Content uploaded by Jad Melki
Author content
All content in this area was uploaded by Jad Melki on Sep 22, 2019
Content may be subject to copyright.
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
391 Official Journal of FIMS (International Federation of Sports Medicine)
ISMJ
International SportMed Journal
Original research article
The prevalence and determinants of anabolic steroid use among
fitness centre attendees in Lebanon
1*Dr Eveline A Hitti, MD, 2Dr Jad P Melki, PhD, 1Dr Afif J Mufarrij, MD
1Department of Emergency Medicine, American University of Beirut Medical Center, Riad El-Solh / Beirut
1107 2020, Lebanon
2Department of Sociology, Anthropology, and Media Studies, American University of Beirut, Beirut,
Lebanon
*Corresponding author. Address at the end of text.
Abstract
Background: Non- medical anabolic steroid (AS) use in non-professional athletes is an increasingly
recognized public health problem in Europe and the United States but poorly studied in the Middle East.
Research question: The aim of this study is to assess the prevalence and determinants of anabolic
steroid use amongst adult fitness centre attendees in the Greater Beirut area, Lebanon. Type of study: A
cross-sectional study design was adopted. Methods: Subjects: The targeted population included all gym
attendees in Greater Beirut aged 18 or above. Professional or career athletes competing in organized
sports were excluded. Questionnaire: A questionnaire was used to survey participants on demographic
information, history of anabolic steroid usage and possible determinants of use. Sampling: A list of 53
fitness centres in the Greater Beirut area was identified. Thirty-three gyms agreed to permit access to
their centres. Trained research assistants distributed the questionnaire to all gym attendees on arrival,
during equally selected day and evening intervals. A total of 523 gym attendees completed the survey.
Results: The prevalence of any history of anabolic steroid use was 10.7%. The majority of users (78.2%)
were aware of the adverse health effects. The main reason for usage reported was body image
enhancement (82.0%). Demographic factors associated with anabolic steroid use were: male gender,
separated/divorced status and full-time employment. Conclusion: Non-medical anabolic steroid use is a
public health concern in Lebanon that should be addressed by monitoring AS use in health clubs and with
educational programs aimed at high-risk groups, health practitioners and health clubs that not only focus
on risk awareness but also on media literacy and body image attitudes. Keywords: anabolic steroids,
epidemiology, media literacy, prevalence, determinants
*Dr Eveline Hitti, MD
Dr Hitti is an Assistant Professor in Clinical Emergency Medicine and Interim Chair of the Department of
Emergency Medicine, at the American University of Beirut Medical Center, Beirut, Lebanon. Dr Hitti
completed her medical and specialty training at Johns Hopkins School of Medicine in Baltimore,
Maryland, USA. Her research interest is in Safety and Quality in Emergency Medicine. She is a fellow of
the American Academy of Emergency Medicine.
Dr Jad Melki, PhD
Dr Melki is an assistant professor of journalism and media studies and the director of the Media Studies
Program at the American University of Beirut. He is also the research director of the International Center
for Media and the Public Agenda (ICMPA) at the University of Maryland, College Park, a visiting faculty at
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
392 Official Journal of FIMS (International Federation of Sports Medicine)
Johns Hopkins University and at the Salzburg Academy for Media and Global Change, Austria. He
received his Ph.D. in journalism and media studies from the University of Maryland.
Email: mf15@aub.edu.lib
Dr Afif Mufarrij, MD
Dr Mufarrij is an Assistant Professor in Clinical Emergency Medicine at the American University of Beirut
Medical Center, Beirut, Lebanon. He completed his specialty training at Henry Ford, Detroit, USA. His
research interest is in psychosocial motivators of emergency health care utilization.
Email:
Introduction
Anabolic steroids (AS) are synthetic substances
that mimic the anabolic and androgenic effects
of the natural male hormone testosterone1, 2. AS
are licensed medically for the management of
osteoporosis, aplastic anaemia, and certain
types of carcinomas3. Since the 1950s, AS have
been used in sports, predominantly in
bodybuilding, to increase muscle mass,
strength, performance, and fatigue resistance4.
More recently, non-medical anabolic-androgenic
steroid (NMAAS) use has become increasingly
prevalent among non-athletes seeking to
enhance their body image5-8. In 1990, the
Anabolic Steroid Control Act made the
possession and distribution of AS for non-
medical purposes a felony in the US9. According
to the Order of Physicians, although not
specifically defined, anabolic steroids still fall
under the category of medications that require
prescriptions. Thus it is illegal for pharmacists to
dispense AS to customers without a prescription
from the treating physician. Furthermore, despite
Lebanon being among the 191 governments that
has adopted the UNESCO International
Convention against Doping in sports treaty 10 ,it
lacks specific laws for monitoring and regulation
of doping among non-athletes. Other countries
that also abide by the international treaty such
as, the USA, Australia, and the UK, have
specific federal laws pertaining to the misuse of
anabolic steroids among the general population
and non-athletes. The Misuse of Drugs Act 1981
(Australia) 11, Controlled Substances Act of 2004
(USA) 12 , and the Misuse of Drugs Act 1971
(UK)13 clearly state that it is illegal to possess,
use, manufacture, supply, import or trade
anabolic steroids without a license or
prescription for its medicinal use.
AS used for physique enhancement are taken in
doses 10 to 100 times the recommended
therapeutic doses14. The side effects at such
levels can range from simple conditions like
acne, hirsutism in females and gynecomastia in
males, to more serious adverse effects,
including liver failure, myocardial infarcts, stroke,
atrial fibrillation, as well as sudden and
premature death15 16, 17. Despite these risks,
NMAAS use is still a major public health problem
among adolescents and adults18. In the UK, the
percentage of reported NMAAS users among
athletes ranges between 5% and 65.8%19. In the
US, NMAAS use by high school students ranges
from 4% to 11%20. The prevalence of this abuse
by the same age group in Australia is 3.2%21.
Use in NMAAS has also been reported in
Sweden22, South Wales23, Germany24, Poland25
and Canada26. Although one study looked at
NMAAS use in neighbouring Jordan14, no study
has investigated usage, prevalence, or drivers of
usage in Lebanon. The objective of this study is
to investigate the prevalence of NMAAS use
among adults attending fitness centres in Beirut,
Lebanon, as well as to assess determinants of
NMAAS use in this population.
Methods
Selection of subjects
A cross-sectional study design was adopted.
The targeted population included all gym
attendees in the Greater Beirut area aged 18
years or above. Professional or career athletes
competing in organised sports were excluded. A
list of 53 fitness centres in the Greater Beirut
area was identified through the telephone
directory. After consultation for participation in
the study, 33 gyms agreed to permit access to
their centres for the study, two had closed down,
four declined to participate and the remainder
did not return phone or email messages
requesting approval. The study was reviewed
and approved by the American University of
Beirut’s Institutional Review Board - the
University’s Research Ethics Board – and it met
the ethical standards of the Helsinki Declaration.
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
393 Official Journal of FIMS (International Federation of Sports Medicine)
Trained research assistants distributed the
questionnaire to fitness centre attendees on
arrival at the fitness centre after securing verbal
informed consent. To reduce possible selection
bias related to gym-attendance time and
research assistant selection, the research
assistants distributed questionnaires during both
the day (08h00-16h00) and evening (16h00-
23h00) time intervals equally and offered the
questionnaire to every attendee that arrived
during any particular scheduled interval. To
secure privacy, subjects were allowed to fill in
the questionnaire in a private area offered by the
gym and the survey was placed in a sealed
envelope after completion.
Questionnaire
The questionnaire was anonymous, self-
completed, comprised of 63-items and took
approximately 10 minutes to complete. It was
adopted from the literature2, 14, pilot-tested on a
group of individuals practicing bodybuilding, and
then adjusted to the Lebanese context, after
consulting some professionals in the field. The
questionnaire included socio-demographical
variables, such as age, gender, weight, height,
marital status, residency, educational level,
student status, work status, monthly income,
and alcohol and tobacco intake. Other questions
aimed at assessing a history of supplement use,
the prevalence and determinants of AS abuse;
these included but were not limited to: the use of
AS, frequency and duration of use, route of AS
use, AS source, reasons for use and/or
discontinuation and awareness of AS adverse
health effects.
Statistical analysis
After completion of data collection, SPSS 18.0
was used for data coding, entry, cleaning and
analysis. Descriptive data were presented as
means ± standard deviations (SD), medians
(interquartile range [IQR]) or percentages.
Bivariate analyses were conducted using the
Chi-square test for categorical variables and the
independent samples t-test for continuous
variables. Multivariate logistic regression models
were constructed to determine the independent
risk factors for androgenic anabolic steroids (AS)
use, using a forward step-wise approach. A p-
value of 0.05 was used for inclusion. Effect
estimates were reported as adjusted odds ratios
(AOR) and 95% confidence intervals (CI). The
deviation contrast method was used, where
each category of the predictor variable except
the reference category was compared to the
overall effect. All p-values were two-sided with
the level of significance set at 0.05.
Results
Subject characteristics
A total of 688 gym attendees were offered the
questionnaire, out of which 523 participated,
giving a response rate of 76%. The mean age
was 25.0 ± 6.1 years with a predominance of
males (82.2%). Demographics of the study
sample are summarised in Table 1. The mean
body mass index was 24.8 ± 3.8 kg/m2 with
54.5% of attendees self-reporting that they are
overweight and 30.6% self-reporting that they
are underweight. The majority of attendees were
single (88.5%), had a university degree (64.7%),
and were employed (63.2%). Only 11.3% had no
monthly income. The rates of alcohol use and
smoking were 59.0% and 41.9% (24.2% current
and 17.6% previous), respectively. The mean
number of days per week spent at the gym was
4.3 ± 1.3 and the mean number of minutes spent
exercising every session was 82.4 ± 33.6, with a
minimum of 25 min per session and up to 300
min per session.
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
394 Official Journal of FIMS (International Federation of Sports Medicine)
Table 1: A descriptive overview of the study sample and a comparison of the determinants of AS use
between users (n=55) and non-users (n=457)
Parameter
All
AS non-user
AS user
p-value
Age in years, mean (± SD)
25.0 ± 6.1
24.41 (± 5.66)
28.28 (± 6.32)
18-25 yrs.
335 (64.7%)
310 (68.4%)
21 (38.9%)
0.000
26-35 yrs.
148 (28.6% )
120 (26.5%)
27 (5.0%)
36-45 yrs.
32 (6.2%)
21 (4.6%)
6 (11.1%)
46+ yrs.
3 (0.6%)
2 (0.4%)
0
Total
518
453
54
Gender, n (%)
Male
419 (82.2%)
355 (79.8%)
54 (100%)
0.000
Female
91 (17.8%)
90 (20.2%)
0
Total
510
445
54
Marital status, n (%)
Single
462 (88.5%)
417 (91.2%)
37 (68.5%)
0.000
Married
54 (10.3%)
38 (8.3%)
13 (24.1%)
Separated/Divorced
6 (1.1%)
2 (0.4%)
4 (7.4%)
Widowed
0 (0.0%)
0
0
Total
522
457
54
Education level, n (%)
No formal education
3 (0.6%)
3 (0.7%)
0
0.000
Primary school
25 (4.8%)
20 (4.4%)
5 (9.1%)
High school
44 (8.4%)
28 (6.2%)
12 (21.8%)
Technical
36 (6.9%)
24 (5.3%)
9 (16.4%)
University/Postgraduate
409 (78.5%)
376 (82.6%)
29 (52.7%)
Other
4 (0.8%)
4 (0.9%)
0
Total
521
455
55
Employed, n (%)
No
191 (36.8%)
184 (40.4%)
5 (9.4%)
0.000
Part-time
71 (13.7%)
61 (13.4%)
10 (18.9%)
Full-time
257 (49.5%)
210 (46.2%)
38 (71.7%)
Total
519
455
53
Household monthly income in
USD, n (%)
None
55 (11.3%)
52 (12.2%)
2 (3.9%)
0.050
<500
66 (13.6%)
61 (14.3)
4 (7.8%)
500-1000
103 (21.1%)
87 (20.4%)
11 (21.6%)
1001-2000
121(24.8%)
102 (23.9%)
19 937.3%)
2001-5000
91 (18.7%)
77 (18.0%)
13(25.5%)
>5000
51 (10.5%)
48 (11.2%)
2 (3.9%)
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
395 Official Journal of FIMS (International Federation of Sports Medicine)
Total
487
427
51
Current Student, n (%)
No
270(52.3%)
214 (47.8%)
46 (83.6%)
0.000
Yes- Full Time
191 (37.0%)
185 (41.3%)
5 (9.1%)
Yes- Part Time
53 (10.3%)
49 (10.9%)
4 (7.3%)
Total
516
448
55
AS: androgenic anabolic steroids, Primary school, includes elementary and middle school years. BMI:
Body Mass Index. US$: United States Dollars.
*Chi-square analysis of AS users and AS non-users, significance at P<0.05
Supplement use
The majority of respondents (62.4%) did not
spend any of their monthly income on AS or
supplements. Of those who did, 32.2% spent
<300 US$, 4.6% spent 300-600 US$ and 0.8%
spent >600 US$. The rates of protein and
creatine supplement use amongst all
respondents were 41.1% and 18.5%,
respectively. Out of 512 participants answering
the question on AS use, 17 (3.3%) reported
current use and 38 (7.4%) reported previous
use; indicating a 10.7% prevalence of any
history of AS use.
Characteristics of AS use
The mean age at starting AS was 22.1 ± 4.6
years (range 18-50). The most commonly
reported reasons for AS use were: to enhance
body image (82.0%), to boost performance
(14.0%), and ‘other reasons’ (4.0%). Figure 1
summarizes the main forms, types, and sources
of AS used. The majority used both pills and
injections (46.3%), Deca 50 type (56.9%), and
obtained the AS from the gym coach or a friend
(32.7% each). The median frequency of AS use
per month was three times (IQR, 2-9).
Figure 1: Pie charts showing the distribution of the (A) Forms (n=54), (B) Types (n=51), and (C) Sources
and (D) reasons for discontinuation of AS (n=55), in gym attendees with a history of AS use
Deca 50
56.8%
Stanazol
21.6%
Testost
erone
cypiona
te
9.8%
Other
11.8%
Types
(B)
Pills
20.4%
Injectio
ns
33.3%
Both
46.3%
Forms
(A)
Gym
coach
33%
Friend
33%
Other
athlete
11%
Other
source
23%
Sources
(C)
Friend's
advice,
18.4%
Side-
effects,
44.7%
Financia
l
reasons,
13.2%
Other,
23.7%
Reason for discontinuation of
AS
(D)
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
396 Official Journal of FIMS (International Federation of Sports Medicine)
When asked how they would feel about
discontinuing AS, 62.0% answered that they
would have no problem stopping, 22.0%
reported concern about losing size, 14.0%
reported concern about losing strength, while
2% reported concern about losing respect.
Among previous users (n=38), the main reported
reasons for discontinuing AS were: friend’s
advice (18.4%), side-effects (44.7%), financial
reasons (13.2%), and other reasons (23.7%)
(Figure 1D).
Out of AS users, 78.2% were aware of the
associated side-effects of NMAAS and 18.9%
were experiencing side-effects at the time of
study. Medical advice regarding AS use was
sought by 20.4% users. The sources of medical
advice were: 42.9% from medical specialist,
35.7% from a family physician, 7.1% from an
emergency physician, or 14.3% from other
sources.
Risk factors for AS use
Gym attendees who had a history of AS use
were older, more commonly males, and had
higher mean weight, height and body mass
index, compared to attendees with no history of
AS use. They were also more likely to be
separated/divorced and employed, yet less likely
to be current students or have a university
degree (Table 1). The rate of previous or current
smoking was also higher in attendees who had a
history of AS use compared with those who did
not (Figure 2). AS-users were also more likely to
consume alcohol on a weekly or daily basis than
non-AS users (Figure 3). On multivariate logistic
regression analysis, demographic risk factors
that were independently and significantly
associated with a history of AS use were:
increased weight (AOR: 1.044 per 1 Kg
increase, 95% CI: 1.020-1.069),
separated/divorced status (AOR: 8.167, 95% CI:
2.132-31.281), employment full-time (AOR:
1.930, 95% CI: 1.128-3.302), and current
smoking (AOR: 1.795, 95% CI: 1.037-3.109).
Gym attendees who had a history of AS use
were also more likely to be protein or creatine
supplement users and spent more days per
week at the gym (Figure 2).
Figure 2: Percent of smoking, protein use and creatine supplementation among as non-users and users
0
10
20
30
40
50
60
70
80
90
100
AS non-
user
AS user AS non-
user
AS user AS non-
user
AS user
Smoking Protein Creatine Supp.
Percent (%)
Never Current Previous
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
397 Official Journal of FIMS (International Federation of Sports Medicine)
Figure 3: Percent of alcohol use among as non-users and users
Discussion
Although the media and policy debates around
NMAAS use have focused on use by minors and
elite-level athletes, recent studies from
Jordanian collegiate students (N= 503), UK
health fitness attendees (N=146) and male
NMAAS users in the US (internet recruitment,
N=1,955) have demonstrated that the
predominant users are in fact neither
adolescents nor competitive sports athletes, but
rather young males from all levels of society,
who are motivated by increased muscle mass
and general appearance14, 19, 27. An internet
based US study of 1955 male adults found that
the majority of users were highly educated,
young males (approximately 30 years old) not
active in organized sports who reported muscle
mass, strength and appearance as the main
motivating factors for usage, whereas the
minority indicated that bodybuilding or
professional sports (6.3% and 5.8%
respectively) were “very important” motivators. In
Poland, 6.2% of young males responding to an
internet survey admitted to using NMAAS, with
83.8% of users admitting that they were
concerned about their physical appearance
compared to 63.4% of non-users25. A study that
looked at queries submitted to the information
service of the Anti-Doping Agency (ADA) in
Denmark found the majority were made by
young male recreational gym users who were
not engaged in competitive sports, of whom 15%
were current NMASS users and another 15%
considered using such substances28. This
present study is the first to look at NMAAS in the
Lebanese setting and found a prevalence rate
for any NMAAS use of 10.7% (previous and
current users) in adult fitness centre attendees
who were not professional or career athletes.
The demographic profile of users in this study
matched that of most other studies19, 25, 29. The
mean age of users was 28.3 ± 6.3 whereas the
mean age of starting AS use was found to be
22.1 ± 4.6 years. All users in this sample were
male and none were female. Though some
studies have reported usage among females
ranging from 2.8% to 7% 19, 20, 29, male gender
has repeatedly been found to be associated with
0
20
40
60
80
100
AS non-user AS user
Alcohol
Percent (%)
Never Less than monthly Monthly Weekly Daily or almost daily
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
398 Official Journal of FIMS (International Federation of Sports Medicine)
NMAAS use19, 20, 25. Users in this study were
more likely to be employed than non-users. This
has also been demonstrated in other studies14,
19, 27. Whereas NMAAS users in a US study
were found to be generally well-educated with
74% holding post-secondary degrees27, only
52.7% of users in this study held post-secondary
degrees compared to 82.6% of non-users in our
sample.
Stacking of steroids is a common behaviour
whereby more than one steroid is used at one
time to achieve synergistic effects, although this
has no scientific support30, 31. The majority of
subjects in this study demonstrated this
behaviour using both pills and injections
(46.3%), with Deca 50 being the most commonly
used steroid (56.9%). Gym attendees who had a
history of AS use were also more likely to be
protein or creatine supplement users.
Polypharmacy has been noted in other studies,
as has the association of NMAAS with protein
and creatine products that are also used to
improve muscle mass, strength and appearance
32, 33. While one study reported NMAAS users
were more likely to use alcohol and illicit drugs
such as cocaine, marijuana and morphine2, this
study did not find an association with alcohol use
but did find that NMAAS users were more likely
to be current smokers (AOR: 1.795, 95% CI:
1.037-3.109).
In most countries NMAAS use is illegal. Methods
of obtaining AS thus vary. Internet is a growing
source of AS in countries where online
purchasing is available19, 27 Other sources cited
in the literature include friends, the “street”,
gyms and coaches and, less commonly,
physicians2, 27. Most respondent in this study
reported obtaining AS from friends or gym
coaches (32.7% each). This, along with the use
of some respondent of drugs not approved by
the Lebanese Order of Pharmacies, (i.e.
Stanazol) suggests the presence of a black
market. Currently no information on the role of
the Lebanese government in addressing AS use
and its monitoring of AS use in health clubs
exists.
Many studies have demonstrated that NMAAS
use is not usually motivated by competitive
sports participation14, 27. This study validates
these findings: the leading reason for NMAAS
use that was reported in the present study was
to enhance body image (82.0%), followed by
boosting performance (14.0%). Furthermore,
58% of those who expressed concern about
stopping NMAAS use were worried about “losing
size” compared to 37% who were concerned
about “losing strength” and 6% who were
concerned about “losing respect” among their
peers and associated exclusion from the group
and isolation from friends. Although the desire to
be more muscular has been linked with NMAAS
use34, compared to the only other study in the
Arab Middle East (Jordan) where use to
enhance physique was reported at only 38.5%14,
this study suggests that importance of body
image in the present study population is
weighted strongly. A study in Australia that
looked at predictors of future NMAAS found
similar results: not only was improved
appearance a common motivator of future
usage, but positive body image and liking one’s
self seemed to be protective against future
NMAAS use35. Given that the effects of media
on body image are reported risk factors for AS
use34, 36, the media consumption habits of the
present study population and their impact on
body image is an area for future investigation
that may explain this pattern.
Public health policy internationally, and in
Lebanon, has focused on educational
campaigns to raise awareness of the dangers of
AS misuse. Studies that have looked at the
effectiveness of such educational programs
have shown variable success37. This study
showed that the majority of attendees with a
history of AS use (78.2%) reported being in fact
aware that AS use poses adverse effects on the
health. This suggests that interventions should
also address drivers of usage not just health risk
education. Given the well-documented effects of
media consumption on body dissatisfaction, the
effectiveness of media literacy campaigns as an
intervention to curb NMAAS should be
investigated. Moreover, other proven
interventions that are applicable to Lebanon
include establishment of support clinics for
addicts38 , addressing socio-cultural factors in
addition to the media, such as peer and parent
pressure 39, alerting and encouraging health
practitioners to recognize the signs associated
with NMAAS use39 and health education of
coaches.
Study limitations
This study has several limitations that should be
considered. The cross sectional design
employed limits the ability to draw any
conclusions on causality of any of the assessed
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
399 Official Journal of FIMS (International Federation of Sports Medicine)
variables and anabolic steroid use. Although
every measure possible was taken to ensure
anonymity of participants, there is still concern
about under-reporting given the legality
concerns surrounding AS usage. Additionally,
only 33 of the 53 gyms approached agreed to
permit access to their centres and members.
This sample may be biased, with gyms where
prevalence is high or where AS are made
available through the coaches opting to forbid
access because of fear of exposure given the
legality concerns. This may lead to an
underestimation of the extent of NMAAS usage
in Beirut.
Conclusion
To the best of these authors’ knowledge, this is
the first study to investigate non-medical
anabolic steroid use habits in fitness centre
attendees in Lebanon and adds to the growing
body of literature indicating that NMAAS is a
growing public health concern in young males
motivated by body image enhancement rather
than competitive sports. Non-medical anabolic
steroid use is a public health concern in
Lebanon that should be addressed by
monitoring AS use in health clubs and with
educational programs aimed at high-risk groups,
health practitioners and health clubs that not
only focus on risk awareness but also on media
literacy and body image attitudes.
Acknowledgements
The authors would like to acknowledge Michael
Oghia for his energy in gathering data and
Miriam Saliba for her valuable technical support.
Address for correspondence:
Dr Eveline A Hitti, Department of Emergency
Medicine, American University of Beirut Medical
Center, Riad El-Solh / Beirut 1107 2020,
Lebanon
Tel.: +961-1-350000; Fax: +961-1-370795
Email: evelineh@yahoo.com
References
1. Graham MR, Davies B, Grace FM, et al.
Anabolic steroid use: patterns of use
and detection of doping. Sports Med.
2008;38(6):505-25.
2. Nilsson S, Baigi A, Marklund B, et al.
The prevalence of the use of androgenic
anabolic steroids by adolescents in a
county of Sweden. Eur J Public Health.
2001 Jun;11(2):195-7.
3. Sekera MH, Ahrens BD, Chang YC, et
al. Another designer steroid: discovery,
synthesis, and detection of 'madol' in
urine. Rapid Commun Mass Spectrom.
2005;19(6):781-4.
4. Hall RC. Abuse of supraphysiologic
doses of anabolic steroids. South Med J.
2005 May;98(5):550-5.
5. Hatoum IJ, Belle D. Mags and Abs:
Media Consumption and Bodily
Concerns in Men. Sex Roles [Internet].
2004; 51(7/8):[397-407 pp.].
6. Smolak L, Murnen SK, Thompson JK.
Sociocultural Influences and Muscle
Building in Adolescent Boys. Psychology
of Men & Masculinity [Internet]. 2005;
6(4):[227-39 pp.].
7. Baird AL, Grieve FG. Exposure to Male
Models in Advertisements Leads to a
Decrease in Men's Body Satisfaction.
North American Journal of Psychology
[Internet]. 2006; 8(1):[115-21 pp.].
8. Denham BE. Effects of Mass
Communication on Attitudes Toward
Anabolic Steroids: An Analysis of High
School Seniors. Journal of Drug Issues
[Internet]. 2006; 36(4):[809-30 pp.].
9. Sturmi JE, Diorio DJ. Anabolic agents.
Clin Sports Med. 1998 Apr;17(2):261-82.
10. UNESCO, editor International
Convention Against Doping In Sport.
General Conference of UNESCO; 2005;
Paris: UNESCO.
11. Drug and Alcohol Office. Steroids the
Facts. In: Department of Health Western
Australia, editor. Western
Australia,,2006.
12. Anabolic Steroid Control Act of 2004,
S2195. Sect. 2 (2004).
13. The Misuse of Drugs ACT 1971. Sect. 2
(1971).
14. Tahtamouni LH, Mustafa NH, Alfaouri
AA, et al. Prevalence and risk factors for
anabolic-androgenic steroid abuse
among Jordanian collegiate students
and athletes. Eur J Public Health. 2008
Dec;18(6):661-5.
15. Sader MA, Griffiths KA, McCredie RJ, et
al. Androgenic anabolic steroids and
arterial structure and function in male
bodybuilders. J Am Coll Cardiol. 2001
Jan;37:224-30.
16. Sader MA, Griffiths KA, McCredie RJ, et
al. Androgenic anabolic steroids and
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
400 Official Journal of FIMS (International Federation of Sports Medicine)
arterial structure and function in male
bodybuilders. J Am Coll Cardiol. 2001
Jan;37(1):224-30.
17. Haller CA, Benowitz NL. Adverse
cardiovascular and central nervous
system events associated with dietary
supplements containing ephedra
alkaloids. N Engl J Med. 2000
Dec;343(25):1833-8.
18. Clark AS, Henderson LP. Behavioral
and physiological responses to anabolic-
androgenic steroids. Neurosci Biobehav
Rev. 2003 Aug;27(5):413-36.
19. Baker JS, Graham MR, Davies B.
Steroid and prescription medicine abuse
in the health and fitness community: A
regional study. Eur J Intern Med. 2006
Nov;17(7):479-84.
20. Bahrke MS, Yesalis CE, Kopstein AN, et
al. Risk factors associated with anabolic-
androgenic steroid use among
adolescents. Sports Med. 2000
Jun;29(6):397-405.
21. Handelsman DJ, Gupta L. Prevalence
and risk factors for anabolic-androgenic
steroid abuse in Australian high school
students. Int J Androl. 1997
Jun;20(3):159-64.
22. Sjöqvist F, Garle M, Rane A. Use of
doping agents, particularly anabolic
steroids, in sports and society. Lancet.
2008 May;371(9627):1872-82.
23. Grace F, Baker J, Davies B. Anabolic
androgenic steroid use in recreational
gym users: a regional sample of the
Mid-Glamorgan area. Journal of
Substance Use [Internet]. 2001; 6:[189-
95 pp.].
24. Striegel H, Simon P, Frisch S, et al.
Anabolic ergogenic substance users in
fitness-sports: a distinct group supported
by the health care system. Drug Alcohol
Depend. 2006 Jan;81(1):11-9.
25. Rachoń D, Pokrywka L, Suchecka-
Rachoń K. Prevalence and risk factors
of anabolic-androgenic steroids (AAS)
abuse among adolescents and young
adults in Poland. Soz Praventivmed.
2006;51(6):392-8.
26. Melia P, Pipe A, Greenberg L. The use
of anabolic-androgenic steroids by
Canadian students. Clin J Sport Med.
1996 Jan;6(1):9-14.
27. Cohen J, Collins R, Darkes J, et al. A
league of their own: demographics,
motivations and patterns of use of 1,955
male adult non-medical anabolic steroid
users in the United States. J Int Soc
Sports Nutr. 2007;4:12.
28. Bojsen-Møller J, Christiansen AV. Use
of performance- and image-enhancing
substances among recreational athletes:
a quantitative analysis of inquiries
submitted to the Danish anti-doping
authorities. Scand J Med Sci Sports.
2010 Dec;20(6):861-7.
29. Bergstein JM, Baker EJ, Aprahamian C,
et al. Soft tissue abscesses associated
with parenteral drug abuse:
presentation, microbiology, and
treatment. Am Surg. 1995
Dec;61(12):1105-8.
30. Rogol AD, Yesalis CE. Anabolic-
androgenic steroids and the adolescent.
Pediatr Ann. 1992 Mar;21(3):175, 83,
86-8.
31. Trenton AJ, Currier GW. Behavioural
manifestations of anabolic steroid use.
CNS Drugs. 2005;19(7):571-95.
32. Tahtamouni LH, Mustafa NH, Alfaouri
AA, et al. Prevalence and risk factors for
anabolic-androgenic steroid abuse
among Jordanian collegiate students
and athletes. The European Journal of
Public Health. 2008 December 1,
2008;18(6):661-5.
33. Baker JS, Graham MR, Davies B.
Steroid and prescription medicine abuse
in the health and fitness community: A
regional study. Eur J Intern Med. 2006
Nov;17:479-84.
34. Field AE, Austin SB, Camargo CA, et al.
Exposure to the mass media, body
shape concerns, and use of
supplements to improve weight and
shape among male and female
adolescents. Pediatrics. 2005
Aug;116(2):e214-20.
35. Dunn M, Mazanov J, Sitharthan G.
Predicting future anabolic-androgenic
steroid use intentions with current
substance use: findings from an
internet-based survey. Clin J Sport Med.
2009 May;19(3):222-7.
36. Yesalis CE. Use of steroids for self-
enhancement: an epidemiologic/societal
perspective. AIDS Read. 2001
Mar;11(3):157-60.
37. Elliot DL, Moe EL, Goldberg L, et al.
Definition and outcome of a curriculum
to prevent disordered eating and body-
Anabolic steroid use among gym attendees in Lebanon International SportMed Journal, Vol.15 No.4, December
2014, pp. 391-401. Available at URL: http://www.ismj.com
401 Official Journal of FIMS (International Federation of Sports Medicine)
shaping drug use. J Sch Health. 2006
Feb;76(2):67-73.
38. Graham MR, Davies B, Grace FM, et al.
Anabolic steroid use: patterns of use
and detection of doping. Sports Med.
2008;38:505-25.
39. Smolak L, Murnen SK, Thompson JK.
Sociocultural Influences and Muscle
Building in Adolescent Boys. Psychology
of Men & Masculinity. 2005;6(4):227.
