Unapproved Weight Gain Supplement as a Cause of Avascular Necrosis: A Cautionary Report



1 Joint Reconstruction Research Center (JRRC), Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, Iran

2 Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran


Avascular necrosis of the femoral head (AVNFH) is a leading cause of end-stage joint disease in the young population
that can lead to total hip replacement in early life. There are various risk factors, including trauma, corticosteroids,
thrombosis, hypertension, and alcohol. There is a growing number of patients with AVNFH and history of self-medication
with herbal supplement used for weight gain in Iran. The present study aimed to demonstrate the prevalence rate of
using unapproved weight gain supplements (UWGS) in patients with AVNFH.
An observational and cross-sectional study was conducted to estimate the prevalence rate of using UWGSs in patients
with osteonecrosis at Imam Khomeini Hospital, Tehran, Iran, from January 2012 to 2018. The data were analyzed in
SPSS software (version 24) through descriptive statistics and tests of means.
Out of 207 patients with AVNFH, 115 cases were male. In total, 44 patients (20.95%) had a history of using UWGSs,
and there had no other risk factors of osteonecrosis of FH.
In conclusion, UWGSs can be a risk factor for AVNFH, and it is necessary to develop educational programs to alert
young population about the side effects of these supplements.
Level of evidence: III


Main Subjects

1. Mok M, Farewell V, Isenberg D. Risk factors
for avascular necrosis of bone in patients with
systemic lupus erythematosus: is there a role for
antiphospholipid antibodies? Ann Rheum Dis. 2000;
2. Kerachian MA, Harvey EJ, Cournoyer D, Chow TY, Séguin
C. Avascular necrosis of the femoral head: vascular
hypotheses. Endothelium. 2006; 13(4):237-44.
3. Kim HK, Bian H, Aya-ay J, Garces A, Morgan EF, Gilbert
SR. Hypoxia and HIF-1α expression in the epiphyseal
cartilage following ischemic injury to the immature
femoral head. Bone. 2009; 45(2):280-8.
4. Kim HK, Stephenson N, Garces A, Aya-ay J, Bian H.
Effects of disruption of epiphyseal vasculature on
the proximal femoral growth plate. J Bone Joint Surg
Am. 2009; 91(5):1149-58.
5. Shah KN, Racine J, Jones LC, Aaron RK.
Pathophysiology and risk factors for osteonecrosis.
Curr Rev Musculoskelet Med. 2015; 8(3):201-9.
6. Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld
Y, Gershwin ME. Pathogenesis and natural history
of osteonecrosis. Semin Arthritis Rheum. 2002;
7. Jones J. Epidemiological risk factors for non-traumatic
osteonecrosis. Orthopade. 2000; 29(5):370-9.
8. Laroche M. Intraosseous circulation from physiology
to disease. Joint Bone Spine. 2002; 69(3):262-9.
9. Chao YC, Wang SJ, Chu HC, Chang WK, Hsieh TY.
Investigation of alcohol metabolizing enzyme genes
in Chinese alcoholics with avascular necrosis of hip
joint, pancreatitis and cirrhosis of the liver. Alcohol
Alcohol. 2003; 38(5):431-6.
10. Suzuki M, Kumagai K, Osaki M, Murata M, Tomita
M, Miyata N, et al. Osteonecrosis of femoral head
in the stroke-prone spontaneously hypertensive
rats, especially old rats. Clin Exp Hypertens. 2008;
11. Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman
JR. Nontraumatic osteonecrosis of the femoral head:
where do we stand today? a ten-year update. J Bone
Joint Surg Am. 2015; 97(19):1604-27.
12. Behnood-Rod A, Afzali Poor Khoshkbejari M,
Pourzargar P, Hassanzadeh M, Moharamzad
Y, Foroughi F. Complementary and alternative
medicine use among Iranian patients attending
urban outpatient general practices. Complement
Ther Clin Pract. 2018; 30(1):58-63.
13. Shankar P, Partha P, Shenoy N. Self-medication and
non-doctor prescription practices in Pokhara valley 
Western Nepal: a questionnaire-based study. BMC
Fam Pract. 2002; 3(1):17.
14. Servidoni AB, Coelho L, Navarro Mde L, de Á􀆵 vila FG,
Mezzalira R. Self-medication profile of ENT patients.
Rev J Otorrinolaringol. 2006; 72(1):83-8.
15. Yousef AM, Al-Bakri AG, Bustanji Y, Wazaify M. Selfmedication
patterns in Amman, Jordan. Pharm
World Sci. 2008; 30(1):24-30.
16. Wardle J, Griffith J. Socioeconomic status and weight
control practices in British adults. J Epidemiol
Community Health. 2001; 55(3):185-90.
17. Brown PJ. Culture and the evolution of obesity. Hum
Nat. 1991; 2(1):31-57.
18. Pollock NJ. Cultural elaborations of obesity-fattening
practices in Pacific societies. Asia Pac J Clin Nutr.
1995; 4(4):357-60.
19. Treloar C, Porteous J, Hassan F, Kasniyah N,
Lakshmanudu M, Sama M, et al. The cross cultural
context of obesity: an INCLEN multicentre
collaborative study. Health Place. 1999; 5(4):279-86.
20. Mansour AA, Odaa AH, Wanoose HL. Corticosteroid
nonprescription use: a cross-sectional hospitalbased
study in Basrah. Med Princ Practi. 2010;
21. Isnard Bagnis C, Deray G, Baumelou A, Le Quintrec
M, Vanherweghem JL. Herbs and the kidney. Am J
Kidney Dis. 2004; 44(1):1-11.
22. Soheilykhah S, Salamam Roughami H, Mohammadi
M. Acute cholestatic hepatitis associated with
teucrium polium. J Shahid Sadoughi Univ Med Sci.
2007; 15(3):97-9.
23. Saberi N, Akhgari M, Bahmanabadi L, Bazmi E,
Mousavi Z. Determination of synthetic pharmaceutical
adulterants in herbal weight gain supplements sold in
herb shops, Tehran, Iran. Daru. 2018; 26(2):117-27.
24. Kisielinski K, Niedhart C, Schneider U, Niethard FU.
Osteonecrosis 15 years after femoral neck fracture
and long-term low-dose inhaled corticosteroid
therapy. Joint Bone Spine. 2004; 71(3):237-9.
25. McKee MD, Waddell JP, Kudo PA, Schemitsch EH,
Richards RR. Osteonecrosis of the femoral head in
men following short-course corticosteroid therapy:
a report of 15 cases. CMAJ. 2001; 164(2):205-6.
26. Burgess TD, Lamming GE. The effect of
diethylstilboestrol, hexoestrol and testosterone on
the growth rate and carcass quality of fattening beef
steers. Anim Sci. 1960; 2(1):93-103.
27. Noble RE. Effect of cyproheptadine on appetite and
weight gain in adults. JAMA. 1969; 209(13):2054-5.