Dietary Supplements: Knowledge and Adverse Event Reporting Among American Medical Society for Sports Medicine Physicians

Analysis of Sports Supplement Consumption in 1688 Federated Road Cyclists

The widespread use of sports supplements (SS) to enhance athletic performance extends to cyclists, although little research has been conducted on this subject within this sport. This descriptive and cross-sectional study involved 1688 federated road cyclists, aiming to analyse the pattern of SS consumption concerning the degree of scientific evidence and different categories. This study categorised SS based on the groups and subgroups established by the Australian Sport Institute (AIS, 2023) based on the level of evidence. Our results showed that 62.5% of the sample cyclists used SS, with an average of 12.2 ± 8.6 supplements consumed per participant. Health status (78.2%), pharmacies (62.5%), and medical doctors (45.7%) were the main reasons, purchase sites, and sources of information for SS consumption, respectively. The most prevalent SS consumed were Sports Gels (94%), Sports Bars (89.3%), and Sports Drinks (73.8%). Notably, 80% of the top ten most consumed SS belonged to the group with the highest level of evidence according to the AIS, with an average of 6.9 ± 3.2 supplements per participant. However, 23.3% of the total SS consumers used prohibited substances. In conclusion, while the prevalence of SS consumption among road cyclists is considerable and the primary sources for purchasing SS and obtaining advice are reliable, there is a notable prevalence of prohibited substance use within the sample.

Challenges in Reporting Adverse Events from Dietary Supplements

In 2008, the Institute of Medicine (IOM) Committee on Dietary Supplement Use by Military Personnel recommended the development of service wide military policies (e.g., education or regulations) to guide commanders in management practices for safe use of dietary supplements (DS). This review summarizes the activities the military has undertaken to advance the safe use of DS by Service Members and develop best practices on reporting adverse events across the Department of Defense (DoD). In March 2022, the Department of Defense issued a DoD Instruction (DoDI) regarding the use of DS by members of the U S. military. This DoDI provides guidelines to establish an official list of prohibited substances. The DoDI also identifies Operation Supplement Safety (OPSS) at CHAMP as DoD's "go to" program for DS use and information about DS and ingredients. Noted are a number of gaps in the reporting of adverse events from DS that need to be addressed by multiple constituencies.

Anabolic androgenic steroid-induced liver injury: An update

Anabolic androgenic steroids (AASs) are a group of molecules including endogenous testosterone and synthetic derivatives that have both androgenic and anabolic effects. These properties make them therapeutically beneficial in medical conditions such as hypogonadism. However, they are commonly bought illegally and misused for their anabolic, skeletal muscle building, and performance-enhancing effects. Supraphysiologic and long-term use of AASs affects all organs, leading to cardiovascular, neurological, endocrine, gastrointestinal, renal, and hematologic disorders. Hepatotoxicity is one of the major concerns regarding AASs treatment and abuse. Testosterone and its derivatives have been most often shown to induce a specific form of cholestasis, peliosis hepatis, and hepatic benign and malignant tumors. It is currently believed that mechanisms of pathogenesis of these disorders include disturbance of antioxidative factors, upregulation of bile acid synthesis, and induction of hepatocyte hyperplasia. Most toxicity cases are treated with supportive measures and liver function normalizes with discontinuation of AAS. However, some long-term consequences are irreversible. AAS-induced liver injury should be taken in consideration in patients with liver disorders, especially with the increasing unintentional ingestion of supplements containing AAS. In this paper, we review the most current knowledge about AAS-associated adverse effects on the liver, and their clinical presentations, prevalence, and pathophysiological mechanisms.

A Threat to Military Combat Power: Dietary Supplements

BACKGROUND

The use of dietary supplements by young warfighters is pervasive and comes with a readiness cost, especially in the deployed setting. Predatory targeting and marketing by various unscrupulous companies put this population at risk for a higher than baseline risk for adverse events.

METHODS

We report on 6 serious adverse events experienced by warfighters while deployed in Kuwait and Afghanistan. Presented is a discussion of current practice gaps and solutions, as well as details regarding how polypharmacy contributes to the seriousness of the threat posed by problematic supplements.

RESULTS

The morbidity associated with the 6 cases of dietary supplement adverse events compromised mission readiness and was costly in terms of health and health care expenditures.

CONCLUSION

The military dietary supplement issue needs exposure, review, and action at the highest levels of government.

Musculoskeletal practices for the preparticipation physical examination

Background

Little is known about the musculoskeletal (MSK) exam providers use during the Preparticipation Physical Examination (PPE). The primary aims of this study were to determine current practice with regards to the MSK screening exam, if goals are being met, and if there may be opportunities for improvement.

Methods

This cross-sectional survey-based study utilized a REDCap instrument that was distributed to members of the American Academy of Family Physicians (AAFP) and the American Medical Society for Sports Medicine (AMSSM). Questions focused on participant demographics and MSK exam practices for the PPE. Descriptive statistics were used.

Results

The study had a total of 616 participants with a response rate of 9 %. The majority of respondents (82 %) were familiar with the 4th Edition PPE Monograph and 80 % either moderately or strongly agreed that they use this as a guideline for their MSK screening exam. The 90 s MSK screening test was implemented by 52 % of the participants. The majority of participants use an orthopedic exam as part of their PPE (82 %). Ninety-two percent of participants felt satisfied that their MSK exam would screen for current injury, while only 42 % were satisfied that it effectively screened for future injury. 86 % of participants agree that the MSK exam should be performed, while 26 % said that they don’t perform a physical exam at all.

Discussion

There is a lack of understanding of the PPE Monograph as there is wide variability in MSK screening techniques providers use despite the majority of participants being familiar with the guidelines described in the monograph. Additionally, providers don’t believe that the MSK exam screens for future injury.

Conclusions

The goals of the MSK portion of the 4th Edition PPE monograph are not adequately being met and there is a need for further research to validate screening exams for the prevention of MSK injury.

Dietary Supplements: Knowledge and Adverse Event Reporting Practices of Department of Defense Health Care Providers

INTRODUCTION

The purpose of the study was to assess the knowledge of dietary supplements (DS) and adverse event (AE) reporting practices of the Department of Defense health care providers. AEs related to use of DS are not uncommon. However, it is estimated that less than 2% of AEs are reported. This is problematic given the Food and Drug Administration relies on AE reports to identify and ultimately remove unsafe products from the market. Inadequate reporting of AE puts all DS users at risk.

MATERIALS AND METHODS

Cross-sectional design was used. Electronic surveys were sent to the Department of Defense health care professionals (HCPs) and Emergency Medicine (EM) physicians asking questions about practices regarding DS and AE knowledge and reporting behaviors. The surveys were open for 5 months. During this period of time, HCPs received three email reminders following the initial email to enhance participation. The computer package IBM SPSS version 25 software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York) was used for statistical analysis. Frequency distributions of the responses were analyzed.

RESULTS

Of the 1,700 surveyed, 270 HCPs and 68 EM physicians completed the surveys. At least 39% of HCPs reported never receiving formal DS training. Seventy-two percent of HCPs reported asking their patients about the use of DS. However, when asked if they knew where to report an AE, only 40% of HCPs knew where to report an AE and only 38% knew how to report an AE. Of the EM physicians, only 38% asked their patients about DS. However, a majority (78%) reported that they had encountered an AE. EM physicians also reported they lacked knowledge regarding where (87%) and how (87%) to report AE.

CONCLUSIONS

It is clear that physician and nonphysician HCPs would benefit from additional training about DS and how and where to report suspected AE. Providing regular training on risks, common AE, and how and where to report an AE would help fill the knowledge gap in the ever-changing DS industry. Addressing these issues and coming up with a solution to integrating AE reporting into clinical care could improve health care practices and increase AE reporting to the Food and Drug Administration, which would have a beneficial impact on patient care, public safety, and mission readiness.

Multi-Criteria Decision Analysis Model for Assessing the Risk from Multi-Ingredient Dietary Supplements (MIDS)

Military personnel use dietary supplements (DS) for performance enhancement, bodybuilding, weight loss, and to maintain health. Adverse events, including cardiovascular (CV) effects, have been reported in military personnel taking supplements. Previous research determined that ingestion of multi-ingredient dietary supplements (MIDS), can lead to signals of safety concerns. Therefore, to assess the safety of MIDS, the Department of Defense via a contractor explored the development of a model-based risk assessment tool. We present a strategy and preliminary novel multi-criteria decision analysis (MCDA)-based tool for assessing the risk of adverse CV effects from MIDS. The tool integrates toxicology and other relevant data available on MIDS; likelihood of exposure, and biologic plausibility that could contribute to specific aspects of risk.Inputs for the model are values of four measures assigned based on the available evidence supplemented with the opinion of experts in toxicology, modeling, risk assessment etc. Measures were weighted based on the experts' assessment of measures' relative importance. Finally, all data for the four measures were integrated to provide a risk potential of 0 (low risk) to 100 (high risk) that defines the relative risk of a MIDS to cause adverse reactions.We conclude that the best available evidence must be supplemented with the opinion of experts in medicine, toxicology and pharmacology. Model-based approaches are useful to inform risk assessment in the absence of data. This MCDA model provides a foundation for refinement and validation of accuracy of the model predictions as new evidence becomes available.

United States Pharmacopeia (USP) comprehensive review of the hepatotoxicity of green tea extracts

As part of the United States Pharmacopeia's ongoing review of dietary supplement safety data, a new comprehensive systematic review on green tea extracts (GTE) has been completed. GTEs may contain hepatotoxic solvent residues, pesticide residues, pyrrolizidine alkaloids and elemental impurities, but no evidence of their involvement in GTE-induced liver injury was found during this review. GTE catechin profiles vary significantly with manufacturing processes. Animal and human data indicate that repeated oral administration of bolus doses of GTE during fasting significantly increases bioavailability of catechins, specifically EGCG, possibly involving saturation of first-pass elimination mechanisms. Toxicological studies show a hepatocellular pattern of liver injury. Published adverse event case reports associate hepatotoxicity with EGCG intake amounts from 140 mg to ∼1000 mg/day and substantial inter-individual variability in susceptibility, possibly due to genetic factors. Based on these findings, USP included a cautionary labeling requirement in its Powdered Decaffeinated Green Tea Extract monograph that reads as follows: "Do not take on an empty stomach. Take with food. Do not use if you have a liver problem and discontinue use and consult a healthcare practitioner if you develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice (yellowing of the skin or eyes)."

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.

Reporting of adverse events related to dietary supplements to a public health center by medical staff: a survey of clinics and pharmacies

BACKGROUND

Dietary supplements are used by >50% of the adult population in Japan, and adverse events related to these products have been reported with their increased use. Thus, an efficient system to gather and report data on these adverse events is essential. To date, however, reporting has been limited. The aim of this study was to address this deficiency by exploring the routine reporting practices of the medical staff employed at clinics or pharmacies in Japan.

METHODS

We conducted a survey of the procedures used by the medical staff to report adverse events related to dietary supplement intake to public health centers in Japan. The survey was conducted in Japan between November 2015 and January 2016. Based on a sample size calculation, questionnaires were administered to 1,700 potential respondents (850 pharmacists and 850 physicians). The questionnaire inquired about the sociodemographic characteristics and dietary supplement-related adverse event-reporting practices.

RESULTS

The response rate was 34.7%, including 286 pharmacists and 304 physicians. Although >30% of the pharmacists and physicians had prior experience dealing with such adverse events, <5% had reported these to a public health center. The survey identified several barriers to reporting, such as "difficulty judging the relationship between an adverse event and the dietary supplement" and "lack of clarity regarding the severity of an adverse event".

CONCLUSION

This is the first study to explore the routine reporting practices of physicians and pharmacists in terms of adverse events related to dietary supplements. Further studies are required to elucidate the severity of these adverse events. Moreover, standard reporting criteria ought to be introduced to improve public health.