A systematic review and meta-analysis on the prevalence of dietary supplement use by military personnel

Vitamin D Abuse in Pursuit of "Gains" Resulting in Acute Kidney Injury

Vitamin toxicity represents an increasingly frequent clinical diagnosis and can be difficult to initially recognize given the plethora of over-the-counter supplements available. The young, active, and heavily male population of the military is especially susceptible to such supplementation pitfalls. Here we present the case of acute renal failure with hypercalcemia that was found to be secondary to unrecognized high-dose over-the-counter vitamin supplementation and subsequent vitamin D hypervitaminosis initiated by the patient in the hope of boosting testosterone production. This clinical scenario demonstrates the dangers of easily accessible, often seemingly benign supplements and the need for greater education and awareness of supplementation use.

Assessment of the Use of Food Supplements by Military Personnel: Study Protocol and Results

Due to their specific mode of operation, military personnel are challenged physically as well as mentally. In most countries, the use of food supplements by military personnel is not regulated, and a high prevalence of supplementation is expected. However, data on this are scarce or very limited, without insights into the importance of supplementation for the intake of bioactive substances. Our goal was, therefore, to develop a study protocol to enable an assessment of the prevalence of using food supplements and an estimate of the contribution of supplementation practices to the dietary intake of specific nutrients and other compounds. The protocol was tested in a study of Slovene Armed Forces (SAF) personnel. Data were collected using an anonymous questionnaire in a sample of 470 participants from different military units-about half from the barracks located across the country, and the other half returning from military operations abroad. To provide meaningful results, we recorded the use of food supplements and functional foods available in single-sized portions (i.e., energy drinks, protein bars, etc.). Altogether, 68% of the participants reported supplementation, most commonly with vitamin, mineral, and protein supplements. Military rank, participation status in military operations, and physical activity were the main determinants of the specific supplements used. Surprisingly, a lower prevalence of overall and protein supplementation was observed in subjects returning from military operations abroad (62 vs. 74%) than in personnel stationed in barracks across Slovenia; however, the frequency of the use of energy drinks and caffeine supplements was higher in this population (25 vs. 11%). The study design allowed for estimations of the daily intake of supplemented bioactive compounds. We describe the challenges and approaches used in the study to support similar studies in the future and within other populations.

The Prevalence of Dietary Supplement Usage in Military Aviators

Background: The prevalence of dietary supplement (DS) and energy drink (ED) usage in military personnel differs from branch to branch and is between 55% and 76% (higher values in special operations forces). Aviators with highly demanding tasks might be especially interested in using dietary supplements. To date, there are only limited data available for this special profession inside the military. Methods: An internet-based survey was conducted on the prevalence of DS and ED usage, the reasons for their usage and the place of purchase for all wings of the German Armed Forces. Results: Of the 181 pilots who participated in the survey, 34% used DSs and 16% EDs. Usage was linked to sports activities but not to the type of aircraft. DSs were purchased on the internet by 50% of the respondents; mostly protein supplements, magnesium and omega-3fatty acids. Only 42% said they would feel an effect from taking DSs. Conclusions: Although the present study showed that the prevalence of usage was comparable to that of the civilian population, the sources of supply and the range of the substances taken give cause for concern. This calls for education and information campaigns to make the pilots aware of the possible risks to their health.

Relative safety and quality of various dietary supplement products U.S. Service Members ask about

CONTEXT

The purpose of this project was to determine types of dietary supplement products U.S. Service Members frequently ask about and identify risks associated with select products that consumers should be aware of when considering their use.

METHODS

Forty-one dietary supplement products frequently asked about through the Operation Supplement Safety's (OPSS.org) Ask-the-Expert portal were selected. Product analysis was performed to verify whether select products were accurately labeled and to identify any risky ingredients contained in these products. Operation Supplement Safety Risk Assessment Scorecard criteria were additionally used as a screening tool to assess a product's relative safety potential.

RESULTS

Among the select dietary supplements, 12 (29.3%) were marketed as pre-workout products; 14 (34.1%) for weight loss; four (9.8%) for male enhancement/testosterone boosters; and 11 (26.8%) as body building supplements. Eleven (26.8%) products had accurate labels; only eight of these had accurate labels plus no risky ingredients listed on the labels. Twenty-six (63.4%) products were misbranded; 10 (24.4%) were adulterated, and six (14.6%) were both misbranded and adulterated. Risky ingredients appeared on 23 (56%) of all product labels. Eight of these 23 products also had additional risky ingredients not listed on the labels but detected through analysis. According to the Scorecard based on label claims, 35 (85.4%) received a rating of "no-go/risky".

CONCLUSIONS

U.S. Service Members and the public at large should be aware that dietary supplements may contain risky ingredients and know how to identify ingredients on the label to evaluate potential risk.

Prevalence of and Factors Associated with Dietary Supplement Use in a Stratified, Random Sample of US Military Personnel: The US Military Dietary Supplement Use Study

BACKGROUND

About 50% of Americans and 70% of US military service members use dietary supplements (DSs).

OBJECTIVES

This cross-sectional survey examined current prevalence of and factors associated with DS use in service members.

METHODS

A stratified random sample of 200,000 service members from the Air Force, Army, Marine Corps, and Navy was obtained from military manpower records, and these service members were asked to complete a questionnaire on their DS use and personal characteristics. Chi-square statistics and multivariable logistic regression examined differences across various strata of demographic, lifestyle, and military characteristics.

RESULTS

About 18% of successfully contacted service members (n = 26,681) completed the questionnaire between December 2018 and August 2019 (mean ± SD age: 33 ± 8 y, 86% male). Overall, 74% reported using ≥1 DS/wk. Multivitamins/multiminerals were the most commonly used DSs (45%), followed by combination products (44%), proteins/amino acids (42%), individual vitamins/minerals (31%), herbals (20%), joint health products (9%), and purported prohormones (5%). In multivariable analysis, factors independently associated with DS use included female gender [OR (female/male): 1.91; 95% CI: 1.73, 2.11], older age [OR (≥40/18-24 y): 1.25; 95% CI: 1.08, 1.44], higher education level [OR (college degree/high school or less): 1.35; 95% CI: 1.19, 1.53], higher BMI [OR (≥30/<25 kg/m2): 1.37; 95% CI: 1.25, 1.52], more weekly resistance training [OR (>300/≤45 min/wk): 5.05; 95% CI: 4.55, 5.61], smokeless tobacco use [OR (user/nonuser): 1.30; 95% CI: 1.17, 1.44], higher alcohol intake [OR (≥72/0 mL/wk): 1.41; 95% CI: 1.29, 1.54], and higher military rank [OR (senior officer/junior enlisted): 1.26; 95% CI: 1.06, 1.51].

CONCLUSIONS

Compared with civilian data from the NHANES, service members were much more likely to use DSs and used different types of DSs, especially combination products and proteins/amino acids often used to purportedly enhance physical performance. Comparisons with previous military data suggest DS use has increased over time.

Peer-to-Peer Social Media Communication About Dietary Supplements Used for Weight Loss and Sports Performance Among Military Personnel: Pilot Content Analysis of 11 Years of Posts on Reddit

Background

Over 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke.

Objective

To understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit.

Methods

A total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use.

Results

A primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used.

Conclusions

Our pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

Prevalence of and Factors Associated with Dietary Supplement Use in a Stratified, Random Sample of US Military Personnel: The US Military Dietary Supplement Use Study

BACKGROUND

About 50% of Americans and 70% of US military service members use dietary supplements (DSs).

OBJECTIVES

This cross-sectional survey examined current prevalence of and factors associated with DS use in service members.

METHODS

A stratified random sample of 200,000 service members from the Air Force, Army, Marine Corps, and Navy was obtained from military manpower records, and these service members were asked to complete a questionnaire on their DS use and personal characteristics. Chi-square statistics and multivariable logistic regression examined differences across various strata of demographic, lifestyle, and military characteristics.

RESULTS

About 18% of successfully contacted service members (n = 26,681) completed the questionnaire between December 2018 and August 2019 (mean ± SD age: 33 ± 8 y, 86% male). Overall, 74% reported using ≥1 DS/wk. Multivitamins/multiminerals were the most commonly used DSs (45%), followed by combination products (44%), proteins/amino acids (42%), individual vitamins/minerals (31%), herbals (20%), joint health products (9%), and purported prohormones (5%). In multivariable analysis, factors independently associated with DS use included female gender [OR (female/male): 1.91; 95% CI: 1.73, 2.11], older age [OR (≥40/18-24 y): 1.25; 95% CI: 1.08, 1.44], higher education level [OR (college degree/high school or less): 1.35; 95% CI: 1.19, 1.53], higher BMI [OR (≥30/<25 kg/m2): 1.37; 95% CI: 1.25, 1.52], more weekly resistance training [OR (>300/≤45 min/wk): 5.05; 95% CI: 4.55, 5.61], smokeless tobacco use [OR (user/nonuser): 1.30; 95% CI: 1.17, 1.44], higher alcohol intake [OR (≥72/0 mL/wk): 1.41; 95% CI: 1.29, 1.54], and higher military rank [OR (senior officer/junior enlisted): 1.26; 95% CI: 1.06, 1.51].

CONCLUSIONS

Compared with civilian data from the NHANES, service members were much more likely to use DSs and used different types of DSs, especially combination products and proteins/amino acids often used to purportedly enhance physical performance. Comparisons with previous military data suggest DS use has increased over time.

The effect of food ration bar enriched with β-alanine, L-arginine, and Nigella sativa on performance and inflammation following intense military training: A double-blind randomized clinical trial

BACKGROUND

There are growing interests in using dietary supplements to improve athletic performance. This study aimed to evaluate the effect of the food ration bar enriched with β-alanine, L-arginine, and Nigella sativa on athletic performance and inflammation following intense military training.

METHODS

This double-blind, randomized, controlled clinical trial was conducted on 54 new cadets. Eligible participants were randomly assigned in a 1:1 ratio to receive food ration bars enriched with arginine (2 g/day), β-alanine (2 g/day), and Nigella sativa (2 g/day) or nonenriched food ration bars during a 2-week military training. Aerobic and anaerobic performances were evaluated by the Cooper and RAST tests, respectively.

RESULTS

A significant increase in anaerobic powers (min, mean, and max) and a significant reduction in fatigue index were observed in the intervention group as compared to the control group, even after the adjustment for confounding factors. Also, increased levels of hs-CRP and TNF-α following military training were significantly lower in the intervention group as compared to the control group (hs-CRP: 0.55 ± 0.1 versus 2.43 ± 0.1 mg/L; p-value: 0.01; TNF-α: 0.12 ± 0.04 versus 0.62 ± 0.04 pg/ml; p-value: 0.03). No significant changes were observed in VO2 max in both groups.

CONCLUSIONS

Our results showed that the combination of β-alanine, L-arginine, and Nigella sativa can improve anaerobic performance and reduce inflammation following intense physical activities. Further studies with long-term duration are needed to confirm the cumulative/synergic effects of these ingredients in trained and nontrained subjects.

Dietary Supplement Use in US Army Personnel: A Mixed-Methods, Survey and Focus-Group Study Examining Decision Making and Factors Associated With Use

BACKGROUND

Dietary supplement (DS) use by Army personnel is high and is a safety and readiness issue.

OBJECTIVE

Our aim was to examine factors motivating use of DSs among US Army personnel and preferred safety education strategies.

DESIGN

This mixed-method study used a validated DS questionnaire and subsequent focus groups that were formed based on questionnaire-identified demographic characteristics. An embedded qualitative dominant design was used.

PARTICIPANTS/SETTING

Data were collected from April to July 2015 from active duty soldiers at 3 military installations in the United States.

MAIN OUTCOME MEASURES

A self-report questionnaire (n = 289) provided data on demographic characteristics, health, exercise, detailed use, and attitudes regarding DS safety and efficacy. Fourteen focus-group sessions (n = 129) examined factors motivating DS use, education strategies, and identified themes and DS-related behaviors.

STATISTICAL ANALYSIS PERFORMED

Descriptive statistics and χ² analyses were conducted.

RESULTS

Of the soldiers who completed questionnaires, 83% were male, 60% were enlisted, and 40% were officers; mean age ± standard deviation was 27.6 ± 0.36 years and 75% used at least 1 type of DS per week: 52% used protein/amino acids, 47% used multivitamins/minerals, and 35% used a combination of products. Focus groups indicated reasons for use included physical appearance, fitness, peer endorsement, ease of access, limited availability of healthy food, occupational demands, and health. Participants requested education from an expert on safe use that was not focused on dangerous products.

CONCLUSIONS

Soldiers are high DS users, especially products marked for purported performance enhancement. Motivating factors for DS use are fitness/appearance and occupational demands, but soldiers lack knowledge of DS regulatory requirements and safety/efficacy. Soldiers wished to receive education on DSs from trusted health care professionals, such as registered dietitian nutritionists, that was not focused on dangerous products. Study findings suggest guidance and education should occur before periods of high DS use, such as deployment.

Dutch Olympic and Non-Olympic Athletes Differ in Knowledge of and Attitudes Toward Third-party Supplement Testing

Knowledge of third-party testing is important for elite athletes using nutritional supplements to reduce the chances of a positive doping incident. Therefore, we compared the self-reported knowledge and attitudes of N = 601 Dutch Olympic status and non-Olympic status athletes toward an independent Dutch third-party tested system (NZVT) for purchasing nutritional supplements (NSs). Most of the athletes believed that contaminated NSs could lead to a positive doping test (68.0%), and found it unacceptable to use a contaminated NS as a result of incomplete labeling (87.8%). More Olympic status athletes were familiar with the NZVT system (71.1%) than non-Olympic status athletes (24.5%, p < 0.001). Of the athletes knowing about NZVT, Olympic status athletes reported more frequently using the NZVT than non-Olympic athletes (81.7% vs. 50.0%, p < 0.001). Apart from status, more females were familiar with and used the NZVT system for purchasing NSs than males, p < 0.01. In conclusion, many athletes were not familiar with nor used the preferred third-party testing supplement system in the Netherlands when purchasing NSs. While doping warnings and regulations have been in place, considering the risk of unintentional doping use for over two decades, the knowledge of Olympic status and non-Olympic status high-level athletes could still be improved, as many are not reporting the use of third-party testing systems.

Healthy lifestyles among military active duty service members, and associations with body-building and weight-loss supplement use

PURPOSE

The purpose of this study was to characterize health behavior profiles among active duty service members and associate these profiles with body-building and weight-loss dietary supplement (DS) use.

METHODS

Based on U.S. active duty service members who completed the 2011 Health-Related Behavior Survey (n = 39,877), we used latent class analysis to place respondents into latent classes (using healthy/unhealthy food consumption, aerobic activity, strength training, and sleep) and examined associations between latent class and DS use.

RESULTS

We identified seven health behavior classes that could be classified by physical activity and diet. Three classes with high activity were further characterized by healthy diet (24%); few unhealthy foods (18%); and unrestricted diet (9%). Three classes with low activity were further characterized by restricted diet (15%), healthy diet (15%), and unhealthy diet (6%). The last class (13%) reported moderate levels of all behaviors. The classes did not vary by sleep. Participant characteristics across most classes were relatively homogenous along demographics and military branch. The active classes had relatively higher usage of body-building and weight-loss DSs.

CONCLUSIONS

Latent classes from health behavior indicators might be considered "market segments", which can be targeted with distinct messaging. Service members appear to consume DSs as part of an otherwise healthy lifestyle.

Conditional Recommendations for Specific Dietary Ingredients as an Approach to Chronic Musculoskeletal Pain: Evidence-Based Decision Aid for Health Care Providers, Participants, and Policy Makers

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons; although such use has become popular for a wide range of pain conditions, decisions to use supplements are often driven by information that is not evidence-based. This work evaluates whether the current research on dietary ingredients for chronic musculoskeletal pain provides sufficient evidence to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. A decision table was constructed to make evidence-informed judgments across factors required for decision-making, and recommendations were made for practice and self-care use.

RESULTS

Nineteen dietary ingredients were included. Conditional evidence-based recommendations were made for the use of avocado soybean unsaponifiables, capsaicin, curcuma, ginger, glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D. In these cases, desirable effects outweighed undesirable effects, but there was uncertainty about the trade-offs, either because the evidence was low quality or because benefits and downsides were closely balanced.

CONCLUSIONS

The evidence showed that certain dietary ingredients, when taken as part of a balanced diet and/or as a supplement (e.g., pill, tablet, capsule, cream), may alleviate musculoskeletal pain with no to minimal risk of harm. This finding emphasizes and reinforces the critical importance of shared decision-making between Operators and their health care providers.

Dietary Ingredients as an Alternative Approach for Mitigating Chronic Musculoskeletal Pain: Evidence-Based Recommendations for Practice and Research in the Military

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons, including pain and related outcomes. This work evaluates current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. The committee made evidence-informed judgments and recommendations for practice and self-care use.

RESULTS

Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Avocado soybean unsaponifiables, capsaicin, curcuma, ginger (as a food source), glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D were conditionally recommended as their benefits outweighed risks, but there was still some uncertainty about the trade-offs. No recommendations were made for boswellia, ginger (as a dietary supplement), rose hip, or s-adenosyl-L-methionine. Recommendations were made against the use of collagen, creatine, devil's claw, l-carnitine, methylsulfonylmethane, pycnogenol, willow bark extract, and vitamin E. Research priorities were developed to address gaps precluding stronger recommendations.

CONCLUSIONS

Currently the scientific evidence is insufficiently robust to establish definitive clinical practice guidelines, but processes could be established to track the impact of these ingredients. Until then, providers have the evidence needed to make informed decisions about the safe use of these dietary ingredients, and future research can address existing gaps.

A Public Health Issue: Dietary Supplements Promoted for Brain Health and Cognitive Performance

Background: Dietary supplements targeting brain health have quickly emerged in the marketplace as cognitive performance becomes an important public health issue. While manufacturers are required to report the exact ingredients and formulations listed on the Supplement Facts labels of products, many reports have indicated such labels are not always truthful, and the content of some products is inconsistent with the ingredients listed on the Supplement Facts label.

Objectives: To identify dietary supplement products and ingredients marketed for brain health and cognitive performance and perform analyses of select products to verify whether purported claims are truthful and product labels accurate.

Design: A scoping review was performed to identify products and ingredients. Products were selected for content analysis, investigated for scientific-sounding claims made, and assessed using an educational tool for potential red flags when reading Supplement Facts labels.

Results: Twelve products were selected from the 650 products being marketed for brain health and queried about by Service Members. Eight (67%) had at least one ingredient listed on the Supplement Facts label not detected through analysis. Compounds not reported on the label were detected in 10 (83%) products. Scientific-sounding claims made are not supported by science and red flags are presented.

Conclusions: There are dietary supplements targeting brain health being marketed to consumers that should be considered adulterated and misbranded. Advertisements and product labels may be deceiving and could put the public at risk. Education is required so that the public can recognize red flags while the U.S. Food and Drug Administration works to “modernize” the current regulations for dietary supplements.

Personality Traits and Occupational Demands Are Linked to Dietary Supplement Use in Soldiers: A Cross-sectional Study of Sensation Seeking Behaviors

INTRODUCTION

Military personnel use dietary supplements (DS) more frequently and in a higher quantity than the general population. Patterns of DS used and the motivation for use among the military population are different than those of the civilian population. Soldiers are much more likely to use potentially dangerous DS purported to enhance physical performance and/or promote weight loss in spite of limited evidence regarding the safety and efficacy of these products. Sensation seeking (SS) behaviors can be associated with risky lifestyle behaviors and may be associated with use of DS by Soldiers. This study assessed Soldiers' SS behaviors in relation to DS use and various demographic factors.

MATERIALS AND METHODS

Demographic and behavioral questionnaires were administered to 289 Soldiers (mean ± SD, 28 ± 6 years, 27 ± 3 kg/m2 BMI, 83% male) at three U.S. military installations. The Brief SS Scale (four 10-point subscales) and Arnett Inventory of SS (two 40-point subscales) were used to assess SS behaviors. Independent sample t-tests determined the significant differences between SS subscale scores of DS users and non-users for each type of DS (i.e., protein, multivitamin, etc.). One-way analysis of variances and Tukey's post hoc comparisons assessed differences in SS scores across demographic categories. Tukey's post hoc analyses assessed SS scores between users and non-users within the DS categories.

RESULTS

Overall, 75% of Soldiers used DS ≥1 time/week. The most frequently used DS were protein/amino acids (52%), multivitamins/multiminerals (47%), "other" supplements (43%), and combination products (35%). Overall, DS users scored higher in experience seeking (8.0 ± 1.7 vs 7.5 ± 2.0; p < 0.05) and novelty (28.4 ± 3.7 vs 26.8 ± 4.7; p < 0.05) than non-users. Protein/amino acid users scored higher than non-users for all six SS traits: experience seeking (p < 0.001), boredom susceptibility (p < 0.001), thrill seeking (p < 0.001), disinhibition (p < 0.01), novelty (p < 0.001), and intensity (p < 0.001). Users of bodybuilding DS scored higher than non-users in four of the six SS traits: boredom susceptibility (p < 0.05), thrill seeking (p < 0.001), disinhibition (p < 0.01), and intensity (p < 0.001).

CONCLUSIONS

Soldiers who use DS that are frequently associated with health risks scored higher for sensation-seeking characteristics which are predictors of risky behaviors. Protein/AA and combination product DS users scored higher in sensation-seeking traits and this may be due to underestimation of risk, anticipation of positive outcomes, and/or high levels of confidence in these types of DS by high sensation seekers. Additional investigation into the association of sensation-seeking behaviors as predictors of harmful DS use is warranted.

A Systematic Review of the Effect of Dietary Supplements on Cognitive Performance in Healthy Young Adults and Military Personnel

Intake of dietary supplements has increased, despite evidence that some of these have adverse side effects and uncertainty about their effectiveness. This systematic review examined the evidence for the cognitive benefits of a wide range of dietary supplements in healthy young adult samples; the aim was to identify if any might be useful for optimising cognitive performance during deployment in military personnel. Searches were conducted in 9 databases and 13 grey literature repositories for relevant studies published between January 2000 and June 2017. Eligible studies recruited healthy young adults (18-35 years), administered a legal dietary supplement, included a comparison control group, and assessed cognitive outcome(s). Thirty-seven of 394 identified studies met inclusion criteria and were included for synthesis. Most research was deemed of low quality (72.97%; SIGN50 guidelines), highlighting the need for sound empirical research in this area. Nonetheless, we suggest that tyrosine or caffeine could be used in healthy young adults in a military context to enhance cognitive performance when personnel are sleep-deprived. Caffeine also has the potential benefit of improving vigilance and attention during sustained operations offering little opportunity for sleep. Inconsistent findings and methodological limitations preclude firm recommendations about the use of other specific dietary supplements.

Association Between Dietary Supplement Use and ICD-9-CM Code Classification in Active Duty US Navy and Marine Corps Service Members

INTRODUCTION

This study is the first to our knowledge to examine associations of survey-reported dietary supplement use with medical record diagnoses, rather than retrospective self-reported supplement use at the time of the medical encounter or case reports of adverse events. Dietary supplement (DS) use and adverse events associations in US Navy and Marine Corps personnel remains unknown. This study assessed associations of DS use in active duty (AD) personnel with ICD-9-CM diagnostic codes from outpatient medical encounters from the Military Health System Data Repository (MDR).

MATERIALS AND METHODS

This cross-sectional investigation used a one-time survey of DS use among AD conducted August through December 2014. Survey data were matched to MDR data accessed in September 2016, and associations between the survey responses and diagnoses were analyzed. Statistical significance was set at alpha level 0.005, and 99.5% confidence intervals (CIs) were calculated. MDR data were matched with survey results for 1,708 personnel. Multivariable logistic regression analyses examined whether use of specific classes of supplements was associated with disease.

RESULTS

Results revealed significant associations between vitamin supplement use and ICD-9-CM-diagnosed diseases of the nervous system (odds ratio [OR]: 1.72, 99.5% CI: 1.11-2.68) and diseases of the musculoskeletal system and connective tissue (OR: 1.59, 99.5% CI: 1.17-2.17). Joint health supplement category use was associated with diseases of the musculoskeletal system and connective tissue (OR: 1.81, 99.5% CI: 1.12-2.94) and injury and poisoning (OR: 1.82, 99.5% CI: 1.10-3.04).

CONCLUSIONS

The percentages of service members with diseases in specific ICD-9-CM diagnostic categories were similar to those reported in other studies using military medical data. There is a greater prevalence of dietary supplement use by the service members who participated in this survey compared with the general population, with 73% of US Navy and Marine Corps personnel reporting use of dietary supplements one or more times per week compared to the estimated 50% of all Americans currently using some form of dietary supplement. The DoD ensures the optimal readiness, performance, and health of its military service members, thus future longitudinal evaluation of dietary supplement use by this population will test the preliminary findings of this study.

Dietary Ingredients Requiring Further Research Before Evidence-Based Recommendations Can Be Made for Their Use as an Approach to Mitigating Pain

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons; although such use has become popular, decisions are often driven by information that is not evidence-based. This work evaluates whether current research on dietary ingredients for chronic musculoskeletal pain provides sufficient evidence to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. Grading of Recommendations, Assessment, Development and Evaluation was used to determine confidence in the effect estimates. The committee used a decision table to make evidence-informed judgments across decision-making factors and recommendations for practice and self-care use.

RESULTS

Nineteen dietary ingredients were assessed. No recommendations were given for boswellia, ginger, rose hip, or s-adenosyl-L-methionine (SAMe); specifically, although ginger can be obtained via food, no recommendation is provided for use as a supplement due to unclear research. Further, there were insufficient strong research on boswellia and SAMe and possible compliance issues (i.e., high number of capsules required daily) associated with rose hip.

CONCLUSIONS

No recommendations were made when the evidence was low quality or trade-offs were so closely balanced that any recommendation would be too speculative. Research recommendations are provided to enhance the quality and body of evidence for the most promising ingredients. Clinicians and those with chronic pain can rely on evidence-based recommendations to inform their decisions.

Prevalence and Predictors of Dietary and Nutritional Supplement Use in the Australian Army: A Cross-Sectional Survey

Dietary supplements (DSs) and nutritional supplements (NSs) can enhance performance, recovery or training adaptations, however, some substances, dosages, and usage protocols are unsafe. Knowledge of the type and extent of use within populations enables strategies to be formulated to promote safe and effective use (where needed) and to avoid adverse side effects. The purpose of this study was to understand DS and NS use by active-duty Australian soldiers. Surveys were distributed by e-mail and hard copy to eligible participants (n = 23,195). Respondents (males n = 1833; females n = 296) comprised 9.3% of the total population. Use of ≥1 DSs/week was reported by 76.4% of males and 86.8% of females, and use of ≥1 NSs/week was reported by 21.7% of males and 20.9% of females. The most commonly used supplements were protein or amino acids (55.6%), multivitamins and minerals (38.2%), other DSs (37.8%), individual vitamins and minerals (33.0%), and combination products (32.8%). Logistic regression revealed the number of DSs respondents used simultaneously was significantly different between males and females, age groups, BMI ranges, and body weight actions. Engagement in special operations was a significant predictor of the use of any DS, individual vitamin and minerals and multivitamin and minerals. Approximately 16% of regular DS users reported experiencing one or more side effects, with the most common being palpitations (10.6%), tingling or numbness in the face, fingers, arms, or legs (5.5%), tremors or shaking (2.9%), flushing (2.3%), headache (2.0%), abdominal pain (1.6%), anxiety (1.4%), and dizziness or confusion (0.9%). The results revealed more prevalent use of several categories of DSs and NSs among some subgroups. Ongoing surveillance of DS and NS use is important for tracking trends in use over time and gauging the effectiveness of any strategies employed to enhance the quality of supplement use.

Essential Features of Third-Party Certification Programs for Dietary Supplements: A Consensus Statement

The presence of performance-enhancing drugs in dietary supplements poses serious anti-doping and health risks to athletes and military service members. A positive drug test, suboptimal health, or adverse event can ruin a career in either setting. These populations need to be certain in advance that a product is of high quality and free from performance-enhancing drugs and other banned substances. However, no regulatory authority conducts or mandates a quality review before dietary supplements are sold. Under the Food Drug and Cosmetic Act, the Food and Drug Administration does not have a role in the premarket safety review of dietary supplements. Due to the increasing demand for high-quality, properly labeled dietary supplements, multiple companies have stepped into this void by offering testing and quality review programs for dietary supplements. Each of these third-party programs has its own quality assurance program with varying testing components. It is difficult for consumers in the sport and military settings to assess whether a particular certification program reduces the risks enough so that they can use a product with confidence. This article puts forward the consensus of the authors on current best practices for third-party certification programs for dietary supplements consumed by athletes and military service members. Also discussed are important ways that third-party programs can develop in the future to improve access to safe, high-quality dietary supplements for these populations.

Retrospective self-reported dietary supplement use by Australian military personnel during deployment to Iraq and Afghanistan: results from the Middle East Area of Operations Health Study

The use of dietary supplements is popular among military personnel. However, there is a lack of understanding about the changes in use during deployment and the specific factors associated with such changes. This study retrospectively examined changes in the pattern of supplement use among Australian veterans during their deployment to Iraq (n = 8848) and Afghanistan (n = 6507) between 2001 and 2009 and identified work-related circumstances that were associated with these changes. The frequency of use of supplements at present and during deployment was assessed. Multiple logistic regression analysis was used to compare the use of supplements among different groups and among those with different deployment experiences. The study found that overall use of supplements was highest on deployment to Afghanistan (27.8%) compared with deployment to Iraq (22.0%, p < 0.001) or after deployment (current use, 21.2%; p < 0.001). Personnel who were younger or who were at the rank of noncommissioned officer were more likely to use dietary supplements. Men were more likely to use body-building supplements, whereas women more often used weight-loss supplements. Those veterans who did not report using supplements regularly on deployment were far less likely to use them subsequently. Combat exposure, mixed duty cycles, and working long hours during deployment were associated with higher supplement use. The findings confirmed that supplement use in the military reflects the unique demands and stressors of defence service.

The Health Threat Posed by the Hidden Epidemic of Anabolic Steroid Use and Body Image Disorders Among Young Men

CONTEXT

The prevalence of body image disorders and anabolic-androgenic steroid (AAS) use is increasing, despite the evidence of their serious adverse health effects and despite the passage of laws regulating their sales. Here we review the evolution of the dual emerging epidemics of body image disorders and AAS use, adverse health effects of AASs, and the need for an integrated health policy and regulatory response.

EVIDENCE ACQUISITION

We searched for studies published prior to June 2018. Quality of evidence was low to moderate because of its observational nature; heterogeneity of eligibility criteria; variable doses; reliance on retrospective self-reported data in many studies; and variable quality of outcome ascertainment.

EVIDENCE SYNTHESIS

Most AAS users are nonathlete young men, who use these substances to look lean and more muscular. Some of these men suffer from "muscle dysmorphia," a form of body dysmorphic disorder. AASs has been associated with cardiovascular disorders, psychiatric disorders, AAS-withdrawal hypogonadism, infertility, neurotoxic effects, musculoskeletal injuries, liver toxicity, and needle-borne infections. Potential adverse effects may be compounded by the use of other substances (e.g., opioids) and high-risk behaviors. Unregulated Internet sales of AASs and selective androgen receptor modulators, which are easily purchased without a prescription, are of concern because of their potential to fuel the epidemic among adolescents and the military.

CONCLUSIONS

Integrated nationwide efforts are necessary to raise public awareness of this epidemic, to study long-term health effects of AASs and treatment strategies, and to reform regulations to stem the epidemics of AAS use and body image disorders.

Using the Dietary Supplement Label Database to Identify Potentially Harmful Dietary Supplement Ingredients

Over half of young adults, athletes, and Military Service Members self-report using at least one dietary supplement (DS) 1 or more times per week. DS may be consumed to improve health, provide more energy, increase muscle strength, and/or enhance performance. The United States Food and Drug Administration (FDA) has raised concerns regarding adulteration, safety, and adverse events associated with DS marketed for brain health and bodybuilding. Some DS products may compromise health as well as lead to a serious adverse event. The National Institutes of Health (NIH) Dietary Supplement Label Database (DSLD), available at https://dsld.nlm.nih.gov/, can be freely accessed and used by researchers, providers, and consumers alike to screen for potentially harmful DS. It was developed to serve the research community and as a resource for health care providers and the public. Herein we provide two examples of how the database can be used to identify DS ingredients of concern in products marketed for brain health and bodybuilding. The search for DS marketed for brain health returned 49 unique DS, and the search on DS marketed for bodybuilding returned 18 unique DS. Search results were cross-referenced with the Operation Supplement Safety High-Risk Supplement List, the FDA Tainted Products Marketed as Dietary Supplements list, the Natural Medicines database, and NIH Office of Dietary Supplements Fact Sheets. Three ingredients found in DS marketed for brain health and two ingredients in DS marketed for bodybuilding were identified as "of concern". Educational tools, including the DSLD, can help consumers and providers make informed decisions regarding DS.

Capturing the Use of Dietary Supplements in Electronic Medical Records: Room for Improvement

Of importance to federal agencies that administer health care facilities is capturing patient use of dietary supplements (DS) to avoid potential drug - supplement interactions. Digital technologies, such as use of the electronic medical record and the electronic health record (EHR) are key to monitoring health care. The particular electronic software package and the health care professional using this software influences how this documentation is recorded. A survey was conducted to determine how information on DS is being collected, recorded, and processed in EHR across federal agencies. Four federal agencies providing direct health care services to large numbers of men and women in the US were surveyed on current practices regarding the recording and processing of information on DS use either on outpatient or inpatient basis. A point of contact for each of the following federal agencies was identified, and a 13-question survey was sent to each for completion: NIH Clinical Center, Department of Defense (DoD) Military Nutrition Committee, Veterans Health Administration (VHA) Office of Specialty Care Services, and the Indian Health Service (IHS), Office of Information Technology. All four agency representatives completed the survey. No agency used the same EHR software reporting system. Most EHR have searchable fields that are in a structured format, but some information is free text and allowed entry by multiple members of the health-care team. Three different medication formulary or drug knowledge databases were utilized across the agencies. Most agencies using EHR management systems have adequately described procedures for entering and charting information on DS. The responsibility for charting, however, varies across agencies whether captured by the admitting doctor, nurse, dietitian, or pharmacist. Direct linkage between the pharmacy system and the drug knowledge database is a feature of the EHR for several but not all federal agencies. An unmet need still exists in the EHR to implement DS/drug interaction checks as many DS products have multiple active ingredients and when taken with other DS or prescription drugs increase the likelihood of an adverse event. Establishing common EHR practices could facilitate monitoring the use and potential interactions of DS with prescribed drugs.

Current regulatory guidelines and resources to support research of dietary supplements in the United States

The U.S. Dietary Supplement Health and Education Act (DSHEA) established the regulatory framework for dietary supplements as foods through the Food and Drug Administration (FDA). DSHEA outlined the legal definition, labeling requirements, and process for adverse event reporting for dietary supplements. FDA also issued formal guidance on current Good Manufacturing Practice to ensure that processes for preparation, packaging, labeling, and storage of supplements and ingredients are documented and meet specifications to ensure purity, composition, and strength. However, efficacy of dietary supplements is not required under U.S. law. Despite regulations to improve the marketplace, many challenges remain; as a result, the quality and safety of products available can be highly variable, especially for botanical and herbal products. The ability of regulators to successfully carry out their mission is hampered by the sheer number of products and manufacturing facilities and a lack of analytical methods for all ingredients and products in the marketplace, this is especially difficult for herbal and botanical dietary supplements. Safety issues continue to exist such as adulteration and contamination, especially with specific product types (i.e. body building, sexual enhancement). Thus, a need remains for continued efforts and improved techniques to assess the quality of dietary supplements, especially with regard to purity, bioavailability, and safety. This review will highlight the existing American regulatory framework for dietary supplements and will describe the remaining regulatory barriers to ensuring that safe and high-quality dietary supplements are offered in the marketplace.

Dietary Supplement Use in a Large, Representative Sample of the US Armed Forces

BACKGROUND

Dietary supplement (DS) use is prevalent among the US Armed Forces personnel, but representative cross-service comparisons and characteristics of personnel using DSs are limited.

OBJECTIVE

Examine DS use and characteristics associated with use in a representative sample of US Armed Forces personnel (Army, Navy, Air Force, Marine Corps, and Coast Guard) using data from the 2011 Department of Defense Survey of Health-Related Behaviors.

DESIGN AND PARTICIPANTS

A stratified random sample of service members (SMs) was contacted and asked to complete a questionnaire assessing personal characteristics and DS use.

RESULTS

Overall, 69% of the 39,877 SMs reported using DSs ≥1 time per week. The most commonly used DSs were multivitamin or multiminerals (50%), antioxidants (34%), individual vitamins or minerals (33%), bodybuilding supplements (27%), fish oils (26%), herbals (16%), and weight-loss supplements (16%). Multiple logistic regression indicated overall DS use was higher among women, those with higher educational levels, Marine Corps SMs, officers, those with higher body mass index, those engaged in greater physical activity and weight training, and people in weight control programs. DS use was lower when peer groups or leadership discouraged substance abuse.

CONCLUSIONS

DS use was considerably higher in the US Armed Forces compared with civilian populations, although many demographic and lifestyle factors associated with use were similar. Some categories of DSs extensively used by SMs such as bodybuilding supplements have been associated with adverse events. Discouraging substance abuse through peer groups and leadership actions may reduce use of unnecessary or dangerous DSs.

Vitamins for Cardiovascular Diseases: Is the Expense Justified?

Despite the knowledge that a well-balanced diet provides most of the nutritional requirements, the use of supplemental vitamins is widespread among adults in the United States. Evidence from large randomized controlled trials over the last 2 decades does not support vitamin supplementation for the reduction of cardiovascular risk factors or clinical outcomes. Many of the vitamins used in common practice likely are safe when consumed in small doses, but long-term consumption of megadoses is not only expensive but has the potential to cause adverse effects. Therefore, a need exists to revisit this issue, reminding the public and healthcare providers about the data supporting the use of vitamins for cardiovascular disease, and the potential for harm and the expense associated with their unnecessary use. In this review, we highlight the scientific evidence from randomized controlled studies regarding the efficacy and safety of vitamin supplementation for primary and secondary prevention of cardiovascular diseases and outcomes. We also draw attention to issues related to widespread and indiscriminate use of vitamin supplements and the need to educate the public to curtail unnecessary consumption and expense by limiting their use based on strong scientific evidence.

The Complementary Health Approaches for Pain Survey (CHAPS): Validity testing and characteristics of a rural population with pain

Objectives

Little is known about patterns and correlates of Complementary Health Approaches (CHAs) in chronic pain populations, particularly in rural, underserved communities. This article details the development and implementation of a new survey instrument designed to address this gap, the Complementary Health Approaches for Pain Survey (CHAPS).

Design

Following pilot-testing using pre-specified criteria to assess quality and comprehension in our target population, and after feedback regarding face-validity from content experts and stakeholders, the final cross-sectional self-report survey required 10–12 minutes to complete. It contained 69 demographic, lifestyle and health-related factors, and utilized a Transtheoretical Model (TTM) underpinning to assess short- and long-term use of 12 CHAs for pain management. Twenty additional items on pain severity, feelings, clinical outcomes, and activities were assessed using the Short-Form Global Pain Scale (SF-GPS); Internal reliability was assessed using Cronbach’s alpha.

Settings/location

Investigators conducted consecutive sampling in four West Virginia pain management and rheumatology practices.

Participants

301 Appalachian adult patients seeking conventional care for pain management.

Results

Response rates were high (88% ± 4.1%). High quality and comprehension deemed the CHAPS an appropriate measurement tool in a rural population with pain. Missing data were unrelated to patient characteristics. Participants predominantly experienced chronic pain (93%), had five or more health conditions (56%, Mean = 5.4±3.1), were white (92%), female (57%), and middle-aged (Mean = 55.6 (SD = 13.6) years). Over 40% were disabled (43%) and/or obese (44%, Mean BMI = 33.4±31.5). Additionally, 44% used opioids, 31% used other prescription medications, and 66% used at least one CHA for pain, with 48% using CHAs for greater than 6 months. There was high internal reliability of the SF-GPS (alpha = .93) and satisfactory internal reliability for each of the five TTM stages across (all) twelve CHAs: precontemplation (0.89), contemplation (0.72), preparation (0.75), action (0.70), and maintenance (0.70).

Conclusions

The CHAPS is the first comprehensive measurement tool to assess CHA use specifically for pain management. Ease of administration in a population with pain support further use in population- and clinic-based studies in similar populations.

Prevalence of supplement use in recreationally active Kazakhstan university students

Background

Little is known about the supplements use and recreational sport practices in Kazakhstan university students. Therefore, the aim of this study was to ascertain supplements use prevalence and their predictors in this population.

Methods

Cross-sectional survey of both undergraduate and graduate level students was completed in 2017 et al.-Farabi Kazakh National University, the largest higher institution in the country, from almost all Schools. A 45-item questionnaire was used to record physical activity, supplements use, lifestyle attributes (smoking, alcohol, sleep, etc.) and eating habits, and adjusted regression models were used to verify predictors of supplements use.

Results

Of the entire sample of 889 students (70% females), 526 (59%) were practicing recreational physical activity (RPA), and walking, jogging and track and field was the most popular activity type (38%). N = 151 (29%) students reported the use of any supplement (31% in men and 27% in women), whereas the most popular supplement type were vitamins. Supplement use was most prevalent in swimmers (55%). Age (odds ratio (OR) 1.19 (95% confidence interval (CI) 1.04–1.37), use of fitness tracker (OR 6.26 (95% CI 3.90–10.03)) and low-fat diet (OR 1.95 (95% CI 1.23–3.10)), but not income predicted supplements use in adjusted models.

Conclusions

With more than half of students exercising regularly, only less than one-third use supplements with a very strong association with fitness tracker use.

Adverse Effects of Nutraceuticals and Dietary Supplements

Over 70% of Americans take some form of dietary supplement every day, and the supplement industry is currently big business, with a gross of over $28 billion. However, unlike either foods or drugs, supplements do not need to be registered or approved by the US Food and Drug Administration (FDA) prior to production or sales. Under the Dietary Supplement Health and Education Act of 1994, the FDA is restricted to adverse report monitoring postmarketing. Despite widespread consumption, there is limited evidence of health benefits related to nutraceutical or supplement use in well-nourished adults. In contrast, a small number of these products have the potential to produce significant toxicity. In addition, patients often do not disclose supplement use to their physicians. Therefore, the risk of adverse drug-supplement interactions is significant. An overview of the major supplement and nutraceutical classes is presented here, together with known toxic effects and the potential for drug interactions.

Methodological approach to moving nutritional science evidence into practice

The Metabolically Optimized Brain study explored nutritional science believed to be ready to place into practice to help improve US service members' cognitive performance and, thereby, optimize mission-readiness. A transparent, step-wise, research approach was used for informing evidence-based decisions among and for various, diverse stakeholders. A steering committee and subject-matter experts convened to devise the protocol and independent systematic reviews were performed to determine the quality of the evidence for nutritional science in 4 areas relevant to military populations: (1) caffeinated foods and beverages; (2) omega-3 polyunsaturated fatty acids; (3) plant-based foods and beverages or their phytochemical constituents; and (4) whole dietary patterns. A research expert panel was asked to then recommend future research directions and solutions likely to benefit warfighters. An implementation expert panel further considered how to apply sound nutritional science in a cost-effective manner. This article summarizes the methodological processes, high-level results, global research recommendations, and priorities for implementation. Specific results of the individual dietary interventions, as well as recommendations for moving this field of research and practice forward, are detailed throughout the current supplement.

Demographic factors associated with dietary supplement prescriptions filled by United States Military Service Members 2005-2013

BACKGROUND

Dietary supplements (DSs) can be purchased over-the-counter but may also be prescribed by medical personnel for specific therapeutic reasons. Few studies have examined this latter source of DSs despite the fact that 79% of physicians and 82% of nurses have recommended DSs to their patients. This investigation examined demographic factors associated with temporal trends in oral DS prescriptions filled by all United States (US) service members (SMs) from 2005 to 2013 (n = 1,427,080 ± 22,139, mean ± standard deviation per year).

METHODS

The Food and Drug Administration National Drug Code database and the formularies of the US Defense Health Agency's Pharmacoeconomic Center were queried to identify DSs available to SMs. The number of these DS prescriptions filled by all SMs from 2005 through 2013 was then obtained from the US Department of Defense Pharmacy Data Transaction System. Data were grouped by American Hospital Formulary System (AHFS) pharmacologic-therapeutic classifications and examined over time. Denominators (number of SMs each year) were obtained from the Defense Health Agency.

RESULTS

Major findings included 1) generally greater prevalence of prescriptions filled by women and older SMs for most AHFS categories; 2) a temporal decline in total prescriptions filled by Marine Corps personnel accounted for by a decline in the prevalence of zinc preparations filled by younger male Marines; 3) a temporal decline in the prevalence of iron preparations filled by women; 4) a temporal increase in the prevalence of prescriptions for replacement preparations filled by women accounted for largely by more prescriptions for calcium compounds; and 5) a temporal decline in the prevalence of prescriptions filled for cathartics/laxatives in older SMs accounted for largely by a decline in prescriptions for sodium/potassium compounds.

CONCLUSIONS

These temporal trends may be associated with the greater health care utilization of women and older SMs as well as the perceptions of prescribers and/or patients on appropriate roles of these substances in medicine and public health.

Temporal trends in dietary supplement prescriptions of United States military service members suggest a decrease in pyridoxine and increase in vitamin D supplements from 2005 to 2013

Dietary supplements (DSs) can be obtained over-the-counter but can also be prescribed by health-care providers for therapeutic reasons. Few studies have documented this later source despite the fact that 79% of physicians and 82% of nurses have recommended DSs to patients. This investigation assessed prevalence and temporal trends in oral DS prescriptions filled by all United States service members (SMs) from 2005 to 2013 (n = 1 427 080 ± 22 139, mean ± standard deviation (SD)/y). We hypothesize that there would be temporal variations in specific types of DSs. Data obtained from Department of Defense Pharmacy Data Transaction System were grouped by American Hospital Formulary System pharmacologic-therapeutic classifications and prevalence examined over time. About 11% of SMs filled one or more DS prescriptions of 235 180 ± 4926 (mean ± SD) prescriptions/y over the 9-year period. Curve-fitting techniques indicated significant linear declines over time for multivitamins (P = .004), iron preparations (P < .001), antacids (P < .001), and vitamin B and B complex vitamins (P < .001). There were significant quadratic trends indicating a rise in early years followed by a leveling off in later years for replacement preparations (P < .001) and vitamin C (P < .001). There were significant quadratic trends (P < .001) for vitamin E indicating a decline in early years and leveling off in later years, and vitamin D indicating little change in early years followed by a large rise subsequently (P < .001). This study identified temporal trends in specific DS categories that may be associated with changing perceptions of prescribers and/or patients of the appropriate roles of DSs in medicine and public health.

New strategies in sport nutrition to increase exercise performance

Despite over 50 years of research, the field of sports nutrition continues to grow at a rapid rate. Whilst the traditional research focus was one that centred on strategies to maximise competition performance, emerging data in the last decade has demonstrated how both macronutrient and micronutrient availability can play a prominent role in regulating those cell signalling pathways that modulate skeletal muscle adaptations to endurance and resistance training. Nonetheless, in the context of exercise performance, it is clear that carbohydrate (but not fat) still remains king and that carefully chosen ergogenic aids (e.g. caffeine, creatine, sodium bicarbonate, beta-alanine, nitrates) can all promote performance in the correct exercise setting. In relation to exercise training, however, it is now thought that strategic periods of reduced carbohydrate and elevated dietary protein intake may enhance training adaptations whereas high carbohydrate availability and antioxidant supplementation may actually attenuate training adaptation. Emerging evidence also suggests that vitamin D may play a regulatory role in muscle regeneration and subsequent hypertrophy following damaging forms of exercise. Finally, novel compounds (albeit largely examined in rodent models) such as epicatechins, nicotinamide riboside, resveratrol, β-hydroxy β-methylbutyrate, phosphatidic acid and ursolic acid may also promote or attenuate skeletal muscle adaptations to endurance and strength training. When taken together, it is clear that sports nutrition is very much at the heart of the Olympic motto, Citius, Altius, Fortius (faster, higher, stronger).

Hepatotoxicity associated with weight loss or sports dietary supplements, including OxyELITE Pro™ - United States, 2013

In September 2013, the Hawaii Department of Health (HDOH) was notified of seven adults who developed acute hepatitis after taking OxyELITE Pro™, a weight loss and sports dietary supplement. CDC assisted HDOH with their investigation, then conducted case-finding outside of Hawaii with FDA and the Department of Defense (DoD). We defined cases as acute hepatitis of unknown etiology that occurred from April 1, 2013, through December 5, 2013, following exposure to a weight loss or muscle-building dietary supplement, such as OxyELITE Pro™. We conducted case-finding through multiple sources, including data from poison centers (National Poison Data System [NPDS]) and FDA MedWatch. We identified 40 case-patients in 23 states and two military bases with acute hepatitis of unknown etiology and exposure to a weight loss or muscle building dietary supplement. Of 35 case-patients who reported their race, 15 (42.9%) reported white and 9 (25.7%) reported Asian. Commonly reported symptoms included jaundice, fatigue, and dark urine. Twenty-five (62.5%) case-patients reported taking OxyELITE Pro™. Of these 25 patients, 17 of 22 (77.3%) with available data were hospitalized and 1 received a liver transplant. NPDS and FDA MedWatch each captured seven (17.5%) case-patients. Improving the ability to search surveillance systems like NPDS and FDA MedWatch for individual and grouped dietary supplements, as well as coordinating case-finding with DoD, may benefit ongoing surveillance efforts and future outbreak responses involving adverse health effects from dietary supplements. This investigation highlights opportunities and challenges in using multiple sources to identify cases of suspected supplement associated adverse events. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Soldier use of dietary supplements, including protein and body building supplements, in a combat zone is different than use in garrison

United States Army personnel in garrison who are not deployed to combat theater report using dietary supplements (DSs) to promote health, increase physical and mental strength, and improve energy levels. Given the substantial physical and cognitive demands of combat, DS use may increase during deployment. This study compared DS use by garrison soldiers with DS use by personnel deployed to a combat theater in Afghanistan. Prevalence and patterns of DS use, demographic factors, and health behaviors were assessed by survey (deployed n = 221; garrison n = 1001). Eighty-two percent of deployed and 74% of garrison soldiers used DSs ≥1 time·week–1. Logistic regression analyses, adjusted for significant demographic and health predictors of DS use, showed deployed personnel were more likely than garrison soldiers to use protein, amino acids, and combination products. Deployed females were more likely to use protein supplements and deployed males were more likely to use multivitamins, combination products, protein, and body building supplements than garrison respondents. Significantly more deployed (17%) than garrison (10%) personnel spent more than $50∙month–1 on DSs. Higher protein supplement use among deployed personnel was associated with higher frequency of strength training and lower amounts of aerobic exercise for males but similar amounts of strength training and aerobic exercise for females. Protein supplements and combination products are used more frequently by deployed than garrison soldiers with the intent of enhancing strength and energy.

Prevalence of Dietary Supplement Use by Athletes: Systematic Review and Meta-Analysis

BACKGROUND

Dietary supplements (DSs) are commercially available products consumed as an addition to the usual diet and are frequently ingested by athletes.

OBJECTIVE

Our objective was to examine the prevalence of DS use by athletes.

DATA SOURCES

PubMed, Ovid MEDLINE, OVID Healthstar, and Cumulative Index to Nursing and Allied Health were searched for original research articles published up to August 2014. Search terms included specific sports, specific DSs, and other terms.

STUDY SELECTION

Studies were selected if they were written in English, involved athletes, and provided a quantitative assessment of the proportion of athletes using specific DSs. Percent of athletes using specific DSs.

SYNTHESIS OF DATA

Methodological quality of studies was assessed by three reviewers using an 8-point scale that included evaluations for sampling methods, sampling frame, sample size, measurement tools, bias, response rate, statistical presentation, and description of the participant sample. Where there were at least two investigations, meta-analysis was performed to obtain summary (pooled) prevalence estimates (SPEs) on (1) DS use prevalence by sport and sex, (2) DS use prevalence by elite versus non-elite athletic status, and (3) specific DS prevalence for all athletic groups combined. Meta-analyses included evaluations of homogeneity and publication bias.

RESULTS

A total of 159 unique studies met the review criteria. Methodological quality was generally low with an average ± standard deviation of 43 ± 16% of available rating points. There was low homogeneity for SPEs when compiled by sport, athletic status, and/or specific DSs. Contributing to the lack of homogeneity were differences in studies' objectives and types of assessments used (e.g., dietary surveys, interviews, questionnaires). Despite these limitations, the data generally indicated that elite athletes used DSs much more than their non-elite counterparts. For most DSs, use prevalence was similar for men and women except that a larger proportion of women used iron while a larger proportion of men used vitamin E, protein, and creatine. No consistent change in use over time was observed because even the earliest investigations showed relatively high use prevalence.

CONCLUSION

It was difficult to generalize regarding DS use by athletes because of the lack of homogeneity among studies. Nonetheless, the data suggested that elite athletes used dietary supplements far more than their non-elite counterparts; use was similar for men and women with a few exceptions; use appeared to change little over time; and a larger proportion of athletes used DSs compared with the general US population. Improvements in study methodology should be considered in future studies especially (1) defining DSs for participants; (2) querying for very specific DSs; (3) using a variety of reporting timeframes (e.g., daily, 2-6 times/week, 1 time/week and <1 time/week); (4) reporting the sampling frame, number of individuals solicited, and number responding; (5) reporting characteristics of volunteers (and non-volunteers, if available); and (6) using similar methods on several occasions to examine possible temporal trends among athletes.

β-Alanine supplementation and military performance

During sustained high-intensity military training or simulated combat exercises, significant decreases in physical performance measures are often seen. The use of dietary supplements is becoming increasingly popular among military personnel, with more than half of the US soldiers deployed or garrisoned reported to using dietary supplements. β-Alanine is a popular supplement used primarily by strength and power athletes to enhance performance, as well as training aimed at improving muscle growth, strength and power. However, there is limited research examining the efficacy of β-alanine in soldiers conducting operationally relevant tasks. The gains brought about by β-alanine use by selected competitive athletes appears to be relevant also for certain physiological demands common to military personnel during part of their training program. Medical and health personnel within the military are expected to extrapolate and implement relevant knowledge and doctrine from research performed on other population groups. The evidence supporting the use of β-alanine in competitive and recreational athletic populations suggests that similar benefits would also be observed among tactical athletes. However, recent studies in military personnel have provided direct evidence supporting the use of β-alanine supplementation for enhancing combat-specific performance. This appears to be most relevant for high-intensity activities lasting 60-300 s. Further, limited evidence has recently been presented suggesting that β-alanine supplementation may enhance cognitive function and promote resiliency during highly stressful situations.

Self-reported side-effects associated with use of dietary supplements in an armed forces population

Approximately 60–70% of Armed Forces personnel consume a dietary supplement (DS) at least once a week and there have been numerous reports of severe adverse events among DS users. This study assessed patterns of DS use and self‐reported side‐effects among 4400 Armed Forces personnel using a paper‐and‐pencil survey. Multivariable logistic regression was used to examine associations between patterns of DS use and self‐reported side‐effects. Sixty‐nine percent of personnel surveyed reported using a DS. Seven percent of DS users reported experiencing abnormal heart beats, 6% tremors, 5% stomach pain, 3% dizziness, and 3% numbness/tingling and they believed these symptoms were associated with the use of DS. After adjustment for use of other DS classes, total supplement use, and demographic characteristics, protein supplement users were more likely than non‐users to report numbness/tingling; combination product users were more likely to report experiencing abnormal heart beats, stomach pain, dizziness, tremors, and numbness/tingling; and users of purported steroid analogues were more likely to report dizziness. Use of more than one DS per week was associated with an increased likelihood of reporting side‐effects. Respondents with a higher body mass index were more likely to report side‐effects. Further research is necessary to determine whether self‐reported side‐effects associated with multiple DS use and some DS classes impact the long‐term health or performance of service members. Surveillance of military populations using surveys like this one may provide a method for detecting adverse health events of DS before they are apparent in the civilian population. © 2015 The Authors. Drug Testing and Analysis published by John Wiley & Sons, Ltd.

Predictors of Dietary Supplement Use by U.S. Coast Guard Personnel

Background

Personnel in Armed Forces entities such as the US Coast Guard (USCG) engage in strenuous tasks requiring high levels of physiological and psychological fitness. Previous reports have found increased prevalence of dietary supplement (DS) use by military personnel to meet the demands of their occupation.

Objective

This study assessed DS prevalence and patterns of use in USCG personnel and compared these findings to reports from other Armed Forces personnel.

Design

Use of DS by USCG personnel (n = 1059) was assessed by survey at USCG installations. Data were weighted by age, sex, and rank to be representative of total USCG demographics.

Results

Seventy percent of USCG personnel reported using a DS at least 1 time/wk. Thirty-three percent used 1–2 DS ≤ 1 time/wk, 18% 3–4 DS ≥ 1 time/wk, and almost 19% ≥ 5 DS ≥ 1 time/wk. Average expenditure on DSs by UCSG personnel was $40/mo. More than 47% of USCG personnel used a multivitamin and mineral, 33% consumed protein supplements, 22% used individual vitamins and minerals, 23% reported taking combination products, and 9% consumed herbal supplements. Increased use of DS use was associated with high intensity operational occupations, participating in high volumes of aerobic exercise and strength training. Use of DS was not associated with age, education or body mass index.

Conclusion

Occupation is an important determinate of DS use. Prevalence of DS use by USCG personnel is greater than reported for other Armed Forces personnel and reflects high levels of participation in aerobic and strength training activities.