190 LEADER

Blood doping “By the early 1990s it was clear Br J Sports Med: first published as 10.1136/bjsm.37.3.190 on 1 June 2003. Downloaded from ...... that EPO was the “drug of choice” for athletes illegally seeking to ˙ increase their endurance VO2MAX, blood doping, and performance.” By the early 1990s it was clear that EPO was the “drug of choice” for M J Joyner athletes illegally seeking to increase their 13 ...... endurance performance. From a tech- nical perspective, EPO had a number of Methods (legal and illegal) of increasing total body advantages including no need for com- plex logistically challenging manoeuvres ˙ O MAX haemoglobin and thereby V 2 are discussed such as blood withdrawal, storage, and reinfusion. In addition, there was no

y the 1930s it was clear that cham- body haemoglobin increased V~O2MAX and reduction in performance or training pion endurance athletes had re- manoeuvres that reduced total body after a period of blood withdrawal, and 9 markably high maximal O2 uptake haemoglobin reduced V~O2MAX. These there was limited “detectability” because B 1 (V~O2MAX). In the 1950s, 1960s, and changes in V~O2MAX appeared to be some- EPO is a “naturally occurring” peptide 1970s, classic studies were performed on what independent of total blood volume hormone. The use of EPO in inter- the physiological determinants of V~O2MAX because volume loading per se had little national competition has been high- and on its key role in endurance impact on V~O2MAX, and likewise manoeu- lighted by a variety of scandals in events performance.2–4 During this time there vres that cause haemoconcentration did such as the . In addition to was much debate on O2 delivery versus not increase V~O2MAX. Therefore, the EPO, there are several EPO analogues

O2 extraction as the “limiting factor” for importance of total body haemoglobin as that are also effective—for example, dar- 56 V~O2MAX. Observations during this era a primary determinant of V~O2MAX was bypoietin. Fortunately these substances, clearly established the role of maximal emphasised. which have a longer half life, are more cardiac output as a determinant of In parallel with these mechanistic easily detectable, and several athletes

V~O2MAX, and very high maximal cardiac studies on the determinants of V~O2MAX, were suspended for darbypoietin use at output values were seen in champion applied observations on athletic per- the 2002 Winter Olympics.15 So, where 2 endurance athletes. In addition, the formance and the role of V~O2MAX, lactate does this leave us in the early 21st important role of blood volume and total threshold, and running economy century as we consider efforts by athletes 34 body haemoglobin as determinants of emerged. As V~O2MAX was seen as a key to increase their circulating haemoglobin 2 7–9 V~O2MAX also emerged (fig 1). In an determinant of performance, the next and improve their endurance perform- effort to better understand the physio- obvious question was whether or not ance? logical determinants of V~O2MAX, studies manoeuvres that increased total body Firstly, it is clear that the studies that were then conducted that attempted to haemoglobin and V~O2MAX would also led to blood doping were not designed to manipulate O2 delivery using a variety of increase performance. A number of improve athletic performance; they were, approaches including altered concentra- studies confirming the positive impact of however, designed to study the determi- http://bjsm.bmj.com/ tions of inspired O2, drugs that speed or increased total body haemoglobin on nants of V~O2MAX in humans. Studies on 12 13 slow the heart, and, as will be discussed performance were then conducted. In the determinants of V~O2MAX then led to here, techniques that altered total body addition, a variety of rumours and innu- the realisation that blood doping could haemoglobin and haemoglobin endo suggested that at least some be a powerful ergogenic aid, and, in the concentration.10 11 endurance athletes were using this tech- modern “commercial” era of sport where In general, by the 1970s it was clear nique in an effort to gain a competitive national prestige and financial benefits that manoeuvres that increased total advantage in international to the athlete were “on the line” during competition.13–15 Thus, the term “blood major competitions, it is not surprising on September 29, 2021 by guest. Protected copyright. doping” was coined. Although it is clear that blood doping became a factor in that blood doping improves perform- international competition. The emer- ance, it is unclear how widespread it was gence of EPO just made these strategies in the 1970s and 1980s as detection was easier and reduced the medical infra- difficult because athletes received a rein- structure needed to manipulate whole fusion of their own red blood cells. body haemoglobin. In both cases, it is By the late 1980s recombinant eryth- unclear how widespread the use of these ropoietin (EPO), a hormone secreted by techniques has been, but it is clear that at the kidney which is an important regula- least some organisations and countries tor of production by the have doped in a systematic manner and bone marrow, became available to treat that an “arms race mentality” has devel- patients with anaemia. Early studies in oped which contributes to a cycle of sus- patients with renal failure, severe anae- picion of use by non-users and subse- mia, and poor exercise tolerance showed quent increased use by those fearful of a that this hormone and the associated competitive disadvantage. Figure 1 Classic data showing the relation increase in whole body haemoglobin and More recently, ideas about how alti- between total body haemoglobin and whole packed cell volume could have profound tude training may affect total body ˙ body maximal oxygen uptake (VO2MAX) for effects on exercise tolerance in these haemoglobin and the optimal combina- 7 94 subjects age 7–30 years. The subjects patients.16 Studies were also conducted tion of training and living at altitude has were all fit and none were overweight. Infor- in trained subjects and athletes that been investigated, and the so-called “live mation such as this set the stage for much of 17 O MAX the work that was to come on the relation showed the expected increase in V~ 2 high, train low” concept has emerged. ˙ when total body haemoglobin was Whether the increases in performance between total body haemoglobin and VO2MAX in humans. increased.13 16 associated with this approach are due

www.bjsportmed.com LEADER 191

solely to increased haemoglobin levels or ...... 9 Kanstrup I, Ekblom B. Blood volume and Br J Sports Med: first published as 10.1136/bjsm.37.3.190 on 1 June 2003. Downloaded from other factors is unclear, but there has Author’s affiliation hemoglobin concentration as determinants of maximal aerobic power. Med Sci Sports Exerc M J Joyner, been an emergence of strategies ranging Department of Anesthesiology, 1984;16:256–62. from the construction of “nitrogen Mayo Clinic, Rochester, MN 55905, USA 10 Ekblom B, Goldberg AN, Gullbring B. houses” or decompression dormitories to Correspondence to: Professor Joyner, Response to exercise after blood loss and 33 the commercial availability of hypoxic Department of Anesthesiology, Mayo Clinic, reinfusion. J Appl Physiol 1972; :175–80. Ekblom B tents to facilitate the non-medical/non- 200 First Street SW, Rochester, MN 55905, 11 , Wilson G, Åstrand P-O. Central USA; [email protected] circulation during exercise after venesection pharmacological manipulation of total and reinfusion of red blood cells. J Appl body haemoglobin.15 At the same time, Physiol 1976;40:379–83. the governing bodies of many sports fed- REFERENCES 12 Berglund B, Hemmingsson P. Effect of erations and the Olympic Committee 1 Robinson S, Edwards HT, Dill DB. New reinfusion of autologous blood on exercise records in human power. Science performance in cross-country skiers. Int J have set upper limits for haemoglobin 1937;85:409–10. Sports Med 1987;8:231–3. and packed cell volume so that any com- 2 Ekblom B, Hermansen L. Cardiac output in 13 Sawka MN, Joyner MJ, Miles DS, et al. petitive advantage associated with dop- athletes. J Appl Physiol 1968;25:619–25. American College of Sports Medicine position 3 Costill DL, Thomason H, Roberts E. Fractional ing would be eliminated or at least regu- stand: the use of blood doping as an utilization of the aerobic capacity during ergogenic aid. Med Sci Sports Exerc distance running. Med Sci Sports lated. 1996;28:i–viii. 1973;5:248–52. So, athletes and those interested in 14 Berglund B, Hemmingsson P, Birgegard G. 4 Farrell PA, Wilmore JH, Coyle EE, et al. improving their performance now have a Plasma lactate accumulation and distance Detection of autologous blood transfusions in variety of “choices” related to increasing running performance. Med Sci Sports cross-country skiers. Int J Sports Med 8 whole body haemoglobin. Traditional 1979;11:338–44. 1987; :66–70. 5 Rowell LB. Human circulation regulation 15 Joyner MJ. News brief: , blood doping and EPO use are illegal, during physical stress. New York: Oxford erythropoietin, and blood doping. Exerc Sport whereas the approaches that result in University Press, 1986:1–416. Sci Rev 2002;3:97–8. hypoxic sleeping or sojourns to high alti- 6 Saltin B, Strange S. Maximal oxygen uptake: 16 Ekblom B, Berglund B. Effect of erythropoietin tude are permitted. In this context, the “old” and “new” arguments for a administration on maximal aerobic power. cardiovascular limitation. Med Sci Sports Scand J Med Sci Sports 1991;1:88–93. era of “doping” to manipulate haemo- Exerc 1992;24:30–7. 17 Stray-Gundersen J, Chapman RF, Levine BD. globin and packed cell volume may be 7 Åstrand P-O. Experimental studies on “Living high-training low” altitude training over, but the search for “legal” ap- physical working capacity in relation to sex improves sea level performance in male and and age. Copenhagen: Ejnar Muksgaard, female elite runners. J Appl Physiol proaches to raise whole body haemo- 1952. 2001;91:1113–20. globin are likely to continue. 8 Åstrand P-O, Rodahl K. Textbook of work physiology. New York: McGraw-Hill Book Br J Sports Med 2003;37:190–191 Company, 1977.

3rd Asia Pacific Forum on Quality Improvement in Health Care http://bjsm.bmj.com/ 3–5 September 2003, Auckland, New Zealand

We are delighted to announce this forthcoming conference in Auckland, New Zealand.

The themes of the 3rd Asia Pacific Forum on Quality Improvement in Health Care are: on September 29, 2021 by guest. Protected copyright.

• Agenda for quality: Improving equity in health care delivery • Improving safety • Leadership for improvement • Measuring quality and benchmarking for change • Evidence based knowledge and education for quality improvement • Improving health systems • Patient/consumer centred quality improvement

Presented to you by the BMJ Publishing Group (London, UK) and Institute for Healthcare Improvement (Boston, USA), supported by the New Zealand Ministry of Health, ACC, and Standards New Zealand.

For more information about the Forum or to register contact: [email protected] or go to: www.quality.bmjpg.com Tel: +44 (0)20 7383 6409 Fax: +44 (0)20 7383 6869

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