Adverse effects of sports supplements in men with Dr Sarah Martin

Welcome to the Australian Prescriber podcast. Australian Prescriber, independent, peer-reviewed and free.

I’m Dr Janine Rowse, your host for this episode and it’s a pleasure to be speaking to Dr Sarah Martin today about the adverse effects of sports supplements in men which she has written about in the February edition of Australian Prescriber. Dr Martin welcome to the program.

Thank you, Janine.

And thank you for the fascinating dive into the demystification of sports supplements which I’m ashamed to admit I knew close to nothing about prior to reading your article. Can you tell us who is taking sports supplements and for what reasons? It seems to me that there’s no real stereotype of who’s using these products and there might be various patient subgroups.

I agree Janine. Australian data suggests that men of all ages and backgrounds are increasingly taking sports supplements. Not just very young men in their 20s. We have rather less data on women, but I think it’s important to remember that supplements are very readily available these days, not just from gyms and online but also from shopping centre stores. Generally, I think supplement use relates to a desire to look better, feel better, build muscle, improve physique and performance, and improve body image.

What are the different agents found in some of the sports supplements, and what are their wanted and unwanted effects I suppose?

We can include energy beverages along with supplements. Ones that contain caffeine and sometimes they also contain taurine which is an amino acid usually found naturally in meat and fish. So these caffeine-containing energy beverages really work as stimulants and in excess can affect the cardiovascular system and also cause agitation and irritability, disturbed sleep. We know a lot less about taurine, but most energy beverages don’t contain enough for therapeutic or adverse effects. If we look at protein supplements, the whey powders and other protein shakes and drinks, creatine is a common component of some of these supplements. Creatine is an amino acid found in the muscles as well as the brain and we can get creatine from seafood and red meat and it’s also made by the liver, pancreas and kidneys.

And it seems to me as well that in particular some of the energy-containing drinks wouldn’t be thought of as sports supplements by patients or indeed their physicians.

Yeah that’s right and I think lots of us see young people with agitation or poor sleep or just feeling quite out of sorts and it’s very helpful to ask about use of these drinks. And they may not even be using them for performance purposes as we might identify, so they might not be using them for muscle building at the gym, they might be just using them for other reasons.

The one subgroup it does spring to mind is students.

Yeah that’s right.

The burning question for me, obviously these supplements cost a fortune, do these supplements actually work and is there any evidence that they’re effective in what they claim to do?

Well there is some evidence of benefit of creatine for high-intensity, short-duration exercise but for the general user who wants to tone up it’s probably safer, cheaper and more effective to focus on diet, good sleep and regular exercise, regular sustained exercise over time. We haven't talked yet about steroids. Some sports supplements that are commercially available particularly online can contain steroids although it's not always clear from the labels. Androgenic steroids may increase protein synthesis and promote muscle growth but their unwanted effects can be significant and serious

And what sort of unwanted effects could those be?

Really if you think from sort of top to toe you can start to think about male pattern balding, so hair loss, mood swings, breast enlargement, damage to the heart and liver, as well as low libido and infertility.

A lot of those clinical presentations could be very easily misdiagnosed if the health professional doesn't question specifically about supplement use.

I agree. And I think most of us are familiar with caffeine side effects such as palpitations and insomnia, but with protein-based supplements in fact people may not have any symptoms, and what we might see instead is a sudden and unexpected decrease in renal function which can be another prompt to inquire about supplement use because excess protein is excreted through the kidneys and too much protein can cause a fall in your EGFR, and in that case, if I asked about supplements and that's where I'm often surprised to find people that I maybe wouldn't have thought were using them, I often advise a week or so without any extra protein before re-testing.

So it’s important for doctors to be aware of any sudden declining renal function to be questioning about these products?

Yeah and that can often lead into quite a good discussion about why people are using increased protein and more generally about what their goals for their health and fitness are. Most of us eat plenty of protein through our diet and often those extra proteins aren't really helping with muscle building.

I imagine that counselling patients about their supplement use can be quite challenging and particularly because it's an area where there are so many mixed sources of information available. How can doctors or pharmacists advise their patients who may be seeking further information about this?

Look I really think that the first step is to enable our patients to disclose their supplement use. So not everyone will come in seeking advice but will be open to discussing it once it's out there on the table. So when we take a medication history I think we're all used to asking about non-prescription medications and vitamin supplements and from there it's a fairly easy step to ask specifically about sports supplements. Remembering though that for a range of reasons there is stigma around supplement use and patients might be apprehensive about disclosure particularly if they're using steroids. If we have concerns that a patient's symptoms might relate to androgenic steroid use, explaining this and then asking if we can discuss any and all supplements and how they used can be helpful. So really, I think it's important to take a non-judgmental view, and users can be quite invested in what they're doing, and might feel very strongly that their supplements are working, so again we talked about exploring a patient's reasons for taking them and what their perceived benefits and risks are. Everyone welcomes it when we affirm their health and fitness and body image goals, but from there we can often extend that discussion into talking about diet, sleep and exercise, and stress, and that can provide quite important extra information. If you have time to have that discussion you can then usually tailor the information to each individual, so it might be discussing links between blood test results and their supplement use, it might be about providing information about the amount of protein that's recommended in our diets, it might be referring to the Australian Sports Commission website which has got a lot of helpful information about body building and increasing muscle mass.

That's great to know.

Yeah. So sometimes it's easy to discourage supplement use whilst affirming overall goals but it can be more complicated, particularly in relation to steroid use. It's important to try and maintain a patient's engagement and ongoing monitoring of their health and well-being.

And I suppose then a really important take-home message for healthcare providers is normalising asking about supplements because like many areas in medicine by simply having the conversation that takes away a lot of the stigma attached. Sarah, are there any groups of patients who taking certain supplements should be viewed as a strict contraindication?

Caffeine-containing supplements should be avoided by anyone with a history of cardiac arrhythmia and similarly any patient with kidney disease or taking nephrotoxic drugs and that includes of course non-steroidal analgesia on a regular basis should be encouraged to cease protein supplement use. If you have a patient that discloses steroid use it's rather more complex. Steroids obtained without a prescription are illegal across Australia. It's important that we provide general advice to cease use. For anyone with fertility problems or trying to start a family, anyone who has increased cardiovascular risk or of course hormone-sensitive cancer, they should be very strongly advised and supported to cease use.

I've learned an enormous amount through this, Sarah, that's been very very helpful. What would be your most important take-home message for healthcare providers with regard to supplement use in men?

I think there's probably two things. The first is to ask about it, and secondly to remember that this is a new area for many of us and just as we do with anything else in medicine buy some thinking time and seek some extra information between the first and follow-up consult.

Fantastic, that's excellent advice. That's unfortunately all we've got time for this episode. Thanks so much for joining us today, Dr Martin.

Thanks Janine, I appreciate the invitation.

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Dr Sarah Martin's full article is available online at Australian Prescriber and like our whole journal it's free. The views of the hosts and guests are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Janine Rowse and thanks for joining us on the Australian Prescriber Podcast.