Analysis of over-the-counter dietary supplements

A Behaviourally Informed Approach to Reducing the Risk of Inadvertent Anti-doping Rule Violations from Supplement Use

For many reasons, athletes' use of supplements is highly prevalent across sports and competitive levels, despite the risk of these products containing a substance on the World Anti-Doping Agency Prohibited List. Contravening anti-doping rules through supplement use could have serious consequences for competitive athletes (e.g., ineligibility from major competitions, loss of medals and funding) due to the principle of strict liability. Indiscriminate supplement use also poses a risk to athlete health. To reduce the possibility of ingesting a supplement containing prohibited substances, independent quality assurance and certification programs have been established (e.g., Informed Sport). However, these programs do not completely eliminate risk, leading to some anti-doping organisations promoting a 'just say no' to supplements stance. Yet, this approach can be problematic as a small number of supplements may be necessary for athletes to consume, in certain situations. Recognising that athletes will continue to use these heavily marketed products, this narrative review describes a theoretically underpinned and systematic approach to preventing inadvertent doping by considering the barriers to and enablers of athlete adherence to risk minimisation supplement use guidelines (RMSUG). By outlining a conceptual shift towards a behaviourally informed approach, this review serves to stimulate the development of multifaceted interventions to prevent inadvertent doping through supplement use. Recognising that risk-minimised supplement use involves a myriad of behaviours, the problem of inadvertent doping through supplement use is framed, and research appraised, through the lens of the Behaviour Change Wheel.

Prevalence of adulteration in dietary supplements and recommendations for safe supplement practices in sport

The prevalence of dietary supplement use among athletes continues to rise with 60-80% of athletes often reporting current or previous use of dietary supplements. While select dietary ingredients have been shown to improve acute performance and enhance training adaptations over time, it is important to still consider the risk vs. reward for athletes before opting to consume a dietary supplement. Previous work has indicated that certain dietary supplements may pose risks for inadvertent doping, may be susceptible to mislabelling, could be banned by certain governing bodies of sport, or pose health risks for certain populations. The purpose of the current narrative review is to summarize the prevalence of adulteration in dietary sport supplement products, outline the risks of inadvertent doping for athletes, and highlight best practices regarding safe supplementation strategies. Analytical studies have found anywhere from 14 to 50% of samples analyzed from dietary supplement products have tested positive for anabolic agents or other prohibited substances. It is important for the consumer to adhere to safe supplementation strategies, which include following serving size recommendations, cross-referencing ingredient profiles with the list of prohibited substances, choosing quality products that have been verified by a third-party certification program, and being cognizant of consuming multiple dietary supplement products with overlapping ingredient profiles. Once these practices have been considered, it is reasonable for an athlete to utilize dietary supplements as a strategy to optimize performance and health, with a low risk of failing a drug test (adverse analytical finding) and experiencing adverse events.

Pharmacy practitioners' practice, awareness and knowledge about herbal products and their potential interactions with cardiovascular drugs

Background: Herbal medicine use is widespread among patients, as community pharmacies may provide such products. Therefore, pharmacy practitioners should be aware of potential herbal products' adverse effects and herb-drug interactions, particularly with medications for comorbid diseases, such as cardiovascular drugs, in which pharmacy practitioners need to have good knowledge to provide patients with relevant advice to get optimal and safe therapeutic outcomes. Accordingly, the study is designed to assess the knowledge and awareness of pharmacy practitioners regarding herbal product dispensing and cardiovascular drug interaction in Jordan and view their role in patients' counselling to set up safe and effective drug use. Methods: A cross-sectional study was conducted in Jordan using an online formatted questionnaire distributed to pharmacy practitioners working in community pharmacies. Descriptive and analytical statistics were performed for the responses using the Statistical Package for the Social Sciences (SPSS) software, version 26. Results: Out of 508 participants, 41.7% had medium knowledge of herbal products pertaining mainly to university education (68.1%); 55.1% of participants dispensed herbal products without prescriptions for obesity and weight reduction (72.8%) and gastrointestinal problems (70.9%); this is because respondents agreed that herbal remedies are safe (28.5%) and effective (38.4%). Whilst the knowledge level of respondents about herbal medicine interaction with cardiovascular medication was medium, with a mean of 1.94, as this interaction may result in potentially serious consequences, 40.7% of respondents strongly agreed to gain more knowledge about the side effects of herbal products and medicine interactions through educational courses. Conclusions: The pharmacy practitioners had medium knowledge of herbal products; however, more attention should be paid to herb-drug interactions in the pharmacy educational curriculum. Additionally, pharmacy practitioners need to refresh their knowledge by attending periodic educational courses and by using reliable resources for information about herbal products in order to provide effective and competent pharmaceutical care.

Dietary Supplements as Source of Unintentional Doping

Background

The substances used in sport could be divided into two major groups: those banned by the World Anti-Doping Agency and those which are not. The prohibited list is extremely detailed and includes a wide variety of both medicinal and nonmedicinal substances. Professional athletes are exposed to intense physical overload every day. They follow a relevant food regime and take specific dietary supplements, which is essential for the better recovery between trainings and competitions. However, the use of “nonprohibited” dietary supplements (DS) is not always completely safe. One of the risks associated with the use of dietary supplements is the risk of unintended doping—originating from contaminated products. The presence of undeclared compounds in the composition of DS is a serious concern. The aim of this study is to evaluate the risk of unintentional doping.

Materials and Methods

Literature search was done through PubMed, Science Direct, Google Scholar, and Web of Science. Studies investigating the presence of undeclared compounds, in dietary supplements, banned by WADA met the inclusion criteria. The last search was conducted in June 2021. The present review is based on a total of 50 studies, which investigated the presence of undeclared compounds in DS.

Results

The total number of analyzed DS is 3132, 875 of which were found to contain undeclared substances. Most frequently found undeclared substances are sibutramine and anabolic-androgenic steroids.

Conclusion

More than 28% of the analyzed dietary supplements pose a potential risk of unintentional doping. Athletes and their teams need to be aware of the issues associated with the use of DS. They should take great care before inclusion of DS in the supplementation regime.

Higenamine in Plants as a Source of Unintentional Doping

BACKGROUND

Higenamine is a β2 agonist of plant origin. The compound has been included in WADA's prohibited list since 2017. Higenamine may be detected in different plants and many food supplements of natural origin.

METHODS

Our literature search was conducted through PubMed, Science Direct, Google Scholar, and Web of Science studies investigating the presence of higenamine in plants that are used in traditional folk medicine or included in food supplements. Our study aimed to assess the risk of adverse analytical findings caused by higenamine-containing plants.

RESULTS

Based on our literature search, Nelumbo nucifera, Tinospora crispa, Nandina domestica, Gnetum parvifolium, Asarum siebodii,Asarum heterotropoides, Aconitum carmichaelii, and Aristolochia brasiliensis are higenamine-containing plants. Based on data from Eastern folk medicine, these plants can provide numerous health benefits. Professional athletes likely ingest these plants without knowing that they contain higenamine; these herbs are used in treatments for different conditions and various foods/food supplements in addition to folk medicine.

CONCLUSION

Athletes and their teams must be aware of the issues associated with the use of plant-based products. They should avoid consuming higenamine-containing plants during and outside of competition periods.

Survey of antidoping knowledge, attitudes and practices amongst elite Indian sportsmen and the way forward

BACKGROUND

Indian sportspersons have reported several antidoping rule violations with several cases suggesting inadvertent use of prohibited substances. This study was designed to evaluate the anti-doping knowledge, attitudes and practices amongst elite Indian sportsmen to suggest future interventions.

METHODS

This study conducted at a Sports institute used an anonymized questionnaire to survey 181 male (18-35 years old) elite young athletes' attitudes toward performance-enhancing substances and anti-doping rules.

RESULTS

Athlete awareness regarding antidoping agencies and antidoping rule violations was poor. 40% or less reported receiving antidoping updates. All reported improvement in antidoping knowledge and attitude changes after attending updates. Health is more important than sporting performance for 80% or more. Very low percentage reported consumption of banned substances amongst themselves and team mates. One-third of these athletes reported not having being tested for banned substances. Athletes who have attended antidoping sessions exhibit significantly higher knowledge levels and a significantly higher 80% reported consulting their Team doctor before any therapeutic drug use as compared with non-attendees.

CONCLUSION

Indian elite athletes report low awareness about anti-doping rules and prohibited substances with low proportion of athletes reporting doping and being tested for doping. Grass root level education, supplement regulation, trained athlete support personnel and accessible reference material seems to be the way forward.

Undeclared Doping Substances are Highly Prevalent in Commercial Sports Nutrition Supplements

Sports nutrition supplements have previously been reported to contain undeclared doping substances. The use of such supplements can lead to general health risks and may give rise to unintentional doping violations in elite sports. To assess the prevalence of doping substances in a range of high-risk sports nutrition supplements available from Dutch web shops. A total of 66 sports nutrition supplements - identified as potentially high-risk products claiming to modulate hormone regulation, stimulate muscle mass gain, increase fat loss, and/or boost energy - were selected from 21 different brands and purchased from 17 web shops. All products were analyzed for doping substances by the UK life sciences testing company LGC, formerly known as the Laboratory of the Government Chemist, using an extended version of their ISO17025 accredited nutritional supplement screen. A total of 25 out of the 66 products (38%) contained undeclared doping substances, which included high levels of the stimulants oxilofrine, β-methylphenethylamine (BMPEA) and N,β-dimethylphenethylamine (NBDMPEA), the stimulant 4-methylhexan-2-amine (methylhexaneamine, 1,3-dimethylamylamine, DMAA), the anabolic steroids boldione (1,4-androstadiene-3,17-dione) and 5-androstene-3β,17α-diol (17α-AED), the beta-2 agonist higenamine and the beta-blocker bisoprolol. Based upon the recommended dose and the potential variability of analyte concentration, the ingestion of some products identified within this study could pose a significant risk of unintentional doping violations. In addition to inadvertent doping risks, the prescribed use of 3 products (4.5%) could likely impose general health risks.

Risk Associated with the Use of Selected Ingredients in Food Supplements

This review focuses on four new product categories of food supplements: pre-workout, fat burner/thermogenic, brain/cognitive booster, and hormone/testosterone booster. Many food supplements have been shown to be contaminated with unauthorized substances. In some cases, the ingredients in the new categories of dietary supplements were medicinal products or new synthetic compounds added without performing clinical trials. Some of the new ingredients in dietary supplements are plant materials that are registered in the pharmacopoeia as herbal medicines. In other cases, dietary supplements may contain plant materials that have no history of human use and are often used as materials to 'camouflage' stimulants. In the European Union, new ingredients of dietary supplements, according to European Food Safety Authority or unauthorized novel food. Furthermore, selected ingredients in dietary supplements may be prohibited in sports and are recognized as doping agents by World Anti-Doping Agency.

Suplementos alimentares: uma fonte de doping não intencional?

Resumo O excessivo consumo de suplementos alimentares, aliado a uma legislação inespecífica e a um controle de qualidade ineficiente, faz com que a saúde dos consumidores seja colocada em risco devido à possível existência de contaminantes, em especial pró-hormônios, esteroides anabolizantes e estimulantes. Estes compostos podem proporcionar um aumento do desempenho esportivo e acarretar uma série de efeitos adversos, sendo assim proibidos pela Agência Mundial Antidopagem. A contaminação de suplementos pode ocorrer de maneira deliberada ou através de más práticas de produção, em que são encontrados traços dessas substâncias. Todavia, ambos os casos exigem atenção, já que uma contaminação de apenas 0,00005% em massa pode levar ao doping. Neste sentido, estima-se que de 6,4% a 8,8% dos casos estejam relacionados ao consumo de suplementos contaminados. Perante estes fatos, os objetivos principais do trabalho foram: fazer uma revisão da literatura tanto em trabalhos nacionais quanto internacionais, no que concerne à contaminação de suplementos alimentares e sua relação com a dopagem não intencional, bem como orientar os consumidores a escolherem produtos mais seguros. Neste sentido, foi possível observar que os suplementos nacionais são, geralmente, mais seguros quanto à presença de substâncias proibidas, principalmente em relação à contaminação por agentes anabolizantes. Contudo, ainda é preciso um melhor controle de qualidade perante a contaminação/adulteração por estimulantes.

Associations between legal performance-enhancing substance use and future cardiovascular disease risk factors in young adults: A prospective cohort study

BACKGROUND

Legal performance-enhancing substances (PES), such as creatine, are commonly used by adolescents and young adults. As PES are mostly unregulated by the US Food and Drug Administration, there has been limited empirical attention devoted to examining their long-term safety and health outcomes. Preliminary studies have demonstrated associations between PES use and severe medical events, including hospitalizations and death. PES could be linked to cardiovascular disease (CVD), the most common cause of mortality in the US, by altering the myocardium, vasculature, or metabolism. The objective of this study was to examine prospective associations between the use of legal PES in young adulthood and CVD risk factors at seven-year follow-up.

MATERIALS AND METHODS

Nationally representative longitudinal cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves III (2001-2002) and IV (2008), were analyzed. Regression models determined the prospective association between the use of legal PES (e.g. creatine monohydrate) and CVD risk factors (e.g. body mass index, diabetes, hypertension, hyperlipidemia), adjusting for relevant covariates.

RESULTS

Among the diverse sample of 11,996 male and female participants, no significant differences by PES use in body mass index, diabetes, hypertension, or hyperlipidemia were noted at Wave III. In unadjusted comparisons, legal PES users (versus non-users) were more likely to be White, be male, be college educated, drink alcohol, and engage in weightlifting, exercise, individual sports, team sports, and other strength training. There were no significant prospective associations between legal PES use at Wave III and body mass index, hemoglobin A1c, systolic and diastolic blood pressure, and cholesterol (total, HDL, LDL, triglycerides) deciles at seven-year follow-up (Wave IV), adjusting for demographics, health behaviors, and Wave III CVD risk factors. Similarly, there were no significant prospective associations between legal PES use and diabetes, hypertension, or hyperlipidemia based on objective measures or self-reported medications and diagnoses, adjusting for demographics, health behaviors, and Wave III CVD risk.

CONCLUSIONS

We do not find evidence for a prospective association between legal PES use and CVD risk factors in young adults over seven years of follow-up, including BMI, diabetes, hypertension, or hyperlipidemia. It should be noted that legal PES use was operationalized dichotomously and as one broad category, which did not account for frequency, amount, or duration of use. Given the lack of regulation and clinical trials data, observational studies can provide much needed data to inform the safety and long-term health associations of legal PES use and, in turn, inform clinical guidance and policy.

Detecting the abuse of 19-norsteroids in doping controls: A new gas chromatography coupled to isotope ratio mass spectrometry method for the analysis of 19-norandrosterone and 19-noretiocholanolone

The detection of 19-norsteroids abuse in doping controls currently relies on the determination of 19-norandrosterone (19-NA) by gas chromatography-tandem mass spectrometry (GC-MS/MS). An additional confirmatory analysis by gas chromatography coupled to isotope ratio mass spectrometry (GC-C-IRMS) is performed on samples showing 19-NA concentrations between 2.5 and 15 ng/ml and not originated from pregnant female athletes or female treated with 19-norethisterone. 19-Noretiocholanolone (19-NE) is typically produced to a lesser extent as a secondary metabolite. The aim of this work was to improve the GC-C-IRMS confirmation procedure for the detection of 19-norsteroids misuse. Both 19-NA and 19-NE were analyzed as target compounds (TCs), whereas androsterone (A), pregnanediol (PD), and pregnanetriol (PT) were selected as endogenous reference compounds (ERCs). The method was validated and applied to urine samples collected by three male volunteers after the administration of nandrolone-based formulations. Before the instrumental analysis, urine samples (<25 ml) were hydrolyzed with β-glucuronidase from Escherichia coli and extracted with n-pentane. Compounds of interest were purified through a single (for PT) or double (for 19-NE, 19-NA, A, and PD) liquid chromatographic step, to reduce the background noise and eliminate interferences that could have affect the accuracy of δ¹³ C values. The limit of quantification (LOQ) of 2 ng/ml was ensured for both 19-NA and 19-NE. The 19-NE determination could be helpful in case of "unstable" urine samples, in late excretion phases or when coadministration with 5α-reductase inhibitors occur.

Reliable identification and quantification of anabolic androgenic steroids in dietary supplements by using gas chromatography coupled to triple quadrupole mass spectrometry

The aim of the present research was the identification and quantification of specific anabolic androgenic steroids (AASs) and other sterane structured compounds in dietary supplements (DSs). The adulteration of DSs by these compounds is of a particular concern in athletes, because it might lead to a positive doping result. The research was focused on the optimization of a highly sensitive and selective GC-based analytical strategy using triple quadrupole MS as detector. Chromatographic method and multiple reaction monitoring (MRM) transitions of 28 target compounds were optimized. Sample clean-up was carried out by using a solid phase extraction (SPE) procedure, while the derivatization of AASs was performed by using N-methyl-N-(trimethylsilyl)-trifluoroacetamide (MSTFA). The method was validated, and the following parameters were investigated: linearity range, limit of detection, accuracy, and precision expressed in terms of intra-day precision. The calibration curves were evaluated by using regression model and resulting in a good determination coefficients (R² ≥ 0.9912). The residuals were scattered randomly around zero. The limits of detection (LODs) were lower than 7.0 ng g^-1 or ng ml^-1 . The accuracy assessment was evaluated in different forms of DSs characterized by high sample-to-sample variability (liquid, powder, tablet, capsule, protein, and herbal-based). Intra-day assay precision was in all cases lower than 20%. The developed analytical method was successfully applied to the analysis of 67 commercially available dietary supplements. In five cases, one or more steroid-type compounds were found in the concentration of 5 ng g^-1 -100 μg g^-1 , which might result adverse analytical findings in athletes.

Legal Performance-Enhancing Substances and Substance Use Problems Among Young Adults

BACKGROUND

Legal performance-enhancing substance(s) (PES) (eg, creatine) are widely used among adolescent boys and young men; however, little is known about their temporal associations with substance use behaviors.

METHODS

We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I to IV (1994-2008). Logistic regressions were used to first assess adolescent substance use (Wave I) and use of legal PES (Wave III) and second to assess use of legal PES (Wave III) and subsequent substance use-associated risk behaviors (Wave IV), adjusting for potential confounders.

RESULTS

Among the sample of 12 133 young adults aged 18 to 26 years, 16.1% of young men and 1.2% of young women reported using legal PES in the past year. Adolescent alcohol use was prospectively associated with legal PES use in young men (odds ratio 1.39; 95% confidence interval [CI] 1.13-1.70). Among young men, legal PES use was prospectively associated with higher odds of problematic alcohol use and drinking-related risk behaviors, including binge drinking (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.71), injurious and risky behaviors (aOR 1.78; 95% CI 1.43-2.21), legal problems (aOR 1.52; 95% CI 1.08-2.13), cutting down on activities and socialization (aOR 1.91; 95% CI 1.36-2.78), and emotional or physical health problems (aOR 1.44; 95% CI 1.04-1.99). Among young women, legal PES use was prospectively associated with higher odds of emotional or physical health problems (aOR 3.00; 95% CI 1.20-7.44).

CONCLUSIONS

Use of legal PES should be considered a gateway to future problematic alcohol use and drinking-related risk behaviors, particularly among young men.

Dietary Supplement and Food Contaminations and Their Implications for Doping Controls

A narrative review with an overall aim of indicating the current state of knowledge and the relevance concerning food and supplement contamination and/or adulteration with doping agents and the respective implications for sports drug testing is presented. The identification of a doping agent (or its metabolite) in sports drug testing samples constitutes a violation of the anti-doping rules defined by the World Anti-Doping Agency. Reasons for such Adverse Analytical Findings (AAFs) include the intentional misuse of performance-enhancing/banned drugs; however, also the scenario of inadvertent administrations of doping agents was proven in the past, caused by, amongst others, the ingestion of contaminated dietary supplements, drugs, or food. Even though controversial positions concerning the effectiveness of dietary supplements in healthy subjects exist, they are frequently used by athletes, anticipating positive effects on health, recovery, and performance. However, most supplement users are unaware of the fact that the administration of such products can be associated with unforeseeable health risks and AAFs in sports. In particular anabolic androgenic steroids (AAS) and stimulants have been frequently found as undeclared ingredients of dietary supplements, either as a result of cross-contaminations due to substandard manufacturing practices and missing quality controls or an intentional admixture to increase the effectiveness of the preparations. Cross-contaminations were also found to affect therapeutic drug preparations. While the sensitivity of assays employed to test pharmaceuticals for impurities is in accordance with good manufacturing practice guidelines allowing to exclude any physiological effects, minute trace amounts of contaminating compounds can still result in positive doping tests. In addition, food was found to be a potential source of unintentional doping, the most prominent example being meat tainted with the anabolic agent clenbuterol. The athletes’ compliance with anti-doping rules is frequently tested by routine doping controls. Different measures including offers of topical information and education of the athletes as well as the maintenance of databases summarizing low- or high-risk supplements are important cornerstones in preventing unintentional anti-doping rule violations. Further, the collection of additional analytical data has been shown to allow for supporting result management processes.

Making Decisions About Supplement Use

The use of dietary supplements is widespread among athletes in all sports and at all levels of competition, as it is in the general population. For the athlete training at the limits of what is sustainable, or for those seeking a shortcut to achieving their aims, supplements offer the prospect of bridging the gap between success and failure. Surveys show, however, that this is often not an informed choice and that the knowledge level among consumers is often low and that they are often influenced in their decisions by individuals with an equally inadequate understanding of the issues at stake. Supplement use may do more harm than good, unless it is based on a sound analysis of the evidence. Where a deficiency of an essential nutrient has been established by appropriate investigations, supplementation can provide a rapid and effective correction of the problem. Supplements can also provide a convenient and time-efficient solution to achieving the necessary intake of key nutrients such as protein and carbohydrate. Athletes contemplating the use of supplements should consider the potential for both positive and negative outcomes. Some ergogenic supplements may be of benefit to some athletes in some specific contexts, but many are less effective than is claimed. Some may be harmful to health of performance and some may contain agents prohibited by anti-doping regulations. Athletes should make informed choices that maximize the benefits while minimizing the risks.

Current Status of Legislation on Dietary Products for Sportspeople in a European Framework

The consumption of nutritional ergogenic aids is conditioned by laws/regulations, but standards/regulations vary between countries. The aim of this review is to explore legislative documents that regulate the use of nutritional ergogenic aids intended for sportspeople in a Spanish/European framework. A narrative review has been developed from official websites of Spanish (Spanish Agency of the Consumer, Food Safety, and Nutrition) and European (European Commission and European Food Safety Authority) bodies. A descriptive analysis of documents was performed. Eighteen legislative documents have been compiled in three sections: (1) Advertising of any type of food and/or product; (2) Composition, labeling, and advertising of foods; (3) Nutritional ergogenic aids. In spite of the existence of these legal documents, the regulation lacks guidance on the use/application of nutritional ergogenic aids for sportspeople. It is essential to prevent the introduction or dissemination of false, ambiguous, or inexact information and contents that induce an error in the receivers of the information. In this field, it is worth highlighting the roles of the European Food Safety Authority and the World Anti-Doping Agency, which provide information about consumer guidelines, prescribing practices, and recommendations for the prudent use of nutritional ergogenic aids.

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.

Cadmium exposure and endometrial cancer risk: A large midwestern U.S. population-based case-control study

Estrogen-mimicking chemicals, such as cadmium, may be associated with increased susceptibility to hormone-dependent cancers, though supporting data are sparse, particularly for endometrial cancer. The Health and Environmental Exposure Research (HEER) study worked with the Arkansas Central Cancer Registry, Iowa Cancer Registry and Missouri Cancer Registry to obtain names of women diagnosed with endometrial cancer who were willing to be contacted for participation in our case control study. Voter registration lists from Iowa and Missouri were used to randomly select similarly aged women as represented in the case population. Participants were interviewed by telephone to obtain information on known or suspected endometrial risk factors. Urine kits were sent to participants for home collection and returned for analysis. Our case-control study consisted of 631 incident cases of endometrial cancer diagnosed from January 2010 to October 2012 and 879 age-matched population-based controls, ages 18-81 years (mean age 65 years). We quantified cadmium amounts in urine and standardized these values through creatinine adjustment. Using data from all survey completers, we developed a multivariable model for endometrial cancer. Creatinine-adjusted cadmium concentration was added to this model. Odds ratio (OR) and 95% confidence intervals (CIs) for endometrial cancer were calculated. After multivariable adjustment, higher creatinine-adjusted cadmium exposure was associated with a statistically significant increase of endometrial cancer risk (OR: 1.22; 95% CI: 1.03-1.44). Our results provide evidence that cadmium may increase the risk of endometrial cancer, possibly through estrogenic effects.

Broadband quantitative NQR for authentication of vitamins and dietary supplements

We describe hardware, pulse sequences, and algorithms for nuclear quadrupole resonance (NQR) spectroscopy of medicines and dietary supplements. Medicine and food safety is a pressing problem that has drawn more and more attention. NQR is an ideal technique for authenticating these substances because it is a non-invasive method for chemical identification. We have recently developed a broadband NQR front-end that can excite and detect ¹⁴N NQR signals over a wide frequency range; its operating frequency can be rapidly set by software, while sensitivity is comparable to conventional narrowband front-ends over the entire range. This front-end improves the accuracy of authentication by enabling multiple-frequency experiments. We have also developed calibration and signal processing techniques to convert measured NQR signal amplitudes into nuclear spin densities, thus enabling its use as a quantitative technique. Experimental results from several samples are used to illustrate the proposed methods.

Illicit drugs and cardiac arrhythmias in athletes

The current management of athletes with cardiac arrhythmias has become complicated by the widespread use of illicit drugs, which can be arrhythmogenic.

The World Anti-Doping Agency annually updates a list of prohibited substances and methods banned by the International Olympic Committee that includes different classes of substances namely, anabolic androgenic steroids, hormones and related substances, β2-agonists, diuretics, stimulants, narcotics, cannabinoids, glucocorticosteroids, alcohol, β-blockers and others. Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular) that can even be lethal and which are frequently sport activity related.

A large use of illicit drugs has been documented in competitive athletes, but the arrhythmogenic effect of specific substances is not precisely known. Precipitation of cardiac arrhythmias, particularly in the presence of a latent electrophysiologic substrate including some inherited cardiomyopathies, at risk of sudden death or due to long-term consumption of the substances, should raise the suspicion that illicit drugs may be a possible cause and lead cardiologists to investigate carefully this relationship and appropriately prevent the clinical consequences.

Scientific and Regulatory Perspectives in Herbal and Dietary Supplement Associated Hepatotoxicity in the United States

In the United States (US), the risk of hepatotoxicity linked to the widespread use of certain herbal products has gained increased attention among regulatory scientists. Based on current US law, all dietary supplements sold domestically, including botanical supplements, are regulated by the Food and Drug Administration (FDA) as a special category of foods. Under this designation, regulatory scientists do not routinely evaluate the efficacy of these products prior to their marketing, despite the content variability and phytochemical complexity that often characterizes them. Nonetheless, there has been notable progress in the development of advanced scientific methods to qualitatively and quantitatively measure ingredients and screen for contaminants and adulterants in botanical products when hepatotoxicity is recognized.

Muscle-building supplement use and increased risk of testicular germ cell cancer in men from Connecticut and Massachusetts

BACKGROUND

No analytic epidemiological study has examined the relationship between use of muscle-building supplements (MBSs) and testicular germ cell cancer (TGCC) risk.

METHODS

We conducted a population-based case-control study including 356 TGCC cases and 513 controls from Connecticut and Massachusetts.

RESULTS

The odds ratio (OR) for ever use of MBSs in relation to risk of TGCC was significantly elevated (OR=1.65, 95% confidence interval (CI): 1.11-2.46). The associations were significantly stronger among early users, men with more types of MBSs used, and longer periods of use.

CONCLUSIONS

MBS use is a potentially modifiable risk factor that may be associated with TGCC.

Quality assurance issues in the use of dietary supplements, with special reference to protein supplements

The use of dietary supplements is widespread in the general population, in athletes and recreational exercisers, and in military personnel. A wide array of supplements is available, but protein-containing products are consistently among the most popular, especially among those who engage in resistance training. There are significant risks associated with the use of unregulated dietary supplements. Risks include the absence of active ingredients, the presence of harmful substances (including microbiological agents and foreign objects), the presence of toxic agents, and the presence of potentially dangerous prescription-only pharmaceuticals. There is ample evidence of athletes who have failed doping tests because of the use of dietary supplements. There is also growing evidence of risks to health and of serious adverse events, including a small number of fatalities, as a result of supplement use. The risk associated with the use of protein powders produced by major manufacturers is probably low, and the risk can be further reduced by using only products that have been tested under one of the recognized supplement quality assurance programs that operate in various countries. Nevertheless, a small risk remains, and athletes, soldiers, and other consumers should conduct a cost-benefit analysis before using any dietary supplements.

National Athletic Trainers' Association position statement: evaluation of dietary supplements for performance nutrition

OBJECTIVES

To help athletic trainers promote a "food-first" philosophy to support health and performance, understand federal and sport governing body rules and regulations regarding dietary supplements and banned substances, and become familiar with reliable resources for evaluating the safety, purity, and efficacy of dietary supplements.

BACKGROUND

The dietary supplement industry is poorly regulated and takes in billions of dollars per year. Uneducated athletes need to gain a better understanding of the safety, eligibility, and efficacy concerns associated with choosing to take dietary supplements. The athletic trainer is a valuable athletic team member who can help in the educational process. In many cases, athletic trainers are asked to help evaluate the legality, safety, and efficacy of dietary supplements. For this position statement, our mission is to provide the athletic trainer with the necessary resources for these tasks.

RECOMMENDATIONS

Proper nutrition and changes in the athlete's habitual diet should be considered first when improved performance is the goal. Athletes need to understand the level of regulation (or lack thereof) governing the dietary supplement industry at the international, federal, state, and individual sport-participation levels. Athletes should not assume a product is safe simply because it is marketed over the counter. All products athletes are considering using should be evaluated for purity (ie, truth in labeling), safety, and efficacy.

Exposure to media predicts use of dietary supplements and anabolic-androgenic steroids among Flemish adolescent boys

This study examined whether different types of media affect the use of dietary proteins and amino acid supplements, and intent to use anabolic-androgenic steroids. A random sample of 618 boys aged 11-18 years from eight schools in the Flemish part of Belgium completed standardized questionnaires as part of the Media and Adolescent Health Study. The survey measured exposure to sports media, appearance-focused media, fitness media, use of dietary supplements, and intent to use anabolic-androgenic steroids. Data were analyzed using logistic regressions and are presented as adjusted odds ratios (OR) and 95 % confidence intervals (CI); 8.6 % indicated to have used dietary proteins, 3.9 % indicated to have used amino acid supplements, and 11.8 % would consider using anabolic-androgenic steroids. After adjusting for fitness activity, exposure to fitness media was associated with the use of dietary proteins (OR = 7.24, CI = 2.25-23.28) and amino acid supplements (5.16, 1.21-21.92; 44.30, 8.25-238). Intent to use anabolic-androgenic steroids was associated with exposure to fitness media (2.38, 1.08-5.26; 8.07, 2.55-25.53) and appearance-focused media (6.02, 1.40-25.82; 8.94, 1.78-44.98). Sports media did not correlate with the use of dietary supplements and intent to use anabolic-androgenic steroids. Specific types of media are strong predictors of the use of supplements in adolescent boys. This provides an opportunity for intervention and prevention through the selection of fitness media as a communication channel. Health practitioners should also be aware that the contemporary body culture exerts pressure not only on girls but also on boys.

Situating Nutri-Ethics at the Junction of Nutrigenomics and Nutriproteomics in Postgenomics Medicine

Food has societal, economic, medical and ethical implications, being fundamental for life. It plays an important role also in sports medicine, since a healthy diet is an important part of an athlete's training. Nutrigenomics and nutriproteomics are emerging as a result of a convergence of nutritional, genomics and proteomics knowledge strands in the postgenomics era. These fields of inquiry present an opportunity for the design of customized diets potentially able to counterbalance the extant obesity epidemic and remedy metabolic diseases, among others. They are noteworthy for sport medicine as well since they could provide athletes with crucial information for personalized training and nutrition, in order to achieve the best results possible and express one's own potential. But they could also be used as a form of personalized doping, thus constituting an advancement of “classical nutrition-based doping” (i.e., the use of nutraceuticals, stimulants and supplements). However, nutrigenomics (or nutriproteomics)-based nutritional doping is different from the first-generation doping because it is specifically tailored to the genomics and proteomics makeup of the athlete, although their effectiveness remain to be discerned in future systematic studies. Against this scientific background, ethical issues of nutrigenomics and nutriproteomics are discussed in the present paper with emphasis on the current limitations and the dizzying potentials of the omics data-intensive research for science and society. Additionally, I discuss the need to communicate uncertainty as a fundamental construct and intrinsic part of postgenomics personalized medicine, not to forget the gaps regarding the lack of adequate governance, and issues over providing a proper nutritional education to athletes as onus of the international sports organizations.

“Let food be your medicine, and medicine be your food”

Hippocrates

Nutritional supplements: prevalence of use and contamination with doping agents

Based upon recent sales numbers, nutritional supplements play a key role in the lifestyle of a substantial proportion of the population. As well as products such as vitamins or minerals, several precursors of anabolic steroids are marketed as nutritional supplements. Another group of commercially available supplements are products for weight loss based upon herbal formulations originating from Ephedra species. Apart from supplements indicating the presence of these active compounds, numerous non-hormonal nutritional supplements were found that were contaminated with non-labelled anabolic steroids. Stimulating agents other than naturally occurring analogues of ephedrine were detected. A major group using dietary supplements are sportsmen, ranging from amateur level to elite athletes. Besides the possible health risks associated with the use of dietary supplements, athletes should take care not to violate the rules of the World Anti-Doping Agency because athletes remain responsible for substances detected in their biofluids, irrespective of their origin. Several analytical methods have been developed to determine the presence of doping agents as contaminants. The present review attempts to address the issues concerning the use of nutritional supplements and the detection of doping agents as contaminants in dietary supplements.

Emerging supplements in sports

CONTEXT

Nutritional supplements advertised as ergogenic are commonly used by athletes at all levels. Health care professionals have an opportunity and responsibility to counsel athletes concerning the safety and efficacy of supplements on the market.

EVIDENCE ACQUISITION

An Internet search of common fitness and bodybuilding sites was performed to identify supplement promotions. A search of MEDLINE (2000-August, 2011) was performed using the most commonly identified supplements, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, and nitric oxide. The search terms supplement, ergogenic aid, and performance were also used.

RESULTS

Six common and newer supplements were identified, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, and nitric oxide.

CONCLUSIONS

Controlled studies have not determined the effects of these supplements on performance in athletes. Scientific evidence is not available to support the use of these supplements for performance enhancement.

Dietary supplements and team-sport performance

A well designed diet is the foundation upon which optimal training and performance can be developed. However, as long as competitive sports have existed, athletes have attempted to improve their performance by ingesting a variety of substances. This practice has given rise to a multi-billion-dollar industry that aggressively markets its products as performance enhancing, often without objective, scientific evidence to support such claims. While a number of excellent reviews have evaluated the performance-enhancing effects of most dietary supplements, less attention has been paid to the performance-enhancing claims of dietary supplements in the context of team-sport performance. Dietary supplements that enhance some types of athletic performance may not necessarily enhance team-sport performance (and vice versa). Thus, the first aim of this review is to critically evaluate the ergogenic value of the most common dietary supplements used by team-sport athletes. The term dietary supplements will be used in this review and is defined as any product taken by the mouth, in addition to common foods, that has been proposed to have a performance-enhancing effect; this review will only discuss substances that are not currently banned by the World Anti-Doping Agency. Evidence is emerging to support the performance-enhancing claims of some, but not all, dietary supplements that have been proposed to improve team-sport-related performance. For example, there is good evidence that caffeine can improve single-sprint performance, while caffeine, creatine and sodium bicarbonate ingestion have all been demonstrated to improve multiple-sprint performance. The evidence is not so strong for the performance-enhancing benefits of β-alanine or colostrum. Current evidence does not support the ingestion of ribose, branched-chain amino acids or β-hydroxy-β-methylbutyrate, especially in well trained athletes. More research on the performance-enhancing effects of the dietary supplements highlighted in this review needs to be conducted using team-sport athletes and using team-sport-relevant testing (e.g. single- and multiple-sprint performance). It should also be considered that there is no guarantee that dietary supplements that improve isolated performance (i.e. single-sprint or jump performance) will remain effective in the context of a team-sport match. Thus, more research is also required to investigate the effects of dietary supplements on simulated or actual team-sport performance. A second aim of this review was to investigate any health issues associated with the ingestion of the more commonly promoted dietary supplements. While most of the supplements described in the review appear safe when using the recommended dose, the effects of higher doses (as often taken by athletes) on indices of health remain unknown, and further research is warranted. Finally, anecdotal reports suggest that team-sport athletes often ingest more than one dietary supplement and very little is known about the potential adverse effects of ingesting multiple supplements. Supplements that have been demonstrated to be safe and efficacious when ingested on their own may have adverse effects when combined with other supplements. More research is required to investigate the effects of ingesting multiple supplements (both on performance and health).

An LC-MS screening method with library identification for the detection of steroids in dietary supplements

For many years anabolic-androgenic steroids (AAS) are by far the most frequently detected pharmacological substances in doping control. In order to improve their performances, professional sportsmen are often tempted to take dietary supplements. However, due to the frequent and widespread occurrence of contaminated supplements, the use of such products is not without risk for the athletes involved. In order to minimize the chances of an unattended positive doping test or serious health problems, fast and reliable screening methods for the detection of anabolic steroids in dietary supplements are needed. A general screening procedure requires the fast and unambiguous detection of a large range of steroids. Gas chromatography-mass spectrometry (GC-MS) has been used intensively in the detection of doping substances for the past 40 years. Over time, many laboratories have delivered spectra to be included in standard reference databases, one of which is maintained by the National Institute of Standards and Technology (NIST) (Gaithersburg, MD, USA). In recent years, however, liquid chromatography coupled to mass spectrometry (LC-MS) has gained popularity. Unfortunately, existing GC-MS libraries are not applicable to LC-MS analysis. In the present study, a new mass spectral library of 88 steroids was developed, along with a fast UPLC-MS method. For the construction of this mass spectral library, three different mass spectra were measured for each steroid, with a sample cone voltage of 30, 60 and 100 V, respectively. This method was then successfully tested on contaminated dietary supplements which had previously been tested by means of a targeted LC-MS/MS method. Overall, the library search was shown to identify the same compounds as the MRM method.

Use of herbal products and potential interactions in patients with cardiovascular diseases

More than 15 million people in the U.S. consume herbal remedies or high-dose vitamins. The number of visits to providers of complementary and alternative medicine exceeds those to primary care physicians, for annual out-of-pocket costs of $30 billion. Use of herbal products forms the bulk of treatments, particularly by elderly people who also consume multiple prescription medications for comorbid conditions, which increases the risk of adverse herb-drug-disease interactions. Despite the paucity of scientific evidence supporting the safety or efficacy of herbal products, their widespread promotion in the popular media and the unsubstantiated health care claims about their efficacy drive consumer demand. In this review, we highlight commonly used herbs and their interactions with cardiovascular drugs. We also discuss health-related issues of herbal products and suggest ways to improve their safety to better protect the public from untoward effects.

Ingredient Consistency of Commercially Available Polyphenol and Tocopherol Nutraceuticals

Label claims of vitamin E succinate and polyphenolic nutraceuticals are assessed. A validated HPLC method was utilized to assess vitamin E succinate products. Three novel LC/MS methods were used to assess the polyphenols, pterostilbene, phloretin, and myricetin, in dietary supplements. The amount of vitamin E succinate varied from 0-130% of the stated label content with two products containing vitamin E acetate rather than vitamin E succinate. Expected polyphenols were found in 7 of the 8 supplement products. None of the polyphenol supplements contained content within 100-120% of label claims. The present study indicates a lack of uniformity in nutraceutical products.

Tetrahydrogestrinone analysis and designer steroids revisited

Anabolic steroids are the main abused class of prohibited substances in doping control. These steroids are associated with enhancement of muscular mass and aggressiveness, resulting in increased performance. Chromatography and MS have a key role among methods developed to detect anabolic steroids in doping control laboratories. However, the classical analytical approach fails in detection of the so-called ‘designer steroids’. This review focuses on the rise of tetrahydrogestrinone, a drug that became synonymous with designer steroids. The reasons why classical methods fail in tetrahydrogestrinone detection are discussed and how the detection was implemented is shown. Alternative strategies for detection of new drugs designed to cheat current analytical methodology are highlighted. Concern for the abuse of veterinary designer drugs and supplements is also acknowledged.

The use of dietary supplements by athletes

Many athletes use dietary supplements as part of their regular training or competition routine, including about 85% of elite track and field athletes. Supplements commonly used include vitamins, minerals, protein, creatine, and various "ergogenic" compounds. These supplements are often used without a full understanding or evaluation of the potential benefits and risks associated with their use, and without consultation with a sports nutrition professional. A few supplements may be helpful to athletes in specific circumstances, especially where food intake or food choice is restricted. Vitamin and mineral supplements should be used only when a food-based solution is not available. Sports drinks, energy bars, and protein-carbohydrate shakes may all be useful and convenient at specific times. There are well-documented roles for creatine, caffeine, and alkalinizing agents in enhancing performance in high-intensity exercise, although much of the evidence does not relate to specific athletic events. There are potential costs associated with all dietary supplements, including the risk of a positive doping result as a consequence of the presence of prohibited substances that are not declared on the label.

Profiling of 19-norandrosterone sulfate and glucuronide in human urine: implications in athlete's drug testing

19-Norandrosterone (19-NA) as its glucuronide derivative is the target metabolite in anti-doping testing to reveal an abuse of nandrolone or nandrolone prohormone. To provide further evidence of a doping with these steroids, the sulfoconjugate form of 19-norandrosterone in human urine might be monitored as well. In the present study, the profiling of sulfate and glucuronide derivatives of 19-norandrosterone together with 19-noretiocholanolone (19-NE) were assessed in the spot urines of 8 male subjects, collected after administration of 19-nor-4-androstenedione (100mg). An LC/MS/MS assay was employed for the direct quantification of sulfoconjugates, whereas a standard GC/MS method was applied for the assessment of glucuroconjugates in urine specimens. Although the 19-NA glucuronide derivative was always the most prominent at the excretion peak, inter-individual variability of the excretion patterns was observed for both conjugate forms of 19-NA and 19-NE. The ratio between the glucuro- and sulfoconjugate derivatives of 19-NA and 19-NE could not discriminate the endogenous versus the exogenous origin of the parent compound. However, after ingestion of 100mg 19-nor-4-androstenedione, it was observed in the urine specimens that the sulfate conjugates of 19-NA was detectable over a longer period of time with respect to the other metabolites. These findings indicate that more interest shall be given to this type of conjugation to deter a potential doping with norsteroids.

Seizures Reported in Association with Use of Dietary Supplements

BACKGROUND

Seizures in persons using dietary supplements (DS) have been reported through the Food and Drug Administration's (FDA) MedWatch system, but not formally reviewed.

METHODS

Sixty-five cases of DS-associated seizures reported to MedWatch from 1993 to 1999 were obtained through the Freedom of Information Act and independently evaluated by three reviewers for probability of causation based on temporal relationship, biological plausibility, and underlying risk factors. Our aims in this review were 1) to assess the probability of causation in each case; 2) to characterize the patterns of use and types of supplements involved in cases of seizures; and 3) to identify trends that may explain potential risks factors for dietary supplement-related seizures.

RESULTS

Twenty seizures were judged as probably related, 13 possibly related, and 10 as unrelated to DS use. Five cases were not seizures, and 17 cases contained insufficient information. In the 20 probably related cases, 19 involved ephedra, 14 involved herbal caffeine, and in one case, the supplement contained no herbal constituents but an array of elemental salts. Ephedra was also associated with 7 of the 13 possibly related cases, and caffeine was contained in 5 of these supplement products. Creatine, St. John's wort, and ginkgo biloba were other DS implicated in possibly related seizure events. Seizures were associated with hypoglycemia in 3 cases, and secondary to stroke in 2 cases and cardiac arrest in 2 cases. Weight loss (45%) and athletic performance enhancement (30%) were the most often cited reasons for supplement use. In most cases, DS use was within manufacturers' guidelines.

CONCLUSION

Ephedra was implicated in 27 of 33 DS-associated seizures reported to the FDA over a 7-year period, further underscoring that significant health risks are associated with use of this herbal product.

Nutritional supplements cross-contaminated and faked with doping substances

Since 1999 several groups have analyzed nutritional supplements with mass spectrometric methods (GC/MS, LC/MS/MS) for contaminations and adulterations with doping substances. These investigations showed that nutritional supplements contained prohibited stimulants as ephedrines, caffeine, methylenedioxymetamphetamie and sibutramine, which were not declared on the labels. An international study performed in 2001 and 2002 on 634 nutritional supplements that were purchased in 13 different countries showed that about 15% of the nonhormonal nutritional supplements were contaminated with anabolic-androgenic steroids (mainly prohormones). Since 2002, also products intentionally faked with high amounts of 'classic' anabolic steroids such as metandienone, stanozolol, boldenone, dehydrochloromethyl-testosterone, oxandrolone etc. have been detected on the nutritional supplement market. These anabolic steroids were not declared on the labels either. The sources of these anabolic steroids are probably Chinese pharmaceutical companies, which sell bulk material of anabolic steroids. In 2005 vitamin C, multivitamin and magnesium tablets were confiscated, which contained cross-contaminations of stanozolol and metandienone. Since 2002 new 'designer' steroids such as prostanozol, methasterone, androstatrienedione etc. have been offered on the nutritional supplement market. In the near future also cross-contaminations with these steroids are expected. Recently a nutritional supplement for weight loss was found to contain the beta2-agonist clenbuterol. The application of such nutritional supplements is connected with a high risk of inadvertent doping cases and a health risk. For the detection of new 'designer' steroids in nutritional supplements, mass spectrometric strategies (GC/MS, LC/MS/MS) are presented.

The continuing story of nutritional supplements and doping infractions

Nutritional supplements can be a source of positive doping cases as some supplements contain prohibited substances without showing this on their label. This problem has existed for some time and has been extensively studied in the past 8 years. The sport of tennis has played a particular role in this problem because of some peculiar doping cases within its community. This article focuses on this particular doping problem, explaining the background and reviewing the available literature. It presents the first 3 years of experience within the Netherlands Security System Nutritional Supplements Elite Sports ("Nederlands Zekerheidssysteem Voedingssupplementen Topsport" or NZVT) and explains the most extensive system established to combat this particular doping problem. The NZVT experience has shown that paper-based quality systems are still prone to possible contaminations, which leads to the conclusion that the best possible solution for athletes who wish to use nutritional supplements must include laboratory-based analysis for doping substances, preferably repeated for every new batch. The most important educational message, however, is to use a nutritional supplement only if it is deemed of benefit by a nutritional expert.

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.