Weight Loss and Ergogenic Aids

Weight Loss and Ergogenic Aids
Annie Laweryson, Erin Prasad, Merryl Landeck and Rebecca Levens

Introduction Conjugated Linoleic Acid Ephedra PGX Hoodia
Weight Loss Ergogenic Aids Conjugated Linoleic Acid Ephedra PGX Hoodia Raspberry Ketones Creatine Beta Alanine Arginine

The Controversy… According to the FDA, weight loss supplements and ergogenic aids are two of the three categories of supplements that are most likely to have problems with adulteration, toxicity and misbranding GMP’s are critical to consider with these NSF for Sport for ergogenic supplements

Conjugated Linoleic Acid
Weight loss Erin Prasad

Scientific name: cis-9, trans-11 conjugated linoleic acid trans-10, cis-12 conjugated linoleic acid or octadecadienoate 18:2 Common name: CLA, Tonalin and Clarinol (brand names) CLA: A group of conjugated octadeadienoic acid isomers derived from linoleic acid A polyunsaturated fatty acid in which scientific interest was peaked in the 1980s when scientific evidence support possible anti-cancer effects. Food sources: Meat- beef and other ruminant animals Dairy products Eggs Vegetable oils Average daily intake (non veg/vegan) in ~ mg/d Suppelment sources: Safflower and Sunflower oils in which the CLA is made under alkaline conditions. Kangaroo meat has the highest concentration of CLA! Linoleic acid is a fatty acid that contains 18 C and two double bonds in cis configuration at 9C and 12C Microbes in the GI tract of ruminant animals convert it through biohydrogenation to the conjugated configuration of cis-9, trans-11(rumenic acid) and trans 10 cis-12. Consumer labs states: CLA is found naturally in milk fat (5mg of CLA per gram of fat) and meat fat (~4mg/g). Grass fed “free range” animals will have higher CLA content than hay/grain fed animals in both milk and meat. Non-fat and low-fat products will have little CLA The predominant form of CLA in milk and meats is the cis-9, trans-11 isomer with much smaller amounts of the trans-10, cis-12 isomer (the form associated with slimming). Increasing the consumption of fatty food sources to achieve high intak of CLA is obviously not recommended for slimming purposes. Further details on the componenets of the CLA supplements to follow…(slide #11) 1, 2, 3, 4 Erin Prasad

Typically used for conditions such as: Weight loss Allergies, asthma, CVD, diabetes, cancer, exercise performance enhancement, hair loss, hypercholerolemia, hypertension, immune function, and rheumatoid arthritis Dosage: No proven safe or effective dose For weight loss/obesity: 1.8-7g/d has been administered Doses greater than 3.4g/d do not offer additional benefit For all other conditions: 2-6g/d with mixed results regarding efficacy Mechanism of Action: Proposed CLA increases energy expenditure CLA suppresses appetite CLA decreases lipogenesis through apoptosis of adipocytes CLA increases lipolysis 1, 3, 4 Erin Prasad

Efficacy for weight loss: Natural standard Study 1 (2010): Overweight or obese children supplemented with CLA gained less weight than the placebo group. Study 2 (2012): Chinese adults supplemented with CLA had an overall reduction in BMI, fat mass, fat percentage, subcutaneous fat, and waist-to-hip ratio. Safety: Considered generally safe for healthy individuals Adverse effects: nausea, diarrhea, and GI upset Cautionary use for: Children and breastfeeding women, CVD, inflammatory disorders, digestive disorders, autoimmune diseases, dermatological disorders, diabetics, or those with liver disease. DNIs: CLA should be taken with caution with medications used for blood thinning, lowering blood pressure, cholesterol or blood sugar. Natural standard: B rating, CLA is a popular supplement marketed to reduce obesity and body fat. Whil some human evidence suggests that CLA may reduce body fat mass and body weight, results of other studies failed to show these effects. Addition research is needed in this area before firm conclusions can be made. Study 1: A study from the American Journal of Clinical Nutrition demonstrated that when 62 overweight or obese children were supplemented 3g/d CLA in chocolate milk for 7 momth, they gained less weight than the placebo group. Note: The supplmented group also showed decreased HDL Study 2: A Chinese study in which 63 individuals were supplemented with 3.4g/d CLA in milk for 12 weeks compared to a placebo group had an overall reduction in BMI, fat mass, fat percentage, subcutaneous fat, and waist to hip ratio. (Not significant results: total cholesterol, triglycerides, LEL, and fasting blood glucose all increased after 12 months and HDL decreased) According to a systematic review from 2012, “The evidence from RCTs does not convincingly show that CLA intake generates any clinically relevant effects on body composition in the long term.” GMPs: also manufactured by reputable companies with 3rd party certification for safe GMPs Safety: there is one report of CLA induced toxic hepatitis in a 46 year old woman than resolved with cessation of supplementation. CLA has been shown to decrease fat content of breast milk and therefore should not be used by the lactating woman GMPs: All but one of 6 CLA supplements tested by Consumer Labs contained the claimed amount of CLA (one had 86%), GRAS product. Erin Prasad 3, 5, 6, 7

What to look for when buying Accessibility: Easily found at Super Supplement and drug stores in weight loss section (non-refrigerated) Price range 90 gel caps of 750mg CLA: $12.99-$22.99 Forms: Soft gels of 750mg, 800mg, 1000mg, or 1400mg all from sunflower or safflower oil Dosing Instructions: Varies among brands and is conflicting, one serving is 1-3 gel caps of 750mg Other ingredients: D-alpha tocopherols Excipients: gelatin, glycerin, color, (beeswax, soy lecithin) Extras: Claims often stated are: Supports body fat reduction Retain lean body mass while burning fat Clean Performance Product Tonalin or Clarinol brand names can be confusing, as they often dominate label CLA in supplements is typically made from safflower oil. Most supplements use oil that is about 80%CLA with the remainder consisting of other fatty acis (palmitic, oleic, stearic, and linolenic). The effectiveness of a CLA supplement may depend on the proportion and amounts of the forms present. However, most products do not specify the ratio of CLA forms. In general, supplements with CLA from safflower oil provide an equal mixture of the trans-10, cis-12 and cis-9, trans-11 forms. Some CLA supplements are enhanced with L-carnitine, green tea, and/or chromium for “extreme” results Erin Prasad

Overall Impressions and Recommendations Scope of Practice: With coordination of care with a physician, it is within the scope of a dietitian to recommend CLA. Lab work for triglycerides, blood sugar, and cholesterol should be monitored carefully Overall impression: Yellow CLA is safe for general population, special populations for which it may be unsafe do exist. It may reduce body fat, but has not been shown to increase lean body mass CLA may alter lipid profile in an unfavorable manner, especially a concern for those with CVD or diabetes (large portion of obese population) Most people are receiving adequate amounts through dietary sources (vegan may be exception) Erin Prasad

Weight Loss Merryl Landeck
Ephedra Weight Loss Merryl Landeck

Ephedra Scientific Name ~ Ephedra sinica
Also known as Ma Huang in traditional Chinese medicine It is an evergreen shrub-like plant native to arid regions of China and Mongolia. Currently grow in China, northern India, Pakistan, Mongolia, and the southwestern United States (8) There are approximately 40 species of ephedra (8) Traditional uses by Chinese herbalists dating back 5,000 years Treatment of respiratory infections, asthma, eczema, hay fever, cough, colds, chills, shortness of breath, bone and joint pain, narcolepsy, and edema (8, 9) Modern uses (prior to FDA ban) Weight loss, athletic performance enhancement, increase energy, sexual dysfunction, hypotension. Still found over-the-counter for asthma and sinus congestion in a safer form (8, 9, 10) Merryl Landeck

Scientific Evidence for Uses of Ephedra
According to Natural Standard, some evidence exists suggesting ephedra is successful as a supplement for weight loss, however, the risks of taking ephedra alkaloids as a dietary supplement outweigh the possible benefits. Merryl Landeck

Mechanism of Action Ephedrine Ephedra contains the alkaloids ephedrine and pseudoephedrine, which have been found to induce CNS stimulation, bronchodilation, and vasoconstriction (8) Ephedrine alkaloids have sympathomimetic properties, simulating stimulated sympathetic nerves which excite the CNS. They stimulate α-1, β-1, and β-2 receptors to increase blood pressure, heart rate, vascular resistance, and cardiac contractibility (11, 12) Suppresses appetite, increases energy expenditure/metabolic rate (thermogenic), lypolitic (9) Ergogenic properties marketed to reduce fatigue; increase strength, power, and speed; decrease reaction time; and improve body composition. Evidence is inconclusive (13) Ephedrine, synthesized chemically is regulated by the FDA as a prescription drug with weak amphetamine-like properties Pseudoephedrine is a nonprescription product found in many cough and cold products- causes vasoconstriction resulting in less fluid in nose, throat, sinuses (11) Merryl Landeck

Efficacy and Safety Studies show sufficient evidence to conclude that short-term use of ephedrine at high doses, or ephedrine and caffeine, ephedra, and ephedra with herbs containing caffeine promotes weight loss (13) Caffeine adds additional efficacy (0.9kg per month weight loss above placebo) (11,13) No data regarding weight loss beyond 6 months Insufficient evidence to support ephedra supplementation for enhancing athletic performance (11,12,13) A meta-analysis found intervention groups to have a 2 to 3-fold increase in psychiatric symptoms, autonomic symptoms, upper GI symptoms, and heart palpitations compared to control (13) Caused 64% of all adverse reactions reported in the U.S, despite accounting for < 1% of all supplement sales (9, 11) Merryl Landeck

Safety and Contraindications
Adverse effects (11,14) Elevated BP Palpitations Headache Insomnia Anxiety Restlessness Psychiatric disturbances Seizure Heart attack Stroke Death DO NOT take ephedra with: MAO-inhibitors or other stimulant drugs (9) Should not be taken by persons with: Heart disease Cardiovascular disease High BP History of stroke Diabetes Hepatitis Myocarditis Diseases of the nervous system Hyperthyroidism High cholesterol Heart rhythm abnormalities Merryl Landeck

Dosage Accessibility Prior to 2004 ban, FDA recommended:
8mg ephedrine every 6 hours up to 7 days (11) Highest recommended dose No more than 25 mg at one time, not to exceed 100 mg/day (9) Typical marketed dose 20 mg, 2-3 times daily (15) Clinical weight loss trials 50 mg, 3 times daily for 2 months (11) Before FDA ban on April 12, ephedra widely available in stores and online Cost avg. $1-$6/day Reports from 1999 estimate 3 billion doses of ephedra sold and 12 million users in the U.S. (11) GMPs questionable (15) Labels fail to list alkaloid content Actual alkaloid content significantly different than what’s listed Contaminants I’ll go into a little bit about the actual FDA ban here and what was involved in that process and then go to the next slide… Merryl Landeck

EphREDra

Overall Impressions Ephedra is an example of how the current system for regulation of dietary supplements can be challenging for ensuring the protection and health of the general public Should supplements with biological activity be evaluated and regulated to the same degree as over-the-counter medications? Or prescription drugs? Are ephedra-free weight loss products, such as bitter orange or caffeine, effective or any safer? Merryl Landeck

PGX: Functional Fiber Supplement
Weight Loss Merryl Landeck

PolyGlycopleX Scientific Name (of main ingredient) Typical usage
Amorphophallus konjac, native to Asia (16) Konjac-mannan from the root is used Typical usage As a dietary supplement to reduce cholesterol levels, constipation, blood sugar, and weight Traditionally a source of food (jelly, tofu, noodles) and medicine in Asian practices Typical dosage (with fl. oz. of water) Day 1-2: 1 softgel with each meal ***1.5g fiber in each softgel Day 3-4: 2 softgels with each meal Day 5-6: 3 softgels with each meal Day 7 and beyond: 4-6 softgels with each meal Merryl Landeck

Mechanism of Action PGX is a proprietary blend of konjac-mannan, sodium alginate, xanthan gum, and MCTs (17) Natural polysaccharide complex: α-D-glucurono-α-D-manno-β-D- manno- β-D-gluco, α-L-gulurono-β-D mannurono, β-D-gluco-β- D- mannan Highly viscous, soluble, fermentable fiber (18) Upregulation of gut-satiety hormone gene expression (PYY, GLP-1) via fermentation & production of SCFAs in large intestine (19) “Volumetric effect”, gastric distension and delayed gastric emptying, the “ileal brake” promotes earlier satiety, slower transit time through small intestine (19,20) Lowers glycemic index of foods, reduces post-meal spikes in blood sugar Lowers cholesterol levels by sequestration of bile acids Aids in weight loss as fiber-rich meals tend to be less calorically dense, lower in fat and added sugars. Merryl Landeck

Natural Standard Scientific Evidence (16)
Merryl Landeck

Safety and Accessibility
Generally well tolerated, low rate of adverse events (21) Minor side effects in gas, bloating, and laxative effects (22) Patent pending delayed viscosity process (17) Caution with blood pressure and blood sugar lowering medications-compounding effects (16) Lack of safety information for pregnant and breastfeeding woman. Widely available online, in drugstores, natural-food stores, and supplement stores. Available in capsules, granules, shakes, and bars Average cost is $30/ 120 softgels (approx. $2.5/day for an average of 15g fiber/day) One can of organic garbanzo beans contains 19g fiber and costs ~$1 – 1.50. Merryl Landeck

GMPs and Overall Impression
All manufacturing, processing and packaging steps required for PGX meet or exceed government and industry standards and Good Manufacturing Practices are adhered to. PGX has a USP Standard as of the 1st of March (17) Green light May be a good alternative for people, overweight or not, who are unable or unwilling to ↑ fiber intake through food sources ↑ satiety on calorie-restricted diets Appropriate dosing Merryl Landeck

Weight Loss Annie Laweryson
Hoodia Weight Loss Annie Laweryson

Hoodia Scientific name: Hoodia gordonii
Traditionally used by San people of Namib desert as and appetite suppressor on long hunts and in times of harsh conditions (16,17) Soft middle of cactus root is chewed Has been used for 1000’s of years (16,17) Hoodia Gordonii is a cactus that grows in the Namib desert in Africa. For thousands of years the San people have used it to suppress hunger and thirst during long hunts and/or during conditions where little food was available. The part of the cactus used by the San people is the soft middle of the root. This is chewed for a long time to stave off hunger. Hoodia is has also been used to help aid with digestion issues or small infections. Hoodia was first marketed in the US in the 90’s as a weight loss supplement. Laweryson, Annie

Hoodia Tricks brain into thinking the body is full
Mechanism of action (16,17,18) P57, exact mechanism unknown Tricks brain into thinking the body is full Increased ATP production in nerve cells of hypothalamus when injected into brain of rats Rats consumed 40-60% less kcal Human studies (16,17,19) One study showed 18 obese people who took Hoodia for 15 days consumed 1000 kcal daily less than the control group Study has never been replicated and never published in a peer reviewed journal Another study showed that overweight women who consumed mg of hoodia per day did not consume fewer kcal than the control group In 1977 the South African Counsel for Scientific and Industrial Research isolated the ingredient in Hoodia that is responsible for its appetite suppressant effects and named it P57. Although the exact mechanism is unknown, one study showed and increase in ATP production in the nerve cells of the hypothalmus occurred in rats who were inject with P57. These rats then consumed 40-60% fewer kcalories. There hasn’t been a lot of human studies done using Hoodia. One study showed that Hoodia consumption resulted in 1000 fewer kcal per day however, this study has never been duplicated nor has it been published and it was also funded by companies trying to market Hoodia so the results are questionable. Another human study that was published showed that the consumption of Hoodia did not have an effect on kcal consumption. Laweryson, Annie

Hoodia Typical dosage: 800 mg bid, 3000-4000 mg/d
Accessibility: Easy to get Natures Way: $ caps Source Naturals: $ capsules Used in teas, patches, capsules, etc. A “typical dose” of Hoodia has not been determined due to lack of research however, it is thought that theoretically 800 mg twice a day or total mg/ d is necessary to see effects. Hoodia is pretty easy to get, you can find it online or in a typical supplement store ranging from $13 to $30 or more. There were three different types at the Super Supplement store in Kenmore ranging from about 15$ to 30$. It is often used in combination with other weight loss substances and can come in a supplement, tea or patch form. Although, I havent found anything on the efficacy of things like a “Hoodia Patch”… Laweryson, Annie

Hoodia GMP’s Safety concerns Contraindications
No scientific standard for assessing quality of hoodia (16) Consumer Lab unable to perform desired testing Safety concerns More Hoodia is being sold than exists (16,17) Products may contain similar species to hoodia or no hoodia at all (16) Contraindications One study showed women receiving 1110 mg bid experienced side effects including nausea, vomiting, skin sensations, elevated BP, increased HR (16,19) As far as GMPs go, there are no standards for assessing Hoodia. Consumer Lab is unable to conduct product quality tests. There are many safety concerns regarding the use of Hoodia. The biggest one being that more Hoodia is sold than exists so you don’t know what you are getting. Most products contain no Hoodia despite being marketed as Hoodia and other products contain plants other than Hoodia. It is thought that plants closely related to Hoodia are used instead of Hoodia. One study showed that women who were taking Hoodia experienced side effects including nausea, vomiting, as well as elevated BP and HR. Although most people taking “Hoodia” don’t experience these symptoms there is still a concern due to lack of research and the possibility that they may occur. Laweryson, Annie

Hoodia Scope of practice Overall impression
Within scope to recommend supplements for weight loss however, would advise against recommending Hoodia Overall impression No real research that supports the use of Hoodia in supplemental form Possibilities? May have better weight loss properties if used similar to how San people use it It is within scope of practice to recommend supplements for weight loss, however, specifically concerning Hoodia, I would say that it is not within scope of practice just because of the fact that we know for sure that there is a question of the quality of the Hoodia supplement (is it even Hoodia and how can this effect my client?!?) as well as the huge lack of research and the possibility that there may be adverse or uncomfortable side effects. It seems like a bit of a reliability risk to me!! Perhaps with more research and/or the use of the actual Hoodia cactus (not just the P57… holistic use vs reductionist usage) there may be better results concerning weight loss, appetite suppressant,etc. Laweryson, Annie

Weight Loss Annie Laweryson
Raspberry Ketones It is within scope of practice to recommend supplements for weight loss, however, specifically concerning Hoodia, I would say that it is not within scope of practice just because of the fact that we know for sure that there is a question of the quality of the Hoodia supplement (is it even Hoodia and how can this effect my client?!?) as well as the huge lack of research and the possibility that there may be adverse or uncomfortable side effects. It seems like a bit of a reliability risk to me!! Perhaps with more research and/or the use of the actual Hoodia cactus (not just the P57… holistic use vs reductionist usage) there may be better results concerning weight loss, appetite suppressant,etc. Weight Loss Annie Laweryson

Raspberry Ketones 1995 Japanese scientist noticed RK are similar to Capsaicin and Synephrin (20, 21) Capsaicin- increased metabolism thus causing a reduction in adipose tissue and TG Synephrine- found in citrus fruits and exerts a lypolytic property on fat cells Food sources: phenolic compounds in raspberries cranberries, blackberries kiwi fruit Raspberry Ketones are a phenolic compound found in red fruit that is responsible for their aromatic properties. RK’s have been recognized by the FDA since In 1995 a Japanese scientist did a little more research and noticed that RK’s are similar to Capsaicin and Synephrin as you can see by the diagram of the molecules (point to screen  ). It is known that Capsaicin may increase metabolism and Synephrine has been found to have lypolytic properties. The thought is that combining these two into one molecule and you get lypolysis as well as elevated metabolism. RK’s are found in fruits such as raspberries, cranberries, as well as blackberries, and kiwi fruits. Laweryson, Annie

Raspberry Ketones Mechanism of action:
Antiobese action conducted during fat decomposition (20,21) RK at 1% and 2% have shown antiobese affects Reported that RK at 5% suppressed weight gain despite over consumption of fructose and glucose Lipolytic effects shown both in vivo & in vitro (20,21) Failed to stimulate lypolysis in the absence of norepinephrine According to the Natural Standard: “Raspberry ketone has been shown to increase fatty acid oxidation, stimulate adiponectin expression and secretion, and inhibit lipid accumulation... Raspberry ketone has been shown to reduce elevated levels of free fatty acids and leptin in high-fat diet-fed mice (11). In humans, raspberry ketone reduced both body weight and body fat (22). A purported mechanism of action includes stimulation of norepinephrine-mediated lipolysis” (taken directly from Natural Standard). Although this research is promising, there needs to be more conducted to further understand the exact mechanism of RKs. Laweryson, Annie

Raspberry Ketones Accessibility: Typical dosage: varies 100-500 mg
Nature Made: $ caps Bio Nutrition: caps Typical dosage: varies mg One study showed 100 mg RK taken 30 min prior to a high fat meal showed some evidence for reducing arteriosclerosis (22) 1-4 mg RK derived from 1 kg of red raspberries (22) RK are widely available through Supplement stores and online. I found them to be available from about $8 up to $40 or $50 depending on the product. At the Kenmore Super Supplements there were a few different options. You can also find RKs combined with other weight loss supplements. Not to be confused with Raspberry leaf!! A typical dose may vary. The studies conducted have used a 100 mg dose however Supplement doses range from mg, the most common being mg. There is no standard dosage, to get an idea of how many raspberries this would be: about 1 kg of raspberries yields 1-4 mg of RK. Laweryson, Annie

Raspberry Ketones GMP: No standardizations for testing RK (22)
Safety Concerns: GRAS, lack of research Contraindications (22): Use cautiously with antidiabetic agents, anti-inflammatory agents, antiobesity agents, certain cancers, cardiac dysrhythmia Insufficient evidence regarding use by children, pregnant or lactating women, allergies, hypersensitivity Possible DNI: Antiandrogens, anticoagulants, antidiabetics, anti- inflammatories, antilipemics, antineoplastics, antiobesity, CNS stimulants, dermatologic agents, heart rate-regulating agents, hepatoprotective agents, hormonal agents, warfarin There are no standardizations for RK and Consumer Lab hasn’t been able to do any product testing. I found different sources saying that they are on the GRAS list.. The Natural standard states: “Raspberry ketone is not on the U.S. Food and Drug Administration (FDA) Generally Recognized as Safe (GRAS) list. However, this omission may be due to the fact that the FDA GRAS list only itemizes products that were approved after According to secondary sources, raspberry ketone has in fact been on the FDA GRAS list since 1965.” There is a whole list of medications and agents that you need to be aware of (point to screen or read a few) so keep in mind what else is going on with your client if they want to use RK’s. Laweryson, Annie

Raspberry Ketones Scope of practice
Within scope to recommend supplements for weight loss Natural Standard grade C for weight loss Overall impressions Appears to be promising Fairly safe Lack of research As far as weight loss goes, I give it a yellow light. It appears to be safe for most people however, there is a long list of contraindications to be cautious of. The Natural Standard gave it a grade C for weight loss and there is a lack of research. Laweryson, Annie

Ergogenic Aid Rebecca Levens
Creatine Ergogenic Aid Rebecca Levens

Creatine Scientific name (30) Types N-amidinosarcosine
N-(aminoiminomethyl)-N methyl glycine. Types Creatine monohydrate (88%) (31) Creatine ethyl ester (86%) (31, 32, 33, 34) Creatine HCl (79%) (31) Dicreatine malate and tricreatine malate (70%) (31) Creatine ester phosphate (62%) (31) Creatine AKG (47.5%) (31, 35) Creatine is an organic acid that comes in a variety of forms. Each of these has differing amounts of free and usable creatine, which is important to note when choosing which form to purchase. The percentage of creatine in each of these forms is noted in the parenthesis (something people can reference later on). I am going to highlight as few aspects of these forms: Creatine monohydrate is the most commonly found form in supplements, and is also the most commonly researched. It has the highest amount of creatine with 88% and is considered the most effective at improving body composition and muscle mass. You can also find a patentent version of creatine monohydrate that is buffered, evidence suggests that this version is less effective than creatine monohydrate (consumer lab link) Creatine ethyl ester (86%) is a formulation of creatine which is more lipophillic, so is thought to have better absorption and bioaviaibitly, but studies show that it does not increase serum and muscle creatine as much as creatine monohydrate due to rapidly degrade in the stomach acid Creatine AKG is creatine attached to an alpha-ketoglutarate molecule, the thought is that this allows the creatine to enter the Krebs cycle more quickly, resulting in the creatine coming into one’s muscles more quickly. The effects of this are unproven. Since most of the research has been conducted on creatine monohydrate the information that follows focuses on this form of creatine. Rebecca Levens

Food Sources Food sources (30,36, 37) Red meat, poultry, and fish
350 mg per 3.5 ounce of red meat Only animal protein sources so may have additional effects for vegetarians Creatine is also naturally found in meat, poultry and fish. In red meat there is only 350 mg per 3.5 ounces in raw meat. Other animal proteins have similar amounts per serving. It should be noted that creatine is heat sensitive so a percentage of it is lost during cooking due to the denaturation process. So essentially, in order to gain athletic performance effects of creatine, food sources do not contain a reasonable amount, so it is beneficial to supplement with creatine. Rebecca Levens

Usage Usage (30) A- Athletic performance enhancement for muscle mass and muscle strength C- performance enhancement for cyclists, high intensity endurance, rowers, runners, sport specific, sprinters, swimmers Creatine has a variety of uses but for the purpose of this presentation we will focus on the ergogenic uses of creatine. In general creatine is use for athletic performance enhancement. In fact natural standard has rated it as an A for effectiveness in increasing muscle mass and muscle strength. Noe: Kelly said to make sure an highlight the fact that this got an A on Natural Standard, this is a big deal  Rebecca Levens

Mechanism of Action Synthesized in the body from dietary amino acids in liver, kidneys and pancreas (30, 37) This is in addition to what we get from food sources Gets stored in skeletal muscles as creatine phosphate (30, 37, 38) High energy substrate to create ATP Increased levels of creatine enhance the ability to regenerate ATP for short energy bursts Improved resynthesis of creatine phosphate during recovery As previously mentioned a small amount of creatine can be obtained from food sources, but primarily it is synthesized in the body from amino acids in the liver, kidneys and pancreas. The creatine will then get stored in the skeletal muscles as creatine phosphate. Creatine phosphate is a high energy substrate which is used to develop ATP. Essentially supplementing with creatine enhances the body natural ability to regenerate ATP for short energy bursts. These high levels of creatine will also result in improved resynthesize of creatine phosphate during recovery periods. Rebecca Levens

Dosage Orally (31) Start with a “loading” dose (30,37)
Powder Capsule Liquid Start with a “loading” dose (30,37) 15-20 grams of creatine per day for 5-14 days Followed a “maintenance” dose (30, 37) 2-5 grams of creatine per day. Results in gradual increase in creatine storage in muscles (30,37) Should occur within 2-4 weeks Mixed evidence of whether the loading dose is actually more beneficial than just taking a constant dose Cycling on and off is recommended (39) Creatine can be taken in the form of a powder, capsule or liquid. The powder can be mixed into water or is also frequently mixed with juice. This due to some evidence that suggests that creatine is better absorbed when consumed with a carbohydrate source. There is some mixed information as to the appropriate dosaging for optimal effects. Some evidence suggests that it is beneficial to start with a loading dose and then move to a maintenance phase. The loading dose consists of grams of creatine per day for 5-14 days. This dosage can be taken all at once or separated in 5 gram doses. The maintenance dose consists of 2-5 grams of creatine per day. (Note that a range of doses is listed since the size of the dosage depends on the size of the athlete). The goal of this process is to gradually increase the creatine storage in muscles. Other research states that taking a constant dose of creatine also produces a positive outcome. While evidence suggests that it is safe to consume creatine daily, sport dieticians often suggest alternating creatine dosing in a five-days-on, five-days-off cycle. This is because there is some evidence that the muscle tissue reaches its saturation of creatine after five days. Rebecca Levens

Safety Avoid with renal patients due to difficulty removing waste product creatinine (38) High doses of 20 grams/day long term may impact kidneys and cardiovascular system Little is known about the potential long terms effects, may impact renal function (38) Possible DNI with nephrotoxic drugs Can cause slight weight gain due to water retention (38) Some people may also experience muscle cramping, diarrhea, and dehydration (38) Caution with caffeine, may decrease effectiveness (38) Overall creatine is considered to be a safe product, when used in appropriate doses short term (1-5 years) . But it should be cautioned with renal patients as well as individuals drugs that may cause nephrotoxicity, such as NSAIDS. (Basically kidney = issues with creatine). Some side effects include weight grain from water retention as well as muscle cramping, diarrhea and dehydration. Another note is that the effectiveness of creatine may be decreased with caffeine consumption, since caffeine may inhibit phosphocreatine resynthesis. Rebecca Levens

Purchasing Creatine Be cautious when purchasing of liquid creatine (31) Creatine breaks down in water Powders and tablets are better Differing amounts of usable creatine (31) Monohydrate form has the most (88%) (31) Be mindful of proprietary blends that do not disclose the amount of creatine Excipients may include carbohydrates (31) Things to note on label: NSF certified for sport GMP Purity assured by HPLC When purchasing creatine, it is best to buy the powder or creatine form. Since creatine breaks down in water, the liquid form is not suggested. In fact on consumer lab, these products had significantly less creatine that what was on the label. As previously described, creatine monohydrate has the most usable free creatine and also has the most research to back it. Be mindful of proprietary blends (as with anything) since this does not disclose the amount of creatine. Some brands have more excipients than others, some form of carbohydrate is frequently seen due to the belief that taking creatine with carbohydrates in absorption. Evidence of a higher quality supplement can be noted by the label having a logo for NSF sport, that they follow GMPs, and the product has purity assured from high-performance liquid chromatography. Rebecca Levens

(yields 5 grams creatine monohydrate) 80 $18.99 $0.23 per serving
Brand Source Dosage Servings Cost Cost per month ALL Max Super Supplements 1 teaspoon (yields 5 grams creatine monohydrate) 80 $18.99 $0.23 per serving $11.27 Bioplex Nutrition Creatine 1 scoop (yields 7 grams creatine monohydrate) 65 $26.50 $0.40 per serving $14.00 Twin Labs 3 capsules (yields 2,100 mg creatine monohydrate) 20 $9.09 $0.45 per serving $49.00 Jarrow Formulas 1 capsule (yields 800 mg creatine monohydrate) 120 $9.07 $0.08 per serving $24.50 This is a table that breaks down the cost when using creatine monohydrate in powder or capsule form. Overall demonstrates that it is more cost effective to buy creatine in the powder form. The more expensive products seems to have the least amount of creatine Cost per month, includes loading dose of 20 grams/day for 1 week, 5 grams per day for the rest of the week. This would cost even less if someone decides to cycle on and off creatine. = 245 grams/month Rebecca Levens

(yields 5 grams creatine monohydrate) 80 $18.99 $0.23 per serving
Brand Source Dosage Servings Cost Cost per month ALL Max Super Supplements 1 teaspoon (yields 5 grams creatine monohydrate) 80 $18.99 $0.23 per serving $11.27 Axis Labs Creatine Ethyl Ester Supper Supplements 3 capsules (yields 2,250 mg creatine ethyl ester) 40 $24.95 $0.62 per serving $67.51 Now Foods 2 capsules (yields 1.5 grams buffered creatine monohydrate) 120 $49.99 $0.42 per serving $68.60 This table compares the different prices of the various forms of creatine. This is more evidence for the fact that creatine monohydrate is the most cost effective. Rebecca Levens

Overall Impression Within scope of practice, especially for sports dietician Green light When taken in appropriate doses for 1-5 years Effect of long-term, high doses of creatine has yet to be established Rebecca Levens

Ergogenic Aid Rebecca Levens
Beta Alanine Ergogenic Aid Rebecca Levens

Beta Alanine Scientific name Also called carnosine or CarnoSyn (40)
3 aminopropanoic acid (40) Also called carnosine or CarnoSyn (40) Food sources Naturally occurring beta amino acid (41) Poultry, beef, pork and fish (40) Usage Exercise performance enhancement (C) (41) Used for exercise that requires power and strength High intensity, anaerobic, strength training and weight lifting Goal is to increase time to exhaustion and improve muscular endurance Beta-alanine has the scientific name of 3 aminopropanoic acid. This supplement is also called carnosine or can be found with the name CarnoSyn. CarnoSyn is the patented form of beta-alanine. Beta-alanine is a non-essential amino acid so is naturally found in the body. Beta alanine is also present in poultry, beef, pork and fish. In these foods a small amount of the beta-alanine is found in it’s free form, most of it is found in a dipeptide, primarily the dipeptide carnosine which is made up of beta-alanine and histidine. You are only able to get a small amount of beta-alanine from food. For instance there is a range of mg of carnosine in ~4 ounces of a meat product. This supplement is primarily used for exercise performance and enhancement, with the goal of increasing time to exhausting and improving muscular endurance in high intensity anaerobic exercises. \ As an aside, it seems that evidence suggests that taking a carnosine supplement is not as effective. The carnosine gets broken down into beta-alanine and histidine and will then be put back together, so essentially it saves a step. Plus it is imperative to have the enzyme that breaks down carnosine functioning properly in order to get the beta-alanine. Beta-alanine is the rate limiting component in all of this (there is decreased activity of this enzyme in vegetarians). Rebecca Levens

Mechanism of Action Works to increase the carnosine levels in the fibers of all types of muscles Increases buffer to decrease effects of pH changes from lactic acid production (40,41) Results in decreased fatigue and increased power (40) Note that carnosine levels can be increased with training alone (41) Beta-alanine works to increase the levels of carnosine in the muscle fibers since beta alanine is a precursor to carnosine (beta alanine + histidine = carnosine). Carnosine is important since it acts as buffering agent to the hydrogen ions the are produced during high intensity exercise. Typically this drop in pH is what causes muscle fatigue so with increased carnosine levels there is decreased muscular fatigue and increased power. Rebecca Levens

Dosage and Safety Orally (40,41) Capsule Powder
There is some variation in the research for dosage 2.4 – 6.4 grams/day (41) 4.8 grams/day for 30 days (40) Increase dosage for 8 weeks starting with 2 grams/day and gradually increasing to 4 grams/day (40) Greater than mg/kg body weight may cause parasthesia (40) Caution with allergy (40) No known interactions with drugs, herbs or food (40) Little information for pregnant and lactating women (40) Beta-alanine can be taken in capsule or powder form. There is some variation in the research regarding the appropriate dosage. Some studies discuss gradually increasing the amount of beta-alanine over the course of 8 weeks, while others suggest a steady dose for a period of time. One of the most common side effects noted was parasthesia, but this was only found in high dosages. As always caution with allergy. Otherwise there are no known interactions with drugs, hers or food and there is little information for pregnant and lactating women, so would not be advisable to recommend to this population. Rebecca Levens

Purchasing Beta Alanine
There is no standardization (41) Can find a variety of excipients/added ingredients NSF certified for sport Easily accessible Online Super Supplements It should be noted that there is no information about beta alanine on consumer labs. Additionally there is no standardization of this product. Although finding a product that is NSF certified for sport is a good certification for ergogenic aids. Most of the beta alanine on the market is in patented form of carnosyn, which is a company that is NSF certified. This is a product that can be found easily online as well as at stores such as super supplements. Rebecca Levens

Brand Source Dosage # Servings Cost Now Foods Supper Supplements
3 capsules (2.5 grams beta-alanine) 40 $29.99 $0.75 per serving ALL Max Nutrition 1 teaspoon (3.2 grams beta-alanine) 31 $18.99 Here is a table that shows some of the brands of beta-alanine, depending on the dosage, an individual will likely be using more than one serving of beta alanine each day, so using the powder is likely a more economical choice. NOW foods states quality GMP assured on the label and used the CarnoSyn form of beta alanine, some excipients in this brand. ALL Max Nutrition is pharmaceutical grade, also used CarnoSyn, mentions GMPs on the label, and no excipients The other beta alanine supplements found at super supplements were combination formulas. As an aside it was difficult to figure out exactly what the patent included, may include other things like carbohydrates, L-histidine, insulin and creatine. Rebecca Levens

Overall Impression Within scope of practice for sports dietician
Yellow light (natural standard) GRAS Possibly safe with appropriate short term use Additional research is necessary due to varied results Overall this is supplement that as nutritionists we can recommend, especially as a certified sports dietician. Overall yellow light since more research needs to be conducted using human trials, especially for long term effects but it is considered GRAS. Just caution with too high of doses. Rebecca Levens

Synergy of Supplements
Mixed evidence (42,43) Some suggests increased benefit of supplementing with both creatine and beta-alanine due the supplements acting differently in one’s body Others note no difference with stacking of supplements Can easily find supplements that contain multiple ergogenic aids As previously noted, creatine works in the body to build muscle strength in order to help with initial explosive movements, while beta-alanine delays muscle fatigue, which helps support these explosive movement. Additionally there was a study conducted on experienced weight trainers which demonstrated that creatine plus beta-alanine supplementation appeared to have the greatest effect on lean tissue accruement and body fat composition. Although another studied illustrated no additive effects of creatine used with beta-alanine in untrained men. Common to find supplements that contain multiple ergogenic aids Rebecca Levens

Ergogenic Aid Erin Prasad
Arginine Ergogenic Aid Erin Prasad

Arginine Scientific name: 2-amino-5-guanidinopentanoic acid
Common name: L-arginine Conditionally essential amino acid first isolated in 1886 Food sources: Nuts (brazil, almonds, cashews) Seeds (sesame, sunflower) Whole grains (oats, barley, buckwheat) Poultry Red meat Dairy products Functions in the body: cell division, wound healing, removing ammonia from body, immune function, release of hormones, lean body mass, blood sugar regulation. L-arginine-the stereoisomer form found in supplements Conditionally essential-can almost always be made in the human body, except for rare genetic disorders or medical conditions requiring dietary sources. 1 cup diced chicken breast contains 2.2 grams arginine 44, 45 Erin Prasad

Arginine Typically used for conditions such as:
CHF, Intermittent claudication, angina, impotence, sexual dysfunction in women, wasting syndrome in AIDS decreased inflammation in infants, improved wound healing, faster recover after surgery And as and ERGOGENIC AID in increased exercise endurance and body building. Dosage: No upper intake established Supplemental: 2-8g/d CHF: 6-20g/d, Angina: 3-6g/d Infants: 261mg/kg for first 28 days of life Mechanism of Action: L-arginine is a substrate for nitric oxide synthase therefore necessary for the formation of nitric oxide Nitric oxide is a vasodialator and contributes to increased blood flow Proposed theory: Increased blood flow to the tissues=increased O2 to muscles= Improved athletic performance. Dosage : studies to follow used 6g/d, not really established Mechanism of action for protein synthesis: as a building block of protein, it plays an important role in body composition, LBM, BS reg, and immune fxn. Also stimulates insulin and growth hormone, promoting uptake of amino acids into a cell for protein synthesis. 44, 45, 46, 49 Erin Prasad

Arginine Efficacy as an Ergogenic Aid Safety: GMPs:
Study 1 (2014): Runners-No significant change in running time. “…L-arginine supplementation did not cause beneficial changes in metabolic and hormonal parameters beyond those achieved with exercise alone.” Study 2 (2012): Strength trainers did not show increase in their strength resistance exercise performance. “It is still premature to recommend nutrition supplements containing L-arginine as an ergogenic aid” Safety: Considered safe in doses up to 20g/d Adverse reactions: Capsule- abdominal pain, bloating, diarrhea, gout, airway inflammation (asthma) IV: urticaria, periorbital edema, pruritis Interactions with medications: Caution with anti-hypertensive drugs or nitrates: blood pressure can drop too low GMPs: All of the L-arginine containing supplements that Consumer Lab selected for review passed. Received a C rating from Natural Standard, unclear scientific evidence. “Despite common use by athletes, the effect of arginine for exercise performance enhancement has not been studied extensively. Well designed studies investigating arginine alone are needed before conclusion can be made. In a January 2014 study, when runners were supplemented with 6g/day of L-arginine for 4 weeks, there was no significant change in total running time. In a February 2012 study, strength trainers were supplemented with 6g of either L-arginine or placebo and had bicep strength test and blood draws at 30, 60, 90, and 120 minutes. Although the supplemented group did have an increased muscle blood volume, they did not show any increase in their strength resistance exercise performance. Safety: Parenteral L-arginine is an FDA approved prescription product. When higher than recommended doses have been used in children, hypersensitivity reactions have occurred and death (6 cases) Additional GMP info: all supplements containing L-arginine sold at Super Supplements uses third party certification 46, 47, 48 Erin Prasad

What to look for when buying
Arginine What to look for when buying Accessibility: L-arginine can be found at any supplement store (AA Section), online, or at drug/grocery store Price range: $9.50 (100 capsules)-$31.99 (1lb) Forms: 500mg or 1000mg tablets or capsules Powder (free form): 1/2tsp contains 1500mg Dosing Instructions: Varies from brand to brand but all fall within recommended dose of 2-8g/d. Excipients: gelatin, magnesium, stearate, and silica Extras: L-arginine is in the form of hydrochloride and often combined with an ornithine or citrulline complex to “support protein synthesis” or “support peak performance” Extras: (From consumer lab)The hydrochloride portion makes up about 17% of the weight of this molecule. Some products include this in the listed amount of L-arginine and some do not. It is important to know how much of the “free” L-arginine you are getting. Regardless of what the front label says, if the ingredients list in the Supplement Facts area on the back label says L-arginine HCl, you need to deduct 17% to determin the amount of actual free L-arginine. Not sure why this combo exists since these interconvert in the urea cycle. May be for those really low on AA? Really necessary? Erin Prasad

Overall Impressions and Recommendations
Arginine Overall Impressions and Recommendations Scope of Practice: Safe and relevant for a RDN to suggest for someone who may be in periods of growth, recovering from surgery or a wound, and lacking dietary sources. Coordination of care with physician should be considered, and necessary in the case of children. Relatively safe Exceptions: When combined with blood pressure meds or nitrates Large doses in infants Yet, it has not been proven effective as an ergogenic aid Something to consider in sports nutrition: If an athlete is getting a placebo effect from an ergogenic aid, unless it is unsafe, there is no reason to ask them to stop taking it. Especially if they truly believe it’s improving their performance. (per Dr. Harris) Erin Prasad

Overall Recommendations
Green Light PGX Creatine Yellow Light Conjugated Linoleic Acid Raspberry Ketones Beta-alanine L-arginine Red Light Epherdra Hoodia Raspberry ketones, hoodia????

References 1, Consumer Labs: Review of CLA (Conjugated Linoleic Acid) Supplements for slimming. eic_Acid_for_Slimming/CLA/. Accessed 2/4/2014. 2. Natural Standard: Conjugated Linoleic Acid (CLA) professional monograph. conjugatedlinoleicacid.asp?. Accessed 2/4/2014. 3. Natural Methods Comprehensive Database: Conjugated Linoleic Acid Accessed 2/4/2014. 4. Kennedy et al. Antiobesity mechanism action of conjugated linoleic acid. Journal of Nutrition and Biochemistry, 2010; 21 (3): 5. Chen SC et al. Effect of conjugated linoleic acid supplementation on weight loss and body fat composition in a Chinese population. Nutrition, 2012; 28(5): 6. Racine NM et al. Effect of conjugated linoleic acid on body fat accretion in overweight and obese children. American Journal of Clinical Nutrition, 2010; 91: 7. Onakpoyaa IJ et al. The efficacy of long-term conjugated linoleic acid (CLA) supplementation on body composition in overweight and obese individuals: a systematic review and meta-analysis of randomized clinical trials. European Journal of Nutrition (systematic review); 51 (20):

Need to be 8 -15

Need to be 16-22

23. Hoodia. Consumer Lab. Website. Update: September 21, Accessed: February, 2014. 24. Hoodia. Natural Standard. Website. Updated: Accessed: February, 2014. 25. Vermaack, Ilze, Hamman, Josias, Vijoen, Alvaro. Hoodia gordonii: An up-to-date review of a commercially important anti-obesity plant. Planta Med. 77 (2011): 26. Blom, W. A., S. L. Abrahamse, R. Bradford, G. S. Duchateau, W. Theis, A. Orsi, C. L. Ward, and D. J. Mela. "Effects Of 15-d Repeated Consumption Of Hoodia Gordonii Purified Extract On Safety, Ad Libitum Energy Intake, And Body Weight In Healthy, Overweight Women: A Randomized Controlled Trial." American Journal of Clinical Nutrition 94.5 (2011): 27. Morimoto, C., Satoh, Y., Hara, M., Inoue, S., Tsujita, T., and Okuda, H. Anti-obese action of raspberry ketone. Life Sci ;77(2): 28.Ushiki, M., Ikemoto, T., and Sato, Y. Anti-obese activities of raspberry ketone. Aroma Research 2002;3(4):361. 29. Raspberry Ketones. Natural Standard Web Site. Updated Accessed February, 2014.

30. Creatine. Natural Standard Website. http://naturaldatabase
30. Creatine. Natural Standard Website &id=873&ds=mechanism&name=CREATINE&searchid= Accessed February 4, 2014. 31. Product Review: Muscle Enhancers (Creatine and Branched-chain Amino Acids). ConsumerLab.com Creatine_HMB_Gluatamine_and_BCAAs/creatine/. Accessed February 5, 2014. 32. Giese MW, Lecher CS. Non-enzymatic cyclization of creatine ethyl ester to creatinine. BBRC ;388(2): 33. Spillane M, Schoch R, Cooke M, Harvey T, Greenwood M. The effects of creatine ethyl ester supplementation combined with heave resistance training on body composition, muscle performance, and serum and muscle creatine levels. JISSN. 2009;6:6-15. 34. Incledon T, Kreider RB. Creatine alpha-ketoglutarate is experimentally unproven. J Sports Med Phys Fitness l40(3): 35. Williams P. Nutritional composition of red meat. Nutrition & Dietetics. 2007;64:S113-S119. 36. Which foods contain creatine. Creapure Website. does-creapure-work/which-foods-contains-creatine. Accessed February 19, 2014. 37. Creatine. Natural Medicines Comprehensive Database Website. chid= Accessed February 4, 2014. 38. Jarrow Formulas Creatine Monohydrate Powder. Pharmaca Website oz/468401/ /Product. Accessed February 6, 2014. 39. Benardot D. Advanced Sports Nutrition. Champaign, Ill: Human Kinetics;2011

40. Beta-alanine. Natural Medicines Comprehensive Database Website. Accessed February 4, 2014. 41. Beta-alanine. Natural Standard Website. Accessed February 3, 2014. 42. Stout JR, Cramer JT, Mielke M, O’Kroy J, Torok DJ, et al. Effects of twenty-eight days of beta-alanine and creatine monohydrate supplementation on the physical working capacity at neuromuscular fatigue threshold. J Strength Cond Res. 2006;20(4): 43. Hoffman J, Ratamess N, Kang J, Mangine G, Faigenbaum A. Effect of creatine and beta-alanine supplementation on performance and endocrine responses in strength/power athletes. Int J Sports Exercr Met. 2006;16(4):

44. L-arginine Supplements Review
asp. Accessed 2/3/2014. 45. Review of L-arginine Supplements, Consumer lab review/arginine/. Accessed 2/3/2014. 46. L-arginine monograph: Natural medicines comprehensive database Accessed 2/4/14. 47 Alvares TS, Conte-Junior CA, Silva JT, Paschoalin VMF, L-arginine does not improve biochemical and hormonal response in trained runners after 4 weeks supplementation. Nutrition Research, 2013; 34 (1): 48. Alvares TS et al, Acute L-arginine supplementation increases muscle blood volume but not strength performance. Applied Physiology, Nutrition, and Metabolism ; 37(1): 49. Alvares et al, Acute L-arginine supplementation does not increase nitric oxide production in healthy subjects. Nutrition and Metabolism, 2012; 9 (54).

Weight Loss and Ergogenic Aids

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