CCPR: Welcome, Dr. Ganson. Tell us about your current work.
Dr. Ganson: I’m an assistant professor at Factor-Inwentash Faculty of Social Work at the University of Toronto. I’ve been focusing my research predominantly on eating disorders and muscle-enhancing behaviors and performance-enhancing substance use among adolescents and young adults.

CCPR: When we talk about performance-enhancing products and substances, what specifically are we referring to?
Dr. Ganson: These products range from readily available over-the-counter creatine monohydrate, whey protein powders, and amino acids to illegal substances like anabolic steroids.

CCPR: What is the scope of the problem?
Dr. Ganson: There are multiple aspects. One is the accessibility factor. Young people can buy many of these legal products at the local pharmacy, grocery store, GNC, or vitamin shop. Another aspect is that similar to vitamins, the FDA doesn’t regulate them and ensure that the products are safe or that they are pure or even contain what they say they do. This obviously can create problems for young people who maybe don’t have the knowledge or wherewithal to think critically about the substances they put in their bodies. They do not know when not to trust the substances, and this can lead to adverse outcomes.

CCPR: How many kids and adolescents are using these products? And how many in the mental health population?
Dr. Ganson: We published a study in 2020 looking at prevalence and correlates of muscle-enhancing behaviors. We looked at 18- to 26-year-olds in the general population and found that upwards of 16% of males had used legal performance-enhancing substances in the past year, such as creatine. For females, it was only about 1%. We found that nearly a third of teen boys were trying to gain weight. Among the clinical population, we particularly see performance-enhancing substance use in men with eating disorders or muscle dysmorphia (Nagata JM et al, Int J Adolesc Med Health 2020. Epub ahead of print).

CCPR: Remind us—what is muscle dysmorphia?
Dr. Ganson: In the DSM-5, it’s a type of body dysmorphic disorder in which the person has an overvalued belief that their musculature is imperfectly formed. It’s a pathological thinking around their bodies. They attempt to change the body to reach an ideal and become more compulsive and wrapped in psychopathology. Use of muscle-enhancing substances is common in these patients because they align with the pathological aspects of those disorders. For example, studies have suggested that use of steroids occurs at higher prevalence among males with muscle dysmorphia (Olivardia R et al, Am J Psychiatry 2000;157(8):1291–1296; Cooper M et al, Int J Eat Disord 2020;53(10):1583–1604).

CCPR: Talk to us about the range of motivations that drive this use.
Dr. Ganson: Athletic performance is a major driver in the general population as well as in youth. Young athletes want to improve their performance and decrease recovery time after exertion. Aside from athletic performance, they’re predominantly used for achieving muscular strength, attempting to alter the body to look muscular, lean, and cut.

CCPR: This kind of substance use isn’t necessarily on the radar of mental health providers.
Dr. Ganson: Correct. Here in Toronto, there was a recent story in the news about the increase in young people calling help lines and needing hospital-level treatment for eating disorders and disordered eating behaviors. For these patients, we have well-researched diagnostic criteria and treatment. However, performance-enhancing substance use is not as well researched or understood. There’s an assumption that these products are safe. Clinicians are not aware of how important it is to really inquire about what kind of substances young people are using and how that may impact their functioning. This is particularly true for boys and men who may not “look” like a traditional eating disorder patient.

CCPR: How do we know when it crosses the line into problem use?
Dr. Ganson: It becomes problematic when it is combined with other behaviors, such as alcohol or polysubstance use. Also, it often occurs amidst other disordered eating and weight control behaviors, like excessive exercise, intermittent fasting, restrictive dieting, etc.

CCPR: Do these drugs threaten physical health as well?
Dr. Ganson: We just published a study looking at whether use of legal performance-enhancing substances prospectively increases cardiovascular disease risks, and we didn’t find significant associations. However, one recent study showed that young people who use these legal substances have more adverse events like going to the hospital or emergency room or even death—compared, for instance, to use of multivitamins, which are generally considered safe (Or F et al, J Adolesc Health 2019;65(4):455–461). The problems may arise when these over-the-counter substances are contaminated or don’t fully describe the contents of the products.

CCPR: Do you have a sense of how many of these products are problematic?
Dr. Ganson: Studies have shown a range of products that are contaminated with banned and dangerous substances. However, consumers often won’t know whether a particular product is toxic at the time of purchase. Another problem is that use of legal performance-enhancing substances can lead to more intense, anabolic-androgenic steroid use, which we found in a recent study. We’ve also shown that legal performance-enhancing substance use can lead to problematic alcohol behavior, like binge drinking and legal issues due to alcohol. These problematic relationships are particularly common among men (Ganson KT et al, Pediatrics 2020;146(3):e20200409).

CCPR: So use of performance enhancers is a gateway process.
Dr. Ganson: Right.

CCPR: Can you talk in more detail about the products that are most commonly used?
Dr. Ganson: Sure—let’s begin with protein supplements, which are quite common. Often, they come in the form of whey protein, which comes from dairy. These products can be in powder form or bars. They are meant to build muscle and lean tissue. They also provide the body with more calories, which will help build muscle mass after workouts. The major risk is from contamination of these products.

CCPR: Is there any evidence that these work?
Dr. Ganson: They can help—after all, they contain calories and protein, so they can help you build muscle mass. However, they are likely not needed if one’s diet already contains enough protein.

CCPR: What about creatine monohydrate? I understand that your study on cardiovascular disease risk factors didn’t find any correlations with use of this product.
Dr. Ganson: Creatine is naturally found in the body. The supplement is meant for increasing muscle mass and improving performance by delaying muscle fatigue. There is science showing it can actually help these things. There is less research on how creatine use impacts young people, but the main concern with creatine is the potential impacts on the kidneys in people with concurrent health problems.

CCPR: What’s Andro?
Dr. Ganson: Andro is short for androstenedione. It is intended to increase the production of testosterone, which of course is meant to increase athletic performance, build muscle, and reduce body fat. This substance is no longer legal and is banned for collegiate and pro athletes.

CCPR: What are the concerns around it?
Dr. Ganson: It can reduce natural testosterone production. Similar to anabolic-androgenic steroids, there are also concerns with cardiovascular, endocrine, psychiatric, and kidney problems (Pope HG et al, Endocr Rev 2014;35(3):341–375).

CCPR: And how about anabolic steroids? Even though they’re illegal, they seem to be ubiquitous within the world of performance enhancement.
Dr. Ganson: They’re probably the most effective means of increasing muscle mass, increasing strength, and increasing muscularity and leanness, though of course they are highly problematic and potentially dangerous. I don’t mean to say everybody who uses legal performance-enhancing substances goes on to use steroids. But there’s certainly a culture within the muscle-building community and performance-enhancing community that believes using steroids is necessary.

CCPR: Is it easy to obtain steroids?
Dr. Ganson: I can’t say yes for sure, but I would assume so—especially in the gym culture of weightlifting and bodybuilding.

CCPR: What amino acids are used?
Dr. Ganson: There are a variety of amino acids, such as hydroxymethyl butyrate (HMB), that are intended to help repair muscle damage or buffer metabolic acidosis resulting from high-intensity workouts. High doses of some amino acids can cause fatty liver disease as well as gout. And again, it may not be only the amino acid that is the problem, but potentially the purity of the contents and an overall constellation of behaviors.

CCPR: Which specific sports communities are more likely to use these substances? And are there are other cultural groups that are more impacted?
Dr. Ganson: Wrestling, football, weightlifting, swimming, and cycling are sports communities where body weight is crucial. You need to have a certain level of strength and/or have a certain body size. Men and boys are more likely to use these substances than women, and sexual minority boys and men are more likely to use these substances than heterosexual men.

CCPR: How do you assess a patient’s use?
Dr. Ganson: Be specific. Ask: “Do you use substances for building muscle or improving athletic performance or exercise performance?” Ask about whey protein, creatine, amino acids, Andro, and steroids. For each one, ask about frequency, dosing patterns, intensity, and purpose. Paint the picture of how and why this person is using these substances. Next, figure out how this relates to the presenting problem and think about how you want to work with the client about changing behavior. Screen for other problems tied to body image. Talk about body image and eating habits, looking for related disorders.

CCPR: Then what?
Dr. Ganson: Provide psychoeducation about the risks involved in using these. If you’re working with minors, parents may need to be involved. Go through the process of getting consent from the youth and provide information to the parent about the substances and the potential hazards. Help parents understand why the teen is using it. What deeper issues need to be addressed?

CCPR: Is there research on such things like motivational interviewing to help these patients? Is there an evidence base?
Dr. Ganson: There’s not a lot there, but motivational interviewing would make sense for the substance use aspects and eating disorder approaches, like cognitive behavioral therapy (CBT), for body image problems. You diminish the need to use some of the substances because you’re resolving the more root issue, which is the muscle or body dysmorphia or any sort of eating disorder. CBT is one of the main treatment modalities for body dysmorphic disorder, exposure-type therapy as well—trying to help people expose themselves to whatever uncomfortable sort of body aspects they’re feeling particularly obsessive about.

CCPR: Tell us more about working with these patients.
Dr. Ganson: Try to get to the crux of why. Why use these substances? What’s the need for improving that performance to a certain level that you feel you can’t attain otherwise? For high school athletes, that may be tied to things like the pressure of getting scholarships—so who’s providing that pressure, and is that pressure necessary? For collegiate athletes, it could be wanting to improve to a certain level to make it into pro sports. Outside of athletics, it could be about body type: Why is it so necessary that you have a certain body type that adheres to a certain ideal? To me, that indicates that there is a larger issue happening that needs to be addressed, whether that be poor self-esteem, not feeling like they fit in, getting bullied, etc. Also, kids in athletics can have a lot of pressure from coaches and parents, and also pressure from themselves to achieve a certain level of status within that sport or within that area.

CCPR: Thank you for your time, Dr. Ganson.