Anabolic Androgenic Steroid Use Prevalence, Knowledge, and Practice Among Male Athletes in Eastern Province of Saudi Arabia

Background: Anabolic androgenic steroids (AAS) are synthetic testosterone like hormones. AAS usage by athletes has increased dramatically over the past decade.
Material and Methods: This study was designed to examine the prevalence, attitude and awareness of AAS abuse among athletes n the Eastern province of Saud Arabia. This was a cross-sectional survey that was conducted among male athletes attending twenty fitness centres in the Eastern Province. It was done during the period from April to August, 2018.
Results: A total of 573 questionnaires were distributed but only 503 participants were included n the final analysis. The frequency of AAS use was 17.69%. The man reason for AAS use was muscle building (68.54%). The man source of AAS was the coaches. 56.18% of the users recognize the harmful effects of AAS. The most commonly used oral AAS form was oxandrolone (61.80%). The most commonly used substance for post cycle therapy was Tamoxifen citrate n 67.42% of the users.
Conclusions: 17.69% of the participants use AAS. Coaches were the man source for AAS. In our study, around half of the gym users have inadequate knowledge about AAS and ts harmful effects. More regulation laws and educational programs are needed.


INTRODUCTION
Performance-enhancing drugs (PED) usage dating back to 776 BC when it was used by Greek and Roman athletes. They used mixtures of wine, herbs along with special plants to win their sports. Different plants were used because of their analgesic effect and enhancing endurance. The first time to use male hormones was in the 1950s by the Soviet Olympic team (1,2).
Anabolic steroids are synthetic substances with testosterone like hormones, but with longer physiological effects in the body. The appropriate term for these compounds is anabolic-androgenic steroids (AAS). "Anabolic" is the dominant action which means building up muscles, while "androgenic" related to sex male characteristics (3). AAS are commonly prescribed for the treatment of male hypogonadism and other conditions that are associated with muscle wasting such as cancer, HIV, malnutrition, renal and hepatic failure (4).
Currently, athletes and others use AAS in supraphysiological doses to boost their performance and to build their muscles. AAS can be taken as oral or intramuscular injection (5,6).
The most commonly used AAS are: Testosterone, Metandienone, Stanazolol, Oxandrolone and others.
Steroids are often used in patterns to lessen the unwanted reactions, or for better anabolic effect. One of these patterns is "cycling" which involves taking multiple doses of steroids over a specific period of time, alternating with drugs free periods. Some combine different types of steroids for a greater anabolic effect and this is called "stacking" (7,8).
Many users often use a pyramid administration schedule "pyramiding", gradually increasing doses during the first half of a cycle before decreasing them in the second half (9,10). In spite of different methods used, no scientific evidence that these patterns could reduce the adverse effects.
Considering the recent spread of AAS use among gym users in the eastern province of Saudi Arabia with the purpose of bodybuilding, there is relatively no enough studies regarding the practice of AAS usage in gym centres of the province. We conducted this study to examine the prevalence, knowledge, and attitude toward AAS usage among male athletes in Eastern Province of Saudi Arabia.

METHODS
This was a cross-sectional survey that was conducted to examine the prevalence, knowledge, practice and attitude toward AAS usage among male gymnasts attending twenty fitness centres in the Eastern Provinces of Saudi Arabia. It was done during the period from April to August, 2018. These fitness centres were located in different areas in the Eastern province including Qatif, Dammam, Saihat, Khobar, Ras Tanura and Al-Hasa. Self-administered as well as online questionnaires, Arabic language, were distributed among gym attendees. A total of 573 questionnaires were distributed. 515 (89.88%) were returned completed. Inclusion criteria were being male, Saudi, older than 15 years and attendees of the selected gyms. Exclusion criteria were being non-Saudi, younger than 15 years, and female.
These questionnaires were created after extensive review of the literature regarding AAS usage. The survey consisted from closed ended questions and multiple response answers. It was divided into three parts: sociodemographic data, type and purpose of using the gym, and the final part questions to assess patterns and practice of AAS use. The study was voluntary and all participants were ensured full confidentiality.
Statistical analysis was performed using IBM SPSS version 21. Standard descriptive and analytics statistics were used to analyse the data. Chi-square test was used to test for significant difference and P-value ≤ 0.05 was considered significant.

RESULTS
A total of 573 questionnaires were distributed. 515 questionnaires (89.88%) were returned completed but only 503 participants were included in the final analysis after exclusion of non-Saudi participants (n=12). 17.69% (n=89) of the participants were AAS users. Table 1 demonstrates sociodemographic data and health status of the analysed sample and were further classified based on current AAS usage.

Description of Gym Utilization among AAS Users in Comparison with Non-Users
The age of the study participants ranging from 15 to more than 45 years. 48.1% (n=242) of the participants in the age group (26-35) years followed by age group (15-25) years 27.4% (n=138). 62.92% (n=56) of the AAS users were in this age group (26-35) years.
Married participants constituted the majority of the sample (63%), but the frequency of AAS use between married participants was around 20% in comparison to single participants (around 14%) which was not statistically significant (P=0.095).
Majority of the Participants 66.2% (n=333) had either university degree or higher education. Forty-six participants (13.8%) of this education level group use AAS and this percentage is lower than users in the lower education level and it was statistically significant (p<0.001).
Almost half of the studied population, 49.1% (n=247) work in private sectors, while 14.3% were unemployed. Although our study showed 57.3% of AAS users were working in the private sector, it does not show statistical significance (P=0.697). Vast majority of the participants (88.9%) have no known medical illness. Monthly income category distribution showed 184 subjects (36.6%) with an average of 5000-1000 Saudi riyals (SR), followed by 135 (26.8%) whose monthly income was less than 5000 SR, and it was not statistically significant (P=0.096).

Duration and Reason for Using the Gym
76.74% of the participants (n=386) admit going to the gym for more than one year. Majority of AAS went to the gym more than one year (94%) and it was statistically significant (P< 0.001). Participants going to the gym for five days or less were 278 (55.27%) and total duration spent at gym more than 1 hour was 324 (64.41%) ( Table 2).
People gave different reasons for going to the gym, muscle building was the main reason in 44.33% (n=223), followed by fitness 32.21% (n=162) and it was statistically significant (P<0.001) ( Table 2).

Patterns, Attitude, and Practice among Anabolic Androgenic Steroid Users
Among AAS users, 66.29% (n= 59) used AAS for more than one year. The main reason for AAS use was muscle building (68.54%) which was statistically significant (P< 0.001) ( Table 4).   The main sources of AAS were from the coaches (55.06%), followed by the internet (16.85%). Cycling pattern (either long or short cycles) was the most pattern between the Majority of the AAS users ( Table 4).
In spite of more than half of AAS users (56.18%) believe that AAS are harmful, only 44.94% underwent medical examination before starting AAS. Majority of AAS users 89.89% (n=80) follow cycling pattern to avoid the complication. 14.61% admitted developing complications with steroid use though types of complications were not specified in the questionnaires) ( Table  5).
Combination (oral and injectable) forms were used by the majority of the AAS users 68.54% (n=61).
Majority of the users used different AAS types either in combination or separately. The most commonly used oral AAS form was; Anavar (oxandrolone) (61.80%), followed by Winstrol (stanozolol) (55.06%), and Dianabol (methandienone) in 52.81% of the participants.
The most used drug for post cycle therapy was Tamoxifen citrate in 67.42% of the users (n=60), followed by Human chorionic gonadotropin-HCG (pregnyl) in 57.30% of the users (n=51).

DISCUSSION
This study examined the Prevalence, knowledge and awareness of anabolic androgenic steroids usage among male athletes in the Eastern Province of Saudi Arabia. In this study, the frequency of AAS users was 17.69% of the participants which is lower that has been reported by similar studies in Saudi Arabia. The frequency of AAS usage was 23.0% in the eastern province, 54.2% in the central region (19) and 24.5% in the western province of Riyadh (20). Our frequency was higher than North region (5.7%) Western region (14.8%). The lowest frequency was in the Southern region (2.3%) (20). A recent cross-sectional survey was carried out among gym users from all the kingdom of Saudi Arabia found the prevalence of AAS use was 9.8%of the participants (19). Other studies in the Middle East showed a higher prevalence of AAS use for example, Jordan (26%) (21), followed by Kuwait (22.7%) (3), and then the UAE (22%) (22). A possible explanation for this difference in prevalence of AAS use might be due to different reasons such as the sample size and the most likely due the possibility of self-underreporting of AAS use.
In spite of the majority of the AAS users (62.92%) were in this age group 26-35 years, the age group was not statically significant in relation to the AAS usage and this similar to the UEA study (22).Though other studies like Riyadh, Jordan, and Kuwait, there was a correlation between the age group and AAS use (3,20,21).
Although the majority of participants are married, there was no significant relationship of AAS use to marital status which was similar to the UEA study (22). On the other hand, other studies such as Althobiti study AAS usage was more between married participants (19).
Our results showed that there was a statistically significant inverse relationship between the use of AAS and level of education (P < 0.001). This relationship was supported by the UEA study (22) and other studies in Saudi Arabia (20,23). A possible explanation is that men with lower level of education go to the gym to build their muscles and boost their physical appearance rather than health and fitness.
As was reported by other studies, our study showed that the majority of the AAS users were employed (20,21). 57.3% of the AAS users were working in the private sectors but still it didn't show statistical significance (P=0.697).
Only 56.18% the AAS users believe that AAS is harmful (though the types of harmful effects were not mentioned) and they insist on using it. No significant difference between AAS    (19,21,22). Almost 90% of the AAS users use cycling pattern to avoid the harmful effects of AAS.
As has been reported by other studies, our study showed that the main reason for AAS use among the AAS users was muscle building (77.53%) and this was statically significant (P< 0.001) (22).
In spite of these AAS are illegal in Saudi Arabia, our participants got these substances by illegal ways. in our survey, the main source was the gym coaches (55.06%) followed by online shopping (16.85%). The main source was inconsistent between studies. for example, some studies reported similar finding as our study (the gym trainers were the main source of AAS) (19,3), while other studies showed the online shopping was the main source (20).
In our survey, majority of users (68.54%), used both oral and injectable AAS forms similar to Kuwait study (3). The most commonly used oral AAS form was; oxandrolone(61.80%) while the most commonly used injectable AAS were Metenolone enanthate (50.56%). This was inconsistent between studies. Some studies found Testosterone was the commonly used AAS between users (19,20).
The most commonly used substance for post cycle therapy was Tamoxifen citrate in 67.42% of the users followed by Human chorionic gonadotropin-HCG (pregnyl) in 57.30% of the users. Substances used in the cycling pattern was not mentioned by other middle east studies.
Almost all AAS users (96.63%) used other hormones, followed by proteins (85.39%) in addition to AAS. Althobiti study reported that the most commonly used other substances were multivitamin/mineral supplements (19,20).
We have some limitations in our study. Females were not included since it is difficult to reach them with the fact that there were no female gyms at the time of the study. Since the use of these substances is illegal, we expect that the AAS use may be underestimated due to self-underreporting. In spite of our study was meant to study the knowledge of the participants, our questionnaires were lacking detailed harmful effects of these substances. I believe that the fact that our study includes AAS patterns used and the types of post cycling therapy considered to be a strength point in our study.

CONCLUSION
Our study reported lower prevalence of AAS among gymnasts in the eastern province in comparison with other studies in Saudi Arabia. This could be due to selfunderreporting of AAS use. Gym coaches were the main source for AAS. In our study, the gym users have inadequate knowledge about AAS and its harmful effects. Oxandrolone was the most commonly used oral AAS. Cycling pattern was the most pattern used by AAS users. The most commonly used substance for post cycle therapy was Tamoxifen citrate.With the increasing numbers of AAS users, organized educational programs are needed to educate the public about the adverse effects of these substances. More restrict regulation are needed for the gyms and gym trainers.