{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T06:15:07Z","timestamp":1783577707042,"version":"3.55.0"},"reference-count":55,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2020,12,15]],"date-time":"2020-12-15T00:00:00Z","timestamp":1607990400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"name":"Pediatric Scientist Development Program","award":["K12HD000850-33"],"award-info":[{"award-number":["K12HD000850-33"]}]},{"DOI":"10.13039\/100000968","name":"American Heart Association","doi-asserted-by":"crossref","award":["CDA34760281"],"award-info":[{"award-number":["CDA34760281"]}],"id":[{"id":"10.13039\/100000968","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["MH115184"],"award-info":[{"award-number":["MH115184"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development","award":["P01-HD31921"],"award-info":[{"award-number":["P01-HD31921"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Legal performance-enhancing substances (PES), such as creatine, are commonly used by adolescents and young adults. As PES are mostly unregulated by the US Food and Drug Administration, there has been limited empirical attention devoted to examining their long-term safety and health outcomes. Preliminary studies have demonstrated associations between PES use and severe medical events, including hospitalizations and death. PES could be linked to cardiovascular disease (CVD), the most common cause of mortality in the US, by altering the myocardium, vasculature, or metabolism. The objective of this study was to examine prospective associations between the use of legal PES in young adulthood and CVD risk factors at seven-year follow-up.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Materials and methods<\/jats:title>\n<jats:p>Nationally representative longitudinal cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves III (2001\u20132002) and IV (2008), were analyzed. Regression models determined the prospective association between the use of legal PES (e.g. creatine monohydrate) and CVD risk factors (e.g. body mass index, diabetes, hypertension, hyperlipidemia), adjusting for relevant covariates.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Among the diverse sample of 11,996 male and female participants, no significant differences by PES use in body mass index, diabetes, hypertension, or hyperlipidemia were noted at Wave III. In unadjusted comparisons, legal PES users (versus non-users) were more likely to be White, be male, be college educated, drink alcohol, and engage in weightlifting, exercise, individual sports, team sports, and other strength training. There were no significant prospective associations between legal PES use at Wave III and body mass index, hemoglobin A1c, systolic and diastolic blood pressure, and cholesterol (total, HDL, LDL, triglycerides) deciles at seven-year follow-up (Wave IV), adjusting for demographics, health behaviors, and Wave III CVD risk factors. Similarly, there were no significant prospective associations between legal PES use and diabetes, hypertension, or hyperlipidemia based on objective measures or self-reported medications and diagnoses, adjusting for demographics, health behaviors, and Wave III CVD risk.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>We do not find evidence for a prospective association between legal PES use and CVD risk factors in young adults over seven years of follow-up, including BMI, diabetes, hypertension, or hyperlipidemia. It should be noted that legal PES use was operationalized dichotomously and as one broad category, which did not account for frequency, amount, or duration of use. Given the lack of regulation and clinical trials data, observational studies can provide much needed data to inform the safety and long-term health associations of legal PES use and, in turn, inform clinical guidance and policy.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0244018","type":"journal-article","created":{"date-parts":[[2020,12,15]],"date-time":"2020-12-15T19:25:11Z","timestamp":1608060311000},"page":"e0244018","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Associations between legal performance-enhancing substance use and future cardiovascular disease risk factors in young adults: A prospective cohort study"],"prefix":"10.1371","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6541-0604","authenticated-orcid":true,"given":"Jason M.","family":"Nagata","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3889-3716","authenticated-orcid":true,"given":"Kyle T.","family":"Ganson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitchell L.","family":"Cunningham","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deborah","family":"Mitchison","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason M.","family":"Lavender","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron J.","family":"Blashill","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Holly C.","family":"Gooding","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stuart B.","family":"Murray","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2020,12,15]]},"reference":[{"key":"pone.0244018.ref001","doi-asserted-by":"crossref","first-page":"1019","DOI":"10.1542\/peds.2012-0095","article-title":"Muscle-enhancing behaviors among adolescent girls and boys","volume":"130","author":"ME Eisenberg","year":"2012","journal-title":"Pediatrics"},{"key":"pone.0244018.ref002","article-title":"Prevalence and correlates of muscle-enhancing behaviors among adolescents and young adults in the United States","author":"JM Nagata","year":"2020","journal-title":"Int J Adolesc Med Heal"},{"key":"pone.0244018.ref003","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/S2352-4642(19)30345-1","article-title":"A call for public policy and research to reduce use of appearance and performance enhancing drugs and substances among adolescents","volume":"4","author":"KT Ganson","year":"2020","journal-title":"Lancet Child Adolesc Heal"},{"key":"pone.0244018.ref004","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1542\/peds.111.1.67","article-title":"Overeating among adolescents: prevalence and associations with weight-related characteristics and psychological health","volume":"111","author":"DM Ackard","year":"2003","journal-title":"Pediatrics"},{"key":"pone.0244018.ref005","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1001\/archpsyc.57.2.133","article-title":"Effects of supraphysiologic doses of testosterone on mood and aggression in normal men: A randomized controlled trial","volume":"57","author":"HG Pope","year":"2000","journal-title":"Arch Gen Psychiatry"},{"key":"pone.0244018.ref006","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1016\/j.drugalcdep.2010.04.020","article-title":"Use of anabolic androgenic steroids in substance abusers arrested for crime","volume":"111","author":"L Lundholm","year":"2010","journal-title":"Drug Alcohol Depend"},{"key":"pone.0244018.ref007","first-page":"411","article-title":"Androgenic anabolic steroid abuse and the cardiovascular system","author":"P Vanberg","year":"2010","journal-title":"Handbook of Experimental Pharmacology. 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