When Teen Boys Use Supplements

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“I’ve started cutting,” my son, a college freshman, recently told me. He meant he was temporarily restricting calories to lose body fat as part of his new focus on bodybuilding. He planned to alternate cutting with “bulking,” or building up muscle mass, aided by over-the-counter supplements like protein powder and creatine.

Everything he was doing was legal, but was it safe? I also have a teenage daughter, and I was attuned to body-image-related issues affecting girls. But I realized the risks for teenage boys were equally worrisome and decided to check with several experts.

Supplement use is widespread

“Almost a third of boys are trying to gain weight or bulk up,” said Dr. Jason Nagata, an assistant professor of pediatrics at the University of California, San Francisco.

Many turn to protein supplements in an attempt to do so. In a 2012 study in the journal Pediatrics, 38.8 percent of high-school boys reported using protein powders or shakes in the previous year.

However, “there’s no evidence that using protein powder is better than getting protein naturally from your food,” said Dr. Pieter Cohen, an internist with Cambridge Health Alliance who’s done extensive research on dietary supplements.

Some protein supplements may provide excessive calories, said Dr. Michele LaBotz, a sports medicine physician in Portland, Maine, and the lead author of “Use of Performance-Enhancing Substances,” a 2016 clinical report by the American Academy of Pediatrics. Building muscles requires just 500 additional daily calories, she said; beyond that, “all of those extra calories … go straight to fat.”

Another popular supplement is creatine, used by close to 17 percent of 12th-grade males, according to the 2016 Monitoring the Future survey. It can boost short-burst performance and increase muscle mass by encouraging water uptake into muscles, said Dr. Matthew Silvis, division chief for primary care sports medicine at Penn State Health Milton S. Hershey Medical Center. “You get bigger muscles because you’re getting more water in your muscles,” he said.

Dr. Silvis was a co-author of a 2018 review of creatine use in sports in the journal Sports Health, which concluded that short-term use of creatine is generally safe, but cautioned that it has been studied only in adults, which the A.A.P. report also noted. “For adolescents, we don’t have any reason to think that it would be unsafe, but it’s not been studied,” he said.

What’s in that supplement?

More concerningly, supplements may contain harmful substances, including some that have been banned. As lead author of a study published in 2018 in the journal Clinical Toxicology, Dr. Cohen found that both pre-workout and weight loss supplements contained what he termed a “cocktail” of experimental stimulants. He also cautions against muscle-building blends, which he considers equally dangerous.

The side effects can be quite serious: A study published last year in the Journal of Adolescent Health found muscle-building supplements nearly three times more likely than vitamins to cause severe medical events including emergency room visits, hospitalizations and death.

“This could be the tip of the iceberg in terms of the kinds of adverse events that are happening,” said S. Bryn Austin, the report’s co-author and the director of the strategic training initiative for the prevention of eating disorders at the Harvard T.H. Chan School of Public Health. She’s working with legislators in Massachusetts and New York on pending bills to ban sales of weight loss or muscle-building supplements to minors in those states.

Better approaches

Instead of supplements, teens are better off focusing on the basics. “Training, nutrition and sleep need to come first,” said Disa Hatfield, associate professor and chair of the department of kinesiology at the University of Rhode Island. “Unless you can say yes to all of those things, supplements should be off the table.”

Dr. Hatfield has firsthand knowledge: a former powerlifter, she was ranked fifth overall in the 2009 World Games in the heavyweight class. She’s no longer competing but still lifts recreationally.

She recommends “a good solid resistance strength and conditioning or resistance training program,” along with a coach or trainer certified through the American College of Sports Medicine or the National Strength and Conditioning Association. Just going to the gym “does not mean you’re going to get stronger,” she said.

Also important: adequate recovery, including sleep. Especially during competition times, she said she tried to get at least eight hours of sleep. Your muscles are “constantly breaking down and rebuilding to be better and bigger and stronger. And especially when it comes to muscle mass and protein synthesis, nighttime is a pretty important part of that.”

During the recovery period, teens should eat about 20 to 30 grams of protein every few hours and before bed, Dr. LaBotz said. “There’s an additional kind of bump in muscle protein synthesis that sets higher during the post-workout phase,” she said, “so there’s this synergy between working out and protein ingestion that actually can really facilitate synthesis of new muscle.”

She also encourages teens to eat enough carbohydrates before working out so they don’t sabotage their efforts. Otherwise, “your body’s going to start to break that muscle down for fuel.”

As a resource for teens and parents, Dr. Cohen recommends the United States Anti-Doping Agency’s nutrition guide.

When to be concerned

In a recent study published online on May 18 in the journal JAMA Pediatrics, Dr. Nagata and colleagues found that young men who took creatine and other similar supplements were three times more likely than nonusers to be using anabolic steroids seven years later. “Some of these performance enhancing substances, which may be legal, can serve as sort of gateway drugs to steroid use,” he said.

Dr. Nagata, whose clinical practice focuses on adolescent eating disorders, has also found that male college students who used supplements were more likely to have disordered eating behaviors and attitudes, including restricting their diets and exercising compulsively.

Eating disorders in general are generally underrecognized in males, he said, which can lead to delays in diagnosis.

Dr. Nagata also cautioned that weight lifting and exercise can evolve into an obsession with being hypermuscular. “There’s something called muscle dysmorphia, which is commonly known as reverse anorexia or ‘bigorexia,’” he said. Regardless of how the person actually looks, he said, “they feel like they are insufficiently muscular.”

Keep the lines of communication open

Above all, it’s important for parents to talk with their kids about using supplements and working out and be aware if their behavior seems to be intensifying.

“I strongly advise parents of adolescents to have a very open conversation with their teenagers,” Dr. Cohen said, and “not be judgmental.”

He added: “Unless you’re an elite athlete, there’s no need to take extra protein or amino acids or anything else … but that often doesn’t stop teenagers from wanting to try this stuff because their friends might be using it, or a coach might say, ‘Hey, you should bulk up.’ So the next step is explaining that there are different levels of risk of the products that are out there.”

As for my son, he’s back home because of the shutdown and has taken over the back porch with his collection of free weights. To my relief, he’s stopped taking supplements other than protein and he’s also given up on cutting: As he explained last weekend, he realized he doesn’t enjoy the level of training and dietary restriction, and the accompanying chronic hunger, required for competitive bodybuilding.

Lisa L. Lewis is a California-based writer covering parenting, public health and education. She’s currently working on a book about adolescents and sleep.