Image and performance-enhancing drugs (IPEDs), such as steroids and human growth hormone, can harm the heart – and it isn’t just elite bodybuilders who are at risk.
With a growing number of everyday gym-goers taking these drugs to improve their fitness or enhance their appearance, what was once a niche issue in competitive sports is quickly becoming a wider public health concern.
For decades, bodybuilders and athletes have used IPEDs including anabolic steroids, human growth hormone, peptides and selective androgen receptor modulators (SARMs), to increase muscle size, boost strength and improve physical appearance.
But in recent years, the number of regular gym-goers using IPEDs has become a growing concern. Estimates from 2014 suggested around 3% of regular gym-goers globally used IPEDs. These figures are now more than ten years old and probably underestimate current use.
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Although the demand to have an unrealistic, idealised body has existed for generations, social media has amplified these pressures. Social media has also made it easier to access IPEDs. These factors might help to explain why people who use apps such as TikTok and Instagram are more likely to use anabolic steroids.
But while social media may be normalising the use of IPEDs to achieve the perfect physique and peak fitness, it’s important gym-goers know about the serious costs these drugs can have on heart health.
Research from Italy shows that competitive male bodybuilders who use IPEDs have a ten-times higher risk of sudden cardiac death compared with athletes who don’t use performance-enhancing drugs.
Studies have shown that female athletes who use IPEDs also have a higher risk of sudden cardiac death compared to non-users – though their risk is slightly (7%) lower compared to men.
These deaths are linked to a range of heart conditions caused or worsened by IPED use. These include cardiomyopathy (disease of the heart muscle), myocardial fibrosis (scarring of the heart), abnormal thickening of the heart wall, early-onset coronary artery disease, heart rhythm disturbances and stroke.
Research shows anabolic steroids can alter cell signalling pathways involved in heart growth and remodelling, disrupt hormonal regulation and increase blood pressure. Steroids can also cause adverse changes in lipid (fat) levels that cause plaques (fatty deposits) to form in the arteries.
Together, these changes weaken the heart and make it less efficient at supplying the body with blood. Even in people who appear fit, this hidden damage can leave the heart more vulnerable to failure, rhythm problems and sudden cardiac events.
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These findings are deeply concerning – not just for elite bodybuilders, but for regular gym users who may be taking unregulated drugs with little awareness of the risks.
Heart changes
At Liverpool John Moores University, we have spent the past six years studying heart health in people who use IPEDs. Our research looked at around 100 users, most in their early 30s, ranging from elite bodybuilders to recreational gym users. These users were then compared against non-users.
We used electrocardiography (ECG), which records the heart’s electrical activity, and echocardiography, an ultrasound scan of the heart. These tools allowed us to assess all four chambers of the heart and detect early signs of heart problems that may not yet be causing symptoms.
We found that IPED users had a larger and heavier left ventricle (the main pumping chamber of the heart). This was due to having a bigger cavity and thicker heart muscle. Notably, these differences in heart shape and structure still existed, even after accounting for increased body size.
Importantly, these changes are linked to reduced heart function. Using advanced imaging techniques, we were then able to show subtle but significant impairments in how the left ventricle contracted and relaxed.
Our research has also identified increased stiffness of the left atrium (the chamber that receives blood from the lungs). This feature is often only seen in the early stages of heart disease.
Similar harmful effects are also seen on the right side of the heart, which plays a key role in pumping blood to the lungs – showing that IPED use affects all chambers of the heart.
Most of the participants in our studies had used a median weekly dose of 1108mg for around seven years – a dose consistent with the typical doses used by the bodybuilding community. The higher the dose and the longer these drugs are used are linked with more negative changes in the heart.
The next step of our research is to examine how a typical four to five month drug “cycle” – a period where users progressively increase the dose and number of substances they use to reach a peak in physique or dose – affects heart structure and function. We especially want to know how it affects the way the heart responds during exercise.
We also plan to look at female IPED users, a group that has largely been overlooked in previous research.
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Reducing risk starts with stopping IPED use – or avoiding them to begin with. While this is the most effective way to reduce risk, harm-reduction approaches such as reducing dose, avoiding black-market drugs, addressing psychological drivers of use, and regular heart screening may help limit damage and encourage safer choices.
However, we still know very little about whether heart damage improves after cessation, particularly after years of use. To address this, our research group plans to follow a group of users for the next ten to 20 years.
With more than one million IPED users in the UK, this is rapidly becoming a significant public health issue. Raising awareness of the harms of IPED use is critical.
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