Sport supplements Sport supplements –– side effectsside effects

Dr Nenad DikicDr Nenad DikicAntiAnti--doping agency of Serbiadoping agency of Serbia

Usage of supplements is only the problem of athlete?

Dwain Chambers Regina Jacobs Kevin Toth John McEwen Melissa Price

Positive on THG!

Patrick Jarrett (2001)Jamaica - sprint

Anton Galkin ( 2004)Russia - Sprint

Irina Korschanenko (2004)Russia - shotput

Ben Johnson (1988)Canada - sprint

Mabel Fonseca (2004)Puerto Rico - wrestling

James Brack (2004)Greece - Baseball

Positive on Stanozolol !

1. Only responsible persons are athletes.

2. Only athletes feel side effects.

The problem of supplementation in sportThe problem of supplementation in sport

•• Optimal nutritionOptimal nutrition

•• Appropriate use of Appropriate use of nutritional supplement nutritional supplement productsproducts

•• ResponsibilityResponsibility

Before supplementationBefore supplementation

InappropriateInappropriate•• CaloriesCalories

•• FluidsFluids

•• CalciumCalcium

•• Iron ...Iron ...

It is ironic that we spend much time addressingIt is ironic that we spend much time addressingmicronutrient issues when many athletes havemicronutrient issues when many athletes have

nutritional issues of a more fundamental naturenutritional issues of a more fundamental nature.

Concerns with SupplementsConcerns with Supplements

1.1. May cause May cause positive drug positive drug tests tests

2.2. NonNon--regulatedregulated

3.3. Not necessaryNot necessary!!

4.4. May be hazardous May be hazardous to Healthto Health

11.. Supplements could be doping positive Supplements could be doping positive !!

CountryCountry ProductsProducts

NetherlandsNetherlands 3131

UKUK 3737

USAUSA 240240

ItalyItaly 3535

GermanyGermany 129129

IOC Nutritional Supplement AnalysisIOC Nutritional Supplement Analysis

+’+’veve %’age%’age

88 25.8%25.8%

77 18.9%18.9%

4545 18.8%18.8%

55 14.3%14.3%

1515 11.6% 11.6%

Schanzer et al

Analysis of Nutritional Supplements Analysis of Nutritional Supplements

•• 634 non634 non--hormonal nutritional supplements hormonal nutritional supplements purchased in 13 countries from 215 different purchased in 13 countries from 215 different supplierssuppliers

•• 94 contained anabolic androgenic steroids 94 contained anabolic androgenic steroids not declared on labelnot declared on label

•• consumption of such nutritional supplements consumption of such nutritional supplements can lead to positive results in doping testscan lead to positive results in doping tests

Int J Sports Med 2004;25:124-129

Results of an International StudyResults of an International Study

22.. Supplements are non regulated Supplements are non regulated

“As a result of the Dietary “As a result of the Dietary Supplement Health and Supplement Health and Education Act passed by Education Act passed by Congress in 1994, Congress in 1994, products marketed as products marketed as dietary supplements are dietary supplements are not reviewed by the FDA not reviewed by the FDA for effectiveness or for effectiveness or safety.”safety.”

Medical LetterMedical Letter, 37:112, Nov. 24, 1995., 37:112, Nov. 24, 1995.

33. Supplements are not necessary ?. Supplements are not necessary ?

“If energy intake is high and a varied “If energy intake is high and a varied diet is consumed, supplementation of diet is consumed, supplementation of the diet with vitamins and minerals is the diet with vitamins and minerals is

not warranted, unless a specific not warranted, unless a specific deficiency is identified.”deficiency is identified.”

Maughan R, Proc Nutr Soc, 2002

“However supplements may be required “However supplements may be required by athletes who restrict energy intake, by athletes who restrict energy intake,

have severe weighthave severe weight--loss practices, loss practices, eliminate one or more food groups from eliminate one or more food groups from their diet, or consume hightheir diet, or consume high--carbohydrate carbohydrate

diets with low micronutrient density.”diets with low micronutrient density.”

Position of Dietitians of Canada, the American Dietetic AssociatPosition of Dietitians of Canada, the American Dietetic Association and ion and the American College of Sports Medicine.the American College of Sports Medicine.

Endorsed by the Coaching Association of CanadaEndorsed by the Coaching Association of Canada

Supplements at the Sydney Olympics, Supplements at the Sydney Olympics, 20002000

2758 Athletes tested2758 Athletes tested

2,167 declared a medication or supplement2,167 declared a medication or supplement

569 did 569 did notnot declare a medication or declare a medication or supplementsupplement

542 took more than 5 a day542 took more than 5 a day1 athlete took 26 !1 athlete took 26 !

Corrigan B & Kazlauskas R Unpublished

Doping control by ADASDoping control by ADAS

•• Doping control on 147 athletesDoping control on 147 athletes

•• 63% (94) use supplements63% (94) use supplements

•• Max number of supplements per Max number of supplements per athlete: 7athlete: 7

4. Supplements may be hazardous to health

EPHEDRINE:EPHEDRINE:

•• Boosts metabolism; burns fat; increases Boosts metabolism; burns fat; increases alertness & endurancealertness & endurance

•• Side effects: anxiety; ventricular Side effects: anxiety; ventricular dysrhythmiasdysrhythmias; hypertension; ; hypertension; hallucinations; addictionhallucinations; addiction

•• Banned by IOC, NCAA, NFLBanned by IOC, NCAA, NFL

Am J Sports Med 2004;32(6):1543-1553

““Ephedra” induced Coronary SpasmEphedra” induced Coronary Spasm

LAD ArteryLAD Artery

Coronary SpasmCoronary Spasm

Adverse Events with Ephedra AlkaloidsAdverse Events with Ephedra Alkaloids

140 reports reviewed140 reports reviewed

Deaths:Deaths: 1010

Permanent Impairment:Permanent Impairment: 1313

Ongoing Treatment:Ongoing Treatment: 88

Full Recovery:Full Recovery: 4242

Unknown:Unknown: 1414

““Of the 10 patients who died or had permanent disabilityOf the 10 patients who died or had permanent disability5 had no pre5 had no pre--existing conditions or concurrent risk factors.”existing conditions or concurrent risk factors.”

(Major reasons for use: weight loss or athletic performance)(Major reasons for use: weight loss or athletic performance)

Haller & Benowitz, NEJM 2000

Possible Side Effects of SupplementsPossible Side Effects of Supplements

•• DehydrationDehydration

•• HeatHeat--Related InjuriesRelated Injuries

•• Nervousness and DizzinessNervousness and Dizziness

•• Changes in Blood Pressure Changes in Blood Pressure and Heart Rateand Heart Rate

•• Heart AttackHeart Attack

Possible Side Effects of Supplement Use (Possible Side Effects of Supplement Use (con’tcon’t.).)

•• StrokesStrokes

•• SeizuresSeizures

•• PsychosisPsychosis

•• DeathDeath

•• Interaction with medicationsInteraction with medications

•• Positive drug tests due to Positive drug tests due to contaminated supplementcontaminated supplement

Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis

Frequency of Adverse EffectsFrequency of Adverse Effects

Dehydration Dehydration 40%40%

PalpitationsPalpitations 24%24%

Abdominal PainAbdominal Pain 15% 15%

Dizziness or Confusion Dizziness or Confusion 13%13%

Numbness of Extremities Numbness of Extremities 2% 2%

Tremors Tremors 2%2%

Top Vitamins & Minerals Top Vitamins & Minerals

•• MultivitaminMultivitamin

•• Vitamin CVitamin C

•• CalciumCalcium

•• Vitamin EVitamin E

•• IronIron

Side effectsSide effects• Multivitamin – various side effects.

• Vitamin C – diarrhea and nausea, interfere with anticoagulant

medications, should be avoided in individuals with a history of renal

stones or hemachromatosis.

• Calcium –constipation, increased risk of urinary stone formation and

kidney dysfunction, interfere with the absorption of other minerals in the

body.

• Vitamin E –should be avoided in people with blood-clotting problems

and in people taking anticoagulant medications.

• Iron –certain diseases such as hemochromatosis should avoid taking

iron supplements.

Top Herbal SupplementsTop Herbal Supplements

•• GinsengGinseng

•• GarlicGarlic

•• Ginkgo Ginkgo bilobabiloba

•• EchinaceaEchinacea

•• GuaranaGuarana

Side effectsSide effects• Ginseng: Headache, insomnia, rash, anxiety, diarrhea, high blood

pressure, hypoglycemic effect

• Garlic: Mild gastrointestinal discomfort , undesirable body odor, itching, rash, interfere with aspirin or anticoagulant medications

• Ginkgo biloba: Headache, dizziness, heart palpitations, and allergic reaction.

– No with aspirin, Vitamin E, garlic, ginger, Coumadin, or Heparin.

– May increase blood sugar in people with diabetes.

• Echinacea: Short-term fever, nausea, and vomiting.

– Should not be taken by people with diabetes, lupus, HIV, multiple sclerosis, turberculosis, or other auto-immune diseases.

• Guarana: May cause jittery nervousness, tremors, dizziness. Adverse effects increase dramatically if used in conjunction with ephedra-containing products.

Variation of side effectsVariation of side effects

• Analysis of 25 commercial ginseng products from a local health food store.

• Concentrations of “marker compounds” were significantly different from the amounts indicated on the labels.

• Siberian ginseng products showed the most inconsistency (versus Asian ginseng).

• Liquid extracts varied more than powdered products.• Variability from product to product was significant.

Top Supplements to Enhance PerformanceTop Supplements to Enhance Performance

•• Among MenAmong Men

–– CreatineCreatine

–– EphedraEphedra

–– Amino AcidsAmino Acids

–– GlucosamineGlucosamine

–– AndrostenedioneAndrostenedione

•• Among WomenAmong Women

–– CreatineCreatine

–– Amino AcidsAmino Acids

–– EphedraEphedra

–– GlucosamineGlucosamine

–– HMBHMB

0

20

40

60

80

100

120

VITAM

INI

MIN

ERALI

AMIN

OKISEL

INE

ENERGETSKI NAPI

CI

KREATIN

BILJN

I PREPARATI

PROTEIN

I

L KAR

NITIN

GLUTAM

IN

UGLJ

ENI HID

RATI

OSTALO

Frequency of food supplementsFrequency of food supplements

0

10

20

30

40

50

60

70

Multivitamini Vitamin C Vitamin E Ostali

VITAMINI

0

2

4

6

8

10

12

14

Multiminerali Kalcijum Magnezijum Elektroliti

MINERALI

Top vitamins and mineralsTop vitamins and minerals

Side effectsSide effects• Creatine: Weight gain, muscle cramping, nausea, diarrhea,

kidney problems.

• Ephedra: Numerous side effects, including tremors, seizures,

heart palpitations, heart attacks, strokes, increased blood

pressure and even DEATH!

• NO if have high blood pressure, glaucoma, or enlarged prostate.

NO with MAO inhibitors, guanethidine, or cardiac glycosides.

Sale of this dietary supplement was officially banned on

April 12, 2004.

• Amino Acids: Increased risk for dehydration and stress on the

kidneys

Side effectsSide effects• Glucosamine: Minimal side effects. Many supplements sold do

not actually contain glucosamine.

• Androstenedione (Steroid produced by the body): Acne,

increased aggressiveness, increased LDL (bad) cholesterol,

decreased HDL (good) cholesterol, decreased sperm

production, stroke, heart attack, heart muscle damage, stunted

growth in teens. Raises estrogen (female hormone) levels in

men.

• HMB (beta-hydroxy-beta-methyl butyrate). HMB is part of the

amino acid, leucine. More research is needed to determine

possible side effects. None have been reported in doses of less

than or equal to 4 grams per day.

““EphedraEphedra--Free?” supplementsFree?” supplements

• Has other stimulants:– Bitter Orange (Synephrine)

– Caffeine

– Guarana

– Cola nut

– Mate

• Marketed as “safer” than ephedra products…

• However, synephrine is virtually identical in action to ephedrine-containing products

Side effectsSide effects

• Bitter Orange (Synephrine): May raise blood pressure or make hypertension worse. Can interact with many medications and cause increased side effects.

• Guarana: May cause jittery nervousness, tremors, dizziness.

• Caffeine: Increased irritability, increased urine output, dehydration, increased heart rate. May also cause stomach upset.

• Cola nut: Restlessness, stomach upset, excitability, and difficulty falling asleep. People with stomach ulcers should avoid cola nut.

• Mate (pronounced “matay”): Associated with increased risk of mouth and throat cancer.

DRUGS vs SUPPLEMENTSDRUGS vs SUPPLEMENTS

DRUGS

• Must be proven be safe beforeapproved for the market.

SUPPLEMENTS

• Must be provenharmful beforeremoved from the market.

How do you know if a product is safe?How do you know if a product is safe?

You Don’t.You Don’t.www.supplementwatch.com

www.consumerlab.com

2003

16,2

mil.

““Nutritional Supplements”Nutritional Supplements”

•• A veritable A veritable “witches“witches--brew” brew” of productsof products

•• Quality control and labeling issuesQuality control and labeling issues

•• Aggressive Aggressive mmarketingarketing practicespractices

•• Health consequencesHealth consequences

•• Need for review of regulatory practicesNeed for review of regulatory practices

Supplements cannot replace meals!??

Eat a Variety of Nutritious FoodsEat a Variety of Nutritious Foods

Choose Food Instead of SupplementsChoose Food Instead of Supplements

FoodFood

FunFun

Offers varietyOffers variety

Doesn’t have to be Doesn’t have to be expensiveexpensive

Contains other healthful Contains other healthful substancessubstances

SafeSafe

SupplementsSupplements

BoringBoring

Lacks varietyLacks variety

Can cost a lot of moneyCan cost a lot of money

Doesn’t contain other Doesn’t contain other health benefitshealth benefits

Can be dangerous to Can be dangerous to your healthyour health

Guidelines for Using SupplementsGuidelines for Using Supplements

•• Get objective information from a professional Get objective information from a professional such as a Registered Dietitian, Nurse, or Doctor such as a Registered Dietitian, Nurse, or Doctor

•• Obtain your health care provider’s approvalObtain your health care provider’s approval

•• Read the label carefullyRead the label carefully

•• Do not exceed dosage recommendationsDo not exceed dosage recommendations

•• Discontinue use if you experience adverse side Discontinue use if you experience adverse side effects and report these to the FDAeffects and report these to the FDA

Guidelines for Using Supplements Guidelines for Using Supplements ((con’tcon’t.).)

•• Purchase supplements from reliable producersPurchase supplements from reliable producers

•• Be aware of sensational claimsBe aware of sensational claims

•• Do not take supplements if you are pregnant, Do not take supplements if you are pregnant, breastfeeding, or taking prescription medicationsbreastfeeding, or taking prescription medications

family members

nutritionists / dietitians

physicians /pharmacists

friends / teammates

coaches / trainers

family members

nutritionists / dietitians

physicians /pharmacists

friends / teammates

coaches / trainers