Going to sleep after an injection is especially dangerous, because he can go into hypoglycemia and not know it.

A popular belief appears to have emerged among bodybuilders that using insulin can assist in achieving substantial gains in muscle mass and muscle definition. The purpose of this paper is not to support or refute these claims but rather, to bring it to the attention of people who are considering the use of insulin for these purposes that this practice carries with it a significant risk, and to provide risk reduction advice to those who choose to use insulin regardless of this risk. It is of relevance to note that there have been reports of several insulin-related deaths among bodybuilders recently.

The Physiological Role of Insulin in the Body

Insulin is a hormone which is manufactured in the pancreas and which has a number of important physiological actions in the body. It is an essential hormone in maintaining the body's blood glucose level so that the brain, muscles, heart and other tissues are adequately supplied with the fuel they require for normal cellular metabolism and normal function. Insulin also plays an essential role in fat and protein metabolism. For example, it promotes transport of amino acids from the bloodstream into muscle and other cells. Within these cells, insulin increases the rate of incorporation of amino acids into protein (amino acids are the building blocks of protein) and reduces protein break down in the body ("catabolism"). These physiological actions probably form the basis of speculation regarding the additional anabolic gains which might be made through the use of exogenously administered insulin.

Normally, blood glucose and blood insulin levels are not both elevated for any extended period of time as these two chemicals influence each other through a feedback system in the body. In the post-absorptive state, the blood insulin concentration tends to decrease during exercise, allowing the blood glucose to be maintained at or above resting levels and to provide increased energy supplies (fuel) to muscle cells. Following a meal, the blood glucose and amino acid levels rise (the absorptive state) and this triggers an increase in insulin release from the pancreas, driving glucose and amino acids from the blood into cells and maintaining the blood glucose level within a certain physiological (operating) range.

Intending users should also be aware that insulin stimulates lipid (fat) synthesis from carbohydrate ("lipogenesis"), decreases fatty acid release from tissues ("lipolysis") and leads to a net increase in total body lipid stores. The development of such increased body fat stores runs counter to the training goals of most body builders, athletes and those seeking to improve their physical appearance.

In striving to become bigger, stronger, more competitive or more physically attractive you should also remember that no matter what you do, your genetic make-up will have an influence on what you are able to achieve. It is important to realize that you cannot look exactly like the role model you admire because you have inherited a different set of genes.

The Glycemic Index Factor

Scientists have discovered that carbohydrate containing foods can be measured and ranked on the basis of the rate and level of blood glucose increase they cause when eaten. This measurement is called the "Glycemic Index" or "G.I. factor". The rate at which glucose enters the bloodstream affects the insulin response to that food and ultimately affects the rate at which this glucose (fuel) is made available to exercising muscles. (2)

Low G.I. foods are those measuring less than 50 on a scale of 1-100. Moderate G.I. foods are those with a reading of 50-70 and high G.I. foods are those measuring 71 or greater on this scale. Pure glucose has a G.I. of 100.

Foods which have a high G.I. produce a rapid increase in blood glucose and blood insulin levels. Examples of such high G.I. foods are potatoes, ice cream, many cereals particularly those with a high sugar content, some varieties of rice (e.g. Calrose) and sweets.

Foods with an moderate G.I. include some brands of muesli, some varieties of rice, white or brown bread, honey and some cereals.

Foods with a low G.I. produce a slower, smaller but more sustained increase in blood glucose levels. Examples of such low G.I. foods are pasta, varieties of high amylose rice, barley, instant noodles, oats, heavy grain breads, lentils, and many fruits such as apples and dried apricots. Low G.I foods are advantageous if consumed at least two hours before an event. This gives time for this food to be emptied from the stomach into the small intestine. Since these foods are digested and absorbed slowly from the gastro-intestinal tract, they continue to provide glucose to muscle cells for a longer period of time than moderate or high G.I. foods, particularly towards the end of an event when muscle glycogen stores may be running low. In this way, low G.I. foods can increase a person's exercise endurance and prolong the time before exhaustion sets in.(2)

High G.I. foods, preferably in the form of liquid foods or glucose drinks of approximately 6% in concentration, can enhance endurance during a very strenuous event lasting more than 90 minutes. ("strenuous" being defined as an athlete exercising at more than 65% of their maximum capacity). Some athletes may prefer food rather than liquid replenishment. Miller(2) suggests glucose enriched honey sandwiches, which have a G.I. factor of 75 or jelly beans, which have a G.I. factor of 80.

Miller suggests that an athlete who is engaged in a prolonged strenuous event
should consume between 30 and 60 grams of carbohydrate per hour during the event.

High G.I. foods are also desirable after completing an exhausting sporting or training event when muscle and liver glycogen stores have been depleted, as they provide a rapidly absorbed source of glucose and stimulate insulin release from the pancreas. This insulin in turn stimulates the absorption of glucose into liver and muscle cells and its storage as hepatic and muscle glycogen, optimizing recovery and preparation for the next training or competitive event.

It has been shown that greatest benefit can be had if an athlete consumes these high G.I. carbohydrate foods as soon as possible after an event, preferably within an hour or less. It is further recommended that a high carbohydrate intake be maintained during the next 24 hours. Miller suggests eating at least one gram of carbohydrate per kilogram body weight each 2 hours after prolonged heavy exercise and at least 10 grams of high G.I. carbohydrate per kilogram body weight over the 24 hour period following this exercise.

For these reasons, an athlete who needs to maintain a high level of activity and performance on consecutive days or more extended periods of time should eat large amounts of high G.I. foods. However, a reasonable quantity of low G.I. carbohydrate food should be consumed before an event in order to improve endurance.

A Natural Method of Maintaining an Elevated Blood Insulin Level

Noting the hypothesis that an elevated blood insulin level may be of some advantage to bodybuilders, Fahey and his colleagues (1993) undertook an experiment in which they fed athletes a liquid meal of "Metabolol", which consisted of 13.0 g protein, 31.9 g carbohydrate and 2.6 g fat per 100 ml and provided 825 kJ of energy.

These researchers demonstrated that it is possible with such intermittent feeding during intense weight training to maintain a person's blood glucose at or above resting levels and at the same time, significantly increase insulin levels for the duration of the workout. This suggests a potentially effective and safe non-drug method for achieving a sustained elevation of blood insulin levels.

The authors of this research commented that "theoretically, this could provide a biochemical environment conducive to accelerating the rate of muscle hypertrophy and inhibiting protein degradation." However, the writer knows of no scientific studies which support this theory.

It is also relevant to note that muscle repair and growth begins in the hours and days following heavy exercise. It is doubtful that the use of insulin just prior to a workout will have any anabolic effects over and above natural processes, at this time. However, use of insulin prior to a workout will certainly expose you to much greater risk of serious harm. If you believe it is beneficial to have a higher insulin blood level during workouts, use the natural method outlined here.

Level of Risk Associated with Insulin Use

The use of all drugs carries some risk along with potential or perceived benefits, whether used for legitimate medical reasons or for other purposes. Insulin carries some risk even when used by an insulin dependent diabetic, as demonstrated by the observation that some diabetics run into difficulties with their treatment from time to time and often require assistance to restabilize their medical condition and insulin requirements. If used by a healthy non diabetic person in whom there is no natural deficiency in insulin production or reduced insulin sensitivity and in the absence of medical advice and monitoring, the risks may be substantially increased.

The major risk associated with insulin is a physical state known as hypoglycemia or "low blood sugar". This occurs when the level of glucose in the blood falls below a certain level required for normal body function. If the blood glucose level is substantially reduced below this normal level and if this is not quickly corrected, there is a risk of disorientation, collapse, coma, permanent brain damage and even death. Exercise and reduced food intake decreases the body's need for insulin and increases the risk of hypoglycemia associated with non-medical use of insulin.

It is difficult to provide a quantitative estimate of risk for any drug but on a scale of risk in relation to other non-medical and unsanctioned drug use, the use of insulin in this manner would rank towards the higher end of the scale. If zero equals "no risk" of harm to a person's health and ten equals "extreme risk", the use of anabolic steroids in a non-medical context might rate towards the middle of the scale of risk (particularly in the medium to long term) whilst insulin would rate higher. This level of risk associated with insulin use will depend on a number of factors:

Whether the person is a diabetic or not: non-diabetics and lean healthy people are more sensitive to the blood glucose lowering effects of insulin than diabetics;
Type of insulin: short acting insulin preparations are considerably safer than long acting preparations because with short acting types, it is much easier to avoid hypoglycemia with adequate food intake. With the non-medical use of longer acting insulin preparations, a person is at real risk of experiencing hypoglycemia late in the day, particularly in between meals, during or after exercise and when asleep. Regardless of this advice, some people are in reality using a mixture of short and long acting insulin preparations and exposing themselves to unnecessary increased risk.
Food intake: the type and timing of food consumed, its glycemic index (the glucose elevating effect) and the amount consumed;
Body weight;
Timing of insulin administration in relation to food intake and exercise;
Individual variation: two different people can respond in a very different way to a given dose of insulin, even if they are of a similar height, weight and other personal characteristics. The fact that a certain dose does not seem to cause a problem for one person does not mean this will be so for another. In addition, the response to insulin will also vary greatly within any one individual over time, according to changes in one or more of the above noted factors.
5-10 Units of a short acting preparation may have little or no observable impact on someone who eats a meal soon before or after but this dose could cause hypoglycemia and collapse in a person who has not consumed adequate food in close proximity to the time when the insulin begins to take effect (insulin starts to take effect within 5-10 minutes if injected by intra-muscular route and in 30-60 minutes if injected by subcutaneous route). Foods with a high glycemic index will maintain the blood glucose level for a short period of time, perhaps an hour or so whilst those with a low glycemic index will provide for more sustained glucose levels.

Risk Reduction Advice

Given the risks of using insulin for non medical purposes, the best advice one can give is not use it in this way. Even the body building magazines such as "Muscle Media 2000" advise: "If you're thinking about using insulin, think twice - it's really risky!"(3) However, if you are not persuaded by this advice and are determined to pursue its use in the hope of achieving some additional anabolic or other gains, you should take the following precautions:

Consider using the natural method of raising your blood insulin level during workouts by consuming glucose containing fluids at intervals during exercise. These fluids may have a protein sparing effect and at the same time, will help maintain keep your blood glucose and blood insulin levels. However, if you decide to use insulin, you should consider the following advice:
Always use insulin in the presence of someone else who knows about and understands the exact risks of using insulin in this manner, so they are able to act quickly and appropriately should something go wrong;
Always use a sterile needle and syringe every time and a clean injecting technique (e.g. don't touch the needle or the skin where you are going to inject, with your fingers and don't breathe on or cough over the injection site before or after injecting.)
Be aware that 1.0 ml of insulin contains one hundred International Units (100 IU), 0.1 ml of insulin contains ten (10) IU and 0.01 ml contains one (1.0) IU. So take care in measuring out your insulin �.it is very concentrated!
Note that 0.01 ml is the volume contained in the space between the smallest graduated markings on a 1.0 ml Terumo diabetic syringe;
Inject by the subcutaneous route (injecting just under the skin and preferably in the abdominal area or outer part of the upper thigh), not intramuscularly or intravenously as using the latter routes can lead to a rapid rise in blood insulin level and a sudden hypoglycemic episode;
Alternate your injection sites in order to minimize tissue damage ("lipoatrophy" or "lipohypertrophy";
Always use a short acting, "regular" insulin (e.g. Actrapid, Insulin Neutral, Humulin R, Hypurin Neutral) rather than a longer acting insulin preparation (e.g. Semilente, Lente or Ultralente);
Use a human insulin rather than an animal insulin preparation if possible (there is little animal insulin available now);

Start with no more than 5 IU (0.05 ml) of this short acting/ regular insulin preparation and increase the dose gradually over a period of one week, to a dose no higher than 20 IU (0.20 ml) per day. Doses above this will expose you to progressively greater risk and most body builders who use insulin believe there is no advantage in taking doses higher than this. Anecdotal evidence amongst bodybuilders suggests increased doses leads to excess bodyfat accumulation.

The writer would caution against users falling into the trap of thinking: "If 20 units is good, 40 units will be twice as good" or "Joe says he injected 20 units and it didn't affect him, so it will be safe for me to inject 30 or 40 units". All drugs have a therapeutic dose range and above this, may be toxic or even lethal. If you are not diabetic, your body does not require additional insulin and there is no therapeutic range for you. In addition, people are different and often respond differently to drugs. An individual may also respond differently to the same drug in the same dose at different times, depending on a wide range of factors such as their general health, alcohol or other drugs taken, food eaten, exercise undertaken before, during or after drug administration and so on.

Don't use a medium or long acting insulin in the middle or latter part of the day, as you may very well experience a hypoglycemic attack whilst you are asleep. If this happens, neither you nor anyone else will be aware of or able to respond to your urgent need for glucose, in order to prevent possible serious harm.

Dietary Guidelines

Close attention to diet is extremely important in people using insulin, whether this is for legitimate medical purposes or for other reasons. You can reduce your risk by consuming an adequate amount and mixture of high and low G.I. carbohydrate foods and drinks immediately after using insulin and at regular intervals (every 2-3 hours) throughout the day.

High G.I. carbohydrates (e.g. sweets, soft drinks and ice-cream) will raise your blood sugar quickly and prevent early hypoglycemia. Low G.I. carbohydrates (e.g. white pasta, high amylose rice, softened whole grain breads and instant noodles) are metabolized more slowly and will keep your blood glucose level up over a more extended period of time, when the medium acting insulin preparations begin to take effect;
55-65% of your total daily energy intake should be in the form of carbohydrates, 15-20% as protein and ~20% as fat. You should seek advice from a dietitian about your daily requirements but most heavy training athletes need to consume between 3,000 and 5,500 Calories per day (depending on the sport and level of training) and between 450 and 800 grams of carbohydrate each day. If you are a body builder who weighs 100 kg and your total energy requirements are calculated to be 4,000 calories/ day, you should aim to eat approximately 570 grams of carbohydrate each day. If your total energy requirements are calculated to be 5,000 calories/ day, you should aim to eat approximately 720 grams of carbohydrate each day (4);
Divide up your calculated total daily carbohydrate requirements over the course of your waking hours and consume frequent carbohydrate meals throughout the day.(4) For example, if you require 4,000 calories per day, you might eat six meals of 650-700 Calories at 2-3 hour intervals.
This would mean eating approximately 90-100 grams of carbohydrate each meal, which for example you will obtain from 7 slices of bread alone or 4-5 slices of bread with 1 � tablespoons of honey or 500 ml of Sustagen or 3 slices of bread eaten with a 450 gram can of baked beans. You can refer to the attached food tables to work out your own requirements according to your own food preferences. You will need to choose a mixture foods from this table with a high, medium or low G.I., according to the nature and level of the training you are doing.
Once again, the writer would strongly recommend that you consult a dietitian who has an interest and experience in sports nutrition, in order to assist you design a dietary program which is best suited to your training goals and needs and to your food preferences. It is equally important that you find a dietitian with whom you feel comfortable telling about your insulin or other performance enhancing substance use, as their advice may otherwise be less than useful to you. If your dietitian does not know about and does not take such substance use into account, their advice may even add to the dangers associated with this substance use.
Always have a source of glucose or other high G.I. food ready at hand, in case you should begin to experience the symptoms of hypoglycemia. If this does occur, you should take this glucose or food without delay. You should eat or drink 15-20 grams of carbohydrate to begin with, which is contained in ~ 2 slices of white or brown bread, two glasses of milk, a half glass of soft drink, a tablespoon of honey or six jelly beans.
Other examples of glucose or other high Glycemic index carbohydrate preparations which you can use include: glucose tablets, glucose powder mixed in a small volume of water, barley sugar, or other sweets or if these are not immediately available, a sugar containing cordial, soft drink or plain sugar dissolved in water. This should be followed by an adequate low Glycemic index carbohydrate meal to prevent further hypoglycemia since the insulin levels are likely to remain high for some hours after the high Glycemic index carbohydrates are used up (metabolized) in the body.

The Crucial Role of the Friend or Peer Observer

If you are going to use insulin, it is essential that you have a friend or peer observer remain with you in case you experience problems. This person really needs to be with you for the whole time while the insulin preparation used is working.

Be aware that the risk of hypoglycemia occurs not at the time of insulin injection but rather, when the insulin starts to take effect. The risk will be greatest when your insulin blood level nears or reaches its highest level, usually 30-60 minutes afterwards if a short acting insulin preparation is used (by subcutaneous injection) and up to 20 hours later if a long acting insulin is used.

Consider giving this paper to the person who is going to be with you when you use insulin, so they are aware of the things to look out for and what to do if you should experience a hypoglycemic reaction. The following instructions are for a peer observer or other person who may find you experiencing difficulty as a result of overdosing on insulin or any other drug or combination of drugs:

Instructions for the Peer Observer Assisting an Insulin User

If the person who has used insulin states that they are beginning to feel any of the following symptoms:

faintness
dizziness
thirst
hunger
nausea
weakness
sweating
Or if you observe that they have become:
confused
disorientated
sweaty
drowsy
You should immediately give them glucose or a sugar containing drink or food as mentioned above. However, you should not try to give a person food or fluids if they are so drowsy that they are unable to swallow it, since they will be at risk of accidentally breathing in (aspirating) this food or fluid. If they cannot readily respond to your questions or your commands, you should assume they are unable to swallow anything safely.

If the person loses consciousness, you should place them in either a "lateral" or "coma" position, tilting the head fully back and jaw forward, in order to ensure an open airway and protect them from possible aspiration. Keep them in this position while medical assistance is being sought (see diagram).
You should then immediately call an ambulance by dialing "911", to get them to a hospital without any delay whatsoever. When the ambulance arrives, you should tell the ambulance officers exactly what the person has taken and what you have observed so the correct treatment can be provided promptly. This is essential as the person's life may be at stake.
Severe hypoglycemia or a combination of alcohol and other drugs, particularly drugs which suppress the central nervous system, can cause a person to stop breathing and their heart to stop beating. Remember, it only takes a few minutes for someone to suffer permanent brain damage or to die, once they stop breathing.
There are several common signs which may be apparent in someone who has overdosed from one or a combination of drugs. These include:

very slow or shallow breathing or no breathing at all (listen close to the person's mouth and nose for breath sounds and look for movement of their chest wall)
snoring or gurgling breathing in someone who is asleep
blue lips and fingernails (caused by lack of oxygen)
no response to shaking, calling their name or pain (try pinching their earlobe and pressing down hard on one of their fingernails with a pen)
very slow, faint pulse or no pulse at all
What To Do in the Event of an Overdose:
stay calm
squeeze earlobe/ press on fingernail of person in an effort to arouse them
if person responds, try to walk them around
if no response, check person's breathing and pulse
if unconscious but breathing, place in lateral or coma position
call an ambulance by dialing 000 - they will give you advice on what to do, which
might include:-
if there is a pulse but the person is not breathing, start artificial respiration,
otherwise known as Expired Airways Resuscitation (EAR), without delay
if no pulse, start cardio-pulmonary resuscitation (CPR)
stay with the person, continuing to administer artificial respiration or CPR until the ambulance arrives. Keep them in the lateral or coma position if they are breathing on their own.
tell the ambulance officers exactly what they may have taken and what you have observed
The writer would like to emphasize once more that this paper should in no way be construed as an encouragement to people to use insulin in an effort to increase muscle mass, sports performance or appearance. Rather, it represents a pragmatic attempt at providing harm reduction advice to people who choose to take the risk of using insulin in this way, despite their knowledge of those risks. The writer recognizes that the well intentioned prevention strategy of telling people to "just say no to drugs" is generally ineffective, both at an individual and population levels and may even even prove counter-productive in many circumstances.
References

1.Fahey, T.D., Hoffman, K. , Colvin, W. and Lautin, G. The Effects of Intermittent Liquid Meal Feeding on Selected Hormones and Substrates During Intense Weight Training. International Journal of Sports Nutrition, 1993, (3) 67-75.
2.Miller, J. The G.I. Factor, A. Hodder and Stoughton, 1996.
3.Phillips, W. Uncensored Q & A, Muscle Media, May 1996, 32-34.
4.Calvert, B. and Frail, H. (dietitians): Personal communication.