ABERDEEN PROVING GROUND, Md. – A recent U.S. Army Public Health Center study conducted with the U.S. Army Research Institute of Environmental Medicine and the Naval Health Research Center revealed active-duty service members were much more likely to use dietary supplements compared to U.S. civilians.
“Our study data found that service members tended to use different types of dietary supplements than civilians,” says Ryan Steelman, an APHC epidemiologist and co-author of several studies with the USARIEM and the NHRC. “Comparisons with previous military data also suggest dietary supplement use in the military population has increased over time.”
Dietary supplements as defined by the Food and Drug Administration are products taken by mouth, such as tablets, capsules, gummies, powders, drinks and energy bars, that contain one or more ingredients used to supplement the diet. These ingredients can include vitamins, minerals, herbs or other botanicals, and amino acids, as well as other chemical and manufactured substances.
The National Institute of Health’s Office of Dietary Supplements describes commonly used supplements as those which contain vitamins such as D and B12, minerals such as calcium and iron, herbs such as echinacea and garlic, and products such as glucosamine, probiotics, and omega-3 fatty acids.
“With the military active-duty members, products typically used to enhance physical performance are most popular,” says Steelman. “These include proteins, amino acids, and products that have a combination of substances, especially multiple stimulants.”
While nearly half of service members in one recent military study consumed sport-related nutritional supplements (sport drinks, sport bars, sport gels), Steelman says the self-reported adverse effects of these products were considered low.
“The dietary supplements that had the highest reports of adverse effects are marketed for weight loss, use before or after workouts, and prohormones,” says Steelman. Steelman and his USARIEM and NHRC colleagues investigated service members’ use of 163 products and found that 13 were of concern due to high proportions of adverse effects.
The study found over one in four persons had experienced an adverse effect. Data suggested higher risks of adverse effects associated with female gender, younger age, higher body mass index, smoking, higher alcohol intake, and consuming more supplements.
The NIH notes that a few dietary supplements may help improve some health conditions in unique populations. But most supplements have not been adequately studied. While inadequate data regarding effectiveness is a concern, the safety of the product – or its potential contaminants – is a greater concern.
The dangers associated with the dietary supplements that are especially attractive to service members have led to the recent publication of new policy on Use of Dietary Supplements in the Department of Defense.
The new policy mandates dietary supplement education for all service members. While this includes the teaching of basic awareness to soldiers and leaders, it will lead to standardized training for personnel who provide health-related services.
A key aspect of the training is to increase awareness of the DOD Prohibited Dietary Supplement Ingredients list. Service members cannot use products on the list without a DOD healthcare provider’s authorization. The list currently includes more than 800 substances. These include controlled substances, other substances banned by the World Anti-Doping Agency or other sports organizations, and other dangerous ingredients.
The list is publicly accessible on the Operation Supplement Safety website and is intended for DOD service members and healthcare professionals alike.
“What is important to understand is that the prohibited list describes ingredients, not the brand names of products sold,” says Andrea Lindsey, director of OPSS, a program under the Uniformed Services University’s Consortium for Health and Military Performance. “But the OPSS site and “Ask an Expert” helpline can help understand the ingredients on the label and determine whether the product should be avoided.”
“I’ve had soldiers ask whether a new product they want to take to enhance their performance or help lose weight is safe,” says Maggie Stover, an Army Public Health Nurse. “It’s an overwhelming question – but at least the OPSS website can assist us in our mission to advocate for the safety and health of the active duty population.”
Service members themselves are primary users of the OPPS site. Users can “Ask the Expert” questions like “Is product X safe?” or “Will I pop positive if I take product Y?”
Ingredients in supplements can be present in varying amounts and described as part of proprietary blends in products. Ingredients can also have several different names for one substance that might appear on a label. The OPSS website lists over 1700 synonyms for the 800 prohibited substances on the DOD Prohibited Dietary Substance Ingredients list.
One example is dimethylamylamine. While also known as DMAA, there are over 30 different possible names for this ingredient that may be used on a product label. Examples include Geranamine, also trademarked as Proviant, and methylhexanamine or MHA. DMAA, a stimulant, was developed as a nasal decongestant. In 2013 the Food and Drug Administration declared DMAA illegal for use as a dietary supplement ingredient since it increases blood pressure, which could lead to heart attack, shortness of breath, and tightening of the chest.
Unfortunately, DMAA is still used in some supplements that claim to help performance enhancement and weight loss. Products containing DMAA have been linked to serious adverse events such as liver injury, cardiac arrest, stroke, brain hemorrhage, and death following physical exertion. Service members are prohibited from using dietary supplement products containing DMAA but may not be aware of its presence in a product, especially if it is listed by one of its other ingredient names.
Because of the increasing number of products on the market with different ingredients or mixtures about which nothing is known, the DOD Prohibited Ingredients list will continue to grow as regulatory entities identify evidence of dangerous substances.
Since the new policy requires DOD healthcare providers to document service members’ use of dietary supplements, as well as any serious adverse effects, in the service member’s medical records additional data may help improve messaging to service members.
While the new policy states that retail facilities on military installations cannot sell products containing ingredients on the DOD Prohibited Ingredients list, service members and healthcare providers should not assume products purchased at a military exchange comply with the DOD policy.
“It’s a new policy, and products are constantly evolving with new ingredients and combinations of ingredients,” says Lindsey. “In addition to our website, we are available to answer questions and provide consults and training to achieve the objectives of the new DOD policy.”
Lindsey encourages everyone to bookmark the OPSS website and its “Ask an Expert” option to assist in making informed decisions about dietary supplements.
Stover also provides some common sense advice: “If something sounds too good to be true, it is. Save your money, and avoid the risks of dietary supplements – don’t take something your healthcare provider hasn’t recommended.”
The U.S. Army Public Health Center focuses on promoting healthy people, communities, animals, and workplaces through the prevention of disease, injury, and disability of Soldiers, retirees, family members, veterans, Army civilian employees, and animals through population-based monitoring, investigations, and technical consultations.
NOTE: The mention of any non-federal entity and/or its products is for informational purposes only, and not to be construed or interpreted, in any manner, as federal endorsement of that non-federal entity or its product