Episode 146 of the Institute of Performance Nutrition's "We Do Science" podcast! In this episode, I (Laurent Bannock) discuss "CBD for Athletes: Efficacious or Risky Business?" with Professor Graeme Close PhD (Liverpool John Moores University, UK).
Discussion Topics Include:
Podcast Episode Transcript:Download PDF Copy
Key Paper(s) Discussed / Referred to:
Related Podcast Episodes:
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We Do Science Podcast
July 17, 2020
"CBD for Athletes: Efficacious or Risky Business?"
with Professor Graeme Close PhD
[00:00:00] LB:Hi, and welcome to the Institute of Performance Nutrition’s We Do Science Podcast. This is episode 146. I’m excited to bring back a regular, so to speak, Dr. Graeme Close. Professor Graeme Close. How you doing, Graeme?
[00:00:15] GC:I’m doing wonderful. Do I get a medal from a third or fourth time of [inaudible 00:00:20]?
[00:00:21] LB: You’re obviously desperate. Look, Graeme. You and I have known each other for seven years or something now and you've contributed a number of times to our podcast here on a number of different topics and areas, including the very first ever podcast that we did with you, me and James Morton.
A topic came up of late that actually, you volunteered to have a chat with me about that is indeed an incredibly interesting area, which we'll come to in a minute. It's related to something that I come up with quite a lot, which is not only how exciting sport and exercise nutrition has started to become, but it's almost addictive, a bit potentially like this topic that we're going to get into, that will be CBD or cannabidiol. I’m going to have you do all the pronunciations and so on.
This represents one of now many options that sports nutritionists and/or consumers of sports nutrition products might be tempted to use. I understand it's a controversial area for a number of reasons, which we'll expand upon. Before we get into this topic with us, just remind us – it shouldn't be necessary, but let's do this anyway, about who you are and what you're up to and then we'll go from there.
[00:01:48] GC:Okay. Yeah. As you said, I’m Professor Graeme Close. I’m a Professor of Human Physiology at Liverpool John Moores University, where I’ve been the – Well, I started my PhD many years ago and I’ve been a lecturer, etc., there for the last decade. Then on top of that, I’m currently the Expert Nutrition Consultant to England Rugby, the Head of Performance Nutrition for the European Tour, [inaudible 00:02:12] in a number of other camps as well when it comes to sport nutrition.
I also, currently the Deputy Chair of the sport and exercise nutrition register, and a real advocate of promoting the register and driving the standards of sport nutrition in the UK and throughout.
[00:02:31] LB:Yeah. Well on that point actually, I guess we've got terms that fly around a lot, like evidence-based, or a phrase I prefer, which is evidence-informed. Of course, as both as a researcher, as an educator, a profession leader, so to speak, you're very much invested in not only the contribution of knowledge that goes into that evidence-based pathway, but also making sure that that information is being appropriately translated and applied appropriately into practice, but also, by the right kinds of people. There's quite a lot of hats, clearly, you've got on there.
That's why, I think, again, that makes this conversation we're about to have quite an important one, because you are able to look at this topic from the perspective of the evidence, but also from what is appropriate for supporting performance, the needs of the athletes themselves. You've actually we're a former professional athlete yourself, a rugby league player. This conversation will lend itself well too as well. Of course, the controversies aren't just about being a controversy. This could be career-ending stuff for some people, if they don't understand this appropriately.
I guess, we should kick this conversation off, Graeme, with I just mentioned cannabidiol, or CBD. These are terms that people will now have heard of. They may not know a lot about them, or they might be thinking cannabis, or marijuana, or maybe they've heard a little bit in the press about some of the medical aspects of this, which are to a certain extent, relevant to this conversation. Given all the work that you've been doing over the years in performance nutrition, how on earth did you get into this particular area of research?
[00:04:26]GC: Yeah, it's a great question. It goes back to what you were just saying a few minutes ago about working in the applied world and being an academic researcher and trying to combine the two worlds. I won't mention his name, but within one of the teams I was working and around about 2016 this was, one of my players asked me about CBD, cannabidiol. I’d never heard of it. It caught me off guard, really.
I went and did some research and what I found out is that it's from the cannabis plant and you're like,“Whoa. Okay. A bit a bit nervous here.” It was an easy conversation back in 2016, Laurent, because it was under a lot of prohibited list. It was an easy conversation, but look, I’ve looked into it, there may be some loose evidence around pain relief, sleep, etc., but it's prohibited by [inaudible 00:05:21]. That's the end of the conversation.
Jump forward to 2018 and we can maybe discuss this and discuss the wisdom of it, why to decide to remove it from the banned list. CBD is no longer prohibited. Now it's a different conversation, because up till then, my conversation was leave it alone. No, my conversation is I’m going to have to learn a bit more about this, because being an academic practitioner, I don't like not knowing much about things.
That's probably started a two or three-year journey for me now, whereby I’ve spent a lot of time reading and researching and we've had one paper published on it. I’m just about to submit my second paper on CBD. I think it’s an exciting area. I think it's an exciting area, because the potential of what it can do. As we'll touch on today, it's also such a risky, or controversial area, because even though CBD isn't banned – Let's get into this. The CBD is one of maybe a 110 cannabinoids in the cannabis plant.
You get the cannabis plant and there's numerous cannabinoids. The two best known, CBD and THC, tetrahydrocannabinol. It's the THC that's a psychoactive substance, or what some people would call the good stuff. What people have realized is that when you can take out the CBD, there appears to be some medical benefits of this. There is actually two known prescribed, regulated CBD products that you can get on prescription for very specific reasons; one, to treat epilepsy, the other one, it's a CBD with THC combination that is allowed to treat some of the spasticity that you get with various disease states.
If you can take the THC out and leave us with CBD, in theory, we've got something that athletes can take. I’m saying in theory, because CBD isn't prohibited. The kicker here is that all the other cannabinoids are still prohibited by [inaudible 00:07:37]. Now THC is a threshold substance, which means that anything over a 150 nanograms per mil in your urine will give a positive test. All the other cannabinoids are prohibited in any concentration. Because we're getting CBD from the cannabis plant, the chances are there's going to be trace amounts of not only THC, but the other things involved.
If we don't know exactly what is in that bottle, even though we may think we're taking a CBD solution, there's a chance we're putting things into our body that are prohibited by [inaudible 00:08:13] and then we've got the consequences that come with it.
[00:08:17] LB:Yeah, it's interesting, because you use – I mean, you use the word consequence, which I think is an important word. I say this all the time on the podcast. The thing we have to remember is although we're talking about sports nutrition, or sport and exercise nutrition, we might use words like performance and so on, or training adaptations. We're still dealing with human beings and human beings have needs that go beyond just their sport.
There may be some crossover, like in rugby, and we'll get into that, where the impact that's involved has lasting effects that goes well beyond the game, might affect them on days off in certain ways that they feel they need to do something about that. I’ll let you explain that further.
The consequences are very interesting, because as you have pointed out that unless it's specifically banned, it's just black and white. You can't go there. Those consequences take on a I guess, a level of hierarchy in someone's mind, don't they? They don't think,“Right. I’m going to take it.” Instant death is involved, like you might with certain poisons, or whatever. When we think about supplements, we generally consider them to be fairly innocuous in terms of a threat to life, or a threat to health.
Of course, we are as performance nutritionist, particularly working with elite athletes, we're very aware of the potential for contamination. From a consumer's perspective, they're not focused on that so much, are they? I think it's worth just quickly going into that, because there's a difference between what we're looking at as practitioners, or researchers and what the consumer is looking at.
[00:09:58] GC:Yeah. With CBD as well, Laurent, there's still arguments from people much higher up the food chain, right up to government level of what it actually is. In certain situations, it's a medicine. The two that I mentioned, the sativex and epidiolex, without doubt, under a medical license and need to be prescribed and dealt with under that way, then the question is is it a food, or is a supplement?
Now the EU have decided at the moment and it could change its mind, but it's what's called a novel food. Because of that, it's going to have to go through a novel foods application, which is long and complex. By, I think, it's March of next year, all companies who want to sell CBD within Europe will have to have submitted their novel foods application. I did read today that the EU are even thinking of changing their mind on that one, so this is how quick this landscape is changing and reclassifying it as an illicit substance.
I believe the UK aren't doing that. The UK are pushing on with this novel food application. I guess, the reason that's important is that to get a novel food license, you need to have done the things that you're talking about where you're evidencing the safety and the quality of it. There was a paper that came out only this year by [inaudible 00:11:20] in the journal of dietary supplements. They looked at 25 CBD products that you could buy in America. Of the 25, only three of them were within 20% of what it said on the label. Well, 15 of them were well below for the amount of CBD and some of them having absolutely negligible CBD in them.
Two exceeded the claims by as much as 50%, which is a worry when we talk about the safety side of it. Three of the 25 were above the legal limit of THC. Three of them were actually an illegal product you can find. Four of them from what I remember, actually had adulterated synthetic cannabinoids in there, which can be really dangerous to health. You're buying this thinking,“Okay, it's just a CBD product.” We've no idea what is in them. We don't know enough yet. I don't think about the safety of it. We don't know enough about the dose and we're probably – we have a lot of products we can't trust that what it's saying on the label is actually in them, if research like this is to be believed.
[00:12:31] LB:Yeah. I guess, what makes this so much worse is the fact that there is huge amounts of information about well, supplements generally. A lot of it just isn't – let's be kind and say, a lot of it's just inaccurate. This is one area which of course is open license for people. Well, they're trying to make a buck, aren't they? You've got businesses trying to sell products, so on and so forth. With the Internet, it's very easy now for an individual to do their own research, so to speak, but they're not necessarily trained in how to research and differentiate quality from flawed information, which is a big problem here, isn't it?
[00:13:10] GC:Laurent, that's a massive important point and I’m glad you took me down that route. I just did a Google search, where I typed in CBD and athletes, just to see what is coming up. The first thing I should say is in 0.48 seconds, you get 1.7 million hits. There's a lot of reading that can be done here. The very first hit you get is entitled Six Benefits of CBD for Athletes. It says, number one, relieves pain. Number two, it's an alternative to non-steroidals. Three, it's a good alternative to opioids. Four, it's going to reduce inflammation. Five, it'll settle your gut. Six, it's going to improve your sleep quality.
It's probably no wonder that there's a product here that isn't prohibited by [inaudible 00:13:56]. There is multiple claims put on it, and these are things that many athletes are looking for. They're looking for improved pain management. They’re looking for improved sleep. I found another article on a – it was on a ski and snowboarding website. It was talking about top tips to recover from ski and snowboard. Number one, it said, unfortunately, the first solution would be painkillers. Number two was an ice pack and number three was CBD oil.
[00:14:26] LB:Really? Wow.
[00:14:28] GC:In such a short period of time, there is stuff putting it right up alongside standard painkillers and ice packs, in first-line treatment for athletic pain and soreness. It is no wonder that athletes are confused. The paper we recently published, where we showed what? 26% of elite rugby players have either used it, or are currently using it. The biggest take-home message for me in that paper is where they were getting their information from.
What we reported in that paper is that almost 80% of the athletes got the information off the Internet, with as little as 15% going to a nutritionist, or a dietitian. About 60%, 70%, something around that mark, was getting their information from another teammate. There's a wealth of misinformation out there. There's loads of caveats that you need to understand with CBD, far more complicated I would say than any other supplement. Yet, athletes are going to the Internet, or the teammate to get the information, rather than qualified supports.
[00:15:34] LB:I want to hang out in this little area for a bit, because this I feel is a really interesting one, because if I look at this through the lens of a practitioner, which of course, I’ve been for many years, you would like to think that okay, you've gone to certain lengths to become trained, educated, you're for example, center registered, you ticked all those boxes. You're in an environment, like a professional team where the team may even have some teamwide policy on no supplements, etc., to be used, or recommended that haven't been tested for banned substances, haven't been approved by the team doctor, so on and so forth.
We're talking about very well-qualified, very experienced members of the team. Yet, the athletes are still taking these things. Is the answer, they just don't respect the practitioner, which may or may not be a case? They're just not listening to them, because the practitioner themselves may not have made enough of an effort to communicate to their team, to their audience and perhaps, they're only in once a week, which is common, or once every other week. Having a conversation with 20, 30, 40 people can be pretty difficult.
Or is something else at play there, where trying to fight against the tide, so to speak, or the speak louder than the noise that exists when the athletes are away from the club and they're on social media, their buddies, their partners, or whatever. Where do you feel the block is? What's the problem there in this regard? You've already made it clear where we're at in terms of what we know and don't know, so to speak. Why does the problem still exist, like you found in your research?
[00:17:29] GC:Let's get a bit controversial. We've been a bit polite from [inaudible 00:17:32]. Let's get into this.
[00:17:35] GC:Unleash. There's multiple reasons. The first one is and it came up a little bit in this research study, the first one we did. We invited 30 teams to take part. We got 25, which was great. We've got a real good response. The main reasons why the ones who didn't take part didn't take part was that the gatekeeper to them, clubs said,“We've told the athletes not to take CBD. Asking them maybe taking it will just confuse them, so you're not even asking them.”
There's definitely a heading beside mentality, because I know for a fact that some of them teams from people I’ve spoken within are taking CBD, despite what they're being told. I’ve said a few times that Dr. No doesn't just die in James Bond films. Do you know what I mean? If we come along and one of the problems – I remember Kev Carell at the EIS, saying that he faced this when he first got the job as head of nutrition is that people see nutritionists as being Dr. No. You can't do this. You can't do that. You can't eat this. Lots of what you can't do.
You've got to remember, athletes are looking for things that they can do. IIt's the easiest thing in the world to keep putting blocks in place. The hardest part of our job is being innovative and creative. If you think about it, this is something now which is on its infancy. It's only been off the wild, prohibited two years. You can count on one hand the number of athlete-based papers on this stuff.
We're probably talking 10 to 15 years to get an evidence-base. Most of our athletes’careers will be over then. If we look in my paper that we put out recently, the interesting thing was when we looked at the – it was about 15% of 18 to 23-year-olds using it. 30% of 23 to 28-year-olds on over 40% of 28 to 33-year-olds.
It's them at the backend of the careers, who are looking for some pain relief because of probably, a career of abuse on the body, of physical collisions. He's only got one or two years left in the career. They're not going to wait 10 years for an RCT. That's the hardest part of my job is that I’ve got to be innovative. I’ve got to come up with new and exciting areas. At the same time, I’m evidence-based and we've got to have that science, so I guess somewhere, there is a conversation and sometimes we probably do need to be ahead of that RCT, especially it's going to be 10 or 15 years before there's a metro analysis out on here, which is our gold standard evidence.
What we can't do however is jumping at where we are, I would say no when we don't know the safety and we don't know about dosing and we don't know what levels will cause a potential problem for an athlete. Somewhere between where we are now and where we need to be. I think at the moment, some athletes are jumping in with both feet, because they’re not understanding the genuine concerns. Likewise, I think there's a lot of people in my world who are sticking their head in the sand and hoping it will go away. Trust me, this will not go away.
One of the reasons it won't go away is I was doing a little bit of a research the other day and I don’t remember the exact figure, but apparently, today it's a 9.3-billion-dollar industry, predicted to hit 20 billion by 2024. If something has got that amount of money behind it, and let's be honest, if it does prove to be effective for pain relief, given that we know there's a big problem in sport where a lot of athletes do become addicted to opiate-based painkillers, we know that chronic use of NSAIDs can have quite negative effects on the stomach and ulcers and things like that.
If the research comes out and says that maybe it can be beneficial for pain relief, then actually, just because it comes from the cannabis plant, should we not be a little bit more open-minded and be willing to do that research? I think it's pretty a decent time to just to mention the difference between the various strains of cannabis.
For example, in Europe, in the UK, CBD has to come from the hemp plant. The hemp is there's two major strains of cannabis. There's a Sativa and the Indica. The Indica is what's purely grown from the good stuff, and I’m doing a little inverted comment. I shouldn’t be calling it good stuff. I’ll get in trouble here, but you know what I mean. That's what's grown to be illicit purposes and what you get in a lot of trouble if it was growing in the loft of your house.
That's the only real reason that cannabis Indica is grown. Now cannabis Sativa is grown for a variety of reasons. The L strain, when it's been proven to have less than 0.3% THC, to a really small amount of THC, then it can be classed as hemp. Hemp, you'll be using it on a daily basis. It's everywhere in society. It's useful in food stuff, in salads, in food supplements, in margarines, in vitamins, in cooking oils. There's industrial use of it. It's used in salts and bath gels. Obviously, we've mentioned the medicines that it's used in. It's used in building materials, in insulation. It's used in textiles, in clothing. It's using so many different – It seems like such a valuable plant, the hemp plant.
We're not talking about marijuana, which is the Indica strain, which is used for illicit purposes. We're talking about the sativa L strain that is then classed at hemp and it's used that way. Perhaps, if this bad boy had a name change. If you would think PA, you’re just telling change its name, wouldn’t you? You’d say, differentiate it from that nasty marijuana and cannabis and maybe just call yourself Sativa.
[00:23:51] LB:Marijuana sounds a little bit more exciting than Sativa. Sativa sounds like some yeast infection. I’m not sure. Look, I guess, this comes back to something that I think both as consumers and as practitioners, we need to weigh up the cost of benefits of all this, don't we? As you rightly say, this is a gray area, particularly if the appropriate governing agencies, bodies and so on are like, this isn't necessarily banned. We've got to understand what it is that we're dealing with. Hence, why it would help if there was a name change.
I guess, it's made worse, Graeme, where you can buy this stuff from a lot of different places, where they will try and dress it up as some unique formula, won't they? Where they'll give it some proprietary name, where it's a set of proprietary ingredients. Maybe we just quickly focus on that, because people – yes, the option is to not take it. If you are going to take it and you can – your decision-making process leads you to the decision to take it, presumably, there's a few things you've got to clear first, which includes where the hell do you even get this? I don't mean brand.
[00:25:08] GC:To be fair, I don't think [inaudible 00:25:10] have thought it through enough what we have done. I said we're going to be controversial. Let's throw it out that way. Because we've removed it. Since then, all you're getting from the likes of you counted open a warning statements about the dangers of it.
I still can't really get my head around why it was ever removed. I guess, the argument is it's not performance enhancing. It's not dangerous to health and it's not illegal, so from that perspective. The issue is that it's just probably created more confusion than what it was before. It was quite easy before it's banned, it's done. Actually, since it's been removed, we have had some cases and two that spring to mind is the US ski athlete, Devin Logan, who accepted a ban for taking CBD. Then more recently, there was a US triathlete, Lauren Goss, who I think that was a CBD [inaudible 00:26:04] she was using for muscle recovery.
Now whether that is because it was contaminated with higher motes, or we don't know, but what we do know is that there's certainly two cases now where people have accepted sanctions for taking a CBD oil. There's lots of questions that we don't know. For example, I’m becoming quite interested in from my world of vitamin D. There's some research that suggests, because it's stored in fat tissue, when you mobilize fat tissue, you can actually sequester it and your vitamin D concentrations increase.
I’ve seen that suggestion being the case for CBD. Where actually, the THC that you take within the CBD, the small amount maybe has the potential to accumulate within fat tissue. If you do a long steady state of exercise, where you've got an increased rate of lipolysis, in theory, you could then actually release a large amount of THC, in theory. We don't know that. That's one potential.
The other thing is we just don't know if it accumulates anyway. We also don't know when it says, as I said before, that it's going to have the right amount in. We just don't. I am confident. That's the first part of your question. The second part is where'd you get it from? Well, actually most shops are now selling it. I know this is an audio, but I’m sat with a bottle of stuff in front of me, because I’m since publishing papers. Various companies are sending me their want to have a look at and wanting to do it the right way and wanting me to do research on it. You can buy it, the CBD in certain UK, in many health food shops.
In the UK, for it to be a load to be sold, it has to have less than 1 milligram of THC in the final bottle. You hear people say, it has to have less than 0.2%. That's a bit of a myth. People have misunderstood the evidence of it. It has to have less than a milligram of THC in the final bottle and it mustn't be easy to extract, the THC from it.
When you buy it in a shop, you should just be buying it with CBD, with small amounts of THC, less than a milligram. The other thing to point out is that the evidence that's looked at what's called full spectrum CBD, that's got all the other cannabinoids in, say that one of the way that it works is by interaction of all of your cannabinoids. Then really small amounts are important. What we're trying to do from an athletic perspective is strip it back to just CBD and take out all the other even small amounts of the other cannabinoids.
As far as I can see, there's no evidence in the literature that that would be effective. We don't know at the moment, even if the type of products being sold have got any efficacy. There's so many unknowns at the moment. My advice is still to athletes, we'd probably need to leave this one alone. My advice to academics like me is it's not going away and it's such an exciting area of research. Anything that's got the potential to have so many effects, very much the body has its own endocannabinoid system. That's maybe a nice little move here, but the way that the body's endocannabinoid system was discovered was by looking at where THC in marijuana was affecting.
What it found is that we've got these CB1 and CB2 receptors. CB1 mainly in the brain. CB2 throughout the body, in multiple cells. THC was binding to these CB1 receptors and having multiple effects. The scientists then start to say actually, why would a body have receptors for the odd chance you're going to smoke an illicit plant? Then what you find is that the body actually does have its own endocannabinoids, so its own production of cannabinoids that bind to these receptors, the two ones being anandamide, which is AEA. Two, arachidonylglycerol, or 2-AG.
We've got our own endocannabinoids that the body will produce in certain times, one to do with pain effects. A fascinating role of the endocannabinoids, Laurent, and I really enjoyed reading this paper, was a study in rats, where when you knock out the CB1 receptor, then what you do is you give the rat the old Pavlovin experiment, where you give it a stimulus of pain and sound a bell. You do that for a while. Then eventually, when you sound the bell, it will respond, thinking it's pain, okay.
If you keep ringing the bell without pain, eventually, the rat forgets that painful stimulus and the CB1 knock out mice, but never forget it. One thing that the same, that the endocannabinoid system may be crucial in is almost putting out of your mind, previous traumatic events. I’ve seen people looking at the endocannabinoid system and potential role of other cannabinoids for post-traumatic stress.
We know that these receptors are really important in pain management. That's why I think it's exciting. We've got an endocannabinoid system that seems to affect everything from the immune system, all the way to thinking. Potentially, we've now got supplements that could maybe help this system. For me, it is exciting. It's just too soon at the moment for athletes.
[00:31:40] LB:I’m pleased you said that, because this is something I wanted to just quickly get into, which is particularly relevant given it's you. We did a recent-ish podcast about paper to podium, not just how good is the science, or the evidence, but how actually translatable is that into a specific context. In this case, we're talking about performance, athletes in particular.
When we're talking about CBD, there's clearly lots of evidence out there, one way or the other. Where is that evidence? If we were to contextualize that evidence, who's it done on, or what is it done on? Therefore, from your perspective, how translatable is that right now into a sport and exercise nutrition environment, where either someone like me is a practitioner working with athletes, or teams, and/or a consumer such as our athlete, should weigh up the strength of the evidence and the relevance of that in their – my favorite, as you know, I’m into context and my way of – my catchphrase for that is you can, but should you? You can, but should you?
[00:32:52] GC:The short answer is limited and no. I’ll give you a longer answer, because I’m going to say, you're not paying me for the short answer, but you're just not paying me, so we'll just deal with it that way. In a clinical setting, I’ll keep going back to it, something Epidiolex, which is used to treat Dravet syndrome, which is work multiple epilepsies a day, the evidence seems pretty strong.
However, that will cost you 32 and a half thousand pound per year to take Epidiolex in the right amounts. One of the reasons for that is that I think, I should know this, but the dose is around about 500 milligrams of Epidiolex. To put that into some perspective, what we're seeing being sold over the counter as a sport product is about 8 milligrams. 500 milligrams in this situation, 8 in that. The FSA have said at the moment, until further research is done, they advise against any more than 70 milligrams in a day. There's a huge issue. People aren't talking about this enough, but the dosing issue.
People are using clinical research and saying, yeah, it's on CBD. Then using that. It's like, we know that a gram of paracetamol works. I’m not going to sell a tablet selling a milligram. For it to work, I need a gram of the stuff. There's maybe a big issue with dosing here. I did some back of the fan packet maths. If I wanted to give CBD oil in the dose, well, the literature suggests it may be effective. To an England rugby squad, for example, it would cost me three quarters of a million pound per year. I’m not sure there's enough evidence out there yet to make me invest three quarters of a million pound in this stuff.
There does appear to be a reasonable evidence-base on things like CBD in pain management in people with MS, for example, and quite a few clinical situations. I said you can count on one hand. I think, you can count on one finger, the amount of studies from an athletic perspective. We've done one where I’ve said, where we've looked at prevalence. I’m just about to try and submit one word. We've tried to look at Doms, a classic Dom study. We only used what it says on the bottle. It's a really small dose. We found no effect on anything; sleep, muscle soreness, or anything like that.
Interestingly, my biggest study where we asked all the athletes about the reported benefit, now obviously there was a big placebo effect here. Despite 80% reporting that they took it for pain relief, only 15%, I think it was 15% said they felt a benefit on pain relief. In the doses we're taking, I’m not convinced this is an effective pain relief.
Interestingly, about 40% said it helped them with sleep. Now, whether that is a placebo effect that we know a lot of athletes struggle to sleep and the thought of having something related to the cannabis plant pre-bed help sleep, who knows, we need some placebo-controlled, randomized control trials on that one.
I certainly think in the doses being given at the moment, I’m very dubious about whether it's going to have any effect from a pain management in the doses that we're given. Also, I’ve recently read them, but maybe it needs to be a loading phase as well of maybe three, four, five weeks. Long answer to a short question, evidence weak are not translatable to athletes at the moment.
[00:36:34] LB:Yeah. Back to our previous conversation, I guess that's maybe why cannabidiol has some value in the placebo arena, because the association we have with the name and some of its perceived benefits by its association with cannabis, etc., could be of interest, couldn't it? Whereas, Sativa, I guess is maybe less convincing. Because we're not recording the video here, I can tell you now that Graeme’s just taken a dose. You just taken a hit.
[00:37:14] GC:What about you just reminding myself of the smell. I wasn't actually taking a dose. [Inaudible 00:37:19] placebo. I was going to try and describe the smell and taste of it, but it will certainly help with the placebo, because it's not the nicest tasting of stuff and there certainly is a distinct smell of it.
We all know the power of placebo. There's a reason why if I was to do this study on sleep, I would have to have a placebo group. The anecdotal reports are coming back from players that are finding it a benefit. We do need to still take that with a pinch of salt. Like I said before, there certainly is enough stuff and there's even small clinical trials now that are looking at pain and sleep and showing some benefits.
Now most of these are when you've got THC in there as well with that – what we call that entourage effect. We certainly need to look at it, because like I keep saying that if it can help with pain and sleep and it's something we've grabbed from a plant – Well, the other thing I’ve read and people argue, but for me, it reads like there is a reasonably solid safety profile on the stuff, probably a lot safer than many other medications currently out there. It needs some research.
[00:38:33] LB:Since you've delved into this, I mean, what is the anti-doping risk here? I mean, let's be absolutely clear, what the risks are.
[00:38:44] GC:Okay. Thanks, Laurent. I said I would be controversial and I’m going to try and answer this in the least controversial way possible. If it comes from the hemp plant and you know for sure it's from a hemp plant, which means it has to have less than either 0.2% or 0.3% THC in it, depending what country you're in. If it comes from the hemp plant and it's been extracted properly and you've got all the evidence around that, my reading is the chance of getting a 150 nanograms per ml of THC in urine is negligible. To put that into any context, some countries are doing at 5 nanograms per ml to test you in the workplace, have you been smoking illicit substances and coming into work in an unfit state? People are looking at that concentration to try and pick it up.
It used to be 59 nanograms per ml with [inaudible 00:39:40], but increased it to a 150. The if, I said at the beginning, if it's from hemp, the chance of hitting a THC concentration of 150 nanograms per ml, in my understanding and this isn't advising anyone to jump over there and say,“Graeme said this, so go and do it.” My understanding is that that would then be negligible. What I don't understand and I don't know if anyone does, I don't know how of the cannabinoids would actually test from.
I’d be very surprised if they’re tested for all a 110 or however, maybe a 113 cannabinoids. We know that all the others are prohibited in even small quantities. I don’t know and nobody knows, because this is a study I want to do. If a CBD product from a hemp plant, what it does to the whole range of cannabinoids. If you were saying in terms of the THC and you used to take it from a hemp plant questionable, then you've asked a question, then why some athletes failed.
This is where you get controversial, isn't it? Making sure I don't move into any slanderous. The obvious explanation is that it's been contaminated. It's not from a hemp plant and the study that I told you earlier about where it said, many had other substances in it and also in much different concentrations. It's probably related to that. That's the [inaudible 00:41:09] paper, where they showed that only three of the 25 label match for claim.
What we can never rule out and I would never make any accusation, but you can never rule out is it's a far better story to tell [inaudible 00:41:23] that you've had a CBD contaminated issue than you have smoked a spliff. Let's be honest. I’ve said this a lot about the amount of claims of contaminated supplements. Yes, we do know that that is a problem. I do not for one minute believe that everybody who failed a dropping test, as far as I know in the UK, there's only ever two or three athletes who ever said it took an illicit substance, performance enhancing substance. All the others took a supplement.
I don't believe there's only ever been three people caught taking a banned drug and all of them were contaminated supplements. It's just an easier and less damaging story for one's reputation. I do think a sport nutritionist and that's who I’m talking to a lot here, a lot of your listeners are people working in that world. If we were to say,“Yeah, go ahead. Take the CBD,” and they fail a doping test, there is always a chance that that athlete may have done something he shouldn't have done, or she have done something she shouldn't have done and blamed it on the CBD and then the blame is back on our doorstep for not doing due diligence.
When it comes to due diligence, what we know and we all know about informed sport and the importance of batch testing. Informed sport at the moment will not test any CBD, or any hemp-based products, so we can't get an informed sports certificate on it. There are other companies such as BSCG, the Banned Substance Control Group that will and they'll give you a hemp certified product, but that still is same, but it's below a certain threshold. Still, nobody can hand on heart say, if taking that in high doses over for a long time, will be a problem. At the moment, I don't think we can do due diligence. In terms of giving our advice to the athletes, we have to at the moment in my opinion, urge on the side of caution.
[00:43:31] LB:Yeah. I guess, another angle here as well is look, we've acknowledged potential strengths and limitations to this. We've acknowledged athletes aren't just athletes. They're human beings. There's going to be more than one reason they might take this. You've mentioned anecdote, the power of anecdote is pretty powerful. Also, we need to bear in mind that their desire to take this is maybe based perhaps more on what as its urban legend, as opposed to the actual real effects. There are other ways of tackling those things that they're taking CBD, or wanting to take CBD for, whether it's sleep, or stress, or anxiety, or pain. There are of course, other solutions for those problems. I mean, if I was in your consulting room, or if you were standing in front of athletes and we were considering that as an option, I mean, how would you tackle that perspective?
[00:44:31] GC:Yeah. I recently did an internal webinar for the EIS. That was basically, Laurent, my final slide. On the final slide, if I remember, it was something on the lines of number one, have the conversation, because it's not going away. Be proud of yourself that the athlete trusts you enough to have the conversation. Because if your athlete's asking you about it, you're in a small minority. You're in the 15%. I think we need to encourage our athletes to have these conversations. That's why I go back to that original player who asked me.
I hope he's listening to this and I should have asked him can I name him, because it keeps me on my toes, because he's so well-read. By the way, it's in a position that you wouldn't think he should be. He's always on top of the literature and he's not asking about dodgy stuff. He'll have read something that I’ve not heard it before and you're like,“Wow, okay. I’ve not heard of that one. I need to.”
Your athletes are speaking about it. One of the questions we asked who's heard of CBD and it was almost a 100%. Your athletes are speaking about it. Get your head out the sand. We have to have a conversation.
The second point then is use that conversation to explain the anti-doping risks, because they are pretty clear. When I’ve explained them to intelligent athletes, not one of them have then wanted to say,“Right. I think it's worth it.” They're not stupid, but maybe not a word, because word it's not banned by [inaudible 00:46:04]. We maybe don't understand all the other connotations that we've just spent the last hour discussing.
The third thing is explain the safety concerns. Explain to them that in a lot of these products, we don't know what amount is safe. We have seen that dangerous compounds are popping up in them, so we don't even know how safe it is. I would then explain the lack of evidence in as much as yes, 500 milligrams is licensed. We can't give anywhere near that. If you were going to take that, be prepared to spend north of 30,000 pounds a year and we still don't know it's going to help you. That will probably stop the conversation at that point. Athletes don't like spending that much money.
I would explain the difference between medical and non-medical for that dosing and also, the entourage effect. Actually, most of the literature that shows that it works is when the whole cannabinoid spectrum is in them. Taking it down to an isolate, we don't know. Then it's a point that you would say,“Right. Thanks for speaking to me. You want to help with sleep? Have we tried.” Now we can go into – I think you've done some great stuff on your course and the diploma and on podcasts on sleep, so get back into first principles.
If it's muscle soreness, what can we do to help with the muscle soreness, the nutritional strategies and all the other strategies we know that's tried and tested to help with it? Then we've got to wait for the research. Actually, volunteer. Let's get involved in the research. It's not going away. Let's try and do some good research and see, the athletes ahead of a curvier. Because as we've spoken before, sometimes we are – In fact, a lot of times here, the simple one I always go back to is when I was an undergraduate, I was told you didn't need more than 0.8 grams per kg body mass of protein. Nobody needs more. Anything else, you're wasting.
You come forward 20 years and we now know that's nearer to 2 grams per kg body mass. I got told when I was a young rugby player from one of my friend's dads who was a bodybuilder,“You need to be having either eggs at breakfast, or these protein shakes.” It was dismissed at my time saying, that's a bodybuilding myth. Come forward 20 years, the bodybuilders had it right. This could well be a case, where they're ahead of the curve. Hopefully, the science if it is out there, will catch up with curve.
[00:48:41] LB:That's exactly why I like the word evidence-informed, as opposed to evidence-based, because we need to appreciate the evidence is it's just a constant moving thing, isn't it? So fluid. I mean, you're right there. We're doing all the research and it's just racing by, isn't it? I mean, speaking of which, so what are the future – what's the future hold in this area for you? I mean, you're obviously excited by this. It's fascinating. Where do you see things go next?
[00:49:07] GC:Yeah. Well, first of all, I saw a real good quote off someone and I can't remember it was, but it was basically saying that,“I don't want to be wrong. For as a scientist, I don't want to be wrong for a day longer than I need to be.” I never mind changing my mind. What I will always say to people is to the best of my knowledge, or at the moment that the evidence would lead me towards. I don't mind holding my hand up, but I might have written something and in three years’time, the evidence has changed. That's science. If it didn't, we wouldn't keep doing science.
To the best of my knowledge, this is where at the moment, what I would like to see done is first of all, attack this from an athlete safety perspective. I would like to get research funding, which I’m currently working to try and get my hands on, whereby I take CBD from the hemp plant, so I know it will be under 0.2%, but I haven't stripped it all out, like some products have tried to do to make it suitable for athletes. I’ve still got the entourage effect to some extent. Take it in non-tested athletes, which will be important in reasonable quantities over a long period of time and measure urinary cannabinoids, blood cannabinoids and try and get an understanding what it's doing. Are we getting in enough?
The other thing we also know is first pass extraction of CBD is very low. If you take in tablet form, you're going to get negligible amounts into a system. That's why it's mainly drops under the tongue, or even people vaping and things like that. I want to see, can we get it into the system in decent enough quantities and what that does to the whole spectrum in urine and blood? What I also want to do is some proper pain studies with a proper dose.
We've got some real pain experts who I’ve recently met in John Moores, not from sports science, but from other departments within the university, who have done some unbelievable research on pain. Got a great model for inducing it, that involves in infusing stair line, so you can quantify pain. I would love to do some real good pain stuff on it. Then working with Dan Owens and people like that, colleagues at university, I wouldn't mind sticking it on some cells and looking at regeneration and what does it do for muscle damage.
I could work on this for the next 20 years, Laurent. This could be genuinely, I listened to your podcast the other week with – I know I said Professor [inaudible 00:51:44], with Professor Jones. I’m the [inaudible 00:51:47], well-known on Twitter. It read something out on nitrates and thought, go and we'll have a look. I cannot in whatever, 10 years later, he's still having a look. This could well be the case of me and CBD. I might need to change my name to –
[00:52:03] LB:Dr. Cannabis?
[00:52:04] GC:Yeah. Great. I’m going to go green CBD, or something on Twitter.
[00:52:09] LB:Graeme Sativa. Would just change your name to Sativa. Close.
[00:52:13] GC:Exactly. I could have been inspired by Andy [inaudible 00:52:16]. There's never no idea, because once I’ve done the study that shows it doesn't accumulate and it's not going to be a problem from an anti-doping perspective, then it's almost like the shackles are off and let's start seeing if it works.
If however it is a problem from that perspective, then it's a conversation with [inaudible 00:52:38], whereby is it worth re-banning it, because it will eventually lead to a doping violation? Will we get to the point where [inaudible 00:52:48] just decide to remove all cannabinoids? There's a big argument to do that.
If you think about why should a product be prohibited, it's dangerous to health, it is performance enhancing, or it's against the spirit of sport, you might get to a point where I don't think it is performance enhancing. I don't know anyone before a game has thought,“You know what I’ll do to get me fired up, I’ll smoke a joint.” I’ve never seen that one coming through. We might get to a point where it's not prohibited. Then who knows?
[00:53:20] LB:We’ll maybe do – we'll follow up on this from a cafe in Amsterdam, Graeme. We could have some fun with that one. Well, I guess, look, my final question for you then, because you've summed up brilliantly everything I wanted to get into on this topic. You'll recall Ron Owen’s comment on supplements, which is if it works it's probably banned. If it's not banned, then it probably doesn't work, which was absolutely right back in the day. Do you think maybe this is shifting slightly, this concept?
[00:53:49] GC:Yeah. You've probably seen – I asked him this. He's not replied to me yet, so I’m still waiting for his reply. I genuinely think it does, because when that came out, I get it and I wonder whether I need to speak to Ron about this, whether it means specifically as performance enhancing, such as caffeine, for example. If we actually look now in our, as you would put it, sport nutritionist toolkit, most of us these days would have vitamin D to correct deficiency in the winter month. A lot of us would have fish oil. A lot of us would have creatine. A lot of us would have caffeine. A lot of us would use protein powders and recovery powders, would use nitrate or beet root juice.
If you're working in power repeated sprint sports, you might have sodium bicarb, or sodium citrate. We might have taurine. I’ve probably missed a few there, but we've got to 10 or 12 though, whereby the evidence now is pretty solid, that there is a benefit. That's before we get on to things like probiotics, the [inaudible 00:54:52] are called zinc acetate, vitamin C. I’d still passionately believe in a food-first approach.
I do however, think certain people have hijacked that term into food-only. I am a strong advocate of food first. I’m not an advocate in sport nutrition of food only. It still offends me why a strength and conditioning coach, if they come across limb occlusions training, where you can occlude a limb, train it and you enhance cellular signaling, that's well done, you're being innovative. If a sport nutritionist says that getting nitrate can help reduce the oxygen cost of exercise, there's certain people saying, that's cheating, that's performance enhancing. Training is performance enhancing. The reason we're trying our guts off is performance enhancing.
I still massively support food first. I still massively support we need to do due diligence on supplements from safety and everything like that. I do believe a targeted supplement approach is a crucial tool in a sport nutritionist toolkit.
[00:56:06] LB:Yeah. Well put, Graeme. I think, my addition to that is I think that there's too much temptation to reduce things to some tweetable summary, because it is quite complicated, isn't it? I think that's what's important for us as practitioners, we need to recognize whether we actually know enough about the topic to actually be able to comment on it, and/or recommend something, which is why things like this podcast is so useful, because it helps increase someone's level of knowledge and awareness and understand the strengths and limitations, not only of the potential intervention, but the strengths and limitations of the practitioner, or the consumer's own understanding of that. Because like you said in your example of you look it up on Google and you see some factual statements about what CBD can do for people, which is far from being factual, but of course, people read that and they believe it, don't they? It can go too far the other way.
[00:57:03] GC:Correct. I don't know how many times was all taught in school, the boy who cried wolf. If we permanently come across by saying,“No. It doesn't work. Can't help. Don't work. Food first don't work.” Eventually, these people are going to leave your bubble and take advice from outside it, because if I was to talk to somebody out of creatine for argument sake in a sport where it's effective, some random in a gym tells them to try it. They try it and they feel a benefit, who knows what the next bit of advice from that random in the gym may be?
We have an obligation, I think, as credible, registered, educated sport nutritionists to make an informed decision. It's not prohibited. We can get it batch tested, which is risk minimization. If there's a solid evidence base that it helps, such as creatine, caffeine, bicarb, [inaudible 00:58:01], all the other ones that we've said before. I didn't mention collagen before and all the great work from Keith Bart and what additional tool. That's now been to our toolbox of helping injured athletes.
Would we be doing our job if we didn't consider that, because we've taken the moral high ground of food only? I personally don't think would be doing a good enough job. Food first, not food only.
[00:58:27] LB:Brilliant. Well, thank you so much, Graeme, for all your time and effort and the clear passion you have for sport and exercise nutrition, which is infectious in itself, has led many people, including myself, to get really into this whole field. If people want to learn from you and follow you, I know you're not just prolific in terms of your research outputs and you're out there on the speaking circuit a lot and obviously, you've contributed a lot to our program, which is awesome. You're out there. You're one of the noises on Twitter and so on as well. How do people follow you? What's the best way of staying in touch with you and your outputs?
[00:59:06] GC:Yeah. If you wanted to find my research, but obviously, there's Research Gate, or the university website. If you're just to type my name and Liverpool John Moores University, you'd get to the web page. On social media, it's @Close_Nutrition. I need everyone to follow that, because Andy Jones is racing ahead of me and asks us well in the distance. We need to correct that imbalance very quickly. Then I’ve just started at world of Instagram as well, where it's just @CloseNutrition on Instagram, there's no underscore. Yeah, I’m pretty easy to find. I don't hide myself.
[00:59:41] LB:Definitely not. Well, look. Thank you, Graeme, once again. It's been a pleasure as always. I’m looking forward to catching up with you again on this and/or other topics which you've got plenty to talk about.
If you want to find all the other podcasts that I’ve done with Graeme, you can learn about those at our website, which is www.theiopn.com, the Institute of Performance Nutrition, where you can also learn about our other outputs and our practice focus training program, our diploma and performance nutrition.
Thank you all for listening. I of course, am Laurent Bannock. I look forward to bringing another episode back to you all very soon. Take care, everyone.
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