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Evidence-based Supplementation for Health

& Performance

AIMS

!   An introduction to the supplement industry •  Quality of supplements •  Supplements for athletes vs the general population

!   Evidence-based supplementation to benefit health •  Fish Oils & Vitamin D

!   Evidence-based supplementation to benefit sports performance •  Caffeine, creatine, beta alanine, sodium bicarbonate,

HMB, L-Carnitine

!   Claims vs Research – Potentials Worth Mentioning •  Multis, Probiotics, L-Carnitine

!   Essential Supplement Knowledge

The Mentoring Lab Extras

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The Supplement Industry An Introduction

Considerations making recommendations

!   Integrity •  Supplements sell

!   Is there strong evidence behind them? !   Are they legal (specific to tested athletes)? !   Are they actually useful?

•  Or are they another tax on willpower? •  Can dose be achieved from dietary sources?

!   Quality will make a small difference •  E.g. multivitamin ingredients

Supplement Contamination

!   In 2012, 44% of UK Anti-Doping positive tests were caused by prohibited substances contained in supplements (Informed Sports)

!   Often poor manufacturing processes •  Found to contain impurities such as lead, broken glass &

animal faeces – FDA (2003)

!   Nutritional supplements contained prohibited stimulants not declared on the label - Geyer et al. (2008)

•  Ephedrine, methylenedioxymetamphetamie & sibutramine

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Evidence-Based Supplementation HEALTH

Fish Oils

!   What are fish oils? •  Eicosapentaenoic acid (EPA) •  Docosahexaenoic acid (DHA)

!   Why EPA and DHA and not ALA? •  Alpha-linolenic acid (ALA) can be converted to EPA and

DHA but only a small amount can be synthesised

Burdge et al. (2002); Burdge & Wooton (2002)

Gender ALA converted to

EPA (approx.) ALA converted to

DHA (approx.)

Men 8% 0-4%

Women 21% 9%

What are the benefits of fish oils?

!   Considered a ‘Nutraceutical’ !   Antihypertensive - Miller et al. (2014) – ACE Inhibitors !   Antihyperlipidemic - Zulyniak et al. (2013) – Statins !   Antiplatelet Activity (Stroke/DVT) – Warfarin !   Antiarrhythmic - Metcalf (2008) - Beta Blockers !   Anti-inflammatory - Kremer (2005) - NSAIDS !   Improvement in Depression - Sublette et al. (2011)

!   Anabolic resistance in elderly - Smith et al. (2010) !   Help facilitate weight loss - Noreen et al. (2010)

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Summary

Why?

- Cardiovascular benefits - Reduces inflammation - May increase strength and size gains - May improve fat loss

When? - Daily dose (dependent on oily fish intake)

What?

- Dose equivalent to EPA & DHA - Dose is goal and individual dependent - 300-1800mg/day - Vegetarian sources do exist (algae)

Vitamin D

!   Actually being defined as a ‘pro-hormone’ !   What is it?

•  Fat soluble ‘vitamin’ •  Synthesised within the body when skin is exposed to

sunlight •  Very small amount obtained from diet

Hamilton (2010)

“Vitamin D should no longer be considered only to have an impact on calcium metabolism and bone morphology, but should be recognized to have a broad impact on the organism as a whole.”

What are the benefits of Vitamin D?

!   Improves immune system - Prietl et al. (2013)

!   Improves bone health via supporting calcium absorption - Hill et al. (2013)

•  Reduces risk of bone loss & fracture risk (elderly)

!   Vitamin D deficiency associated with development of CVD, cancer, IBD & AI disorders - Holick, (2007)

!   Reducing depressive symptoms - Shaffer et al. (2014) !   Potentially improves strength - Tomlinson et al. (2015)

!   Potentially improves fat loss - Ortega et al. (2008)

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Considerations – Skin Pigmentation

!   Studied for 7-8 wk in the fall, winter, spring & summer in Cali on low African ancestry & high European ancestry skin reflectance.

!   Low (~20 min/d, ~18% body surface area exposed) and high (~90 min/d, ~35% BSA exposed) sun exposure.

”To achieve 25(OH)D ≥75 nmol/L, we estimate that EA individuals with high sun exposure need 1300 IU/d

vitamin D intake in the winter and AA individuals with low sun exposure need 2100-3100 IU/d year-round”

Hall et al. (2009)

Influence of Vitamin D status on Fat Loss

!   2 hypocaloric diets in women – Ortega et al. (2008)

•  Stratified by Vitamin D Status <50 nmol/l or >=50 nmol/l •  Higher group had significantly greater body fat loss

(-1.7kg) than the lower (-0.5kg)

!   4000IU’s Vitamin D vs Placebo – Carillo et al. (2013)

•  12 Week RT programme •  Strong inverse association between change in 25-

hydroxyvitamin D with change in waist-hip ratio •  Peak power also significantly increased at 4 weeks in

supplemented group only

Vitamin D & Waist-Hip Ratio

Carrillo et al. (2013)

Change in 250HD (ng/mL)

Cha

nge

in W

aist

-to-

Hip

Rat

io 0.10

0.08

0.06

0.04

0.02

0.00

-0.02

-0.04

-0.06

-0.08

-0.10 -10 0 10 20 30

Placebo Vitamin D

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Summary

Why?

- >50% of population are deficient - Immune function/ overall health - Muscle function - Fat Loss

When? - Cumulative dose (daily/weekly/monthly) - Take with fats for optimal absorption

What?

- Ideally, get blood tested and supplement accordingly - 2500 – 4000IU/day - Corrective bolus doses of up to 300,000IU

Vitamin D Supplementation vs. Others?

!   Vitamin C RNI - 40mg/day (BNF, 2015) •  45g broccoli •  1 small green pepper •  1 small orange

!   Vitamin B6 RNI - 1.2mg/d for females, 1.4mg/d for males (BNF, 2015)

•  200-230g chicken

!   2500IU of Vitamin D •  6250ml of whole milk •  143 LARGE eggs

Evidence-Based Supplementation PERFORMANCE

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Caffeine

!   Naturally-occurring stimulant (CNS) !   Available in a number of different formats

•  Food (Chocolate), Drink (Tea & Coffee/Energy Drinks), Tablets, Powder

!   Is a mild diuretic !   Caffeine

•  Tolerance adaptation •  Dependency is a real risk

!   Metabolism •  Absorbed in around 45mins •  Half life 4-6 hours

Caffeine Content

Food Stuff Serving Size Caffeine content (mg)

Coffee 150ml 50-120

Tea 150ml 15-50

Hot Chocolate 250ml 10

Milk Chocolate 50g 40

Coca Cola 330ml 50

Pepsi 330ml 40

Red Bull 250ml 80

Amino Energy 9g Sachet 100

Caffeine Tablets 1 Tablet 100-200

The amount of caffeine in a beverage depends on how concentrated the beverage is made e.g. Strong coffee

Performance benefits of Caffeine

!   Spares muscle glycogen - Greer et al. (2001)

!   Increases muscle fibres excitability - Olorunshola & Acie, (2011)

!   Reduces reaction time - Duvnjak-Zaknick et al. (2001)

!   Increases alertness & improves decision making, especially when sleep-deprived - Kamimori et al. (2015)

!   Increases force/strength – Placket (2001)

!   Improves muscular endurance - Carr et al. (2001)

!   Improves endurance performance - Desbrow et al. (2010)

!   Reduces RPE - Backhouse et al. (2011)

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Are there any other benefits?

!   Reduces appetite •  Some conflicting data on this - Gavrieli et al. (2011); Gavrieli et

al. (2013); Schubert et al. (2014)

!   Stimulates lipolysis •  Increased fat oxidation Astrup et al. (1990)

!   Metabolism •  Small increase in metabolism - Astrup et al. (1990)

Summary

Why?

- Improved endurance performance - Improved anaerobic performance - Improved reaction speed/concentration - May increase strength

When? - Taken 60 minutes prior to competition - Can be taken before important training sessions

What? - Tea/Coffee does not have same efficacy - Consider decreasing daily consumption - Ergogenic doses range from 2-6mg/kg

Creatine (Monohydrate)

!   The most well researched supplement ever!? ! Creatine monohydrate is the form that is ‘proven’ !   Beware of ‘new versions’

•  Creatine Ethyl Ester (CEE), Krealkalyn, Tricreatine malate

!   Non-responders do exist – Syrotuik, (2004) !   Side effects - weight gain and stomach cramps? -

Sergej, (2008)

NB: Creatine does not cause muscle cramps, dehydration, kidney damage, cancer. In other words, watching blue movies will do you

more harm! (You’ll go blind!)

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Benefits of Creatine

!   Biggest ergogenic effect in repeated high intensity efforts with short recovery - Izguierdo et al. (2002)

•  Isometric strength improved after only a few days - Cramer et al. (2007)

•  Increase the training load that can be tolerated therefore increased hypertrophy - Bemben et al. (2005)

!   Why can it improve RT adaptations? •  ↑ Training quality & ↑ strength - Rawson et al. (2003)

•  ↑ Recovery - Cottrell et al. (2002)

•  Anabolic signalling. Satellite cell proliferation. Amplifies training induced adaptations - Olsen et al. (2006)

Benefits for the endurance athlete?

!   Increased muscular endurance - Chwalbiñska-Moneta (2003)

•  Lactate Threshold occurs at a higher intensity. •  Increased time to exhaustion.

!   Increased glycogen storage •  Increased glycogen storage - Nelson et al. (2001)

•  Fall in blood glucose during exercise reduced - Engelhardt et al. (1998)

Are there any other benefits?

!   Improved cognitive function •  As little as 5g/d of creatine has a significant ↑ on both

working memory and intelligence - Rae et al. (2007)

!   Vegetarians increased lean tissue and performance •  V with Cr had a significantly ↑ in TCr, PCr, lean tissue,

and total work performance - Burke et al. (2003)

!   Sleep deprivation •  Creatine group had significantly less decline in

performance after sleep deprivation - McMorris et al. (2006)

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Summary

Why?

- Increased muscle strength - Increased muscle size - Improved intermittent sprint performance - Improved recovery & glycogen storage

When? - Ideally taken with food/carbohydrates - After training tends to be the best time

What? - To é muscle size, consider ‘loading’ - Loading is 5-7 days of 20g (4 doses) - ~5g per day as maintenance dose

Beta Alanine

!   What is Beta Alanine? •  An intracellular buffer of Hydrogen Ions (H+) through

increasing muscular stores of Carnosine

!   Common side effect •  Paraesthesia (tingling sensation on the skin)

!   What are the performance benefits? •  Only applicable in certain sports/situations

•  90 seconds absolute minimum

•  Delayed Fatigue - Derave, (2007) •  β-alanine attenuated fatigue caused by exhaustive dynamic

contractions of the quadriceps vs placebo •  ∴ greater force production in later stages of fatiguing exercise

Carnosine & Beta Alanine

!  Carnosine is typically higher in fast-twitch (type II), compared to slow twitch (type I), muscle fibres

!   “Muscle carnosine was significantly increased by 58.8% and 80.1% after 4 and 10 wks with BA supplementation”

Hill et al. (2006)

Car

nosi

ne m

mol

.kg-1

dm

Β-Ala

Placebo

19.9±1.9 30.1±2.3 34.7±3.7

23.6±2.4 25.5±2.0 23.9±2.5

0 w 4w 10w

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Summary

Why? - Increases muscle carnosine levels - Buffers hydrogen ions - Improve anaerobic performance

When?

- Daily timing does not matter, little & often is best - Don’t take in ‘aerobic base training’ periods?

What? - 4 - 10 weeks of 80mg/kg bodyweight - 40mg/kg maintenance dose thereafter - Single doses of 10-20mg/kg e.g. 1.5g

Sodium Bicarbonate

!   Anaerobic Exercise leads to lactic acid production !   ↑ Lactic Acid = ↓ muscle pH !   This has several effects:

•  Calcium binding is affected •  Some enzymes are inhibited •  Free nerve endings are stimulated

"The ingestion of Sodium Bicarbonate (NaHCO3) results in an expansion of the bicarbonate pool in the blood and a more alkaline extracellular environment. In certain situations, a considerable ergogenic effect may be realised."

Matson & Tran (1983)

What are the performance benefits of sodium bicarbonate?

!   Improved anaerobic performance •  In 1500m running performance - Bird et al. (1995)

•  In 200m swimming performance - Lindh et al. (2008) •  30-km Cycling (Citrate) - Potteiger et al. (1996)

!   Common side effect is gastrointestinal distress (sometimes severe)

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Summary

Why?

- Buffers Hydrogen Ions - Increases Blood Bicarbonate Pool - Decreases blood pH - Improved Anaerobic Performance

When? - Taken 60-90 minutes prior to competition - Can be taken before important training sessions

What? - Ergogenic dose circa 300mg/kg - Must test tolerance, side effects common - Added CHO seems to minimise side effects

Potentials Worth Mentioning Claims vs Research

Multivitamins and Minerals

!   What is a multivitamin and mineral? •  A dietary supplement that contains a mixture of vitamins,

minerals and sometimes extra ‘stuff’

!   Is a multi necessary? •  Useful if you lack vitamins and minerals in your diet •  May prevent/correct nutrient deficiencies

!   What does the research show? •  Insufficient evidence for reducing cancer risk - Huang et al.

(2006)

•  Insufficient even when it contains antioxidants - Lin et al. (2009)

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Probiotics

!   What is a probiotic? •  Live bacteria that stimulates the growth of micro-

oganisms, especially those with health benefits

!   12 week weight loss then 12 week maintenance diet supplemented with Lactobacillus probiotic or placebo – Sanchez et al. (2014)

•  No sig. difference in men •  In women, probiotic group showed more weight loss in

WL & continued WL into maintenance diet •  Probiotics potentially increase leptin sensitivity?

What are the health benefits?

!   Travelling athletes !   After taking antibiotics

Nagpal et al. (2012)

Elite Sports Supplements

!   Tart Cherry Juice •  Antioxidant properties •  May aid sleep due to natural melatonin content…

•  DOMS…

!   Beetroot Juice •  Reduces oxygen cost of exercise •  Dependent on dietary nitrate intakes?

“Acute and chronic BR supplementation did not reduce running V˙O2 or improve 1500-m TT performance of a group of elite distance runners, but two responders to BR were identified” - Boorsma et al. (2014)

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Branched Chain Amino Acids (BCAAs)

!   What are the BCAAs? •  Leucine •  Isoleucine •  Valine

!   What are the potential benefits? •  Low protein intakes – helps promote MPS •  Bump up low protein meals

HMB (β-Methylbutyrate)

!   What is HMB? •  An active metabolite of Leucine that reduces muscle

protein breakdown. It appears to have an anti-catabolic role for muscle.

!   Conflicting results among studies •  Potentially due to the training protocols within the

studies •  Some *misleading* data

Agu, J (2016)

Potentially works if volume is high enough

!   3g/day of HMB or placebo !   2-week high volume cycle

•  Mon – Thurs: 3 max sets of 8-12 repetitions (60-90s rest) of squats, leg press, bench press, deadlifts, pull-ups, military press, bent over rows, barbell curls & extensions

•  Fri: 3 x 1-RM attempts on the squat, bench press & deadlift for a total of 9 max working sets + Wingate testing on Sat

!   CK & cortisol increased placebo not HMB !   Strength decreased in placebo but not HMB !   Wingate peak power decreased in placebo only

Davis et al. (2012)

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Summary

Why? - Maybe beneficial in overreaching phase - Reduces protein breakdown following intense resistance training

When? -  Timing not crucial -  Daily Dose

What? - 3 x 1g with water / juice every day, divided over the course of the day

L-Citrulline

!  One of three dietary amino acids in urea cycle !   Supplementation increases L-argnine levels

more effectively than equivalent doses of l-arginine itself – Schwedhelm et al (2008)

!  Citrulline is often combined with malate due its suggested role as a component of the

citric acid cycle.

L-Citrulline

!   Perez-Guisado & Jakeman, (2010) •  Significantly increased chest repetitions by approximately 53% &

decreased soreness by 40% at 24 and 48 hours post-workout

! Bendahan et al (2002) •  CM ingestion resulted in a significant reduction in the fatigue •  34% increase in rate of oxidative ATP production in exercise

! Hickner et al, (2006) •  No significant differences in steady-state submaximal respiratory

exchange ratio and VO2max Treadmill time to exhaustion

“Currently, there is no conclusive evidence that citrulline ingestion enhances athletic performance. More research into this supplement is required” - Stear, et al. (2010)

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Chinese (Alternative medicine)

!   “Supplements including Chinese herbs are used by athletes globally due to their purported ergogenic properties. However, the preponderance of scientific evidence does not support the use of those examined here (Cordyceps, Ginseng, Rhodiola, Tribulus). In addition, commercial products containing Chinese herbs have occasionally been found contaminated with prohibited substances.”- Burke et al. (2010) BJSM

Effect Change Reference Maca (Lepidium meyenii)

Serum levels of luteinizing hormone No

Gonzales (2003)

Follicle-stimulating hormone No Prolactin No Testosterone No 17-beta estradiol No GRE activation No

HornyGoatWeed(Epimedium)

IncreaseTestosterone Yes – Rats No - Humans Shindel (2010)

Increasebonedensity. Yes (Paired with 300mg Ca) Zhang (2007)

Curcumin Anti-inflammatory Effective for ulcerative colitis – however, alongside standard treatments Hanai (2006)

Cancer Preventative No effect on PGE2 Improved markers of colon cancer (smokers) Carroll (2001)

Tribulus Terrestris Libido

No Saudan (2008) Rogerson (2007) Neychev (2005)

Testosterone No

Rogerson (2007) Muscle Strength No

Body Composition No

Body Composition Specialist PTs…

Practical Resources ‘Prescribing Supplementation’

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Websites and Apps

!   Banned substances – WADA App ! GlobalDRO – Medications

!   Medication and Supplement interactions ! Examine.com

Ask a Doctor!

!   Blood testing can be done by a Doctor !   Low Iron, Vitamin D etc can easily be detected

•  Corrective supplement advice will be given

!   Very few performance enhancing supplements •  Compared to the number available

!   Most common benefit is correcting deficiency !   Very few work for normal healthy individuals •  i.e. mega dosing rarely increases the effects

!   Lots of myths due to financial incentive !   Some interesting supplements on the fringes •  Use with hyper-compliant clients?

SUMMARY