Changes in hemoglobin values in elite cross-country skiers from 1987-1999

The construction of categories in sport: Unfair advantages, equality of opportunity and strict attainability

On 8 September 2020, the Swiss Federal Supreme Sport dismissed the double appeal by Caster Semenya against the decision of the Court for Arbitration of Sport to uphold the World Athletics regulations restricting testosterone levels in female runners. On 24 February 2021, Semenya appealed to the European Court of Human Rights. This is the most recent episode of an international legal case which was ignited at the 2009 Berlin World Track Championship, when Semenya was 18 years old. Semenya's case has generated an intricate web of questions for classification in sport that are yet to be resolved. In this paper we aim to disentangle them. We proceed as follows: we describe the problem of binary classification related to Semenya's case and introduce the concept of property advantage, and the fair equality of opportunity principle. We compare Semenya's case with Eero Mantyranta's case and fail to identify a way according to which the two cases could justifiably be treated differently. We then discuss three possible ways to organize sport categories based on the combination of Loland's fair equality of opportunity principle and our strict attainability criterion, and outline the implications of each alternative for international sports law regulation. Finally, we summarize and outline the legacy of Semenya for the construction of categories in sport.

Blood manipulation: current challenges from an anti-doping perspective

The delivery of oxygen is the limiting factor during whole-body endurance exercise in well-trained individuals, so manipulating the amount of hemoglobin in the blood results in changes in endurance exercise capacity. Athletes began using novel erythropoiesis-stimulating agents well before they were approved for medical use. Older manipulation practices, such as autologous blood transfusions or the administration of first-generation recombinant human erythropoietins, are still widely abused due to challenges in their detection. More recent performance enhancement maneuvers include efforts to mask doping and to induce increased endogenous erythropoietin expression. Confessions by athletes have revealed an ongoing yet extremely sophisticated modus operandi when manipulating the blood. In this review, weaknesses in detection methods and sample collection procedures are scrutinized and strategies developed to circumvent the test system discussed.

Human genetic variation: new challenges and opportunities for doping control

Sport celebrates differences in competitors that lead to the often razor-thin margins between victory and defeat. The source of this variation is the interaction between the environment in which the athletes develop and compete and their genetic make-up. However, a darker side of sports may also be genetically influenced: some anti-doping tests are affected by the athlete's genotype. Genetic variation is an issue that anti-doping authorities must address as more is learned about the interaction between genotype and the responses to prohibited practices. To differentiate between naturally occurring deviations in indirect blood and urine markers from those potentially caused by doping, the "biological-passport" program uses intra-individual variability rather than population values to establish an athlete's expected physiological range. The next step in "personalized" doping control may be the inclusion of genetic data, both for the purposes of documenting an athlete's responses to doping agents and doping-control assays as well facilitating athlete and sample identification. Such applications could benefit "clean" athletes but will come at the expense of risks to privacy. This article reviews the instances where genetics has intersected with doping control, and briefly discusses the potential role, and ethical implications, of genotyping in the struggle to eliminate illicit ergogenic practices.

Biomarker monitoring in sports doping control

Biomarker monitoring can be considered a new era in the effort against doping. Opposed to the old concept in doping control of direct detection of a prohibited substance in a biological sample such as urine or blood, the new paradigm allows a personalized longitudinal monitoring of biomarkers that indicate non-physiological responses independently of the used doping technique or substance, and may cause sanctioning of illicit practices. This review presents the development of biomarker monitoring in sports doping control and focuses on the implementation of the Athlete Biological Passport as the current concept of the World Anti Doping Agency for the detection of blood doping (hematological module). The scope of the article extends to the description of novel biomarkers and future concepts of application.

Detection of EPO doping and blood doping: the haematological module of the Athlete Biological Passport

The increase of the body's capacity to transport oxygen is a prime target for doping athletes in all endurance sports. For this pupose, blood transfusions or erythropoiesis stimulating agents (ESA), such as erythropoietin, NESP, and CERA are used. As direct detection of such manipulations is difficult, biomarkers that are connected to the haematopoietic system (haemoglobin concentration, reticulocytes) are monitored over time (Athlete Biological Passport (ABP)) and analyzed using mathematical models to identify patterns suspicious of doping. With this information, athletes can either be sanctioned directly based on their profile or targeted with conventional doping tests. Key issues for the appropriate use of the ABP are correct targeting and use of all available information (e.g. whereabouts, cross sectional population data) in a forensic manner. Future developments of the passport include the correction of all concentration-based variables for shifts in plasma volume, which might considerably increase sensitivity. New passport markers from the genomic, proteomic, and metabolomic level might add further information, but need to be validated before integration into the passport procedure. A first assessment of blood data of federations that have implemented the passport show encouraging signs of a decreased blood-doping prevalence in their athletes, which adds scientific credibility to this innovative concept in the fight against ESA- and blood doping.

[Liver and sport]

The liver is a vital organ and plays a central role in energy exchange, protein synthesis as well as the elimination of waste products from the body. Acute and chronic injury may disturb a variety of liver functions to different degrees. Over the last three decades, the effects of physical activity and competitive sport on the liver have been described by various investigators. These include viral hepatitis and drug-induced liver disorders. Herein, we review acute and chronic liver diseases potentially caused by sport. Team physicians, trainers and others, responsible for the health of athletes, should be familiar with the risk factors, clinical features, and consequences of liver diseases that occur in sports.

Erythropoiesis-stimulating agents and other methods to enhance oxygen transport

Oxygen is essential for life, and the body has developed an exquisite method to collect oxygen in the lungs and transport it to the tissues. Hb contained within red blood cells (RBCs), is the key oxygen-carrying component in blood, and levels of RBCs are tightly controlled according to demand for oxygen. The availability of oxygen plays a critical role in athletic performance, and agents that enhance oxygen delivery to tissues increase aerobic power. Early methods to increase oxygen delivery included training at altitude, and later, transfusion of packed RBCs. A breakthrough in understanding how RBC formation is controlled included the discovery of erythropoietin (Epo) and cloning of the EPO gene. Cloning of the EPO gene was followed by commercial development of recombinant human Epo (rHuEpo). Legitimate use of this and other agents that affect oxygen delivery is important in the treatment of anaemia (low Hb levels) in patients with chronic kidney disease or in cancer patients with chemotherapy-induced anaemia. However, competitive sports was affected by illicit use of rHuEpo to enhance performance. Testing methods for these agents resulted in a cat-and-mouse game, with testing labs attempting to detect the use of a drug or blood product to improve athletic performance (doping) and certain athletes developing methods to use the agents without being detected. This article examines the current methods to enhance aerobic performance and the methods to detect illicit use.

Blood profiles in elite cross-country skiers: a 6-year follow-up

Following the doping scandals at the World Championships in cross-country skiing in 2001, the International Ski Federation decided to generate individual blood profiles. From 2001 to 2007, 7081 blood samples from 1074 male and female elite cross-country skiers were collected and analyzed for hemoglobin concentration [Hb] and % reticulocytes (%rets). Data were applied to blood algorithms wherefrom blood model scores were calculated. From 1997-1999 to 2001-2002, the mean [Hb] was reduced by 0.9 g/dL to 15.3 g/dL in male skiers and by 0.4 g/dL to 13.8 in female skiers. From 2002-2003 to 2006-2007, the combination of increases in [Hb] and decreases in %rets led to pronounced increases in mean OFF-model scores. [Hb] was 0.2 g/dL higher at Olympic Games/World Championships (WOCs) than at World Cups competitions <4 weeks before and after WOCs. [Hb] and %rets increased with altitude in both genders. Since the introduction of an enlarged blood testing program, the mean [Hb] values were lowered to close to normal levels, but over the last 2-3 years there has been a small elevation and an increase in OFF-model scores, which may indicate a change in the manipulations used to elevate the [Hb].

The Swedish Blood Pass project

Manipulation of the blood's oxygen carrying capacity (CaO(2)) through reinfusion of red blood cells, injections of recombinant erythropoietin or by other means results in an increased maximal oxygen uptake and concomitantly enhanced endurance performance. Therefore, there is a need to establish a system--"A Blood Pass"--through which such illegal and unethical methods can be detected. Venous blood samples were taken under standardized conditions from 47 male and female Swedish national and international elite endurance athletes four times during the athletic year of the individual sport (beginning and end of the preparation period and at the beginning and during peak performance in the competition period). In these samples, different hematological values were determined. ON(hes) and OFF(hre) values were calculated according to the formula of Gore et al. A questionnaire regarding training at altitude, alcohol use and other important factors for hematological status was answered by the athletes. There were some individual variations comparing hematological values obtained at different times of the athletic year or at the same time in the athletic year but in different years. However, the median values of all individual hematological, ON(hes) and OFF(hre), values taken at the beginning and the end of the preparation or at the beginning and the end of the competition period, respectively, as well as median values for the preparation and competition periods in the respective sport, were all within the 95% confidence limit (CI) of each comparison. It must be mentioned that there was no gender difference in this respect. This study shows that even if there are some individual variations in different hematological values between different sampling times in the athletic year, median values of important hematological factors are stable over time. It must be emphasized that for each blood sample, the 95% CI in each athlete will be increasingly narrower. The conclusion is that there is a physiological basis for establishing an individual-based "Blood Pass" system, mainly for athletes competing at the international level. On indications of manipulations of hemoglobin concentration and red cell mass by deviations from established "Blood Pass" data, more specific methods can be applied.

Hemoglobin levels and athletic performance in elite speed skaters during the olympic season 2006

OBJECTIVE

To test the hypotheses that the hemoglobin (Hb) distribution curve in elite male and female long track speed skaters is not normally distributed and that there is a positive relationship between competitive success and Hb concentration.

DESIGN

A venous blood sample was taken before the events from all skaters. The Hb concentration distribution curves of all ranked from 1 to 30 were tested for normality. In addition, individual Hb concentrations were plotted against ranking in the matching events.

SETTING

2006 major championships and Olympic winter games.

PARTICIPANTS

All elite male and female speed skaters (217 men and 200 women) competing in major international championships in 2006 and in the Olympic winter games 2006.

MAIN OUTCOME MEASUREMENTS

Hb concentration and individual ranking in the matching event.

RESULTS

The mean Hb levels in men and women were 15.7 +/- 0.8 g/dL and 14.0 +/- 0.7 g/dL, respectively. The distribution curve in men would meet the criteria for normal distribution when 4 values from 2 skaters with naturally high Hb levels were neglected. In the women, the distribution curve did not meet the criteria for normality because of low frequency in the right side of the distribution curve and a high frequency at the left side. The curve failed to have a steep drop off at the right side. When plotting Hb concentration against ranking, there is no correlation and relationship between Hb concentration and competitive success.

CONCLUSIONS

The Hb concentrations are within the normal range for endurance athletes, and there is no indication that the values are titrated toward the upper allowed limit. In addition, there is no relationship between Hb concentration and competitive success in elite speed skaters.

4. The use and misuse of performance‐enhancing substances in sport

Doctors need to know if a patient is an athlete subject to drug testing, and to be aware of the legal situation surrounding drugs they prescribe such patients. Antidoping laws generally exist in order to provide a safe and fair environment for participation in sport. These laws should prevent and protect athletes from subjecting themselves to health risks through the use of unsafe, but performance-enhancing drugs. Because of difficulties in proving intent to cheat, the World Anti-Doping Agency enforces a principle of strict liability for positive test results for banned substances. An area of major controversy with respect to liability is the "sports supplement" industry, which is poorly regulated when compared with prescription drugs yet is a potential source of doping violations. Medical practitioners can be found guilty of anti-doping violations if they traffic banned drugs, prescribe these to athletes or otherwise assist athletes in taking banned substances. Medical practitioners are also now required to complete paperwork (therapeutic use exemption forms) to enable athletes to take banned substances which are required on medical grounds for specific illnesses.

Ergogenic aids: a review of basic science, performance, side effects, and status in sports

The use of drugs and supplements to enhance performance has become a part of mainstream athletics. Many team physicians and sports medicine practitioners are unfamiliar with the benefits and risks of these products and thus are unable to educate young athletes on this topic. In spite of numerous reports on the health risks of anabolic steroid use, 1 to 3 million Americans have used them. Human growth hormone has been tried by up to 5% of 10th graders, although no scientific study has shown that it is an effective performance-enhancing drug. Amphetamines and similar compounds may be the most widely abused drug in baseball; recently, they have come under increased scrutiny in sport. Erythropoietin is a highly effective aerobic enhancer that has been linked to multiple deaths in cyclists and other endurance athletes. The neutraceutical industry, led by supplements such as creatine, ephedra, and androstenedione, remains unregulated by the Food and Drug Administration and has serious issues with quality and side effects. An understanding of these products is essential for the sports medicine practitioner to provide sound, safe advice to the athlete.

Pharmacokinetics/pharmacodynamics of recombinant human erythropoietins in doping control

The purpose of this paper is: (i) to compare recombinant human erythropoietin (rHuEPO) pharmacokinetics in athletes and healthy individuals; and (ii) to report pharmacokinetic/pharmacodynamic (PK/PD) studies performed in athletes. Effect parameters in PK/PD studies included: (i) red blood cell variables (haematocrit, reticulocyte count); and (ii) markers of iron metabolism (serum soluble transferrin receptors [sTfR], ferritin [fr] and sTfR : fr ratio). To understand the choice of these markers, we first performed a brief review of the pharmacological effects of rHuEPO. Few studies have been conducted in healthy individuals and there are minimal references concerning pharmacokinetics in athletes. A 'flip-flop' phenomenon was noted after subcutaneous administration. The pharmacokinetics appeared linear from 50-1000 U/kg, but this linearity was not observed at the lowest dose of 10 U/kg. A negative-feedback loop of endogenous erythropoietin production occurred at the end of treatment. The half-life of the terminal part of the curves seemed to be slightly higher in athletes (36-42 vs 32 hours) than in untrained individuals and total clearance tended to be greater (17.5 vs 6.5 mL/h/kg). In conclusion, more investigations are needed to better understand the relationship between rHuEPO administration and changes in haematological and iron-metabolism parameters in athletes, particularly after chronic low-dose administration of rHuEPO.

Abnormal hematologic profiles in elite cross-country skiers: blood doping or?

OBJECTIVE

There is widespread public concern about fairness in sports. Blood doping undermines fairness and places athletes' health at risk. The purpose of this study was to examine the prevalence of abnormal hematologic profiles in elite cross-country skiers, which may indicate a high probability of blood doping.

SETTING AND PARTICIPANTS

Samples were obtained as part of routine International Ski Federation blood testing procedures from participants at the World Ski Championships. Sixty-eight percent of all skiers and 92% of those finishing in the top 10 places were tested.

MAIN OUTCOME MEASURES

Using flow cytometry, we analyzed erythrocyte and reticulocyte indices. Reference values were from the 1989 Nordic Ski World Championships data set and the International Olympic Committee Erythropoietin 2000 project.

RESULTS

Of the skiers tested and finishing within the top 50 places in the competitions, 17% had "highly abnormal" hematologic profiles, 19% had "abnormal" values, and 64% were normal. Fifty percent of medal winners and 33% of those finishing from 4th to 10th place had highly abnormal hematologic profiles. In contrast, only 3% of skiers finishing from 41st to 50th place had highly abnormal values.

CONCLUSIONS

These data suggest that blood doping is both prevalent and effective in cross-country ski racing, and current testing programs for blood doping are ineffective. It is unlikely that blood doping is less common in other endurance sports. Ramifications of doping affect not only elite athletes who may feel compelled to risk their health but also the general population, particularly young people.

Erythropoietin concentrations and isoforms in urine of anonymous Olympic athletes during the Nagano Olympic Games

The ordinary doping control urine samples of 36 anonymous participants (cross-country skiers, biathlon athletes, and curling athletes) of the 1998 Nagano Olympic Games were analyzed for erythropoietin and erythropoietin isoforms. The urine erythropoietin concentration (IU/l) was determined with a competitive radioimmunoassay method and the isoforms were studied by electrophoresis and given as milli albumin mobility units (mAMU). Erythropoietin was detectable in 23 out of 36 specimens (64%). The biathlon and curling athletes had similar urine concentration of erythropoietin. The group of 16 cross-country skiers had significantly (P < 0.05) increased urine concentration of erythropoietin as compared to curling athletes and four of them had urine erythropoietin concentrations between 3.6 and 5.1 IU/l. The electrophoretic mobility of erythropoietin was determined in all eight samples with urine concentration of erythropoietin of more than 2 (range 2.1-5.1) IU/l. No single urine specimen with a median erythropoietin electrophoretic mobility below the cut-off level of 670 mAMU (indicative of doping with recombinant erythropoietin) was registered. Erythropoietin in urine was detected in 71% and the isoforms of Epo characterized in 29% of the anonymous Olympic endurance athletes. The urine concentration of erythropoietin in the biathlon and curling athletes were similar to those of non-athletes. The group of cross-country skiers had higher levels of erythropoietin in urine. These higher levels of urine erythropoietin in cross-country skiers are partly due to more concentrated urine specimens.

Hematological indices in elite cyclists

BACKGROUND

Blood testing is a major concern in sports. Sporting federations have introduced cut-off values for hematological variables to limit blood manipulations. To date, no reference margins have been established to adjust single- or multivariable blood tests to the exercise adapted blood cell system of athletes. We studied hemoglobin (Hb), hematocrit (Hct), blood cell variables and changes in vascular volumes in male and female national team cyclists to evaluate the influence of exercise on these variables and the results of blood tests, and to estimate normal ranges in athletes for blood tests.

METHODS

1628 blood samples of 169 male and 55 female athletes were considered. Samples were analyzed automatically, blood cell indices and vascular volumes were calculated. Overall averages and seasonal differences were estimated.

RESULTS

Hb-average was: 15.4 +/- 0.8 g dL(-1) for male and 13.9 +/- 0.7 g dL(-1) for female cyclists, Hct: 45 +/- 2.9% and 40.7 +/- 2.7%. Blood variables and vascular volumes showed significant seasonal changes. 1-6% of all samples were found above the currently used limits for blood testing. This is in accordance with the data from the normal population. Nevertheless, EPO misuse or blood manipulations cannot totally be excluded.

CONCLUSION

Athletes display seasonal adaptations in their blood profile which should be considered in testing regulations. The presented data might be used as reference values for indirect single- and multivariable blood tests.

Strategies for rhEPO detection in sport

This article examines available strategies for the detection of recombinant erythropoietin (rhEPO) abuse in sport. RhEPO was quickly recognized as an effective but hazardous performance-enhancing agent. In the absence of a valid procedure to detect rhEPO doping, at-competition health checks were introduced, which excluded athletes from competition when their hemoglobin or hematocrit values exceeded an arbitrary limit. This limited the danger to athletes, but did nothing to eliminate the use of rhEPO. Through the last decade, both direct and indirect methods for detecting rhEPO were investigated. No single indirect marker was found that satisfactorily demonstrated rhEPO use. A combination of blood and urine tests together formed the procedure and strategy approved by the International Olympic Committee (IOC) for detecting rhEPO use at the Sydney Olympics. However strategies for testing for EPO are as important as the developed laboratory analytical procedures. The use of extensive out-of-competition testing and analysis within the IOC accredited laboratory system is critical to any testing program. At-competition blood tests have merit as true health checks and will also be needed to detect acutely useful agents such as hemoglobin-based oxygen carriers. However the persistence of the "health check" rationale for on-site at-competition rhEPO testing has led to much wasted testing effort, as rhEPO use by athletes will rarely occur near to or at the time of the competition for fear of detection. Thus, direct testing methods (such as the rhEPO urine test) especially will fail due to the completed metabolism and elimination of administered rhEPO before the test, unless the international sporting federations use the information gathered to assist in targeted out-of-competition testing. This article discusses the limitations of testing at competition and proposed strategies for dealing with various phases of EPO doping in detail, concluding that no one single currently used strategy will detect all users of rhEPO. The development of strategies to diagnose rhEPO abuse may serve as a model to detect other biological agents.

Detection of DNA-recombinant human epoetin-alfa as a pharmacological ergogenic aid

The use of DNA-recombinant human epoetin-alfa (rhEPO) as a pharmacological ergogenic aid for the enhancement of aerobic performance is estimated to be practised by at least 3 to 7% of elite endurance sport athletes. rhEPO is synthesised from Chinese hamster ovary cells, and is nearly identical biochemically and immunologically to endogenous epoetin-alfa (EPO). In a clinical setting, rhEPO is used to stimulate erythrocyte production in patients with end-stage renal disease and anaemia. A limited number of human studies have suggested that rhEPO provides a significant erythropoietic and ergogenic benefit in trained individuals as evidenced by increments in haemoglobin, haematocrit, maximal oxygen uptake (VO2max) and exercise endurance time. The purpose of this review is to summarise the various technologies and methodologies currently available for the detection of illicit use of rhEPO in athletes. The International Olympic Committee (IOC) banned the use of rhEPO as an ergogenic aid in 1990. Since then a number of methods have been proposed as potential techniques for detecting the illegal use of rhEPO. Most of these techniques use indirect markers to detect rhEPO in blood samples. These indirect markers include macrocytic hypochromatic erythrocytes and serum soluble transferrin receptor (sTfr) concentration. Another indirect technique uses a combination of 5 markers of enhanced erythropoiesis (haematocrit, reticulocyte haematocrit, percentage of macrocytic red blood cells, serum EPO, sTfr) to detect rhEPO. The electrophoretic mobility technique provides a direct measurement of urine and serum levels of rhEPO, and is based on the principle that the rhEPO molecule is less negatively charged versus the endogenous EPO molecule. Isoelectric patterning/focusing has emerged recently as a potential method for the direct analysis of rhEPO in urine. Among these various methodologies, the indirect technique that utilises multiple markers of enhanced erythropoiesis appears to be the most valid, reliable and feasible protocol currently available for the detection of rhEPO in athletes. In August 2000, the IOC Medical Commission approved this protocol known as the 'ON model', and it was subsequently used in combination with a second, confirmatory test (isoelectric patterning) to detect rhEPO abusers competing in the 2000 Sydney Summer Olympics. This combined blood and urine test was approved with modifications by the IOC in November 2001 for use in the 2002 Salt Lake City Winter Olympics.