Goals & Objectives

1. Review a brief history of

supplements
2. Discuss how to examine
supplement claims
3. Review some common
supplements
4. Examine supplements
specific for triathletes &
endurance athletes
5. Ask Questions!
Historical Perspective

 Ancient History
 Aztecs
 Chinese
 Greeks
 Ergogenic
 Ergon
(work/energy)
 Gennan (generate)
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) in USA 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 e.g.

 IOC, NCAA, UCI, USAC, WADA,

MIAA

 Law enforcement penalties

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 & Athletes
 Ground rules
 Specific supplements
 Proven Performance effects
 Side effects
Banned Substance List

 S1 - AAS
 Nandrolone (a steroid)
 Clenbuterol (asthma medications in other countries)
 S2 – other hormones and related substances
 EPO, hGH, IGF-1, hCG, insulin, & corticotrophins
 Tendon injections for injury recovery - requires Declaration of
Use
 DM (type 2 diabetes) patients - need Therapeutic Use
Exception (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 Anti-Estrogenic 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/Oxygen transfer
 Blood doping
 M2 - Chemical & Physical Manipulation
 Tampering
 IV infusions (even if non-banned 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
 Fentanyl, Morphine
 S8 - Cannabinoids
 S9 - Glucocorticosteroids
 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 (red blood cell) mass and plasma volume
increases
 Hct & Hgb (hemoglobin) decrease due to expanded
plasma volume
 By increasing Hgb & Hct
 increases O2 carrying capacity
 decreases ratings of perceived exertion
 increases VO2 Max a measure of aerobic fitness very
important for endurance exercise
 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

 Comes from Ephedra sinica plant
 Ma huang
 Known to relieve respiratory ailments
 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
 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 better for strength and

power
 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
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 (250-
750mg)
 (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 150-
200mg/kg bodyweight about
100cups
 Tolerance to caffeine appears after 4-
5 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 (muscle cells)
 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
 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 (training, nutrition, recovery)
 2nd Tier
 MVI / Ca++/Vit D
 Whey Protein/P+C
 Fish Oil**
 3rd Tier
 Other ergogenic aid? E.g. caffeine supplementation
On-line Resources for help
 Important Web Sites
 http://www.theathlete.org/wada.htm
 World Anti-Doping Agency
References
 Anantaraman, R., Carmines, A.A., Gaesser, G.A., & Weltman, A. (1995).
Effects of carbohydrate supplementation on performance during 1 hour of
high intensity exercise. International Journal of Sports Medicine, 16, pp. 461-
465.
 Armstrong, L.E. (2002, June). Caffeine, body fluid-electrolyte balance, and
exercise performance. International Journal of Sport Nutrition & Exercise
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 Audran, M., Gareau, R., & Matecki, S. (1999). Effects of erythropoetin
administration in training athletes and possible indirect detection in doping
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 Bell, D.G., Jacobs, I., Ellerington, K. (2001). Effect of caffeine and
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Science in Sports and Exercise, 33(8), pp. 1399-1403.
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 Costill, D.L., Dalsky, G.P., & Fink, W.J. (1978). Effects of caffeine ingestion on
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 Cottrell, G.T., Coast, J.R., & Herb, R.A. (2002). Effect of recovery interval
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 Dawson, R.T. (2001). Drugs in sport – The role of the physician. Journal of
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 Delbeke, F.T., Van Eenoo, P., Van Thuyne, W., & Desmet, N. (2002,
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