Lauren Fleshman speaks out- "I definitely do think that's an ethical violation."

In high school, the kids with asthma were the back if the packers.

Now it seems like it's almost been a prerequisite to make a WC or Olympic team.

If your going to say thyroid meds and inhalers are illegal then you have to also include antidepressants and Adderall. How many people/parents go to their PCPs and cry depression and ADHD so they or their children can get ahead. No testing is ever performed to confirm a diagnosis. Of course you will be able to train harder if you're have depression or ADHD. Where do you draw the line.

yuppie tent user wrote:

Reberathing wrote:

Not real altitude training in other words. Faking it.

Correct. The generator partially simulates altitude conditions. It does not duplicate them. Some studies have shown that using a tent is slightly less effective at stimulating RBC production and related physical effects than actual altitude training. It is a good but not perfect alternative for those of us who have things like jobs and families that prevent us from moving to an altitude training location.

This is not the point of altitude for a determined cheater. The point is to move to and from altitude so your blood values are irregular to mask doping. Add an extra bonus to the altitude loophole. You can extract blood at altitude for undetectable reinfusion later.

If there isn't a 'living at altitude' thread already, the science is inconclusive.

I'm not saying I think she's suddenly a liar because she's a model, or that models don't have integrity. I'm just saying, as others have suggested on this thread, she has become a bit more of a PR hound in recent years, which makes me question what she puts out there and why she is putting it out there. In general, if someone is desperate to get their message and name out there, I'm naturally less eager to consume what they're saying.

(But that is not to say I think she doesn't have good intentions in putting this out there and providing a fuller picture of Salazar and his gray area. I'm glad she said what she said, and clearly many others agree.)

Goucher and Fleshman seem to offer two very different stories about why Salazar likes thyroid meds. Goucher says it's about weight loss. Fleshman says it's about allowing harder training, whether in the form of more grueling workouts or altitude tents.

Are these the only reasons why elite runners would use thyroid meds? (I seem to recall some discussion about synergies between thyroid meds and steroids.)

Do either or both of these explanations make sense medically or physiologically? Is there any systematic evidence for either or both of these effects?

What are the costs of using thyroid supplements this way? Does such use suppress the thyroid, thus requiring long term medication?

Do we have any idea how widespread thyroid use is among elite runners? Is it just a NOP thing, or are others doing it?

PS As far as I can see, none of the big three thyroid meds are on the 2015 Prohibited List. The Doping Code says nothing about getting unnecessary prescriptions for otherwise allowed substances. So it seems that thyroid meds fall completely in the gray area. Their use is consistent with the Code, but they may not pass the smell test by being against the spirit of the sport.

I feel like itsbeen a while so this isn't a troll post, but when was Fleshmans last race? Where is her next race? Where does she currently train?

( i don't follow females as much as males )

Bleu wrote:

If your going to say thyroid meds and inhalers are illegal then you have to also include antidepressants and Adderall. How many people/parents go to their PCPs and cry depression and ADHD so they or their children can get ahead. No testing is ever performed to confirm a diagnosis. Of course you will be able to train harder if you're have depression or ADHD. Where do you draw the line.

By "Illegal" I assume you mean "banned by the doping code," not "against the law."

ADHD meds based on amphetamines are covered by the WADA code, which bans all stimulants, including "those not expressly listed." Non-stimulant ADHD meds may also be covered, depending on their mechanism of action.

That we can't always draw bright lines, or enforce those lines easily, does not mean that rules are useless, or that all rules can be evaded..It simply means that there may always be some gray areas in which reasonable people may agree, and/or that it will be impossible to detect all cheating.

Either, neither or both? wrote:

So it seems that thyroid meds fall completely in the gray area. Their use is consistent with the Code, but they may not pass the smell test by being against the spirit of the sport.

For sure. Their use as a PED was summarized as inconclusive the last time I read anything on the topic. But, I am very late to know on most of the useful PED stuff.

Some PEDs really mess with your thyroid function. I don't remember what the well-known PEDs are that do this.

Makes sense. Thanks.

The messages each got was likely tailored to her perceived personal needs. If Kara looked a little heavy as a new mother, Salazar might have been inclined to sell thyroid hormone as a weight-loss panacea. In Fleshman's case, weight wasn't her issue but fatigue.

Keep in mind that thyroid hormone, like a lot of hormones, actually has a panoply of effects on metabolism, not just a few localized ones. I found this skeptical piece written by a pharmacist in 2013 interesting (I should probably post it in its own thread):

Is thyroid replacement a performance-enhancing drug?

Has one physician uncovered the secret to Olympic Gold medals? And is that secret as simple as undiagnosed low thyroid function? That’s the question posed in a recent Wall Street Journal column entitled U.S. Track’s Unconventional Physician (http://online.wsj.com/article/SB10001424127887323550604578412913149043072.html). Like the story that Steven Novella described yesterday, this narrative describes the medical practice of Dr. Jeffrey S. Brown, who sees thyroid illness where others see normal thyroid function. He has his critics, but his high-profile athlete patients have won a collective 15 Olympic gold medals. Case closed & Q.E.D.? Not quite. The WSJ actually does a pretty good job questioning the validity of Brown’s claims, which are far removed from the current medical consensus:

In athletic circles, Brown is a medical hero. He’s a paid medical consultant to Nike. The most renowned running coach at Nike, Alberto Salazar, calls Brown the best sports endocrinologist in the world. And athletes in growing numbers are coming to share Brown’s belief that heavy training can suppress the body’s production of the thyroid hormone, leaving them too exhausted to perform at peak. On the wall of the medical office of Jeffrey S. Brown is a photograph of Carl Lewis, the nine-time Olympic gold medalist. Lewis is one of several former or current patients of Brown’s who have climbed the Olympic podium, including Galen Rupp, who won a silver medal in the 10,000 meters at the London Olympics. “The patients I’ve treated have won 15 Olympic gold medals,” said Brown. Among endocrinologists, Brown stands almost alone in believing that endurance athletics can induce early onset of a hormonal imbalance called hypothyroidism, the condition with which he diagnosed Lewis and Rupp. Brown said he knows of no other endocrinologists treating athletes for hypothyroidism, a fatigue-causing condition that typically strikes women middle-aged or older. Several endocrinology leaders had never heard of hypothyroidism striking young athletes.

Now when I read “unconventional” and “stands alone” my skeptical alarm starts ringing. There is no shortage of debate about thyroid disease, ranging from the utter nonsense offered by “alternative health” practitioners to valid scientific discussions about the thresholds where normal function is considered abnormal and subject to treatment. Brown is an endocrinologist, however, and he’s treating elite athletes who are pushing their physical conditioning far beyond that seen by most medical doctors and almost all endocrinologists. So what’s the basis of the concern? The WSJ story goes on to discuss two different issues: What the proper threshold is for thyroid disease, and whether thyroid replacement is performance enhancing. Let’s take each of these in turn. I’ve covered thyroid diseases and its related pseudoscience before, and a summary of the standard approach is necessary before we look at the some of the broader questions that have emerged from the story. All I know about these patients is what the WSJ is describing, so for the sake of brevity I’m going to focus on the types of cases that Dr. Brown appears to be identifying and ignore other causes of thyroid disease, which would require different treatment approaches.

The Diseased Thyroid

Simplistically, they thyroid gland acts as a sort of thermostat for the body. If it runs too high, you’re hyperthyroid: heat intolerant, anxious, a high heart rate, and maybe some diarrhea. If it runs low, you’re hypothyroid: cold, tired, constipated, and possibly even depressed. These multi-organ effects are triggered by the presence or absence of two thyroid hormones: thyroxine (T4) and liothyronine (T3). Normal thyroid function is something you never notice. But low thyroid function is common (4-10 % of adults), particularly in women. The overwhelming majority of cases (95%) of low thyroid, or hypothyroidism are primary, and the major cause of primary hypothyroidism (in parts of the world where we get adequate iodine) is autoimmune thyroid disease (Hashimoto thyroiditis). That is, the body attacks its own thyroid. As the thyroid’s function decreases, and T4 levels drop, the pituitary releases thyroid stimulating hormone – it’s effectively trying to “turn up the thermostat” to continue my analogy. A highly elevated TSH signifies thyroid dysfunction. There are other tests that can be done to confirm the diagnosis, including measurements of circulating T4 and antibody measurements, but TSH is the test we rely on as the primary diagnostic test.

Like any laboratory measurement, what’s considered a “normal” TSH is based in part on clinical studies, but also on the testing standard. Most labs identify an upper limit of TSH at 4 to 5 mU/L, but there are proponents of both higher and lower thresholds. Consequently there will be variations in practice between physicians in what they consider a “high” TSH and what’s considered “normal”. There is also some debate about a condition called “subclinical hypothyroidism”, where there are some laboratory signs of a thyroid dysfunction (a “normal” T4 and a slightly elevated TSH), but it’s not sufficient to warrant a diagnosis. A Cochrane Review suggested that treating subclinical hypothyroidism doesn’t seem to result in meaningful differences in symptoms or quality of life, nor does it decrease cardiovascular morbidity. But neither did these studies look at the performance impact in elite athletes.

Not unexpectedly, Dr. Brown is a proponent of a using a low threshold to diagnose thyroid disease, setting a threshold that most endocrinologists consider normal:

According to American College of Endocrinology literature, the range of normal TSH level is broad, from 0.5 to an upper limit of near 5, depending on a patient’s gender, age and other factors. In practice, many endocrinologists consider TSH levels above 4—combined with symptoms such as fatigue—evidence of an underactive thyroid. Brown and a small camp of other endocrinologists argue that thyroid insufficiency can be signaled by a TSH level as low as 2, for which Brown cites some recently published research. By their standards, about 10% of the population is hypothyroid—double the 5% that is cited by mainstream endocrinology. Jeffrey Garber, American College of Endocrinology president, said hypothyroidism increasingly is being diagnosed in people who don’t have it, by endocrinologists whom Garber labeled as “alternative.” “The alternative crowd is saying, ‘Gee, this is why you’re not feeling better, because these [mainstream] doctors are clueless,’ ” Garber said. So if this reporting is accurate, Brown is looking at the same test results and seeing what he believes to be thyroid disease, where his peers see normal thyroid function.

Perhaps not surprisingly, Brown has his defenders, including bloggers who rail against “mainstream” endocrinologists who “stubbornly cling to the outdated ideas that hypothyroidism is easy to diagnose”. Sound like familiar rhetoric? It will if you’re a regular reader of this blog – every “maverick” physician will invariably have their defenders. But they’re usually not Olympic gold medalists:

Medical privacy rules forbid Brown from naming all the athletes he has treated for that condition. But among those who have publicly acknowledged being treated for thyroid problems by Brown or unnamed other physicians are American runners Ryan Hall, Galen Rupp, Amy Yoder Begley, Bob Kennedy and Patrick Smyth. “I knew hypothyroidism was kind of like something that was being diagnosed more among elite runners,” said Smyth, a marathoner who in 2011 started feeling chronically tired. When a physician near his California home found no evidence of thyroid dysfunction, Smyth flew to Houston to see Brown, who conducted some blood tests and diagnosed him with the condition. Smyth, now retired, said the medication never enhanced his performance.

The WSJ suggests that there may be some relationship between the rigorous training and the thyroid function itself, in which case the thyroid supplementation is simply restoring “normal” function. This seems to be what Brown believes, seeing dysfunction where other physicians see normal thyroid activity. Setting aside whether or not these athletes actually do have “low” thyroid, we can ask if thyroid treatment is actually offering a performance benefit when administered to patients with a TSH between what appears to be Brown’s cutoff of 2 and the standard cutoff of 4 or 5. Certainly Brown thinks so, or he wouldn’t be prescribing thyroid replacement. Given the extent to which these athletes push their bodies, even a subtle amount of fatigue, if ameliorated, could potentially improve performance. And overtraining leading to fatigue is likely a risk for athletes training at this intensity. From this perspective, it raises the question of whether thyroid replacement can be considered a form of doping – a recovery-enhancement or fatigue-deferring boost not available to athletes who didn’t go see Dr. Brown. T4 is a hormone, after all, and it will have effects on fatigue and recovery from exercise.

One of the differences that thyroid replacement has from other forms of sports supplementation is that there is a clear peak point – normal thyroid function. Thyroid replacement in the absence of real deficiency could create a hyperthyroid state which would possibly hurt athletic performance as much a hypothyroidism. Overt hyperthyroidism causes anxiety, insomnia, weakness, perspiration, and mood swings – nothing an athlete wants. Even subtle hyperthyroidism could have negative effects for elite athletes. And the long-term consequences are significant. Thyroid replacement is a life-long commitment. And long-term it has side effects including cardiovascular and bone risks – excess thyroid is a definite “bone eater”, with bone resorption stimulated and osteoporosis being the result.

Conclusion

The Wall Street Journal‘s profile of Dr. Brown and his unorthodox management of elite athletes raises interesting questions about the basis of disease, the conditions for drug treatment, and the implications on the ethics of sports. Over time, thyroid replacement could go one of two ways. It could continue to be treated like inhaled anti-asthma medications, where asthmatic athletes who require treatment would otherwise be at a serious disadvantage in athletic competitions. We’d consider this simply a leveling of the playing field for those athletes. Or it could be that thyroid replacement could be scrutinized even more closely, perhaps requiring better documentation to justify use in an athlete, requiring clearly-demonstrated medical need based on a specific set of parameters, recognizing that there’s thyroid replacement, and then there’s unnecessary supplementation. From my personal perspective, I’m skeptical of medical mavericks who haven’t yet produced enough evidence to convince their peers and change the medical consensus. Until I see the evidence, I’m staying skeptical of Dr. Brown’s approach.

If you have ADHD and or depression you are permitted to take meds. If you don't have these conditions your using the drugs to dope.

Q: Guess where Goucher got her thyroid medication?

Answer: Dr. Browne.

knock-knock wrote:

Q: Guess where Goucher got her thyroid medication?

Answer: Dr. Browne.

Is that the same Browne that wrote the song "Running on Empty", that was in Forrest Gump??

I always thought it was suspicious, the way Forrest just kept going and going...

Thanks for posting this article. Very informative. My TSH was 2.66 last I had it checked. I guess I just didn't see the right doctor :P

KMB wrote:

Makes sense. Thanks.

Then, lots of blah...blah...blah...WSJ...blah...blah...blah

Makes sense. Thanks.

Seriously, that was helpful. If I read what you posted right, the goal is to "fine-tune" thyroid levels so they are in the high normal range. Doing that could give these these guys (& gals) an advantage, regardless of whether they had an "exercise-induced thyroid deficiency."

From talking to endocrinologists, having too much thyroid sounds like it'd be unpleasant enough to be obvious. So it seems it would be easy to tell if you overshoot.

txRUNNERgirl wrote:

Thanks for posting this article. Very informative. My TSH was 2.66 last I had it checked. I guess I just didn't see the right doctor :P

I went to the Cleveland Clinic site the other day because I was curious about the prevalance of hypothyroidism in the U.S. population. It gave the "clinical" prevalence as 0.3% and the "biochemical" prevalance as 6.4%.

This means that about 1 in 300 people is hypothyroid and has symptoms to match, but 1 in 16 will have an abnormality on serum testing (probably an elevated TSH in conjunction with a normal or low-normal T4, suggesting a "compensated" or "pre-hypothyroid" state). That is a huge difference.

A lot of conditions can transiently throw off the interplay between your pituitary gland, hypothalamus and thyroid gland. This is why this test, perhaps more than even most others, should be done more than once.

When your doc is serious about trying to figure out if your thyroid is intrinsically unwell, he or she will usually do a TRH stimulation test.

You probably knew most or all of this. Whatever the case, I hope you are feeling better now.

I don't get it. Everyone is jumping over 'all this new evidence' that really doesn't boil down to anything new.

From all that has come out, we know this:

- Salazar, along with many of his athletes, does not hold "the ethics of sport" in any particular importance

-Salazar, and the NOP as a whole, push the limits of what is legal while still staying within the letter of the law in order to maximize performance

-Salazar and his athletes are being evasive about the above two points because they do not make for particularly good PR

What we don't know:

- Whether there has been any illegal behaviour. There is some smoke, certainly, but the damning evidence is all related moreso to the "pushing of limits".

-Whether other programs (especially in the US) adopt similar strategies regarding antiinflammatories, inhaled corticosteroids, and thyroid medication

It's good that all of this has come to light, because it allows us to have a frank discussion about what the goals of anti-doping legislation should be. Is this kind of behaviour any different than other kinds of micro-doping? Probably not. Should it be regulated more strictly? Probably. Should we punish (ban) those involved in it up to this point? Probably not.

What I would LIKE to see is Salazar and his athletes own up to their behaviour (and I'm hoping they have stayed within the letter of the law). I think its pretty clear that they can't just "deny, deny, deny" and let it go away. They had a plan based on stretching the limit and they should take ownership of that plan.

By the way, for all those jumping on the albuterol salazar bandwagon - albuterol is not a steroid.

asdfasdfasfasdfasdfasdfasdf wrote:

...

From all that has come out, we know this:

...

-Salazar, and the NOP as a whole, push the limits of what is legal while still staying within the letter of the law in order to maximize performance...

It is not at all obvious to me that we know this.

Fleshman joined Oiselle after 2012, proclaiming "the fire still burns" and all this ballsy-sounding stuff. Has she even broken 15:50 since then?(!) The talk-the-talk to walk-the-walk ratio is off the charts vs. Huddle or Flanagan.

Of course her sponsor isn't complaining – people like her on Twitter, people buy the gear. But can you fault a letsrunner for wanting those who present themselves as elite to actually, you know, perform that way? Look at Rupp – even before the current allegations, he couldn't go two lackluster RACES, let alone years, without being torn a new one on these boards.

Maybe kudos are in order for grabbing more attention than any number of actual Olympians and AR-holders put together – and realizing she can maintain her "voice," fanbase, and perception of being an elite without actually competing. But it'd be nice if Oiselle's resident ballsy goddess talked with her feet once in a while.

People would accuse her of being doped if she was still running 15-flat. Damned if you do, damned if you don't.