Contaminated nutritional supplements – legal protection for elite athletes who tested positive: A case report from Germany

Intended or Unintended Doping? A Review of the Presence of Doping Substances in Dietary Supplements Used in Sports

Introduction: The use of dietary supplements is increasing among athletes, year after year. Related to the high rates of use, unintentional doping occurs. Unintentional doping refers to positive anti-doping tests due to the use of any supplement containing unlisted substances banned by anti-doping regulations and organizations, such as the World Anti-Doping Agency (WADA). The objective of this review is to summarize the presence of unlabeled doping substances in dietary supplements that are used in sports. Methodology: A review of substances/metabolites/markers banned by WADA in ergonutritional supplements was completed using PubMed. The inclusion criteria were studies published up until September 2017, which analyzed the content of substances, metabolites and markers banned by WADA. Results: 446 studies were identified, 23 of which fulfilled all the inclusion criteria. In most of the studies, the purpose was to identify doping substances in dietary supplements. Discussion: Substances prohibited by WADA were found in most of the supplements analyzed in this review. Some of them were prohormones and/or stimulants. With rates of contamination between 12 and 58%, non-intentional doping is a point to take into account before establishing a supplementation program. Athletes and coaches must be aware of the problems related to the use of any contaminated supplement and should pay special attention before choosing a supplement, informing themselves fully and confirming the guarantees offered by the supplement.

Prohibited Contaminants in Dietary Supplements

CONTEXT

With the increasing use of unregulated dietary supplements, athletes are at continued risk from adverse medical events and inadvertent doping.

EVIDENCE ACQUISITION

A review of Clinical Key, MEDLINE, and PubMed databases from 2012 to 2017 was performed using search terms, including dietary supplement, contamination, doping in athletes, inadvertent doping, and prohibited substances. The references of pertinent articles were reviewed for other relevant sources.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Poor manufacturing processes and intentional contamination with many banned substances continue to occur in dietary supplements sold in the United States. Certain sectors, such as weight loss and muscle-building supplements, pose a greater threat because they are more likely to be contaminated.

CONCLUSION

Athletes will continue to be at risk for adverse events and failed doping tests due to contaminated dietary supplements until legislation changes how they are regulated. In the interim, there are several steps that can be taken to mitigate this risk, including improved education of medical staff and athletes and use of third party-certified products.

Prolonged intrahepatic cholestasis and renal failure secondary to anabolic androgenic steroid-enriched dietary supplements

The illegal enrichment of anabolic androgenic steroids in over-the-counter dietary supplements is well documented, but the health consequences have not been widely recognized. Three recent reports document cholestatic jaundice and nephropathy due to these compounds. We present 3 additional cases of anabolic androgenic steroid-enriched dietary supplement-induced hepatotoxicity and 1 case of renal failure, and we review the literature and the relevant features of this growing health concern. Recognition of this entity could obviate the need for invasive diagnostic testing and hospitalization and facilitate diagnosis and appropriate counseling.

Severe hepatotoxicity following ingestion of Herbalife nutritional supplements contaminated with Bacillus subtilis

BACKGROUND/AIMS

Nutritional supplements are widely used. Recently, liver injury after consumption of Herbalife preparations was reported but the underlying pathogenesis remained cryptic.

METHODS

Two patients presented with cholestatic hepatitis and pruritus, and cirrhosis, respectively. Viral, alcoholic, metabolic, autoimmune, neoplastic, vascular liver diseases and synthetic drugs as the precipitating causes of liver injury were excluded. However, both patients reported long-term consumption of Herbalife products. All Herbalife products were tested for contamination with drugs, pesticides, heavy metals, and softeners, and examined for microbial contamination according to standard laboratory procedures. Bacteria isolated from the samples were identified as Bacillus subtilis by sequencing the 16S rRNA and gyrB genes.

RESULTS

Causality between consumption of Herbalife products and disease according to CIOMS was scored "probable" in both cases. Histology showed cholestatic and lobular/portal hepatitis with cirrhosis in one patient, and biliary fibrosis with ductopenia in the other. No contamination with chemicals or heavy metals was detected, and immunological testing showed no drug hypersensitivity. However, samples of Herbalife products ingested by both patients showed growth of Bacillus subtilis of which culture supernatants showed dose- and time-dependent hepatotoxicity.

CONCLUSIONS

Two novel incidents of severe hepatic injury following intake of Herbalife products contaminated with Bacillus subtilis emphasize its potential hepatotoxicity.

Supplements and the endocrine system in athletes

In the world of athletes' nutrition, there are many ethical concerns, because there is the suspicion that in practice, large doses of supplements in athletes are not taken for nutritional purposes. It is beyond the scope of this article to highlight the possible roles of supplements or methods of supplementation in the improvement of athletic performance in elite athletes. Instead, the author briefly reviews some of the substances taken by athletes, with particular attention to their mechanisms of action and the pathways involved. Very often, the effects of many supplements are hormone-related, or supplements influence hormone secretion. Examples of possible links between "supplements or ergogenic compounds" and the endocrine/metabolic system are addressed.

Dietary supplementation of high-performance Canadian athletes by age and gender

OBJECTIVE

To determine dietary supplementation practices and opinions, preferred means for dietary supplement (DS) education, and antidoping opinions among elite Canadian athletes varying in age and gender.

DESIGN

A descriptive, cross-sectional survey.

SETTING

Elite athlete training centers in Calgary, Canada and surrounding area.

PARTICIPANTS

A total of 582 high-performance athletes (314 male, 268 female).

MAIN OUTCOME MEASURES

High-performance athletes representing 27 sports with a mean age of 19.96+/-3.91 years completed a validated questionnaire assessing DS practices and opinions by recall. Sport categories included varsity, Canadian Sport Centre Calgary (CSCC), and National Sport School (NSS).

RESULTS

There was extensive DS use, with 88.4% of participants taking>or=1 DS (mean of 3.08+/-1.87 DS per user) during the previous 6 months. Overall, sport drinks (22.4%), sport bars (14.0%), multivitamins and minerals (13.5%), protein supplements (9.0%), and vitamin C (6.4%) were most frequently reported. Older athletes were significantly more likely to report greater DS usage; to be advised by teammates, health food store retailers, and magazines; to prefer supplementation education via individual interviews; to claim awareness of anti-doping rules; and to perceive anti-doping compliance. Relative to gender, significant differences were observed for the types of DS reported; supplementation advisors; justifications for DS use; and awareness of anti-doping regulations.

CONCLUSIONS

Utilization of this validated and reliable questionnaire has the potential for broad use and provides insight into the factors that influence DS use in elite athletes.

Creatine and other supplements

Ergogenic dietary supplement use is highly prevalent among adolescent and collegiate athletes, and use is increasing. To make appropriate recommendations for or against use by individual athletes, physicians who work with adolescent athletes should be knowledgeable about the most commonly used supplements and be able to access high-quality information about others. This article first discusses the legal and regulatory environment of dietary supplements. Several of the most commonly used supplements are then discussed in detail, including creatine, beta-hydroxy-beta-methylbutyrate, protein, amino acids, stimulants, alkalotic agents, glycerol, vitamins, and minerals. Finally, the "Gateway Theory" as it may relate to adolescent supplement and other drug use is discussed.

Supplement use in sport: is there a potentially dangerous incongruence between rationale and practice?

BACKGROUND

Supplement use by athletes is complex and research supports the alarming notion of misinformed decisions regarding supplements.

HYPOTHESIS

A frequent divergence between the type of supplements chosen by athletes and the rationale dictating the supplement use is hypothesized. Thus, a potentially dangerous incongruence may exist between rationale and practice.

TESTING THE HYPOTHESIS

In the continued absence of reliable data on supplement use, an alternative approach of studying the reasons underlying supplement use in athletes is proposed to determine whether there is an incongruence between rationale and practice. Existing data from large scale national surveys can be used to investigate this incongruence.

IMPLICATIONS OF THE HYPOTHESIS

In this report, analyses of distinctive patterns between the use and rationale for use of supplements among athletes are recommended to explore this potentially dangerous phenomenon.