Dietary Supplement Use in the Military Evaluating Claims and

Dietary Supplement Use in the Military: Evaluating Claims and Making Informed Decisions MAJ Sue Love, PA-C Acting Director, U.S. Army-Baylor Emergency Medicine PA Doctoral Program Learning Objectives Define supplement Discuss multiple supplements and potential side effects Discuss the prevalence of supplement use in the military population Discuss alternate choices to supplement use and the DOD policy on supplement use Discuss credible published and online sources of dietary supplement education A Dietary Supplement is... a tablet, capsule, powder, soft-gel, or liquid product that contains at least one of the following: Vitamin Herb or botanical Mineral Amino acid A concentrate, metabolite, constituent, or extract of any of the above The Law Dietary Supplement Health and Education Act (DSHEA): 1994 Dietary supplements are NOT regulated like food and drugs Manufacturers are free to market supplements without proof of safety or efficacy No FDA approval necessary to sell No established dosage guidelines No purity restrictions Some supplements have been shown to be contaminated with street drugs Do YOU Need a Dietary Supplement? When You May Need a Dietary Supplement You eat a very low-calorie diet You eat an all-plant diet (vegan) You are in a certain stage of the life cycle (e.g., a pregnant, breastfeeding or childbearing-age woman) Your doctor may prescribe a supplement for you if: You have a disease, infection, or injury or recently had surgery You have a nutritional deficiency You are taking medications that interfere with your body’s use of specific nutrients Are service members using dietary supplements? What dietary supplements are service members using? Frequency of Use - Marines 100 90 80 70 60 50 40 30 20 10 0 25 9 21 23 20 None <1/week 1/week 1/day >1/day Note: Excludes Electrolyte/CHO Replacements Ref: 1MARDIV Survey, Camp Pendleton, 2000 % Reported Daily Use- Marines 25 20 15 10 5 0 ec tro /C HO Pr ot ei n/ AA e he dr a fe in e g G in se n Cr ea tin M VI El Ref : 1MARDIV Survey, Camp Pendleton, 2000 Ep Ca f Prevalence of Use – Military Divers Top 10 Supplements n=139 1. Multivitamin 2. Vitamin C 6. Sports Bars 7. Protein 3. Caffeine 4. Multimineral 8. Potassium 9. Vitamin E 5. Calcium 10. Sports Drinks Top Vitamin & Minerals Consumed n-1567 Multi-Vitamin Vitamin C Calcium Vitamin E Iron Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis Top Herbal Supplements Consumed Ginseng Garlic Ginkgo biloba Echinacea Guarana Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis Top Performance Enhancers Consumed Among Men Creatine Ephedra Among Women Creatine Amino Acids Amino Acids Glucosamine Androstenedione Ephedra Glucosamine HMB Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis Why do Soldiers consume dietary supplements? Promote General Health Performance Enhancement Prevent Illness Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis Promises, Promises “Naturally speed up metabolism” and “Burn fat” (Weight Loss Aids) “Builds muscle mass” (Ergogenic Aids) “Delays fatigue” and “Increases energy” (Performance Enhancers) “Prevents disease” (Vitamins, Minerals, and Herbs) Athletes and Supplements “More than 50% of elite athletes stated they would be willing to take a substance that would guarantee them an Olympic gold medal, even if they knew that taking the substance would be fatal in a year.” Dr. Robert Voy, a former physician for the U.S. Olympic cited an informal study – The Ergogenics Edge Mel Williams Why the concern?? Adverse events Military unique risks Lack of regulation by FDA (DSHEA 1994) Contamination Possible Side Effects of Supplement Use Dehydration Heat-Related Injuries Nervousness and Dizziness Changes in Blood Pressure and Heart Rate Heart Attack Possible Side Effects of Supplement Use (con’t.) Strokes Seizures Psychosis Death Interaction with medications Positive drug tests due to contaminated supplement Frequency of Adverse Effects Dehydration Palpitations Abdominal Pain 40% 24% 15% Dizziness or Confusion Numbness of Extremities 13% 2% Tremors 2% Source: MAJ S Corum, MBA, RD: Dietary Supplement Consumption in Active Duty Enlisted European Population, Feb-Nov 2003. Note: Preliminary Data Analysis Test Time! Dietary supplements are bad and don’t work. T F DOD has a strict policy regarding dietary supplement use. T F A high percent of service members obtain supplement information from health care providers. T F Proper dietary practices can yield an ergogenic effect. T F I know where to refer my patients to reputable dietary supplement education resources. T F Test Results!! Dietary supplements are bad and don’t work. Test Results!! DOD has a strict policy regarding dietary supplement use. Test Results!! A high percent of service members obtain supplement information from health care providers. Test Results!! Proper dietary practices can yield an ergogenic effect. Test Results!! I know where to refer my patients to reputable dietary supplement education resources. Documented Ergogenic Effect Use of this substance has been shown to be beneficial with a wide margin of safety Creatine A nitrogenous compound synthesized by Arg, Gly, Met Claims Maintains ATP levels during exercise Extends performance in repetitive bouts of short duration, high intensity exercise Enhance muscle gains Reality Helps to maintain ATP levels Improves high intensity, repetitive exercise performance Enhance gains in muscle fiber volume Diarrhea, nausea Kidney problems β-HMB A metabolite of BCAA leucine (amino acid) Claims Builds muscle Prevents breakdown of lean tissue during sustained endurance events or extended periods of inactivity Reality May reduce muscle breakdown 1.5 - 3.0 g/d X 3weeks increased muscle mass & strength and minimized exercise induced muscle damage Sports Drinks Glucose Electrolyte Solution (GES) (During) Claims Drinking during exercise allows for greater exercise duration before muscles fatigue Reality Glycogen stores likely depleted in 2-4 hours Feeding 50-100 g/hr may extend this by 50% 6-8% concentration q 15-20 min extends endurance in ex> 60 min Williams C.Proc Nutr Soc 57: 1-8 1998 Coyle, EF Am J Clin Nutr 61: 968S-979S, 1995 Carbohydrate (Before) Claims Primary fuel source for anaerobic and high intensity aerobic workouts Reality Replenishes stores used during exercise 55-65% daily calories Quick energy source Carbohydrate/Protein Post-Exercise Claims Enhances glycogen re-synthesis and protein uptake Improves muscle building after exercise Reality Right mix may aid in recovery 1.5:1 to 4:1 Ingested within 60 minutes after exercise Helps with tissue recovery Tarnopolsky MA et al. J Appl Physiol, 83: 1877-1883, 1997. Protein Claims Promotes muscle weight gain Reality Make and repair muscle tissue Forms antibodies which protects against bacteria and viruses 1.5-2.0g/kg/day Water Claims Prevents dehydration Improves aerobic and work capacity Thermoregulation Reality ALL TRUE Performance decrements with > 2% dehydration Best if exercising <60 min Replace appropriately Water For each 1% drop in weight due to dehydration: HR increases 4 beats/minute Core temp increases 0.15 degrees Mean sweat rate decreases by 29 grams/hour Drink ~1 liter for q 2.2# lost Sawka, MN et al. J Appl Physiol 59:1394-401. (1985) Proceed with Caution CAUTION ! Caffeine A central nervous system stimulant Claims Promotes use of free fatty acids by muscle Spares muscle glycogen and extends endurance capacity Increases mental alertness Delays fatigue Doherty, M Int J Sport Nutr 8: 95-104 1998 Reality Short term effects 3-6 mg/kg 1 hour improves aerobic and anaerobic 18% improvement in exercise time at 100% VO2 max Increase UO Increase heart rate CAUTION ! Ginseng Medicinal root from the Araliacae plant family Claims Provides a stimulant effect that enhances athletic performance Relieves stress Improves aerobic capacity Bahrke MS Sports Med 29: 113-33 2000. Reality Insufficient evidence to support effect on athletic performance 1-8 weeks no effect on aerobic performance Not for long-term use >4g/kg nervous, HTN CAUTION ! Comfrey Claims Heal wounds Mend broken bones Improve respiratory symptoms Reality May cause liver toxicity if ingested Not recommended for internal use or use on broken skin Still used by many for bruises, scrapes, sprains, etc. CAUTION ! No Proven Benefit Androstenedione A natural occurring hormone Claims Increases muscle mass and strength Reality Studies do not support claims Wallace (1999) no improvement in strength or muscle gain 200 mg/d no effect Decreases body fat Liver CA Rassmussen BB. Androstenedione does not stimulate muscle protein anabolism in young healthy men. JCEM 2000 Raise testosterone levels Yohimbine A chemical compound from the bark of the Yohimbe tree Claims Increases muscle mass Boosts testosterone levels Natural aphrodisiac Promotes weight loss Increases energy levels Relieves depression Reality No well-controlled research exists to substantiate claims as ergogenic, anabolic or thermogenic aid DNE 40mg/d Anxiety, increase HR and BP, kidney failure Dangerous Bitter Orange/Synephrine Derived from fruit of a citrus aurantium plant Claims Increases metabolic rate Reality No credible research or scientific results have supported claims May raise blood pressure Burns fat Promotes weight loss Increases energy levels Dehydroepiandrosterone (DHEA) A naturally occurring hormone Claims Slows aging Improves memory Stimulates libido Reality Appears to be beneficial in persons older than 55 years No anabolic benefit in young adults More research is needed Alleviates depression Boosts energy Promotes weight loss Builds muscle mass/increases strength Wallace MB MSSE, 1999; Corrigan Med J Aus 1999 Strong Theoretical Rationale Vitamins Vitamin A Vitamin C Vitamin E Branched Chain Amino Acids Leucine, Isoleucine, Valine Claims Prevents fatigue Prolongs endurance Reality Scientific data limited Low BCAA levels linked with fatigue and muscle wasting Sufficient quantities can be achieved through balanced diet Prevents losses in lean body mass Omega Fatty Acids Found in fish and certain plant sources Claims Increases growth hormone Reduces blood clotting Reduces blood pressure Suppresses inflammation Protects the heart Reality Appears to protect the heart by changing characteristics of blood clotting Thought to increase blood circulation and enhance oxygen delivery Regular consumption of fish has been linked with a reduction of heart attacks No data to support ergogenic benefit Glutamine The most abundant free amino acid Claims Reality Enhances immune function Decreases risk of infection Enhances recovery after long endurance events Evidence supporting use in athletes is not well substantiated Beneficial effects are well documented in aiding recovery of hospitalized patients Use to prevent upper respiratory tract infections after strenuous exercise has not been demonstrated Not worth your money Medium Chain Triglycerides Gamma Oryzanol Choline Smilax Officianalis Inosine Dangerous Ephedra Also known as Ma Huang, Ephedrine and Yellow Horse Claims Raises metabolism Aids in weight loss Enhances athletic performance Improves alertness Reality RAND reviewed 550 articles 20 met criteria >8wks, control Not well supported as ergogenic aid 1-3# > wt loss vs. control No post intervention Ephedra Also known as Ma Huang, Ephedrine and Yellow Horse Irritability, anxiety, insomnia, N/V, palpitations, tachicardia, HTN, headache In all reports 84 deaths, 26 MI, 56 CVA, 30 “other” cardiac events Removed from NEX, AAFES,MCX Gammhydroxybutyric Acid Gammabutyrolactone Butadione Claims Increases growth hormone levels Reality Banned by FDA in 1990 Induces muscle relaxation Promotes muscle recovery No studies have ever shown GHB to positively change body fat levels, muscle mass or strength DEATH Chaparral Claims Treatment of arthritis Anti-cancer agent Analgesic Reality Liver toxicity Liver transplants required in 2 patients Not recommended due to its toxicity Wallace MB MSSE, 1999; Corrigan Med J Aus 1999 ?? Supplements cannot replace meals! Getting Power Performance Talk to a registered dietitian Eat meals and snacks before and after performance to refuel your muscles Use whole foods: fruits, vegetables, starches, and dairy foods to fuel your body Getting Power Performance (cont) Carbohydrates are the best source of energy Target sports diet = 60% carbohydrate To increase muscle, focus on extra strength training with adequate protein Research shows athletes do NOT need more vitamins/minerals than non-athletes. Choose Food Instead of Supplements Food Fun Offers variety Doesn’t have to be expensive Supplements Boring Lacks variety Can cost a lot of money Doesn’t contain other health benefits Can be dangerous to your health Contains other healthful substances Safe Guidelines for Using Supplements Get objective information from a professional such as a Registered Dietitian, Nurse, or Doctor Obtain your health care provider’s approval Read the label carefully Do not exceed dosage recommendations Discontinue use if you experience adverse side effects and report these to the FDA Guidelines for Using Supplements (con’t.) Purchase supplements from reliable producers Be aware of sensational claims Do not take supplements if you are pregnant, breastfeeding, or taking prescription medications What is the DoD Policy?? Personal Responsibility Program Aviator DoD Drug and Alcohol Program EDUCATION!! Force Health Protection What keeps the warfighter deployable? Heat Injury Prevention Immunizations Weight management/maintenance Physical Fitness Dietary supplement education Dietary Supplement Awareness/Education Resources PPNC – Dietary Supplements Materials Now Available NEHC Webpage http://www-nehc.med.navy.mil/hp/nutrit/index.htm Web Resources USACHPPM (http://chppm-www.apgea. army.mil/dhpw/Wellness/dietary.aspx) NEHC http://www-nehc.med.navy.mil/ hp/nutrit/index.htm The International Society of Sports Nutrition (www.sportsnutritionsociety.org) Supplement Watch (www.supplementwatch.com) American College of Sports Medicine (www.acsm.org) Conclusion Safety and efficacy of herbal and other dietary supplements Side effects associated with supplement use DOD policy on supplement use Online sources of dietary supplement education QUESTIONS???