Use of Nutritional Supplements in Sports : Risks, Knowledge, and Behavioural Related Factors

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Nutr Hosp. 2009;24(2):128-134
S.V.R. 318
Use of nutritional supplements in sports: risks, knowledge, and

behavioural-related factors
O. Molinero and S. Márquez
Department of Physical Education and Institute of Biomedicine. University of León. Spain.
A large number of recreational and elite athletes use
nutritional supplements in hopes of improving perfor-
mance. These aids can be costly and potentially harmful,
and the advertised ergogenic gains are often based on lit-
tle or no scientific evidence. Due to the lack of regulation
Una gran cantidad de deportistas, tanto recreacionales
of the dietary supplement industry, an abundance of sup-
como de elite, utilizan suplementos nutricionales con la
plement products of dubious value, content, and quality
esperanza de incrementar el rendimiento. Estas ayudas
are now available around the world. Many supplement
pueden tener un coste económico elevado y ser potencial-
products contain substances that are prohibited in sport
mente peligrosas para la salud, basándose muchas veces
or that have been associated with significant morbidity
sus supuestos beneficios en un escaso o nulo apoyo cientí-
and mortality. For athletes, lack of knowledge or misin-
fico. Debido a la falta de regulación de la industria de
formation has been established despite numerous sources
suplementos nutricionales, existe una enorme cantidad de
of information being available, and the reasons for, and
productos en el mercado que son de valor, contenido y
implications of, unsupervised and unrestricted supple-
calidad dudosos. Muchos suplementos contienen sustan-
ment use require further attention. In addition to the
cias prohibidas en el deporte y que se han asociado con
necessity of an appropriate regulation of dietary supple-
morbilidades y mortalidades significativas. A pesar de la
ments, nutritional education and scientifically sound gui-
gran cantidad de datos disponibles, resulta llamativa la
dance for athletes is required. Intervention and preven-
información escasa o errónea por parte de los deportistas
tion efforts should be particularly targeted to adolescents.
y se debe prestar especial atención a las implicaciones de
(Nutr Hosp. 2009;24:128-134)
un uso de suplementos no supervisado correctamente.
Además de la necesidad de una regulación adecuada, los
Key words: Nutritional supplements. Ergogenics. Sports.
deportistas deben recibir una correcta educación nutri-
cional y una información sustentada en datos científicos
rigurosos. Los esfuerzos de intervención y de prevención
han de ser especialmente importantes en los adolescentes.
(Nutr Hosp. 2009;24:128-134)
Palabras clave: Suplementos nutricionales. Ergogenia.
Deporte. Conducta.
gral component of physical performance. The pro-
gress in understanding of human metabolism and
Since the time people began to participate in sports
exercise physiology made clear in the last few deca-
competition, nutrition has been perceived as an inte-
des that manipulation of nutrient intake had the poten-
tial to positively influence sport performance, resul-
ting in and explosion of products with specific
Correspondence: Sara Márquez.
applications to exercising individuals. Today, supple-
Departamento de Educación Física y Deportiva.
ment use is a widespread and accepted practice by
Universidad de León.
athletes, with a high prevalence of use and a large
24071 León, España.
E-mail: [email protected]
range of different types and brands of products. Glo-
Recibido: 25-XI-2008.
bal supplement use in athletes is estimated to range
Aceptado: 30-XII-2008.
from 40 to as high as 88 percent,1,2 with over thirty

thousand supplements being commercially-available
In the European Union, The Food Supplements
in the USA.3 More than 3 million people in the USA
Directive 2002/46/EC13 requires that supplements be
alone use, or have used, ergogenic supplements,4 and
demonstrated to be safe, both in quantity and quality,
supplement use is also widespread among athletes at
and, only those supplements that have been proven to
high school and collegiate levels.5,6
be safe may be sold without prescription. Although to a
Aggressive marketing has led millions of recreatio-
degree that differs from one member state to the other,
nal and elite athletes to use nutrition supplements in
there is an established view that food supplements
hopes of improving performance. Unfortunately, these
should not be labelled with drug claims but can bear
aids can be costly and potentially harmful, and the
health claims. Under the EU Directive, a so-called
advertised ergogenic gains are often based on little or
“positive list” has been created listing the allowable
no scientific evidence. No benefits have been convin-
vitamins, minerals and permitted chemical forms
cingly demonstrated for different aminoacids; some
(sources) of these vitamins and minerals that may be
supposed ergogenic supplements, such as chromium
used in food supplements and has been widely critici-
picolinate and DHEA have adverse side effects, and
sed for its inconsistent inclusion/exclusion criteria and
the safety of the other products remains in question.7 In
for the costs involved with adding items to the list. The
spite of potential risks, the retail sale of dietary supple-
industry in some European countries has opposed the
ments is generating in Western countries an enormous
Directive, and the Advocate General subsequently said
expenditure, which is largely the result of aggressive
that the EU’s plan to tighten rules on the sale of food
advertising aimed at high school, college, and recrea-
supplements should be scrapped, although it was ove-
tional athletes, all eager for anabolic-steroid-like gains
rruled by the European Court, which decided that the
through dietary aids.8 Nutrition supplements appeal to
Directive was necessary and appropriate to protect
a large number of consumers willing to pay for alleged
public health. The Food Standards Agency of the Uni-
benefits that are too good to be true.9
ted Kingdom has successfully rebutted the EU’s
The regulation of supplements and sports foods is a
attempt and, by virtue of the derogation in Article 4.6
contentious area. There is no universal system of regu-
of the Directive, which permits the continued use of
lation of sports foods and supplements, and countries
vitamins and minerals not on the “positive lists”, the
differ in their approach and practice. A dietary supple-
UK supplement market will remain semi-regulated at
ment is defined in the USA under the Dietary Supple-
least until 2009.14 Unless strong evidence is found for
ment Health and Education Act of 199410 (DSHEA) as
adverse effects, health warnings are therefore not likely
a product that is intended to supplement the diet and
to be placed on nutritional supplements.15 The problem
contains any of the following dietary ingredients: a
is how to obtain the strong evidence in the absence of
vitamin, a mineral, an herb or other botanical (exclu-
rigorous regulation which severely limits the validity
ding tobacco), an amino acid, a dietary substance for
of data collected.16
use by people to supplement the diet by increasing the
The range of products that collectively form the
total dietary intake, or a concentrate, metabolite, cons-
sports supplement industry are described by terms such
tituent, extract, or combination of any of the above.
as “dietary supplements”, “ergogenic aids”, “therapeu-
Furthermore, it must also conform to the following cri-
tic nutritional supplements” or “sports supplements”.
teria: intended for ingestion in pill, capsule, tablet,
They are supposed to provide a known nutrient require-
powder or liquid form not represented for use as a con-
ment to optimise training or competition performance
ventional food or as the sole item of a meal or diet labe-
(sports drinks or bars, carbohydrate gels), to contain
lled as a “dietary supplement”. Therefore, following
nutrients in large quantities in order to treat a known
the DSHEA, the Food and Drug Administration (FDA)
nutritional deficiency (iron supplements) or to directly
regulated dietary supplements as foods, and not as
enhance performance or maintain/restores health and
drugs. Supplement manufacturers were not required to
immune function (creatine, caffeine, ginseng).17 There
prove the safety or effectiveness of their products, and
is an ever-increasing range of supplements and sports
the FDA could take action only after a dietary supple-
foods that are easily accessible to athletes and coaches.
ment had been proven harmful.10 As a result, a new
It is of primary importance for the sports nutrition pro-
group of products flooded the USA and international
fessional to have a thorough working knowledge of the
market: the “pro-hormones” or compounds including
various sports foods and supplements in order to pro-
androstenedione, DHEA, 19-norandrostenedione and
vide sound advice about appropriate situations of use,
other metabolites found in the steroid pathways that
possible benefits, potential side effects and risks asso-
can be converted in the body to testosterone or the ana-
ciated with use. The current focus of the sports supple-
bolic steroid nandrolone,11 and which have generated
ment industry is on compounds and nutrients that act as
an important polemics in the context of doping and
cofactors, intermediary metabolites or stimulants of
inadvertent doping outcomes. By June 2010, new FDA
key reactions in exercise metabolism, assuming that an
rules will ensure dietary supplements to comply with
extra-charge of the system with additional amounts of
current good manufacturing practices, and be manufac-
these compounds will optimize metabolic and will
tured with “controls that result in a consistent product
result in enhanced sports performance. Scientific theo-
free of contamination, with accurate labelling”.12
ries are hyped into persuasive marketing tactics
Nutritional supplements in sports
Nutr Hosp. 2009;24(2):128-134

announcing an amazing “scientific breakthrough”.
roid-related compounds such as androstenedione,
However, while a scientific theory should be develo-
DHEA, 19-norandrostenedione) and stimulants such as
ped in preparation for a study (or to explain the data
ephedrine or related substances. Athletes consuming
collected in a study), it cannot be accepted as proof of
such supplement products may jeopardize their spor-
the efficacy of a supplement until verified by actual
ting status, and their health. The principle of strict liabi-
research, conducted under a special code of rules and
lity that applies in sport means that innocent ingestion
published only after a review process by other scien-
of prohibited substances is not an acceptable excuse,
tists. Obviously, this process costs time and money,
and athletes testing positive are liable to penalties. Alt-
and most supplement companies don’t invest in this
hough it is undoubtedly the case that some athletes are
research because they can successfully sell their pro-
guilty of deliberate cheating, some positive tests are
ducts to a public who do not appear to demand real proof
likely to be the result of inadvertent ingestion of prohi-
of their claims. The process of substantiating the perfor-
bited substances present in otherwise innocuous die-
mance benefits or outcomes from nutrient supplementa-
tary supplements.21 In any case, sport practitioners have
tion is difficult and has a series of requirements which
particular responsibilities in addressing this issue, and
are rarely accomplished: appropriated subject popula-
athletes need to be aware of the problems that can
tion, valid and reliable performance tests, use of an
follow supplement.25 Athletes should make enquiries at
appropriate placebo, control of extraneous factors and
the anti-doping agencies within their countries for
the test environment that might influence test perfor-
advice on the specific risks identified with supplement
mance, or maintenance of normal dietary and exercise
use, and any initiatives to reduce this risk.26
training habits, use of appropriate statistical techniques
Although there is some evidence of deliberate adul-
to minimise the chance of statistical error.18 Scientific
teration of products, presence of undeclared banned
studies which follow those guidelines have demonstra-
products may be the result of contamination or poor
ted that under specific conditions ergogenic aids can
labelling within lax manufacturing processes. In a
have some positive effects on performance, lean body
study carried out some years ago,27 634 supplements
mass, strength and changes in body composition.19 For
from 215 suppliers in 13 countries were analysed, with
some supplements there are sound trials demonstrating
products being sourced from retail outlets (91%), the
efficacy in the laboratory setting but not in the sports set-
Internet (8%) and telephone sales. Although none of
ting. Furthermore, most of the research that has been
these supplements declared pro-hormones as ingre-
undertaken has failed to support the claims of the majo-
dients, ninety-four of the supplements were found to
rity of nutritional ergogenic aids.20
contain hormones or pro-hormones that were not stated
on the product label, and a further 10% of samples pro-
vided technical difficulties in analysis such that the
Risks of nutritional supplements in sports
absence of hormones could not be guaranteed. Of the
“positive” supplements, 68% contained pro-hormones
The absence of compelling regulation has lead to
of testosterone, 7% contained pro-hormones of nandro-
considerable variation in concentrations, terminology
lone, and 25% contained compounds related to both. In
and combinations of supplements, even within the
relation to the total number of products purchased per
same country, making it extremely difficult to conduct
country, most of the positive supplements were bought
detailed studies commensurate with pharmaceutical
in the Netherlands (26%), in Austria (23%), in the UK
industry type clinical trials. Thus, side effect profiles
(19%) and the USA (19%). According to the label, all
are yet to be fully elucidated. In any case, information
positive supplements were from companies located in
from medical registers21 shows that while the overall
only five countries: the USA, the Netherlands, the UK,
risk to public health from the use of supplements is
Italy and Germany. More recently, products intentio-
low, cases of toxicity and side effects include allergic
nally faked with high amounts of “classic” anabolic
reactions to some products (i.e. royal jelly), overexpo-
steroids such as metandienone, stanozolol, boldenone,
sure as a result of self-medication and poisoning due to
dehydrochloromethyl-testosterone, oxandrolone etc.
contaminants. During the 1980s, deaths and medical
have been detected on the nutritional supplement mar-
problems resulted from the use of tryptophan supple-
ket. The sources of these anabolic steroids are probably
ments;22 products containing Ephedra and caffeine are
Chinese pharmaceutical companies, which sell bulk
a more recent source of medical problems, sometimes
material of anabolic steroids. In the last few years new
causing deaths in susceptible individuals.23 Moreover,
‘designer’ steroids such as prostanozol, methasterone,
the problems of doping in sport and the increasing use
androstatrienedione etc. have been offered on the nutri-
of nutritional supplements by athletes are issues that
tional supplement market, and in the near future also
intersect, and there is evidence that some of the appa-
cross-contaminations with these steroids are expec-
rently legitimate dietary supplements on sale contain
ted.28 Paper-based quality systems are still prone to
ingredients that are not declared on the label but that
possible contaminations, which leads to the conclusion
are prohibited by the doping regulations of the Interna-
that the best possible solution for athletes who wish to
tional Olympic Committee and of the World Anti-
use nutritional supplements must include laboratory-
Doping Agency.24 These include pro-hormones (ste-
based analysis for doping substances, preferably repea-
Nutr Hosp. 2009;24(2):128-134
O. Molinero and S. Márquez

ted for every new batch. The most important educatio-
using nutritional supplements. The most frequently
nal message, however, is to use a nutritional supple-
used supplements overall were energy drinks (73%),
ment only if it is deemed of benefit by a nutritional
calorie replacement products of all types (61%), multi-
vitamin (47%), creatine (37%), and vitamin C (32%).
An additional risk of reliance on supplements is the
Many athletes did not consider sports drinks and calo-
displacement of the athlete’s real priorities. Long-term
rie replacement products as supplements. In this study
training, optimal nutrition, adequate sleep and reco-
it was observed that females were more likely to obtain
very, state-of-the-art equipment and other factors on
information regarding supplementation from family
which depends a successful performance cannot be
members, and males from a store nutritionist, fellow
replaced by the use of supplements. However, they
athletes, friends, or a coach. Female athletes were more
often appear less exciting or more demanding than
likely to take supplements for their health or because of
claims made for many nutritional supplements. Athle-
an inadequate diet, while men reported taking supple-
tes can sometimes be side-tracked from the true ele-
ments to improve speed and agility, strength and
ments of success in search of easy short-cuts from
power, or for weight/muscle gain.
nutrients and drugs. Most sports physicians and dieti-
The use of the traditional (single and multivita-
tians are familiar with individual athletes who fail to
min/mineral supplements) and non-traditional supple-
address some of the basic elements of good training
ments (herbals, botanicals, and other biologic and
and lifestyle while are reliant on supplements.17 The
nutrient supplements) by female athletes has been
reasons for taking supplements should be further inves-
investigated in 162 collegiate female varsity athletes.33
tigated in relation to psychological factors such as
More than half of all athletes used some type of supple-
blocked or unattainable goals and the extent to which
ment at least once a month (65%). 36% of the sample
supplement use is perceived as a transitional milestone
used a multivitamin and mineral with iron, while 12%
on the road to becoming a serious athlete.
reported amino acid/protein supplement use and 17%
used an herbal/botanical supplement. The most fre-
quently cited reason for supplement use was “good
Knowledge and motives for the use
health” (60%), and a major source of information on
of nutritional supplements
supplements reported was family (53%). Reasons for
and prevalence of supplement use have also been com-
One of the early studies analyzing motives for the
pared among 247 varsity athletes and 204 nonvarsity
use of supplements in sports was carried out by Massad
(control) athlete Canadian university students.34 Sup-
et al in 1995.30 Factors influencing nutritional supple-
plements were used by 99% of varsity athletes and 94%
ment use by 509 high school students were assessed by
of controls. Varsity men most often reported using
administering The Nutritional Supplement Use and
sports drinks, and used these (and carbohydrate gels,
Knowledge Scale. Significant differences between
protein powder, and creatine) more than varsity
supplement use by gender and sports category were
women. Caffeine products were most often reported by
observed, and greater knowledge about supplements
other groups. Health professionals and the Internet
was associated with less use, suggesting that education
were the most reported information sources, while
about supplements can be a deterrent to use. Some
friends most often recommended supplements. Many
years later, a survey of 236 university student athletes
subjects indicated knowing little about supplements
was conducted to determine supplement use, perceived
and wanting to learn more.
efficacy of supplements, availability and use of nutri-
A recent report16 provided the first analysis of rela-
tion services, and perceived nutrition knowledge of
tionships that exist between supplement use and the
athletic trainers.31 Results showed that 88% used one or
rationale for their use in the maintenance of health. The
more nutritional supplements, yet perceived efficacy
study cohort had access to specialist support staff (e.g.
was moderate. Primary sources of nutrition informa-
team doctors or nutritionists) to receive medical sup-
tion were athletic trainers (40%), strength and condi-
port for their daily training regime and healthy diet.
tioning coaches (24%), and dietitians (14%). Athletes
Survey data collected among high performance British
perceived athletic trainers to have strong nutrition
athletes were reanalysed for association between the
knowledge. Many (24%) did not know whether a dieti-
supplement used and the motives for using such subs-
tian was available, which led to the suggestion that die-
tances for health maintenance. Of the 874 respondents,
titians must accelerate their marketing efforts to stu-
60% reported supplement use. In some cases, the moti-
dent athletes, work closely with athletic trainers to
ves for use and the supplements used show a great deal
provide sound nutrition information, and provide servi-
of incongruence. This suggested a lack of knowledge
ces that meet the needs of a diverse population of stu-
or understanding of nutritional supplements’ effects,
dent athletes.
except vitamin C, which was associated, but not
Another survey, conducted to examine the source of
strongly with preventing illness. No other supplement
information and usage of nutritional supplements in
pairing with motive for use revealed either a strong or
115 male and 88 female varsity university athletes,32
intermediate association. Athletes’ responses were also
found that 89% of the subjects had or were currently
inconsistent regarding medical advice informing sup-
Nutritional supplements in sports
Nutr Hosp. 2009;24(2):128-134

plement use. Thus, many athletes apparently did not
use increases with age, especially among male preado-
take supplements because of medical advice; however,
lescents, and that gender differences are particularly
when asking about individuals providing information
marked among older preadolescents. A high commit-
and advice regarding doping issues, medical practitio-
ment to sport training represented a risk factor of ergo-
ners appeared to be the most common information
genic supplementation only when it was linked to cer-
tain psychological dispositions such as a high ego
Interest in supplements to treat injury, and sources of
orientation and a low task orientation.40 Findings were
supplement information has been recently investigated
consistent with previous literature suggesting that high
among 145 college athletes35 who used athletic training
levels of ego orientation tend to predict legal or illegal
room and weight training facilities. The majority of
abuse of ergogenic aids and eating disorders.41 Moreo-
athletes experienced injury during their college athletic
ver, it was observed that a high sense of personal confi-
career and a part expressed an interest in supplements
dence appears to enhance the probability that youngs-
for injury treatment. Overall, 17% of participants were
ters who were involved in intensive training would
interested in supplements to improve circulation, 34%
resort to nutritional supplements.40
for joint and soft tissue repair, and 22% to reduce
The association between sports participation and the
inflammation. Males were more likely than females to
use of legal and illegal substances has been explored by
rely on strength coaches (37% vs 20%) for supplement
several authors, which have suggested that athletes are
information. Athletic trainers (71%), coaches (60%),
at greater risk than non-athletes for their use.42,43 Howe-
and physicians (41%) were the primary professionals,
ver, an only study have examined whether this rela-
and the internet (79%), magazines (68%), and televi-
tionship is a lasting one, by analyzing data on approxi-
sion (52%) the most popular sources of media for sup-
mately 15,000 adolescents from the USA National
plement information. It was concluded that future rese-
Longitudinal Study of Adolescent Health.44 Use of ana-
arch should identify if athletes are more likely to
bolic steroids and legal performance-enhancing dietary
increase supplement use when they are injured or if
supplement use were assessed six years later. Results
supplement use is more prevalent among athletes who
obtained indicated that males were more likely than
are prone to injury.
females to use anabolic steroids and legal supplements,
and differences were greater for those who participated
in sports during high school. Moreover, high school
Behavioural-related factors
sports participation was associated with increased like-
lihood that adolescents would use legal supplements in
Very few authors have examined the psychological
young adulthood. An additional interesting finding was
benefits of the use of nutritional supplements in sports.
the existence of a positive relationship between the use
A study reported that the consumption of a carbohy-
of legal dietary supplements and anabolic steroids use,
drate-containing drink with the additional ingredients
which confirmed the Gateway Theory.45 This theory
of caffeine, taurine and glucuronolactone) enhanced
predicts a positive relationship between the use of licit
the performance of a battery of tests, including psycho-
or legal substances and the use of hard or illicit subs-
motor traits. Unfortunately, this work did not distin-
tances, with a developmental trajectory or sequence of
guish the contribution of caffeine, and the authors con-
substance use, where the use of illicit substances is pre-
cluded that the results reflected the effects of the
ceded by the use of licit substances. Results from the
combination of ingredients.36 There are claims that gin-
study highlight the important role that the social envi-
seng supplementation may be valuable for athletic trai-
ronment during adolescence has on future health beha-
ning in producing improved levels of psychomotor per-
viours, and suggests that the sporting context experien-
formance and wellbeing,37,38 although other studies
ced during early adolescence may have lasting effects
found a failure of supplementation to improve psycho-
on the use of performance-enhancing substances.
logical function.39
An only research has investigated the relationship
between preadolescents’ use of nutritional ergogenic
Education and intervention programs
aids (creatine and amino acids) and gender, age, athle-
tic participation, and sport-relevant psychological fac-
Physicians who deal with athletes should be aware
tors (i.e., sport success motivation, task and ego orien-
of the supplements being utilized by athletes, the athle-
tation, self-efficacy). 2,450 children, aged 11-to
tes’ desired effects and the efficacy of the supplement,
13-years, participated in the study. Because sport prac-
the adverse effects, and whether the supplement is ban-
tice might either be competitive/performance oriented
ned by leagues or organizations in which the athletes
or educational/recreational in nature, it was hypotheti-
are competing. When working with athletes they need
sed that an association exists between the use of ergo-
to ask about drug or supplement use. A basic know-
genic aids and the practice of competitive sport, and
ledge of ergogenic substances may help to establish
that the use of substances increase with adolescents’
rapport with athletes using these agents. Physicians
level of training intensity and level of participation in
and dietitians should be aware that doses used by athle-
competitive sports. Results suggested that substance
tes are far in excess of the ones reported by the litera-
Nutr Hosp. 2009;24(2):128-134
O. Molinero and S. Márquez

ture, and that new substances are constantly being
1. Silver MD. Use of ergogenic aids by athletes. J Am Acad Ortho-
Adolescents may be at particular risk, because the
paed Surg 2001; 9: 61-70.
pressure to win at all costs, extensive coverage in lay
2. Williams M. Nutrition for health, fitness & sports. McGraw-
publications, and hype from manufacturers with exci-
Hill. New York, 2005.
ting and emotive claims all favour the use of supple-
3. Tekin KA, Kravitz L. The growing trend of ergogenic drugs
ments by young athletes.
and supplements. ACSM’S Health Fitness J 2004; 8: 15-18.
46 The American Academy of
4. Palmer ME, Haller C, McKinney PE, Klein-Scwartz W,
Pediatrics policy statement on the use of performance
Tschirgi A, Smolinske SC, et al. Adverse events associated
enhancing substances (2005)47 condemns the use of
with dietary supplements: an observational study. Lancet 2003;
ergogenic aids, including various dietary supplements,
361: 101-106.
by children and adolescents. Nutritional campaigns
5. Krumbach CJ, Ellis DR, Driskell JA. A report of vitamin and
mineral supplement use among university athletes in a Division
must inform athletes, their parents and their coaches,48
I institution. Int J Sport Nutr 1999; 9: 416-25.
and a number of studies have demonstrated that effec-
6. Froiland K, Koszewski W, Hingst J, Kopecky L. Nutritional
tive education programs can reduce adolescents’ inten-
supplement use among college athletes and their sources of
tions to use dietary supplements.
information. Int J Sport Nutr Exerc Metab 2004; 14: 104-20.
7 Moreover, research
7. DesJardins M. Supplement use in the adolescent athlete. Curr
conducted in various settings has led to the conclusion
Sports Med Rep 2006; 1: 369-373.
that coaches are the most influential persons on athle-
8. Sánchez-Benito JL, León Izard P. Estudio de los hábitos alimenta-
tes’ behaviour, being perceived as knowledgeable and
rios de jóvenes deportistas. Nutr Hosp 2008; 23: 619-626.
credible information sources.49,50 Education in supple-
9. González Gallego J, Collado PS, Mataix J. Nutrición en el
deporte. Ayudas ergogénicas y dopaje. Díaz de Santos: Madrid.
ment use advice could become a required part of the
accreditation process for coaches.15
10. US Dietary Supplement Health and Education Act of 1994. Public
Two widely used intervention programs are ATLAS
Law 103-417.
and ATHENA. Almost one half of male and female stu-
Retrieved on 13-11-08.
11. Di Luigi L. Supplements and the endocrine system in athletes.
dents participate in high school-sponsored athletics, and
Clin Sports Med 2008; 27: 131-151.
high school also is a time when classroom health promo-
12. U.S. Food and Drug Administration. FDA Issues Dietary Supp-
tion curricula are less effective. The ATLAS (Athletes
plements Final Rule.
Training and Learning to Avoid Steroids) program is a
2007/new01657.html. Retrieved on 27-10-2008.
sport team-centered prevention which targets adolescent
13. Directive 2002/46/EC of the European Parliament and of the
Council of 10 June 2002 on the approximation of the laws of the
male athletes’s use of anabolic steroids, human growth
Member States relating to food supplements.
hormone, alcohol and other drugs, and use of sport sup-
14. Food Standards Agency. Full regulatory impact assessment.
plements, while improving health nutrition and exercise
The food supplements (England) regulations 2003. http://www.
practices. Seven weekly, 50-minute class sessions deli- Retrieved on
vered by coaches and student team leaders, and seven
15. Neiper A. Nutritional supplement practices in UK junior natio-
weight-room sessions taught by research staff have been
nal track and filed athletes. Br J Sports Med 2005; 39: 645-649.
reported to induce maintained beneficial effects in ado-
16. Petroczi A, Naughton DP, Mazanov J, Holloway A, Bingham J.
lescent football players, demonstrating the potential of
Limited agreement exists between rationale and practice in ath-
letes´supplement use for maintenance of health: a retrospective
team-based interventions to enhance adolescents’
study. Nutr J 2007; 6: 34.
health.51 The more recently developed ATHENA (Athle-
tents/6/1/34. On Retrieved 15-10-2008.
tes Targeting Healthy Exercise and Nutrition Alternati-
17. Burke L, Cort M, Cox G, Crawford R, Desbrow B, Farthing L,
ves) program parallels ATLAS in its school-based,
Minehan M, et al. Supplements and sports foods. In: Bourke L,
Deakin V (eds). Clinical Sports Nutrition, McGraw-Hill: Sid-
team-centered format and the promotion of healthy
ney, 2006; 485-580.
nutrition and effective exercise training as alternatives to
18. Sherman WM, Lamb DR. Proceedings of the Gatorade Sports
harmful behaviors.52 However, ATHENA’s objectives
Science Institute Conference on Nutritional Ergogenic Aids. Int
are to reduce the young female athlete’s disordered
J Sport Nutr Suppl Vol 5, 2005.
eating habits and to deter use of body-shaping substan-
19. Williams MH. Nutritional ergogenics in athletes. J Sports Sci
1995; 13: S63-S74.
ces. The scripted, coach-facilitated, peer-led 8-session
20. Ellender L, Linder MM. Sports pharmacology and ergogenic
programme, is incorporated into a team’s usual training
aids. Prim Care 2005; 32; 277-292.
activities. The ATHENA program has been reported to
21. Shaw D, Leon C, Kolev S, Murray V. Traditional remedies and
significantly alter the targeted risk factors and reduced
food supplements. A 5-year toxicological study (1991-1995).
Drug Saf 1997; 17: 342-356.
ongoing and new use of diet pills and body-shaping
22. Roufs JB. Review of L-tryptophan and eosinophilia-myalgia
substances (amphetamines, anabolic steroids, and sport
syndrome. J Am Diet Assoc 1992; 92: 844-850.
supplements).Very recently, it has been reported that the
23. Dhar R, Stout CW, Link MS, Homoud MK, Weinstock J, Estes
beneficial behavioral outcomes seem to increase over
NA 3rd. Cardiovascular toxicities of performance-enhancing
substances in sports. Mayo Clin Proc 2005; 80: 1307-1315.
time and were evident following high school
24. Maughan RJ. Contamination of dietary supplements and posi-
graduation.53 These findings illustrate the utility of a
tive drug test in sport. J Sports Sci 2005; 23: 883-889.
structured process to define curriculum content, and the
25. Pipe A, Ayotte C. Nutritional supplements and doping. Clin J
program’s positive results also confirm the sport team’s
Sport Med 2002; 12: 245-249.
26. Burke LM. An overview of sports foods and supplements. In:
potential as a vehicle to effectively deter health-harming
Burke LM (ed). Applied Sports Nutrition. Human Kinetics:
Champaign, Illinois, 2006.
Nutritional supplements in sports
Nutr Hosp. 2009;24(2):128-134

27. Geyer H, Parr MK, Mareck U, Reinhart U, Schrader Y, Schan-
41. Troutman J, Duda JL. Psychological predictors of current and
zer W. Analysis of non-hormonal nutritional supplements for
intended future use of legal and illegal ergogenic supplements
anabolic-androgenic steroids-results of an international study.
among competitive bodybuilders. J Sports Exerc Psychol 1999;
Int J Sports Med 2004; 25: 124-129.
21: 113-123.
28. Geyer H, Parr MK, Koehler K, Mareck U, Schänzer W, Thevis
42. Bell A, Dorsch KD, McCreary DR, HoveyR. A look at nutritio-
M. Nutritional supplements cross-contaminated and faked with
nal supplement use in adolescents. J Adolesc Health 2004; 34:
doping substances. J Mass Spectrom 2008; 43: 892-902.
29. De Hon O, Coumans B. The continuing story of nutritional sup-
43. Tercedor P, Martín-Matillas M, Chillón P, Pérez-López IJ,
plements and doping infractions. Br J Sports Med 2007; 41:
Ortega FB, Warnberg J et al. Incremento del consume de tabaco
y disminución del nivel de práctica de actividad física en ado-
30. Massad SJ, Shier NW, Koceja DM, Ellis NT. High school ath-
lescentes españoles. Estudio AVENA. Nutr Hosp 2007; 22: 89-
letes and nutritional supplements: a study of knowledge and
use. In J Sport Nutr 1995; 5: 232-245.
44. Dodge TL, Jaccard JJ. The effect of high school sports partici-
31. Burns RD, Schiller MR, Merrick MA, Wolf KN. Intercollegiate
pation on the use of performance-enhancing substances in
student athlete use of nutritional supplements and the role of
young adulthood. J Adolesc Health 2006; 39: 367-373.
athletic trainers and dietitians in nutrition counselling. J Am
45. Kandel D. Stages and Pathways of Drug Involvement Exami-
Diet Assoc 2004; 104: 246-249.
ning the Gateway Hypothesis, Cambridge University Press:
32. Froiland K, Koszewski W, Hingst J, Kopecky L. Nutritional
New York,