The use of legal performance-enhancing substances (PESs) is common among adolescents, particularly boys.1  Approximately one-third of all youth use creatine, protein powders, or dietary supplements,24  and an even greater proportion of athletes and college students do so.5,6  Although previous studies have correlated legal PES use with future use of illegal PESs,7,8  in a study in this issue of Pediatrics, Ganson et al9  explore a broader role for PESs as a gateway to alcohol and other substance use.

There are 2 key points to recognize when addressing this topic:

  1. “PES” is a misleading term. Most legal supplements marketed for athletic performance enhancement are ineffective at increasing muscle mass or athletic performance beyond what can be achieved through appropriate nutrition and training.1,10  They are not truly performance enhancing.

  2. Many adolescents, both athletes and nonathletes, are using PESs primarily in pursuit of a more muscular appearance, rather than for performance-oriented goals. This recognition has spurred an evolution of terminology, with increasing use of “appearance and PESs” in place of the more traditional PES (which will be used in this commentary).

Ganson et al9  found that alcohol use in adolescent boys correlates with increased legal PES use in young adulthood and is prospectively associated with a variety of problematic alcohol-related behaviors later in adulthood, even after controlling for baseline alcohol use. Female PES users reported higher rates of self-injurious or risky behaviors while under the influence of alcohol compared with nonusers. As the authors point out, these findings lend further credence to the idea that legal PES use is an indicator of potential future alcohol and substance abuse issues and should be integrated into the gateway hypothesis regarding patterns and progression of substance use through adolescence and early adulthood.11  This link between PES use and alcohol-related problems is yet another reason to discourage even legal PES use among adolescents and young adults and suggests that pediatricians should incorporate PES-related questions into their counseling and screening for alcohol and substance use.

In this study, the authors also explore the relationship between muscle dysmorphia (ie, a pathologic preoccupation with muscularity), substance use, and problematic alcohol behaviors. The authors highlight evidence that muscle dysmorphia is associated not only with PES use but with substance use disorders as well.1214  The authors postulate that young men who pursue extreme muscularity tend to conform to more traditional norms of masculinity15  and may be more likely to engage in risk-taking, including alcohol use and other problematic drinking-related behaviors. However, the data in this article are from 1994 to 2008. Since then, there has been significant evolution of desired body type among girls and women, with a number of media outposts claiming “strong is the new skinny.”16  We need updated information on potential changes in more recent trends of PES use by young women and of the impact of these changes on their future risk-taking behavior.

Many families do not understand the distinction between dietary supplements (including PESs) and products sold as food or as over-the-counter medications. These are sold side-by-side on retail shelves and online, but the regulatory and safety profiles of these categories are markedly different. The US Food and Drug Administration oversight of dietary supplements is far looser than for food and medications. There is widespread evidence that many over-the-counter dietary supplements lack stated ingredients, contain unlabeled ingredients (including potential allergens), or are contaminated with impurities or illegal or dangerous substances, such as steroids and stimulants,1719  In 2015, the New York Attorney General found only 25% of tested dietary supplements contained ingredients consistent with the label.20  Because of the unknown composition of these substances, users are at risk for suffering from side effects or harmful drug-drug interactions.21  In fact, thousands of people visit emergency departments each year because of adverse effects of dietary supplements.10 

Ganson et al9  call for legislation that would provide greater oversight of and restrict access to legal PES use by adolescents. However, the current political climate in the United States would seem to make these changes unlikely in the near future. Therefore, it is imperative that pediatricians are proactive in counseling patients and caregivers against PES use. This is particularly crucial in young athletes and those with muscle dysmorphia because these populations are more likely to be drawn to PESs and have a subsequent risk of alcohol-related problems later in life. Young athletes already report an earlier age of initial intoxication and are more likely to drink alcohol, binge drink, and drive drunk than their peers.22  With the findings of this study, Ganson et al9  add additional evidence that this population is at risk for alcohol-related morbidity and addressing PES use may be an additional preventive measure that may be helpful in minimizing this risk. For pediatricians uncomfortable with initiating discussions on PES use with their patients, an American Academy of Pediatrics–supported role-play simulation is available.23 

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-0409.

PES

performance-enhancing substance

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.