INVESTIGATING THE PREVALENCE OF DRUG-INDUCED LIVER INJURY (DILI) AMONG ATHLETES WHO CONSUME UNREGULATED PRE-WORKOUTS AND WEIGHT-LOSS POWDERS IN PAKISTAN

Abstract

Background: The unregulated dietary supplement market in Pakistan has expanded dramatically, with pre-workout powders and weight-loss formulations widely available through online platforms and local sports nutrition retailers without regulatory oversight by the Drug Regulatory Authority of Pakistan (DRAP). Drug-induced liver injury (DILI) represents the leading cause of acute liver failure in many countries, yet systematic Pakistani data on supplement-induced hepatotoxicity among athletes remains critically absent.

Objectives: To determine the prevalence of DILI among Pakistani athletes consuming unregulated pre-workout and weight-loss supplements, identify hepatotoxic ingredients in sampled products, assess severity grading of liver injury, and examine associations between consumption patterns and liver function test (LFT) abnormalities.

Methods: A mixed-methods observational study was conducted across five major cities of Pakistan (Lahore, Karachi, Islamabad, Peshawar, and Quetta) involving 380 athletes aged 18-35 years who reported regular consumption of unregulated supplements for at least three months. Comprehensive liver function tests (ALT, AST, ALP, GGT, total bilirubin, albumin, and PT/INR) were performed. DILI was diagnosed and graded using CIOMS/RUCAM scale criteria. Chemical analysis of 87 supplement products was conducted at PCSIR laboratories. Multivariate logistic regression identified risk predictors.

Results: DILI prevalence was 37.9% (n=144/380) in the study cohort. Weight-loss supplement users showed the highest DILI prevalence (34.7%), followed by combined product users (42.1%). Severity grading revealed 38% mild (Grade 1), 31% moderate (Grade 2), 19% moderate-severe (Grade 3), 9% severe (Grade 4), and 3% acute liver failure (Grade 5). Chemical analysis detected adulterants including sibutramine (28%), dinitrophenol (DNP, 12%), and hidden anabolic steroids (39%) alongside hepatotoxic declared ingredients including DMAA (34%), synephrine (48%), and supraphysiological caffeine levels (61%). Duration of supplement use and polypharmacy were independent risk predictors for DILI (OR: 3.81 and 2.47 respectively, p < 0.01).

Conclusion: DILI prevalence among Pakistani athletes using unregulated supplements is alarmingly high. The widespread presence of undisclosed hepatotoxic adulterants in marketed products demands urgent regulatory action by DRAP, mandatory product screening, and structured public health education for athletes and coaches.