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Supplements.............................
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- 2. What are supplements? •Categories • Vitamin/mineral • Botanical/herbals • Amino acid/Performance • Enzyme supplements BLUF: Any substance to enhance your dietary intake that is NOT considered a food.
- 3. • Between 2007and 2010, supplement use increased. • 50% of US adults have used a supplement in the past month, more common in women Men Women Men Women Men Women Men Women Navy Spec Ops Army Rangers Army Special Forces Navy Marine Corp 0% 10% 20% 30% 40% 50% 60% 70% 80% 55% 65% 60% 71% 60% 76% 61% 71% 76% 18% 29% 27% 36% 25% 40% 24% 33% 37% Supplement use in the Military Vitamin/Mineral Supplement
- 5. Dietary Supplements AndThe Law • Dietary Suppl. Health and Education Act (DSHEA): 1994 • Dietary supplements are NOT regulated or tested like drugs • Manufacturers are free to market supplements without proof of efficacy (varying data) or safety. • Only 0.3% of the 55,000+ dietary supplements have been studied regarding side effects. • No FDA approval needed to sell • No purity restrictions • Some supplements have been shown to be contaminated with street drugs or may have extra/less than what is on the label. • 2015: Only 20% of herbal supplements contained the ingredient on the label. • 2008: Certain flavors of Total Body Formula and Total Body Mega Formula contained dangerous levels of Selenium and chromium (17x recommended dose)
- 6. 2007: New FDARules • Musts be properly labeled • Manufactured according to specified standards • Product controls and appropriate documentation • Manufacturers specify the quality criteria they follow
- 7. Safety • Biggest concernis liver disease • Other side effects • Rhabdomyolysis • Heat Stroke • Kidney Damage • Heart disease (palpitations, heart attack, stroke) • Bleeding • Gynecomastia • Muscle cramps • Stacking causes more side effects 2004 2012 Dietary/Herbal 7% 20% Body Building Supplements 2% 7% Other Supplements 5% 12%
- 8. Dietary Supplements • Wheyprotein (amino acids) • Creatine • Energy boosters • Nitric oxide producers • Testosterone “boosters” • Plant extracts • Vitamins
- 10. Whey Protein • Similarprotein to milk • Contains all amino acids • Reported benefits • Increase muscle mass, strength, power • Does not help for endurance/long aerobic events • Side effects • Nausea • Bloating • Cramps
- 11. Creatine • Converted intoinitial energy source for muscle • May increase in blood flow and muscle size • Increased strength, power spring performance (short burst of high intensity exercise), muscle mass • May have some benefit in “high” responders (ie vegetarians) • No difference between types of creatine • Increase in muscle size is related to water retention • Caution • Muscle Cramps • Dehydration Kidney damage DRINK WATER
- 12. Nitric Oxide Producers •NO dilates blood vessels • Increases power and recovery • Research: no data • But only lasts seconds • Little data to support claims of increased performance
- 13. Testosterone “Boosters” • Manydifferent kinds, acting on different pathway of testosterone metabolism • Contains various herbal supplements, may include Yohimbine or Saw Palmetto • May have undeclared drugs (anabolic steroids, SARMs, aromatase inhibitors) • Thought to decrease muscle damage • Side effects • Weight gain • Long term problems of high testosterone (heart disease, heart attacks) • Gynecomastia • Hormone imbalances/mood changes
- 14. SARMs • Unapproved, experimental •Marketed as “research only” or “legal steroids” or “steroid alternative” • Cannot be used in sporting competitions • May cause positive UA for use of anabolic steroids
- 15. Caffeine • Recommended daily intake400 mg per day
- 16. Vitamins & Herbals Thereis conflicting data on safety and efficacy.
- 17. Saw Palmetto •Used toprevent prostate cancer, but no data/support •Side effects include dizziness, nausea, vomitting Yohimbe Bark • Used as aphrodisiac and for erectile dysfunction • May help blood flow; stimulant • AVOID in children, pregnancy • DANGEROUS in large doses or prolonged period of time palpitations, high blood pressure
- 18. Ginkgo •May benefit memoryand blood flow •Caution: • Seed flesh is poisonous • Causes seizures, fainting • Can cause bleeding Ginseng •May help memory, fatigue •Caution: • Can cause bleeding • high blood pressure
- 19. Ephedra (Ma Huang) •Used as appetite suppressant, increase energy, weight loss, but there is no data/support • Caused heart palpitations, strokes, liver injury • Banned 2004 by FDA Kava • Used for anxiety and fatigue •BANNED in Switzerland, Germany, Canada – FDA “warning” in US •BEWARE LIVER FAILURE
- 20. Vitamin A Recommended DailyIntake: 600 mcg daily Toxic Dose: >9000 mg daily Symptoms • Nausea, vomiting, irritability, blurry vision, altered mental status • Muscle weakness, seizures, bone fractures, high cholesterol, joint pains
- 21. Vitamin B Vitamin B-1Rec. Intake: 1.5 mg Vitamin B-2 Rec. Intake: 1.7 mg Vitamin B-3 Rec. Intake: 20 mg Vitamin B-6 Rec. Intake: 1.3 mg Vitamin B-12 Rec. Intake: 2.4 mcg Toxicity • Fast heart rate, low blood pressure/fainting, heart rhythm problems, weakness, flushing, wheezing, headache, diarrhea, vomiting, paralysis, difficulty walking, nerve symptoms • Chronic toxicity: liver damage
- 22. Vitamin C Rec. Intake:Male 90 mg, Female 75 mg per day Toxicity • Kidney stones • Diarrhea, nausea • Teeth de-calcification (enamel breaks down) Vitamin D Rec. Intake: 600 IU daily Toxicity • Muscle weakness , weight loss, headache, nausea, vomiting, irritable • Constipation, back pain, high blood pressure, palpitations
- 23. Vitamin E Recommended dose:15 mg per day (short term of high doses 1000 mg per day for less than a week, ok) Toxicity • Nausea, stomach upset and cramping, diarrhea • Significant Bruising/bleeding • Muscle weakness
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- 29. Military Readiness Impact •Heat injuries limit deployability • Rhabdomyolysis is a cause for MEB referral • Many stimulants also cause volume depletion • Decreased stamina • Use of testosterone boosters may contribute to aggressive behaviors • Some supplements have street drugs • Positive drug tests • Altered mental status (DMAA)
- 30. Should I continueto take supplements? • Most supplements are a mixture of vitamins and herbals • Make sure you know what you are putting in your body • The “best” supplement is no supplement • Otherwise a “simple ingredient” supplement list • Everything in moderation (ie check toxic doses, check scary herbals), be careful about “stacking” • Dietary supplements generally unnecessary with a well- balanced diet • Many supplements have unstudied effects and not all the claims are supported by science
- 31. The consumption ofthese supplements (Espinar and Trenavar) present serious risk to health. Currently two SMs from USARAF have been evacuated to Walter Reed awaiting liver transplants. Fact: Supplements may be adulterated with prescription and/or illegal drugs! FDA does not oversee supplement safety. For supplement safety alerts and announcements visit OPSS: http://hprc-online.org/dietary-supplements/opss PROHIBITED ITEMS
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- 33. Resources • NCCAM http://nccam.nih.gov •Office of Dietary Supplements, NIH http://ods.od.nih.gov • Natural Medicines Comprehensive Database Accessed via AMEDD Virtual Library • http://www.medpagetoday.com/MeetingCoverage/AASLD/42744 • http://www.jag-lawfirm.com/dietary-supplement-side-effects.html • https://sciencebasedmedicine.org/who-takes-dietary-supplements-and-why/ • http://www.nutricompany.com/news/supplement-usage-united-states.php • https://naturaldatabase.therapeuticresearch.com/logon.aspx?s=ND&cs=dod • http://www.nlm.nih.gov/medlineplus/herbalmedicine.html • http://www.rain-tree.com/plantdrugs.htm • http://www.lenntech.com/recommended-daily-intake.htm • Musabayane, C. The effects of medicinal plants on renal function and blood pressure in diabetes mellitus. Cardiovasc J Afr 2012; 23: 462-468. • Klempner, S et al. Complementary and Alternative Medicines in Prostate Cancer: From Bench to Bedside? The Oncologist 2012; 17: 830-837. • Bunchorntavakul, C et al. Review article: herbal and dietary supplement hepatotoxicity. Aliment Pharmacol Ther 2013; 37: 3-17. • Posadzki, P et al. Herb-drug interactions: an overview of systematic reviews. Br J Clin Pharmacol 2012; 75(3): 603-618.
- 34. DIETARY SUPPLEMENTS: BERESPONSIBLE, KNOW THE RISKS KNOWN RISKS OF PREWORKOUT STIMULANTS and BODY-BUILDING/WEIGHT-LOSS SUPPLEMENTS: • Failed drug tests • Addiction / dependence • Muscle / tendon rupture • Headaches • Insomnia • Palpitations • Anxiety • Gynecomastia (breast tissue in a male) • Fatigue • Dehydration • Electrolyte abnormalities • Liver failure / liver transplant • Kidney failure • Rhabdomyolysis • Cardiac arrhythmias • Coronary ischemia / heart attack All of the above have occurred in Bagram personnel. It’s just a matter of time before we see the last one: • DEATH Don’t roll the dice. FACTS: • 2011: 17% of active duty DoD taking body- building supplement ≥1x daily • 2011: Jack3d and >12 supplements banned for sale on military bases …contained dimethylamylamine • Dietary supplements often adulterated with anabolic steroids, amphetamines, narcotics • Dietary supplement industry is UNREGULATED • No proof of safety • No proof of efficacy • No verification of content • No pre-market approval • No formulation standards • No product registration • RECOMMEND look for third-party testing: Nathaniel Nye, MD, Maj, USAF, MC // 455 EMDG // Sports Medicine physician Craig Joint Theater Hospital Outpatient Clinic // nathaniel.s.nye.mil@mail.mil
- 35. Recommendations: • Gather dataon actual prevalence of supplement use at Bagram • Some communities are higher users than others • Improve public awareness of risks of supplement use • Encourage responsible supplement use: • Start by eating a HEALTHY DIET – “cut the crap” • Stay WELL-HYDRATED • Focus on FEWER INGREDIENTS • Take only supplements that are THIRD PARTY TESTED • Prohibit sale of supplements that have not been tested by third party
- 37. Maj Nye, I agreewith everything you said but one of the things I have learned is they are going to take stuff no matter how much you advise on diet, sleep, and the other. There is no arguing the "amped" up feeling they get and you can equate it to telling the entire military to stop drinking. They will just get pissed at you and not listen to your advice any more. Instead of saying no supplements, I like to give them some ideas of substitutes. I also included a few slides on pre-workout because this is such a big issue. Getting them to focus on fewer ingredients (appropriately labeled) with third party tested products is a fair compromise. I always ago back and watch some of their operational clips on YouTube to remind me what drives their behavior. They blast dark metal, pound some pre-workout, and give each other a ton of smack talk to fire themselves up to roll outside the wire and put their life on the line. There is a reason Somali's kicked our butt hyped up on Khat and our guys know this. Stimulants in their mind equate to staying alive. You are doing 100% the right thing by helping them see the contamination and focusing on good behaviors without supplements. Just try to give something up for those who are going to take something no matter what. -COL Givens COL Melissa Givens MD, MPH, CSCS Medical Director, Consortium for Health and Military Performance Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences melissa.givens@usuhs.edu (301) 295-0529 AN INSIDER PERSPECTIVE… BUT… Do we want our highest value human weapons systems taking dangerous substances into their bodies??
Editor's Notes
- #10 In excess can cause: nausea, bloating, cramps Considered a “better” protein than casein or soy because of rapidly increasing Aas in the body