Triathlon and Doping

I read an article in slowtwitch.com .  It is well informed article and helps to understand the problem of doping.  What happened with the Postal Service Team and the Americans cyclists’ writings affidavits to “Bañarse en salud,” prompt me to write an article from the medical point of view. “Bañarse en salud” is an expression in Mexico when people (mainly politicians) make a comment apposite to their thinking and behaviors to please the audience.

http://d3epuodzu3wuis.cloudfront.net/Leipheimer,+Levi,+Affidavit.pdf

http://d3epuodzu3wuis.cloudfront.net/Hincapie,+George+Affidavit.pdf

The ethic in the peloton of "it's OK if you don't get caught" shouldn't take us by surprise. That's precisely the American ethic concerning gays in the military. It's OK to be gay, just don't get caught being gay.

In cycling, then, the twin historic axioms of Do what you need to do to perform, and here's the name of Dr. So-and-so, but we don't want to know about it, and It's perfectly legal if nobody finds out, ought to explain why drugs are notoriously hard to boot from the peloton.

Triathlon has several things going for it.

First, it was primarily a U.S.-based sport in its formative years, and while Americans seem to have little problem taking drugs that will inhibit performance, we seem––as a society––to pooh-pooh the converse.

Second, we don't get our top athletes from cycling. We get them from swimming and running. This is not to say that there are no cheats in these disciplines, but that cheating is not historically a skill one is taught by mentors like it has been in European cycling.

Third, ours is not a team sport. Drugs don't come to you in triathlon. You've got to go find them. On which street corner does one go for black-market EPO?

Fourth, the economics of drug-taking is better effected in team sports. If you're a corrupt doctor or pharmacist you've got one-stop shopping and a deep pocket with a group of 20 or 30 willing fellas wearing the same jersey colors. Where does a struggling triathlete go for financial relief? Might Blue Cross have negotiated a group discount with Amgen on behalf of 50 or 100 needful pro triathletes seeking EPO?

For those who think I'm being unfair to cycling, or that I'm beating a good sport when it's down, the drug-related dynamics to which I refer in cycling are those which take place at the highest level and not, I perceive, at the club or recreational level. Furthermore, when I'm talking about drugs in triathlon, I'm of course referring to drugs at the pro level (except as stated further below). Cycling is a great sport––too great for the stain of drugs to bring it down.

There are some worrisome occurrences on this side of the pond, though. You can go to seminars where doctors and coaches will make the case that it's perfectly legitimate to inject yourself with supplemental human growth hormone and testosterone. Their reasoning? That as you age your endocrine glands naturally diminish their production, and it's only smart to make up the difference.

Not only that, they say, it's only the practice of good health, since testosterone is responsible for bone mass retention in men just as estrogen is for women. But testosterone does a lot more than that, and it would be silly to think that male athletes are testosterone-boosting just to prevent osteoporosis. The problem is that there are "health and training professionals" who're justifying it, and that sounds so very much like what we hear from those in the European peloton who've been caught.

True, these workshops are generally marketed to cyclists, but I shudder at the implications. These seminars are not for pros, but for age-group athletes. Imagine that. Age-groupers armed with vials and needles.

http://www.slowtwitch.com/mainheadings/features/drugs.html#THURSDAY

I have spoken previously of culture and the article above helps me explain what I try to convey.  I have written different articles regarding this matter in the blog: 11 déc. 2012 Triathletes, Here We Go Again. CULTURE!  23 nov. 2012 BIOLOGICAL PASSPORT AND TRIATHLON II. “EL PLEITO RATERO.”  4 oct. 2012 TRIATHLON EDUCATION V. Lying.  I will speak of related subjects because we have a similar problem with drug trafficking in Mexico.  The government decided to send the Army against the “narcos” but the outcome was not the one expected.  Lives and collateral damages were too many to say that it was the best strategy.  The Mexican Government needed to do something, but without education is very difficult to change the culture a bit.  The culture reproduces itself like The Greek Mythological Hydra. http://www.wisegeek.com/in-greek-mythology-what-was-the-hydra.htm#did-you-know  

What is happening in cycling is quite similar.  The culture is untouchable; American cyclists in Europe are just afraid of continuing with their behavior at this point.  Even though in Europe would not be persecuted; but they are afraid of being caught in the USA by the judicial system.  Seven years back, we were riding in Veracruz and a cyclist approached us and spoke about his experience in Spain.  I thought he was just disappointed with what he experienced there because of what he said to us: “Everybody dopes there, including the amateurs.”  He left our peloton after venting his anger, but the conversation came back to me after the affidavits from US Postal Team.  But what are we after when testing for doping?  EPO is not proven as a performance enhancing drug unless you have kidney failure or you hematocrit is extremely low.  I know a patient who was a runner with kidney failure taking EPO, she was not faster after EPO but mentioned that she felt less tired when her hemoglobine increased from 11 to 13.  In Mexico City the majority of the working doctors have a hematocrit around 50 for multiple reasons and they feel tired all the time.  But let us see a report from somebody that works treating related subjects.  No Evidence That EPO Doping Helps in Cycling By Todd Neale, Senior Staff Writer, MedPage Today

Published: December 06, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Blood transfusions?  The majority of the athletes have a hematocrit close to 50 and a unit or two is not going to change anything if the athlete does not have speed and the race last less than two hours.  We have adolescents with 48 when they are fully hydrated after waking up.

Testosterone?  Once more, you will not improve your speed if you do not train going fast.  Perhaps if somebody is 9^th place regularly, he/she can make a podium on testosterone.  Testosterone does not go away easy; that is the reason why Floyd Landis got cut.  Even if you give testosterone IV, it last at least 72 hours depending on the dosage and hydration.  Recovery is faster with testosterone that is the reason why people use it.  If you sleep well, take naps, eat properly, YOU DO NOT NEED TESTOSTERONE.  If somebody is using testosterone to recover is because he is too lazy to train or recover and in that situation he/she is not going to be close to the podium.

Testing is necessary and it has been done adequately.  Doping is an endemic problem, cyclists took doping substances as M & M from what we read in their affidavits but the outcome would be the same without drugs from what we said above.  WE NEED TO EDUCATE CYCLISTS AND ATHLETES.  By the way, very few people cycling finished college.  Of the competitors at the Tour de France finishing college you can count them with your hand. 

Should they have a college degree to compete in the Tour de France?  No, humanity and the Tour de France competitors need less schooling and more education.  Education is our strongest point in our team working with adolescents, but most of the time we are too late to influence what will come.  Once more, as the New Zealand educational program said:

http://www.msd.govt.nz/documents/about-msd-and-our-work/work-programmes/policy-development/interagency-plan.pdf

Conduct problems are the single most important predictor of later chronic antisocial behaviour problems including poor mental health, academic underachievement, early school leaving, teenage parenthood, delinquency, unemployment and substance abuse. The pathway for many affected young people typically leads on to youth offending, family violence and, ultimately, through to serious adult crime. The inter-agency plan aims to counter this trend.

New Zealand bike road recognition during championship.

We do not have to do the police work as it is the case when it is too late.  We have to educate and have programs to educate our children.

Triathlon and talent identification

20 years back we did not need talent identification because few athletes were doing triathlon and there were resources available; those resources are not there anymore neither the time to spend with so many athletes.  We need to make fast decision about the level of involvement with athletes depending on the degree of commitment they have for the sport.  We have spoken about it previously (24 mai 2012 TALENT IDENTIFICACION ADDICTIONS).

Talent identification has to do with education and secondary with our “soma.” It depends on the adaptive patterns. Somebody has to live healthy in order to overcome addictions; so knowing the adaptive patterns is important when we speak about talent.  A practical and clever Ecological definition of an addiction is given by Gregory Bateson, Mind and Nature, A Necessary Unity (1979).  Bateson puts adaptation vs. addiction. I go by this definition because it gives me the opportunity to be a better human being without “hard” addictions and it guides me to overcome my addictions in a practical way:

Addiction is the name of the large class of changes induced by environment and experience that are not adaptive and do not confer survival value (193).

When we speak of psychiatric disorders we should think in the Batesonian definition of an addiction.  A Psychiatric Disorder is equal to addiction according to Bateson.  The thought/behavior/pattern is repetitive in psychiatric disorders; Bateson calls the insane repetitiveness addiction.  What we call disorder in psychiatry it is an addiction in the Ecological Batesonian sense.  Let´s take a practical example now that you learned about clinical trials in the previous post and practice how to read an article. 

Arch Gen Psychiatry.2012;69(12):1295-1303. doi:10.1001/archgenpsychiatry.2012.271 

 
Comented by the one below:

ADHD at age 41: Absent or antisocial or moody/anxious

Nassir Ghaemi, MD, Psychiatry/Mental Health, 08:44PM Nov 1, 2012

There is an article: Clinical and Functional Outcome of Childhood Attention-Deficit/Hyperactivity Disorder 33 Years Later.

Recent article available online first in the Archives of General Psychiatry provides a fascinating and long-needed long-term prospective follow-up of childhood ADHD into adulthood. This was a 33 year prospective follow-up, which can finally tell us what ADHD is and becomes after childhood.

I've always thought that making childhood psychiatric diagnoses was like taking a still picture of a runner in motion - everything's blurry. You don't really know the anwer until the child becomes an adult (and by then it's too late to do anything for the child).

So what does this study tell us?

At age 41, 135 men who had been diagnosed with childhood ADHD around age 8 were compared to 136 age matched men with no prior childhood ADHD. Some interesting results, based on my interpretation, not necessarily those of the authors:

1.  ADHD persisted in 22% of the adults. In other words, consistent with a large older literature, ADHD goes away in 80% of children by the time they become adults.  This contrasts with the common assumption these days that most children with ADHD should stay treated for it into adulthood.

2.  ADHD was diagnosed in 5% of the adult control group, who had NOT had childhood ADHD.  What does this mean, especially in the context of the National Comorbidity Survey data showing a 3% epidemiological prevalence of adult ADHD in the US?  Maybe it means that "adult ADHD" is not an illness, but rather represents the cognitive baseline of the general population, whereby 95-97% of the population has normal concentration, but a small percentage (3-5%) have decreased concentration - just as some of us are somewhat more anxious than others, and some of us are more shy than others,  as part of normal personality traits. These are not all disease, but normal variations in personality or cognition. 

3.  The most clear cut adult psychiatric diagnosis in children with ADHD was antisocial personality disorder (16% vs 0% of controls).  Does this suggest that much "ADHD" in children is not ADHD, but conduct disorder that later declares itself as antisocial personality?

4.  Not surprisingly, substance abuse was common (14% in the ADHD group versus 5% in controls).

5.  Mood and anxiety disorders (common causes of impaired attention) were more common in the ADHD group than controls, contrary to the interpretation of the authors (statistical nonsignificance is not equal to nonexistence, a common statistical mistake).  The results were 9% versus 6% for mood disorders, and 13% versus 9% for anxiety disorders - in other words, about a one-third increase rate for the ADHD group for both conditions (p-values are irrelevant for this kind of study with multiple comparisons, which was not statistically powered for this subgroup analysis).  (Diagnosis were based on standard research SCID interviews, but were conducted by clinical psychology graduate students, not trained psychiatrists). 

The authors conclude:  "The multiple disadvantages predicted by childhood ADHD well into adulthood began in adolescence, without increased onsets of new disorders after 20 years of age".

What could we conclude (somewhat differently than the authors)?

Almost 80% of children with ADHD do not continue to have the condition into adulthood.

The epidemiological prevalence of "adult ADHD" is consistent with the baseline normal variations of cognitive function in adults who never had childhood ADHD.

A common adult outcome of childhood ADHD is antisocial personality.  

Mood and anxiety disorders are one-third more common in adults who had childhood ADHD.

The authors don't tell us what percentage of adults with ADHD did not have antisocial personality or mood and anxiety disorders, which could themselves cause attentional impairment, but it would be interesting to know if this group would exceed the 5% non-ADHD baseline of ADHD-like cognitive impairment in adults.  What strikes me the most is what I put in red:
The most clear cut adult psychiatric diagnosis in children with ADHD was antisocial personality disorder (16% vs 0% of controls).

The predictive power of the childhood precursors of antisocial personality disorder provides ample justification for early intervention. Greater understanding of subgroups within the broad category of antisocial children and adults should assist with devising and targeting interventions. http://bjp.rcpsych.org/content/182/44/s11.full Some countries, as New Zealand, go directly to make interventions to avoid the antisocial personality in the future, when the adolescents become adults. They do it with the aboriginal population mainly, because this behavior/diagnosis is related to factors as poverty and degree of education. http://www.fordham.edu/images/undergraduate/psychology/all%20overheads/tryon/First%20Year/spring%20cts/Psychosocial%20Treatments%20for%20Conduct%20Disorder-PDF.pdf In Mexico, we do not have a way to deal with this kind of addictions and the society promotes this antisocial behavior.  Our talent identification depends on the degree of antisocial behavior developed already in the athlete.  Our Nobel Prize Winner, Octavio Paz recognized the main feature of this disorder and wrote a book title: THE LABERITH OF SOLITUDE: “Lying plays a decisive role in our daily life, in our politics, our love-affairs and out friendships, and since we attempt to defeat ourselves as other our lies are brilliant and fertile, not like the gross invention of other people.” http://books.google.com.mx/books?id=Ei5m7_T2G80C&pg=PA40&lpg=PA40&dq=LABYRINTH+OF+SOLITUDE+LYING&source=bl&ots=sE4rwNYEqH&sig=5b4ltEF8543bplNLRBjvZkejw9U&hl=en&sa=X&ei=13jYUJzlIubQ2AXi64CoBQ&ved=0CDgQ6AEwAQ#v=onepage&q=LABYRINTH%20OF%20SOLITUDE%20LYING&f=false In practice, most New Zealand mental health programmes, broadly defined, in relationship to conduct disorders is focused on tertiary prevention i.e. attempting to reduce the impacts of the disorder made especially obvious by significant harm to others such as assault with a deadly weapon, forced sex, and aggravated robbery. The natural history of the disorder, however, is for an escalating pattern of offending, often with roots in the first five years of life. Because tertiary prevention of conduct disorders is expensive, often ineffective, and too late to prevent irreparable damage to others, including family, there is increasing interest in other types of prevention. Now there is also evidence that early intervention programmes that target aggressive and non-compliant behaviour in children can reduce delinquency later in life.

http://temata.massey.ac.nz/massey/fms/Te%20Mata%20O%20Te%20Tau/Publications%20%20Mason/M%20Durie%20Whanau%20as%20a%20model%20for%20early%20intervention

%20in%20conduct%20disorders.pdf

As I mentioned in previous posts, countries as New Zealand and Australia have children that feel ashamed of their behavior at the age of five compared to Mexico, where children get angry if they are confronted by an adult for his/her behavior.  An athlete mentioned to me about knowing the existence of this research.

Delinquency is the target of these programs in New Zealand, but non-compliance is a huge problem encounter in countries like Mexico.  This lack of education is an insurmountable handicap and, if we want to create champions, we should start at a very early age training/educating kids.