Dietary Supplements and Nutrition Fads: An Update

Maureen Molini, MPH, RDN, CSSDRegistered Dietitian Nutritionist, UNR Student Health Center

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Dietary Supplements

• “Dietary ingredient” intended to add further nutritional value to the diet

• Vitamin, mineral, herb or botanical, amino acid, concentrate, metabolite, extract

• Many different forms• Tablets, capsules, soft gels, gel caps, liquids or powders

Conventional food = “Nutrition Facts” panel

Dietary supplement = “Supplement Facts” panel

www.FDA.gov

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Supplement use is widespread and sales are big business

Source: FDA, CDC, Academy of Nutr & Dietetics

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Dietary Supplements

• In the US dietary supplements are regulated by the Food & Drug Administration (FDA) under the Dietary Supplement Health and Education Act (DSHEA) which establishes legal definitions and label guidelines.

• Defines dietary supplements as a category of food• Dietary supplements are not pre-approved by the FDA

– DSHEA does not ensure safety, effectiveness or quality.

• Is it safe? Is it effective? Is it contaminated?

www.FDA.gov

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Increased concern with tainted supplements

• 1990’s ma huang (ephedra) linked to organ damage and deaths – banned 2004

• Recently banned substance methylsynephrine(oxilofrine) – stimulant that increases BP, not approved for use in US as supplement or rx drug.

2016 study - Analyzed 27 brands and found presence in 14 of them – doses ranged from 0.0003-75mg/cap or tablet

Cohen et al., Drug Test Analysis. 2016.

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Other unlisted additives found…• 2014 study – other pharmaceuticals or those no longer

approved by FDA d/t side effects– 1,3-dimethylamylamine (DMAA) – at least a dozen

supplements for wt loss , enhanced brain function and improved athletic performance

– N, a-diethyl-phenylethylamine (N, a-DEPA) – similar in structure to methamphetamine

• Cohen, Travis, Venhuis, 2014. Drug Test Analysis

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From the FDA’s Investigations

• 5-20% of supplements marketed to athletes –even those marketed as “natural” – may contain banned substances that are included either intentionally or from cross-contamination.

Source: USA Today, 2015

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Supplement Safety

• When advised by a medical professional to target specific needs, supplements can benefit health and generally consumed w/out ill effects:

• For example:– Folic acid women of childbearing age– B12 over 50 yrs. of age– Ca + Vitamin D for bone health– Fe for anemia

• www.nsf.org– NSF certified

• For sport - screen supplements for ~265 banned substances. Phone application available

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Ergogenic Aids: Update

• Ergogenic Aid: Anything that will improve or enhance physical performance– A supplement, drug or food component– When to use?

• Safe, legal, effective, no side effects, when the effect of timing is known

• Estimated 60% of all elite athletes use 1 or more Schroeder et. al; J Sports Sci. 2002

• Nearly 45% of collegiate athletes Greenwood et. al; Clin J Sport Med. 2000

• Adolescent athletes may be as high as 30% McGuire et. al; Clin J Sport Med. 2000

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Beta Alanine

• High intensity exercise – appears most effective for exercises lasting between 60-240 sec.

• May increase carnosine, a lactic acid buffer (reduce acidosis), which may increase exercise capacity

• Dose 6.5g/d for 28 days maximizes carnosine concentration in skeletal muscle

• Maintenance dose 1.6g/d will keep carnosine levels elevated in muscle

• Remains unclear whether improves performance• High doses may cause paranesthesia, but slow release forms

do notHobson, et.al, 2012 Amino Acids

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Branched Chain Amino Acids (BCAA)

• BCAA’s including leucine, isoleucine & valine• Used by endurance athletes as an energy

source late in exercise when muscle CHO stores low

• Leucine – anabolic trigger to stimulate muscle protein synthesis (3-4g post workout). – Key aa in whey, a protein in milk

• Whey – fast; casein – slow– More sustained availability of aa to muscles

J Sport Sci 29:S57, 2011

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Caffeine

• Ergogenic Aid for aerobic exercise (endurance)• Caffeine increases lipolysis and spares muscle

glycogen = able to do more work– Other possible mechanisms of action:

• Reduce perception of pain by elevating B-endorphins• Maintaining high CNS drive by reducing central fatigue

blocking adenosine (adenosine receptor binding)• Increase ease of muscle fiber recruitment, reducing the

mental drive necessary for a given exercise intensity

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Caffeine

• Dose = 3 – 4mg/kg body wt– 150# (68kg) = 200-270mg

• Can work for regular caffeine users as well as those that limit caffeine

• Caffeine provided around (45-60 min prior) a session of aerobic exercise can increase energy expenditure and fatty acid oxidation

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Creatine• Found in meat & fish – meat eaters ingest ~1g/day• Most widely used nutritional supplement among athletes,

including adolescents. • Works by increasing the rate of phosphocreatine re-

synthesis during the recovery phase of intermittent high-intensity exercise, making repeated bouts of high-intensity exercise possible while delaying muscular fatigue – can elevate serum creatinine, particularly in individuals

with compromised kidney function

• Safe when used in the recommended doses

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Creatine

• Monohydrate is form used in studies, no evidence other forms are more effective (“micronized” /microdosing”)

• Supplementing 20-25g for 5-7 days, followed by 5-10g daily for up to 2 mos– Increases muscle creatine content by ~20%

• Does not cause muscle cramping• Has not been shown to cause kidney damage in healthy

athletes, even those eating high amounts of protein– Increase an athlete’s ability to train

• Improved strength and powerJ Intl Soc Sports Nutr, 9:33 2012

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“Pre workout”

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•275mg of caffeine•1.8g of Beta-Alanine

•3g Creatine blend•Explosive energy, focus, endurance, strength

and power*Push yourself and your workout as far as

you can. Then, push further.

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Beetroot Juice

• Potent source of dietary nitrate– Occurs naturally in vegetables such as arugula,

rhubarb, celery, spinach & red beetroot– Dietary nitrate Nitric oxide (NO) (especially

during times of low O2 availability e.g exercise) – 200-500ml (~8-16oz) consumed ~2-3 hrs prior to exercise

– Appears to be safe (beeturia – red hued urine)– Unknown if high intakes of nitrates over a long

period of time will have negative health consequences

Wylie et al. J Appl Physiol, 2013

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Beetroot Juice

• Research w/older adults and HTN• Several studies using well-trained cyclists and

rowers– Recent meta-analysis

• Showed a small performance improvement in laboratory exercise tests (time to task failure)

• Effect seen at all exercise intensities • 500 ml beetroot juice ingested daily for 6 days prior to

exercise (~500mg nitrate)• More research needed for most effective dose and who

might benefit most. Int J Sport Nutr Exer Metab. 22:64, 2012

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Dietary Nitrate (NO3) Nitrite (NO2) Nitric Oxide (NO)

• NO reduces the oxygen cost of exercise (greater endurance)

greater O2 delivery to working muscles

increases the capacity for high intensity exercise -

aerobic energy production in mitochondria of the muscle is more efficient (ATP production per unit of O2 H2O)

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Nitric Oxide (NO)

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Dietary sources of nitrate [mg/100g fresh wt. (3.53oz.)]

• Very low <20mg = artichoke, asparagus, eggplant, garlic, onion, green bean, mushroom, pea, pepper, potato, sweet potato, tomato

• Low 20-<50 = Broccoli, carrot, cauliflower, cucumber, pumpkin,

• Mid 50-<100 = Cabbage, dill, turnip• High 100-<250 = Chinese cabbage, endive, leek, fennel,

parsley• Very high >250 = Celery, cress, chervil, lettuce, red beetroot,

kale, spinach

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Vitamin & Mineral Update

• Daily Values (DV’s) set by the FDA are based on the National Academy of Medicine’s Recommended Dietary Allowances (RDA’s), which vary slightly by age and sex– FDA recently updated DV’s– Labels must use new DV’s starting July 2018

•DV’s for nutrients like sodium, dietary fiber and vitamin D are being updated based on newer scientific evidence from the Institute of Medicine and other reports such as the 2015Dietary Guidelines Advisory Committee Report, which was used in developing the 2015-2020 Dietary Guidelines for Americans. Daily values are reference amounts of nutrientsto consume or not to exceed and are used to calculate the percent Daily Value (% DV) that manufacturers include on the label. The %DV helps consumers understand the nutrition information in the context of a total daily diet.

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www.FDA.gov

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DV Updates• Vitamin C (Bell peppers, broccoli, strawberries, orange & cranberry juice) :

DV rising from 60mg to 90mg. Smokers need 125 mg.– Taking more than 1000 mg at one time can cause diarrhea

• Vitamin D (Herring, halibut, sardines, tuna, egg yoks, fortified milks):DV doubling from 400 IU to 800 IU– Taking more than 4,000 IU/d may lead to high blood Ca+

• Vitamin K (Leafy greens, artichokes, asparagus, broccoli, cabbage):DV increasing from 80 mcg to 120 mcg- Affects thinness of blood and may interfere w/drugs (warfarin & Coumadin)

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DV Updates• Vitamin E (nuts, oils, whole grains, leafy greens): DV decreasing

from 30 IU to 22.5 IU (15mg) - high doses may not be safe

• Calcium (milk, yogurt, cheese, leafy greens, soybeans) – DV increasing from 1000 mg to 1300 mg (for children 9-18) Premenopausal women & men up to age 70: 1000 mg Postmenopausal women & men over age 70: 1200 mg

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Calcium…cont.

• Taking >1000 mg/d may increase risk of kidney stones & fractures

• Taking >2000 mg/d may raise risk of prostate ca• Ca supplements have no impact on heart, strokes, or

other CVD– New review of evidence – four clinical trials and 27

observational studies - by an expert panel• Found no increased risk in people taking 2000-2500 mg/d

J Am Heart Assoc. 2016

Ann. Intern. Med. 2016

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DV Updates

• Folic Acid (leafy greens, beans, broccoli, cereals, papaya): New DV is 400 mcg – pregnant women should take supplement w/400 mcg

• Magnesium (leafy greens, whole grains, beans, nuts): DV increasing from 400mg to 420mg.– More than 350 mg from supplements may cause diarrhea

& stomach cramps

• B12: DV dropping from 6 mcg to 2.4 mcg– Adults over 50 should get most from a supplement or

fortified food because they may not make enough

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DV Updates

• Iodine: CDC warns women in 20’s & 30’s may not be getting enough, which is essential for developing brain during pregnancy

• Chromium: DV dropping from 120mcg to 35 mcg– Does not appear to lower bs in T2 diabetics

• Selenium: DV decreasing from 70 mcg to 55 mcg (Americans get ~100 mcg from food)– Unclear whether supplements raise risk of DMT2 &

prostate cancer

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DV Updates

• Potassium (Potatoes, bananas, leafy greens): DV increasing from 3,500 mg to 4,700 mg

• Zinc: DV reducing from 15 mg to 11 mg• Copper: DV dropping from 2 mg to 0.9 mg

– Too much Zn (>40 mg from food & supplements combined) can reduce copper absorption

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Multivitamins

• “Can provide a safety net for people who are eating reasonably well but night not be sure they’re getting all the recommended levels of essential vitamins and minerals to avoid deficiency.” -Howard Sesso, MD (Physicians Health Study II)

– May matter more as people age• Calorie needs tend to decrease, appetite lower and

absorption less

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Multivitamins

• Worth taking if it supplies nutrients like Vitamins D (600 IU/d until age 70, then 800IU) and B12 that you may not get enough from food

• Won’t “support” heart, brain, immunity, healthy appearance

• No more than $5/month for a high-quality MVI

Center for Science in the Public Interest, Nov 2016

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Multivitamins

• Claims: – Immunity – ”Antioxidants support normal immune function”

• 3 clinical trials (~2,150 older men & women), MVI users were just as likely to get sick and stay sick as long as placebo takers J Am. Geriatri. Soc. 2007; BMJ, 2005, JAMA, 2002

– Heart Health – “B-vitamins help promote heart health”• At least 12 clinical trials have shown that B-vitamins don’t reduce the risk of heart attacks

or strokes Cochrane Database Syst. Rev. 1:CD00612, 2013

– Eye Health – “Vitamins, A, C & E and Leutin support healthy eyes”• Male MD’s who took MVI for 11 years had 9% lower risk of cataracts than those who

took a placebo Opthamology, 2014

– Muscle Function - “Mg, Vitamin D and B6 support muscle function”• No good evidence for B6. Still not known if Mg or Vitamin D do.

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Brands of MVI’s to Recommend• Premenopausal women:

• CENTRUM Adults• CVS SpectraVite Adult• NATUREMADE Multi Complete Tablets• WALGREENS Adults• WALMART Equate Complete Adults Under 50

• Postmenopausal women (too much Ca for men):• CENTRUM Silver Women 50+• CVS One Daily Women’s 50+ Advanced• ONE A DAY Women’s 50+ Healthy Advantage• WALGREENS Women 50+

• Men:• CENTRUM Men• CENTRUM Silver Adults +50• CVS One Daily Men’s Health• NATUREMADE Multi for him

CHEWABLE:

Center for Science in the Public Interest, 2016

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Nutrition Fads

A fad diet is a diet that makes promises of weight loss or other health advantages such as longer life without backing by solid science, and in many cases are characterized by highly restrictive or unusual food choices.

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How to spot a potential fad

• Is there promise of a quick fix or cure?• Are there reasons to mistrust the person, organization or

company involved?• Are they trying to sell something? • Are the authors qualified?• Do the facts sound too good to be true?• Does the information come from personal opinions rather

than scientific evidence?• Is content missing reviews or verification by medical experts?• Are the claims based on a single study that may draw the

wrong conclusion?

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Coconut Oil & MCT’s

• Claims: “Superpowers” “Protect against cancer” “Dissolve kidney stones” “lose excess body fat”– 92% of it’s fat is saturated– 60% Medium chain triglycerides MCT, 40% LCT

– Evidence is scarce:• 40 obese women decreased kcals by 200/d and exercised 4

days/wk– ½ used @TBS coconut oil (240 kcals), ½ used soybean oil

» After 3 mos, both groups lost same wt. = 2#, av. waist cir. same = 38”

Lipids 44:593, 2009

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Coconut Oil & MCT’s

• MCT’s formulated from coconut oil extracts (100% MCT’s)– Several small studies lasting 1-4 mos. Modest

effect on wt. loss• 31 overwt. or obese men & women – 1,500-1,800

kcals/d (12% of kcals - 1-2 TBS – of MCT oil or olive oil)» MCT oil users lost ~4# more than olive oil users (4 mos.)

Am J Clin Nutr. 87:621, 2008

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Coconut Oil & MCT’s

• Alzheimers:– Accera, Inc. – powder w/100% MCT’s (“Axona” –

“medical food”) 140 pts w/mild to moderate Alz.– 45 days – MCT takers scored better on test of

cognitive impairment (no difference after 90 days)

• Heart Disease: – conventional coconut oil increases cholesterol levels in rats,

rabbits & hamsters» 10 yrs ago “virgin coconut oil” emerges – “cold pressed”

Studies scarce – only study in 17 yrs. – Malaysia – young men and women - 20% kcals from coconut oil – LDL increased 8%, HDL increased 7% Am J Clin Nutr. 94:1451, 2011

Nutr. Metab. 6:31, 2009

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Apple Cider Vinegar

• Fermented juice made from crushed apples– Acetic acid – Naturally fermented foods (probiotics) are high in

beneficial Lactobacillus bacteria• May not settle into gut permanently, but affect

microbiota by influencing gene expression of bacteria already there

• Claims: helps w/weight loss, DMT2, heart disease, bacterial infections

Ther Adv Gastroenterol 6(4):295, 2013

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Spirulina

• Blue green algae • 4TBS = 81kcals, 16 g protein, 60% DV riboflavin, 44% DV

Fe and Thiamin, 14% DV Mg, 11% DV K

• Claims: cures allergies & candida, helps, w/weight loss

• Pregnant and breastfeeding women should avoid• May interact w/anticoagulant, antiplatelet and

immunosuppressant drugs• Those w/PKU should avoid d/t high protein content• Contamination w/heavy metals a concern

National Nutrition Database for Standard Reference Release, Accessed April 19, 2016

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Spirulina

• 2015 – double-blind, placebo-controlled, randomized trail; 40 subjects w/HTN– Consuming 2 g for 3 mos. = improved BMI, body

wt, BP.

– Not enough evidence at this time to recommend it for specific health conditions

Eur Rev Med Pharmacol Sci. 20:150, 2016

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Ketogenic Diet (KD)

• High fat, low CHO, adequate protein diet designed to mimic the effects of fasting or starvation

• The original version KD for seizure control – 4:1 (90% of energy from fat) or

3:1 (87% of energy from fat)

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Ketogenic Diet (KD)

• Seizures assoc. w/certain mitochondrial disorders

• 1923 – Otto Warburg – CA cells dysfunctional metabolic process, not a genetic one

• Normal cells – mitochondrial oxidative phosphorylation• Cancer cells – aerobic glycolysis (disturbed metabolic process)

Current research underway - malignant tumors – GBM -

• KD future research – ALS, TBI, Stroke, depression, Parkinson's, Alzheimer's

Complete Nutr. 15(4):69, 2015

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Nutrigenomics

• DNA Diet https://www.dnafit.com/diet/#order

• The DNA Diet: Simplified

“People have different genetic make ups and carry different genes and our ability to digest certain foods may well be dependent on whether we have the gene required to create the enzyme which can metabolize and break down that food.If you are eating foods which your body cannot efficiently break down, this may mean your body might be storing those extra calories and adding to the flab you are trying to get rid of.Eating the foods that do not complement your genes might leave you always feeling always hungry, under nourished, lethargic and a myriad of other unpleasant side effects.” Source: EasyDNA

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