Ask the Flight Surgeon / By CPT Karl Swinson, MD, MPH: Q: Hey doc, I am interested in taking some exercise supplements. I know we are supposed to adhere to AR 40-8, but it isn’t very specific. What can I take and what can’t I take?
FS: With the exercise community gaining traction and speed nowadays the supplement market has exploded in popularity and diversity of products. With many of these products being over the counter (OTC) you may wonder why so many of these products are not flight compatible. The answer, while being multifactorial, is quite simple. At the end of the day we want to mitigate risk in the flight environment. If our aircrew are taking supplements that are not regulated by the U.S. Food and Drug Administration (FDA), that have varying side effects for different people, may have adverse reactions with current medication profile, and may be taken to overcome some underlying medical issues (joint pain, weakness, etc.), unwanted risk enters the flight environment. This is why we have to strictly limit what aircrew can and can’t take. For a brief synopsis there are three classes of “herbal and dietary supplements” in the Army Aeromedical Policy Letters (APLs).
Class 1 – you can take these without any approval from your flight surgeon (FS) or aeromedical physician assistant (APA), but you MUST report this on your annual flight physical. The list includes: a single multivitamin daily, vitamins C, E, B6, B12 (oral not injectable), calcium, folate, protein supplements (shakes, capsules, nutrition bars) and sports drinks (run of the mill, without added supplements, i.e. Gatorade).
Class 2 – you may take these, but you must first get approval from your FS or APA and also list these on annual flight physical. The list includes: Vitamins A, K, D, Niacin, Riboflavin, Thiamine. Minerals – Magnesium, Zinc, Chromium, Selenium, Copper. Glucosamine with or without chondroitin. Echinacea, Saw Palmetto, Creatine, Ginseng (this is prohibited for 24 hours before flight).
Class 3 – All other preparations not specifically listed above are disqualifying without review by your FS/APA and with U.S. Army Aeromedical Activity (AAMA) approval.
Notice how all of these, even Class 1, are required to be documented on your flight physical and discussed with your FS/APA.
Now, let’s also get the protein supplements a little more broken down since they are common in the exercise world and the most utilized worldwide. Any of the protein types are compatible with flight. This includes whey, vegetable, animal, casein, etc., if there are no other added supplements, they are acceptable. Even branch chain amino acids (BCAAs) that have become common are acceptable. These are just 3 amino acids out of about 20 that are needed to make a complete protein profile in the human body. Be sure not to overdo it with taking protein supplements, a majority of the daily intake should come from natural whole foods with only a little from supplements. A good goal is to aim to take in approximately 1 gram of protein per pound of body weight per day (total protein intake), if the goal is for muscle building and strength gains (170 pound person would aim for 170 grams of protein per day). As far as timing of protein supplements, whey protein is rapidly absorbed and best taken right before or after exercise. Casein protein is slower digesting and best before bed to maintain a higher metabolism and prevent muscle breakdown during sleep. Regarding BCAAs, these can be taken right before or after exercise to help with muscle rebuilding, the proper dose is about 5 grams before or after exercise.
Next on the list of most common supplements aside from our Class 1 supplements and one of the most studied in the exercise world is creatine. Creatine is a non-essential dietary protein-like compound found in meat. Our body makes it naturally, but taking it exogenously increases the amount our body stores in muscle cells. Once it enters the muscle cells the body attaches a high energy phosphate to it making creatinephosphate. This can be used by the body to create adenosine triphosphate (ATP – the body’s primary energy molecule) for rapid energy needs (weightlifting). That is the basics of how creatine works, it has been studied extensively and shown to be safe in most people as well as help with strength gains, athletic performance and increasing endurance. However, there is a rare possibility for issues with liver and kidney dysfunction and muscle cramping with creatine, making it a Class 2 supplement. Your FS/APA needs to discuss the risks and benefits from the use of this supplement in an attempt to prevent any side effects and recognize early if any occur. In addition, since this does help with athletic performance, we need to be sure there aren’t any underlying issues that are covered up by taking this supplement (muscle wasting, fatigue, etc.). Lastly, it is possible to take too much creatine, this can cause gastrointestinal distress, so before you decide to run to your nearest supplement store, discuss proper dosing of creatine with your FS/APA, especially since you aren’t authorized to start taking it without their consent.