Fact Sheet
The Dietary Supplement Dilemma

What are dietary supplements?
Dietary supplements are products that contain nutrients or other food components that people use in an effort to gain something they feel may be lacking in their diet. Many athletes take them hoping to gain an “edge” or “advantage” on the competition. They include such things as vitamins, minerals, extracts, probiotics, fatty acids, botanicals, herbs, amino acids, enzymes, metabolites and glandulars.

What do we know about the dietary supplement industry?
The dietary supplement industry has become an extremely lucrative business in Canada. There are thousands of products on the market promising cures for everything from the common cold to cancer. This industry is currently under-regulated and so manufactures have not had to provide scientific evidence to support their claims and are under no regulatory obligation to ensure that their products contain exactly what is listed on their labels. Manufactures use the internet extensively and spend millions of dollars advertising the benefits of their products. The constant bombardment of information from the media can make it very confusing for consumers and clinicians to know the facts and the potential dangers of using these products.

What attracts us to use them?
As a testimony to the success of advertising, many Canadians are looking to dietary supplements for a wide variety of reasons such as: weight loss, muscle gain, personal fitness, improved appearance, higher energy levels, anti-depression, competitiveness, fighting the effects of ageing, disease prevention and disease treatment. Many of the product advertisements are written in pseudo-scientific language and refer to the results of studies that fail to meet even the most basic concepts of the scientific process. The bottom line is that many Canadians are convinced that dietary supplements are a safe and easy way to improved health and happiness.

What are some of the concerns regarding dietary supplements?
Natural doesn’t mean safe - Many supplements claim they are safer than medications because they are derived from natural sources. Remind your patients that most prescription drugs are derived from plants and that while they are completely natural some plants are poisonous.
Contamination – some dietary supplements have been found to contain lead, broken glass, animal feces and substances such as anabolic steroids.
Spiking – some manufactures add substances such as ephedrine to their products and then fail to declare them on the label.
Labeling - there is no guarantee that the supplement you are using contains what is listed on the label and that it does not contain some unlisted surprises.
Misleading labeling – products such as ephedrine may be listed on the label under a variety of misleading names such as Ma Huang, Yellow Horse, Desert Herb and Sea Grape.
Medication Interactions – some supplements have been shown to interact with medications. For example, at high doses glucosamine may have an additive anticoagulant effect.
Supplement Interactions – ephedrine and caffeine are a dangerous combination found in many “Fat Burner” products and are associated with a number of deaths. Some people take a veritable cocktail of supplements on a daily basis without knowing the immediate or long term health consequences.
Medical Condition Interactions– we know that some supplements can effect the management of specific medical conditions. For example, glucosamine may elevate blood sugar levels and so diabetics who start using this product should initially be monitored more closely.
Lack of Research – little research has been done on the efficacy and the long term effects of using these products.
Excessive use – many people are taking more than the recommended doses of these products often because they are convinced that if a little is good than more must be better.
Costs – many of these products are expensive and some people are wasting hundreds of dollars/month on products with no proven efficacy.
Athletes – with no guarantees on the contents of a dietary supplement, athletes that use them risk testing positive for a banned substance. More information on this issue can be obtained from the Canadian Center for Ethics in Sports at www. cces.ca or 1-800-672-7775.

What is Health Canada Doing?
As of 01 January 2004, Health Canada will take 6 years to progressively implement the Natural Health Products Regulations. These regulations are aimed at ensuring that the manufactures of dietary supplements sold in Canada comply with good manufacturing practices to ensure that the label accurately reflects what is in the bottle and that there is research to substantiate any health claims that are made before a product is offered for sale. Unfortunately, this will not prevent your patients from buying whatever they want from the internet.

Take Home Messages:
1. The majority of dietary supplements do not work
2. Natural does not mean safe
3. You can’t trust the label
4. Dietary supplements can cause serious side effects
5. Dietary supplements can interact with medications and complicate the management of many medical conditions
6. Be sure to ask your patients if they are taking supplementsWebsites:
www.substancewatch.com
www.quackwatch.com
www.consumerlab.com
www.cces.ca
www.wada-ama.org
www.asda.org.au/athletes/fact.htm

CASE STUDY:
Philip is a 43-year-old male who was diagnosed with metabolic syndrome 6 months ago. At that time, he was leading an inactive lifestyle and his BMI was 33.2, BP 152/92, total cholesterol 6.28, LDL 4.3, triglycerides 3.6, HDL 0.85, fast blood sugar 6.3 and his ECG was normal. He was advised that he needed to make some serious lifestyle changes to see if this would reduce his risk factors. He has progressed to doing 45 minutes of treadmill walking followed by 30 minutes of general body exercises 3 times a week at a local fitness facility. He presents to you complaining that he has recently started feeling a generalized body tightness when he exercises and that towards the end of his workouts he occasionally gets painful cramping in his legs.

1. What are some things that could trigger this change? Some areas to explore would be:
a. Sudden large increases in workload
b. Inadequate hydration
c. Medication changes
d. Possible electrolyte imbalances due to strict dieting
e. Dietary supplement use
Philip admits that in an effort to accelerate his fitness he recently started taking creatine on the advice of his fitness instructor. He did not find it helpful so he has been taking double the recommended dose.

2. What are the common side effects associated with of creatine use?
a. Water retention
b. Abdominal cramping, nausea, diarrhea
c. Sleep disturbance
d. Muscle tightness and cramping
e. Compartment syndrome

3. What important advice could you provide Philip at this time?
Philip should be advised to discontinue the creatine as it is very likely the cause of his muscle tightness and cramping. This would also be a good time to remind him that dietary supplements are unregulated and many of them do contain products that could be harmful to his health. He should also be reminded that he is doing very well and encouraged to continue with his new active lifestyle.

Major Darrell Menard OMM MD Dip Sport Med
Sport Medicine Consultant
DCOS Force Health Protection