Prevalence and awareness of anabolic androgenic steroid use among male body builders in Jazan , Saudi Arabia

Purpose: To examine the prevalence and awareness of anabolic-androgenic steroid (AAS) use among male bodybuilders visiting gyms in Jazan region, Saudi Arabia. Methods: A cross-sectional survey was conducted among 500 male bodybuilders visiting gyms in the Jazan region of Saudi Arabia. Information on demographics, as well as the use of AAS, was included in a self-administered questionnaire. Results: The prevalence of AAS in Jazan was 31.0 % (95 % CI, 26.9 49.6), and it was higher among those in the 30 34 years 45.3 % (95 % CI, 36.9 54.0). Its prevalence was also significantly higher among athletes who received higher education 37.4% (95 % CI, 31.8 43.4). The most common types of AAS used are Deca-Durabolin (57.6 %) and testosterone (52 %). Thirty percent of the participants who used AAS suffered from depression and aggressive behavior while 18 % of them were hypertensive. The participants were not well aware of the adverse effects of anabolic steroids use. Conclusion: The prevalence of the anabolic steroids is high among bodybuilding males visiting gyms in Jazan region, Saudi Arabia. Health educational programs are required to increase the awareness about the side effects of anabolic steroids among bodybuilders.


INTRODUCTION
Anabolic-androgenic steroids (AAS) are a type of synthetic steroid hormones related to the hormone testosterone [1,2].These drugs are available by prescription and used to treat cases caused by an abnormal low production of testosterone, such as delayed puberty and impotence [1].
Serious side effects are noted among users of anabolic steroids.These include increase aggressiveness, euphoria, diminished fatigue, increased libido, and mood swings [3].The side effects also comprise high blood pressure, liver tumors and cancers, fluid retention, and jaundice [1].Other side effects include severe acne, kidney tumors and tremors [4].In men, AAS can even cause shrinking of testicles, development of breasts and prostate cancers, baldness, reduced sperm count, and infertility [4][5][6].Hall and Hall (2005), in their review, suggested that anabolic steroid abuse has become a major problem in the United States, with more than 1 million individuals abusing these drugs [7].Another study conducted among health club users in the South Wales area revealed that AAS use is prevalent (70 %) among recreational gym users [8].Studies regarding the prevalence of AAS use among adolescents reported lifetime prevalence ranging from 1 % to 5 % [9].
In the Middle East, the number of gym users taking anabolic steroids is steadily increasing.Recent studies in Jordan found that 26 % of bodybuilders reportedly used anabolic steroids [10].The use of anabolic steroids among gym users in United Arab Emirates was estimated at 22 % [2]  It should be noted that no previous study was conducted on the use of anabolic steroids among male bodybuilders using gym facilities in Jazan, Saudi Arabia.The main objective of this paper is to estimate the prevalence of anabolic steroid and its awareness among male bodybuilders visiting gyms in the Jazan region.

Study design and setting
An observational cross-sectional survey was conducted in the Jazan region.Jazan (or Gizan) region lies in the southwest corner of Saudi Arabia, north of the border with Yemen; the region is sub-divided into 14 governorates.The region is one of the 13 regions comprising the Kingdom of Saudi Arabia and has a population of approximately 1.5 million.

Sampling procedure
Using the statistical formula for cross-sectional study design, the sample size for this study was estimated to be 500 participants.The calculation was based on the prevalence of AAS = 50 %, 95 % confidence interval (CI), error below 5 %, and a non-response rate of 25 %.The research team excluded the governorates that did not have any gym facilities.After exclusion, we ended up with six governorates.We, then, randomly selected one gym from each selected governorate.The selected governorates were Sabya, Samtah, Abu Arish, Jazan, Baish, and Ahad AL-Masaraihah.The final sample size was distributed among the selected gyms proportionate to the actual bodybuilders' size in each gym.In each selected gym, the study participants were identified using systematic random sampling.

Data collection
A self-administered questionnaire was used for data collection.The questionnaire was designed after consulting a number of previous studies conducted in the same domain [2,12].The final version of the questionnaire involved approximately 50 multiple-choice questions.The questions included sections on background characteristics of study participants, types of AAS used, reported side effects, and questions concerning knowledge and attitude in relation to AAS use.

Statistical analysis
The statistical analysis was performed using SPSS ver.20.0 (SPSS Inc.Chicago, IL, USA) software.The prevalence of anabolic steroid use among the study subjects was calculated using 95 % confidence intervals (CI).The Chi-square test/ Fisher's exact test was used to evaluate the prevalence of use among the different subgroups.The p value less than 0.05 was used to indicate statistical significance.

Ethical considerations
Ethical approval for this study was obtained from the College of Medicine, Jazan University, Jazan.Saudi Arabia (approval no.CLC 432-2015/2016 Module).Participants signed the study consent before answering the survey questionnaire.It was made clear to all participants that they had the right to not participate in the study or withdraw from the survey at any time if they wished to do so.Also, subjects' privacy was ensured at all study stages.The survey data was kept confidential and utilized for study purposes only and the whole ethics procedures is conducted in accordance with the International ethical guidelines for biomedical research involving human subjects [27].

RESULTS
A total of 500 questionnaires were distributed among male bodybuilders visiting gyms.A total of 465 questionnaires were included in the final analysis (93 %), and the rest of the questionnaires (7 %) were excluded from the study due to non-response.Table 1 shows the demographic characteristics of the study population.According to the table, more than 50 % of the study participants received higher education.The majority of male bodybuilders were between 20 -34 years, which represented approximately 80 % of the total.About 42 % of the samples were students, and 45 % were employed.Forty percent of the samples have a monthly income between $261 and $1333, and about 25 % drew income less than $260.More than 35 percent of them had been using steroids for less than a year while 15.3% of them had been using steroids for two years and more.
According to Figure 1, 56 % of the participants agreed that anabolic steroids can cause side effects while 58.6 % of them believed that AAS use has a beneficial effect on them.Sixty-one percent of the participants had no knowledge about the sexual problems arising out of AAS use.Thirty-one percent of the participants knew that AAS can increase blood pressure while 47 % of them knew about the behavioral changes due to AAS abuse.

DISCUSSION
This study shows the prevalence of AAS use among male bodybuilders visiting gyms in the Jazan region.Most of our study participants had information about AAS benefits (e.g.increasing muscle size and endurance), but their knowledge about the side effects of AAS was very low.This explains the lack of public awareness about the risk of AAS use.Interestingly, our study revealed that there is a significant association between AAS use and high level of education.The prevalence of AAS use was higher among bodybuilders who received higher education, which means that awareness is independent of AAS use.Other studies concluded that spreading awareness about the side effects of AAS may not be the only effective strategy for limiting their abuse [12].

Limitations of the study
The study had few limitations.First, the research team did not ask for more details about the content and dose of AAS.Second, the study utilized a self-administered questionnaire to collect data on AAS use and their side effects.
No other confirmation method was used to document AAS use among study participants.
Finally, the study was based on a cross-sectional study design, which is not appropriate for assessing associations, and the causal relationships between the variables cannot be established properly.

CONCLUSION
The prevalence of anabolic steroid use is high among male bodybuilders visiting gyms.The most common types of AAS used are Deca-Durabolin and testosterone.It is highly recommended that Regional Health Authorities in Jazan region should increase awareness and knowledge about the side effects of anabolic steroids' use.This can be achieved by distributing leaflets that explain the serious side effects of AAS use.

Figure 1 :
Figure 1: Correct response on knowledge about AAS and its side effects while AAS use among Iranian youths training to be bodybuilders was about 13 % [11].In Kuwait, 22.7 % of the general population and 4.2 % of college students are AAS users [12].Evidence suggests that an increasing number of deaths of athletes in the age group of 20 -30 years is due to heart diseases resulting from AAS use [13].AAS are toxic to the cardiac tissue and leads to cardiomyopathy with impaired systolic and diastolic functions [14,15].The use of AAS also leads to increased LDL and decreased HDL in the blood, which represents a great risk for coronary heart disease [4,16-18].There are still a limited number of studies suggesting AAS-induced atherosclerosis [19,20].

Table 1 :
Background characteristics of the study population (n = 465) According to Table 4, the most common types of AAS used are Deca-Durabolin (57.6 %) and testosterone (52 %).Bodybuilders usually use AAS as a course for a predefined period of time.The course usually has more than one type of steroid as mentioned in Table 4.The same table illustrates the route of administration of AAS.

Table 3 :
Distribution of AAS users and non-users according to some selected characteristic (n = 465)