Dietary Supplements - Risk Assessment

A sports pharmacist will spend a large portion of their time discussing dietary supplements with athletes, coaches, parents and other athlete support personnel. An evidence-based, factual, risk-reduction approach is realistic.

Sports Pharmacist Tips.

If they choose to use:

1. Use your professional judgement for dietary ingredient review, scientific evidence and the indication or reason the athlete desires to use the product.

2. Always consider only products tested by one of the trustworthy, independent 3rd part testing companies that screens for PES to the sensitivity required for athletes: Informed Sport, BSCG, and NSF-Certified for Sport (place in the comments if you are aware of others that test for PES contamination).

3. Confirm the lot number (also known as batch number) is listed as a tested product on the websites listed above. If the lot number is not listed, the athlete has a higher risk of testing positive for doping, even with a brand name product the athlete thinks they can trust. Their career in sports is on the line, so don't bend the rule here about the lot number.

4. Always review the High Risk List from USADA for the manufacturer and/or product. If it is found on the list, rebranded by the company or otherwise suspicious, recommend against use of the product for your patient-athlete. Student athletes may also find additional products after logging into Axis for NCAA banned substances.

Why is Risk Reduction Necessary?

Athletes tested for anti-doping frequently test positive after taking a dietary supplements contaminated with a performance-enhancing substance or masking agent. About one in four athletes blame a supplement for their positive test result (Lauritzen 2022). Post-market analysis of dietary supplements continue to reveal the high rate of products containing ingredient not listed on the label that are prohibited in sport (Kuzhuharov 2022). These are called "undeclared ingredients" and it's not just athletes who are at risk of exposure to these chemical.

If the general public were tested for anti-doping or the presence of prescription medicines or designer chemicals they weren't knowingly taking, the rate would likely match those found in post-market testing for athletes, about one in three to one in four products (check out the excellent work by Pieter Cohen). Frequently, drugs like sibutramine, anabolic steroids, hygenamine, and 1,3-dimethylamylamine are hidden in sports supplements, weight loss products, and even products sold as multivitamins.

The International Olympic Committee Consensus Statement on Dietary Supplements and the National Athletic Trainers' Association providing a decision tree for using or not using dietary supplements. The sports pharmacist will be realistic and unbiased in reviewing or recommending products like creatine or the few others that are proven to improve athletic performance that are not prohibited for use in sport.

If the decision to use a dietary supplements is the choice an athlete makes, the sports pharmacist helps ensure they are a well-informed consumer.

USP standard is generally trusted for pharmacists making recommendations to the public consumers to trust a label, but this is not enough to protect from contamination. It confirms the ingredients match the label to meet USP Standards, but this does not screen for undeclared performance enhancing agents.

Sports Pharmacy knowledge is a valuable tool in dietary supplement assessment, using a standard drug evaluation, as follows:

1. legal status - is the supplement a controlled substance (e.g. DEA or other government list), a "research chemical" not approved for human use or otherwise listed as a "poison" by any country

2. clinical effectiveness and safety evaluation (e.g. if it's not a recognized dietary ingredient, should the athlete be enrolled in an IRB approved clinical trial to use an unapproved ingredient?)

3. health risk for the individual based on their sport and other health factors

4. status in sport of substance, research it -- if its not yet specifically listed as banned, does it have a similar biological effect or chemical structure that do qualify it as prohibited now or in the future

5. is there a more cost effective alternative or food that could be used instead

Use the tools that help make the athlete an informed consumer.

OPSS Scorecard

USADA Supplement Connect

NIH Dietary Supplements for Exercise and Athletes

Is the athlete having a side effect or problem with the product?

If you recognize a problem, side effect or injury caused by a dietary supplement, report it with or for the athlete.

Contact the FDA and the FTC.gov

Advertising: Report a health product you believe is advertised falsely, contact the FTC. You also can contact your state Attorney General's office, your state department of health, or your local consumer protection agency.

To report a fraudulently labeled product, call your local FDA office.

Health concern: To report an adverse reaction or illness that may be related to the use of a supplement or other health care product, call a doctor or other health care provider immediately. You also may want to report your reaction or illness to FDA MedWatch. Call 1-800-FDA-1088 (1-800-332-1088) to request a report form, or file a complaint online. Patients' names are kept confidential.

Additional Resources from the Consumer's Market and Responsible Manufacturers

Consumer Healthcare Products Association

Council for Responsible Nutrition

Cohen PA, Sharfstein J, Kamugisha A, Vanhee C. Analysis of Ingredients of Supplements in the National Institutes of Health Supplement Database Marketed as Containing a Novel Alternative to Anabolic Steroids. JAMA Netw Open. 2020 Apr 1;3(4):e202818. doi: 10.1001/jamanetworkopen.2020.2818. PMID: 32293681; PMCID: PMC7160690.

Cohen PA, Avula B, Wang YH, Zakharevich I, Khan I. Five Unapproved Drugs Found in Cognitive Enhancement Supplements. Neurol Clin Pract. 2021 Jun;11(3):e303-e307. doi: 10.1212/CPJ.0000000000000960. PMID: 34484905; PMCID: PMC8382366.

Kozhuharov VR, Ivanov K, Ivanova S. Dietary Supplements as Source of Unintentional Doping. Biomed Res Int. 2022 Apr 22;2022:8387271. doi: 10.1155/2022/8387271. PMID: 35496041; PMCID: PMC9054437.

Lauritzen F. Dietary Supplements as a Major Cause of Anti-doping Rule Violations. Front Sports Act Living. 2022 Mar 25;4:868228. doi: 10.3389/fspor.2022.868228. PMID: 35399596; PMCID: PMC8990797.