Editorial

Are we making the most of supplements?

I was going to call this editorial ‘To supplement or not to

supplement?’ I think the evidence, however, is now so

strong that supplementation is a necessity rather than a

luxury (even for the general population, never mind the

additional needs of the physically active), that I’ve changed

the question to ask, are we making the most of supplements?

Now I know that there will be some reading this who will

have similar views to me and there will be those who

consider that supplements just make a very expensive urine,

but hopefully I will have made a strong case for them by the

end of this editorial.

I think it useful to consider first the body’s reaction to

injury and healing in order to appreciate why I feel so

strongly about the need for supplements. I’m not just talking

about injury in elite athletes, but injury in the general

population. Clearly the needs of sports people and elite

athletes simply exaggerate the need. When I was studying

for my Physiotherapy qualification I remember coming

across a paper by Evans (1980) talking about the healing

process and the role of inflammation. The inference was that

there is a natural healing time for the body when injured and

whilst this can’t be accelerated it can be delayed if the ideal

environment for healing is not present. This raises the

obvious question, what is meant by the ideal environment?

Well, at the macro level, that question doesn’t need a degree

in rocket science to answer. Clearly the body needs the right

materials, vitamins, minerals, right balance of ions, etc. in

enough quantities to enable it to have the ideal environment

in which to heal.

If that concept is accepted, and I would argue that that is

the very concept that most therapists base their ‘treatment’

on, then we need to discuss where supplements fit in.

Before I continue, I almost forgot to discuss the argument

that those against the use of supplements always make at

this point. If we eat a balanced diet and ensure that we eat

five portions of fresh fruit or vegetables per day we get

enough nutrients so don’t need any supplements. A report in

1936 to the US Senate stated that the farms and ranges

across America were so depleted of minerals that 99% of the

public had a deficiency in a ‘vast array of minerals’. The

Earth Summit in Rio de Janeiro in 1992 confirmed that the

average farm soil across the world was 75% depleted

of minerals and this figure was even worse in America with

1466-853X/$ - see front matter q 2004 Published by Elsevier Ltd.

doi:10.1016/j.ptsp.2004.09.001

a figure of 85%. Since 1992 the only change is that the

problem has got worse (Hattersley, Thomas, & McTaggart,

2002). What does this actually mean? Well to get some idea,

although not the whole picture, a repeat study looking at the

chemical composition of food between 1940 and 1991

found, for example, that carrots had 75% less magnesium,

48% less calcium, 48% less iron and 75% less copper. The

results for other food types found similar reductions in

essential minerals. For example, all fruits were found to

have 27% less zinc and apples and oranges were found to

have 67% less iron (Hattersley et al., 2002).

Given the importance to human physiology of all these

minerals such information is crucial to optimal health and

promoting ideal conditions for healing. This information

also blows the above argument about daily fruit portions

clear out of the water.

What about vitamins? On a very simple level it has been

estimated that if, for example, everyone in the USA took

several hundred milligrams of vitamin C a day, more than

100,000 lives would be saved from cardiac disease alone

(Cass & English, 2002). Vitamin C is usually the one cited

as making ‘expensive urine’ if you consume too much, but

this vitamin has been shown to be so important not only in

short term but also long term health that again this argument

needs to be considered. Researchers tested this concept by

measuring excretion of vitamin C in the urine to see how

much was actually needed to saturate tissue levels. They

found that only one quarter of participants reached their

maximum at 1500 mg per day whereas over half required

more than 2500 mg per day to reach their maximum. Some

participants did not reach their maximum even at 5000 mg

per day (Cass & English, 2002). The antioxidant properties

of vitamin C are also essential to human physiology and the

healing process, but it would take a much longer article to

give full justice to this topic.

Glucosamine has received a great deal of positive press

recently with respect to the benefit supplementation can

play to joint health, particularly in sports people. Numerous

double-blind clinical studies have shown the efficacy of

glucosamine supplements in maintaining healthy cartilage,

healthy joints (Lopes Vaz, 1982; Muller-Fassbender, Bach,

Haase, Rovati, & Setnikar, 1994; Pujalte, Llavore, &

Ylescupidez, 1980; Tapadinhas, Rivera, & Bignamini,

Physical Therapy in Sport 5 (2004) 169–171

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Editorial / Physical Therapy in Sport 5 (2004) 169–171170

1982) and a recent 3-year study reported joint space increase

in a glucosamine treated group whilst the placebo group

showed a decrease (Reginster et al., 2001).

What about the argument that there is a danger of

overdose? A look at the figures published by the Council for

Responsible Nutrition (CRN) shows that vitamin C has no

observed adverse effect (NOAEL) recorded for daily intakes

in excess of 1000 mg, and suggest an upper safe limit of

2000 mg and yet the official RDA (recommended daily

allowance) is still at 90 mg for men and 75 mg for women.

Vitamin E which is another key vitamin has a NOAEL

figure of 800 mg yet the RDA figure is 15 mg. This is the

same story for the majority of both vitamins and minerals

(Hathcock, 2004), so it is difficult to accept the argument of

overdose on face value.

The key point in all of this is that whenever

supplements are used they need to be used not in

isolation but in a balanced complex of both vitamins

and minerals to get the best synergistic effect. Hopefully

through the discussion above, I have demonstrated enough

evidence to support the idea that supplements are needed

to ensure the human body has the best possible chance of

healing at the optimal rate, which will enhance the

treatments we in sports medicine offer to our patients. If

this has made you at least re-think your attitude toward

supplements, the next step is to research what sup-

plements are available on the market (not the place of this

editorial) to ensure that only quality supplements are

recommended. The reason I mention this is that in 2003 a

major issue arose in the supplementation market in

Australia when Australia’s major supplement manufac-

turer Pan Pharmaceuticals had its production line shut

down for 6 months by the Australia Therapeutic Goods

Administration (TGA) and over 600 products were

recalled because of quality breaches and falsification of

test results and substitution of ingredients (ABC online,

2003).

This is not the only worry, however, for sports people,

particularly those at the elite level, and their medical support

teams. Which supplements to trust and recommend is also

an area for grave concern. An article by Pipe and Ayotte

(2002) reported the findings of an IOC nutritional

supplement analysis. This found ‘a significant proportion

of the products contained or were contaminated with banned

substances (Cve) not listed as ingredients by the manu-

facturer’. Of the products tested, 25% of those tested in

Holland, 18.9% in the UK, 18.8% in the USA, 14.3% in

Italy and 11.6% in Germany were found to be positive. In

response to this and other concerns of athletes USANA

Health Sciences a Utah-based company in the USA issued a

press release in January 2004 ‘offering an up to one million-

dollar (CDN) guarantee to athletes testing positive for

banned substances in world-class amateur or professional

competition as a result of using USANA nutritional

products’ (Blake, 2004). This appears to be the first

guarantee offer of its kind within the supplement

manufacturing domain and one to be welcomed and

encouraged within this very important and under-regulated

market.

Before I get onto the contents of this issue I’d just like to

congratulate all those who have just competed at the

Olympics in Athens where dreams have been both realised

and dashed. Congratulations also to all of the medical staff

who have, in some instances, worked miracles to enable

their athletes to compete.

Now onto the final issue for this year. Staying on the

subject of supplements first of all, in our first original

research article Sindberg and colleagues report a double-

blind study using a combination of essential fatty acids and

antioxidants combined with physiotherapy on chronic

tendon disorders. The findings are very interesting in that

the treatment group demonstrated a significant reduction in

pain compared to the placebo group. Surprisingly for a

muscle group that is so often injured, there is a dearth of

publications on hamstring injuries. In our second article,

Rolls and George have studied the relationship between

hamstring length and injury and report no significant

correlation for these two parameters. In the case study by

Herrington, two patients with functionally unstable ACL

deficient knees demonstrate that with appropriate rehabili-

tation they can achieve return to high stress sports despite

not showing any change in passive joint laxity. Herrington

questions the importance of passive joint laxity as an

indicator of functional outcome. In another original research

article, Sole and colleagues report their findings of a study

considering the association of parameters of balance with

injury in netball and in our final article Fredericson and

colleagues report a fascinating study of femoral diaphyseal

fractures using bone scans and MRI.

Also in this final edition for volume 5, we have an article

titled ‘Write for us Right for You’ that we promised earlier

in the year. This is aimed at the novice/potential author with

some stepping stone tips to becoming published. I hope that

this is a catalyst for many would be authors to aspire to

writing their first peer reviewed article, which we look

forward to receiving.

Once again I am sure you will agree that this edition

offers many thought provoking concepts and arguments to

consider and I hope you enjoy it. Have a good Christmas

when it comes and we’ll see you again in the New Year.

Best wishes

Kevin Foreman

References

ABC online (2003). 7.30 Report [www page]. URL http://www.abc.net.au/

7.30/content/2003/s844037.htm

Blake, B.A. (2004). USANA offers one million-dollar guarantee to top

athletes (news release) [www page]. URL http://www.usanacanada.

com/en/company/ag/

Cass, H., & English, J. (2002). User’s guide to vitamin C. Basic Health

Publications Inc., USA, ISBN: 1-59120-021-0 .

Editorial / Physical Therapy in Sport 5 (2004) 169–171 171

Evans, P. (1980). The healing process at cellular level: A review.

Physiotherapy, 66(8), 256–259.

Hathcock, J. N. (2004). Vitamin and mineral safety (2nd ed.). Washington,

DC: Council for Responsible Nutrition.

Hattersley, J., Thomas, P., & McTaggart, L. (2002). Vitamin supplements

and why we need them. What doctors don’t tell you, 13(9), 1–12.

Lopes Vaz, A. (1982). Double-blind clinical evaluation of the relative

efficacy of ibuprofen and glucosamine sulphate in the management of

osteoarthrosis of the knee in out-patients. Current Medical Research

and Opinion, 8(3), 145–149.

Muller-Fassbender, H., Bach, G. L., Haase, W., Rovati, L. C., & Setnikar, I.

(1994). Glucosamine sulphate compared to ibuprofen in osteoarthritis

of the knee. Osteoarthritis and Cartilage, 2(1), 61–69.

Pipe, A., & Ayotte, C. (2002). Nutritional supplements and doping. Clinical

Journal of Sport Medicine, 4, 245–249.

Pujalte, J. M., Llavore, E. P., & Ylescupidez, E. R. (1980). Double-blind

clinical evaluation of oral glucosamine sulphate in the basic treatment of

osteoarthrosis. Current Medical Research and Opinion, 7(2), 110–114.

Reginster, J. Y., Deroisy, R., Rovati, L. C., Lee, R. L., Lejume, E., Bruyere,

O., Giacovelli, G., Henrotin, Y., Dacre, J. E., & Gossett, C. (2001).

Long-term effects of glucosamine sulphate on osteoarthritis pro-

gression: a randomised, placebo-controlled clinical trial. Lancet,

357(9252), 251–256.

Tapadinhas, M. J., Rivera, I. C., & Bignamini, A. A. (1982). Oral glucosamine

sulphate in the management of arthrosis: a report on a multi-centre open

investigation in Portugal. Pharmatherapeutica, 3(3), 157–168.