A summary of PINES First Online Symposium

At PINES’ first online symposium, five speakers took a deep dive into the topic of Athlete Safety and Dietary Supplements. The 2.5-hour program was well-attended, with registrants from 37 countries. Here’s a brief summary of each talk.

Supplements and Doping Risk from the 90’s to the present
Erik Duiven MSc, Doping Authority Netherlands
Supplement causes up to 9% of all doping violations. Although supplement manufacturers are supposed to list all ingredients on a label, that does not always happen. Most ingredients get clearly declared, but ingredients of “proprietary blends” and some others can be deliberately not
declared. Contaminated supplements happen either knowingly or by an honest mistake, such as a machine didn’t get cleaned properly. According to WADA policies, athletes who fail a drug test have to explain how the contaminant got into their bodies. Hence, consuming a prohibited substance comes with great risks. Today’s laboratories can test supplements very precisely—the equivalent of far less than one sugar cube dissolved in an Olympic swimming pool. In the US in 1994, supplement manufacturers were no longer required to prove the supplement was safe and effective (unlike with medicines). The result is it’s a jungle out there!!! For a long time,WADA encouraged athletes to not take any supplements. But in reality, 80% to 90% of athletes who need to perform optimally take supplements. Saying “just don’t take supplements” doesn’t work and athletes want help making safe supplement decisions. In 2004 Geyer et al. purchased 634 nutritional supplements from 13 countries and found 15% were contaminated with ingredients (mainly prohormones) not listed on the label. This spurred the development of independent testing per batch (such as with Informed Sport) and industry paying to prove their products are free from doping. The manufacturer sends samples to a lab and gets test results per batch. Products free of doping substances get put into a public database . Over the years, 1.3% of the supplements tested positive for doping substances, leaving the manufacturer to resolve the problem. In 2021, Duiven looked at 66 supplements and discovered 38% were positive for banned substances and 4.5% even contained a high-enough level to cause health problems. One supplement contained 40 times the typical daily dose of an ADHD med! The product was deliberately spiked with two newly designed stimulants and an old medicine ingredient and was not just contaminated. Today, we acknowledge that athletes want to take supplements and they need to be taught how to mitigate the risk. Athletes are often young and misguided; we need to help then do the right thing. The AIS program to help them chose the lowest-risk supplements has been successful, with no cases reported in 2022. Sports dietitians can help by teaching them how to read labels, say no to taking a supplement, and foster a clean sporting environment.

Herbals as a fast-growing supplement market for athletes
Anne Nugent PhD and Bridin McDaid PhS, Queens University, Ireland

Herbals are growing in popularity among athletes and are hard to classify. Is an herbal a supplement, a food, a food ingredient, or a medicine? In Ireland and the UK, the classification depends on how it is used (e.g., for treatment or prevention?) and if it makes health claims. In the US, approximately 74% of people use any kind of dietary supplements. This is more than 25-33% of people in Europe, and depending on the sport, 11%-100% of athletes, An online survey of amateur athletes reported 16% took botanicals and 60% took nutritional supplements. Currently, botanical intake is low and is more likely to be used by amateur athletes who get information from the internet, peers, or coaches. These athletes need education regarding how to use an herbal supplement to maximize performance. That said, research on botanicals lags behind other supplements. In light of the fact that botanicals have been used for a long time, they are not all bad. More varieties of botanicals are now available as novel foods and are claimed to be “safe for use.” But as is the case with most supplements, the dose is the poison. The WADA prohibited list includes substances but not the whole herb or plant. This leads to confusion. For example, is beetroot juice a botanical? The WADA list is of little help and creates challenges to determine safety. To best support athletes, the safest message is Food first, but not always food only. A credit-card size information sheet with a decision tree can help athletes figure out if the supplement can fit into their program.

Athlete compliance toward third party testing
Floris Wardenaar PhD, Arizona State University, USA

“Food only” does not always help athletes optimize their health and performance. For example, athletes can have difficulty getting enough vitamin D, beta-alanine, and iron from food only. Supplements can help to balance an unbalanced diet. Given 9% of doping violations in the US are related to consumption of illegal substances not listed on the label, athletes need to take ownership of their supplement choices. They can minimize risk by using third-party tested supplements, including NSF Certified for Sports, Informed Choice, HASTA, BSCG, and the Dutch NZ/VT. Yet, based on currently non yet published data, only about 24% of high school and 30% of collegiate athletes are consistently using third-party tested products. More athletes need to do that. The two-thirds of athletes who do not consistently use third-party tested substances are at higher risk of failing a drug test. We need to educate those athletes about third-party testing, as well as how to eat a balanced, effective sports diet (and be less likely to take any type of supplement.) Athletes who talk with a sports dietitian and those who have been taught to look for the “safe supplement” logo on the label are more likely to consistently use third party tested supplements.

Implementing a supplement monitoring system for athletes
Angela Dufour RD, Canadian Olympic Committee, Canada

Even though the “Food first” message is preached to Canadian athletes, their support teams needed a monitoring and tracking system. The Canadian App for Supplement Tracking (CAST) system was developed to safe-guard and protect athletes from inadvertent doping violations from
possibly contaminated supplement use. In 2019, after an inadvertent doping violation in Canada, an advisory group was formed to identify the need for better supplement polices, as well as ways to track, monitor, and educate Canadian athletes on safe supplement use. Canada now has a Position Statement on Sport Supplement Use in Canadian Sport. It remains on the Canadian Olympic and Paralympic Sports Institute Networks and individual websites. A minimum operating standards document currently directs all members of the integrated sports science team and athletes to make better informed decisions around supplement use, recognizing the “no supplements” stance is not a practical approach. The National Supplement Advisory Group (NSAG) created an easy, standardized method for all national athlete pool athletes and their teams to search for safe third party tested supplements and record their use. With the help of an app developer (ZoneIN), they created a one-of-a-kind app to help guide and track supplement use and reduce the risk of ADVs from the use of sports supplements in Canada. CAST is now free for Canadian National Pool Athletes and is supported by Sport Canada and Own the Podium. The athlete can search international products by entering the term or by scanning the barcode. This helps the athlete make point of choice decisions about third party tested products. CAST tracks history of all supplements the athlete purchases and consumes and can be pushed to NSO individual athlete monitoring systems (AMS). The app scans across three databases to see if the supplement is third party tested and is updated live as databases are updated. The app can tell the athlete if the product is third party tested and ask if the supplement was recommended by sports medicine doctor, RD, or physiologist. It notifies the RD if the supplement was not third party tested and asks the athlete to log it with follow up from the RD to educate the athlete on better alternative choices. CAST is currently being piloted with some national sports organizations, and evaluation is planned as the next steps.

AIS Supplement Framework Implementation – Impact and Evolution
Gary Slater PhD, Australian Institute of Sport, Australia

The AIS Supplement Framework was developed after the internet opened the door to sport supplement access and usage. In 1998, 100% of a subsample of AIS swimmers used supplements, of which one-third were risky. The AIS needed a way to monitor and manage the situation. They developed the AIS Supplement Framework, which classifies supplements into 4 categories, A,B,C, or D:

Group A. Safe, effective, permitted. Has strong scientific evidence for use in sport. The group includes sports drinks, gels, electrolyte supplements,, iron, vitamin D, zinc, caffeine, creatine, etc..

Group B. Has emerging scientific support, deserving of further research. Examples include polyphenols, anti-oxidants, tastants, collagen, curcumin, etc.

Group C. Scientific evidence does NOT support benefits to the athlete. Examples include BCAA/Leucine, vitamin E, HMB, prebiotics, etc.

Group D. Banned or at high risk of being contaminated and could lead to a positive doping test

The AIS Supplement Framework is a very helpful resource, with information for practitioners as well as athletes to help determine if a supplement is safe, effective, and permitted. Resources for athletes include handouts for each group and/or product, and decision-making trees to help athletes make educated choices. (Some popular supplements for which today’s athletes seek information include magnesium, fish oil, zinc, protein, iron, D, and curcumin.) Keeping the Framework up to date is resource intensive, given the number of new products that appear in the marketplace. The AIS Supplement Framework Committee, comprising sports physicians, sports dietitians, and sport scientists reviews the current classifications and considers submissions from the high performance system for new supplement ingredient classifications. The support of international experts is often sought to assist the Framework Committee in guiding classification of specific supplements. The Framework continues to be well utilized both domestically and internationally, and strategic partnerships with groups like Sport Integrity Australia have further helped to manage risk. The intake of high-risk supplements has declined, despite overall supplement consumption potentially increasing. Last year, no supplement-related Adverse Analytical Findings were reported in Australia.

Summary
The take home messages are:
• Supplement contamination is still an issue in 2023.
• Using Third Party Tested supplements has mitigated a lot of problems.
• Botanicals have little research to back their claims despite having been used for thousands of years.
• Products may be third-party tested but still be harmful.
• The CAST app for third-party testing is impressive.

References:
Geyer H, M Parr, K Koehler, et al. 2008 Nutritional supplements cross-contaminated and faked with doping substances. J Mass Spectrom 43(7):892-902
Duiven E, L van Loon, L Spruijt at al. 2021 Undeclared doping substances are highly prevalent in commercial sports nutrition supplements. J Sports Sci Med 2022:20(2):328-338