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Cayuga Sports Medicine Conference - Supplements Update 2010

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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)
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

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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 Berglund, B., & Hemmingson, P. (1987). Effect of reinfusion of autologous blood on exercise performance in cross-country skiers. International Journal of Sports Medicine, 8, pp Branch, J.D. (2003, June). Effect of creatine supplementation on body composition and performance: A meta-analysis. International Journal of Sport Nutrition & Exercise Metabolism, 13(2), pp Brien, A., & Simon, T.L. (1987). The effects of red blood cell infusion on 10km race time. Journal of the American Medical Association, 257, pp Brown, G.A., Vukovich, M.D., Reifenrath, T.A., Uhl, N.L., Parsons, K.A., Sharp, R.L., & King, D.S. (2000). Effects of anabolic precursors on serum testosterone concentrations and adaptations to resistance training in young men. International Journal of Sport Nutrition and Exercise Metabolism, 10, pp Buckley, J., Abbott, M., Martin, S., Brinkworth, G., & Whyte, P. (2002). Effect of oral bovine colostrums supplement on running performance. Journal of Science and Medicine in Sport, 5, pp

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78 References Kutscher, E.C., Lund, B.C., & Perry, P.J. (2002). Anabolic steroids: A review for the clinician. Sports Medicine, 32(5), pp Lage, J.M.M., Panizo, C., Masdeu, J., & Rocha, E. (2002). Cyclist’s doping associated with cerebral sinus thrombosis. Neurology, 58, pp Latzka, W.A., Montain, S.J. (1999, July). Water and electrolyte requirements for exercise. Clinics in Sports Medicine, 18(3), pp Lemon, P.K. (2000). Beyond the zone: Protein needs of active individuals. Journal of the American College of Nutrition, 19(5), pp. 513S-521S. Lemon, P.K. (1998). Effects of exercise on dietary protein requirements. International Journal of Sport Nutrition, 8, pp Miller, S.L., Maresh, C.M., Armstrong, L.E., Ebbeling, C.B., Lennon, S., & Rodriguez, N.R. (2002, December). Metabolic response to provision of mixed protein-carbohydrate supplementation during endurance exercise. International Journal of Sport Nutrition & Exercise Metabolism, 12(4), pp Longobardi, S., Keay, N., Ehrnborg, C., Cittadini, A., Rosen, T., Dall, R., Boroujerdi, M.A., Bassett, E.E., Healy, M.L., Pentecost, C., Wallace, J.D., Powrie, J., Jorgensen, J.O., & Sacca, L. (2000, April). Growth hormone (GH) effects on bone and collagen turnover in healthy adults and its potential as a marker of GH abuse in sports: A double blind, placebo-controlled study. The Journal of Clinical Endocrinology & Metabolism, 85(4), pp

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