Through the Maze

January 29, 2015
Without a clear understanding of supplementation, high school athletes may easily head down the wrong path. Athletic trainers can point them in the right direction.
By Tavis Piattoly

Tavis Piattoly, MS, RD, LDN, is the cofounder and Director of Sports Nutrition Education for My Sports Dietitian (www.mysportsdconnect.com), where he works with athletes from high school to the pros. He's also the Sports Dietitian for Tulane University Athletics, the NFL Players Association's Trust Program, Fairchild Sports Performance in Houston, and Traction Center for Sports Excellence in Baton Rouge, La. He can be reached at: [email protected].


John is a 15-year-old high school football player with an unbalanced diet and an inconsistent sleep schedule. He constantly lacks the energy required to perform at high levels on the field. Looking for an added boost, he asks his mom to take him to the local dietary supplement store.

Although they inform the salesperson upon arriving that John has undergone numerous surgeries to try to correct an abnormal heartbeat, the associate recommends a product that contains a combination of caffeine, bitter orange, and guarana. This is a potentially lethal concoction of stimulants for someone with a heart condition. Fortunately, John consults with a sports dietitian before trying the product and does not consume it, avoiding any potential negative side effects.

However, similar scenarios occur all too often across the country, and they don't all have such happy endings. High school athletes are increasingly looking to dietary supplementation to get bigger, stronger, faster, and gain a competitive edge, but as John's example illustrates, product recommendations don't always come from nutrition experts. In the midst of input from numerous parties, athletic trainers need to be the voice of reason when it comes to advising high school athletes on safe and healthy supplementation.

MUCH CONFUSION
Research shows the reasons for turning to supplementation are varied. In 2007, the Louisiana High School Athletic Association and I conducted a study of 25,000 high school athletes in the state and found many tried dietary supplements to gain weight, increase strength, reduce body fat, and/or have more energy. Our investigation also indicated that coaches, teammates, and friends were most often the people recommending these products, but the athletes taking the supplements were alarmingly uninformed about what they were consuming.

The dietary supplement industry is an ever-growing market and currently offers more than 50,000 options, including vitamins, minerals, herbal supplements, weight-loss products, protein powders and shakes, and pre-workout boosters. With so many choices available, it's understandable that a high school athlete would become confused about which brand to trust, what dosage is appropriate, and what is safe to take.

Protein supplementation is one of the biggest areas of confusion. In a 2008 study published in the Journal of Strength and Conditioning Research, Duellman et al., reported that high school athletes taking protein supplements often did so under the misconception that using more than the recommended dosage was required to gain maximum weight and muscle, which can lead to a "more is better" mentality with other products.

I've seen this firsthand in my own practice. A former client habitually loaded himself with eight scoops of a stimulant-laden pre-workout supplement before powerlifting meets, despite a recommended serving size of one to two scoops. On more than one occasion, he experienced severe chest pain, rapid heartbeat, and heart palpitations, but still competed. This young man is very fortunate he did not experience a cardiac event from misusing the product.

ROLE OF AT's
It's clear that athletes need more education when it comes to appropriate dietary supplementation, and because very few high schools utilize sports dietitians, athletic trainers play a critical role. But before they can advise their players, athletic trainers need to educate themselves on supplementation.

Since dietary supplements do not need to be evaluated by the U.S. Food and Drug Administration before being marketed to consumers, it's vital that athletic trainers investigate what a product contains before recommending it to athletes. This starts with looking at the label. What would seem like a simple task of reading ingredients is complicated by a laundry list of products that are difficult to identify. Many times, these items fall under the catchall heading of "proprietary blend," an increasingly common way supplements are being formulated. A product will advertise that the blend contains several different types of vitamins and minerals but won't list the individual dosage of each ingredient.

Athletic trainers also have to be wary of products that advertise benefits but have little scientific evidence to support their claims, such as L-arginine, L-glutamine, Tribulus terrestris, D-aspartic acid, agmatine sulfate, and deer antler velvet spray. The latter product in particular gained notoriety recently for its supposed effectiveness at increasing growth hormones, yet no research has ever supported this claim. It's vital to make sure that any product a student-athlete is taking or you recommend has been studied extensively. (See "A Closer Look" for a further breakdown of product labels.)

Unfortunately, even if a supplement label lists all the ingredients and the quantity of each one, it still might not be revealing the whole truth. A recent study by Informed Choice Labs, a quality assurance program for sports nutrition products, randomly selected 58 protein powders off the shelves of well-known supplement stores and found that 25 percent contained anabolic steroids. An additional 11 percent tested positive for stimulants that were not indicated on the label, and others contained substances banned by the NCAA and several state athletic associations, such as bitter orange. To determine if a dietary supplement is safe and free of contaminants, steroids, and stimulants, athletic trainers should check to see if it has been evaluated by one of these third-
party agencies: Informed Choice (www.informed-choice.org), NSF (www.nsfsport.com), or Banned Substance Control Group (www.bscg.org).

It can also help to develop a system to categorize supplements that high school athletes understand. I created one that rates them as "good," "bad," or "ugly," which my high school clients have responded well to. In my opinion, "good" products use quality branded raw materials, such as beta-alanine (Carnosyn), creatine (Creapure), and beta-hydroxymethylbutyrate (BetaTor). They also include a dosage of two to four branded ingredients that have demonstrated positive results with no side effects in research. I rate products as "bad" if they don't use high-quality raw materials, only have a dosage of one ingredient that has demonstrated positive results in research, and are not tested by a third-party agency. Supplements earn an "ugly" distinction in my system if they contain a banned substance.

Once athletic trainers are in tune with the ins and outs of dietary supplementation, they can begin helping athletes with supplement decisions. It's good practice to start by evaluating each player's eating habits. Oftentimes, high school athletes turn to supplementation as a quick fix to improve their energy and performance, but the answer can frequently be found by making changes to their diet. Better nutrition practices alone could lead to the muscle growth, fat loss, improved strength, and faster recovery that they are looking for.

Athletic trainers can also partner with a local sports dietitian to get the message across. Seven years ago, I had a high school athletic trainer ask me what type of supplements I would recommend to his football team. My answer was, "I want to know what they are eating first." This comment sparked a partnership that resulted in the first high school sports nutrition program in Louisiana. I continue to assess and evaluate more than 30 of the school's football players each year with the support of their head coach, athletic trainer, and parents.

Lastly, one of the most important lessons athletic trainers can impart on their players is to be careful when purchasing products at a supplement store. As John's story illustrates, salespeople are often not knowledgeable about dietary supplements, and few have formal education in nutrition, biochemistry, chemistry, or pharmacology. Therefore, most do not understand all the facets of safety, such as ingredient profile, dosage, branded ingredients, and third-party testing companies.

THE "GOOD" LIST
Despite the dangers that can accompany uninformed supplement consumption, I believe some can be beneficial for high school athletes to support general health, facilitate recovery, and maximize muscle growth and strength. I commonly recommend supplements containing omega-3 fatty acids, multivitamins, vitamin D, calcium, protein, and/or creatine depending on the individual's specific needs.

Omega-3 Fatty Acids: Omega-3s act as a natural anti-inflammatory agent. I tell my high school clients that taking two to three grams of omega-3 fatty acids in triglyceride-based fish oil after a workout may reduce soreness. Past studies have shown that subjects reported less pain after exercise when taking omega-3 fatty acids compared to those consuming NSAIDs.

Multivitamin: The majority of the high school athletes I work with do not eat enough fruits and vegetables daily and are missing out on the key vitamins and minerals essential for growth, development, and overall health. I recommend multivitamins to these clients because, although they will not give the athletes more energy, they can act as an insurance policy for anything missing from a diet.

Because female athletes are often iron-deficient, they should look for multivitamins that contain iron. But since males already produce iron naturally, they should avoid it in their multivitamin.

Vitamin D: Sports medicine literature in recent years has increasingly focused on the potential impact that inadequate vitamin D levels may have on athletic performance. Insufficient amounts have been associated with decreased testosterone, increased muscle weakness, slower muscle recovery, higher rates of muscle injury, and lower bone strength. Since our food supply does not contain a variety of vitamin D-rich options, I recommend that high school athletes take a supplement to reach normal levels.

Calcium: Occasionally, I recommend calcium supplements for female high school athletes. This only occurs when they meet certain criteria--if their diet is low in calcium intake and/or they are engaged in sports that put impact on their skeletal system, such as volleyball, basketball, and cross country.

Protein: The most commonly used dietary supplements by high school athletes are protein powders. One of the biggest myths regarding protein supplementation is that it will help increase mass and build muscle when more than one gram of protein per pound of bodyweight is consumed.

However, protein's main function is repairing damaged muscle. New research has demonstrated 20 to 30 grams of whey protein (roughly one to two scoops in powder form) is the optimal dose to maximize muscle protein synthesis post-workout. Other benefits of protein supplementation include increased immune health, lubricated joints and tendons, and longer periods of satiety.

Creatine: Over the past 10 years, creatine has received intense scrutiny as a supplement in the medical community. In my professional opinion, it can be safe and beneficial for high school athletes. Research has shown that creatine supplementation can improve work capacity, improve muscular strength, and increase muscle mass. Recent data also suggests it may be effective at reducing inflammation. (See "Support for Creatine.)

Athletes who are engaged in a weightlifting regimen three to five days a week and follow a periodization program designed to improve muscle hypertrophy and strength benefit the most from creatine supplementation. They should also be eating a well-balanced diet with sufficient calories to support energy expenditure and use a brand that has been third-party tested.

Most creatine labels recommend a loading phase of 20 grams a day taken in five-gram doses four times per day for six days, followed by a maintenance dose of five grams a day for six to eight weeks. Since there is little research evaluating the loading phase in athletes under 18, I wouldn't recommend this protocol for high school athletes until further studies confirm it is safe. Instead, I suggest a dose of five grams before and after a weightlifting session. If athletes lift during the season, they should only take creatine on lifting days.

There are more than seven forms of creatine found in dietary supplements and all are marketed as the most effective form for athletes. However, creatine monohydrate still remains the top recommended form and has out-performed all the others.

The world of dietary supplementation can be a confusing place for high school athletes. This makes it imperative for athletic trainers to become informed so they can properly advise their players. It will take continued outreach efforts between athletic trainers and sports dietitians to educate young athletes about when and where to incorporate supplements into their diets. But with increased awareness and better information, they can supplement safely and experience positive results.

To listen to a podcast by the author that discusses "the good, the bad, and the ugly" of pre-workout supplements, go to: bit.ly/1whlCdT.


SIDEBAR: SUPPORT FOR CREATINE
Although there is limited research specifically evaluating the safety of creatine supplementation in athletes under 18, the field is growing. Supplementing those findings are studies that show creatine supplementation can be well tolerated by infants, children, and teenagers. Here's a closer look at four studies in which creatine has proved beneficial:

Youth Athletes
A 2009 study by Juhasz et al., examined the effects of creatine by administering a loading dose of five grams, four times a day, for five days versus a placebo and measured mechanical power output and swimming performance in highly trained junior competitive swimmers. Subjects consisted of 16 male swimmers with an average age of 16.

Results: After five days of creatine supplementation, the average power of one minute continuous rebound jumps increased by 20.2 percent. Furthermore, the swimming time was significantly reduced in both the first and second sessions of swimming for the creatine group, while times remained unchanged in the placebo group. There were no reported side effects.

Muscular Dystrophy
A 2004 study published by Mark Tarnopolsky in the Journal of Neurology examined the effects of creatine supplementation (0.1 g/kg of bodyweight/day) in 30 boys with Duchenne muscular dystrophy for four months.

Results: The subjects demonstrated an improvement in hand grip strength and fat-free mass with no side effects.

Acute Lymphoblastic Leukemia (ALL)
Children with ALL are commonly treated with corticosteroids, which negatively impact bone and muscle. A 2008 study in Pediatric and Blood Cancer by Bourgeois et al., examined 0.1g/kg of bodyweight/day of creatine monohydrate in nine children with ALL for two 16-week periods (16 weeks of creatine supplementation followed by a six-week washout and 16 subsequent weeks of creatine). The dosage was equivalent to 6.8 grams for a 150-pound person. The control group was 50 children with ALL who were receiving chemotherapy.

Results: The children who took creatine demonstrated significant increases in height, lumbar spine bone mineral density, whole-body bone mineral content, and fat-free mass. Children in the control group had an increase in BMI, while children in the creatine group demonstrated a decrease in BMI. There were no side effects in the children taking creatine.

Traumatic Brain Injury
In several studies from 2006 and 2008, Sakellaris et al., examined the effects of high-dose creatine supplementation (0.4 g/kg of bodyweight/day) for six months in youth ages one to 18 who were suffering from traumatic brain injury. The dose was equivalent to 27 grams a day for a 150-pound person.

Results: The subjects who were supplementing with creatine demonstrated improvements in post-traumatic amnesia, duration of intubation, time in intensive care, communication, locomotion, and cognitive function. There were no side effects reported.

SIDEBAR:
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FEEDBACK

I wanted to email you regarding a recent article in your October 2014 issue titled 'Through the Maze' written by Tavis Piottoly, MS, RD, LD. As a fellow dietitian (RD) I enjoyed the article and felt it was well written with one exception...

As Tavis discusses supplementation, specifically multivitamins, he notes that he advises male athletes to use a multivitamin without iron "since males already produce iron naturally." While I would agree most often male athletes do not need additional iron supplementation, neither males nor females actually produce iron - humans can recycle iron already in our bodies but to maintain iron stores it has to come from an exogenous source. The difference in supplementation with men vs. women often comes down to loss (i.e. menstration) not the fact that men naturally produce it while women don't, which this article implies. This distinction should be made in order to avoid any further confusion for your readers.

Rob Masterson, RD, CNSC
Huron Valley-Sinai Hospital Clinical Dietitian
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