ISSUE 38 / SEPTEMBER 2015 Supplements in sport

Supplement use in sport – a worrying game of Russian roulette for athletes today

By Stephen Smith, BSc, CISSN, Dip ISSN, Neil Chester, PhD, Graeme Close, PhD, School of Sport and Exercise Sciences, Liverpool John Moores University

SUMMARY

This article aims to address the increasing problem of inadvertent doping in sport as a consequence of the use of supplements. The authors offer advice to athletes and support staff on how the risk of such doping can be minimised. We present a review of the evidence outlining the prevalence of doping attributed to supplement use, together with information that highlights the significant consequences of falling foul of anti-doping regulations. Clear recommendations will also be provided to help athletes minimise the risk of inadvertent doping.

Introduction Perhaps more alarmingly, research suggests that many athletes are not Evidence has clearly shown that even aware of the issues surrounding athletes are at risk of ingesting food and the contamination of supplements with supplement products which have been prohibited substances.2 It is important to inadvertently contaminated with banned note that no supplement company can substances.6 On January 16, 2015, UK guarantee its products are completely free Anti-Doping (UKAD) issued a press from contaminants, even those that have release stating that two Welsh athletes gone through approved testing processes had received bans for anti-doping rule such as those provided by specialised violations as a consequence of the use of quality assurance programmes such as contaminated supplements. This resulted ‘Informed-Sport’. Consequently, all we can in a six-month ban for one athlete, and do as practitioners is give the best advice a four-month ban for the other.14 And to athletes on how to minimise the risk. these two are not isolated cases: indeed, there are many reports of athletes who are alleged to have ingested prohibited New regulations substances unintentionally. Evidence suggests that ‘inadvertent doping’ is According to the revised World Anti- actually a significant risk for athletes Doping Code (WADC), which came into using nutritional supplements,6,7 possibly force on January 1, 2015, new regulations due to the increased frequency of their use mean that there are now much stronger by the modern athlete. sanctions for those doping inadvertently

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as a consequence of supplement the risk and possibility of contamination ‘coaches contamination.15,16 far more likely.4 Where supplements are contaminated with prohibited substances can now Recent changes to the regulations include: there is a significant risk that an athlete consuming such supplements would fail also receive • Intentional doping, involving any a drugs test and thus be subject to the prohibited substance or method, appropriate sanctions.7 sanctions carries a four-year ban The main causes of contamination are: if they are • Inadvertent doping as a consequence of the use of a supplement contaminated • Cross-contamination of products due to found to be with a prohibited substance would mass manufacturing processes, where typically carry a two-year ban – unless products containing substances that evidence can be provided to demonstrate are banned under WADA regulations complicit in no significant fault, in which case the (such as ephedrine, sibutramine, sanction may be reduced to a reprimand methylhexaneamine, prohormones, ana- an anti-doping bolic steroids, clenbuterol and peptide • Refusing to take a test, evading testing or hormones) are manufactured in the same violation’ trying to thwart the testing process, will factories and using the same machines all be sanctioned with bans of up to four as those for nutritional or ergogenic years supplements. Thus, residues of prohibited substances (in amounts that would • ‘Limitation periods’ – the time result in a positive drugs test) are able to frame within which an Anti-Doping contaminate otherwise innocuous products Organisation can charge a person for – simply due to insufficient cleaning of committing an anti-doping rule violation manufacturing machines3 – have been increased from eight to ten years • Raw material sourcing and poor quality control, possibly due to the sports • Athlete Support Personnel (ASP), such supplement industry being less closely as coaches, trainers and nutritionists, regulated than the pharmaceuticals can now also receive sanctions if they industry3,4 are found to be complicit in an anti- doping violation, prohibiting them from • The addition of undeclared active working with athletes ingredients to supplement products in an attempt to increase the efficacy of a • It will be considered an anti-doping particular product.4,11 rule violation for an athlete to associate with any ASP currently sanctioned for a The drug surveillance company HFL (now doping offence. LGC)3 investigated the potential of raw materials being the source of contamination in nutritional supplements. In the Supplement use and inadvertent doping investigation, 120 samples from ‘controlled’ and ‘uncontrolled’ sources were screened Sports supplements are big business, with for prohibited substances. ‘Controlled’ the UK market in 2013 being valued at £301 implied that these suppliers were aware million,5 and – like any industry – maximising of the consequences of prohibited profit is often the primary objective. Modern substances in sport and their manufacturing communication and relaxed global trading processes attempted to address the issue are making it easier for entrepreneurs to of contamination, whereas ‘uncontrolled’ set up their own supplement companies implied that these suppliers did not and retail outlets, using mass production explicitly address such issues. wholesale websites to source suppliers. With increased availability of supplements, Although samples were sourced from from both online and high-street retailers, across the globe, the majority were from partnered with appealing and sometimes China (70%) and India (12.5%). Of the 120 deceptive marketing, supplements are an samples tested, the presence of at least one attractive option for athletes.1,3,4 prohibited substance was revealed in 35% of them. The nature of the substances detected Furthermore, regulations surrounding the varied from anabolic steroids (n = 21; 17.5%) production of nutritional supplements are to stimulants (n = 25; 20.8%). Interestingly, not as tightly controlled as those within of those samples from controlled sources the pharmaceutical industry, thus making (n = 39), 12.8% revealed traces of prohibited

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substances and of those samples from such as vitamin C, multivitamins and ‘uncontrolled’ sources (n = 29), 55.2% revealed magnesium, have also been found to ‘the label traces of prohibited substances. be contaminated with stanozolol and metandienone.8 provides no Additional studies have performed product analysis to determine the presence of Furthermore, although sports supplements guarantee contaminants prohibited in sport. In one directed towards the bodybuilding market study, nearly 15% of the 634 products are generally explicit in terms of their regarding the tested contained anabolic steroids and pro- pharmacological ingredients, there is still hormones that had not been declared on some concern over accessibility. In a study content of the the label. Products from the Netherlands by Abbate and colleagues,1 a total of 24 accounted for the highest proportion (25.8%) commercially available products from product’ testing positive for a prohibited substance; fitness shops (n = 7) and an online fitness 19% of products purchased in the UK also store (n =17) were analysed. Although 23 of tested positive.6 the 24 products tested contained anabolic steroids, 16 were different to those indicated A more recent study conducted in 2013 on the label. screened 114 products,12 including protein powders and energy supplements, These results highlight a number of serious purchased from leading European sports issues: supplement brands. Despite the fact that some of the products carried claims that they 1) The ease in which individuals can access were ‘tested by an independent laboratory’ sports supplements containing prohibited and were ‘drug free’, 10% of these were found substances to contain traces of prohibited anabolic steroids and/or stimulants. 2) The fact that the label provides no guarantee regarding the content of the Worryingly, even ‘classic’ anabolic product steroids such as stanozolol, boldenone and oxandrolone have been identified in tests on 3) The risk to health that individuals are nutritional supplements. Supplements not exposing themselves to if they make the specifically aimed at sports performance, decision to use such products.

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Given the explicit nature in which such following the ingestion of a pre-workout products are marketed and the names of ‘formula’ containing methylhexaneamine.10 some of the products – for example ‘Tren Bomb’, ‘X-Tren’, ‘Straight Drol’ and ‘Ultra Mass’ – it is perhaps not surprising that they Safeguarding the athlete pose significant risk to the user, particularly as a young or naive athlete might not Protecting athletes from the risk of recognise that the ingredients are indeed inadvertent doping should certainly be a prohibited and their use associated with primary concern for support personnel. many potential dangers. Indeed, although avoiding supplements altogether may be an unrealistic expectation, The most common supplements associated some athletes may be taking supplements with inadvertent doping include pre- that are either unnecessary or that lack workout formulas, ‘fat burners’ and herbal sufficient scientific evidence to support their supplements, often containing stimulants efficacy. In these cases, support personnel such as ephedrine, sibutramine and should work to educate the athlete and methylhexaneamine.8 One of the main monitor their supplement use, promoting a issues is that manufacturers re-label the balanced and varied diet rather than the use ingredients, or list only the natural source of of multiple supplements.4 the active ingredient. For example, ephedrine may appear on the label as Ma Huang or In an attempt to safeguard athletes against Ephedra Sinica. Methylhexaneamine can inadvertent doping and indeed to investigate appear in products labelled as containing the potential causes, various supplement geranium oil extract, geranium stem or testing schemes have been developed – for geranamine.11,18 Research has however example, those conducted by Informed- confirmed that geranium does not in fact Sport. Some select manufacturers have contain methylhexaneamine and is simply opted in to the testing programmes offered an elaborate ploy by manufacturers to hide by these companies, which are certified to the presence of a prohibited substance.11 an internationally recognised standard to It is extremely unlikely that athletes (or detect contaminants in accordance with the Figure 1. The Informed-Sport even general support staff) within clubs WADA Prohibited List.4 logo that adorns those products would be aware of the multiplicity of names which are part of a quality that can be used to describe an ingredient assurance programme designed and therefore it is easy to see how genuine Further issues: contaminated meat to minimise the risks associated mistakes can be made. with supplement contamination Supplement contamination is not the only The consequences of the adulteration of cause for concern as the risk is further supplements can be significant. Indeed, amplified by the potential ingestion of the use of such products has been found to meat products contaminated with banned result in severe health effects, none more so substances such as clenbuterol, which is than the death of a female marathon runner used in some countries to promote muscle

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growth in cattle.9,13 For example, in Mexico certification – for example, look for the during the 2011 FIFA U17 World Cup, over Informed-Sport logo (Figure 1) ‘If unsure, half of the doping control samples tested positive for clenbuterol. As a result, meat • Log the batch numbers of any supplements referring was tested from team hotels and 30% of it used, so that if a positive test is recorded, demonstrated concentrations of the drug evidence is available to support the case to reputable between 0.06 and 11 µg.kg-1.13 In the case that everything possible was done to avoid of the footballers, they avoided sanctions; contaminated or banned products information however, Spanish cyclist Alberto Contador was less fortunate and was stripped of his • Read and analyse the labels on products sources 2010 Tour de France and 2011 Giro d’Italia and, if in doubt about an ingredient, consult titles for positive samples containing anti-doping organisations for advice, as published by the same drug. Contador faced a fine of they will be able to provide information as €2,485,000 and a two-year ban for the same to whether it is prohibited or is a derivative offence, despite the Court of Arbitration for of a prohibited substance UKAD and Sport (CAS) accepting that contaminated meat was the likely cause.17 • Take responsibility for your own drinks WADA is best and feeding bottles during training/ It is therefore recommended that support competition, so as to protect from sabotage practice’ personnel consider putting measures in place to minimise the risk of ingestion of • Ensure you have your own personal stock contaminated foods when travelling abroad. of supplements and avoid sharing with Such measures might include contacting team mates and fellow athletes. This may in advance the accommodation booked to be a particular issue in team sports where request information about sourcing of meat there are multiple users of a particular products: for, although the use of clenbuterol supplement (eg, a large tub of protein as a growth promoter in livestock is powder). Although sabotage may not prohibited in many countries, there are still be expected to be a major issue in this some where this is not strictly enforced – for instance, contamination could be. example, China.9

Recommendations for practitioners Recommendations for athletes With the new additions to the World Anti- Ultimately, raising awareness of inadvertent Doping Code, practitioners and support doping – and how it might occur – should be staff should exercise extreme caution the main priority in the attempt to reduce its when recommending or prescribing occurring. supplements to athletes. Ultimately, you cannot completely protect athletes from the Athletes should make every effort to risk of inadvertent doping – even Informed- consider the following precautions: Sport cannot guarantee complete cover from contamination. It is vital, therefore, • Avoid products that are advertised as that athletes and their support staff do as promoting extreme muscle growth, much as possible to minimise the risk of strength or fat loss, and be extremely inadvertent doping, cautious of the false claims made by many unscrupulous manufacturers Athlete support personnel need to ensure that they are up-do-date and compliant with • Exercise caution when considering the use anti-doping rules and regulations. It would of herbal supplements. Remember many be valuable for staff to encourage athletes pharmacologically active ingredients to disclose use of all supplements and over- originate from plant sources. Also, many the-counter medication. If unsure, referring herbal supplements have not been fully to reputable information sources published characterised and therefore may well by UKAD and WADA is best practice. contain a prohibited substance Moreover, qualified individuals should be providing the nutrition and supplement • Be wary of purchasing products from advice – ideally those who are registered with the Internet and from independent sport the Sport and Exercise Nutrition register supplements retailers. Buy only from (SENr). Sports clubs should therefore be reputable companies and only use products encouraged to employ such staff: it is unfair that have gone through a recognised to expect strength and conditioning staff to quality assurance programme involving remain up to speed with current nutritional batch testing which can be verified with practice and scientific evidence for

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supplements. Certainly, players and coaches It is also recommended that practitioners should not rely on internet forums or social construct their own procedures and policies media to gain their nutritional advice! in relation to supplement selection and use. For example, they could adopt a policy It is crucial that athletes are educated about of only working with selected brands that the issue of inadvertent doping and how they undergo batch-testing and comply with a can avoid it. Case study examples should recognised quality assurance programme be presented to athletes to demonstrate (ie, Informed Sport) – ideally where the how other athletes have fallen into the trap, whole product range is included and not just with the consequences clearly outlined. selected products that go to the elite athletes. Sound nutrition advice is also important, Any supplement that is recommended to perhaps demonstrate to athletes that should be supported with the necessary some supplements may not be required, certification. Practitioners should ensure especially those that might be present in that they can demonstrate that all possible sufficient quantities in a wide variety of steps have been taken to avoid inadvertent nutrient dense foods. doping.

AUTHORS’ BIOGRAPHIES

Dr Graeme Close, ASCC, PhD, rSEN, fBASES A former professional Rugby League player, Graeme is now a Reader in applied physiology and sport nutrition at Liverpool John Moores University, where he is the programme leader for the MSc in sport nutrition. His research is focused on basic and applied sport nutrition and he has published more than 75 papers and review articles. He is accredited with the UKSCA, BASES and SENr, currently the deputy chair of SENr and has recently been awarded a fellowship with BASES. He is also expert nutrition consultant to England Rugby, lead nutritionist with British Ski and Snowboard and nutrition consultant to several European Tour golfers.

Dr Neil Chester, phd Neil lectures in exercise physiology at Liverpool John Moores University and has research interests focusing on many aspects of drug use in sport. Recent and current projects include herbal supplement use, supplement use in Rugby League and WADA-funded projects examining the use of over-the-counter drugs amongst elite athletes and the issues surrounding asthma medication in sport. Neil is also a member of the UK Anti-Doping Research Advisory Group.

Stephen Smith, Bsc, CISSN, Dip ISSN Stephen Smith is a performance nutritionist and MSc sports nutrition student at LJMU. He currently works in MMA, triathlon and cycling, and is the performance nutritionist for GB Ice Climbing.

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Alberto Contador was stripped of his 2010 Tour de France and 2011 Giro d’Italia titles for positive samples containing clenbuterol. The Court of Arbitration for Sport later accepted that contaminated meat was the likely cause.

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