1. High Intensity Training Workshop and Performance Optimization Roundtable Sponsored by the Human Performance Resource Center September 13-14, 2010 Uniformed Services University for the Health Sciences, Bethesda, MD

2. Nutrition, Supplements, and High Intensity Training Programs Patricia A. Deuster, PhD, MPH Professor and Scientific Director CHAMP

3. Objectives Present picture of dietary supplement use among active duty personnel Discuss concerns and red flags regarding dietary supplements Describe nutrition and dietary supplements information associated with extreme exercise programs Introduce new DoD classification system for dietary supplements

5. Supplement Use by Age

6. Supplement Use by Gender

7. Supplement Use by Service

8. Body Building Supplements and Drinking

9. US Army Survey 9.1% took combination products: CellTech, Hydroxycut, Nitrotech, or Xenadrine) 37.5% took multivitamins/multiminerals 18.7% tookprotein and amino acids 17.9% used single vitamins/minerals 8.3% used herbal supplements 2.7% used steroid analogs Lieberman et al. AJCN. July 28, 2010

10. Reasons for Use US Army Survey 64.2% to improve general health 31.1% to increase energy 24.9% to increase muscle strength 16.7% to enhance performance Persons who strength trained were 8.3 times more likely to take protein and amino acid products Lieberman et al. AJCN. July 28, 2010

11. Characteristics of Body Building Supplement Users 18 to 25 yo A Marine Unmarried BMI 25 – 30 Physically active Heavy drinker Stephens et al. found an association between the use of ergogenic supplements and specific health risk behaviors.

12. Hidden Ingredients Dietary supplements deliberately contaminated with: –Prescription drug ingredients –Ingredients under clinical investigation w/an IND –Ingredients approved as drugs in other countries –Ingredients removed from US market for safety reasons –Analogues of prescription drug ingredients –Controlled substances 12

13. Red Flags Product categories: weight loss, performance enhancing, bodybuilding Label claims like: –Alternative to [approved drug products] –Do not take if you have any medical condition, if you are taking any prescription medications, or if you are pregnant –May cause positive result in drug test Labels primarily in a foreign language Directions and warnings resembling FDA approved drug products

14. Trends from Iraq Warfighters are taking mostly combinations of or “stacked” products readily available at exhanges on base “RIP-ITs” are stocked at all DFACs (energy drink supplements) Most readily available products: NO products

16. Rip It ® 16 oz Energy Drink

17. Side Effects Observed in Theatre Multiple case reports of syncope, palpitations and lightheadedness from NO products Warfighters who become dehydrated appear at increased risk of side effects from caffeine and other vasoactive components Case reports of liver toxicity, possibly secondary to NO products Rhabdo also seen, but no clearly identifiable supplement connection: possibly secondary to heat, dehydration and vasoactive components

18. Various Programs P90X CrossFit TRX ® Military Athlete Gym Jones

19. P90X Multiple supplements promoted

23. Nutritional Guideline: Military Athletes 6 Days a Week: –Eat lean meat, vegetables, fruit, nuts, seeds, and drink water. –Don't eat carbs (bread, spuds, rice) or sugar. 1 Day a Week: –Cheat like a mother! –Beer, pizza, ice cream - you name it!

24. Supplement Guideline: Military Athletes Supplement diet with protein shakes & creatine to improve strength & recovery –Whey protein is best: Key ingredient is Leucine –Drink 10 min before & 15 min after training –Creatine - Take 20-25 grams/day for 5 days, then continue with 5 grams/day afterward β-Alanine: Take to decrease fatigue, improve recovery, cut body fat and increase lean body mass

25. CrossFit No products promoted - but

26. http://www.nastyenergy.com/

27. TRX ® Partners with Precision Nutrition –No supplement promotions found, but must be member to access information

28. Gym Jones No products promoted Blogs on nutrition

29. Gym Jones Drink solution containing 88-90% carbs and 10-12% protein –Several supplements on the market that fit this profile. Check ingredients to learn protein source –Whey peptides are ideal for recovery Glutamine contributes to ammonia burden –Soy protein does not readily produce ammonia

30. Proposed DoD DS Classification System Combines potential benefit with probability of adverse event to estimate risk Can be used to assess acceptability of risk May be used to prioritize resources, develop educational materials, and standardize response actions Can be revised as new evidence and/or adverse events emerge

31. Dietary Supplement Risk Matrix 1-Safe2-Safe 7-Use w/ Caution 9-Do Not Use 3-Safe4-Safe 8-Use w/ Caution 11-Do Not Use 5-Use w/ Caution 6-Use w/ Caution 10-Do Not Use 12-Do Not Use Minimal Concern Low Concern Moderate Concern High Concern Safety Benefit High Potential Moderate Potential Low Potential

32. http://www.humanperformanceresourcecenter.org/

34. Summary Supplement use is problematic, particularly in the deployed setting Body building and performance enhancing are primary supplements of concern Supplements co-exist with HIT programs Some HIT programs promote supplements that could be harmful, especially in the deployed setting

35. ?

36. Protein/Creatine/Amino Acids/Nitric Oxide, Arginine Brand Name/Supplement NameKey Ingredients BSN/Endorush** L-Arginine-Alpha-Ketoglutaric (AKG) Acid BSN/Cellmass** Sodium Cratine Phosphate Matrix, Creatine Ethyl-Ester B-Alanine Creatinol-O- Phosphate-Malic Acid Interfusion, Creatine-Alpha-Aminobutyric Acid Matrix BSN/Epozine-O2** L-Arginine AKG, L-Arginine Aspartate, L-Arganine Pyroglutamate, L-Arginine Ethyl Ester, creatine sodium phosphate, creatinol-O-phosphate, Creatine Magnesium Chelate, BSN/NO-XPLODE** L-Arginine AKG, Di-creatine malate, Creatine Ethyl-Ester B-Alanine Composite, Sodium Creatine Phosphate Matrix, Creatinol-O-Phosphate Malic Acid Interfusion, Creatine-Alpha-Aminobutyric Acid Matrix BSN/Nitrix** L-Arganine AKG, L-Arginine Ethyl Ester, Creatine Ethyl-Ester B-Alanine Composite, Sodium Creatine Phosphate Matrix, Creatinol-O-Phosphate-Malic Acid Interfusion, Creatine-Alpha-Aminobutyric Acid Matrix BSN/True Mass Whey protein concentrate, whey protein isolate, calcium caseinate micellar Casin BSN/Volumize** Leucine Alpha-Aminobutyric Acid Matrix, Valine Alpha-Aminobutyric Acid Matrix, Isoleucine Alpha-Aminobutyric Acid Matrix, Leucine Nitrate, Valine Nitrate, Isoleucine Nitrate ProLab/Creatine Monohydrate Creatine Monohydrate ProLab/Pure Whey Whey protein concentrate ProLab/Advanced Whey Protein Whey protein concentrate, whey protein isolate EAS/100% Whey Protein Whey protein concentrate, whey protein isolate Muscletech/Na-NO Vapor Hardcore** L-Arginine, Creatine Monohydrate Creatine Monohydrate, Creatinol-o-phosphate, creatine taurinate, L-arginine, L- glutamine, L-leucine, L-isoleucine, L-valine Creatine Monhydre, Creatine Malate, Creatine Taurinate, L-Lysine HCL, L-valine, L- valine Alpha-ketoglutarate, L-isoleucine pyroglutamate, L-leucine Ketoisocaproate, L-leucine pyroglutamate, L-leucine alpha-ketogluarate,

37. Protein/Creatine/Amino Acids/Nitric Oxide, Arginine Brand Name/Supplement NameKey Ingredients Muscletech/IntraVol**Creatine Monohydrate, L-Arginine Muscletech/Anabolic Halo Hardcore**L-Leucine Muscletech/CreakicCreatine Monohydrate Body Fortress/Premium ProteinWhey Protein concentrate, whey protein isolate Muscletech/Mesotech CompleteWhey protein concentrate, Creatine Monohydrate, Amino Acids Muscletech/Na-NOX9 Hardcore**L-Arginine MRI/NO2 PlatinumL-Arginine MRI/NO2 BlackArginine Alpha-ketoglutarate MRI/WAR (Workout Anabolic Recovery)Amino Acids Muscletech/Celltech**Creatine Monohydrate Muscletech/Nitrotech**Whey protein concentrate, whey protein isolate, creatine monohydrate ** indicates proprietary blend and amount of key ingredients are unknown

38. Steroids/Prohormones Brand Name/Supplement NameKey Ingredients Powerlab/Halotest-254-cholor-17a-methyl-andro-4-ene3, 17b-diol Powerlab/Pirmabol2a-17a-dimethyl-17b-hydroxy-5a-androstan-3-one Powerlab/Androdrol 4-cholor-17a-methyl-androst-1,4-diene-3-17b-diol, 2,3a-epithio-17a-methyl-5a- androstan-17b-ol, 13-ehtyl-3-methoxy-gona-2,5(10)dien-17-one, 2a-17a-dimethyl-17b- hydrox-5z-androstan-3-one, 6 bromoandrostenedione GNC/Mega Man DHEAdehydroepiandrosterone (DHEA) Caffeine/Stimulants Brand Name/Supplement NameKey Ingredients BSN/Endorush**Methylxantine (Caffeine and Caffeine-Alpha-Ketoglutaric Acid) BSN/NO-XPLODE**methylxanthine (Caffeine) Premier Nutrition/Rocket Shot**Caffeine Anhydrous Stacker/Black Jax Energy Shot**Caffeine Anhydrous Muscletech/Na-NO Vapor Hardcore**Caffeine Xenadrine/Xenadrine Ultra & RZR-X**Caffeine Anhydrous Muscletech/Myoshock**Caffeine Anhydrous Muscletech/Gakic**Caffeine Anhydrous Twinlab/Ripped Fuel 5XCaffeine Twinlab/Ripped Fuel ExtremeCaffeine Five Hour Energy/Five Hour Energy Shot**Caffeine BSN/Thermonex**Caffeine Anhydrous, Yerba Mate Leaf (25% caffeine), AMP/Energy Drink**Caffeine Full Throttle Energy Drink**Caffeine, Guarana Monster Energy Drink**Caffeine, Guarana MRI/Black Powder**Caffeine Red Bull Energy DrinkCaffeine ** indicates proprietary blend and amount of key ingredients are unknown