Performance enhancement: not just for athletes anymore
MicheleLaBotz, M.D., FAAP
AAP Technical Report
Use of performance-enhancing substances (PESs) traditionally has been considered an
issue in athletes, and prevention and screening efforts have primarily focused on
that population. However, patterns of pediatric use of PESs have changed significantly
over the past few years, with reports of increased rates of use by non-athletes, primarily
for appearance-related concerns. This includes use of “diet pills” for weight loss,
as well as protein, creatine and anabolic agents to enhance muscularity.
The greatest medical risk with attempts to enhance performance/appearance occurs with
diversion of controlled substances, according to the report. Several classes of drugs
frequently are diverted for these purposes. The following rates of non-medical use
have been reported in recent national surveys of high school students: amphetamines,
12%, anabolic steroids, 7% and synthetic human growth hormone, 11%.
Protein, creatine most common
Although generally not considered as dangerous as drugs, the PESs most commonly used
by adolescents typically are sold as dietary supplements. Protein and creatine are
at the top of the list. Recent surveys of high school students report protein supplement
use by 39% of boys and 18% of girls.
Pediatricians may find the following information helpful when counseling patients
on protein supplementation:
Protein supplements typically are in the form of powders, shakes or bars. They commonly
contain 20-30 grams (g) of protein per serving, which is similar to the amount contained
in a 3-4 ounce (oz) chicken breast.
Young athletes may require up to 2 g protein/kilogram (kg) body weight/day (almost
70 g in a 150-pound athlete). This often is readily met with a typical American omnivorous
Vegetarians and others who are restricting their diet may benefit from nutritional
consultation, but several easy changes can greatly increase dietary protein intake,
Traditional yogurt has 7 g protein/6 oz serving, while Greek yogurt provides 17 g
and cottage cheese has 21 g.
Nonfat dry milk contains 12 g protein per half cup. This can be added to soups, sauces
or beverages as a “hidden” source of added protein.
Peanuts, almonds and cashews all contain over 20 g protein per 100 g serving.
Creatine use has been reported by 18% of 12th-grade males and almost 2% of 12th-grade
Creatine is stored in skeletal muscle and helps replenish adenosine triphosphate during
maximal effort activities of short duration.
The body requires about 1 g ingested creatine/day, which can be found in 2-3 servings
of meat or fish.
There is no added benefit to extra creatine.
Pediatricians should remind families that Food and Drug Administration regulation
of supplements is much looser than for items sold as foods or drugs. However, it can
be very difficult for consumers to distinguish these categories, as supplements often
are intermingled on shelves with food and/or over-the-counter drugs at point of sale.
Analysis of supplements sold as PESs revealed that 25% were contaminated with anabolic
steroids, 20% with heavy metals and 11% with stimulants.
Concerns regarding contamination and lack of FDA regulation of dietary supplements
prompted attendees of the 2016 AAP Annual Leadership Forum to adopt a resolution calling
for enhanced education and advocacy.
Risk factors, different motivation
Risk factors for PES use include: male, higher body mass index, body dissatisfaction,
training in commercial gym and exposure to appearance-oriented fitness media. While
use of PESs correlates with substance abuse and other high-risk behaviors, PES use
typically is “goal oriented,” whereas most other substance use in adolescents is recreational.
This calls for a different approach when counseling on PES use.
Adolescents base their decisions regarding PES use largely on their hope for benefit,
and this significantly outweighs any potential concern about adverse consequences.
Therefore, prevention efforts are best focused on the lack of benefit of PES use,
and pediatricians can provide information on alternative methods for achieving their
Emphasize the following when counseling patients:
The overwhelming majority of initial claims by supplement manufacturers regarding
muscle-building, weight loss or performance enhancement are debunked after further
Even the most favorable studies on the effects of PESs on athletic performance cannot
rival the 30% strength gains that are reported in youth strength-training studies
of several months’ duration.
Adherence to fundamental principles of training, rest and nutrition remains the best
way for patients to achieve healthy fitness and appearance-related goals.
Dr. LaBotz, a lead author of the clinical report, is a former member of the AAP Council
on Sports Medicine and Fitness Executive Committee.