Oral corticosteroids abuse for the purpose of weight

gain : First assessment in Algeria

Meriem Hadjilah ( meriemhadjilah@gmail.com )
University of Algiers Benyoucef Benkhedda
Sarah Fiala
University of Algiers Benyoucef Benkhedda

Article

Keywords:

Posted Date: September 21st, 2022

DOI: https://doi.org/10.21203/rs.3.rs-2046646/v1

License: This work is licensed under a Creative Commons Att ribution 4.0 International License.
Read Full License
Oral corticosteroids abuse for the purpose of weight
gain: First assessment in Algeria
Meriem Hadjilah1,* and Sarah Fiala2
1 Pharm.D, Faculty of Pharmacy, University of Algiers I, Algiers, 16006, Algeria
2 MPharm, PhD; Senior lecturer in Pharmaceutics and Drug Delivery, Faculty of Pharmacy, University of Algiers I,
Algiers, 16006, Algeria
* meriemhadjilah@gmail.com

ABSTRACT

While it is generally recognised that drug abuse only concerns illicit drugs and narcotics, other classes of medicines can also be
abused such as oral corticosteroids; the use of which has been diverted for the purpose of gaining weight in many developing
countries.
The aim of this study was to investigate the possibility of an abuse of oral corticosteroids for the purpose of weight gain in the
Algerian population and assess its extent and sociodemographics. A questionnaire was designed to extract sociodemographic
information and clinical history from participants. The patients included in the study were recruited from all subjects who had
shown an interest in weight gain.
One hundred and eleven individuals out of 600 (18.5% used corticosteroids for the purpose of weight gain with an average age
of 25.62 ± 5.62 years old; and an over-representation of women (N=70, 63.1%, P<0.05). The majority of participants (N=71,
63.97%) obtained the drugs directly from a pharmacy with no medical prescription.
A significant number of the Algerian population interested in gaining weight is involved in corticosteroids abuse; this issue
raises the need for public awareness of the potential adverse effects of corticosteroids and their devastating consequences.

Introduction
The use of medication for non-medical reasons is defined as “abuse” and is reported as a public health issue in several countries
around the globe.1–5 It applies to a wide range of medications, ranging from those having the potential to cause addiction to
others with no such risk.6–8 Regulations and medical training programs have been implemented in order to limit the spread
of this phenomenon.9, 10 For instance, they distinguish between prescription-only medicines (POMs) which require a valid
physician’s prescription and dispensation by a pharmacist, and over-the-counter medicines (OTCs), which are sold directly
without a medical prescription. Despite the fact that POMs are –according to regulations- limited in accessibility, research has
revealed that they can be freely obtained over the counter without valid prescriptions in many developing countries.11, 12
Corticosteroids are one of the most concerning drugs associated with abuse due to their wide therapeutic use (pulmonary,
immune, hematologic, gastrointestinal, ophthalmologic, rheumatologic, dermatologic and endocrine conditions) and their
numerous adverse effects including osteoporosis, water retention, immunosuppression, hypertrichosis, skin atrophy, psychiatric
disturbances and acne.13–17 They are abused in their topical, injectable and oral forms as well as in conjunction with other
medicines.18–23 Despite their designation as prescription-only medicines, in some countries they can be purchased from
pharmacies without a prescription or from street vendors.11, 23 In most cases, weight gain was the adverse effect sought as a
desirable outcome and was considered the primary incentive for the abuse of the oral form.11, 21, 23–25
Although the abuse of oral corticosteroids for the purpose of weight gain has been previously examined in other developing
countries, it has yet to be investigated in Algeria hence the need for such research to provide the public health authorities with a
better understanding of the factors that influence its occurrence. In order to determine its prevalence for the purpose of weight
gain, we surveyed the population who wanted to gain weight about the methods they tried, what influenced their decision and
how they obtained the corticosteroids. The aim of this study was, therefore, to determine the extent of oral corticosteroid abuse
for weight gain in Algeria and outline the sociodemographic and clinical profile of corticosteroid abusers and thus lay the
groundwork for adequate solutions to this public health issue.
Results
Characterization of the study sample
Six hundred subjects, who were interested in gaining weight and met the eligibility criteria, completed the questionnaire. Our
sample size of n=600 ensures a 95% confidence level with a margin of error E=3.99% from the true value. The mean age of the
sample was 25.73 (±5.58) ranging from 15 to 67 y.o. As presented in Table 1, the respondents were predominantly females
(N=435, 72.5%), in their twenties (N=480, 80%), students (N=290, 48.3%), have a university education level (N=551, 91.8%),
and live in an urban area (N=556, 92.7%). It is interesting to note that the majority of respondents were within the healthy
weight range (N=424, 70.7%, BMI = 20.92 ± 3.23).

Corticosteroids abuse
Among the 600 participants in the study who have shown an interest in gaining weight, 111 (18.5%) used corticosteroids. The
demographics of this sample of corticosteroid users was further analysed (Table 2). It was found that there was a significant
difference between men and women when it comes to using corticosteroids where women were overrepresented (N=70, 63.1%,
p < 0.05). The mean age of men and women who used corticosteroids was 26.41±5.91 and 25.11±5.43, respectively. The
mean BMI was 22.26 ±3.85 for men and 21.33 ±3.98 for women, both within the healthy weight range. Furthermore, most of
corticosteroid users (N=97, 87.4%) have a university education level (P<0,001). With regards to the corticosteroid molecule
choice, Betamethasone was the corticosteroid mostly used as a way of gaining weight for more than half the participants (N=56,
50.45%) Another corticosteroid that is largely used is prednisolone (N=35, 31,53%). Then follows the other corticosteroids:
dexamethasone, prednisone, hydrocortisone and methylprednisolone (14.41%, 13.51%, 9% and 4.5% respectively, Figure 2).
Irrespective of the drug molecule used, most corticosteroids users consumed corticosteroids for 8 to 30 days (N=38, 34.2%).
A significant difference in the duration of use is noted between men and women (P < 0.05). Men were more inclined to use
corticosteroids for 1 to 7 days; women on the other hand, mostly used corticosteroids for 8 to 30 days. Participants responded
almost equally to the question of satisfaction with the weight gain (49.5% unsatisfied compared to 50.5% satisfied). However,
when asked if willing to stop the use of corticosteroids, only twenty participants did not show the motivation to stop using the
drug. Reassuringly, ninety-one were willing to discontinue taking corticosteroids. In order to determine if this willingness to
stop was related to the satisfaction with weight gain, we assessed the correlation of the two variables. The participants who
were willing to stop the usage of corticosteroids were almost equally distributed between satisfied and unsatisfied (45.1% and
54.9%) with weight gain. However, among those who showed no motivation to stop the corticosteroids, 75% were satisfied
with the weight gain (the results are significant at P < 0.05). When asked about the source of the idea of taking corticosteroids
for the purpose of weight gain, most respondents said it was recommended by a friend or a relative (N=65, 56.58%, Figure 3),
42 others (37,83%) obtained information on the use of corticosteroids from social media (Facebook, Instagram). The rest of the
participants’ answers were almost equally devised between pharmacist advice, medical prescription and youtube with the rates
12,61%, 14,41% and 11,71% respectively. Furthermore, the majority of participants obtained the drugs directly from a pharmacy
with no medical prescription (N=71, 63.97%, Figure 3), while others (N=20, 18.01%) asked for a medical prescription before
acquiring them, and few (N=9, 8.1%) had access to leftover medicines (from ancient drugs prescriptions). Regarding the
participants awareness of corticosteroids’ side effects, the internet was mentioned as the main source of information (N=31,
27.91%, Figure 3). We can notice that doctors (N=14, 12.61%) and pharmacists (N=7, 6.3%) were not mentioned much as a
source of information regarding the side effects; in fact, the percentage of the two healthcare professionals combined does not
exceed that of the internet search source (18.91%).

Discussion
In the present study we found that 18.5% of the population desiring to gain weight, have used corticosteroids for that purpose,
which is similar to the findings of a Moroccan study on fattening practices, which revealed that 20.73% of women desiring
to gain weight used corticosteroids.25 We have examined the gender differences in corticosteroids abuse: women who used
corticosteroids to put on weight and improve their figure were over represented. Given that their mean BMI was within the
healthy range, this suggests that women who abused corticosteroids did not want to acquire weight because they perceived
themselves as "too skinny", but rather desired to become overweight on purpose. In the Algerian society, corticosteroids
abusers were probably driven by the cultural belief that overweight and obese women are more beautiful or more likely to find
a husband (mean age ∼ = 25). The continuous pressure women face to get married before their thirties and the constant fear
of withdrawal or rejection from society may be another factor leading to search for a fast and effective way to put on weight
despite what the consequences might be. This concern appears to be present in other developing countries such as Iraq where
a similar study confirmed that 88,8% of corticosteroids abusers for weight gain purposes were females with a mean age of
29.24 A study in Morocco assessed cultural perceptions and weight gain practices among Moroccan Saharawi women using
traditional meals and oral corticosteroids (OCSs). It was found that OCSs were used to increase appetite and weight to help the

2/10
women be attractive (culturally).25 On the other hand, women’s abuse can be related to the wedding ceremony itself; because
most brides wear enormous traditional costumes, some may assume that the outfits would look better on them if they were
overweight. Another way to explain these results, there is a misconception among Algerians about the ideal body weight,
which could be related to a self-distorted body image. It affects both men and women and is not related to their educational
level since almost 92% of the participants had a university level, in contrary to a study conducted in Iraq where less than 3,5%
of corticosteroids abusers have reached a university level.24 Thus, people can have a high educational level, but still their
unawareness of the health risks and their distorted self-body image can push them to abuse medications. It is important to note
that the above-stated psychological and sociological factors behind the corticosteroids abuse are only presented as hypotheses to
encourage further research. In this study, it was found that betamethasone was the most used corticosteroid for weight gain. Yet,
other studies in Iraq showed that dexamethasone was the most frequently abused oral corticosteroid.12, 24 The predominant use
of betamethasone in Algeria and dexamethasone in Iraq may be explained by their high and equal glucocorticoid activity and
thus faster weight gain compared with other corticosteroids.26 Moreover, we assessed the correlation between the participants’
satisfaction with weight gain and their willingness to stop the corticosteroids. More than a third of the corticosteroid users
group consumed those prescription-only medicines for a period longer than one month. It is noteworthy that the majority of
respondents who showed no motivation to stop the corticosteroids were satisfied with results. The reason explaining these two
observations could be previous experience of weight loss after attempts to stop taking corticosteroids. Indeed, different patterns
of weight gain can be observed depending on the duration of corticosteroid use. An American comparative study has shown
that early corticosteroids withdrawal patients gain significantly less weight than chronic corticosteroids treatment patients.27
Another explanation could be the dependence developed by the participants on corticosteroids and the depression experienced
upon the withdrawal. Although uncommon, corticosteroids can induce dependence based on their propensity to induce
euphoria; Prednisone was the most implicated corticosteroid in the dependence.28 Although for the majority of participants,
the use of corticosteroids for weight gain was recommended by their peers or relatives, the fact that a percentage as high as
27.01% of the corticosteroid intake was suggested by a healthcare professional indicates a dangerous approach by medical
doctors, pharmacists and pharmacy-sale assistants. The issue is more alarming in Iraq where doctors were the main source of
corticosteroids abuse as they were responsible for 51.7% of the steroid prescriptions for weight gain.24 Moreover, although
medical doctors and pharmacists were supposed to be the first portal for drug information and counselling, their contribution
to the participants’ awareness of the side effects of corticosteroids was very poor. Instead, the participants used unreliable
sources such as internet and social media in order to obtain such information. Irrespective of the source of recommendation, the
majority of our respondents (63.97%) acquired the drugs by free-purchase in pharmacies, which is consistent with the data
collected from another Iraqi study indicating that 53.4% of interviewed participants obtained non-prescribed corticosteroids
from the pharmacy and 36.9% from street vendors.11 Hence, in addition to the previously discussed cultural believes (e.g.,
linking beauty to obesity) and the inadequate awareness of side effects, the absence of strict controls to limit the free sale of
prescription-only medicines play a critical role in the wide spread of corticosteroids abuse in developing countries such as Iraq,
Morocco, Congo and India.11, 22, 25, 29 Pharmacists are key players that can remedy to the situation by refusing the delivery
of corticosteroids without a valid prescription. Corticosteroids should be subject to legal and ethical restrictions in order to
limit their abuse. This study however presents some limitations including the absence of a control group. As we only set out to
evaluate the profile of corticosteroid abuse, we deemed unimportant to include a group of normal healthy controls. Yet, the
limited clinical background history, the possible concomitant use of other drugs and the failure to obtain corticosteroids level
from the sample, are other potential aspects that could limit the generalizability of the findings. Although this study was not the
first study to point out and explore the abuse of oral corticosteroids for the purpose of weight gain; to the best of our knowledge,
it was the first to be conducted in Algeria. Further research with a larger sample is needed to explore the potential abuse and
dependency over corticosteroids and other diverted drugs such as Cyproheptadine, Pizotifene and Sulpiride; as well as the
pathophysiological mechanisms involved in the dependency.

Methods
Study design and sample
This study took place in Algeria and lasted for a time period of 3 months. Qualitative and quantitative data were gathered
virtually (on social media) and face-to-face. The digital form was published on social media (Facebook, Instagram) in both
Arabic and French to overcome the volunteers’ language barrier. The paper format was distributed at a community pharmacy
in Algiers with a very high flow of patients. The participants included in the study were recruited from all subjects of both
genders, who had shown an interest in weight gain. We excluded from the study participants with health conditions requiring a
long-term therapy with corticosteroids, and those who were unable to submit a complete form. A pilot analysis was undertaken
then the questionnaire was revised and adjusted according to the feedback.
The study sample went through a non-probability selection process (Figure 1). The volunteers who showed an interest
in gaining weight and met the eligibility criteria were asked to complete the first part of the questionnaire, which collected

3/10
socio-demographic data (age, gender, level of education, etc.). Those who claimed to have used corticosteroids as means of
gaining weight were asked to fill out the second part of the questionnaire, which investigated the clinical aspects of corticosteroid
abuse.
The study methods were carried out in accordance with the guidelines of the Research Ethics Committee of the National
Institute of Public Health and with the ICMJE recommendations. The Research Ethics Committee of the National Institute of
Public Health approved the study protocol. Informed consent was obtained from each participant after discussing the nature
and scope of the study. Privacy was respected and the participants’ names were not requested in the survey.

Data analysis
Continuous variables were described as the mean ± standard deviation (±Std) and categorical variables as frequencies and
percentages. For statistical analysis, we used the Statistical Package for Social Sciences (IBM SPSS, version 28). Differences
between groups of continuous variables were tested for statistical significance using one-way ANOVA after verifying the
normality of distribution of data (Skewness, kurtosis, Shapiro-Wilk test, histograms and Q-Q plots). The chi-square test was
used to compare nonparametric data. Statistical differences were considered significant at P value ≤ 0.05.

References
1. Lyden, J. & Binswanger, I. A. The united states opioid epidemic. In Seminars in perinatology, 3, 123–131 (Elsevier, 2019).
2. Riggs, P. Non-medical use and abuse of commonly prescribed medications. Curr. medical research opinion 24, 869–877
(2008).
3. Abood, E. A. & Wazaify, M. Abuse and misuse of prescription and nonprescription drugs from community pharmacies in
aden city—yemen. Subst. Use & Misuse 51, 942–947 (2016).
4. Albsoul-Younes, A. & et al., W. Abuse and misuse of prescription and nonprescription drugs sold in community pharmacies
in jordan. Subst. use & misuse 45, 1319–1329 (2010).
5. Chaturvedi, H. K. & Mahanta, J. Sociocultural diversity and substance use pattern in arunachal pradesh, india. Drug
alcohol dependence 74, 97–104 (2004).
6. Reeves, R. R. & et al., L. Abuse of medications that theoretically are without abuse potential. South. Med. J. 108, 151–157
(2015).
7. Lessenger, J. E. & Feinberg, S. D. Abuse of prescription and over-the-counter medications. The J. Am. Board Fam.
Medicine 21, 45–54 (2008).
8. Wang, G. S. & Hoyte, C. Common substances of abuse. Pediatr. Rev. 39, 403–414 (2018).
9. Manchikanti, L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician (2007).
10. Ram, A. & Chisolm, M. S. The time is now: improving substance abuse training in medical schools. Acad. Psychiatry 40,
454–460 (2016).
11. Mansour, A. A. & Odaa, e. a. Corticosteroid nonprescription use: a cross-sectional hospital-based study in basrah. Med.
Princ. Pract. 19, 182–187 (2010).
12. Alfetlawi, B. G. & Al-Jumaili, e. a. Evaluating factors related to the abuse of oral corticosteroids among community
pharmacy customers: using theory of reasoned action. Innov. pharmacy 11 (2020).
13. Kapugi, M. & Cunningham, K. Corticosteroids. Orthop. Nurs. 38, 336–339 (2019).
14. Carmen, A. Corticosteroids and Steroid Therapy New Research. Pharmacology – Research, Safety Testing and Regulation
(Nova Biomedical, 2015).
15. Warrington, T. P. & Bostwick, J. M. Psychiatric adverse effects of corticosteroids. In Mayo Clinic Proceedings, 10,
1361–1367 (Elsevier, 2006).
16. O’Donnell, J. Adverse effects of corticosteroids. J. Pharm. Pract. 2, 256–266 (1989).
17. Buchman, A. L. Side effects of corticosteroid therapy. J. clinical gastroenterology 33, 289–294 (2001).
18. Meena, S. & Gupta, e. a. Topical corticosteroids abuse: A clinical study of cutaneous adverse effects. Indian journal
dermatology 62, 675 (2017).
19. Nagesh, T. & Akhilesh, A. Topical steroid awareness and abuse: a prospective study among dermatology outpatients.
Indian journal dermatology 61, 618 (2016).

4/10
20. Fadale, P. D. & Wiggins, M. E. Corticosteroid injections: their use and abuse. JAAOS-Journal Am. Acad. Orthop. Surg. 2,
133–140 (1994).
21. Goldberg, R. L. & Wise, T. N. Corticosteroid abuse revisited. The Int. J. Psychiatry Medicine 16, 145–149 (1987).
22. Mputu Malolo LC, N. M. P. & Nuapia BELO Y, e. a. Socio-cultural behavior comparative study of the misuse of
cyproheptadine combined with dexamethasone in kinshasa population, democratic republic of congo. Int. J. Medicine Res.
2, 145–149 (2017).
23. Karia, S. & Dave, e. a. Cyproheptadine and dexamethasone abuse. Natl. J. Med. Res. 3, 88–89 (2013).
24. Younis, A. A. & Al-Admawi, W. I. e. a. The abuse of corticosteroids among iraqis for weight gain purpose in babylon, iraq:
A unique experience. Addict. Disord. & Their Treat. 8, 111–115 (2009).
25. Rguibi, M. & Belahsen, R. Fattening practices among moroccan saharawi women. EMHJ-Eastern Mediterr. Heal. Journal,
12 (5), 619-624, 2006 (2006).
26. Heming, N. & Sivanandamoorthy, e. a. Immune effects of corticosteroids in sepsis. Front. Immunol. 9, 1736 (2018).
27. Rogers, C. C. & Alloway, e. a. Body weight alterations under early corticosteroid withdrawal and chronic corticosteroid
therapy with modern immunosuppression. In Transplantation proceedings, 2, 800–801 (Elsevier, 2005).
28. Anfinson, T. J. & Channappa, e. a. Drug dependence involving prednisone: two cases and a review of the literature.
Psychopharmacol. bulletin 41, 154–163 (2008).
29. Saraswat, A. & Lahiri, e. a. Topical corticosteroid abuse on the face: A prospective, multicenter study of dermatology
outpatients. Indian J Dermatol Venereol Leprol 77, 160–6 (2011).

Acknowledgements
We would like to thank Dr. Nacima Mohabeddine for authorizing us to conduct the face-to-face part of the survey in her
pharmacy.

Author contributions statement

The authors confirm contribution to the paper as follows: study conception and design: M.H. and S.F.; data collection: M.H.;
analysis and interpretation of results: M.H. and S.F.; draft manuscript preparation: M.H. and S.F. All authors reviewed the
results and approved the final version of the manuscript.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Additional information
Competing interests The authors declare no competing interests.

5/10
 Corticosteroids use
No Yes
Count(%) Mean±Std Count(%) Mean±Std
Age (years) 25.75±5.57 25.62±5.62

Gender* Male 124(25.4%) 41(36.9%)

Female 365(74.6%) 70(63.1%)

Educational level* Illiterate 0(0%) 0(0%)

Primary 1(0.2%) 1(0.9%)
Secondary 0(0%) 5(4.5%)
High school 34(7%) 8(7.2%)
University 454(92.8%) 97(87.4%)

Employment Unemployed 69(14.1%) 18(16.2%)

Student 248(50.7%) 42(37.8%)
Employed 171(35%) 50(45%)
Retired 1(0.2%) 1(0.9%)

Area of residency Urban 455(93%) 101(91%)

Rural 34(7%) 10(9%)

BMI (Kg/m²) 20.75±3.0 21.67±3.94

Weight range Underweight 104(21.3%) 20(18%)

Healthy weight 355(72.6%) 69(62.2%)
Overweight 21(4.3%) 18(16.2%)
Obese 9(1.8%) 4(3.6%)
*Statistically significant (P<0.05)

Table 1. Relative rates of corticosteroids users stratified by age, gender, educational level, employment, BMI, weight range
and area of residency

6/10
 Male Female
Mean±Std Count(%) Mean±Std Count(%)
Age(years) 26.41±5.91 25.11±5.43
BMI(kg/m²) 22.26±3.85 21.33±3.98

Duration of use 1-7 days 16(39%) 17(24.3%)

8-30 days 6(14.6%) 32(45.7%)
1-3 months 11(26.8%) 13(18.6%)
More than 3 months 8(19.5%) 8(11.4%)

Awareness of side effects Unaware 18(43.9%) 22(31.4%)

Aware of some 21(51.2%) 33(47.1%)
Aware of most 2(4.9%) 15(21.4%)

Willingness to stop Willing to stop 35(85.4%) 56(80%)

Not willing to stop 6(14.6%) 14(20%)

Satisfaction with weight gain Unsatisfied 19(46.3%) 36(51.4%)

Satisfied 22(53.7%) 34(48.6%)

Weight range Underweight 6(14.6%) 13(18.6%)

Healthy weight 25(61%) 45(64.3%)
Overweight 8(19.5%) 9(12.8%)
Obese 2(4.9%) 3(4.3%)

Table 2. Baseline clinical characteristics of corticosteroids users

7/10
Figure 1. Participants’ flow diagram

8/10
Figure 2. Mean count of the different oral corticosteroids used for weight gain

9/10
Figure 3. Sources of (A) recommendation of corticosteroid use for weight gain, (B) obtaining oral corticosteroids, and (C)
information about corticosteroids and their side effects.

10/10
Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.

STAT.xlsxSTAT1.pdf