Integrative Sports Medicine: Understanding The Role and Use of Supplements for the Everyday Athlete

Rick: Welcome to the Tuesday webinar series “Chiropractic Economics” webinars for doctors of chiropractic. I’m Rick Vach, editor-in-chief, Chiropractic Economics. Today’s webinar, “Integrative Sports Medicine: Understanding the role and use of supplements for the everyday athlete,” is sponsored by Fullscript.

And as always, our program is being recorded and will be archived at Chiropractic Economics website, chiroeco.com/webinar for one year. Our expert is on board today to speak with you and when his presentation is complete, we’ll follow with a Q&A period. You can submit questions throughout the presentation by clicking on the appropriate icon on the right side of your screen.

Our presenter today is Peter Woznik, a Board-Certified Naturopathic Doctor, a Certified Strength and Conditioning Specialist, and a Certified Sports Nutritionist. He has a private practice in Cambridge, Ontario, Canada, and is a research and education medical writer with Fullscript’s Integrative Medical Advisory Team.

Thank you for taking the time to participate in our webinar and for sharing your expertise regarding integrative sports medicine supplements. But before we get started, Dr. Woznik can you please give us a brief background on your work with Fullscript?

Dr. Woznik: Absolutely. So I am a medical writer with Fullscript on the Integrative Medical Advisory Team under the research and education pod. So what we do is produce and present curated content for a healthcare practitioner such as yourselves.

Rick: Thank you very much. Now, we’re gonna hand it over to you for the presentation.

Dr. Woznik: Okay, sounds great. So welcome, everyone. Good afternoon. Good morning to my colleagues in the West Coast. Very excited to be chatting with you folks today about integrative sports medicine, in particular, on how to help your athletes with the latest information in sports supplementation. So let’s just dive straight in.

Okay, so a fairly obvious conflict of interest, but I do work at Fullscript, who does sell supplements to you folks. And so I just wanted to bring to light that this is a potential conflict of interest, all fairly obvious, but believe it’s important to go over that.

So today, we’ll be discussing the sports supplement industry right off the bat, give you guys some trends, some data on where things are at and where things are going. We’ll then go into an athlete’s needs and how they might be different from your other patients in terms of their needs for macronutrients, calories, and also in terms of needs intra-exercise as well.

Then we’ll get into it, we will get into the evidence on sports supplements ingredients, what you guys have been waiting for. We also developed two protocols in terms of pain, inflammation, and immune support, and how these protocols can support your patients. And we’ll be going into quality considerations as well.

So looking at something on regulations, talking about those, answering, you know, essentially commonly asked questions in regards to those. And then going into third-party certifications and anti-doping considerations.

It is my hope by the end of this presentation that you are more aware of trends in the sports supplement industry, when athlete’s needs are different for macro- and micro-nutrients. Just what kind of high-level evidence there is for popular sports supplement athletes? Popular sports supplements, in general, and how anti-inflammatory and immune-boosting supplements can help your athletes. Lastly, again, just getting some familiarity with some third-party certifications for supplementation.

Okay, so let’s chat about the sports supplement industry, the state of the industry, where things are going. First off, the first question is, what is a sports supplement? Well, it’s ingredients of varying kinds: amino acids, botanicals, concentrate, constituent, enzyme, extract, glandular, metabolite, mineral, probiotic, or vitamin. And across different delivery forms, so bars, capsules, gelcaps, liquids, tablets, and powders.

Now, we see some of these a little bit more and less in athletes, you know, we might see more. For example, amino acids, we might see more metabolites, vitamins and minerals, you know, bars, liquids and powders, that kind of thing. Frankly, just to get in, in terms of these delivery forms, just to get in a higher dose of some of these kinds of things because capsules don’t do it very well.

What are sports supplements used for? Well, the obvious one being performance, broken that down a little bit, we’ll be talking about endurance performance in terms of aerobic and anaerobic. And talking about just strength as well.

Perhaps less intuitively, we’ll be talking about recovery and injury risk reduction and their carryover to performance. We’ll be talking about how some supplement, some things benefit this, in particular. And this has a less obvious carryover to performance just because an athlete will be able to train more harder for longer, that kind of thing. Have less risk of being on the bench on the sideline with an injury.

Where is the sports supplement market at currently? Well, globally, in 2020, it grossed $17 billion, and in over just another 8 years is projected to double in size to $33 billion. So it’s growing rapidly.

How many people use sports supplements? Well, a surprising number of the general population, well, half people use sports supplements, and even more athletes and even more elite athletes tend to use sports supplements. So lots of people are using them.

Where are they getting their information from? Well, a lot are getting their information…a lot of athletes are getting their information from coaches and trainers, 50%, and a family, some 31%, a few get it from physicians. That’s our hope today, to upgrade your knowledge further so that we can maybe move the needle in a positive way in this direction to better equip physicians to talk about this.

Let’s go into an athlete’s needs and how they may be different versus other patients of yours. Firstly, covering sedentary macronutrient recommendations, looking at the U.S., Canada, WHO. And finding that, you know, all the carbohydrate recommendations line up somewhere around the 50% mark, let’s say protein somewhere around 20%, and let’s say fat somewhere around 30%. What we’ll be talking about next is how your athletes may need more carbohydrates and protein than this.

So let’s chat about carbohydrate intake. And the big thing, big concept to focus on here is glycogen. Glycogen i.e. stored carbohydrates in our muscles. This is the primary fuel source for moderate and especially intense exercise.

Throughout the presentation today, I think it’s important to discuss numbers to get into exactly what kinds of numbers we’re talking about because this can help to inform your treatment. So for example, we can store about 300 to 700 grams of carbohydrates, i.e. glycogen in our muscles depending on size, but also depending on the size of the athlete. But also depending on carb loading as well, essentially, carbohydrate intake and how much the athlete is or is not consuming.

And so, basically this is the fuel source for, as I said, moderate to intense exercise. So an athlete’s carbohydrate intake needs to be in line with the volume of high intensity and moderate-intensity exercise that they’re going through. So, if they are blasting through, you know, most or all their glycogen in a day, then I think discussing the 300 gram to 700-gram number is important to help inform you in terms of the kind of volume of carbohydrates that they need to eat per day.

In order to talk about more specifically, in terms of volume of hours per day of exercise, and carbohydrate targets, in particular. What we’re seeing here is that less than an hour per day versus over three hours per day. We may need something like three times the amount of carbohydrates in terms of gram per kilogram body weight per day, as carbohydrate intake may need to be much higher.

Carbohydrate timing can be important as well. Essentially, what I want you to glean from this is four hours prior and then immediately after can be important for athletes in order to help to replete, replenish this glycogen. We’ll be talking shortly about supplementation during exercise. But the main point here is that carbohydrate timing can be important before and right after exercise.

Protein, so our recommended daily allowance, RDA for protein for the average person being 0.8 grams per kilogram. What we’re seeing here in athletes for optimum performance is somewhere between two to three times that amount. So let’s say around 1.6, let’s say even as much as 2.4 for athletes interested in fat loss. So coming in pretty close to this number of 2.2 grams per kilogram, which would be basically a gram per pound of bodyweight protein.

Let’s talk about timing. Every three hours probably maximizes muscle protein synthesis for people. But also something like every three hours, just is helpful for getting in the dose of protein that we need to get in for athletes. So let’s take an athlete slightly larger than 90 kilograms, about 200 pounds. Let’s say they’re trying to hit a target of 2 grams per kilogram body weight, nice and easy math working out to 180 grams. What this works out to for five meals and snacks would be 36 grams. So this is a manageable size of protein to get in in a meal kind of thing.

Whereas, you know, if an athlete was doing intermittent fasting, where they’re only having one meal per day and trying to get 180 grams in that one meal, that would be tricky. So basically, you know, eating more often, in general, will help an athlete to just hit this dose of protein per day. In addition to maybe increase in muscle protein synthesis as well, if you’re having that slightly more often.

Casein deserves a special mention as a certain kind of protein here because it spikes insulin, it’s less insulinogenic than, for example, whey protein. And so the utility of casein is high before sleep or perhaps before fasting, because what it does is minimizes losses in fat oxidation i.e. maintains fat oxidation and doesn’t appear to impact insulin. Versus if you were to have whey protein before bed, it might reduce fat oxidation during the night a bit versus casein.

A few more notes on protein quality, with the big caveat of dietary restrictions, allergies, and intolerances, which are highly variable based on your patients. Let’s discuss essential amino acid content, leucine amino acid content, and just overall the digestible indispensable amino acid score.

So let’s go first to this guy over here. Basically, what this is showing is how quickly a certain kind of protein will run out of certain amino acids. So, for example, rice and hemp having a lower score. So when consuming these proteins on their own the body will run out of certain amino acids quicker versus something like casein or whey. When we look at once again, casein, especially whey in terms of essential amino acid content, leucine content, we need the least amount of whey to hit a good strong dose of these to stimulate muscle protein synthesis and recovery.

One question we get a lot in terms of protein is collagen. Collagen is a protein but it is an incomplete protein, meaning it doesn’t have all the essential amino acids, it lacks tryptophan. And so what’s going on here is it’s not going to stimulate muscle protein synthesis, as well as let’s say whey protein powder. Does have uses for sure, absolutely, uses in tendon and ligament repair, 5 to 15 grams per day does tend to benefit tendon and ligament repair over the course of 3 months, I believe it was in the studies. And in non-athletes, it tends to benefit hair, skin, and nails, but that was kind of just beyond the scope of this particular examination.

When talking about our next macronutrient fat, fat intake. Fat intake needs to be proportional to an athlete’s body weight goals, whether that means weight loss, weight gain. Depending on the athlete’s individual preferences depending on the demands of the sport, it needs to be proportional to their weight goals. Generally, that intake may be optimized around the 20% to 35% mark or so. Basically, less than this may start to compromise a few different things. May start to compromise libido, testosterone hormones, may start to reduce intake significantly for fat-soluble vitamins A, D, E, and K. And may start to reduce intake of omega-3s, which we’ll discuss more later on in this presentation are important for inflammation response.

We get a lot of questions on ketogenic diet as well. There’s a question mark here just because we’ll go over the benefits and potential drawbacks, and then it’s up to you to make the decision with your athlete patients. So there does appear to be beneficial aspects of glycogen sparing especially for light to maybe moderate physical activity, intensity. Basically, what this is going to do, the body’s going to become more reliant on free fatty acids for fuel versus glycogen. And as we’ve spoken previously, there are limited glycogen stores depending on how quickly they’re used up. May last a couple hours, that kind of thing. But if your patient is big into, you know, long endurance events, ultra-marathons this kind of thing, then it may be beneficial for them, this is because this fatty acid fuel source basically doesn’t almost ever run out in most people, and so can be above benefit for light, maybe moderate exercise.

Maybe body composition benefits as well, if a person is able to firstly maintain a caloric deficit, and secondly, maintain that for long term enough. Some people just with that intake will naturally go too high and not produce a caloric deficit, whether they’re having too much bacon or whatever it might be. And then other people will just not be able to, and then this one being fairly common, will not be able to maintain a no to a very low carbohydrate diet, i.e. avoid starches, avoid sugars for the long-term in order to maintain this diet.

Potential drawbacks of ketogenic diet, basically coming down to the glycogen issue we spoke about. If they perform repeated bouts of high-intensity activity close together, they may be essentially running out of glycogen, not replenishing glycogen stores enough. And then it may hamper their recovery and performance as a result. So if there’s a lot of these back-to-back, ketogenic diet, your athletes may struggle with that.

While we’re on the topic of fats and fat metabolism, I believe it’s prudent to go over a few fat supplements and the evidence or not for them. So first one, L-carnitine is involved in fatty acid transport. Basically, what I want you to glean from this is as a fatty acid makes its way into the cell, what carnitine does is help it to move into the mitochondria to then be burned off and turned into ATP. So that is the theory. Unfortunately, in overall inconsistent evidence for fat metabolism, and ultimately performance enhancement, especially when looking at aerobic endurance exercise where we would expect to see these kinds of benefits.

Let’s look at conjugated linoleic acid next, which has strong evidence in animals for body composition. So it was studied in humans, optimistically doesn’t tend to hold up in terms of the kind of magnitude of effect. Small magnitude of effect if any, on body composition, and ultimately no effects overall on performance.

Medium-chain triglycerides being the last fat-related supplement for now. They’ve derived from coconut oil. And due to being shorter molecules, they may enter the mitochondria immediately to be burned. However, ultimately, unfortunately, no or little to no ergogenic effect for once again, things like aerobic endurance activity and others.

Okay, let’s go over an athlete’s needs for calories. So to get an athlete’s total daily energy expenditure, where we must go firstly, is to calculate the resting metabolic rate. Mifflin-St Jeor equation has the highest or rather lowest degree of error in calculating this. Basically, we’re plugging in their weight, height, and age, spitting out resting metabolic rate. Multiplying that by physical activity factor, we get an approximation of an athlete’s total daily energy expenditure.

Now, if we want to get more specific than that, we can look at training volume, and overall approximate calorie needs, associated with that. So let’s say an athlete is training in a low volume i.e. 30, 40 minutes per day less than an hour per day, three times per week. What they might expect is an additional 200 to 400 calories per day additional requirement. Versus looking at a higher training volume of let’s say three to six hours per day, five to six days per week, we’re getting into several thousands and an elite athletes sky almost being the limit here.

If we’re getting more specific than that, where we’re going next is technology. So for example, smartphones will have accelerometers and GPS and so may be well suited to certain kinds of activity. Better than this would be technology with a heart rate monitor. We all know of ones that exist for the wrist or some that exist for the finger. We all know the ones that exist for the chest strap. It appears the chest strap is probably best at being able to monitor the heart especially if it’s up and down during, for example, high-intensity interval training, stuff like that.

And then these chest straps can link to smartphones now, you know, besides the watch, and so these chest straps have GPS as well. And so these do a pretty good assessment, at least the most accurate we can do outside of an exercise physiology lab in order to approximate your athlete’s calorie needs.

While we’re talking about calorie needs, calorie intake, let’s talk about fat loss for a second, weight loss. Once again, calories needs like fat intake should be based off on an athlete’s body weight goals. Again, are they trying to maintain, increase, or decrease? A note on decrease in [inaudible 00:21:06] fat loss, in particular, while there are 3500 calories in a pound of fat, we do find that the 500 daily deficit doesn’t necessarily always equate to a pound of fat loss per week. Mainly because of the phenomenon where there tends to be reduced metabolism as a person loses more weight, this can be minimized with resistance training, but there does tend to be this phenomenon. So it doesn’t always work out nicely like that.

Okay, so let’s go over some considerations during exercise, fluid intake, electrolytes, and macronutrients. This would be a great opportunity for me to take a drink. Let’s go over these. So overall for endurance training, hydration, electrolytes, and carbohydrate intake is optimized, roughly speaking, by 6 to 12 ounces of 6% to 8% carbs or sugar drink, sports drink every 15 to 30 minutes. Now, if the duration of exercise is particularly long, if things are particularly intense, if the weather is particularly hot, and if the person, for example, sweats more than average, then these things may change, they may need more hydration, and/or electrolytes. But this is to give a rough approximation in terms of what may optimize these things in the majority of circumstances. That applies to endurance training.

Now, let’s chat about resistance training. So carbohydrate intake supplementation during exercise probably isn’t beneficial for things like muscle protein synthesis, unless the duration, you know, becomes very long, or we’re getting into glycogen depletion territory. Protein supplementation intra-workouts, maybe before, maybe after the workout might matter. However, what this again comes down to, as we spoke about on the protein slide is the daily dose probably mattering more. And if an athlete is supplementing pre-workout or intra-workout, it’s going to probably just help them hit their protein goals, hit their protein target for the day just because they’re getting in an additional dose of protein versus, you know, the mechanism being through something else.

Okay, let’s get into the meat and potatoes, forgive the pun, of sports supplement ingredient research, and literature, and what the evidence says, what you guys have been waiting for. Okay. So first of all, more broadly target performance. We’ll look at beta-alanine, creatine, taurine, arginine and citrulline, and caffeine. Okay, first off, beta-alanine very interesting ingredients, it is the rate limiting ingredients to form carnosine and carnosine buffers, proton i.e. acid buildup here, which otherwise may lead to fatigue. So it’s helping us to avoid fatigue by essentially helping to balance pH.

Now, the dose being 2 grams, two to three times per day for over 2 to 4 weeks. One interesting thing here is the fact that beta-alanine tends to benefit both untrained and trained athletes. There’s overall a trend in this literature for things to more easily benefit untrained athletes, and have a harder time benefiting trained athletes, but beta-alanine tends to benefit both. Overall, beta-alanine provides a 3% to 10% improvement in exercise capacity. Not too shabby at all with the strongest effects between half a minute to 4 minutes and with diminishing effects up to 10 minutes.

Now, one of the things to watch out for to educate your patients on rather is the paresthesia, the tingling/prickling sensation that many people will feel with beta-alanine supplementation, and to educate them that it is harmless. It’s not histamine-mediated, or it feels like it might be. It’s just a neurological reaction that will go away within an hour or so. Again, harmless and can be frightening, can be disconcerting if a patient doesn’t know and supplements with it. So keep an eye out for that.

Creatines are perhaps the most widely studied sports supplement out there. Once again, I believe it’s very beneficial to get into the numbers because there are 120 to 140 grams of creatine in the average person. And this can be increased. What we’re looking to do when we’re supplementing with creatine is increase this by 10% to 30%. As a refresher, what creatine does is powers that around 10 seconds of high-intensity activity zone, less than this being ATP, more than this shift into a different fuel source. Basically, what creatine and phosphocreatine does is help to buffer ATP from ADP, helps to increase ATP, and replenish ATP concentrations.

So the dose, so what the loading dose is, is 5 grams a day four times a day, for 5 to 7 days. Again, what we’re trying to do, we’re trying to make an impact in these fairly large stores of creatine in the body. And so we’re going to need a dose like that if we want to see ergogenic effects, sooner and quicker kind of thing. Because you can supplement with 3 to 5 grams per day, just, you know, from the get-go right at the beginning. But the athlete isn’t going to see the performance effects for probably something like a month’s time. And so that’s why the loading dose can be important. Creatine monohydrate is probably still king in terms of different forms of creatine. There are claims for different forms of creatine maybe having more effect or maybe being retained for longer. That’s probably not the case.

Where does creatine have its effects? In high intensity, that around 10-second mark, repetitive exercise, high-intensity interval training, a strong effect of 10% to 20% for this. It tends to benefit strength overall, upper body and lower body, upper body a little bit more, things like bench press. Are there adverse effects? Is there mass gain? There may be mass gain in the short term, especially during the loading phase kind of thing. But even this doesn’t appear to have ergolytic effects. Doesn’t appear to have any negative effects on performance, due to a couple things, due to the fact that the muscle is being better hydrated. So generally a person will have improved heat tolerance and recovery from the muscle being better hydrated, even though they may weigh a little bit more. And you would think that that would decrease their, for example, endurance performance. But that doesn’t appear to be the case. Is there negative effects on kidney function? In healthy and even clinical populations this does not appear to be true. So that’s a very common question we get for creatine.

Taurine, it’s one of the popular amino acid in energy drinks. How does taurine work? It might improve the contractility of muscle cells, how hard they contract. And it probably improves lipolysis, it probably improves the breakdown of fats at the 1 to 3 grams per day. Quick notes, various energy drinks may not have a high enough dose. There are small benefits of taurine for aerobic endurance exercise, again helping with lipolysis. There are mixed results on strength performance in terms of contractility in muscle cells overall. There are no ill effects on its own when we were just looking at taurine by itself. Maybe if a person is having three to four energy drinks to try and get in a therapeutic dose of taurine, then they might run into some issues just with the caffeine dose, among other things, but no ill effects on its own.

Arginine and citrulline. So citrulline helps the formation of arginine which helps the formation of nitric oxide, which is theorized to improve vasodilation. Question mark there, possibly what’s more likely based on recent systematic reviews, is that it helps with calcium and muscle contraction, calcium controlling muscle contraction. It may also help with angiogenesis, generation of new blood vessels to better supply muscles to help to prevent fatigue. Citrulline needing a slightly lower dose than arginine, 6 to 12 grams one hour before exercise. This is another trend here as well, that generally we want to have these ingredients about an hour before exercise or to hit a therapeutic window in order to hit peak blood concentrations.

Ergogenic effects for arginine, overall, no support for performance benefit, especially when we compare it to citrulline. Citrulline does appear to have a small impact on anaerobic performance and a larger effect on aerobic performance. Also, an effect on strength as well something like increasing the reps, let’s say, 3 reps 6% kind of thing. Maybe some minor adverse effects. For example, citrulline 15%, of focus in these studies tended to notice GI discomfort, and arginine may lower blood pressure. So if they’re on antihypertensive medication then caution there.

Caffeine, the one we all know and the one many of us love, caffeine. So what does caffeine do? How does it help with exercise? Well, it appears to just amp up the CNS, central nervous system, i.e. reduce ratings of perceived exertion, reduce pain, rather increase muscular contraction force. And with reducing pain, what I mean is basically the ability to push through the burning from lactic acid or whatever it might be during exercise.

So dose-wise, 3 to 6 milligrams per kilogram body weight one hour before exercise again. So let’s say we take 4.5 milligrams per kilogram what that would translate into, for 70-kilogram athletes 300 milligrams of caffeine. And so we’re looking at about, let’s say, three cups of coffee, maybe a little bit more. So it tends to be a little bit more coffee than people might guess before performance benefit.

Ergogenic effects, overall 10% improvement in any exercise modality. More beneficial as approaching fatigue, more effect in longer endurance events, and more muscular power overall, i.e. moving around higher weights in lower amounts of time, i.e. more quickly. Does tend to be an increased risk of adverse effects, about 400 milligrams per day, i.e. higher risk for insomnia, anxiety, tachycardia, headaches, that kind of thing, though, is very individual, very individual. We all know of people who can seemingly tolerate herculean amounts of caffeine, and those of us who can’t seem to tolerate much at all, so highly, highly individual.

Let’s shift more toward recovery, and body composition ingredients: BCAAs, HMB, and EGCG. BCAAs branched-chain amino acids, the one many people know of: leucine, isoleucine, valine. Now, this ingredient is not as intuitive as you’d think. The claims are on maximizing muscle protein synthesis and minimizing breakdown, but there are mixed results. The dose being 200 milligrams per kilogram body weight, something like 14 grams for a 70-kilogram individual, 2-3:1:1 leucine, isoleucine to valine.

So let’s get into some of the details on BCAAs because, it is not necessarily intuitive and it may be counter to what you have heard before. There may be decreased muscle protein synthesis with BCAAs. And let me explain why. So at this one important study we looked at we found that…what the study designers found out, is one, they gave two groups. They gave them both 6 grams of whey and 5 grams of leucine, same thing. And then they gave the second group additional BCAAs. So isoleucine and valine, okay. So the first group without BCAAs, the second group with. What they found was better muscle protein synthesis in this group.

Now, why might that be? They theorized that what the BCAAs did with the isoleucine or valine did was saturated the transporters for leucine and prevented leucine from getting into the cell to stimulate muscle protein synthesis in this group. Whereas, in this group, leucine had an easier time getting into the cell to stimulate muscle protein synthesis. Now, it does appear though that BCAAs may help to reduce DOMS, delayed onset muscle soreness with a moderate effect overall in a pharma 2019 systematic review. It appears that they may help to decrease oxidative damage and muscle soreness with no effects noted, no ill effects noted.

HMB, what is that? Hydroxy-Methyl-Butyrate is a metabolite of leucine. So leucine breaks down into KIC which breaks down into HMB. Why did people start to look for HMB? Well, researchers found that, you know, for leucine, 10 to 20 times the concentration needed to maximize muscle protein synthesis was needed to prevent breakdown of proteins. So they’re thinking, well, maybe there’s another metabolite, maybe there’s a leucine metabolite here that’s involved in proteolysis or prevention in breakdown in protein.

How HMB appears to work is there’s some anti-inflammatory activity, decreased tumor necrosis factor-alpha, and interleukin-6, stimulating mTOR, and increasing IGF-1, these kind of anabolic pathways. Does it result in increased muscle protein synthesis? Maybe, mixed results. We’ll chat a bit more in a second. However, it does appear to help with carbohydrate and fat metabolism.

The dose being 3 grams per day, i.e. maybe 1 gram three times a day. So this is an example where the effects are different based off if the athlete was trained or untrained. In untrained athletes, HMB does tend to result in additional muscle mass gain, in trained athletes, not so much. Perhaps reductions in fat mass, i.e. helping out with this carbon fat metabolism. And increases in strength are unlikely in this group. So untrained athletes additional muscle mass gain, trained athletes, reductions in fat mass up to 6 grams per day being well tolerated.

EGCG i.e. epigallocatechin-3-gallate is the main polyphenol in green tea. Does help to improve endurance and fat oxidation in rodents, doesn’t tend, unfortunately, to hold up in humans kind of like CLA. Study dose 300 milligrams per day, we looked at a lot of different outcomes here for EGCG and there was no significant improvement in aerobic performance, you might think that. Antioxidant activity, fat and glycogen oxidation, you might think there might be something there. Inflammatory and immune markers, resistance training, weight loss, and hunger, you might think they’d do something there, but unfortunately, there isn’t, it’s not currently.

In 2016 meta-analysis they did of non-athletes, they did find moderately increased calmness. However, even in these results, EGCG was rarely on its own in isolation. It was frequently paired with things like L-theanine which we know to increase calmness. So even this increased calmness is unlikely due to EGCG. Is well tolerated up to 900 milligrams per day for 14 days, showed no adverse outcomes. Once again caution if it is with caffeine and caffeine intake.

Okay, let’s chat about protocols, pain and inflammation first, and then immune. So in the pain and inflammation protocol, we have curcumin, omega-3s, and magnesium. Curcumin, the extract from turmeric, main polyphenol rather. And what we find here with the dose is it’s highly variable based on the formulation, i.e. 180 milligrams Theracurmin not the same as Meriva, but they both use formulations having good evidence. Reduced inflammation, i.e. tumor necrosis factor-alpha, interleukin-6, IL-8, and IL-10, decreased muscle damage. Decreased DOMS, delayed onset muscle soreness, and just general speedier recovery, great evidence here. Maybe mild GI disturbances. In the systematic review what they found was that it tended to be pretty mild because there weren’t any withdrawals from the study based on these GI disturbances.

When we look at omega-3s, what we find with EPA and DHA is generally an inhibition rather of COX-2 inhibitors. And generally affecting the metabolism of arachidonic acid, reducing that helping to generate more five-series leukotrienes, which have less potent anti-inflammatory effects versus arachidonic acid. So we found that 2 to 3 grams per day EPA plus DHA, in roughly two to one ratio, having the biggest effect. Reducing inflammation, right TNF-α, IL-6 reduce muscle damage, reducing DOMS, right, just like with curcumin. However, increasing range of motion unlike curcumin, and improving reaction time and mood unlike curcumin across several different sports, half a dozen different sports in the study. Maybe poor palatability, especially with the liquid formulation, maybe GI distress, things like [inaudible 00:40:49]. But in terms of more serious adverse effects, the FDA notes that up to 3 grams per day is safe even in regards to bleeding tendencies.

Magnesium. So a mineral used in over 300 enzymatic reactions in the body has good evidence for helping protein synthesis, cellular energy production, cell growth, and replication. Dose being somewhere around the neighborhood of 300 to 500 milligrams. Tends to help with inflammation and DNA damage from exercise, tends to maybe even help with strength one-rep maxes, jump distance. This tends to be getting into the weeds a little bit but this is only found in short-term supplementation, magnesium, and once again, in untrained athletes, which can be a common feature of some supplements.

Does tend to significantly reduce migraines by 60%, a large magnitude of effects, great evidence here. This was evidence in non-athletes but, if your athlete does suffer from migraines can be a big impact for them. Unfortunately, weak evidence for prophylactic use for leg cramps. Over 360 milligrams per day you may notice diarrhea via an osmotic effect with magnesium.

Okay, let’s jump straight into immune support: Zinc, vitamin C, vitamin D. Okay, so zinc helps to support immune health and other functions including cardiovascular health as well, testosterone, and muscular strength. We want 25 milligrams per day, the recommended dose. 2011 Cochrane Review found decreased severity and decreased duration of the common cold when taken within 24 hours, helped to blend the oxygen and immune markers surge post-exercise in athletes. May be unpalatable, may cause nausea, especially on an empty stomach. So cautions for that, with an upper limit of 40 milligrams per day, i.e. if you go above this for long periods of time, you run the risk of low copper, things like that. Maybe altered iron, reduced immunity, reduced HDL, well, that is old evidence.

It does tend to counteract reactive oxygen species vitamin C, this is what we know, decreases in ROS with vitamin C. Is there an ergogenic effect, is there an ergogenic benefit of vitamin C? Probably not. Probably no improvements in muscle strength function. Probably not improving exercise training adaptations. Maybe reducing exercise training adaptations. The RDA for vitamin C, being 75 to 90 milligrams. This is in non-active patients, and 200 milligrams maintaining concentrations of vitamin C in immune cells. 200 to 1,000 milligrams to decrease ROS. But there may be impaired performance of over 1,000 milligrams i.e. impaired signaling of ROS, it may quench ROS too much in muscle cell mitochondria. And so this may blunt some of the beneficial changes over 1,000 milligrams, but it’s really all about the patient’s oxidant status.

So another Cochrane meta-analysis looked at over 200 milligrams supplementation per day. So in sedentary folks, risk of getting common cold had a borderline effect, but in athletes, reduced common cold risk by half. So it really is all about the patient’s oxidant status, i.e. if they’re sedentary, they’re just not gonna be generating as many oxidants as athletes are, because they’re not gonna get as much benefit for vitamin C borderline versus reduced risk by half. Though, it should be noted that, in sedentary folks, vitamin C still improved the duration and severity of the common cold. Over 2000 milligrams may notice diarrhea, abdominal cramps, that kind of thing, and from an osmotic effect, once again.

Vitamin D, so fat-soluble vitamin but more than that, a hormone as well technically, impacting more things in bone growth, impacts immune function. Impacts protein synthesis maybe i.e. because it impacts the protein synthesis maybe because there are mixed results there. There’s some evidence to show it may improve strength, may improve one-rep maxes when we start to reach a therapeutic blood level of vitamin D. In non-athletes what we found was 400 to 1,000 IUs reduced respiratory infections by 8%. But in athletes, what we need to produce that similar effect was 4,000 to 10,000 IUs. So, athletes may need something on the order of 10 times the amount of vitamin D.

Now, there may be cautions of vitamin D and hypercalcemia, tends to be very rare. For example, this one study found one case of toxic hypercalcemia with 20,000 measurements over 10 years, one woman had a blood level of 364. Remember, we’re talking something like 40 here being the recommended blood level. She was taking 50,000 IUs of vitamin D, 3,000 milligrams of calcium, one to four times a day for over three months. So more, not always better.

Okay, so we’re almost at the end here. Let’s quickly go over regulations, third-party certifications, and anti-doping, and then we’ll have time for some questions from you folks. Okay, so in terms of regulations, so most consumers don’t know that supplements do not need to be approved by the FDA. They do not need to be tested for safety, efficacy, identity, and known effects are not required to be disclosed to consumers. Approval is only required for new dietary ingredients. Globally, it’s estimated that 14% to 18% of supplements may be adulterated willfully or not adulterated, meaning mislabeled ingredients, additional added ingredients, legal or not. We’ll chat more about adulteration with hormones in a second.

First, let’s go over some third-party certifications. What these do, these are great for your WADA friendly athletes, i.e. athletes who need to be WADA compliant, World Anti-Doping Association compliant. NSF for sport, being the most common one. Annual product identity testing. Tested for 280 banned substances. And you can even scan the product labels to see if this lot number has been certified. Pretty cool. Informed for sports, testing on every single batch, random blinded post-market testing as well. And informed choice testing less frequently but still has the label scanning features. And BSCG, Banned Substances and Control Group drug-free certification test for 500 banned substances and other illicit drugs. Similar database searches and label scan features.

Anti-doping, a few notes on anabolics. So as I mentioned, Geyer et al in 2004, 15% of non-hormonal supplements had unlabeled anabolic-androgenic steroids. Fortunately, when the study was repeated in 2015, this number fell to 0.7%, but can be a concern. So let’s look at the WADA banned substances list for a second. The laundry list is Bold, underline being my emphasis just to draw your attention to a few different things. You know, anabolic steroids obviously being on here, but SARMs as well. SARMs have been gaining popularity. Anything modifying hormone levels, estrogen levels, you know, be they anti-estrogenic substances or aromatase inhibitors. Beta-2 agonist, right, remember puffers, CBD, prednisone, AMPK activators, morphine, ephedrine.

Let’s talk about AMPK activators just quickly. There may be more than 100 natural ingredients that may possess AMPK activating properties, berberine, certain mushrooms, curcumin, EGCG, ginger, ginseng, I3C and DIM, licorice, resveratrol, Rhodiola. So what are some of my clinical thoughts on that and treating WADA athletes, in particular? Well, starting with diet first. That’s great. And if we’re going supplement routes, being careful and ideally choosing a third-party certified for sport. Failing that, may be third-party certified otherwise. Trying to avoid non-certified products, in general, to practitioner’s discretion. Probably avoiding proprietary blends. Very quick, non-proprietary blends is that they don’t have to list the amount of herbs, yeah, amount of individual herbs, so this may be an issue. And lastly, probably not recommended from this on the tainted product list.

Okay, summary, we made it. So overall, your athletes may need more protein. They may need more carbohydrates, at least proportional to their activity log, and especially high intensity, and fat intake, overall proportion to weight goals. We went over the best and most recent evidence for efficacy and safety of various sports supplements, covered some third-party certifications and some WADA compliance bits.

Okay, guys, so I understand this webinar will be online. So what I’ll do is I’ll go fairly quickly through this summary table here. You can go see the recording online, later on, pause it on any one of these three slides here to look at dose and the way things impact. And then just the last thing I’ll do is very quickly go through the references here, you can pause it on any one of these slides again, to go on to the references, which is useful. If you have more specific questions based on any one of these claims or any one of these great systematic reviews, or meta-analyses that we tend to have here.

So thank you so much, guys, I appreciate coming out and I’m happy to answer any questions.

Rick: Thank you Dr. Woznik. That was really informative. We have a few minutes for questions here. First off from Brandy, she asked, “Do you have any recommendations of drinks to replenish electrolytes for patients who suffer from diabetes?”

Dr. Woznik: Sure, so with diabetes, we want to be careful of sugar intake. Of course, there are, you know, electrolyte drinks out there with instead, artificial sweeteners, for example, things like Gatorade Zero, Powerade Zero, stuff like that. This is maybe a good way to go. There are, you know, some mild evidence of maybe spiking insulin a little bit with artificial sweeteners, but other than that, the evidence is pretty good for them not having an impact. And certainly going to be better than, you know, something like a full sugar, Gatorade for their diabetes. But there are also electrolyte powders out there that won’t have sugars, won’t have, you know, much artificial sweeteners at all. And so trying to track those down could be an option as well.

Rick: Thank you, Alfred notes, very good presentation, but goes too fast through the slides. Can we get a copy of the notes?

And yes, we will be providing that online. And we’re gonna email all participants when it’s up.

Another question we received, are there any products you know that have most of the performance ingredients together that you mentioned?

Dr. Woznik: Great question. Great question. What I’d recommend is trying to consult the summary table there, when you’re looking through. And kind of going back to what I was saying earlier about ideally, you know, using third-party tested combination products out there. But that should…I won’t recommend any ones in particular, but generally sticking to the third-party certified stuff. And then using our table here when trying to see if the quantities of ingredients line up with those particular combination products. There’s a lot of different ones out there.

Rick: All right, thank you. Another question, is intermittent fasting something that you recommend for athletes?

Dr. Woznik: Sure. So it’s kind of a similar discussion to a ketogenic diet, actually, that there may be body composition benefits. So intermittent fasting maybe body composition benefits for persons able to maintain that daily caloric deficit, just like with a ketogenic diet. Just like with anything, we want to maintain resistance training to make sure they’re holding on to muscle mass when they’re undergoing that weight loss.

I’d say cautions in terms of, you know, just fatigue, how the athlete feels they’re recovering. You know, maybe we’re not getting in enough protein enough times throughout the day. And then the big one, which I was referring to as we’re going through, is make sure that we’re trying to hit that protein dose. That’s gonna be harder on an intermittent fast, it’s gonna be very hard if you’re doing just one meal per day. It’s not impossible with two meals per day but just the caution in terms of how your athlete’s feeling that and performing overall with that. And if the body composition benefits are working, and if they are worth it.

Rick: All right, thank you. Another question. How long would it take for someone to become fat-adapted on a ketogenic diet and therefore spare glycogen more?

Dr. Woznik: Right. So when I was mentioning that a ketogenic diet may help with light to moderate activity. It might help with moderate activity if the person is more fat-adapted, i.e. if they’ve been eating a ketogenic diet, very low carbohydrate diet, for hard to say, but probably something on the order of months versus weeks or years. Probably not weeks or years, probably something on the order of, let’s say, several months, might take a person to become fat-adapted. They may go through the keto flu, which may be from different things, but maybe from deficiencies of certain electrolytes. Actually, and then the first question about low carb electrolyte products, they’d probably benefit from some of those.

Rick: All right, thank you. And we just had another question come in. What are your thoughts on cycling on creatine?

Dr. Woznik: Sure. Well, in terms of the daily rather, in terms of the total amount of creatine in the body, as I was saying, that 100 grams per day kind of thing. We know that we have a certain creatine efflux that creatine is leaving through creatinine. And so we know that, you know, for example, in certain proteins of beef and salmon, we might get, you know, something like a gram or two of creatine per day.

And so, it’s kind of a question. So if we’re doing cycling, then I mean, what’s going to happen is, you know, these reserves will start to fall from their increased amount here, back down to the 120 to 140. And we’re gonna start to lose, you know, some of the benefits with that, unless we’re keeping up the maintenance here. And so, kind of the question of the motivations behind the cycling that are often based on worries, you know, for kidney health or other things. Whereas we find, you know, very, as I was saying, very little risk with creatine. So what I would tend to recommend would be a maintenance dose, and you could go to a slightly lower maintenance dose, maybe 3 grams, or maybe even 2 grams, if you prefer.

But I’d recommend overall, you know, just an ongoing maintenance dose unless a person’s heading to build fatigue or supplement fatigue, where they’re just, you know, kind of fed up with taking supplements fair enough. But then, you know, in order to get them back to good levels of creatine more quickly, then I’d undergo something like the loading phase, maybe at a lower dose, depending on how long they’ve been off of it. But yeah, this will get you back to the stores in about a week’s time. Whereas if you do just the maintenance phase, it’s gonna take about a month’s time for you to hit those, again, that 10% to 30% increase.

Rick: All right, thank you. We’ve filled our time. So at this time, I’d like to thank our sponsor Fullscript, and Dr. Peter Woznik for today’s webinar. And thank you all for attending. Remember, this webinar, including our speaker’s PowerPoint presentation has been recorded, we’ll alert you via email when the webinar is available online. Thank you again for attending, and we look forward to seeing you next time. Have a great day.

Dr. Woznik: Thank you.