Classic Chocolate by The Cheat System Diet

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Diabetes. Although there has been interest in using oral pea protein for diabetes, there is insufficient reliable information about the clinical effects of pea protein for this purpose.
• Exercise-induced muscle damage. It is unclear if oral pea protein is beneficial for exercise-induced muscle damage. Details: A small clinical study in healthy, untrained males shows that taking a specific type of pea protein (Nutralys S85 Plus, Roquette) 0.3 grams/kg 3 times daily for 5 days after a 90-minute whole-body high-intensity eccentric exercise bout does not reduce surrogate markers of exercise-induced muscle damage, including creatine kinase, lactate dehydrogenase, and myoglobin, when compared with whey protein or water (104758). However, the study may have been inadequately powered to detect a difference between groups and is further limited by double-blinding restricted only to the protein supplements. The water control did not match the taste, texture, or calorie content of the protein supplements. Another small clinical trial in healthy, physically active older adults shows that taking pea protein 25 grams daily for 10 days prior to and 3 days after a single 20-30 km endurance walk does not improve markers of muscle damage when compared with placebo and may be less effective when compared with whey protein (111729).
• Exercise-induced muscle soreness. It is unclear if oral pea protein is beneficial for exercise-induced muscle soreness. Details: A small clinical study in healthy, untrained males shows that taking a specific type of pea protein (Nutralys S85 Plus, Roquette) 0.3 grams/kg 3 times daily for 5 days after a 90-minute whole-body high-intensity eccentric exercise bout does not reduce exercise-induced muscle soreness when compared with whey protein or water (104758). However, the study may have been inadequately powered to detect a difference between groups and is further limited by double-blinding restricted only to the protein supplements. The water control did not match the taste, texture, or calorie content of the protein supplements. Another small clinical trial in healthy, physically active older adults shows that taking pea protein 25 grams daily for 10 days prior to and 3 days after a single 20-30 km endurance walk does not improve muscle soreness when compared with whey protein or placebo (111729).
• Hyperlipidemia. Although there has been interest in using oral pea protein for hyperlipidemia, there is insufficient reliable information about the clinical effects of pea protein for this purpose.
• Hypertension. It is unclear if oral pea protein hydrolysate is beneficial for hypertension. Details: A small clinical study in adults with elevated blood pressure shows that taking a pea protein hydrolysate 3 grams daily for 3 weeks reduces systolic blood pressure by 6 mmHg when compared with placebo. Taking the same product at a dose of 1.5 grams daily does not reduce blood pressure (94973).
• Irritable bowel syndrome (IBS). Oral pea protein has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small open-label study in patients with diarrhea-predominant IBS shows that taking two tablets of a specific product (Gelsectan, Noventure) containing pea protein, grape seed extract tannins, xyloglucan, and xylo-oligosaccharides (doses unknown) before breakfast and dinner daily for 6 months improves IBS-related symptoms, including diarrhea, pain, bloating, defecatory frequency, stool consistency, and defecatory urgency when compared to baseline (108881). The validity of this study is limited by a lack of placebo control group.
• Muscle strength. Clinical research on the impact of oral pea protein on muscle strength is mixed. Its effects might be similar to whey protein. Pea protein may be more effective in individuals with lower baseline muscle strength. Details: A clinical trial in physically active, but non-resistance trained, young male adults participating in a 12-week upper body resistance training program shows that taking a specific type of pea protein isolate (Nutralys, Roquette) 25 grams twice daily over the training program does not augment training-induced increases in muscle thickness or strength when compared with whey protein or isocaloric placebo. However, a post hoc analysis of participants with the lowest muscle strength at baseline shows that pea protein supplementation increases bicep muscle thickness more than placebo and to a similar degree as whey protein (95426). Additionally, a very small clinical study in trained adults shows that taking pea protein 24 grams twice daily during an 8-week high-intensity functional training program improves muscle strength to a similar degree as whey protein, while neither supplement appears to impact muscle thickness or body mass (102013). The small study size and lack of an isocaloric, protein-free control limits conclusions that can be drawn from this study.
• Obesity. Although there has been interest in using oral pea protein for obesity, there is insufficient reliable information about the clinical effects of pea protein for this purpose.
• Postoperative recovery. Oral pea protein has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in adults undergoing gastrointestinal resection due to cancer shows that consuming a beverage (Providextra, Fresenius Kabi) containing pea protein hydrolysate 11% and carbohydrates 89% the night before (400 mL) and the morning of surgery (200 mL) reduces postoperative hospital stay by almost 2-fold when compared with conventional preoperative fasting (94933). It is unclear if these findings are due to pea protein, carbohydrates, or the combination. More evidence is needed to rate pea protein for these uses.

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POSSIBLY EFFECTIVE

• Food allergies. Clinical research in infants 1 month of age and older with IgE-mediated allergy to cow's milk protein shows that administering either a partially hydrolyzed rice protein formula supplemented with lysine and threonine or a hydrolyzed cow's milk formula until age 24 months results in similar overall growth. Hydrolyzed rice protein formula is also similarly effective to hydrolyzed cow's milk formula for improving the rate of tolerance to cow's milk (97798).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Exercise-induced muscle soreness. Preliminary clinical research shows that taking rice protein isolate (Oryzatein rice protein, Axiom Foods) 48 grams in water immediately after resistance training three times weekly for 8 weeks is as effective for reducing muscle soreness and increasing perceived recovery as taking whey protein isolate 48 hours after each individual session (95674). The validity of this finding is limited by the lack of a placebo comparator group.
• Muscle strength. Preliminary clinical research shows that taking rice protein isolate (Oryzatein rice protein, Axiom Foods) 48 grams in water immediately after resistance training three times weekly for 8 weeks is as effective for increasing muscle mass and muscle strength as taking whey protein isolate 48 hours after each individual session (95674). The validity of this finding is limited by the lack of a placebo comparator group.

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LIKELY EFFECTIVE

• Cystic fibrosis. Long-term nebulized hypertonic sodium chloride improves lung function and reduces pulmonary exacerbations in patients with cystic fibrosis. Details: Meta-analyses of clinical research in adults with cystic fibrosis show that, when taken along with a bronchodilator and other standard therapies, nebulized hypertonic sodium chloride in concentrations of 3% to 7%, up to 10 mL twice daily for 4 weeks, increases forced expiratory volume at one second (FEV1) when compared with isotonic saline (sodium chloride 0.9%) (26230,26230). This benefit was not seen at 48 weeks. Other clinical research in adults with cystic fibrosis shows that inhaling sodium chloride 7%, 4 mL twice daily for 48 weeks, does not improve FEV1 when compared with isotonic saline. However, chronic treatment with hypertonic saline does reduce the number of pulmonary exacerbations and increase the number of patients without pulmonary exacerbations when compared with isotonic saline (29402). It is not clear if this benefit occurs in children with cystic fibrosis. The Pulmonary Clinical Practice Guidelines Committee of the Cystic Fibrosis Foundation recommends that individuals with cystic fibrosis aged 6 years or older use nebulized hypertonic saline long-term to improve lung function, reduce the number of exacerbations, and improve quality of life (29403).

POSSIBLY EFFECTIVE

• Amphotericin B nephrotoxicity. Oral sodium chloride seems to prevent nephrotoxicity associated with use of amphotericin B. Details: Clinical research shows that administering oral or intravenous sodium chloride 150 mEq daily during treatment with amphotericin B can attenuate the rise in serum creatinine levels and preserve renal function when compared to treatment with amphotericin B alone (26226).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Bipolar disorder. It is unclear if oral sodium is beneficial in preventing lithium level fluctuations in patients with bipolar disorder. Details: A moderate-sized open-label clinical study in adults with type I bipolar disorder receiving lithium carbonate shows that taking sodium chloride 1 gram daily for 12 weeks along with dietary salt restriction of 1 gram daily reduces the percentage of patients with lithium level fluctuations above 0.8 mEq/L, but does not significantly affect serum sodium, potassium, aldosterone, or creatinine levels when compared with controls who were not salt restricted, but were advised not to consume additional salt at the table (112909). However, the interpretation of these findings is limited by missing data in both groups.
• Canker sores. Although there is interest in using topical sodium chloride for canker sores, there is insufficient reliable information about the clinical effects of sodium chloride for this condition.
• Congestive heart failure. It is unclear if oral sodium is beneficial in patients with acute decompensated heart failure requiring decongestive therapy with diuretics. Details: A moderate-sized clinical study in adults hospitalized with acute decompensated heart failure requiring high-dose intravenous furosemide shows that taking sodium chloride 2 grams three times daily for up to 96 hours does not affect patient weight or serum creatinine levels when compared with placebo (112911). However, the clinical relevance of this study is unclear and it may have been inadequately powered to detect a difference between groups.
• Conjunctivitis. Although there is interest in using ophthalmic sodium chloride for conjunctivitis, there is insufficient reliable information about the clinical effects of sodium chloride for this condition.
• Hyponatremia. Although there is interest in using oral sodium chloride for hyponatremia, there is insufficient reliable information about the clinical effects of oral sodium chloride for this condition.
• Pharyngitis. Although there is interest in using topical sodium chloride for pharyngitis, there is insufficient reliable information about the clinical effects of sodium chloride for this condition.
• Prematurity. It is unclear if oral sodium is beneficial for premature infants. Details: Preliminary clinical research in infants born at less than 32 weeks' gestation shows that adding sodium 4 mEq/kg daily to enteral feedings, starting from the 7th day after birth and continuing through the 35th day, reduces the risk of developing hyponatremia and improves weight gain when compared with adding water (98180). A small, open-label clinical study in newborns less than 35 weeks gestation shows that high sodium intake, defined as an average of 0.25% sodium in maintenance fluids, for 48 hours on day 2 and 3 after birth results in less weight loss within the first 72 hours of life when compared with control, but does not improve mortality, length of hospital stay, or complications from prematurity (112908). However, interpretation of these findings is limited by varied concentrations of sodium as an intervention. More evidence is needed to rate sodium for these uses.

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LIKELY SAFE ...when used orally in food amounts. Pea protein is commonly consumed as a food (94935,94970,94981).

POSSIBLY SAFE ...when pea protein is used orally in medicinal amounts, short term. Pea protein has been used with apparent safety in doses of up to 50 grams daily for up to 12 weeks (95426,94934,102013,104758,104759). ...when pea protein hydrolysate is used orally, short term. A pea protein hydrolysate has been used with apparent safety at doses of up to 3 grams daily for up to 3 weeks (94973).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using in amounts greater than those found in food.

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POSSIBLY SAFE ...when rice protein is consumed in food. Rice protein has generally recognized as safe (GRAS) status in the United States for use in food products at concentrations of up to 34.3% (97812). ...when hydrolyzed rice protein is used topically on the hair and skin. The Cosmetic Ingredient Review Expert Panel has concluded that hydrolyzed rice protein is safe for use in cosmetic ingredients based on cutaneous tolerance testing in individuals with non-sensitive skin (97802).

CHILDREN: POSSIBLY SAFE
when hydrolyzed rice protein with additional lysine and threonine is used in infant formula as the sole source of nutrition in infants less than 6 months of age, and then as part of the diet until 24 months of age. However, hydrolyzed protein formulas are only recommended for use in infants unable to tolerate cow's milk or other proteins. Breast milk or standard formula is recommended for most infants (97794,97795,97798,97799). Rice is a source of inorganic arsenic, which is known to negatively impact long-term health. The amount of inorganic arsenic in rice protein products or hydrolyzed rice protein-based formulas is not known. Look for products that declare the inorganic arsenic content and provide information regarding its potential risk (97793).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using in amounts greater than those found in food.

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LIKELY SAFE ...when used orally and appropriately. Sodium is safe in amounts that do not exceed the Chronic Disease Risk Reduction (CDRR) intake level of 2.3 grams daily (100310). Higher doses can be safely used therapeutically with appropriate medical monitoring (26226,26227).

POSSIBLY UNSAFE ...when used orally in high doses. Tell patients to avoid exceeding the CDRR intake level of 2.3 grams daily (100310). Higher intake can cause hypertension and increase the risk of cardiovascular disease (26229,98176,98177,98178,98181,98183,98184,100310,109395,109396,109398,109399). There is insufficient reliable information available about the safety of sodium when used topically.

CHILDREN: LIKELY SAFE
when used orally and appropriately (26229,100310). Sodium is safe in amounts that do not exceed the CDRR intake level of 1.2 grams daily for children 1 to 3 years, 1.5 grams daily for children 4 to 8 years, 1.8 grams daily for children 9 to 13 years, and 2.3 grams daily for adolescents (100310).

CHILDREN: POSSIBLY UNSAFE
when used orally in high doses. Tell patients to avoid prolonged use of doses exceeding the CDRR intake level of 1.2 grams daily for children 1 to 3 years, 1.5 grams daily for children 4 to 8 years, 1.8 grams daily for children 9 to 13 years, and 2.3 grams daily for adolescents (100310). Higher intake can cause hypertension (26229).

PREGNANCY AND LACTATION: LIKELY SAFE
when used orally and appropriately. Sodium is safe in amounts that do not exceed the CDRR intake level of 2.3 grams daily (100310).

PREGNANCY AND LACTATION: POSSIBLY UNSAFE
when used orally in higher doses. Higher intake can cause hypertension (100310). Also, both the highest and the lowest pre-pregnancy sodium quintile intakes are associated with an increased risk of hypertensive disorders of pregnancy, including gestational hypertension and pre-eclampsia, and the delivery of small for gestational age (SGA) infants when compared to the middle intake quintile (106264).

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ANTIHYPERTENSIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = A Theoretically, a high intake of dietary sodium might reduce the effectiveness of antihypertensive drugs.  Details High intake of dietary sodium can increase systolic and diastolic blood pressure (26222). Also, high intake of sodium may necessitate increased use of antihypertensive medications to achieve blood pressure control in some patients, such as those with chronic kidney disease (26223).

CORTICOSTEROIDS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Concomitant use of mineralocorticoids and some glucocorticoids with sodium supplements might increase the risk of hypernatremia.  Details Mineralocorticoids and some glucocorticoids (corticosteroids) cause sodium retention. This effect is dose-related and depends on mineralocorticoid potency. It is most common with hydrocortisone, cortisone, and fludrocortisone, followed by prednisone and prednisolone (4425).

LITHIUM Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = B Altering dietary intake of sodium might alter the levels and clinical effects of lithium.  Details High sodium intake can reduce plasma concentrations of lithium by increasing lithium excretion (26225). Reducing sodium intake can significantly increase plasma concentrations of lithium and cause lithium toxicity in patients being treated with lithium carbonate (26224,26225). Stabilizing sodium intake is shown to reduce the percentage of patients with lithium level fluctuations above 0.8 mEq/L (112909). Patients taking lithium should avoid significant alterations in their dietary intake of sodium.

SODIUM-CONTAINING DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Concomitant use of sodium-containing drugs with additional sodium from dietary or supplemental sources may increase the risk of hypernatremia and long-term sodium-related complications.  Details The Chronic Disease Risk Reduction (CDRR) intake level of 2.3 grams of sodium daily indicates the intake at which it is believed that chronic disease risk increases for the apparently healthy population (100310). Some medications contain high quantities of sodium. When used in conjunction with sodium supplements or high-sodium diets, the CDRR may be exceeded. Additionally, concomitant use may increase the risk for hypernatremia; this risk is highest in the elderly and people with other risk factors for electrolyte disturbances.

TOLVAPTAN (Samsca) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = C Theoretically, concomitant use of tolvaptan with sodium might increase the risk of hypernatremia.  Details Tolvaptan is a vasopressin receptor 2 antagonist that is used to increase sodium levels in patients with hyponatremia (29406). Patients taking tolvaptan should use caution with the use of sodium salts such as sodium chloride.

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General ...Orally, pea protein seems to be well tolerated.
Serious Adverse Effects (Rare):
Orally: Anaphylaxis in sensitive individuals.

Immunologic ...Orally, pea protein may cause allergic reactions in individuals sensitive to other foods. A case series describes 6 children who had anaphylactic reactions to pea protein present in a number of food items. Other symptoms included angioedema, urticaria, and asthma. All the children had a history of allergies to other foods including peanuts, tree nuts, chickpeas, lentils, or kidney beans (102012).

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General ...Orally, rice protein seems to be generally well tolerated. Enterocolitis associated with rice protein has been rarely reported in young children (97806,97811). Although rice protein is considered hypoallergenic, allergies to the proteins in rice have been reported when used topically and orally (97802,97806,97811).

Dermatologic ...The Cosmetic Ingredient Review Expert Panel has concluded that hydrolyzed rice protein is safe for use in cosmetic ingredients based on cutaneous tolerance testing in individuals with non-sensitive skin (97802). However, topical application of undiluted hydrolyzed rice protein has been rarely reported to cause redness (97802).

Gastrointestinal ...Orally, rice protein has been rarely reported to cause enterocolitis symptoms of vomiting, diarrhea, and dehydration, possibly leading to acidosis and lethargy, in infants and young children (97806,97811). Rarely, enterocolitis symptoms are associated with an allergy to rice protein (97806,97811).

Immunologic ...Orally, rice protein has been rarely reported to cause enterocolitis. These symptoms have been possibly associated with an allergy to rice protein (97806,97811). In one case report of allergic enterocolitis, boiling did not adequately degrade the proteins involved in the IgE-mediated response. However, processing at high temperatures in a retort pouch allowed for adequate degradation (97806).
Hydrolysis of rice protein with enzymatic decomposition, typically used for oral consumption, reduces dermatologic allergic symptoms in most people (97802).

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General ...Orally, sodium is well tolerated when used in moderation at intakes up to the Chronic Disease Risk Reduction (CDRR) intake level. Topically, a thorough evaluation of safety outcomes has not been conducted.
Serious Adverse Effects (Rare):
Orally: Worsened cardiovascular disease, hypertension, kidney disease.

Cardiovascular ...Orally, intake of sodium above the CDRR intake level can exacerbate hypertension and hypertension-related cardiovascular disease (CVD) (26229,98176,100310,106263). A meta-analysis of observational research has found a linear association between increased sodium intake and increased hypertension risk (109398). Observational research has also found an association between increased sodium salt intake and increased risk of CVD, mortality, and cardiovascular mortality (98177,98178,98181,98183,98184,109395,109396,109399). However, the existing research is unable to confirm a causal relationship between sodium intake and increased cardiovascular morbidity and mortality; high-quality, prospective research is needed to clarify this relationship (100312). As there is no known benefit with increased salt intake that would outweigh the potential increased risk of CVD, advise patients to limit salt intake to no more than the CDRR intake level (100310).
A reduction in sodium intake can lower systolic blood pressure by a small amount in most individuals, and diastolic blood pressure in patients with hypertension (100310,100311,106261). However, post hoc analysis of a small crossover clinical study in White patients suggests that 24-hour blood pressure variability is not affected by high-salt intake compared with low-salt intake (112910). Additionally, the available research is insufficient to confirm that a further reduction in sodium intake below the CDRR intake level will lower the risk for chronic disease (100310,100311). A meta-analysis of clinical research shows that reducing sodium intake increases levels of total cholesterol and triglycerides, but not low-density lipoprotein (LDL) cholesterol, by a small amount (106261).
It is unclear whether there are safety concerns when sodium is consumed in amounts lower than the adequate intake (AI) levels. Some observational research has found that the lowest levels of sodium intake might be associated with increased risk of death and cardiovascular events (98181,98183). However, this finding has been criticized because some of the studies used inaccurate measures of sodium intake, such as the Kawasaki formula (98177,98178,101259). Some observational research has found that sodium intake based on a single 24-hour urinary measurement is inversely correlated with all-cause mortality (106260). The National Academies Consensus Study Report states that there is insufficient evidence from observational studies to conclude that there are harmful effects from low sodium intake (100310).

Endocrine ...Orally, a meta-analysis of observational research has found that higher sodium intake is associated with an average increase in body mass index (BMI) of 1. 24 kg/m2 and an approximate 5 cm increase in waist circumference (98182). It has been hypothesized that the increase in BMI is related to an increased thirst, resulting in an increased intake of sugary beverages and/or consumption of foods that are high in salt and also high in fat and energy (98182). One large observational study has found that the highest sodium intake is not associated with overweight or obesity when compared to the lowest intake in adolescents aged 12-19 years when intake of energy and sugar-sweetened beverages are considered (106265). However, in children aged 6-11 years, usual sodium intake is positively associated with increased weight and central obesity independently of the intake of energy and/or sugar-sweetened beverages (106265).

Gastrointestinal ...In one case report, severe gastritis and a deep antral ulcer occurred in a patient who consumed 16 grams of sodium chloride in one sitting (25759). Chronic use of high to moderately high amounts of sodium chloride has been associated with an increased risk of gastric cancer (29405).

Musculoskeletal ...Observational research has found that low sodium levels can increase the risk for osteoporosis. One study has found that low plasma sodium levels are associated with an increased risk for osteoporosis. Low levels, which are typically caused by certain disease states or chronic medications, are associated with a more than 2-fold increased odds for osteoporosis and bone fractures (101260).
Conversely, in healthy males on forced bed rest, a high intake of sodium chloride (7.7 mEq/kg daily) seems to exacerbate disuse-induced bone and muscle loss (25760,25761).

Oncologic ...Population research has found that high or moderately high intake of sodium chloride is associated with an increased risk of gastric cancer when compared with low sodium chloride intake (29405). Other population research in patients with gastric cancer has found that a high intake of sodium is associated with an approximate 65% increased risk of gastric cancer mortality when compared with a low intake. When zinc intake is taken into consideration, the increased risk of mortality only occurred in those with low zinc intake, but the risk was increased to approximately 2-fold in this sub-population (109400).

Pulmonary/Respiratory ...In patients with hypertension, population research has found that sodium excretion is modestly and positively associated with having moderate or severe obstructive sleep apnea. This association was not found in normotensive patients (106262).

Renal ...Increased sodium intake has been associated with impaired kidney function in healthy adults. This effect seems to be independent of blood pressure. Observational research has found that a high salt intake over approximately 5 years is associated with a 29% increased risk of developing impaired kidney function when compared with a lower salt intake. In this study, high salt intake was about 2-fold higher than low salt intake (101261).

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