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Summit on Human Performance and Dietary
Supplements Summary Report
MaryElizabeth Arensberg, PhD, RD, LD, FADA
Rebecca Costello, PhD
Patricia A. Deuster, PhD, MPH, FACSM
DonnamariaJones, PharmD
GwenTwillman
The use of dietary supplements to enhance human per- he use of dietary supplements to enhance human
formance among active individuals, athletes, the military, Tperformance among athletes, the military, and
and other tactical populations is an increasingly popular other tactical populations is an increasingly pop-
topic that often is not well understood. There are impor- ular topic that often is not well understood. To review the
tant differences in nutrient needs between the general evidencebaseanddiscusskeyissues,theNationalStrength
public and active adults. The United States has an established andConditioning Association, National Institutes of Health
regulatoryframeworkfordietarysupplements,andthesafety Office of Dietary Supplements, the American Society for
and quality of dietary supplements can be strengthened Nutrition, and the EAS Academy hosted a Human Perfor-
througheducation,third-partycertification programs, and mance and Dietary Supplements Summit August 9 to 10,
increasedattentiontoseriousadverseeventreporting.This 2012, in Bethesda, Maryland (Table 1).
summary highlights these key issues, as well as research Morethan200professionals from the medical, nutrition,
needs,areasforfutureconsideration,andothertopicsthat and athletic performance fields, as well as the military,
werediscussedduringtheHumanPerformanceandDietary participated in the summit. This summary highlights the
SupplementsSummit,heldAugust9to10,2012,inBethesda, key topics covered, research needs, future study consid-
Maryland. Nutr Today. 2014;49(1):7Y15 erations,anddiscussionpointsaspresentedatthesummit,
without further elaboration.
Mary Elizabeth Arensberg, PhD, RD, LD, FADA, is director, Health Policy Phillips, MS,RD,CSSD,Athletes’PerformanceandCorePerformance;PaulM.
andPrograms,AbbottNutrition Products Division of Abbott, Columbus, Ohio. Coates,PhD,NationalInstitutesofHealth(NIH)OfficeofDietarySupplements;
Rebecca Costello, PhD, is scientific consultant, National Institutes of Ellen Coleman, MA, MPH, RD, CSSD, Academy of Nutrition and Dietetics
Health (NIH) Office of Dietary Supplements, Bethesda, Maryland. Sports and Cardiovascular Nutrition Practice Group; R.C., (NIH) Office of
DietarySupplements;JohnE.Courtney,PhD,AmericanSocietyforNutrition;
Patricia A. Deuster, PhD, MPH, FACSM, is professor and scientific di- Kim Crawford, PhD, RD, CSSD, LDN, University of Pittsburgh; P.A.D., Uni-
rector, Consortium for Health and Military Performance, Department of formed Services University of the Health Sciences; Johanna T. Dwyer, DSc,
Military and Emergency Medicine, Uniformed Services University of the RD,NIHOfficeofDietarySupplements;DaveEllis,RD,CSCSCollegiateand
Health Sciences, Bethesda, Maryland. Professional Sports Dietitians Association; Daniel Fabricant, PhD, Food and
Donnamaria Jones, PharmD, is deputy director, Uniformed Services Uni- Drug Administration; Philip Gregory, PharmD, FACN, Natural Medicines
versity Center Alliance for Dietary Supplement Research Department of ComprehensiveDatabaseandCreightonUniversity;TravisHarvey,PhD,CSCS,
Military and Emergency Medicine, Uniformed Services University of the 75th Ranger Regiment; Craig Horswil, PhD, University of Illinois Chicago,
Health Sciences, Bethesda, Maryland. DepartmentofKinesiologyandNutrition;RickKingston,PharmD,SafetyCall
International; Danny McMillian, PT, DSc, OCS, CSCS, University of Puget
GwenTwillman, is managing director, Education and Professional De- Sound; Stuart Meyers, OpTac International; CDR Rochelle Nolte, MD, US
velopment, American Society for Nutrition, Bethesda, Maryland. Public Health Service; Rob Skinner, MS, RD, CSSD, Skinner Consulting;
This article is a summary report of the 2-day Human Performance and MarieSpano,MS,RD,LD,CSCS,CSSD,MarieSpanoNutritionConsulting;
Dietary Supplements Summit held August 9 to 10, 2012, in Bethesda, Keith Wheeler, PhD, FACSM, Abbott Nutrition; and Ed Wyszumiala, NSF
Maryland. International.
SummitPlanningCommittee:M.E.A.,AbbottNutrition;R.C.,NIHOfficeof The authors currently are employed or consulting for the organizations
Dietary Supplements; Cindy Davis, PhD, National Institutes of Health (NIH) noted. The summit was developed and supported by the National Strength
Office of Dietary Supplements; P.A.D., Uniformed Services University of the and Conditioning Association, the National Institutes of Health’s Office of
Health Sciences; Catherine Dratz, Abbott Nutrition; Steve Hertzler, PhD, RD, Dietary Supplements, and the American Society for Nutrition; it was spon-
AbbottNutrition;D.J.,UniformedServicesUniversity;VirginiaMeier,National sored in part by the EAS Academy of Abbott Nutrition.
Strength and Conditioning Association; Torrey Smith, National Strength and Correspondence:MaryElizabethArensberg,PhD,RD,LD,FADA,HealthPolicy
Conditioning Association; Anne Thurn, PhD, NIH; G.T., American Society and Programs, Abbott Nutrition Products Division of Abbott, Department
for Nutrition; and Keith Wheeler, PhD, FACSM, Abbott Nutrition. 107740, 625 Cleveland Ave, Columbus, OH 43215 (mary.arensberg@
Summit Faculty: Pamela A. Anderson, PhD, RD, Abbott Nutrition; abbott.com).
Carmen Caraballo, MS, RD, US Military Academy; Amanda Carlson- DOI: 10.1097/NT.0000000000000013
\
Volume 49, Number 1, January/February 2014 Nutrition Today 7
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 1 Objectives of the Summit on 1994 Dietary Supplement Health and
HumanPerformanceandDietary Education Act
Supplements Thefirstamendmentisthe1994DietarySupplementHealth
and Education Act, which provides the overall regulatory
& Define the nutrition needs of active adults and athletes framework for dietary supplements to help ensure safety
& Discuss dietary supplement use in active adults, elite by establishing specific labeling and notification require-
athletes, and tactical populations ments, authorizing the FDA to develop rules for good
manufacturing practices, and giving the FDA authority to
& Examinetheimpactofdietarysupplementsonperformance, removeadietary supplement from the market if the FDA
competition, and training 1
finds the product is ‘‘unsafe.’’
& Discuss the translation and application of the available
evidence for educating appropriate audiences 2006 Dietary Supplement and Nonprescription
& Review certification, testing, safety issues, and adverse events DrugConsumerProtection Act
& Identify research gaps and opportunities for further research This second amendment requires companies that manufac-
ture or distribute dietary supplements to report information
2
about serious adverse events to the FDA.
Afewdecades ago, sports nutrition science was in its in- Labeling requirements for dietary supplements are simi-
fancy. Athletes and fitness enthusiasts struggled for ways lar to those of conventional foods. Both must have the
tobestdefinetheirnutritionneedsandbalancethemwith following:
the demands of rigorous training and busy lifestyles. Today, & statements of identity/descriptive names; in addi-
science-basedsolutions are available in the form of sports tion, a dietary supplement also must state that it is a
dietary supplements, conventional foods, and functional ‘‘supplement’’;
foods,developedspecificallyassportsnutritionproducts. & nameandplace of business of the company manufactur-
These products can provide a framework for good nutri- ing, packing, and distributing the product;
tion and can offer quality, balanced nutrition, and con- & nutrition labeling panelVthe Nutrition Facts panel for
venience. The key to understanding the differences in conventional foods and Supplement Facts panel for
these types of products is to consider the form, composi- dietary supplements;
tion, labeling, and use of each. & complete ingredient listing (Table 2), net contents of
the product, and serving size;
DIETARYSUPPLEMENTREGULATIONS & dietarysupplementsalsomustlistanaddressandphone
IN THEUNITEDSTATES numberforserious adverse event reporting.
Thesummithighlightedthedietarysupplementregulatory Advertisements and labels for dietary supplements can-
framework in the United States. Like all foods, dietary not make disease claims, such as stating the product will
supplements and conventional foods marketed for sports help prevent, treat, cure, or mitigate an illness/disease.
nutrition are regulated by the US Food and Drug Admin- However, dietary supplements, like conventional foods,
istration (FDA). Federal law defines dietary supplements can make health claims. Health claims describe a relation-
as products taken by mouth that contain a ‘‘dietary ingre- ship between a substance and a disease or the reduc-
dient’’ and are intended to ‘‘supplement’’ the diet: tion of risk for a disease. The FDA must preapprove the
& The ingredients in dietary supplements may include vi- health claims, and the product’s label must contain a
tamins, minerals, herbs, or other botanicals, amino acids, disclaimer specifying that the statements were not eval-
enzymes, organ tissues, glandulars, concentrates, me- uated by the FDA. Both dietary supplements and con-
tabolites, constituents, and/or extracts. ventional foods also can make nutrient content claims
& Dietary supplements are available in tablet, capsule, that are preapproved by the FDA (eg, sugar free, low fat,
liquid, powder, soft gel, or gel cap form. or low sodium).
& Manufacturers cannot promote these products as con- Dietary supplements and conventional foods can make
ventionalfoodsorforuseastheonlyitemofamealordiet. structure/function claims (eg, calcium builds strong bones,
or fiber maintains bowel regularity). However, manufac-
The Federal Trade Commission prohibits using unfair or turers of dietary supplements must provide notification to
deceptive practices to sell any dietary supplement or con- FDAofthese claims (no later than 30 days after marketing
ventional food. Dietary supplements also must meet the a product with a structure/function claim) and add a dis-
requirements of 2 amendments of the US Food, Drug, and claimer on the product’s label that the statements were not
Cosmetic Act that are specific to dietary supplements. evaluatedbytheFDA.Inaddition,structure/functionclaims
8 Nutrition Today\ Volume 49, Number 1, January/February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 2 Regulations for Ingredients in understand how nutrient needs are estimated and the po-
Conventional Foods and Dietary tential impact of performance activities. Dietary Reference
3
Supplements Intakes(DRIs) arecalculatedusing‘‘referencepeople’’of
specific height, weight, sex, physical activity, and environ-
Ingredient safety mental conditions. However, many active people do not
Manufacturers are responsible for ensuring the safety of fit into these standard reference categories. The Military
4
their products; the regulations governing safety of DRIs were derived from the DRIs to meet the increased
ingredients used in conventional foods vs dietary activity levels and greater environmental stresses faced by
supplements differ in several ways. military populations and are used to develop menu stan-
Ingredients added to conventional foods must meet one of dards for the military.
these requirements: Some special populations, such as individuals who are
veryfitandactiveand/orareperformingatenvironmental
& Havebeeningeneraluseinfoodspriorto1958(whenthe extremes (eg, combat personnel, first responders, and
Food Additives Amendment to the Federal Food, Drug, professional athletes), may require adjustments in their
and Cosmetic Act was enacted) DRIs. Whereas recommendations for vitamins and min-
& ComplywithaUSFoodandDrugAdministration(FDA)Yissued
food additive regulation (specifies amount and purpose of erals remain fairly constant for active versus inactive in-
ingredient) dividuals,needsforwater,electrolytes,energy,and,under
& Be generally recognized as safe (GRAS) by qualified experts, certain circumstances, macronutrients (carbohydrate, pro-
meaningsafeuseoftheingredienthasbeendevelopedunder tein, and fat) may differ.
scientific procedures or through commonuseinfood,sothere Theestimated energy requirement is the average dietary
is ‘‘general recognition of safety’’ among qualified experts
(FDA premarket notification of GRAS ingredients is energy intake needed to maintain energy balance in a
voluntaryVlisting available at http://www.accessdata healthy adult of defined age (in years), sex, height (in
.fda.gov/scripts/fcn/fcnNavigation.cfm?rpt=grasListing) meters),weight(inkilograms),andphysicalactivitylevel
(PAL).3ThePALfactorsarebasedontheactivitylevelsof
Ingredients used in dietary supplements must meet one of the general population (Table 3), which are possibly too
these requirements:
low for very active people.
& Have been in general use prior to October 15, 1994 For example, a competitive or tactical athlete could ex-
(when the Dietary Supplement Health and Education Act pendupto6000kcal/d,whichmayrequireaPALof3or
was implemented) more. The estimated energy requirement equations for
& Be in compliance with the notification for a new dietary
ingredient (NDI), which requires a 75-d premarket adults are as follows:
notification to FDA, unless the NDI and any other ingredients
in the dietary supplement have been present in the food Adult Men EER ¼½662ðÞ9:53age þPA
supply and used for food ½ðÞ15:91 weight þðÞ539:6 height
& For more information about the safety of dietary ingredients,
visit http://www.fda.gov/Food/DietarySupplements/Alerts/ Adult Women EER ¼½354ðÞ6:91age þPA
default.htm and http://ods.od.nih.gov/factsheets/list-all/ ½ðÞ9:36 weight þðÞ726 height
Abbreviation: NDI, new dietary ingredient. where PA is the physical activity coefficient derived from
the PAL (Table 3). Acceptable macronutrient distribution
arerequiredtohavesubstantiation,supportedbycompetent ranges for carbohydrate, protein, and fat are 45% to 65%,
and reliable scientific evidence. 10%to35%,and20%to35%oftotalcalories,respectively.
Four principal issues guide whether a claim is substantiated: However,different ranges are recommended to meet the
carbohydrateandproteinneedsofveryactiveindividuals.
& meaning of the claim being made, TheRecommendedDietaryAllowanceforprotein,which
& relationship of the evidence to the claim, covers requirements for nearly all healthy, nonathletic
& quality of the evidence, and adults, is set at 0.8 g/kg per day. Yet, protein intake rec-
& totality of the evidence. ommendationsinthe sports nutrition literature vary from
1.2 to 2.0 g/kg per day, based on body composition, type
5
DIFFERENCESBETWEENNUTRIENT of exercise, and health status.
NEEDSOFTHEGENERALPUBLICAND Although the DRIs provide an evidence base from which
ACTIVEADULTS to derive nutrient recommendations, they are incomplete
for athletes and others engaged in strenuous activity. Op-
Another area addressed at the summit was nutrient needs timal intakes before, after, and during exercise and spec-
and human performance. When considering the use of di- ificity for individuals of varying body composition are not
etary supplements for human performance, it is helpful to addressed by the DRIs. Recommendations are available
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Volume 49, Number 1, January/February 2014 Nutrition Today 9
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 3 Physical Activity Coefficients (PA values) for Use in Estimated Energy
Requirement Equations
LowActive Very Active (PAL 1.9Y2.5)
(PAL: 1.4Y1.59) Active Typical Daily Living Activities,
Typical Daily (PAL 1.6Y1.89) Plus at Least 60 min of Daily
Sedentary Living Activities, Typical Daily Living Moderate Activity, Plus an
(PAL 1.0Y1.39) Plus 30Y60 min of Activities, Plus Additional 60 min of Vigorous
Typical Daily Daily Moderate 60 min of Daily Activity or 120 min of
Living Activities Activity Moderate Activity Moderate Activity
MenQ19y 1.00 1.11 1.25 1.48
WomenQ19y 1.00 1.12 1.27 1.45
Abbreviation: PAL, physical activity level.
from other sources, such as the American Academy of Nu- evolve according to their individual goals, using an ap-
trition and Dietetics, the Dietitians of Canada, the American proach such as this multistep process:
College of Sports Medicine, and many professional journals & Step 1: Provide comprehensive education, helping ath-
and publications. letesseehownutritionalstrategiescanhelpthemachieve
DIETARYSUPPLEMENTUSEINACTIVE their goals
ADULTS,ATHLETES,ANDTACTICAL & Step 2: Offer clear and concise materials to promote
POPULATIONS understanding of dietary supplement use
& Step3:Provideguidanceonhowtoconfiguresolutions
Thesummitexploredthe uses of dietary supplements by specific to their goals
different population groups. There is some research on the & Step4:Givefollow-upguidanceonhowtoexecutetheir
efficacy of various dietary supplements and their impact on plans.
both health and human performance, but it is limited. The Professional and Collegiate Athletes
role of dietary supplements in human performance is to
supportthephysiologicalneedsofametabolicsystemunder Formanyathletes,overreaching+overtraining=performance
stress and to complement the body’s effort to mobilize fuel, incompetence.Forprofessional athletes, a long in-season
maintain focus, or accelerate recovery. Several dietary sup- grind and short off-season restorative period increase the
plements are shown to complement training and human potential for underrecovery and deconditioning. Sports
3,6 dietitians often see professional athletes suffering from
performance,andothersstillareunderstudy. Clear and
concise information on dietary supplement strategies that chronicfatiguebecauseofunderresting,stimulantoveruse,
can benefit active populations and influence goal achieve- drug use, and binge alcohol use similar to what occurs in
ment is needed, but reinforcing the role of conventional the general population. In addition, some athletes may have
foods also is important. Following are considerations for off-season binge-eating patterns that can result in chronic
several specific populations. dehydration, poor sleep, anxiety, and vulnerability to ex-
ertion and environmental stressors.
The National Collegiate Athletic Association (NCAA) has
The nutrition needs of very active establishedspecific sports nutrition rules that govern how
adults require more study. teamscanfeedtheirplayers(eg,specifyinginstitutionsmay
provide only 1 training table meal per day to a student
athlete, but that institutions may provide fruit, nuts, and
bagels at any time).
Active Adults and Athletes The NCAA also has rules that allow student athletes to
Active adults and athletes often view dietary supplements receivenutritionalsupplementsforadditionalcaloriesand
asawaytoimprovetheirperformance,helpthemachieve electrolytes. Permissible nutritional supplements cannot
a goal faster, and maintain their health. Most active adults contain any NCAA-banned substances and are identified
and athletes do not question whether the dietary supple- accordingtoclassesVcarbohydrate/electrolytedrinks,energy
ments that they take actually are improving their perfor- bars, carbohydrate boosters, and vitamins and minerals.
mance. They may take a product simply because of the The NCAA recently adopted a policy that schools must
label ‘‘promises.’’ Sports dietitians can help active adults designate an individual as the athletic department’s re-
and athletes develop nutritional strategies and plans that source for questions related to nutritional supplements,
10 Nutrition Today\ Volume 49, Number 1, January/February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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