Abstract
This cohort study uses data from the National Longitudinal Study of Adolescent to Adult Health database to describe the association between anabolic-androgenic steroid use and legal performance-enhancing substances in young adults.
Anabolic-androgenic steroids are schedule III drugs that are often used without a prescription to increase muscle mass and tone for appearance or performance enhancement.1,2 Use of anabolic-androgenic steroids is associated with negative physiological (eg, cardiovascular, neuroendocrine, musculoskeletal, and renal) health outcomes.1 Anabolic-androgenic steroids are also associated with mood and substance-use disorders, aggression, and violence.1 The use of anabolic-androgenic steroids is frequently observed among adolescents in the United States and is more prevalent among adolescent boys (3.3% of boys reporting use) compared with adolescent girls (2.4% of girls reporting use) nationwide.3 Although the use of anabolic-androgenic steroids is cross-sectionally associated with legal performance-enhancing substances, including creatine monohydrate,1,2 there is a paucity of longitudinal data determining predictors of anabolic-androgenic steroid use. Here, we examine the longitudinal association between legal performance-enhancing substances and subsequent use of anabolic-androgenic steroids in a population-based cohort of young adults. We hypothesized that legal performance-enhancing substance use in young adulthood would be associated with subsequent anabolic-androgenic steroid use at 7-year follow-up.
Methods
We analyzed prospective cohort data from 12 695 participants in the National Longitudinal Study of Adolescent to Adult Health, which began in 1994 and has surveyed over 20 000 adolescents in grades 7 to 12 across the United States. Subsequent waves, of which there are presently 5, have tracked participants to their early 40s. The study is still ongoing.
The University of North Carolina institutional review board approved the National Longitudinal Study of Adolescent to Adult Health, and written informed consent was obtained from all participants. As a secondary analysis of de-identified information, the present analysis was not considered to be human subject research and did not require separate institutional review board approval. This nationally representative sample included data available at both wave III (2001-2002; participants aged 18-26 years; n = 14 322) and wave IV (2008; participants aged 24-32 years; n = 14 800) of the study. At wave III, participants were asked if they had used “legal performance-enhancing substances for athletes (such as creatine monohydrate or androstenedione)” in the past year. At waves III and IV, participants were asked if they had ever used anabolic-androgenic steroids. Logistic regression analysis was conducted using Stata, version 15.0 (StataCorp Inc) with legal performance-enhancing substances (exposure, wave III) and anabolic-androgenic steroid use (outcome, wave IV). Data were adjusted for use of anabolic-androgenic steroids (wave III), age, race/ethnicity, household income, and body mass index using sample weighting to yield nationally representative estimates. Because this analysis incorporates national sample weighting from the study, all percentages are weighted. Data were missing from 229 participants (1.5%) for legal performance-enhancing substances and from 78 participants (0.5%) for anabolic-androgenic steroids. Significance (2-tailed test) was set at α = .05.
Results
The overall cohort of 12 695 young adults included 50.8% males with a mean (SE) age of 21.8 (0.1) years. At wave III, 16.1% of young men and 1.2% of young women reported using legal performance-enhancing substances in the previous year. At the 7-year follow-up (wave IV), 4.2% of men and 0.8% of women reported anabolic-androgenic steroid use within the past year. Among young men, 12.5% of those who used legal performance-enhancing substances vs 2.7% of those who did not use performance-enhancing substances reported anabolic-androgenic steroid use at the 7-year follow-up (Figure) (P < .001). Among young men, use of legal performance-enhancing substances at wave III was associated with higher odds of anabolic-androgenic steroid use at wave IV (adjusted odds ratio, 3.18; 95% CI, 1.90-5.32; P < .001) compared with nonuse of legal performance-enhancing substances when adjusting for age, race/ethnicity, income, body mass index, and wave III anabolic-androgenic steroid use. There was no statistically significant association between legal performance-enhancing substance use at wave III and anabolic-androgenic steroid use at wave IV among young women (adjusted odds ratio, 0.18; 95% CI, 0.02-1.78; P = .14).
Figure. Prevalence of Anabolic-Androgenic Steroid Use at 7-Year Follow-Up Among Young Men Aged 24 to 32 Years Who Did vs Did Not Report Use of Legal Performance-Enhancing Substances at Ages 18 to 26 Years.
Error bars indicate 95% CIs.
Discussion
Use of legal performance-enhancing substances among young adult men (aged 18-26 years) was significantly prospectively associated with anabolic-androgenic steroid use at 7-year follow-up (aged 24-32 years). To our knowledge, this is the first longitudinal investigation of this association among a nationally representative sample. Results suggest that legal performance-enhancing substance use may serve as a gateway to anabolic-androgenic steroid use. This has significant implications for regulation of legal performance-enhancing substances, which are relatively common among the adolescent and young adult population,1,2 accessible over the counter, and unregulated by the US Food and Drug Administration.4 The notion that use of legal performance-enhancing substances may lead to a 3-fold increased risk for future use of illicit anabolic-androgenic steroids provides support for increasing state and federal regulation of these products. Limitations to this study include self-reported data, lifetime (as opposed to 12-month) assessment of anabolic-androgenic steroids use, inability to distinguish between prescription or nonprescription anabolic-androgenic steroid use, and inability to analyze associations between specific substances (ie, creatine monohydrate or androstenedione) and anabolic-androgenic steroid use.
Conclusions
The current study suggests that use of performance-enhancing substances among young men may increase vulnerability for anabolic-androgenic steroid use in young adulthood. Health care professionals should monitor and screen for anabolic-androgenic steroid use among adult men who have previously used legal performance-enhancing substances and refer patients to mental health and substance abuse treatment when appropriate.
References
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