Adverse Side Effects of Dietary Supplement Use

Adverse Side Effects of Dietary Supplement Use
Anthony E. Johnson, MAJ, MC, USA
Chief, Orthopedic Surgery
Team Physician, Al Army Soccer
McDonald Army Health Center
576 Jefferson Avenue
Fort Eustis, VA 23604-5548
Phone: (757) 314-7602 (DSN 826)
Fax: (757) 314-7601
E-Mail: Anthony.E.Johnson@US.ARMY.MIL

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ABSTRACT:
Introduction: An ergogenic aid is any agent used to enhance energy production and/or utilization
with the intent to improve performance in a particular sport or activity. Dietary supplements are
consumed for their potential ergogenic effects by soldiers seeking to improve physical
performance. However, these agents are not regulated by the US FDA. The long-term health
effects of these unregulated dietary supplements are unknown. The purpose of this study is to
establish the incidence of dietary supplement use in a U. S. Army combat unit and to present a
review of the literature on the documented adverse reactions related to dietary supplements use.
Methods: 750 Soldiers rangers from a U. S. Army combat unit were administered an anonymous,
self-reported, survey concerning recreational and competitive athletic participation, participation in
weight training, ergogenic supplement use and sources of nutritional information. Al surveys were
administered by the battalion surgeon. The data was analyzed using the Pearson's Chi-square
with continuity correction method of analysis.
Results: 294 soldiers (39.5%) completed the questionnaire. One hundred and nine (56.1%) of
the responders admitted to using at least one dietary supplement. The average age of the
respondent was 23 years. Dietary supplement use was associated with participation in
recreational athletics and weight training. Protein supplements were the most common
supplement; fol owed by creatine and thermogenics respectively. Less than 1% used anabolic
steroids. The most commonly cited source for nutritional information concerning ergogenic
supplements is another soldier, fol owed closely by fitness magazines. Less than 10% cited the
unit surgeon or local nutritionist.
Conclusions: Dietary supplement use in the surveyed unit is similar to rates reported for other
athletic organizations. As the long-term health effects are unknown, the decision to consume
dietary supplements should be careful y deliberated. Unit surgeons and team physicians are
uniquely situated to advise these soldiers.
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Introduction:
An ergogenic aid is any agent used to enhance energy production and/or utilization.1
These agents are used to enhance performance in a particular sport or activity. Use of ergogenic
aids in the U. S. military is not new. {Table 1}
Neutraceutical or dietary supplement use by athletes has received appreciable attention
recently.3, 5-10 However, dietary supplement users vary across a wide spectrum.1, 6, 11-19 Nor is the
use of neutraceuticals limited to purely athletic endeavors. Many “novel neutraceutical” therapeutic
strategies have been reported in the treatment in the various disorders to include: pediatric irritable
bowel syndrome, 20 ulcerative colilitis,21 osteoarthritis, 22-23 and pain management.24 The myriad
uses for dietary supplements has added to the confusion regarding the efficacy and, more
importantly, the safety of over the counter dietary supplements consumed by the general public.25
The Dietary Supplement and Health Education Act in 1994 was enacted, in part, to standardize the
manufacture and marketing of dietary supplements.26
The ability to enhance physical performance is as attractive to soldiers as their competitive
amateur or professional athlete counterparts. The Committee on Military Nutrition Research
recommended the further study of nutritional supplementation for the military, especial y the
forward deployed personnel.27 However, the incidence of dietary supplement use in the active duty
population is not known. The purpose of this study is to establish the incidence of dietary
supplement use in a U. S. Army combat unit and to present a review of the literature on the
documented adverse reactions related to dietary supplements use.
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Methods:
After appropriate IRB approval, 750 active duty service members assigned to the U. S.
Army 1st Ranger Battalion were administered an anonymous, two-page, single encounter, self-
response, closed-ended food frequency questionnaire under the supervision of the Ranger
Battalion Surgeon during a one week period from July – August 1999. The survey was modeled
after similar surveys used by the National Col egiate Athletic Association.7 Random error was
control ed by using the single intake model which minimized day to day variability and the large
sample size. Systemic error, chiefly in the form of under-reporting, was anticipated. The
questionnaire was a qualitative, rather, than quantitative survey.
We col ected data on age, participation in competitive athletics, participation in recreational
athletics, participation in weight training, ergogenic use, type of agent used, as wel as the sources
of information on nutrition and supplements. Participation in the different types of exercise by
users vs. non-users of dietary supplements was compared with a 2X2 contingency test (Pearson's
Chi square with continuity correction). Ninety-five percent confidence intervals (95% CI) were
calculated for the frequency of competitive athletics and weight training in the supplement users
using the Modified Wald Equation as there was fewer than 5 who did not participate in those forms
of exercise. Age between users vs. non-users of dietary supplements was compared with a Mann-
Whitney rank sum test.
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Results:
39.2% of the 750 soldiers responded to the survey. Reasons for non-participation were:
(1) time constraints due to the high operational tempo of the surveyed unit, (2) training, (3) leave.
Of the 294 rangers responding to the survey, 37% (N=109) admitted to using dietary supplements.
The average age of the dietary supplement user, as wel as the non-user, was 23 years. There
was no significant difference in age between users and non-users (p > 0.05). There was no
significant difference in participation in competitive athletics between users and non-users (p >
0.05). More users (89.9%) than non-users (71.4%) participated in recreational athletics. There
was a significant difference in participation in recreational athletics between users and non-users (p
< 0.001). There was a significant difference in participation in weight training between users and
non-users (p = 0.001). More users (96.3%) than non-users (82.2%) participated in weight training.
{Figure 1} The vast majority of rangers had participated in competitive athletics (96.3% of
supplement users vs. 92.4% of non-users). This difference in competitive athletic participation was
not significant (P<0.8).
The most commonly used dietary supplement was whole protein supplements such as
whey protein; used by 62.3% of the dietary supplement users. {Figure 2} Creatine and
thermogenics were used by 45.8% and 44% of the users respectively. Anabolic steroids used was
reported by less than 2% of the responders (N=2).
Other soldiers were the most commonly cited reference for their nutrition information, used
by 59% of the soldiers overal . {Figure 3} Fitness magazines were a close second (46%),
fol owed by the internet (18%). The unit surgeon was the least cited source of information at 6%
fol owed by nutritionist at 8%.
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Discussion:
The dietary supplement industry is a multi-bil ion dol ar industry.18,26,28 {Figure 4} The
marketing of dietary supplements is mostly based on generalized, scientifical y unproven claims.3,26
It has been estimated that 89 brands of supplements currently exist offering over 300 products.57
Over 78% of these products claim to contain unique ingredients that promise various results
loosely based on science.57 Only 59% of the 235 unique ingredients found in the products being
advertised have any toxicological data on file.57 The long-term health effects of these products
have not been methodical y evaluated. However, as dietary supplements are not marketed for the
purpose of treating any ailment, they are considered food products. Thus they are not under the
same high level of scrutiny of the Food and Drug Administration provided to products designated
as medications.5,26,58 In documented cases of adverse side effects associated with dietary
supplement use, the burden of proof rests with the government and not with the manufacturer to
demonstrate a causative link.59-61 However, several authors have reported adverse outcomes
associated with dietary supplement use. {Table 4} For this reason, the major athletic governing
bodies (INTERNATIONAL OLYMPIC COMMITTEE, NATIONAL COLLEGIATE ATHLETIC
ASSOCIATION, and AMATEUR ATHLETIC UNION) have banned or strictly govern dietary
supplement use. Until the efficacy, safety, and long-term health effects of these substances
can be firmly established, care should be used with dietary supplement use.
Our data supports that the soldiers participating in this survey consume ergogenic
supplements at rates similar to other athletic populations. 1,5,58,66,67 {Table 5} Our results are also
in line with the literature in that supplement use is inversely correlated to nutritional knowledge.68-70
Other athletes and fitness magazines (whose profits are partial y generated by dietary supplement
advertisements) are the most common source of information cited by amateur athletes.57
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A major limitation of our study is the low response rate. The low response rate suggests a
level of systematic error as this may have been a result of self exclusion of soldiers with higher
usage in a form of under-reporting as wel as an identification bias.71-74 However, no statistical
method can ful y correct reporting deficiencies, and some studies suggest such efforts may
confound the findings.75
We attempted to control other known biases. Recal bias was limited in the usage of yes
or no questions rather and quantification of the supplements consumed. Also, the surveys were
administered anonymously in order to minimize the social desirability bias. After a pre-survey
block of instruction, the unit surgeon stepped out of the room, no personal identification data was
solicited, and the surveys were placed into a box as the participants exited the room. The proctor
was available to answer questions as necessary. The other factors identified for the low response
rate can be directly related to the unit’s high operational tempo. As a result, our survey effectively
surveyed the soldiers in the recuperative phase of the training cycle. A study of the soldiers in the
active phase of the training cycle may reveal a different pattern of supplement use. Since the goal
of supplement use is to optimize performance in demanding situations, further study in this area is
warranted. While our goal is to establish the usage rates of dietary supplements in this U. S. Army
unit, each military unit has its own inherently unique culture. Similar studies in different sub-
populations to include combat support and service support units as wel our sister services are
required.
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Conclusions:
The use of various forms of ergogenic aids is not new to the U. S. Military. Dietary
supplements, however promising, are promoted based on loose science and marketed with little
scrutiny. There is legitimate reason for concern for care givers of dietary supplement users as the
long term health effects of these compounds are unknown, use of supplements is inversely
correlated with nutritional knowledge, and knowledgeable sources are the least utilized resource of
information for supplement use. Dietary supplements complicate peri-operative considerations.76-76
Supplements also pose preventative medicine issues as there is a tendency for supplement users
to partake in other high risk behaviors.28 Active duty personnel, especial y elite ground troops, are
attracted to dietary supplements at rates similar to competitive athletes. Further study in this field
is necessary.
The unit surgeon, as the chief advisor to the unit commander for healthcare issues and the
most readily available medical professional to the soldiers, is uniquely situated to best counsel our
soldiers on the potential hazards of dietary ergogenic supplement use but is an underutilized
resource according to out study. Unit surgeons should familiarize themselves with the various
forms of dietary supplements available so that they advise the troops accordingly.
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