1. Cayuga Sports Medicine Conference - Supplements Update 2010
70 slides of content
By Lee A. Mancini, MD, CSCS*D, CSN Assistant Professor UMass Medical School
Faculty UMass Sports Medicine Fellowship
Certified Strength and Conditioning Specialist with Distinction
Certified Sports Nutritionist

2. Background
Former D-I athlete / 1999 Boston Marathon
Numerous Sprint / Olympic Distance Tris
15 years as Certified Sports Nutritionist
15 years as Certified Strength & Conditioning Specialist
UMass Sports Medicine Physician
Sports Nutrition consultant
Boston Red Sox Organization
Lowel Devils (NJ AHL affiliate)
Worcester Ice Cats (STL Blues AHL)
Holy Cross
UMass Amherst
Assumption College
Nichols College
Lived in Ithaca my entire life - graduated from Lansing High School…

3. Goals & Objectives Review a brief history of supplements
Discuss how to examine supplement claims
Review some common supplements
Examine supplements specific for triathletes & endurance athletes
Ask Questions!

4. Historical Perspective
Ancient History
Aztecs
Chinese
Greeks
Ergogenic
Ergon
gennan

5. 20th Century & Supplements
Brown-Sequard in 1889
1950s Dr. Ziegler
Methandrostenolone
IOC
1968 1st list of banned substances
1976 Montreal Olympic Games

6. The Supplement Industry
Nutrition Labeling and Education Act (NLEA) 11/9/1990
Dietary Supplement Health and Education Act (DSHEA) 10/25/1994
Multibillion dollar industry
1994 = 8.3 billion
1999 = 14 billion
2009 = 23.7 billion

7. 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),

8. Three Questions
Is it effective?
Is it safe?
Is it legal?

9. Is it Legal? Governing bodies have banned substance lists
IOC, NCAA, UCI, USAC, WADA, MIAA
Triathletes - USAT falls under USADA
Law enforcement penalties
Possession
Federal offense
1 year and 1,000$
Selling
Federal felony
5 years and 250,000$

10. 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

11. Supplements & Triathletes
Ground rules
Specific supplements
Proven Performance effects
Side effects
USAT follows USADA prohibited list

12. Banned Substance List S1 - AAS Nandrolone
Clenbuterol (asthma in other countries)
S2 - hormones and related substances
EPO, hGH, IGF-1, hCG, insulin, & corticotrophins
PRP given IM prohibited
PRP tendon injections - requires Declaration of Use
DM pts - need TUE for insulin

13. 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

14. 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

15. Banned Substance List Prohibited Methods
M1 - Enhancement of O2 transfer
Blood doping
M2 - Chemical & Physical Manipulation
Tampering
IV infusions (even if non-banned substance unless in hospital setting)
M3 - Gene doping

16. 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

17. Banned Substance List S7 - Narcotics S8 - Cannabinoids
Fentanyl, Morphine
S8 - Cannabinoids
S9 - Glucocorticosteroids
PO, IV, PR, IM - (DOE/TUE)
Topical
P1 - ETOH
P2 - Beta-Blockers

18. Commonly Used Banned Substances

19. Erythropoietin & Blood Doping
Natural hormone secreted by the kidney formation RBCs
r-HuEPO,Darbopoetin (Aranesp)
Blood removed from athlete
U.S. cyclists
Hemopure (based on bovine Hgb)
2001 Giro d’Italia cycling marathon
Enhances erythropoiesis by stim proerythroblasts formation

20. Epo & Doping - Physiology
Endurance Exercise
RBC mass and plasma volume increases
Hct & Hgb decrease due to expanded plasma volume
By increasing Hgb & Hct
increases O2 carrying capacity
decreases ratings of perceived exertion
increases VO2 Max

21. 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

22. Epo & Doping - Adverse Effects
Because of increased RBC volume - causes increased blood viscosity
HTN
Seizures
DVTs, PEs
Stroke
Case report - cerebral sinus thrombosis

23. 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

24. Ephedra Chinese herb, 5000yrs Known to relieve respiratory ailments
Comes from Ephedra sinica plant
Ma huang
Known to relieve respiratory ailments
Mixed into herbal teas
Sale of it alone is prohibited
Make methamphetamine

25. 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

26. 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

27. 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

28. 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
2/17/2003

29. Legal Ergogenic Aids

30. 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

31. 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)

32. 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

33. 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 Gualano et al) Double Blind, Randomized - 3 months
BOTTOM LINE - NO evidence on any effect on kidney function

34. 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
( meta-anlysis J Ath Train - Lopez et al.
(Br J Sports Med Dalbo et al)
BOTTOM LINE - No increased risk of dehydration, cramping, or issues with sweating or heat regulation

35. Creatine - Summary For Triathletes not very beneficial
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
NOT BANNED by IOC, UCI, WADA, USAC

36. 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 Million Dollars

37. 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

38. 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, 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, J Str Cond Res) - no side effects
3 g/day - small increases in 1RM, small decrease in fat mass, small increase in muscle mass
The Blond Bomber - Dave Draper

39. 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

40. 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

41. 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

42. 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

43. Caffeine - Proven Effects
Effects have been studied for 100 years
Most studies = 2-9mg/kg per day ( mg)
(Costill et al., 1978) - 300mg, cycle at 80% VO2 Max until exhaustion
90.2 minutes vs 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

44. Caffeine - Adverse Effects
Anxiety, heart palpitations, trembling, and facial flushing
Dose related
Lethal half-dose of caffeine is mg/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

45. Caffeine - Summary Banned 1962 IOC Removed 1972
Urine 12mcg/ml = 9mg/kg
6-7 cups = mg
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…

46. Beta Alanine Delays fatigue 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
Delays fatigue

47. 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
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

48. 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

49. 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

50. 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

51. NO / Arginine - Summary Legal - not banned
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

52. Macronutrient Ergogenic Aids

53. Carbohydrates Macronutrient Aids muscle recovery & glycogen stores
Source of instant energy as well
Insulin spike
6-8% CHO solution
8 T in 1 Gallon

54. Carbohydrates - Proven Effects
Evidence shows CHO beverages better than H2O
Study - cyclists 70% VO2 max, improved TTE 30 minutes
Mouth wash study (6.4% maltodextrin)
Central Drive vs. Metabolic Drive
Aerobic endurance

55. Carbohydrates - Summary
Proven performance effects
No adverse side effects
Not Banned
But is there something better?…

56. 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

57. 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 Apr;24(2):134S-139S.

58. 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

59. 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 vs. 1318
Ready, Saunders

60. CHO + PRO - Proven Effects
Study by Kreider in 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)

61. 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

62. Carbohydrate + Protein - Summary
Proven Benefits
Safe
4-2:1 Ratio
During & After
Not BANNED

63. Case #1… 17yo male HS athlete Test = 2xs NL Estradial = 3xs NL
HDL <10
LDL = 252
10 week cycle
Went from 145 to 190
What do you do?…

64. Case #1…Revisited 17yo male HS athlete 3 Months later Off D-Bol
Test = WNL
Estradial = WNL
HDL = 42
LDL = 104
ECHO - WNL
Weight now = 163

65. Scenario… 19yo patient comes to your office…
Wants to start taking supplement X.
What do you say?…

66. Supplement Pyramid - What should I take?
Solid Foundation
Base - T / N / R
Ask the 3 ?s
2nd Tier
MVI / Ca++/Vit D
Whey Protein/P+C
Fish Oil**
3rd Tier

67. Wrapping it up
Educate
Open mind
Supplement Pyramid
Sports specificity

68. Caveat Emptor 1-800-233-0393 (US-ADA) www.usantidoping.org
One final warning
Delbeke et al., 2002
OTC Pyruvate
USAC Position Statement - 1/26/06
Warning: Any athlete who takes…does so at his or her own risk of committing a doping violation
UCI, US-ADA, WADA, or IOC
Remember, the athlete is ALWAYS responsible for what he or she puts into his or her body
(US-ADA)

69. On-line Resources for help
Important Web Sites
NCAA site on banned substances
World Anti-Doping Agency

70. Thank You

71. 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
Armstrong, L.E. (2002, June). Caffeine, body fluid-electrolyte balance, and exercise performance. International Journal of Sport Nutrition & Exercise Metabolism, 12(2), pp
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Barr, S.I. (1999). Effects of dehydration on exercise performance. Canadian Journal of Applied Physiology, 24 (2), pp
Bell, D.G., Jacobs, I., Ellerington, K. (2001). Effect of caffeine and ephedrine ingestion on anaerobic exercise performance. Medicine and Science in Sports and Exercise, 33(8), pp

72. References
Below, P.R., Mora-Rodriguez, R., Gonzalez-Alonso, J., & Coyle, E. (1995). Fluid and carbohydrate ingestion independently improve performance during 1h of intense exercise. Medicine & Science in Sports and Exercise, 27, pp
Berglund, B., Birgegard, G., White, L., & Pihlstedt, P. (1989). Effects of blood transfusions on some hematological variables in endurance athletes. Medicine & Science in Sports and Exercise, 21, pp
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73. References
Buick, F., Gledhill, N., Froese, A.B., Spriet, L., & Meyers, E.C. (1980). Effect of induced erythrocythemia on aerobic work capacity. Journal of Applied Physiology, 48, pp. R636-R642.
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74. References
Costill, D.L., Dalsky, G.P., & Fink, W.J. (1978). Effects of caffeine ingestion on metabolism and exercise performance. Medicine and Science in Sports and Exercise, 10, pp
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75. References
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76. References
Graham, T.E. (2001, 11). Caffeine and exercise: Metabolism, endurance, and performance. Sports Medicine, 31, pp
Graham, T.E., Hibbert, E., & Sathasivam, P. (1998). Metabolic and exercise endurance effects of coffee and caffeine ingestion. Journal of Applied Physiology, 85, pp
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77. References
Hawley, J.A., Burke, L.M., Angus, D.J., Fallon, K.E., Martin, D.T., & Febbraio, M.A. (2000). Effect of altering substrate availability on metabolism and performance during intense exercise. British Journal of Nutrition, 84(6), pp.
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Kennedy, M.C. (2000). Newer drugs used to enhance sporting performance. Medical Journal of Australia, 173, pp
Kreider, R.B. (1999, February). Dietary supplements and the promotion of muscle growth with resistance exercise. Sports Medicine, 27(2), pp

78. References
Kutscher, E.C., Lund, B.C., & Perry, P.J. (2002). Anabolic steroids: A review for the clinician. Sports Medicine, 32(5), pp
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