1. Proven Sports Supplements: and Recent Fads Sandra H Counts, PharmD July 22, 2016

2. Scott’s Better Half

3. Disclosure I, Sandra Counts, Pharm D, do not have any relevant financial relationships with commercial interests to disclose.

4. Objectives 1. Describe the importance of including supplements in the medication history 2. Be able to list examples of how supplements may positively and negatively affect athletic performance 3. Be aware of trustworthy resources for information on supplements 4. Review a few of the latest popular sports supplement fads

5. 20 Minutes...GO!

6. Supplement Rules and Regs Treated by FDA as ‘foods’ not drugs ‘Structure -function’ claims…but not diseases. Can claim ‘mood support’ but can’t claim helps depression. Purity, Efficacy, Safety an issue Need for reliable info sources

7. NCAA Rules and Regs NCAA Nutritional/Dietary Supplements Warning: Before consuming any nutritional/dietary supplement product, review the product with the appropriate or designated athletics department staff. There are no NCAA approved supplement products. 1. Dietary supplements, including vitamins and minerals, are not well regulated and may cause a positive drug test result. 2. Student-athletes have tested positive and lost their eligibility from using dietary supplements. 3. Many dietary supplements are contaminated with banned drugs not listed on the label. 4. Any product containing a dietary supplement ingredient is taken at your own risk. Check with your athletics department staff prior to using a s –http://www.ncaa.org/sites/default/files/2016_17_%20Banned_%20Drugs_%20 Educational_%20Document_20160531.pdfupplement.

8. ACCURATE MED LIST IS IMP! Vits, Mins Herbals Workout powders Coaches The local Gym –Do you routinely ask athletes about them? –How do you phrase your questions?

10. Why Worry about Supplements? 1. Supplements are commonly used. As many as 2 in 3 college athletes and up to 100% of athletes in some sports, as such as weight lifting 2. Supplements can cause side effects that negatively interfere with performance. (nausea, anxiety), or even enhanced bleeding after injury or surgery 3. Supplements can interact with Rx meds

11. Examples Stimulant drinks (Red Bull etc) + ADHD med such as Adderall = anxiety, chest pain, trouble sleeping, can even trigger panic attacks.

12. Examples Mood Support vitamin containing herbal St John’s Wort + Birth Control Pill = pregnancy risk!

13. Examples Caffeine + Zanaflex/tinazidine a muscle relaxer, can lead to low BP, dizziness, and fainting. Combination of these 2 is not recommended. Ditto for Caffeine + duloxetine (Cymbalta), Rx antidepressant

14. Herbs and Bleeding Supplements that are known or suspected to increase bleeding risk include: Ginkgo bilobaFish oil GarlicDong quai GinsengFeverfew GingerSaw palmetto

15. HANDOUT What supplements have the best evidence for safety and efficacy for improving athletic performance? See chart- Row 3 Caffeine Creatine Antiox Vits C and E Whey protein Beta Alanine Pycnogenol

16. Caffeine by the Numbers People experience side effects >400mg sleeplessness, heart palpitations, headaches, nausea, and anxiety. The NCAA allows caffeine within limits. But urine concentrations >15 mcg/mL are prohibited. It usually takes about 800 mg of caffeine to achieve this concentration. (about 8 cups of regular coffee or 2 Starbucks Grandes)

17. The Science of Caffeine J Int Soc Sports Nutr.J Int Soc Sports Nutr. 2010 Jan 27;7(1):5. International society of sports nutrition position stand: caffeine and performance. 1.) Caffeine is effective for enhancing sport performance in trained athletes when consumed in low-to-moderate dosages (~3-6 mg/kg) and overall does not result in further enhancement in performance when consumed in higher dosages (>/= 9 mg/kg). 2.) Caffeine exerts a greater ergogenic effect when consumed in an anhydrous state as compared to coffee.

18. 3.) It has been shown that caffeine can enhance vigilance during bouts of extended exhaustive exercise, as well as periods of sustained sleep deprivation 4.) Caffeine is ergogenic for sustained maximal endurance exercise, and has been shown to be highly effective for time-trial performance. 5.) Caffeine supplementation is beneficial for high-intensity exercise, including team sports such as soccer and rugby, both of which are categorized by intermittent activity within a period of prolonged duration. 6.) The literature is equivocal when considering the effects of caffeine supplementation on strength-power performance, and additional research in this area is warranted. 7.) The scientific literature does NOT support caffeine-induced diuresis during exercise, or any harmful change in fluid balance that would negatively affect performance. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824625/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824625

19. Caffeine Content website: https://cspinet.org/caffeine-chart 200-400 mg per cup

20. Caffeine content, misc Hot teas60-135 mg Soft drinks FDA limit 71 mg/12 oz –Pepsi MAX 69mg/12 oz –Mtn Dew54 mg –Mtn Dew 20 oz90 mg Energy Drinks- 3 x more caffeine –Bang300/16 oz –Redline 316/8 oz –Rockstar Citrus Punched 240/16 oz –5 Hour energy shot208/2 oz –Red Bull80/8 oz

22. Caffeine content, misc Caffeinated snack foods –Crackheads600 mg/box –Crackheads Expresso Bean candy 200mg/28 –Wired Waffles200 mg –Bang! Caffeinated Ice Cream125mg/4 oz Weight loss supplements/other –Zantrex-3300 mg –Caffeine powder 1/16 tsp200 mg –Caffeine Liq1 tsp80 mg

24. OMG!!

28. FAD: Caffeinated “Pre-Workout” Powders Caffeine:160 mg/scoop!! Take 1-2 scoops/day

29. Creatine

30. Creatine Safety Natural Database, accessed 7.22.16 1. SAFETY LIKELY SAFE...when used orally and appropriately. Creatine supplementation appears to be safe when used in appropriate doses in healthy adults Creatine has been safely used daily for 1-5 years 2. Interactions with Lab Tests: SERUM CREATININE (SCr): Creatine is metabolized to creatinine. Higher than normal serum creatinine levels can result in patients taking creatine, despite normal renal function 3. Interactions with Diseases or Conditions: BIPOLAR DISORDER: Two cases of hypermania or mania have been reported for bipolar patients who took creatine monohydrate 3-5 grams daily for 4 weeks. There is some concern that creatine may worsen mania in patients with bipolar disorder.

31. Creatine Side Effects Natural Database, accessed 7.22.16 Orally, creatine can cause gastrointestinal pain, nausea, and diarrhea Case reports have found that 25% of male collegiate athletes taking creatine have muscle cramping. A theoretical increase in risk of dehydration due to intracellular fluid shifts has led creatine manufacturers to caution about adequate hydration with supplementation. Patients engaging in strenuous exercise and/or exercising in hot environments may want to avoid creatine supplementation.

32. Creatine Effectiveness- Mixed Results Natural Database, accessed 7.22.16 1. In trained athletes: PRO: Research in trained athletes shows that taking creatine orally, 20-35 grams or 240-350 mg/kg body weight daily for 3-7 days, sometimes continuing with a lower maintenance dose, improves performance during high-intensity bursts of cycling, sprinting, swimming, or rowing, ie SPURT SPORTS. CON: However, there is also research using similar dose regimens that shows NO benefit Limited clinical research using lower creatine doses, 2-9 grams daily for 5-9 days, also has mixed results, with some studies showing benefit and some not. Creatine can increase muscle strength and prevent acute strength loss followed by aerobic exercise, measured with bench press or leg press exercises. However, other research shows no benefit

33. Creatine Effectiveness- Mixed Results Natural Database, accessed 7.22.16 2. In young, recreationally active men: Taking creatine orally 10-25 grams (lower doses than the trained athletes) daily for 5-7 days improves performance during high-intensity bursts of cycling, sprinting, or jumping. However, other studies using 20-30 grams daily for 3-5 days, or 280 mg/kg daily for 4 days, report no benefit. These and other similar regimens have also been associated with increases in muscle strength in some studies but not in others. BOTTOM LINE: Many variables seem to determine the effect of creatine on performance, including the subject's training status, the type of sport being tested, diet, age of the subject, and the dose regimen of creatine. It is possible that the benefit in certain sports is offset by weight gain from creatine supplementation

34. Beta – Alanine Int J Sport Nutr Exerc Metab. 2014 Feb;24(1):14-27Int J Sport Nutr Exerc Metab. The effects of beta-alanine supplementation on performance: a systematic review of the literature. –There appears to be some evidence from this review that supplementation with BA may increase athletic performance. –However, there is insufficient evidence examining the safety of BA supplementation and its side effects. – It is therefore recommended to err on the side of caution in using BA as an ergogenic aid until there is sufficient evidence confirming its safety. So what side effects should we watch for?

35. Beta – Alanine Safety From Natural Database: (accessed 7.22.16) Can cause dose-dependent flushing and paresthesias, starting on the scalp within 20 minutes of the dose, spreading to most of the body, and lasting for about an hour. Described as severe with a dose of 40 mg/kg, tolerable with 20 mg/kg, and very mild with 10 mg/kg. At the lowest dose it only occurred in 25% of subjects. In some studies, beta-alanine has been given as frequently as 8 times per day so that each dose can be kept below 10 mg/kg.

36. Pycnogenol Natural Database accessed 7.22.16 An extract from the bark of the French maritime pine tree. Athletic Performance:. Some preliminary clinical research shows that taking pycnogenol 200 mg daily for 30 days significantly improves treadmill exercise capacity in recreational athletes. Pycnogenol is well-tolerated and has not been linked to serious side effects in several short-term studies.

37. Whey Protein Whey Protein is used for building muscle, increasing lean body mass, and improving strength. Whey contains a variety of nutrients and high concentration of amino acids compared to other protein sources. Whey protein can improve some measures of athletic performance. Taking whey protein 1.2-1.5 grams/kg in combination with strength training for 6-10 weeks increases lean body mass, strength, and muscle hypertrophy vs. placebo.

38. Antioxidants- Vits C & E Natural Database accessed 7.22.16 1. Antioxidants such as Selenium, Vitamin C and E are often taken by athletes in an effort to prevent muscle damage and breakdown during exercise. 2. Some clinical research shows that vitamin C might help prevent exercise-induced respiratory tract infections that can occur occasionally following intense exercise, such as running a marathon. 3. Population research also suggests that higher dietary intake of vitamin C and E is associated with improved physical performance in elderly patients. But there is NO reliable evidence in which taking vitamin C or E improves athletic performance in young, healthy athletes.

39. EVIDENCE BASED RESOURCES! 1. Some EMRs include supplements in their drug databases and can check for interactions 2. Prescribers Letter Natural Database (the “cadillac” of references), requires a subscription 3. Free Website at Penn St

40. www.naturaldatabase.com Or call (209) 472-2244

41. Free Herbal Website @ Penn State http://pennstatehershey.adam.com/content. aspx?productId=107http://pennstatehershey.adam.com/content. aspx?productId=107

42. Med Hx is key- None of this can happen if you don’t ask!!

43. Objectives 1. Describe the importance of including supplements in the medication history 2. Be able to list examples of how supplements may positively and negatively affect athletic performance 3. Be aware of trustworthy resources for information on supplements 4. Review a few of the latest popular fads

44. Resources We are happy to help! Me 864 933-4658 –Sandra Counts, PharmD Our Sports Med Fellows –Tyler Bailey –Andrea Ray Pitts Our Fellowship Faculty –Dr Scott Counts –Dr Chris Clemow

45. Questions? Sandra H Counts, PharmD AnMed Health Family Medicine 864.933.4658 cell Sandra.counts@anmedhealth.org