Nutrition, Pharmacological and Training Strategies Adopted by Six Bodybuilders: Case Report and Critical Review.

The purpose of this study was to report and analyze the practices adopted by bodybuilders in light of scientific evidence and to propose evidence-based alternatives. Six (four male and two female) bodybuilders and their coaches were directly interviewed. According to the reports, the quantity of anabolic steroids used by the men was 500-750 mg/week during the bulking phase and 720-1160 mg during the cutting phase. The values for women were 400 and 740 mg, respectively. The participants also used ephedrine and hydrochlorothiazide during the cutting phase. Resistance training was designed to train each muscle once per week and all participants performed aerobic exercise in the fasted state in order to reduce body fat. During the bulking phase, bodybuilders ingested ~2.5 g of protein/kg of body weight. During the cutting phase, protein ingestion increased to ~3 g/kg and carbohydrate ingestion decreased by 10-20%. During all phases, fat ingestion corresponded to ~15% of the calories ingested. The supplements used were whey protein, chromium picolinate, omega 3 fatty acids, branched chain amino acids, poly-vitamins, glutamine and caffeine. The men also used creatine in the bulking phase. In general, the participants gained large amounts of fat-free mass during the bulking phase; however, much of that fat-free mass was lost during the cutting phase along with fat mass. Based on our analysis, we recommend an evidence-based approach by people involved in bodybuilding, with the adoption of a more balanced and less artificial diet. One important alert should be given for the combined use of anabolic steroids and stimulants, since both are independently associated with serious cardiovascular events. A special focus should be given to revisiting resistance training and avoiding fasted cardio in order to decrease the reliance on drugs and thus preserve bodybuilders' health and integrity.

Competing interest statement

Conflict of Interest

The authors submit no conflict of interest regarding the publication of this article.

Bodybuilding differs from most sports because the participant’s physique, rather than athletic performance, is judged. The ultimate goal of bodybuilders is to achieve a large muscle mass that is defined and symmetrical. Often their training periods are divided into bulking and cutting phases. The latter is emphasized in the weeks before the competition and is oriented for a decrease in body fat, while the first comprises the noncompetitive phase and is oriented for increasing muscle mass. To achieve their purposes, bodybuilders utilize a combination of resistance training, extreme diets, nutritional supplements and drugs.[1-3]. However, many of these strategies are based on common sense, rather than on scientific evidence, which may impose considerable health risks with no proven benefits.[4] Many bodybuilding practices came to light due to reported cases of deaths, injuries and/or serious health problems occurring in bodybuilders.[5-10] However, analysis of individual cases in clinical settings usually lacks important details. It is interesting to note that it has been reported that bodybuilders refuse to be treated and/or do not comply with medical recommendations, even in the presence of diagnosed health problems,[5,6] probably because they are convinced that their current practices are vital for their success However, many practices may not be necessary or can be even counterproductive. Therefore, employing a critical view of these practices and proposing an evidence-based approach may help bodybuilders to preserve their health while still achieving the desired results. The purpose of this study is to report and analyze the practices adopted by six bodybuilders (two male Bodybuilders, two Men’s Physique competitors and two women competing in the Wellness category) in the light of scientific evidence in order to offer a critical view and propose evidence-based alternatives for people involved or willing to be involved with bodybuilding.

Material and Methods

Experimental procedures

Since this is an observational study, the researchers were not responsible for the interventions. All data were provided by the participants and their coaches after the competition. Bodybuilders and their coaches were requested to describe in detail all their practices (training, diet, nutritional supplements and pharmacological agents). When any doubt arose, competitors/coaches were directly contacted to give further details. This procedure was facilitated by the fact that some authors of the present study were involved with bodybuilding, either as coaches or athletes.

Participants

All participants were amateur bodybuilders competing according to the standards of the International Federation of Bodybuilding and Fitness (IFBB). The participants were two male Bodybuilders in the same category (MB1 and MB2), two Men’s Physique competitors belonging to the same category (MP1 and MP2) and two women competing in different Wellness categories (W1 and W2). MB1 was 26 years old, had 10 years of experience with resistance training and was in his second competition. The other participants were in their first competitions; MB2 was 28 years old and had 10 years of experience with resistance training; MP1 and MP2 had 22 and 19 years, respectively, and both had 2 years of experience with resistance training. W1 was 24 years old and had 4 years of experience with resistance training. W2 was 35 years old with 11 years of resistance training experience. All participants were among the best of their categories in the competition analyzed. MB1 won his category and was overall champion. MB2 was second place. W1 placed second in her category and W2 placed third. MP1 and MP2 were fifth and third, respectively. Participants were fully informed of the study aims and read and signed an informed consent form authorizing the use of their data. The study was approved by an Institutional Ethics Committee and conformed to the principles outlined in the Declaration of Helsinki.

Anthropometry and body composition

Body weight was determined with an electronic scale to the nearest 0.1 kg with subjects barefoot and wearing swim suits. Barefoot standing height was measured to the nearest 0.1 cm with a stadiometer. Participants were evaluated for body composition before and after the bulking and cutting phases. Body composition was assessed by an experienced examiner using a whole-body tetrapolar bioimpedance analyzer (Inbody230, Biospace, Seoul, Korea) with an eight-point tetrapolar electrode system. The participants were oriented to stand upright and to grasp the handles of the analyzer, thereby providing contact with eight electrodes (two for each foot and hand). Five segments (right and left arm, trunk, right and left leg) were independently analyzed using two different frequencies (20 and 100 kHz). The input variables included the patients’ age, sex, height and actual body weight. The percentage body fat was computed through the proprietary algorithms, displayed on the analyzer’s control panel and recorded.

All tests were performed in the morning (~8 a.m.). Before anthropometric analysis, resting blood pressure was measured via auscultation by an experienced examiner after the participants had rested for 20 minutes in a sitting position. Heart rate was measured using a Polar A360 (Polar Electro Oy, Oulu, Finland).

Results

Participants were evaluated for body composition before and after the bulking and cutting phases. For each volunteer, the first date refers to the beginning of the bulking phase, the second date is the end of the bulking and beginning of the cutting phase and the third date represents the end of the cutting phase (Table 1). During the bulking phase, participants generally increased fat-free mass without altering fat mass, with the exception of MP2 whose fat-free mass did not change. The most notable increase was in W2, who showed a 20% increase in fat-free mass in only one month. All participants lost large amounts of body fat during the cutting phase, with a larger relative loss being achieved by MB2 and MP1 who dropped their body fat percentage by less than half during this period. However, during the cutting phase, all competitors besides MP1 lost fat-free mass, with the highest loss in MB1 and W1, who lost almost 10% of his fat-free mass. Their training routines are shown in Tables 2, 3 and, 4. The participants aimed to train each muscle group once a week with multiple sets of multi- and single-joint exercises performed to volitional fatigue. During the bulking phase, the male Bodybuilders and Wellness competitors performed sets of 8–12 repetitions with 2–3 minutes of rest between sets. During the cutting phase, the number of repetitions increased to 12–15 and the rest intervals dropped to 45–60 seconds. The participants also increased the time spent in fasted cardio during the cutting phase. Men’s Physique competitors trained with 8–15 repetitions and 50–70 seconds of rest during both the bulking and cutting phases. Regarding pharmacological agents, MB1 and MB2 used 500 mg/week of testosterone enanthate, 200 mg/week of boldenone and 150 mg/week of trenbolone acetate during the bulking phase. During the cutting phase, MB2 used 400 mg/week of testosterone propionate, 200 mg/week of stanozolol and 160 mg/week of oxandrolone during the cutting phase. MB1 used the same combination as MB2 during the cutting phase, but also added 400 mg/week of drostanolone propionate. During the cutting phase there was also the introduction of ephedrine (15–45 mg/day) and hydrochlorothiazide (50–300 mg/day). Both MP1 and MP2 used 500 mg/week of testosterone propionate during the bulking phase. During the cutting phase, they changed to 320 mg/week of testosterone enanthate, 420 mg/week of oxandrolone, 250 mg/day of caffeine, 15 mg/day of ephedrine and 120 mg/day of theophylline. W1 and W2 used 200 mg/week of stanozolol and 200 mg/week of nandrolone decanoate in the bulking phase and 200 mg/week of stanozolol, 100 mg/week of testosterone propionate, 140 mg/week of oxandrolone and 300 mg/week of drostanolone propionate during the cutting phase. They also added ephedrine (15–45 mg/day) and hydrochlorothiazide (50–300 mg/day) during the cutting phase. Nutritional supplements used in the bulking phase were whey protein concentrate, chromium picolinate, omega 3 fatty acids, branched chain amino acids (BCAA), vitamin C, poly-vitamins, glutamine and caffeine for both male Bodybuilders and Wellness participants. Male participants also ingested creatine monohydrate.

Table 1.

Characteristics of the subjects.

	Date (month-day)	Height (cm)	Body Weight (kg)	Fat free mass (kg)	Body fat (%)	Rest systolic blood pressure (mmHg)	Rest diastolic blood pressure (mmHg)	Rest heart rate (bpm)
Male bodybuilder 1	08-11	168.1	82.1	65.9	19.7	140	75	80
	09-30		89.3	73.7	17.5	116	62	76
	11-14		72.6	66.8	8.0	123	79	81
Male bodybuilder 2	08-11	171.5	87.4	71.7	18.0	141	83	70
	09-30		92	73.4	20.2	165	81	59
	11-14		75.5	69.5	7.9	111	81	102
Wellness 1	08-11	148.3	51.4	39.5	23.2	137	77	76
	09-30		57.6	45.8	20.4	138	76	86
	11-14		53.7	46.4	13.5	130	80	89
Wellness 2	08-30	169.1	63	48.2	23.4	126	69	86
	09-30		71.5	58.0	18.9	132	77	74
	11-14		65.2	55.0	15.7	133	79	82
Men’s Physique 1	08-18	190.0	94.3	80.5	14.6	136	72	74
	09-26		99.9	87.7	12.2	136	65	84
	11-14		92.2	87.6	5.0	120	72	62
Men’s Physique 2	06-27	180.5	90.6	81.3	10.2	151	81	82
	08-21		89.8	81.2	9.6	166	75	82
	11-14		81.5	76.6	6.0	124	82	104

The first date is the beginning of the bulking phase, the second date is the end of the bulking and beginning of the cutting phase and the third date is the last measurement made before the competition in the end of the cutting phase.

Table 2.

Resistance training during the bulking and cutting phases of men bodybuilders competitors

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Bulking
Chest (3 exercises, with 10 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Back (3 exercises, with 10 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	45-60 minutes of cardio (bicycle/treadmill) at moderate intensity in the fasted state	Quadriceps (3 exercises, with 10 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Biceps (3 exercises, with 10 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	45-60 minutes of cardio (bicycle/treadmill) at moderate intensity in the fasted state
Anterior and middle deltoids (3 exercises, with 8 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Trapezius (2 exercises, with 6 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)	Hamstrings (2 exercises, with 6 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Triceps (3 exercises, with 10 sets in total, 8-12 reps and 2-3 minutes intervals between sets)	Calves (2 exercises, with 7 sets in total, 15-20 reps and 2-3 minutes intervals between sets)
Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)	Posterior deltoids (1 exercise, with 4 sets in total, 8-12 reps and 2-3 minutes intervals between sets)		Calves (2 exercises, with 7 sets in total, 15-20 reps and 2-3 minutes intervals between sets)	Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)
Cutting
Back (3 exercises, with 10 sets in total, 12-15 reps and 45-60" intervals between sets)	Chest (4 exercises, with 10 sets in total, 12-15 reps and 45-60" intervals between sets)	2 hours of cardio in the fasted state Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 45-60" intervals	Quadriceps (3 exercises, with 11 sets in total, 12-15 reps and 45-60"intervals between sets)	Biceps (3 exercises, with 10 sets in total, 8-12 reps and 45-60" intervals between sets)	2 hours of cardio in the fasted state Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 45-60" intervals between sets)
Trapezius (2 exercises, with 6 sets in total, 12-15 reps and 45-60" intervals between sets)	Anterior and midle deltoids (3 exercises, with 9 sets in total, 12-15 reps and 45-60" intervals between sets)	between sets	Hamstrings (2 exercises, with 8 sets in total, 12-15 reps and 45-60" intervals between sets)	Triceps (3 exercises, with 10 sets in total, 8-12 reps and 45-60" between sets)	Calves (2 exercises, with 7 sets in total, 15-20 reps and 45-60" intervals between sets)
Posterior deltoids (2 exercises, with 6 sets in total, 12-15 reps and 45-60" intervals between sets)	Calves (2 exercises, with 8 sets in total, 15-20 reps and 45-60" intervals between sets)		Hip adductors (1 exercise, with 4 sets in total, 12-15 reps and 45-60" intervals between sets)
Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 45-60" intervals between sets)			Calves (2 exercises, with 8 sets in total, 15-20 reps and 45-60" intervals between sets)

Table 3.

Resistance training during the bulking and cutting phases of women wellness competitors

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Bulking
Abdominals (1 exercise, with 4 sets, 15-20 reps and 1-2 minutes intervals between sets)	Chest (2 exercises, with 7 sets in total, 8-12 reps and 1-2 minutes intervals between sets)	60 minutes of cardio (bicycle/treadmill) at moderate intensity in the fasted state	Hamstrings (2 exercises, with 6 sets in total, 8-12 reps and 1-2 minute intervals between sets)	Back (2 exercises, with 6 sets in total, 8-12 reps and 1-2 minute intervals between sets)	60 minutes of cardio (bicycle/treadmill) at moderate intensity in the fasted state
Quadriceps (3 exercises, with 10 sets in total, 8-12 reps and 1-2 minutes intervals between sets)	Anterior and midle deltoids (2 exercises, with 6 sets in total, 8-12 reps and 1-2 minutes intervals between sets)	Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)	Gluteus (2 exercises, with 6 sets in total, 8-12 reps and 1-2 minute intervals between sets)	Trapezius (1 exercise, with 3 sets in total, 8-12 reps and 1-2 minute intervals between sets)	Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)
Hip adductors (1 exercise, with 3 sets in total, 8-12 reps and 1-2 minutes intervals between sets)	Triceps (2 exercises, with 5 sets in total, 8-12 reps and 1-2 minutes intervals between sets)		Calves (2 exercises, with 6 sets in total, 15-20 reps and 1-2 minute intervals between sets)	Biceps (2 exercises, with 6 sets in total, 8-12 reps and 1-2 minute intervals between sets)
Calves (1 exercise, with 4 sets in total, 8-12 reps and 1-2 minutes intervals between sets)				Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 2-3 minutes intervals between sets)
Cutting
Quadriceps (4 exercises, with 12 sets in total, 12-15 reps and 45"-60” intervals between sets)	Chest (2 exercises, with 7 sets in total, 12-15 reps and 45"-60” intervals between sets)	2 hours of cardio (bicycle/treadmill) at moderate intensity in the fasted state	Gluteus (3 exercises, with 6 sets in total, 12-15 reps and 45"-60” intervals between sets)	Back (2 exercises, with 7 sets in total, 12-15 reps and 1-2 minute intervals between sets)	2 hours of cardio (bicycle/treadmill) at moderate intensity in the fasted state
Hip adductors (1 exercise, with 4 sets in total, 12-15 reps and 45"-60” intervals between sets)	Anterior and middle deltoids (2 exercises, with 6 sets in total, 12-15 reps and 45"-60” intervals between sets)	Abdominals (1 exercise, with 8 sets in total, 12-15 reps and 45"-60” intervals between sets)	Hamstrings (2 exercises, with 6 sets in total, 15-20 reps and 45"-60” intervals between sets)	Trapezius (1 exercise, with 3 sets in total, 12-15 reps and 1-2 minute intervals between sets)	Abdominals (1 exercise, with 4 sets in total, 15-20 reps and 1-2 minutes intervals between sets)
Calves (1 exercise, with 8 sets in total, 15-20 reps and 45"-60” intervals between sets)	Triceps (2 exercises, with 6 sets in total, 12-15 reps and 45"-60” between sets)		Calves (2 exercises, with 6 sets in total, 15-20 reps and 45"-60” intervals between sets)	Biceps (2 exercises, with 6 sets in total, 12-15 reps and 1-2 minute intervals between sets)
Abdominals (2 exercises, with 8 sets in total, 15-20 reps and 45"-60” intervals between sets)				Abdomen (2 exercises, with 8 sets in total, 15-20 reps and 1-2 minute intervals between sets)

Table 4.

Resistance training during the bulking and cutting phases of men’s physique competitors

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Bulking
Chest (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)	Quadriceps (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between	Back (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)	Rest	Biceps (2 exercises, with 6 sets in total, 8-15 reps and 50"-70' intervals between sets)	Quadriceps (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between
Anterior and medial deltoids (2 exercises, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)	Hamstrings (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)	Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)		Triceps (2 exercises, with 6 sets in total, 8-15 reps and 50"-70' intervals between sets)	Hamstrings (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)
Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)				Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)
Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)				Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)
Cutting
Chest (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)	Quadriceps (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)	Back (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)	Rest	Biceps (2 exercises, with 6 sets in total, 8-15 reps and 50"-70' intervals between sets)	Quadriceps (3 exercises, with 9 sets in total, 8-15 reps and 50"-70' intervals between sets)
Anterior and medial deltoids (2 exercises, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)	Hamstrings (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)	Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)		Triceps (2 exercises, with 6 sets in total, 8-15 reps and 50"-70' intervals between sets)	Hamstrings (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)
Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)				Calves (1 exercise, with 4 sets in total, 8-15 reps and 50"-70' intervals between sets)
Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)				Abdominals (1 exercise, with 8 sets in total, 15-20 reps and 50"-70' intervals between sets)

Discussion

This manuscript aimed to describe and analyze the practices adopted by six bodybuilders of both sexes in the light of scientific evidence. Data will be discussed separately for pharmacological agents, training, nutrition and supplements, as follows.

Pharmacological agents

MB1 and MB2 used 750 mg/week of anabolic steroids during the bulking phase. During the cutting phase the amount increased to 760 mg/week in MB2 and 1160 mg/week in MB1, which resulted in more than 105–165 mg/day. Considering that the normal testosterone production in men is 4–11 mg/day,[11-14] the dosage is 9–41 times higher than the natural androgen production. Although MP1 and MP2 were taller and heavier, the amount of hormone used by them was lower than MB1 and MB2 during the bulking phase (500 mg/week), but increased to 720 mg/week during the cutting phase. This is probably due to the characteristics of their categories, since Men’s Physique requires a less muscular body than Bodybuilding. W1 and W2 used 400 mg/week of steroids during the bulking phase and 740 mg/week during the cutting phase, resulting in 57 and 105 mg/day, respectively. Considering that women produce 0.2–0.4 mg testosterone/day,[11,12,14,15] the amount of androgen used was 142–285 and 264–528 times their natural androgen production during the bulking and cutting phases, respectively. The amount of androgen used by the studied bodybuilders in both phases was extremely high when compared with endogenous production. This high dosage has already been reported in the literature.[16] The hormone dosage during the cutting phase increased in all competitors, except for MB2. This might be related to the alleged effects of testosterone in promoting fat loss[17-19] and also to counteract muscle catabolism that usually accompanies extreme fat loss strategies. However, this strategy did not seem to be effective, since most of the participants, lost fat-free mass during the cutting phase, which is in accordance with other studies that also demonstrated that use of anabolic steroids was not able to generate positive changes in body composition.[20,21] The participants also changed the type of anabolic steroid used from the bulking to cutting phases. In the bulking phase, the participants commonly used testosterone enanthate, boldenone, nandrolone undecanoate and trenbolone. In the cutting phase, the drugs of choice were propionate, stanozolol, propionate drostanolone and oxandrolone. However, there was an exception for the Men’s Physique participants who used testosterone propionate during the bulking phase and enanthate during the cutting phase. Indeed, it has been demonstrated that athletes typically use anabolic steroids in a “stacking” regimen, which means the use of different drugs simultaneously in order to increase the potency of each drug.[22] Drug choice was based on the belief that some drugs would result in greater fat loss than others. However, this practice is not supported by the literature. Previous studies have shown that endogenous testosterone per se may be associated with fat loss.[17,18] However, some studies reported no reduction in body fat with anabolic steroid use[20,21] while others reported reductions in body fat in healthy people[19], [23], [24], the obese[25] and clinical settings,[26-28] irrespective of the drugs used. If we consider that testosterone acts in the adipose tissue through androgen receptors,[29-31] it is not plausible to believe that different drugs would result in different effects in body fat or muscle accretion, since they will act on the same receptor.[30] Additionally, the use of large amounts of anabolic steroids may increase its conversion to estrogen, which may have a negative impact on fat loss. Although recent studies reported that testosterone aromatization may not influence body composition at therapeutic doses,[32] its effects at higher doses are unkonwn. The effects of androgens on the cardiovascular system are widely studied and recognized. Briefly, misuse of androgens can cause myocardial infarctions, alterations in serum lipids (decreased HDL and increased LDL), elevation in blood pressure and increased risk of thrombosis (for review see Hoffman et al.[22]). In the present study, all participants showed resting systolic blood pressure values higher than optimal in at least one of the three measurements performed. MB1, MB2 and MP2 showed blood pressure values that characterized hypertension at some time.[33] Although blood exams were not available, all participants reported that their HDL values were suboptimal in previous exams. It is important to stress that both higher blood pressure and low HDL are associated with cardiovascular events caused by anabolic steroids.[34] Even though no participant had reported any serious cardiovascular events in the past, these altered values could expose them to an increased risk. Moreover, the literature provides many cases of serious cardiovascular events associated with anabolic steroid abuse in bodybuilders.[6,35-37] The increased cardiovascular risk associated with steroid use seems to be undeniable.[6,38] Additionally, many studies confirm that the abuse of anabolic substances produces profound and partly irreversible changes in various organs and systems, and that these changes tend to be related to the type, duration and amount of anabolic steroids used. The effects of major concern are those on the liver, cardiovascular and reproductive systems, and on the psychological status of anabolic-androgenic steroid users.[20,39-42] Certainly not all effects occur in all persons, nor are the effects necessarily obvious.[22] In addition to dosage, one must consider the duration of use to arrive at a total exposure. In this sense, the use in bodybuilding seems to be particularly alarming since it combines large doses and long periods of use.[38,42] Although it is recommended to not exaggerate the medical risks associated with anabolic steroids,[22] it is important to emphasize that an attitude of personal invulnerability to their adverse effects is certainly misguided.[41] Bodybuilders usually rely on individual cases of steroid users that did not develop health problems to suggest that steroid use may be safe; however, one must know the difference between increased risk and certainty of the occurrence of an event. The use of ephedrine and diuretics in the cutting phase may also impose an imminent risk to the bodybuilders’ health. Ephedrine misuse has been associated with serious cardiovascular events[43,44] and diuretics have been anecdotally associated with the death of some bodybuilders and their misuse is associated with health problems.[45,46] Dehydration could have a negative impact on muscle metabolism without positively affecting fat metabolism, since there seems to be a close relationship between cellular hydration and nitrogen balance.[47] In addition, previous studies have reported that hypo-osmolality is associated with increased lipolysis and decreased protein breakdown.[48,49] Therefore, diuretic use may not be only hazardous to the bodybuilders’ health, but also counterproductive to their objectives.

Training

Resistance training

All participants split training sessions in order to train each muscle group every week. Although a recent review suggests that a higher training frequency may result in higher muscle hypertrophy,[50] there are studies in which trained participants obtained significant results with this type of routine.[51] Moreover, Ahtiainen et al.[52] reported that trained men were only able to repeat a training session 6-7 days after performing nine sets of lower body exercise. Therefore, training one muscle group every week seems to be supported by the current literature. One criticism regarding the splitting routine involves exercise choice, since it did not consider that shoulder and upper limb muscles are highly involved in multi-joint upper body exercise.[53-56] Additionally, previous studies have shown that gains in elbow flexor muscle size and strength were similar for subjects that performed elbow flexions or lat pull-downs.[57] Moreover, other studies showed that the addition of single-joint exercises did not increase the gains in muscle size and strength in untrained[58] or trained subjects.[59] A counterpoint to this argument can be made with the study of Soares et al.[60] in which upper limb muscles recovered faster after seated rows than during isolated elbow flexions. Probably, the difference may be related to the exercise used, since the ratio of activation of latissimus dorsi to biceps during seated rows is higher than during lat pull-downs,[61] which could have led to lower elbow flexor damage in the study of Soares et al.[60] Considering that testosterone increases muscle recovery,[62] protein synthesis[63] and satellite cell activity,[64], [65] the accretion of isolated exercises would have difficulty in inducing a state of overtraining in bodybuilders using anabolic steroids. However, testosterone may impair tendon adaptation to resistance training[66] and anabolic steroids users showed a markedly increased risk of tendon ruptures, particularly in the upper-body.[67] This is particularly interesting, because upper body tendon rupture are not common among people that do not have a history of anabolic steroid use. In a cross-sectional cohort study, Kanayama et al.67 reported that the hazard ratio for a first ruptured tendon in anabolic steroid users versus nonusers was 9.0, and upper body tendon ruptures occurred in 17% of the anabolic steroid users, while none occurred in nonusers. The unnecessary and excessive use of isolated exercises may cause excessive strain in upper body tendons, thus aggravating the problem. The empirical evidence is that all participants of our study had a history of joint pains and one participant had a severe shoulder injury prior to the preparation period. Therefore, considering that isolated exercises bring little, if any, benefit for muscle size and strength and that upper body tendons are particularly vulnerable in anabolic steroid users, it would be advisable to decrease the volume of upper body isolated exercise. During the cutting phase, male Bodybuilder and Wellness competitors increased the number of repetitions performed and decreased the time intervals between sets. Men’s Physique participants kept their training routines with high repetitions and short rest intervals between sets during the whole period, since their purpose was not to promote large increases in muscle mass. Although the use of high repetition and low workloads for acquiring muscle definition is a common practice,3 previous studies have shown that exercises performed with a lower number of repetitions and higher workloads are more efficient than high repetition, high volume training in elevating metabolism[68] and promoting fat loss[69,70] Additionally, considering that low carbohydrate ingestion during the cutting phase may compromise exercise performance,[71] using low repetition with high load and long rest intervals during this phase may be advantageous, since this type of training rely less on the glycolytic system.[72,73] We noted with caution the use of isolated knee adductions for women. According to the participants, the exercise was included to induce specific hypertrophy of the hip adductors and modify the shape of the thighs. Although there is evidence that a training program composed only of leg press and knee extension promotes significant hypertrophy of the hip adductors,[74] the use of isolated exercises may be granted if there is a need to bring specific adaptations for this muscle group. However, it is important to note that women are more prone to develop patellofemoral problems than men and this incidence may be related to weakness of the posterolateral complex.[75,76] Therefore, the use of isolated knee adductions may create an imbalance in the hip joint and increase the probability of developing knee injuries. Therefore, our suggestion is to avoid isolated hip adduction or, if it is necessary for aesthetical reasons, it is recommended to introduce exercises for hip abductors and external hip rotators to prevent patellofemoral problems, as previously used in the studies of Fukuda et al.[77,78]

Aerobic training

Male Bodybuilders and Wellness competitors performed 45–60 minutes of aerobic exercise in the fasted state 2 days per week in the bulking phase. In the cutting phase weekly frequency was kept constant but the duration of each session increased to 2 hours. Men’s Physique competitors did not perform aerobic exercise in the bulking phase, but added 40 minutes of fasted aerobic exercise in the cutting phase. Although the participants reported that performing exercise in the fasted stated is a common practice among bodybuilders, a previous study showed that it brings no benefit in terms of fat loss[79] and can even negatively impact energy expenditure and fat metabolism.[80] Probably, this negative effect on metabolism was offset by the use of large doses of ephedrine and caffeine, which have been shown to increase metabolism and fat oxidation.[81], [82] Based on the current body of scientific evidence, it is highly advisable to discourage the performance of fasted aerobic exercise in order to prevent negative alterations in metabolism and reduce the need for thermogenic ingestion. Thus, the participants could have equivalent results while decreasing the amount of drugs used. Additionally, the performance of high volumes of aerobic exercise has a negative impact on muscle hypertrophy.[83] The loss of fat-free mass even with an increase in anabolic steroid use during the cutting phase may be evidence for that phenomenon. Considering that the higher the exercise intensity, the higher the fat loss[83,84] and that some studies suggest that the effect of regular low-intensity aerobic exercise on body fat is negligible,[85] it would be recommended to reduce the volume of aerobic exercise and increase its intensity. Another strategy to prevent muscle loss would be to prefer cycling to running, since the latter may have a more negative interaction with resistance training[83], [85] Taken together, high intensity interval training on the cycle ergometer would be preferable to long duration and low-intensity running for both losing fat and preserving fat-free mass.

Nutrition

Unfortunately, it was not possible to retrieve detailed nutritional plans because the participants’ diets constantly changed according to their perceptions; i.e. carbohydrate ingestion increased if they felt that they were losing too much fat-free mass and decreased in order to reduce body fat. In general, their bulking diets were hypercaloric, high protein (2.5 g of protein per kg of body mass, with each meal containing 0.33 to 0.55 g of protein per kg of body weight) and low fat (~15% of calories coming from fat). The major sources of carbohydrate were rice, potatoes, bread and oatmeal. Dietary protein usually came from chicken, lean red meat, egg whites and whey protein concentrate. As competition approached, the competitors increased their protein ingestion to ~3 g/kg of body weight and decreased carbohydrate ingestion by 10–20%. Their fruit and vegetable ingestion was extremely low and their sources of vitamins and minerals seemed to be mainly nutritional supplements. The combination of high protein, low fiber and high vitamin ingestion seems to be common among bodybuilders, and has been previously linked to health problems, especially in the gastrointestinal system.[5] It is important to note that the literature recommends the ingestion of 1.2 to 2 g of protein per kg of body weight for strength athletes[86-88] and there seems to be no benefit in increasing ingestion above this level.[82] Moreover, previous studies suggested that the maximum amount of protein needed to increase muscle anabolism is around 0.25 g/kg,[89], [90] which is less than the actual amount ingested by the participants. This extra amount of protein is probably oxidized or eliminated by urea, as suggested by Witard et al.[90] Recent research shows that a higher protein intake (1.8 vs. 0.85 g/kg) seems to add no benefit in novice athletes.[91] Therefore, the practice of increased protein intake, also popular in commercial gyms,[92], [93] is not substantiated by the current literature. During the cutting phase, participants increased their protein intake, as previously reported [1,2], [94] The benefits of high-protein diets on weight loss have been highlighted by Leidy et al.[95] Phillips & Van Loon[71] recommended increasing protein intake to 1.8 to 2.7 g/kg in order to optimize the ratio of fat-to-lean tissue mass loss during hypoenergetic periods. Additionally, Helms et al.[96] suggested that 2.3-3.1 g/kg FFM is appropriate for lean, resistance-trained athletes in hypoenergetic conditions. However, it is important to note that, among the studies used to support high-protein diets in the mentioned reviews, only two used protein intakes over 2 g/kg[97,98] and only one compared the effects of different protein intakes.[98] However, in this study the low protein group ingested only 1 g/kg of protein, which is below the recommended values. The results of meta-analyses indicate that the quantity of protein necessary to promote weight management and preserve lean mass lies somewhere between 1.2 and 1.6 g/kg.[99-101] Therefore, it is important that people involved with bodybuilding become aware that high protein intakes are not obligatory to preserve lean mass while losing fat. This can be particularly valuable for people who do not tolerate severe restrictions in carbohydrate or fat.

Nutritional supplements

Supplements most frequently used for participants of both sexes were concentrated whey protein, chromium picolinate, omega 3 fatty acids, BCAA, poly-vitamins, glutamine and caffeine. Regarding protein supplementation almost all subjects used whey protein. This is not a surprise considering that the most studied type of protein supplementation during resistance training is whey protein in its various forms. On the other hand, the greater part of the data available till now seems to suggest that there is no advantage in assuming whey protein compared to other types of protein.[102] As suggested by a recent meta-analysis the use of whey protein supplementation concomitant with resistance training results in no benefit when compared to other types of protein.[103] In general, studies comparing protein from different sources have found no significant differences or conflicting results. Thus, even though body builders seem to prefer whey protein as a protein source for supplementation, there is no convincing data at the moment that could support the hypothesis of a greater muscle mass growth using whey protein over another high-quality source.[102] The male bodybuilders analyzed, but not the women, also used creatine in the bulking phase. Several studies have suggested a positive effect of creatine supplementation on muscle strength, power and lean body mass.[104-106] Specifically for bodybuilders, the benefits of creatine may be related to the increased capacity for repeating high intensity efforts,[106] which can increase training performance and result in muscle size gains. Creatine supplementation has also been associated with increased anabolic signaling[107,108] reduced myostastin levels,[109] increased satellite cell activity, augmented myonuclei number[110] and increased IGF mRNA[111] which can be related to greater increases in muscle size as compared to placebo.[107,112] However, creatine supplementation is associated with body water retention,[113] which may be counterproductive during the cutting phase. This explains why the bodybuilders suspended its use in the weeks before competition and why it was not used by the women. Caffeine was used in order to increase fat loss, due to its supposedly thermogenic effect. However, previous studies reported that caffeine alone offers no benefits over a placebo in thermogenesis[114,115] and fat loss.[116,117] The only evidence for a positive effect of caffeine on body composition seems to be when combined with ephedrine. Ephedrine’s thermogenic effects are probably mediated by an increase in intracellular concentrations of cAMP. However, cAMP is broken down by the enzyme phosphodiesterase, and there is also some evidence that adenosine released from the cells in response to sympathetic stimulation can inhibit the release of beta-receptor agonists and/or act on specific receptors to inhibit the accumulation of cAMP.[118] Methylxanthines, in particular caffeine, have the ability to inhibit both the effects of adenosine and phosphodiesterase resulting in an increased thermogenic effect when caffeine is combined with ephedrine as compared to ephedrine alone.[116-118] On the other hand, previous studies suggested that the concomitant ingestion of caffeine and creatine may counteract the beneficial effects of creatine in muscle performance.[119,120] Therefore, due to the poor evidence for a positive effect of caffeine on body composition and the negative interaction with creatine, as well as the side effects associated with caffeine abuse,[121] bodybuilders should be conscious about its use, particularly because its effect seems to be relevant only when combined with ephedrine, which is also potentially hazardous to health. Although chromium picolinate was used with the purpose to induce fat loss and decrease carbohydrate craving, previous studies found no benefits of chromium picolinate supplementation in inducing fat loss[108,122,123] and appetite control.[123] However, a previous study suggested that chromium picolinate was beneficial in a subpopulation of patients with high carbohydrate craving, suggesting it may be beneficial for patients with atypical depression who also have severe carbohydrate craving,[124] which may be the case in some bodybuilders. It is important to note that the safe dose of chromium was not established and the amount used by the participants was significantly above the recommended upper limit, which could have a negative health impact.[108,122,123] BCAA are commonly used to increase muscle anabolism, increase recovery and prevent catabolism. Previous studies have shown that BCAA may improve anabolic profile after resistance training when compared to a placebo,[125,126] however, its effects were only seen when BCAA intake was compared to fasting. Considering that the participants already had high protein ingestion coming from animal sources and whey protein supplementation, BCAA would hardly bring any benefit for bodybuilders, as shown in previous studies evaluating anabolic signaling[127,128] and changes in fat free mass in response to resistance training.[129] Moreover, its effect in preserving fat free mass is also questionable.[130] Glutamine, reported to be used for avoiding catabolism and increasing recovery, is another supplement of questionable applicability in bodybuilding. A previous study reported no advantages in muscle performance, body composition or protein degradation when glutamine was combined with resistance training,[131] and a recent review concluded that glutamine was associated with an improvement in the perception of muscle weakness, but did not improve muscle strength recovery.[132] Bodybuilders reported using omega 3 fatty acids for cardiovascular protection. Although there is evidence that ingestion of food rich in omega 3 may bring health benefits, the evidence for its supplementation is controversial.[133-135] However, considering that there is no evidence for adverse events associated with omega 3 supplementation and that the participants’ diets were poor in omega 3, supplementation may be warranted.

Overall analysis

It is important to highlight the body composition results obtained in the present study. Although the competitors used large amounts of anabolic steroids and nutritional supplements in order to improve body composition during all the periods analyzed, their fat-free mass did not change substantially from the beginning to the end of the study. Even in the presence of supra-physiological doses of testosterone, most of them lost fat-free mass during the cutting phase, which suggests a state of overtraining and/or undernutrition derived from mistakes in training, nutrition and/or recovery.

Bodybuilders seem to risk their health in order to increase fat-free mass and then risk their health again to lose fat, but end up losing most of the fat-free mass previously acquired. Maybe it would be more reasonable to gain smaller amounts of muscle mass while minimizing fat gain and then adopt strategies to lose body fat while preserving lean mass. This would virtually extinguish the traditional bulking and cutting phases and promote less aggressive variations in body composition, in addition to decreasing reliance on anabolic steroids and stimulants. The analysis of bodybuilding practices in light of the scientific body of evidence allowed us to find many practices that could negatively impact bodybuilders’ health and/or have no potential benefits. With regard to joint problems, the combination of high volumes of upper limb exercises with anabolic steroid abuse may predispose bodybuilders to tendon ruptures. As for cardiovascular risks, the combination of anabolic steroids and stimulants is particularly alarming, since both are independently associated with serious cardiovascular events. In the case of the women, the massive doses of anabolic steroids were surprising. The bodybuilders analyzed relied on a monotonous diet, poor in fiber, vitamins and minerals, associated with the massive use of supplements that have no potential benefits, which may result in health problems and elevated costs. Based on these findings, we recommend the adoption of an evidence-based approach by bodybuilders with a more balanced and less artificial diet. With regard to training, special focus should be given to decreasing training volume, revisiting exercise choice and avoiding fasted cardio in order to decrease the reliance on drugs and thus preserve bodybuilders’ health and integrity.

The present study has some important limitations. The small number of subjects does not allow generalization, so we cannot confirm if the procedures described here are adopted by the majority of bodybuilders. However, due to the experience of the researchers as coaches and/or athletes along with the reports of the participants, we have strong empirical evidence to believe that many competitors, as well as the general public that take bodybuilders as models, adopt many of the procedures described here. We opted to analyze a small number of subjects in order to gain more detail and retrieve reliable data. Another limitation is that, because of the retrospective characteristic of the study, we were not able to ask for complementary exams or perform specific assessments that would help to clarify many issues, especially regarding health risks. Finally, it is undeniable that the practices adopted by the participants of the study were somehow successful, as they were well ranked in their categories. This apparent success may lead to the fallacy known as “cum hoc ergo propter hoc”, and attribute their success to some of their practices. However, there are many intervenient factors, such as drug abuse and genetics, that have to be considered and, more importantly, one must question if their results could have been better if adopting alternative practices. The question that remains is: would they have better results if they adopted a scientific-based approach? Or would they have the same results, but with fewer health risks? Answering these questions is beyond the scope of this study; however, based on a critical analysis and the available literature, we suggest that many practices described here should be avoided or even abolished. Future research aiming to test the use of evidence-based alternatives in bodybuilding preparation is granted.