A dietary supplement is defined as a product intended to augment the diet that contains at least one of

the following (1):

•  Vitamin
•  Mineral
•  Herb
•  Botanical
•  Amino acid
•  Any dietary substance used to increase total dietary intake
•  Any concentrate, metabolite, constituent, extract, or combination of the above

As many as 53% of adult Americans take dietary supplements (2). The most common reasons given for taking supplements are:

1. Preventing/treating a perceived nutrient deficiency (e.g. individuals who spend most of their time indoors frequently suspect their vitamin D levels may be low)
2. Providing a convenient nutrient-delivery form (e.g. protein bars are quick, easily transportable, and frequently used by individuals who cannot otherwise readily eat a full meal)
3. Direct performance-enhancing effects or ergogenic (e.g. caffeine is believed by many gamers to enhance cognitive performance)
4. Belief that use of one or more supplements is ubiquitous in their field (e.g. supplement brand partnerships are commonplace in esports, and esports athletes)
5. Belief that other players’ routines, including supplements, are in part responsible for their success

Regardless of reason, it is important to understand that supplements aren’t, strictly speaking, necessary. In fact, it is impossible for a supplement to overcome a detriment in a fundamental area (sleep, stress, exercise, social situation, nutrition, hydration). It is best practice to recommend an individual focus on their fundamentals, and refer appropriately, BEFORE considering supplement use.

The most influential piece of legislature regarding supplements in the United States is the Dietary

Supplement Health and Education Act (DSHEA). This act, passed in 1994, allowed for the United States

Food and Drug Administration (FDA) to regulate dietary supplements as a food rather than as a type of

pharmaceutical drug.

Prior to DSHEA, supplement companies were directly responsible for proving clinical safety and efficacy

of their products. Only then would the product be allowed to enter the market.

Since the passing of DSHEA, supplement companies are allowed to put a product on the market without

approval (3). It has become the FDA’s responsibility, rather than the supplement company’s, to prove

adulteration/contamination, misbranding, or risk of illness/injury with any particular supplement.

For context, this change in process was considered a “win” for both supplement companies and the FDA.

The supplement companies didn’t like the lengthy and costly process of proving clinical safety and

efficacy prior to product release. The FDA didn’t have the manpower to review the countless new

supplements trying to enter the marketplace. DHSEA saves both of these parties considerable time and

money.

As products can enter the market without any review, the downsides for DHSEA lay entirely with the

consumer. It is not until AFTER enough reports that a product has hurt or killed individuals that the FDA

steps in and pulls the product from the shelf.

Savvy (and unethical) supplement producers can then turn around and do one of the following:

•  Pull the product, slap a new label on it, and put it right back on the market
•  Sell it to other supplement companies who then use the product as filler for their own

The consumer is not protected in any of these situations.

Another piece of DSHEA put the FDA in charge of establishing Good Manufacturing Processes (GMPs) to

ensure quality from supplement producers. In a recent report by the FDA, over 70% of manufacturers

are in violation of GMPs (4)!

Here are some relevant statistics on current supplement production:

• A meta-analysis of 23 different studies showed contamination rates in supplements to range from 12-58% (5)
• One study found 18.8% (45 of 240) of randomly tested supplements purchased in USA to be contaminated with anabolic androgenic steroids (6)
• Another study found 10-15% of supplements contain prohibited substances that would cause an individual to test positive on a drug test (7)
  • They further calculated that 6.4-8.8% of positive drug tests in professional athletes to be inadvertently caused by contaminated supplement use

Even if we take the lowest reported number (10%), this is quite scary. Here’s some perspective:

If you are religiously taking a single supplement, odds are that at least one batch in the year (assuming a monthly supply) is likely contaminated.

More important even than the positive drug test is the health risk associated with these contaminants.

In the world of supplements, contamination is understood to be any non-declared substance found within a particular product. As such, the list of possible contaminants is essentially infinite. Here is a list of some of the more common examples:

‘Heavy’ fillers (supplements are sold by weight, and replacing active ingredient with a heavy filler can cut costs drastically)

• Sand
• Gravel
• Metal filings
• Unintentional impurities (normally due to poor facility management)
• Bugs
• Dirt
• Waste

Cross contamination with other compounds that share the same equipment (again, normally due to poor facility management) Intentional adulteration (to improve likeability of a product)

• Steroids
• Stimulants
• Other performance enhancing compounds

Depending on the combination of impurities ingested, the negative potential health effects can vary widely. Some of the most common serious effects include:

• Hepatotoxicity
• Cardiac issues
• Hormonal issues
• Carcinogenesis
• Death

However, the extent of damage isn’t limited to physical health. An esports athlete testing positive on a drug test can lead to social damage, loss of sponsors, and direct sports penalties. All of this should not be taken lightly!

Due to this massive problem, several companies have been created that conduct 3 rd party testing for supplements. These companies have no financial conflict of interest with the supplement producer. They do the following:

•  Audit the facility to ensure GMP standards are adhered to
•  Test batches to ensure what’s on the label matches the contents
•  Drug test the product to ensure there are no drugs that would test positive on a drug test
•  Ensure there are no unsafe levels of contaminants

The downside to having these companies is that 3rd party verified supplements tend to cost more. They need to pass the cost of getting the certification on to the consumer in order to ensure profitability (it costs as much as 10,000$ per batch to get tested). Also, the cost of testing is normally prohibitive for newer and smaller supplement companies, meaning you see big brands dominate the space.

• A quick note on pharmaceutical grade supplements – they also are held to a similarly high standard, but are typically only available through clinicians.

The most common 3rd party verification companies are as follows:

•  NSF for Sport
  • https://www.nsfsport.com/

•  Informed Sport
  • http://www.informed-choice.org/

•  Informed Choice (slightly less diligent than Informed Sport)
  • https://www.informed-sport.com

•  BSCG
  • https://www.bscg.org/

•  Consumer Labs
  • https://www.consumerlab.com/

•  USP (specifically for vitamins/minerals)
  • www.usp.org

You can go to each of these websites and type in whatever product you want (e.g., protein powder). The results will be all of the products they have verified, which you can then use as a shopping list.

It makes no difference which company you go with, however, I will note that many organizations only officially recognize NSF as it is the most popular. Here are some notes from my personal practice:

•  For vitamins/minerals, I search USP first
•  For non-vitamins/minerals, I search NSF first
  • If NSF yields too few results, or products that aren’t exactly what I’m looking for, I will then search Informed Sport, then Informed Choice
•  Upon last check, BSCG has the only verified CBD products
•  I normally don’t use Consumer Labs as it has a paywall

Verified does not mean safe and effective. It only means that what’s on the label matches what’s inside
and that it won’t make you flag on a drug test.

There are many supplements with minimal long-term safety data. Also, many products are built by
combining ingredients. The ingredients may be safe individually, but the product can hit the shelves
before we know what happens when the ingredients are mixed together (this is a serious issue, think
back to your chemistry classes and remember how individually safe/stable compounds can cause all
sorts of reactions when mixed).

The most prevalent issue is poor dosing. Supplements are expensive to produce, so the companies will
play off your ignorance to cut corners. For example, they know that consumers have heard omega-3
fatty acids are good for them. They also know that 99% of consumers have no idea what dose is needed
to be clinically effective. They can get away with a dose that is not effective at all and cut their costs
considerably. I laugh when I see fish oil capsules where a single serving provides 250mg of omega-3. You
need ~10x this dose in a day!

The last point I want to share is that based on your individual circumstances, the supplement could be
anywhere from harmful to beneficial. Big range, right? It’s impossible to know without first considering
your unique situation. Genetics is one example – people are inherently responders or non-responders to
certain supplements based off their DNA.

In short, the unfortunate reality is that it is far more likely that what works for one individual won’t work
for another.

As a healthcare professional, if you are going to recommend a supplement, the hardline you should take
is to recommend only 3rd party verified supplements. This protects both you and the consumer.
If you are unsure if a particular supplement is right to recommend for a specific individual, then consult
a performance dietitian. They’ll also be able to recommend an exact dosing protocol.

1. S. 4325–103rd Congress: Dietary Supplement Health and Education Act of 1994. Public law 103-
417, October 25, 1994.

2. Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT. Why US adults use dietary supplements.
JAMA Intern Med. 2013;173:355-361.

3. Mathews NM. Prohibited Contaminants in Dietary Supplements. Sports Health. 2018
Jan/Feb;10(1):19-30. doi: 10.1177/1941738117727736. Epub 2017 Aug 29. PMID: 28850291;
PMCID: PMC5753965.

4. Long J. FDA GMP inspectors cite 70% of dietary supplement firms. Natural Products Insider.
2013.

5. Martínez-Sanz JM, Sospedra I, Ortiz CM, Baladía E, Gil-Izquierdo A, Ortiz-Moncada R. Intended or
Unintended Doping? A Review of the Presence of Doping Substances in Dietary Supplements
Used in Sports. Nutrients. 2017 Oct 4;9(10):1093. doi: 10.3390/nu9101093. PMID: 28976928;
PMCID: PMC5691710.

6. Geyer, H., Parr, M. K., Mareck, U., Reinhart, U., Schrader, Y., & Schänzer, W. (2004). Analysis of
non-hormonal nutritional supplements for anabolic-androgenic steroids – results of an
international study. International journal of sports medicine, 25(2), 124–129.
https://doi.org/10.1055/s-2004-819955

7. Outram, S., & Stewart, B. (2015). Doping through supplement use: a review of the available
empirical data. International journal of sport nutrition and exercise metabolism, 25(1), 54–59.
https://doi.org/10.1123/ijsnem.2013-0174