THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 4 - APRIL 2003
Ephedra Use Under Fire
Deaths Amplify Safety Concerns
The impact of suspicions about the role of ephedra in the recent deaths of two professional athletes is resounding from sports locker rooms to health clubs to the homes of everyday people looking for help losing weight. Anxiety and questions about one of the most popular supplements on the market are sure to spill over to physicians' offices.
The deaths of Minnesota Vikings' offensive lineman Korey Stringer in 2001 and Baltimore Orioles' pitching prospect Steve Bechler in February are also creating legal shockwaves. Developments in the Bechler case appear to be influencing events in a wrongful death lawsuit that Stringer's family filed against the Vikings and its medical team. Four days after Bechler's death, attorneys for the Vikings filed court papers linking ephedra with Stringer's death.1 Though the postmortem toxicology screen did not test for ephedra, bottles of ephedra supplements were purportedly found in his locker.
In response, Stringer's legal team filed a memorandum claiming that the Vikings promoted the use of dietary supplements and that Stringer could not be faulted for using them.2 Allegations include Vikings players selling an ephedra supplement in the locker room and that the team hired a supplement representative to speak at the 2001 training camp.
The medical examiner who did the autopsy on Bechler reported that ephedra use probably contributed to Bechler's death. A toxicology analysis in Bechler's case has since confirmed the presence of ephedrine in his blood. Attorneys for Bechler's family are reportedly preparing a lawsuit against the maker of the ephedra supplement found in Bechler's locker.
Setting the Stage
Among some active people, epehedra, also called ma huang, is used to enhance performance and promote weight loss. Because users believe it gives them an energy boost, it is also marketed by some companies as an alternative to club drugs. The herb has 35 related alkaloids, one of which is ephedrine, a compound regulated by the Food and Drug Administration (FDA) as a drug.
Products containing ephedra alkaloids have been banned by the International Olympic Committee for several years; such products have also been banned by the National Collegiate Athletic Association (NCAA) and the National Football League. The National Federation of State High School Associations has urged, through its Sports Medicine Advisory Committee, that student-athletes and their parents consult with their physicians before taking any supplement. Though the NCAA banned ephedra in 1997, student-athletes still use the supplement. According to a 2001 survey,3 students across nearly all sports, particularly women's teams, increased their use of the supplement between 1997 and 2001. (The survey also found that many students began taking ephedra in high school.) In August 2002, the NCAA added ephedra to the panel of drugs that it tests for year-round in division 1 and 2 schools.
The FDA issued its first advisory on the adverse effects of ephedra in 1994. Because of growing concerns about safety, in 2001 the FDA commissioned the Rand Corporation to study the weight loss and athletic performance claims for ephedra as well as its safety profile. The report,4 released on February 28, analyzed clinical studies and case reports and found that the supplement promoted modest, short-term weight loss but did little to improve athletic performance in the absence of caffeine. The group found a relationship between ephedra use and catastrophic events, including heart attack, stroke, seizures, and psychiatric symptoms.
Results of the published Rand report prompted the FDA to request stronger warning labels on products that contain ephedra and to warn supplement manufacturers against making unsubstantiated claims for their products. The Ephedra Education Council, a supplement industry group, supported the FDA actions but emphasized that no serious events had occurred during any of the clinical studies.
Responses Are Varied
It's impossible to miss the parallels in the deaths of Bechler and Stringer. According to news reports, both arrived at training camp in suboptimal physical shape and were struggling with rigorous workouts and warm weather. And supplements containing ephedra were reportedly found in their lockers after their deaths.
Gary I. Wadler, MD, a supplement expert and associate professor of clinical medicine at New York University School of Medicine in Manhasset, New York, says he remains puzzled by Bechler's death. "He didn't take that much, he wasn't that overweight, he wasn't working out that hard, and it wasn't that hot and humid," says Wadler, who is a strong opponent of ephedra use. "So why couldn't they reverse the heatstroke? No one had addressed that adequately."
Gary A. Green, MD, clinical associate professor in the Department of Family Medicine at the University of California, Los Angeles (UCLA), says the combination of taking a substance like ephedra and being unacclimatized, deconditioned, and dehydrated could have been like "a perfect storm." He says it's unlikely that any one of these factors alone would have been fatal. Ephedra use, though, might have been like adding fuel to the fire, says Green, who is also a researcher at the Olympic Analytical Laboratory at UCLA. "The bottom line is that ephedra increases metabolism and the heat the body generates," he says.
Not all medical professionals believe that ephedra was a major contributor to Bechler's death. Richard B. Kreider, PhD, professor and chair of the Exercise and Sports Nutrition Laboratory at Baylor University, in Waco, Texas, and two of his colleagues issued their observations in an online statement.5 They state that: "...even if Mr Bechler did consume the supplement, it was probably the least of the contributing factors leading to his death—and it may not have been a factor at all." Kreider and his colleagues said that the thermogenic effects of ephedra and caffeine are relatively small, increasing resting caloric expenditure by 5 to 10 kcal per hour.
They are concerned that the intense focus on implicating ephedra may overshadow more powerful strategies for preventing heatstroke deaths, such as ensuring that athletes are properly screened, conditioned, acclimatized, and supervised.
Physicians will continue to confront ephedra and other supplements in sports settings because the perceived energy boost has historically been a strong lure for some athletes, says Wadler. "Ephedra didn't come out of the clear blue sky. Amphetamines, called 'greenies' in the 1970s, were the genesis," he says. "Physicians should know that ephedra combined with caffeine is the modern-day equivalent of amphetamines."
Lewis G. Maharam, MD, a sports medicine specialist in private practice in New York City, says the physician's role is to be a leader in getting medical information about supplement safety to players and the team officials. "And I'd suggest enlisting the aid of a sports nutritionist—together they tell the athletes what's banned and not banned," says Maharam, who is also medical director of the New York City Marathon and several other marathons. He says a 45-minute seminar before the season starts would be a good starting point, and the physician and nutritionist should be available to answer individual questions. Maharam says physicians and nutritionists can also help identify and safely manage athletes who need to lose weight.
Resources are available for physicians who seek answers to athletes' drug and supplement questions. Maharam says he's had good results using the US Anti-Doping Agency hotline (1-800-233-0393).
Physicians who counsel athletes about supplements should know that ephedra isn't the only supplement that the FDA has concerns about. A useful resource is the supplement advisory section on the FDA Web site (https://www.cfsan.fda.gov/%7Edms/ds-warn.htm). Green adds that a useful teaching point for physicians is to warn athletes that many dietary supplements have been shown to contain amounts and substances that aren't listed on the package. Such additives can have unintended health consequences. An analysis of 20 ephedra products6 found that norpseudoephedrine, a schedule-4 controlled substance, was often present. "That's not a surprise," says Green of the results "The supplement industry is poorly regulated, and there are no penalties."
Green is deeply concerned that although ephedra packaging advises that people with cardiac conditions and other chronic illnesses should not take the supplement, some of those who take ephedra do so without knowing they have underlying conditions. He points out that the patients who participated in clinical studies of ephedra underwent extensive cardiac screening. Substances that come with such warnings should be used under a physician's supervision, he says. "If ephedra has legitimate medical uses, then let's make it a drug."
Better Bounce for Military Boots
Better insoles for military boots have long been on the wish list of physicians who treat military recruits. Demanding training and long work hours spent in boots without adequate shock absorption have led to a high occurrence of lower-extremity overuse injuries in soldiers.
Researchers from the University of Exeter, Great Britain, who reported their findings in the March issue of Medicine & Science in Sports & Exercise, have tested four models and settled on one that combines 6 mm of soft polyurethane foam attached to a stiffer, vinyl foam footbed with a raised heel. This insole had the greatest impact absorption, was most effective in slowing peak impact force, and reduced the bend of the ankle, which has been suggested to reduce Achilles tendon strain.
Of the four models tested, the standard-issue insole used in the United Kingdom's Royal Marines offered the least shock absorbency. The combination design that was most protective also offered the greatest durability.
How to Diagnose 'Hot Tub Lung'
Unwinding in a hot tub is common among active people, but a hypersensitivity to a bacterium spread by the hot water mist may make some patients ill. Flulike symptoms associated with hot tub use were first described in 1997. A November 2002 report in Mayo Clinic Proceedings presents two more cases and offers clues about the cause of the lung inflammation.
Researchers have known that the symptoms were caused by Mycobacterium avium complex growing in hot tubs, but it was not known if the lung symptoms represented an infection from or a hypersensitivity to the bacteria. Based on biopsies, radiographs, and the fact that the condition resolved without antibiotics, the Mayo Clinic researchers believe that hot tub lung is a hypersensitivy pneumonitis.
Clues to hot tub lung include progressively worsening respiratory symptoms and pulmonary function, along with ground-glass opacities on chest radiographs. The two patients in the Mayo study improved with the use of corticosteroids and discontinuing the use of indoor hot tubs. (The mist is not as easily inhaled when the hot tub is located outdoors.) Researchers suggest that physicians include routine questions about hot tub use in the workup of patients who have respiratory problems.