EPHEDRA USE IN A SELECT GROUP OF ADOLESCENT ATHLETES
1Case Western Reserve University and MetroHealth Medical Center,
2Mayo Clinic College of Medicine, Mayo Sports Medicine Center, USA
06 April 2006
Journal of Sports Science and Medicine (2006) 5, 407 - 414
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|Ephedra-containing dietary supplements are consumed to improve
sports performace, but may carry risks of cardiac and neurological
adverse events. Little is known of their use by young athletes. Our
aim was to determine the prevalence and patterns of ephedra use among
high school athletes. An anonymous survey was performed in Rochester,
Minnesota on high school athletes who participated in fall sports
during 2003-04. Parental consent was obtained for athletes under age
18 years. Surveys were distributed at preparticipation examinations
and in- school survey stations. The response rate to the survey was
68.2%, or 311 respondents out of a possible 456 with consent (or 26%
of all 1197 athletes eligible prior to the consent process). Seven
of 311 (2.3%) respondents used dietary supplements containing ephedra.
Only one of seven users (14.3%) knew that the supplements they used
contained ephedra. Ephedra use was more common in boys (five) than
girls (two). Ephedra use was only found in 17 and 18-year-olds. The
most common sports among ephedra users were football, track and field,
and weightlifting. This study suggests that Ephedra use was infrequent
among the young athletes in this population. However, ephedra users
were generally unaware that the dietary supplements they consumed
contained ephedra. Users were more likely to participate in football,
track and field, and weightlifting. Ephedra users were likely to obtain
supplements from their peers, and were largely uninformed of the content
of their supplements.
WORDS: Ephedrine, sports, supplements, performance enhancement,
dietary supplements were thought to be gaining popularity in the
United States until the Food and Drug Administration (FDA) announced
the ban on their sale in December of 2003 (FDA, 2004;
The ban went into effect in April of 2004, but just one year later
was over-ruled by a federal court (Thiessen, 2005).
As of December 2005, ephedra has yet to return to the retail market
in the U.S., but internet sales have started again. In addition,
athletes may also be able to purchase ephedra in other countries,
or in the form of traditional Eastern medicines, which were not
covered in the ban. Little evidence exists on the use of ephedra
by adolescent athletes, but they are known to be regular consumers
of ergogenic aids and nutritional supplements of all kinds (Massad,
Ray et al., 2001;
Smith and Dahm, 2000;
Sobal and Marquart, 1994).
Ephedra alkaloid stimulants are derived from the plant genus ephedra
(also known as ma huang). The ergogenic effects of ephedra are similar
to ephedrine, and include increased energy, time to exhaustion,
power output, running speed, and weight loss (Bell et al., 2002;
Hardy et al., 2003:
Jacobs et al., 2003;
Pittler and Ernst, 2004).
Adverse effects, however, may include nervousness, tachycardia,
insomnia, psychosis, nephrolithiasis, hypertension, seizures, myocardial
infarction, stroke, and death (Andraws, 2005;
Maglione et al., 2005).
A growing number of case reports of these adverse effects are appearing
in the medical literature (Bent et al., 2003;
Chen et al., 2004;
Myers et al., 1999;
The relative incidence of adverse events is unknown, but is suspected
to be higher than currently documented due to underreporting (Haller
and Benowitz, 2000; Perotta, 1996). Considerable debate continues on the safety of ephedra.
Our objective was to examine patterns and prevalence of ephedra
usage by high school aged athletes in Rochester, Minnesota. All
three public high schools in Rochester, Minnesota were surveyed.
Their combined enrollment for grades 9-12 was 5,557 students in
2004, with a graduation rate of 90%. The community is a mid-sized
city of approximately 100,000 residents, and is 120 km from the
nearest large city (Minneapolis). The population served by the public
schools is primarily suburban, with a small percentage (less than
20%) of rural and urban children.
This is, to the best of our knowledge, the first epidemiological
study of ephedra use in a population of adolescent athletes. We
hypothesized that ephedra would be used by small numbers of athletes.
Due to its purported ergogenic effects, we suspected that it would
be used more commonly in sports requiring high levels of sustained
energy expenditure (running, swimming, soccer), and those in which
weight loss is emphasized (wrestling or gymnastics).
This study was an anonymous survey of high school
athletes who participated in the fall sports season in 2003. The
study was approved by the Institutional Review Board of our institution,
who mandated parental consent in this study. The surveys were first
distributed at our sports medicine center's annual preparticipation
examinations (PPEs) in August of 2003, and subsequently distributed
directly to athletes during the 2003-2004 school years at the area
public high schools. Parental consent was obtained (for athletes
under age 18) in person for the PPEs, and by mail otherwise. Parents
who did not respond to the initial mailing were sent a second request.
To minimize possible biases, athletes and coaches were not informed
in advance of the plans for the survey. Athletes gave personal written
assent at the time of the survey.
Surveys were administered in the schools by two of the study investigators.
At the first two schools, announcements were made for the students
to report to the survey area during their free periods for a mandatory
meeting with researchers. The third school had more strict rules
for student's freedom to roam through the school; therefore surveys
were distributed directly to the students' desks during their free
periods. In all cases, students were separated from school personnel
and coaches, and were given the right to decline the survey. Responses
were collected anonymously in sealed boxes. Due to the anonymous
nature of the study, we could not determine which students completed
the survey. No identifying marks were allowed on the survey instrument,
and we were not permitted to record which athletes declined the
survey, therefore a second attempt to reach missing athletes was
Athletes provided demographics, including all sports they played.
They reviewed a list of supplements, including all ephedra-containing
products available at local vendors and many other sources (Table
1). The selection items "creatine", "protein",
"ephedra", "ephedrine", and "other"
were also included on the list, without additional "brand names".
Athletes were instructed to select those supplements used in the
past 12 months (this time period was prior to the FDA ban). For
each supplement, they were asked to provide the following information:
average frequency of use (rarely =less than once per week, weekly,
daily), dosage (if known), source of information (magazine, online,
friends, coach, other) and place of supply (gym, store, online,
friends, coach, other). They were also asked if they perceived a
benefit or had side effects from the supplement. In a separate question,
they were asked if any of the supplements they used contained ephedra.
Survey answers were managed with a standard statistical spreadsheet
program. When a supplement was written into the "other"
category, its content was verified prior to categorization. Differences
between the median ages for the groups were evaluated using the
Wilcoxon Rank Sum test. For determination of gender differences,
the Fisher's Exact Test was applied. For analysis of patterns of
use, and sports played, descriptive statistics alone were used.
Parental and athlete consent
At the PPE, 100 athletes presented with parents, of which 49 agreed
to give consent (49%). For in-school surveys, consent forms were
sent for all fall sports athletes (n = 1197). A total of 397 (33.2%)
parental responses were received in the two mailings, with 307 (77.3%)
consents given. At the time of the survey in the schools, 100 athletes
18 years or older were surveyed. No athlete refused personal consent.
Subjects and supplements used
The total number of athletes eligible for survey at the time of
school survey was 456 (49 from PPE, 307 minors with mailed parental
consent, and 100 students age 18 and over). Of these, a total of
316 eligible participants completed the questionnaire. The remaining
athletes were unable to be located at the time of survey. Five individuals
failed to provide demographic information and therefore were excluded.
None of these five athletes reported ephedra use. A total of 311
subjects (169 males (54.3%) and 142 females (45.7%)) completed the
study yielding a 68.2% response rate (or 26% of the 1197 eligible
athletes prior to the consent process). (see demographics - Table
2). A total of 34 athletes (10.9%) used supplements of any kind.
Ephedra was used by 7 (2.3%) athletes: 5 males and 2 females. The
average age of ephedra users appeared higher than nonusers (17.5
vs. 16.4 years), but the difference was not quite statistically
significant (p = 0.069). However, all ephedra users were age 17
(n = 4, or 6.9% of 17-yr-olds) or 18 (n = 3, or 3.3% of 18-yr-olds).
Protein supplements were used by 26 athletes (8.4%). Creatine was
used by 14 (4.5%), including 12 males and 2 females. Four athletes
took both creatine and ephedra. All four were male American football
Patterns of ephedra use
Although seven athletes reported taking dietary supplement products
that contained ephedra, only one identified the supplement as an
ephedra-containing product. The others identified the supplement
by brand name, but concomitantly indicated that they had not taken
ephedra when asked directly on the questionnaire. Supplements (in
general) were used in 21 different sports. The
seven sports with the highest usage rates are shown in Figures 1
and 2. These include all sports
in which ephedra was used. The type of "weight lifting"
done by athletes was not specified. This is not a school-sponsored
sport, but was reported a sport "also played" by the athletes.
There was no way to verify which type of weight lifting (i.e. power
lifting, "Olympic" lifting, or body-building) was done.
Patterns of use and beliefs about ephedra are shown in Table
3. Ephedra was used most commonly in American football (5 users), and boys
track and field (3 users). One female weightlifter and one girls
track and field athlete used ephedra. Four of seven ephedra users
thought that it improved their performance. Only one user claimed
a side effect from the supplement, but did not report what the side
effect was. Ephedra tended to by used on a rare basis (less than
once per week; 5 of 7 users) or weekly basis (2 of 7). Creatine,
for comparison, was used on a daily basis by forty three percent
of its users.
Acquisition of ephedra
Sources of information about supplements are shown in Table
4. Because some athletes had more than one source, the number
of responses was sometimes greater than the number of athletes who
used each supplement. All results are reported as number of athletes
who obtained information from each source, however. The most common
source of information about supplements was friends of the athletes
for both ephedra and creatine by a large margin (86% and 93% respectively).
The internet was listed as a source of information more commonly
for ephedra than for creatine (19% vs. 11%). Ephedra-containing
supplements were most commonly obtained from friends (47% of responses).
The source of creatine supply, for comparison, was a retail store
(73% of responses). Ephedra-containing supplements were also purchased
from the internet more commonly than creatine (27% vs. 7%).
This report represents the first epidemiological
study of ephedra usage in a population of adolescent athletes. Our
most notable finding was that only one in seven users of ephedra
acknowledged that their dietary supplements actually contained ephedra.
This information has many potential implications: 1) there may be
an increased safety risk if any substance is taken unknowingly,
or in inappropriate dosages. Coaches, parents, athletes, and medical
staff should read labels or seek product information to learn the
content of any supplements used, 2) In drug testing of athletes,
adolescents may be more at risk to test "positive" accidentally
due to unknowingly taking a banned substance, and 3) In future research,
inquiries regarding the use of supplements should include brand
name products, not just the ingredient in question.
Limitations of the study are as follows: 1) Athletes from only one
city were surveyed. It is possible that usage may vary from city
to city or state to state, depending on local trends or access to
supplements. Although numbers were small, we so no apparent differences
among the three schools surveyed 2) The overall response rate 26%
of all eligible athletes is somewhat low, due in large part to the
parental consent mandate (see below). Of the eligible athletes with
parental consent or personal assent, however, the response rate
was good (68%), and a large number of athletes age 18 and over was
able to give personal assent. 3) No comparison was made between
athletes and non-athletes, or those students participating in non-school
sponsored sports. While this was not the aim of our research, this
does raise questions of the true prevalence of ephedra usage. 4)
There is a possibility of false positive and false negative responses
to this survey, as there was no measure to verify content and validity.
To it's credit, however, the survey was designed with the assistance
of our survey research center, and included clear, plainly written
instructions to the participants. 5) No data was collected regarding
the sport-specific positions or events played by ephedra users.
In track and field, for instance, runners may be more likely to
use ephedra for energy gains, while throwing athletes may use creatine
for strength enhancement.
Ephedra usage by young athletes
Ephedra usage in this population is not surprising, as it has been
reported in older populations of older athletes. For example, the
NCAA has detected ephedrine/ephedra in a number of athletes during
routine screenings, and has noted an increase in the frequency of
detection, with eight of 60 (13.3%) of positive test results attributed
to ephedra or ephedrine (NCAA News Staff, 1999). Based on previous research, use of supplements in collegiate
athletes raises the question of use at a younger age (LaBotz and Smith, 1999). We also noted that most users learned about their supplement
from their peers. This highlights the potential usefulness of in-school
or peer-based educational programs about the topic. Finally, a small
percentage of users obtained information about or purchased their
supplement from the internet. This source should be considered in
any future regulation or intervention measures, especially considering
its increasing popularity.
Although the rate of ephedra use in our study appears to be low
(2.3% overall, 6.9% of 17-yr-olds), we are concerned that this may
be an under-estimation of its usage. In particular, as the rate
of creatine usage has been reported to be higher in other high school
populations, we suspect that ephedra use may be more common as well.
The study by McGuine et al. (2001) for example, identified creatine use in 30% (405/1349)
of high school football players in the nearby State of Wisconsin
while our rate was 11.3%. It is also possible that fewer athletes
used ephedra after recent deaths of professional athletes rumored
to be associated with the supplement. It is likely that ephedra
use has declined since the FDA ban. This does not diminish the importance
of our study, however, as ephedra appears to be returning to the
U. S. market, and our findings may be applicable to other supplements.
Finally, even our extensive list of ephedra-containing supplements
may be incomplete. If athletes taking other ephedra-containing supplements
didn't recognize the ingredients (as was the case in six out of
seven athletes in this study) then an under-reporting bias would
be further introduced.
Parental and athlete consent
The requirement for parental consent in this study may have induced
a selection bias. Other research suggests that mandating parental
consent for epidemiological studies may result in an under-reporting
of adverse behaviours (Pokorny, 2001).
We did request waiver of parental consent, but were denied for a
number of reasons, including our institutional review board's ruling
that ephedra was a "dangerous" substance. In support of
our findings, however, we were able to study a number of athletes
in the population (age 18 years and older), without parental consent.
We were also fortunate to have a 100% consent rate from the athletes
who presented for the survey. Further study on the issue of parental
consent for research in minor athletes would be worthwhile, as this
continues to be controversial (Santelli, 1995).
Ephedra was used by a small number of high school
athletes in this select population. These athletes were unlikely
to know that their supplements contained ephedra. Athletes typically
obtain ephedra from peers, and are unlikely to know the dosage taken.
Users tend to be older than non-users and are more likely to participate
in American football, track and field, and weight lifting. Future
study is warranted to determine the prevalence of use in the United
States after the over-ruling of the FDA ban, and its use in other
athletic populations. Without such data, it will be difficult to
estimate the frequency of adverse events, or to provide counseling
regarding its use.
We would like to thank
Miss Brianna J. Crawford and Miss Erin J. Effle for their assistance
with data management, Mr Duane M. Ilstrup for statistical support,
and the Athletic Directors for each of the Rochester, MN public
schools for their support.
Ephedra is an herbal stimulant used as an ergogenic aide.
ephedra users most commonly obtain it from their friends.
athletes are likely to take ephedra unknowningly.
Michael P. SCHAEFER
Employment: Assistant Professor of PM&R at Case Western
Reserve University and MetroHealth Medical Center, and a former
Attending Physician and graduate of the Mayo Clinic Graduate
School of Medicine.
Research interests: Clinical sports medicine, nutritional
supplements, and musculoskeletal rehabilitation
Employment: Associate Professor of Physical Medicine and
Rehabilitation at the Mayo Clinic College of Medicine.
Research interests: Use of nutritional supplements, shoulder
and elbow injuries, golf injuries, and diagnostic and therapeutic
Employment: Assistant Professor of Orthopedics at the Mayo
Clinic College of Medicine.
Research interests: Women's issues athletics, orthopedic
sports medicine and nutritional supplements
Employment: A counseling psychologist and research coordinator
at the Mayo Clinic Sports Medicine Center.
Research interests: Clinical sports psychology and nutritional