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American Journal of Lifestyle Medicine http://ajl.sagepub.


Do Supplements Benefit Exercise?

Karen Kuczmarski AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2008 2: 293 originally published online 17 May 2008 DOI: 10.1177/1559827608317769 The online version of this article can be found at:

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vol. 2 no. 4

American Journal of Lifestyle Medicine

Karen Kuczmarski, PharmD, CPh

Do Supplements Benet Exercise?

Abstract: It is a known fact that exercise will have beneficial effects on ones health. Nutritional supplementation is on the rise, resulting in a billion-dollar industry. However, because these medications are not regulated by the Food and Drug Administration, it is difficult for the public to determine what is safe and effective. Health care providers have to be aware of this lack of knowledge and educate their patients on which supplements are beneficial and which may be harmful to their health. Keywords: supplements; protein; creatine; 1-carnitine; vitamins re health and exercise priorities in our lives? According to the Centers for Disease Control and Prevention (CDC), more than half of US citizens do not include regular physical activity in their weekly routine.1 The CDC and the American College of Sports Medicine advise individuals to participate in at least 30 minutes of moderate exercise on most, if not all, days of the week.2 It has been established that routine exercise is beneficial at controlling weight, reducing depression and anxiety, and decreasing ones risk for obesity, heart disease, type 2 diabetes, hypertension, colon cancer, and early death.3-5 From 2001 to 2005, CDC data from the Behavioral Risk Factor Surveillance System (BRFSS) demonstrated an increase in the trend of regular physical activity among men and women from 48.0% to 49.7% and 43.0% to 46.7%, respectively.6 Although it was not a huge increase, the hope is that these percentages will continue to rise each year. All health care professionals should encourage their patients to maintain a healthy, active lifestyle. When incorporating an exercise regimen into a weekly routine, people should always first consult a physician. This is imperative to develop a regimen that is safe and beneficial for ones age and any preexisting health conditions. In addition, individuals should consult and drug interactions. Herbal medications are not regulated by the Food and Drug Administration (FDA) as prescription drugs because they are considered dietary supplements.7 Due to this lack of regulation, the manufacturer of the product is not required to undergo any clinical testing of the medication to prove effectiveness of its so-called claim. Also, there is no method of control in place to establish that the product is manufactured in sanitary conditions with pure, consistent amounts of ingredients.7

Unfortunately, as with most nutritional supplements, there is little or no evidence to support their safety and efcacy, specically long term.
their physician or pharmacist regarding any over-the-counter medications or supplements they may use to enhance their physical training, specifically muscle building. Over-the-counter medications are often misconstrued as safe because they are available to the public without a prescription. However, vitamins, cough/ cold products, and pain medications are still drugs and should be taken only when necessary, according to the labeled directions. In addition, herbal supplements are viewed in the same manner because they are considered natural. However, these are still medications and have the potential for adverse reactions Due to this, each batch of natural products may contain varying amounts of active ingredient as well as impurities.8 There can be several, if not hundreds, of ingredients in many natural supplements, including those that may be contaminating the product such as metals, unlabeled prescription drugs, and microorganisms.8-11 The FDA is allowed to step in and take action only if it is able to prove a product is unsafe through clinical evidence.12 Unfortunately, this typically occurs only after an individual has undergone a severe adverse reaction. In general, purchasing herbal or nutritional supplements with a USP Good Manufacturing Practice,

DOI: 10.1177/1559827608317769. From Florida HospitalCelebration Health, Celebration, Florida. Address for correspondence: Karen Kuczmarski, PharmD, CPh, Florida HospitalCelebration Health, 400 Celebration Place, Celebration, FL 34747; e-mail: Copyright 2008 Sage Publications
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American Journal of Lifestyle Medicine

July Aug 2008

or GMP, seal on the package label is recommended.13,14 By maintaining this status, the manufacturers are demonstrating that their product is made in a clean environment with consistent amounts of both active and inactive ingredients.13,14 However, it does not prove the efficacy of the product. It also exhibits that the manufacturer has a method of producing, packaging, labeling, and storing the products in a properly controlled environment.12-14 Periodic inspections must be completed for the business to advertise this rating. So, what does all this talk about supplements have to do with exercise? Many individuals, specifically athletes or bodybuilders, use supplements as a means to increase the results of their physical activity or training. In the United States, roughly $12 to $15 billion is spent on nutritional supplements.15 Athletic supplements attribute to about $800 million of that total.15 Unfortunately, as with most nutritional supplements, there is little or no evidence to support their safety and efficacy, specifically long term. If a patient expresses interest in a supplement, a health care provider must fully explain the potential reactions, some of which may be unknown, associated with the drugs use. In the long run, it is the patients decision to weigh the risks versus the benefits in choosing whether to supplement. Protein, 1-carnitine, creatine, and multivitamins are some of the most highly sought supplements. Protein is essential because it is composed of amino acids, which are involved in tissue and muscle growth and repair.16,17 It is available in meat, fish, eggs, and poultry or as whey, casein, egg, soy, or rice protein supplements.16,17 Amino acids, such as glutamine, lysine, leucine, and arginine, can be found in free form in various supplements; however, it is not known whether taking higher levels of these amino acids may be toxic.18 Protein provides some energy, but it is mainly used by athletes after physical activity. It is thought that by supplying higher amounts of amino acids after intense exercise, tissue damage may be repaired more rapidly, allowing for a much shorter recovery time.16

At this point, there is no strong evidence showing that consuming more protein or amino acids will increase muscle mass.16,17 In addition, protein consumed through supplementation has no added benefit when compared with that obtained from food. Typically, supplements are used for convenience because an individual will be able to obtain the desired amount of protein in 1 serving. Protein requirements vary depending on the type of training one is undergoing. For strength athletes, most sources recommend protein intake of 1.6 g/kg, and for endurance athletes, it is 1.3 g/kg.16,19 Typically, protein intake is considered safe, but excessive protein supplementation can lead to dehydration, gastrointestinal pain, or even kidney problems.16,18 Because protein is metabolized by the kidneys, it is important that one stays well hydrated whenever consuming supplements.16,18 L-carnitine is an amino acid that is used by athletes for its ability to facilitate the transport and metabolism of long-chain fatty acids into the mitochondria for beta-oxidation and energy generation.20 Based on these actions, it is thought to enhance endurance and increase fat burn.20,21 Typically, L-carnitine is dosed at 2 to 6 g per day and has been studied for up to a period of 6 months. However, most evidence has shown that the supplement does not provide much benefit; therefore, it is not highly recommended.20,21 Creatine is often used by individuals who want to gain muscle mass.22,23 It is synthesized in the kidney and liver and is involved in the production of adenosine triphosphate (ATP). ATP may be referred to as energy building blocks that allow many processes to occur in the body, such as muscle contraction.22,23 By supplementing with creatine, it is thought that one will have increased energy, muscle size, and strength.22,23 Creatine appears to have benefit in resistance training.15,22-27 There was no improvement demonstrated in endurance training.22-25,27 Typically, dosing consists of a loading dose of 5 g 4 times a day (4-6 days) followed by a maintenance dose of 2 g per day for up to 12 weeks.15,22,23 According to the Physicians Desk

Reference, individuals supplementing with creatine should drink 6 to 8 glasses of water per day to prevent dehydration.15,25,26 The most common adverse effects noted with the medication include weight gain (1.6-2.4 kg), gastrointestinal upset, nausea, dehydration, and muscle cramping.15,22-27 In addition, any individual with kidney disorders may want to avoid supplementation with creatine because there is conflicting evidence regarding its effect on renal function.28 In general, because long-term safety data are not available, use of creatine should be limited to no more than 12 weeks. Vitamins and minerals are often taken at higher than the daily recommended value because it is thought that during intense training, larger doses may be more beneficial.24 However, a study completed using 10 to 50 times the recommended daily intake of vitamins found in a classic multivitamin proved after 8 months to have no added benefit.24 Because vitamins A, D, B3, and B6 may be toxic at higher doses, it is not recommended to consume mega-doses of vitamins.24 A basic multivitamin with minerals should be sufficient for most individuals. With the amount of nutritional supplements available today and the lack of randomized, long-term, controlled trials to demonstrate safety and efficacy, it is almost impossible to recommend use of a supplement without hesitation. However, as health care providers, it is our responsibility to evaluate our patients health status and any medications they are taking. We also can thoroughly research current data to provide patients with the most accurate knowledge available to aid them in making an informed decision regarding supplementation. AJLM References
1. Centers for Disease Control and Prevention. Available at: http://www.cdc .gov/nccdphp/dnpa/physical/health _professionals/index.htm. 2. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402-407.

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3. Kruger J, Blanck HM, Gillespie C. Dietary and physical activity behaviors among adults successful at weight loss maintenance. Int J Behav Nutr Phys Act. 2006;3:17. 4. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: Government Printing Office; 2000. 5. US Department of Health and Human Services. Physical Activity and Health: Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 1996. 6. Kruger J, Kohl HW III. Prevalence of regular physical activity among adultsUnited States, 2001 and 2005. Morb Mortal Wkly Rep. 2007;56:1209-1212. 7. Fontanarosa PB, Rennie D, DeAngelis CD. The need for regulation of dietary supplements: lessons from ephedra. JAMA. 2003;289:1568-1970. 8. Boullata JI, Nace AM. Safety issues with herbal medicine. Pharmacotherapy. 2000;20:257-269. 9. Gilroy DJ, Kauffman KW, Hall RA, et al. Assessing potential health risks from micorcystin toxins in blue-green algae dietary supplements. Environ Health Perspect. 2000;108:435-439. 10. Fugh-Berman A. Herb-drug interactions. Lancet. 2000;355:134-138. 11. National Center for Complementary and Alternative Medicine, National Institutes










of Health. Herbal Supplements: Consider Safety, Too. Available at: http://nccam.nih .gov/health/supplement-safety/. Accessed March 8, 2008. Flanagan K. Preoperative assessment: safety considerations for patients taking herbal products. J PeriAnesth Nurs. 2001;16:19-26. US Food and Drug Administration. Dietary Supplements. Available at: http://ods.od _pf.asp#h7. Accessed March 8, 2008. USP Verified Dietary Supplements. Available at: dietarySupplements/index.html?USP_Print. Accessed March 8, 2008. Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics. 2006;117:e577-e589. Supplementwatch, Inc. Protein. Available at: suplib/supplement.asp?DocId=1216. Accessed March 8, 2008. Natural Standard Database. Protein. Available at: http://www.naturalstandard .com/. Accessed March 8, 2008. Beltz SD, Doering PL. Efficacy of nutritional supplements used by athletes. Clin Pharm. 1993;12:900-908. Tarnopolsky M. Protein requirements for endurance athletes. Nutrition. 2004;20:662-668. Supplementwatch, Inc. Carnitine. Available at: suplib/supplement.asp?DocId=1065. Accessed March 8, 2008.

21. Stuessi C, Hofer P, Meier C, Boutellier U. L-carnitine and the recovery from exhaustive endurance exercise: a randomised, double-blind, placebocontrolled trial. Eur J Appl Physiol. 2005;95:431-435. 22. Supplementwatch, Inc. 2008. Creatine. Available at: http://www supplement.asp?DocId=1090. Accessed March 8, 2008. 23. Natural Standard Database. Creatine. Available at: http://www.naturalstandard .com/. Accessed March 8, 2008. 24. Schwenk TL, Costley CD. When food becomes a drug: nonanabolic nutritional supplement use in athletes. Am J Sports Med. 2002;30:907-916. 25. Balsom PD, Ekblom B, Soderlund K, et al. Creatine supplementation and dynamic high-intensity intermittent exercise. Scand J Med Sci Sports. 1993;3:143-149. 26. Hultman E, Soderlund K, Timmons JA, Cederblad G, Greenhaff PL. Muscle creatine loading in men. J Appl Physiol. 1996;81:232-237. 27. van Loon LJ, Oosterlaar AM, Hartgens F, Hesselink MK, Snow RJ, Wagenmakers AJ. Effects of creatine loading and prolonged creatine supplementation on body composition, fuel selection, sprint and endurance performance in humans. Clin Sci. 2003;104:153-162. 28. Pline KA, Smith CL. The effect of creatine intake on renal function. Ann Pharmacother. 2005;39:1093-1096.

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