Corresponding author: Elma Omeragic ( elma.omeragic@ffsa.unsa.ba ) Academic editor: Guenka Petrova
© 2021 Elma Omeragic, Aleksandra Marjanovic, Jasmina Djedjibegovic, Amila Turalic, Mirza Dedic, Haris Niksic, Aida Lugusic, Miroslav Sober.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Omeragic E, Marjanovic A, Djedjibegovic J, Turalic A, Dedic M, Niksic H, Lugusic A, Sober M (2021) Prevalence of use of permitted pharmacological substances for recovery among athletes. Pharmacia 68(1): 35-42. https://doi.org/10.3897/pharmacia.68.e54581
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Objectives: Food supplements and medicines which are not on the list of prohibited substances of the World Anti-Doping Agency are included in the group of permitted pharmacological agents for athlete’s recovery.
The aim of this study was to describe qualitatively and quantitatively food supplements (FS) and over-the-counter drugs use among athletes in the last six month.
Methods: This was a cross sectional study. Data on food supplements and the over-the-counter drugs, usage were collected during 2018 by self-administered, anonymous questionnaire.
Results: A total of 112 athletes completed the survey. A total of 51.8% (n = 58) athletes reported the use of food supplements. The use of medical supplements was reported by 50.0% (n = 56) of athletes, 26.8% (n = 30) reported using ergogenic supplements, 1.8% (n = 2) using of sports food and 4.5% (n = 5) using other supplements. The use of over-the-counter drugs was reported by 35.7% (n = 40) of athletes. The over-the-counter analgesic drugs were used by 95% (n = 38) of over-the-counter drug users. Concomitant administration two or more over-the-counter drugs was reported by 40% (n = 16) athletes. Doctors and coaches had no advisory role in the use of food supplements or over-the-counter drugs.
athletes, drugs, food supplements, OTC analgesic drugs, sport
Food supplements and medicines which are not on the list of prohibited substances of the World Anti-Doping Agency are included in the group of permitted pharmacological agents for athlete’s recovery. These pharmacological agents are freely available for sale, are globally extremely popular, and are utilized in both professional and recreational sportsmen (
The benefit of supplementation in sports is controversial. A well-designed diet that ensures the optimal intake of energy and nutrients is the basis of a well-planned training and sports results. There is still insufficient evidence to support that dietary intervention which implies favoritism of food supplements could improve the effectiveness of training and athletic performances. On the other hand, inadequate and excessive use of food supplements can lead to significant side effects and impairment of the athlete’s health (
Exercising beyond certain intensity, or for a prolonged period, can cause pain and discomfort. The feeling of pain caused by training can harm the training itself and decrease the performance of the athlete during the competition (
In those situations, athletes often decide to take the medicines that reduce pain (analgesics) and that are sold directly to a consumer without a prescription from a healthcare professional (Over-the-counter drug). Also, athletes with minor injuries very often continue training or competing, treating emerging health problems with over-the-counter (OTC) analgesics (e.g. non-steroidal anti-inflammatory drugs, paracetamol, acetylsalicylic acid etc.) (
In general, the results of studies examining the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on performance in sport show that there is no unique evidence of the prophylactic effect of pre-training NSAIDs on muscle pain and inflammation caused by training (
Although many authors have considered the excessive intake of food supplements and OTC analgesics among athletes, there is little data on the frequency, type, quantity, age and gender distribution of food supplements and OTC analgesics among athletes origin in Bosnia and Herzegovina. The aim of our study was to quantitatively and qualitatively analyze the intake of food supplements and OTC drugs among the athletes in Bosnia and Herzegovina.
This was a questionnaire-based cross-sectional study carried out from March to November 2018 at Bosnia and Herzegovina. A 15-items questionnaire, structured by the authors of the paper for this research, was used (Appendix 1). The clarity, contents comprehensibility and layout acceptability of the questionnaire were pretested on a small sample of athletes (n=10). For this purpose, the questionnaire was piloted with 10 athletes from the local Athletic club Sarajevo. Following modifications to the questionnaire, as a consequence of the pretest work, it was issued to track and field athletes at domestic competitions. These meetings included National championship for seniors and veterans in karate; National Competition Championship seniors, veterans and students in weightlifting; Bosnia and Herzegovina Senior Athletics Championships; Bosnia and Herzegovina Basketball Cup; Bosnia and Herzegovina Football Cup and Bosnia and Herzegovina Volleyball Cup. The research project was approved by the Academic Council of the Faculty of Pharmacy. This study follows the principles of the Declaration of Helsinki. Survey design (non-interventional) is not considered a clinical trial under the Directive 2001/20/EC and Regulation (EU) No 536/2014. The questionnaire was anonymous and self-administered. The participant’s information with the clearly stated purpose of the survey and a statement on agreement to participate in the study by completing the survey was presented in a separate paragraph preceding the first question of the survey. All participants who completed the questionnaire and returned it were deemed to have provided consent. The eligibility criteria were current athletes, Bosnia and Herzegovina (BiH) origin and BiH residence. The sample size was calculated by using a free online tool (Reasoft sample calculator, <URL: http://www.raosoft.com/samplesize.html>) based on the desired confidence level (95%), the tolerable margin of error, estimated population size and estimated response distribution. For the population size, we use the information of a total number of registered athletes (n = 1450) for above mention competitions given by the competition organizers. A total of 140 questionnaires were completed. Although all participants fulfilled the eligibility criteria, 28 questionnaires were excluded due to inconsistent or incomplete reporting so the final number of participants was 112. The obtained margin of error was 8.9%. Statistical analysis was performed using IBM SPSS Statistics 21 Premium software (IBM, USA). Data are presented as the mean as mean±standard deviation or a percent. The significance of the proportions between the categorical variables was tested by chi-square (χ2) test.
A total of 112 athletes completed the survey. All participants met the predefined eligibility criteria. The participants mean age was 22.5±4.5 years (range 18–36 years) and the distribution by age of both genders is shown in Figure
In the total sample, the most common sports were athletics (n = 30, 26.8%) and football (n = 24, 21.4%), followed by a karate (n = 16, 14.3%), basketball (n = 13, 11.6%), volleyball (n = 11, 9.8%), handball (n = 10, 8.9%) and weightlifting (n = 7, 6.3%) Descriptive statistics of the sample are presented in Tables
Variables | Category | N (%) |
---|---|---|
Gender | Man | 73 (65.2%) |
Women | 39 (34.8%) | |
Athletes with coach | Yes | 112 (100%) |
No | 0 (0%) | |
Athletes with a doctor/physician | Yes | 76 (67.8%) |
No | 34 (30.5%) | |
Unknown* | 2 (1.7%) |
Sport | Number | Average age (years) | Average height (cm) | Average weight (kg) | Frequency % (n) of food suplement users | Frequency % (n) of OTC medicines users |
---|---|---|---|---|---|---|
Athletics | M 16 | 22.3±3.7 | 177.2±10.6 | 71.0±16.6 | 12.5 (2) | 0 (0) |
F 15 | 22.4±3.6 | 176.9±10.6 | 71.2±16.8 | 60.0 (9) | 40 (6) | |
Weight lifting | M 3 | 23.7±7.6 | 182.7±3.5 | 99.9±24.3 | 66.7 (2) | 100 (3) |
F 4 | 23.8±3.6 | 165.5±3.1 | 63.9±11.9 | 75.0 (3) | 100 (4) | |
Karate | M 7 | 23.7±3.1 | 174.3±6.8 | 64.5±8.4 | 42.9 (3) | 42.8 (3) |
F 9 | 23.5±3.1 | 172.5±7.2 | 63.4±8.0 | 11.1 (1) | 55.6 (5) | |
Handball | M 10 | 20.6±0.5 | 192.1±4.8 | 90.7±0.4 | 50.0 (5) | 40.0 (4) |
Basketball | M 13 | 20.4±2.1 | 197.3±.0 | 92.0±11.6 | 38.5 (5) | 15.4 (4) |
Volleyball | F 11 | 18.3±2.6 | 173±8.7 | 61.2±6.1 | 9.1 (1) | 9.1 (1) |
Football | M 24 | 27.6±3.6 | 184.91±.9 | 78.7±6.8 | 0.0 (0) | 45.8 (11) |
Supplements | Frequency (n) |
---|---|
All | 51.8 (58) |
Medical supplements | 50.0 (56) |
Vitamins | 43.8 (49) |
Vitamin A | 16.1 (18) |
Vitamin B complex | 9.8 (11) |
Vitamin C | 14.3 (16) |
Vitamin D | 0.9 (1) |
Multivitamin | 13.4 (15) |
Minerals | 17.0 (19) |
Calcium | 8.0 (9) |
Magnesium | 15.2 (17) |
Iron | 1.8 (2) |
Zinc | 2.7 (3) |
Multimineral | 3.6 (4) |
Other supplements | 4.5 (5) |
Fatty acids | 1.8 (2) |
Dextrose | 0.9 (1) |
Royal Jelly | 1.8 (2) |
Ergogenic supplements | 26.8 (30) |
BCAA Amino acids | 10.7 (12) |
Glutamine | 6.3 (7) |
L-carnitine | 4.5 (5) |
Creatine | 12.5 (14) |
Whey protein | 12.5 (14) |
Sports food | 1.8 (2) |
Sports bar | 1.8 (2) |
A total of 58 (51.8%) athletes have reported a using of food supplements (FS) in the last 6 months.
The distribution by gender group in the sample of FS users did not differ significantly from the sample of non-FS users (χ2 = 11.283; p > 0.05). The representation of one gender-age group differed significantly in the sample of FS users in comparison with the sample of non-FS users. Female athletes aged between 18 and 23 years were significantly (χ2 = 16.334; p < 0.05) more represented among FS user (11.1%) than in the non-FS user group (0.0%). For both gender categories, the most intensive consumption of FS was between the age of 18 and 23 years.
All the athletes had their own coach.
The distribution of age-gender groups in the sample of FS users who had a doctor did not differ significantly from the group of non-FS users with a doctor (χ2 = 10.188, p > 0.05).
The intake frequency of vitamins (66.7%), minerals (72.0%) and ergogenic supplements (73.3%) for most of the FS users was once daily.
Concomitant use of two or more supplements was reported in 40 (69.0%) of the FS users (Table
Distribution (%) according to the number of used supplements in the total sample and among FS users.
Number of FS | Total sample (N=112) | FS Users (N=58) | ||||
---|---|---|---|---|---|---|
Men | Women | Total | Men | Women | Total | |
1 | 11.6 | 4.5 | 16.1 | 22.4 | 8.6 | 31.0 |
2 | 4.5 | 8.9 | 13.4 | 8.6 | 17.2 | 25.8 |
3 | 3.6 | 6.3 | 9.9 | 6.9 | 12.1 | 19.0 |
4 | 2.7 | 1.8 | 4.5 | 5.2 | 3.4 | 8.6 |
5 | 2.7 | 0.0 | 2.7 | 5.2 | 0.0 | 5.2 |
6 | 0.0 | 0.9 | 0.9 | 0.0 | 1.7 | 1.7 |
7 | 2.7 | 0.0 | 2.7 | 5.2 | 0.0 | 5.2 |
9 | 0.9 | 0.9 | 1.8 | 1.7 | 1.7 | 3.4 |
Total | 28.6 | 23.2 | 51.9 | 55.2 | 44.8 | 100.0 |
One athlete 18 years old reported taking 9 different food supplements at the same time. The highest percentage of concurrent users of two or more preparations is among men athletes aged from 18 to 23 years (19.6%) and women athletes aged from 18 to 23 years (17.9%).
The sport with the highest frequencies of food supplement use was weightlifting (n = 5, 71.4%), followed by handball (n = 5, 50.0%), basketball (n = 5, 38.5%), athletics (n = 11, 35.5%), karate (n = 4, 25.0%), volleyball (n = 1, 9.1%,) and football (n = 0, 0.0%).
A total of 40 (35.7%) athletes reported using over-the-counter drugs. The most frequently used over-the-counter drugs were analgesics. The use of OTC analgesic drugs were reported the 95% (n = 38) of OTC drug users. The most commonly used OTC analgesic drugs were non-steroidal anti-inflammatory drugs (acetylsalicylic acid, ibuprofen, diclofenac, dexketoprofen, etoricoxib) (n = 31, 27.7%) and paracetamol (n = 12, 10.7%).
The distribution by the age-gender group in the total sample differed significantly in the group of OTC drug users and among the group of non-OTC drug users (χ2 = 30.25, p < 0.05). The established differences suggest that the characteristics of the groups (defined by a combination of gender and age) are associated with the use of the OTC drugs in the tested athletes. Males aged between 24 and 30 years were significantly (χ2 = 9.17; p < 0.05) more represented among OTC user (20.0%) than in the non-OTC user group (7.5%). Also males aged over 30 were significantly (χ2 = 6.77; p < 0.05) more represented among OTC user (15.0%) than in the non-OTC user group (5.0%). For both gender categories, the most intensive consumption of OTC was between the age of 18 and 23 years.
There was no significant difference in the distribution in the OTC drug users athletes with a doctor/physician and among non-OTC drug users with a doctor/physician (χ2 = 3.52, p > 0.05). Among OTC drug users (n = 40), the number of used OTC drugs varied in the range of 1–5, (mean±SD: 1.6±0.9) over the last six months. Concomitant use of two or more OTC drugs was reported in 16 (40%) of the OTC drug users (Table
The highest proportion of users (up to 100%) of two or more OTC analgesics was observed among athletes in individual sports (weight lifting and karate) (Table
Distribution (%) by the number of medicines used in the total sample and OTC drug users.
Number of medicines | Total sample (N=112) | OTC drug users (N=40) | ||||
---|---|---|---|---|---|---|
Men | Women | Total | Men | Women | Total | |
1 | 13.4 | 8.0 | 21.4 | 37.5 | 22.5 | 60.0 |
2 | 6.3 | 2.7 | 9.0 | 17.5 | 7.5 | 25.0 |
3 | 0 | 0.9 | 0.9 | 0 | 2.5 | 2.5 |
4 | 0 | 0.9 | 0.9 | 0 | 2.5 | 2.5 |
5 | 0.9 | 0.9 | 0.9 | 2.5 | 2.5 | 5.0 |
7 | 0 | 0.9 | 0.9 | 0 | 2.5 | 2.5 |
9 | 0 | 0.9 | 0.9 | 0 | 2.5 | 2.5 |
Total | 20.6 | 15.2 | 35.8 | 57.5 | 42.5 | 100.0 |
In the OTC analgesics group of athletes, 31.6% used two or three analgesics at the same time. The most common combinations involved the simultaneous use of one NSAID and the medicinal product representing a combination of paracetamol, propyphenazone, codeine and caffeine (25%), one NSAID and paracetamol (25%) and the simultaneous use of two NSAIDs (16.8%).
Most of the OTC analgesic drug users (59.0%) used these medications once a day, 30.8% once a week and 10.6% as needed (weekly, monthly or semiannually).
Although many authors have considered supplementation among athletes, there is very little information on the frequency of use, type and dosage of supplements, and the age and gender distribution of supplement users among athletes in Bosnia and Herzegovina. To date, to our knowledge, only one study has been conducted that has quantitatively and qualitatively examined food supplementation by elite athletes. It was conducted by the Faculty of Pharmacy in University Sarajevo, Department of pharmaceutical analytics in cooperation with the Anti-Doping Control Agency of Bosnia and Herzegovina. The study was included an analysis of doping control forms (n = 442) completed at national and international competitions as well as out of competitions from 2010 to 2012 in Bosnia and Herzegovina. Compared to these results, this study shows a slightly higher frequency of supplementation (34.5% vs. 51.8%). The difference between the results of these two studies can be partly explained by the different methodology used in the data collection, the period in which consumption of FS was examined among athletes and the way the survey was done (
Namely, the study conducted by
Also, a lower rate of reporting the use of supplements, noted in a 2015 study, is possible because of the insincerity of athletes due to fear of sanctions which would be implied based on a positive doping control results.
The overall percentage of athletes who used supplements in this study (51.8%) was slightly lower compared to the results of studies by other authors who analyzed the use of food supplements among athletes over longer periods (6–12 months). A study which examining the use of food supplements in Singapore’s elite athletes in the last 12 months found that 77% (73% of men and 81% of women) of the analyzed athletes were used food supplements (
The results of our study regarding the age-gender distribution of food supplement users show a partial agreement with the results of a previous study on the use of food supplements conducted in Bosnia and Herzegovina according to which the most dominant group among FS users were men aged in the range 18–29 years, while a trend was noted of slight increase of FS consumption among the female athletes only after 24 years of age (
According to the results in this study, there is not a significant influence of doctors/physicians or trainers on the FS consumption among athletes. Also, a study conducted by Omeragic and coworkers (
Among FS users (n = 58), the number of used supplements varied in the range of 1–9, (a mean of 2.7±2.0) over the last six months.
Concomitant consumption of food supplements is a common practice among athletes(
The sport discipline was another variable with influence in the frequency of food supplements use (Table
The results on the frequency of OTC drugs use and the type of OTC drugs used among athletes, obtained by this study are consistent with those of other authors. According to the results in this study the most commonly used OTC drugs among the athletes who completed the questionnaire were OTC analgesics drugs, mostly NSAIDs and paracetamol. Earlier studies, also, shown that the use of over-the-counter analgesic drugs are commonplace in elite sports as well as in recreational and student-athletes (Ciocca et al. 2005). In a study of 1261 international athletes at the 2007 Pan-American Games, Da Silva and coworkers found that 63% (n = 792) of the athletes were using NSAIDs (Paoloni 2009). Additional, in a study of high school football players, 75% had used NSAIDs in the previous 3 months, and 15% were using NSAIDs daily (
Considering the results of previous studies, a single dose of 500–1000 mg of paracetamol, which among the OTC analgesics users, was the most common intake dose, should not exert a significant ergogenic effect or pose any risk of possible side effects. The highest percentage of OTC drug users in this study (27.7%) used the NSAIDs, and the most commonly used analgesics in this group were diclofenac (17.0%) and ibuprofen (9.7%). NSAIDs are generally the most commonly used over-the-counter analgesics among athletes (
Furthermore, this study found that the largest number of OTC analgesic users among athletes in individual sports: weight lifting (M and F 100%), karate (M 42.8% and F 35.6%) and athletics (M 0% and F 33.3%). Among athletes in team sports, most users of analgesics are football players (M 37.5%). Also, these drugs were administered at significantly lower doses than those which, according to some studies, showed a certain effect on performance in sports, which should preclude their use to enhance performance in sports. However, one should not forget the wide range of side effects that may result from the use of NSAIDs. Use of NSAIDs at or above the therapeutic doses has been associated with the development of hyponatremia during exercise (6%) (Küster 2013), renal failure, ulcerative bleeding, cardiovascular disorders (9%), gastrointestinal disorders (10%), kidney dysfunction (
The use of paracetamol at therapeutic doses is not associated with serious side effects. Rare, mild to moderate side effects that may occur due to the short-term administration of therapeutic doses of paracetamol (>3 g/day) may be nausea, vomiting, diarrhea, and abdominal pain. Liver failure occurs with acute paracetamol poisoning (>10g) (
According to the presented results, we can conclude that a substantial proportion of athletes that were included in this survey use food supplements and over-the-counter medications. Also, the established mean number of used supplements among athletes who use food supplements and OTC analgesics, as well as the total percentage of athletes FS and OTC analgesics users with simultaneous consumption of two or more supplements and medicines can lead to the assumption that there exists the irrational use of supplements and medicines among the athletes included in this survey.
The most significant limitation of this study is the insignificant number of athletes in certain types of sports analyzed, such as weightlifting where the number of athletes who initially completed the survey was only 8. Also, some sports were not covered at all with the survey conducted in this study. However, since this is the first study to monitor the frequency and type of food supplements and OTC drugs used among athletes in Bosnia and Herzegovina, these preliminary results are extremely important and can help to address this question and to expand our understanding of the use of food supplements and OTC drugs by athletes of various sports within their competitive seasons.
The authors have no funding to report.
The authors have declared that no competing interests exist.
Item | Type of question (open/closed) | Answer options (for closed questions only) |
---|---|---|
National origin | Closed | „BiH“ or „other“ |
Current place of residence | Closed | „BiH“ or „other“ |
Current age (years) | Open | / |
National origin | Open | / |
Body height (cm) | Open | / |
Current body weight (kg) | Open | / |
Gender | Closed | „Man” or „Female“ |
Sport | Open | |
Do you have a coach? | Closed | „Yes” or „No” |
Do you have a doctor/physician? | Closed | „Yes” or „No” |
Have you taken any dietary supplements (e.g. vitamins, minerals, sports food) or OTC medications in the last 6 months? | Closed | „Yes” or „No” |
What vitamins do you take in the last 6 months and how often? | Open/Closed | Specify the name of the preparation and indicate next to it “Daily” or “Weekly” or “Monthly” or “Semi-annual” or “Annual” |
What minerals do you take in the last 6 months and how often? | Open/Closed | Specify the name of the preparation and indicate next to it “Daily” or “Weekly” or “Monthly” or “Semi-annual” or “Annual” |
What sports food do you take in the last 6 months and how often? | Open/Closed | Specify the name of the preparation and indicate next to it “Daily” or “Weekly” or “Monthly” or “Semi-annual” or “Annual” |
What OTC medicines do you take in the last 6 months and how often? | Open/Closed | Specify the name of the preparation and indicate next to it “Daily” or “Weekly” or “Monthly” or “Semi-annual” or “Annual” |