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

 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…

1.
2.
3.
4.
5.
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!

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Ancient History
 Aztecs
 Chinese
 Greeks
Ergogenic
 Ergon
 gennan

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Brown-Sequard in 1889
1950s Dr. Ziegler
 Methandrostenolone
IOC
 1968 1st list of banned substances
 1976 Montreal
Olympic Games

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

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2002 Health & Diet
Survey
 73% - 18 and older had used in past year
2006 J of Adolescent
Health
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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.

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

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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

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Ground rules
Specific supplements
Proven Performance effects
Side effects
USAT follows USADA prohibited list

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

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

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S5 - Diuretics and Masking
Agents
Masking Agents
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Plasma Expanders -
Albumin, Dextran,
Glycerol (supplements banned)
Alpha-reductase inhibitors - Finasteride
 Epitestosterone
Diuretics
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Furosemide
Spironolactone

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Prohibited Methods
M1 - Enhancement of
O2 transfer
 Blood doping
M2 - Chemical &
Physical Manipulation
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Tampering
IV infusions (even if nonbanned substance unless in hospital setting)
M3 - Gene doping

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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

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S7 - Narcotics
 Fentanyl, Morphine
S8 - Cannabinoids
S9 - Glucocorticosteroids
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PO, IV, PR, IM -
(DOE/TUE)
Topical
P1 - ETOH
P2 - Beta-Blockers

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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)
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2001 Giro d’Italia cycling marathon
Enhances erythropoiesis by stim proerythroblasts formation

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Endurance Exercise
 RBC mass and plasma volume increases
 Hct & Hgb decrease due to expanded plasma volume
By increasing Hgb & Hct
 increases O2 carrying capacity
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 decreases ratings of perceived exertion increases VO2 Max

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

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Because of increased
RBC volume - causes increased blood viscosity
HTN
Seizures
DVTs, PEs
Stroke
Case report - cerebral sinus thrombosis

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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

 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

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Stimulant that mimics effect
Norepi & Epi
Increases fat burning, Heart rate
Thermogenic effect
 Increases resting metabolism, calorie expenditure
 Causes appetite suppression

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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

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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

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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

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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

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Overwhelming evidence Meta-analysis
(Nissen et al., 2003)
 1.09% increase in strength per week
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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)

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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

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KIDNEY ISSUES?
Because creatinine is breakdown product of creatine concern over kidney function
 (Crowe et al., 2003) Four year study, NCAA 3 yr study
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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

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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
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(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

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Most widely used supplement
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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
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For Triathletes not very beneficial
NOT BANNED by IOC, UCI, WADA,
USAC

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

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Meta-analysis (Nissen et al., 2003) of 9 studies
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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
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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

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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

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

 #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

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Structure is similar to adenosine
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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

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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

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Anxiety, heart palpitations, trembling, and facial flushing
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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

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Banned 1962 IOC
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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…

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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

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Most research past 3 years
2006 study by Hoffman in Nutr
Research
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College football players
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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
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4.8g/day vs. placebo
400M sprints
Knee extensions - 5 x 30 reps
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2008 study by Kendrick in Amino
Acids
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6.4g/day vs. placebo
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10 week lifting program
Strength, LBM, Body Fat% no change
2009 study by Smith in J Int
Soc Sports Nutr
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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

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

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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

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1989 Study by Elam in J Sports Med Phys
Fitness
 5 week progresive strength program
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1g arginine + 1g ornithine
Increase muscle strength/LBM
2006 Study by Campbell in Nutrition
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10 men (30-50yo), 4g/day
4 days lifting/wk x 8 weeks
1RM BP, Anaer power, aerobic capacity,
Body comp, & Quad endurance
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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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L-Arginine alpha-ketoglutarate
(AAKG)
Pre-Cursor NO
Increase protein synthesis
Increase GH levels
Increase strength/power
No documented adverse effects
BUT no evidence that it improves aerobic capacity or endurance performance
Legal - not banned

 Macronutrient
 Aids muscle recovery
& glycogen stores
 Source of instant energy as well
 Insulin spike
 6-8% CHO solution
 8 T in 1 Gallon

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Evidence shows CHO beverages better than
H2O
Study - cyclists 70% VO2 max, improved TTE 30 minutes
2004 - Mouth wash study
(6.4% maltodextrin)
 Central Drive vs. Metabolic
Drive
Aerobic endurance

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What about Protein?
J Am Col Nutrition - 2004
Whey vs. CHO - 10 weeks
Whey
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 more strength gains more bodyfat loss less lean muscle wasting lower pre-workout cortisol levels
Greater BONE DENSITY

 Whey/ Milk Proteins are more effective than Hydrolyzed Soy
Protein for stimulating Protein
Synthesis & AA deposition in muscle.
= Greater Lean Mass gains with training
= Greater Strength in long-term
 J Am Coll Nutr. 2005
Apr;24(2):134S-139S.

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July 2009 Study in J Appl Physiol
Whey vs. Casein vs. Soy
10g EEA mix after strength training
Men and Women - 12 weeks
Whey - More BCAAs
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NON-WORKOUT
90% muscle recovery/growth vs. casein
25% more vs. soy
WORKOUT
125% more vs. casein
30% more vs. soy
Whey greater body comp changes
Whey greater strength gains

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Combination of 6g EAAs and
35g CHO
 10X Insulin, 3X AA, 4X Pro vs.
CHO, PLA
Studies showing superiority
 VO2 Max
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75% - 29% (24mins)
85% - 40% (12)
Reduced post-exercise muscle damage
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CPK - 216 vs. 1318
Ready, Saunders

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Study by Kreider in 2002 - placebo,
Carb, & CHO/PRO
Resistance training - 10X more insulin,
3X increase AA in skeletal muscle, 3
1/2X increase in protein synthesis in skeletal muscle
CHO - repletes glycogen stores, creates anabolic environement through insulin
PRO - increases muscle growth & decreases muscle breakdown (Rennie
& Tipton in 2000)

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BCAAs - 20% AA in body
Higher amounts in animal proteins
Oxidation rises 300 to 500% during exercise
Levels drop by 25% in the 90 minutes following a workout
1999 study by Mero - showed increase
LBM, decrease BF%
30K race times 3:30 to 3:05 hrs with
BCAA supplementation vs water, and carb (Kreider 1999)
Greer et al. in 2007 in Int J Sport Nutr &
Exerc Metab - CHO, BCAA
Review by Negro (2008 J Sports Med
Phys Fit) - DOMS, Imp immune function via exer-related cytokine production

 Proven Benefits
 Safe
 4-2:1 Ratio
 During & After
 Not BANNED

 17yo male HS athlete
 Test = 2xs NL
 Estradial = 3xs NL
 HDL <10
 LDL = 252
 10 week cycle
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Went from 145 to 190
What do you do?…

 17yo male HS athlete
 3 Months later
 Off D-Bol
 Test = WNL
 Estradial = WNL
 HDL = 42
 LDL = 104
 ECHO - WNL
 Weight now = 163

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 MVI / Ca++/Vit D
 Whey Protein/P+C
 Fish Oil**


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One final warning
 Delbeke et al., 2002
 OTC Pyruvate
USAC Position Statement - 1/26/06
Warning: Any athlete who takes…does so at his or her own risk of committing a doping violation
UCI, US-ADA, WADA, or IOC
Remember , the athlete is ALWAYS responsible for what he or she puts into his or her body
1-800-233-0393
(US-ADA) www.usantidoping.org

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Important Web Sites http://www1.ncaa.org/membership/ed_outreach/healthsafety/drug_testing/banned_drug_classes.pdf
 NCAA site on banned substances http://www.theathlete.org/wada.htm

World Anti-Doping Agency

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Anantaraman, R., Carmines, A.A., Gaesser, G.A., & Weltman, A. (1995).
Effects of carbohydrate supplementation on performance during 1 hour of high intensity exercise. International Journal of Sports Medicine, 16, pp. 461-465.
Armstrong, L.E. (2002, June). Caffeine, body fluid-electrolyte balance, and exercise performance. International Journal of Sport Nutrition & Exercise
Metabolism, 12(2), pp. 189-207.
Audran, M., Gareau, R., & Matecki, S. (1999). Effects of erythropoetin administration in training athletes and possible indirect detection in doping control. Medical Science in Sports and Exercise, 31(5), pp. 639-645.
Ball, T.C., Headley, S.A., Vanderburgh, P.M., & Smith, J.C. (1995). Periodic carbohydrate replacement during 50 min of high-intensity cycling improves subsequent sprint performance. International Journal of Sports Nutrition, 5, pp.
151-158.
Barr, S.I. (1999). Effects of dehydration on exercise performance. Canadian
Journal of Applied Physiology, 24 (2), pp. 164-172.
Bell, D.G., Jacobs, I., Ellerington, K. (2001). Effect of caffeine and ephedrine ingestion on anaerobic exercise performance. Medicine and Science in Sports and Exercise, 33(8), pp. 1399-1403.

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Below, P.R., Mora-Rodriguez, R., Gonzalez-Alonso, J., & Coyle, E. (1995). Fluid and carbohydrate ingestion independently improve performance during 1h of intense exercise. Medicine & Science in Sports and Exercise, 27, pp. 200-210.
Berglund, B., Birgegard, G., White, L., & Pihlstedt, P. (1989). Effects of blood transfusions on some hematological variables in endurance athletes. Medicine & Science in Sports and Exercise,
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Berglund, B., & Hemmingson, P. (1987). Effect of reinfusion of autologous blood on exercise performance in cross-country skiers. International Journal of Sports Medicine, 8, pp. 231-233.
Branch, J.D. (2003, June). Effect of creatine supplementation on body composition and performance: A meta-analysis. International Journal of Sport Nutrition & Exercise
Metabolism, 13(2), pp. 198-207.
Brien, A., & Simon, T.L. (1987). The effects of red blood cell infusion on 10km race time. Journal of the American Medical Association, 257, pp. 2761-2765.
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Buckley, J., Abbott, M., Martin, S., Brinkworth, G., & Whyte, P. (2002).
Effect of oral bovine colostrums supplement on running performance. Journal of Science and Medicine in Sport, 5, pp. 65-79.

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Buick, F., Gledhill, N., Froese, A.B., Spriet, L., & Meyers, E.C. (1980). Effect of induced erythrocythemia on aerobic work capacity. Journal of Applied
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Cater, J.M. (2004). The effect of carbohydrate mouth rinse on 1-h cycle time trial performance. Medicine & Science in Sports and Exercise, 36 (12), pp.
2107-2111.
Catlin, D.H. MD, & Murray, T.H. PhD. (1996, July). Performanceenhancing drugs, fair competition, and Olympic sport. Journal of the American
Medical Association, 276(3), pp. 231-237.
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