1 complementary and alternative medicine, dietary supplements, and medications

1

Complementary and Alternative Medicine,

Dietary Supplements, and Medications

2

Learning Objectives

• To define complementary and alternative medicine (CAM) in relationship to conventional medicine.

• To discuss characteristics of CAM users and practitioners and their implications for primary care clinicians.

3

Learning Objectives

• To review research in progress on CAM modalities for common problems.

• To discuss issues CAM use raises for primary care clinicians related to communication and liability.

4

Complementary and Alternative Medicine (CAM)

• a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (1)

• healing therapies that typically fall outside the Western biomedical model of disease, diagnosis, and treatment (2)

(1) Eisenberg 1993; (2) Drivdahl 1998

5

Complementary and Alternative Medicine (CAM)

The list of what is considered to be CAM changes continually

as those therapies that are proven to be safe and effective become adopted into

conventional health care and as new approaches to health care emerge.

NCCAM 2003

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Major Domains of CAM

• Alternative medical systems• Mind-body interventions• Biologically-based treatments• Manipulative and body-based

methods• Energy therapies

NCAAM 2003

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Who uses CAM?

• Surveys show marked increase in past 50 years in US and other industrialized countries (1).

• Between 1990 to 1997, increase from 34% to 42% of US households reporting CAM use (2).

• In 1997 in US, more visits to CAM practitioners than to all primary care providers (2).

(1) Kessler 2001; (2) Eisenberg 1998

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Who uses CAM?

• Surveys of primary care clinic populations show 28-47% utilization of CAM.

• 21% of patients in primary care practices reported using CAM for the same health problem for which they sought conventional care on that visit.

Palinkas 2000

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Who uses CAM?

• Herbal therapy is used by 12-14% of the US population, up from 2.5% in 1990.

• 16-18% of patients taking prescription medications also take herbal remedies.

Kaufman 2002

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Why do people use CAM?

• Desire for health and wellness (1)

• Prevention• Pain

– Musculoskeletal pain accounted for 1/3 of all CAM use among primary care patients (2).

– Between 60 and 94% of rheumatic disease patients use CAM (3).

(1)Wolsko 2002; (2) Palinkas 2000; (3) Ramos-Remus 1999

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Why do people use CAM?

• Very few individuals rely exclusively upon alternative modalities (1).

• Most individuals who use CAM do so because of preference, related to the perception that the combination of CAM and conventional treatments are superior to either alone (2).

(1) Astin 1998; (2) Eisenberg 2001

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Who practices CAM?

• Wide variation in background and approach

• Diversity in training programs

Barrett 2000

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Who practices CAM?

• No standardization of approach to accreditation and licensure

• Controversies about regulation

Chez 1999

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Who practices CAM?

Some common beliefs and values

• The body has self-healing potential.

• Body mind and spirit are all important.

• Therapy must be individualized.

• People are responsible for their own healing.

Curtis 2003

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Who practices CAM?

• More nonphysicians than physicians practice CAM

• Increasing numbers of dual-trained MDs– American Board of Medical Acupuncture– American Board of Holistic Medicine

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Who practices CAM?

How did I get to be

a “dual-trained MD”?

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What about communication?

• Between 40 and 70% of CAM users do not disclose their use to their physician.

WHY?

• Patients usually say that they do not report because they are not asked.

Eisenberg 2001

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Why does this matter?• The substantial overlap between use of

prescription medications and herbal supplements raises concerns about unintended interactions.

• Patient use of CAM is often a clue to values and preferences that need to be acknowledged.

Kaufman 2002

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How can we communicate?

1. Always ask! “What else are you doing for your health?”

2. Be open and nonjudgmental.

3. Consider patient preferences and values.

4. Encourage self-monitoring of results.

Eisenberg 1997

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How can we communicate?

5. Coordinate care as appropriate.

6. Be honest about your lack of knowledge and open to education.

7. Monitor safety and efficacy, arrange follow-up.

8. Document all discussions and advice.

Eisenberg 1997

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EBM and CAM

While some scientific evidence exists regarding

some CAM therapies,

for most there are key questions that are yet to

be answered through well-designed scientific studies—

questions such as whether they are safe and

whether they work for the diseases or medical conditions for which they are used.

NCCAM 2003

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Where are we now?

There is an urgent need for more and better trials of CAM therapies!

There may be hope:• OAM funding FY 1992: $2 M• NCCAM funding FY 2003: $113.2 M

.

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Research in Progress

NCCAM funded Research Centers Program

• 12 Centers for CAM Research, each with focus on a particular condition

• 4 Centers for Dietary Supplements Research• Many clinical trials in progress, for example

– 18 on acupuncture – 16 on cancer

www.nccam.nih.gov/clinicaltrials

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Biologically-based therapies

• Safety of “natural” products

• Efficacy of glucosamine and/or chondroitin for pain of osteoarthritis

– NIH-GAIT www.nihgait.org


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Mind-body approaches

• Some now mainstream – Clinical hypnosis– Cognitive therapy– Biofeedback

• Meditation for fibromyalgia– Transcendental meditation– Mindfulness meditation– Relaxation response

Hadhazy 2000

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Manipulative therapies: chiropractic

• Most accepted professional therapy• Good review of safety • Current trials of effectiveness for

– Chronic neck pain– Low back pain

Stevinson 2002

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Manipulative therapies: massage

Low back pain

• Comparison with acupuncture & self-care (1)• Combined with education and exercise (2)

(1) Cherkin 2001; (2) Furlan 2002

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Alternative medical systems: Traditional Chinese Medicine (TCM)

Current trials of acupuncture for• Fibromyalgia• Knee osteoarthritis• Repetitive stress disorder• TMJ pain


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“Frontier Medicine Program”

NCCAM initiative to encourage research on widely used CAM practices for which there is “no plausible biomedical explanation” – Energy therapies– Homeopathy– Prayer– Spiritual healing


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Where does this leave us?

Many conventional treatments

• have been adopted without good quality research

• are costly

• are invasive

• are likely to have adverse effects

• AND often provide inadequate relief.

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Where does this leave us?

CAM interventions generally

• are low cost

• are low-risk

• are free of serious side effects

• AND are widely used.

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Advising patients about CAM

Use evidence forefficacy safety

to place therapy on continuum

recommend

accept

discourageWeiger 2002

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Towards Integration

Liability Risks Based on Evidence• Support for safety and efficacy• Support for safety, inconclusive for

efficacy• Support for efficacy, inconclusive for

safety• Indication of serious risk or inefficacy

Cohen 2002

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Framework for approaching CAM

in clinical situations

• Protect against dangerous practices.• Permit practices that are harmless and that

may help.• Promote and use practices that are

safe and effective.• Partner with patients and encourage

communication about CAM.

Jonas 2000

35


in clinical situations

Question:

Is “permit” the right word here?

Do physicians have the power to “permit” practices that their

patients choose?

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Integrative Medicine

a combination of

mainstream medical therapies

and

CAM therapies

for which there is high-quality scientific evidence of safety and effectiveness

NCCAM 2003

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requires a paradigm shift from

• the disease-centered approach of

conventional biomedicine to

• an approach in which patient values and participation of patients are central.

Maizes 1999

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Towards Integration

The satisfaction that patients report from relationship-centered and individualized CAM therapies serves to remind us:

We can never know with certainty what therapy- alternative or otherwise- will work for an particular patient, no matter what randomized controlled clinical trials indicate.

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Towards Integration

Our patients’ use of CAM invites us• to ask and listen to our patients,• to contribute what evidence based

medicine offers, • to advocate for better evidence-based

research, and at the same time

• to acknowledge the existence of other types of information that may be more relevant to a given individual or for a particular situation.

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in clinical situations• Protect against dangerous practices.• Permit practices that are harmless

and that may help.• Promote and use practices that are

safe and effective.• Partner with patients and encourage

communication about CAM.

Jonas 2000

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Partner with patients and communicate about CAM

• ASK!

• “Build” a history that includes CAM use. (Don’t “take” one.)

• When patients tell, LISTEN!

Haidet 2003

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• an opportunity to bring together

strengths and balance weaknesses of

different systems of health care

• “a coming together of heart, head, and hand”

Owen 2001

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“Could this be a healing process

in itself”?

Owen 2001

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An Integrative Approach to Complementary and

AlternativeMedicine

in Primary Care Settings

Maureen A. Flannery MD, MPH

Department of Family Practice

University of Kentucky College of Medicine

Sports Sports SupplementsSupplements

Sports Sports SupplementsSupplements

Andrew Gregory, MDAndrew Gregory, MD

Assistant Professor, Orthopedics/ Assistant Professor, Orthopedics/ PediatricsPediatrics

Team Physician, Vanderbilt UniversityTeam Physician, Vanderbilt University

Jan. 10, 2002Jan. 10, 2002

Definition: Ergogenic Aids

• Ergo = work• Gennan = to produce• Any substance or method used to

enhance performance through increased energy utilization:– production– control– efficiency

Classification

• Drugs:– Hormones– Stimulants– Narcotics– Diuretics– B-Blockers

• Supplements:– Prohormones?– Amino Acids– Metals– Antioxidants– Herbs

Prevalence:

• Estimated 11% of HS athletes, college, and professional.

• Majority of Olympic swimmers, cyclists, sprinters, & weight lifters

• 2/3 of the 1998 Tour de France teams

• Billion Dollar Industry

Reasons:

• Have to use them to be Have to use them to be competitivecompetitive

• Need the edgeNeed the edge• Not genetically giftedNot genetically gifted• Dissatisfaction with size/ weightDissatisfaction with size/ weight• Peer/ Team PressurePeer/ Team Pressure

Hormones• HGH• EPO• BHCG• Steroids

Human Growth Hormone

• Normally secreted by the pituitaryNormally secreted by the pituitary• Normal function of GH is growth and Normal function of GH is growth and

development of every body system, development of every body system, including bone and muscleincluding bone and muscle

• Can be stimulated by propanolol, Can be stimulated by propanolol, vasopressin, clonidine, and levodopavasopressin, clonidine, and levodopa

• Synthetic growth hormoneSynthetic growth hormone

Side Effects:

• Acromegaly (may be irreversible)Acromegaly (may be irreversible)• Peripheral NeuropathyPeripheral Neuropathy• Coronary Artery DiseaseCoronary Artery Disease• CardiomyopathyCardiomyopathy• Diabetes, Hypothyroidism, arthritisDiabetes, Hypothyroidism, arthritis• No available urine test available, but No available urine test available, but

banned by NCAA and IOCbanned by NCAA and IOC

Erythropoietin

• Hormone released by the kidneys in response Hormone released by the kidneys in response to low Hctto low Hct

• Stimulates RBC production from bone marrowStimulates RBC production from bone marrow• Has recently been manufactured by Has recently been manufactured by

recombinant DNA techniquerecombinant DNA technique• Can increase Hct in renal patients by up to Can increase Hct in renal patients by up to

35%, lasting up to 7 months35%, lasting up to 7 months• Used most by cyclistsUsed most by cyclists

Blood Doping

• Induced Erythrocythemia: An increase in Induced Erythrocythemia: An increase in Hb following reinfusion of an athlete’s Hb following reinfusion of an athlete’s bloodblood

• Goal: to increase the oxygen-carrying Goal: to increase the oxygen-carrying capacity of Hbcapacity of Hb

• Has been used as far back as 1947Has been used as far back as 1947• 1984: seven US Olympic cyclists guilty1984: seven US Olympic cyclists guilty• Banned by IOC in 1985Banned by IOC in 1985

Pathophysiology

• Muscles depend on ATP for energy• Aerobic metabolism = breakdown of

glycogen in presence of O2 >>>ATP• Aerobic metabolism-higher yield of ATP• More O2 carrying capacity>>more ATP

production, more energy to muscle• 1 U PRBC>>500 ml / min increase in O2

carrying capacity

Methods:

• Autologous reinfusion method: 2 units blood removed 4-8 weeks prior to competition & frozen c glycerol

• Hb / Hct returns to pre-transfusion levels• Reinfusion 1-7 days prior to event• Can produce up to 25% improvement in

endurance, with poorer conditioned athletes showing greatest benefits

Side Effects:

• Heterologous blood: transfusion rxn (3-10%), Hepatitis (10%), HIV (?%)

• Autologous blood: bacterial infections• Polycythemia: increased viscosity

>>CHF, HTN, CVA• Most young healthy athletes show no

side effects

Detection:

• Blood doping and Erythropoietin: banned by IOC

• No known urine test to detect• Testing: Measured Hct >50• Measurement of serum Fe and

Bilirubin to detect hemolysis after frozen PRBC transfusion

Anabolic Steroids• The ultimate ergogenic aid aka

“Juice”• Creates the Superhuman Athlete• Testosterone derivatives

(cholesterol)• Produced in the adrenal/ testes

Anabolic/Androgenic Steroids

• Anabolism - Constructive• Catabolism - Destructive• Anabolic effects : inc. skeletal mm mass• anticatabolism• Androgenic effects: secondary sexual

characteristics - pubic hair, genital size• No Pure Anabolic Steroids

History of Steroids• First Available - 50’s (Dianabol)• Drug Banned - 60’s• Testing Initiated- ‘76• Athletes Banned - ‘83 Pan Am Games• Schedule III Controlled Substance - ‘90

Anabolic Steroid Control Act• US Dietary Supplement Act - ‘94 no

FDA approval if no “drug intent”

Administration:

• Athletes may take up to 40-100x therapeutic dose Athletes may take up to 40-100x therapeutic dose (200-2000 mg/ wk)(200-2000 mg/ wk)

• IM adm bypasses the liver/ PO does notIM adm bypasses the liver/ PO does not• ““Stacking”: using various aids in combinationStacking”: using various aids in combination• ““Cycling” : gradual inc. then taper over 6-10 weeks, Cycling” : gradual inc. then taper over 6-10 weeks,

1-3 cycles /year, “bridging” between1-3 cycles /year, “bridging” between• Illicit - Nandrolone, Stanozolol (Winstrol), Methelone, Illicit - Nandrolone, Stanozolol (Winstrol), Methelone,

Tibolone, OxandroloneTibolone, Oxandrolone• Medical - Testosterone, Enanthate, Undelanoate, Medical - Testosterone, Enanthate, Undelanoate,

Dehydrotestosterone (patch)Dehydrotestosterone (patch)

Desired Effects:

• Increase in strength• Increase in weight• Increase in aggressiveness• Increased capability of sustaining

repetitive, high intensity workouts• Enhanced performance

Side Effects:

• CV: MI - hypertension, inc. LDL, dec. HDL, CV: MI - hypertension, inc. LDL, dec. HDL, cardiac hypertrophy, thrombosiscardiac hypertrophy, thrombosis

• Endocrine: virilization, testis atrophy, Endocrine: virilization, testis atrophy, azospermia, priapism, prostatic hypertrophy/ azospermia, priapism, prostatic hypertrophy/ CA, gynecomastia, erectile dysfct, libidoCA, gynecomastia, erectile dysfct, libido

• Liver : peliosis hepatitis, hyperplasia, Liver : peliosis hepatitis, hyperplasia, adenoma, no carcinoma, elevated LFTsadenoma, no carcinoma, elevated LFTs

• MS: epiphyseal closure, inc. bone density, MS: epiphyseal closure, inc. bone density, dec. tendon strengthdec. tendon strength

Side Effects (cont’d):• Skin: acne, hirsuitism, striae, androgenic Skin: acne, hirsuitism, striae, androgenic

alopecia, inc. sebaceous glandsalopecia, inc. sebaceous glands• Metabolic: hypernatremia, kalemia, Metabolic: hypernatremia, kalemia,

phosphatemia, calcemia, “prediabetic”phosphatemia, calcemia, “prediabetic”• Psychiatric : aggressiveness, extreme mood Psychiatric : aggressiveness, extreme mood

swings - depression/ mania, dependence, swings - depression/ mania, dependence, other drug use, “Reverse Anorexia”other drug use, “Reverse Anorexia”

• Long Term - dec. life spanLong Term - dec. life span

Specific Side Effects

• Women (Virilzation):– Clitoril enlargement,

Deepening of voice, Male pattern baldness, dec. breast size, libido

• Children: – premature closure of

growth plate in long bones & thus short stature

“Prohormones”• Androstenedione • DHEA• Androstenediol• Norandrostenedio

ne• Norandrostendiol

Androstenedione

• 1/2 of the “ Mark McGuire Special” • A natural steroid hormone found in

all animals and some plants• Metabolite of DHEA• Precursor of testosterone• Synthesized in Adrenals/ Gonads• Metabolized in the liver to

testosterone

Effects:

• Benefits: Same as TestosteroneBenefits: Same as Testosterone– Increased energyIncreased energy– Enhanced recovery and growth from exerciseEnhanced recovery and growth from exercise– heightened sexual arousal and functionheightened sexual arousal and function– greater sense of well-beinggreater sense of well-being

• Plasma levels of testosterone increased from 140% Plasma levels of testosterone increased from 140% to 330% of normal levels after 50mg and 100mg to 330% of normal levels after 50mg and 100mg dosesdoses

• SE’s : Same as Testosterone• Banned by IOC, NCAA, NFL

DHEA (Dehydroepiandrostero

ne)• What it is: A hormone produced by

adrenal gland• Claims: Anabolic effect• What is does: Increases

testosterone levels• Banned by the NCAA, NFL

Stimulants• Caffeine• Amphetamines• Cocaine• Ephedrine

Amphetamines

• Have been used as far back as WWII when soldiers used them to delay fatigue

• First study in 1959 showed significant improvement in performance

• Available data suggest Amphetamines can improve performance in sports where speed, power and endurance are required

Side Effects:

• Related to drugs’ effect on CNS: insomnia, Related to drugs’ effect on CNS: insomnia, instability, agitation and restlessnessinstability, agitation and restlessness

• Confusion, paranoia, hallucinationsConfusion, paranoia, hallucinations• Dyskinesias, especially in facial musclesDyskinesias, especially in facial muscles• Cardiac complications: HTN, arrhythmiasCardiac complications: HTN, arrhythmias• GI disturbancesGI disturbances• Severe rebound of fatigue and depression Severe rebound of fatigue and depression

after discontinuanceafter discontinuance

Caffeine

• A Methylxanthine: same class as A Methylxanthine: same class as theophylline and theobrominetheophylline and theobromine

• Exerts its’ effects by:Exerts its’ effects by:– Translocation of Calcium for more muscular Translocation of Calcium for more muscular

availabilityavailability– Increase in cAMP by inhibition of Increase in cAMP by inhibition of

phosphodiesterasephosphodiesterase– Blockage of adenosine receptors, blocking the Blockage of adenosine receptors, blocking the

sedative properties of adenosinesedative properties of adenosine

Caffeine (cont’d)

• Is banned by IOC and NCAA in large dosesIs banned by IOC and NCAA in large doses• Legal limit = 15 micrograms / mlLegal limit = 15 micrograms / ml• Equal to 6-8 cups of coffee at one sitting, with Equal to 6-8 cups of coffee at one sitting, with

testing within 2-3 hourstesting within 2-3 hours• Beneficial most in endurance events, such as Beneficial most in endurance events, such as

cyclingcycling• Doses up to 5 mg / kg were required to see Doses up to 5 mg / kg were required to see

benefits. Doses of 17 mg/kg produce the benefits. Doses of 17 mg/kg produce the maximum legal limit.maximum legal limit.

Side Effects:

• Similar to s/e of other stimulants:– insomnia, irritability, nervousness– Tachcardia, arrthymias, and possibly

death!

Ephedrine• What it is: Is a drug found in herbal products What it is: Is a drug found in herbal products

containing Ma haung, anti-asthmatic medications, containing Ma haung, anti-asthmatic medications, and many cold and cough products.and many cold and cough products.

• Claims: Increases body fat lossClaims: Increases body fat loss• What really does: Acts as a CNS stimulant, delays What really does: Acts as a CNS stimulant, delays

fatigue by sparing body glycogen reserves. fatigue by sparing body glycogen reserves. Increase in B/p respiratory, heart rate, insomnia, Increase in B/p respiratory, heart rate, insomnia, and nervousnessand nervousness

• Max dose : 24 milligams per day!!!!!!Max dose : 24 milligams per day!!!!!!

Amino Acids• Creatine• L-Carnitine• Choline• Inosine• HMB (B-OH-B-

Methylbutyrate)

Amino Acids

• Essential amino acids: found in a balanced Essential amino acids: found in a balanced dietdiet

• Recommended protein intake: 0.8 g /kg/dayRecommended protein intake: 0.8 g /kg/day• Athletes may benefit from up to 1.4 -2.4 Athletes may benefit from up to 1.4 -2.4

g/kg/dayg/kg/day• Most beneficial for athletes on a poor diet, or Most beneficial for athletes on a poor diet, or

vegetariansvegetarians• In endurance athletes, up to 10% of energy In endurance athletes, up to 10% of energy

expenditure is from protein breakdownexpenditure is from protein breakdown

Creatine

• The Other 1/2 of the “Mark Mcguire The Other 1/2 of the “Mark Mcguire Special” - The Creatine Craze - Sales Special” - The Creatine Craze - Sales expected to reach $200 million in 1998expected to reach $200 million in 1998

• Use has spread: Use has spread: – 13% of HS athletes13% of HS athletes– 80% of University of Nebraska football team80% of University of Nebraska football team– 50% of NFL players50% of NFL players– Vast majority of Olympic sprinters, cyclists, and Vast majority of Olympic sprinters, cyclists, and

sprinterssprinters

Creatine

• Methylguanidine-acetic acid - made from glycine, arginine & methionine

• Estimated Daily requirement: 2gms• Available in meats and fish (1/2 EDR)• Sold as Creatine Monohydrate• Stored in Skeletal MM• 2000 NCAA banned distribution in training

rooms

Pathophysiology:

• Energy Substrate for muscle contraction• Creatine binds Phosphorus as substrate for

formation of ATP (main source of energy of contraction)

• PCr also buffers Lactic Acid• After PCr is depleted must resort to glycolysis

for ATP production• Net result: sustained muscular contraction,

delayed fatigue

Benefits:

• Improved performance in repeated bouts of Improved performance in repeated bouts of high intensity strength work and sprintshigh intensity strength work and sprints

• Single sprint activity results are equivocalSingle sprint activity results are equivocal• Does not enhance endurance exerciseDoes not enhance endurance exercise• More work with less lactic acid productionMore work with less lactic acid production• No studies on competetion benefitsNo studies on competetion benefits• 1998 ACSM meeting: 19/19 studies

showed significant ergogenic benefit

Dosing:

• Loading Phase: 20-30 gm/d, x 5 -7 daysLoading Phase: 20-30 gm/d, x 5 -7 days• Maintenance phase: 2-5 gm/dayMaintenance phase: 2-5 gm/day• Loading increases PCr stores by 10-40%Loading increases PCr stores by 10-40%• Normal resting levels of creatine: 100-150 Normal resting levels of creatine: 100-150

mM/kgmM/kg• Most striking benefits occur in subjects with Most striking benefits occur in subjects with

lower resting Cr levellower resting Cr level• After saturation of tissues, excessive After saturation of tissues, excessive

supplementation is renally excretedsupplementation is renally excreted

Side Effects:

• Muscle CrampingMuscle Cramping• DiarrheaDiarrhea• DizzinessDizziness• DehydrationDehydration• Biggest danger: getting “impure” Biggest danger: getting “impure”

creatinecreatine• Significant WEIGHT GAIN common 2nd to Significant WEIGHT GAIN common 2nd to

water retentionwater retention

The Perfect Supplement?

• “The secret is to find something that is The secret is to find something that is effective in improving performance, but not effective in improving performance, but not against the rules, and with no side effects” against the rules, and with no side effects”

• “…“…no clear evidence of harmful side effects no clear evidence of harmful side effects of creatine use has emerged…”--The of creatine use has emerged…”--The Physician and Sportsmedicine, June 1998Physician and Sportsmedicine, June 1998

• Long term effects of Creatine not yet studied: Long term effects of Creatine not yet studied: Concerns focus on effects to kidney, Concerns focus on effects to kidney, pancreas, and liver.pancreas, and liver.

Counseling your patients

• Creatine may or may not improve performance

• Weight gain will occur• Side effects (especially long-term) not well

known• Need to have renal and liver fct. Monitored

– should not be used in patients with chronic kidney/ liver disease

• Do not exceed the recommended dose

• Synthesized in Liver/ Kidney from Lysine & Methionine

• found in meats & dairy products• Assists in Fat transportation into muscle

mitochondria for oxidation, sparing Glycogen & may prevent lactic acid accumulation

• Improved endurance performance not shown in studies

L-Carnitine

HMB• Metabolite of KIC (ketoisocaproate)

which is a metabolite of leucine• Leucine & KIC found to have

anticatabolic effects• decreased mm proteolysis, inc.

lean mm mass, inc. strength• no known side effects

Choline• Precursor for the neurotransmittor

Acetyl Choline & the lipoprotein Lecithin (Phosphattidylcholine)

• choline depletion in marathoners• no studies supporting

Inosine• Increases myocardial contractility• no performance enhancement in

runners/ cyclists

Metals/ Minerals• Chromium• Magnesium• Boron• Vanadium

Chromium• Insulin Cofactor• inc. AA uptake into mm cells• increase mm mass, dec. body fat• found in meats, grains, raisins, apples, &

mushrooms• SE’s: anemia, chromosomal damage,

cognitive impairment & interstitial nephritis in excessive doses

Magnesium• Involved in ptn synthesis & mm

contraction• + effects on oxygen consumption

& lactate production• no change in performance

Boron• Originally thought to inc.

testosterone levels• not born out in studies

Vanadium• What it is: Non-essential trace mineralWhat it is: Non-essential trace mineral

• Claims: Anabolic effect, enhances insulin Claims: Anabolic effect, enhances insulin actionaction

• What it does: No studies to show anabolic What it does: No studies to show anabolic effect. Doses>10gms/day causes abd. Pain, effect. Doses>10gms/day causes abd. Pain, cramps, green tongue,diarrhea, wt. losscramps, green tongue,diarrhea, wt. loss

Antioxidants• Vitamins E & C• potential damage from free

oxygen radicals produced by lipid peroxidation in exercise

• exercise performance is not improved

Herbs• Ginseng• Yohimbe• Tribulus

Terresteris• Ma haung

Ginseng• What it is: A root from an Asian plant (panax What it is: A root from an Asian plant (panax

ginseng).ginseng).• Claims: Enhanced performance. Improved Claims: Enhanced performance. Improved

recovery rate.recovery rate.• What it really does: Acts as an adaptogen- may What it really does: Acts as an adaptogen- may

boost immune system and protect cells. May boost immune system and protect cells. May cause insomnia, and should not be used if B/p is cause insomnia, and should not be used if B/p is elevated.elevated.

• Dose: 100-200mg per day used occ.2-3 weeks on Dose: 100-200mg per day used occ.2-3 weeks on 1-2 weeks off1-2 weeks off

• What it is: Supplement derived from tree bark.

• Claims: Anabolic effect, Increased virility

• What it does: Stimulant effect, no anabolic effect. Can cause nervousness, HA, nausea, Vomiting, increased B/P

Yohimbe

• What is it: A plant hormone• Claims: Anabolic effect• What it does: Increases

testosterone levels• Banned by NFL

Tribulus Terresteris

Miscellaneous:• Bicarbinate

Loading• Coenzyme Q• Linoleic Acid

Bicarbonate Loading

• Used prior to competition to neutralize Used prior to competition to neutralize lactic acid produced by anaerobic activitieslactic acid produced by anaerobic activities

• Lactic acid>>lower pH>>fatigueLactic acid>>lower pH>>fatigue• May improve runners’times if taken 30 min May improve runners’times if taken 30 min

prior to competition : best in intermediate prior to competition : best in intermediate distances 800-1500 meter eventsdistances 800-1500 meter events

• 300mg/kg required300mg/kg required• Terrible GI s/e in 50% of users--cramps, Terrible GI s/e in 50% of users--cramps,

diarrhea, ^ BPdiarrhea, ^ BP

Coenzyme Q10 Conjugated

(coQ10,Ubloquinone) Linoleic Acid

• Produced by the body in mitochondria

• claims: Enhances performance, delays fatigue, prevents injury

• What really does:Functions as an antioxidant

• Safe levels:60-200mg/day but also$$$$$

• Naturally occurring fatty acid found in beef ,lamb and dairy

• claims: decreases body fat ,increases muscle gain,antioxidant

• What really does: No effect on performance

References• Blue J, Lombardo J, Nutritional Aspects of Blue J, Lombardo J, Nutritional Aspects of

Excercise: Steroids & Steroid-like compounds, Excercise: Steroids & Steroid-like compounds, Clinics in Sports Medicine, Vol 18, Num 3, July Clinics in Sports Medicine, Vol 18, Num 3, July 1999, pp 667-6891999, pp 667-689

• Stricker P, Other Ergogenic Agents, Sports Stricker P, Other Ergogenic Agents, Sports Pharmacology, Vol 17, Num 2, April 1998, Pharmacology, Vol 17, Num 2, April 1998, pp283-297pp283-297

• Agee R, Ergogenic Aids, ASMI Lecture, Nov. 99Agee R, Ergogenic Aids, ASMI Lecture, Nov. 99

Useful Resources• Organizations:Organizations:• A) Gatorade sports science Institute 800-616-4774A) Gatorade sports science Institute 800-616-4774

• B) Herb Research Foundation 303-449-2625 B) Herb Research Foundation 303-449-2625 • C) USOC Drug Information Hotline 800-233-0393C) USOC Drug Information Hotline 800-233-0393

• Web Sites:Web Sites:• FDA:http//vm.cfsan.fda.gov/~dms/aems.html• U.S. pharmacopeia:www.usp.org/did/mgraphs/botanica/index.htm• Dietary Supplements Reference: http://dietary-

supplements.info.nih.gov• USOlympicCommittee: www.usoc.org• IOC: www.olympics.org• NCAA: www.ncaa.org

1 complementary and alternative medicine, dietary supplements, and medications

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