Supplements Update 2010

Report
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
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