Patterns of Athlete Medication Use at the 2018 PyeongChang Paralympic Games: A Descriptive Cohort Study.

OBJECTIVE: Medication use among elite athletes has received growing attention over the past decades. However, only limited studies have focused on para athletes, and trends in medication use among this cohort remain unclear. The aims of this study were (1) to describe the pattern of medication use in elite Paralympic athletes, with a particular focus on analgesics, (2) to analyze whether medications declared by athletes were included in the 2018 World Anti-Doping Agency's prohibited list and monitoring program, (3) to report on a variety of novel supplements, and (4) to review whether athlete analgesic needs will be met by the new Olympic & Paralympic Model Formulary. DESIGN: This is a retrospective, descriptive cohort study. RESULTS: Of all athletes who underwent doping control, 21% declared the use of an analgesic medication. Athletes with limb deficiency and para snowboarders declared the most analgesic medications in their respective categories. It was determined that 84% of the athletes' analgesic medication needs were provided from the new Olympic & Paralympic Model Formulary. CONCLUSIONS: Analgesic use among athletes who participated at the 2018 PyeongChang Winter Paralympics was high. Para snowboarders and athletes with limb deficiency declared the most analgesics. The new Olympic & Paralympic Model Formulary adequately addressed the medication needs of the athletes attending the 2018 games.

Frequency and type of adverse analytical findings in athletics: Differences among disciplines.

Athletics is a highly diverse sport that contains a set of disciplines grouped into jumps, throws, races of varying distances, and combined events. From a physiological standpoint, the physical capabilities linked to success are quite different among disciplines, with varying involvements of muscle strength, muscle power, and endurance. Thus, the use of banned substances in athletics might be dictated by physical dimensions of each discipline. Thus, the aim of this investigation was to analyse the number and distribution of adverse analytical findings per drug class in athletic disciplines. The data included in this investigation were gathered from the Anti-Doping Testing Figure Report made available by the World Anti-Doping Agency (from 2016 to 2018). Interestingly, there were no differences in the frequency of adverse findings (overall,~0.95%, range from 0.77 to 1.70%) among disciplines despite long distance runners having the highest number of samples analysed per year (~9812 samples/year). Sprinters and throwers presented abnormally high proportions of adverse analytical findings within the group of anabolic agents (p < 0.01); middle- and long-distance runners presented atypically high proportions of findings related to peptide hormones and growth factors (p < 0.01); racewalkers presented atypically high proportions of banned diuretics and masking agents (p = 0.05). These results suggest that the proportion of athletes that are using banned substances is similar among the different disciplines of athletics. However, there are substantial differences in the class of drugs more commonly used in each discipline. This information can be used to effectively enhance anti-doping testing protocols in athletics.

Doping in the Ultimate Fighting Championship (UFC): A 4-year epidemiological analysis.

BACKGROUND: Doping is a practice that is present in many sports and organizations, including mixed martial arts and the Ultimate Fighting Championship (UFC). The aim of this study is to explore the epidemiological patterns of doping among UFC athletes. METHODS: We screened the official United-States-Anti-Doping-Agency® (USADA) website, the annual USADA reports and the official UFC website for information on fighters and anti-doping rule violations (ADRVs). Our dataset included gender, age, weight class, testing numbers, date of ADRV, type of ADRV, and duration of suspension. Appropriate statistical tests were conducted to assess for statistical significance. RESULTS: USADA tested 1070 UFC athletes 2624 times as of late 2015 up till the end of 2019 (N = 1070). A total of 209 adverse findings were recorded; out of which, 102 ADRVs were committed by 93 athletes (8.7%) from all weight divisions. This constituted an adverse finding rate of 16.55 per 1000 test and an ADRV rate of 8.08 per1000 test. Mean age of sanctioned athletes was 32 years. Use of anabolic steroids was significantly the most common ADRV recorded (p = 0.018). The men's heavyweight division had an ADRV rate of 19.3 per 1000 tests, significantly higher than that of women's bantamweight division at 2 per 1000 tests (p = 0.03), women's featherweight division at 0 per 1000 tests (p = 0.009), and men's flyweight division at 3 per 1000 tests (p = 0.035). ADRV rate showed a significantly increasing trend among men's weight divisions (p < 0.001). CONCLUSION: Doping is present in mixed martial arts. Increasing testing numbers, raising awareness and education on the risks of doping, and conducting further research on the issue is key to help resolve this problem.

Male Fertility Before and After Androgen Abuse.

PURPOSE: Previous research has found that male users of androgens are diagnosed approximately twice as often with infertility. We therefore set out to investigate the fertility in men using androgens. METHODS: The study included 545 males who tested positive for androgens in an anti-doping test program in Danish fitness centers during the period from January 3, 2006, to March 1, 2018. The confirmed androgen users were matched by birth year with 5450 male controls. We followed this cohort from 10 years prior to testing positive until the end of follow-up in May 2018. RESULTS: During the 10-year period prior to testing positive, the group of androgen users experienced a 26% lower fertility rate than the controls (rate ratio [RR] 0.74; 95% CI, 0.60-0.90; P = 0.0028). However, in the years following the doping sanction, they made a significant catch-up, and at completed follow-up the total fertility rate was only 7% lower than expected (RR 0.93, 95% CI, 0.84-1.03). The prevalence of assisted reproduction was 5.69% in the group of androgen users and 5.28% in the control group (P = 0.69). CONCLUSION: Androgen use was associated with a temporary decline in fertility and most androgen users achieved parenthood without any help from the health care system. Overall, the fertility rate and the prevalence of assisted reproduction among androgen users were close to those in the background population.

Endogenous transient doping: physical exercise acutely increases testosterone levels-results from a meta-analysis.

PURPOSE: Although endogenous testosterone levels are demonstrated to be affected by both acute exercise and resistance training, the dynamic regulation of androgen production after physical activity is still a matter of debate. This meta-analysis was designed to assess whether physical exercise acutely affects testosterone levels in men. METHODS: The literature search was conducted to identify longitudinal trials evaluating the acute change of both total testosterone (TT) and free testosterone (fT) after physical activity in adult men. Sensitivity analyses were performed considering the sample collected (blood or saliva), the intensity of the physical exercise and the interval between the end of the exercise and the sample collection. RESULTS: Forty-eight studies were included in the analysis, accounting for 126 trials. A total of 569 patients were enrolled (mean age 29.7 ± 13.1 years). The physical activity increased acutely TT (standardized mean difference 0.74, 95%CI: 0.56, 0.91 nmol/L), considering both serum and saliva samples (p < 0.001). Testosterone increased after moderate (p < 0.001) and high-intensity (p < 0.001) exercises, but not after mild physical activity (p = 0.19). Moreover, the testosterone increase was evident when measured immediately at the end of the exercise and within 30 min (p < 0.001), but not after 30 min (p = 0.930). Similar significant results were obtained considering fT, while SHBG did not change after physical activity (p = 0.090). CONCLUSION: The comprehensive evaluation of the acute physical activity effect on testosterone levels identified a clear increase after exercise, irrespective of the sample collected. The main determinant of this fluctuation was the exercise intensity, with a mechanism that seems to be mostly SHBG independent. In particular, moderate/intense physical activity resulted able to increase endogenous androgenic production, albeit acutely and transitory. TRIAL REGISTRATION NUMBER: PROSPERO registration ID: 157348.

Analysis of doping control test results in individual and team sports from 2003 to 2015.

Background: Determining the prevalence of doping in sport might be useful for anti-doping authorities to gauge the effectiveness of anti-doping policies implemented to prevent positive attitudes toward doping. Using questionnaires and personal interviews, previous investigations have found that the prevalence of doping might be different among different sports disciplines; however, there is no sport-specific information about the proportion of adverse and atypical findings (AAF) in samples used for doping control. The aim of the present investigation was to assess the differences in the frequency of adverse analytical and atypical findings among sports using the data made available by the World Anti-Doping Agency. Methods: The data included in this investigation were gathered from the Testing Figures Reports made available annually from 2003 to 2015 by the World Anti-Doping Agency. These Testing Figures Reports include information about the number of samples analyzed, the number of AAFs reported, and the most commonly found drugs in the urine and blood samples analyzed. A total of 1,347,213 samples were analyzed from the individual sports selected for this investigation, and 698,371 samples were analyzed for disciplines catalogued as team sports. Results: In individual sports, the highest proportions of AAF were 3.3% ± 1.0% in cycling, 3.0% ± 0.6% in weightlifting, and 2.9% ± 0.6% in boxing. In team sports, the highest proportions of AAF were 2.2% ± 0.5% in ice hockey, 2.0% ± 0.5% in rugby, and 2.0% ± 0.5% in basketball. Gymnastics and skating had the lowest proportions at (≤1.0%) for individual sports, and field hockey, volleyball and football had the lowest proportions for team sports (≤1.4%). Conclusion: As suggested by the analysis, the incidence of AAF was not uniform across all sports disciplines, with the different proportions pointing to an uneven use of banned substances depending on the sport. This information might be useful for increasing the strength and efficacy of anti-doping policies in those sports with the highest prevalence in the use of banned substances.

Are nutritional supplements a gateway to doping use in competitive team sports? The roles of achievement goals and motivational regulations.

OBJECTIVES: The study investigated the moderating role of achievement goals and motivation regulations on the association between self-reported nutritional supplement (NS) use, doping likelihood, and self-reported doping behaviour among competitive athletes. METHOD: Four hundred and ninety seven competitive team sport athletes (64% males; M age=23.54 years, SD=5.75) completed anonymous questionnaires measuring self-reported use of prohibited substances and licit NS; beliefs about the "gateway" function of NS; achievement goals; and motivational regulations. RESULTS: Hierarchical linear regression analysis showed that self-reported doping was associated (Adjusted R2=33%) with NS use, a stronger belief that NS use acts as a gateway to doping, amotivation, controlled motivation, mastery approach, and performance avoidance goals. Higher likelihood to use doping substances in the future was associated (Adjusted R2=41.7%) with current NS use, stronger belief that NS act as a gateway to doping, autonomous motivation, and performance avoidance goals. A series of moderated regression analyses showed that NS use significantly interacted with mastery approach, mastery avoidance, performance avoidance goals, autonomous motivation controlled motivation, and with amotivation in predicting self-reported doping. Finally, NS use significantly interacted with mastery approach goals, performance avoidance goals, and controlled motivation in predicting future doping likelihood. CONCLUSIONS: Achievement goals and motivational regulations are differentially associated with both doping likelihood and self-reported doping, and may account for the observed association between self-reported NS use and doping substances; thus, providing an alternative explanation to the "gateway hypothesis" that emphasizes the role of motivation.

Performance profiling as an intelligence-led approach to antidoping in sports.

The efficient use of testing resources is crucial in the fight against doping in sports. The athlete biological passport relies on the need to identify the right athletes to test, and the right time to test them. Here we present an approach to longitudinal tracking of athlete performance to provide an additional, more intelligence-led approach to improve targeted antidoping testing. The performance results of athletes (male shot putters, male 100 m sprinters, and female 800 m runners) were obtained from a performance results database. Standardized performances, which adjust for average career performance, were calculated to determine the volatility in performance over an athlete's career. We then used a Bayesian spline model to statistically analyse changes within an athlete's standardized performance over the course of a career both for athletes who were presumed "clean" (not doped), and those previously convicted of doping offences. We used the model to investigate changes in the slope of each athlete's career performance trajectory and whether these changes can be linked to doping status. The model was able to identify differences in the standardized performance of clean and doped athletes, with the sign of the change able to provide some discrimination. Consistent patterns of standardized performance profile are seen across shot put, 100 m and 800 m for both the clean and doped athletes we investigated. This study demonstrates the potential for modeling athlete performance data to distinguish between the career trajectories of clean and doped athletes, and to enable the risk stratification of athletes on their risk of doping.

Toward Prevention of Doping in Youth Sport: Cross-Sectional Analysis of Correlates of Doping Tendency in Swimming.

Doping is recognized as one of the most important problems in sports, but a limited number of studies have investigated doping problems in youth athletes. This study aimed to evaluate doping tendency (potential doping behavior (PDB)) and correlates of PDB in youth age swimmers. The participants were 241 competitive swimmers (131 females; 15.3 ± 1.1 years of age, all under 18 years old). Variables included predictors and PDB (criterion). Predictors consisted of sociodemographic factors (gender and age), sport-related variables (i.e., experience in swimming and sport achievement), variables explaining coaching strategy and training methodology, consumption of dietary supplements (DS), knowledge about doping, and knowledge about sports nutrition and DS (KSN). In addition to the descriptive statistics and differences between genders, a multinomial regression using PDB as the criterion (negative-, neutral-, or positive-PDB, with a negative-PDB as the reference value) was calculated to define associations between predictors and criterion. With only 71% of swimmers who declared negative-PDB results indicated an alarming figure. Boys with better KSN were more negatively oriented toward positive-PDB (OR: 0.77, 95%CI: 0.60-0.95). In girls, lower competitive achievement was evidenced as a risk factor for neutral-PDB (OR: 0.39, 95%CI: 0.24-0.63). Also, higher neutral-PDB (OR: 0.88, 95%CI: 0.81-0.96) and positive-PDB (OR: 0.90, 95%CI: 0.83-0.99) were identified in girls who began with intensive training in younger age. Because of the alarming figures of PDB, there is an evident need for the development of systematic antidoping educational programs in youth swimming. In doing so, focus should be placed on girls who began intensive training at an earlier age and those who did not achieve high competitive results.

Doping among high school students: findings from the French ESPAD survey.

BACKGROUND: The increasing use of doping by youth is a growing public health concern. The present study aimed to calculate robust estimates of the prevalence of doping among French high school students and study factors related to the use of licit vs. banned agents. METHODS: The European School Project on Alcohol and other Drugs (ESPAD), a nationally representative school-based survey, was distributed across France from April to May 2015, generating a final sample size of 6642 students. Multilevel modelling was used to examine covariates of doping to enhance athletic performance in sport in this population. RESULTS: Overall, 2.3% of students used banned agents, and 6.1% used licit and banned substances to improve athletic performance. Significant gender differences existed for both, with males more prone to doping than females. Our findings provide support for the existing gateway hypothesis that nutritional supplementation leads to doping banned agents. Multilevel modelling revealed the presence of both school and class-level influences on individual use of licit substances, vs. solely class-level factors impacting the use of banned agents, suggesting a strong peer-effect. CONCLUSIONS: These findings support the need to engage in early doping prevention through high schools. Programmes should draw attention to the role of licit substances, including nutritional supplementation, in the progression to using banned agents and encompass the continuum of adolescent risk taking through a behaviour-based approach to doping prevention.

The Potential of Specialized Media in Public Health: Analysis of Health-Related Content in Sports Newspapers.

Sports-specialized newspapers are one of the print media with the highest number of readers in Spain. However, little is known about the health coverage in this type of print press. The aim of the study was to analyze any health-related material in sports newspaper coverage and describe the main characteristics. This is an observational and cross-sectional study, performed in relation to the three most read daily Spanish sports newspapers (MARCA, AS, SPORT). A descriptive analysis was conducted to assess the health-related materials selected after a careful search over a period of 30 days. During this time, a total of 815 units of analysis were identified. On average, 14.79% (n = 645 pages) of the full content (n = 4362) included health-related material. The Liga BBVA section was the most frequent to contain health-related content by a significant margin (p = 0.01). The main covered topics were injuries to soccer players (52%), doping (21%), and other diseases in athletes or their relatives (8.6%) with no significant differences (p = 0.10). Photographs (87.4%) were the most frequent visual material used in the health content, followed by infographics (12.6%). Press releases were the most frequent source of information (58%). Spanish sports newspapers include a high proportion of health-related material, especially in terms of providing detailed descriptions of athletes' sport injuries, mainly related to soccer.

The team effect on doping in professional male road cycling (2005-2016).

This article questions organizations' (clubs, teams, etc) responsibility in doping use from the case of anti-doping rules violations (ADRVs) sanctioned by the Union Cycliste Internationale in professional cycling. We built a database with 271 caught riders among 10 551 professional riders employed from 2005 to 2016 in the three first world divisions. We developed a time-discrete event history model with a multilevel perspective to consider if the ADRV is related to the characteristic of a rider's career path (level 1) and/or the team by which the rider is employed (level 2). Our results confirm two hypotheses: Beginning a career before 2005 or after the age of 22 increased the risk of being caught. Each additional year in the pack increased the risk, despite the fact that a sanctioned rider's career duration average is 7.8 years (3.9 for the others). These caught riders have experienced a more tumultuous career with team changes and an interrupted path. A 2.45 Median Odds Ratio led us to assert a team effect on ADRV. By a team residual effect calculation, we identify 17 teams with a significant effect within the 129 that experienced an ADRV. Our results allow us to emphasize that to understand doping we must take into account work and employment condition, as well as team's organization. This approach completes the dominant "methodological individualism" perspective that considers athletes as analytical units and provides guidelines to the anti-doping bodies that focus their action on individuals.

[Interdisciplinarity in research on health issues]. / De l'interdisciplinarité dans la recherche sur des dossiers sanitaires.

The text sets out to examine so-called "interdisciplinary" research practices when researchers work on health issues. The article specifies the author's approach, which departs from both a normative posture and a purely epistemological approach, instead opting to study an interdisciplinary act in progress. Based on an ANR report led by Trabal, Collinet and Terral (2014), the research presented mobilizes the latest developments in socio-informatics to examine forms of interdisciplinarity in two areas - doping and obesity. It appears that the research on doping is marked by strong asymmetries between disciplines, and that "true" interdisciplinarity is often postponed when it does not seem to lend itself to a simple mode of coordination. In the case of obesity, we observe that practices are marked by staging and display work; the demand for interdisciplinarity is combined with a desire to structure a professional identity. In all cases, we were able to identify some trails that have been blazed to enable researchers to respond jointly to disciplinary and interdisciplinary injunctions. The promise is an interesting figure that relies on a postponement of proof, made possible by weak codification of interdisciplinarity.

Adverse cardiovascular effects of doping in athletes.

The use of doping substances and methods is prevalent not only among elite athletes, but also among amateur athletes and other athletes. However, the abuse of substances and methods of doping has been associated with the occurrence of numerous adverse health effects. Cardiovascular effects are the most deleterious. The objective of this manuscript is to study through a review the literature, adverse cardiovascular effects after the abuse of substances and doping methods in athletes. Three major classes of products have more cardiovascular side effects; they are anabolic, stimulants and narcotics. It is possible to predict their use according to the desired objectives. Anabolic doping is used by sportsmen who practice strength sports, stimulants are used by those who practice speed sports, while endurance sportsmen prefer products that improve the transport of oxygen. Cases of myocardial infarction, hyperlipidemia, hypertension, venous thrombosis, arrhythmogenesis, heart failure and sudden cardiac death have been observed. The doping substances of varied nature seem to have adverse cardiovascular effects whose physiopathology remains a research and investigation track. Further randomized trials are needed to better understand the interaction of these doping substances taken in a combined way in athletes.

Identification of Factors Associated with Potential Doping Behavior in Sports: A Cross-Sectional Analysis in High-Level Competitive Swimmers.

Background: Doping behavior, including the misuse of performance-enhancing drugs, is currently a serious problem in sports, and the efficacy of preventive efforts directly depends on information regarding the associations among different precipitating factors (PF) and doping behavior. This study aimed to establish the PF of potential doping behavior (PDB) in competitive swimmers. Methods: The study included 301 swimmers from Slovenia (153 females, 16.4 ± 2.4 years), tested during the 2017 National Championship. Variables were collected by previously validated questionnaires, which included questions on sociodemographics, sports-related factors, consumption of dietary supplements, knowledge of doping, factors of hesitation, and doping-related factors (i.e., number of doping tests, opinion about the presence of doping in sport). The PDB (positive, neutral, or negative intention toward doping) was observed as a criterion, while other variables were included as predictors in multinomial regression analyses (with "negative" as reference value), which additionally controlled for gender and age category (cadet-, junior-, and senior-level) as confounders. Results: The results confirmed higher susceptibility to doping in males (positive: odds ratio (OR): 2.77, 95% confidence interval (CI): 1.27⁻6.04), those swimmers who reported higher alcohol consumption (neutral: OR: 2.18, 95%CI: 1.06⁻4.16, positive: OR: 2.14, 95%CI: 1.05⁻4.37), and those regularly used dietary supplements (positive: OR: 3.62, 95%CI: 1.25⁻10.52). Competitive achievement in Olympic- (neutral: OR: 0.57, 95%CI: 0.41⁻0.81, positive: OR: 0.59, 95%CI: 0.39⁻0.88), and non-Olympic disciplines (positive: OR: 0.54, 95%CI: 0.35⁻0.83) was protective against PDB. Swimmers who were more concerned about the negative social consequences of doping behavior (i.e., condemnation by family and friends) were less likely to declare a positive intention toward the PDB (family condemnation: OR: 0.69, 95%CI: 0.56⁻0.86, friends' condemnation: OR: 0.65, 95%CI: 0.52⁻0.80). Conclusions: The results of the study provide more precise insight into the specific factors associated with PDB in swimming. The established precipitating factors should be incorporated into targeted anti-doping campaigns in this sport.

Doping risk and career turning points in male elite road cycling (2005-2016).

OBJECTIVES: Determine whether career paths of elite male professional riders explain the risk of being sanctioned for an Anti-Doping Rules Violation through the International Cycling Union. DESIGN, METHODS: A discrete-time logit model explored the link between career path and ADRV risk in a database of 10,551 riders engaged in the first three world divisions (2005-2016), including 271 sanctioned riders. RESULTS: Despite a longer career (7.8years), sanctioned riders have a precarious path. The odds of finding a sanctioned rider within those who experienced a career interruption is 5.80 times higher than for a non-caught one. 61% of the caught riders have experienced a team change. The odds of finding a caught rider within those who experienced such a change is 1.35 times higher. 44% of caught riders start before 23years, vs 34% for non-sanctioned ones. The odds of being sanctioned are 1.69 times higher for doped riders beginning before 23. The odds of finding a sanctioned rider are 1.94 times higher among those starting their careers before 2005 (establishment of Pro Tour), than those who started in 2008 or after. In that year, the Cycling Anti-Doping Foundation and the biologic passport were both launched. CONCLUSIONS: Caught riders could have extended their more precarious careers with doping. The post-2005 generation effect could mean that riders are cleaner or slicker at hiding doping. The higher risk of being caught for riders starting after 23 might indicate that an early professional socialization reduces the risk by teaching them to be cleaner, or better at hiding doping.

The use of steroids by gym athletes: an attempt to diagnose the problem scale and possible causes.

BACKGROUND: Anabolic-androgenic steroids (AAS) are said to be frequently used by both professional and amateur athletes. In addition to having a negative impact on health, steroids defy the concept of fair play. The aim of the study was to evaluate the scale of the problem related to using anabolic-androgenic steroids (AAS) by gym athletes and to analyze possible causes. METHODS: The study involved 435 participants aged between 18-66 (mean age 27.49±7.48). Out of them, 61.4% were male and 38.6% were female. The subjects were divided into two groups: Group A included 154 (35.4%) amateur and recreational athletes and group B included 281 (64.6%) professional athletes concerned with fitness, bodybuilding and powerlifting. A survey prepared by the authors was conducted in the study, and it consisted of 23 closed questions about AAS use, body confidence, and exercise dependence. In addition, a stadiometer and a body composition analyzer were utilized to take necessary measurements. RESULTS: Between 1-23% of group A participants admitted to using AAS. For group B, it was between 7-30%. Males were reported to use AAS more frequently than females in both groups. With regard to group A, differences in body confidence and exercise dependence were found between males using and not using AAS. Exercise dependence was reported to be different between group A and group B participants. This was true for both males and females. Also, it was shown that group A and group B females differed in terms of metabolic age, body mass and body composition (fat mass, fat-free mass, muscle mass, and total body water). CONCLUSIONS: Most gym athletes do not use AAS. Amateur athletes tend to use AAS more frequently than professional athletes. Factors that contribute to AAS use are: male gender, low body confidence, young age, and long training.

Doping in Two Elite Athletics Competitions Assessed by Randomized-Response Surveys.

BACKGROUND: Doping in sports compromises fair play and endangers health. To deter doping among elite athletes, the World Anti-Doping Agency (WADA) oversees testing of several hundred thousand athletic blood and urine samples annually, of which 1-2% test positive. Measures using the Athlete Biological Passport suggest a higher mean prevalence of about 14% positive tests. Biological testing, however, likely fails to detect many cutting-edge doping techniques, and thus the true prevalence of doping remains unknown. METHODS: We surveyed 2167 athletes at two sporting events: the 13th International Association of Athletics Federations Word Championships in Athletics (WCA) in Daegu, South Korea in August 2011 and the 12th Quadrennial Pan-Arab Games (PAG) in Doha, Qatar in December 2011. To estimate the prevalence of doping, we utilized a "randomized response technique," which guarantees anonymity for individuals when answering a sensitive question. We also administered a control question at PAG assessing past-year use of supplements. RESULTS: The estimated prevalence of past-year doping was 43.6% (95% confidence interval 39.4-47.9) at WCA and 57.1% (52.4-61.8) at PAG. The estimated prevalence of past-year supplement use at PAG was 70.1% (65.6-74.7%). Sensitivity analyses, assessing the robustness of these estimates under numerous hypothetical scenarios of intentional or unintentional noncompliance by respondents, suggested that we were unlikely to have overestimated the true prevalence of doping. CONCLUSIONS: Doping appears remarkably widespread among elite athletes, and remains largely unchecked despite current biological testing. The survey technique presented here will allow future investigators to generate continued reference estimates of the prevalence of doping.