Weight Loss and Ergogenic Aids
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Weight Loss and Ergogenic Aids Annie Laweryson, Erin Prasad, Merryl Landeck and Rebecca Levens Introduction Weight Loss Conjugated Linoleic Acid Ephedra PGX Hoodia Raspberry Ketones Ergogenic Aids Creatine Beta Alanine Arginine The Controversy… According to the FDA, weight loss supplements and ergogenic aids are two of the three categories of supplements that are most likely to have problems with adulteration, toxicity and misbranding GMP’s are critical to consider with these NSF for Sport for ergogenic supplements Conjugated Linoleic Acid Weight loss Erin Prasad Conjugated Linoleic Acid Scientific name: cis-9, trans-11 conjugated linoleic acid trans-10, cis-12 conjugated linoleic acid or octadecadienoate 18:2 Common name: CLA, Tonalin and Clarinol (brand names) CLA: A group of conjugated octadeadienoic acid isomers derived from linoleic acid A polyunsaturated fatty acid in which scientific interest was peaked in the 1980s when scientific evidence support possible anti-cancer effects. Food sources: Meat- beef and other ruminant animals Dairy products Eggs Vegetable oils Average daily intake (non veg/vegan) in ~150-220mg/d Suppelment sources: Safflower and Sunflower oils in which the CLA is made under alkaline conditions. 1, 2, 3, 4 Erin Prasad Conjugated Linoleic Acid Typically used for conditions such as: Weight loss Allergies, asthma, CVD, diabetes, cancer, exercise performance enhancement, hair loss, hypercholerolemia, hypertension, immune function, and rheumatoid arthritis Dosage: No proven safe or effective dose For weight loss/obesity: For all other conditions: 1.8-7g/d has been administered Doses greater than 3.4g/d do not offer additional benefit 2-6g/d with mixed results regarding efficacy Mechanism of Action: Proposed CLA increases energy expenditure CLA suppresses appetite CLA decreases lipogenesis through apoptosis of adipocytes CLA increases lipolysis 1, 3, 4 Erin Prasad Conjugated Linoleic Acid Efficacy for weight loss: Natural standard Study 1 (2010): Overweight or obese children supplemented with CLA gained less weight than the placebo group. Study 2 (2012): Chinese adults supplemented with CLA had an overall reduction in BMI, fat mass, fat percentage, subcutaneous fat, and waist-to-hip ratio. Safety: Considered generally safe for healthy individuals Adverse effects: nausea, diarrhea, and GI upset Cautionary use for: Children and breastfeeding women, CVD, inflammatory disorders, digestive disorders, autoimmune diseases, dermatological disorders, diabetics, or those with liver disease. DNIs: CLA should be taken with caution with medications used for blood thinning, lowering blood pressure, cholesterol or blood sugar. GMPs: All but one of 6 CLA supplements tested by Consumer Labs contained the claimed amount of CLA (one had 86%), GRAS product. 3, 5, 6, 7 Erin Prasad Conjugated Linoleic Acid What to look for when buying Accessibility: Easily found at Super Supplement and drug stores in weight loss section (non-refrigerated) Price range 90 gel caps of 750mg CLA: $12.99-$22.99 Forms: Soft gels of 750mg, 800mg, 1000mg, or 1400mg all from sunflower or safflower oil Dosing Instructions: Varies among brands and is conflicting, one serving is 1-3 gel caps of 750mg Other ingredients: D-alpha tocopherols Excipients: gelatin, glycerin, color, (beeswax, soy lecithin) Extras: Claims often stated are: Supports body fat reduction Retain lean body mass while burning fat Clean Performance Product Erin Prasad Conjugated Linoleic Acid Overall Impressions and Recommendations Scope of Practice: With coordination of care with a physician, it is within the scope of a dietitian to recommend CLA. Lab work for triglycerides, blood sugar, and cholesterol should be monitored carefully Overall impression: Yellow CLA is safe for general population, special populations for which it may be unsafe do exist. It may reduce body fat, but has not been shown to increase lean body mass CLA may alter lipid profile in an unfavorable manner, especially a concern for those with CVD or diabetes (large portion of obese population) Erin Prasad Ephedra Weight Loss Merryl Landeck Ephedra Scientific Name ~ Ephedra sinica Also known as Ma Huang in traditional Chinese medicine It is an evergreen shrub-like plant native to arid regions of China and Mongolia. There are approximately 40 species of ephedra (8) Currently grow in China, northern India, Pakistan, Mongolia, and the southwestern United States (8) Traditional uses by Chinese herbalists dating back 5,000 years Treatment of respiratory infections, asthma, eczema, hay fever, cough, colds, chills, shortness of breath, bone and joint pain, narcolepsy, and edema (8, 9) Modern uses (prior to FDA ban) Weight loss, athletic performance enhancement, increase energy, sexual dysfunction, hypotension. Still found over-the-counter for asthma and sinus congestion in a safer form (8, 9, 10) Merryl Landeck Scientific Evidence for Uses of Ephedra According to Natural Standard, some evidence exists suggesting ephedra is successful as a supplement for weight loss, however, the risks of taking ephedra alkaloids as a dietary supplement outweigh the possible benefits. Merryl Landeck Ephedrine Mechanism of Action Ephedra contains the alkaloids ephedrine and pseudoephedrine, which have been found to induce CNS stimulation, bronchodilation, and vasoconstriction (8) Ephedrine alkaloids have sympathomimetic properties, simulating stimulated sympathetic nerves which excite the CNS. They stimulate α-1, β-1, and β-2 receptors to increase blood pressure, heart rate, vascular resistance, and cardiac contractibility (11, 12) Suppresses appetite, increases energy expenditure/metabolic rate (thermogenic), lypolitic (9) Ergogenic properties marketed to reduce fatigue; increase strength, power, and speed; decrease reaction time; and improve body composition. Evidence is inconclusive (13) Ephedrine, synthesized chemically is regulated by the FDA as a prescription drug with weak amphetamine-like properties Pseudoephedrine is a nonprescription product found in many cough and cold products- causes vasoconstriction resulting in less fluid in nose, throat, sinuses (11) Merryl Landeck Efficacy and Safety Studies show sufficient evidence to conclude that short-term use of ephedrine at high doses, or ephedrine and caffeine, ephedra, and ephedra with herbs containing caffeine promotes weight loss (13) Caffeine adds additional efficacy (0.9kg per month weight loss above placebo) (11,13) No data regarding weight loss beyond 6 months Insufficient evidence to support ephedra supplementation for enhancing athletic performance (11,12,13) A meta-analysis found intervention groups to have a 2 to 3-fold increase in psychiatric symptoms, autonomic symptoms, upper GI symptoms, and heart palpitations compared to control (13) Caused 64% of all adverse reactions reported in the U.S, despite accounting for < 1% of all supplement sales (9, 11) Merryl Landeck Safety and Contraindications Adverse effects (11,14) Elevated BP Palpitations Headache Insomnia Anxiety Restlessness Psychiatric disturbances Seizure Heart attack Stroke Death DO NOT take ephedra with: MAO-inhibitors or other stimulant drugs (9) Should not be taken by persons with: Heart disease Cardiovascular disease High BP History of stroke Diabetes Hepatitis Myocarditis Diseases of the nervous system Hyperthyroidism High cholesterol Heart rhythm abnormalities Merryl Landeck Accessibility Dosage Prior to 2004 ban, FDA recommended: Highest recommended dose 8mg ephedrine every 6 hours up to 7 days (11) No more than 25 mg at one time, not to exceed 100 mg/day (9) Typical marketed dose 20 mg, 2-3 times daily (15) Clinical weight loss trials 50 mg, 3 times daily for 2 months (11) Before FDA ban on April 12, 2004 ephedra widely available in stores and online Cost avg. $1-$6/day Reports from 1999 estimate 3 billion doses of ephedra sold and 12 million users in the U.S. (11) GMPs questionable (15) Labels fail to list alkaloid content Actual alkaloid content significantly different than what’s listed Contaminants Merryl Landeck EphREDra Overall Impressions Ephedra is an example of how the current system for regulation of dietary supplements can be challenging for ensuring the protection and health of the general public Should supplements with biological activity be evaluated and regulated to the same degree as over-the-counter medications? Or prescription drugs? Are ephedra-free weight loss products, such as bitter orange or caffeine, effective or any safer? Merryl Landeck PGX: Functional Fiber Supplement Weight Loss Merryl Landeck PolyGlycopleX Scientific Name (of main ingredient) Typical usage Amorphophallus konjac, native to Asia (16) Konjac-mannan from the root is used As a dietary supplement to reduce cholesterol levels, constipation, blood sugar, and weight Traditionally a source of food (jelly, tofu, noodles) and medicine in Asian practices Typical dosage (with 12-16 fl. oz. of water) Day 1-2: 1 softgel with each meal ***1.5g fiber in each softgel Day 3-4: 2 softgels with each meal Day 5-6: 3 softgels with each meal Day 7 and beyond: 4-6 softgels with each meal Merryl Landeck Mechanism of Action PGX is a proprietary blend of konjac-mannan, sodium alginate, xanthan gum, and MCTs (17) Natural polysaccharide complex: α-D-glucurono-α-D-manno-β-Dmanno- β-D-gluco, α-L-gulurono-β-D mannurono, β-D-gluco-β- Dmannan Highly viscous, soluble, fermentable fiber (18) Upregulation of gut-satiety hormone gene expression (PYY, GLP-1) via fermentation & production of SCFAs in large intestine (19) “Volumetric effect”, gastric distension and delayed gastric emptying, the “ileal brake” promotes earlier satiety, slower transit time through small intestine (19,20) Lowers glycemic index of foods, reduces post-meal spikes in blood sugar Lowers cholesterol levels by sequestration of bile acids Aids in weight loss as fiber-rich meals tend to be less calorically dense, lower in fat and added sugars. Merryl Landeck Natural Standard Scientific Evidence (16) Merryl Landeck Safety and Accessibility Generally well tolerated, low rate of adverse events (21) Minor side effects in gas, bloating, and laxative effects (22) Patent pending delayed viscosity process (17) Caution with blood pressure and blood sugar lowering medications-compounding effects (16) Lack of safety information for pregnant and breastfeeding woman. Widely available online, in drugstores, natural-food stores, and supplement stores. Available in capsules, granules, shakes, and bars Average cost is $30/ 120 softgels (approx. $2.5/day for an average of 15g fiber/day) One can of organic garbanzo beans contains 19g fiber and costs ~$1 – 1.50. Merryl Landeck GMPs and Overall Impression All manufacturing, processing and packaging steps required for PGX meet or exceed government and industry standards and Good Manufacturing Practices are adhered to. PGX has a USP Standard as of the 1st of March 2013 (17) Green light May be a good alternative for people, overweight or not, who are unable or unwilling to ↑ fiber intake through food sources ↑ satiety on calorie-restricted diets Appropriate dosing Merryl Landeck Hoodia Weight Loss Annie Laweryson Hoodia Scientific name: Hoodia gordonii Traditionally used by San people of Namib desert as and appetite suppressor on long hunts and in times of harsh conditions (16,17) Soft middle of cactus root is chewed Has been used for 1000’s of years (16,17) Laweryson, Annie Hoodia Mechanism of action (16,17,18) P57, exact mechanism unknown Increased ATP production in nerve cells of hypothalamus when injected into brain of rats Tricks brain into thinking the body is full Rats consumed 40-60% less kcal Human studies (16,17,19) One study showed 18 obese people who took Hoodia for 15 days consumed 1000 kcal daily less than the control group Study has never been replicated and never published in a peer reviewed journal Another study showed that overweight women who consumed 1110 mg of hoodia per day did not consume fewer kcal than the control group Laweryson, Annie Hoodia Typical dosage: 800 mg bid, 3000-4000 mg/d Accessibility: Easy to get Natures Way: $13.50 60 caps Source Naturals: $21.49 60 capsules Used in teas, patches, capsules, etc. Laweryson, Annie Hoodia GMP’s Safety concerns No scientific standard for assessing quality of hoodia (16) Consumer Lab unable to perform desired testing More Hoodia is being sold than exists (16,17) Products may contain similar species to hoodia or no hoodia at all (16) Contraindications One study showed women receiving 1110 mg bid experienced side effects including nausea, vomiting, skin sensations, elevated BP, increased HR (16,19) Laweryson, Annie Hoodia Scope of practice Within scope to recommend supplements for weight loss however, would advise against recommending Hoodia Overall impression No real research that supports the use of Hoodia in supplemental form Possibilities? May have better weight loss properties if used similar to how San people use it Laweryson, Annie Raspberry Ketones Weight Loss Annie Laweryson Raspberry Ketones 1995 Japanese scientist noticed RK are similar to Capsaicin and Synephrin (20, 21) Capsaicin- increased metabolism thus causing a reduction in adipose tissue and TG Synephrine- found in citrus fruits and exerts a lypolytic property on fat cells Food sources: phenolic compounds in raspberries cranberries, blackberries kiwi fruit Laweryson, Annie Raspberry Ketones Mechanism of action: Antiobese action conducted during fat decomposition (20,21) RK at 1% and 2% have shown antiobese affects Reported that RK at 5% suppressed weight gain despite over consumption of fructose and glucose Lipolytic effects shown both in vivo & in vitro (20,21) Failed to stimulate lypolysis in the absence of norepinephrine Laweryson, Annie Raspberry Ketones Accessibility: Nature Made: $10.74 60 caps Bio Nutrition: 13.99 60 caps Typical dosage: varies 100-500 mg One study showed 100 mg RK taken 30 min prior to a high fat meal showed some evidence for reducing arteriosclerosis (22) 1-4 mg RK derived from 1 kg of red raspberries (22) Laweryson, Annie Raspberry Ketones GMP: No standardizations for testing RK (22) Safety Concerns: GRAS, lack of research Contraindications (22): Use cautiously with antidiabetic agents, anti-inflammatory agents, antiobesity agents, certain cancers, cardiac dysrhythmia Insufficient evidence regarding use by children, pregnant or lactating women, allergies, hypersensitivity Possible DNI: Antiandrogens, anticoagulants, antidiabetics, antiinflammatories, antilipemics, antineoplastics, antiobesity, CNS stimulants, dermatologic agents, heart rate-regulating agents, hepatoprotective agents, hormonal agents, warfarin Laweryson, Annie Raspberry Ketones Scope of practice Within scope to recommend supplements for weight loss Natural Standard grade C for weight loss Overall impressions Appears to be promising Fairly safe Lack of research Laweryson, Annie Creatine Ergogenic Aid Rebecca Levens Creatine Scientific name (30) N-amidinosarcosine N-(aminoiminomethyl)-N methyl glycine. Types Creatine monohydrate (88%) (31) Creatine ethyl ester (86%) (31, 32, 33, 34) Creatine HCl (79%) (31) Dicreatine malate and tricreatine malate (70%) (31) Creatine ester phosphate (62%) (31) Creatine AKG (47.5%) (31, 35) Rebecca Levens Food Sources Food sources (30,36, 37) Red meat, poultry, and fish 350 mg per 3.5 ounce of red meat Only animal protein sources so may have additional effects for vegetarians Rebecca Levens Usage Usage (30) A- Athletic performance enhancement for muscle mass and muscle strength C- performance enhancement for cyclists, high intensity endurance, rowers, runners, sport specific, sprinters, swimmers Rebecca Levens Mechanism of Action Synthesized in the body from dietary amino acids in liver, kidneys and pancreas (30, 37) This is in addition to what we get from food sources Gets stored in skeletal muscles as creatine phosphate (30, 37, 38) High energy substrate to create ATP Increased levels of creatine enhance the ability to regenerate ATP for short energy bursts Improved resynthesis of creatine phosphate during recovery Rebecca Levens Dosage Orally (31) Start with a “loading” dose (30,37) 2-5 grams of creatine per day. Results in gradual increase in creatine storage in muscles (30,37) 15-20 grams of creatine per day for 5-14 days Followed a “maintenance” dose (30, 37) Powder Capsule Liquid Should occur within 2-4 weeks Mixed evidence of whether the loading dose is actually more beneficial than just taking a constant dose Cycling on and off is recommended (39) Rebecca Levens Safety Avoid with renal patients due to difficulty removing waste product creatinine (38) Little is known about the potential long terms effects, may impact renal function (38) High doses of 20 grams/day long term may impact kidneys and cardiovascular system Possible DNI with nephrotoxic drugs Can cause slight weight gain due to water retention (38) Some people may also experience muscle cramping, diarrhea, and dehydration (38) Caution with caffeine, may decrease effectiveness (38) Rebecca Levens Purchasing Creatine Be cautious when purchasing of liquid creatine (31) Differing amounts of usable creatine (31) Creatine breaks down in water Powders and tablets are better Monohydrate form has the most (88%) (31) Be mindful of proprietary blends that do not disclose the amount of creatine Excipients may include carbohydrates (31) Things to note on label: NSF certified for sport GMP Purity assured by HPLC Rebecca Levens Brand Source Dosage ALL Max Super Supplements Bioplex Nutrition Creatine Serving s Cost Cost per month 1 teaspoon 80 (yields 5 grams creatine monohydrate) $18.99 $0.23 per serving $11.27 Super Supplements 1 scoop (yields 65 7 grams creatine monohydrate) $26.50 $0.40 per serving $14.00 Twin Labs Super Supplements 3 capsules (yields 2,100 mg creatine monohydrate) 20 $9.09 $0.45 per serving $49.00 Jarrow Formulas Super Supplements 1 capsule (yields 800 mg creatine monohydrate) 120 $9.07 $0.08 per serving $24.50 Rebecca Levens Brand Source Dosage ALL Max Super Supplements Axis Labs Creatine Ethyl Ester Now Foods Serving s Cost Cost per month 1 teaspoon 80 (yields 5 grams creatine monohydrate) $18.99 $0.23 per serving $11.27 Supper Supplements 3 capsules (yields 2,250 mg creatine ethyl ester) $24.95 $0.62 per serving $67.51 Supper Supplements 2 capsules 120 (yields 1.5 grams buffered creatine monohydrate) $49.99 $0.42 per serving $68.60 40 Rebecca Levens Overall Impression Within scope of practice, especially for sports dietician Green light When taken in appropriate doses for 1-5 years Effect of long-term, high doses of creatine has yet to be established Rebecca Levens Beta Alanine Ergogenic Aid Rebecca Levens Beta Alanine Scientific name Also called carnosine or CarnoSyn (40) Food sources 3 aminopropanoic acid (40) Naturally occurring beta amino acid (41) Poultry, beef, pork and fish (40) Usage Exercise performance enhancement (C) (41) Used for exercise that requires power and strength High intensity, anaerobic, strength training and weight lifting Goal is to increase time to exhaustion and improve muscular endurance Rebecca Levens Mechanism of Action Works to increase the carnosine levels in the fibers of all types of muscles Increases buffer to decrease effects of pH changes from lactic acid production (40,41) Results in decreased fatigue and increased power (40) Note that carnosine levels can be increased with training alone (41) Rebecca Levens Dosage and Safety Orally (40,41) Capsule Powder There is some variation in the research for dosage 2.4 – 6.4 grams/day (41) 4.8 grams/day for 30 days (40) Increase dosage for 8 weeks starting with 2 grams/day and gradually increasing to 4 grams/day (40) Greater than 10-20 mg/kg body weight may cause parasthesia (40) Caution with allergy (40) No known interactions with drugs, herbs or food (40) Little information for pregnant and lactating women (40) Rebecca Levens Purchasing Beta Alanine There is no standardization (41) Can find a variety of excipients/added ingredients NSF certified for sport Easily accessible Online Super Supplements Rebecca Levens Brand Source Dosage # Servings Cost Now Foods Supper Supplements 3 capsules (2.5 grams beta-alanine) 40 $29.99 $0.75 per serving ALL Max Nutrition Supper Supplements 1 teaspoon (3.2 grams beta-alanine) 31 $18.99 Rebecca Levens Overall Impression Within scope of practice for sports dietician Yellow light (natural standard) GRAS Possibly safe with appropriate short term use Additional research is necessary due to varied results Rebecca Levens Synergy of Supplements Mixed evidence (42,43) Some suggests increased benefit of supplementing with both creatine and beta-alanine due the supplements acting differently in one’s body Others note no difference with stacking of supplements Can easily find supplements that contain multiple ergogenic aids Rebecca Levens Arginine Ergogenic Aid Erin Prasad Arginine Scientific name: 2-amino-5-guanidinopentanoic acid Common name: L-arginine Conditionally essential amino acid first isolated in 1886 Food sources: Nuts (brazil, almonds, cashews) Seeds (sesame, sunflower) Whole grains (oats, barley, buckwheat) Poultry Red meat Dairy products Functions in the body: cell division, wound healing, removing ammonia from body, immune function, release of hormones, lean body mass, blood sugar regulation. 44, 45 Erin Prasad Arginine Typically used for conditions such as: CHF, Intermittent claudication, angina, impotence, sexual dysfunction in women, wasting syndrome in AIDS decreased inflammation in infants, improved wound healing, faster recover after surgery And as and ERGOGENIC AID in increased exercise endurance and body building. Dosage: No upper intake established Supplemental: 2-8g/d CHF: 6-20g/d, Angina: 3-6g/d Infants: 261mg/kg for first 28 days of life Mechanism of Action: L-arginine is a substrate for nitric oxide synthase therefore necessary for the formation of nitric oxide Nitric oxide is a vasodialator and contributes to increased blood flow Proposed theory: Increased blood flow to the tissues=increased O2 to muscles= Improved athletic performance. 44, 45, 46, 49 Erin Prasad Arginine Efficacy as an Ergogenic Aid Study 1 (2014): Runners-No significant change in running time. “…L-arginine supplementation did not cause beneficial changes in metabolic and hormonal parameters beyond those achieved with exercise alone.” Study 2 (2012): Strength trainers did not show increase in their strength resistance exercise performance. “It is still premature to recommend nutrition supplements containing L-arginine as an ergogenic aid” Safety: Considered safe in doses up to 20g/d Adverse reactions: Capsule- abdominal pain, bloating, diarrhea, gout, airway inflammation (asthma) IV: urticaria, periorbital edema, pruritis Interactions with medications: Caution with anti-hypertensive drugs or nitrates: blood pressure can drop too low GMPs: All of the L-arginine containing supplements that Consumer Lab selected for review passed. 46, 47, 48 Erin Prasad Arginine What to look for when buying Accessibility: L-arginine can be found at any supplement store (AA Section), online, or at drug/grocery store Price range: $9.50 (100 capsules)-$31.99 (1lb) Forms: 500mg or 1000mg tablets or capsules Powder (free form): 1/2tsp contains 1500mg Dosing Instructions: Varies from brand to brand but all fall within recommended dose of 2-8g/d. Excipients: gelatin, magnesium, stearate, and silica Extras: L-arginine is in the form of hydrochloride and often combined with an ornithine or citrulline complex to “support protein synthesis” or “support peak performance” Erin Prasad Arginine Overall Impressions and Recommendations Scope of Practice: Safe and relevant for a RDN to suggest for someone who may be in periods of growth, recovering from surgery or a wound, and lacking dietary sources. Coordination of care with physician should be considered, and necessary in the case of children. Relatively safe Exceptions: When combined with blood pressure meds or nitrates Large doses in infants Yet, it has not been proven effective as an ergogenic aid Erin Prasad Overall Recommendations Green Light Yellow Light PGX Creatine Conjugated Linoleic Acid Raspberry Ketones Beta-alanine L-arginine Red Light Epherdra Hoodia References 1, Consumer Labs: Review of CLA (Conjugated Linoleic Acid) Supplements for slimming. http://www.consumerlab.com.buproxy.bastyr.edu:2048/reviews/CLA_Conjugated_Linol eic_Acid_for_Slimming/CLA/. Accessed 2/4/2014. 2. Natural Standard: Conjugated Linoleic Acid (CLA) professional monograph. http://www.naturalstandard.com.buproxy.bastyr.edu:2048/databases/herbssupplements/ conjugatedlinoleicacid.asp?. Accessed 2/4/2014. 3. Natural Methods Comprehensive Database: Conjugated Linoleic Acid. http://naturaldatabase.therapeuticresearch.com.buproxy.bastyr.edu/. Accessed 2/4/2014. 4. Kennedy et al. Antiobesity mechanism action of conjugated linoleic acid. Journal of Nutrition and Biochemistry, 2010; 21 (3): 171-79. 5. Chen SC et al. Effect of conjugated linoleic acid supplementation on weight loss and body fat composition in a Chinese population. Nutrition, 2012; 28(5): 559-65. 6. Racine NM et al. Effect of conjugated linoleic acid on body fat accretion in overweight and obese children. American Journal of Clinical Nutrition, 2010; 91: 1157-64. 7. Onakpoyaa IJ et al. The efficacy of long-term conjugated linoleic acid (CLA) supplementation on body composition in overweight and obese individuals: a systematic review and meta-analysis of randomized clinical trials. European Journal of Nutrition (systematic review); 51 (20): 127-34. References: 1. Ephedra (Ephedra spp.), ma huang. Natural Standard Website. http://www.naturalstandard.com.buproxy.bastyr.edu:2048/databases/herbssupplements/all/ephed ra.asp?. Accessed February 4, 2014. 2. Ephedra. EBSCO CAM Review Board. http://therapy.epnet.com/nat/GetContent.asp?siteid=EBSCO&chunkiid=21697. 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