Close Encounters of the Nutritional Kind
Number 3 – Choosing supplements
There is perhaps no other area of sports nutrition (maybe carbohydrate but see Blog 1) that divides opinions like supplements. Some “nutritionists” believe that they should be the focus of any nutrition plan whilst others categorically state that they are an expensive waste of time and everything you need can be obtained from a balanced diet. Moreover, we read (on a far too regular basis) another athlete failing a drugs test for supplement contamination. My personal opinion is that supplements do have a place in elite sport, but as you will see from my performance nutrition tree, only once we have picked off the low hanging fruit. So how do I go about choosing what supplements to use with my athletes whilst at the same time doing everything I possibly can to reduce the risk? This (longer than normal) blog will walk you though my thought processes.
Above. My performance nutrition tree. I always tell athletes to pick off the low hanging fruit. We focus on getting the Timing, Type and Total amount of food spot on first and then work our way up the tree if needed.
This is a lot more complex than I can do justice to in a blog but let me give it a try. I follow 4 fundamental rules:
- Assess the need (2 stages to this)
Stage 1 in assessing the need this involves looking to see if there is any science to support the claim and if the science is relevant to the athlete in question. I will not engage with a supplement that may have amazing claims if there is simply no scientific rationale for what is being suggested. If there is a scientific rationale but the published evidence is weak then I am willing to move onto the next stages of my decision process. Sometimes a product may have a really small benefit that no scientific study can prove but if there is science to support why it could work I believe it is probably worth a shot. Lets look at some examples.
I guess the first example is quite controversial – ZMA. As far as I can see, I cannot see any scientific explanation as to why Zinc or Magnesium in non-deficient people will improve sleep. If you can please let me know. Plus when we look at the only published paper I can see on the benefits of ZMA on strength again questions must be raised. So this one does not pass my science assessment.
I said above the science must be in the right context. A good example here is beta-alanine. There is great evidence that beta-alanine improves performance, especially in exercise lasting 1-4 mins. But that does not mean it is useful for all sports. There are some sports where it is unlikely to help (long distance events) so giving it just adds a risk that is largely unnecessary. Another good example here is Cherry Juice for muscle soreness. Whilst there have been some great studies showing this can help muscle soreness, it must be stressed that in many of these trials the participants in the study were instructed to follow a low polyphenolic diet avoiding fruit, vegetables, tea, coffee and wholemeal grains. Questions must therefore be asked as to the effectiveness of this on athletes on a proper diet. However, given the standard of some athletes diets perhaps it is a good supplement!
Stage 2 of assessing the need is to see if the product in question can be obtained in a normal diet. A great example here is calcium. Whilst there is evidence that extra calcium may be useful in some instances such as bone healing we could always follow Joe Marler’s advice and achieve this through increasing our milk intake! Caffeine is another good example. Yes a supplement may work but please don’t discount a good coffee which has been proven to be equally as effective!
Above. England forward Joe Marler who credited his speedy return from a leg fracture to his increased milk intake.
Once you have assessed the need it is time to move onto Rule 2.
- Assess the risk
Assessing the risk is not just checking the risk of failing a doping violation. It is also crucial we assess the risk to the athlete’s health. After all, the first rule we should always follow is to protect the health of our athletes at all times. When I was a rugby player one supplement we were advised to take for fat loss was Hydroxycut. This product “guaranteed” fat loss but what it did not state on the label was that it also ran the risk of liver failure. It is our job as sport nutritionists to check that the products we are advising have been through the appropriate safety checks. And if we cannot find that data should we really be advising it?
Assessing the risk of contamination has been made easier with the development of the Informed Sport testing programme. Although by no means perfect, and it still must be emphasised that there is no such thing as “guaranteed drug free”, all supplements that have been through the Informed Sport testing process will have been screened for the most common contaminants. This at present gives us our most effective risk minimisation. The Informed Sport website provides batch numbers of the products that have been tested for you to check these out. I MUST stress, that there is a growing trend for companies to use the Informed Sport logo without testing, or putting the logo on their website despite only testing isolated products, not their entire range as the website may suggest. It is therefore CRUCIAL that people check the Informed Sport website rather than simply trusting the logo.
I would therefore advise that only fully trained people make this decision. My advice is always to look for a SENr accredited practitioner. My research group have recently been alarmed about the number of non-trained staff within sports teams that are making supplement decisions, many of which do not themselves feel qualified. I often say that we would never ask a S&C coach to prescribe antibiotics if the team could not afford a club doctor so why do we expect them to prescribe supplements? This is simply not fair on the athletes and must stop.
- Identify a suitable product
Once we have assessed the need and the risk, it is time to find a suitable supplier. Quite simply at the moment I only work with companies that are on the Informed Sport register or as a minimum commit to LGC batch testing. There are now many of these companies so it really is not that hard. The problem in professional sport is when commercial departments make the decision over the nutrition team, i.e. they go with the company that gives the most product for free. Unfortunately, many clubs still do not believe they should pay for supplements so often cheap/free wins over quality. This is slowly changing but in my experience unfortunately it still occurs with some teams (I’m delighted to say non that I directly work with).
- Continually Assess the benefits
The final rule is simple. Continue to assess the benefits. If you are giving a supplement to an athlete because you have assessed the need and discovered it could help please remember that papers publish “mean data” and you are working with “individual athletes”. If you give a product the correct way, for the appropriate amount of time and you see no performance benefits then you must ask yourself is there any point in continuing? Remember, that every supplement carries a risk so if there is no benefit then remove that risk.
And that’s it, when you do that you find you will end up with quite a small bespoke list for your client. Below is a list that we put together a few years ago for the RFU. It probably needs doing again and writing this has reminded me to do it as evidence changes.
And by reducing the number we take allows us to implement them safely and effectively. For example, we know beta-alanine works but only when given at 3-6g per day for 4-6 weeks. Many people give far less than this or stop before it has even begun to work. We know fish oils may work (if deficient in oily fish) but only if we give about 1g of EPA/DHA per day. Many commercially available supplements are a fraction of this dose. By taking fewer supplements, this allows us to get the dose and timing right of the ones we think may work.
Above. Simple traffic light system to help chose a supplement.
I put together this simple supplement decision tree (below) a couple of years ago that summarises the thought processes I have just described.
Above. Simple decision tree to help make a decision on supplements.
Another key consideration for the elite practitioner is supplement administration. How many of you have gone through this entire process and then have a shared tub of protein on site that all players and staff have their hands in and out of daily? Ever thought that they may be contaminating the sample themselves at this stage for the rest of the squad – or ever considered the hygiene of this? Careful thought MUST be given to dispensing supplements and for this I again suggest you speak with a SENr accredited practitioner.
OK, I know this is a long blog and I apologise for that, but I wanted to conclude with a final thought, a curve ball so to speak. And one I have still not got clear in my own head so I welcome your thoughts on this. When does a food become a supplement? Is fortified breakfast cereal a supplement since it has added vitamins in it, is Red Bull (or similar drinks) a supplement because of the caffeine and what about high-protein porridges that you can now purchase that has extra milk protein. And if you answer yes to the last one, what about milk powder in instant coffee – surely that does not need testing? There is currently a suggestion that common food items such as bread, milk etc should be supplemented with vitamin D to reduce NHS costs. If this does go ahead does that mean we will now have to test our daily bread?
I think this just goes to show the complexity of this for the athlete and for you advising them. My worry is that we are now in danger of “The Boy who cried Wolf”, i.e. if we get too carried away and tell athletes to avoid everything then they are in danger of not believing us about the real risky products – and that is very concerning. For now, I think we reserve our caution to the supplement industry, we hopefully trust the food industry and if in doubt we get qualified advice.
Until the next Close Encounter of the Nutritional Kind