In this issue of American Family Physician, Drs. Jenkinson and Harbert review current evidence regarding common sports supplements.¹ Supplements are routinely used in attempts to increase athletic performance, enhance personal appearance, retain sexual vigor, and promote longevity. The use of sports supplements is not new; literature shows that ancient Greeks used deer muscle to enhance speed and lion heart to enhance bravery.² Increasing adulation (and compensation) of modern-day athletes has upped the ante even further. Some athletes are even willing to trade health risks for Olympic success.³ The use of sports supplements has also crossed into mainstream culture. Overall, 2 to 7 percent of high school students self-report using anabolic steroids,^4,5 with even more using creatine.⁶

Why do professional and recreational athletes use performance-enhancing supplements? The answer is simple—many of the supplements work. Unfortunately, in the 1970s, the medical community created a credibility gap with the athletic community by trying to convince high-level athletes that anabolic steroids were ineffective. However, athletes found that steroids clearly increased muscle bulk and significantly augmented athletic performance. As a result, athletes became reluctant to trust information from physicians about supplements.

Another factor that radically changed the landscape of supplement use was the Dietary Supplement Health and Education Act (DSHEA).⁷ Passed in 1994, the DSHEA effectively deregulated the sale of products marketed as nutritional supplements. DSHEA defines dietary supplements as products (other than tobacco) that are intended to supplement the diet and that contain a dietary ingredient. This dietary ingredient could be a vitamin, mineral, herb, amino acid, concentrate, metabolite, or almost any other naturally occurring substance. Because many commercial drugs are derived from natural compounds, the line between what is a drug and what is a nutritional supplement has become blurred. As a result, the supplement industry has exploded, with sales reaching nearly $20 billion per year.⁸ With associated promotional and quasiscientific material readily available in the locker room and on the internet, physicians are often the last source of information that athletes consult.

Physicians must, therefore, provide straightforward and accurate information when discussing sports supplements with athletes (young and old). Key points of discussion include the safety, effectiveness, legality, and ethics of supplement use. Although anabolic steroids are effective, they are not safe. Anabolic steroid use for performance enhancement is illegal and unethical, and should be strongly discouraged. Many other supplements, however, are legal and are safe when used in appropriate doses. Providing balanced information about sports supplements allows patients to make informed choices, maintains the credibility of the scientific community, and allows physicians to intervene when boundaries have clearly been crossed. It should be noted that the American Academy of Family Physicians opposes the use of drugs to enhance athletic performance.⁹