Most sport parents have heard their athletes talk about how much they need this or that supplement to perform better, stay healthier, or train harder. If your athlete is set on supplements, you can help them minimize the risks from those products by understanding red flags, identifying high-risk supplements, and using only third-party certified supplements.

Here, Tammy Hanson, Director of Elite Education at the U.S. Anti-Doping Agency (USADA), explains how to minimize the health and anti-doping risks from supplements.

1. Understand the Potential Risks from Supplements

Dietary supplements come in many forms, including gels, protein powders, and multi-vitamins. These products are regulated post-market, which means that neither the Food and Drug Administration (FDA) nor any other regulatory body evaluates the contents or safety of supplements before they are sold online and at major retailers.

Even though there are many safe supplements on the market, post-market regulation makes it very hard to determine which products are truly safe and actually contain what’s listed on the labels. Contamination and the use of unhealthy, low-quality, or unlisted ingredients continues to be a big problem in the growing supplement industry.

“We know that the majority of ingredients are being outsourced from other countries, which increases the risk of cross-contamination,” explains Hanson. “Supplement companies can leave out or omit ingredients on the ingredient list. They can change the name of ingredients. Yes, the FDA can pull something off store shelves if they deem it unsafe—but only after they’ve deemed it unsafe, which could be too late.”

Given the potential for unknown ingredients and quantities of those ingredients, some supplements pose a health risk, and unfortunately, there are many documented cases of this issue. Some supplement companies may also intentionally use potent ingredients that increase the effects of the product but are prohibited for athletes subject to anti-doping rules.

2. Recognize Red Flags

Researching supplements and recognizing red flags can help consumers reduce their risk if they decide to use supplements. You can start researching supplements by checking to see if the product or manufacturer is on the USADA High Risk List or the FDA Tainted Supplements list before use. These lists are not all inclusive, but they are a good starting place for ruling out risky supplements known to be contaminated or contain harmful ingredients.

You should also consider these red flags while evaluating and researching any supplement you might use.

1. Products sold exclusively on the internet may be risky, as some companies try to avoid regulations this way.
2. Some products list ingredients by chemical names to deliberately confuse consumers.
3. Products that make claims like “newest scientific breakthrough” and “quick fix” are risky.
4. Products that claim to treat or prevent a disease, or be “an alternative to prescription medication” are risky.
5. Products that claim to be “FDA Approved” or “USADA Approved” are risky – these organizations don’t approve supplements.

More information about red flags is available here.

3. Use Third-Party Certified Supplements

Third-party certification simply means that products are tested by an independent company to confirm that the product’s label matches its contents. If athletes choose to use supplements despite the known risks, USADA has always recommended that athletes use only dietary supplements that have been certified by a third-party program that tests for substances prohibited in sport. Even if your athlete isn’t subject to anti-doping rules or being tested, avoiding potentially contaminated supplements is good practice, and safer for your athlete.

USADA doesn’t test products or offer certification, but it does currently recommend NSF Certified for Sport as the program best suited for athletes to reduce the risk from supplements. Look for the NSF Certified for Sport label on products, which means it has been tested by NSF not only to confirm that the product contains what it claims to contain, but also that it’s free of any substances that are banned by the World Anti-Doping Agency (WADA).

Some brands use “NSF Certified” and “NSF Certified for Sport” interchangeably in their marketing, so be sure to check on NSF for Sport’s website or app to ensure that the product is specifically tested for banned substances. Finally, when purchasing supplements, the safest way to purchase NSF Certified for Sport products is directly through that supplement company’s website rather than a third-party provider.

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Takeaway

USADA and TrueSport recommend a ‘food-first’ approach to fueling whenever possible. The fewer supplements your athlete uses, the lower the potential for contamination risks. For example, if your athlete needs more calcium in their diet, prioritizing calcium-rich foods like yogurt and nuts and seeds provides not just calcium, but also other vital nutrients. Similarly, rather than using a whey protein supplement, opting for regular milk, silken tofu, or low-fat Greek yogurt in smoothies can provide the same amount of protein without risk of contamination.

Here, TrueSport Expert Kristen Ziesmer, a registered dietitian and board-certified specialist in sports dietetics, explains what exactly these supplements are providing, if they’re necessary, and what natural alternatives exist.

What are hydration supplements?

The hydration supplements that are currently popular are low-to-no calorie electrolyte tablets and powders. The common electrolytes found in these drinks include sodium, potassium, magnesium, and chloride. Electrolytes are required to help your body maintain fluid balance. They are necessary—but are also found in most foods, and likely don’t need to be supplemented.

Electrolyte tablets are supplements

It’s important to remember that even though these hydration tablets may seem innocuous, they still fall into the supplement category and that means they aren’t subject to the same regulations as foods. Supplements are regulated post-market, so no regulatory body reviews the contents before they reach consumers and that increases the chance of both intentional and unintentional contamination. If the supplement isn’t certified as NSF Certified for Sport, it may contain substances not listed on the label, substances in different quantities than identified, and substances that are prohibited in sport, says Ziesmer. “People often don’t realize that even things like electrolyte tablets or sports drink mixes can fall into the supplement category,” she says. A food-first approach to fueling is safer than supplements, and especially when it comes to electrolyte-infused drinks, it’s easy to get the same nutrients through real food.

Electrolyte tablets are expensive

Unfortunately, these tablets also come at a high cost, often nearly a dollar a tablet or packet, depending on the brand. “I strongly urge families to stop spending so much money on these fancy hydration supplements,” says Ziesmer. “They’re prohibitively expensive and they can truly be replaced by adding a bit of salt to water.”

Electrolyte tablets are not necessary for young athletes

Ultimately, while these electrolyte tablets and mixes may give water a fun flavor, they aren’t necessary for performance, says Ziesmer. And they’re certainly not necessary outside of practice or competition, since a standard diet will typically provide plenty of sodium, potassium, and magnesium. Often, these packets or tablets of electrolytes primarily contain high amounts of sodium, which is inexpensive and easy to add to any meal just by sprinkling a bit more salt on your food.

That being said, there are some situations where electrolyte products can be helpful, especially if you have a picky eater who doesn’t get enough sodium through food or a very heavy or salty sweater.

Electrolyte drinks should not replace other sports drinks

You may have seen low-or-no calorie electrolyte drinks and assumed that they would be healthier due to their low sugar content. However, those carbohydrates from sugar are actually necessary for athletes to perform! “You can make your own homemade sports drink by diluting fruit juice with water and adding a pinch of salt and a bit of granulated sugar,” says Ziesmer. “But you do need carbohydrates in addition to electrolytes, especially if you’re training for more than 45 minutes or you’re going to be sweating a lot.”

Replacing electrolyte supplements with food

Fortunately, there are two very simple ways to ensure your athlete is getting enough electrolytes in their diet: Add a pinch of salt in their water bottle or pack a salty snack. “I like putting a pinch of salt and a splash of fruit juice in a water bottle,” says Ziesmer. This gives your athlete the sodium they need, plus a fun flavor and a small amount of simple carbohydrates, which speeds the transport of sodium through the body. “If your athlete is already eating salty snacks like pretzels or chips, or any processed food, they’re likely getting plenty of sodium,” she adds. “You don’t need to add additional sodium on top of that.” Athletes can also get sodium from many sauces and condiments, such as soy sauce, BBQ sauce, and hot sauce.

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Takeaway

While your athlete may benefit from sports drinks that contain electrolytes and calories from simple carbohydrates during practice, they likely don’t need expensive electrolyte beverages or mixes outside of sport. A pinch of salt added to a water bottle is going to be just as effective while saving money and avoiding any issues of contamination in supplements.

Here, Amy Eichner, PhD, a Special Advisor on Drugs and Supplements for the U.S. Anti-Doping Agency, is breaking down what each label is required to tell you—and what they aren’t. We also get into some of the ethical gray areas of supplement labeling, so you know what to look out for.

There are regulations for both—but they’re not perfect

“There are regulations that dictate what has to go on either label, but they are different,” explains Eichner. “You do have to list everything that’s in either type, but the FDA (Food and Drug Administration) doesn’t evaluate supplement labels before products go to market. Companies can miss listing things or avoid listing things, and no one is going to catch it beforehand.” As such, there are many cases where a tainted supplement is to blame for a positive anti-doping test or health issue. By using a supplement facts label, a company evades a lot of scrutiny from the FDA, whereas food that carries a nutrition label is required by the FDA to only use food ingredients that are “generally regarded as safe.”

“Proprietary blends” make supplements difficult to regulate

Supplements are required to list all ingredients, but they don’t need to include amounts. “This means that a supplement facts panel can have proprietary blends, where the full amount of each ingredient isn’t listed,” says Eichner. In this case, you’ll be able to see what is in a certain supplement, like a greens powder, but often, the creators will use a proprietary blend to use a much smaller amount of pricier ingredients on the list while adding a lot more of the cheaper ingredients. So, you don’t always get a useful product!

Daily Value (DV) is rarely defined for supplements

A nutrition facts panel has to list certain vitamins, minerals, and macronutrients, as well as the DV of each and what percentage of that is in each serving. “But for a lot of supplement ingredients, there isn’t a defined DV,” says Eichner. “For example, there’s no defined requirement for Horny Goat Weed or another herbal ingredient.”

Supplements can get more specific

You may be wondering why some ingredients on supplements seem more specific than those on a nutrition label. That’s because supplements are allowed to list the pieces of a plant used (e.g., seeds or roots) while food products cannot. Similarly, supplement labels can add sources of ingredients, such as ‘from grass fed cows’ on a whey protein powder. Foods cannot list these specifics on their nutrition labels.

Claims differ between the two

“It’s much more difficult for a food than a supplement to make a claim about how it affects your health,” says Eichner. For instance, if a supplement has vitamin D, it’s possible for that label and advertising to say that it supports immune health, whereas a food that’s high in vitamin D can’t list that on the label.

Read the badges and claims carefully and check what they really mean

Food products have a lot of specifications and regulations around the marketing claims that they’re able to make, and they are more tightly regulated, says Eichner. “With supplements, athletes should not blindly accept or respect any kind of certification or stamp of approval,” she adds. Many supplements—especially big containers of powders—tend to have a bunch of badges on the front, which is smart marketing because it makes you assume that the brand has done a lot to ensure that a powder is high quality. But any marketer with a knowledge of Photoshop can create badges that make a product seem legitimate without doing the work to certify it with a third party.

For instance, you may see something that claims it uses “clean-sourced ingredients,” but that doesn’t mean anything. Any stamp of approval that’s worth anything will have some kind of a self-verifiable database behind it. If you do need to use a supplement, look for third-party certified supplements.

Watch for fake ‘clean’ claims

Because of the looser rules around marketing claims, you need to read supplement labels critically. “A lot of the advertising phrases and logos that these companies use don’t have a legal meaning, or aren’t being used legally,” says Eichner. “The term ‘organic’ has a legal meaning, but it’s often used without verification on supplements. Similarly, an advertising claim that says something is ‘doping substance free’ or ‘super-duper healthy’…those are just words. They don’t have legal meaning. And even some that have legal meanings, like a ‘Good Manufacturing Practice’ label, simply mean that they’re claiming to be in compliance with the current standards for manufacturing set by law.”

Stick to whole foods to avoid tainted supplements

With extremely rare exceptions—like the infinitesimal chance that poppy seeds were mishandled and consumed in such vast quantities that they show up as an opioid in a drug test—whole foods simply pose less risk to athletes who are trying to eat safely and stay clean. “If you’re buying a food item that has been correctly identified as a food, you’re fine,” says Eichner. “The more your food resembles its original packaging, the better. So, if you’re eating an orange or a banana, or your food is recognizably muscle tissue from an animal, then you’re in good shape.”

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Takeaway

While the labels on food products and supplements look similar, the rules governing each are very different. Supplements are less tightly regulated than food products, so opt for products that have a nutrition facts label, and ideally, are as whole food-based as possible.

Inflammation sounds scary, but for athletes, it’s a natural part of the training and competition process. Here, TrueSport Expert Stephanie Miezin, MS, RD, CSSD, explains what inflammation really means for an athlete, why it’s not always a bad thing, and how to naturally lower levels of chronic inflammation.

Inflammation isn’t a bad thing

Inflammation is the natural and necessary process of the body trying to deal with an issue. It can come from many things: exercise, muscle damage or trauma, and the immune system removing pathogens in the body. We all think that inflammation is inherently bad, but it’s happening for a reason.

You may not want to decrease inflammation

Everyone wants to decrease inflammation, but there is a purpose for it. For things to heal and get better, inflammation needs to occur. For athletes, muscle damage occurs naturally through physical activity and the body’s repair process will generally include some sort of inflammatory process.

Your goals matter

If an athlete is training frequently and needs to recover quickly, decreasing some inflammation is useful. On the other hand, if somebody is prioritizing adaptation to exercise (lifting heavy at the gym, for example), that means letting that inflammatory process take its course, so it may be better to skip anti-inflammatory strategies.

Skip anti-inflammatory supplements

There are a lot of anti-inflammatory foods like tumeric, tart cherry juice, and antioxidant-rich foods that have been shown to decrease different markers of inflammation. When it comes to antioxidants and anti-inflammatory foods, ‘food first’ is recommended. We’ve seen that with supplements, some research has found that increased inflammation or increased oxidation can occur, so the supplements are actually backfiring.

It’s also important to remember that foods that are high in anti-inflammatories and antioxidants are generally good to eat regardless. For instance, foods that naturally contain the antioxidant vitamin C, like oranges, berries, or red peppers, contain so much more than just that one vitamin. They have beta carotene, which turns into vitamin A, and they have fiber and other phytonutrients.

Food can also cause inflammation

While some foods can help lower inflammation, other foods can exacerbate it. Refined sugar—that’s added sugar, not natural sugar from fruit or grains—can increase inflammation. More specifically, the high glucose load that comes in when an athlete eats a lot of refined sugar can lead to increased oxidation, which can harm cells and lead to inflammation. If blood glucose is going out of a healthy range frequently, that can lead to inflammation that builds up over time. Saturated fat is also associated with increased inflammation, as are fried foods, particularly those fried in oil that’s been heated and cooled multiple times.

…But athletes still need to eat

While refined sugars and fried foods might add to inflammation, it’s critical not to undereat in an attempt to avoid extra sugar. Instead, try to eat healthfully with whole foods—including plenty of unrefined or less refined carbohydrates—80 percent of the time. For young athletes who are really active, it might be difficult to meet all their energy needs with ultra-healthy foods, so focus on nutrient-dense sources like vegetables, protein, and whole grains in the appropriate quantities. If athletes are under-fueling, that’s going to lead to low energy availability and potentially poor immune system function and increased risk of infections.

Inflammation can’t be “cured” with food

Instead of looking to food to cure suspected inflammation issues, consider first where that inflammation may be coming from. For athletes, high training volume and intensity, especially for prolonged periods, could be the root of excessive inflammation. While dietary strategies may be able to help, they very likely won’t be as effective as focusing on adjusting training to better manage inflammation.

Inflammation is a moving target

Testing for inflammation, or even what the appropriate inflammation levels are, is difficult. There are some blood markers like C-Reactive Protein (CRP) and interleukin proteins 6, 8, and 10 that are used for research purposes, but even those are only part of the picture, and the ‘right’ level for people will vary. And even symptoms aren’t perfect indicators. Feeling sore is the obvious one for athletes, but even that might be related to delayed onset muscle soreness (DOMS) rather than systemic inflammation.

Inflammation shouldn’t be your focus

Ultimately, the best offense for inflammation is a good defense. Rather than stressing about testing certain blood markers, take control of your training and fueling before it becomes a concern. Avoid overtraining and build your diet from colorful fruits and vegetables that are rich in antioxidants and fiber. Overall, people don’t need to be worrying about inflammation as much as they might think.

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Takeaway

To prevent inflammation, athletes should avoid overtraining and eat a whole food-based diet that contains plenty of colorful fruits and vegetables, protein, and whole grains. And remember: some inflammation is a good thing.

The problem with protein powders

Unfortunately, protein powders, like all supplements, are regulated post-market by the Food and Drug Administration (FDA). That means despite the list of ingredients on the back of the tub or bag, you can’t guarantee that you know what’s in them. In fact, over the years, many professional athletes have tested positive for banned substances like anabolic steroids that were eventually traced back to an off-the-shelf supplement that was tainted with the steroids. Even choosing a supplement that has been third-party tested and is certified safe for sport, can’t fully guarantee that it doesn’t contain a substance that might have negative health effects. So first and foremost, understand the risk that comes with taking any supplement.

It creates a supplement-first mentality

The more a young athlete relies on supplements now, the more they think it’s okay to do so later. It might not seem like much, but it’s a slippery slope. It might start with opting for a protein powder over a filet of salmon and some steamed veggies for dinner, but can quickly progress to a point where an athlete is eating bars, gels, and powders for most meals, and adding pills and capsules throughout the day, instead of simply eating a well-balanced, nutrient-dense diet. Supplements generally should only be used on the recommendation of a doctor or registered dietitian in response to a diagnosed deficiency…a coach or friend shouldn’t be the one to recommend any supplementation.

Young athletes need more than protein alone

The other problem with a post-game protein powder mixture is that it often skips other vital nutrients your athlete needs to replenish, including carbohydrates. And even if the powder is more ‘recovery based’ and includes carbs, it misses other important micronutrients and fiber that your athlete should be getting from a meal. A chicken wrap or whole grain peanut butter and jelly sandwich is just as portable and protein-packed as a shake, but with much denser nutritional content. It’s also a lot more satisfying.

Athletes don’t need as much protein as you think

Protein might seem hard to find, but a well-rounded diet with plenty of whole foods, including meat, seafood, beans, dairy, nuts and/or soy products, can easily provide the protein your athlete needs in a day. The National Institute for Health acknowledges that athletes have elevated demands for protein and says that as a general recommendation for maintaining health, athletes should aim for between 0.8 and 1.2 grams of protein per kilogram of body mass daily. It’s important to do the math before leaning into supplements that may pack as much as 40 grams of protein into a serving. For a 100-pound (45.3 kg) 12-year-old athlete, for example, that would mean needing roughly 45.3 grams of protein per day. That could be as simple as eating 2 eggs (14 grams), 1 serving of steak (25 grams), and two tablespoons of peanut butter (8 grams) for plenty of protein over the course of a day.

What do you do for convenient protein instead?

One of the main reasons athletes turn to protein powder is because it’s easy and convenient. If your athlete loves a post-exercise protein shake, you can still whip one up easily without the powder—and it’ll be tastier and more nutrient-dense. Swap the scoop of protein powder for a serving of low fat Greek or Icelandic yogurt, which has between 20 and 30 grams of protein per serving.

Here’s one of our favorites, but feel free to experiment depending on your athlete’s preferences. Simply blend all the ingredients together, adding milk as needed to achieve a texture your athlete will enjoy.

• 1 serving of plain Greek yogurt (2 percent or 0 fat)
• Chopped frozen banana
• Handful of frozen blueberries
• Teaspoon of cocoa powder
• Tablespoon of peanut butter or almond butter
• Handful of spinach
• Splash of milk
• Maple syrup to taste

Don’t have time for that? Check the label on the chocolate milk options at the convenience store: Often, there will be a lower fat, higher protein option that just contains milk, cocoa, and sugar, but packs nearly 20 grams of protein. Find out more about other protein sources here. We also have a few easy post-practice recipes here.

If your athlete is lactose-intolerant or vegan, swap a smoothie for something like lactose-free milk paired with an apple, or use soy yogurt in the smoothie instead.

Still interested in protein powder?

Dr. Amy Eichner, PhD, the Special Advisor on Drug Reference and Supplements at the U.S. Anti-Doping Agency, believes in a food-first mentality, but she does understand that some athletes are still going to turn to protein powders for convenience. She explains:

You can definitely get enough protein from your diet, and that’s always going to be better and have less risk of contamination, but protein powders can have their place in an athlete’s diet. Some athletes, especially older ones with busy schedules, are under a lot of pressure between school, work, training, and extracurriculars. Honestly, it can just be hard to get a square meal. But if you are going to use a protein powder, choose a complete protein that contains all eight essential amino acids that your body can’t make (like a whey protein), one that doesn’t have a lot of added sugar, and one that’s third-party certified.

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TAKEAWAY

Protein powders should not replace eating nutrient-dense, protein-rich meals for athletes. Athletes have elevated protein needs, but they can usually be met with whole foods that are rich in protein.

Iron and vitamin D are two common athlete nutrient deficiencies that can have a big impact on athletic performance and overall health. But treating them with food or supplements isn’t the only answer—finding out the reason for the deficiency is just as important.

Laura Lewis, PhD, Director of Science at the U.S. Anti-Doping Agency, explains that before an athlete considers supplementing with a pill or liquid form of iron or vitamin D, it’s important to consult a doctor and get bloodwork to confirm a deficiency exists. “It’s really important not to just self-manage and assume you’re nutrient deficient,” says Lewis. “You always want to get your levels assessed, and it’s really important to find out the reason for the deficiency. You want to fix the cause of that deficiency as well as resolve the immediate need for the nutrient.”

Here, Lewis explains signs and symptoms of these common nutrient deficiencies, as well as how they can be treated.

IRON

Signs and impacts of deficiency

“When you’re low on iron, you may get quite pale and look washed out,” says Lewis. “You may also be very tired, irritable, unable to concentrate on schoolwork, or even struggling to get out of bed.”

“In terms of trying to do any sporting activity, an athlete may really struggle,” says Lewis. “Sometimes, your legs feel like jelly, particularly after a hard effort. You just don’t feel you have the ability to recover between those efforts. You’ll be constantly out of breath. You might also have a massive decline in a task that was easy at one point, so that now it’s become super hard.”

Why the deficiency exists

Iron is an essential component of red blood cells. If we don’t have enough iron, our bodies can’t continue to maintain those red cell levels at an appropriate level and the numbers start to decline. Left untreated, a mild iron deficiency can ultimately spiral into severe anemia.

“With iron deficiency, there can be some quite drastic causes, like a major blood loss, which you’d probably know about. But alternatively, there could be internal bleeding or ulcers,” says Lewis. “Or if you have celiac disease or inflammation in the gut, you may not be absorbing the iron that you’re taking in.”

The other main reason for a deficiency is that you don’t have a good source of iron in your diet, or the source is insufficient. Vegetarians, vegans, and athletes going off to college and only eating plain pasta are all athletes who may be at risk of low iron.

“There’s also a lot of pressure on young women to have lower energy diets, so often you’re seeing young women doing a lot of high training load but then trying to keep their energy intake quite low to maintain a low body mass. They’re at high risk,” says Lewis. “There is a fair amount of pressure on boys to lower body composition as well, which can affect their overall iron intake.”

How to address deficiency with food and when to supplement

First, figure out the reason for the deficiency. “If there’s something more sinister going on, like an ulcer or an energy deficiency issue, it’s really important to get to the bottom of that,” says Lewis. “Otherwise, if you do try and treat the problem, it might work for a little bit, but then you’re going to go back to square one.”

If you’re just not eating enough iron rich foods, that’s fairly easy to identify and fix through dietary practices: Adding iron-rich foods like red meat or legumes to your diet is a simple starting point. “Working with a registered dietitian is a good place to start if you’re really struggling and if you want someone to work out exactly how much iron you’re taking in with your diet,” says Lewis. “But there are a lot of cereals and breads that are fortified with iron, various legumes and other vegetables have iron, and even dark chocolate is actually quite a good source of iron!”

Before we talk about supplements, it’s important to note that too much iron is a bad thing. That’s why it’s important to get bloodwork to make sure that low iron is actually a problem before starting any kind of supplemental routine.

Vegan or vegetarian athletes doing a high amount of training will likely need to use an iron supplement because it will be quite hard for them to get enough iron, says Lewis. “You have heme iron sources or non-heme iron sources, and the non-heme iron sources like vegetables and grains don’t absorb as well,” she explains. “Steak is going to trump spinach in terms of what the body can absorb. So often, the vegans and vegetarians will end up having to go to an iron supplement.”

Ferrous sulfate is one of the most common types of iron that’s easily absorbed into the body. If a doctor has approved supplementation, Lewis recommends finding a source that contains a minimum of 50 milligrams of elemental iron. “Ask a doctor or a dietitian to help navigate the different sources,” she adds. “Liquid iron is often recommended for people who have trouble absorbing it, or if they get gastrointestinal problems from taking iron in pill form.”

If you’re taking an iron supplement, take it with food and a source of vitamin C to promote optimal absorption. Lewis suggests having it at breakfast with a few sips of orange juice. “But on the flip side, caffeine, calcium, and tannins in tea actually block iron absorption. So, an iron supplement with your milky coffee in the morning would not be so good,” she adds.

You don’t necessarily need to supplement forever: How long you supplement for depends on the reason why you were deficient in the first place. Usually, a dietitian or the doctor would want to do a follow up between six weeks and three months after, depending on what the cause was. They might recommend another blood test. Then, you may check in every six months or yearly after that, just to make sure that you didn’t go back down into a low state.

Vitamin D

Signs and impacts of deficiency

Low vitamin D can result in low bone density, so the first warning sign of a deficiency might be a stress fracture.  But you may also have similar symptoms to low iron: fatigue, muscle weakness, poor sleep, pain, a weakened immune system, and even depression. Ultimately, a blood test is necessary to determine if an athlete has low vitamin D.

Why the deficiency exists

“People who are going to be at risk of low vitamin D are those who don’t go outside very much and see the sun. So particularly in parts of Canada or in Europe, where there are really long nights and short days, it can be an issue,” says Lewis. “But in the U.S., we’re so worried about going out in the sun because of the potential for skin damage, so even if you’re outside often, you won’t absorb much vitamin D if you’re covered up.”

How to address deficiency with food and when to supplement

Food isn’t the issue here, sunshine is. “While we don’t want people to be getting skin cancer, getting at least an hour of sun in that middle part of the day goes a really long way to ensuring that you’re getting your vitamin D dose naturally,” she says. “If you’re going for a run midday, I recommend covering the top parts of your arms and legs and wearing a hat, but then letting your lower arms and your lower legs stay exposed. That’s enough: You don’t have to be in a bikini to get that healthy dose of sun exposure!”

Vitamin D can be a bit tricky because it’s not a quick fix. Your vitamin D levels take a long time to change in either direction. So, it can be the middle of summer when you actually present with low vitamin D from the winter before! And it’s going to also take quite a long time to build it back up again.

Unfortunately, you can’t really supplement vitamin D with just food (although consuming vitamin-D rich foods such as fatty fish and fortified dairy products are a good start)—but that doesn’t mean you should start supplementing if you haven’t confirmed low vitamin D. Get tested first. “If a doctor does decide that you need to supplement, there are various options, and there are some slow-release tablets where you only have to take one and it lasts for three months,” Lewis says. “But the doctor has to decide the best dose for you.”

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TAKEAWAY

Both iron and vitamin D deficiencies can result in negative health effects and a decrease in athletic performance. Both should be diagnosed by a doctor who looks at an athlete’s bloodwork and helps the athlete determine the root cause of the deficiency before prescribing a supplement or a food-focused fix. Talk to a doctor or dietitian if you suspect your athlete has a deficiency in either nutrient, and in the meantime, ensure that your athlete is eating plenty of iron-rich food sources and maintaining some sun exposure when possible.

Amy Eichner, PhD, the Special Advisor on Drug Reference and Supplements at the U.S. Anti-Doping Agency, weighs in with the hard truth that collagen powders aren’t necessarily as effective as you might believe.

1: Collagen is everywhere

Collagen is the main structural protein in your body and makes up much of the cartilage in joints, as well as tendons and ligaments and other kinds of connective tissue in the body. It’s really important for the basic structure of the body, says Eichner. In addition to joints and other connective tissues, it’s in our lungs, gums, eyes, organs, blood vessels, and many other tissues — collagen is the reason these tissues are strong, yet flexible and stretchy.

2: You may have already used collagen without realizing it

Collagen is useful as a scaffolding for all kinds of wound healing. “Collagen is used in internal sutures, so people who have surgery may receive collagen sutures (stitches) that dissolve inside the body,” says Eichner. “For instance, if you have a tendon surgery or muscle surgery, such procedures often require several layers of tissue suturing. Sutures used on the innermost layers are often made from a collagen because the material is very strong, accepted by the body, and will just gradually be replaced or dissolved by the body.”

3: You can’t take collagen to make collagen

Many athletes are interested in how you can improve your cartilage as a way to improve joint health. But to truly support collagen production in your body, taking collagen may not be the best way to do it.  Collagen is an incomplete protein that, once taken, will be completely dissolved in the gastrointestinal system into its component parts. The final destiny of those component parts may be new collagen, but there’s a good chance they will be used for other things as well. In fact, Eichner explains that taking a collagen powder to improve the collagen in your joints is akin to taping an aspirin to your forehead if you have a headache.

“Eating collagen or rubbing it on your skin in a cream will not automatically shuffle more collagen peptides directly to areas of cartilage damage,” she says. “Consuming collagen isn’t a bad thing, but it’s not a complete protein. It’s very more important to consume complete proteins (proteins that contain all the essential amino acids that your body cannot make) to support all aspects of your athletic metabolism, including collagen creation.

4: Want more collagen? Eat your fruits and veggies.

Another surprising thing about collagen is that in order for your body to properly manufacture it, vitamin C is absolutely required. The chemical synthesis of collagen inside the body is energy intensive, and the presence of vitamin C makes the necessary chemical reactions possible. What happens when collagen production doesn’t happen?

“People may be most familiar with ancient stories of scurvy, an illness suffered by sailors long ago where they would develop skin lesions, bruising, and their gums would disintegrate so their teeth fell out. Ultimately, many of them would die from internal hemorrhaging” says Eichner. “Eventually, a connection between scurvy and the lack of fresh produce was made, but it would still be hundreds of years before vitamin C was identified as the key.”

And yes, scurvy still exists today among people who don’t eat fruit or vegetables regularly. So if you want better collagen production, start with ensuring your diet has plenty of sources of vitamin C!

5: Lack of collagen production is also determined by your genes

There are 28 different types of collagen and there are many diseases associated with collagen failures, but unfortunately, most are genetic—aside from scurvy—says Eichner. “That just goes to show how critical your own body is in making collagen,” she adds. “You can’t eat collagen and then make more collagen. You can’t put it on your skin, in your hair, in your eyes with eyedrops, or anything like that to improve your joints.”

6: “Natural” collagen isn’t a “better protein”

Collagen powders have a bit of a health halo around them because they contain a single ingredient and are touted as ‘clean.’ But Eichner argues that it doesn’t really matter if something is derived from something that’s natural. “A collagen powder is no less processed than a whey protein powder,” she adds. “And arguably, it’s gone through more processing than a whey protein, since whey comes directly from milk, whereas collagen needs to be derived from animal parts and enzymatically broken down.”

One thing is incontrovertible: Athletes do need protein to produce collagen. And ideally, athletes will turn to food first. “Food is always going to be better because there’s less risk of contamination when your proteins come from foods. Plus, you’re getting all these other things that you need, such as fiber and other micronutrients,” Eichner says. “But I think protein powders can have their place. Look for a complete whey protein that has all the amino acids and pick one that’s been third-party tested.”

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TAKEAWAY

If you’re trying to boost collagen production, skip the collagen powders and focus on a protein-rich diet of real foods that are packed with complete sources of protein instead.

Through this five-part series on supplements, you will find an overview of the dietary supplement industry so that you can decide if the potential benefits of dietary supplements outweigh the risks. And, if you find you do need to use supplements, how you can better choose a low-risk product.

If a dietary supplement is the most realistic way for an athlete to obtain necessary dietary ingredients, how do you pick the safest one?

There is no risk-free way to choose a supplement, as the only way to have zero risk is to not use supplements. But you can reduce the risk significantly by following USADA’s Decision-Making Flow Chart.

If using a dietary supplement is needed, the best way to reduce the risk of using a low-quality or contaminated product is to choose one that is certified by a USADA-recommended third party.

How do I find supplements that actually work?

Alicia Kendig Glass, Sports Dietitian at the United States Olympic & Paralympic Committee, gives her opinion on some trending supplements and what works in the Q&A below.

What are your thoughts on the use of supplements for athletes?

When it comes to supplements, I critically evaluate an athlete’s training program, their goals, and their diet. I will not even allow the utterance of the word “supplement” until all those aspects are optimized.

What vitamins and minerals do you recommend?

Most athletes do fine without taking any multivitamins.

I don’t usually recommend any kind of multivitamin, even to elite Olympians and Paralympians. My approach is always food first.
On the other hand, if an athlete has a clinically diagnosed deficiency, then we will treat it.

For example, there are always a handful of athletes diagnosed with sport anemias, and we treat those with an oral iron supplement.
Our approach to supplements is very clinical. We don’t ever dose an athlete with something unless there is a very good rationale for doing so, which means a blood test to confirm their current nutrients status. There are some athletes who we find have hemochromatosis, a genetic condition that makes iron levels too high. We would never suggest iron for those athletes.

I will sometimes recommend vitamin D to an athlete who has a low blood test value. Depending on the time of the year and if they’re training inside or outside, I may recommend a low dose to get them through the winter months when sunlight exposure is limited. But, I warn them that more is not better.

Recently, I had a bobsled athlete that I was treating for low vitamin D. The next time I saw her she complained of tingling in her fingertips. I sent her for a blood test and she had toxic levels of vitamin D. She admitted that she had tripled her dose because her coach told her she should take more. Her symptoms resolved once we got her back on the correct dose.
Things like this can happen to anyone.

In another case, the father of one of our athletic trainers ended up in the ER because of vitamin D toxicity. He didn’t realize it at the time, but all the supplements he was taking for his eyes and skin were adding up to a mega dose of vitamin D, which then exacerbated his symptoms of diabetes. Not only did he not realize vitamin D could be toxic, but he didn’t realize how much he was taking.
This is common when people take more than one supplement. Things end up “stacking.”

Too much vitamin D can also block the absorption of other fat-soluble vitamins.

What about creatine and protein powder?

So many athletes ask me if they should take creatine. For some reason, people just think this is a magic ingredient. I always ask myself, “Are the demands of the sport going to be supported by what this active ingredient does?”

I did have a vegan athlete who was a sprinter and she wasn’t eating the food sources for creatine (meat). She responded well to creatine. But, if I’m working with vegan or vegetarian athletes, I will often start with making sure they are getting enough quality protein in their diet first.

Another situation where protein powders can be helpful is for older athletes who have an increased need for quick recovery and may have a more difficult time maintaining lean muscle mass. In some cases where an athlete must train smarter instead of harder, and they are having a hard time sustaining lean mass, a simple whey protein can help.

What is a nitric oxide booster? Would you recommend it to athletes?

Nitric oxide boosters advertise to increase blood flow to your muscles, therefore increasing your ability to perform and recover faster.

I completely avoid any supplement that advertises to be a nitric oxide (NO) booster. Those supplements

are just too risky for me to even navigate. The ingredients claim to deliver the same results as substances prohibited in sport, so I just don’t trust them.

On the other hand, there are great functional foods that can offer slight improvements in oxygen uptake and muscle efficiency. Beet juice is my favorite!

Caffeine and energy drinks are everywhere these days. What should an athlete do if they’re fighting sluggishness and fatigue?

Caffeine can be a great help for those athletes who can handle it. Some athletes are distracted or jittery on caffeine. It’s not for everyone.

I do not recommend that athletes obtain caffeine through supplements or energy drinks though, because oftentimes, the caffeine dose is listed as part of a ‘proprietary blend,’ which doesn’t list the individual doses. This makes it difficult to be certain about how much caffeine is actually consumed.

Energy drinks are particularly bad because they can also contain hidden sources of caffeine or other stimulants like yohmbine. The cumulative effect of multiple stimulants can harm performance and health.

We know that supplement labels can be inaccurate, so if an athlete doesn’t like coffee (which can also be hard to dose), we will recommend a No Doz or other over-the-counter product with a known amount of caffeine.

What is carnitine? Can it help an athlete?

I have had athletes ask me about carnitine, but I don’t recommend it. Some athletes want to take carnitine because they think it will make the body burn more fat.

The research that I’ve reviewed is not convincing and more evidence is needed to suggest that carnitine does indeed work for an elite athlete population – that principle applies for any dietary supplement ingredient. The evidence needs to be specific and beneficial to an elite athlete population, specific to an athlete’s sport or discipline.

Can you tell us more about beta-alanine?

When dosed properly, beta-alanine increases carnosine in the muscle, which then acts as a lactate buffer.

For athletes whose efforts last 40 seconds to about four minutes, it can help delay anabolic metabolism, which is when your muscle has too much lactic acid built up to function optimally.

Beta-alanine is no magic pill – it just delays this threshold slightly. But, it can be beneficial in training.

Beta-alanine is found in meats, but at very low levels, so you’d have to eat a lot of it. For it to work, it requires a loading phase of 3-4 weeks at high dose and then you back off. If you get a high-quality product, it’s very expensive.

I had a high jumper once who just wanted to take anything and everything, and he thought “more is better.” I asked him, “How is this going to help you? You are not even doing a lactate-accumulating sport!” For the high jumper, I recommended that he not waste his time or money on beta-alanine.

Do you think athletes can benefit from taking probiotics?

I’m a big fan of probiotics. There are many good food sources like yogurt, kefir, ceviche, and other fermented foods.

I will sometimes recommend a probiotic supplement for athletes traveling internationally because finding trusted food sources overseas can be difficult.

There is still a lot of research to be done. We are not in a place where we can pull out a menu of recommendations for probiotics. We still have a lot to learn about all the different strains, how high of a dose is required, and how long dosing of probiotics is necessary for various benefits.

Research is suggesting that improved gut health has very wide health effects on the whole body, both mentally and physically.

What is tart cherry? What can it do for athletes?

I’ve been asked a lot recently about vitamin C mega-dosing and the use of functional foods like tart cherry to reduce the stress on the body from heavy training.

Although there is evidence that tart cherry juice has benefits to fight inflammation for elite athletes, I often need to remind athletes who choose to consume tart cherry juice after workouts, that tart cherry juice should not take the place of other recovery snacks that contain both carbohydrates and protein. There is no protein in tart cherry juice.

One thing athletes need to realize is that if they do want high doses of vitamin C, it’s better to get it through foods. The water-soluble vitamins are highly unstable, and more importantly, mega-doses of antioxidants in dietary supplement form can actually stunt training responses. If they take it in a capsule or tablet, much of it could already be degraded.