Dr. Hector Lopez on Dietary Supplements

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First published on www.MohrResults.com, August 2007

Today we’ve got Mohr Results Inc Advisory Board member, Dr. Hector Lopez, in the hot seat.  Dr. Lopez is one of the leading physicians in the strength training and nutrition worlds.  We always get excited to hear about Dr’s who stress prevention versus reaction - well, Hector is leading the fight in that battle.  Not only is he a medical physician, but he has bachelor and master degrees in nutrition and exercise physiology and is a certified strength and conditioning specialist!  Without further ado, let’s talk to the good Doc - today we’re covering dietary supplements!

1.  Are there any supplements that are a "must have" in folks daily diets?

Well, the very nature of a “dietary supplement” would exclude any of them as being “must have” per se given a comprehensive whole-food diet.  However, having said that, if I were obliged to choose ONLY 1 supplement, it would have to be a high quality fish oil supplement (rich in the long-chain PUFAs, EPA/DHA).  There is an overwhelming body of scientific literature which supports viewing fish oil (EPA/DHA) as a “pleiotropic” supplement.  When I say pleiotropic, I am simply referring to the many mechanisms by which fish oil may promote and support multiple organ systems.  The omega-3 fatty acids found in fish oil have remarkable effects on many molecular signals/biochemical pathways which include but are not limited to:  systemic and local inflammation via eicosanoid metabolism (the pathways which involve COX-1, COX-2 and LOX enzymes and generate the inflammatory mediators known as the 2-series prostaglandins and leukotrienes, respectively), enzymes and factors involved in lipid/fat oxidation and fat utilization (including blood lipid metabolism), insulin sensitivity, anti-catabolic effects on muscle protein, among others.  It is interesting to note that with the current dietary omega-6:omega-3 ratio approaching 20:1 to even 30:1, supplementing with fish oil is essentially addressing an often “subclinical” macronutrient deficiency state!  To make matters worse, the dysfunctional omega-6:3 ratio is compounded by the amount of hydrogentated vegetable oil and refined, non-fibrous carbohydrate (typically high GI and high Insulin Index).  The result is that fish oil supplementation may benefit just about every organ system within human physiology including the nervous, cardiovascular, musculoskeletal, endocrine, renal, respiratory and even gastrointestinal systems.  Outside of fish oil, given the available epidemiological evidence, other potentially “must have” supplements could include: a low-potency multivitamin/mineral product, ‘green-food’ supplements, fiber complex product (including various soluble and insoluble fibers), and high-quality supplemental protein.  Ultimately, what is “must have” for one patient, client or athlete may vary completely for another.  Therefore, it underscores the importance of individualization on a case by case basis according to medical history, goals, preferences, lifestyle, occupation, training demands, age, etc.

2.  What are your thoughts on beta alanine, one of the newest supplements to hit the market?

Ah yes...beta-Alanine definitely appears to be an up and coming “real deal” in the world of performance nutrition (and even wellness nutrition).  Beta-alanine is the rate-limiting substrate for synthesizing carnosine within muscle.  Carnosine is a dipeptide (2 amino acids bonded together) composed of beta-alanine and L-histidine found in many tissues throughout the body, but is found in highest concentrations in fast twitch (type II) skeletal muscle.  It has been shown consistently in the literature, that intramuscular carnosine stores may be increased with supplemental beta-alanine.  So you may ask, how does this help the average person looking to improve their muscle strength, size, power and fitness?  Well, it turns out that carnosine has physiochemical properties that make it a phenomenal buffer to the build-up of H+ ions within hard-working muscle.  H+ ions tend to accumulate within muscle as the muscle continues contracting and building up metabolic waste products causing the “pH” to drop or acid level to increase.  Because a buildup of H+ ions in muscle is one of the major causes of fatigue and decreased muscular performance, it stands to reason that increasing the amount of this buffer can prolong a training session, working set of strength training exercise, and prevent fatigue that occurs when running at a high intensity.  Over time, the end result is an accumulation of more intense/ productive workouts that individuals can recover from, resulting in augmented training response.  In other words, people may get bigger, faster, stronger coupled with positive changes in body composition (muscle to fat ratio)!  There is some great work being done in this area by one of the leading performance nutrition scientists…my friend and colleague, Dr. Jeff Stout out of the University of Oklahoma.  Drs. Harris and Mark Tallon have also put out some fantastic science on beta-alanine.

The doses required to see an effect appear to be working up to 3g to 6g spread out over (divided in) 4 to 6 doses throughout the day.  It is known to cause a “tingling” much like a ‘niacin flush’, which is improved by taking much smaller doses, or consuming with food, or other amino acids.

Now, our group of physicians (PPP) has an interest in taking the available data on beta-alanine in performance nutrition, and extending it into promoting increased functional outcome and recovery for patients in the clinical world.  That is beyond the scope of this interview, but stay tuned for some of our work in the future.  There are multiple nutritional strategies and supplements that may encourage recovery and rehab from musculoskeletal injuries…not only in athletes, but also patients with various diagnoses.  We’re excited about the potential in this area and hope to contribute to pushing the forefront of existing clinical science and practice.

3. Assuming diet is in tip top shape and training is smart, would you recommend a supplement(s) for someone trying to pack on additional size? And why (or why not)?

Absolutely, this would be based on the individual...their budget, training history, schedule, etc.

The most practical supplements would revolve around macronutrients first. Most athletes would still benefit from a “fast-acting” protein source in the “peri-workout” period (in conjunction with a readily available carbohydrate source such as maltodextrin, dextrose, surcrose, waxy maize, trehalose, etc.) in order to augment the muscle protein synthetic response to strength training, and minimize the catabolic drive when recovering from the exercise bout. It can come in the form of EAA (essential amino acids), high quality whey isolate, or hydrolyzed whey/casein.  Presumably, they have their macronutrition in order such that a “blend” with slower acting micellar casein would not be necessary. However, there is some interesting data emerging, which supports what many of us ‘in the know’ have suspected and observed empirically for quite some time. It is regarding the need to follow-up the rapid rise in plasma amino acids (hyperaminoacidemia) achieved peri-workout from ‘fast-acting’ protein sources, with a more sustained delivery of amino acids over the course of the 2 to 6 hours post-workout, and beyond into the recovery period. The carbohydrate to protein ratio in the “peri-workout” recovery beverage should vary according to the volume and activity of training, the individual’s body composition, response and tolerance for carbohydrate. Including carbohydrate in your pre/post recovery drink is critical if you are interested in gaining muscular weight, and optimizing your training performance in the gym.  Taken together, for those interested in gaining size a carb:protein fast-acting peri-workout drink encourages muscular substrate repletion (recovery), positive nitrogen balance, counter regulatory hormone control (cortisol, glucagon, epinephrine and norepinephrine), and a shift in the physiologic environment from catabolic to a more anabolic one.

The next supplement would include a high quality functional fatty acid blend (supplying EPA/DHA) for reasons stated above.  Again, presuming as you mentioned in your question that the diet is “top notch”, this would be less pressing.  However, in light of data on the content of heavy metals and halogenated organics in the wild and farmed fish supply, it may behoove many to re-consider getting ALL fish oil needs via whole foods.  Also, these macronutrient products are hardly “supplements”, they are more like ‘accessory’ macronutrition.

• Protein (high quality whey isoloate, and/or whey-casein hydrolysate)
• EAA (overweighted in the BCAAs)
• Lipids
• DHA/EPA fish oil (shooting for 2 to 6 grams of supplemental DHA/EPA daily)
• CLA (although effect size is not as impressive in humans as in mice, still intriguing and relatively consistent evidence of nutrient partitioning properties)

With respect to “micronutrition” (vitamins/ minerals/ metabolites) we (PPP) ascribe to Rational PolysupplementationTM as a guideline which ends up representing more of a philosophy.  Rational PolysupplementationTM is the practice of utilizing two or more micronutrient or bioactive metabolites with different mechanisms of action that still complement each other in the interest of optimizing the physiologic/biochemical response. 

We can think of supplements along a hierarchy of sorts based on the strength of the available scientific evidence, coupled with our empirical evidence.  The supplements would include:

• Creatine Monohydrate
• EAA/ BCAA (especially L-leucine)
• Carnitines (Acetyl-L-Carnitine, L-Carnitine-L-tartrate, Proprionyl-L-Carnitine)
• L-arginine (and other guanidine derivatives, e.g. citrulline)
• L-glutamine
• Magnesium, Zinc, and Molybdenum status
• Phytonutrient extracts/ Flavonoids and insulin sensitizers including but not limited to: Cinnamon, R-ALA, Cordyceps, Rhodiola

The first tier (protein and lipids) of supplements above have more “robust” evidence to support an individual trying to add muscular bodyweight or size.  The second tier would include the evidence-based “heavyweight champion” of all ergogenic supplements…Creatine.  The literature continues to pour-over with additional ‘putative’ or potential mechanisms by which creatine supplementation may amplify gains in size, strength, and power in conjunction with an appropriate nutrition and exercise regimen.  These additional mechanisms (in conjunction with resistance/strength exercise) include an increase in satellite cell (akin to muscle stem/progenitor cells) activation, increased myogenic growth factor expression, glycogen storage/GLUT-4 activation, and others.  I would add however, that the advantages of essential amino acids over whole protein sources, exist in KINETICS and EFFICIENCY.  When consuming essential amino acids, there is an efficient increase in muscle protein synthesis (gram for gram) that is difficult to replicate with whole protein (combined essential + non-essential aminos).  Additionally, there is evidence to support a “performance” and ergogenic benefit (not simply a recovery/structural repair benefit) of BCAA, particularly leucine.  The performance benefit likely involves an improvement in glucose and energy metabolism, resulting in increased power output, work capacity/endurance performance and decreased perceived exertion.  Leucine stands as the “king of the hill” for performance/ body composition benefits amongst all amino acids.  Leucine can activate protein synthesis and mTOR (regulator of cell growth) independent of insulin.  So, “spiking” some of your protein meals/shakes with additional leucine is not a bad idea!

Carnitine supplementation also appears to hold promise in acting to insulate mitochondrial and plasma muscle membranes from effects of high-intensity and/or prolonged exercise.  Essentially, any activity or situation that may challenge the energy systems or produce transient episodes of hypoxia/ischemia increases the demand for L-carnitine.  Some interesting work out of UConn (Drs. Kraemer and Volek), has emerged connecting carnitine supplementation with skeletal muscle AR (androgen receptor) up-regulation.  Hmm…seems like it would be of interest to most strength/power athletes or anyone looking to increase muscle hypertrophy/size… doesn’t it?

Mineral status in some hard-training athletes has been a source of debate in the sports nutrition/nutritional biochemistry field.  However, we have seen situations where everything seems to be where it should be, yet the outcomes (strength/muscle mass) are disappointing.  When zinc, magnesium and/or molybdenum status is sub-optimal, athletes often find that correcting these sub-clinical deficiencies results in a rebound super-compensation in strength and size gains.  These minerals are important co-factors in hundreds of biochemical pathways, some of which are key to muscle growth and accruing LBM.

There appears to be flavonoid and phytonutrient extracts that hold promise for individuals looking to augment muscle size, strength and performance.  Insulin sensitizing nutrients allow individuals in a hypercaloric state to help partition energy toward the lean tissues and away from adipose.  Further, although the science here is admittedly ‘soft’, there may be a role for use of certain “adaptogens” in hard-training athletes to maintain a positive fitness/adaptation : training stress ratio.

Remember, though, with all this said, your original question was “if nutrition is optimal.”  So I’m not suggesting everyone run out and buy each of those products; every situation is unique, so you have to assess your own to determine your needs.

4.  Everyone wants to lose weight and they often turn to fat loss supplements.  What are your thoughts, Doc?

When it comes to supplementing for ‘fat loss’, I am a little more conservative.  We tend to see patients and clients who come to us using the latest thermogenic supplement, and end up ultimately disappointed.  Although, these supplements can be another “tool” to have in an individual’s toolbox to stimulate fat-loss with LBM retention, they need to be used judiciously.  Unfortunately, judicious use of thermogenics is the exception rather than the norm.  Also, here is where the application of Rational Poly-supplementationTM is more important.  There are some definite advantages to the use of thermogenics as part of a larger plan to further tweak and nudge the rate of fat loss along.  However, oftentimes we see our patients/clients rebound quickly, when they are used too early in the fat loss cycle.  Not to mention how taxing (CNS & Hypothalamic-Pituitary-Adrenal axis) dieting, rapid fat loss and body composition changes can be on the body.  So, why drive the system even harder toward the “stressed” end of the spectrum, prematurely during the weight/fat loss process?  There is some interesting data (unfortunately, some are only animal studies) on various compounds that have thermogenic/body-composition enhancing potential.  Without getting into too much detail of the specific herb/phytonutrient compounds, there are strategic combinations of bioactives that may stimulate lipolysis, lipid oxidation, insulin sensitivity, LBM retention, while minimizing oxidative and sympathetic stress, and certain adverse effects of the stimulant-overloaded/ sympathomimetic thermogenic products.  The newer generation thermogenic products will address the aforementioned factors, in part by including some nutrients with “anxiolytic” or calming characteristics such as L-theanine, adaptogens such as Bacopa, Ashwaghanda, etc.

Ultimately, I am a big believer in an integrated, mulit-faceted approach to effective, long-term fat loss.  It is not until the nutrition + psychological/social (behavioral) + resistance training + energy systems training or "cardio" + regulated FEEDBACK (like continuous quality improvement systems) are packaged and buttressed together that clients/patients will experience optimal results in body composition, health, wellness and performance.  Hence, the solution will require real collaboration and bridging the gap that exists between the Health Care Practitioners / Physicians (Medicine) <<---AND--->> Fitness / Nutrition Professionals (Wellness/ Fitness/ Performance).

5.  NO products - hot or not?

I definitely have mixed feeling on this one.  I’ll tell you why.  First, the aspects about “NO products” that I am not as fond of has more to do with the marketing and claims in the industry regarding NO than the actual products themselves.  For those who don’t already know, NO (nitric oxide) is a key signaling molecule produced in the body which plays numerous roles in just about every physiological system.  Clearly, the cornerstone of all “NO products” is the inclusion of one or more versions of the conditionally essential amino acid arginine.  The rationale follows that since arginine is the major substrate for the NOS (nitric oxide synthase) enzymes (particularly eNOS), having more arginine available for fluxing through the pathway increases the end product output…i.e. Nitric Oxide.  With increased nitric oxide available within the vascular bed to cause smooth muscle cell relaxation (VASODILATATION), there is increased blood flow, potential nutrient (amino acids, glucose, etc.) and hormone delivery, and metabolic waste extraction.  Not to mention the possibility of increasing the transient, yet infamous “pump”.  Therefore, in theory augmenting blood flow to skeletal muscle in an individual who is engaging in weight training may promote recovery from intense training and muscle hypertrophy over time.  I think one of NO’s major functions as it relates to the exercising individual is to match bioenergetic supply with demand.  NO is released by the endothelium of terminal arterioles and larger feeder arteries that supply muscle in response to pulsatile flow and blood vessel wall stress; both of which increase during exercise.  Most of the products also include other components to help activate and increase expression of eNOS (trans-resveratrol, certain ginsengosides, ellagic acid and other flavonoids), for which the science is “softer”, yet there is enough to speculate and suggest a potential interactive or additive effect for potentiating vascular bed NO production.  My problem with some of these products is the addition of agents that increase sympathetic drive, and promote vasosonstriction, thereby nullifying the very endpoint that these products are trying to increase.  So, it is like trying to pour water into a bucket that has holes in it…the classic scenario of “shooting yourself in the foot”.  This would be an example of “IRRATIONAL Polysupplementation”.

Now on to discuss some of the potential health/wellness merits of L-arginine and NO-potentiating products.  This is where the concept of cross-over benefits comes into play.  The cross-over applications extend from the goals of performance and/or aesthetics for sports, bodybuilding, etc. to the goals of health, wellness and rehabilitation for patients, laypersons and athletes alike.  There is a substantial body of literature which lends itself to the merits of arginine supplementation for:  improving endothelial/ vascular health, insulin sensitivity, blood pressure, wound/injury healing, cardio-metabolic risk factors and body composition.  I also found the study on arginine alpha-ketoglutarate out of Baylor in Dr. Kreider’s lab intriguing.  The results included an increase in 1RM bench press strength, peak power, and decreased rate of fatigue.  At first glance, the absolute strength increase doesn’t seem to hold with the potential mechanisms of action for arginine.  However, keep in mind that there are nNOS (neuronal nitric oxide synthase) protein complexes along the CNS (central nervous system) and PNS (peripheral nervous system).  Simply speculation and conjecture…but could this explain some of the findings from the study?  Again, a full discussion is beyond the scope of this interview...maybe some other time. ;-)

Keep in mind that ascribing to a typical “fitness lifestyle” is one of the most effective ways of keeping your NO generating capacity at full throttle.  Regular exercise training, good nutrition [high in MUFA, PUFA with good omega 6:3 ratio from alpha-linolenic acid, fish oil DHA/EPA; low in trans fats/hydrogenated vegetable oil; high in phytonutrient-rich/ fibrous, antioxidant dense veggies, fruits, spices, cocoa and teas; complete high quality proteins], reducing cardio-metabolic risk factors (hyperlipidemia, high blood pressure, poor glucose tolerance and insulin resistance), keeping a good body composition, adequate testosterone status, and abstaining from cigarette smoking all go a long way toward keeping NO levels and signaling at their peak!  So, this could be an interdependent, closed-loop phenomenon, where healthy NO production may help to keep your physiology primed for continued NO release; and vice-versa, where healthy nutrition, exercise training, and endothelial function optimizes NO levels.

So, the bottom line is that “NO” potentiating products may hold some promise for improving not only the training effect over time, but also with reducing multiple negative cardio-metabolic risk factors.  There may in fact be something to the overwhelming market demand for “NO products”, as maybe the effect size is small and requires larger sampling, or we are measuring the wrong outcomes, with the wrong instruments?  We (PPP) still keep it in our armamentarium, or “bag of tricks” as the potential benefit:risk ratio is still very favorable.  Also, we can’t really get into integrating rehab/therapeutic exercise + supplementation and nutritional strategies for musculoskeletal/sports injury repair and recovery in our interview, but suffice it to say that this is definitely a project we are working on…it’s on the horizon. ;-)   

6.  Anything new on the horizon that may stand head and shoulders above the rest of the supplements out there?

From a standpoint of the horizon in the field of performance nutrition, I am particularly excited about the prospect of applied nutra-genomics in conjunction with exercise genomics.  The initial impact of molecular biomics (proteomics, metabolomics and genomics) will be to provide more answers to previous questions about molecular mechanisms in exercise physiology and nutritional biochemistry.  Then, the fun begins with applied genomics, where we can begin to predict how an individual will respond to certain exercise and/or nutritional interventions.  In this fashion, we will be better capable to customize a tailored prescription for exercise, nutrition and/or supplementation.

Now, from the nutritional supplement standpoint: Structured lipids and applying components of the endo-cannabinoid system will be something else to look out for.  Finally, I think you may simply see various forms or metabolites of bioactive nutrients or compounds that have already had some success in the sports nutrition industry, but possibly with different delivery systems to affect bioavailability and potency (e.g., polyamines and agmatine or other guanidine compounds).       

Finally, you will likely see continued interest and growth of the “functional/ fortified” or “augmented/ enhanced” foods market.  In this category, manufacturers will continue finding creative ways of trying to deliver bioactive nutrient components to various foodstuffs (e.g., an effective application of this is JavaFit coffee, with Dr. Jose Antonio as their CSO).

Finally, as many of our friends and colleagues have been urging us to get our PPP website off the ground for years, it is right around the corner.  There are 2 websites in development.  One will be more clinically/academically focused on our facilities, services offered, locations, current clinical research projects, and academic projects.  The other will be focused on performance nutrition, fitness, training/strength & conditioning.  So, there you have it….websites for the two “worlds” that PPP is attempting to bridge and marry.  We will keep you and your readers updated as our websites become available!   
       
Hector Lopez, MD, MS, CSCS

Dr. Lopez is a founding partner of Physicians Pioneering Performance, LLC.  Clinical interests include: physical medicine and rehabilitation, optimal aging, obesity, and spine/ sports/ musculoskeletal medicine.  Dr. Lopez received dual Bachelor’s degrees in Molecular Biology and Nutritional Science, with a Master’s degree in Nutritional Biochemistry and concentration in Exercise Physiology. 

For more information about healthy eating and incorporating a variety of nutrients in the diet, check out Mohr Results - Grocery Shopping Made Easy DVD!