Scars

Skin is an important barrier that protects the body from outside elements.  After ones skin breaks, the body starts to heal itself.  During the healing process, the body may not produce the exact epidermal layer as before, resulting in scars that can become upsetting and unsightly.  Preventing and treating scar tissue formation is best done by limiting physical/chemical trauma or infections which cause inflammatory reactions that increase the prevalence of scars.¹ 

Overview

Many OTC scar treatments are classified as cosmetics.  If the product were to be classified as a drug, data is needed to show that the product is both safe and effective.  Cosmetics on the other hand are not required to register with the FDA, and do not need safety or efficacy data.  Therefore, it is common for manufacturers to claim that cosmetic results vary by individual, making the company not responsible for an ineffective product.² 

Vitamin E

Vitamin E ointment is an oil based agent that has antioxidant capabilities.  Research has shown that the topical application of Vitamin E is no more effective at treating scars than non-medicated emollient type ointments (Aquaphor).  Vitamin E ointment may also­­­ irritate the skin more than Aquaphor.^1,2  With the current literature review, Vitamin E ointment does not appear to be effective in treating the appearance of scars.

Mederma

Mederma is a popular ointment consisting of onion extract as its active ingredient (Allium cepa) which is thought to provide anti-proliferative and anti-inflammatory effects.  Research has not found significant differences in scar appearance after 12 weeks of post-op application when comparing Mederma and Aquaphor.³   Further studies have shown that onion extract gel is no more effective than petrolatum (Vaseline) at treating redness and itching.^4,5  Additionally, most studies conducted using  Mederma are poorly designed and have not shown positive results relating to scar treatment.¹  Therefore, until further well conducted studies are available, Mederma should not be considered an effective product.

 

Silicone

Silicone may help in scar reduction by keeping the tissue moist, modulating growth factors, and increasing a static charge.^2,6  A benefit to silicone is that it has very few side effects and can be used for up to 12 hours per day for 3-6 months.⁷  Individuals at a high risk of developing abnormal scars may be treated with silicone gel sheets (Neosporin Scar Solution Silicone Scar Sheets, Scar FX Silicone Sheet, Dr Blaine’s Complete Scar Care Treatment) or silicone gels (2^nd Skin Scar Gel) as research indicates that their use reduces scarring.²  Limited information indicates the efficacy of silicone sheets in decreasing the appearance of scars, therefore additional research is needed to confirm this treatment option.

 

Pressure

Mechanical pressure (compression of the scar site) has been shown to decrease the production of scars.¹  Although some clinicians question the practice of mechanical pressure, research to determine the effectiveness of this procedure is unethical as it would withhold accepted treatment from control subjects and will subsequently not be conducted.⁶ Therefore mechanical pressure will continue to be used until proven ineffective.

MEBO (Moist exposed burn ointment)

MEBO (moist exposed burn ointment) is a Chinese herbal compound that also contains sesame oil and beeswax.  MEBO is very oily compound that has a strong odor.  Studies have found that the administration of MEBO decreases scaring and redness.^1,8  One study found that those with partial thickness skin grafts, when treated with MEBO, had significantly better scar quality and wound healing compared to Tegaderm, topical antibiotic ointment, and Sofra-Tulle dressing.⁸  Another study compared MEBO and silver sulfadiazine administration in burn victims.  The results found similar healing rates with easier visibility to the healing process in MEBO than the opaque silver sulfadiazine.  Although MEBO is less expensive than silver sulfadiazine, MEBO needs to be applied more often, increasing labor costs.⁹ Additional research continues to show that MEBO decreases treatment time and reduces infection risk (consequently decreasing scar risk). ¹⁰  MEBO is safe and effective in pregnant women and infants.¹¹  MEBO should be applied every 4-6 hours to exposed wounds or every 10-12 hours for covered wounds.¹¹  Therefore, research indicates that MEBO is effective, but additional studies are needed to solidify this data.

Conclusion

In conclusion, it appears that Vitamin E ointment and Mederma are not effective in treating the appearance of scars.  Most studies find that Vitamin E ointment and Mederma have equivalent treatment outcomes compared to Aquaphor, with Aquaphor costing significantly less.  After surgery, mechanical pressure at the surgical site is the standard of care to decrease scar tissue formation.  This will continue to be the standard of care until proven otherwise.  Silicone may eventually prove to be effective in scar treatment but additional research is needed for this to occur.  MEBO does appear to be effective at decreasing scar appearance.  Additional research needs to be conducted on MEBO to include it in standard of care guidelines for treating and preventing scars.   In conclusion, additional research needs to be conducted on all treatments in order to determine what the appropriate standard of care should be when treating and preventing scars.

 

 

Citations:

1. Chen MA and Davidson TM.  Scar Management: Prevention and Treatment Strategies.  Current Opinion in Otolaryngology & Head and Neck Surgery. 2005. 13:242-247.
2. Morganroth P, Wilmot AC, Miller C.  Over-the-Counter Scar Products for Postsurgical Patients: Disparities Between Online Advertised Benefits and Evidence Regarding Efficacy.  Journal of the American Academy of Dermatology.  2009. 61:e31-47.
3. Chung VQ, Kelley L, Marra D, Jiang SB.  Onion Extract Gel Versus Petrolatum Emollient on New Surgical Scars: a Prospective Double-Blinded Study. Dermatologic Surgery. 2006. 32:193–197.
4. Jackson BA and Shelton AJ. Pilot Study Evaluating Topical Onion Extract as Treatment for Postsurgical Scars. Dermatologic Surgery. 1999. 25: 267–269.
5. Saulis AS, Mogford JH, Mustoe TA.  Effect of Mederma on Scarring in the Rabbit Ear Model.  Plastic and Reconstructive Surgery. 2002. 110;1:177-183.
6. Shih R, Waltzman J, Evans GRD.  Review of Over-the-Counter Topical Scar Treatment Products.  Plastic and Reconstructive Surgery.  2007. 119;3:1091-1095.
7. Mutalik S.  Treatment of Keloids and Hypertrophic Scars.  Indian Journal of Dermatology Venereol Leprol. 2005. 71:3-8.
8. Atiyeh BS, Amm CA, El Musa KA.  Improved Scar Quality Following Primary and Secondary Healing of Cutaneous Wounds. Aesthetic Plastic Surgery. 27;5:411-417.
9. Ang ES, Lee ST, Gan CS, See P, Chan YH, Ng LH, Machin D.  The role of alternative therapy in the management of partial thickness burns of the face–experience with the use of moist exposed burn ointment (MEBO) compared with silver sulphadiazine.  Ann Acad Med Singapore.  2002. 29(1): 7-10.
10. Al-Numairy, Ali. Clinical Use of MEBO in Wounds Management in U.A.E.  International Journal of Cosmetic Surgery & Aesthetic Dermatology. 2000. 2;1:27-33.
11. Wound Healing- MEBO.  Sekunjalo Health Care.  [2010-2012}. 10/14/2012. http://www.sekhealth.com/Wound_Healing.aspx.

Green Tea

Green Tea Extract and Weight Loss

For centuries green tea has treated ailments in countries such as China and Japan.  Only recently has it become a hot topic in the West.  Current research has shown that green tea extract may help prevent or delay the onset of Parkinson’s disease and certain cancers (bladder, esophageal, ovarian, and pancreatic).  Greater evidence shows the ability of green tea extract to treat genital warts.  This article though will specifically focus on green tea ability to aid in weight loss.1,2,3

Green tea is steamed (black and oolong teas are fermented) which inactivates oxidative enzymes and helps maintain the chemical properties within the tea leaves, specifically caffeine and epigallocatechin gallate (EGCG).  Although caffeine has been shown to have weight loss properties, EGCG is the clinically relevant compound in green tea extract that is thought to aid in weight loss.  Researchers are currently unsure of EGCG’s mechanism of action but think that it involves thermogenesis (increasing energy expenditure).1,3,4

Research
Currently, contradictory evidence is available pertaining to the efficacy of green tea extract and the initiation of weight loss.4,5,6,7 Additional research has found that green tea extract does not help one maintain a lower weight after substantial weight loss.7  Other findings suggest that green tea extract is less effective in people who consume high amounts of caffeine on a daily basis.6,7  Studies also conclude that people of Asian heritage have a greater weight loss response to green tea extract than Caucasians.  This may be linked to caffeine consumption, not genetics, as Asians tended to consume less caffeine than Caucasian in the conducted studies.6

Dosing
EGCG:  Normal dosages for weight loss trials range from 270 to 800mg per day of epigallocatechin gallate and 125 to 625 mg/day of other catechins.  At this time daily dosages of up to 800mg per day for four weeks have been tolerated and are considered safe.1,2
Caffeine:  On average a cup of green tea contains about 10-80mg of caffeine.1  Green tea supplements are not regulated and can have higher or lower amounts of caffeine.

Drug Interactions:
Amphetamines/Ephedrine:  In theory green tea may increase the risk of severe adverse effects such as MI, stroke, and seizure.
Anticoagulants/Antiplatelets:  Green tea may increase bleeding risks in patients who also take antiplatelet (clopidogrel) or anticoagulant (warfarin) medications.  Concerns also exist as green tea may have Vitamin K activity, counteracting warfarin’s effects.
Cimetidine (Tagamet):  Cimetidine decreases caffeine clearance, therefore increasing caffeine concentrations within the body.
Folic Acid: Green tea consumption may decrease the bioavailability (how much the body is able to use) of folic acid.
Iron:  Green tea consumption may decrease the iron absorption.1,2

Adverse Effects:  Side effects include headache, dizziness, bloating, upset stomach, gas, and diarrhea.  Adverse effects specifically related to caffeine are nervous system side effects such as dizziness, insomnia, agitation, and tremors but are mainly seen in high doses.  Case reports have found that very high blood concentrations of green tea extract and its metabolites can be hepatotoxic.1,2

Conclusion
Research indicates that persons of Asian heritage and those consuming low daily amounts of caffeine have the greatest efficacy when using green tea extract for weight loss.  The addition of green tea extract to a diet regimen should be considered safe if the dose is not more than 800mg/day of EGCG for more than 4 weeks.  One should consult their primary care provider or a healthcare professional before starting a new medication regimen.  Therefore, green tea extract may not be an effective weight loss product for all, but it can provide a select group of people an advantage to help lose weight.

Citations
1. Green Tea Extract.  Natural Medicines Comprehensive Database.  09/24/2012.
2. Green Tea Extract.  Lexi-Comp Online.  09/24/2012.
3. Shixian Q, VanCrey B, Shi J, Kakuda Y, Jiang Y.  Green Tea Extract Thermogenesis-Induced Weight Loss by Epigallocatechin Gallatte Inhibition of Catechol-O-Methyltransferase.  Journal of Medicinal Food.  2006;4:451-458.
4. Dulloo AG, Duret C, Rohrer D, Girardier L, Mensi N, Fathi M, Chantre P, Vandermander J.  Efficacy of a Green Tea Extract Rich in Catechin Polyphenols and Caffeine in Increasing 24-H Energy Expenditure and Fat Oxidation in Humans.  The American Journal of Clinical Nutrition.  1999;70:1040-1045.
5. Diepvens K, Kovacs EMR, Vogels N, Westerterp-Plantenga MS.  Metabolic Effects of Green Tea and of Phases of Weight Loss.  Physiology & Behavior.  2006;87:185-191.
6. Hursel R, Viechtbauer W, Westerterp-Plantenga.  The Effects of Green Tea on Weight Loss and Weight Maintenance: a meta-analysis.  International Journal of Obesity.  2009;33:956-961.
7. Kovacs EMR, Lejeune MPGM, Nijs I, Westerterp-Plantenga MS.  Effects of Green Tea on Weight Maintenance After Body Weight Loss.  British Journal of Nutrition.  2004;91:431-437.

Coenzyme Q10

Coenzyme Q10

Coenzyme Q10 (ubiquinone or CoQ10) is a fat-soluble vitamin that acts as an antioxidant, cell
membrane stabilizer, and a cofactor in metabolic pathways (ex. synthesizes ATP during oxidative
respiration).1,2,3,4 Ubiquinone is produced by the body and decreases after 20 years of age. With
CoQ10’s antioxidant activity, people may think that additional supplementation may increase one’s
lifespan, but this is not true. 4

Relationship with Athletics
Research has found that Coenzyme Q10 improves oxygen transport in cardiac cells mitochondria.
In theory then, Coenzyme Q10 increases heart muscle oxygen intake, leading to increased athletic
performance and endurance.3 Other research has shown that CoQ10 supplementation protects against
creatine kinase and lactate dehydrogenase leakage from muscles.2 When these enzymes stay inside
muscles, the ability of the muscle to increase energy production (ATP production) improves.

Is CoQ10 Effective in Enhancing Athletic Performance?
Research has found that when testing CoQ10 administration and athletic performance, increased serum
CoQ10 levels do not equate to a significant increase in athletic performance. 1,5,6 One published study
did show an increase in anaerobic performance, but was conducted with sedentary males, not athletes. 7
The majority of research showing a positive relationship between CoQ10 and athletic performance were
not presented in peer-reviewed journals, but at conference proceedings, decreasing the weight of the
studies outcomes.8

Coenzyme Q10 supplementation is thought to be able to treat or enhance the treatment of coenzyme
Q10 deficiency, certain mitochondrial dysfunctional disorders, congestive heart failure (CHF), HIV/
AIDS, hypertension (high blood pressure), statin (Lipitor, Zocor, etc.) induced muscle pain, migraine
headaches, and may decrease the risk of cardiac events after a heart attack (MI). 4,9,10

Anthracyclines: Doxorubicin (Adriamycin) is a chemotherapeutic agent that causes cardiotoxicity.
Recent research has indicated that this may be due to its inhibition of CoQ10 mitochondrial enzymes in
the heart. Preliminary research suggests that CoQ10 supplementation may protect against doxorubicin
induced cardiotoxicity.4,9

Blood Pressure: Literature has indicated that beta-blockers such as propranolol (Inderal) and metoprolol
(Lopressor, Toprol XL) when coadministered with CoQ10 may lead to an increased risk of hypotension
(low blood pressure). 4,9

Cholesterol: It appears that the depletion of CoQ10 caused by the administration of statins (Lipitor
(atorvastatin), Zocor (simvastatin), Pravachol (pravastatin), etc.) is dose dependent. Higher statin doses
lead to decreased CoQ10 levels. Currently it is not clear how statins decrease CoQ10 levels or if CoQ10’s
depletion even causes side effects. Evidence is also lacking for if CoQ10 supplementation will reduce the
side effects of statin medications. 4,9

Coumadin (warfarin): CoQ10 is structurally similar to Vitamin K. Therefore CoQ10 may antagonize the
anticoagulant effects of warfarin, leading to decreased INR levels and consequently an increased risk of
blood clots. 4,9

Smoking: Cigarette smoking depletes the Coenzyme Q10 stores in the body. 4,9

Whether CoQ10 is placed into a gel capsule, fast melting tablet, or an effervescent wafer, all
formulations seem to have the same availability within the body. Dividing the administration of the
daily dose into two or three times a day increases tissue uptake and plasma CoQ10 levels compared to
single daily dosing. 4,9

Doses of CoQ10 are usually considered safe at levels of 1200mg/day or below. Higher doses have
been observed and no adverse effects were reported.(Lexi) Most trials involving cardiovascular and
neurologic testing used a daily dose of 300mg. Many exercise trials used similar dosing patterns such as
100-300 mg per day. 4,9

Side Effects
Nausea, vomiting, diarrhea, appetite suppression, and heartburn. 4,9

Ongoing research continues to lead medical professionals to a conclusion that CoQ10 supplementation
can treat or improve multiple disease states. While CoQ10 supplementation may provide benefits
in other areas of healthcare, it is unreasonable with the current data available to state that CoQ10
supplementation has a significant effect on athletic performance. Therefore, it appears that the
supplementation of CoQ10 does not increase athletic performance with the literature available at this
time.

Mizuno K, Tanaka M, Nozaki S, Mizuma H, Ataka S, Tahara T, Sugino T, Shirai T, Kajimoto Y, Kuratsune H, Kajimoto O, Watanabe Y.
Antifatigue effects of conenzyme Q10 during physical fatigue. Nutrition. 2008;24:293-299.
2. Sen CK. Antioxidants in Exercise Nutrition. Sports Medicine. 2001;31(13):891-908.
3. Bojanic V, Radovic J, Bojanic Z, Lazovic M. Hydrosoluble Vitamins and Sport. Acta Medica Medianae. 2011;50(2):68-74.
4. Ubiquinol. Natural Medicine. 09/12/2012.
5. Malm C, Svensson M, Ekblom B, Sjodin B. Effects of ubiquinone-10 supplementation and high intensity training on physical
performance in humans. Acta Physiol Scand. 1997;161:379-384.
6. Weston SB, Zhou S, Weatherby RP, Robertson SJ. Does exogenous coenzyme Q10 affect aerobic capacity in endurance athletes?
International Journal of Sport Nutrition and Exercise Metabolism. 1997;7(3):197-206.
7. Gokbel H, Gui I, Belviranli M, Okudan N. The Effects Of Coenzyme Q10 Supplementation on Performance During Repeated Bouts of
Supramaximal Exercise in Sedentary Men. Journal of Strength and Conditioning Research. 2010;24(1):97-102.
8. Rosenfeldt F, Hilton D, Pepe S, Krum H. Systematic review of effect of coenzyme Q10 in physical exercise, hypertension and heart
failure. Biofactors. 2003;18:91-100.
9. Ubiquinol. Lexi-Comp Online. 09/12/2012.
10. Rosenfeld FL, Pepe S, Ou R, Mariani JA, Rowland MA, Nagley P, Linnane AW. Coenzyme Q10 improves the tolerance of the
senescent myocardium to aerobic and ischemic stress: studies in rats and in human atrial

Exercise, Athletic Performance, and Alcohol

In 2001, the NCAA found that 80% of student athletes had consumed alcohol making it the most widely consumed drug among college athletes. While athletes use alcohol to celebrate, decrease mental stress, and increase team bonding, most athletes do not realize how alcohol affects their athletic performance. This article focuses on the myths, truths, and research regarding alcohol consumption and its effects on athletic performance.

Myth:  Beer provides a sufficient amount of carbohydrates and rehydrates the body after exercise.  When comparing carbohydrate counts, a 12oz regular beer has 12 grams of carbs, a 12oz light beer has 5 grams of carbs, while 12oz of orange juice has 38 grams of carbs.³ Although the beer does provide energy, its carbohydrates are considered “empty calories.”   This is because alcohol does not provide glucose that is readily available for use in muscles.⁴ In regards to rehydration, research shows that 10ml of excess urine is produced for every gram of ethanol ingested.² Mathematically, if a 25ml drink is 40% ethanol (10ml alcohol and 15ml water), the total urine output would be approximately 80-100ml, with a resulting net negative water balance of 65-85ml.² Therefore, alcohol leads to dehydration and does not contain a substantial amount of carbohydrates compared to other food sources.

Fact:  The human body only metabolizes one “drink” per hour and remedies such as drinking coffee or taking a “cold shower” do not increase alcohol metabolism.

During Performance:  Athletic performance while directly under the influence of alcohol is decreased due to increased fluid loss, changes in ventilation, and difficulties associated with coordination and concentration.

Hangover Effect:  Alcohol consumption the night before exercise also causes a decline in athletic performance.  Rugby players who consumed their normal amount of alcohol on Friday night returned to the playing field 16 hours later.  Those who consumed alcohol were observed to have decreased their maximum aerobic capacity (VO2 max) by 11.4% compared to those who did not drink alcohol. Reaction time is also impaired by alcohol consumption. One study found that Navy pilots who were legally drunk 14 hours before testing had significantly increased reaction times in simulated flights compared to those who did not consume alcohol.  Ethanol ingestion also decreases muscle glycogen while increasing lactic acid production, which results in negative aerobic performances.  Therefore, alcohol should not be consumed the night before athletic events due to its impairment of reaction time and aerobic performance.

Post Exercise Consumption:  Post exercise alcohol consumption decreases muscle recovery.  Studies show that drinking alcohol 90 minutes after heavy eccentric exercise increases muscle breakdown and significantly decreases athletic performance.  It has also been found that alcohol consumption within 3 hours of exercise significantly decreases blood glucose levels.  This is very destructive as low blood glucose means an inadequate amount of carbohydrates are available for muscle recovery.  When muscles do not recover properly, athletic performance will suffer.

Injury:  A minimal amount of studies have been conducted on the relationship between alcohol use and athletic injury.  O’Brien et al found an injury rate of 54.8% in athletes who drank at least one beer per week.  Those in the nondrinking athletic population had a significantly less (p<0.05) injury rate of 23.5%, indicating that alcohol does increase injury prevalence.

Interactions:  Alcohol should be avoided in those taking acetaminophen (Tylenol) as co-administration can increase the risk of Tylenol induced hepatotoxicity.  Ethanol should also be avoided in those taking NSAID’s (ibuprofen, naproxen, or aspirin) and corticosteroids (prednisone) as co-administration can lead to an increased prevalence of blood loss due to stomach/intestinal ulcers.  Additional information regarding medication and disease states interacting with alcohol can be found in our Journal Article.

Bans:   The NCAA currently only bans ethanol or ethanol-containing compounds during riflery competitions.  The World Anti-Doping Agency (WADA) which is sponsored by the International Olympic Committee prohibits alcohol use in-competition during aeronautic (FAI), archery (FITA), automobile (FIA), karate (WKF), motorcycle (FIM), and powerboat (UIM) performances.

After reviewing the literature, it is found that alcohol has no place in athletes due to its detrimental effects on athletic performance.  Additional in-depth information and detailed review explanations are available in the Journal Article.

Citations

1. Green GA, Uryasz FD, Petr TA, Bray CD.  NCAA Study of Substance Use and Abuse Habits of College Student Athletes.  Clinical Journal of Sport Medicine.  2001;11:51-56.
2. Shirreffs SM, Maughan RJ.  The Effect of Alcohol on Athletic Performance.  Current Sports Medicine Reports.  2006;5:192-196.
3. Reents, Stan.  Sport and Exercise Pharmacology.  Human Kinetics. 2000.
4. O’Brien CP, Lyons F.  Alcohol and the Athlete.  Sports Medicine. 2000;5:295-300.
5. Centers for Disease Control and Prevention.  Alcohol and Public Health: Frequently Asked Questions.  08/17/2012.  http://www.cdc.gov/alcohol/faqs.htm. 
6. Roeggla G, Roeggla H, Roeggla M, Binder M, Laggner AN.  Effect of Alcohol on Acute Ventilatory Adaptation to Mild Hypoxia and Moderate Altitude.  Annals of Internal Medicine.  1995;122:925-927.
7. Barnes MJ, Mundel T, Stannard SR.  Acute Alcohol Consumption Aggravates the Decline in Muscle Performance Following Strenuous Eccentric Exercise.  Journal of Science and Medicine in Sport.  2010;13:189-193.
8. Burke LM, Collier GR, Broad EM, Davis PG, Martin DT, Sanigorski AJ, Hargreaves.  Effect of Alcohol Intake on Muscle Glycogen Storage After Prolonged  Exercise.  Journal of Applied Physiology.  2003;95:983-990.
9. El-Sayed M, Omar A, Lin X.  Post-exercise Alcohol Ingestion Perturbs Blood Haemostasis During Recovery.  Thrombosis Reasearch.  2000;99:523-530.
10. O’Brien CP.  Alcohol and Sport: Impact of Social Drinking on Recreational and Competitive Sports Performance.  Sports Medicine.  1993;15(2):71-77.
11. Vingren JL, Koziris LP, Gordon SE, Kraemer WJ, Turner RT, Westerlind KC.  Chronic Alcohol Intake, Resistance Training, and Muscle Androgen Receptor Content.  Medicine and Science in Sports and Exercise.  2005;1842-1848.
12. Vila L, Ferrando A, Voces J, Cabral de Oliveira C, Prieto JG, Alvarez AI.  Effect of Chronic Ethanol Ingestion and Exercise Training on Skeletal Muscle in Rat.  Drug and Alcohol Dependence.  2001;64:27-33.
13. Ethanol.  Clinical Pharmacology.  08/15/2012.
14. Ethanol.  Lexi-Comp Online.  08/15/2012.
15. NCAA.  2011-12 NCAA Banned Drugs. http://fs.ncaa.org/Docs/AMA/legislative_actions_issues/2011-12_Banned_Drugs_Educational.pdf.  08/13/2012.
16. World Anti-Doping Agency.  The 2012 Prohibited List: International Standard. http://www.wada-ama.org/Documents/World_Anti-Doping_Program/WADP-Prohibited-list/2012/WADA_Prohibited_List_2012_EN.pdf.  08/13/2012.

I’m not vegan, do I still need Vitamin b12 supplementation?

Vitamin B12 (cobalamin) is a water soluble vitamin involved in the production of red blood cells, the maintenance of nerve function, and the synthesis of DNA.  Cobalamin is a protein bound micronutrient found in animal food sources such as fish, shellfish, meat, eggs, and dairy products.
Vitamin B12 deficiencies are rare as the body stores several years worth of Vitamin B12 in the liver.  Most cobalamin deficient patients are vegetarians (decreased animal food sources), malnourished (energy-restrictive diets), or have decreased stomach acid.
Studies have shown that athletic performance only improves if subjects had low Vitamin B12 levels before starting supplementation.  High doses of Vitamin B12 in subjects with adequate Vitamin B12 levels do not increase red blood cell formation or athletic performance.
The recommended daily allowance of Vitamin B12 is 2.4mcg/day if 14 years and older, 2.6mcg/day if a pregnant female, and 2.8 mcg/day for lactating females.  Higher doses are also commonly used in patients (1000-10,000mcg/day).
Medications similar to omeprazole (Prilosec) and ranitidine (Zantac) decrease the amount of Vitamin B12 that enters the blood stream.  Metformin (Glucophage) may actually block Vitamin B12 absorption, also decreasing Vitamin B12 levels.  For more information on other medications that interact with Vitamin B12 please look at our newsletter article that is available at the end of August.
If you do decide to supplement with Vitamin B12, look for USP verified vitamins, as these have been tested for quality.  Patients should also avoid time release or sustained release Vitamin B12 tablets as both have decreased effectiveness.
Please contact a healthcare provider before initiating any type of vitamin, supplement, or medication regimen as it may interact negatively with performance or your health.  For more in-depth information on Vitamin B12 please look at our newsletter article that is available at the end of August.

 

Citations
1. Wolinsky Ira.  Sports Nutrition: Vitamins and Trace Elements.  1996.  CRC Press.
2. Natural Standard Patient Monograph.  Vitamin B12.  The Mayo Clinic.  07/04/2012.  http://www.mayoclinic.com/health/vitamin-B12/NS_patient-vitaminb12.
3. Pharmacist’s Letter.  Vitamin B12.  2011; 27(8):270811.
4. OH RC, Brown DL.  American Family Physician.  2003 Mar 1;67(5):979-986.
5. Barr SI, Rideout CA.  Nutritional Considerations for Vegetarian Athletes.  Nutrition. 20:696-703; 2004.
6. Campbell WW, Geik RA.  Nutritional Considerations for the Older Athlete.  Nutrition.  20:603-608; 2004.
7. Lukaski HC.  Vitamin and Mineral Status: Effects on Physical Performance. Nutrition. 20:632-644; 2004.

Athlete Foot

Athlete’s foot (tinea pedis) is the most common fungal infection and develops in moist areas especially between toes and other areas of the foot.1  These microscopic organisms are normal inhabitants of your skin, and their growth stays in check as long as your skin is clean and dry. However, damp, close, warm environments allow these microorganisms to thrive and overpopulate causing the infection.2  Athlete’s foot is contagious and can be spread by contact with infected towels, floors, and shoes.

Symptoms:  The most common symptoms of athlete’s foot include itching, stinging, and burning between your toes and on the soles of your feet.  Itchy blisters, excessive dryness, and skin cracking/peeling skin can also occur.1

Prevention:  Hygiene plays a vital role in managing the infection. Since fungi thrive in moist environments, keeping feet and footwear dry is necessary to combat the infection.

Treatment:  Treatment should be started with nonprescription antifungals. These include terbinafine (Lamisil AT), miconazole (Micatin), clotrimazole (Lotrimin AF), and tolnaftate (Tinactin). Before applying the cream, the area should be washed and dried.  Clotrimazole, miconazole, and tolnaftate should be applied twice a day, while terbinafine should only be applied once daily.  Treatment should be continued for four weeks or one week after all the symptoms have cleared.3,4,5,6,7 If not better after four weeks one should seek medical attention.

Caution:  Topical corticosteroid creams (ex. hydrocortisone) when used alone for treatment can act as a fertilizer for fungus and may worsen the fungal infections.3  When steroids are given in combination with antifungal agents, treatment is effective and itching and swelling decreases.  Therefore, single therapy topical corticosteroid creams have no therapeutic value in treating athletes foot. 3

 

 

Citations:

1 “Athlete’s foot”. Mayo Clinic Health Center. Retrieved 13 July 2012

2 Al Hasan M, Fitzgerald SM, Saoudian M, Krishnaswamy G (2004). “Dermatology for the practicing allergist: Tinea pedis and its complications”. Clinical and Molecular Allergy.

3. Crawford F, Hollis S.  ”Topical treatments for fungal infections of the skin and nails of the foot.” 2009.

4.  Clotrimazole.  Lexi-Comp Online.  08/05/2012.

5.  Miconazole. Lexi-Comp Online.  08/05/2012.

6.  Tolnaftate.  Lexi-Comp Online.  08/05/2012.

7.  Terbinafine.  Lexi-Comp Online.  08/05/2012.

Pre-race itchy watery eyes, runny nose, and sneezing?

The night before your big race and you start having symptoms of itchy watery eyes, runny nose, and sneezing.  What can you take that won’t inhibit your performance the next day?

 

Loratadine (Claritin) and fexofenadine (Allegra) are non-drowsy antihistamines that should not affect athletic performance.  Cetirizine (Zyrtec) has been shown to be mildly sedating—11% of patients taking this medication will become tired.  Medications such as diphenhydramine (Benadryl) should be avoided because it will cause tiredness (diphenhydramine is the active ingredient in many over the counter sleep aid products).  

 

Loratadine (Claritin) is taken as a one 10 mg tablet daily.

Fexofenadine (Allegra) recently became an over-the-counter medication and is commonly dosed in adults as a one 180mg tablet once daily or a 60mg tablet twice a day.  Fruit juice may decrease the amount of fexofenadine that enters the body, so Allegra should be taken with water and separated from fruit juices by about an hour.

 

Cetirizine (Zyrtec) is dosed as a one 10mg tablet taken daily.

 

Diphenhydramine (Benadryl) can impair mental and physical abilities by causing sluggishness, confusion, and muscle weakness that can carry on into the next morning.  Benadryl can also cause dry mouth, dry eyes, and thicken lung secretions.  Although most side effects cause the body to slow down, in a small percentage of the population (mainly children), diphenhydramine can cause the opposite effect and make a person feel excited and awake.  This is, of course, an undesired reaction the night before a big race.
Therefore, loratadine (Claritin) and fexofenadine (Allegra) are the best antihistamines to use before a race because they are the least likely to affect athletic performance.   Zyrtec should only be taken if you have tried it before and had no adverse side effects.  Bendaryl should be avoided.

 

Citations
Loratadine.  Lexi-Comp Online.  07/19/2012.
Cetirizine.  Lexi-Comp Online.  07/19/2012.
Fexofenadine.  Lexi-Comp Online.  07/19/2012.
Diphenhydramine.  Lexi-Comp Online.  07/19/2012.
Comparison of Antihistamines.  Pharmacist’s Letter.  2008;24(7):240707.
Diphenhydramine.  Clinical Pharmacology.  07/25/2012.

Fish Oil

Fish Oil

 

Fish oil basics: EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are the omega-3 fatty acids in fish oil supplements.   Omega-3 fatty acids such as EPA and DHA are thought to replace omega-6 fatty acids in cell membranes, decreasing inflammatory processes.1,2  

 

Effects on Breathing: Fish oil taken at 5g/day (EPA to DHA ratio 3.2:1) has been shown to be ergogenic (increase performance) in elite athletes suffering from exercise induced bronchoconstiction (EIB).  EIB is inflammation of the lungs stimulated by exercise.  It is similar to asthma but cannot be pre-treated with pharmacological agents.  EPA and DHA are thought to decrease EIB’s inflammatory effects, leading to better respiration.2,3  While this is great news for elite athletes, the daily dose of fish oil that is generally recommended as safe is 3 grams per day (EPA to DHA ratio 2:1).  While higher doses have been tolerated, side effects may include the inhibition of blood clot formation, red blood cell deformation, and an enlarged liver.1

 

Effects on Mood:  Fontani et al found that fish oil dosed at 4g/day increased vigor while decreasing anger, anxiety and depression.4  Although this study did not measure athletic performance , we can presume that athletes who supplement with fish oil may have a better training environment leading to increased performance and recovery.

 

Fish oil Controversy:  Contradictory evidence exists comparing the ergogenic effects of fish oil on muscle recovery and inflammation in muscles and joints.2  The debate surrounds studies that suggest fish oil is either ergogenic or has no effect, and so athletes should not be worried about a decrease in performance by supplementing with fish oil.  Information has also surfaced that higher doses of fish oil (5g/day) increase brachial artery blood flow.2   Although this study did not measure athletic performance, translating these findings to athletic performance indicates that fish oil may increased oxygen uptake within muscles resulting in increased performance.  

 

Administration:  Current recommendations indicate that 3 grams of fish oil per day is generally safe while doses higher than this can be taken after consulting a provider.  Some studies also show that the physiological and peroxidative effects of fish oil are increased if co-administered with Vitamin E.1
Side Effects:  Adverse reactions may include burping, upset stomach, and a recurring fishy taste.  One way to limit the fishy taste is to store the tablets in the freezer.  If you are allergic to fish, you should not consume fish oil products.  If you are taking warfarin or are on an anti-platelet agent such as clopidogrel, you should contact your provider before initiating fish oil supplementation.5  As always, if you are planning on starting a new over the counter regimen such as fish oil supplements, you should contact a medical professional before starting.  

 

Citations

1. Lowery LM.  Dietary fat and sports nutrition: a primer.  Journal of Sports Science and Medicine.  2004;3:106-117.
2. Simopoulos AP.  Omega-3 Fatty Acids and Athletics.  Current Sports Medicine Reports.  2007;6;4:230-236.
3. Calder PC, Lindley MR, Burke LM, Stear SJ, Castell LM.  A-Z of nutritional supplements: dietary supplements, sports nutrition foods, and ergogenic aids for health and performance Part 14.  British Journal of Sports Medicine.  2010;44:1065-1067.
4. Fontani G, Corradeschi F, Felici A, Alfatti F, Bugarini R, Fiaschi AI, Cerretani D, Montorfano G, Rizzo AM, Berra B.  Blood profiles, body fat and mood state in healthy subjects on different diets supplemented with Omega-3 polyunsaturated fatty acids.  European Journal of Clinical Investigation. 2005;35:499-507.
5. Fish Oil.  Lexi-Comp Online.  07/19/2012.

What is up with these Chocolate Milk Commercials?

If you have been watching TV this spring and summer you have probably noticed professional athletes such as Chris Lieto (triathlon), Dara Torres (swimming), Mirinda Carfrae (2010 Ironman World Champion), Carmelo Anthony (NBA), and others promoting chocolate milk as part of team REFUEL “got chocolate milk?TM”.   This new ad campaign is due to recent research proving that chocolate milk aids in performance and in helping muscles rebuild and recover.1,2,3,4,5

What the research says:  In 2006, Karp et al. conducted a study comparing chocolate milk, fluid replacement (Gatorade), and carbohydrate replacement drinks (Endurox).  Subjects completed a cycling interval set designed to deplete muscle glycogen stores and then drank the randomly assigned liquid.  After four hours of rest, they cycled again at 70% VO2max.  Food was not allowed during the recovery period, but subjects were allowed to drink as much water as they desired.  Results of the study concluded that during 70% VO2max exercise, time to exhaustion and total work performed were significantly greater when subjects had ingested chocolate milk and Gatorade compared the Endurox.2

 

Since the initial findings of Karp et al, additional research indicates that chocolate milk may be a better recovery drink than fluid or carbohydrate replacement.3   Other findings show that chocolate milk delays muscle soreness and lessens the decrease in muscle performance after strenuous exercise.4  Another study concluded that chocolate milk provides greater improvements in VO2max and body composition (increased lean muscle and decreased fat) compared to carbohydrate replacement or placebo.5

 

Although it is not entirely clear why chocolate milk exerts ergogenic effects, many think it is due to the enrichment of vitamins and electrolytes, fat content, and carbohydrate (glucose, fructose, and sucrose) to protein ratio.2  While there is evidence that chocolate milk is ergogenic, athletes who suffer from lactose intolerance and those who experience gastrointestinal intolerances with milk may want to avoid chocolate milk, because these symptoms may decrease athletic performance or recovery.  In light of these results, more research will continue to be done to determine which recovery drinks work most efficiently.   

 

For additional information please visit www.gotchocolatemilk.com

 

Citations:

1. Got Chocolate Milk?. 2012 America’s Milk Processors.  www.gotchocolatemilk.com
2. Karp JR, Johnston JD, Tecklenburg S, Mickleborough TD, Fly AD, Stager JM.  Chocolate Milk as a Post-Exercise Recovery Aid.  International Journal of Sport Nutrition and Exercise Metabolism.  16:78-91;2006.
3. Thomas K, Morris P, Stevenson E.  Improved endurance capacity following chocolate milk consumption compared with 2 commercially available sports drinks.  Applied Physiology Nutrition and Metabolism. 34:78-82;2009.
4. Cockburn E, Stevenson E, Hayes PR, Robson-Ansley P, Howatson G.  Effect of milk-based carbohydrate-protein supplement timing on the attenuation of exercise-induced muscle damage.  Applied Physiology Nutrition and Metabolism.  35:270-277;2010.
5. Ferguson-Stegall L, McCleave E, Ding Z, Doerner PG, Liu Y, Wang B, Healy B, Kleinert M, Dessard B, Lassiter DG, Kammer L, Ivy JL.  Aerobic Exercise Training Adaptations are Increased by Post-exercise Carbohydrate-Protein Supplementation.  Journal of Nutrition and Metabolism.  Vol. 2011, Article ID 623182, 11 pages, 2011.

Bee Stings

If I get stung by a bee while exercising, what do I do?

Get to safety: For bee stings, the venom released into the injection site releases a signal that increases the ability of other bees to locate the victim.  This increases the risk of further stings.1,2,3,4  Reaching safety is more important than treating the sting immediately.
Remove the stinger:  Honey bees leave a stinger at the injection site that needs to be removed as fast as possible.  To remove the stinger either scrape it away with a credit card or fingernail, or use a tweezer to pull it out of the skin. Contrary to popular belief, the amount of time it takes to the remove the stinger affects the size of the irritated area (weal size) more than the technique used to remove the stinger. Visscher et al. found no difference in weal size at ten minutes after being stung if the stinger was not removed within 2 seconds (comparing removal via credit card or tweezers).1  This is due to the fact that while the stinger in place it continues to inject venom through a valve system that does not rely on contraction or compression of the venom sac.1  Therefore, try to remove the stinger as fast as possible and wash the area with soap and water, hydrogen peroxide or alcohol.  Remove any jewelry that may be affected when swelling occurs.2,3  Wasps and yellow jackets, on the other hand, do not leave their stinger at the injection site, so one will only need to treat the reaction.

Treatment:  Minor local reactions appear as a red welt with slight swelling at the site of the sting.  These reactions are best treated with over-the-counter agents.  Lidocaine (brand name?), pramoxine (brand name?), and dibucaine (brand name?) treat itching because they decrease the sensation of the affected area.   These drugs should not be used for more than 7 days at a time.  Camphor and menthol also decrease itching and irritation and can be applied 3-4 times a day for 7 days.  Topical hydrocortisone also decreases inflammatory response and provides pain and itching relief.  Oral and topical antihistamines such as Benadryl also work very well at decreasing itching.  Cold compresses should be applied every ten minutes to decrease itching, swelling, and pain.  Try to limit scratching as this can break the skin and potentially lead to a bacterial infection. 2,3,5

Larger local reactions which appear as extreme redness and swelling may expand over a couple of days and might require seeing a prescriber.  These reactions may take a few days to dissipate (5-10 days).  This should be treated like a minor local reaction and a physician might add an oral steroid for treatment.2,3,5

Severe allergic reactions such as anaphylaxis may also occur.  This would include hives, itching, difficulty breathing, swelling of the throat and tongue, weak rapid pulse, dizziness, and loss of consciousness.  Treatment for anaphylactic reactions involves the use of an EpiPen (epinephrine shot) and 911 should be called immediately.2,3,4,5

Prevention:  It has been found that taking an oral antihistamine before being stung (premedicating), significantly decreases the reaction.  Although some would argue that antihistamines such as Benadryl increase drowsiness which decreases performance, non-drowsy antihistamines such as Claritin, Zyrtec, and Allegra do not alter performance and may already be taken daily for seasonal allergy symptoms.  If one does not have seasonal allergies and does not already take such medications, premedicating before going outside every day may become burdensome.3

In patients who already know they have a high propensity to severe allergic reactions with insect stings, one should be advised to carry an auto-injector and to wear a medical alert bracelet in case an emergency were to happen.3

Citations

1. Visscher, P., & Vetter, R. S. Removing bee stings. Lancet 1996; 348(9023), 301.
2. Mayo Clinic Staff.  Bee Stings.  The Mayo Clinic.  07/07/2012.  http://www.mayoclinic.com/health/bee-stings/DS01067/.
3. Management of Insect Bites.  Pharmacist’s Letter 2008; 24(8):240815.
4. Freeman TM.  Hypersensitivity to Hymenoptera Stings.  N Engl J Med 2004; 351:1978-1984.
5. How to Manage Bites and Stings.  Pharmacist’s Letter 2012; 28(6):280613.