The NCAA News - News and Features

September 14, 1998

Creatine boom creates administrative challenges

BY KAY HAWES
STAFF WRITER

Nearly every home run Mark McGwire has hit recently has produced a mention in the media of two dietary supplements he has acknowledged taking -- creatine and androstenedione.

Creatine, a compound produced naturally in the human body from three amino acids, has been promoted as a way to build muscle mass and recover more quickly from workouts.

Androstenedione, also promoted as a way to build muscle mass and recover more quickly from workouts, is an adrenal hormone that is converted to testosterone in the body.

Androstenedione is banned by the NCAA and several other governing bodies in sports. However, creatine is not banned by any governing body in sports. It is enjoying a meteoric rise in popularity with athletes from the professional level all the way down to junior high school.

Much of the recent discussion about creatine -- in the media, in locker rooms and in athletics department offices around the county -- has produced debate about whether the substance is appropriate for college student-athlete consumption.

Also at issue is whether or not institutions should distribute it, encourage its use, advise students against taking it, or even ban it entirely.

A legal alternative to steroids?

Creatine is a compound that is found in meat and fish. It also is created by the human liver and kidneys. It first gained widespread popularity after the 1992 Summer Olympics in Barcelona, Spain, when gold-medalists Linford Christie (100-meter run) and Sally Gunnell (400-meter hurdles) credited their quick recovery and increased training to its use.

Now used by professional athletes such as the NFL's John Elway and Troy Aikman, Baltimore Orioles outfielder Brady Anderson and many others (including McGwire), creatine reportedly had sales exceeding $100 million last year. It has been estimated that sales of creatine will top $200 million this year.

Its manufacturers tout creatine as a safe and legal alternative to steroids, claiming that it builds muscle mass, adds energy and reduces recovery time.

Others in the scientific and medical community remain cautious.

The Association of Professional Team Physicians reported that 85 percent of its members recommend against taking creatine, pending further studies.

Of 115 professional sports teams surveyed about creatine use by USA Today, 71 teams responded and 21 opposed its use. While 16 teams approved, 34 teams left the question of creatine use up to their players.

The Tampa Bay Buccaneers have banned creatine from the locker room, and the San Diego Padres discouraged its use last season after attributing a string of hamstring and groin injuries to its use.

The NFL has a "cautionary general policy" on creatine.

Physicians and sports scientists at the annual meeting of the American College of Sports Medicine in late June were so interested in the topic that the meeting's session on creatine was standing-room only.

William J. Kraemer, a professor of applied physiology at Pennsylvania State University and Jeff S. Volek, a graduate student in kinesiology at Penn State, issued "Creatine Supplementation: Current Comment from the American College of Sports Medicine," a summary of what is -- and is not -- known about creatine.

The researchers said that they knew of no health hazards associated with creatine, but they added that the physiological mechanisms by which creatine enhances performance remain poorly understood. Also poorly understood are the long-term side effects.

"We don't really have a lot of answers, especially concerning the long-term effects," Volek told The Chronicle of Higher Education. "We know a lot about the acute effects of creatine loading, but there haven't been any long-term studies addressing issues of physiological adaptation or adverse side effects. This is a relatively new supplement."

Creatine's effects also seem to vary from one individual to another.

"The research shows that for some people it's effective at increasing body weight and muscle mass, and for some people it's not," said Priscilla Clarkson, professor of exercise science at the University of Massachusetts, Amherst.

Is it safe?

Like all supplements, creatine is not regulated by the Food and Drug Administration, nor is it subject to the testing procedures that apply to pharmaceuticals. Creatine is not considered a food either, so the substance's manufacturers are not required to list exact ingredients on container labels. (See "Athletes buying trouble with dietary supplements" in the May 11 issue of The NCAA News).

The FDA said in April that it was uncertain whether creatine "was absolutely safe for long-term use at levels currently being recommended."

The FDA also recommends that creatine be used only with a doctor's advice. However, its availability in chewing gum, flavored wafers and even as an additive in juice smoothies seems to indicate how unlikely it is that many consumers are consulting their doctor first.

Much of the discussion surrounding creatine's safety focuses on whether adequate research has been done on the supplement's long-term side effects.

"Creatine is a compound that has developed enormous popularity before there had been any organized research in the positive and negative effects of it," Baltimore Orioles orthopedist Dr. Michael Jacobs told The Baltimore Sun recently. "The companies that manufacture it have pushed it without the (scrutiny) that goes with pharmaceuticals."

Another individual associated with creatine research, Steven Scott Plisk, director of sports conditioning at Yale University, said, "There is a misperception that creatine has not been around very long and that little is known about it. In fact, it has been used in the United Kingdom since the early 1980s without any problems. There are well over 100 clinical trials, far more than would be expected if it were simply a body-building supplement. It's pretty impressive the amount of research done over the decades."

Plisk acknowledged that long-term research is lacking, but said that if creatine caused long-term side effects, there would be indicators in the shorter studies. "With anabolic steroids, you see some signs in the short term that warn you about what's coming in the long term," he said. "And you don't see any of that with creatine."

Short-term side effects that have been reported anecdotally include weight gain, stomach discomfort, dehydration, and muscle cramping, strains and pulls.

"Right now there have been no documented side effects, although most studies have only looked at it for three months," said Clarkson. "It seems fairly safe. We probably would have seen something if there were serious long-term side effects. We haven't seen people dropping in the streets or anything, but again, I would like clinical trials to be sure."

Plisk, who is writing a manuscript on creatine for the National Strength and Conditioning Association with Richard B. Kreider, an associate professor of human-movement sciences and education at the University of Memphis and a proponent of creatine's use, points to Krieder's online reviews as evidence that extensive research has been done on creatine.

Krieder's studies, some of which have been supported by Experimental Applied Sciences, a Colorado-based company that develops and distributes nutritional supplements, may be accessed online at www.css.edu/users/tboone2/asep/jan3.htm and www.sportsci.org/traintech/creatine/rbk.html.

"The point that a lot of people aren't getting is that creatine is part of a fuel pathway and the muscle effects are secondary," Plisk said. "Creatine does what a lot of sports supplements claim to do. It lets you train harder and build more muscle."

NCAA-sponsored research

While several studies have focused on whether creatine has a positive effect on performance, fewer have focused on the other effects of creatine use.

In June 1997, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports recommended funding for research on the "physiological effects of creatine other than performance."

This project was approved by the NCAA Research Committee, and grants were awarded to the University of Kansas, Pennsylvania State University and Georgia Institute of Technology. The one-year studies are beginning this fall, with a projected August 1999 completion date.

"The emphasis in these three projects is looking at the physiological effect of creatine use other than performance, both in a controlled laboratory setting and on the field," said Randall W. Dick, NCAA assistant director of sports sciences. "This area of research has not been emphasized in previous studies and is important information for our student-athletes and the sports medicine community as a whole."

Dick said that longer studies may be planned, depending on the preliminary results.

NCAA reviews creatine distribution

Before Management Council meetings this July, NCAA institutions in all three divisions were relying upon an official NCAA interpretation stating that it was "permissible to provide dietary supplements (e.g., weight-gain supplements, creatine) to student-athletes during the academic year but not during the summer."

For now, institutions in Division I and Division III may still provide those supplements to student-athletes, but Division II institutions may not. And, Division III institutions probably won't be able to provide the supplements after October.

A recommendation from the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports was forwarded to the Division II and III Management Councils and the Division I Championships/Competition Cabinet in July. The recommendation asked that the Management Councils sponsor noncontroversial legislation to amend NCAA Bylaw 16.4.2 to add the distribution of weight-gain muscle/strength-building supplements as a nonpermissible expense at all times.

In Division I, there was also Proposal No. 98-59, proposed legislation from the Big East Conference that also would amend Bylaw 16.4.2 to make such supplements a nonpermissible expense. The Division I Management Council referred the proposal to the Championships/Competition Cabinet and back to the Com_mittee on Competitive Safeguards and Medical Aspects of Sports.

"There was general concern and a significant breadth of opinion relative to the merit of such supplements," said Robert A. Bowlsby, chair of the Division I Management Council and athletics director at the University of Iowa.

"There was concern about distributing them from a budgetary standpoint and also some concern about where students might get them if they were not distributed by the institution," Bowlsby said. "There was just a feeling that the council wanted additional clarification on all of these issues."

Proposal No. 98-59 will be reviewed during the Championships/Competition Cabinet's upcoming meeting, as will the recommendation from the Committee on Competitive Safeguards and Medical Aspects of Sports. Previously, the cabinet has indicated that it supports the current interpretation, which permits supplement distribution during the academic year but not during the summer.

In Division II, the Management Council issued an interpretation that would not permit distribution of weight-gain muscle/strength-building supplements at any time. That interpretation is in effect now.

"We supported the position of the committee that these supplements should not be a permissible expense at any time," said Lynn L. Dorn, chair of the Division II Management Council and women's athletics director at North Dakota State University.

"In addition to that, we had a discussion about creatine and substances not on the banned list. We encouraged further study of those substances and their impact if they are performance-enhancing."

In Division III, the Management Council approved sponsorship of Division III-only noncontroversial legislation to amend Bylaw 16.4.2 to preclude providing weight-gain muscle/strength-building supplements to student-athletes at all times.

The council will review a draft of that noncontroversial legislation in October, and if approved, the legislation precluding institutions in Division III from supplying creatine to student-athletes would go into effect upon notification to the membership.

"The decision by the Management Council in Division III will send a clear message that we are concerned about the welfare of the student-athlete," said John S. Biddiscombe, chair of the Division III Management Council and athletics director at Wesleyan University (Connecticut).

"Given the limited information available about the substance, we thought it was inappropriate for institutions to distribute it to student-athletes. That's consistent with our philosophy not to provide enhancements to student-athletes that are not provided to other students."

Is distributing creatine a liability?

Could distributing creatine pose a potential legal liability to an institution? It's a question that many athletics administrators and even presidents are asking. Some institutions have decided to stop distributing the substance until more information is available.

"I think universities that distribute creatine -- or any supplement -- open themselves up to litigation," said Massachusetts' Clarkson. "I think that unless they can document that it's fully safe and effective, then they open themselves up to litigation. And they can't do that because long-term data are not there.

"At this point, I think institutions have to be responsible in what they provide and in the advice they give. I don't think they should facilitate creatine distribution."

The University of Maryland, College Park, football team conducted a six-week creatine trial last spring, but coach Ron Vanderlinden told The Baltimore Sun last month that the athletics department has prohibited university personnel from distributing creatine.

"As of last July, we are not permitted to use creatine," Vanderlinden said. "There is nothing that has proven to be detrimental. However, it's a new enough substance that long-term results still aren't really clear. So our athletics administration and medical community has said, 'Let's not do it until the results are long term.' "

Even if a university isn't distributing creatine, it can help its student-athletes with advice on what to use and where to get it, Yale's Plisk said.

"We've actually resolved a pretty good policy at Yale that I agree with," Plisk said. "We don't purchase it for our student-athletes, and we don't recommend it. But we try to give them no-nonsense information, and we refer our athletes to vendors that provide information about what they're purchasing."

Plisk warned that the market is being flooded with low-quality product, and he points out that purchasers should ask for a manufacturer's certificate of analysis.

"I can live with not providing it to the athletes because I understand the complexities of that," Plisk said. "But we still owe a duty to the kids not to stick our heads in the sand and say, 'Don't talk to me about it.' Our athletes know what it is. They hear about it; they read about it. Some of them even go to the library and read the studies on it."

NCAA General Counsel Elsa Kircher Cole cautions institution administrators to think their decision over carefully.

"A school needs to be as educated as it can be before it makes a decision to distribute a substance," Cole said. "If a student had an adverse reaction and sued, the school would likely be held to the standard of 'what information about the substance a reasonable person would rely upon in the course of his or her business.' "

Cole added, "In this kind of a situation, I think there could be a great deal of liability if the school fails to inform itself properly."

Is management a middle ground?

David Ellis, coordinator of performance nutrition at the University of Nebraska, Lincoln, said that requiring proper management of supplement use -- whether an institution decides to distribute creatine or not -- may be the answer.

"This kind of an issue is not black and white," Ellis said. "Management is the right solution. Supplementation is not going away. It's not going anywhere but up. This is going to be huge in our lifetime."

Ellis noted that media hype surrounding supplement use will continue to entice young athletes to take substances that are unproven and, perhaps, dangerous.

"The media seems to have a love affair with talking about silver bullets, and that makes them higher in these young athletes' eyes. The popular press is giving these people marketing exposure that they could never have gotten themselves."

The whole issue of food and food supplements should be managed by a professional, Ellis said.

"I think that it's time to mandate that NCAA Division I institutions hire qualified health professionals to do longitudinal body composition management and nutrition support," he said.

"It's just easier for everybody to say, 'I don't want to spend the money on a dietitian,' and take the cost-cutting road. Athletes will stop asking professionals in the athletics department and go ask people at the gym or at the (supplement) store."

Ellis notes that, along with planning feeding plans for student-athletes and tracking body composition, he also tracks claims from the supplement industry.

"If it is legitimate, we put it in a managed system. We don't leave it to the winds," Ellis said. "It can work to the advantage and to the welfare of the athlete. The key is that it requires management.

"If there's nobody managing it, then there's liability. Mom and Dad don't have to be right to hire a lawyer. Institutions need to have somebody who keeps up and who has a knowledge of the compound and doesn't deal with Joe Blow on the Internet."

Ellis also said that proper food management would reduce reliance upon supplements, as would changing current rules to permit more institution-subsidized meals.

"I'm an advocate of educating about the power of food supply. Food is our biggest ally for the health and well-being of these student-athletes," he said.

"And these kids need our help. One subsidized meal a day is simply not enough to address their unique needs. We need to deregulate feeding rules so we can have the power to feed and fuel a diverse population of student athletes.

"Give us the power to feed our athletes and you will disempower supplements."

Competitive-safeguards panel takes action against 'andro'

Neither creatine nor androstenedione are banned by Major League Baseball and both are supposed to increase strength, but that's where any similarities between the two end.

The difference between the two supplements -- from their modes of action to their very different classifications by the NCAA and other organizations -- is an important distinction to understand.

Pronounced "andro-STEEN-die-own," and often called "andro" for short, this substance is found naturally in the human body in the adrenal glands and in the gonads. It is also found naturally in meat and some plants, and it can be produced synthetically.

Androstenedione is referred to as a "metabolic precursor" to testosterone, because the body converts it into testosterone.

Athletes who use androstenedione typically experience elevated testosterone levels. More testosterone can translate into more muscle mass and more strength.

Androstenedione's elevation of testosterone levels also means the substance is banned by the NCAA, and it can be detected in a urinary drug test indirectly through the use of the testosterone/epitestosterone (t/e) ratio.

"Although it's not yet considered an anabolic steroid under the Anabolic Steroids Control Act, androstenedione is considered a banned anabolic agent by the NCAA," said NCAA director of sports sciences, Frank D. Uryasz.

Last year the NCAA Committee on Competitive Safeguards became aware of reports of androstenedione availability and began specifically listing the substance on the Association's list of banned substances. A direct method of detecting the substance itself is being developed.

Androstenedione's use as an ergogenic aid can be traced to East Germany, where it was reportedly administered as a nasal spray and orally, Uryasz said.

Androstenedione is also banned by the International Olympic Committee and the NFL, but not by MLB, the NBA or the NHL. Pittsburgh Steelers tackle Paul Wiggins was recently suspended for four games after he tested positive for androstenedione, and shot put world-record holder Randy Barnes faces a lifetime ban for using it.

While manufacturers of androstenedione say it does not pose the same hazards as anabolic steroids, the Association of Professional Team Physicians has cautioned that "its chemical structure is that of a steroid" and possible side effects might include heart and liver problems, acne, breast enlargement and personality disorders.

The substance's resemblance to anabolic steroids also has been cause for concern by officials within the NCAA.

"Androstenedione is an anabolic agent," Uryasz said. "The NCAA's concern about its availability caused the Association to contact the U.S. Food and Drug Administration and the U.S. Drug Enforcement Agency (DEA) in January. The DEA informed the NCAA that it was investigating whether this compound (and others) meets the definitions established under the Anabolic Steroids Control Act."

DEA representatives contacted for this article declined to comment for publication.

Like other supplements, androstenedione is available over the counter and it is not tested by the Food and Drug Administration (see "Athletes buying trouble with dietary supplements" in the May 11 issue of The NCAA News).

It is available in capsule and pill form, and while General Nutrition Centers -- the nation's largest nutritional supplement chain -- has taken androstenedione off its shelves, it is available at about 20 percent of the nation's Wal-Marts. It is also widely available over the Internet.

Androstenedione's availability, banned status and popularity with home-run hitter Mark McGwire should prompt coaches and athletics administrators to have a serious discussion about the substance with their student-athletes.

"NCAA student-athletes should be counseled to avoid the use of this compound," Uryasz said.

"Further, they should be warned that many supplement products do contain banned drugs, including androstenedione."

-- Kay Hawes

© 1998 National Collegiate Athletic Association