Home Posts tagged "Supplements"

Are BCAAs Worth the Hype?

Today's guest post comes from the team at Examine.com, my top resource for cutting-edge research in health and performance. As a member, I get monthly updates/summaries on a variety of topics in this regard - and it's been invaluable for helping me to stay on top of what's new in my field.

This post is timely, as they have a 30% off sale to celebrate the 11th anniversary of their site launching (you can learn more HERE). In today's post, they touch on a popular - but often misunderstood- supplement: branched chain amino acids (BCAAs).  Enjoy! -EC

Given the importance of protein for exercise, branched chain amino acids (BCAAs; isoleucine, leucine, and valine), which contribute heavily to muscle synthesis, are commonly marketed by supplement companies as being able to provide benefits for resistance training performance, recovery, and body composition. Are they effective, or a waste of money?

The Study

This systematic review of 12 randomized controlled trials assessed the effects of BCAA supplementation on physical performance, muscle damage, and body composition.

Studies that met the following criteria were included:

  • Assessed healthy people who were at least 18 years old, without chronic disease.
  • Utilized BCAA supplementation in isolation compared to a matched control group.
  • Assessed physical performance, muscle damage, or body composition as an outcome.

The sample size of the included studies ranged from 9 to 46, with an average of about 22 participants per study. The studies were published between 2008 to 2018, and study length varied from 1 day to 8 weeks. The average BCAA dose was 19.5 grams per day and was compared to either water, carbohydrate, artificial sweetener, or taurine (a non-essential amino acid). Ten of the studies recruited nonathlete participants, one recruited experienced runners, and one recruited soccer and rugby athletes.

Blood Parameters

Eight studies assessed the effects of BCAA supplementation on blood parameters associated with muscle damage. Seven of them assessed creatine kinase (CK), three assessed lactate dehydrogenase, two assessed lactate, two assessed aldolase, and one article assessed myoglobin and interleukin 6 (IL-6).

Of the seven studies assessing CK, three reported a decrease in CK in the BCAA group compared to placebo following an exercise protocol designed to induce muscle damage (24, 72–96, and 48 hours after exercise in each study, respectively).[4][11][12]

Of the three studies assessing lactate dehydrogenase and of the two studies assessing aldolase, one reported that both markers were lower 72 and 96 hours after an exercise protocol designed to induce muscle damage in a BCAA group, compared to placebo.[11]

Of the two studies assessing lactate, one found that it was lower in the BCAA group than the placebo group immediately after a cycling exercise protocol.[6]

The only study assessing myoglobin and IL-6 found no effect of BCAAs following an exercise protocol designed to induce muscle damage.[2]

Body Composition

Two studies evaluated participant body weight and lean mass. One of these studies found that BCAAs prevented body weight and lean mass loss during an 8-week calorie-restricted diet, compared to a control group consuming a carbohydrate supplement.[9] Notably, the supplement used in the study demonstrating an effect of BCAAs also contained 1,000 mg of citrulline malate and 2,500 mg of L-glutamine. The placebo was a standard electrolyte sports beverage.

Performance:

  • Repetitions performed: Three studies assessed repetitions performed, one of which reported that the BCAA group performed more squat exercise repetitions than a placebo group. The same study reported improvements in body composition.[9]
  • Total distance performed: Two studies assessed distanced performed, with no differences between groups in either study.
  • Strength: Five studies assessed strength, one of which reported a greater increase in 3RM strength on squats and bench press in the BCAA group, compared to the placebo group. The same study reported improvements in body composition.[9]
  • Vertical jump: Three studies assessed vertical jump performance, none of which found an effect of BCAAs.
  • Power: Three studies assessed power, none of which found an effect of BCAAs.
  • Perceived exertion: Two studies assessed perceived exertion, one of which found an improvement at 75 and 90 minutes during a cycling protocol in a group consuming BCAAs, compared to a group consuming a carbohydrate-based electrolyte beverage.[3]
  • Muscle soreness: Six studies assessed muscle soreness and pain, four of which found a reduction in subjective muscle pain in groups consuming BCAAs, compared to a placebo.[2][4][7][11] One reported an effect of BCAAs, as compared to an artificially-sweetened beverage 48 and 72 hours following an eccentric exercise protocol.[2] A second study reported that BCAAs reduced muscle soreness 24 and 48 hours after an exercise protocol designed to induce muscle damage, compared to an artificially-sweetened beverage.[4] A third study reported that consuming BCAAs with taurine reduced muscle soreness 48 hours after an exercise protocol designed to induce muscle damage as compared to a carbohydrate-based placebo,[7] and in another study, consuming BCAAs before an eccentric bicep curl protocol reduced muscle soreness at 72 and 96 hours, as compared to a starch-based placebo.[11]

Note

While several studies demonstrated positive effects of BCAAs, several points must be considered:

  • The background protein intake of the participants probably moderated the benefits of BCAAs. Since BCAAs are three essential amino acids, and therefore found in protein food sources, BCAAs might be less useful for individuals already consuming adequate protein. Of the eight studies reporting benefits of BCAAs, three did not utilize a dietary control or report participants’ total protein intake, only requiring that participants maintain their usual dietary habits, [4] [11][7] and another study did not control participants’ dietary intakes nor provide information on their intake.[6] In one study, participants maintained an overall protein intake of about 1.2 grams per kg of body weight per day (g/kg/day), which the authors noted was lower than the recommended range for resistance training individuals (1.4–2.0 g/kg/day).[12] Another study utilized a calorie and carbohydrate-restricted diet, providing 35–40% of calories from protein.[9] One study asked participants to maintain their habitual intake while assessing their calorie and macronutrient intake during the study, reporting that the BCAA group derived about 69% of total energy from carbohydrates, while information was not provided on fat or protein intake.[3] One study provided all food to participants, providing 1.5 g/kg/day of protein to both BCAA and placebo groups.[2]
  • None of the studies compared BCAAs to another source of amino acids (e.g., a protein supplement or protein from food) except for one study utilizing both taurine and starch in comparator groups.[7]
  • Even if BCAAs were to provide a small benefit on markers of muscle damage or soreness, using BCAAs for this purpose might become redundant if training volume is managed appropriately to avoid excessive muscle damage in the first place.

The Big Picture

Several other review papers have been published assessing the utility of BCAAs for resistance-trained individuals. Here are a few that were published recently:

A 2021 meta-analysis[13] previously reviewed in Study Summaries assessing the effects of BCAAs on muscle soreness and markers of muscle damage found that BCAA supplementation reduced CK levels at less than 24 hours after exercise, as well as 24 and 48 hours after exercise, while improving muscle soreness at less than 24 hours only. However, the observed effects were small.

A 2021 narrative review[14] assessing the effects of BCAAs on muscle strength and hypertrophy concluded that “... the proposed benefits of BCAA used in the marketing of supplements appears to be at odds with the overall state of the current literature, which does not support the efficacy of supplementation on muscle strength and hypertrophy."

A 2017 meta-analysis[15] assessing the effects of BCAAs on muscle soreness and markers of muscle damage, reported that BCAAs reduces CK at less than 24 hours and 24 hours after exercise compared to a placebo, with no effects on lactate dehydrogenase or muscle soreness.

In a 2017 systematic review[16] assessing the effects of BCAAs on markers of muscle damage, 6 of 11 studies reported a beneficial effect of BCAAs.

At the end of the day, limited evidence suggests that BCAAs might reduce muscle soreness and indirect markers of muscle damage in resistance-training people. However, studies demonstrating the benefits of BCAAs utilized non-protein comparator groups, and often failed to report information on participants’ total protein intake. BCAAs probably don’t have utility for people already consuming adequate protein and managing training volume appropriately.

Note: We'll link to the studies referenced in this article in the first comment below.

Wrap-up

If you're looking for more detailed reviews like this, I'd strongly encourage you to check out Examine.com. Their membership offering is second-to-none and is something I review every month to stay on top of the latest research. And, it's on sale for 30% off through Monday to celebrate their 11th anniversary. You can learn more HERE.

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How to Stay on Top of the Latest Research

I pride myself on having a training philosophy that is rooted in both “in the trenches” anecdotal experience and evidence-based practice. Both can be challenging to develop, but for different reasons.

Building a sample size in your head helps you to make judgment calls when the research isn’t necessarily there, or you need to make inferences based on limited information. As an example, as I've written previously here, research has demonstrated that lat strains that are managed conservatively have a return to pitching timeline of ~100 days. That information is great if you’re seeing an athlete from Day 0 post injury, but where should that individual’s progress be at Day 40? That’s where in the trenches experience helps. Unfortunately, it takes a ton of time - and learning from mistakes along the way.

Evidence-based information can be accessed much easier and without the need for years of experience. Unfortunately, though, there is a ton of it to sift through. There are countless scholarly journals out there, and full-text access isn’t always easy to come by. Moreover, We often take for granted that study designs are all acceptable if something makes it to publication. The truth is that some scholarly journals have much lower publication standards than others. it could be a full-time job just pouring over all these journals, but it could be five full-time jobs to make sure they’re all legitimate.

Who has time for that? Certainly not me. Luckily, the good folks at Examine.com have built out an amazing team whose focus is particularly in this evidence based arena. And, they’ve got an awesome new resource - Examine Personalized - I’m excited to tell you about because I’m going to be utilizing it myself. Here's how it works:

I love this approach because it's both curated content: just like you follow certain people on social media to get the information you want, this allows you to select which categories mean the most to you. Here are the 25 categories you can select from for your targeted education:

One recent update covered 275 studies over 149 pages in these 25 categories. This is going to save me a lot of time and, more importantly, make me a more informed professional. And, it'll help me to come up with ideas for content for my writing and videos on this site, as some of my most popular articles of all time have related to me building on what I've learned from evidence-based research. You can learn more HERE - and save 30% during their current 11th anniversary sale.


 

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CSP Elite Baseball Development Podcast: Making Sense of Supplements with Angie Asche

We're excited to welcome sports dietitian Angie Ashe to this week's podcast. Angie does an outstanding job with nutritional counseling for a variety of athletes, and has a lot of experience working with baseball players in particular. In this episode, we delve into the controversial topic of nutrition supplementation.

A special thanks to this show's sponsor, Marc Pro. Head to www.MarcPro.com and enter the coupon code CRESSEY at checkout to receive 10% off on your order.

Show Outline

  • How Angie goes about starting nutritional conversations with her athletes and teaching them what they can do before looking to dietary supplements
  • Why athletes should be maximizing what they are eating and drinking before worrying about what supplements they should be taking
  • What supplement story initially sparked Angie’s interest in the world of supplements as a dietician
  • Where athletes can be misguided by the hype around supplements
  • What supplements Angie sees as must-haves in all peoples’ diets
  • What boxes Angie looks to check before recommending dietary supplementation in youth athletes
  • Why individuals need to be aware of the post-market testing model exploited by the supplement industry in order to understand the importance of buying third party verified products
  • How being conscious of ingredients on supplement labels can make it easier for consumers to identify safe and ethical supplements
  • What supplements are a complete waste of money
  • What athletes need to know about popular supplements such as BCAAs, collagen powders, probiotics, and glutamine
  • What to look for and stray away from when investing in protein powders
  • What guidelines Angie recommends for consuming creatine and how it can be used to improve athletic performance
  • With the heightened popularity of preworkout and energy drinks, why athletes should be cognizant of the source of their caffeine consumption and what Angie recommends for caffeine intake in one’s diet
  • What research says about the benefits of drinking coffee and how obtaining caffeine from healthy sources is often overlooked for healthy living and improving human performance
  • How individuals should be concerned about consuming more processed protein sources as more people are moving away from animal consumption and towards alternative diets
  • Where Angie goes to learn more about nutrition and stay up to date on the research of the field
  • What Angie’s go-to smoothie is for skinny individuals looking to gain weight
  • Where Angie sees future research in the nutrition community heading

You can follow Angie on Twitter at @EleatNutrition and on Instagram at @EleatNutrition.

Sponsor Reminder

This episode is brought to you by Marc Pro, a cutting-edge EMS device that uses patented technology to create non-fatiguing muscle activation. Muscle activation with Marc Pro facilitates each stage of the body’s natural recovery process- similar to active recovery, but without the extra effort and muscle fatigue. Athletes can use it for as long as they need to ensure a more full and quick recovery in between training or games. With its portability and ease of use, players can use Marc Pro while traveling between games or while relaxing at home. Players and trainers from every MLB team - including over 200 pro pitchers - use Marc Pro. Put Marc Pro to the test for yourself with their new "Try Before you Buy" program, and use promo code CRESSEY at checkout at www.MarcPro.com for 10% off on your order.

Podcast Feedback

If you like what you hear, we'd be thrilled if you'd consider subscribing to the podcast and leaving us an iTunes review. You can do so HERE.

And, we welcome your suggestions for future guests and questions. Just email elitebaseballpodcast@gmail.com.

Thank you for your continued support!

Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!

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Can You Trust the Research You’re Reading?

Today's guest post comes from the bright minds at Examine.com, who just released their new continuing education resource, Examine Research Digest. I love their stuff, and I'm sure you will, too. -EC

The internet is one of the last true democracies.

It’s a place where anybody with the necessary tools (a computer and an internet connection) can actively shape the perception of information...even if they have no qualification to do so.

Though the democratization of information is a good thing, one would assume that certain topics like scientific research would remain steeped in their foundations, because...well...that's how they remain reliable.

Unfortunately, in efforts to keep up with the demands for new, sexy content, many writers have taken to regurgitating information with little to no understanding of its context or how it affects you: the end reader. This is one of the many ways information gets skewed.

It’s often said that misinformation is a symptom of misinterpretation. The very definition of words can mean different things to different people.

questi8-n

One example of this is during research when a conclusion is reported as "significant." When scientists use this term, it implies "statistical significance." What this means is that the probability of the observations being due to the intervention is much greater than simply by chance.

This is very different than the general understanding of “significant.” Think of it this way: if your deadlift goes up from 405 to 410, that could be considered statistically significant in science. Would you say "my deadlift went up significantly," though? Probably not!

Now imagine how this simple misunderstanding of a term can impact the interpretation of a study. Something that may mean very little to a researcher is taken out of context by a well meaning blogger, eventually ending up as a eye-catching headline in your Facebook timeline.

A second way that information becomes misinformation is through the process of simplification.

When scientific studies are written, they are done so to most effectively relay their findings to other scientists, facilitating future studies and discoveries on the topic in question. If you’ve ever read a research study, you know that this approach to writing hinges on the use of precise terminology and complex verbiage so that nothing gets misinterpreted.

Unfortunately, this approach is less than ideal for relaying important findings to the people who can apply it. This leaves a few options:

1. "Dumb down" the content, hoping nothing gets lost in translation.

2. Keep as-is, with the understanding that it won't be able to reach as many people as intended.

3. In the most egregious option, data gets turned into "sound bites" that are easily transmitted by traditional media outlets.

Once one or more of these things happen, all traces of relevance to the original source get lost and misinformation starts to get spread. Moreover, another equally insidious way misinformation gets spread is by shifting focus onto one study (cherry-picking) rather than the entire body of evidence.

The internet has rapidly increased the speed of the news cycle. Information that once had time to be verified has taken a backseat to "as-it-happens" tidbits on Twitter. For the media to keep up, more factually inaccurate information gets disseminated in far less time.

Now, appreciate the fact that a news organization only has so much air time or so many words to talk about a new publication, and you can see how there isn't enough time to allow an adequate in-depth analysis of past studies or how the new study fits into the overall body of evidence.

Remember the media screaming “a high-protein diet is as bad as smoking?” Or that “fish oil caused prostate cancer?” These are perfect examples of two well-intentioned studies blown way out of proportion.

Pills

This leads to the fourth and final way misinformation gets spread: the reliance on controversy to gain an audience.

Earlier this year a blog post theorizing the connection between creatine consumption and cancer took social media by storm. The writers were savvy enough to understand that a title proclaiming creatine to be harmful had far more appeal than yet another post confirming its athletic performance benefits.

This sort of thing isn’t a new occurrence, but for some strange reason, audiences never tire of it. Once an controversial article starts getting shared, a case of broken telephone comes into play, transforming once-quality research into misinformation. As an industry, this is a problem we need to address.

"Epilogue" from EC

In spite of all this misinformation, there are people still fighting the good fight - and that's why I’m a big fan of Examine.com. They wrote our most popular guest post ever (on the science of sleep). And, whenever people ask me about supplementation, I refer them to Examine.com.

To that end, for those who want to be on the cutting edge of research, and want something that counters the overwhelming amount of misinformation, I'd recommend Examine.com's fantastic new resource, the Examine Research Digest (ERD).

ERD-intro-images

Before a study is presented in ERD, it's analyzed and reviewed by the researchers, then all references and claims are double-checked by a panel of editors. Subsequently, a final pass is done by a review panel of industry and academic leaders with decades of experience. Because you have a panel from different backgrounds, you know that you’re getting the complete picture, not the analysis of a single person.

Needless to say, I'm excited to take advantage of this resource personally to stay on up-to-date on some of the latest nutrition and supplementation research - and its practical applications for my clients and readers. I'd strongly encourage you to do the same, especially since it's available at a 20% off introductory price this week only. You can learn more HERE.

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Supplementation Without Evidence: How to Approach Things that *Might* Work Intelligently

Today, we've got a guest post from Kamal Patel on the ever-controversial topic of supplementation. Kamal was instrumental in creating the great new resource, the Examine.com Stacks Guide. Enjoy! -EC

Science is a process used to uncover the truth, or at least get as close to the truth as possible. It isn’t the only option out there, but it is definitely the best one currently available to us and has served humanity very well.

Thing is, with all the praise science gets (deservingly so), people sometimes forget it is a process. Just because something is “unproven” does not mean it’s crap - it just means that enough research hasn’t been conducted. People are too quick to think that “proven” is synonymous with “effective” and that “unproven” is synonymous with “not effective.”

Consider creatine. We all know that it works for increasing power output because of the mountain of evidence and anecdotes for it, but what if we went back in time to 5 years before creatine had human evidence? What if we also took a few kilograms of our favorite white powder with us in this time machine; would the fact that no evidence existed at this point somehow render the powder completely useless?

No. Things work whether you like them or not, and things fail whether you like them or not. Science just shows us which is which, it doesn’t make them so. The only real difference is in the questions left unanswered.

FlPills

These ‘unproven’ supplements can still be really good, but they have to be approached differently from other ‘proven’ supplements. In the end they are both potential options for your usage, but the body of evidence needs to be considered.

How to approach unproven agents for yourself

When you come across a supplement which looks promising but doesn’t have much evidence for it, ultimately the choice of whether or not to use it is up to you. You can honestly run out and buy anything if you want, but at the least: look into the toxicology of it.

Take something like arginine - if you overdose on it, the side effects are diarrhea. Then you take something like Thunder God Vine, where the side-effect is gradual death of the immune system. Big difference!

How to responsibly approach unproven agents for others

It is difficult to recommend unproven supplements for others because unproven supplements tend to also have less safety data. There’s a difference between modifying your own body and recommending something to someone else. It’s something to approach cautiously.

You can easily tell somebody to “just take 5 grams of creatine a day and forget about it” - since it’s well researched that’s a safe statement. In the case of unproven supplements, you need to read over the evidence with them and let them come to their own decisions. A lot more prudency is needed here.

In the end though, unproven options could be amazing. Take cissus for example (which we’ve talked about here before): the one study on it was conducted in men with work-related muscle and joint soreness (a rare population to get studied in regards to joint health, almost everything is in osteoarthritis) and it has a very good reputation with athletes. It is a prototypical “unproven supplement that could be great but we do not have enough evidence yet.”

Stacking the known and the unknown

It is clear that stacks should be focused primarily around what is known to work and is known to be safe, but given the possibilities out there for personalizing your own stack, you can be smart about it. At the very least learn how to approach these things so you remain safe, add in new compounds so you can clearly attribute what supplement did what, and use a trial and error approach to find what works for you.

Eric said that the question he hates being asked the most is: “What supplements should I take?” That’s pretty much the same question we get: “What supplements should I take for ______?”

And that’s why we created our Stack Guides. It’s not just about “take this” and “don’t take that” - it’s a lot more subtle than that. There are promising supplements out there (like cissus), and you need to be a bit more nuanced than that.

stackbooks

We’re an independent, 100% transparent and unbiased source. Since we don’t sell any supplements, you know that our recommendations are all based on sound science, not us trying to make a quick buck.

Each stack also includes:

  • Stacks catered not only to a goal (ie. fat loss) but also demographics (ie. for people who cannot easily tolerant stimulants)
  • Nonsupplemental tips to help maximize efficacy
  • Practical considerations when dealing with the components, like how to easily avoid minor side-effects of inconveniences
  • Safety information on possible drug-drug interactions (although not all could be mentioned, referring to your medical doctor is still mandatory)
  • Tips to help future supplement additions
  • Free lifetime updates - as new research comes out, the stack guides will be updated accordingly

Note from EC: I've reviewed the resource and it's fantastic. I really could have used something this incredibly thorough when I was an "up and comer"in the industry and blowing far too much money on supplements that simply didn't work. If you're someone who purchases supplements regularly, I view this guide as an investment and not an expense; it'll actually save you a lot of money (especially since it's on sale at an introductory price this week). Click here to learn more.

About the Author

Kamal Patel is the director of Examine.com. He has an MBA and an MPH (Master of Public Health) from Johns Hopkins University, and was pursuing his PhD in nutrition when he opted to go on hiatus to join Examine.com. He is dedicated in making scientific research in nutrition and supplementation accessible to everyone.

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Cissus Quadrangularis Supplementation: What You Need to Know

Today's guest post comes from the guys at Examine.com, who take unbiased looks at all sorts of topics related to health and fitness.  They'll be discussing a supplement of which you may have never heard, but should be aware. This post is timely, as their popular Supplement-Goals Reference Guide is now on sale to celebrate their hiring of new researchers to kick out great new content.

Cissus Quadrangularis is a traditional medicine used to reduce inflammation and accelerate post-fracture bone regeneration. It is one of the "go-to" recommendations for athletes struggling with joint pain.

However, many authorities have not taken official positions on cissus because, despite the vast collection of anecdotal benefits, there have been few human studies on the supplement.

Studies published in eastern journals have suggested cissus speeds up bone healing, but the dosage amount was not disclosed. Also available as evidence is a documented failure to ease hemorrhoids and a study suggesting cissus can reduce weight in obese people. Researchers in the second study had funding issues and dosed the supplement in the form of gum, taken with water before a meal. Gum and water before a meal will reduce food intake, regardless of the kind of gum taken. Not very compelling evidence!

There is good news, however. The first preliminary human trial on joint pain in adult athletes and cissus has finally been published and results are promising. Adults with nonpathological joint pain due to exercise took 3,200mg of cissus daily. After eight weeks, subjects reported a reduction in joint symptoms by about a third.

The study lacked a placebo control, and cissus was not tested against a reference drug, so more evidence will be required determine cissus’ true efficacy.

450px-Cissus_quadrangularis_MS0938

Muscles and Joints

Cissus has a few properties that may benefit the musculoskeletal system. The following has been observed in rats:

  • Cissus is anti-inflammatory agent, though with questionable potency.

  • It is a painkiller with a quick onset.

  • It has minor muscle relaxant and sedative properties, which occur within 30 minutes of supplementation.

Due to its mild sedative effect, high doses of cissus should not be used as a preworkout.

Effects on Bone

Cissus increases IGF signalling in bone cells, which promotes mineral retention and growth. These effects have been observed in low concentrations, which suggests oral supplementation is a suitable way to take cissus. Rodent studies have shown that cissus promotes bone growth, mineral density and increases the bone’s ability to withstand force.

There are numerous studies published in eastern journals that support cissus’ positive effects on bone regeneration, but methodologies vary and actual evidence is scant.

Other properties

The sedative effects associated with cissus supplementation are not well studied, but it has been observed to enhance sleep time in benzodiazepine-induced animals. This suggests that cissus might best be supplemented before bed.

The herb has also traditionally been used to reduce stomach ulceration. Animal studies support this property.

Take-aways:

  • Cissus quadrangularis is a well-known supplement for reducing exercise-induced joint pain.

  • There is a serious lack of scientific evidence for the effects of cissus quadrangularis.

  • It is a potentially relaxing compound, not suited for a preworkout.

  • Cissus quadrangularis has promising but unproven benefits for bone regeneration.

  • It the future, it may be used to treat and prevent ulcers.

Looking for more unbiased reviews of supplements - both popular and obscure - to which you'll constantly be referring for years to come?  Check out the Supplement-Goals Reference Guide; it's a fantastic product that is "Cressey Approved" - and on sale through this Friday at midnight. Perhaps the coolest part is that you get a lifetime of updates, so when new research emerges, the reviews are updated to reflect this new information.

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Stuff You Should Read: 7/15/09

Here's a collection of stuff I encourage you to check out this week: The Return of BSP - I really enjoyed CP staff member Brian St. Pierre's latest blog post on supplements.  Some people just need a smack in the face to wake up from idiocy. Research links Nicotine to Pre-Diabetes - And you thought that only junk carbs, poor genes, and a lack of exercise makes folks insulin resistant.  In reality, it sounds like smoking does as well. Self-Ankle Mobilization to Increase Dorsiflexion - Here's a cool new video Bill Hartman just posted on ankle mobilizations.  I've used stuff like this in the past on my own ankle and it definitely makes the mobilization more effective.

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Bogus Workouts and The Official Blog of

Today's blog will serve as somewhat of a rant on how pro athletes and their training and nutrition are marketed to consumers.  I'll talk about a few examples, but first I'll pose a question: does NASCAR really need an official laundry detergent?  Anyway, I digress; let's get to the meat and potatoes. About once a week at Cressey Performance, we get a sales pitch - either via email, phone, or in-person - from a supplement salesman.  Generally, this person is not a regular exerciser, and almost all of the time, he/she shows very little knowledge of the product.  However, this individual always has plenty of confidence in its efficacy - which shouldn't be surprising, as these folks are almost always involved in some kind of supplement pyramiding scheme.  Needless to say, I get pretty tired of it. Usually, these salesmen drop the "It's the official <insert product genre here> of <insert pro sports team here> and <insert popular athlete here> swears by it."  An example might be "It's the official calf raise apparatus of Cressey Performance, and Tony Gentilcore swears by it."

Earlier this week, I heard that "XYZ is the official juice of ABC and JKL swears by it" - where ABC is a MLB team.  I couldn't help but laugh, as 74% of my athletes are baseball players (many of them pros) - so you could say that I know nutrition at the pro level pretty well.  If there is going to be an official drink of Major League Baseball, it's probably some kind of beer.  If you think they are pounding this magical Kool-Aid, you've got another thing coming.

Perhaps my favorite marketing scheme is when a magazine publishes a workout program from some pro athlete - and I know it's just flat-out untrue.  How can I be so sure?  I know their strength coach!  We've known for quite some time that editors write the programs for pro bodybuilders in some of the older muscle magazines out there, but nobody seems to grasp that they often do the same for the athletes they profile.  About two years ago, I heard that a 6-10 NBA guy notorious for his long arms and defense and rebounding prowess could bench press 455 pounds.

First off, I knew his strength coach, who told me that he would be lucky to do half that amount.

Second, the risk-reward of that 455 bench press is completely out of whack, and I know there is no way a strength coach (at least one who would like to keep his job at the pro level) would even let an athlete with a huge contract attempt that weight.

Third, I can count on one hand the number of times I've seen anyone bench that much raw.  In each case, they were shorter guys with short arms and big bellies to shorten the range-of-motion.  A 455-bench press is a HUGE raw bench, and the chances of an athlete in a sport with such a huge aerobic component hitting it are slim to none.

Just some food for thought: buyer beware when you hear claims like these.  Feel free to share some of your favorite examples below.

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T-Nation Strength and Size Roundtable: Part 3

Writer Greg McGlone rounded up five of the biggest, baddest, strongest, and best-informed hombres in the iron game, and invited them to share their "secrets" with those of us who also want to get bigger, badder, stronger, and better-informed. In part 1, the coaches discussed the viability of building size and muscle at the same time, along with a comparison between compound and isolation movements. In part 2, they tackled the topic of whether you have to look strong to be strong, along with a fascinating discussion of training splits. Today, the topics include nutrition, supplementation, recovery, and some final thoughts. Continue Reading
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Invincible Immunity

by Eric Cressey

Of all the lousy things that can happen, this has to be one of the worst. Imagine...You've just completed the most successful bulking cycle of your life, adding twenty pounds of mass; you're on top of the world. Now, all you have to do is train properly and eat plentifully in order to solidify your gains. With your knowledge of diet and training, it should be a snap. Then everything hits the fan... Your girlfriend is so proud of you for making such great gains and transforming your physique that she can't keep her hands off of you. The day before, she had shared a soda with a friend who had just come from the gym. That friend had taken a sip from the water fountain at the gym and accidentally touched her lips to the spout. Ten minutes earlier, that skanky "human sweat gland" guy who spends five hours on the elliptical cross trainer each day had just made out with that same water fountain. That morning, he had kissed his wife goodbye before leaving for his job at the DMV. That wife is the teacher of a kindergarten class. Incidentally, that class happened to be riddled with the flu, and some kid had blown chunks all over her nice new blouse the day before. Sure she cleaned it up, but she still wound up with the flu. Thanks to this incredibly unlikely downward spiral, you are now home sick from work, pitying yourself as you watch the same episode of Sportscenter eight times in a row. All the while, you're thinking about how you would much rather be deadlifting like a madman and showing off your gains at the gym! Unfortunately, you cannot go back in time to prevent yourself from coming down with the flu. Although it may be beneficial to look back and figure out if there was anything you could have done to strengthen your immune system (avoiding overtraining, paying attention to post-workout nutrition, taking certain supplements, getting plenty of sleep, etc.), you need to focus on the task at hand: beating the flu! You see, bodybuilders, powerlifters, and other athletes have to take into account how sickness affects performance and physical appearance, whereas normal folks just worry about "getting rid of their sniffles." Before we get to the specifics, though, I should mention that the term "flu" that we so often use is short for influenza. Influenza (also known as Grippe or Grip) is really only one of several common kinds of viral respiratory infections. Also including on this list are the common cold (upper respiratory infection or acute coryza), pharyngitis, laryngitis, tracheobronchitis, and viral pneumonia (1). Regardless of the clear differences in the nuts and bolts of each infection, they are generally all lumped together and called the flu by the general public. While this oversimplification is erroneous, the human immune system must be strong to prevent and in many cases overcome any type of infection. And, if you're anything like me, you detest the idea of getting loaded up on medications, sugary cough syrups, and lozenges just because your nose is running faster than a sprinter with a rocket up his butt. All that being said, let's get to work on finding a universal approach to maintaining your gains and getting back to optimal health as soon as possible. Diet Proper diet seems like a no-brainer, right? One would think so, but I'm constantly amazed at how people vehemently adhere to this primitive urge that tells them to stuff themselves full of crap foods just because they feel like crap! These crap foods are usually "comfort" foods: Mom's cookies, white toast with cinnamon, sugar, and butter, hot chocolate, a whole gallon of ice cream?. These foods may have made you feel better as a kid when they were used to take your mind off the "boo-boo" on your knee, but they'll only make thing worse when you are a sick adult. They might make you feel all warm and toasty on the inside, but they'll quickly make you soft and fluffy on the outside if you overindulge. So what should you eat and what should you avoid? For starters, remember that total calories are of foremost importance. Don't fall into the trap of dropping calories too low out of fear of gaining fat while "on the shelf." Instead, it's important to assume the mindset of maintaining the status quo physique-wise while bringing the immune system up to par. If you gain a little fat, don't sweat it. Remember, it's a lot easier to shed a little fat than it is to regain a few pounds of lost muscle. In reaching your daily caloric goal, as usual, spread your intake out over six smaller meals. Maintenance caloric intake is highly variable, so rather than multiplying your body weight by a certain number to find your target, base your intake on slightly below (100-150 calories) what you would take in on a normal rest day. This decrease should account for the extra time spent on the couch or in bed. Specific macronutrient recommendations are also of little value in this instance due to individual variations in terms of carb tolerance. As such, adhere to your typical macronutrient ratios with the only exception being a slight reduction in carb intake to compensate for the diminutive calorie reduction and reduced training effect. Furthermore, make sure that you keep protein high (1-1.5g/lb lean body mass) in order to remain in positive nitrogen balance and stop muscle protein catabolism in its tracks. From all our cutting cycles, we're all well aware that protein needs increase during times of stress, and sickness is certainly one of those times. In a study of critically ill children in hypermetabolic and catabolic states, researchers found that a higher protein intake was associated with positive nitrogen balance, whereas a low intake (with total calories held constant) led to a continued state of negative nitrogen balance and muscle protein catabolism (2). A big steak probably won't sound too appealing when you're sick, though, so low carb protein powders (such as Xtreme Ultra Peptide), cottage cheese, omelets, and other "easy to get down" protein sources might turn out to be your best friends. Next, only consume low-glycemic carbs. When you're sick, your body isn't primed for sucking up simple sugars like it is when you've just completed a training session. So, the typical bodybuilding "no-no" foods should be even more off-limits than usual. Your best bet is to focus carb intake early in the day when muscle cells are most receptive to storing glycogen. Keep fats (especially healthy fats) up as well - possibly at the expense of carbohydrates. In the aforementioned study of critically ill children, fat was used preferentially for oxidation. Meanwhile, a high carbohydrate intake was associated with lipogenesis (fat formation) and decreased fat oxidation (2). Thirty percent of total calories is a good figure in order to support endogenous testosterone and overall energy levels (as fat is the primary source of energy at rest). Your body will be forming plenty of new immune cells as you fight off sickness, and fatty acids constitute an important component of each new cell membrane. Therefore, in order to give the body the best raw materials available, make sure that you're getting plenty of omega-3 fatty acids. However, don't fall into the trap of overdoing the omega-3s or fat in general; very high fat diets are associated with impaired lymphocyte (one of the five kinds of leukocytes, or white blood cells) function (3). Furthermore, while fish oil has proven effective in enhancing immune function in certain clinical situations (e.g. rheumatoid arthritis, ulcerative colitis) and in animals, studies of healthy humans are yet to yield consistently favorable results to substantiate the claim that omega-3s enhance immunity (4). As such, there does not appear to be any greater benefit (at least not yet) to increasing omega-3 PUFA intake during times of sickness. Simply stick to your normal intake levels, relying on healthy sources such as fish oil and flaxseed oil for your supplemental fat intake. The last dietary concern that warrants mention is water intake. You might think that because you aren't training, you don't need to worry much about pushing the H2O- big mistake. The body loses a significant amount of fluids each day independent of training. We're constantly losing water as we dissipate heat through our skin and in our breathing without even knowing it. Factor in increased mucus production, the sweating that may be associated with a fever, the fact that your body is constantly constructing new cells (especially during sickness), not to mention your higher protein intake, and you can begin to realize the importance of really emphasizing water intake. Shoot for at least one gallon (preferably more) of water daily. Supplementation First and foremost, be sure to get a flu shot each fall. The optimal time to do so is mid-September through November, as it takes at least a week for the shot to really kick into protective-mode. If you need proof that the influenza vaccine is worth the fee (if you even have to pay for it), look no further than a study conducted on a Brazilian airline company's employees. As I'm sure you can imagine, flight attendants and those in related roles are a population segment that is extremely susceptible to the flu due to their interactions with so many customers (often in confined spaces). Prior to flu season, each of 813 employees received either an influenza vaccination or a placebo. Seven months later, the employees who had received the vaccines showed 39.5% fewer episodes of flu-like illness than the placebo. Additionally, the vaccine group was absent from work due to sickness 26% less often than the placebo group (5). From a weight-training standpoint, that 26% corresponds to a lot of missed training sessions. In addition to the flu shot and your regular multivitamin, you should definitely include the following: Vitamin C Vitamin C (ascorbic acid) is the first immune-booster that comes to mind. A vital component of every cell in the human body, ascorbic acid is perhaps most notably found in high concentrations in leukocytes (white blood cells). The leukocytes are constantly being produced in the bone marrow as safeguards against bad stuff like cottage cheese gone sour, reruns of those obnoxious Subway commercials with Jared, curling in the squat rack, and, oh yeah, infections. During infection, in order to prevent oxidative damage, the vitamin C within the leukocytes is used up faster than a post-training shaker bottle full of Relentless (4)! Thus, it should come as no surprise that reduced leukocyte vitamin C levels are associated with less than optimal immune function. (6) In the worst vitamin C deficit scenario, scurvy, the immune response is entirely inadequate (and sometimes nonexistent) in each of the many components of the immune system. In fact, overall vitamin C status is often measured via an assessment of levels in the leukocytes (4). In terms of preventative supplementation, a true consensus has not yet been met regarding the efficacy of vitamin C in reducing the occurrence of common colds. Several respected studies have found that Vitamin C supplementation is of little value in preventing the common cold (7), whereas others have reported decreased incidences of reported common cold infection among individuals who received large doses of a vitamin C supplement (8,9). However, other studies have verified the assertions that supplementation with vitamin C improves several aspects of the human immune response, effecting positive changes in proliferation and/or function of in three of the five types of leukocytes: lymphocytes, neutrophils, and monocytes (10-16). Adequate vitamin C status is often defined as "a circulating pool of 1500mg" (7). Due to the fact that water-soluble vitamins like vitamin C are not stored by the body as well as fat-soluble vitamins, ascorbic acid must be continuously replenished through diet and supplementation. Doses of up to 10g per day have been used in numerous studies without serious toxicity symptoms. The side effects of such high consumption may include diarrhea and, in serious cases, kidney stones or urate crystals (due to increased uric acid release in the urine). Antonio and Stout state that these risks have "been greatly overstated" (7). Based on the available literature, I recommend 2-2.5g of supplemental vitamin C daily during normal training conditions and 4-5g daily during flu-like symptoms and times increased of training stress. Also, be sure to spread your intake throughout the day in 500mg doses. Dosages of 500mg are proven to increase cellular ascorbic acid absorption by up to 40%, whereas dosages greater do not increase this absorption (17). Vitamin E Perhaps as important as vitamin C is Vitamin E, which works synergistically with selenium in tissues to reduce lipid membrane damage by reactive oxygen species (ROS) during infections (4). Vitamin E has proven effective in improving various parameters of the immune function, including enhanced lymphocyte production, improved antibody response to vaccine, reduced pulmonary viral titers (a measure of virus prevalence in respiratory infections), and "preventing an influenza-mediated decrease in food intake and weight loss" (18-20). No decrease in food intake? Maybe that steak won't sound so bad after all! All that being said, even the slightest deficiency in vitamin E can easily compromise one's immune response. And, the current RDA of 30 IU is barely adequate in preventing deficiency in sedentary, normally healthy individuals, let alone in athletes, the elderly, and the sick and diseased. Granted, one may derive a considerable amount of vitamin E from diet alone, but in order to receive sufficient vitamin E to attain an enhanced immune benefit, one must supplement in excess of the RDA (especially on low-fat diets). Vitamin E is recognized as one of the least toxic vitamins, although one may experience some minor symptoms (nausea, diarrhea, muscle weakness) with very high dosages (7,21). As such, 800-1200 IU throughout the year (regardless of whether you're sick or healthy) is an optimal approach. Glutamine Glutamine is well known as the most abundant amino acid in the human body (including both the plasma and tissue pool). In fact, the intramuscular free amino acid pool is more than 60% glutamine, and the glutamine in skeletal muscle accounts for about 90% of the body's total glutamine pool. Although over 40% of the body's glutamine is devoted to fueling the GI tract, this amino acid also plays a role in the functioning of many other parts of the body, including the liver, brain, muscles (duh!), hair follicles, kidneys, and - you guessed it - the immune system (7,22-24). Adequate levels of glutamine are necessary to ensure optimal proliferation and function of lymphocytes, macrophages, and neutrophils (25,26). Traditionally, because the body can synthesize glutamine endogenously (mostly in the muscle tissue), it has been classified as a nonessential amino acid. However, this classification is made under the assumption that the body is not enduring a stressful physiologic trauma such as sickness (23). Many researchers have now begun to classify glutamine as a conditionally essential amino acid during times of sickness, infection, and malnutrition. Because glutamine is a crucial substrate for a variety of metabolic processes, it is only logical that the body requires increased amounts of the amino acid during infection in order to "bolster" the immune system while maintaining normal physiological functioning (24,26). Unfortunately, as you can see in many cancer patients, the body's response to infection, injury, and stress is protein catabolism. Initially, plasma glutamine levels are depleted. Next, in order to sustain its metabolic processes and replenish plasma glutamine levels, the body takes glutamine from skeletal muscle. Normally, this isn't a problem, as skeletal muscle glutamine synthesis matches glutamine release. However, during times of stress, there is a problem: numerous organs, including the liver and bowel, show marked increases in glutamine uptake during infection. These increases, in combination with the needs of the immune system, GI tract, and the regular metabolic processes, cause glutamine release from skeletal muscle to exceed glutamine synthesis. In fact, skeletal muscle glutamine release may double during infection (23,27). In summary, during infection: 1. Glutamine use increases 2. Glutamine supply decreases 3. A concentration gradient across the muscle cell membrane cannot be reached (23) 4. Your beloved quad sweep becomes fuel for your GI tract and, essentially, your body's lunch. Think about it for a second: when you're sick, is your body going to care more about ensuring appropriate internal organ functioning or maintaining sleeve-splitting biceps? Luckily, numerous studies have proven that exogenous glutamine can help to: maintain positive nitrogen balance (and glutamine levels in skeletal muscle), increase plasma glutamine levels, prevent decreases in ribosomal concentrations, improve muscle protein synthesis rates, and enhance immune function (through such mechanisms as encouraged lymphocyte proliferation) (7, 28-32). Also, let's not forget that glutamine?s "immunoenhancing" effects make it an effective year-round, recovery-promoting supplement (albeit in smaller doses) for hard training athletes who are more susceptible to infection, especially during and shortly after periods of intensive training (7,33,34). Glutamine supplementation is also associated with increased plasma GH concentration, which may also assist in immunity (7,35). During illness, shoot for 0.35-0.4g glutamine per kg body weight, and spread your intake out throughout the day in 3-5g doses. Based on the published clinical studies and for absorbability reasons, I recommend glutamine peptides. L-glutamine (free form), however, tastes better, generally costs less, and will also yield favorable results. Personally, I'll stick with peptides, but it's your call; just make sure to get it in you in some form! Zinc Although most people primarily associate zinc with growth and development, this trace mineral also plays a crucial role in proper immune function. A deficiency of zinc relates to diminished immune response, including low T- and B-cell (the two broad categories of lymphocytes) counts in bone marrow due to decreased proliferation, and reduced antibody production (just to name a few). In some mice, only thirty days of inadequate zinc intake caused an 80% reduction in immune capacity. As such, it should come as no surprise that zinc deficiencies are prevalent in numerous immune system-stressing chronic illnesses, including HIV, renal disease, and alcoholism (4,36). While the complications of zinc deficiency are well established, studies on the benefits of zinc supplementation in enhancing immune function have yielded mixed, but mostly favorable results. Numerous studies have found that zinc supplementation initiated upon the onset of a cold or upper respiratory tract infection decreases the sickness' duration and severity (7,37-39). In a study of twenty burn victims, fewer pulmonary infection rates and shorter hospital stays were observed in patients who received a trace mineral supplement that included zinc (40). Meanwhile, zinc supplementation in long distance runners prevented the typical increase in reactive oxidative species normally seen with endurance activity (41). In terms of preventative supplementation, researchers found that of 609 school children that were given either a zinc supplement or a placebo, those who supplemented with zinc had 45% fewer acute lower respiratory infections over the 120-day study (42). If you take nothing else from all these studies, at least walk away from this article cognizant of how important sufficient intake is, especially for athletes (who are more likely to be deficient than the general population). While high-dose supplementation can actually lead to immunosuppression, moderate supplementation throughout the year with slightly increased dosages beginning at the onset of flu- or cold-like symptoms is an effective and safe supplementation approach (7). During sickness, take at least 25mg zinc (but not more than 100mg) per day. An optimal approach would be to get this supplemental intake in the form of a ZMA supplement, as it will enable you to meet your zinc needs while increasing anabolic hormone levels, improving recovery, and promoting deep, restful sleep. Miscellaneous: the other stuff Here are a few other supplements that are often thrown into the immunity discussion, but will probably not be worthwhile additions to your immune effort: Vitamin A (preformed vitamin A is known as beta-carotene): Although vitamin A is of unquestionable importance to proper immune functioning, there is no definitive evidence to suggest that supplemental vitamin A offers additional benefits over normal dietary intake, especially in those with already adequate status. Excessive vitamin A intakes have been associated with suppression of T- and B-cell function, thus causing a greater susceptibility to infection. Toxicity can also become an issue with higher intakes. Vitamin A deficiency is very uncommon in wealthier nations. As such, if you feel that you need to get more beta-carotene than you diet alone provides, make sure to select a multivitamin with at least 5000 micrograms (4,7). Echinacea: Although a few studies have emerged that show slightly (and relatively insignificantly) shorter respiratory tract infection durations in patients treated with echinacea, most have demonstrated that the herbal product has little or no effect on preventing and treating sickness. This uncertainty is complicated by the fact that there are nine species of the plant, different parts (leaves, stem, roots, flowers) of the plant can be used, and different forms are available (e.g. powder, liquid extract, capsule). Essentially, even if echinacea was definitively proven effective, an argument would still exist over which species, form, and delivery produces the best results. At this point, there is not enough evidence to recommend echinacea as a worthy supplement (7,43-45). Arginine: This nonessential amino acid has shown promise in improving immune response and wound healing via improved lymphocyte production in individuals with compromised health status. Other studies, however, have shown that arginine supplementation is of no benefit in attempting to enhance the immune response, especially in healthy individuals (7). Given that some clinical trials use upwards of 20g L-arginine per day (mostly without appreciable immunity-related results), forty capsules per day seems like far too risky an investment even if you enjoy being a human guinea pig. Then again, even if you do decide to give arginine a try, be careful; excessive intakes can actually blunt the immune response (46). Lifestyle/Training An adequate amount of sleep during sickness is of the utmost importance. The old "8-hours at night" recommendation still holds true...as a minimum. You should also be shooting for a nap or two during the day. It seems like a no-brainer to say that you shouldn't be training when you're sick, but I'm constantly amazed at how many people still go the gym in spite of their wheezing, sore throats, and aches. Before you stumble off the couch and over to your local gym, ask yourself if your body could really recover from a heavy training session if it hasn't even recovered from the flu. The answer should be a resounding "NO!" If it isn't, maybe it will help to think about how your decision to go train will impact others; you'll probably make half the people in the gym sick just like the "human sweat gland" did to you. Stay home, if not for your own sake, then for the sake of everyone else who enjoys his or her health and visits to the gym. Get over the flu and then get back to the gym! Conclusion There you have it: a comprehensive approach to getting back to the gym as soon as possible. To recap: 1. No comfort foods 2. Maintenance calories (factoring in reduced activity level) 3. Normal protein intake 4. Slightly reduced carb intake, consisting of low GI carbs only 5. Normal healthy fat intake 6. Regular Multivitamin 7. 4-5g vitamin C in 500mg doses throughout the day 8. 800-1200 IU vitamin E in 400 IU doses throughout the day 9. 0.35-0.4g glutamine peptides/kg body weight in 3-5g doses throughout the day 10. ZMA supplement (or zinc equivalent providing 25-100mg/day) 11. No training until symptoms are gone 12. R&R It might not sound as appetizing or heart-warming as a bowl of chicken soup, but it beats Nyquil... References 1. The Merck Manual of Diagnosis and Therapy. http://www.merck.com/pubs/mmanual/section13/chapter162/162b.htm; 1995 accessed Sept 2002. 2. Coss-Bu JA et al. Energy metabolism, nitrogen balance, and substrate utilization in critically ill children. Am J Clin Nutr 2001 Nov;74(5):664-9. 3. Calder PC et al. Fatty acids and lymphocyte functions. Br J Nutr 2002 Jan;87 Suppl 1:S31-48. 4. Field C. et al. Nutrients and their role in host resistance to infection. J Leukoc Biol 2002 Jan;71(1):16-32. 5. Mixeu MA et al. Impact of influenza vaccination on civilian aircrew illness and absenteeism. Aviat Space Environ Med 2002 Sep;73(9):876-80 6. Schwager, J. et al. Modulation of interleukin production by ascorbic acid. Vet Immunol Immunopathol. 1998 Jun 30;64(1):45-57. 7. Antonio, J., & Stout, J. Sports Supplements. Lippincott Williams & Wilkins, 2001. 8. Hemila, H. Vitamin C and common cold incidence: a review of studies with subjects under heavy physical stress. Int J Sports Med 1996 Jul;17(5):379-83. 9. Hemila, H. Vitamin C and acute respiratory infections. Int J Tuberc Lung Dis 1999 Sep;3(9):756-61. 10. Kennes, B. et al. Effect of vitamin C supplements on cell-mediated immunity in old people. Gerontology 1983;29(5):305-10. 11. Penn, ND. et al. The effect of dietary supplementation with vitamins A, C and E on cell-mediated immune function in elderly long-stay patients: a randomized controlled trial. Age Ageing 1991 May;20(3):169-74. 12. Shilotri PG, & Bhat KS. Effect of mega doses of vitamin C on bactericidal ativity [sic] of leukocytes. Am J Clin Nutr 1977 Jul;30(7):1077-81 13. de la Fuente, M. et al. Immune function in aged women is improved by ingestion of vitamins C and E. Can J Physiol Pharmacol 1998 Apr;76(4):373-80. 14. Patrone, F. et al. Effects of ascorbic acid on neutrophil function. Studies on normal and chronic granulomatous disease neutrophils. Acta Vitaminol Enzymol 1982;4(1-2):163-8. 15. Prinz, W. The effect of ascorbic acid supplementation on some parameters of the human immunological defense system. Int J Vit Nutr Res 1977; 47:248-57. 16. Woollard, KJ. et al. Effects of oral vitamin C on monocyte: endothelial cell adhesion in healthy subjects. Biochem Biophys Res Commun 2002 Jun 28;294(5):1161-8. 17. Voldani, A. et al. New evidence for antioxidant properties of vitamin C. Cancer Detect Prev. 2000;24(6):508-23. 18. Meydani, SN et al. Vitamin E supplementation enhances cell-mediated immunity in healthy elderly subjects. Am J Clin Nutr. 1990 Sep;52(3):557-63. 19. Meydani, SN et al. Vitamin E supplementation and in vivo immune response in healthy elderly subjects. A randomized controlled trial. JAMA. 1997 May 7; 277(17):1380-6. 20. Han, SN et al. Effect of long-term dietary antioxidant supplementation on influenza virus infection. J Gerontol A Biol Sci Med Sci 2000 Oct;55(10):B496-503. 21. Beharka A. et al. Vitamin E status and immune function. Methods Enzymol 1997;282:247-63 22. Yeh, SL et al. Effects of glutamine-supplemented total parenteral nutrition on cytokine production and T cell population in septic rats. JPEN J Parenter Enteral Nutr. 2001 Sep-Oct;25(5):269-74. 23. van Acker, BA et al. Glutamine: the pivot of our nitrogen economy? JPEN J Parenter Enteral Nutr. 1999 Sep-Oct;23(5 Suppl):S45-8. Review. 24. Newsholme, P. Why is L-glutamine metabolism important to cells of the immune system in health, postinjury, surgery or infection? J Nutr. 2001 Sep;131(9 Suppl):2515S-22S; discussion 2523S-4S. Review. 25. Saito, H. et al. Glutamine as an immunoenhancing nutrient. JPEN J Parenter Enteral Nutr. 1999 Sep-Oct;23(5 Suppl):S59-61. Review. 26. Ziegler, TR. Glutamine supplementation in cancer patients receiving bone marrow transplantation and high dose chemotherapy. J Nutr. 2001 Sep;131(9 Suppl):2578S-84S; discussion 2590S. Review. 27. Karinch AM. et al. Glutamine metabolism in sepsis and infection. J Nutr 2001 Sep;131(9 Suppl):2535S-8S; discussion 2550S-1S. 28. Wilmore, DW. The effect of glutamine supplementation in patients following elective surgery and accidental injury. J Nutr. 2001 Sep;131(9 Suppl):2543S-9S; discussion 2550S-1S. Review. 29. Boelens PG. et al. Glutamine alimentation in catabolic state. J Nutr. 2001 Sep;131(9 Suppl):2569S-77S; discussion 2590S. Review. 30. Yoshida, S. et al. Effects of glutamine supplements and radiochemotherapy on systemic immune and gut barrier function in patients with advanced esophageal cancer. Ann Surg. 1998 Apr;227(4):485-91. 31. Valencia, E. et al. Impact of oral L-glutamine on glutathione, glutamine, and glutamate blood levels in volunteers. Nutrition. 2002 May;18(5):367-70. 32. Yoshida, S. et al. Glutamine supplementation in cancer patients. Nutrition. 2001 Sep;17(9):766-8. 33. Castell LM., & Newsholme EA. The effects of oral glutamine supplementation on athletes after prolonged, exhaustive exercise. Nutrition 1997 Jul-Aug;13(7-8): 738-42. 34. Rosene, MF. et al. Glutamine supplementation may maintain nitrogen balance in wrestlers during a weight reduction program. Med Sci Sports Exerc 1999;31(5): S123. 35. Welbourne, TC. Increased plasma bicarbonate and growth hormone after an oral glutamine load. Am J Clin Nutr. 1995 May;61(5):1058-61. 36. Fraker, PJ. et al. The dynamic link between the integrity of the immune system and zinc status. J Nutr 2000 May;130(5S Suppl):1399S-406S. 37. Prasad AS. et al. Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2000 Aug 15;133(4):245-52. 38. Al-Nakib, W. et al. Prophylaxis and treatment of rhinovirus colds with zinc gluconate lozenges. J Antimicrob Chemother. 1987 Dec;20(6):893-901. 39. Mossad, SB. et al. Zinc gluconate lozenges for treating the common cold. A randomized, double-blind, placebo-controlled study. Ann Intern Med. 1996 Jul 15;125(2):81-8. 40. Berger MM. et al. Trace element supplementation modulates pulmonary infection rates after major burns: a double-blind, placebo-controlled trial. Am J Clin Nutr. 1998 Aug;68(2):365-71. 41. Singh A. et al. Exercise-induced changes in immune function: effects of zinc supplementation. J Appl Physiol 1994 Jun;76(6):2298-303. 42. Sazawal S. et al. Zinc supplementation reduces the incidence of acute lower respiratory infections in infants and preschool children: a double-blind, controlled trial. Pediatrics. 1998 Jul;102(1 Pt 1):1-5. 43. Gunning, K. Echinacea in the treatment and prevention of upper respiratory tract infections. West J Med. 1999 Sep;171(3):198-200. 44. Brinkeborn RM. et al. Echinaforce and other Echinacea fresh plant preparations in the treatment of the common cold. A randomized, placebo controlled, double-blind clinical trial. Phytomedicine. 1999 Mar;6(1):1-6. 45. Grimm, W, & Muller, HH. A randomized controlled trial of the effect of fluid extract of Echinacea purpurea on the incidence and severity of colds and respiratory infections. Am J Med. 1999 Feb;106(2):138-43. 46. Wiebke EA. et al. Effects of L-arginine supplementation on human lymphocyte proliferation in response to nonspecific and alloantigenic stimulation. J Surg Res 1997 Jun;70(1):89-94.

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