Trimeta… what?

Kamila Valieva struggling in her free skate at the 2022 Beijing Olympic Winter Games


  • Hard training damages your body
  • Training time at competition-specific intensities is limited
  • Doping not only helps you in competition, but also helps you train ‘better’
  • Trimetazidine delays fatigue-induced loss of coordination, helping technical-skill-sports
  • p.s. anti-doping authorities suck at information security

Just over a year ago I watched in awe as Kamila Valieva became the first woman to land a quadruple jump in an Olympic Games in the women’s team competition. A few days later, I learned that the medal ceremony had been delayed and it was widely speculated that it was due to a doping volation. Over a year later, and those medals have still not yet been awarded as the investigation is still ongoing.

For reasons which should be obvious, the Russians were the first to come to mind (they had also won the team competition). Not long after hearing news of the delay, an official IOC statement let us know that there was a doping violation, but they couldn’t reveal who it was because of legal protections which exist for athletes under the age of 16. Since Valieva was the only athlete in the competiton under the age of 16 in the competition, we now know that whoever handled that communication from the IOC needs to go back to information security school.

Predictably enough, in the days following, I was embroiled in some ‘lively’ online discussions regarding the Valieva incident. The scope for arguments about this sort of thing are endless, since the incident stands at the intersection of politics, sports, medical science, entertainment, and probably a whole host of other topics which I haven’t thought of. What I realised while engaging in these discussions is how little the average person knew about anything (and yet, how confident the average facebook commenter is when speaking about those same things). What was particularly interesting to me was the lack of understanding of how high performance sports works, and subsequently how this led to a poor understanding of how doping works. In this article, I hope to cover the aspects of doping and sports related to the Kamlia Valieva incident thoroughly enough that a reader might leave with a better understanding of both.

First – a very rough overview of how high-level sports works. An athlete trains, improves, and eventually is so good at a particular event that they compete with other athletes with the aim of winning a competition such as the olympics. A lot of people like to watch these contests on TV, and that desire for this particular kind of entertainment is what drives the economics of sport. We like to tell ourselves that sport is all about higher ideals and healthier societies, and to some extent it is, but the driving force behind elite-level sport is entertainment value. If you’ve ever wondered why a professional footballer gets paid more than a professional pole-vaulter, it literally all comes down to how many and how often people watch these athletes on TV.

But what about the athletes? To get a better athlete – that is, an athlete who is more likely to win, you just train them more, or harder, or some combination of those factors, right? Not quite. One of the first misconceptions about elite athletes that you run into is that they spend all of their time training. I suppose it stems from the thought that being a full-time athlete is akin to doing sport as a full-time job, and as such you show up for ‘work’ for the usual 40 hours a week or so. This is not how you get high-performing athletes, and having spent a lot of time in the world of elite sport, I am increasingly suspicious of anyone who also believes that sitting at a desk for 40 hours a week (or more) can result in ‘high performance’ at any task.

I am increasingly suspicious of anyone who also believes that sitting at a desk for 40 hours a week can result in ‘high performance’ at any task

Most people understand that doing sport at a high level is very strenuous, but what a lot of people don’t know is that it is also damaging to the body. Yes – doing strenuous physical activity regularly is good for your health for so many reasons, but training at the elite level, believe it or not, is actually not good for your health. Have you ever been on a long hike, or done a strenuous ropes course race with work colleagues, or even played a game of pick-up football in the park with some neighbours, only to find yourself riddled with aches and pains the next day? That soreness is a result of your body’s natural process of inflammation, and the cause of that inflammation is the damage that you have done to yourself. (fear not – it is also a sign that your body is conducting repairs on itself)

When you lift a heavy weight, for example, you are actually putting lots of small tears in your muscles. In other words, when you lift weights, you are tearing your muscles in a controlled way. Don’t be alarmed though, the whole idea behind this is that your body works to repair the damage and when it does those repairs, it builds back stronger. That process is called adaptation, and that is the name of the game when it comes to making any kind of progress in sports. An everpresent danger, when considering all of this, is to train too hard. How hard is “too hard”? It depends. If an athlete isn’t eating or sleeping well, even a relatively low training load might be too hard. The important takeaway is this though – you need to rest in order to get stronger from training, and if either the training is too much, or the rest not enough, an athlete can slowly get worse despite seeming to train very hard.

“In other words, when you lift weights, you are tearing your muscles in a controled way”

What does this have to do with doping and Kamila Valieva?

In amongst all the idiots in the comments section who understood so little of the subject matter that they didn’t have anything useful to contribute, I struck up a very interesting discussion with a pharmacologist who knew a lot about how trimetazidene (the banned substance in Valieva’s sample) worked. He was very insistent that it couldn’t possibly have a performance-enhancing effect for a figure skater. Trimetazidine is a heart medication that people take to treat angina – those chest pains which are often associated with clogged arteries around the heart, and it does this by being anti-ischemic. It is not a coincidence that the mechanism by which Trimetazidine works is very similar to another anti-ischemic heart medication which also recently got some attention for being used as a doping agent by high profile Russian athletes – Meldonium.

It is not a coincidence that the mechanism by which Trimetazidine works is very similar to that of Meldonium

So how do these medications actually work? Trimetazidine and Meldonium both work to shift the equilibrium of muscle metabolism away from oxygen/fat-burning and towards glycogen-burning. Why does a heart medication need to do this? The muscles of the heart strongly favour oxygen metabolism over glycogen. Under stress, heart muscle that doesn’t have good circulation can become ischemic, and this can cause lactate buildup which is the source of a lot of chest pains. By shifting the preference for fuel in heart muscle, you can prevent this ischemia.

Of course, the heart muscles aren’t the only ones affected by these medications. Skeletal muscle (the muscles most people picture when you say “muscle”) is, to a somewhat lesser extent, also impacted. Not only do you have a little more oxygen floating around in your bloodstream for fuel (is the amount significant? probably only marginally, but at a high level of competition, small differences can make a big difference), but you also have a situation in which muscles can delay the onset and severity of ischemia by preferentially switching fuel sources to glycogen-burning earlier than they normally would. The delay of ischemia also means that the stress on your central nervous system is lowered simply because, again, more oxygen-rich blood to go around. The end result of all these small shifts is that when you’re working out, you get to spend a longer time in that “fresh” state than you normally would, before the onset of fatigue and the resulting loss in coordination.

The end result of all these small shifts is that when you’re working out, you get to spend a longer time in that “fresh” state

So that is the crux of it. At the very lowest levels of understanding, ordinary folk think that doping only works by directly making you faster or stronger on the day of competition, i.e. having a strong cup of coffee just before a race. When people start to understand sport a little better, they realise that doping can be used to not only train harder, but recover faster, and in this way they see how important random out-of-competition testing is. But understandably, almost nobody can see why an anti-ischemic heart medication can make a figure skater a better figure skater. The current scientific evidence points to a small but possibly insignificant bump in endurance performance from taking the drug – a performance gain on the scale of a cup of coffee or some creatine powder – both legal supplements. People like my pharmacologist friend probably underestimate just how physically demanding figure skating is at the highest level, since they are so adamant that a small bump in endurance doesn’t make a difference to a figure skater. However, what’s really being missed is that the fatigue-related loss of coordination that practitioners of skill sports try very hard to avoid can be significantly delayed by these kinds of anti-ischemia medications, and that is the main performance enhancing effect of them when used as a doping agent in this context.

In speed skating for example, this advantage is obvious. Speed skating is, after all, all about speed. We skate around in circles at speeds that peak above 60km/h balanced on a sliver of steel 1.1mm in width. An enormous amount of energy output is required to reach those speeds, and at the same time, a huge amount of finesse and fine motor control is required to safely traverse the course while maintaining those speeds. The only way to gain this ability and proficiency is to spend as much time as possible at those high speeds. But even at the highest levels, the most well-conditioned athletes only have a maximum of 2-5 minutes to spend at their top speed per week (not consecutively – in very short bursts with a lot of rest in between). The reason for this is that once you start to fatigue, you lose coordination, and even the slightest loss of precision in your movements means that you can’t skate as fast, and that you should do something that isn’t top-speed work otherwise you risk learning bad habits (and falling). It’s quite cruel, because your perceived feeling is that you aren’t that tired, and cardiovascularly, the training isn’t all that hard, but try as you might, you just can’t skate very fast.

high-quality motor-learning work can only be done when a skater is in a reasonably ‘fresh’ state, and any method of prolonging that state would confer a significant advantage

For a figure skater, I can only imagine that this challenge is similar – that a lot of the best, high-quality motor-learning work can only be done when a skater is in a reasonably ‘fresh’ state, and any method of prolonging that state would confer a significant advantage. As for the positive test, and getting caught, we can only speculate on the reasons. I suspect that everyone on the “quad squad” (so named because they are the only women to land quadruple jumps in Olympic competition) coached by Eteri Tutberidze was taking Trimetazidine but since Valieva was only 15, her body took longer to metabolise the medication and subsequently clear it from her system.

At the end of the day, I’m not sure the pharmacologist I spoke to was entirely convinced by what I said, but I was certainly grateful for his explanation of how trimetazidine worked. Indeed there is even a Popular Science article which argues that trimetazidine likely has no performance enhancing effects. It is well-sourced, and contains quotes from relevant experts. This is the kind of article that even makes me seriously question if I might have it all wrong, but then I remember how specific expertise can be. All the cardiologists, pharmocologists, and even exercise physiologists who were interviewed and quoted in the piece are experts in their fields posessing a level of expertise far surpassing my own in their field, but none of them seem to know anything about the physiological requirements of a skill-sport, and none of them have considered the performance enhacing implications of the anti-ischemic effect of the drug. In other words, they aren’t stupid, they just have blind spots that my particular experience and perspective can help illuminate.

So what? The investigation is still ongoing, no medals have been awarded in the team event, and who knows what the results of the investigation will be, or what consequences lie in wait for the athletes involved. Is trimetazidine performance-enhancing? In my expert opinion, I believe there is no doubt. Even if it isn’t, it’s on the banned substances list, and all the athletes have to follow the same rules. Testing positive for it in December ought to result in an automatic 4-year ban, backdated to the date of the test – 24th December 2021. Taking her age into consideration, that ban might be reduced to 2 years on appeal, but what is clear is that she would have been ineligible to participate in the Olympic Games, and therefore all of her results from those games must be invalidated, which includes the win by the Russian team in the women’s team event. I wait with bated breath on the results of the investigation.

I wait with bated breath on the results of the investigation.

As a postscript, what is interesting about the investigation so far is that nobody has requested the testing of the B-sample. When an athlete submits a sample at a doping-test, the sample is split into A and B samples. The A sample is the one that gets tested and the B sample functions like a backup in case something goes wrong with the tests, or the A sample is somehow lost in transit or otherwise compromised. The implication here is that nobody doubts that there was trimetazidine in her sample, and I find that an interesting avenue that this case has taken.

Often the first thing that happens is the athlete requests a test of the B-sample, if only to delay the process and give their legal team more time. Very recently, Australian 800m runner Peter Bol had a doping test turn up Erythropoietin (EPO) and the result leaked to the press causing all kinds of kerfuffle. He immediately requested that the B-sample be tested and, surprisingly enough, it came back clean and he was exonerated. Again, this raises all kinds of questions about information security (I, for obvious reasons to regular readers of this website, have opinions on information security, and even some expertise on the matter). A doping allegation is not something that is easily shaken from an athlete’s reputation, even when they are exonerated, but when an athlete gets a positive test, the standard procedure is to provisionally suspend them, pending the outcome of an investigation. Obviously Bol’s positive test should have been kept under wraps, the B-sample tested, him exonerated, and aside from a little stress and a month or so’s missed training and competition, no harm done. But in the current landscape of constant news cycles and social media, it is exceedingly difficult to hide a doping suspension, even a short-lived one. The material damage to Bol from a few months of being accused of being a doped athlete are probably minimal, but the experience has still upended his life and disrupted his training enough that it might impact his results in future competitions.

A doping allegation is not something that is easily shaken from an athlete’s reputation, even when they are exonerated

As for Kamila Valieva, there are many difficulties with regard to information security in this case. Trickiest of all is that she was ‘caught’ by a doping test administered in Russia (although the lab which analysed the sample was in Sweden; Russian labs are, for reasons which should be obvious, not accredited by WADA anymore). From a legal perspective, what actually happened is that she had a positive test, then was cleared by the Russian Anti-Doping Agency (RUSADA), and it is that decision which is being challenged by WADA (World Anti Doping Agency), the ISU (International Skating Union), and the IOC (International Olympic Committee). Is it realistic to keep all of this under wraps for the duration of the investigation and lengthy legal process? Is it fair to the other medal-getters for nobody to have received their medals a year after the competition? What is clear is that even though Kamila was cleared by CAS (Court of Arbitration for Sport) to compete in the long program, with the caveat that if she was to medal (on paper, a near-certainty) that the medals would be witheld until the conclusion of the investigation, the controversy and media storm had already done its damage – when she skated, her mind wasn’t present, she made many mistakes, and finished outside the medals highlighting in a very real way that information security isn’t just an academic discussion, and that information leaks can do real damage to real people.

And finally – SHE’S JUST A KID FFS!

And finally – SHE’S JUST A KID FFS! If you’re serious about legal protections for younger athletes, then don’t fucking say anything to the press. Who the hell even thinks to dope a bunch of kids just so that they can figure skate really well. This is not the first, and it won’t be the last time I rage about this. When I coached the Danish junior speed skating team at Junior World Championships in Obihiro, Japan in 2011, we watched as Laurent Dubreuil edged out Pavel Kulizhnikov in an extraordinarily fast 500m contest, then we discovered to our dismay that Pavel had failed a doping test, and as it would turn out, not his last – his second involving the famous anti-ischemic heart medication Meldonium. I already feel great sadness for athletes who are caught up in a state-sanctioned systematic doping system because they don’t have any realistic choice in the matter, but in the end they suffer the most. But when I discover that these systems are doping literal children, then I despair for humanity. When did this become ok in anyone’s head? It’s just sport; at the elite level it’s just for entertainment, and at the lower levels I suppose it’s about important life lessons regarding discipline, goal-setting, and other self-help books. Maybe somewhere along the way, it’s about public health too, I just don’t know anymore.

For the sake of all the future Kamila Valievas out there, I hope we can imagine then build a better world perhaps not completely free of doping, but at least more resistant to it, and certainly more resistant to kids being doped to be used as pawns in some nationalist dick-measuring contest. What probably disturbs me the most about all of this is that if she hadn’t been caught, we would all be singing the praises of this prodigiously-talented 15-year-old who broke all the world records and won all the gold medals. Then who knows… years later there might be an obituary that nobody notices talking about a former superstar figure skater who unexpectedly succumbed to a heart condition in her 40s, then when The Powers That Be™ are questioned on whether or not it was all worth it, they reply with an emotionless “yes”. Fuck that. We can do better. We must do better.

1 Comment on Trimeta… what?

  1. I really enjoyed reading this article. It allowed me a better understanding of how doping actually works. Your angle, taken from your long experience in top sport, offers valuable insight. I fully subscribe to your final remarks on how criminal doping minors actually is!

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