Was Lance Armstrong lying to Oprah Winfrey?

To quote Gordon Farquhar at the BBC:

http://www.bbc.co.uk/sport/0/cycling/21085940

“Armstrong is an accomplished liar. Serious questions remain over the analysis of blood tests taken from Armstrong in 2009 and 2010 following his comeback. Usada says the tests "built a compelling argument consistent with blood doping. Armstrong has not yet admitted to doping on his return to the sport in 2009. Wada president John Fahey doesn't buy Armstrong's assertion that he was clean during his comeback. Tests were carried out on 38 of his blood samples from that time by the Australian Institute of Sport, which concluded that the chances of the blood values recorded occurring naturally were one in a million. The tests were not part of the recognised anti-doping programme, but Fahey wants Armstrong under oath again on this”.

I couldn’t agree more. In his Oprah interview Armstrong makes the case that the sport is cleaner and it is harder to cheat because of out-of-competition testing and the athlete biological passport. Yet as I have said on this blog before, his blood samples in 2009 and 2010 were highly suspicious. The data that makes them suspicious (plasma volume, reticulocyte count) are the same that would raise warnings on the passport. This is the basis for the “one in a million” comment from Prof. Chris Gore mentioned in the above quote.

If Lance Armstrong was not lying to Oprah and he was in fact clean in 2009 and 2010, it calls into question the whole biological passport system. The only resolution is for Armstrong to work with UCI, WADA and Chris Gore to explore how such anomalous blood results could have occurred by chance. As some have suggested on my blog (step forward “anonymous”) perhaps he used hypoxic tents in Italy? If we don’t know how this happened there could be a whole lot of “false positive” passport results and athletes could be accused unnecessarily.

Or perhaps Armstrong was just lying? It has been known

Lance Armstrong on the Oprah Winfrey Show

I can’t wait to hear the 112 questions Oprah tried to ask Lance Armstrong. None of them I think are likely to be the ones scientists want to know (or at least this scientist). So here are my alternative questions?

1               Who designed his doping program (though we can all guess this)?

2               Was his program more sophisticated than his rivals?

3               How was it evidence-based? For example was the performance titrated individually versus body haemoglobin or was there just an optimum hemoglobin concentration that the all the climbers in the team aimed for?

4               We know how blood doping worked. But what benefit did he feel he get from steroids (both corticoid and anabolic)? How was this evidence-based?

5               Did some people get doped and still not perform better?

6               Was the Armstrong phenomenon in part that he was ideally suited to being doped i.e. was blood oxygen content more rate limiting for his performance than his rivals?

Oprah won’t ask these of course (and to be fair they are not really prime time TV questions)

But she might ask these two

1                                 Would he still have win seven Tours if nobody was doping?

2                                 Would he still have win seven Tours if everyone had the same doping team?

On a non-science level I hope he doesn’t leave any grey areas about his moral standing. He should come as clean as Landis and Hamilton. I won’t hold my breath, however. 

Sports personality of the year: what’s it got to do with drugs in sport?

Athletes as role models

Tonight in Britain the BBC will host a veritable orgy of UK sport self-aggrandizement as it celebrates its Sports Personality of the Year Award. And why not? 2012 has been a year like no other. The short list has been extended from ten to twelve [1] and includes eleven Olympic and Paralympic gold medallists (many with more than one gold) the Tour de France winner, US open tennis champion and the US PGA golf champion who heads the current money list in both Europe and the USA. The complete short list is: Nicola Adams, Ben Ainslie, Jessica Ennis, Mo Farah, Katherine Grainger, Sir Chris Hoy, Rory McIlroy, Andy Murray, Ellie Simmonds, Sarah Storey, David Weir and Bradley Wiggins. Double Olympic gold medallists Charlotte Dujardin and Laura Trott didn’t even make this top 12.

So there is no doubt we have an elite set of athletes who are role models for being single minded in achieving success. And I should add coaches as the UK cycling supremo David Brailsford could walk into a top job in any FTSE 100 company given his organizational and motivational skills.

But should these athletes be role models in life as well as in sport? During the summer here was much grumbling about the lifestyle and uncouth nature of premiership footballers compared to our Olympic heroes. Indeed even the crowds were different as I noted when I watched Team GB playing football at Wembley compared to England. Watching football at the Olympics was an altogether more wholesome experience, not least because of the much higher proportion of women and children in the crowd. The feeling was more good-natured and less tribal – much more like watching an “American” football or baseball match [2].

We should be careful not to view this all through middle class rose-tinted spectacles. Some of my best experiences of watching football have been standing in the terraces at a lower league English football match when your side scores the winning goal and the stadium literally rocks. And UK Olympic gold medallists are far more likely to come from privileged private school backgrounds than their premiership football counterparts [3].

Yet the question remains should we look up to our elite sports people as role models for life as well as sports performance? I have always thought we should take athletes on their own terms, warts and all. If they play or run fast, I don’t care about their personal life or habits. Ryan Giggs may have an unsavoury love life but, even though he plays football for Manchester United, I can still admire him as an athlete.

How does this relate to drugs in sport? Well in order to be banned a doping agent or method needs to fail two out of three tests. The three tests are that it is: performance enhancing; harmful to health; and against the “spirit of sport”. The latter is defined by the World Anti Doping Agency” as the celebration of the human spirit, body and mind, characterized by values such as: Ethics, fair play and honesty; Health; Excellence in performance; Character and education; Fun and joy; Teamwork; Dedication and commitment; Respect for rules and laws; Respect for self and other Participants; Courage; Community and solidarity. Motherhood and apple pie were surprisingly left of this list, but you can get the drift of this message.

Recreational drugs are banned in many sports even though there is no good data that they are performance enhancing (cocaine springs to mind). But they are still harmful to health and against the spirit of sport. Two strikes means you are out. Giving evidence to the UK House of Commons Science and Technology Committee in 2006 the then UK Minister of Sport Richard Caborn said that he would wish to “look very seriously” at the Prohibited List with a view to removing what he believes are “social drugs”. The Minister felt that WADA’s role was to root out cheats in sport and to stop athletes using drugs which enhance performance, rather than to be in the “business of policing society” [4].

What do people think today? I assumed that Richard Caborn’s views would be commonplace. I was therefore surprised when I asked the question of to my University of Essex undergraduate students. They were strongly of the opinion that elite athletes are role models and therefore if they are caught taking recreational drugs they should be banned from sport. Of course it is possible that those who spoke up in the lecture were the most anti-drug, but I didn’t get that impression. It seems the youth of today do really care about their sportspeople as more than just athletic machines. They want them to be great people as well as great athletes. Not for the first time in my 50^th decade, I felt a bit out-of-touch with young people and somewhat humbled by their idealism.

Notes

[1]  http://www.bbc.co.uk/sport/0/sports-personality/19886193

[2] I should note in passing that there was nothing quite so wholesome about some of the football. Senegal were one of the dirtiest teams I have ever watched. It was a bit like watching Holland play Spain in the last world cup final - the most brutal tackles you would see in a Sunday pub league intermixed with the silky skills of a top premiership club.

[3]        http://www.guardian.co.uk/education/2012/aug/13/olympics-2012-gb-medallists-private-schooling

[4]        http://www.publications.parliament.uk/pa/cm200607/cmselect/cmsctech/67/67.pdf

Taking drugs in the cause of public engagement in science

A prophet is welcome in his own country! This is just a belated note to thank everyone who turned up at the Café Scientifique event in Colchester a couple of weeks ago. Café Scientifique run great popular science events and it was brilliant to give a talk in my current hometown after traipsing all over the country promoting the book. And what better place than the Love Bistro? As usual a great array of questions  - though it is always a danger when they let the clinicians in as they think they know more than the rest of us (OK in many cases they actually do, but I like to keep an aura of my own scientific mystique). Anyway I advertised live performance enhancing drug taking though pseudoephedrine, caffeine and alcohol may not have been quite what the audience was expecting. Still my demonstration of blood doping using red wine seemed to go down well. Next time I’ll inject, but drinking is so much more fun…..

So what about the science? Well taking all those drugs led me to think I really have got to see if they work. One of my undergraduate students is doing a meta-analysis on the performance benefits – or not – of pseudoephedrine, the stimulant that was banned, unbanned and then re-banned by WADA. The scientific reviews I cited in my book were not convinced of its efficacy; let’s see if the most recent data is more convincing. I’ll report back when I have the data. 

Should veteran age grouper athletes be allowed to take testosterone?

I was recently asked to give an interview to a US web page – a link to the podcast can be found at the bottom of this blog [1]. In part their interest was in a scientific view about testosterone doping in veteran athletes. A triathlete – Kevin Moats – had failed a drug test for testosterone. Moats claimed that he was taking the drug on his doctor’s advice due to his low testosterone levels. However, he had no therapeutic use exemption (TUE) so was banned.

This is an area I should have perhaps covered more in my book. Although there is no general clinical agreement on when – or indeed if - testosterone therapy should be given to older men, it is clear that in many countries reporting to your doctor with fatigue, depression and low sex drive can get you a prescription for anabolic steroids with relative ease.

This raises a number of issues:

1 Is there a clinical need for testosterone replacement therapy?

In females there is a clear menopause and hormone replacement therapy is a commonly accepted treatment to alleviate some of the associated symptoms (though the risk/reward ratio of such a therapy is controversial). In males there is no clear menopause. It is true that sex hormone levels decline with age. However, there is no clear indication that this is associated with adverse symptoms, not whether there can be reversed by testosterone administration.  But there is clear anecdotal evidence of benefit. To get to the bottom of this, the US National Institute on Aging has recently funded a large-scale clinical trial (the T-Trial) involving 800 men age 65 and older with low testosterone levels [2].

So to answer the first question testosterone may be of clinical benefit as people get older, but the evidence is not yet clear cut.

2 Should athletes on testosterone therapy be given a therapeutic use exemption (TUE)?

In sports drug testing the absolute testosterone levels are not measured, as urinary excretion of the drug is so variable. Instead the ratio of Testosterone:Epitestosterone in the urine is measured (epitestosterone is an inactive form of the hormone that does not increase muscle mass). This ratio is normally close to 1. Steroid doping will increase the T levels, but not the E. If the T/E ratio then rises above 4 it triggers a positive test. Carbon isotope ratio (CIR) testing can then confirm whether artificial testosterone had been used (as the synthetic drug is synthesized from plant sources it behaves differently to normal human testosterone in this test). Someone on testosterone replacement therapy could therefore easily trigger a positive test even if his absolute testosterone levels were not abnormally high as he would have a high T/E ratio due to the presence of the synthetic plant-derived testosterone.

So surely a TUE would be justified? Maybe so, but there are two good arguments against this. First if raising your testosterone levels to “normal” means raising them to those of a young person, is not this in itself cheating compared to rival veteran athletes who choose not to supplement? In which case allowing a TUE might put pressure on all athletes to supplement in order to compete on a level playing field. Second, once you have the exemption it would be a simple matter to increase the amount of steroids you take. This could give rise to supraphysiological levels of anabolic steroids of the kind used  - and abused - by younger athletes. Yet the doctor’s note would forgive all. I suspect this second pragmatic, practical reason is why TUE’s in this field will be rarely – if ever – permitted.

3 Can older athletes raise their testosterone levels without failing a doping test?

A quick look at any nutritional web site will reveal a whole host of products that claim to be able to increase testosterone levels “naturally”. Maca and Tribulus are two of those in current vogue. It is true that increasing the body’s own metabolic pathways should not fall foul of the testers. However, there are two problems with this approach. First athletes should beware as many supplements contain other banned substances, either by accident or design. But secondly, and equally as important, there is no evidence that these products have any affect at all on testosterone levels. Anecdotal evidence and personal testaments are no substitute for scientific studies, which invariably show negative results [3, 4].

So to summarize: we don’t know whether testosterone is clinically necessary, using it will get you banned and there are no validated supplements that can help. As a 49-year-old fatigued male with a somewhat lower sex drive than I had as a teenager, I am tempted to say “It happens to us all as we get older: just get over it and enjoy your sport”. Or of course take the therapy and compete for fun.

(these sentiments are not of course aimed at those with very low testosterone levels caused by pathology or injury, where therapy is clearly necessary and important).

[1] Doping in Amateur Sports: http://www.bengreenfieldfitness.com/2012/11/doping-in-amateur-sports/

[2] The Testosterone Trial - Can testosterone treatment improve unwanted effects of aging in older men?  http://rt5.cceb.upenn.edu/portal/page/portal/T-Trial%20Portal/T-TrialPublicPageMain

[3         Srikugan, L., Sankaralingam, A., and McGowan, B. (2011) First case report of testosterone assay-interference in a female taking maca (Lepidium meyenii), BMJ case reports 2011

[4]        Gauthaman, K., and Ganesan, A. P. (2008) The hormonal effects of Tribulus terrestris and its role in the management of male erectile dysfunction--an evaluation using primates, rabbit and rat, Phytomedicine : international journal of phytotherapy and phytopharmacology 15, 44-54.