau, 2003), and the Midwest regions (Ara´ujo, Andreolo, & Silva, 2002). In the northeast, fewer studies have been published (Iriart & Andrade, 2002; Santos, Rocha, & Silva, 2011; Schwingel et al., 2012). It was the increased demand and supply of AAS and the low number of studies in Northeast Brazil that led us to conduct the present study—aimed at investigating the prevalence of AAS use by bodybuilders in the city of Jo˜ao Pessoa, Para´ıba. Furthermore, we wanted to study selected socioeconomic parameters, training characteristics, body image perception, reasons for AAS use, and which steroids were consumed by these users.
METHODS Sample
This is a cross-sectional, quantitative, exploratory study. The selection of gyms took place through a survey at the Regional Council of Physical Education (CREF 10 PB/RN), which provided a list containing the records of the 122 registered gyms of Jo˜ao Pessoa city, Paraiba, as well as the owner’s name, address, and telephone number. The gyms were selected by area of the city, whose geographical criteria are determined by the Municipal Infrastructure of the city/SEINFRA, with 20 gyms in the north, 40 in the south, 49 in the east, and 13 in the west. Given the nonuniform distribution of the number of gyms per region (16.39% in the northern region, 32.79% in the southern region, 40.16% in the eastern region, and 10.66% in the west), the equivalent contribution of each region to the total number of gyms was conducted in order to ensure a proportional contribution by area of the city. A simple random probability sampling without replacement was used to select the fitness centers’ sampled. In case of refusal, a new selection in the same region was performed to replace the gym that had refused to participate. The sample size calculation was performed using the Epi Info program (version 6.04), where the parameters used to define the number of gyms were the expected frequency for AAS consumption of 50% (ratio that maximizes the sample size), accuracy of 10%, and confidence interval of 95%. The final representative sample included 9 gyms in the north region, 16 in the south, 21 in the east, and 6 in the west. Fifty-two gyms in total were visited, representing 42.62% of the 122 recorded gyms in CREF/PB. Among the gyms visited, only 2.45% refused to participate. 510 bodybuilders, representing both consumers and non-consumers of ergogenic substances, completed questionnaires. They included both genders (aged between 18 and 57 years). An experienced researcher was present for any questions. This study was approved by the Ethics Committee on Human Research of the Federal University of Para´ıba–UFPB under the Protocol 1223/2007.
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Instruments for Data Collection
Data were collected using a modified structured questionnaire (Ara´ujo et al., 2002; Silva et al., 2007) containing 48 objective and subjective questions related to selected socioeconomic status (gender, age, education level, family income, and marital status), physical activity level (time practicing bodybuilding, workout frequency, time spent during each exercise session), and type/name of the substance used, length of use, location of purchase, purpose for use, consumption guidance, and possible adverse effects. The questionnaire was structured to be answered voluntarily and anonymously. Individuals were encouraged to be at ease and completed the questionnaire within the weight room of the gym. Prior to the beginning of the study, the questionnaire was piloted in two randomly selected gyms, where it was completed by 80 participants. These data were not included in the total sample. Procedures for Data Collection
Following the pilot study and training of researchers, the 52 establishments visited were included in the study from October 2007 to March 2008. During the visit, a Free Informed Term of Consent (FITC), whose aim was to report on the procedures used during the research, was presented to the manager of the premises to obtain the consent of the owners to administer the questionnaires. The interviews were conducted using a convenience sample, with the collaboration of bodybuilding instructors, which indicated the students that should participate. Before the interviews, the participants were given a consent form regarding the scope of the study and, after reading it and consenting, the interviews were conducted. The importance of the reliability of data provided was stressed. Among the potential participants approached, 10.23% refused to participate. Processing and Data Analysis
Univariate analysis of the data provided frequencies, measures of central tendency, medium and dispersion, variance, and standard deviation. The dependent variable, use of AAS, was related to other variables to determine associations. We used chi-square (χ 2 ) analysis with a significance level set at 5% (p < .05). We adopted a probability of less than 5% to reject the null hypothesis or no association. Statistical analysis was performed using SPSS (Statistical Package for Social Science), version 15.0 for Windows. RESULTS
Of 510 individuals surveyed, 20.6% (n = 105) reported being users of AAS, being 98.1% male (n = 103). Concerning the demographic and socioeconomic profiles of AAS users (Table 1), there was a positive association (p < .05) with age of users between 23 and 27 years old (41%), with individuals who were in high school (46.7%), users who trained in gyms in the southern area of the city
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F. RANIELLE DE SIQUEIRA NOGUEIRA ET AL.
TABLE 1. Demographic and socioeconomic data of users of AAS in the city of Jo˜ao Pessoa (2007–2008) Users
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Variable Age groups (years) 18–22 23–27 28–32 33–37 38–42 43–48 >48 Total Education Elementary school Middle school High school Graduated Others Total Family income 1–3 3–5 5–7 >7 Total Marital status Single Married Divorced Total Academy area North South East West Total ∗
Not Users
N
%
N
%
N
%
36 43 15 8 1 2 0 105
34.2∗ 41.0∗ 14.3 7.6 1.0 1.9 0.0 100
179 105 64 28 16 5 2 399
44.9 26.3 16.0 7.0 4.0 1.0 0.5 100
215 148 79 47 26 7 3 505
42.6 29.3 15.6 9.3 5.1 1.4 0.6 100
12 49 42 1 1 105
11.4 46.7 40.0 1.0 1.0 100
23 194 161 20 7 405
5.7 47.9 39.8 4.9 1.7 100
35 243 203 21 8 510
6.9 28.0 29.8 4.3 1.6 100
47 19 13 25 104
45.2∗ 18.3 12.5 24 100
121 81 76 124 402
30.1 20.1 18.9 30.8 100
168 100 89 149 506
33.2 19.8 17.6 29.4 100
72 32 1 105
68.5∗ 30.5 1 100
317 80 7 404
78.5 19.8 1.7 100
389 112 8 509
76.4 22 1.6 100
29 41 19 15 104
27.9 39.4∗ 18.3 14.4 100
66 147 148 40 401
16.5 36.7 36.9 10.0 100
95 188 167 55 505
19.0 37.2 33.1 10.9 100
χ2 (p value) χ 2 = 11.861 ∗ (.0065)
χ 2 = 5.893 (.207)
χ 2 = 8.599 ∗ (.035)
χ 2 = 8.841 ∗ (.014)
χ 2 = 11.009 ∗ (.012)
means p < .05.
(39.4%), with family income between one and three minimum salary (45.2%), and those who were single (68.5%).3 Regarding data related to the time practicing bodybuilding, training frequency, and time spent during each workout, we observed the majority of AAS users trained for over 4 years (49.5%), usually attended the gym five times weekly (62.6%), and spend approximately 1 hour training (51.4%), while most nonusers trained for less than 6 months (26%), attended the gym five times per week (58%), and also spend 1 hour per training session (44.6%), as shown in Table 2. Among the AAS reported, 81.1% belonged to Group E1 (Deca-Durabolin, Winstrol, Anavar, Sustanon, Deposteron, Estandron-P, Primabolan, and Hemogenin), 11.3% to Group E2 (ADE–injectable oils, Glicopan) 4.1% to Group E3 (Mineral Oil, Clen3
Total
The reader is referred to Hills’s criteria for causation, which were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, A. B. (1965). The environment and disease: Associations or causation? Proceedings of the Royal Society of Medicine 58:295–300.). Editor’s note.
buterol, Lipobastil), 2.3% to Group E4 (Androgenol, Equifort, WinstrolVet), and 1.3% to the Group E5 (GH), as shown in Table 3. When users were asked whether they achieved improvement with the use of such substances, 87% (n = 94) reported and judged such an improvement. Regarding the knowledge of the adverse effects caused by the use of these substances, 80.8% (n = 84) of users reported knowing the effects caused by use/abuse. In the present study, physical appearance proved to be important, since 91.4% (n = 96) of AAS users were concerned about this. When asked if some aspect of their appearance made them depressed, angry, or anxious, 37.1% (n = 39) reported such feelings. According to the Protocol Stunkard, Sorenson, and Schlusinger (1983)4 (Figure 1), most AAS users reported their current body image was number 4 (36.2%, n = 38) and number 5 (32.4%, n = 4
This protocol, using pictograms which contain nine silhouettes that are on an ordinal scale, is self-reported judgments about past, current, or ideal body image of the respondents. Editor’s note.
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ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
TABLE 2. Time practicing bodybuilding, weekly training, and time spent per training session regarding the anabolic-androgenic steroid users and nonusers bodybuilders in the city of Jo˜ao Pessoa – PB (2007–2008) Users
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Variable Time practicing bodybuilding 3 hours Total ∗
N
Not Users %
N
Total %
N
%
12 7 7 13 14 52 105
11.4 6.7 6.7 12.4 13.3 49.5∗ 100
105 66 52 53 33 95 404
26.0 16.3 12.9 13.1 8.2 23.5 100
117 73 59 66 47 147 509
23.0 14.3 11.6 13.0 9.2 28.9 100
4 12 23 65 104
3.8 11.5 22.1 62.6 100
21 70 78 234 403
5.2 17.4 19.4 58.0 100
25 82 101 299 507
4.9 16.2 19.9 59.0 100
17 54 26 7 1 105
16.1 51.4∗ 24.8 6.7 1 100
28 179 176 13 5 401
7.1 44.6∗∗ 43.9 3.2 1.2 100
45 233 202 20 6 506
8.9 46.0 39.9 4.0 1.2 100
χ2 (p value) χ 2 = 32.299 ∗ (.000)
χ 2 = 892 (.827)
χ 2 = 14.512 ∗ (.006) ∗∗ (.045)
means p < .05.
34), already looking for who would like to match silhouettes with number 4 (32.4%, n = 34) and number 5 (40%, n = 42), (Figure 2). Recounting their appearance from the previous year, 29.5% (n = 31) of AAS users reported having the silhouette of number 3 and 26.7% (n = 28) of the number 2 (Figure 2). Among the 510 bodybuilders, 55.5% (n = 283) also reported using dietary supplements and 10.7% (n = 53) site injection of oil for appearance purposes. Regarding the association of the use of these substances and AAS, there was a significant statistical association (p < .005) (Table 1). DISCUSSION
This research aimed to document the prevalence of AAS use and the socioeconomic profile of bodybuilders freTABLE 3. Substances used by bodybuilders (n = 60) in gyms of Jo˜ao Pessoa city Groups E1 (AAS) E2 (ADE, Glicopan) E3 (Mineral oil, Clenbuterol, Lipobastil) E4 (ASS for veterinary use) E5 (GH) Total
N
%
180 25 9 5 3 225
81.1% 11.3% 4.1% 2.3% 1.4% 100
Note. E1(AAS): Deca-Durabolin, Winstrol, Anavar, Sustanon, Deposteron, Estandron-P, Primabolan, and Hemogenin; ADE: Injectable Oil; GH: Growth Hormone. Gave the sum of using one or more substances, as users concurrently used.
quenting gyms in the city of Jo˜ao Pessoa. It was observed that younger individuals (between 23 and 27 years of age), with a family income between one and three minimum salaries, unmarried, with at least 4 years of training experience and regular users of the gym (5× per week), constitute the typical user of this type of substance. These data can be of great importance to relevant policy makers in guiding projects and actions related to the prevention and treatment of the study population, exposed to substances that are illegal and especially deleterious to health. Considering that the lifestyle of the population changes as a function of the economic and structural conditions of each region, studies conducted in Brazil about the prevalence of AAS use have been concentrated in the south (Frizon, Macedo, & Yonamine, 2009; Silva et al., 2002; 2007), the southeast (Silva, & Moreau, 2003), and the Midwest (Ara´ujo et al., 2002) regions. In the northeast, few studies have been published (Iriart & Andrade, 2002; Santos et al., 2011; Schwingel et al., 2012). Given the above, this study fills a gap in the literature for information about the prevalence of AAS use and the profile of AAS users in these regions. Some discussion is warranted regarding the methodological aspects of the studies cited above. Unlike the others, the present study was designed, so that the sample size was representative of the entire population of bodybuilders in the city of Jo˜ao Pessoa, PB, allowing, in this way, inferences related to all bodybuilding practitioners within the city. Only Silva et al. (2007) have used a similar methodological design. In the study by Iriart & Andrade (2002), conducted in a poor neighborhood in the city of Salvador, Bahia (Brazil), young bodybuilders were
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F. RANIELLE DE SIQUEIRA NOGUEIRA ET AL.
FIGURE 1. Set of silhouettes proposed by Stunkard et al., 1983.
studied. In addition, the researchers used qualitative methodology with focus groups and semistructured interviews, which do not permit generalization of the findings to the population of the municipality. Additionally, in the study by Silva & Moreau (2003), just three gyms in S˜ao Paulo were evaluated, and only 3% of the questionnaires were completed by users, creating a serious bias in the findings and impossibility of extrapolating the data. Comparisons with other studies on this subject are complicated, especially given the wide variety with regard to the number of respondents, sample selection, methodology, and application of the protocol for data collection. Use of the questionnaire as an instrument of data collection in the present study is justified because of its easy application, low cost, security, anonymity, low rejection rate, and the fact that it is the most common method used by na-
tional and international institutions (Smart et al., 1980). Despite this, the questionnaire utilized was not previously validated, which is a limitation of the present study. The prevalence of use of AAS observed can be considered high (20.6%, n = 105). These data are similar to that reported by Ara´ujo et al. 2002 in Goiania, Brazil (24%, n = 183). On the other hand, Silva & Moreau (2003) in S˜ao Paulo, Brazil, found a prevalence rate of 8% (n = 16, of 209 interviewed). The wide variation in the prevalence estimates of use in these studies may be due to the potential methodological limitations already mentioned, in addition to the generation of false-positive data. The AAS user’s profile observed in this survey corresponds to young men (between 23 and 27 years), family income between one and three minimum salaries, unmarried, with at least 4 years of training experience, with
FIGURE 2. Distribution percentage of users of AAS according to which physical appearance they would like.
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ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
a low education level, regular gym use (5× a week), and an elevated concern with body image. Among users, 98.1% were men. This same trend of increased use by men was observed in studies by Kanayama, Boynes, Hudson, Field, and Pope (2007) and Tahtamouni et al. (2008). This finding is not surprising, since, as stated by Kanayama, Hudson, and Pope (2010), women rarely want to be extremely muscular, and that continued use of AAS is related to the development of masculine characteristics. The preoccupation with body image also seems to be a recurring theme in other studies, in terms of reasons reported for using AAS. The main reasons for use of AAS are based on the demands of increased sports performance, the admiration received from another person, obtaining the “perfectly toned” body, an increased libido, and an improved well-being (Cohen, Collins, Darkes, & Gwartney, 2007; Parkinson & Evans, 2006). Concerning the type of drugs used, we observed that substances such as Deca-Durabolin, Winstrol, and ADE are part of the group of substances, which are most commonly used. These findings are in agreement with Alberto, Iriart, and Chaves (2009), Silva et al. (2007), and Araujo et al. (2002). The fact that Deca-Durabolin and ADE are among the most widely used substances, probably lies in their relatively low cost, as discussed by Albert et al. (2009). This emphasizes the issue of sale of these drugs that require a prescription for purchase and are easily obtained in veterinary pharmacies or on the “black market” (Domingues & Marins, 2007; Silva et al., 2007). In spite of the efforts of the National Agency for Sanitary Surveillance (ANVISA), aiming to control and track the sales of controlled medicine with the launch of the National System of Management of Controlled Products—SNGPC, the sales of such substances without medical prescription are still high (Santos et al., 2011). A point of concern is the fact that 80.8% (n = 84) of AAS users know the adverse effects of using these substances. This finding complements that of Silva et al. (2007), where about half of the subjects (48.7%) who had used AAS would do it again. Similar findings were observed in the study of Santos et al. (2011): 34.9% of the participants knew that ASS were damaging drugs. Investigating the use of dietary supplements to improve the physical performance and aesthetic appearance is important since studies have demonstrated an association between the use of supplements and banned substances such as AAS (Dunn & White, 2011). The relationship found in the present study through a linear regression between the use of supplements and AAS (r = −0.7608, p < .000) shows this pattern of behavior. This can lead to the assumption that there may be an increased risk that consumers of food supplements also become consumers of AAS. In this regard, the “gateway theory,”5 developed 5
The reader is reminded that the concept of a “gateway drug” empowers specific “drugs,” while disempowering the novice user, in a linear cause and effect manner for a process, which is dynamic, complex, nonlinear, multidimensional, and bounded (time, place, culture, age, gender, ethnicity, etc.) among other relevant considerations. Editor’s note.
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some years ago, suggests a development trajectory or sequence of use of a substance, where the use of illicit substances is preceded by the use of legal ones (Degenhardt et al., 2011).
CONCLUSION
Data from this study confirm the trend found in other regions of Brazil, where there is a high prevalence of AAS use by practitioners of physical activity. Most important, we demonstrated the youth are the user profile of these substances and their use is motivated by aesthetic concerns. More studies in Brazil’s Northeast should be performed. A disturbing finding is that these bodybuilders use AAS even knowing its side effects. Moreover, the relationship found between consumption of dietary supplements and AAS, previously observed in other studies, suggests that there may be greater chances for consumers of dietary supplements becoming AAS users under yetto-be documented necessary endogenous as well as exogenous conditions. Thus, the results of this study identify and contribute to the understanding of an old problem, which appears to be growing, that requires relevant policy maker to implement a series of effective actions as well as new innovative ones, which open untried intervention pathways for their resolution. There is a need, for example, for evidence-based intervention campaigns aimed specifically at young bodybuilders to prevent the use of AAS, taking into account the context in which they are inserted. The role of health professionals working with this population (physical educator, nutritionist, endocrinologist) should be central.
Declaration of Interest
The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
THE AUTHORS Fabiana Ranielle de Siqueira Nogueira has received the degree in physical education from Federal University of Para´Iba (UFPB). She is also a specialist in bodybuilding and fitness from the University Gama Filho (UGF) and is a research member of Laboratory for the Study of Physical Training Applied to Performance and Health of the Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil. Her main interests include bodybuilding and fitness, sports nutrition, doping in sport and exercise, body image
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in sports and exercise, and anabolic-androgenic steroids in public health and health promotion.
Aline de Freitas Brito has received the degree in physical education from Federal University of Para´Iba (UFPB). Master’s in physical education. She is a PhD student in the Post Graduate Program in Natural Products and Synthetic Bioactive (UFPB). She is an acting professor in the Department of Physical Education (DEF), UFPB, of the disciplines: School and Health; Exercise Prescription, Bodybuilding, and Fitness Academy. Her main interests include hemodynamic responses to exercise cardiac autonomic modulation, and responses of smooth muscle in response to exercise.
Rachel Linka Beniz Gouveia has received the degree of bachelor of dentistry, bachelor of human anatomy and physiology, bacharelada legal sciences at the University Center of Jo˜ao Pessoa ˆ She is specialist in (UNIPE). public health education by UNAERP, expert Sanitary and Epidemiological Surveillance by UNAERP, law specialist Work by ESMAT13, and has the MS degree in biological sciences (Physiology) from the Federal University of Pernambuco (UFPE) and PhD in biomedical sciences (human physiology), University of S˜ao Paulo (USP). Currently, she holds the position of adjunct professor at the Federal University of Para´ıba (UFPB), the Center for Health Sciences for Health (CCS), Jo˜ao Pessoa, Brazil, and teaching in the discipline of human physiology, and an acting professor in the Department of Physical Education (DEF), UFPB.
GLOSSARY
Caio Victor Coutinho de Oliveira has received the degree in nutrition from Federal University of Para´ıba (UFPB), with expertise in nutritional bases of physical activity: sports nutrition from Gama Filho University (UGF). He has the master degree in nutrition sciences (UFPB). Currently, he is a professor at Maur´ıcio of Nassau Faculty (FMN) and Institute for Educational Development Courses (IDE-Recife) as well as researcher member of the Laboratory for the Study of Physical Training Applied to Performance and Health - LETFADS/UFPB. He has experience in clinical and sports nutrition, acting on the following topics: diets, athletes, dietary supplements, professional soccer, molecular biology, and markers of oxidative stress and muscle damage.
Thaiza Isidro Vieira has received the degree of full degree in physical education. She is physical education specialist, expert in foundations of education: interdisciplinary teaching practices. She is linked to the Laboratory for the Study of Physical Training Applied to Performance and Health of the Federal University of Para´ıba (UFPB), Jo˜ao Pessoa, Brazil, and currently teaching in the Department of Education of the State of Para´ıba.
ADE (Injectable Oils): oils of local intramuscular application for immediate impact such as injections of vitamin complex for veterinary use formed by the fatsoluble vitamins A, D, and E (ADE) and mineral oil into smaller muscle groups considered, with the desire of many fans that will put tica. Despite being dangerous and without technical and scientific support, this practice is becoming increasingly common, producing serious harmful effects and physical deformations among users. Anabolic–Androgenic Steroids (AAS): Hormones are responsible for the harmony of the vital functions of organisms. AAS are synthetic forms of the main male hormone, testosterone, which mimics the anabolic effects of testosterone, with the aim of activating protein metabolism, retaining nitrogen, bringing the ribonucleic acid (RNA) activity, and promoting synthesis anabolic effect of growth. Body Image: has received great attention and appreciation in contemporary society, and has been associated with youth using and misusing a range of substances to achieve and to maintain “the ideal body.” It is an individual’s perception of their own body. Personal evaluation of the individual self is physical and biological. Body image is also the mindset of the individual self and his/her relationship to others. Collateral Effects: any variant or deviant condition from normal. A different effect from that considered for a main drug. This term should be distinguished from an adverse effect, which refers to an unwanted side effect, as a drug may cause other potentially beneficial effects in addition to the primary purpose. Ergogenic: Substances or devices are used with the goal of improving athletic performance and recovery from exercise. Thus, the purpose of the use of ergogenic
ANABOLIC–ANDROGENIC STEROID USE AMONG BRAZILIAN BODYBUILDERS
is to increase performance through increased physical power, mental strength or mechanical threshold, and thus prevent or delay the onset of fatigue.
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