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Can a placebo make you a better cyclist?

20 Jul 2020

Could ‘honest fake’ drugs be the next big thing? Cyclist investigates the placebos that work even when you know they’re placebos

Words James Witts Photography Rob Milton

Everyone knows the placebo effect. The idea is that people will feel the effects of a drug as long as they believe it is working, even if it turns out to be a sugar pill. It’s used frequently in medicine and already has a place in pro cycling.

Marco Pinotti, former T-Mobile rider and now performance coach at CCC Pro Team, says, ‘I remember a doctor prescribing a pill to a rider and telling him, “Take this, but if you’re selected for doping control, take this other one [to give the impression of masking its illegality].” The rider rode well but later found out they were just antioxidants. The doctor was playing mind games with the “old-school” athlete.’

There are many who still think Lance Armstrong’s performances owed a certain amount to the placebo effect. It wasn’t just that he pumped himself full of EPO and steroids, but that he believed they worked more than others did.

Bryan Saunders is a researcher at São Paulo University in Brazil, and he is convinced that placebo is one of the strongest legal performance aids. ‘It’s not as beneficial as caffeine, but is shown to be greater than nitrates [from beetroot] and beta-alanine.’

And the effect is not simply in the mind, he adds. ‘The psychological component is well known but we now understand that placebo effects are also neuro-biological. Something happens in the brain that generates a physical response that reduces pain.’

Knowledge is power

But hang on, you cry, if a rider knows they’ve taken a placebo, surely it won’t work? Actually, evidence suggests that placebo responses can be learned through a Pavlovian-like process termed ‘pre-conditioning’. Taking that further, there’s growing evidence that knowing you’ve taken a placebo with no pre-conditioning still leads to measurable performance gains.

‘It’s called open-label placebo or “honest fakery”,’ says Saunders. ‘We recruited 28 well-trained female cyclists from São Paulo. The first session was a VO2 max test, then on two occasions they performed a 1km TT with or without the intervention.

‘We also had them fill out questionnaires for their training and supplementation history, as well as their supplement beliefs and tests on their life outlook – how positive they are, for example – to identify the relationship between belief and performance.’

Saunders spent time explaining how important it was to believe in this honest fakery. Red capsules were chosen as red is a stimulatory colour, although its proposed potency would stem from no more than 200mg of flour.

The results? On average, the riders improved by 0.7%. That’s not much but, as Saunders says, at elite level that’s the difference between triumph and despair.

You might think that’s flaky, that the riders simply worked harder, but despite the speed increase there was no change to the heart rate, blood lactate or rate of perceived exertion over the two tests.

‘It seems expectation plays a role, with many saying they thought of the capsule working halfway through the test. One rider in particular was a strong believer in pills, taking 18 supplements a day. But even a couple who felt they’d ridden worse because it was an inert substance actually improved.

‘But four riders went backwards. They believed nothing would happen and that hurt their performance. This is nocebo.’

The concept of open-label placebo is gaining traction, and eagle-eyed capitalists have cottoned on with the launch of pills such as Zeebo Relief, which states proudly on the label that it is ‘Pure Honest Placebo’ and highlights that it contains ‘No Active Ingredients’.

Whether they deserve £20 of your hard-earned money is debatable. What is clear, however, is that a placebo doesn’t have to be a pill at all.

‘A placebo could be your lucky pants, or it could be putting your left sock on first, or putting your bottle down with your right hand,’ says Saunders. ‘All these things have performance effects and show how amenable we are.’

Just look at Pinotti: ‘I remember my first year as a bike rider [aged 16]. I always wore a small Casio watch but removed it before the start of my third race. I raced really well and never wore that Casio in competition again.’

How can I use this?

‘Belief is everything,’ says Pinotti. ‘If you believe in a type of training, in a certain food, even if they’re not the best, you’ll race better.’ It’s this belief that could lie behind Team Ineos’s marginal gains. Whatever the merits of bespoke mattresses and beetroot smoothies, arguably it’s riders trusting that their support team has ticked every performance box that helps them grow.

Genetics may also play a part. Saunders is looking at the connection between caffeine, open-label placebo and placebomics, a relatively new field that examines whether genetics predisposes individuals to responding better or worse to a placebo.

‘We’re investigating genes that are known to metabolise caffeine and inhibit adenosine connections in the brain, which stimulates the increase of catecholamines and dopamine,’ he says. ‘Some people respond better to caffeine than others. If those same people respond better to placebo, too, it stands to reason they’ll respond better to a caffeine placebo.’

And as caffeine’s a proven performance enhancer, but can cause heart problems with excessive intake, the benefits are clear.

Whether you pop an empty pill or spend every day in the same pair of lucky pants, you just have to believe.