Catterson, Paul

Hodgson, Andrew

Khanbhai, Tamim

Lewis, Nathan A.

Mazur, Jordan

Pedlar, Charles

Smith, Casey

Sygo, Jennifer

St Mary's University Open Research Archive

https://research.stmarys.ac.uk/TITLERise of intravenous nutrition products among professional team sport athletes: reasons to beconcerned?AUTHORLewis, Nathan A.; Hodgson, Andrew; Khanbhai, Tamim; et al.JOURNALBritish Journal of Sports MedicineDATE DEPOSITED6 December 2022This version available athttps://research.stmarys.ac.uk/id/eprint/5573/COPYRIGHT AND REUSEOpen Research Archive makes this work available, in accordance with publisher policies, for research purposes.VERSIONSThe version presented here may differ from the published version. For citation purposes, please consult the publishedversion for pagination, volume/issue and date of publication.   1Lewis N, et al. Br J Sports Med Month 2022 Vol 0 No 0Rise of intravenous nutrition products among professional team sport athletes: reasons to be concerned?Nathan Lewis,1,2 Andrew Hodgson,3 Tamim Khanbhai,4 Jennifer Sygo,5 Jordan Mazur,6 Casey Smith,7 Paul Catterson,8 Charles Pedlar   1,9,10USE OF INTRAVENOUS NUTRITION PRODUCTS IN SPORTThe authors regularly interact with profes-sional team sport players in European and American leagues and their multidisci-plinary support teams, and we are aware of players receiving regular intravenous nutrition (IVN) products. Furthermore, this is often evident in blood biomarker profiles where specific nutrients are beyond the upper- bound measurement limit of the clinical laboratory. The precise prevalence of IVN use is not known, however, anecdotally some players are receiving IVN as often as weekly as part of a pregame or postgame routine. So- called ‘drip bars’ and concierge IVN services are easily accessible, although seemingly devoid of appropriate regulation.1 These offer a menu of IVNs containing nutri-ents such as B vitamins, amino acids, glutathione, vitamin C and electrolytes, claiming to boost health and performance, restore hydration, accelerate recovery and so on. Further, players might request parenteral administration of nutrients such as iron and vitamin B12 from a team physician when not otherwise indicated. Typically, sports physician- administered IVNs are reserved for clinical presenta-tions such as anaemia, significant defi-ciencies with accompanying symptoms, or in race medicine (eg, severe dehydration/collapse caused by ultramarathon running in the desert).2 While these are distinctly different from the self- directed IVN use described above, there is cross- over regarding the potential risks and benefits.Guidance for players and practitioners in the peer- reviewed Sports Medicine/Sports Science literature describing the evidence base and risks associated with IVNs is largely absent. IVNs are not mentioned in recent nutrition consensus statements, and this is consistent with the principle of reducing needle use in sport and a ‘food first’ approach taught in sports nutrition courses around the world. A ban on needle use by athletes at the Olympic Games has been in place for all recent Games except for appropriate medical use, and where a therapeutic use exemp-tion (TUE) is obtained. Similarly, the World Anti- Doping Agency prohibit intra-venous infusions over 100 mL (per 12 hours) unless a TUE is obtained; however, these controls are not mirrored across all sports leagues.IS THERE ANY EVIDENCE OF BENEFIT TO ATHLETES BEYOND PLACEBO?IVN products are often used as a means of addressing tiredness, fatigue, or recovery, but the evidence is sparce and not supportive. We are aware of just two studies assessing vitamin injections in otherwise healthy participants; neither of which yielded an effect for the injection group. Tin May et al observed no effect of 1 mg of cyanocobalamin (synthetic B12) or placebo injections (3 /week) for 6 weeks in a double- blind manner, on various tests of physical performance, or any differ-ence versus the placebo.3 A cross- sectional study of elite Polish track and field athletes reported 34% (n=82) received vitamin B12 injections across a 6- year period.4 While a beneficial effect of vitamin B12 was observed on red cell parameters, there was no additional benefit when the athlete’s vitamin B12 concentration was above 700 pg/mL. Furthermore, where a vitamin B12 deficiency exists, one study found no additional benefit of an injection over oral supplementation.5RISKSIt is well known that the gut–liver axis actively protects the human from infec-tion, from the acidity of bile to the intri-cate immune pathways in the epithelial mucosa, and the dynamic role of the gut microbiota providing protection against toxicity (eg, heavy metals).6 Bypassing these mechanisms appears foolhardy unless there is a significant clinical ratio-nale, and no studies have addressed the long- term impact. However, via biomarker profiling we have observed vitamin B6 and cobalamin (vitamin B12) often beyond the measurement range of the laboratory, in a subgroup of profes-sional players. These observations may be the direct result of intravenous therapies, although inadvertent intake via fortified foods and energy drinks may also be caus-ative. While the long- term effects of high cobalamin are unknown, the long- term effects of vitamin B6 are classically associ-ated with peripheral neuropathy.7 Athletes regularly receiving parenteral iron risk liver disease, and indeed high body stores (hepatic iron concentration) have been observed in road cyclists.8Given that the long- term effects of supratherapeutic doses of B vitamins and other nutrients are unknown in athletes, it does not appear to be worth the risk, especially given the lack of evidence- based benefits. There are also the direct risks related to venous access including infection and thromboembolic complica-tions. More than this is the reputational risk to sport if it is normalised for athletes to regularly partake in self- directed IVN use with a worrying shift away from what ‘works’ (according to scientific standards), to that which is unproven. Furthermore, some athletes risk an antidoping violation by participating in self- directed IVN use.FUTURE DIRECTIONSA greater understanding of the prevalence of regular IVN use among athletes needs to be established. Qualitative study may provide important information on the draw and motivating factors for athletes to seek IVN, perhaps informing alternative strategies for education and resources to meet nutritional and performance needs. In parallel, governing bodies and players associations in the professional leagues need to provide guidance over the poten-tial risks of IVN use. The ‘food first’ and ‘no needle’ messages need to be amplified among all athletes and multidisciplinary support teams to avoid what was previ-ously a ‘last resort’ treatment becoming 1Orreco Limited, Business Innovation Unit, NUIG, Galway, Ireland2English Institute of Sport, Sports Training Village, University of Bath, Bath, UK3Department of Haematology, Sligo University Hospital, Sligo, Ireland4Tottenham Hotspur FC, Enfield, UK5Toronto Raptors, OVO Athletic Training Center, Toronto, Ontario, Canada6San Francisco 49ers, Santa Clara, California, USA7Dallas Mavericks Inc, Mavericks Training Center, Dallas, Texas, USA8Newcastle United Football Club, Department of Medicine, Benton, UK9Faculty of Sport, Allied Health and Performance Sciences, St Mary’s University Twickenham, London, UK10Institute of Sport, Exercise and Health, University College London, London, UKCorrespondence to Professor Charles Pedlar, Faculty of Sport, Allied Health and Performance Sciences, St Mary’s University Twickenham, Twickenham TW1 4SX, London, UK;  pedlarc@ stmarys. ac. ukEditorialProtected by copyright. on August 17, 2022 at St Mary's University, Twickenham.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2022-105883 on 16 August 2022. Downloaded from 2 Lewis N, et al. Br J Sports Med Month 2022 Vol 0 No 0Editorialnormal without scientific evidence of benefit.Twitter Charles Pedlar @pedlarcrContributors CP and NL originally proposed the editorial. All authors contributed to generating the material content of the article. CP and NL wrote the article. All authors edited and approved the final article.Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.Competing interests NL, CP, AH are consultants with Orreco who provide blood biomarker monitoring services to professional athletes.Patient consent for publication Not applicable.Ethics approval Not applicable.Provenance and peer review Not commissioned; externally peer reviewed.© Author(s) (or their employer(s)) 2022. No commercial re- use. See rights and permissions. Published by BMJ.To cite Lewis N, Hodgson A, Khanbhai T, et al. Br J Sports Med Epub ahead of print: [please include Day Month Year]. doi:10.1136/bjsports-2022-105883Accepted 30 June 2022Br J Sports Med 2022;0:1–2.doi:10.1136/bjsports-2022-105883ORCID iDCharles Pedlar http://orcid.org/0000-0002-3075-9101REFERENCES 1 Shmerling RH. Drip bar: should you get an IV on demand? In: Harvard health Blog, 2018. 2 Givan GV, Diehl JJ. Intravenous fluid use in athletes. Sports Health 2012;4:333–9. 3 Tin May T, Ma Win M, Khin Sann A.et al. The effect of vitamin B12 on physical performance capacity. Br J Nutr 1978;40:269–73. 4 Krzywański J, Mikulski T, Pokrywka A, et al. Vitamin B12 Status and Optimal Range for Hemoglobin Formation in Elite Athletes. Nutrients 2020;12. doi:10.3390/nu12041038. [Epub ahead of print: 09 Apr 2020]. 5 Wang H, Li L, Qin LL. Oral vitamin B(12) versus intramuscular vitamin B(12) for vitamin B(12) deficiency. Cochrane Database Syst Rev 2018;3:Cd004655. doi:10.1002/14651858.CD004655.pub3 6 Duan H, Yu L, Tian F, et al. Gut microbiota: a target for heavy metal toxicity and a probiotic protective strategy. Sci Total Environ 2020;742:140429. 7 Hemminger A, Wills BK. Vitamin B6 Toxicity. In: StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC, 2022. 8 Deugnier Y, Loréal O, Carré F, et al. Increased body iron stores in elite road cyclists. Med Sci Sports Exerc 2002;34:876–80.Protected by copyright. on August 17, 2022 at St Mary's University, Twickenham.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2022-105883 on 16 August 2022. Downloaded from 

Rise of intravenous nutrition products among professional team sport athletes: reasons to be concerned?

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Rise of intravenous nutrition products among professional team sport athletes: reasons to be concerned?

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