Vitamins and Supplements for Athletes? Only in Special Cases
Bert R. Mandelbaum, MD, DHL (Hon)
|October 21, 2015
Supplements Send Thousands to the ED
Sports medicine physicians get questions all the time about nutritional
supplements and performance-enhancing drugs. We hear from professional
athletes looking for an edge that could transform their careers and from
amateurs who don't have to submit to drug tests. And with the news
reported this month that supplements send 23,000 Americans to emergency
departments every year, those questions are taking on a new urgency.[1]
The supplement business is lucrative; it took in about $32 billion in 2013.[2] Too often the companies behind these pills are selling hype and false
hope. People hear marketing fluff on TV and can't sort it out.
So how can we help athletes make the right choices?
Risks of Vitamins and Supplements
It would be dishonest to start by saying that no drug is going to help
your performance. Anabolic steroids can make you bigger and stronger.[3] Caffeine and creatinine can provide some temporary zip and zest.[3] A handful of other substances have shown a handful of other benefits.[3]
But all of these substances come with real risks. Steroids can raise the
risk for cardiovascular disease and male infertility.[3] I have seen several deaths that I can attribute to some combinations.
Caffeine at high levels can impair concentration and cause gastrointestinal upset.[3] Creatinine can cause muscle cramps and weight gain.[3]
And dangers lurk in unexpected places. One of the problem substances I
see the most is cannabis. Athletes are around marijuana a lot. Some don't
realize it is banned by the US Anti-Doping Agency, and not just at the
lowest levels.[4]
Even some everyday foods can cause athletes to run into trouble. In some
countries, like Mexico, even beef may be tainted by clembuterol, an anabolic steroid.[5]
The National Collegiate Athletic Association (NCAA) sanctions athletes
for a serum caffeine level above 15 mcg/mL.[6] It would take about 15 cups of coffee to get there, but it happens.[6]
Otherwise innocuous vitamins are often bottled with dangerous contaminants
or banned drugs. If you are taking care of athletes, it is your role to
help educate them to understand that almost 25% of all supplements may
be tainted with some banned substance.[7]
Nothing Replaces a Balanced Diet
One point I make in these conversations is that vitamins are extraneous
for most people who eat a balanced diet. A good example is eicosapentaenoic
acid (EPA), an omega-3 fatty acid. In the late 1970s, researchers studied
Inuit who were eating only fish and had little incidence of cardiac disease.[8]
Some people extrapolated from this finding that folks in the United States
who were eating Big Macs could avoid heart disease by swallowing fish
oil supplements without changing their diet. Forty years later, no one
has proved this.[8] The story of vitamin E is similar.[9] Over and over, we have isolated one molecule from a healthy diet of whole
foods and expected it to work miracles. And over and over, we've been
disappointed.
Some athletes hope that their supplements can compensate for the unhealthy
foods they eat. But in the case of antioxidants, that doesn't seem
to work. Researchers have measured free radicals and watched the levels
shoot up when their subjects drank a pint of vodka. With antioxidants,
you can deflect that a little, but the effect is not robust enough to
counteract the negative effects.[10]
What is a balanced diet? The American College of Sports Medicine and the
Academy of Nutrition and Dietetics guidelines are helpful. For those who
want more specific recommendations, I always say that the Mediterranean
diet is by far the best way to go. It features fish, fruits, nuts, and
vegetables and not much beef and animal fat. And it's been shown in
prospective trials to extend life.[11]
I recommend adding or subtracting carbohydrates, proteins, and fats based
on which of these macronutrients an individual needs. The needs of the
couch potato are very different from those of the triathlete. And the
needs of the 16-year-old on a high school track team are different from
those of a 70-year-old master runner.
A Few Exceptions
However, there are specific situations where I do recommend supplements.
For example, when athletes are exercising so hard that they lose a lot
of electrolytes, it may be hard for them to compensate for these deficits
with diet alone, especially in very hot and humid climates.[12] In these cases, I think it's a good thing to take multivitamins and
particularly magnesium, calcium, and zinc.
A growing number of people are vitamin-D deficient, and this has been associated
with stress injuries and even cancer. I also sometimes recommend vitamin
D, calcium, and sometimes iron for competitive female athletes. As athletic
women grow older, their need for calcium goes up, especially when their
hormones are naturally cycling down.[13]
Athletes who truly need supplements should look for products that are independently
certified to contain the ingredients listed on the label and not contaminants
or substances banned for athletic competition. One organization that provides
such certification is NSF International, through its Certified for Sport program.[14]
Amateur athletes don't have to contend with drug tests. They're
in a position to consider some substances that, from a therapeutic perspective,
are normally off-limits to the professional or elite athlete. For example,
male master athletes may want to consider testosterone supplements if
they are coping with androgen deficiency, which can reduce their muscle
mass and strength.[15]
Female master athletes may benefit from estrogen replacement because they
run an increased risk for injury to the joints with reduced estrogen levels.[16] Each of these judgments and decisions should always be made in concert
with a physician, as there are significant risks, as well potential benefits,
in both cases. Take the initiative. Broach this subject with your patients
who are athletic.
Risky Even When Indicated
Recently we have observed that testosterone supplementation can increase
the risk for thrombosis.[15] Estrogen replacement can increase the risk for breast cancer and heart disease.[16] If athletes are truly deficient in a hormone, then discuss the pros and
cons of supplementation with them before writing a prescription.
None of this is exciting or dramatic. In fact, it pretty much boils down
to moderation and common sense. But as sports medicine professionals,
that's sometimes all we have to sell.
References
1.Geller AI, Shehab N, Weidle NJ, et al. Emergency department visits for
adverse events related to dietary supplements. N Engl J Med. 2015;373:1531-1540.
2.NBJ's global supplement & nutrition industry report. Nutrition
Business Journal. 2014.
http://newhope360.com/site-files/newhope360.com/files/uploads/2014/Global_Report%20summary.pdf Accessed October 16, 2015.
3.Ellender L, Linder MM. Sports pharmacology and ergogenic aids. Prim Care.
2005;32:277-292.
Abstract
4.The World Anti-Doping Code: the 2015 prohibited list international standard.
World Anti-Doping Agency. September 20, 2014.
http://www.usada.org/wp-content/uploads/wada-2015-prohibited-list-en.pdf Accessed October 16, 2015.
5.Calvo C, Gowar R. Mexico ban beef to avoid doping risk at World Cup.
Reuters. May 21, 2014.
http://www.reuters.com/article/2014/05/22/us-soccer-world-mexico-beef-idUSKBN0E200F20140522 Accessed October 16, 2015.
6.SCAN/CPSDA. Caffeine and athletic performance. NCAA Sport Science Institute.
December 10, 2014.
http://www.ncaa.org/health-and-safety/sport-science-institute/caffeine-and-athletic-performance Accessed October 16, 2015.
7.Pells E. Study shows quarter of supplements tainted by steroids. USA
Today. December 5, 2007.
http://usatoday30.usatoday.com/sports/2007-12-05-2555291010_x.htm Accessed October 16, 2015.
8.O'Connor A. Fish oil claims not supported by research. New York Times.
March 30, 2015.
http://well.blogs.nytimes.com/2015/03/30/fish-oil-claims-not-supported-by-research/ Accessed October 16, 2015.
9.Mathur P, Ding Z, Saldeen T, Mehta JL. Tocopherols in the prevention
and treatment of atherosclerosis and related cardiovascular disease. Clin
Cardiol. 2015;38:570-576.
Abstract
10.Puddey IB, Croft KD, Abdu-Amsha Caccetta R, Beilin LJ. Alcohol, free
radicals and antioxidants. Novartis Found Symp. 1998;216:51-62; discussion
63-67, 152-158.
11.Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet
and health status: an updated meta-analysis and a proposal for a literature-based
adherence score. Public Health Nutr. 2014;17:2769-2782.
Abstract
12.Hawley JA, Dennis SC, Noakes TD. Carbohydrate, fluid, and electrolyte
requirements of the soccer player: a review. Int J Sport Nutr. 1994;4:221-236.
Abstract
13.Rizzoli R. Nutrition: its role in bone health. Best Pract Res Clin Endocrinol
Metab. 2008;22:813-829.
14.About the NSF Certified for Sport® Program. NSF. 2015.
http://www.nsf.org/consumer-resources/what-is-nsf-certification/dietary-sports-supplements-certification/nsf-certified-for-sport-program Accessed October 16, 2015.
15.Seftel AD, Kathrins M, Niederberger C. Critical update of the 2010 Endocrine
Society clinical practice guidelines for male hypogonadism: a systematic
analysis. Mayo Clin Proc. 2015;90:1104-1115.
Abstract
16.Martín-Millán M, Castañeda S. Estrogens, osteoarthritis
and inflammation. Joint Bone Spine. 2013;80:368-373.
Medscape Orthopedics © 2015 WebMD, LLC
Any views expressed above are the author's own and do not necessarily
reflect the views of WebMD or Medscape.
Cite this article: Vitamins and Supplements for Athletes? Only in Special Cases.
Medscape. Oct 21, 2015.