Exercise in gymnasiums is a feasible way to be physically active in the United Arab Emirates (UAE). Chronic diseases pose significant public health issues among the UAE population. ¹ In particular, attitudes about obesity management need improvement. ² There is a lack of public awareness of the importance of engaging in physical activity in the UAE, resulting in high levels of sedentary behavior among young adults. ³ Promotion of the benefits of physical activity are therefore required among the UAE population. ⁴

It is acknowledged, however, that gymnasium use may progress from simple exercise regimens to a desire for image enhancement that leads some to bodybuilding. ⁵ Among gymnasium users in the UAE, bodybuilding, either for non-competitive (recreational) or competitive purposes, is a popular sport. The motivation for bodybuilding is manifold and ranges from the improvement of body image and well-being through to participation in competitive sport. ⁶

Many gymnasium-users take supplements to improve their performance or image enhancement. In a study in Sharjah, it was shown that about half of the men exercising in gyms were using dietary supplements. ⁷ In another study, in Dubai, it was reported that people who were consuming dietary supplements had a high level of knowledge about the supplements that they used and consequently, adverse events were infrequent. ⁸

Dietary supplements are used widely among bodybuilders. However, in addition, some bodybuilders may use hormonal products, which pose a potential health risk ⁹ and may lead to illegal doping in the competitive areas of bodybuilding. ^{10 , 11} Some bodybuilders in the Gulf region reportedly use anabolic steroids, ¹² reflecting an increased prevalence of anabolic-androgenic steroid (AAS) use generally across the Eastern Mediterranean Region. ¹³

Many factors contribute to performance enhancement by bodybuilders and its progressive normalization. ¹⁴ There is a growing body of evidence which suggests that anabolic androgenic steroids are used globally by a diverse population, with varying motivations, including bodybuilders. ¹⁵ As the trend of bodybuilding is transforming to create a well-defined and moderately muscular body, it is speculated that fitness doping is becoming increasingly common. ¹⁶ However, the boundary between natural performance enhancement and doping might be blurred for the bodybuilders. Considering the potential adverse effects of AAS use on health, it is important to consider intervention strategies to prevent misuse, both in sport and in the general population. ¹⁷ Such strategies include targeted education and a greater understanding on doping attitudes through tools such as the Performance Enhancement Attitude Scale (PEAS). ¹⁸

Pharmacists are well-placed and highly accessible resources of drug information for the public. The opportunity exists to increase pharmacy-led initiatives that support the antidoping movement.

Antidoping assessments and education raise awareness of doping. It is suspected that bodybuilders might be sensitized to the problems of performance enhancement attitude just by filling out the pre-intervention survey. This awareness of perceptions associated with doping, in addition to the educational flyer developed for antidoping education for bodybuilders, was expected to influence attitudes toward higher concern for the risk of performance enhancement substances among bodybuilders in the study population.

Of the 322 bodybuilders who filled out the pre-intervention survey, 254 completed the post-intervention surveys (79% response rate). ²⁹ For the analysis, 22 respondents were removed due to the lack of matching email or mobile numbers used as identifiers in the pre-survey to post-survey tracking. Other respondents were excluded from the study by not being located in the UAE or reporting they were not consuming dietary supplements. A final total of 218 respondents were used for the data analysis. The majority (98.2%) of study participants found the antidoping educational flyer to be informative, while four (1.8%) participants responded that it was not informative enough.

The study population constituted of 80 bodybuilders of non-sports employment, 16 full-time bodybuilders, 111 university students, and 11 school students. All were male. The Kruskal Wallis test showed a significant difference in the distribution of post-intervention (p-value 0.002) PEA scores but not in pre-intervention (p-value 0.07) among the four subgroups of this study population.

When the average score is compared among the four groups by the median test, the median (average) of the overall pre-score across the groups (p-value <0.027), and the average of the overall post-score showed significant difference between the groups (p-value 0.001). It implies that while the median showed a significant difference among full-time bodybuilders, primarily an employee, university students, and school students pre-intervention 29, 24, 22, 25, and post intervention 21, 16.5, 13, 11 respectively, the changes in distribution of PEA scores among them were significant only after the intervention. School students showed the greatest impact of attitude change.

With the intervention of the educational flyer and sensitization, the PEA was changed favorably towards recognition of concerns associated with doping among the participants. Agreement to pro-doping statements in the PEAS survey decreased, meaning disagreement increased with the intervention as shown in Table 1. For tabulation, “strongly agree” and “agree” were combined; likewise, responses of “slightly agree” and “slightly disagree,” and “disagree” and “strongly disagree” were combined.

As per the Wilcoxon sign rank test, the average performance enhancement attitude levels before and after were significantly different in the study sample. The distribution of attitude scores were reduced from before to after the intervention with statistical significance in addition to median of agreement decreased for 7 out of 8 items ( Table 2).

The median score for the pre-intervention survey was 24, and for the post-intervention survey was 14. The decrease in median score demonstrated a movement away from supporting use of performance enhancement substances and toward an anti-doping awareness.

The aim of this study was to assess any changes in the attitude of bodybuilders in the UAE about the use of supplements and doping, following the introduction of an antidoping educational flyer. The major finding was that there were significant changes in the attitudes of the study population to performance enhancement through supplement use and doping practices following pharmacy-led education with introduction of an antidoping flyer. Analysis of the responses to the eight-item PEAS survey revealed significantly different scores between pre- and post-intervention, suggesting less support for the use of performance enhancement substance among study participants. Using median, statistical tests proved the significance of the decrease in all eight survey items. Educational interventions and sensitization of sports people have shown similar results in the following studies.

It was found that doping susceptibility perceptions can be immediately reduced with educational interventions. The face-to-face intervention was observed to be more sustainable than online interventions among high-level athletes. ²⁰ Nevertheless, a mobile application was found to be a practical method for disseminating anti-doping education. The application improved knowledge and decreased favorable doping attitudes among coaches. The mobile application had educational modules on nutritional supplements, substances, rules, leadership, and fair play. ²¹ Practical strength training advice provided in addition to anti-doping education to youth athletes was found beneficial in decreasing PEA. ²² PEA was found in many studies among gym users and athletes. Such studies proposed educational interventions to decrease PEA. ^{7 , 8 , 23}

Sensitizing those who have potential for doping needs to start early, even in schools. Students who were professionally involved in sports perceived performance enhancement as more acceptable than other students. ²⁴ Body image, nutritional supplement use, and weight change behaviors influence adolescents' PEA. ²⁵ Media literacy interventions were effective to decrease doping behaviors of adolescent students. ²⁶ It is accepted that attitudes and knowledge about doping are influenced by educational activity. ^{27 , 28} In addition, it is also possible that the studies itself had sensitized participants against PEA as assumed in our study.

This study showed that the PEAS short-form survey, along with the introduction of an antidoping educational flyer provided by a sports pharmacy team, resulted in decreasing PEA among bodybuilding populations in the UAE. The decline of PEA was significant for all eight items of the PEAS. Bodybuilders, regardless of level of profession in the sport or level of competition, showed reduction in their attitude scores in the post-intervention survey. This study shows the potential for pharmacy-led educational interventions for bodybuilder athletes to influence favorable PEA, in support of the antidoping movement. Future studies are required to understand PEA among bodybuilders deeply and how favorable PEA can be sustained.