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Football player Rob Ninkovich announced today that the league has suspended him for four games for taking a banned substance. Ninkovich explained, “Few things are more important to me than my name and reputation. This might call that into question for some, which has me heartbroken. I don’t want to cut any corners. I want to do things the right way, with high integrity, and that’s what I have always wanted to stand for.”

He continued, “Any supplement I’ve ever used was bought at a store. I was unaware something I bought had a substance in it that would give me a positive test because it wasn’t listed [as an ingredient]. One thing I have learned is that if a supplement is not NSF certified there are no regulations that ensure that what is on the label is 100 percent accurate. That is a hard lesson for me to learn at this stage in my career, but I take responsibility for it. It’s a mistake I made and it hurts that I won’t be there for my teammates.”

Patients frequently ask me about supplements, particularly protein powders. Pop culture nutrition is fickle. Not too long ago, we emphasized carbohydrates and feared dietary fat. Today, we are scared of carbohydrates and worship protein. As such, people who are already getting more than enough protein often feel they need even more and turn to a protein supplement.

Protein powders, like other supplements, are largely unregulated. Generally speaking, we have no idea if the contents match the listed ingredients or if the quantities reported on a bottle’s nutrition label are accurate. Back in 2008, I read a study (which I unfortunately cannot find right now) that analyzed actual protein content in various powders and found that most did not contain nearly as much protein as advertised.

Furthermore, as odd as it may initially sound, realize that manufacturers have incentive to add secret ingredients. Competition is fierce; a quick search of GNC.com yielded 512 different protein supplements. Consumers often make their selections based upon the perceived results or testimonials of others. If you are a supplement manufacturer and you want your product to stand out among the rest, to be the one that is perceived as yielding the best results, the one that gets talked about and recommended in the locker room, you may decide it is in your best interest to slip in an unlisted ingredient that produces the desired effect.

Whenever an athlete like Ninkovich gets busted and blames his supplements, the common reaction is to assume they are lying and covering for having purposely taken a performance enhancer. That may indeed be true, but we have to remember that what we often see as an excuse is also a completely plausible explanation.

You may or may not get drug tested the way that many professional athletes do, but the uncertainty of supplement contents can still impact you. Might an ingredient, listed or otherwise, interact with one of your medications, make you nauseous, give you a headache, accelerate your heart rate, or damage your liver? You could have no adverse reactions at all, wind up dead, or anywhere in between. That’s the risk.

If you use a supplement or are considering taking one, think about the potential ramifications, and remember that the lesson Ninkovich apparently learned today is actually an important lesson for us all.

He Said, She Said: Supplements

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He Said

As both a practitioner and a patient myself, I support the idea that everybody should have the freedom to pursue the healthcare path that feels right to the individual in question. The same freedom, I believe, should also extend to practitioners to be able to offer the modes of care that meet their own standards of ethical practice.

Approaches often evolve in response to new education and research. Earlier in my career, I worked at a medical center where selling supplements to patients is a significant part of their way of doing business. As I learned more about the science behind supplements and about the industry itself, I grew increasingly uncomfortable with this approach. Because of that background, you will not find any supplements or products of any kind for sale at Soolman Nutrition and Wellness LLC.

During our sessions, the topic of supplementation does occasionally arise, usually brought up by patients who have heard or read that a particular supplement regimen may help with whatever conditions are ailing them. However, we must remember that supplement manufacturers are allowed to make whatever health claims they would like – well-founded or otherwise – on the bottle just so long as they also have the standard disclaimer, “These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.”

In other words, the claims made on the bottle may be wildly inaccurate and have absolutely no credible research to support them, but the FDA does not have the power to intervene. Generally speaking, regulation within the supplement industry is reactionary, not proactive. Not only can manufacturers say whatever they want about their products, but they also do not have to prove their products are safe before they go to market. The FDA only steps in when a problem arises, as it did in the 1990s when people died from the anti-obesity supplement commonly known as fen-phen.

Furthermore, the FDA does not regulate the contents of supplements themselves, and oftentimes actual products do not contain what is listed on the bottle. Back in 2008, for example, I attended a talk during which a dietitian presented an independent research study that found that the hardly any of the tested protein powders contained the amount of protein advertised on the label. John Oliver, in his funny yet factual breakdown of the Dr. Oz debacle and the supplement industry in general, reveals that one in three supplements contains no trace of the plant advertised on the bottle. “If one in three milk bottles didn’t contain milk,” he says, “you might think twice about pouring the white mystery liquid all over your cereal.”

Even information regarding legitimate substances, such as vitamins, is skewed. Vitamins get their distinction because a deficiency in any one of them can cause a specific disease. For example, vitamin C deficiency causes scurvy, which is one of the reasons why the British navy began providing limes for their sailors in the 1800s. During Europe’s Industrial Revolution, children no longer received the same sunlight exposure as they did in generations past and consequently developed rickets, an indicator of vitamin D deficiency.

However, just because an adequate amount of a vitamin will prevent a deficiency-related disease does not mean that a benefit exists to taking excessive amounts. The United States Department of Agriculture’s Dietary Reference Intakes include tolerable upper intake levels, defined as “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population,” for most vitamins, yet we can easily – and unknowingly – exceed these upper limits through supplementation.

For all of these reasons, unless a patient’s situation suggests the contrary, I recommend doing our best to get our nutrients through food first and only bringing in supplements when necessary. If it does look like a supplement is warranted, I suggest my patient run it by his or her primary care physician.


She Said

The topic of supplementation often comes up in my nutrition counseling sessions with patients and their families. Since I am not a medical prescriber, I always refer patients to their primary care physician when it comes to questions about supplements. While I usually suggest that patients try to receive most of their nutrients from actual food sources rather than pills or powders, there is some promising research on specific supplements that may help those struggling with eating disorders (EDs).

As one would guess, those struggling with EDs are usually deficient in many different nutrients due to extreme restriction and/or purging or laxative abuse, and this can compromise every organ in the body. These nutrient deficiencies can lead to a number of medical issues for the individual, including (but not limited to) osteoporosis, anemia, and heart and kidney problems.

Many supplements have been studied in their relation to EDs. For example, zinc supplementation has been linked to improvement in appetite, taste perception, and mood as well as enhanced weight restoration and menstruation in anorexic girls and women. Supplementation with essential fatty acids, specifically EPA and DHA, has also been found to aid in weight restoration while decreasing preoccupation with and anxiety around food in those with anorexia. For those struggling with bulimia, supplementation with electrolytes such as potassium and magnesium is often prescribed due to the large amount of electrolytes that are lost through purging.

A number of my patients struggling with EDs are either vegetarians or vegans, which can result in nutrient deficiencies including calcium, iron, and vitamin B12. Calcium deficiency can lead to osteoporosis, which can be tested for by doing a DEXA bone scan. Iron and vitamin B12 deficiencies can be detected by blood tests. In some cases, supplementation with these nutrients might be suggested to aid in the prevention or management of medical conditions.

At the end of the day, I try to focus on food with my ED patients, as most nutrients are best absorbed from dietary sources. But in some severe cases, supplementation might be indicated if the individual is unable (or unwilling) to eat the foods necessary to attain these nutrients. Refeeding can be a very uncomfortable experience for those struggling with EDs. Most of my patients who are refeeding experience painful bloating, cramps, constipation, and delayed gastric emptying, which can make it feel nearly impossible to eat anything at all. In those situations, supplementation with certain nutrients might be indicated until the individual is able to start eating normally again.

If you are considering supplements for either your own or your child’s ED, please consult with your physician before trying anything on your own. Your physician will be able to assess any nutritional deficiencies through a number of diagnostic tests and then can guide you in the right direction.