Filed under: Risks
Service members should be careful about taking dietary supplements because many of these products contain hidden active ingredients that can result in harmful effects.
The most common types of dietary supplements found to contain “undeclared” ingredients (that is, substances not listed on the label) are those marketed for weight loss, sexual enhancement, and bodybuilding. The Food and Drug Administration (FDA) has identified over 600 tainted dietary supplements. FDA specifically warns against the use of products that claim to be “alternatives” to FDA-approved drugs or “legal” alternatives to anabolic steroids.
Dietary supplements don’t require approval by FDA before being put on the market, and without laboratory testing there is no way to know the contents of a product. If you’re considering a dietary supplement, be sure to check the label to see if the product has been evaluated by an independent third-party organization.
For more information, please visit Operation Supplement Safety (OPSS), including the OPSS High-Risk Supplement List.
An “adverse event” can occur as a result of taking some dietary supplements. Learn how to identify an adverse event from the Operation Supplement Safety (OPSS) FAQ, and find out where you can go to report one. And for healthcare providers, HPRC has a helpful video, “How to probe for dietary supplement use and report adverse events.” (Click on the “Video” tab to access the link.) Documenting adverse events is an essential part of how the Food and Drug Administration (FDA) evaluates potentially dangerous dietary supplements, so it’s very important to report potential problems.
For older men, it’s especially important to lead a healthy and physically active lifestyle since the risk for certain chronic diseases increases with age. Multiple studies have found that as little as 30 minutes a day of moderate- to vigorous-intensity exercise can significantly lower a man’s risk for heart disease and related risk factors such as diabetes, high cholesterol, and high blood pressure. Age is also a significant risk factor for developing prostate and colorectal cancers, which makes prevention and risk-factor management even more important for older men.
Exercise has been linked to lower risk and rates of death for prostate, lung, and colorectal cancers, the three most common cancers experienced by men. So get out there! Take a brisk walk, go for a jog, swim, bike, play tennis, even certain heavy outdoor yard work is acceptable for this purpose. If you need more structure, try a gym—many fitness centers offer military discounts on memberships and personal training sessions. Some military facilities also offer group and family recreational activities. The important thing is to find an exercise routine that you enjoy. If it’s not fun or motivating then it’s not likely to become part of your lifestyle.
The benefits of an active lifestyle are numerous, but prevention is one goal to keep your regular exercise program on the right track. Be sure to consult with your physician before starting an exercise routine, especially if exercise is new for you. Living a healthy lifestyle and getting screened for health complications are important ways to maintain readiness, resilience and optimal performance.
Bitter orange is an extract from the immature green fruit of the Citrus aurantium plant, also known as Seville orange. It is sometimes used in small amounts in food as a flavorant and often used in weight-loss supplements. The terms “bitter orange,” “bitter orange extract,” or “Citrus aurantium” are often used interchangeably with the ingredient name “synephrine,” but bitter orange (the extract from Citrus aurantium fruit) is actually a complex mixture of many compounds, including synephrine and octopamine. Although both synephrine and octopamine occur naturally in the Citrus aurantium plant, they also can be made in a laboratory.
Many safety concerns have been raised with regard to synephrine and octopamine, which are both stimulants. The National Collegiate Athletic Association (NCAA) bans both of them, but the World Anti-Doping Agency (WADA) bans only octopamine. Bitter orange is frequently used in "ephedra-free" products since 2004, when the Food and Drug Administration (FDA) banned ephedra for its association with serious adverse cardiovascular effects. Combinations of stimulants—such as bitter orange and caffeine, commonly found together in weight-loss and bodybuilding products—can cause hypertension and increase heart rate in otherwise healthy adults. A major concern with products that list bitter orange (or synephrine, or octopamine) on the label is that the amount of stimulants in the product is sometimes very difficult—if not impossible—to determine. Service members should exercise extreme caution when considering whether to use supplements containing bitter orange.
No conclusive, peer-reviewed, scientific evidence clearly establishes that bitter orange is any safer than ephedra. For more information on bitter orange and ephedra, read the monographs in HPRC’s Dietary Supplement Classification System series.
For more answers to common questions we’ve received about dietary supplements, please visit our Operation Supplement Safety (OPSS) FAQs.
Lately, HPRC has been receiving a lot of questions about the use of banned supplements in the military, but the fact is: There isn’t a list of banned dietary supplements currently available. It isn’t always easy to determine whether a dietary supplement product is safe or not, so the Department of Defense (DoD), together with HPRC, provides helpful resources on the Operation Supplement Safety (OPSS) website to help you choose supplements wisely. With regard to the military’s stance on supplements in general, please see the OPSS FAQ about a "banned list," which is pertinent to all service branches.
Some dietary supplements, including ones sold on military installations, contain potentially harmful and problematic ingredients. For some tips about how to avoid these, read the OPSS infosheet “Red Flags—What You Need to Know.” In addition, some other potentially dangerous ingredients include prescription drug ingredients and their analogs, drugs banned by FDA for safety reasons, controlled substances (such as anabolic steroids), and untested/unstudied new active drug ingredients, which may not be listed on the product label.
One way to ensure that a dietary supplement product is safe is to see if it is third-party verified. Third-party certification organizations have developed criteria for evaluating and authenticating the quality of a supplement—the ingredients, the dosage levels, the level of contaminants, the label claims, and whether the manufacturing facilities follow Good Manufacturing Practices (GMP).
The Natural Medicines Comprehensive Database (NMCD) is the gold standard for evidence-based information on dietary supplement products and ingredients and is an HPRC partner. (Subscription is free if you have a “.mil” email address; visit the OPSS FAQ for more information.) NMCD rates products on a scale of 1 to 10 based on safety and effectiveness. We encourage you to consider only using products rated 8 or above.
To avoid potential problems, talk with your healthcare provider or dietitian before using dietary supplements. Also, see FDA’s list of tainted bodybuilding products, which includes important public notifications.
Operation Supplement Safety (OPSS) is a joint military initiative between the Human Performance Resource Center (HPRC) and the Department of Defense (DoD) to educate service members and retirees, their family members, leaders, healthcare providers, and DoD clinicians about dietary supplements and how to choose them wisely.
OPSS has partnered with Natural Medicines Comprehensive Database (NMCD) to provide all DoD personnel with access to evidence-based information on dietary supplements, including Natural Medicines Brand Evidence-based Ratings (NMBER)®.
Now there is an Operation Supplement Safety & Natural Data (OPSS & ND) app available that can help you make an informed decision by giving you:
- Dietary supplement safety and effectiveness (NMBER) ratings.
- Interaction ratings between drugs and natural medicines, known as “adverse reactions.”
- Effectiveness ratings for natural medicines by medical condition and more.
To access the app you must first visit HPRC’s link to NMCD and sign up for your free account. Click on the Warfighter version and use your valid .mil email address. Once you’ve created your free account you will have access to the full version of the app. Up-to-date reviews of commercially available products, Natural Medicines Brand Evidence-based Ratings (NMBER)® for commercially available products, an Effectiveness Checker, and more will be at your fingertips.
If you have questions, please use the “Ask the Expert” button on the OPSS home page.
West Nile. Dengue. Malaria. Chikungunya. No, that’s not a typo. Chikungunya (pronounced “chik-en-gun-ye”), a mosquito-borne virus that primarily occurs in Africa, Asia, and the Indian subcontinent, and Warfighters deployed to these regions have been exposed to this risk for some time, now, however, it is reportedly spreading to Europe and the Americas. Most of the cases in the U.S. involve individuals who have recently traveled abroad, but the Centers for Disease Control and Prevention (CDC) just reported the first locally acquired case, in Florida.
The viral illness is characterized by fever and severe joint pain, but other symptoms include headache, muscle pain, joint swelling, and rash. There is currently no antiviral drug for Chikungunya, and treatment is aimed at relieving symptoms. Most patients will recover fully on their own, although sometimes symptoms persist for several months.
It’s important to know your environment. If you’re being deployed to these regions or even going there on vacation, there are things you can do to protect yourself from mosquito bites and mosquito-borne infections. Wearing long pants, shirts with long sleeves, and insect repellent while outdoors reduces the chance of an insect bite. Other precautions include removing standing water from containers such as flowerpots and buckets and placing screens over open windows and doors.
If you think you could have been infected, you should see your doctor, especially if you have recently traveled to high-risk regions. Visit the Center for Disease Control (CDC) for more information about Chikungunya.
Inhalation of major air pollutants has been found to decrease lung function and exacerbate symptoms of exercise-induced bronchospasms, including coughing, wheezing, and shortness of breath. In order to meet oxygen demands during light- to moderate-intensity exercise, you take in more air with each breath. And when you breathe through your mouth, you bypass the nose’s natural filtration of large particles and soluble vapors. As your exercise intensity increases, you breathe faster and deeper, which also increases the amount of pollution inhaled and the depth it travels into your respiratory system.
If you live in or near a busy city, you are exposed to even more combustion-related pollutants—such as nitrogen oxides (NOx), carbon monoxide (CO), particulate matter (PM), and ozone—that can inflame your airways and worsen asthmatic responses. Exposure to freshly generated emissions is most common near areas of high vehicular traffic.
While indoor exercise is often a good alternative to limit exposure to outdoor pollutants, some indoor conditions may be just as toxic. Nitrogen dioxide (NO2)—the more toxic NOx—is usually higher in gas-heated homes and indoor areas with poor ventilation. Carbon monoxide poisoning is also more likely to occur indoors. When carbon monoxide is in your system, the blood carries substantially less oxygen, reducing performance and eventually leading to carbon monoxide poisoning. Be sure to choose well-ventilated areas for indoor exercise.
Particulate matter and ozone are two significant pollutants you may be exposed to outdoors. Inhalation of high levels of particulates has been shown to reduce exercise performance as much as 24.4% during short-term, high-intensity cycling. Women may be more vulnerable than men to certain particulates, associated with greater decrements in performance. Ultrafine particle concentrations are highest in freshly generated automobile exhaust, and these small particles can be carried deep into the lungs. However, the further away you are from fresh exhaust, the less concentrated the particulates.
Bad ozone occurs lower in the atmosphere; it is not directly emitted into the air but is created from chemical reactions between NOx, volatile organic compounds (VOCs), heat, and sunlight. Ozone levels also are higher in summer than in winter; and especially in larger, hotter cities, concentrations tend to peak around midday when solar radiation is highest. Exposure to ozone during exercise has been found to increase resting blood pressure, reduce lung function, and decrease exercise capacity.
The risks associated with not exercising at all are far greater than the risks of exercising outdoors; it just takes a little more planning on days and in conditions when pollution is bad. When planning outdoor exercise activities, follow these tips to limit your exposure to pollutants:
- Avoid exercising in areas of heavy traffic, such as along highways and during rush hour.
- During summer, exercise earlier in the morning, when ozone levels and temperatures are not as high.
- Check the domestic or international air-quality ratings to determine if it’s safe to exercise outside. Limit your time outside on Code Red and Code Orange days. Environmental conditions on these days are not healthy, especially for children, the elderly, and people with existing respiratory conditions.
- Exercise indoors when the air quality indicates high ozone and particulate levels.
- Before any demanding physical activity, limit your carbon monoxide exposure by avoiding smoky areas and long car rides in congested traffic.
Last summer the Netherlands removed the weight-loss dietary supplement product Dexaprine from the market due to reports of serious adverse events, but the results of research into the cause has just been released. A recent article in Drug Testing and Analysis described at least 26 cases of Dexaprine toxicity reported to the Dutch Poisons Information Center. Testing revealed the existence of “a cocktail of synthetic stimulants” including synephrine, oxilofrine, deternol, yohimbine, caffeine, and theophylline, and possibly ß-methyl-ß-phenylethylamines. (Problematic forms of phenylethylamines, including ß-methylphenylethylamine. were discussed in an April 2014 article in the New England Journal of Medicine.) For more information about tainted weight-loss dietary supplements, see the Food and Drug Administration’s information. Note that this product is still available in the U.S. and online.
Do you really know what’s in your energy drink? HPRC put together a new resource that points out some common ingredients found in energy drinks. Our ingredient label includes some hidden sources of caffeine and other ingredients that can have stimulant effects on your body. It also highlights other information that you might see on a label, including warnings. So check out the energy drinks infosheet, and then go to Operation Supplement Safety (OPSS) for more information about how to choose dietary supplements safely.