Insulin Use by Bodybuilders

To the Editor.In the United States, more than 1 million elite and recreational athletes use performance-enhancing drugs for muscle building purposes.1 These performance-enhancing drugs, such as anabolic-androgenic steroids, clenbuterol, erythropoietin, and -hydroxybutyrate, have potential health consequences. Complications from the predominantly illicit and unsupervised use of these compounds include liver damage, lipid abnormalities, and myocardial infarction.1, 2 Many performance-enhancing compounds are injected, placing users at risk for infection with human immunodeficiency virus, hepatitis B and hepatitis C viruses, and abscesses.2 Recently, insulin has been used as a performance-enhancing drug by bodybuilders.3-5

Twenty self-identified anabolic-androgenic steroid injectors, recruited from local gyms, were interviewed regarding their injection practices. Eighteen (90%) of the 20 anabolic steroid users were white and 2 (10%) of the 20 were Hispanic. Eighteen (90%) of the 20 had first used anabolic steroids before 22 years of age. Five (25%) of the 20 anabolic-androgenic steroid injectors reported insulin use to increase muscle mass. None of the anabolic-androgenic steroid injectors reported insulin use to treat a medical condition. Those using insulin reported injecting a dose of 10 IU of regular insulin a mean of 44 times (range, 20-60) in the 6 months prior to the interview. Information regarding insulin administration and dosage reportedly was disseminated by "word-of-mouth." Most reported consuming sugar-containing foods or drinks after injection. None of the individuals reported hypoglycemia. Individuals reported obtaining insulin from "black-market" dealers and from pharmacies.

Anabolic steroid users self-administer insulin because insulin promotes anabolic processes and inhibits catabolism in muscle, liver, and adipose tissue by increasing the synthesis of glycogen, fatty acids, and proteins, and promoting the entry of glucose and amino acids into the muscle and fat cells.6

A MEDLINE literature search (1966-1998) was conducted to examine reports of insulin use among bodybuilders. Two reports of hypoglycemia have been reported in bodybuilders who self-administered insulin and 1 letter discussed insulin use among bodybuilders.3-5 Self-induced insulin hypoglycemia has been reported in a bodybuilder who administered regular insulin for anabolic purposes.3 Following a seizure during a weight-training session, the patient regained consciousness and admitted to administering 80 IU of regular insulin in both thighs every hour over a 3- or 4-hour period each day while ingesting large amounts of carbohydrates. Prior to the seizure, the patient had self-administered 320 IU of regular insulin over the previous 4 hours and trained without eating. A second report revealed a bodybuilder who developed severe brain damage after prolonged neuroglycopenia after he administered an excessive amount of insulin intravenously.4

The bodybuilders described herein may represent only a selected portion of anabolic steroid injectors in one geographic location; nevertheless, health care professionals need to be aware of insulin use among bodybuilders and counsel patients about the associated dangers.

Josiah D. Rich, MD, MPH
Brian P. Dickinson, ScB
Nathan A. Merriman, ScB
Brown University
Providence, RI

Peter M. Thule, MD
Atlanta VA Medical Center and Emory University
Atlanta, Ga

1. Yesalis CE, Kennedy NK, Kopstein AN, Bahrke MS. Anabolic-androgenic steroid use in the United States. JAMA. 1993;270:1217-1221. MEDLINE

2. Dickinson BP, Rich JD. Infections secondary to anabolic steroid misuse and their prevention. J Performance Enhancing Drugs. 1996;1:146-150.

3. Reverter JL, Tural C, Rosell A, Dominguez M, Sanmarti A. Self-induced insulin hypoglycemia in a bodybuilder. Arch Intern Med. 1994;154:225-226. MEDLINE

4. Elkin SL, Brady S, Williams IP. Bodybuilders find it easy to obtain insulin to help them in training. BMJ. 1997;314:1280. MEDLINE

5. Dawson RT, Harrison MW. Use of insulin as an anabolic agent. Br J Sports Med. 1997;31:259. MEDLINE

6. Guyton AC, Hall JE. Textbook of Medical Physiology: Insulin, Glucagon, and Diabetes Mellitus. 9th ed. Philadelphia, Pa: WB Saunders Co; 1996:971-982.

This work is supported by the National Institutes of Health, National Institute on Drug Abuse, Bethesda, Md, K2O DA00268 grant (Dr Rich), and the Veterans Affairs Merit Review Grant (Dr Thule).

Brain Damage?

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