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Dietary supplements and their associated adverse events are not uncommon in the U.S. military, and selected dietary supplements have been associated with a number of nontraumatic deaths in service members. Specific ingredients and dietary supplement products in the civilian community are often associated with multiple adverse events and some have subsequently been removed from the marketplace; the most notable in the last decade is ephedra. We present case reports for two soldiers who were taking commercially available dietary supplements containing multiple ingredients to include the sympathomimetic, 1,3-dimethylamylamine (DMAA); both collapsed during physical exertion from cardiac arrest and ultimately died. A presentation of their clinical courses and a discussion of the history and pharmacology of dietary supplement ingredients, including DMAA, are provided. Our cases highlight concerns that DMAA in combination with other ingredients may be associated with significant consequences, reminiscent of previous adverse events from other sympathomimetic drugs previously removed from the market.

According to recent studies, over 50% of the general population (and nearly 70% of military personnel) report regular use of dietary supplements (DS). Military personnel may be at greater risk for adverse reactions to DS because of operational environments and stressors (extreme heat, altitude, or sleep deprivation) associated with military deployments and training. As a recent example, the Department of Defense placed a medical hold on all DS containing the ingredient 1,3-dimethylamylamine in response to several fatalities linked to the use of this product. This study investigated product certification for DS in military commissaries (grocery stores), exchanges (department stores), and civilian retail stores. Overall, only 12% of the available products were certified by an independent scientific agency. Consumers should be aware that most over-the-counter DS do not have independent certification of product integrity. Although "third-party certification" does not ensure DS safety or effectiveness, it is important that consumers and health care providers are made aware that such product screening takes place, to help patients make more informed decisions about the purchase and use of DS.

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