The Effect of Protandim Supplementation on Oxidative Damage and Athletic Performance
Condition: Oxidative Stress
Study type: Interventional

Summary: 
      Nutrition supplementation with antioxidants have been discussed as a way to further enhance
      overall well-being of athletes, promote faster recovery, and improve overall performance. The
      use of Protandim, a nutritional supplement containing 5 botanicals (Bacopa extract 150 mg;
      milk thistle 225mg; ashwagandha 150 mg; green tea 75 mg; turmeric 75 mg) has shown promise in
      an earlier study by reducing oxidative stress and increasing the amount of the anti-oxidant
      enzymes in the blood.

      The purpose of this study was to examine the effect of ~90 day Protandim supplementation on
      5-km running performance and on acute and long term oxidative damage as assessed by blood
      markers. Secondarily, another purpose of this study examined the effect of Protandim
      supplementation on other blood parameters (such as antioxidant enzyme concentrations) and
      measures of quality of life. The experiment was double-blind, placebo controlled. The study
      addressed two main questions and two secondary questions:

      Main Question 1: Does regular supplementation of Protandim (675 mg/day for 90 days) improve
      5-km running times? Hypothesis: Protandim would improve 5-km running time by 0.5 min (SD
      1-min). This is equivalent to an effect size of 0.5. The placebo group will have no change in
      performance.

      Main Question 2: Does regular supplementation of Protandim (675 mg/day for 90 days) reduce
      oxidative damage at rest as assessed by lipid peroxides (TBARS) in runners? Hypothesis: Based
      on the data by Nelson et al. (2006), oxidative damaged would be reduced by 40% (effect size =
      4.8).

      Secondary Question 1: Does regular supplementation of Protandim (675 mg/day for 90 days) in
      runners reduce the increase in oxidative damage post-race compared to pre-race as assessed by
      lipid peroxides (TBARS)? Hypothesis: Based on the data by Kyparos et al. (2009), we expected
      a 45% increase in TBARS post-exercise compared to pre-exercise (effect size of 3.6). However,
      we expected that those that are on Protandim for 90 days will only have 31% increase in TBARS
      post-race (effect size = 2.5) [based on changes in pre-post lipid peroxides from Arent et al.
      (2010)].

      Secondary Question 2: Does regular supplementation of Protandim (675 mg/day for 90 days)
      improve quality of life according to WHOQOL-BREF (Skevington, Lotfy, O'Connell, & Group,
      2004)? Hypothesis: There would be a statistical improvement in the quality of life
      post-Protandim supplementation which a small effect size improvement of 0.33.
    

Detailed description: 
      Forty apparently healthy community runners 18-55 yrs of age was recruited to participate in
      this study that will require six total visits to the University of Louisville, which included
      three sessions at the running track at University of Louisville.

      A about 120 mL of blood was withdrawn from a peripheral vein for the duration of the study
      (about 105 days). Runners was recruited from running clubs across the local community. These
      participants will be randomized into two groups (Protandim, Placebo). The groups will be sex
      and performance matched after the initial 5-km race.

      Each subject underwent six testing sessions.

      Session 1 (Initial Screening Day)

      Subjects signed consent form and completed a questionnaire to clear them for physical
      activity. Age, weight, and height was recorded. Subjects was asked to list all the
      nutritional supplements they are taking, including multivitamins. They were asked to list the
      5-km personal best time, and when that was done. They reported most recent 5-km time and when
      that was achieved. Then they were asked to refrain from taking any multivitamins or
      nutritional supplements for the duration of the study. The subjects recorded what they ate
      during the 24 hr prior to the test day, and then they were asked to eat the same thing and do
      same activity before the all follow up tests. Then a training diary was given to them to fill
      in for the duration of the study. The training diary included intensity, training duration,
      and mileage per week. After, they were given six quality of life questionnaires [World Health
      Organization's WHOQOL-BREF quality of life assessment to fill out at home (one each for
      Session 1-6)]. A pregnancy test was also conducted in the females.

      Session 2 (Baseline, About 15 days after Session 1)

      Subjects were fasted in the morning when they arrived at University of Louisville for their
      pre-exercise blood sampling. They brought their 24-hr dietary recall with them and their
      quality of life forms. Approximately three teaspoons of blood was withdrawn 30-60 minutes
      prior to exercise for analysis of several blood parameters. Then subjects were required to
      partake in a 5-km time trial at the University of Louisville track. The runners raced
      together in groups of 6 to 10 runners per race according to their estimated 5-km time. The
      estimated 5-km time is their own best estimate. Time trials have greater logical validity
      compared to time-to-exhaustion tests so that is why time-trials are selected as the
      performance measure.

      About 10-20 minutes post-exercise, another three teaspoons of blood was withdrawn from each
      subject. Only after their post-exercise blood draw will the subjects be able to eat.

      Based on the performance of the 5-km time trials, males and females were ranked separately.
      This was done in randomized blocks of two for males, and then randomized into blocks of two
      for females. For example, the males was ranked from the 5-km race from the fastest runner to
      the slowest runner. First and second place males were placed in a block of two. Third and
      fourth place males were placed in a block of two. And so on. Then a fair coin was flipped. If
      heads, the first ranked runner in the first pair went to Group 1, otherwise, the second
      ranked runner in the pair went to Group 1. This was done for each block of two males (each
      pair of two males). The same is then performed for the women. This randomization allowed for
      the same mean 5-km running times in each group as well as maintaining similar male to female
      ratios.

      Session 3 (About 7 days after Session 2)

      Subjects were fasted in the morning when arrived at University of Louisville for their
      pre-exercise blood sampling. They brought their 24-hr dietary recall with them and their
      quality of life forms. Approximately three teaspoons of blood were withdrawn 30-60 minutes
      prior to exercise for analysis of several blood parameters (the analytes are listed in Table
      3). Then subjects partook in a 5-km time trial at the University of Louisville track.

      About 30-minutes post-exercise, another three teaspoons of blood were withdrawn from each
      subject. Only after their post-exercise blood draw were the subjects be able to eat.

      Depending on the group, they were given approximately a 100 day supply of Protandim or
      Placebo (corn starch and food coloring). The study was double blinded so neither the
      researchers nor the subjects knew which group is the Protandim group and which group was the
      Placebo group. They ingested 1 pill per day, ideally with breakfast (675 mg per day, 1 pill
      per day). The subjects were given the complete supply of pills during this session, right
      after the second blood sample was taken. The subjects was classified as Group 1 or Group 2
      based on their five kilometer results from the first session. The pill bottles were labeled
      Group 1 or Group 2. The pill bottles were dispensed by the research team according to group
      number after their second blood sample. Subjects were asked record the daily intake of the
      pills in their training diary. Once the study was completed, subjects were asked to return
      the pill bottles to the research staff. That way, the researchers were able to account for
      any missed days.

      Session 4 (About 23 Days after Session 3)

      Subjects were fasted in the morning when arrived at University of Louisville for their
      pre-exercise blood sampling. They brought their 24-hr dietary recall with them and their
      quality of life forms. Approximately three teaspoons of blood were withdrawn. There was no
      5-km running race performed in this session. A pregnancy test was performed in the females.

      Session 5 (about 30 Days after Session 4)

      Subjects were fasted in the morning when they arrived at University of Louisville for their
      pre-exercise blood sampling. They brought their 24-hr dietary recall with them and their
      quality of life forms. Approximately three teaspoons of blood were withdrawn. There was no
      running race performed in this session. A pregnancy test was conducted in the females.

      Session 6 (About 30 days after Session 5)

      Subjects were fasted in the morning when they arrived at University of Louisville for their
      pre-exercise blood sampling. They brought their 24-hr dietary recall with them and their
      quality of life forms. They also brought any unused pills for proper documentation. A
      pregnancy test was conducted in the females. Then, approximately three teaspoons of blood
      were withdrawn 30-60 minutes prior to exercise for analysis of several blood parameters. Then
      subjects partook in a 5-km time trial at the University of Louisville track.

      About 30-minutes post-exercise, another three teaspoons of blood was withdrawn from each
      subject. Only after their post-exercise blood draw were the subjects be able to eat.

      Things to Consider: The between subject-variability in oxidative stress biomarkers is large
      (Mullins et al. 2013) and suggests that there may be responders and non-responders to an
      oxidative stress challenge (Mullins et al. 2013). Individuals who have large increases in
      oxidative stress (i.e. responders) could be reflecting an inability to regulate redox
      homeostasis and warrant additional support (i.e. with antioxidant supplementation with
      Protandim). It is also necessary to obtain week-to week and month to month coefficient of
      variation in markers of oxidative stress so that meaningful changes in these markers can be
      evaluated. Thus, the placebo group allowed us to obtain the week-to-week and month to month
      coefficient of variation. As well, for the same reason, it is necessary to obtain
      week-to-week and month to month variation in running performance, thus, the placebo group
      will allow for the development of the coefficient of variation in performance.

      Measuring dietary data is troublesome. First, questionnaires don't give details about
      antioxidant intake - rather they give outcomes like fruit and veg intake, etc. More in depth
      measures wouldn't be worth the trouble. Thus, having subjects record what they eat (and their
      physical activity) during the 24 hr prior to the test day, and then having to ask them to eat
      the same thing and do same activity before the follow up tests at seven days and 90 days was
      required.

      Environmental conditions was recorded on the days of the three time trials (wind,
      temperature, % humidity, barometric pressure).

      Statistical Analyses

      Once all the data was collected and analyzed, LifeVantage revealed which group was which. The
      main dependent variables measured were the 5-km finishing time, TBARS, SOD, and both the
      quality of life questionnaire. Based on a 5-km time improvement of 2.5% or about 30 seconds
      (SD = 1 minute) with Protandim, and no improvement in the placebo group, about 32 runners in
      total would be needed (Effect size = 0.5, statistical power = 80%, alpha error probability =
      5%, Correlation amongst repeated measures = 0.90, F-test Family, ANOVA repeated measures,
      between factors, G*Power 3.1.2, Universität Kiel, Germany). Accounting for a 20% attrition
      rate (8 subjects), a total of 40 subjects were recruited (20 per group).

      Possible Risks of Ingesting Protandim: We did expect there to be any side effects for the
      typical Protandim consumer. However, according to the Protandim website
      (http://www.protandim.com/faqs), some individuals have natural allergic responses to one of
      the ingredients, just as some people are allergic to pine pollen or penicillin. These
      allergic responses to Protandim generally appear as gastrointestinal disturbances (i.e.,
      stomach ache, diarrhea, vomiting) or sometimes as a headache or rash on the hands or feet.
      The symptoms disappear if Protandim is discontinued. However, according to the Natural
      Standard Database (https://naturalmedicines.therapeuticresearch.com/), each botanical has
      been shown to have rare side effects. They are listed there.
    

Intervention name(s): Protandim Dietary Supplement; Placebo Group
Intervention type(s): Dietary Supplement; Other
Intervention description(s): This was a randomized, block design, controlling for 5-km performance and sex. Subjects were given 675 mg per day (1 pill per day) of Protandim for 90 days. Subjects ran a 5-km time trial before and after the supplementation period. Blood samples were taken pre and post supplementation.; This was a randomized, block design, controlling for 5-km performance and sex. Subjects were given 675 mg per day (1 pill per day) of corn starch for 90 days. Subjects ran a 5-km time trial before and after the supplementation period. Blood samples were taken pre and post supplementation.
Other intervention name(s): Protandim Group; Experimental Group; Control Group
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Supportive Care
Keywords: Athletic performance; Running; Dietary supplementation; Quality of life; Running performance; oxidative damage