Positive Drug Tests from Supplements
Louise M Burke PhD
Department of Sports Nutrition, Australian Institute of Sport, Belconnen 2616, Australia. Email: lburke=AT=ausport.gov.au
Sportscience 4(3), sportsci.org/jour/0003/lmb.html, 2000 (2546 words)
Reviewed by Gary Green MD, UCLA Department of Family Medicine, Los Angeles, CA 90095
In many sports, athletes compete under a code of conduct that prohibits the use of specified drugs and related compounds. These sports use a system of drug testing to monitor compliance with the code. Recently, there has been speculation that some of the positive drug tests recorded by certain athletes have resulted from the use of supplements and special sports foods rather than deliberate use of banned products. This speculation has been particularly strong in the case of positive tests for the steroid, Nandrolone. Experts are divided over whether there has been a recent increase in the rate of Nandrolone positives among athletes, or whether there is simply more publicity about these tests. What is striking is that these positive tests appear to have occurred in clusters–for example, among British athletes–and they have often involved well-known athletes who should know better (or be smarter about being caught). Some athletes have claimed that these doping outcomes have occurred inadvertently, through the use of dietary supplements or sports foods. Is this claim true, or will supplement use become the "dog ate my homework" routine for drug users? The short answer is that supplement use is a possible cause of a doping positive, but the extent of the problem is not known.
One of the good things that may come out of the confusion surrounding this issue is the chance to warn athletes about the trust they put in supplements and sports foods. The regulation of these products varies between countries, and in this article I will compare the situation in two countries: Australia and the US. But first I will consider how an athlete might ingest a banned substance through the use of supplements, and what type of substances could be contained in supplements and sports foods.
Here is a list of some ingredients in supplements and sports drinks that are either directly banned by the International Olympic Committee's Medical Commission or that have been shown to cause a positive doping outcome in some people:
Now that these products are named on the IOC list of prohibited substances, an athlete who declares an intake of these substances will be deemed to have doped. An athlete who takes these products and gives a urine test carries a risk of testing positive. The newer pro-hormone products androstenedione, androstenediol, and DHEA may lead to an elevated testosterone/epitestosterone ratio (Bowers, 1999; Uralets and Gillette, 1999), and the 19-nor products may lead to a positive test for metabolites of the steroid Nandrolone.
An inadvertent doping outcome could arise from supplement use in a number of ways:
The risk of these problems lies with the level of education of athletes about possible sources of banned substances, and the accountability of the supplement industry to guarantee the content and correct labeling of product.
In Australia, the Australian Sports Drug Testing Agency (ASDA), an independent statutory authority established under a 1990 Federal Government Act, is responsible for maintaining awareness and understanding of anti-doping issues among athletes, coaches and sports medicine/science professionals. This role supports ASDA’s primary function of conducting a comprehensive drug-testing program to deter elite athletes from taking prohibited substances. ASDA provides information about banned and permitted medications (both prescription and non-prescription) via its "Drugs in Sport Handbook" publication, pamphlets, a website, and an information phone hotline. Although ASDA would appear to be the appropriate body to publicize information related to the sports safety of supplements, little information is currently available. The only advice provided to athletes is that they are responsible for their use of supplements and that it is not possible to guarantee the safety of these products.
The production and sale of sports supplements in Australia falls under the jurisdiction of two government bodies: the Australian and New Zealand Food Authority (ANZFA), which controls sports food products, and the Therapeutic Goods Administration (TGA), which controls pills and other formulations marketed as therapeutic goods. Sports foods and energy formulations such as sports drinks, sports bars, sports gels and liquid meal supplements generally fall within Standards R9 and R10 of the ANZFA Foods Standards code. These standards make provision for a range of acceptable formulations and permitted additives, as well as a list of permitted or compulsory education messages for presentation on product packaging. It is up to individual states and territories to adopt these standards within their Food Laws, and to check and regulate that these laws are upheld. There is no requirement to take sport safety issues into account within the relevant standards for sports food products. A positive drug test is not likely to be an outcome from using most of the mainstream products (sports drinks and bars) produced by major food companies. However, a small number of sports foods, usually produced by smaller manufacturers targeting a niche market of athletes, contain added ingredients such as herbals and botanicals.
The availability and marketing of dietary supplements fitting the pill, powder or other non-food form fall within the jurisdiction of the TGA, under the Australian Therapeutic Goods Act 1989. This act distinguished two classes of products: drugs and therapeutic devices. Although dietary supplements may be packaged in a way suggesting medical or scientific rigor, as therapeutic devices they are regulated at an entirely different level to prescription pharmaceutical products. Therapeutic devices are further classified into categories of "registrable" and "listable" products, with almost all dietary supplements falling within the "listable" or less regulated category. Although they need to comply with relevant statutory standards, for example to exclude ingredients banned by Australian Customs laws, they are considered low-risk self-medications and are not subjected to a comprehensive review of quality, safety and efficacy. They are expected to comply with a recognized code of good manufacturing practice and with advertising regulations that permit only limited therapeutic claims. In practice these products receive little investigation of quality and claims unless they are the subjects of serious complaints regarding health and safety issues. There is no requirement of manufacturers to provide information or safeguards related to sports safety issues for athletes, even for products that are manufactured specifically for sports performance. However, the risk of a doping outcome from Australian products is greatly reduced by the fact that pro-hormones (e.g., DHEA, androstenedione, 19-norandrostenedione, 19-norandrostenediol and related compounds) are banned as ingredients in over-the-counter preparations and supplements in Australia.
Since athletes now have ready access to supplements from overseas via mail order, Internet sales and personal importation, it is important that they have a global understanding of the regulation of supplements. In countries such as the US, there is less regulation of the production and marketing of supplements than under the Australian system. For example, pro-hormones are permitted ingredients in over-the-counter preparations, supplements and sports foods. All forms of food and non-food supplements fall under the jurisdiction of the Food and Drug Administration (FDA). The Dietary Supplement Health and Education Act (DSHEA), passed in 1994, reduced the regulation of dietary supplements and broadened the category to include new ingredients, such as herbal and botanical products. The DSHEA shifted responsibility from the manufacturer to the FDA to enforce guidelines for safety and claims, but the FDA is allowed to investigate a supplement only after a safety problem has been reported. Requirements for good manufacturing practice and accurate labeling are included in the DSHEA, but there has been little enforcement.
In the absence of rigorous government evaluation, quality control of supplement manufacturing is trusted to supplement companies. Large companies that produce conventional supplements such as vitamins and minerals, particularly to manufacturing standards used in the preparation of pharmaceutical products, are likely to achieve good quality control. This control includes precision with ingredient levels and labeling, and avoidance of undeclared ingredients or contaminants. However, there is evidence that such control does not occur with all supplement types or manufacturers:
So we where do we go from here? Here are some ideas that might help to reduce the rate of positive doping outcomes:
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