Sophie GosselinEmergency Medicine

McGill

Food supplements

in the athlete

Objectives

• to better understand the pharmacology of the most popular molecules.

• know the most common and lethal adverse reactions associated with their use.

• to determine when ED physicians should– ask about them – suspect as potential cause for symptoms– suggest referral for nutritional counselling.

Food supplements

• Economic market of several billions of USD.

• Expansion in the last 5 years – Internet– Lack of regulation– Target group vulnerability

Food supplements

• Target group

– Athletes

– Teenagers•Body image•Peer pressure•Unsupervised•Unrealistic objectives about training

Food supplements

• Ergogenic aid: any means of enhancing energy utilization including energy production, control, and efficiency.

– Stimulants; amphetamines, ephedrine, caffeine

– Reduce tremor and HR; Beta blockers

– Bodyweight gain or loss; AAS, GH, B2 agonists, diuretics

Strategy is to increase energy consumption, metabolism while decreasing adipose tissue formation to the benefit of squeletal muscle

Food supplements

• Creatine• Anabolic steroids• Clenbuterol• Amino acids• GHB• Chromium picolinate• Caffeine, ephedrine, Mg, , EPO, GH

Creatine

• Formed in kidney, liver @ rate of 2 g/day

• Meat and fish• Typical diet 1-2 g per day• 95% in muscles (1/3 free Cr, 2/3 PCr)• Irreversible conversion to creatinine

Creatine

• Not for aerobic activities• Acute side effects:

– Gastrointestinal aches– Muscle cramping ( H2O retention in fibers)– No long term side effect if therapeutic doses

and schedules

• Case reports of rhabdomyolysis or quadriceps compartment syndrome after use.

Anabolic steroids

• mid 1950’s strenght enhancing properties of testoterone.

• Minimizing androgenic effect while preserving anabolic ones.

• No synthetic molecule dissociating two properties

• Two categories IM vs PO group.• Androstenedione most popular now.• DHEA banned by FDA in 1996

– Media attention cause manufacturers to sell it as nutritional aid rather than therapeutic drug.

– Wild yams sold in health food stores.

Androstenedione

• Endogenously produced• Prohormones

Androstenedione

• Ergogenic effects– Unclear rate of conversion to Testosterone when PO– Studies 300 mg/d users ingests 2-3 times this dose

• Anabolic effects– Induces protein synthesis– Binding to cell cytoplasm– Studies at best weak agents

• Androgenic effects– Male differenciation in utero– Maturation of external genitalia– Secondary sex characteristics– Regulation sperm production

Androstenedione

• Data on side effect in users is minimal.• Some suggest aromatization to estrogen when

PO.• Unclear if produces the side effect of other AAS

– Hepatic failure– Hepatocellular carcinoma– Testicular atrophy– Azoospermia– Because no alpha 1 7 alkylation– No increase LFT’s

Anabolic steroids

• Cardiovascular– Sudden death, AMI, cardiac hypertrophy

• Atherogenic model lipoprotein• Thrombosis model clotting factors• Vasospasm model vascular nitric oxide system• Decrease HDL 53%, increase LDL 36%• Increase fibrosis in myocytes

• Endocrine– Feedback inhibition of LH– Women and children most at risk

Anabolic steroids

• Musculoskeletal– Growth spurt of adolescence– Premature epiphyseal plate fusion and short stature– Predisposition to tendons rupture with local injections– Abnormal collagen fibers formation (type III)

• tendinitis

• Metabolic– Abolish a negative nitrogen balance– Promoting retention Na, K, Po4 – Decreased urinary excretion of Ca

• Psychiatric– Agressivity, mood swings, cognitive impairments

Anabolic steroids

• DHEA• Few sides effects reporte• Irreversible virilization of women, hirsutism,

voice deepening, hair loss• Irreversible gynecomastia• Increase risk of uterine and prostate cancer

that accompagnies unopposed elevation in testosterone or estrogen.

Clenbuterol

• Systemic B2 agonist (stimulant)• Reduce fatigue, sensitivity to pain,

bronchospasms, tremors• Increase alertness, reaction time,

concentration, endurance, • Promotes muscle growth • Large reduction in body fat

Clenbuterol

• Stimulate protein deposition in muscles by 20%

• Reduces glycogen and body fat deposition

• Skeletal muscles:– Increases glycolytic capacity– Induces a true hypertrophy vs hyperplasia– Shift fiber type I (slow twitch) to II (fast)

Clenbuterol

• Approved in Europe, Canada for livestock.

• Most symtoms are tachycardia, tremors, headaches, dizziness, nausea, fever.

• Case report of ventricular arrhythmias but patient also undergoing hypocaloric diet.

Amino-acids

• The protein shake• Daily requirement 0.8g/kg/d• Some benefit from extra 0,5g/kg/d• Beta hydroxy beta methyl butyrate• Glutamine• L-Carnitine

Anticatabolic effects

Amino-acids

• No studies have shown any benefit

• No major side effect

• No well designed studies either

GHB

• Popular in USA as liquid X• Release GH and burn fat during periods of

inactivity, such as sleep.• Investigated to treat EtOH WD in Europe• Use is illicit • Potentiates dopamine R in brain and GABA R

GHB

• Side effects: – related to decrease LOC– absences types seizures.

• OD setting:– Seizures – Respiratory depression– Exacerbation with Et-OH– No response with naloxone– Flumazenil in animals studies

Chromium picolinate

• Essential trace element• Low GI absorption• Popularity after found increase chromium loss

during exercice

• Claims it increases glycogen synthesis• Enhances action of insulin• Increase incorporation of AA in muscles

Chromium picolinate

• Major side effects• Use should be discouraged• Part of many “combo products”

• Anabolic steroid effect at dose of 200ug/day• Anecdotal report of anemia, cognitive

impairment• Interstitial nephritis. • Gastritis and GI intolerance if

– > 200 ug/d – more than one month “ treatment”

Route of administration

• PO• IM• SC for EPO• Needle sharing

– Across users– Across times

Available products

• Different brands• Differents dosages• Purity issues• Combinations within same product

Drug abuse

• Users are adolescent• Increased risk of engaging in other drug use

– marijuana– Et-Oh– Smoking– IV drug use

Possible scenarios

• Gastrointestinal symptoms • MSK: tendinitis, myalgias• Renal failure• Chest pain• Yearly “medicals” in sports clinics.Parallel with Viagra, nitrates and chest

pain

Conclusion

• Likely increase in incidence.• Easy to get, unregulated• Mosty long term adverse effects• Symptoms that are frequent chief

complaints in our ED.• We might not know unless we ask• Fragile, “uneducated”, unsupervised

clientele.