Cayuga Sports Medicine Conference Supplements Update 2010 By Lee A. Mancini, MD, CSCS*D, CSN Assistant Professor UMass Medical School Faculty UMass Sports Medicine Fellowship Certified Strength and Conditioning Specialist with Distinction Certified Sports Nutritionist Background Former D-I athlete / 1999 Boston Marathon Numerous Sprint / Olympic Distance Tris 15 years as Certified Sports Nutritionist 15 years as Certified Strength & Conditioning Specialist UMass Sports Medicine Physician Sports Nutrition consultant Boston Red Sox Organization Lowel Devils (NJ AHL affiliate) Worcester Ice Cats (STL Blues AHL) Holy Cross UMass Amherst Assumption College Nichols College Lived in Ithaca my entire life - graduated from Lansing High School… Goals & Objectives 1. 2. 3. 4. 5. Review a brief history of supplements Discuss how to examine supplement claims Review some common supplements Examine supplements specific for triathletes & endurance athletes Ask Questions! Historical Perspective Ancient History Aztecs Chinese Greeks Ergogenic Ergon gennan 20th Century & Supplements Brown-Sequard in 1889 1950s Dr. Ziegler Methandrostenolone IOC 1968 1st list of banned substances 1976 Montreal Olympic Games The Supplement Industry Nutrition Labeling and Education Act (NLEA) 11/9/1990 Dietary Supplement Health and Education Act (DSHEA) 10/25/1994 Multibillion dollar industry 1994 = 8.3 billion 1999 = 14 billion 2009 = 23.7 billion The Supplement Industry 2002 Health & Diet Survey 73% - 18 and older had used in past year 2006 J of Adolescent Health 79% used in past year 48% used in past month Creatine - 8% vs. 2% Weight Loss - 7% vs. 15% Timbo, BB, Ross, MP, McCarthy, PV, Lin, CT. (2006) Dietary supplements in a national survey: Prevalence of use and reports of adverse events. Journal of American Dietetic Association, 106 (12), 1966-74. Three Questions Is it effective? Is it safe? Is it legal? Is it Legal? Governing bodies have banned substance lists IOC, NCAA, UCI, USAC, WADA, MIAA Triathletes - USAT falls under USADA Law enforcement penalties Possession Federal offense 1 year and 1,000$ Selling Federal felony 5 years and 250,000$ Is it Legal? - Selling One’s Soul Sports Psychology…1987 Take a banned substance guarantee gold medal - and not get caught 195 of 198 said YES Take a banned substance - top athlete for 5 years - and then die in year 6 Over 50% said YES Supplements & Triathletes Ground rules Specific supplements Proven Performance effects Side effects USAT follows USADA prohibited list Banned Substance List S1 - AAS Nandrolone Clenbuterol (asthma in other countries) S2 - hormones and related substances EPO, hGH, IGF-1, hCG, insulin, & corticotrophins PRP given IM prohibited PRP tendon injections requires Declaration of Use DM pts - need TUE for insulin Banned Substance List S3 - Beta-2 Agonists Salbutamol (Ventolin, ProAir, DuoNeb) Salmeterol (Advair, Serevent), Others need TUE (terbutaline) Oral use is prohibited S4 - Agents with AntiEstrogenic Activity Aromatase inhibitors SERMs - tamoxifen Other Anti-Es clomiphene Banned Substance List S5 - Diuretics and Masking Agents Masking Agents Plasma Expanders Albumin, Dextran, Glycerol (supplements banned) Alpha-reductase inhibitors - Finasteride Epitestosterone Diuretics Furosemide Spironolactone Banned Substance List Prohibited Methods M1 - Enhancement of O2 transfer M2 - Chemical & Physical Manipulation Blood doping Tampering IV infusions (even if nonbanned substance unless in hospital setting) M3 - Gene doping Banned Substance List Prohibited Substances IN Competition S6 - stimulants Pemoline, Prolintane Ephedrine and methylephedrine - U > 10mcg/ml Pseudophedrine - U > 150mcg/ml (D/C >24hrs prior) Athletes w/ ADD/ADHD Need TUE Not Prohibited Caffeine Banned Substance List S7 - Narcotics S8 - Cannabinoids S9 - Glucocorticosteroids Fentanyl, Morphine PO, IV, PR, IM (DOE/TUE) Topical P1 - ETOH P2 - Beta-Blockers Commonly Used Banned Substances Erythropoietin & Blood Doping Natural hormone secreted by the kidney formation RBCs r-HuEPO,Darbopoetin (Aranesp) Blood removed from athlete 1984 - 10 U.S. cyclists Hemopure (based on bovine Hgb) 2001 Giro d’Italia cycling marathon Enhances erythropoiesis by stim proerythroblasts formation Epo & Doping - Physiology Endurance Exercise RBC mass and plasma volume increases Hct & Hgb decrease due to expanded plasma volume By increasing Hgb & Hct increases O2 carrying capacity decreases ratings of perceived exertion increases VO2 Max Epo - Proven Effects EPO for 26 days at 50 IU/kg led to 7% increase in power 9% increase VO2 Max Increase Hct After 6 weeks of EPO - 17% increase in cycling time to exhaustion IV r-HuEPO works in days Epo & Doping - Adverse Effects Because of increased RBC volume - causes increased blood viscosity HTN Seizures DVTs, PEs Stroke Case report - cerebral sinus thrombosis Epo & Doping - Summary Proven Performance effects for Endurance Athletes Significant Risks Banned by IOC in 1990 Banned by USADA Banned by UCI UCI testing since 1997 Hct 50 for men, 47 for women UCI Certificate Ephedra Chinese herb, 5000yrs Known to relieve respiratory ailments Comes from Ephedra sinica plant Ma huang Mixed into herbal teas Sale of it alone is prohibited Make methamphetamine Ephedra -Mechanism of Action Stimulant that mimics effect Norepi & Epi Increases fat burning, Heart rate Thermogenic effect Increases resting metabolism, calorie expenditure Causes appetite suppression Ephedra - Proven Effects Over 52 studies in literature (Shekelle et al., 2003) All studies were less than 6 months Average 1.0kg per month greater than placebo Doses ranged from 25 to 120mg per day Dose related effect Ephedra - Adverse Effects Wide variety of side effects Heart palps, HTN, anxiety, hyperthermia, headaches, & cardiac arrhythmias Effects all stopped 48hrs after discontinuing FDA 800 adverse incidents >90% exceeded recommended doses FDA 284 serious adverse events - 5 deaths, 5 heart attacks, 11 strokes, & 4 seizures 50% of these people < 30 yo Ephedra - Summary 2/17/2003 Proven effect on fat loss 0.82% all sales, 64% adverse 4/12/04 Government bans Ephedra 2006 US Court of Appeals upheld “Legal Ephedra” bitter orange UCI - U > 10mcg/ml Legal Ergogenic Aids Creatine 1832 Chevreul - Greek word flesh Made from Arg, Gly, & Meth, 95% - skeletal muscle CrP + ADP => ATP + Cr, enz = Creatine kinase Intense exercise ATP used first 10 secs Also buffers muscle pH delays muscle fatigue Over 150 studies done, 93% in the past ten years Creatine - Proven Effects Overwhelming evidence Meta-analysis (Nissen et al., 2003) 1.09% increase in strength per week Increase 0.36% LBM per week (2.2 kg in 6 weeks) 15 lbs added to 1RM Bench Press (6 weeks) 25 lbs added to 1RM Back Squat (6 weeks) 61 Studies - 45 found to improve endurance performance (running, swimming, rowing, & biking) Ergogenic effect on repeated high intensity sprints (lasting 30 seconds to 3 minutes) Creatine - What about longer distances? Events lasting longer than 3 minutes - 25 studies - 8 found no improvement, 17 did Improved times in 5M and 15M sprints but slower times in 6K runs (by 26 seconds) Long distance endurance events - additional muscle mass and water retention may slow athletes down Creatine - Adverse Effects KIDNEY ISSUES? Because creatinine is breakdown product of creatine concern over kidney function (Crowe et al., 2003) Four year study, NCAA 3 yr study No significant adverse effects up to five years after ingesting creatine (Dempsey et al., 2002) (Eur J of App Physiol 2008 Gualano et al) Double Blind, Randomized - 3 months BOTTOM LINE - NO evidence on any effect on kidney function Creatine - Adverse Effects Main reported side effect = GI distress Case reports of muscle cramping, No studies showed increased cramping No effect on body fluid balance or heat regulation (2009 - meta-anlysis J Ath Train Lopez et al. (Br J Sports Med - 2008 - Dalbo et al) BOTTOM LINE - No increased risk of dehydration, cramping, or issues with sweating or heat regulation Creatine - Summary Most widely used supplement 30% Pro teams supply 50% Male Div 1 use 14% High School 75% High School informed from who? Proven Strength & Anaerobic effects GI & Cramping side effects No effect on kidney function For Triathletes not very beneficial NOT BANNED by IOC, UCI, WADA, USAC HMB ß-hydroxy-ß-methylbutyrate Metabolite of Leucine Found in catfish, citrus fruit, & breast milk Believed to preserve LBM during fat loss Anti-catabolic 1998 Sales 50-60 Million Dollars Proven Recovery Effects (Nissen et al., 1997) - Exercise induced muscle damage after heavy resistance training 1.5g/day or 3.0g/day - decreased protein breakdown Increased muscle recovery (Knitter et al., 2000) - 3g/day HMB for 6 weeks 20K run - monitored LDH, CPK levels Statistically significant - LDH & CPK levels post exercise in HMB group Proven Performance Effects Meta-analysis (Nissen et al., 2003) of 9 studies 0.28% increase LBM per week (6-8 weeks) 1.40% increase in 1RM strength per week (Nissen et al., 1996) - 1.5g/day and 3.0g/day for 6 weeks, increased strength (Kreider, 1999) - 3g/day for 8 weeks Increases in LBM, decreases fat mass Increases in upper and lower body 1RM strength (Lamboley, 2007 - Int J Sport Nutr Exerc Metab) - Aerobic training 3/wk x 5 wks (3g/day) - Inc VO2Max 13.4% vs. 8.4% placebo, no change in body comp (Watson, 2009 - J Str Cond Res) - no side effects 3 g/day - small increases in 1RM, small decrease in fat mass, small increase in muscle mass The Blond Bomber - Dave Draper Adverse Effects No reported side effects from any studies (Juhn, 2003) - Using HMB for 8 weeks No change renal fx, LFTs, Lipid panel (Crowe et al., 2003) - Using HMB for 6 wks No change in serum Test, BUN, Cr, Chol, TGs Summary of HMB Not Banned Safe at the present Increases maximal strength Maintains LBM, Decreases fat mass Cost - 40$ for 200 pills 4 pills = 1 gram HMB Servings 4 pills x 3 times/day = 12 pills daily 17 day supply $80 per month Caffeine #1 Drug used in the world 82-92% adults use daily Methylated xanthine alkaloid derivative 1,3,7-trimethylxanthine Metabolized in liver p450 3 Main metabolites Theobromine, theophylline, Paraxanthine most potent Caffeine - Mechanism of Action Structure is similar to adenosine Binds to adenosine cell membrane receptors Found everywhere Stimulates CNS, increases release of Epinephrine Increases HR, MR, resp center output decreases perceptions of pain, & fatigue One main effect on performance is by increasing fat oxidation - which spares muscle glycogen Caffeine - Proven Effects Effects have been studied for 100 years Most studies = 2-9mg/kg per day (250750mg) (Costill et al., 1978) - 300mg, cycle at 80% VO2 Max until exhaustion 90.2 minutes vs. 75.5 minutes Increase max power in cyclists from 904 Watts to 964 Watts (also vs. placebo) Decrease race times from marathons to short sprints lasting less than 90 seconds (Graham, 2001) Studies in all three components of triathlon supporting this Caffeine - Adverse Effects Anxiety, heart palpitations, trembling, and facial flushing Dose related Lethal half-dose of caffeine is 150200mg/kg bodyweight about 100cups Tolerance to caffeine appears after 45 days Only takes 3 days of use to develop dependency and withdrawal symptoms after stopping Mood shifts, headaches, tremors, & fatigue - 12h to 7d Caffeine - Summary Banned 1962 IOC Removed 1972 Urine 12mcg/ml = 9mg/kg 6-7 cups = 700-800mg Proven effects on performance Because of side effects at higher doses - 3-6mg/kg better Because of tolerance & withdrawal - better to not take daily, but prior to specific competitions Definite benefits for triathletes 2005 IOC Removed completely from banned list UCI, WADA… Beta Alanine ß-alanine is amino acid Carnosine (ß-alanyl-L-histidine) Enzyme carnosine synthetase Frequent sprints Animal protein Supplementation can increase beta-alanine by 80% Chemical buffer in myocytes Delays fatigue Beta Alanine - Ergogenic Effects Most research past 3 years 2006 study by Hoffman in Nutr Research College football players 30 days of 4.5g/day vs. placebo 60 sec anaer power test 3 - 200 yd shuttle run 2007 study by Derave in J Appl Physiol 4.8g/day vs. placebo 400M sprints Knee extensions - 5 x 30 reps 2008 study by Kendrick in Amino Acids 6.4g/day vs. placebo 10 week lifting program Strength, LBM, Body Fat% no change 2009 study by Smith in J Int Soc Sports Nutr 1.5g qid (6g/day) x 3 weeks, then 1.5g bid (3g/day) x 3 weeks, 22yo (46 men) 6 weeks 6 x 2:1 minute cycling VO2 TTE,VO2peak,LBM Beta Alanine - Summary Building block of carnosine Legal - not banned by any sports governing body No documented side effects Ergogenic effects Increases muscle [carnosine] Reduces fatigue - blood pH, buffer Some studies have also shown no improvement on performance Nitrous Oxide / Arginine L-Arginine alpha-ketoglutarate (AAKG) Arginine is a conditionally essential AA - 60% athletes 2 main effects Acute - NO increase blood flow & nutritient delivery increase exercise capacity Chronic - anabolic GH effects, protein synthesis NO / Arginine - Ergogenic Effects 1989 Study by Elam in J Sports Med Phys Fitness 5 week progresive strength program 1g arginine + 1g ornithine Increase muscle strength/LBM 2006 Study by Campbell in Nutrition 10 men (30-50yo), 4g/day 4 days lifting/wk x 8 weeks 1RM BP, Anaer power, aerobic capacity, Body comp, & Quad endurance Only 1RM, Anaer power, [arg] p<0.5 2008 Study by Little in Int J Sport Nutr Exerc Metab Power, Muscle End, Max Str, - No change in body comp More studies continue to show benefits NO / Arginine - Summary L-Arginine alpha-ketoglutarate (AAKG) Pre-Cursor NO Increase protein synthesis Increase GH levels Increase strength/power No documented adverse effects BUT no evidence that it improves aerobic capacity or endurance performance Legal - not banned Macronutrient Ergogenic Aids Carbohydrates Macronutrient Aids muscle recovery & glycogen stores Source of instant energy as well Insulin spike 6-8% CHO solution 8 T in 1 Gallon Carbohydrates - Proven Effects Evidence shows CHO beverages better than H2O Study - cyclists 70% VO2 max, improved TTE 30 minutes 2004 - Mouth wash study (6.4% maltodextrin) Central Drive vs. Metabolic Drive Aerobic endurance Carbohydrates - Summary Proven performance effects No adverse side effects Not Banned But is there something better?… PRO vs. CHO What about Protein? J Am Col Nutrition - 2004 Whey vs. CHO - 10 weeks Whey more strength gains more bodyfat loss less lean muscle wasting lower pre-workout cortisol levels Greater BONE DENSITY Protein Quality Whey/ Milk Proteins are more effective than Hydrolyzed Soy Protein for stimulating Protein Synthesis & AA deposition in muscle. = Greater Lean Mass gains with training = Greater Strength in long-term J Am Coll Nutr. 2005 Apr;24(2):134S-139S. Protein Quality July 2009 Study in J Appl Physiol Whey vs. Casein vs. Soy 10g EEA mix after strength training Men and Women - 12 weeks Whey - More BCAAs NON-WORKOUT 90% muscle recovery/growth vs. casein 25% more vs. soy WORKOUT 125% more vs. casein 30% more vs. soy Whey greater body comp changes Whey greater strength gains Carbohydrate + Protein - Proven Effects Combination of 6g EAAs and 35g CHO 10X Insulin, 3X AA, 4X Pro vs. CHO, PLA Studies showing superiority VO2 Max 75% - 29% (24mins) 85% - 40% (12) Reduced post-exercise muscle damage CPK - 216 vs. 1318 Ready, Saunders CHO + PRO - Proven Effects Study by Kreider in 2002 - placebo, Carb, & CHO/PRO Resistance training - 10X more insulin, 3X increase AA in skeletal muscle, 3 1/2X increase in protein synthesis in skeletal muscle CHO - repletes glycogen stores, creates anabolic environement through insulin PRO - increases muscle growth & decreases muscle breakdown (Rennie & Tipton in 2000) PRO + CHO - BCAAs BCAAs - 20% AA in body Higher amounts in animal proteins Oxidation rises 300 to 500% during exercise Levels drop by 25% in the 90 minutes following a workout 1999 study by Mero - showed increase LBM, decrease BF% 30K race times 3:30 to 3:05 hrs with BCAA supplementation vs water, and carb (Kreider 1999) Greer et al. in 2007 in Int J Sport Nutr & Exerc Metab - CHO, BCAA Review by Negro (2008 J Sports Med Phys Fit) - DOMS, Imp immune function via exer-related cytokine production Carbohydrate + Protein - Summary Proven Benefits Safe 4-2:1 Ratio During & After Not BANNED Case #1… 17yo male HS athlete Test = 2xs NL Estradial = 3xs NL HDL <10 LDL = 252 10 week cycle Went from 145 to 190 What do you do?… Case #1…Revisited 17yo male HS athlete 3 Months later Off D-Bol Test = WNL Estradial = WNL HDL = 42 LDL = 104 ECHO - WNL Weight now = 163 Scenario… 19yo patient comes to your office… Wants to start taking supplement X. What do you say?… Supplement Pyramid What should I take? Solid Foundation Base - T / N / R Ask the 3 ?s 2nd Tier MVI / Ca++/Vit D Whey Protein/P+C Fish Oil** 3rd Tier Wrapping it up Educate Open mind Supplement Pyramid Sports specificity Caveat Emptor One final warning Delbeke et al., 2002 OTC Pyruvate USAC Position Statement - 1/26/06 Warning: Any athlete who takes…does so at his or her own risk of committing a doping violation UCI, US-ADA, WADA, or IOC Remember, the athlete is ALWAYS responsible for what he or she puts into his or her body 1-800-233-0393 (US-ADA) www.usantidoping.org On-line Resources for help Important Web Sites http://www1.ncaa.org/membership/ed_outreach/healthsafety/drug_testing/banned_drug_classes.pdf NCAA site on banned substances http://www.theathlete.org/wada.htm World Anti-Doping Agency Thank You References Anantaraman, R., Carmines, A.A., Gaesser, G.A., & Weltman, A. (1995). 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