THE FIGHT DOCTOR TOO MUCH OF A GOOD THING … OR NOT ENOUGH? By Dr. Margaret Goodman
D oes blood doping exist in boxing? It’s expensive, labor-intensive and not easily available. Manipulation of blood and blood components is banned by the Voluntary Anti-Doping Association (VADA, which I run), the World Anti-Doping Agency (WADA) and most international and national sports organizations. Unfortunately, blood doping in any form is all too common in combat sports, regardless of anti-doping experts’ attempts to curb its use. How many fighters knowingly or unknowingly blood dope? Do fighters simply “play” the odds that they won’t be caught? What are the risks? Are there legal ways to blood dope? Your red blood cells carry oxygen from your lungs to your organs and muscles. The more red blood cells you have, the more oxygen is delivered to your muscles to increase stamina and endurance and lessen fatigue. Even a small increase in red blood cells in an elite fighter can drastically improve their training and chances to easily make it through 12 rounds. There are several ways blood doping or blood manipulation is accomplished: Autologous transfusion: This involves drawing your own blood weeks or even months before a bout, storing it and then re-infusing back to you. By the time you re-inject your own blood, your bone marrow has already made up for the loss, thus giving you a surplus of red blood cells. Since you are using your own blood, it is more difficult to detect. Homologous transfusion: This method involves a transfusion from a compatible donor – matched to your blood type, then transfusing it to boost your blood count.
EPO/Erythropoietin injection: EPO is produced in your kidneys to stimulate your bone marrow to produce red blood cells. It is legally used in cancer chemotherapy and kidney failure patients. It is only given by injection. Synthetic oxygen carriers: Synthetically produced substitutes for blood have also been developed for those acutely needing blood or when other methods aren’t available. Any form of intravascular manipulation of blood or blood components: An example would be using large amounts of IV fluid (which is also prohibited) to dilute a blood count. Before anyone thinks blood doping is the answer to success – it can carry considerable risk. The average male has 5 liters (around 10.5 pints) of blood; the average female has 4-4.5 liters (8.5-9.5 pints). Increasing the amount of blood in your body is like adding too much oil in an engine, resulting in sludge and engine failure. The medical risks can range from blood clots to heart attack to stroke to kidney failure to death. How is blood doping detected? The Athlete Biological Passport (ABP) was introduced to expose cheaters by monitoring alterations in the blood-count profile, looking for unusual fluctuations that suggest doping. WADA-accredited laboratories can also detect synthetic EPO use. There are limitations to the ABP. It must be collected several times throughout the calendar year to prove detection. Commissions often perform no out-of-competition tests and seldom include blood, so following the ABP isn’t possible unless a fighter is enrolled in an anti-doping program. The time to confirm EPO detection can vary. Some newer-generation EPO-like drugs can remain in the system for weeks instead of days. That increases detection. Then there are the professional and ethical implications of blood
Option 2: Live high-train low has always been considered the most effective method to stimulate red blood cell production, with training at lower elevations to continue maximum workouts. This must also be done for 3-4 weeks. Option 3: Live low-train high (artificial) is intermittent hypoxic training using hypoxic masks or altitude chambers (tents). Many fighters use this technique where they train in an altitude simulator mimicking the elevated environment. Less stress is placed on the musculoskeletal system and it doesn’t disrupt a fighter’s routine. There is a limit to how much altitude training of any kind or tents or masks will result in natural stimulation of EPO production. Nevertheless, the harmful effects are avoided and it is legal.
doping, which include suspension, fight cancellation, loss of title and permanent damage to a fighter’s reputation. It took Lance Armstrong years of cheating and a final “falling on his sword” interview with Oprah Winfrey in 2013 to admit to using EPO and transfusions during his multiple Tour de France campaigns. VADA has had several athletes test positive for blood doping via EPO or newer similar substances that affect red blood cell production. We continue to include testing on every urine sample. Too many are still playing Russian Roulette with their reputation and health in the hopes they won’t be caught. Are there legal ways for boxers to improve their oxygen-carrying capacity? Altitude training was researched before and after the 1968 Mexico City Olympics, which took place at approximately 7,400 feet, where endurance events had slower finishing times – all thought due to the lower oxygen levels. This resulted in numerous scientific investigations defining “altitude” as elevation above 5,000 feet. High altitude exposure is thought to increase EPO release from the kidneys and stimulates the bone marrow to produce more red blood cells. Athlete altitude training variations appeared: 1. live high, train high; 2. live high, train low; or even 3. live low- train high using artificial means. Option 1: Live high-train high becomes a constant stimulus on the athlete’s body because it is always in a hypoxic state (a state of low oxygen). But it can reduce exercise intensity unless the fighter stays at the elevations for weeks. Live high-train high is the go-to for many elite boxers like Nebraska’s Terence Crawford, who trains in Colorado. Canelo Alvarez may train in northern Nevada at elevations over 5,000 feet. It’s another reason Big Bear, California, is a fighter favorite at 6,700 feet.
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What’s new on the horizon regarding blood doping? WADA will be adding the non- medical use of carbon monoxide to its 2026 prohibited list stating that the technique can increase erythropoiesis (red blood cell increase). Everyone knows that carbon monoxide gas can be fatal when inhaled at certain doses. We have detectors in our homes; it’s sadly been a go-to method for suicide attempts. However, it has been discovered that repeated use at low doses can be performance-enhancing by increasing red blood cell production. During the 2024 Tour de France, several teams were using the technique at the beginning and end of altitude training to measure the effects of training. Although there was no proof any team used the technique to cheat, the UCI (Union Cycliste Internationale) governing cycling asked WADA to ban the technique. The use of carbon monoxide for diagnostic purposes is not prohibited. Feel free to send your “Fight Doctor” questions to comeoutwriting@gmail.com and I will respond in an upcoming issue.
Anthony Joshua employs the “live low, train high using artificial means” style of altitude training.
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