Dietary Supplements in Sports

2004_TX_Proof

Texas — site of upcoming AMSSM annual meeting [Dallas, 4/15 – 4/20]

One of the studies in our March 2016 CJSM which has generated substantial interest is original research from the Department of Military and Emergency Medicine, Uniformed Services University of the USA: “Dietary Supplements: Knowledge and Adverse Event Reporting among American Medical Society for Sports Medicine (AMSSM) Physicians.

The AMSSM, one of our affiliated societies, is having its annual meeting coming up in Dallas April 15 – 20, and we’re looking forward to joining in those proceedings [the official hashtag of the meeting is #AMSSM16 — keep that in mind you Twitter folks].  The physician membership is not infrequently surveyed about a variety of matters of interest to practicing sports medicine clinicians; the results of these surveys often provide invaluable data to researchers who have published in the CJSM pages.

Examples of this include “Concussion Practice Management Patterns among Sports Medicine Physicians” and “Cardiovascular Preparticipation Screening Practices of College Team Physicians.” 

Regarding the study on dietary supplements (DS), the authors looked at a variety of issues.  Of note, they found that majority of survey respondents (71%) reported that athletes under their care had experienced an adverse event associated DS use.

Not all of us who read this blog or subscribe to the journal are AMSSM members, of course, and so I thought it might be time for a poll, asking this very question: have you ever taken care of an athlete who has experienced an adverse DS event?  Please, take the poll, and if you can, send us a comment on this blog identifying the DS, the adverse outcome, and possibly the sport in which your athlete was participating.

We hope to see you in Dallas!

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A Sharapova Moment

The world of sports medicine is never boring, but who knew things could get this interesting?

In the first weeks of March, there have been at least two major stories that have transcended the borders of ‘sports medicine’ and become topics of debate for the world at large — I speak of the proposed ban on tackling in schoolboy rugby (and the continued debate on tackling in American football) and Maria Sharapova’s admission that she failed a drug test at the recent Australian Open.  For both stories, the boundaries of the discussion have gone well beyond the lines of the playing fields and the walls of the academy.

Social media has seen these topics trending. The mainstream media have been profiling the issues as well.  The Economist weighed in on the debate about tackling. And this morning I found the New York Times prominently featuring Ms. Sharapova’s story, including articles on the drug meldonium [for which Sharapova tested positive] and on the issue of the World Anti-doping Agency’s (WADA) use of emails to notify individuals about changes on WADA’s banned substance list.

Many people have an opinion on the subjects.   We’ve been running a poll on this blog regarding the issue of tackling, while our friends at the British Journal of Sports Medicine (BJSM) have been running a Twitter poll on the Sharapova issue: who is responsible, the player or her support staff [currently the poll is 74%/26% stating it’s the athlete’s responsibility].

In the New York Times article and in the BBC, former WADA-president Dick Pound has stated his opinion that Sharapova’s failed drug test was ‘reckless beyond description.’

I must say I take issue with this and empathize with Ms. Sharapova, who stated that she received in December the WADA email noting that meldonium was now on the banned substance list, but “…I did not look at that list.”  Meldonium was a PED legal until 2016, when it was placed on the ‘banned substances list.’ As a professional inundated with emails, alerts, pronouncements, and more, I confess to a certain degree of information overload even when it comes even to items vital to my licensure and ability to practice.  Have I ever received an email from the Medical Board that I have deleted?  Have I ever received notification from my hospital staff office of some new change in policy which I glossed over?  Yes and yes.

Regarding the WADA emails, other athletes in the NY Times article have offered this opinion: “Some dismissed the messages as irrelevant to their own regimens or too complicated to be useful.”  That certainly resonates with me and my professional world.

I am not writing this to absolve Ms. Sharapova, and I applaud her for her prompt and open admission of personal responsibility. That stance is right and proper.  But I would hardly deem her action “reckless beyond description.”

In CJSM we have published over the years several studies on banned substances. One of the pieces of original research just published in our March CJSM sheds some further light on this issue, I think: Dietary Supplements: Knowledge and Adverse Event Reporting Among American Medical Society for Sports Medicine Physicians.  Read more of this post

High Altitude Medicine

I was thinking about Mt. Everest the other day.

Mount_Everest_by_Kerem_Barut

Mount Everest. Photo by Kerem Barut.

No, I will NOT be attempting the mountain myself!  In my youth I had such dreams……the story of Sir Edmund Hilary and Sherpa Tenzing Norgay thrilled and inspired me.

I think one of the defining experiences of middle age is to be certain that some dreams will never be fulfilled; to be content with that realization; and also, to know that there are other dreams, other challenges that can excite.

Yes, I am middle aged!

What got me to thinking about the mountain?  I am sure you have read, there was a terrible accident taking the lives of at least thirteen Sherpas which occurred last week. In reading the reports of that event, I realized that the spring summit period for the mountain had begun:  a narrow window in May  represents a period during which a huge number of ascents are attempted.  For instance, it was May 1996 when the climbing expeditions described by John Krakauer in ‘Into Thin Air’ took place.  This book introduced me to the reality of commercial climbing on the mountain.

If anything, it would seem that ever-greater numbers of people with perhaps limited technical climbing skills are attempting Everest:  an article in today’s New York Times notes that there are 334 expeditions planned for the 2014 climbing season!  This same article also notes in the wake of this most recent climbing disaster involving the Sherpas that this group of expert climbers–so vital to the performance of expeditions on the mountain–is planning a ‘work stoppage.’  I do not know all their demands, but the Times article notes that the stoppage was proposed in the wake of the Nepali government’s offer of a mere $400+ dollars as compensation for the families of the dead climbers.

On a more quotidian front, May represents for us here at CJSM our own challenge:  bringing out the third issue of the journal for 2014!  It’s too soon to say goodbye, however, to the March 2014 issue, and in light of the events on Everest I did want to commend to you an excellent piece in that issue:  The Canadian Academy of Sport and Exercise Medicine Position Statement:  Athletes at High Altitude.

As I’ve said, I, at least, may never make any Himalayan summits….but I fully expect as a sports medicine physician to care for people who succumb to one of the variety of altitude illnesses described in this article.  As the position statement emphasizes, injuries and illnesses associated with high altitude are no longer seen only in mountaineering: athletes, including many from the endurance disciplines, will train at altitude; and many athletes, of all types, will compete at altitude (think Mexico City Olympics, or even coastal Californian on a long-weekend’s ski trip to Aspen).  Staying ‘on top’ of the current thinking regarding this issue would be de rigueur for any of us clinicians caring for athletes. Read more of this post

Gender Issues in Sport

I was taken by an editorial that I read in the New York Times this weekend:  The Trouble With Too Much T.  If you didn’t have the chance to see it yourself already, by all means click on the link and read this piece.

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Caster Semenya, South African Olympian

The authors, Katrina Karkazis and Rebecca Jordan-Young, give a broad overview of how current sports governing bodies determine if an athlete is ‘really’ female.  Of note, Karkazis and Jordan-Young are also the principal authors of  The American Journal of Bioethics critique of the current gender-testing policies of the IOC, IAAF and other governing  bodies.

They lead with the well-known story of Caster Semenya, the South African woman who, in 2009, was barred from international competition and was compelled to undergo testing after the Berlin World Championships (she has subsequently been reinstated, and in the 2012 London Olympics was the flag-bearer for the S. African team and earned a silver medal in the 800m).  After the uproar that ensued over the Semanya case, the previously mentioned sports governing bodies instituted new gender-testing policies and interventions to redress the ‘problem.’

The new policies, as described in the editorial, are arguably no improvement and, it seems, a step in the wrong direction.

In the editorial, the authors tell the story of four female athletes with endogenously high levels of testosterone (‘T’) who all went through a battery of tests: physical examination (including genital inspections), blood tests, MRI, and psychosexual histories.  They then underwent surgery:  gonadectomy and (inexplicably) clitoral surgery.  They were required to do this to lower their levels of T, and they all subsequently were allowed to return to competition.

The essence of the current gender policies is 1) an identification of abnormally high levels of endogenous T; 2) a ‘therapeutic proposal’ which would be offered to athletes who test ‘too high’ and which include medications and/or surgery; 3) a disqualification from elite sport for women who elect not to have their T altered with said ‘therapeutic proposal.’

We’ve discussed some aspects of this issue in a previous blog post, our review of David Epstein’s sublime book ‘The Sports Gene.’ Epstein devotes an entire chapter (‘Why Men Have Nipples’) to female athleticism, and the powerful role that testosterone can often play in elite performance.  After reading this editorial, I thought it was time to write another post and poll the readership about aspects of this issue.

I can sympathize with the need to screen for use of exogenous testosterone, the systemic abuse of which led to most of the superior performances produced by East German athletes in the 1970’s.   Read more of this post

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