Yulia Zak, MD
Michael Pettei, MD
Robert Karp, MD
Department of Pediatrics
SUNY-Downstate Medical Center
Brooklyn, NY
PreTest
Q1. True or False. A young adult with a BMI of 22 kg/m2
may see himself as being "too skinny" without having an eating disorder
Q2. Best answer. Which of the following is a purely tonic exercise
A. Weigt lifting
B. Use of nautilus
C. Swimming
D. They are all tonic excercises
Q3. True or False
It is an accepted fact that fat soluble vitamins have potential toxicities at dosages above the RDI. but water soluble ones do not.
Q4. Loss of sexual potency is a realtively common consequence in men with supplememtal use of androgens and prohormone such as androstenedione
Objectives:
On completion of this module, the resident will be able to:
1. Appreciate the importance of perception as opposed to reality with respect to body habitus
2. Distinguish between impact on health and fitness for tonic vrs. dynamic activities
2. Evaluate pharmacologic, as opposed to nutritional effects of micronutrients
3. Describe toxicities of both fat and water soluble
- 5 ways that water soluble vitamins can be toxic
4. Describe metabolic effects of hormone supplements and consequences of their use
5. Counsel a young person embarking on "body building" as a means to change self image
Facilitator's preparation
The facilitator should review:
1. Essentials of micronutrient and protein intake, as well as concepts of RDA and DRI in Pediatric Nutrition Notes, http://www.hscbklyn.edu/peds/Karp/main.html
2. "Toxic effects of water-soluble vitamins" by Alhadeff, L., Gualtieri, T., & Lipton, M. (1984). Nutrition Reviews, 42(2):33-40.
3. Issues of self-perception as described in the modules on obesity and anorexia nervosa.
4. "Popular ergogenic drugs and supplements in young athletes" by Calfee, R. & Fadale, P. (2006). Pediatrics, 117(3):577-589.
Background
The advertisement shown below appeared in newspapers and magazines throughout much of the world during the early and mid-20th century. Charles Atlas sold tension springs and a directive for the scrawny youth of his day, promoting "dynamic tension" exercises as an inexpensive substitute for lifting weights. Many professional bodybuilders consider dynamic tension an excellent system for introduction to body building, but Altas' ads sold his system of exercises by generating a fear of not being a "real man" who is "truly masculine" in the readers.
Figure 1. Charles Atlas "dynamic tension" advertisement.
In today's world, body building is a more complex phenomenon. Adherents are likely to use weight lifting and tension machines (Nautilus-type) rather than dynamic action. These means for physical fitness primarily promote tonic rather than dynamic activities with profoundly different metabolic effects.
Concomitant means for body building include combinations of hormone and nutrient supplements. It has been taught in the past, and perjaps continues to be taught, hat fat soluble vitamins have potential toxicities while water soluble ones do not. As shown by Aldaheff and colleagues, this is a fallacy. There are five categories of toxicities intowhich overdosages of water soluble vitamins can fall. The use of DRI (Daily Reconeded Intake) rather than RDI (Recommended Daily Intake) requires an appreciation of potential toxicities. See Nutrition Notes (PI) and Assessment of Nutritional Status (PII S2)
Resultant issues are perceptions of body habitus, impact of different forms of physical activity, and beneficial and adverse pharmacologic effects of high dose micronutrients and anabolic steroids. Physicians must be able to counsel young men and women who embark on body-building using these supplements inappropriately. The following case study examines potential harm done with these practices and how to intervene effectively.
A Case Study - Part 1
Will was always the class weakling. He was picked on from childhood because he was small and too skinny. At least that's what Will thought. He was preoccupied with a desire to be tough looking. Will is now 19 years old and a college sophomore. He's still a shy fellow. And just as in high school, he's not doing well when he tries to talk to girls. They tend to giggle when he comes near. In reality, Will is quite fit with a classic distant runner's body habitus of 2 pounds weight for every inch of height: 70" at 140lbs. (lb/in2 x 703 = BMI in kg/m2) His BMI is 20.1 kg/m2, at the low point in the BMI vs morbidity/mortality curve (see Figure 2). "Too bony," thinks Will when he looks in the mirror. "Gotta bulk up."
Will has a buddy who has joined a weight club. Will visits and then becomes a regular. The guys there teach him how to use weights and various other machines. There is almost no dynamic action (activities promoting muscle movement, such as running or swimming) in the gym other than a Nautilus machine. The effects of his weight program are almost immediate. Will gains about 20 pounds (to 160 lbs), and it is mostly muscle. His BMI rises to 23 kg/m2.
Will is still not happy. He wants more. Friends suggest that he go on a program of increasing his vitamin and protein intake and that he begin to use androstenedione as a hormonal supplement. "It's legal and it works," they say as they navigate through the local health and nutrition supplement store to get what they want. Will starts a hormone / vitamin / mineral / protein regimen. Now he really bulks up. He gains another 30 pounds to 190 (BMI= 27.3 kg/m2.). He has rippled muscles, and his waist and chest expand. Will now sees the person he wanted to be. And he is euphoric. All seems well to him except for an occasional thought that hormones might be dangerous. "But I'll worry about that later," he thinks.
Figures 2 and 3. Age-specific relation between body-mass index and the risk of death (left) and chronic disease (right) among women (Panels A) and men (Panels B). Data are from the American Cancer Society Cohort 17 and June Stevens, University of North Carolina. Adapted from Willett, W.C., Dietz, W.H., & Colditz, G.A. (1999). Guidelines for healthy weight. New England Journal of Medicine, 341(6): 427-434.
Q1: What is the association between BMI and morbidity and mortality?
As shown in the figure, BMI levels in the obesity and overweight ranges correlate with morbidity and mortality. At lower ranges, adjustment is required to address the weight loss associated with tobacco use as well as for undiagnosed disease causing weight loss. Prior to his interest in bulking up, Will had a figure associated with health and longevity, even though it did not match his perception of what he should look like. After increasing his BMI from 20.1 kg/m2 to 27.3 kg/m2 through gaining muscle mass, he has increased his relative risk of hypertension, coronary artery disease, type 2 diabetes, cholelithiasis, and death.
Q2: How does Will's perception of being too skinny affect his decision to bulk up using tonic exercises?
Perceptions of obesity derive from past experience within a culture. Semi-starvation is the natural state of humankind. Past hunger, living with famine, or diseases like tuberculosis that are associated with wasting create a communal memory informing parents, grandparents, family, and friends as to what "good health" is supposed to look like. This has been one of the explanations for families failing to recognize obesity.
Simply stated, overweight and obesity in contemporary medical life is defined at a lower level of fat deposition, weight to height ratio, or BMI than it is by the lay public. Overweight children, those with a BMI from 85th to 95th percentiles, look "just right" to families with a memory of hunger, famine, wasting, starvation.
This phenomenon does not, however, completely describe the need for many men (and some women) to "bulk up". For men, it is likely that the need to look strong and act aggressively affects their place in the hierarchy seeking reproductive privilege. Abundant data from various animal species show that the male is the one to present himself in a way that represents their reproductive value.
Q3: What is the difference between dynamic and tonic exercise?
Dynamic exercises are those that promote continuous activity against gravity (e.g. walking, running, bicycling) and against resistance (e.g. swimming, Nautilus). They have a different effect on body habitus than those that only increase muscle tone against resistance (e.g. weight lifting, tension training). The former "dynamic" exercise builds muscle slowly and only in proportion to the need for motion. Moreover, dynamic exercise has positive effects on bone density and cardiovascular fitness. There is only modest weight gain (of muscle) for the lean.
Dynamic exercise is an essential component in a weight loss regimen for the overweight or obese. By contrast, purely tonic exercise will only increase muscle mass. It has no cardiovascular effects, nor is there an impact on bone density. The muscle mass increase, however, is dramatic.
Some overweight and obese youth may take up weight training as a part of a fitness regimen. Mixing dynamic and tonic activities is the key to a successful enhancement of fitness and weight loss.
A Case Study - Part 2
Will's sister, Nicole, is a third year medical student. She is worried about Will.
A chance to role play
You are a second year male pediatric resident. You were a cross country runner in college, and are still an active athlete. You take at least one long run of about 10 miles each week with enough short runs in-between to keep in shape. Nicole, another character in the role play, is one of the medical students assigned to your floor. She tells you about Will. She asks, "you are a pretty good athlete, perhaps you could give him guidance. I am concerned about all those vitamins and protein supplements he takes and since androstenedione is a precursor of testosterone, it can't be good for him. Plus, I really don't like his personality change. He says that he is happy and acts euphonic. But I'm worried." Will is the 3rd character.
You,the resident, get Will's number and arrange to meet him at the health club. But first, you need to know more about the potential impact of excess micronutrients and anabolic steroids. The resident in the role play gets to read the following Q's and A's. Will and Nicole do not.
Q4: At what point does micronutrient intake become pharmacologic rather than nutritional?
As discussed in Nutrition Notes, a micronutrient is a chemical or mineral needed for metabolic functioning that is not available without intake. There are differences in individual requirements based on heredity, caloric and other nutrient intake. The Recommended Daily Allowance (RDA) is set at a point where almost all individuals have their metabolic needs met and no toxic effects are found. The Daily Recommended Intakes (DRIs) are actually a set of four reference values: Estimated Average Requirements (EAR), Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels, (UL). They are set at a higher level, where some of the nutrients' effects are pharmacologic, and metabolic processes can be altered by high doses of a nutrient. Toxic levels (TL) are possible, and at high levels (especially with supplement use) all nutriments should be considered drugs. The U.S. Food and Drug Administration continues to struggle with the concept of regulating rather than recommending limits on their use.
Stop: Let Resident present this to Will in a way that he would understand; Nicole too.
Q5: We know that fat soluble vitamins can be toxic. Are water soluble vitamins also potentially toxic?
The classic toxicities of lipid-soluble vitamins (A, D, K, and E) derive from the fact that they are stored in the liver for long periods of time.
Table 1. Toxicities of Fat soluble Vitamins.
TEACHING CAPTION: see Nutrition Notes for further discussion The quotations are from the classic English nutrition text Davidson and Passmore's 8th edition of Human Nutrition and Dietetics, 1984 Churchill Livingstone London. pp132-45.
Less well known are the ways that water soluble vitamins can be toxic.
Alhadeff et al. list the followin ive ways that water soluble viamins can be toxic
Table 2. The five ways water soluble vitamins can be toxic.
1. direct toxic effects,
Example: Vitamin C causes Gastroenteritis; Niacin leads to flushing
2. lead to dependency/withdrawal states upon discontinuation,
Example. Rebound scurvy following C withdrawal
3. mask signs of underlying disease,
Example. Vitamin C permits iron absorbtion in GI bleed
4. Interferes with laboratory tests
Example. Vitamin C inactivates tests for GI bleeding
5. interact with other drugs/vitamins (see Table 3).
Example: Excessive folate intake hides need for B12
TEACHING CAPTION: An aditional consequence is that one might consume excess fat soluble vitamins in the process of increasing water soluble vitamin intake (e.g., taking several once a day multi-vitamin preparations each day). Use of DRI to determine intake requires an appreciation of these potential toxicities.
Stop: Let Resident present this to Will in a way that he would understand; Nicole too.
The following table lists the unique potential toxicities of water soluble vitamins:
Let the residents categorize the consequences for several of the nutrients
Table 3. Function and consequences of deficiency and overdose of water-soluble vitamins.
CAPTION: Imagine a middle aged man who takes Vitamin C to a level suggested by the late Linus Pauling -- Until there is some diarrhea , e,g., until there is irregularity. He arrives at his physician for a yearly check-up. The physician hears about the irregulkarity and suspects that his patient has a colon polyp or tumor. The physician does a rectal examination and checks the guaiac test for blood. "Negative, that's good," she says. The physician orders a hemoglobin level. It is 14.6g/dL; "that's OK, too. No sign of colon cancer."
This scenario could be that pf a patient with colon cancer whose presence is masked by mega dose use of Vitamin C. Ask resident', "why?"
Here's why:
- Category 1: Direct toxicity of GI disfunction
- Category 3: Masks signs of disease by increasing iron absorbtion and raising the hemoglobin level to normal
- Category 4: Inactivates the peroxidase reaction that would show blood in the stool
Q6: What hormone supplements are commonly used by young athletes, and what are the consequences associated with them?
Performance-enhancing supplements used by young athletes today include anabolic-androgenic steroids, steroid precursors (androstenedione and dehydroepiandrosterone), growth hormone, creatine, and ephedra alkaloids. Up to 1/3 of high school anabolic steroid users, however, are non-athletes who use these substances to improve their appearance (Calfee & Fadale) without realizing that they pose substantial health risks.
Anabolic-androgenic steroids are estimated to be used by 4-11% of high school boys and up to 3.3% of high school girls. They have been shown to enhance contractile and structural protein synthesis, increasing muscle mass and strength via both hypertrophy and hyperplasia by creating an anabolic and anti-catabolic state. However, their inhibition of LH and FSH causes testicular atrophy and possible infertility. Peripheral aromatization of steroids to estrogen leads to irreversible gynecomastia in young men. Young women may acquire a deepened voice, clitoromegaly, and loss of breast tissue. Other adverse effects include premature balding, acne, precocious puberty, hypertension, atherosclerosis, left ventricular hypertrophy, cholestasis, elevated liver enzymes, hepatitis, aggression, depression, and premature closure of epiphyses.
Androstenedione and dehydroepiandrosterone (DHEA) are prohormones that are consumed by 4-5.3% of high school adolescents despite lack of demonstrated athletic benefit. Upon internalization, DHEA is modified to androstenedione, which is then modified to testosterone or estrone. There is an initial rise in testosterone levels that becomes undetectable after several hours. Continued use leads to increased estrogen levels, which can lead to male gynecomastia. Additional harmful effects include changes in lipid profiles, down regulation of endogenous testosterone, priapism, potential prostatic hyperplasia, and female virillization.
Growth hormone, which is used by roughly 3.5-5% of high-school athletes, is transformed into insulin-like growth factor 1, which increases protein synthesis, lipid catabolism, and bone growth. Consequently, individuals perceive a decrease in subcutaneous fat. However, there is no evidence that the hormone improves muscle function; on the contrary, patients with acromegaly due to excess of endogenous growth hormone have weaker muscles. Additionally, growth hormone may cause premature closure of epiphyses, jaw enlargement, hypertension, increased lipid levels, glucose intolerance, slipped capital femoral epiphysis, and papilledema with intracranial hypertension.
Creatine is consumed as a nutritional supplement by 8.2% of 14- to 18-year-old students. It has been shown to increase strength and performance in short-duration, anaerobic activities, as well as delay the onset of fatigue in 70% of its users by increasing muscle stores of and speeding up the replenishment of phosphocreatine by as much as 20%. Increases in fat-free body mass have also been demonstrated. Unfortunately, high doses of creatine also cause early weight gain of 1.6-2.4 kg, dehydration, muscle cramps, GI distress, and compromised renal function.
Ephedrine is a CNS stimulant with alpha and beta-adrenergic properties that is similar in structure to amphetamine and pseudoephedrine (which is found in over-the-counter decongenstants). One study revealed that 26% and 12% of high school female and male athletes, respectively, had tried ephedrine supplements. Adolescents seek ephedrine for its "quick energy" and fat loss, although most studies conducted to date show no improvement in athletic performance in ephedrine users. A wide spectrum of adverse reactions have been described, however, including hypertension, tachycardia, arrhythmias, anxiety, tremors, insomnia, seizures, psychosis, strokes, myocardial infarctions, and death.
TEACHING CAPTION: Assume that Will is taking the prohormones Androstenedione and dehydroepiandrosterone (DHEA). Let the resident, his "sister," and attendees engage him in a discussion. "Will" should be sufficiently resistant to enhance the discussion.
Summary Discussion
The residents in the play we have created have abundant information. Let three assigned residents act out the triad of resident, Will, and Nicole and see if they come to a summary that could be
"Young adults are affected by both the social environment of their youth and of their peers. Under circumstances shown above, not unusual ones, a young adult might find him or herself taking pharmacologic doses of vitamins as well as hormone and hormone like substances. This behavior is rife with potential consequences. It is necessary to look for likely problems in young men and women who are making radical changes in their appearance. Contrary to a commonly taught "truths" of the path. Water soluble vitamins are potentially toxic."
References
Alhadeff L, Gualtieri T, Lipton M. Toxic effects of water-soluble vitamins. Nutrition Reviews, 1984;42(2):33-40.
Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics, 2006; 117(3):577-589
Davison, S (ed) 1988) Davidson and Passmore Human nutrition and dietetics8th edition. Churchill Livingstone, London.
Annotated Answers
A1. The answer is True. Perceptions play an important role in determining satisfaction with weight. While the BMI shown is at the bottom of the BMI vrs morbidity curve, some psychologicaly sound individuals will want to increase their BMI
A2. The answer is a. Exercises can be dynamic (running, etc), a mix of dynamic and tonic (nautilus and swimming) or purely tonic. A purely tonic regimen will have ill effects.
A3. The answer is False. This module is committed to makiung the point that water soluble vitamins in pharmacologic doses are potentially toxic
A4. The answer is true. Malse sexuality is goverened by a complexity of influences superseeding a simply quantitative measure of male hormones.
In fact, a down regulation of androgen production can lead to a feminization. Women taking these drugs may develop coarening of the skin, facial hair and general masculinization.
