B90075 Applied Health Studies

Introduction and Background

Anabolic Steroid (AS) is a synthetic derivative of the male sex hormone, the testosterone and it is found to have both anabolic and androgenic effect in an individual. Anabolic effect relates to increase in skeletal mass whereas androgenic effect refers to masculinisation features. Due to this property, many athletes favour consuming AS to gain weight, endurance, and strength (Nakhaee, Pakravan and Nakhaee 2013). As AS is a derivative of testosterone, it is a prepared in a way to mimic all actions of testosterone such as growth of muscles, increase in red blood cells and other androgenic effects. The action of the drug starts after the steroid enters the blood stream and distributes to different cells in the organ. After entering the cytoplasm of cells, the steroid-receptor complex modifies genetic functions and stimulates the synthesis of new proteins. Steroids have the ability to alter functions of many organs such as heart, brain and kidney (Jones et al. 2018). However, the effect on different organs depends on the type of proteins produced.

Use of anabolic steroid (AS) is highly prevalent among sports athletes to increase their muscle strength and mass. Nakhaee, Pakravan and Nakhaee (2013) suggest increased use of AS among athletes to overcome body dissatisfaction and gain body mass and strength without extra effort. In case of U.S., the prevalent rate of AS is found to be less than 10 % and in Iran, it is about 20%. However, one of the significant issues regarding the use of this steroid is that it is associated with many dose related side-effects. Jabari et al. (2016) explains that supra-physiological doses can increase risk of hypertension, atherosclerosis and myocardial infarction in athletes.  Current research also documents about the role of AS on cardiovascular health of athletes. As stated by Hassan, Salem and Sayed (2009), AS use has detrimental effect on cardiovascular health. It contributes to elevation of blood pressure, reduction of high density lipoprotein and sudden cardiac death. There is also evidence regarding the difference in cardiac outcome among steroid users and non-users. For example, Neto et al. (2018) states that high dose of AS leads to increased ventricular mass and increased thickness of intraventricular septum.  Chances of hemodynamic implications are huge.  Baggish et al. (2017) reported about the long term consequences of AS use and by employing cross-sectional cohort design, the study revealed that compared to non-users, AS users have reduced left ventricular systolic function and diastolic function. The cumulative increase in plaque volume for each 10 year was also found to be highest in AS users. Hence, likelihood of myocardial dysfunction and accelerated coronary atherosclerosis can be high in athletes using the drug.  Review of the above evidence suggests that taking AS without consideration of does and side effects may lead to poor health outcome in athletes. New researchers should focus on uncovering more facts about the topic and assessing the credibility and reliability of past work. This may help to raise awareness regarding the adverse consequences of AS among athletes.

The use of AS is associated with legal consequence in many countries in terms of legislations. However, in many countries use of AS is allowed as it is considered as prescription drug. However, after review of research literature related to the effect of AS on cardiac health, it is identified that illicit AS has become a public health issue in many country. With the rise in reports related to cardiovascular abnormalities caused due to AS use, special attention is being given to comprehensively understand the role of AS in the development of cardiovascular abnormalities. The issue and the topic have been poorly understood. Review of current evidence related to contribution of AS in development of cardiovascular abnormalities and comparison with past evidence may help to determine the validity of each research findings. This is also necessary because many research studies were found to have conditions that reduced the internal validity of the study.  Critical analysis and evaluation of research evidence may also help to extent to which the drug can impair health of athletes. Hence, conducting systematic review of research literature on finding out the adverse impact of anabolic steroid use on cardiac health of young and adult athletes is important to validate the research findings and promote government action’s to restrict use of drugs among athletes. It may also help to increase awareness about the ill-effect of AS in new athletes entering the sports field.

Aim and objectives

The main of the systematic review is to evaluate the adverse effect of AS use on cardiac health of new and young athletes.

The main objectives of the systematic review are as follows:

• To identify the cause behind cardiovascular effect associated with the use of AS among athletes
• To assess and describe different types of cardiovascular abnormalities caused due to the use of AS drug
• To suggest ways to curb use of AS drugs among young athletes.

Methodology: Research design

The research design in any research is the overall strategy that the researchers select for integrating the different elements of the study in a logical and coherent manner, thereby assuring that the research problem would be adequately addressed. Research design is considered to be the systematic approach used by the researchers for conducting the study and represents the synchronization of data in a plausible manner (Flick 2015). Qualitative research method was considered appropriate and rational for the present study as the same would result in an exploratory research looking deep into the relevant literature aligned with project aim (Taylor, Bogdan and DeVault 2015). The research design was decided upon as it had the potential to analyze the negative impact of anabolic steroids by categorizing the results into proper themes addressing the research question.

Search strategy

For gaining deep insight into the topic of effects of anabolic steroids on cardiovascular health of athletes, a systematic literature review was carried for the present research. This method was found to be highly advantageous for fulfillment of the objectives of the project and drawing in a distinct conclusion from the research that is aligned with the aim of the project. According to Silverman (2016), best available studies on a certain subject can be effectively analyzed by carried out a systematic literature review.  Systematic reviews are directed towards identification and summarization of the key findings of previously carried out primary as well as secondary research so that implications for future changes in practice can be understood for the respective field.  In the present research the objective was to search for relevant literature in a planned manner and from a vast pool of studies and analyzing the same for coming to a logical conclusion. The review was therefore undertaken by adhering to a discreet research design on the basis of pre-set methodology.

Databases

Systematic literature reviews are to be conducted with the help of appropriate electronic databases from where relevant literature is to be extracted. These databases act as beneficial tools used for gaining access to wide pool of sources. Researchers are supposed to identify the correct databases among many that can contribute is significantly to the present research (Flick 2015).For the present systematic literature review, the databases that were used were PubMed, Science Direct, CINAHL and Proquest. These are useful scientific databases that house an extensive pool of journal articles. It is worth mentioning that the articles retrieved from these databases are peer-reviewed, and thus credible and trustworthy. Full text articles are available, adding to the benefits of using these databases. Updated access can be gained across a wide range of reputed journals from across the globe.

Keywords

Keywords are the terms used in the process of searching for relevant literature that make the search process focused and apposite. Such words are considered on the basis of the defined objectives of the research that make up the research question (Silverman 2016). In the present systematic review, the following keywords were used-

Inclusion and exclusion criteria

Inclusion criteria and exclusion criteria are the most important elements of a systematic literature review. These are the set of characteristics that the prospective studies must have or not have in order to be integrated in the study (Silverman 2016). The inclusion and exclusion criteria referred to for the present systematic literature review are as follows-

Data collection

Suitable literary sources were retrieved in a logical and systematic manner through appropriate search strategy. The exact impact of anabolic steroids used for performance enhancement in sports was to be highlighted through the present study. After retrieval of the full text articles matching the inclusion criteria, the same were considered for analysis. The papers were thoroughly scrutinized for gaining understanding of the contribution of the article to the research (Flick 2015).

Data analysis

Systematic literature reviews allows for a precise assessment of the research efforts, key inferences drawn and the limitation of the study. It is crucial to categorize the inferences drawn from a wide range of studies so that logical conclusions can be drawn. Thematic analysis identifies patterns across data sets significant to the particular research question (Taylor, Bogdan and DeVault 2015). Thematic analysis of the extracted information was considered as the data analysis method in the present study. The information was presented under relevant headings that together contributed to the results section on impact of AS on cardiovascular health of athletes. 

Results: Risk of cardiovascular effects due to the use of AAS

Baggish et al. (2010) studied the association between long term anabolic-anabolic steroid use and left ventricular dysfunction. The authors argued that though illicit anabolic androgenic steroid (AAS) is being used in a widespread manner, there is a need of characterizing the long term effects of the same. A 2 dimensional, tissue-Doppler, and speckle-tracking echocardiography was carried out for assessing the left-ventricular (LV) ejection fraction, LV systolic strain, and conventional indices of diastolic function. 12 long term users of AAS were recruited and the number of non users was 7. The age of the participants, duration of weightlifting career prior to the study and present intensity of weight lifting were similar between the two groups. It was found that AAS users had significantly lower longitudinal strain (16.9% [14.0, 19.0] versus 21.0% [20.2, 22.9]; p = 0.004), lower LV ejection fraction (50.6% [48.4, 53.6] versus 59.1% [58.0, 61.7]; p = 0.003 by Wilcoxon rank sum test, two-tailed); and radial strain (38.3 [28.5, 43.7] versus 50.1 [44.3, 61.8]; p = 0.02). The study therefore concluded that cardiac dysfunction is sever in users of AAS and increases the risk of poor heart conditions such as failure. This area needs further research, as mentioned by the researchers.

Self-administration of AAS has been known to be a widespread practice among a large pool of athletes for the purpose of increasing muscular strength and lean body mass (Akcakoyn et al. 2014). The researchers therefore carried out a study for investigating atrial conduction abnormalities in athletes using AAS. Electrochemical coupling interval along with tissue Doppler imaging (TDI) was used as the study technique. 33 individuals known to be competitive bodybuilders were recruited. Of this, 12 used AAS while 18 were non users. The cross-sectional study concluded that when individuals use AAS in supraphysiologic doses on the long run, the risk of inter and intra Atrial electromechanical delay (AEMD) is higher. This suggests an association between AAS and development and recurrence of atrial fibrillation. Future research is warranted in the field of atrial arrhythmias and supraphysiologic dose of AAS.

Millions of athletes have been reported to use illicit anabolic-androgenic steroids (AAS). Since the cardiovascular associations were less known till date, Baggish et al., (2017), carried out a cross-sectional cohort study, with 140 male weightlifters, between the age 34 and 54 years. Of them, 86 were AAs users while the rest were not. Transthoracic echocardiography and coronary computed tomography angiography, were carried out, and the three primary outcome measures were LV diastolic function (early relaxation velocity), LV systolic function (left ventricular ejection fraction), and atherosclerosis (coronary artery plaque volume). Users of AAS had reduced LV systolic function (mean ± SD left ventricular ejection fraction = 52±11% versus 63±8%; P<0.001) and diastolic function (early relaxation velocity = 9.3±2.4 cm/second versus 11.1±2.0 cm/second; P<0.001). Long term use of AAS had a strong association with coronary atherosclerotic burden [95% confidence interval] in rank of plaque volume for each 10-year increase in cumulative duration of AAS use: 0.60 SD units [0.16–1.03 SD units]; P=0.008). The inference drawn was that athletes are at high risk of suffering myocardial dysfunction that remains an under-recognized health concern for the public. Public health initiatives are needed for curbing exposure to drugs and practitioners are to be provided with clinical information for translating into better patient care practices.

Ahlgrim and Guglin (2009) reported a case study on use of androgenic anabolic steroid by a 41 year old national level bodybuilding athlete. The underlying concept was that use of AAS is a cause of dilated cardiomyopathy. The individual had presented with severe systolic dysfunction and heart failure even after receiving optimal medical therapy. After review of literature it was found that cardiomyopathy was mostly partially reversible when anabolic use was discontinued. It was concluded that anabolic steroids might be one of the lesser significant causes of cardiomyopathy in individuals who are young and healthy.

Thiblin et al. (2015) had commented that non-therapeutic use of AAS has been found to lead to varied adverse effects, one of which is related to the cardiovascular system. Since intensive studies were needed for understanding the association between cardiovascular outcomes and AAS, the researchers investigated cardiovascular mortality and morbidity in people with AAS use. 2013 men had enrolled in a cohort between 2002 and 2009 for their initial test for AAS. Mortality and morbidity were retrieved after cohort entry on the basis of national registries. It was found that 409 (20%) were tested positive for the use of AAs. The individuals had double the chances of cardiovascular rate of morbidity and mortality when compared to those who were tested negative (adjusted hazard ratio (aHR) 2.0; 95% confidence interval (CI) 1.2–3.3). The main inference drawn from the study was that non-therapeutic use of AAS acts as an independent risk factor for premature death and cardiovascular mortality leading to hospitalizations.  

Effects on cardiovascular system due to the use of AAS

As highlighted by Gheshlaghi et al.  (2015) anabolic steroids has been the most common drug abuse among athletes from different domains. The research carried out focused on evaluating cardiovascular outcomes related to anabolic consumption among body building athletes. 267 male athletes were recruited between the age of 20 and 45 years who had consumed AAS for more than two months with at least one dose in a week. Measurement of Triglyceride (TG), High-density lipoprotein (HDL), low-density lipoprotein (LDL), and hematocrit (Hct) levels was done and data was measured with the help of ANOVA, K2 test and correlation coefficient. The results were that there existed no significant differences regarding TG, HDL and total cholesterol among the two groups. However, difference existed in terms of LDL and Hct levels (P = 0.01 and P = 0.041, respectively). Diastolic and systolic blood pressure was also increased significantly. Increase in systolic and diastolic pressure is known to cause severe vascular disorders. Nevertheless, the researchers reminded the researchers that the relation between AAs and blood pressure might remain in controversy until more research is carried out.

The paper of Climstein et al. (2003) was based on the previous findings that individuals suffered altered systolic function and myocardial fiber changes as a result of AAS use. 23 power and strength athletes were recruited in the study who presented a current and past history of AAS consumption along with 23 control individuals. Assessment of resting and immediate post-exercise transthoracic left ventricular wall cardiokymograms was done. 32.61% of individuals demonstrated abnormal wavefronts. The statistical difference between overall proportions of waveform types could be identified (p<0.01). Thus it was stated that high intensity training without and with AAS supplementation led to induction of alterations in the motion of left ventricular wall in cardiac system. In this alignment the researchers suggested understanding the underlying physiologic and pathologic adaptations.

It was pointed out in the research papers that users of AAS have the belief that resistance taking in conjunction with steroid intake enhances physique. Grace et al. (2003) carried out a research with the experimental aim of investigating the impact of administration of AAS along with resistance training on rate pressure and blood pressure in male amateur bodybuilders. 16 individuals using AAS were recruited in the study along with 16 individuals forming the control group. Measurements were obtained for Systolic and Diastolic Blood Pressure, RPP, Resting Heart Rate and Body Composition. It is to be noted that measurements were done before, during and after the AAS cycle referring to a particular time interval. The control group demonstrated no significant changes in the morphological or cardiovascular characteristics. Nevertheless, the study showed increase in arterial blood pressures and diastolic blood pressure (p<0.05 and p<0.01) when difference measured between pre and post period. It was indicated that AAS users who are borderline hypertensives must not use the same since cardiovascular system is highly affected.

Underlying cause of effects on cardiovascular system due to the use of AAS

There exists no clear concept about potential cardiac adaptation for resisting training (Luijkx et al. 2012). As per the researchers, there is also uncertainty regarding the exact effects of androgenic anabolic steroids (AAS) on cardiac adaptation in athletes. However, the clinical relevance of the issue is of much importance. The researchers aimed at elucidating the impact of resistance training and use of AAS on athlete’s cardiac function and dimensions.156 male participants were recruited of age between 18 and 40 years who underwent cardiac magnetic resonance (CMR). Of them, 52 were non-athletes, (maximum of 3 exercise hours/week), 52 were strength (low dynamic–high static, LD–HS) trained athletes and 52 were strength–endurance (high dynamic–high static, HD–HS) athletes (athletes ≥6 exercise hours/week). The results indicated that no statistical significance was there between non-AAS using LD-HS athletes and non-athletes. Those LD-HS athletes using AAS had larger RV and LC volumes. AAS-using LD–HS athletes showed lower ejection fractions of both ventricles (LV/RV EF 51/48% versus 55–57/51–52%) and lower E/A ratios (LV/RV 1.5/1.2 versus 1.9–2.0/1.4–1.5) which are indication of diastolic function. Thus the researchers stated that strength athletes using AAS have impaired ventricular function, different biventricular systolic dysfunction and cardiac dimensions as compared to those not using AAS. It was further stated that there is a need of raising the awareness level regarding AAS use.  

For investigating the reversibility of adverse cardiovascular effects of chronic abuse of AAS a research was carried out by Urhausen, Albers and Kindermann (2003). 32 powerlifters and bodybuilders underwent Doppler echocardiography and cycle ergometry wherein blood pressure was measured during exercise and at rest. 15 weightlifters were also recruited in the study that did not use AAS. The main finding was that systolic blood pressure was higher in those using AAS (p<0.05). For each of the groups, systolic left ventricular function was within the normal range. The researchers concluded that strength athletes tend to present concentric left ventricular hypertrophy even after years of discontinuation of AAS use. Since the study was a cross-sectional one, further research was needed that considered longitudinal data.

Hassan, Salem and Sayed (2009) contributed to the study area by conducting a study for evaluation of functional and structural alterations suffered in the heart as a result of AAS for enhancing performance. Two-dimensional, M-mode, tissue Doppler imaging (TDI) and strain rate imaging (SRI) were considered in 25 adult males.15 bodybuilders were recruited in group 1, 5 bodybuilders not using AAS were recruited in group 2, and 5 nonathletic constituted negative were recruited in control group. Simultaneously, 30 adult albino rats were considered for the study that was divided into control and experimental group. The result of the echocardiograph indicated that those with steroid use had left ventricular dimension to be smaller alongside thicker walls. Disturbance in the banding pattern of cardiac muscle fiber was distinct. Further, there was interrupted Z-bands, loss of striation, dehiscent intercalated disc. It was noted that supraphysiological doses led to severe deleterious effects in the experimental animals as well as athletes. Early detection of systolic dysfunction is needed for those using steroids at an early age.

Ismail et al. (2012) investigated the effect of use of anabolic steroid on cardiac system with the help of cardiovascular magnetic resonance (CMR). The hypothesis of the study was that major hypertrophy and LV remodeling could be found in AAS users. 23 recreational body builders had been recruited in the study of which 15 used AAS. CMR was carried out and LV remodeling index had been calculated. It was found that significant left ventricular hypertrophy was distinct in those using AAS along with increased peak wall thickness and increased indexed LV mass. In this regard it was concluded that pattern of LV remodeling might mimic hypertrophy cardiomyopathy. The consumption of the drug is to be considered when differential diagnosis of done in the patient cohort for unexplained LV hypertrophy.

Changes in cardiac dimensions, blood pressure and sympathetic modulation in athletes using AAS were measured by Neto et al. (2017). It was hypothesized that those using AAS suffer from cardiac autonomic disorders. 45 male bodybuilding athletes were recruited for the study. Three groups were made and while the control group had 5 individuals, the user and non-user groups had 15 individuals each. The range of analysis carried out included Hemodynamic parameters, linear and nonlinear analyses of heart rate variability and electrocardiography and echocardiography. The results pointed out that bodybuilders using AAS presented a higher blood pressure. The cardiac autonomic alteration was marked and there was a shift towards vagal attenuation and modulation predominance. Increased sympathetic modulation had a distinct association with structural changes in the individual’s heart. The identified association might make up for a key mechanism linking abuse of AAS to higher chances of cardiovascular complications.

Lunghtetti et al. (2009) in their research paper presented a case study of cardiogenic shock and myocardial infarction as suffered as a doped athlete. It was previously known that doping agents increases the risk of heart disease such as acute myocardial infarction. The person of the case study was a 50 year old Caucasian bodybuilder who was known to use erythropoietin and nandolone for a long time. The person developed, as a result of the long standing abuse, ventricular septal defect that was further accompanied by acute myocardial infarction. Research indicated that the mechanical complication was the underlying cause of cardiogenic shock. Treatment was provided with orthotopic heart transplantation. It was concluded that intense isometric exercise, and abuse of drugs such as nandolone and erythropoietin, lead to acute myocardial infarction through coronary thrombus formation.

Anabolic androgenic steroids (AAS) have been denoted to be the most commonly used doping agent among athletes. Montisci et al. (2011) studied three different case studies of sudden cardiac death and one death as a result of congestive heart failure among healthy AAS using athletes.  One case of concentric cardiac hypertrophy with focal fibrosis was observed, two cases of dilated cardiomyopathy with patchy myocyte death were observed and one case of eosinophilic myocarditis was observed. The data was in alignment with previous studies that cardiac abnormality noted in AAS abusers mostly relate to left ventricular hypertrophy which has a relation with fibrosis and myocytolysis. The case where drug induced eosinophilic myocarditis was noted demonstrated an exceptional cardiovascular substrate. The mentioned characteristics present the risk of suffering from ventricular arrhythmias and congestive heart failure. It was lastly mentioned that any cause–effect relationship between abuse of steroid and cardiac death must be identified through a rigorous methodology. 

Discussion 

Pharmacological use of performance enhancing compounds for aiding athletic performance is known to be evident phenomena since a long time. Over several years, it has been indicated that athletes have considered consuming a wide range of compounds for improving performance (Carbone et al. 2017). As commented by Bird et al. (2016) the use of anabolic androgenic steroids (AAS) has increased in the recent past though the concerns and challenges regarding the side effects have come into limelight in a gradual manner through research. Among the different performance enhancing drugs, AAS is a noteworthy one, the underlying reasons for which are diverse. Nevertheless, the overriding factor is thought to be linked to effect on the physique of athletes. AAS have recently undergone a massive transition in terms of its usage as non-competitive, recreational and amateur use is also noted (Nieschlag and Vorona 2015). Consequently, the noted high-level use of such compounds also implies that health professionals are continually coming in contact with abuse cases of AAS. The negative impact of using AAS on the overall health of the athletes, and particular boy system has been under scrutiny for the past few years. Concerns have been generated across the medical spheres regarding the far-reaching impact on the cardiovascular system of individuals (Carbone and D’Andrea 2017).

The present systematic review highlighted that the risk of suffering cardiovascular diseases as a result of long term as well as short term use of AAS is high among athletes. When use in supraphysiologic doses, AAS increases the risk of intra- and inter- atrial electromechanical delay and recurrence of atrial fibrillation. In a previous research, Berge, Andersen and Bahr (2017) stated that there exists a lack of strong research that has highlighted the mortality rate among athletes as a result of negative impact of the steroids on cardiovascular system. What has continuously come into prominence is that the risk of suffering poor health outcomes is high and adequate enough to cause mortality. Corrado and Zorzi (2018) in this regard had highlighted that the potential side effects of steroids are not to be undermined since these increase the risk of cardiovascular system changes. Conditions of excess dose of AAS clearly have a negative effect on cardiovascular risk profile, and heterogenous population has been studied in this regard repetitively. The higher prevalence of risk is likely mediated through different plausible factors.

Adding to a large pool of studies, the present systematic review highlighted that the most common cardiovascular effects of AAS among athletes are increase in arterial blood pressures and diastolic blood pressure, alterations in the motion of left ventricular wall in cardiac system, and cardiomyopathy. The underlying mechanisms involved in changes in cardiovascular system of athletes known to consume AAS are highly complex and multiple (Santos-Lozano et al. 2017). The present literature review points out that impaired ventricular function, different biventricular systolic dysfunction, disturbance in the banding pattern of cardiac muscle fiber, interrupted Z-bands, loss of striation, dehiscent intercalated disc, left ventricular hypertrophy relation with fibrosis and myocytolysis and coronary thrombus formation are some of the underlying causes of cardiovascular system changes. D’Andrea et al. (2016) suggested that experimental and clinical approaches are required in the near future that would be focusing on the mechanisms through which AAS are associated with cardiovascular risk and the cellular processes that contribute to such conditions. Additional efforts in research would need to be diverse for coming up with strategies that can combat the negative effects of AAS on cardiovascular system.

The most prominent strategy that would aid in prevention of widespread use of AAS among athletes is identified as increase in awareness level of individuals. The concerns sports authorities must work in collaboration with health care agencies to inform athletes about the ill effects of steroids and other similar performance enhancing drugs. Since inadvertent and deliberate doping is increasing at an alarming rate, there is much need of influencing the attitudes and perceptions of athletes regarding use of AAS (Angell et al. 2012). Based on the research of Achar et al. (2010) and Loland (2017) it can be recommended that sports agencies must consider carrying out educational sessions for athletes both young and adult so that they can be presented with information. Research findings and case study reports are to be presented through such sessions so that individuals are informed of the actual consequences of using AAS in relation to cardiovascular health (Angell et al. 2012).

Conclusion 

In conclusion, it is clear that the existing literature related to the cardiovascular impact of androgenic anabolic steroids (AAS) is focused on a particular direction. Though contradictions exist in certain areas most of the literature point out the negative impact on the cardiovascular system of athletes, young and adult. The contradictions might be due to factors such as route, type and dose of administration of AAS. Androgenic anabolic steroids, unlike other performing enhancing drugs, are used widely apart from competitive purpose such as recreational use. The health impact on the individuals is therefore more widespread. The evidence is in support of this that highlight that long term abuse of AAS in athletes increases different cardiovascular risks. The most common routes of alterations in the cardiovascular system are by the adverse changes in diastolic and endothelial functions. The most commonly suffered effects are thrombotic risks and blood pressure changes. Since research is not conclusive at this point of time, there is an urgent need of carrying out more rigorous studies in this field. Case study evidence along with end-point data are needed in future for coming to a distinct conclusion in this area. Research efforts must be based on the limitations of methodologies considered in existing research. In terms of practice, there is an urgent need of raising the awareness level of athletes regarding the deleterious impact of anabolic steroids. Key stakeholders are to come forward and work collaboratively for implementing education campaign strategies. In a nutshell, health impact of anabolic steroids on athletes demands much attention at the earliest.

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