Patricia A. Deuster, PhD, MPH, CNS Charity J. Thomasos, LtCol, BSC, USAF Christ

Patricia A. Deuster, PhD, MPH, CNS Charity J. Thomasos, LtCol, BSC, USAF Christiane Minnick, MAc Looking for the Edge– Guide to Herbs and Supplements Dietary Supplements Looking for the Edge– Dietary Supplements In This Guide Dietary Supplements and the Law Combining and Stacking Supplements Shop Smart: Consumer Safety Tips Performance-Enhancing Agents Dietary Supplements for Weight Loss Other Supplements The Good, the Bad, and the Ugly Facts Energy Drinks Key Points Dietary supplements (DS) sold on military installations are not always • safe, effective or legal. Manufacturers of DS are not required to conduct research on safety or • effectiveness. The Food and Drug Administration must prove a prod- uct is unsafe before it can be taken off the market. If you use DS, select high quality products with certification (USP– • United States Pharmacopeia–and others) labels. The label assures consumers that the product has been tested and verified in terms of its ingredients and manufacturing process. Combining and stacking of DS increases the potential for undesired • and unsafe side effects. Energy drinks are regulated like DS and the long-term effects of their • combined ingredients are unknown. T he most common reasons active duty personnel give for using DS in- clude improving performance, increasing muscle mass, enhancing en- ergy level, accelerating recovery, increasing alertness, boosting their immune system, and improving joint function. The best sources of information on DS are dietitians, sports nutritionists, physicians, or pharma- cists. The purpose of this chapter is to provide an overview of dietary sup- plements, describe various issues associated with dietary supplements (legal, interactions), and provide basic information on a number of commonly used supplements. This will not be inclusive as new products appear on a regular basis, but the information is for educational purposes and provides sensible guidelines for use. Individuals who spend money on supplements should be aware that these products target our human desire for health and performance short- cuts. Some may be detrimental and dangerous: if it sounds too good to be true, it probably is. The consequences of taking various supplements, ei- ther alone or in combination, should be carefully considered, and informa- tion obtained for making that decision should be from reputable sources. 2 Dietary Supplements and the Law Well over 50% of the US population take some type of dietary supple- ments. Sales of vitamins, minerals, herbs, meal supplements, sports-nutri- tion supplements, and specialty supplements were in excess of $94 billion in 2007. To understand why dietary supplement use is a concern, one must appreciate their history. In 1994 the Dietary Supplement Health and Education Act (DSHEA) was passed by Congress for several reasons: Limit impediments to marketing and promoting dietary supplements. • Provide for wide availability of supplements to consumers. • Enhance information available to consumers. • The passing of DSHEA gave the Food and Drug Administration (FDA) regulatory control over DS, and the law required that the label of a DS pro- vide the name and quantity of each ingredient. However, it is incumbent upon the manufacturer to provide the information and the consumer as- sumes that information on labels is truthful and not misleading, and the contents are reflective of the label. This is, more than often, not the case. ConsumerLab.com, a product-certification company, conducted a survey of nearly 1,000 supplements and found that one in four had quality problems. The FDA also regulates whether new ingredients can enter the mar- ketplace or existing ones should be removed for safety reasons. However, federal rules requiring makers of DS to test all their ingredients were not part of DSHEA. The FDA also regulates what claims may (or may not) be made, but they do not monitor claims. The regulations within DSHEA contain many gaps. Some of the gaps and potential concerns include: The manufacturer is responsible for ensuring that products are prop- • erly labeled. Supplement ingredients sold in the United States before October 15, • 1994 are presumed to be safe and are therefore not subject to review by the FDA for safety. The manufacturer is responsible for ensuring the product is safe. • The FDA is responsible for proving a product already on the market is not • safe. Government resources to monitor DS quality are limited. • In June, 2007, FDA imposed new regulations, which had been man- dated by DSHEA. The FDA established regulations that dietary supple- ments must be produced in a quality manner, do not contain contaminants or impurities, and are accurately labeled. Supplement manufacturers will now be required to test all of the ingredients in their products to make sure they are neither adulterated nor contaminated. Click for more information on this new ruling. Purity is a concern: Supplements may be contaminated with heavy metals and even prescription medications. 3 Combining and Stacking Supplements Once it is known what a supplement contains, consideration should be given to what might happen when multiple supplements are combined, or “stacked.” The practice of “stacking” is a concern. Many variations of “stack- ing” exist. Several examples of stacking and how they work are listed: “Additive,” or, 1+1=2. This suggests that when two supplements are • combined, the effect is equal to the sum of the individual effects. An example of this concept might include calcium and vitamin D. “Antagonize,” or, 1+1=0. In this case, the effects of one supplement • may actually negate the effects of another. One example is the com- bination of creatine and caffeine: Studies have shown that caffeine antagonizes the effects of creatine. “Synergize,” or, 1+1=3. This is seen when two supplements are com- • bined and their effect is greater than the sum of their individual effects. One well known example is ephedra and caffeine: When taken together, they stimulate the nervous system more than when used alone. “Potentiate,” or, 1+1=10 is similar to synergism, but to a much greater • degree. Two examples are vitamin C and iron, and ginseng and caf- feine. Vitamin C enhances the absorption of iron, which is a good thing, but if ginseng is taken with caffeine, it may be detrimental, as ginseng has been shown to increase the effects of caffeine, to possibly cause nervousness, sweating, insomnia, and/or an irregular heartbeat. Although many stacking combinations are available, the effects of in- gredient combinations are, for the most part, unknown. One stacking ap- proach that has proven deadly is the “EAC” stack, with ephedra, aspirin and caffeine. Now that ephedra is banned, ephedra-free products are being used, but the combination remains dangerous and should be avoided. Products commonly considered as “stackers” are shown below and on the next page. Some are trade names and many are potentially danger- ous because they act as thermogenic agents, which means they increase energy expenditure. The problems with combining multiple ingredients should be considered. Table 1. Common “Stackers” Muscle Milk A blend of casein and whey proteins, combined with fats and other substances. NO2 or NO Products contain many ingre- dients, but typically arginine (described below). 4 Table 1. Common “Stackers” Hydroxycut A classic EAC stacker that has resulted in a number of deaths: Avoid. GAKIC A NO product with Glycine-l- arginine-alpha-ketoisocaproic acid. Epovar A NO product with Magnesium Orotate and Potassium Orotate. Zantrex 3 A thermogenic product with many forms of caffeine. Xenadrine EFX A thermogenic product with synephrine and many forms of caffeine. Company was fined for false advertising. Triflex A combination of glucosamine, chondroitin and methylsulfonyl- methane. Arginine Ethyl Ester A NO product. Redline A line of products high in caffeine and other substances. ZMA A combination of vitamin B6, magnesium, and zinc, among other ingredients. Lipo-Products (Lipo-6, Lipo- AMP, Lipo-THIN Lipo-Com- plex) Contains many combinations of ingredients—thermogenic agent: Avoid. Animal Cuts May contain up to 20 ingre- dients, including synephrine - thermogenic agent: Avoid. Metabolic XXX (Drive, Booster, Action, or Optimizer) Contains many combinations of ingredients—thermogenic agent: Avoid. 5 Be a Smart Shopper: Consumer Safety Tips Supplements should be clearly labeled with “Seals of Approval.” The seals include “CL” for a Consumer Lab seal of approval and “USP” for US Pharmacopoeia. These for-profit and not-for-profit agencies inspect the product and assign scores or ratings if they contain no contaminants, have standardized doses, can be absorbed by the body, can be broken down by the body, and the company that produces the products has quality control standards in place during production and manufacturing to ensure safety and purity. Choose supplements with certification approval seals! Click to choose verified dietary supplements. Click for information about dietary supplements from the FDA. Click for information about dietary supplements from the Office of Dietary Supplements. Individual Products Discussed It would be impossible to discuss all of the dietary supplements and herbals available. However, some are used more than others. Although not inclusive, the following products will be discussed: Bitter Orange Boron Branched Chain Amino Acids Caffeine Carnitine Choline Chondroitin Sulfate Chromium Chrysin CoEnzyme Q10 Conjugated Linoleic Acid Cordyceps Creatine DHEA Ephedra Fish Oil Ginkgo Biloba Ginseng Glucosamine Glutamine Guarana HMB Hoodia Hydroxycitric Acid/ HCA 6 uploads/Geographie/ dietary-supplements-guide.pdf

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