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Exercise is medicine.

Enhancing Athletic Performance Part 3

The foundation of enhancing athletic performance is essentially the same goal that health-care providers have for their in their patients, which is to optimize health. For the athlete, detailed sports-specific training regimens should be recommended as well as appropriate sports-specific caloric and macronutrient needs. Furthermore, every athlete should at least be on an appropriate multivitamin, no matter what the lifestyle deficiencies may be. The fact that JAMA in 2002 stated, "It appears prudent for all adults to take vitamin supplements," applies even more so to athletic populations. Once the basic needs of the athlete are addressed (i.e., sports--specific training, caloric needs, and lifestyle optimization), then the athlete and associated team will be in a better position to determine appropriate supplemental ergogenic aids. Part 3 of this article briefly details specifics on the known natural ergogenic aids, most of which are deemed unbanned by athletic organizations, and then lists banned substances in international sports competition.

Creatine Monohydrate The ISSN has called creatine "the most effective nutritional available to athletes to increase high intensity exercise capacity and muscle mass during training."' This supplement is one of the most extensively studied for its performance-enhancing effects. The ergogenic effects appear to be (1) increasing the amount of energy available in the form of ATP and (2) increasing cellular hydration.

More than 95% of the body's creatine is stored in muscle tissue in a readily available phosphorylated form, phosphocreatine. Hence, creatine is especially rich in animal protein. While creatine can be made in the body, it requires significant resources, including the amino acids (AA), magnesium, methionine, B12, and folate among others. Phosphocreatine is able to supply ATP, the body's energy currency, for quick bursts of high-intensity activity lasting around 10 sec. Once these high energy phosphates are depleted, the body relies more heavily on anaerobic metabolism. Supplementation of creatine is thought to "supersaturate muscle" and allows for greater performance of short, explosive movements. Creatine appears to increase muscle water content, and research appears to show that hydrated muscle tissue is able to both synthesize new muscle tissue and resist protein breakdown. (2-4)

Studies on weight training and high-intensity interval exercise show creatine as a reliable and beneficial training aid. Kerksick et al. showed that 4 weeks of creatine supplementation significantly improved both strength and lean body mass when loaded at 20 g/d for 5 days followed by 5 g/d. (5)

Another study, on 23 untrained males divided into a creatine group or a placebo group, showed greater power output and less fatigue in the creatine group. (6) The creatine dose was 5g 4 x/d for 6 days. Both before supplementation and 7 days after supplementation, participants did a 30 sec of maximal sprinting on a bicycle ergometer. This was repeated 5 x with 2 min rest in between. There was a 7.6% increased power obtained in the creatine group, while the placebo group saw no improvement.

Lean body mass gains can be significantly greater with creatine than with controls while weight training. A review by Kreider el al. says that most evidence shows that short-term creatine supplementation can generate greater muscle gain and greater power output, thus enhancing performance. (7)

Creatine has now been studied extensively in several reviews, and long-term studies on safety show it to be safe in adults and adolescents without renal disease. Creatine increases recovery from intense exercise and increases lean body mass. (2)

Dosing is typically done in divided doses of 20 to 30 g/d for 5 days followed by a maintenance dose of 2 to 5 g/d for 3 wks. Taking creatine postworkout with small amounts of glucose, such as grape juice, can improve muscle saturation benefits. (2)


Beta-alanine is a precursor, along with histidine, of carnosine, which is found in high concentrations in skeletal muscle. Beta-alanine has been shown to increase carnosine levels. (9), (10) It is widely assumed that carnosine has performance benefits in its ability to resist pH changes in muscle. Ergogenic effects include greater number of repetitions during resistance exercise, fatigue resistance, generation of greater force with the legs, optimization of hormonal response to exercise, and improvement in body composition.(10-14)

Common side effects are a "pins and needles" sensation (acute paresthesias), burning, itching, or a flushing on the ears and scalp. Many people use these side effects to adjust their dosing, reducing it if they experience them.

Dosages range from 800 mg to 7 g daily in divided doses.

Branched-Chain Amino Acids (BCAAs)

BCAAs (leucine, isoleucine, and valine) have been shown to increase protein synthesis, decrease protein breakdown, and speed recovery from exercise. BCAAs are probably the most beneficial aspect of protein intake for the athlete. Research suggests they may have some acute performance enhancement effects and play a key role in body composition. BCAAs have been shown to spare muscle protein breakdown and promote muscle protein synthesis. (15-17) They have some impact on exercise performance, perceived exertion, optimization of body composition, and recovery. 1618. (22) Suggested doses of BCAAs are between 6 and 12 g/d. Given that dosages of BCAAs are so high, it may be more practical to recommend this supplement in powder form rather than capsule. Mixing BCAAs powder into a small amount of high-glucose fruit juice, such as grape juice, may help increase compliance by masking the bitter taste and increasing absorption and utilization. (16), (18-22)

Beta-Hydroxy Beta-Methylbutyrate (HMB)

HMB is derived from the BCAA leucine. Using HMB at levels from 1 to 3 g/d while undergoing weight training may increase strength results and have positive impacts on lean muscle gains. (23-25) Older or untrained individuals can also benefit from supplementation. (26) Vukovich et al. in 2001 showed that 3 g of HMB daily over 8 wks given to elderly men and women led to significantly greater loss in fat compared with a placebo group. (26)

A study by Knitter et al. showed that HMB might protect against muscle damage from exercise. (27) Well-trained runners were supplemented with 3 g/d over 6 wks. Compared with placebo, HMB-supplemented runners had lower markers of muscle damage.

HMB supplementation along with creatine may behave in a synergistic fashion. (28)

The dose of HMB shown to be effective is 1 to 3 g/d.


The consensus of studies show that caffeine, as opposed to coffee, has value in endurance exercise performance, anaerobic exercise outcomes, exercise recovery, and weight loss.(29-32) on pure caffeine consumption shows an ergogenic effect, whereas coffee consumption is equivocal. Users of caffeine will develop some tolerance, whereas nonhabitual users may experience slightly better benefits. Concerns about caffeine and risk of dehydration are unfounded, according to the research. Caffeine's absorption occurs rapidly and is detectable in blood within 15 min of intake, reaching peak levels at 1 hr. Caffeine is cleared from the system in about 6 to 12 hrs, depending on the individual's metabolism.(29-31)

Caffeine exerts strong influence on the nervous system, affecting both the CNS and PNS. It acts to increase mental focus and fine motor skills. B-endorphin concentrations also rise with caffeine consumption, possibly resulting in decreased pain perception during intense activity. (33) Nervous system activation by caffeine plays a strong role in sports requiring bursts of speed and intensity. (33), (34)

Caffeine spares muscle glycogen and shifts metabolism toward the increased use of fat both from subcutaneous and intramuscular compartments. (35) Given that fat oxidation is a key component of endurance sports, caffeine can improve outcomes in long-distance events. (36) It also has an interesting impact when dosed along with carbohydrate. A carbohydrate beverage spiked with caffeine can significantly bolster carbohydrate oxidation and muscle glycogen synthesis more than carbohydrate alone. (37-39) This may be due to caffeine's ability to hasten the absorption of glucose from the digestive tract to the bloodstream.

In high-intensity exercise, caffeine increases catecholamine production, increasing both lipolysis and glycogenolysis. (29-31) This along with increased activation of the CNS may be the mechanism responsible for better performance in high-intensity endeavors. Schneiker et al. showed that caffeine intake increased sprint performance 8.5% and 7.6% over placebo in the first and second bouts, respectively. It also increased power output compared with placebo. (38)

Caffeine's suspected activity as a fat-loss aid comes from its epinephrine-inducing effects. Studies as far back as 1990 showed that as little as 100 mg of caffeine, the equivalent in (1/3) cup of coffee, could increase thermogenesis in even habitual coffee drinkers.[degrees] Studies on caffeine have repeatedly shown increased fat oxidation, making it a known fat-loss aid. (29-32)

Caffeine consumption shows impact when taken 15 to 60 min prior to exercise at a dose of 6 mg/kg bodyweight. For a 160-pound individual, this is the equivalent of about 430 mg of caffeine. (29-31)

Green Tea Extract (GTE)

Green tea has been consumed in Asian countries for centuries. Habitual green tea consumption is correlated with lower weights and less body fat. (44) Studies have shown that extracts of green tea catechins can increase oxidation of fat both at rest and during exercise. (42), (43)

Dulloo et al. showed that GTE intake elevated 24-hr resting energy expenditure with increase fatty acid oxidation when compared with an equal amount of caffeine taken alone. (42) A 90-day clinical trial combining GTE with a low-calorie diet resulted in significantly greater weight loss compared with a nontreatment group (30 lbs vs. 11 lbs). (41) Interestingly, the activity of GTE may have particular use against abdominal fat."

Ichnose et al. conducted a double-blind, placebo-controlled trial of GTE intake over 10 wks. (46) Exercise testing was done before and after the 10 wks supplementation. Both the placebo and GTE contained equal amounts of caffeine content. At the conclusion, no changes in performance parameters were noted between groups. However, there was a statistically significant increase in fat utilization for the GTE group, but no change in the placebo group.

GTE can cause a transient feeling of nausea in susceptible populations. It also frequently comes along with caffeine, both of which separately can aid in fat loss. (44)

GTE dosage is usually 300 mg to 500 mg daily.

Sodium Bicarbonate (Baking Soda)

Due to the fast accumulation of protons (H+) and carbon dioxide (CO2) during high-intensity anaerobic activity, buffering capacity in muscle and blood is essential. The chief buffering compound is the bicarbonate ion (HCO3-).

Sodium bicarbonate appears to provide a reservoir of bicarbonate ions and thus gives one greater capacity to resist fatigue-induced pH changes at the muscle cell. Several studies have shown that supplemental sodium bicarbonate can stabilize pH changes for exercise lasting from 1 to several m n.(2), (47-50)

There appear to be no safety issues with sodium bicarbonate intake aside from occasional digestive upset; therefore, one should acclimate to closing before using it in competition.

Sodium bicarbonate can be taken prior to exercise or as a loading dose several days before an event. The pre-exercise dose is 0.3 g/kg body weight taken in water between 60 and 90 min before an exercise bout. (2) The loading dose of bicarbonate is taken over a 5-day period and consists of 5 g taken 2 x/d for 5 days. (2)

Sodium Phosphate

Studies indicate that supplementation with sodium phosphate can increase maximal oxygen uptake/maximal aerobic capacity and anaerobic threshold, thus enhancing endurance exercise capacity. (2), (51-53), (56) Sodium phosphate loading also seems to improve mean power output and oxygen uptake. (2), (54-56) Other forms of phosphate (i.e., calcium phosphate, potassium phosphate) do not appear to have ergogenic effect. The dosage is 1 g taken 4 x/d for 3 to 6 days (2)

Whey Protein

Whey protein is rich in essential AAs and contains high amounts of sulfur-containing AAs (e.g., cysteine), glutamine, and BCAAs. It is a popular meal replacement for athletes due to its high biological value.

Whey protein supplies cysteine needed for the synthesis of glutathione, the body's main antioxidant.(57) Any supplement that can aid the body's endogenous production of antioxidants probably plays a role in lessening damage and speeding recovery from exercise. (58), (61) Glutathione levels are reduced during exercise.(59)

Ultraendurance events, such as marathons and triathlons, can increase oxidized glutathione levels by 189%. (60)

Whey enhances body levels of cysteine, taurine, glutamine, and BCAAs, among others. This can have consequences in several areas, including immune function.(60-63) Nothing can interrupt training more than illness.

Whey protein also has merit as a fat-loss and muscle-building aid, which may make it useful as a preworkout meal compared with carbohydrate, which may slow fat loss. (64) Whey protein also shows a powerful ability to regulate hunger and binge eating for weight contro1. (65) A study by Akhavan et al. showed that whey protein taken before an all-you-can-eat pizza meal significantly lowered food intake, postmeal glucose, and insulin levels in response to the mea1. (66)

Whey protein can provide benefit when timed appropriately with exercise. Whey protein postworkout may be one of the most beneficial things that one can do to maximize lean body mass. Whey protein is low glycemic but insulinogenic at the same time. (66), (67) This may create a unique opportunity for muscle growth without fat gain, especially in a postworkout setting.

The addition of a small amount of carbohydrate may be more beneficial in terms of muscle gain. In studies analyzing postworkout intake of protein alone, carbohydrate alone, or a combination of both, protein and carb together generates the greatest insulin response. This enhances muscle glycogen synthesis and storage and has benefit for athletes in terms of recovery. (68), (69) Adding fat to the mix is not beneficial and may blunt this response.(70)

Combining whey protein and creatine may have synergistic benefit. Men supplementing their diets with a combination of whey protein and creatine together (1.2 g/kg/day of whey with 0.1 g/kg/day creatine) enjoyed greater improvements in strength and muscle mass compared with placebo. (71)

While many people are dairy intolerant, whey seems to be handled well by most. It has low levels of lactose, and tends to be digested easily.

Dosages tend to be the following: preworkout 5 to 10 g, postworkout 25 to 50 g, and meal replacement 15 to 30 g.

Conjugated Linoleic Acids (CLA)

CLA is a family of isomers of linoleic acid found mostly in beef, lamb, and dairy. Studies in the past have been confusing because different mixtures of isomers of CLA appear have to different biological effects. According to a 2013 review by Filippo et al., supplementing with CLA may help with fat loss and preserve lean mass when CLA is combined with resistance training. (72-75) Recent research also indicates that CLA may increase testosterone levels.(75)


Ingesting glycerol with water appears to prevent dehydration by enhancing hydration status during prolonged exercise, thus enabling the athlete to perform longer and more efficiently. (76), (77) Unfortunately, glycerol has the potential to mask blood doping, and as a result has recently been added to the World Anti-Doping Agency's (WADA) prohibited list's See the full list on the previous page.

Conclusion e above natural substances have preponderance of evidence relative to other nutraceuticals indicating they are either "apparently effect" or "possibly effective" for enhancing athletic performance.(2) Most of these natural ergogenic aids are considered legal in international sports competition, with the exception of glycerol. Some athletic organizations, such as the NCAA, have also banned caffeine above a certain level in the urine.(79)

As natural health-care providers, our goal is to assist our patients and clients in optimizing their health. The closer one gets to optimal health on the health continuum, the more likely one will perform better in life and in athletic competition. Many nutritional supplements appear to enhance athletic performance that are not discussed above. However, in most cases, research has not caught up with the many other athletic performance aids being used in the field. An ergogenic aid is defined as any external influence that aids in athletic performance beyond what a sufficiently healthy person can do. That kind of definition still leaves much room for debate.

World Anti-Doping Agency's Banned List 2013

Anabolic Androgenic Steroids

Exogenous: 1-androstendiol, 1-androstendione, bolandiol, bolasterone, boldenone, boldione, calusterone, clostebol, danazol, dehydrochlormethyltestosterone, desoxymethyltestosterone, drostanolone, ethylestrenol, fluoxymesterone, formebolone, furazabol, gestrinone, 4-hydroxytestosterone, mestanolone, mesterolone, metenolone, methandienone, methandriol, methasterone, methyldienolone, methyl-1-testosterone, methylnortestosterone, methyltrienolone, methyltestosterone, mibolerone, nandrolone, 19-norandrostenedione, norboletone, norclostebol, norethandrolone, oxabolone, oxandrolone, oxymesterone, oxymetholone, prostanozol, quinbolone, tanozolol, stenbolone, 1-testosterone, tetrahydrogestrinone, trenbolone

Endogenous: androstenediol, androstenedione, dihydrotestosterone, prasterone, testosterone

Other anabolic agents: clenbuterol, selective androgen receptor modulators (SARMs), tibolone, zeranol, zilpaterol

Hormones and Related Substances

erythropoietin (EPO), growth hormone (hGH), insulin-like growth factors (e.g. IGF-1), mechano growth factors (MGFs), gonadotrophins (e.g. LH, hCG), insulins, corticotrophins (ACTH)


All beta2--agonists including their D- and L--isomers (except formoterol, salbutamol, salmeterol, and terbutaline when administered by inhalation and Therapeutic Use Exemption is obtained)

Hormone Antagonists and Modulators

Aromatase inhibitors, including but not limited to: aminoglutethimide, anastrozole, exemestane, formestane, letrozole, testolactone

Selective estrogen receptor modulators (SERMs), including but not limited to: clomiphene, cyclofenil, fulvestrant

Agents modifying myostatin function(s), including but not limited to: myostatin inhibitors

Diuretics and Other Masking Agents

Diuretics: acetazolamide, amiloride, bumetanide, canrenone, chlorthalidone, etacrynic acid, furosemide, indapamide, metolazone, spironolactone, thiazides, triamterene

Other masking agents: epitestosterone, probenecid, alpha-reductase inhibitors, plasma expanders (e.g., glycerol)


adrafinil, adrenaline, amfepramone, amiphenazole, amphetamine, amphetaminil, benzphetamine, benzylpiperazine, bromantan, cathine, clobenzorex, cocaine, cropropamide, crotetamide, cyclazodone, dimethylamphetamine, ephedrine, etamivan, etilamphetamine, etilefrine, famprofazone, fenbutrazate, fencamfamin, fencamine, fenetylline, fenfluramine, fenproporex, furfenorex, heptaminol, isometheptene, levmethamfetamine, meclofenoxate, mefenorex, mephentermine, mesocarb, methamphetamine (D-), methylenedioxyamphetamine, methylenedioxymethamphetamine, methylamphetamine, methylephedrine, methylphenidate, modafinil, nikethamide, norfenefrine, norfenfluramine, octopamine, ortetamine, oxilofrine, parahydroxyamphetamine, pemoline, pentetrazol, phendimetrazine, phenmetrazine, phenpromethamine, phentermine, 4-phenylpiracetam (carphedon), prolintane, propylhexedrine, selegiline, sibutramine, strychnine, tuaminoheptane

Narcotics buprenorphine, dextromoramide, diamorphine (heroin), fentanyl, hydromorphone, methadone, morphine, oxycodone, oxymorphone, pentazocine, pethidine

Cannabinoids cannabinoids (i.e., hashish, marijuana)


Alcohol ethanol

Beta Blockers acebutolol, alprenolol, atenolol, betaxolol, bisoprolol, bunolol, carteolol, carvedilol, celiprolol, esmolol, labetalol, levobunolol, metipranolol, metoprolol, nadolol, oxprenolol, pindolol, propranolol, sotalol, timolol

Banned Methods enhancement of oxygen transfer (i.e., blood doping and artificially enhancing the uptake, transport, or delivery of oxygen) chemical and physical manipulation (can include tampering with samples, substitution and/or alteration of urine, catheterization, and intravenous infusion) gene doping

The International Olympic Committee and the US Olympic Committee are among 625 sports organizations worldwide that have adopted World Anti-Doping Agency (WADA) "Code" banning the above 192 performance-enhancing substances and methods.


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by Jade Teta, ND, CSCS, and Keoni Teta, ND, LAc, CSCS |
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Author:Teta, Jade; Teta, Keoni
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Date:Jul 1, 2014
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