As US swimmer Michael Phelps fiercely splashed his way to a record 19 Olympic medals at the London Games last summer,1 most spectators sat on their couches and watched in awe at his near-superhuman abilities. Few people doubt the physical differences among athletes and non-athletes. While many people struggle to run a mile in 10 minutes, world record-holder Hicham El Guerrouj of Morocco ran the fastest mile in 3 minutes and 43 seconds;2 most sports viewers would jump ship at the mere thought of doing a cartwheel, while US Olympic gold medalist Gabrielle Douglas spun, leaped, and kicked her way to becoming a modern legend known as the “Flying Squirrel.”3
One experience that does unite most modern humans is the desire to be a better version of oneself. Athletes yearn to run faster, jump higher, train longer. Non-athletes long to be thinner, healthier, or more energized. Millions of Americans turn to herbal and dietary supplements with these objectives every year,4 and that athletes also consider these products as a natural way to improve their wellbeing and performance should be easily understood. As sports nutrition consultant Susan Kundrat, RD, wrote for the Gatorade Sports Science Institute, “Athletes, coaches, and health professionals who work closely with athletes are consistently looking for sound, effective ways to enhance health and performance with foods, fluids, and dietary supplements.”5
Still, dietary and herbal supplements almost always have a negative reputation when discussed in the context of sports. During the recent 2012 Summer Olympic Games, mainstream media outlets and several sporting and anti-doping organizations vilified supplements, calling them ineffective and risky, and warned athletes to steer clear.6 These reporters and officials make both the problem and solution seem clear and simple: supplements are unequivocally ineffective and dangerous, and athletes should stop taking them. Upon closer inspection, however, the facts reveal a different story.
The Blame Game: Illegal, Misbranded Products Posing as Dietary Supplements
From a Czech kayaker and Welsh boxer to an American NASCAR driver and a Greek high-jumper, many athletes who test positive for banned substances attribute it to a dietary supplement. In one of the best-known cases, a Jamaican-born sprinter for Great Britain named Linford Christie tested positive for ephedrine at the 1988 Seoul Olympics.7 He blamed the outcome of the test on his consumption of a ginseng (Panax spp., Araliaceae) tea that allegedly contained undisclosed, prohibited ingredients. Christie was let off the hook and took home a silver medal.
Steven Dentali, PhD, chief science officer of the American Herbal Products Association (AHPA), expressed doubts over Christie’s excuse. “Was the tea ever identified or just claimed to be the source?” asked Dr. Dentali. “Attributions of herbal effects, good or bad, must begin with proper determination of what was actually ingested. With the available evidence, the Christie case does not rise to the level of a banned substance found in an herbal product” (oral communication, July 26, 2012). (About 10 years later, Christie tested positive for 100 times the limit of a prohibited anabolic steroid and was banned from the Olympics for 2 years. Many sources report that he spuriously attributed this to eating avocados.)
The Christie situation embodies the most complex — and likely the most significant — issue of the supplements-doping controversy: Are the supplements blamed for failed drug tests really at fault or are these athletes bluffing in order to maintain a false innocence? In other words, who is telling the truth? In most cases, unfortunately, the answer is unclear.
“Misbranded supplements and athletes blaming supplements is an issue that cuts both ways,” said Edward Wyszumiala, head of the dietary supplements, functional foods, and athletic banned substances programs at NSF International, a nonprofit organization that monitors and sets standards for consumer goods. “For example, we’ve seen cases recently where a NASCAR driver was blaming his positive doping test on a dietary supplement, but when the story was investigated further, it was proven he was actually not taking a contaminated supplement, but actually a pharmaceutical product. On the other side, there have been cases that have been traced back directly to a contaminated supplement” (email, July 20 and August 23, 2012).
The World Anti-Doping Agency (WADA) is an independent organization responsible for sports-related anti-doping activities like standards-setting and drug testing.8 It works with governments of numerous countries, sporting organizations, and analytical laboratories to address doping in sports. When an athlete fails a doping test, WADA’s World Anti-Doping Code states that a tribunal of officials will consider the athlete’s arguments if he or she wishes to appeal.9 This tribunal can be one of a variety of sports arbitration boards, such as the American Arbitration Association (AAA), the Court of Arbitration for Sport, or other international bodies.
According to Gabriel Dollé, director of the Medical and Anti-Doping Department of the International Association of Athletics Federations (IAAF) — the world-governing body of international athletics — the burden of proving a supplement was at fault falls on the athlete. The arbitration boards, he said, do not test supplements, although the IAAF can order a counter-analysis if it has doubts over the test or submitted evidence.
“The IAAF orders very rarely counter-analysis of supplements,” said Dr. Dollé (email, September 11, 2012).
Sometimes, the US Anti-Doping Agency (USADA) — an independent Olympics-related anti-doping organization — will take part in the testing of supplements on behalf of American athletes, said Amy Eichner, PhD, USADA’s special advisor on drugs and supplements. “If the results indicate that a prohibited substance plausibly could have come from a supplement, it is up to the arbitration panel of independent judges to determine whether the evidence bears this out. The arbitration panel makes that decision,” she said. If testing results do not indicate a supplement, any potential appeal will likely be dropped and the initial penalties enforced (e-mail, July 25 and September 11, 2012).
Reduced penalties are possible if the athlete “can establish to the satisfaction of the tribunal how the substance entered his or her system, demonstrate that he or she was not at fault or significant fault, or in certain circumstances did not intend to enhance his or her sport performance.”10 Most importantly, said Dr. Dollé, the athlete must show that he or she took steps to ensure the supplements taken did not contain prohibited ingredients. Ignorance about what is present in a dietary supplement, or any other nutritional product chosen by an athlete, is considered an unacceptable defense.
If the athlete can convince the panel that a supplement was at fault, the panel may decrease the athlete’s penalty, as was the case with US swimmer Jessica Hardy. At the 2008 US Olympic trials in Omaha, Nebraska, Hardy qualified for several Beijing Olympics swimming events. She also tested positive for the banned substance clenbuterol and was no longer eligible to compete in Beijing.11 Hardy took the case before AAA, which found that she satisfactorily demonstrated that the AdvoCare® Arginine Extreme dietary supplements she was taking contained clenbuterol based on analysis done by the “father of drug testing in sports,” Don Catlin, MD, of Anti-Doping Research Inc., in Los Angeles.13 AAA ruled that she had taken various measures in an attempt to ensure that her supplement was safe, including the following: she had a promotional endorsement contract with the Plano, Texas-based AdvoCare; she spoke with AdvoCare representatives about the supplements’ purity prior to taking them; the company’s website stated that its products were “formulated with quality ingredients” and were considered “natural bodybuilding;” she obtained the supplements directly from AdvoCare; and several additional examples. Hardy’s penalty was decreased from a 2-year ban to a 1-year ban — the maximum possible reduction — and she was permitted to compete in the 2012 Olympic Games in London, where she won a gold and a bronze medal.12
Dr. Dollé noted, however, that a very small percentage of investigations conclusively find that a sports supplement was contaminated.
“Most of the time,” said Dr. Dollé, “athletes do not even attempt to test the supplement. Cases of spiked supplements are difficult to investigate because the content changes from one batch to another and that the athlete, most of the time, no longer has the batch he used at the time of the doping control.”
Even when an arbitration panel agrees with athlete-produced evidence, supplement companies often contest the lab findings and an absolutely conclusive answer remains somewhat at large.14 Regarding the AdvoCare and Hardy case, the company argued that it specifically tested the lots of products provided to the swimmer, as well as every lot of every ingredient (M. Miller, email, October 2, 2012). It appears that the analysis groups employed by the company, NSF International and Informed-Choice, did not find clenbuterol while Anti-Doping Research, which Hardy hired to test the products, did find it. This might be explained by various analysis/certification companies’ usage of different testing and validation processes. AdvoCare also asserted that it was absent from some of the meetings and thus unable to present its findings to the officiating organizations. Ultimately, the ruling favored Hardy.13
Anthony L. Almada — a co-investigator on a number of university-based clinical trials on sports nutrition products and CEO of the sports nutrition brand GENr8 — voiced concern for the difficulty in establishing an appropriate threshold of detection for substances in varying dosage frequencies and sizes.
“Testing for banned substances is a step forward, but the sensitivity of the testing methods, the testing ‘limbo’ of how low can a lab’s analytical methods go in detecting a banned substance, is rarely if ever considered by a dietary supplement manufacturer,” said Almada (email, September 20, 2012).
Government and Industry Response
The dietary supplements industry often stresses the fact that if a product labeled as a dietary supplement does contain prohibited or designer pharmaceutical ingredients, it is no longer a dietary supplement and is instead a drug being sold illegally as a supplement. It also often claims that companies participating in such activities, referred to as economically motivated adulteration, represent a small, rogue portion of the industry and that most manufacturers and retailers are reputable businesses.
“I think that’s a bit of miscalculation on the industry’s behalf,” said Daniel Fabricant, PhD, director of the US Food and Drug Administration’s (FDA) Division of Dietary Supplement Programs. “It is their reputation, after all. It’s really incumbent on the industry to remain vigilant. The problem isn’t going to auto-correct. Saying it’s not your problem doesn’t make it go away” (oral communication, September 6, 2012).
According to Dr. Fabricant, FDA has no official data on the number of companies marketing tainted products as sports supplements. He did note, however, that sports supplements represent one of the top 3 areas of concern for FDA, along with supplements marketed for weight loss and sexual enhancement.
“If there’s a drug in a supplement, generally it’s not there by accident,” he said. “And [drug substances are] not at levels that would indicate a cross-contamination problem. They’re at large levels intended to have a profound biological effect. I don’t think there’s one archetype that participates in these activities. We’ve seen tainted products in a variety of different environments of distribution. You know, retail, internet. You name it, we’ve seen it — a variety of large and small. There’s not one type, per say, that fits the bill.”
Sometimes dietary supplement trade publications reinforce the image of an industry whose problems have been unfairly exaggerated. NutraIngredients USA, for example, reported after the London Olympics that the synthetic substance DMAA — a banned stimulant also called methylhexaneamine, or MHA — was implicated in only one Olympics doping ban.16 (Some companies say DMAA can be found in extremely small quantities in the oil of the geranium plant [Pelargonium graveolens, Geraniaceae], and therefore, according to the companies, is actually a natural product, although at least 3 peer-reviewed analytical studies have determined that it is synthetic.*15 This lone DMAA doping case represented 12.5% of the 8 total 2012 Summer Olympics doping cases. According to the Anti-Doping Database, 172 professional athletes have tested positive for DMAA since 200917 — a number that includes failed drug tests in all sports, not just the 2012 Olympics, and thus provides a more comprehensive assessment. (The most suspensions occurred in 2011 when 95 athletes tested positive for DMAA.)
Although many mainstream media stories (and some sports governing bodies) claim that dietary supplements are not regulated and thus athletes have no protection against adulterated sports supplements, in fact, FDA can provide some degree of enforcement through market surveillance, inspections of facilities’ Good Manufacturing Practices (GMPs), and more.
“We’re really looking to use whatever tools we have at our disposal to take action on manufacturers who are really marketing drugs as dietary supplements,” said Dr. Fabricant.
In August of 2012, for example, the largest online retailer of bodybuilding supplements — Bodybuilding.com — was ordered to pay $8.1 million for selling steroid products labeled as dietary supplements, which FDA uncovered at a GMP inspection in 2008.18
“The inspections revealed some of the challenges the firm had, let’s just say,” said Dr. Fabricant. “We get a lot of information on just visiting a firm. It’s part of our authority, you know, getting eyes into the firm and seeing what’s going on.”
Still, FDA has experienced a high rate of non-compliance with GMP inspections, according to Dr. Fabricant. Furthermore, inspections do not prevent tainted products from entering the marketplace, nor do they offer total protection against the few banned substances that are legal for normal consumers not involved in professional sports.
“It seems the FDA has greatly increased the number of GMP inspections,” said USADA’s Dr. Eichner, “which is great, but the fact that so many companies — roughly half* — have failed such inspections speaks to poor quality-control across the industry. Hopefully improved compliance with GMP regulations will help, but GMP regulations don’t require companies to test for contamination by substances prohibited in sport, and companies could be compliant with GMP but still produce a supplement that contains a prohibited substance (such as [the hormone] DHEA).” (*Editor’s Note: FDA spokesperson Sebastian Cianci confirmed this figure, noting that more than half of the firms inspected by FDA for GMPs thus far during 2012 had problems needing correction [email, September 21, 2012]. GMP non-compliance can be due to a variety of reasons and is not necessarily indicative of manufacturers spiking supplements with banned substances or illegal drugs.)
“If someone has spec sheets around that indicate that something that shouldn’t be there was added to the product, of course that would obviously get uncovered in an inspection,” said Dr. Fabricant. “If it’s something that is completely criminal and has been hidden all the way, then that’s a different scenario. I think the issues are, ‘Does the FDA regulate dietary supplements?’ Yes. We have different tools to do that with. But the bottom line is that manufacturers and distributors are ultimately responsible for insuring their products are safe and in compliance with all applicable laws and regulations.”
Most anti-doping and sports organizations’ solution is to strongly caution athletes against using all dietary supplements. It seems entirely unavoidable, however, that all athletes will abstain. Some researchers have estimated that anywhere from 65 to 99% of elite athletes use dietary supplements,19 a figure likely impacted by the intense pressure they experience to maintain certain body weights and extreme physical abilities. If an athlete chooses to take a dietary supplement or an herbal product, various measures and certification programs can enable him or her to be more confident that it does not contain a prohibited substance.
“We encourage [athletes] to be fully informed and educated about the risks, and to weigh the risks and the benefits carefully as they make their own decision,” said Dr. Eichner. “While there may be high-quality herbal products on the market, to an athlete it is difficult to distinguish between legitimate herbal products and those that are adulterated or spiked with prohibited substances.”
USADA advises athletes to choose single-ingredient or few-ingredient herbal and dietary supplement products. “Dietary supplements that contain fewer ingredients require fewer manufacturing steps (on average) than products containing dozens (or many dozens) of ingredients,” said Dr. Eichner. “The more ingredients there are, the more opportunities for error in manufacturing and identification, and the greater chance for ingredient interactions with other supplements or drugs.
“They should also do enough of their own research on the company that they feel comfortable in using their products,” she continued. “This research would include visiting Supplement411.org, the FDA website, the [Federal Trade Commission] website, the Better Business Bureau, and also the companies’ own websites. Athletes who want health benefits from a particular plant should generally be aware of adulteration issues globally and query herbal companies about how they avoid purchasing adulterated raw materials.”
While certified laboratories and anti-doping organizations test athletes’ urine and blood samples for prohibited substances, neither WADA nor anti-doping agencies test dietary supplements for ingredient purity or approve labs to conduct such testing. A few independent companies and organizations do provide these services. The Banned Substances Control Group’s BSCG Certified Drug Free™ program certifies that products contain no banned substances.20 BSCG — run by Dr. Catlin as chief science officer and his son Oliver Catlin as president — was one of the first to start certifying dietary supplements, almost 8 years ago, and currently certifies products for more than 30 dietary supplement manufacturers. Dr. Catlin also serves as CEO of the nonprofit Anti-Doping Research.
“At the beginning, we stated we could test for all the substances on the WADA list as we could in urine,” said Oliver Catlin (email, September 26, 2012). “As we gained more experience, we realized the difficulty that dietary supplements present through their variability, making testing them particularly demanding. While urine samples present a fairly standard matrix and are relatively easy to analyze, dietary supplement matrices can present much greater challenges. To ensure that we can detect everything in our menu in every product, we conduct a unique step called product validation. During validation we actually spike all the compounds we test for into a representative sample of a product and run it through our tests to demonstrate that we can detect the substances if they were to be present and to establish the detection levels for that unique matrix.”
“The process begins with initial ingredient review [of the product’s stated ingredients] to ensure that nothing listed is banned or could lead to a positive drug test if used as directed. Once accepted to the program,” continued Catlin, “BSCG tests all finished batches of a product in order for a product to be certified. In so doing, we are auditing not only the raw materials that went into the product but also the manufacturing process, the 2 areas where accidental or purposeful contamination can be introduced.”
SPORT SAFE Testing Service provides testing and education for student athletes.21 NSF also has a sports supplements testing program, which is currently supported by several professional US sports organizations, including Major League Baseball, the National Football League, the Professional Golfers’ Association, the Ladies Professional Golf Association, and the National Hockey League.22
“Each supplement we test, we screen for over 170 of the listed WADA-banned substances,” said Wyszumiala. “For companies looking to certify selective batches, the costs can be a few thousand dollars a year if their manufacturer is already GMP-certified by NSF. For larger programs that certify all lots of their products, the costs can go into the tens of thousands of dollars for a product line.”
Currently, NSF’s Certified for Sport® program has certified products from about 44 manufacturers.23 In order to have products certified, manufacturers must submit their products to a strict testing and review process, which includes analysis of the product’s formulation, labeling, ingredient suppliers, and toxicology, as well as inspections of the manufacturing facilities to ensure that “that no banned substances are stored or manufactured at the facility.”22 Inspectors also conduct a variety of tests and analyses each year to assess the product for any heavy metals, pesticides/herbicides, disintegration, or banned substances, and to ensure that the label accurately lists what the product contains. If a manufacturer’s product satisfies all components of the process, it can feature the NSF label and be listed on NSF’s website as a Certified for Sport company. In addition, Wyszumiala suggests that companies conduct tests on random batches and/or raw ingredients.
Dr. Dentali, of the trade group AHPA, noted the website KeepSupplementsClean.org,24 a resource AHPA created in order to help educate industry and consumers on supplement issues, including international enforcement efforts.
In addition to efforts from within the industry, US legislators are seeking to eradicate products containing banned substances that pose as dietary supplements. On July 25, 2012, US Senators Orrin Hatch (R-Utah) and Sheldon Whitehouse (D-RI) proposed the Designer Anabolic Steroid Control Act of 2012.25 If passed through Congress and signed by the President, this bill — which does not apply to botanicals or their derivatives — would amend the Controlled Substances Act so that the Drug Enforcement Administration has more authority to regulate anabolic steroids and products containing these substances that are illegally being marketed and misbranded as dietary supplements.
“The bill corrects the terrible design and drafting of previous anti-steroid legislation from 1990 and 2004,” said Rick Collins, a New York lawyer whose firm represents numerous sports nutrition and dietary supplement companies (email, September 22, 2012).
But Collins noted that the designer-steroids problem is partly attributable to the original law itself, which he said enumerates only specific steroid compounds and thus inadvertently fostered creative efforts to bypass the Controlled Substances Act through marketing a plethora of unlisted, synthetically designed steroids.
“The new bill, if passed, is structured to accomplish what Congress likely intended in its prior botched efforts: to criminalize a long list of specific compounds as well as unlisted steroidal substances that are similar to them,” said Collins.
The Illegal and Legal Uses of Botanicals in Sports
Although the term doping carries a negative connotation, it does not always indicate that a substance is harmful. According to WADA, which publishes an annual document listing the substances banned in sports competitions worldwide, a substance will be prohibited if it meets at least 2 of the following criteria: “1) It has the potential to enhance or enhances sport performance, 2) It represents an actual or potential health risk to the athlete, or 3) It violates the spirit of sport.”26
Of the approximately 200 substances and methods on WADA’s 2012 Prohibited List, only one whole botanical is prohibited: cannabis (Cannabis spp., Cannabaceae). WADA additionally prohibits the use of several botanical derivatives and their synthetic counterparts, including the stimulants ephedrine, methylephedrine, and pseudoephedrine, all of which come from ephedra (Ephedra spp., Ephedraceae); the stimulant cocaine, which comes from coca (Erythroxylum coca, Erythroxylaceae); the stimulant cathine, which comes from the African medicinal plant khat (Catha edulis, Celastraceae); and morphine and diamorphine (heroin), which are derived from the opium poppy (Papaver somniferum, Papaveraceae) and considered by WADA to be narcotics. (All of the above are illegal in dietary supplements in the United States).
Instances in which botanicals are implicated in doping sometimes make headlines. Most recently, on August 6, 2012, an American judo fighter was sent home from the 2012 London Olympics after testing positive for cannabis, which he claimed was due to eating a cannabis brownie.27 Although it seems rather surprising that an athlete would consume the widely illegal substance, the Anti-Doping Database reveals that cannabis has been implicated in about 38 failed doping tests since 1997,28 likely due to its recreational popularity. Several cases document South American soccer players testing positive for cocaine and morphine and attributing it to drinking traditional Bolivian coca leaf tea and eating poppy seed bread, respectively.29 Again in 2011 — even after poppy seeds’ effects were made famous by an episode of the television comedy Seinfeld in which the sitcom’s character Elaine fails a drug test after eating poppy seed muffins — a New Zealand triathlete tested positive for morphine and argued that he had consumed poppy seed bread.30 Studies have confirmed that consuming the parent plant or parts of the parent plant can yield traces of these isolated substances, and sometimes officials sympathize with the athletes’ claims by reducing penalties or completely exonerating them.29,30 Still, these cases are seldom.
“Adequate information does not exist to support the view that sports doping with botanical materials is an issue,” said AHPA’s Dr. Dentali. “Ephedrine-containing products are not allowed in foods, including dietary supplements in the United States. Most everyone is aware that poppy seeds may trigger a positive drug test, and generally speaking athletes are smart enough to know that drinking coca leaf tea might produce the same result” (e-mail, July 30, 2012). (A peer reviewer of this article noted that in Canada, low-dose ephedrine hydrochloride [8 mg] as well as the herb ephedra are widely available for purchase as licensed natural health products [NHPs]. NHPs, which include vitamins, minerals, herbs, homeopathic preparations, and more, are regulated as a special class of drugs in Canada, not as the United States regulates dietary supplements, which are considered foods.)
Coca, ephedra, and khat are the only traditionally used herbs whose derivatives are explicitly prohibited in sports, and the testing of additional herbs or other medicinally active plants for performance-enhancing properties is not common nor easy due to their complex chemistry and pharmacology.31 Because different countries have a more accurate and detailed knowledge of culturally used herbs and substances, each can issue warnings for any botanical products suspected of affecting doping test results.
“There are many specialized, local botanical products used traditionally around the world, and monitoring them and their use is something left up to the local regulatory body,” said NSF’s Wyszumiala (email, July 20, 2012).
During the 2008 Beijing Olympics, for example, the Chinese Olympic Committee decided to forgo the use of traditional Chinese medicine (TCM) to treat athletes in order to avoid potential doping problems, and also banned products containing the herb Chinese angelica, or dong quai (Angelica sinensis, Apiaceae) for the same reasons.31
WADA previously prohibited the botanical stimulant caffeine,32 which is found in many common food plants including coffee (Coffea arabica, Rubiaceae), chocolate (Theobroma cacao, Sterculiaceae), and tea (Camellia sinensis, Theaceae), as well as the popular Argentinian herbal beverage yerba maté (Ilex paraguariensis, Aquifoliaceae), among others. During this ban, athletes could not have 12 mg or more of caffeine per liter of urine. This would be caused by drinking at least 5 cups of coffee, at least 6 cups of tea, or eating 2-3 chocolate bars shortly preceding the collection of urine samples.29 In 2004, WADA lifted its ban on caffeine, stating that it is “ubiquitous in beverages and food” and “metabolized at very different rates in individuals.”32 Caffeine remains on the organization’s monitoring list, and some WADA officials continue to express concerns for the stimulant, especially when formulated in high-dosage pills.33
“Herbal or plant-derived stimulants can be a very interesting dilemma,” said Oliver Catlin. “Some things like ephedrine are clearly banned, while other plant-derived stimulants like theobromine, which is in chocolate, are not considered banned. For an athlete, the pathway of determining what is or is not legal is challenging especially when the language in the stimulant section of the WADA Prohibited List includes, ‘and other substances with a similar chemical structure or similar biological effect(s).’ Determining what does or doesn’t qualify under this clause can be a difficult job, and a moving target.”
Even in regards to dietary and herbal supplements that are legal for use in sports, such as caffeine, many critics claim that athletes can receive all their nutritional and performance needs from diet and that there is no evidence these products actually work. In September 2012, for example, the Chief Medical Officer of Fédération Internationale de Football Association (FIFA) told the media that soccer players’ widespread usage of dietary supplements was “alarming” because it is “definitely not based upon the scientific evidence or literature.”34 He continued, “Scientists and nutritional specialists agree that a well-balanced diet will supply the body with the appropriate amount of nutrients it needs for top performance.”
WADA and IAAF take similar positions.
“Athletes do not necessarily need supplements,” said Dr. Dollé of IAAF . “As a question of principle, we never engaged in recommending or advising supplements. Firstly, because it would not be consistent with our consensus statement, secondly, because we do not have the resources to test the supplements.”
Some criticize anti-doping organizations for their one-way, hard-line stance against supplements.
“That mentality is certainly understandable as they don’t want athletes to get caught up with inadvertent positive tests,” said Catlin, “but is not in line with the reality that we face today, namely that athletes do take and will continue to take dietary supplements. The reality is that many supplements are indeed fine to take, while others can lead to positive drug tests and health complications. I really do appreciate [anti-doping organizations’] position and of course worked with them myself for many years. I just wish they could take a broader look at the supplement issue and accept the realities that athletes use them. I believe that if they did accept supplements and could help athletes find natural and safe alternatives to drugs that it would create trust and could help the anti-doping cause.”
It is also important to assess the accuracy of anti-doping groups’ claims of supplement inefficacy. A review of the evidence suggests some botanical supplements can produce performance-enhancing effects. According to a 2012 article, “Herbs in Exercise and Sports,” published in the Journal of Physiological Anthropology, caffeine is documented as improving athletic performance in swimmers, endurance runners, and cyclists, as well as improving mental alertness.35 The International Society of Sports Nutrition’s (ISSN) 2010 recommendations for athletic supplements list caffeine as being “apparently effective,” which the authors define as, “supplements that help people meet general caloric needs and/or the majority of research studies in relevant populations show is effective and safe.”36 The authors continued, “Suggestions that there is no ergogenic value to caffeine supplementation [are] not supported by the preponderance of available scientific studies.”
ISSN recommended green tea extract as “possibly effective” (defined as “supplements with initial studies supporting the theoretical rationale but requiring more research to determine how the supplement may affect training and/or performance”) for its ability to increase energy expenditure in humans and possible use for weight loss.36
Ginseng, one of the most commonly marketed herbs for athletes, also has been referred to as the most studied herb for performance enhancement. Research has shown various species of ginseng, particularly Asian ginseng (P. ginseng), to increase exercise endurance, lower blood pressure, support oxygen consumption, abbreviate post-exercise recovery, enhance chest and leg strength, and reduce stress responses through its adaptogenic properties.35,37 Other studies, however, have found no significant effects on physical performance.38 (One review article suggested that many of the ginseng trials used a relatively low dosage level, i.e., usually those equivalent to about 8 mg total ginsenosides per day, compared to higher dosage levels used in traditional Chinese medicine.39)
The Australian Institute of Sport (AIS) lists beet (Beta vulgaris, Chenopodiaceae) root juice as a Class B supplement (“Considered for provision to AIS athletes under a research protocol”) presumably due to its nitrate contents and several studies showing that consuming beetroot juice prior to exercise can enhance performance.40 Furthermore, a 2010 double-blind, controlled clinical trial, published in the Journal of the International Society of Sports Nutrition, found that male weightlifters taking a fenugreek extract (Trigonella foenum-graecum, Fabaceae; Torabolic™, Indus Biotech) experienced significantly increased “upper- and lower-body strength and body composition in comparison to placebo” and had no side effects.41 Another study on TestoSurge®, a fenugreek extract, found that it increased testosterone levels and the bioavailability of testosterone when compared to placebo.42
According to 2 studies, ginger (Zingiber officinale, Zingiberaceae) root extract has been shown to improve pain and joint stiffness in osteoarthritic individuals after standing and walking.5 A study on rhodioloa (Rhodiola rosea, Crassulaceae) root extract, which is marketed for athletic-enhancing functions in the United States, reported that an acute dosage (200 mg) significantly increased endurance and somewhat increased oxygen intake in participants completing 17 minutes of cycling,5 although this effect was no different than placebo after 4 weeks of taking the supplement.43 A small study examining the use of an extract made from the traditional Chinese herb astragalus (Astragalus membranaceus, Fabaceae) determined that it improved athletic endurance, though the study was criticized for its lack of standardization.5 A 1997 study on cayenne pepper (Capsicum spp., Solanaceae) taken by male long-distance runners found it increased “respiratory exchange ratio and blood lactate concentration both at rest and during exercise,” but that it had “no effect on oxygen consumption or energy expenditure.”38
Several additional herbs exhibit the ability to decrease pain, inflammation, and other conditions that can negatively affect athletic performance, but have not been studied specifically in athletic situations.5 Additional research has found no effect in athletic performance for some herbs, including cordyceps (Cordyceps sinensis and C. spp., Clavicipitaceae), yohimbe (Pausinystalia johimbe, Rubiaceae), puncture vine (Tribulus spp., Zygophyllaceae), and Eurycoma longifolia (Simaroubaceae) root, possibly due to short supplementation period and/or low concentration of E. longifolia.5,35,37 More studies are warranted to support the initial investigations into botanicals’ effects on sports and athletic performance.
According to Almada, most clinical trials performed on botanicals and other dietary supplements for sports performance “lack a key investigative, due diligence step” — testing the study’s products for banned substances.
“Is it not sufficiently inspiring to the crafty, unscrupulous marketer to have a ‘special batch’ made just for a study, adulterated with a ‘special ingredient’ since the university research lab invariably does not have the capability, nor intent, to analyze what is being studied for banned substances? Testing study products for banned substances, by an expert independent lab, should be standard protocol before undertaking the study.”
The relationship between professional athletes and dietary and herbal supplements is nothing less than complex. Despite the oft-negative representation and reputation of dietary supplements in and among mainstream media outlets as well as major sporting and anti-doping organizations, little hard evidence proves that herbal dietary supplements pose a risk in this context. Some evidence even suggests that various botanicals can have safe, beneficial effects on athletic performance. Still, evidence fails to exonerate all cases of potentially intentional adulteration by dietary supplement manufacturers. In order to progress toward resolving these issues, responsible parts of the dietary supplements industry, analysis labs, sports and anti-doping organizations, and the media must collaborate to support athletes through education, vigilance, and open-mindedness toward the reality of the situation.
*See feature article “New Research Supports Synthetic Origin of DMAA in Supplements” in HerbalGram 95 for more details on this topic.
1. Phelps sets record for Olympic medals. New York Daily News. July 31, 2012. Available at: http://articles.nydailynews.com/2012-07-31/news/32966485_1_michael-phelps-yannick-agnel-ricky-berens. Accessed September 14, 2012.
2. Tymn M. Mile trivia. Running Times Magazine. May 2004. Available at: http://runningtimes.com/Article.aspx?ArticleID=6385&PageNum=&CategoryID=. Accessed September 14, 2012.
3. Ross S. Douglas wins gold in gymnastics individual all-around. NBC News. August 2, 2012. Available at: www.nbcchicago.com/news/sports/Gabrielle-Douglas-and-Aly-Raisman-164740506.html. Accessed September 14, 2012.
4. Rise in supplement use by US adults. Natural Products Insider. April 13, 2011. Available at: www.naturalproductsinsider.com/articles/2011/04/rise-in-supplement-use-by-us-adults.aspx. Accessed September 14, 2012.
5. Kundrat S. Herbs and athletes. Gatorade Sports Science Institute. Sports Science Exchange 96. 2005;18(1). Available at: www.gssiweb.com/Article_Detail.aspx?articleid=704. Accessed September 14, 2012.
6. Aschwanden C. Athletes, stop taking supplements. Slate magazine. July 26, 2012. Available at: www.slate.com/articles/health_and_science/medical_examiner/2012/07/dietary_supplements_at_the_olympics_why_athletes_risk_false_drug_charges_.html. Accessed September 14, 2012.
7. Linford Christie. United Kingdom Athletics website. Available at: www.uka.org.uk/e-inspire/hall-of-fame-athletes/linford-christie/. Accessed August 22, 2012.
8. About WADA. World Anti-Doping Agency website. Available at: www.wada-ama.org/en/About-WADA/. Accessed June 25, 2012.
9. World Anti-Doping Code. World Anti-Doping Agency. 2009. Available at: www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-The-Code/WADA_Anti-Doping_CODE_2009_EN.pdf. Accessed September 14, 2012.
10. Questions & answers on strict liability in anti-doping. World Anti-Doping Agency website. Available at: www.wada-ama.org/en/Resources/Q-and-A/Strict-Liability-in-Anti-Doping/. Accessed July 26, 2012.
11. World Anti-Doping Agency (WADA) v. Jessica Hardy & United States Anti-Doping Agency (USADA). CAS 2009/A/1870. Arbitral Award delivered by the Court Of Arbitration For Sport.
12. Jessica Hardy events and results. London 2012 Olympic and Paralympic Games website. Available at: www.london2012.com/athlete/hardy-jessica-1134700/events/. Accessed September 14, 2012.
13. Abrahamson A. Jessica Hardy, AdvoCare file suit against each other. Swimming World Magazine. January 30, 2009. Available at: www.swimmingworldmagazine.com/lane9/news/20137.asp. Accessed September 14, 2012.
14. Burke L. Positive drug tests from supplements. SportsScience. 2000;4(3). Available at: http://www.sportsci.org/jour/0003/lmb.html. Accessed September 14, 2012.
15. Smith T. New research suggests synthetic origin of DMAA in supplements. HerbalGram. 2012; (95):46-49. Available at: http://cms.herbalgram.org/herbalgram/issue95/hg95-feat-dmaa.html.
16. Starling S. London Olympics 2012: DMAA responsible for 1 of 8 doping busts. NutraIngredients. August 14, 2012. Available at: www.nutraingredients.com/Regulation/London-Olympics-2012-DMAA-responsible-for-1-of-8-doping-violations. Accessed September 14, 2012.
17. Advanced search: methylhexaneamine. Anti-Doping Database website. Available at: www.dopinglist.com. Accessed August 17, 2012.
18. Bodybuilding.com execs fined for selling steroids. Natural Products Insider. August 2, 2012. Available at: www.naturalproductsinsider.com/news/2012/08/bodybuilding-com-execs-fined-for-selling-steroids.aspx. Accessed September 14, 2012.
19. Kim J, Chun Y-S, Kang S-K, Cho H-C. The use of herbal/traditional products supplementation and doping tests in elite athletes. Int J Appl Sports Sci. 2010;22(2):137-149.
20. Banned Substances Control Group website. Available at: www.bscg.org. Accessed September 14, 2012.
21. SPORT SAFE Testing Service website. Available at: www.sportsafe.com. Accessed September 14, 2012.
22. How to get certified. NSF Certified for Sport website. Available at: www.nsfsport.com/how_certified.asp. Accessed July 25, 2012.
23. Certified for Sport companies. NSF International website. Available at: www.nsf.org/Certified/consumer/listings_results.asp?KeyWords=&ProgramCode=BANNEDSUB&CompanyName=&ProductName=&SearchType=QUICK&prog_add=N&ShowCompany=N&p_special=ABS&p_abs=Y . Accessed July 25, 2012.
24. KeepSupplementsClean website. Available at www.keepsupplementsclean.org. Accessed September 14, 2012.
25. Sens. Hatch and Whitehouse introduce Anabolic Steroids Control Act; AHPA endorses legislation [press release]. Silver Spring, MD: American Herbal Products Association. July 25, 2012. Available at: www.ahpa.org/Default.aspx?tabid=69&aId=803.
26. The 2012 Prohibited List International Standard. The World Anti-Doping Code, World Anti-Doping Agency. August 24, 2011. Available at: www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-Prohibited-list/2012/WADA_Prohibited_List_2012_EN.pdf. Accessed October 3, 2012.
27. U.S. judoka expelled for marijuana. Reuters. August 6, 2012. Available at: http://www.nbcolympics.com/news-blogs/judo/u-s-judoka-expelled-for-marijuana.html. Accessed September 14, 2012.
28. Advanced search: cannabis and marijuana. Anti-Doping Database website. Available at: www.dopinglist.com. Accessed August 17, 2012.
29. Yonamine M, Garcia PR, de Moraes Moreau RL. Non-Intentional Doping in Sports. Sports Med. 2004;34(11):697-704.
30. Graham O’Grady blames poppy seeds for doping glitch. Triathlete.com. March 24, 2011. Available at: http://triathlon.competitor.com/2011/03/news/graham-ogrady-blames-poppy-seeds-for-doping-glitch_24598. Accessed July 26, 2012.
31. Stafford L. Concerns over use of African herbs during the 2010 World Cup. HerbalGram. 2010;(86):24-25. Available at: http://cms.herbalgram.org/herbalgram/issue86/article3520.html.
32. What is the status of caffeine? Questions and answers on 2012 Prohibited List. World Anti-Doping Agency website. Available at: www.wada-ama.org/en/Resources/Q-and-A/2012-Prohibited-List/. Accessed July 25, 2012.
33. Habashy A. AOC warns of caffeine use amid Stilnox ban. Yahoo!7 Sport. July 3, 2012. Available at: http://au.sports.yahoo.com/news/aoc-warns-caffeine-amid-stilnox-070548712.html. Accessed October 3, 2012.
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HISTORY OF HERBS IN SPORTS
Public disapproval of doping increases with each news report of an athlete’s failed drug test. The stance of official organizations reflects this, as WADA vowed to collect 5,000 samples in order to make the London Games the most tested and allegedly “cleanest” Olympics ever.1 Still, doping scandals continue and some might find themselves reminiscing about a time when all athletes performed their sports wholesomely and without any outside aid.
What many spectators do not realize, however, is that the practice of ingesting substances — often botanicals — with the hopes of enhancing sports performance has existed to some extent for thousands of years.2 In fact, athletes were never tested for performance-enhancing substances and illegal drugs until the 1960s, when the death of a Danish cyclist, who passed out while riding and had a severe crash, was attributed to an amphetamine overdose.2,3
The Ancient Greeks are reported to have ingested herbs and fungi for performance enhancement, as well as to have used honey to boost energy and carbohydrate levels.2 Physicians gave Olympic athletes bread prepared with spices and juices extracted from the poppy, and Roman gladiators allegedly ingested caffeine and the bitter alkaloid strychnine from the nux-vomica tree (Strychnos nux-vomica, Loganiaceae). The Roman naturalist Pliny the Younger (61 – 12 CE) recorded that runners would attempt to increase their muscle mass and strength by consuming a plant called mare’s tail (Hippuris vulgaris, Hippuridaceae).
According to John Riddle, PhD, a history and botany professor at North Carolina State University and an expert on the use of botanicals during ancient times through Classical Antiquity, the 1st century Greek physician Galen, who attended to Roman emperor Marcus Aurelius, got his start as a doctor for gladiators (email, July 18, 2012). Dr. Riddle’s 1997 book, Eve’s Herbs: A History of Contraception and Abortion in the West, reports that Galen wrote of “an athletic trainer [who] required his men to sleep on a botanical bed of chaste tree [Vitex agnus-castus, Lamiaceae],”4 which was a reputed male contraceptive and erectile function preventative, in order to preserve their energy.*
Centuries later, in the late 1800s, an American long-distance walking athlete reportedly chewed coca leaves during a trek of approximately 110 miles completed within 24 hours.5 Additional performance-enhancing substances during this period typically consisted of “sugar cubes dipped in ether, mixtures of brandy and cocaine, caffeine, cordials containing alcohol, and even nitroglycerine and strychnine.”6
During the 1950s, the Union of Soviet Socialist Republics (USSR) began to study adaptogenic substances, including many herbs, with the goal of enhancing performance and work output of athletes, soldiers, and government workers.7 According to the book Adaptogens: Herbs for Strength, Stamina, and Stress Relief (Healing Arts Press, 2007) by David Winston and Steven Maimes, “The Soviets’ pursuit of superior military strength, performance in the Olympic Games, political power, and the excellence of the well known Bolshoi Ballet mattered so much to them that whatever they could do to accomplish the goal of dominance was pursued.” Of the approximately 4,000 plants investigated, 12 herbs were considered adaptogens, including Siberian ginseng (now sold in the United States as “eleuthero”; Eleutherococcus senticosus, Araliaceae), rhodiola, and schisandra (Schisandra spp., Schisandraceae). Government scientists studied these herbs in Olympic athletes, miners, truck drivers, factory workers, and more, with results indicating improved physical performance and lower rates of sickness and fatigue, although the results published in Russian-language journals are difficult to access. One of the lead researchers of the Soviet adaptogens project, Israel I. Brekhman, created a multi-herb adaptogen product (sometimes marketed in the United States as “Prime One®”), which was reportedly used by more than 100 American athletes at the 1996 Atlanta Olympic Games.
1. Wilson S. 9 athletes suspended for doping in lead-up, 2 new procedures at ‘most tested’ Olympics ever. The Washington Post. July 25, 2012. Available at: www.washingtonpost.com/sports/9-athletes-suspended-for-doping-in-lead-up-2-new-procedures-at-most-tested-olympics-ever/2012/07/25/gJQAnMwW9W_story.html.
2. Papagelopoulos PJ, Mavrogenis AF, Soucacos PN. Doping in Ancient and Modern Olympic Games. Orthopedics. 2004;27(12). Available at: www.healio.com/orthopedics/journals/ORTHO/%7B938E8E86-5151-451A-BD36-CAB0E26D9746%7D/Doping-in-Ancient-and-Modern-Olympic-Games. Accessed July 25, 2012.
3. Aschwanden C. The top athletes looking for an edge and the scientists trying to stop them. Smithsonian magazine. July-August 2012. Available at: www.smithsonianmag.com/science-nature/The-Top-Athletes-Looking-for-an-Edge-and-the-Scientists-Trying-to-Stop-Them-160284335. html. Accessed July 26, 2012.
4. Riddle J. Eve’s Herbs: A History of Contraception and Abortion in the West. Cambridge, Massachusetts: Harvard University Press. 1997.
5. Heggie V. Sports doping, Victorian style. The Guardian. June 19, 2012. Available at: www.guardian.co.uk/science/blog/2012/jun/19/sports-doping-victorian-style. Accessed July 26, 2012.
6. Ravilious K. Barry Bonds steroid debate highlights history of drugs in sports. National Geographic News. June 22, 2007. Available at: http://news.nationalgeographic.com/news/2007/06/070622-barry-bonds.html. Accessed July 25, 2012.7. Winston D, Maimes S. Adaptogens: Herbs for Strength, Stamina, and Stress Relief. Rochester, Vermont : Healing Arts Press. 2007.