It’s just over 10 years since the sports-nutrition market enjoyed a global boost. Rewind to Thursday July 18, 2013 and Team Sky’s Chris Froome, leading the Tour de France, began to haemorrhage energy on the second of the day’s double ascent of Alpe d’Huez. With fewer than 5km to the finish line, a bonking Froome flung his right arm in the air, signalling for Richie Porte to hand him an energy gel. Taking provisions from a teammate or team car is prohibited in the last 20km of a stage, incurring Froome and Porte a 20-second penalty apiece. “I was really low on sugar levels,” the Brit said afterwards. “Going up Alpe d’Huez twice is hard.”
The sugar hit had the desired effect, as Froome maintained a five-minute lead over Alberto Contador en route to the first of four Tour victories. But did the sugar surge really ease Froome’s bonking? It’s been shown that carbohydrate oxidation rates nestle at around 1g per minute. That means a 30g gel will take around 30 minutes to peak in the blood and then fuel working muscles. Froome’s reaction was near instantaneous. So, what was going on? Well, it could have been down to the power of placebo…
Power of placebo
“Many people might describe placebo as a genuine effect but not attributable to an active intervention,” explains Bryan Saunders, researcher at Sao Paolo University in Brazil and authority on placebo. More precisely, a positive outcome brought about from the belief that you’ve received positive input.
In a clinical setting, the placebo effect’s worked its wonders across a range of patients, from Parkinson’s sufferers to those enduring back pain. There’ve been similarly positive results in the sporting sphere. In 2006, Professor Chris Beedie, now of the University of Kent, showed that cyclists given a placebo improved their 10km time-trial time by 1.3% and 3.1%, respectively, after they believed they’d ingested a moderate and large dose of caffeine when in fact they’d consumed a cornflour pill, known as a ‘dummy pill’.
More recently, in 2015, a study led by Ramzy Ross saw club runners who injected themselves with a new, fictional wonderdrug, OxyRBX, which they’d been told delivered similar performance benefits to EPO but was actually a saline solution, improved their 3km race time by 1.2%.
Psychological and neurobiological boost
But how? Historically, placebo was regarded as a purely psychological phenomenon, namely if you truly believe you’ll rack up a KOM or QOM ascending your local hill, you will rack up a KOM or QOM ascending your local hill. Much of the research focused on two psychological mechanisms: expectancy and classical conditioning. The former’s underpinned by an individual’s belief that the effect will occur, whether that’s delivered verbally, via an environmental cue like seeing a PhD certificate on a practitioner’s office wall or by interactions. This could take the form of mingling with competitors who’ve improved their performance after a stint at altitude.
A classical conditioning response refers to a “conditioned stimulus” (the placebo) eliciting a “conditioned response” (the placebo effect) thanks to its previous coupling with an “unconditioned stimulus”, which as an example could be the drug that’s purported to nestle within the pill.
The advent of neuroscience, however, has begun to dig deeper into placebo’s empirical roots. “The psychological component’s well known but we now understand that placebo effects are also neurobiological,” says Saunders. “Something happens in the brain that generates a physical response that reduces pain, for instance. You feel better and that raises the pain tolerance of exercise performance.”
Fuelled by fake oxygen
Research has identified myriad placebo effects deriving from myriad neurobiological pathways. Fabrizio Benedetti of Turin University has conducted numerous studies examining the neurological repercussions of placebo. One study saw subjects given ‘fake oxygen’ at altitude to determine its impact on fitness. Normally, as many of you breathless cyclists will know from sportives in mountainous regions like the Alps and Pyrenees, blood oxygen levels drop as altitude rises. This results in a loss of power and speed. A climber (sans bike, of course) ascending with an oxygen tank on their back goes some way to reducing these losses.
Which made it all the more remarkable that the subjects inhaling ‘fake’ oxygen maintained their performance as they climbed. Why, Benedetti concluded, was that while their blood oxygen levels dropped, so did their levels of the neurotransmitter prostaglandin E2, otherwise known as PGE2. With no supplementary oxygen, normally PGE2 levels rise at altitude, leading to symptoms of altitude sickness and general pain. Taking oxygen lowers PGE2, resulting in less pain, less fatigue and faster climbing. Which is exactly what happened with the fake oxygen. The climbers had been fooled into faster ascending.
State-of-the-art technology, like functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), has identified that placebo effects act on the dopaminergic (reward) and endogenous opioid (pain) systems in the body. The fake oxygen altitude experimented tapped into this opioid system.
No need for deception
So, placebo and its benefits on exercise, via a cascade of psychological and biological changes, is a very real phenomenon. The problem is, prescribing a one-size-fits-all performance solution to send you riding faster and stronger is impossible as placebo relies on belief and deception. You think the capsule you’ve swallowed will crank up your effort, so it does. But dispense a go-faster pill and tell the recipient it’s packed with cornflour and, understandably, the placebo effect is killed because the belief is no longer there. Well, that’s what you’d think. But experiments by the likes of Saunders have revealed that this isn’t necessarily the case.
“The use of deceptive placebo in practice is inherently fraught with ethical constraints and trust issues, meaning alternative methods must be employed in practice,” says Saunders. “This has led to the development of an alternative approach through which placebo effects might be generated, namely open-label placebo (OLP). This concept, also termed ‘honest placebo’, consists of openly informing the individual that they are receiving an inert intervention; in other words, a placebo. Although apparently counterintuitive, since placebo effects are often believed to stem from the individual’s belief that they are receiving an active treatment, there’s a growing body of evidence demonstrating the efficacy of this method in a clinical practice. While data in the sport and exercise sector remain scarce, preliminary evidence does exist with scope for further work and real-world application.”
To that end, Saunders and his team in Brazil recruited 28 well-trained female cyclists. At the first session, they undertook a VO2max test and became familiar with the protocol, while on two further occasions they performed a 1km TT with or without the intervention.
After ingesting two red and white capsules, the participants were then required to wait 15 minutes for “the pills to work”, during which time they could chat with the physician and ask questions. They were then taken to the laboratory next door, where they performed a 1km cycling time-trial. The control session began with a 20-minute wait in the same room with the same physicians, during which time they could chat freely, before being taken to the lab for the same exercise test. Performance significantly improved with the OLP compared to the control session. “We’ve recently seen similar results in both male and female cyclists over a 4km time-trial, too,” says Saunders.
Again, in the seemingly mystical world of placebo, what is going on? Well, in one of the original OLP studies by Professor Ted Kaptchuk of Harvard University, he identified four key ways that the information is imparted to the individual – in Saunders’ case, the time-triallists – to stimulate the same physiological mechanisms as a deceptive placebo: placebo effects are powerful; the body may automatically respond to taking placebo pills, similar to Pavlov’s dogs who salivated when they heard a bell; a positive attitude helps but is not entirely necessary as the response may be automatic; taking the pills is the critical component.
Expect to improve
Whether deceived or knowingly taken a placebo, it’s all around the idea that fears, hopes and expectations trigger chemical reactions, which changes physiology and improves performance.
“Expectation is a big one,” says Saunders. “In our study, one rider in particular was a strong believer in pills, taking 18 supplements a day. But even a couple of athletes who felt they’d ridden worse because it was an inert substance actually improved.”
When it comes to placebo and expectation, scientists have begun to realise greater improvements dependent on various factors. For instance, they’ve shown capsules are more effective than tablets; large capsules are better than small capsules; expensive medication is better than cheap alternatives. Colour makes a difference, too, with red pills effective at easing pain and blue versions good for easing anxiety. A caffeinated placebo’s also been shown to exert a stronger effect than a sodium bicarbonate one.
This expectation doesn’t have to come packaged in pill form, of course. Doctor David Martin is currently chief scientist and director of performance at Apeiron Life, a Californian health and wellness start-up aimed at transforming the lives of top executives. But in a former life (1994 to 2015) he was senior sport scientist at the lauded Australian Institute of Sport (AIS). He garnered a reputation for turning good athletes into great ones, which he felt had a trickle-down effect.
“I’d been around a lot of successful athletes including Anna Meares and Cadel Evans,” he says. “That paid off when working with younger riders. They were impressionable when I met them; they might have read an article where I was mentioned and thought, ‘I’m working with David Martin of the AIS. Oh man, that’s brilliant’. I had no idea how powerful an environment that is, of how important placebo is.”
“I took this into the world of technology,” he adds. “So, if I monitored their sleep and said their sleep hadn’t been good, for example, they would feel tired; if I measured heart rate variability with a tool like Omegawave and told them they should be good this week, they’d come good that week. I’d created a big technology placebo. But in essence, it’s the Pygmalion effect, which is simply the power of believing in someone.”
Fuelled by illegal thoughts
As the OxyRBX trial above highlighted, this power of belief is particularly strong when it comes to illegal ergogenics and is an idea that reaches beyond the lab. In Willy Voet’s Breaking the Chain, the soigneur relayed a story from working with Richard Virenque. Before a vital time-trial, the Frenchman requested a special concoction he’d heard about from a rival team. Voet was no stranger to crossing the line but had deep reservations about injecting Virenque with a solution he knew nothing about. However, he gave in and injected the Frenchman. “God, I felt good,” Virenque commented after the time-trial. “That stuff’s just amazing. We must get hold of more.”
In truth, Voet had substituted the wonder drug with a sugar solution, commenting, “There’s no substitute for self-belief. The bottom line was that there was no more effective drug for Richard than the public. A few injections of ‘allez Richard’ coursing through his veins, a big hit of adoration to raise his pain threshold, a course of worship to make him feel invincible.”
It’s clear that if you believe something will improve performance, there’s a fair chance it’ll have a positive effect. Which brings us onto Lance Armstrong. The seven-time non-winner of the Tour de France fuelled himself on EPO and anger for years, and you can see why with a 2007 study showing a 54% improvement in time to exhaustion after just four weeks’ use. But the evidence isn’t unequivocal. A 2017 study published in the medical journal The Lancet saw half of 48 cyclists given EPO injections for eight weeks, while the other half took a saline solution. Though the EPO riders exhibited higher concentrations of haemoglobin, it did nothing to improve performance. “It’s quite possible that all the stuff Armstrong was taking was useless,” said lead author Adam Cohen. “Maybe it was simply the mental aspect.”
It might seem far-fetched but it begs the question: did Lance Armstrong simply believe his illegal cocktail worked more than his contemporaries? Did the Texan have greater belief? From day one, he’d certainly had belief in his ability. When asked if he was the new Greg Lemond, he responded, “No, I’m the new Lance Armstrong.”
Which we could all be thanks to the power of placebo. Well, maybe not. But research by the likes of Saunders does highlight the power of the mind and its impact on cycling performance. Believing you can is the first step to reaching your cycling goals, whether that’s completing the Etape du Tour or tackling your first cyclocross event this winter. Strengthen your mind and body this off-season and 2024 will be a year for goal-getting.
*Cover image by John Berry