PEPonline Professionalization of Exercise Physiologyonline An international electronic journal for exercise physiologists ISSN 1099-5862 Vol 5 No 5 May 2002   Exercise Physiology Quackery and Consumer Fraud Tommy Boone, PhD, MPH, MA, FASEP, EPC Professor and Chair Department of Exercise Physiology The College of St. Scholastica Duluth, MN 55811 “What does quackery have to do with exercise physiology?  A great deal.  It is about the integrity of the emerging profession.  If exercise physiologists learn this lesson early on, exercise physiology will not become another ordinary (or even questionable) group of practitioners.  In so doing, they may also avoid use of gimmicks to either sell themselves or to make a buck at the expense of the profession and the public sector.”  -- Dr. Robert Robergs Quackery in Healthcare ANYONE INTERESTED in an immediate cure for back pain or cancer can find it in newspaper ads and on TV, and many people are looking.  Their pain or loss of hope drives them to reading the ads, even questionable ones with questionable cures.  Often the cures are said to result from some special device.  Few seem to question that unproven companies are selling the device via mail or Internet.  There are also special outlets for all kinds of questionable devices, but this is not new to anyone.  Or, at least, it should not be new.  Ads for medical devices that claim cures outside of standard medical practice have existed for many decades.  Many of these devices are fancy looking pieces of equipment.  They are used to treat everything, which is the first indication they are useless.  Another indication is that they are used by “quacks”.  Surprised?  Everyone knows about quacks and quackery.  People have grown up hearing about the unethical physician or some other healthcare practitioner.  It is often times in the form of a joke or “…can you believe that” kind of statement.  It is the worst kind of person who pretends to be something he/she is not, especially when the device or information is misleading and harmful.  Instead of practicing medicine or helping people with their health problems, quack medical devices and false statements misinform and even harm the public.  As in the past, some quacks are educated professionals while others are not.  Today, part of the problem may be that there are increasingly too many diploma mills and questionable distance learning programs of study.  Why is it that so few professionals seem to care?  Is it because they have not taken the time to question the medical devices and false statements?  Is it that they do not care either way?  Perhaps, it is little more than persuading people to pay for devices to make money.  It is about devices with electric shocks and vibrations, and it is about mysterious ingredients that are supposed to render fast cures for all kinds of diseases.  And, it is about testimonials without scientific evidence.  All of this should not come as a surprise. Yet, people are willing to use machines that shake, rattle, suck, shock or warm your body in place of advances in modern medicine.  A quick reading indicates that there is essentially no hard science on the healing potential of many supplements, magnets, aromatherapy, and a host of other alternative therapies, yet the claims for these products are common.  And, unfortunately, the new technology that supposedly heals is also said to reduce weight, tone muscles, and offer any combination of other so-called therapeutic benefits.  Technology is relative, however.  Despite the use of the word today in association with computers and cell phones, technology has always been a new and hopeful step to better health and wellness.  It was equally popular throughout the 20th century with “the Electric Belts, the Body Batteries, the MacGregor Rejuvenator, the Stimulator, the Dynamizer, the Oscilloclast, the Pathoclast, the Calbro Magnowave, the Orgone Energy Accumulator, and the Psycograph” to mention a few [1].  Today, with one foot in the 21st century, the questionable “science” continues with an increasing number of new technologies that are said to build muscle, trim the waist, burn fat, and improve physical and mental health.  Instead of using the mind to come to terms with the physical challenges, the shape of the head (Phrenology), the position of the stars, the today’s “newer” version of the electric belt to create the ideal stomach muscles, and other so-called devices are increasingly commonplace.  There appears to be no serious steps toward society’s understanding of quackery and consumer fraud.  If sitting in a box with wires attached to the arms and legs will correct physical ailments, then people will not only sit in the box but buy the box as well.  They appear powerless to do otherwise.  Quackery in Exercise Physiology To separate “reasonable and safe” promotion of products from “unreasonable and potentially unsafe products” and, thus fraud and quackery in health and fitness (and in exercise physiology) from ethical practice, it is important to evaluate the exercise physiologist’s involvement in the promotion of health-fitness products.  Some of these products, if not most, are untested testimonials touting claims that are nothing less than infomercials. The intent is to cause the reader to not think about the practice of exercise physiologists and sports professionals who earn money by marketing ineffective health and fitness products or support claims for such products that are not supported by published studies are practicing quackery.  They may know that the product does not work and, frankly, they appear to not mind.  They may want the student or the athlete to believe that it works by arguing that the science has not caught up with it.  Or, they may believe in the product but think that exercise physiologists simply are not smart enough to understand its benefits.  It really does not matter which is correct.  When someone offers a product to run faster, another product to burn fat and build lean muscle tissue, and yet a third to win athletic events when the information about the product(s) is not based on established medical knowledge or scientific principles, it is quackery.  If an exercise physiologist offers advice that is not based on solid scientific research or stems from questionable research practice, he or she is a quack.  It is not Whether it Works, It is Whether People Think it Works Herein lies the problem since there are people who know how to sell and there are people who need help.  Unfortunately, people will sell anything to make money, even when the product is reported to have no effect on performance.  And, they do not want just a little money.  They want a roomful of money, and they want people clamoring to get to them.  Flat out, without hesitation, it is just as wrong to sell a car for five times its value as it is to sell a product that has no value.  The reason is that life is not or should not be about cheating and unethical practices to earn or get that which is not rightfully earned.  Life is about taking a chance, working hard, and being fair and honest in dealing with others.  It is not about and should not be about greed and a willful intent to inflict harm on others.  Similarly, athletics should not be about cheating through the use of unproven or illegal supplements with the purpose to increase performance.  So, what does this have to do with exercise physiology?  Everything!  Exercise physiologists are linked to exercise and to athletics.  Some coach athletes, others are athletes themselves, and still others teach and do research to better understand sports performance and training techniques.  Hence, it is about the integrity of the emerging profession, and it is about the scientific understanding of training.  Most importantly, it is not about spot reduction, pills that are said to increase lean muscle mass, and gimmicks that strength the low back, increase flexibility, or to make a buck at the expense of the public sector.  What gimmicks?  Okay, what about the “30 Day Trial” offers on TV, such as The Gazelle “Freestyle Elite” exercise machine.  Is it consumer fraud?  Is it quackery?  It is reported to burn fat, target and tone the body, and all with your own certified personal trainer.  So, what could be wrong with buying it?  What if the machine is not everything it is said to be?  Anyone can stand on the street corner and sell exercise equipment.  In this case, there is very little difference from selling cars.  Neither the car salesman nor the well-built TV salesman of exercise equipment is likely to understand the ethics of practicing exercise physiology.  Exercise physiologists are (or should be) in the business of professional healthcare, athletics, and rehabilitation.  Their connection with the public sector is through their knowledge first and, if appropriate, through the sale of health and fitness equipment or nutritional supplements second.  Those who sell equipment or supplements understand (or should understand) the ethics of selling.  It is not about money or, at least, it should not be about money.  It is not the art of creating conditions by which the buyer is convinced to purchase a piece of equipment or product that is useless and/or harmful.  There is a difference. To Think as an Exercise Physiologist Quackery is not limited to medicine.  All professions have some form of quackery.  It starts out with the wrong way to think and actions for the wrong reasons.  Hence, it is not enough to have graduated from an exercise physiology program.  Rather, it is extremely important that the study of professionalism is integrated in the educational process.  A great exercise physiologist is someone who is constantly thinking like an exercise physiologist.  Someone who starts his/her day with the belief that ethical behavior is important, that knowing what the exercise physiologist stands for, and that knowing what the professional association stands for are important in thinking right and doing the right thing on behalf of the profession of exercise physiology.  For example, is it ethical to advocate that endurance athletes and strength-power athletes should consume more protein than non-athletes?  In this case, to think like an exercise physiologist is to know the literature and to express it in an objective manner.  Note what Lowenthal and Karni [24] say about this: “Estimates of protein requirement for athletes range from .45 grams to .73 grams per pound of body weight.  This additional protein does not mean that athletes should eat high-protein diets or take protein supplements, however.”  The authors also state that government surveys demonstrate that most Americans eat one and a half times the RDA for protein, and that athletes consume even more.  It is obvious or it should be that athletes meet the high protein requirement through their diet, not through supplementation.  To argue otherwise is groundless and scientifically not a plausible rationale. Having said this, it is understandable to expect exercise physiologists to have their own views and insights about the profession’s body of knowledge.  It is also understandable that, according to Wheatley [2], “We all construct the world through lenses of our own making and use these to filter and select.”  Yet how can exercise physiology mature into a solid research-based profession if its education is not built on the scientific method?  It would also appear that it is not possible to construct the new exercise physiology without embracing responsible thinking resulting from the scientific interpretation.  Clearly, as an example, if an exercise physiologist believes athletes need vitamin supplementation, then the scientific view is simply that of choosing a daily multivitamin pill that contains no more than 100% of the RDA [24].  To think as an exercise physiologist means that his or her beliefs are based on the scientific literature.  He or she understands the motivation behind advertisements and the editor’s need to cover costs through payments from companies that sell nutritious products.  Specifically, it is reasonable that the editors (and, for certain, the exercise physiologist) understand that exercise increases the need for thiamine and riboflavin.  But, collectively, they also understand that the increased need can be met by increased quantities of food ingested by athletes who eat a well-balanced diet.  Professionalism Requires a Professional Perspective Most exercise physiologists would be hard-pressed to define the exercise physiology perspective.  For decades, exercise physiologists have not come to terms even with the subject matter much less the definition of exercise physiology.  It is as if exercise physiologists have been on autopilot without an examination of themselves.  Sharing and leveraging knowledge within the ASEP perspective allows for a relationship that is unique and necessary.  Without it, exercise physiologists are prone to make claims individually where a sharing point of view is generally better.  The professional perspective invites an overview of the potential for quackery in exercise physiology.  For example, in 1977, the Federal Trade Commission (FTC) settled charges with Life Fitness, a manufacturer of exercise equipment, that it made claims without scientific evidence to support the benefits of weight-loss that supposedly resulted from its Lifecycle stationary exercise cycle.  It is the same story that “my machine is better than your machine” when it comes to burning calories and fat.  FTC stepped in to stop them from misrepresenting the benefits of the Lifecycle [3].  This is not the first time.  The FTC has also settled charges with other manufacturers of home fitness equipment that have unsubstantiated claims for their products. Ask an exercise physiologist and you should find a professional perspective on products, regardless of the origin or type, consistent with a scientific interpretation.  It is unethical to speak in favor of a product (that purports to reduce fat, increase metabolism, and/or preserve or build muscle) if there are no data to support the claims.  In other words, the “perspective” on health and fitness ought not to be misleading, false, or fraudulent.  The advertising claims must be substantiated by good research.  If that is not the case, the only professional perspective is to do the right thing.  Consumer testimonials and advertisement endorsements cannot be allowed to influence the professional view about a product.  That is, knowing what to say is not enough if the exercise physiologist has not developed the self-discipline to say the right thing.  This is why it is important for professors to teach professionalism.  Just because a large company develops and markets exercise equipment, such as the NordicTrack, Inc., it should not be allowed to misrepresent the results of any study relating to health or fitness.  To do so is the same sort of thing as quackery, and this view should not come as a surprise.  For more detailed information about misleading, false, and fraudulent claims that have resulted in the imposition of restrictions on various health and fitness related products by the FTC, refer to McArdle and colleagues [3, pages 240-244]. Do the Right Thing  Mackay [4] wrote the following about the stonecutter: “He hammers at his rock a hundred times without denting it.  On the hundred-and-first blow, the rock will split in two.”  This is pretty much what it is like when the truth is more work than an unsubstantiated claim.  It is not the giving in, regardless of the benefit (financial reward, grant money, position) associated with a popular product that makes sense.  If the product is not worth its claims, then it should not be marketed.  The truth about a product is everything.  Do the right thing even if it means hammering at it for a hundred-and-one-times.  The trick is to wait for the scientific evidence before agreeing to use testimonials and endorsements, media publicity, television infomercials, or the Internet commercial home pages for untested products.  To understand when a pseudo exercise physiologist is tricking students or others into believing a certain message about a product is important.  The quack may not have impressive technological equipment to support the product, but he or she will argue for the benefits of the ingredients in helping a person look better, feel better, run faster, or jump higher.  His/her goal is to sell the product.  Hence, they will tell the person who is thinking about the product anything they think he or she needs to hear to sell it.  They will use research-like language to increase sales.  The trick, again, is to do the right thing and not make claims for products that do not work.  Even if there was an ounce of benefit, there is the question of whether it is ethical.  Exercise Physiologists as Role Models  The PhD exercise physiologist has a responsibility in representing him- or herself before others in the most professional manner possible.  They should teach, do research, and consult with special emphasis on critical thinking and scientific analysis to support their claims.  If they do so, their students will learn to think similarly and, most importantly, they may avoid mortgaging their reputation for financial gain.  The interest rate charged on shaky thinking and poor performance is too high.  We’ve all heard of colleagues and others who believe that everything is negotiable.  The problem, of course, is that the statement is not true.  There is nothing but the truth, and anyone who thinks he or she can walk in two directions at the same time is not thinking straight. Exercise physiologists in the academic setting, in particular, are involved in all aspects of health, fitness, athletics, and rehabilitation.  They have a major responsibility to think straight, especially in the area of ergogenic aids.  It seems that everyone is interested in enhancing capacity for exercise and training, and they want to do so now.  They are not willing to work or compete on just their innate ability.  Instead, they are willing to ingest almost anything to influence energy supply and/or physiologic function.  Megadose quantities of vitamins, health food concoctions, biotechnology products, and a host of other nutritional supplements (creatine monohydrate, L-carnitine, L-lysine, chromium, potassium chloride, royal jelly, Siberian ginseng, and dozens of others) are often illegal and unsubstantiated.  There is either little direct, specific research or no research to support the claims to improve physical work.  Since it is obvious that athletes, (and, in particular, those who are not bound by a rulebook) believe it is okay to use any substance that is likely to improve performance, the exercise physiologist has a great opportunity to argue the inappropriateness of the supplements.  They should also take the opportunity to not only help students and athletes alike separate unsubstantiated claims from facts reported by good research, but to argue that the use of ergogenic aids is often unethical.  There is the potential for fraud (which is essentially the same thing as quackery), financial waste, and the real possibility of physical harm.  There is also the question of why the prohibited substances (by the United States Olympic Committee) are discussed in class.  Even if there should be a benefit to exercise performance, why teach about the role of amphetamine use, steroids, blood-boosting erythropoietin, and other illicit drugs?  Why are exercise physiologists writing about the use of anabolic steroids?  Isn’t the use of steroids illegal, except for medical purposes?  Perhaps, it is necessary to lecture and write about steroids to help athletes and/or students understand the dilemma.  The quest for improved strength and cardiovascular endurance should coincide with ethical teaching that argues against the use of drugs.  And, it is important to remember that research by exercise physiologists can clearly show the lack of benefit for certain ergogenics.  In fact, this should be the rationale for why most nutritional ergogenic studies are done – to disprove false marketing claims! Less Than Honest is Less Than Professional For example, within the competitive environment of academics where grants are important for promotion and tenure, it is an accepted understanding that to get a grant is a big deal.  In some cases, it is essential for survival, but is it okay to be half-right or half-honest?  Truth is absolute or it is not truth.  Truth is not something that allows for a claim that something is half right or half wrong, yet interpreted as a truth without understanding the compromise.  Leaders must provide a “reality” based on truth that results from solid research.  As leaders in health and fitness, exercise physiologists must function as examples of straight thinking and responsible professionals.  This requires a certain mental toughness that involves respect for honesty and professionalism.  Having said this, exercise physiologists must learn to be their own person, to maximize their own strengths, hopes, and expectations.  In short, they must learn to be jealous of what they know while not tolerating incompetence or quackery.  Professional exercise physiologists cannot tolerate a bad apple or be seduced by offers of money or fame.  Their integrity must rest on their research knowledge of how things work.  The urgency here is simply that not even the most aggressive of the exercise physiologists can avoid the visibility of their actions.  Indeed, the commercial companies understand this point all too well.  Hence, this means that the titillating grant monies must be painstakingly and unequivocally consistent with the very best scholarly thinking.  Product Development Requires Professional and Ethical Thinking The important thing is to never share misinformation or create feelings of shared beliefs that lack credibility.  To do so is terrible and trying for those who would kill for an edge or for a moment of glory.  Being a “leader” in the field means that the exercise physiologist is able to swim upstream without grant money or even when it is not popular or less profound.  Think about it for a moment.  An education is about the spirit of gaining new knowledge, investing the knowledge, and applying the knowledge.  It is about the freedom to make the best decisions based on the best science.  To do less or to allow less to influence professional thinking is to set the stage for an outrageous flood of fraudulent ideas and unethical thinking. The indisputable fact is simply this:  All professions must not ignore unprofessional or mis-guided behavior.  Every member is responsible for balancing the ethical budget.  Every member must live a shared responsibility and passion for growing the profession.  But, let’s face it, there are ambitious exercise physiologists who are creating their own businesses on the backs of their customers.  It is not a secret any longer.  Rather, it is the entrepreneurial spirit if not the dream of many to market a product.  However, the difference in doing so versus not doing so raises the question of power and whether it is acquired correctly or incorrectly.  To be sure, it is a conflict when respect and affection are given to a product that does not deserve either.  The implication is obvious.  If it is determined that exercise increases free radical formation, then exercise physiologists would recommend supplements of antioxidant vitamins.  Until then, given that the research remains unclear whether exercise itself is the problem, it is inappropriate to argue for supplementation to avoid exercise-induced free radicals that “may” accelerate atherosclerosis [27].  Recognizing Quacking in Exercise Physiology Well-documented evidence concerning the assumed benefits of exercise nutrition is absolutely important to the integrity of exercise physiologists who believe in the purported benefits of ergogenic aids.  If the emerging field of exercise nutrition is not well founded on solid research, then the application of a nutritional supplement and ergogenic aid to improve athletic work capacity is quackery.  The following information should be helpful in recognizing quackery in exercise physiology: 1. An exercise physiologist might be a quack if he or she refers to him- or herself as having special academic training in exercise nutrition.  Point in fact, there are very few academic programs that address with detail and specificity the role of nutrition and all of its ramifications on exercise performance. 2. If the exercise physiologist concludes that athletic performance is directly related to a well-balanced nutritious diet, good genetics, and excellent training, then anyone who is consistently pitching “increased protein intake during exercise” is very likely a quack. The scientific “data provide no rationale for increasing protein intake when exercising” [5, 6, 27].  Another way to approach the question of how much protein does an athlete need is to define the intensity and type of exercise.  For recreation exercisers who typically exercise at low-intensity (30% to 50% VO2 max), the RDA of 0.8 g/kg/d appears sufficient [5]. For endurance athletes who train at higher intensities, protein may be increased to 1.2 to 1.4 g/kg/d [7].  The key word here is “may be increased” because it certainly is possible to train at intensities without increasing protein intake.  Athletes who primarily strength training, protein may be increased to around 1.4 to 1.6 g/kg/d [8].  The real question is whether the athlete who engages in strength training is eating a nutritiously balanced diet to begin with.  Interestingly, Brotherhood [9] concluded that the “average athlete’s diet is about 16% protein”.  This value exceeds 1.5 g/kg/d or the equivalent of 88% more than RDA [5].  3. If the exercise physiologist concludes that athletic performance is directly related to a well-balanced nutritious diet, good genetics, and excellent training, then anyone who is consistently pitching “vitamin supplementation during exercise” is very likely a quack.  Clearly, the research from the past several decades has consistently supported the scientific fact that vitamin supplementation is unnecessary for the athlete on a well-balanced diet [5].  In short, “no research evidence exists to support the claim” [10, 29] that added vitamins increase exercise performance.  Here again, the central concern of some exercise physiologists might be whether the athlete’s diet is deficient.  Of course, if it is, then the diet ought to be corrected by developing better eating habits.  Supplementing a deficient diet with vitamins is not straight thinking when the problem is the lack of a well-balanced diet to begin with. 4. The exercise physiologist who tells students or athletes that he or she has the answer to the “competitive edge” to insure victory at the next competition is a quack, especially if he or she professes to be the only person with such knowledge.  As an example, the comment may be about the athlete’s intake of iron.  Obviously, it is essential for the transport and delivery of oxygen in the blood to and within the muscle tissues.  But so are a multi-faceted number of other considerations that allow for the highest VO2 response (and thus energy for muscle contraction) during endurance exercise.  The idea that supplementation of iron to improve body iron stores to increase exercise performance in individuals who are not anemic is not supported by the research of reputable exercise physiologists [11].  In short, it is clear that athletes who ingest a balanced diet do not need micronutrient supplementation [12, 13].  5. Exercise physiologists who suggest to others that the standard “three ingredients” mentioned in statement #2 is stupid or out-dated information in favor of their approach as being better than the conventional thinking of the profession are quacks.  The third factor, in particular, “training” increases work capacity.  Physical and/or psychological training are ergogenic aids since either or both can directly improve the physiology of exercise performance.  As strange as it might sound, it is not beyond the quack to push “whatever” product if there is a dollar sign attached to it.  It is no wonder there are so many different types of shoes to run in and the specificity of clothing that almost exceeds the multiplicity of a diamond.  Money is the quack’s reward for pushing his or her unproven products.  This is why carnitine and pure oxygen inhalation products are reported to be ergogenic aids.  Carnitine ingestion is supposed to increase lipid catabolism and spare glycogen, and inhaling pure oxygen is supposed to speed recovery from intense exercise!  But, there is no scientific evidence that the products work.  6. Exercise physiologists are quacks if athletes are encouraged to use and/or purchase products from a company they consult with that leave the impression of “precision manufactured” to insure a quick and dramatic improvement in health and/or cardiovascular function.  As an example, in the Eastern Michigan study that appeared in the May 2001 issue of the Journal of Exercise Physiologyonline [47], the authors reported that “Analysis of…HDL cholesterol and LDL cholesterol revealed no effect of supplmentation” [p. 33].  In contrast, though, note the content of the advertisement published in May 2002 issue of Muscular Development [42] – “…the placebo group in the Eastern Michigan study actually experienced lower ‘good’ HDL cholesterol…than the Xenadrine group [that] experienced lower ‘bad’ cholesterol than the placebo group…subjects who took Xenadrine improved their good cholesterol and lowered their bad.”  Quite stunning! Right.  The truth of the matter is none of the content is true.  Again, the authors reported no significant differences.  Who is at fault?  This is a serious question of ethics.  For certain, judging from the advertisement paid for by Cytodyne Technologies, then Cytodyne and its employees, including any exercise physiologists who work for them, are guilty of fraud and mis-representation of the scientific data.  7. Exercise physiologists who consult with companies that have been penalized by the FTC for carrying out unethical marketing practices are engaged in quackery (i.e., unless they were hired to fix the problem).  If exercise physiologists do not understand the difference between a grant to fund dietary supplement research and money that pays for hired-service, they are stupid.  This is the bottom line.  If exercise physiologists understand the deceptive nature of the company’s funding procedure and engage in the work anyway, they are not neither ethical nor qualified to represent the public’s best interest.  8. Exercise physiologists who allow their names and research work to be associated with advertisements that misrepresent the research data and findings are part of the team of quacks that exist to make money at the expense of others. It is a known fact that the dietary supplement industry is in the business of making money.  This is exactly why the Federal Trade Commission (FTC) is so important.  The FTC exists to protect the consumer from “unfair or deceptive acts or practices.  Exercise physiologists who look the other way (perhaps, as authors) are part of the problem that the FTC is trying to correct.  Ensuring accurate information is ethical; whereas, publishing false information is unethical.  The FTC’s primary responsibility is in regards to health and fitness claims in advertising, including print and broadcast ads, infomercials, catalogs, and direct marketing.  The bottom line: Advertising for any product, including Xenadrine, must be truthful, not misleading.  The claims must be substantiated by solid research, not misrepresented or re-written.  Unqualified health and/or fitness claims are not permissible under FTC law.  Therefore, when exercise physiologists are directly or indirectly involved in the marketing of dietary supplements, they have an obligation to make sure that the claims are presented correctly and truthfully.  If they fail at their obligation, they are part of the problem.  Rather than using their scientific expertise to prevent fraudulent, deceptive, and unfair practices in the marketplace, they are the quacks. 9. If exercise physiologists suggest they know something about food supplements and ergogenic aids, metabolism, and athletics that other educated exercise physiologist do not know, it is quackery.  Take the example, “Look, I’m an athlete.  I workout everyday.  And, I workout hard.  I also win.  Just look at me.  You can see that I am different.”  While the topic may be one of many to increase exercise performance, athletes have no business taking megadoses of vitamins, chromium, selenium, or magnesium.  It is unethical to encourage the use of these supplements.  There is no serious science to the contention that they are necessary when deficiencies are not present in the first place.  Megadoses of vitamins cannot substitute for training [22], and they are not necessary for the training effect [23].  The same holds true for the speculation that chromium intake enhances lean body mass [24], and “there is no evidence that selenium or copper has an impact on acute or chronic exercise responses” [22].  The same can be said for calcium, chlorine, magnesium, phosphorus, and sulfur. 10. If exercise physiologists are using their friends to sell food supplements, if they are using the phone or their email to increase their sales, and if they are believers in the product without scientific data to support their beliefs, then they are quacks.  Here, the obvious is true.  Either the money is too good to speak out against fraudulent behavior or the exercise physiologist actually believes his/her own “pseudoscience”.  Either way, it is a significant problem when bogus “facts” and fictional statements are used to justify conclusions.  Exercise physiologists who engage in these practices are quacks.  They may understand what it means to evaluate a dietary supplement via a controlled experiment, but they  appear predisposed to ignoring the strict conclusions from statistical analysis and/or simply misinterpret the data to support the alternative possibility.  Ethical exercise physiologists are not going to ignore statistical findings that contradict the investment made by a company.  They are not going to use the phrase, “He/she [referring to another exercise physiologist] is simply out-of-it or too old to get with the new thinking.”  Instead, the unethical practice is to advocate or market unproven dietary supplements without really caring about what is actually true. 11. Exercise physiologists who promise quick athletic results (big muscles, a six-pack waist line, a huge increase in maximum oxygen consumption, decreased running times, and so forth) with misinformation are quacks.  Despite the hypothesis that caffeine is said to increase reliance on lipid (and thus spare muscle glycogen) during endurance exercise, the research is contradictory [14, 15, 16, 17, 18].  Similarly, if the promises that carnitine is the key to transportation of acylated FFAs into mitochondria, the misinformation is a form of quackery.  There are no known or substantiated ergogenic benefits to ingestion of carnitine [10].  12. If exercise physiologists use anecdotes, case histories, testimonials, and non-human research to support claims for a product without equal attention to peer-reviewed scientific publications with human subjects, then they are quacks.  Take, for example, dichloroacetate (DCS), even though it has not been approved by the FDA [10], research suggests that it reduces lactate accumulation in the blood along with increased rate of ATP regeneration from oxidative phosphorylation [19].  The problem is that there is too little direct research with humans subjects to know for certain. 13. If the exercise physiologist states that his/her method is logical and right because the information from other exercise physiologists cannot be right since they do not run races, lift weights, understand athletes, or have the first-hand knowledge of the product, then they are quacks.  In instances like this, the quack may try to convince the athlete that training produces a zinc deficiency.  So, what is the athlete going to do?  The athlete does not want an impaired immune response, yet the quack has convinced the athlete that zinc supplementation is the only answer!  Here is the problem.  There simply is “insufficient” evidence to conclude that training decreases zinc and has a negative impact on exercise performance [20, 21].  Most non-research oriented individuals do not understand that “…a great deal of data presented in the literature is inappropriately collected and incorrectly interpreted” [25]. 14. Exercise physiologists who state that most athletic problems are due to a faulty diet that can be corrected with nutritional supplements are quacks.  This idea is really no different from the notion that some exercise physiologists believe it is okay to exploit any pharmacologic ergogenic aid, such as erythropoietin (EPO), anabolic-androgenic steriods, or even amphetamines to run faster, lift more weight, or accelerate the athlete’s central nervous system responses during exercise.  Of course, it is not okay.  The use of blood doping to increase oxygen transport capacity is unprofessional and unethical.  It should also be obvious that it is entirely inappropriate and unprofessional to encourage athletes to use amphetamines to increase muscular strength. 15. Exercise physiologists who believe that it is “your” right to try different products, drugs, and/or supplements even though they have not been demonstrated to be effective or safe are quacks.  To argue that it is your right to do what you want to do is not a safe, logical, or scientific approach to understanding exercise nutrition.  It is your right to supplement your diet with copper, but why?  The effect of exercise training on serum copper is questionable [26].  Also, there appears to be no reliable exercise research to evaluate the physiological benefit of copper supplementation. Leadership From Within Exercise nutrition is obviously a worthy area of instruction, research, and application to health and athletics.  It is part of the body of knowledge of exercise physiology.  In fact, ASEP Board Certified exercise physiologists are expected to know information about dieting and nutrition, fitness, and athletics.  They must know whether the information is trustworthy and that the products and services are safe and do what they are intended to do.  It is not all about profits and consulting fees.  It cannot be.  That is why “…the FTC ordered the producers of The Enforma System for weight loss – Fat Trapper and Exercise in a Bottle – to repay customers $10 million for having used spurious information in selling their product” [30].  Resolving the issue of quackery is largely a function of the leadership within the academic settings.  And, in particular, since the costs of buying into quackery also includes disillusionment and even physical harm, exercise physiologists who teach and/or do research in exercise nutrition and ergogenic aids must back their claims by good research.  Like an inventor, exercise physiologists who have an interest in exercise nutrition must have both the vision of a scientific-based application of ergogenic aids and the belief that it is important to think right about the application of nutrition in exercise physiology.  The risk lies in taking action to do what is right.  It involves change, uncertainty, and the willingness to rethink attitudes and behaviors [31]. Leadership is about credibility.  It is also about doing the right thing for the right reason.  It is about striving for perfection with the confidence that growth and development in athletics is directly related to hard work and dedication.  It is not about making money or the contagious notion that a pill (or several hundred magical pills) is necessary to win a competition.  After all, life is not about winning at all costs.  Rather, regardless of the advertisements, both electronically and in print, and regardless of the pressure to succeed at all costs, life should be about living and learning to do so with integrity.  True leadership is the ability to turn misinformation into correct information.  It is about using scientific based information that gives hope to possibilities.  Life is not about supporting training or competition when there is no scientific research to substantiate nutritional supplements.  So, the assertion that there is an increase in lean body mass and strength from beta-hydroxy beta-methylbutyrate (HMB) supplementation [32] or that there is an increase in testosterone levels and thus muscle growth and strength from boron supplementation [33] should be based on solid science with years of controlled research.  Similarly, whether the proposed ergogenic value of branched-chain amino acids (BCAAs) supplementation for strength and endurance athletes is real or not requires much more research [34].  Hypotheses and theoretical assumptions are the beginnings of research and not answers in and of themselves.  Therefore, even though plasma choline may decrease after exercise, it does not mean that it leads to an automatic problem with acetylcholine release and disturbed neuromuscular function [35, 36].  There are no scientific data to support choline supplementation [37].  It is the same with chromium picolinate.  In fact, in 1996, the FTC ordered Nutrition 21 and two other companies to stop making unsubstantiated claims about supplementation (such as decreased body fat, increased muscle mass and energy) [38]. Exercise Physiologists and the Rules of Science The burden of proof is directly the responsibility of the exercise physiologists who claim the “x” dietary supplement does what it is advertised to do.  Hence, it is their responsibility to conduct good research studies to confirm that that the supplement, for example, burns fat faster than any other product on the market.  Science is not about personal experiences, subjective judgments, or emotional testimonials.  It is about objectivity and scientific evidence.  This understanding is exactly what sets exercise physiology apart from so-called fitness professionals.  Professional exercise physiologists understand the need for rigorous evidence and the review of the research design, the statistical data, and the authors’ conclusions within the context of a peer-reviewed scientific journal.  They also understand the placebo effect, the factor of faith, sensational claims, and testimonials.  To understand a claim requires years of research, hundreds of research papers, and thousands of hours of critical reflection and scientific contemplation beyond personal beliefs and observations.  The science of exercise physiology embraces editors (not testimonials), editorial boards (not delusional thinking), and shared accuracy in scientific thinking (not misinterpretation derived from notoriety).  Experts in the field understand the enabling yet controlling function of research that allows for a shared set of scientific beliefs.  As a result, athletes benefit from the objective standards of measurement used in determining a general consensus as to a physiologically-effective and safe ergogenic aid.  Hence, the rules of science dictate that advertisements are founded in scientific evidence.  If elements of the ad should suggest something less than substantiated by science, then the advertiser and the consultants are either incompetent or quacks. For example, advertisements that claim unsubstantiated conclusions present a risk if not an abuse to consumer health or safety.  The deceptive behavior of the dietary supplement industry is obvious to the scientific community.  Equally important to understand is that the “Build Muscle, Burn Fat, No Bullsh..” -- Muscular Development (42) display of “how to develop big muscles” is full of nonsense and misleading information.  Unfortunately, young high school students, college-age students, and many adults simply do not get the message.  The monthly publication of Muscular Development is an advertisement not a scientific publication!  Products like hydroxycut, America’s most popular fat-burner is not science, and Myoplex Low Carb bar, said to decrease body fat without sacrificing protein for muscle growth may have been scientifically formulated, but certainly not scientifically tested or proven to maximize muscle growth.  The big news is this – there is no scientific research to support the claims advertised in Muscular Development for: Andro Poppers for increasing testosterone up to 98% within 40 minutes Cyclo Z-Mass for increasing serum testosterone or even subsequent gains in “pure” strength Metamyosyn V4 protein as the only multi-substrate protein blend in the world scientifically developed to build lean muscle ProM3 to gain an additional 20 lbs of lean muscle Xenadrine EFX as an unprecedented fat-loss supplement Isomatrix as “the” protein that produces more body transforming effects than any other protein on the market Pro Performance Mega Joint as the sports nutrition formula that contains high quality ingredients for joint health and integrity TRAC as the most advanced creatine transport formula ever developed, and the most effective way to take creatine Dymetadrine Xtreme, the most effective method to increase strength by over 17% in just 45 minutes Methoxy-Pro that stimulates significant increases in lean muscle while simultaneously reducing body fat levels, along with dramatic improvements in recovery times and my point is that the list of supplements goes on and on: Megathropin CarbFX Human Growth Complex Equi-Gan Protein Plus HP BetaLean Cimaterol T-100 Anabolic Activator Nitro-Tech Cell-Tech NO2 Muscle Building Hemodilator Ultra Growth Fuel with big results in just 4 weeks 1-AD CytoPro Zenotrope, and on and on and on…. Raising the Question of Ethical Practice Many individuals in business build their companies because they worship money.  They profit and become giants with their products and customers because their only true “god” to worship is the profit.  The problem is too many of our young athletes are growing up thinking that it is okay to take supplements and/or do essentially anything it may take to win.  From a very early age, sports and athletics are turned into a business mentality that breeds unethical thinking and practice.  What a difference it would make to the health and fitness well-being of our athletic programs throughout the United States if professional exercise physiologists could see their way to get pass the muddy water of crooked thinking so aptly displayed by the Muscular Development and other such general market publications.  It’s time for exercise physiologists to come together on this point.  It’s time we had a voice on this issue before us, and in sharing ideas and getting politically active in converting a borrowed way of thinking from yesterday to an ethical seizing of the moment today.  It is also important that we come to an understanding of the rules and regulations that bear directly to a profession’s Code of Ethics.  The ASEP “…Code provides guidance for decision-making concerning ethical matters, and serves as a means for self-evaluation and reflection regarding the ethical practice of exercise physiology” [43].  As an example, note the values central to ethical practice illustrated in Codes 4, 6-9 by which “Exercise physiologists: 4) …are expected to conduct health and fitness, preventive, rehabilitative, educational, research, and other scholarly activities in accordance with recognized legal, scientific, ethical, and professional standards.  6) …are expected to call attention to unprofessional health and fitness, preventive, rehabilitative, educational, and/or research services that result from incompetent, unethical, or illegal professional behavior.  7) …should contribute to the ongoing development and integrity of the profession by being responsive to, mutually supportive, and accurately communicating academic and other qualifications to colleagues and associates in the health and fitness, preventive, rehabilitative, educational and/or research services and programs.  8) …should participate in the profession's efforts to establish high quality services by avoiding conflicts of interest and endorsement of products in the health and fitness, preventive, and/or rehabilitative services and programs.  9) …should participate in and encourage critical discourse to reflect the collective knowledge and practice within the exercise physiology profession to protect the public from misinformation, incompetence, and unethical acts.  Just recently, the editors of The Exercise Standards and Malpractice Reporter [44] published a small piece about dietary supplements and college students.  Their two reports were based on survey information published originally in Medline Plus [45,46]. In general, the Reuters Health reports reveal that many college students use numerous nutritional supplements including ephedra, androstenedione, and creatine.  Herbert and Herbert [44] state that “…health and fitness facilities who are in the business of selling supplements should reconsider…their patron’s apparent appetite for those products with the potential for harm, injury, claim and suit related to selling such products.”  Ethical Facets of Exercise Physiology Professionalism Leadership in exercise physiology is no place for placing emphasis on making money over integrity and ethical practice.  As leaders initiate change, they should be cautious about making things possible at the expense of unnecessary mis-information and/or possible harm to clients, athletes, and others in the public sector.  As leaders, our job is to be responsible in creating equilibrium in thinking right on behalf of our opportunities and alternatives to traditional work and/or practice in exercise physiology.  We must work at this understanding even when we are prisoners of our own hope and expectations resulting from our work.  It is my hope that ethical practice sustains our drive and vision of what inspires us and those we lead.  Hence, when exercise physiologists are recognized for their professional thinking and publications, the integrity of the process adds to their dignity and self-worth.  We should not ignore the potential for injustice and wrong doing when faith is placed more in one’s opinion and belief system than in the importance of scientific thinking that is defined by research that either supports or refutes the basis for a product’s assumed benefit.  Having said this, there is therefore no such thing as professionalism within exercise physiology when solutions to problems are a function of arrogance.  Let me explain further.  During the past several months, the Editor-in-Chief of the Journal of Exercise Physiologyonline, Dr. Robert Robergs, and I (founder of JEPonline in 1998) became aware of a "related problem" to a research study we published in the May 2001 issue [47].  It appears that subsequent to the publication of the manuscript those responsible for the advertisements that represent the products of by Cytodyne Technologies took the original findings published in JEPonline and misinterpreted the authors' data and the conclusions written in the form of an “advertisement” by Suzanne Mathis.  To my knowledge, the advertisement has now appeared in two general market publications.  It will appear in many others as well until ASEP finds a way to stop Cytodyne Technologies [48].  To understand the difference between professional and unprofessional, between ethical and unethical, between quackery and honesty, and simply between right and wrong, read the May issue of 2002 Muscular Development [42].  Refer to the advertisement entitled “Winning the war against fat” and, then, read the May 2001 article in JEPonline.  Any respectable researcher will understand the fraud and quackery demonstrated by those responsible for the marketing piece from Cytodyne Technologies.  Frankly, it is very troubling when big business can pull the wool over the eyes of the public and get away with it.  As an example, the paid advertisement states that “…resting energy expenditure was greatly increased for the Xenadrine group.  This means that the Xenadrine subjects were burning far more calories without even exercising.”  Wrong!  The actual finding, as reported by the authors, is that “…resting energy expenditure…did not increase during the supplementation period….”  The authors did not report a statistically significant increase in resting energy expenditure.  The advertisement is nothing more than consumer fraud.  Respectable researchers understand this point as well.  So, why don't the MD’s Advisory Board of Scientific Experts and Contributors supervise and/or evaluate advertisements is indeed a question that needs an answer.  Or, is it more simply a question of yet another big business playing the science game to look professional while actually promoting its products at the expense of its readers?  This is Nothing New It is improper not to act responsibly for our actions in regards to those we influence either directly or indirectly by our work.  In fact, we have the duty to help clarify wrong from right so that we might help athletes, clients, and others in the public sector with a certain vulnerability and dependence on crooked thinking.  It is the essence of the professional relationship and the trust that is the backbone of the exercise physiology Code of Ethics.  Our very practice depends upon our understanding of what our Code means to the professionalization of exercise physiology.  It does more than cover a page with ink.  It symbolizes our professionalism and, therefore, it differentiates what we are from other groups of individuals, occupations, and/or technical careers (many often defined by weekend warrior certifications).  Leadership is about accepting the responsibility for self-regulation.  It is about appreciating the guidance that the Code of Ethics offers (and requires of its members).  To be regulated from within means literally that certain beliefs and behaviors may not be acceptable.  It may even extend to restricting advertising or the promotion of an idea outside of the context of demonstrated scientific findings.  All of this allows for the idea that the regulated profession is comprised of the “…practitioner who will not pursue his own interests at the expense of the client….” [49].  This implied promise, according to Edge and Groves, requires the practitioner to act as a professional gatekeeper as part of his/her professional duties. Leadership is inspiring when shared to educate students, athletes, and others to think straight, whether it is supplementing physical training with conjugated linoleic acid (CLS), creatine (Cr), dehydroepiandrosterone (DHEA), dihydroxyacetone and pyruvate (DHAP), ephedra, gamma-oryzanol, glandulars, glutamine, glycerol, L-carnitine, medium-chain triglycerides (MCT), phosphatidylserine (PS), or sodium bicarbonate.  Most exercise physiologists understand this point, especially since “…dietary supplements do not have to be proven safe or effective to be sold” [39, 40].  Others still need to re-exam their thinking.  It is a matter of integrity and, clearly, the capacity to study a new idea that challenges accepted thinking is the test of integrity.  It is also daring and intimidating, but it serves a purpose beyond each of us.  Timothy D. Noakes [41] captured the importance of this point in the 1996 J.B. 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