In a position statement, the Association makes a series of key points in which they emphasise a natural supplement is not necessarily a safe supplement as well as urging the use of products by established manufacturers with known good quality standards.
Other points to be considered by athletes include being personally responsible for any substances consumed and that ignorance would not be accepted as an excuse in relation to a positive doping test.
However, the paper’s view came in for some criticism by Dr Mark Tallon, managing partner of food law firm Legal Foods, who questioned the authors’ approach in reaching a final verdict.
“The review as it relates to dietary supplements does not stand up to scientific scrutiny and it is unclear how the authors draw their conclusions based on the references, they site, which are on the large part other reviews rather than actual ingredient specific well-controlled Double-Blind, Randomised, Controlled Trial (DB-RCT).”
“Examples cited by the authors related to over cardiovascular safety include caffeine, fat burners containing ephedra, nicotine, guarana and ginseng.
“This are all suggested to be ‘legal supplements’ and that is not the case in at least two cases. Ephedra in 2005 was banned as a supplement under Regulation (EU) 2015/403 and in 2004 in the USA. Nicotine is a novel food and thus not a legal food without prior authorisation in the EU and UK.”
The paper, which appears in the European Journal of Preventive Cardiology, states: “Nutritional supplements are commonly viewed as risk-free substances that may improve performance.”
The paper’s authors go on to state that some nutritional supplements, including various plant and ‘natural’ extracts, may pose a serious health risk and athletes may even risk contravening anti-doping rules.
“Athletes who use supplements often have no knowledge regarding their effects on sports performance and overall health,”
“It is reported that most athletes get nutritional advice from coaches, fellow athletes, family members and friends, suggesting that more wide-reaching educational interventions, at an early age, are necessary.”
World Anti-Doping Agency
The paper, written by researchers from World Athletics and the International Testing Agency (ITA), goes on to discuss the cardiovascular effects of doping substances, prescribed and over-the-counter medicines, legal performance-enhancing supplements, and experimental drugs during sports.
Whilst the World Anti-Doping Agency (WADA) keeps a list of prohibited drugs, nutritional substances are not included since many are unregulated and unlicensed.
The paper estimates the use of legal supplements by athletes varies between 40% and 100% depending on the sport and level of competition and includes caffeine, creatine, energy drinks/gels/bars, beetroot juice, and proteins.
“Caffeine is a prime example of a natural substance that is considered safe,” says first author Dr Paolo Emilio Adami of World Athletics, the global governing body for track and field.
“While caffeine improves performance, particularly aerobic capacity in endurance athletes, its abuse may lead to fast heart rate (tachycardia), heart rhythm disorders (arrhythmias), high blood pressure, and in some cases sudden cardiac death.”
In response Dr Tallon, points out the study makes statements on the safety of caffeine by referencing a study by Gurly as support for the authors’ views.
“This paper was about ‘caffeine containing’ products and not a specific toxicological study on caffeine as taken as an isolated substance.
“In well controlled trials in subjects without pre-existing health conditions including in athletes, caffeine has been shown to be safe up to doses of at least 3mg/kg as per EFSAs review in 2015.
“The authors also refer to a news article that is not peer reviewed of which it is title concerns Creatine and not caffeine.
“Therefore, how any inference can be made about caffeine is confusing at the least and misleading at worse.
“Of course, the reference to guarana a caffeine containing substance can be considered in light of the caffeine safety data but nowhere in the paper do the reference a specific study on guarana alone.”
Along with discussions concerning legal ergogenic supplements such as creatine, β-Alanine, Sodium bicarbonate and nitrates, the paper delves into the ethical considerations of taking nutritional supplements.
Dr Tallon took issue with the work here, stating that, “Other references to the likes of Beta-alanine is very concerning and demonstrates how little the understand of the published literature.
“All the way back in 2006 we assessed heart rate, blood pressure and indeed we looked at cardiac troponin as part of the initial work on Beta-alanine supplementation (Amino acids paper Harris and Tallon..).
Since then, multiple studies and reviews conclude its safety when used as directed including a systematic review by Dolan et al in 2019 covering over 100 human studies.”
“Of course, the strangest commentary is on creatine. This is one if not the most studied ergogenic aid with almost three decades of safe use,” adds Dr Tallon.
“The comments again are not factual or based on a robust analysis of the peer viewed data.
I would refer anyone to read a very well-constructed Q&A by Dr Jose Antonio and his co-authors in 2021 (JISSN) covering the myths perpetuated in this paper.”
The authors go on to discuss that athletes should be aware that supplement use exposes them to a risk of ingesting prohibited substances or prohormones and precursors of prohibited substances.
The greatest risk to athletes’ health, they state is the use of ‘cocktails’ and transference of effects of several substances, which might interact to the worse or the use of designer peptides produced in laboratories without rigorous safety standards.
“Unfortunately, it is common practice for athletes to ignore dosing recommendations and use multiple drugs simultaneously,” the paper says.
“Sportspeople should be aware that supplement use exposes them to the risk of ingesting prohibited substances since they are regulated as food ingredients and not subject to the rigorous safety standards of pharmaceutical products.”
Good quality standards
Dr Adami continues: “Athletes should be aware that natural supplements and substances are not necessarily safe and should only be used if recommended by professional nutritionists.
“It is fundamental to use products from well-established manufacturers with known and internationally approved good quality standards.”
Dr Adami, who is the Medical Manager of the Health and Science Department at World Athletics, adds that athletes are always personally responsible for any substances they consume.
“Ignorance is not accepted as an excuse in relation to a positive doping test,” he says. “In those with established cardiovascular disease, a sports physician or sports cardiologist should always be consulted prior to using any performance aid or supplement.”
Commmenting on the paper's findings, Dr Adam Carey, Chair of the European Specialist Sports Nutrition Alliance (ESSNA) adds: “Over the last decade or so, our industry has seen ever-increasing interest from active consumers. The aim of sports nutrition products is to help this group supplement a balanced diet and lead healthy and active lifestyles.
"These products are very safe, as long as consumers clearly understand the conditions under which they should be used and are bought from reputable manufacturers and suppliers.
"ESSNA’s kitemark helps consumers to identify products from our members, whose membership of ESSNA is a promise to the public that they abide by our strict Code of Practice which sets high standards in terms of compliance with applicable law," Dr Carey continues.
"The sports nutrition sector is strictly regulated and clear legislation has long been in place in the EU and the UK to protect consumers from potentially dangerous ingredients and misleading claims.
"Also, scientific research on sports nutrition plays vital role in further clarifying the right use of supplements, as long as it is based on robust, independent scientific evidence and meets the standards of rigor, and consumer education on sports nutrition products is crucial, to ensure sportspeople make informed choices.
"For years, ESSNA has worked to directly educate consumers through various initiatives such as sports nutrition guides and useful toolkits aimed at educating the consumers on what to look out for from a sports nutrition product”.
Source: Eur J Prev Cardiol
Published online: doi.org/10.1093/eurjpc/zwab198
“Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology.”
Authors: Adami PE et al.