Hazards of Supplement Use in Recreational Sports

Ron Maughan Outline of talk

Prevalence of use

Cost-benefit analysis

A few supplements that may be useful in specific situations

Potential risks of supplement use Reasons for supplement use

Supplements are a multi- billion dollar business Most of the money is made from recreational athletes rather than from elite performers Their concerns are different from those of the elite athlete

Surveys generally suggest that supplement use: Varies across different sports and activities Increases with level of training/performance Increases with age Is higher in males Is strongly influenced by perceived norms Surveys generally suggest that supplement use: Varies across different sports and activities Increases with level of training/performance Increases with age Is higher in males Is strongly influenced by perceived norms

But many surveys are flawed because of: Inappropriate sample selection Non-validated survey instruments Lack of clear definition of supplements

The power of advertising Consumers generally do not discriminate between scientific evidence and advertising hype Supplement sellers often have large budgets and can use effective advertising Scientists are cautious and often not good at communication A closer look . . . JUNE 11TH One Athlete’s day 10.10am 3g L-lysine with 30mg Vit B6 4 phosphate tablets 2 scoops protein powder 3 teaspoon acetylglutamine 3g Vit C 3 tablets detox 50 mg zinc

Drank isotonic drink whilst training

1.45pm 3g L-lysine with 30mg Vit B6 3g Vit C 3 tablets detox 50 mg zinc

11.00pm3g L-lysine with 30mg Vit B6 3g Vit C 3 tablets detox 1 scoop protein powder 3 teaspoon acetylglutamine Issues in Supplementation

Efficacy: does it work? If so, under what conditions?

Safety: are there any possible adverse effects of acute or chronic use even in excessive doses?

Ethics: is its use in sport legitimate? What can the scientists tell us?

Performance in laboratory tests varies by about 1-10% on a day to day basis

For an effect to be detected, it must be bigger than the daily variation

Small effects will appear as no effect MARATHON 2003

% diff 1 G. Abera (ETH) 2:07:56 2 S. Baldini (ITA) 2:07:56 0.00 3 J. Ngolepus (KEN) 2:07:57 0.01 4 P. Tergat (KEN) 2:07:59 0.03 5 S. Ramadhani (TAN) 2:08:01 0.06 6 A. El Mouaziz(MOR) 2:08:03 0.08 7 L. Bong-Ju (KOR) 2:08:10 0.16

We can’t measure this difference in the laboratory, so we have to recognise that our information is limited. 2004 Men’s Coxless Four FINAL Official result3:30 ET | 8/21/2004 | Schinias Centre | Schinias

Name Country Time 1 Ed Coode Great Britain 6:06.98 2 Cameron Baerg Thomas Herschmiller Barney Williams Canada 6:07.06 Final , Great Britain 3:57.90 NR Tatyana Tomashova, 3:58.12 PB Maria Cioncan, Romania 3:58.39 PB Natalya Yevdokimova, Russia 3:59.05 PB Daniela Yordanova, Bulgaria 3:59.10 PB Lidia Chojecka, 3:59.27 SB The difficulties in assessing efficacy are magnified many times when there is a less well-defined endpoint Even with a very large investment of time and money, it is unrealistic to expect proof of efficacy in areas such as: Wound healing Muscle soreness Immune health Joint health Weight gain Weight loss Evidence of Safety?

People take risks in the pursuit of their goals

Sometimes they need protection from the consequences of their own actions

Safety of supplements is usually ignored Costs and Benefits It is important to think through the process of supplement use by a thorough cost-benefit analysis. A full analysis cannot be completed for most supplements as several parts of the equation are unknown. The sensible athlete will want to see positive reasons for using any supplement.

Costs Benefits

Financial Improved performance Health risks “Insurance policy” Performance Better health Drugs Free samples Supplements may be useful if:

A diagnosed deficiency cannot be corrected easily and promptly by changes to the diet A nutrition solution cannot be implemented immediately An athlete will not eat a varied diet There may be a beneficial effect on health or performance with no risk Supplements with something to offer Good evidence for performance effects in some situations:

Creatine Some evidence for performance Caffeine related or health-related effects: Arginine/glutamine Bicarbonate Carnitine Echinacea Β-Alanine? Glucosamine Antioxidants Nitrate? Vitamin C Zinc Supplements: Adverse effects

Some products contain impurities (lead, broken glass, animal faeces, etc) because of poor manufacturing practice Some products do not to contain expensive ingredients listed on the label but only inexpensive materials

Magnesium: Of nineteen products, two failed testing. One contained almost 50% more magnesium than claimed. At its upper serving size the product also exceeded the allowed amount of lead.

Creatine: Half of the creatine products passed the testing (ie, half failed!). One product contained less than 1% of the claimed amount of creatine and contained more creatinine than creatine.

Sexual enhancement: Of 22 sexual enhancement products, only 9 (41%) passed.

Nutrition bars: Of 30 products tested, 60% failed to meet labelling claims and only 12 products met all criteria.

“Testing by the New York Department of Health and the UF Food and Drug Administration has found that these products contain high levels of lead and mercury, which can cause serious health problems” www.spirulina.com FDA Analysis of Spirulina:

° Vitamin B12 content is due mainly to contamination with animal or insect faecal matter

° 15 flies ° 164 fly fragments ° 41 maggots ° 59 maggot fragments ° 1 ant ° 5 ant fragments ° 1 cicada ° 1 cicada pupa ° 763 insect fragments ° 9 ticks ° 4 mites ° 1000 ostracods ° 2 hairs rat/mouse ° 10 bird feathers ° 10 water fleas ° . . . “Creatine Serum”

“3 g creatine per ml”

“No side effects” “Creatine Serum“

50

40 50 mmol/l solution 30 20

10 Creatine (mmol/l) Creatine 0,610 0 CREATINE CREATINE SERUM MONOHYDRATE (Harris et al., J. Sports Sciences 2004) Plasma creatine (mmol/l) 1000 200 400 600 800 0 0 min Cr monohydrate Creatine Serum 5g (Harris et al., J. Sports Sciences 2004) Sciences Sports J. al., et (Harris 30 min Cr ‘serum’ 10 ml10 60 min

More serious

Some folate supplements may contain less than 25% of the stated dose

If folate supplements really reduce neural tube defects in pregnancy, this is serious Supplements: Adverse effects

Some products contain impurities (lead, broken glass, animal faeces, etc) because of poor manufacturing practice Some products do not to contain expensive ingredients listed on the label but only inexpensive materials Athlete specific problems: Some products contain doping agents that are not declared on the label Take the money and run Six of seven British track athletes who tested positive for 19- NA in 1999-2000 used the same company’s dietary supplements The IOC Study: Cologne, 2001

634 non-hormonal nutritional supplements were obtained in 13 countries from 215 different suppliers 11 different anabolic androgenic steroids were found 94 (15%) samples contained prohormones not declared on the label ("positive supplements") No reliable data were obtained for 66 samples (10%) Samples contained prohormones of nandrolone and testosterone In most supplements, only trace levels were present For details, see: www.dopinginfo.de How does contamination occur?

Contamination may occur from two main causes: 1. Cross-contamination during the production process: the same equipment and storage facilities are used for supplements and for doping agents 2.Deliberate adulteration: many products are completely ineffective. Adding pharmaceuticals may mean that the consumer sees a benefit from using the product Can it be an accident?

Undeclared ingredients in supplements

Muscle building Anabolic steroids

Tonics Stimulants: caffeine, ephedrine

Weight loss Anorectics: sibutramine

Male enhancement Viagra, Cialis

Label of a glutamine product

Centro Espanol de Medicina y Fisioterapia del Deporte General Pardinas 92, 315 , "We declare that GM (glutamine) is controlled and produced in a chemical and technical high standard, so that no contamination with banned substances occurs" Not declared ingredients:

Oxandrolone 6.5-26.2 µg per capsule German Sport University Cologne Institute of Biochemistry Manufacturer’s guarantees

500 mL of water containing 5 g of creatine and 1.0, 2.5, or 5.0 µg of 19-norandrostenedione. 2.5 µg in 5 g is 0.00005%

2.5 µg in 500 g is 0.0000005% “1-T matrix”

3 supplements ordered by telephone from U.K. company (U.S. manufacturer) Ingredients not indicated on the label: Metandienone in all supplements Caffeine+ephedrine+pseudoephedrine in one supplement Therapeutic dose of metadienone: 5-10 mg per day ‘Recommended’ dose: 10-43 mg per day (Geyer et al., 2004)

“Some Hydroxycut products are associated with a number of serious liver injuries. The FAD has received 23 reports of serious health problems ranging from jaundice . .. .to liver damage requiring liver transplant. One death due to liver failure has been reported to the FDA.“ Remember: if it looks too good to be true, it probably is.

Eight U.S. referral centers that are part of the DILIN from 2004-2013. Consecutive patients with liver injury referred to a DILIN center were eligible. The final sample comprised 130 (16%) of all subjects enrolled (839) who were judged to have experienced liver injury caused by HDS. 45 had injury caused by bodybuilding HDS, 85 by non- bodybuilding HDS, and 709 by medications. Liver injury caused by HDS increased from 7% to 20% during the study period. Bodybuilding HDS caused prolonged jaundice (median, 91 days) in young men, but did not result in fatalities or LT. Liver injury from non-bodybuilding HDS is more severe than from bodybuilding HDS or medications, as evidenced by more unfavorable outcomes (death or transplantation). Not just liver . . .

British Journal of Cancer (2015) 112, 1247–1250. doi:10.1038/bjc.2015.26 www.bjcancer.com Published online 31 March 2015 http://www.nature.com/bjc/journal/v112/n7/full/bjc 201526a.html Muscle-building supplement use and increased risk of testicular germ cell cancer in men from Connecticut and Massachusetts N Li et al Epidemiological study to examine the relationship between use of muscle-building supplements (MBSs) and testicular germ cell cancer (TGCC) risk

Population-based case–control study including 356 TGCC cases and 513 controls from Ct and Ma

The odds ratio (OR) for ever use of MBSs in relation to risk of TGCC was significantly elevated (OR=1.65, 95% confidence interval (CI): 1.11–2.46).

The associations were significantly stronger among early users, men with more types of MBSs used, and longer periods of use JUNE 11TH One Athlete’s day 10.10am 3g L-lysine with 30mg Vit B6 4 phosphate tablets 2 scoops protein powder 3 teaspoon acetylglutamine 3g Vit C 3 tablets detox 50 mg zinc

Drank isotonic drink whilst training

1.45pm 3g L-lysine with 30mg Vit B6 3g Vit C 3 tablets detox 50 mg zinc

11.00pm3g L-lysine with 30mg Vit B6 3g Vit C 3 tablets detox No acetylglutamine 1 scoop protein powder 3 teaspoon acetylglutamine Caffeine An unexpected consequence

Many of the papers in the scientific literature have used commercially available dietary supplements Where there was an effect, this may have been due to the presence of an undeclared drug Where there was no effect, this may have been due to the absence of the active ingredient Risk management

Athletes, and those who care for them, should take precautions:

Use supplements only when a benefit is likely

Use supplements and doses that are “safe”

Use products that are “low risk”

BUT, how do you assess risk? http://www.informed-sport.com/ Does this guarantee purity?

Use of supplements that have been batch tested reduces the risk It does not guarantee freedom from substances that cause harm or adverse finding There is a finite limit to sensitivity of tests Not all prohibited substances are tested for Human error and criminal activity are possible The active ingredient is not tested for “The use of supplements does not compensate for poor food choices and an inadequate diet. Athletes contemplating the use of supplements and sports foods should consider their efficacy, their cost, the risk to health and performance, and the potential for a positive doping test.” IOC Consensus Statement on Sports Nutrition Maughan’s Rules of Dietary Supplements for Athletes

1. If it works, it’s probably banned 2. If it’s not banned, then it probably doesn’t work 3. There may be some exceptions

Summary and Conclusions

Some supplements contain ingredients that may cause an athlete to fail a drugs test or harm health

In many cases, these are not listed on the label

Athletes can manage the risk by limiting supplement use and by using products from “safe” sources

Food contamination presents a challenge for the athlete and for those who are responsible for doping control Thank you!