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Cayuga Sports Medicine Conference - Supplements Update 2010

Cayuga Sports Medicine Conference - Supplements Update 2010. By Lee A. Mancini, MD, CSCS*D, CSN Assistant Professor UMass Medical School Faculty UMass Sports Medicine Fellowship Certified Strength and Conditioning Specialist with Distinction Certified Sports Nutritionist. Background.

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Cayuga Sports Medicine Conference - Supplements Update 2010

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  1. Cayuga Sports Medicine Conference - Supplements Update 2010 By Lee A. Mancini, MD, CSCS*D, CSNAssistant Professor UMass Medical School Faculty UMass Sports Medicine Fellowship Certified Strength and Conditioning Specialist with Distinction Certified Sports Nutritionist

  2. Background Former D-I athlete / 1999 Boston Marathon Numerous Sprint / Olympic Distance Tris 15 years as Certified Sports Nutritionist 15 years as Certified Strength & Conditioning Specialist UMass Sports Medicine Physician Sports Nutrition consultant Boston Red Sox Organization Lowel Devils (NJ AHL affiliate) Worcester Ice Cats (STL Blues AHL) Holy Cross UMass Amherst Assumption College Nichols College Lived in Ithaca my entire life - graduated from Lansing High School…

  3. Goals & Objectives • Review a brief history of supplements • Discuss how to examine supplement claims • Review some common supplements • Examine supplements specific for triathletes & endurance athletes • Ask Questions!

  4. Historical Perspective • Ancient History • Aztecs • Chinese • Greeks • Ergogenic • Ergon • gennan

  5. 20th Century & Supplements • Brown-Sequard in 1889 • 1950s Dr. Ziegler • Methandrostenolone • IOC • 1968 1st list of banned substances • 1976 Montreal Olympic Games

  6. The Supplement Industry • Nutrition Labeling and Education Act (NLEA) 11/9/1990 • Dietary Supplement Health and Education Act (DSHEA) 10/25/1994 • Multibillion dollar industry • 1994 = 8.3 billion • 1999 = 14 billion • 2009 = 23.7 billion

  7. The Supplement Industry • 2002 Health & Diet Survey • 73% - 18 and older had used in past year • 2006 J of Adolescent Health • 79% used in past year • 48% used in past month • Creatine - 8% vs. 2% • Weight Loss - 7% vs. 15% Timbo, BB, Ross, MP, McCarthy, PV, Lin, CT. (2006) Dietary supplements in a national survey: Prevalence of use and reports of adverse events. Journal of American Dietetic Association, 106 (12), 1966-74.

  8. Three Questions • Is it effective? • Is it safe? • Is it legal?

  9. Is it Legal? • Governing bodies have banned substance lists • IOC, NCAA, UCI, USAC, WADA, MIAA • Triathletes - USAT falls under USADA • Law enforcement penalties • Possession • Federal offense • 1 year and 1,000$ • Selling • Federal felony • 5 years and 250,000$

  10. Is it Legal? - Selling One’s Soul • Sports Psychology…1987 • Take a banned substance guarantee gold medal - and not get caught • 195 of 198 said YES • Take a banned substance - top athlete for 5 years - and then die in year 6 • Over 50% said YES

  11. Supplements & Triathletes • Ground rules • Specific supplements • Proven Performance effects • Side effects • USAT follows USADA prohibited list

  12. Banned Substance List • S1 - AAS • Nandrolone • Clenbuterol (asthma in other countries) • S2 - hormones and related substances • EPO, hGH, IGF-1, hCG, insulin, & corticotrophins • PRP given IM prohibited • PRP tendon injections - requires Declaration of Use • DM pts - need TUE for insulin

  13. Banned Substance List • S3 - Beta-2 Agonists - • Salbutamol (Ventolin, ProAir, DuoNeb) • Salmeterol (Advair, Serevent), • Others need TUE (terbutaline) • Oral use is prohibited • S4 - Agents with Anti-Estrogenic Activity • Aromatase inhibitors • SERMs - tamoxifen • Other Anti-Es - clomiphene

  14. Banned Substance List • S5 - Diuretics and Masking Agents • Masking Agents • Plasma Expanders - Albumin, Dextran, Glycerol (supplements banned) • Alpha-reductase inhibitors - Finasteride • Epitestosterone • Diuretics • Furosemide • Spironolactone

  15. Banned Substance List • Prohibited Methods • M1 - Enhancement of O2 transfer • Blood doping • M2 - Chemical & Physical Manipulation • Tampering • IV infusions (even if non-banned substance unless in hospital setting) • M3 - Gene doping

  16. Banned Substance List • Prohibited Substances IN Competition • S6 - stimulants • Pemoline, Prolintane • Ephedrine and methylephedrine - U > 10mcg/ml • Pseudophedrine - U > 150mcg/ml (D/C >24hrs prior) • Athletes w/ ADD/ADHD • Need TUE • Not Prohibited • Caffeine

  17. Banned Substance List • S7 - Narcotics • Fentanyl, Morphine • S8 - Cannabinoids • S9 - Glucocorticosteroids • PO, IV, PR, IM - (DOE/TUE) • Topical • P1 - ETOH • P2 - Beta-Blockers

  18. Commonly Used Banned Substances

  19. Erythropoietin & Blood Doping • Natural hormone secreted by the kidney formation RBCs • r-HuEPO,Darbopoetin (Aranesp) • Blood removed from athlete • 1984 - 10 U.S. cyclists • Hemopure (based on bovine Hgb) • 2001 Giro d’Italia cycling marathon • Enhances erythropoiesis by stim proerythroblasts formation

  20. Epo & Doping - Physiology • Endurance Exercise • RBC mass and plasma volume increases • Hct & Hgb decrease due to expanded plasma volume • By increasing Hgb & Hct • increases O2 carrying capacity • decreases ratings of perceived exertion • increases VO2 Max

  21. Epo - Proven Effects • EPO for 26 days at 50 IU/kg led to • 7% increase in power • 9% increase VO2 Max • Increase Hct • After 6 weeks of EPO - 17% increase in cycling time to exhaustion • IV r-HuEPO works in days

  22. Epo & Doping - Adverse Effects • Because of increased RBC volume - causes increased blood viscosity • HTN • Seizures • DVTs, PEs • Stroke • Case report - cerebral sinus thrombosis

  23. Epo & Doping - Summary • Proven Performance effects for Endurance Athletes • Significant Risks • Banned by IOC in 1990 • Banned by USADA • Banned by UCI • UCI testing since 1997 • Hct 50 for men, 47 for women • UCI Certificate

  24. Ephedra • Chinese herb, 5000yrs • Comes from Ephedra sinica plant • Ma huang • Known to relieve respiratory ailments • Mixed into herbal teas • Sale of it alone is prohibited • Make methamphetamine

  25. Ephedra -Mechanism of Action • Stimulant that mimics effect Norepi & Epi • Increases fat burning, Heart rate • Thermogenic effect • Increases resting metabolism, calorie expenditure • Causes appetite suppression

  26. Ephedra - Proven Effects • Over 52 studies in literature (Shekelle et al., 2003) • All studies were less than 6 months • Average 1.0kg per month greater than placebo • Doses ranged from 25 to 120mg per day • Dose related effect

  27. Ephedra - Adverse Effects • Wide variety of side effects • Heart palps, HTN, anxiety, hyperthermia, headaches, & cardiac arrhythmias • Effects all stopped 48hrs after discontinuing • FDA 800 adverse incidents - >90% exceeded recommended doses • FDA 284 serious adverse events - 5 deaths, 5 heart attacks, 11 strokes, & 4 seizures • 50% of these people < 30 yo

  28. Ephedra - Summary • Proven effect on fat loss • 0.82% all sales, 64% adverse • 4/12/04 Government bans Ephedra • 2006 US Court of Appeals upheld • “Legal Ephedra” - bitter orange • UCI - U > 10mcg/ml 2/17/2003

  29. Legal Ergogenic Aids

  30. Creatine • 1832 Chevreul - Greek word flesh • Made from Arg, Gly, & Meth, 95% - skeletal muscle • CrP + ADP => ATP + Cr, enz = Creatine kinase • Intense exercise ATP used first 10 secs • Also buffers muscle pH - delays muscle fatigue • Over 150 studies done, 93% in the past ten years

  31. Creatine - Proven Effects • Overwhelming evidence Meta-analysis (Nissen et al., 2003) • 1.09% increase in strength per week • Increase 0.36% LBM per week (2.2 kg in 6 weeks) • 15 lbs added to 1RM Bench Press (6 weeks) • 25 lbs added to 1RM Back Squat (6 weeks) • 61 Studies - 45 found to improve endurance performance (running, swimming, rowing, & biking) • Ergogenic effect on repeated high intensity sprints (lasting 30 seconds to 3 minutes)

  32. Creatine - What about longer distances? • Events lasting longer than 3 minutes - 25 studies - 8 found no improvement, 17 did • Improved times in 5M and 15M sprints but slower times in 6K runs (by 26 seconds) • Long distance endurance events - additional muscle mass and water retention may slow athletes down

  33. Creatine - Adverse Effects • KIDNEY ISSUES? • Because creatinine is breakdown product of creatine - concern over kidney function • (Crowe et al., 2003) Four year study, NCAA 3 yr study • No significant adverse effects up to five years after ingesting creatine (Dempsey et al., 2002) • (Eur J of App Physiol 2008 - Gualano et al) Double Blind, Randomized - 3 months • BOTTOM LINE - NO evidence on any effect on kidney function

  34. Creatine - Adverse Effects • Main reported side effect = GI distress • Case reports of muscle cramping, No studies showed increased cramping • No effect on body fluid balance or heat regulation • (2009 - meta-anlysis J Ath Train - Lopez et al. • (Br J Sports Med - 2008 - Dalbo et al) • BOTTOM LINE - No increased risk of dehydration, cramping, or issues with sweating or heat regulation

  35. Creatine - Summary • Most widely used supplement • 30% Pro teams supply • 50% Male Div 1 use • 14% High School • 75% High School informed from who? • Proven Strength & Anaerobic effects • GI & Cramping side effects • No effect on kidney function • For Triathletes not very beneficial • NOT BANNED by IOC, UCI, WADA, USAC

  36. HMB ß-hydroxy-ß-methylbutyrate • Metabolite of Leucine • Found in catfish, citrus fruit, & breast milk • Believed to preserve LBM during fat loss • Anti-catabolic • 1998 Sales 50-60 Million Dollars

  37. Proven Recovery Effects • (Nissen et al., 1997) - Exercise induced muscle damage after heavy resistance training • 1.5g/day or 3.0g/day - decreased protein breakdown • Increased muscle recovery • (Knitter et al., 2000) - 3g/day HMB for 6 weeks • 20K run - monitored LDH, CPK levels • Statistically significant - LDH & CPK levels post exercise in HMB group

  38. Proven Performance Effects • Meta-analysis (Nissen et al., 2003) of 9 studies • 0.28% increase LBM per week (6-8 weeks) • 1.40% increase in 1RM strength per week • (Nissen et al., 1996) - 1.5g/day and 3.0g/day for 6 weeks, increased strength • (Kreider, 1999) - 3g/day for 8 weeks • Increases in LBM, decreases fat mass • Increases in upper and lower body 1RM strength • (Lamboley, 2007 - Int J Sport Nutr Exerc Metab) - Aerobic training 3/wk x 5 wks (3g/day) - Inc VO2Max 13.4% vs. 8.4% placebo, no change in body comp • (Watson, 2009 - J Str Cond Res) - no side effects • 3 g/day - small increases in 1RM, small decrease in fat mass, small increase in muscle mass The Blond Bomber - Dave Draper

  39. Adverse Effects • No reported side effects from any studies • (Juhn, 2003) - Using HMB for 8 weeks • No change renal fx, LFTs, Lipid panel • (Crowe et al., 2003) - Using HMB for 6 wks • No change in serum Test, BUN, Cr, Chol, TGs

  40. Summary of HMB • Not Banned • Safe at the present • Increases maximal strength • Maintains LBM, Decreases fat mass • Cost - 40$ for 200 pills • 4 pills = 1 gram HMB • Servings 4 pills x 3 times/day = 12 pills daily • 17 day supply • $80 per month

  41. Caffeine • #1 Drug used in the world • 82-92% adults use daily • Methylated xanthine alkaloid derivative • 1,3,7-trimethylxanthine • Metabolized in liver p450 • 3 Main metabolites • Theobromine, theophylline, • Paraxanthine most potent

  42. Caffeine - Mechanism of Action • Structure is similar to adenosine • Binds to adenosine cell membrane receptors • Found everywhere • Stimulates CNS, increases release of Epinephrine • Increases HR, MR, resp center output decreases perceptions of pain, & fatigue • One main effect on performance is by increasing fat oxidation - which spares muscle glycogen

  43. Caffeine - Proven Effects • Effects have been studied for 100 years • Most studies = 2-9mg/kg per day (250-750mg) • (Costill et al., 1978) - 300mg, cycle at 80% VO2 Max until exhaustion • 90.2 minutes vs. 75.5 minutes • Increase max power in cyclists from 904 Watts to 964 Watts (also vs. placebo) • Decrease race times from marathons to short sprints lasting less than 90 seconds (Graham, 2001) • Studies in all three components of triathlon supporting this

  44. Caffeine - Adverse Effects • Anxiety, heart palpitations, trembling, and facial flushing • Dose related • Lethal half-dose of caffeine is 150-200mg/kg bodyweight about 100cups • Tolerance to caffeine appears after 4-5 days • Only takes 3 days of use to develop dependency and withdrawal symptoms after stopping • Mood shifts, headaches, tremors, & fatigue - 12h to 7d

  45. Caffeine - Summary • Banned 1962 IOC • Removed 1972 • Urine 12mcg/ml = 9mg/kg • 6-7 cups = 700-800mg • Proven effects on performance • Because of side effects at higher doses - 3-6mg/kg better • Because of tolerance & withdrawal - better to not take daily, but prior to specific competitions • Definite benefits for triathletes • 2005 IOC Removed completely from banned list • UCI, WADA…

  46. Beta Alanine • ß-alanine is amino acid • Carnosine (ß-alanyl-L-histidine) • Enzyme carnosine synthetase • Frequent sprints • Animal protein • Supplementation can increase beta-alanine by 80% • Chemical buffer in myocytes • Delays fatigue

  47. Most research past 3 years 2006 study by Hoffman in Nutr Research College football players 30 days of 4.5g/day vs. placebo 60 sec anaer power test 3 - 200 yd shuttle run 2007 study by Derave in J Appl Physiol 4.8g/day vs. placebo 400M sprints Knee extensions - 5 x 30 reps 2008 study by Kendrick in Amino Acids 6.4g/day vs. placebo 10 week lifting program Strength, LBM, Body Fat% - no change 2009 study by Smith in J Int Soc Sports Nutr 1.5g qid (6g/day) x 3 weeks, then 1.5g bid (3g/day) x 3 weeks, 22yo (46 men) 6 weeks 6 x 2:1 minute cycling VO2 TTE,VO2peak,LBM Beta Alanine - Ergogenic Effects

  48. Beta Alanine - Summary • Building block of carnosine • Legal - not banned by any sports governing body • No documented side effects • Ergogenic effects • Increases muscle [carnosine] • Reduces fatigue - blood pH, buffer • Some studies have also shown no improvement on performance

  49. Nitrous Oxide / Arginine • L-Arginine alpha-ketoglutarate (AAKG) • Arginine is a conditionally essential AA - 60% • athletes • 2 main effects • Acute - NO increase blood flow & nutritient delivery - increase exercise capacity • Chronic - anabolic GH effects, protein synthesis

  50. NO / Arginine - Ergogenic Effects • 1989 Study by Elam in J Sports Med Phys Fitness • 5 week progresive strength program • 1g arginine + 1g ornithine • Increase muscle strength/LBM • 2006 Study by Campbell in Nutrition • 10 men (30-50yo), 4g/day • 4 days lifting/wk x 8 weeks • 1RM BP, Anaer power, aerobic capacity, Body comp, & Quad endurance • Only 1RM, Anaer power, [arg] p<0.5 • 2008 Study by Little in Int J Sport Nutr Exerc Metab • Power, Muscle End, Max Str, - No change in body comp • More studies continue to show benefits

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