CARB BOOM! (Strawberry Banana flavor) by Carbboom Nutrition Inc

POSSIBLY EFFECTIVE

• Diarrhea. Low-quality evidence shows that oral cooked green bananas might be helpful for the management of acute and persistent diarrhea due to various causes in children. Details: Many clinical studies in children aged 5 months to 5 years with acute diarrhea of various etiologies shows that consuming cooked green bananas with or without rice for up to 14 days increases recovery rates by 30% to 266% when compared with control (93451,93462,93463,106469). Consuming cooked green bananas also reduced the need for rehydration therapy and the incidence of dehydration (93462,93463,106469). Clinical trials used cooked green bananas 50-100 grams per day in children aged 6-12 months, 100-200 grams per day in children aged 12-24 months, and 300 grams per day aged 24 months to 5 years (93451,93462,93463,106469). A moderate size, open label clinical study among children aged 6-35 months hospitalized with persistent diarrhea in Bangladesh shows that consuming a diet of green banana mixed with rice suji increases the number of children who recover within 5 days when compared with a full-strength rice suji diet but is equivalent to the standard treatment (control) of 75% strength rice suji diet (112150). Duration of hospital stay is also similar with green banana and 75% strength rice suji and shorter than with full strength rice suji. There is also less relapse at home among children who had been given the green banana rice suji diet in hospital compared with the 75%-strength rice suji. The validity of the study is limited by the lack of blinding. Clinical research also shows that bananas might be beneficial for diarrhea associated with enteral feeding in adults with critical illness. Adding banana flakes (Kanana Banana, Corpak Co) 1-3 tablespoons every 8 hours to the feeding tube seems to be as effective as routine medical treatment involving feeding rate adjustments and use of antidiarrheal agents for reducing symptoms and duration of diarrhea. After 7 days of treatment, 57% of patients in the banana group were free of diarrhea compared with only 24% of patients in the group receiving routine treatment (93453).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Allergic rhinitis (hay fever). Although there has been interest in using oral banana flower for allergic rhinitis, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Athletic performance. It is unclear if oral banana is beneficial for athletic performance. Details: Preliminary clinical research in trained male cyclists shows that consuming 0.4 grams/kg carbohydrate orally from ripe bananas with water 10-20 minutes prior to a 75 km cycling time trial, and 0.15-0.2 grams/kg carbohydrate from bananas with water every 15 minutes during the trial, modestly improves cycling time and oxygen consumption when compared with water alone. This regimen is equally effective to the same dose of carbohydrate from a 6% carbohydrate beverage (Gatorade) (93459,93465). However, another study from the same group of researchers found conflicting results with the use of carbohydrates from banana for this purpose (100995). It is possible that the consumption of carbohydrates in general, not the use of bananas specifically, is beneficial for athletic performance. However, other preliminary clinical research in trained male runners shows that consuming a banana and drinking plain water does not improve the time to run 10 km on a treadmill when compared with plain water alone. No benefit was seen with the consumption of other carbohydrate drinks when compared with plain water; it is possible that the duration of exercise was too short to identify an improvement in performance (93457). Further research is needed to clarify the benefits of banana, if any, for athletic performance.
• Burns. It is unclear if topical banana leaf is beneficial in patients with burns. Details: Preliminary clinical research in adults and children with partial thickness burns shows that daily changes of a banana leaf dressing with povidone iodine reduces pain during dressing changes. Furthermore, wound healing is as effective as a boiled potato peel bandage with povidone iodine, with no increased need for skin grafting (93454). When compared with Vaseline gauze dressing for 8 days following skin graft treatment for burns in adults, banana leaf dressing increases speed of epithelization from 11.7 days to 8.7 days, and improves average pain, pain during dressing removal, and ease of dressing removal. By the 8th day, complete epithelization was present in 57% of the wounds dressed with banana leaves when compared with 0% of the wounds dressed with Vaseline gauze (93455).
• Cancer. Although there has been interest in using topical banana green fruit for cancer, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Constipation. It is unclear if oral green banana is beneficial in patients with constipation. Details: Preliminary clinical research in children with functional constipation shows that consuming cooked green bananas, 30 grams daily for 8 weeks, improves stool consistency and abdominal pain and reduces straining and pain during defecation when compared with baseline. Consuming cooked green bananas with a conventional laxative such as polyethylene glycol plus electrolytes or sodium picosulfate also appears to decrease the dose of laxative needed in these children when compared with baseline (100996). The validity of these findings is limited by the lack of a comparator group.
• Contraception. Although there has been interest in using oral banana root for contraception, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Cough. Although there has been interest in using oral banana flower for cough, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Depression. It is unclear if oral banana is beneficial in patients with depression. Details: A large cross-sectional study in the general Chinese adult population has found that moderate, but not high, banana consumption is associated with a lower likelihood of depressive symptoms in males. However, high banana consumption is associated with a higher likelihood of depressive symptoms in females (106471).
• Diabetes. It is unclear if oral banana starch is beneficial in patients with diabetes. Details: Two small clinical studies in adults with type 2 diabetes shows that taking banana starch 24-57.2 grams orally daily for 4-28 days does not improve serum glucose levels, glucose variability, glucose control scores, or insulin levels when compared with control starches (110619,93448).Other preliminary clinical research in obese patients with type 2 diabetes shows that taking banana starch 24 grams in 240 mL of water each day for 4 weeks reduces body weight when compared with a taking soymilk powder in water. However, banana starch did not improve lipid levels or body fat (93448). Other preliminary clinical research in patients with type 2 diabetes shows that taking desiccated banana 250 grams daily for 12 weeks does not improve lipid levels or glycemic response when compared to baseline (93452).
• Exercise-induced muscle soreness. It is unclear if oral banana is beneficial for exercise-induced muscle soreness. Details: Preliminary clinical research in trained cyclists shows that consuming 0.4 grams/kg of carbohydrates orally from mini-yellow bananas with water 20 minutes prior to a 75 km cycling time trial, and 0.2 grams/kg of carbohydrates from banana every 15 minutes during the trial, decreases muscle soreness ratings 1.5 hours after the time trial when compared with water alone. Consuming carbohydrates from Cavendish bananas in the same manner did not decrease delayed onset muscle soreness, although cyclists reported less muscle cramping with both types of bananas when compared with water (100995). It is unclear whether carbohydrates from banana are any more effective than other carbohydrate sources or whether these results are generalizable to other types of exercise.
• Gastroesophageal reflux disease (GERD). Although there has been interest in using oral banana fruit for GERD, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Hangover. Although there has been interest in using oral banana fruit for hangover, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Headache. Although there has been interest in using topical banana leaves for headache, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Hypercholesterolemia. It is unclear if oral banana is beneficial in patients with hypercholesterolemia. Details: Preliminary clinical research shows that taking desiccated banana 500 grams orally daily for 12 weeks reduces levels of total cholesterol by 7.5% when compared with baseline in patients with hypercholesterolemia. Taking 250 grams daily does not seem to reduce total cholesterol levels; however, high-density lipoprotein (HDL) cholesterol levels increase by 14.5% (93452). The validity of these findings is limited by the lack of a comparator group.
• Hypertension. Although there has been interest in using oral banana fruit for hypertension, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Hypokalemia. Although there has been interest in using oral banana fruit for hypokalemia, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Inflammatory bowel disease (IBD). Although there has been interest in using oral banana fruit for IBD, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Joint pain. Although there has been interest in using oral banana flower for joint pain, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Kidney stones (nephrolithiasis). Oral banana stem has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with calculi of at least 5 mm shows that taking a specific Ayurvedic product (Herbmed) containing banana stem 250 mg and Crateva nurvala 250 mg orally daily for 3 months moderately improves symptoms associated with urinary calculi and reduces the size of the calculi by 11% to 33% when compared with baseline (93460). It is not clear if this is due to banana stem, Crateva nurvala, or the combination. Also, the validity of this finding is limited by the lack of a comparator group.
• Menorrhagia. Although there has been interest in using oral banana fruit for menorrhagia, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Obesity. It is unclear if oral banana is beneficial in patients with obesity. Details: Preliminary clinical research in obese patients with type 2 diabetes shows that taking banana starch 24 grams in 240 mL of water orally each day for 4 weeks reduces body weight by 1 kg more when compared to a control group consuming soymilk powder in water (93448).
• Peptic ulcers. Although there has been interest in using oral banana fruit for peptic ulcers, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Shigellosis. It is unclear if oral green banana is beneficial in patients with shigellosis. Details: Clinical research in children 6-60 months of age who are being treated with antibiotics for shigellosis shows that eating cooked green banana 250 grams per liter of a rice-based diet for 5 days improves symptoms of diarrhea, including the presence of fecal mucus and blood, when compared with a rice-based diet alone. Adding banana to the diet decreased the number of daily stools by 70% in those consuming banana compared to 50% in children consuming the rice diet alone (93461).
• Skin grafts. Although there has been interest in using topical banana leaves for skin grafts, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Smoking cessation. Although there has been interest in using oral banana fruit for smoking cessation, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Stroke. Although there has been interest in using oral banana fruit for stroke, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Tuberculosis. Although there has been interest in using oral banana flower for tuberculosis, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Vaginitis. Although there has been interest in using oral banana root for vaginitis, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Vitamin A deficiency. Although there has been interest in using oral banana fruit for vitamin A deficiency, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Warts. Although there has been interest in using topical banana leaves or peels for warts, there is insufficient reliable information about the clinical effects of banana for this purpose.
• Wound healing. Although there has been interest in using topical banana leaves, peels, or green fruit for wound healing, there is insufficient reliable information about the clinical effects of banana for this purpose. More evidence is needed to rate banana for these uses.

(Read more about BANANA)

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.

(Read more about SODIUM)

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Cardiovascular disease (CVD). Pooled analyses of clinical research show that taking freeze-dried strawberry powder or eating fresh strawberries for 3-12 weeks can reduce levels of C-reactive protein, a marker of inflammation and risk factor for CVD, by 0.47-0.63 mg/L when compared with placebo. These analyses report conflicting effects on blood pressure and lipid levels (103881,103882), with one analysis reporting small improvements that are not clinically significant (103881). It is unclear whether strawberry can prevent CVD or related outcomes.
• Diabetes. Preliminary clinical research in adults with type 2 diabetes shows that taking freeze-dried strawberry powder 50 grams daily for 6 weeks reduces glycated hemoglobin (HbA1c) by 0.47% compared to an increase of 0.15% with placebo. However, there were no changes in serum glucose, anthropometric measurements, blood lipids, or blood pressure. Also, the short duration of supplementation makes it unclear whether the change in HbA1c was due to strawberry (100113,100119).
• Hyperlipidemia. Data on the effects of strawberry on serum lipids are conflicting. Clinical research in adults with abdominal obesity and elevated serum lipids shows that taking freeze-dried strawberry powder 50 grams daily for 12 weeks reduces total and low-density lipoprotein (LDL) cholesterol when compared with either placebo or taking 25 grams of freeze-dried strawberry daily. In those taking 50 grams daily, levels of LDL cholesterol decreased by approximately 21% from baseline, compared with a 2% reduction in those taking placebo. However, strawberry did not improve levels of high-density lipoprotein (HDL) cholesterol or triglycerides (100109). Another study also reported reduced levels of total and LDL cholesterol (112318), while others report no changes in any lipid levels (112320,112321). In a meta-analysis, strawberry was associated with mean decreases of 11 mg/dL in LDL levels, and 12 mg/dL in total cholesterol, as well as increases in high-density lipoprotein (HDL) cholesterol (112323).
• Hypertension. Preliminary clinical research in postmenopausal women with pre- or stage I hypertension shows that taking freeze-dried strawberry powder 25 or 50 grams daily for 8 weeks does not reduce blood pressure when compared with placebo. However, over 50% of the included women were also taking at least one blood pressure lowering medication (100111).
• Obesity. Clinical research in adults with obesity or abdominal obesity and elevated serum lipids shows that taking freeze-dried strawberry powder 50 grams daily for 12 weeks does not reduce body weight or adiposity when compared with either placebo or freeze-dried strawberries 25 grams daily (100109,100116). Similarly, preliminary clinical research in adults with type 2 diabetes who are overweight or obese shows that taking freeze-dried strawberry powder 50 grams daily for 6 weeks does not improve weight loss when compared with placebo (100113). Evidence from mainly small, lower-quality studies is mixed as to whether taking strawberries has beneficial effects on cardiovascular risk factors when compared to control in obese individuals (100109,100116,100118).
• Osteoarthritis. Preliminary clinical research in obese adults with osteoarthritis shows that taking freeze-dried strawberry powder 50 grams daily for 12 weeks reduces some, but not all, measures of pain by up to 45%, compared to no change in those taking placebo (100116). More evidence is needed to rate strawberry for these uses.

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POSSIBLY EFFECTIVE

• Athletic performance. Regular consumption of whey protein in conjunction with exercise may improve muscle strength and performance. However, inconsistent consumption of whey protein, as well as intake of whey protein without concomitant exercise, may not be beneficial. Details: Most clinical research shows that taking whey protein 1.2-1.5 grams/kg or 30-33 grams daily in combination with strength training for 6-21 weeks can increase lean body mass, strength, and muscle hypertrophy in healthy young adults (16728,16729,16748,46552,85765,85910,91806,96025,102173). Higher doses of whey protein, such as 46-77 grams daily, have also been shown to increase strength when combined with athletic training (98886,98888). Some clinical research shows that whey protein hydrolysate (Lacprodan HYDRO.365, Arla Food Ingridiens Group P/S) twice daily for 1 week may slightly improve running speed (91793). However, less frequent intake or lower doses of whey protein do not seem to be beneficial for muscle strength. Some clinical research in middle-aged males shows that taking whey protein 35 grams three times weekly with resistance training for 14 weeks does not improve strength or muscle mass when compared with placebo (46736,85893). A small clinical study in trained males shows that taking whey protein 25 grams daily has no effect on body mass or strength after 2 weeks of detraining and 4 weeks of retraining when compared with maltodextrin (96021). Also, consuming whey protein without concomitant exercise does not seem to improve body composition or strength. Some clinical research shows that whey protein does not improve muscle mass or strength in obese postmenopausal patients who are losing weight through diet without exercise (98889). Some research has compared whey protein to other types of protein. A meta-analysis of preliminary clinical research, as well as individual clinical studies, show that whey protein is similarly beneficial to soy, beef, chicken, and dairy (casein with whey) protein for improving muscle strength (85941,98871,98888,105591). However, the validity of these findings is limited by the small size and high heterogeneity of the studies.

POSSIBLY INEFFECTIVE

• Chronic obstructive pulmonary disease (COPD). Oral whey protein does not seem to improve COPD symptoms. Details: Clinical research in adults with COPD shows that taking a specific whey protein supplement (ImuPower) 12 grams twice daily for 6 weeks can improve shortness of breath, but not lung function, exercise tolerance, or quality of life, when compared with placebo (86302). Other clinical research shows that taking a pressurized whey protein supplement 20 grams daily for 16 weeks, in combination with strength training for weeks 8-16, does not improve exercise tolerance, lung function, or muscle function when compared with placebo (86025).
• Osteoporosis. Oral whey protein does not seem to improve bone mineral density in older adults. Details: Clinical research shows that taking whey protein 30-45 grams daily for up to 2 years does not improve bone density when compared with a low-protein placebo in postmenopausal patients and males over 70 years of age (86074,91796). Taking whey protein 20-60 grams daily for 36 weeks also does not improve bone density when compared with an isoenergetic placebo in overweight or obese adults undergoing an exercise program (96027). The effect of whey protein in patients with osteoporosis has not been evaluated.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Age-related cognitive decline. It is unclear if oral whey protein is beneficial for age-related cognitive impairment. Details: Preliminary clinical research in older adults with subjective cognitive decline shows that taking whey peptide 1 gram for 12 weeks does not improve memory, executive functioning, or attention when compared with placebo. However, in a subgroup of patients with high levels of fatigue, whey peptide modestly improved memory (98885).
• Asthma. It is unclear if oral whey protein is beneficial in children with asthma. Details: A very small clinical study in children with asthma shows that taking a specific type of whey protein (HMS 90, Immunotec Inc.) 20 grams daily for 30 days does not improve lung function when compared to baseline (85833). The validity of this finding is limited by the lack of a comparator group.
• Atopic dermatitis (eczema). It is unclear if consuming infant formula containing whey protein reduces the risk of developing eczema. Details: A high-quality meta-analysis of small clinical studies shows that use of infant formula containing hydrolyzed whey protein for 4-6 months is no better than standard milk formula for reducing the risk of eczema (105585). This is in contrast to older meta-analyses that found benefit after consumption of fully or partially hydrolyzed whey protein (85987,86007,86048). However, these older publications had notable conflicts of interest and did not include small negative studies (105585). In 2011, the US Food and Drug Administration (FDA) allowed a qualified health claim in healthy infants with a family history of allergy who are not solely breastfed. It stated that feeding a formula of 100% partially hydrolyzed whey protein instead of formula containing intact cow's milk proteins from birth up to 4 months of age may reduce the risk of atopic dermatitis throughout 1-3 years of age. However, the FDA has concluded that there is very little scientific evidence to support this claim (102311).
• Atopic disease. It is unclear if consuming infant formula containing whey protein reduces the risk of developing atopic disease. Details: A high-quality meta-analysis of small clinical studies shows that use of infant formula containing hydrolyzed whey protein for 4-6 months is no different than standard milk formula for reducing the risk of atopic disease. However, there was a non-significant trend to reduced risk in the hydrolyzed whey protein group (105585). This finding conflicts with older meta-analyses which found benefit with hydrolyzed whey protein formula (85987,86007). However, these older publications had notable conflicts of interest and did not include small negative studies (105585).
• Cystic fibrosis. It is unclear if oral whey protein is beneficial for children or adults with cystic fibrosis. Details: A small clinical study in patients with cystic fibrosis shows that taking pressurized whey protein, 20 grams in children and 40 grams in adults, daily for 28 days, improves lung function in children, but not adults, when compared with baseline (85995). The validity of this finding is limited by the lack of a comparator group.
• Diabetes. It is unclear if oral whey protein is beneficial for improving glycemic control in people with type 2 diabetes. Details: A small clinical study in patients with well-controlled diabetes shows that consuming a 220 kcal drink containing whey protein concentrate 50 grams (Beit Haemek Advanced Technologies, Beit Haemek) before a meal lowers blood glucose levels by 28% and increases insulin levels in the first 3 hours after a meal when compared with drinking water (91795). However, whey protein does not seem to have long-term benefit on glycemic control when added to an exercise regimen. Another small clinical study in middle-aged males with type 2 diabetes shows that adding 20 grams of whey protein daily for 10 weeks to high-intensity mixed-mode interval training (MMIT) does not further improve glycemic control or body composition when compared to MMIT with placebo (98883).
• Exercise-induced asthma. It is unclear if oral whey protein is beneficial for exercise-induced asthma. Details: A small clinical study in patients with exercise-induced asthma shows that taking whey protein 30 grams daily for 10 days improves lung function when compared to baseline (85791). The validity of this finding is limited by the lack of a comparator group.
• Exercise-induced muscle damage. It is unclear if oral whey protein is beneficial for attenuating exercise-induced muscle damage; evidence is conflicting. Details: A meta-analysis of small heterogeneous clinical studies in trained and untrained adults shows that supplementation with a median dose of whey protein 25 grams (range 20-120 grams) given after and/or before exercise modestly improves muscle recovery measured over 3 days when compared with control (98881). Individual studies included in the analysis used whey protein 1.5 grams/kg daily for up to 2 weeks (86044), and whey protein isolate or whey protein hydrolysate (NatraPro or NatraBoost XR, MG Nutritionals) 25 grams three times in 24 hours (85915). Other small studies have not found benefit, but it is unclear if they were adequately powered. One small clinical study in healthy untrained males shows that taking whey protein 36.6 grams daily, starting 7 days before and continuing until 4 days after arm exercise, does not prevent muscle soreness over 5 days or attenuate reductions in strength (96024). Another small study in untrained healthy males shows that taking whey protein isolate (biPro, Eden Prairie) 0.3 grams/kg three times daily for 5 days does not reduce self-reported delayed onset muscle soreness, but may reduce creatine kinase, a biomarker of muscle damage, when compared with water (104758). Whey protein may not be beneficial for recovery from exercise in trained athletes. Small clinical studies show that consuming a whey protein beverage before or after exercise does not improve muscle recovery for trained adult and adolescent athletes when compared with a carbohydrate or non-caloric control (86303,91799,105592).
• Hepatitis. It is unclear if oral whey protein is beneficial for hepatitis. Details: A small clinical study in patients with chronic hepatitis B shows that taking a specific type of whey protein (Immunocal) 12 grams twice daily for 12 weeks can reduce liver transaminase levels and can increase glutathione (GSH) levels when compared with baseline. However, whey protein supplementation does not seem to improve liver function in patients with chronic hepatitis C (85687). The validity of these findings is limited by the lack of a comparator group.
• HIV/AIDS. It is unclear if oral whey protein is beneficial for improving immune function in children with HIV/AIDS. Details: One small clinical study in children with rapidly progressive HIV infection shows that taking whey protein at levels corresponding to 20% to 50% of total required protein for 4 months does not affect CD4 or CD8 cell count or the ratio of CD4+/CD8+ when compared with baseline. However, the occurrence of acute co-infections might be reduced with whey protein supplementation when compared with control (85781).
• HIV/AIDS-related wasting. Although oral whey is an adequate source of protein, it is unclear if it is better than other protein sources for reducing HIV/AIDs-related wasting. Details: A small open-label clinical study in malnourished patients with HIV shows that taking whey protein (dose unspecified) daily for 14 weeks increases muscle and fat mass when compared with baseline (85693). The validity of these findings is limited by the lack of a comparator group. Another small study in patients with HIV, stable weight, and a history of unintentional weight loss shows that taking whey protein 40 grams daily for 12 weeks does not affect weight or muscle mass when compared with taking an isocaloric control (85921). These study findings are limited because they cannot be generalized to patients with active weight loss or wasting. Another limitation is the higher dropout rate in the whey protein group due to gastrointestinal adverse events.
• Hyperlipidemia. It is unclear if oral whey protein is beneficial for lowering cholesterol levels. Details: A very small clinical study in overweight males with hyperlipidemia shows that taking whey protein 26.6 grams daily while participating in a resistance training program for 12 weeks reduces total cholesterol levels when compared with baseline but not when compared with placebo (85941). A meta-analysis of small heterogeneous clinical studies in healthy adults, as well as those with obesity and/or mild hypertension, shows that consuming whey protein alone or with other interventions seems to reduce lipid levels when compared with control (105586). However, most included studies were in patients without hyperlipidemia; it is unclear if whey protein is beneficial in patients with hyperlipidemia. Furthermore, these findings are limited by the variability in whey protein dosing, study duration, and patient population.
• Hypertension. It is unclear if oral whey protein reduces blood pressure. Details: Preliminary clinical research shows that drinking a beverage containing whey protein 2.6 grams daily for 12 weeks does not lower blood pressure in patients with mild hypertension when compared with placebo (85835). Also, taking whey protein 28 grams twice daily in water for 8 weeks reduces 24-hour systolic and diastolic blood pressure by 2.9 mm Hg and 2 mmHg, respectively, when compared with maltodextrin or casein in adults with mild hypertension and prehypertension. There were also improvements in endothelial function (96019).
• Mitochondrial myopathies. It is unclear if oral whey protein improves symptoms in patients with mitochondrial myopathies. Details: A small clinical study in individuals with mitochondrial diseases shows that taking a whey protein supplement 10 grams daily for one month does not improve muscle strength or quality of life when compared with placebo (85984).
• Nonalcoholic steatohepatitis (NASH). It is unclear if oral whey protein improves NASH. Details: A small clinical study in patients with untreated NASH shows that taking whey protein 20 grams daily for 12 weeks can reduce liver function tests, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and reduce hepatic macrovesicular steatosis when compared with baseline (85961). The validity of these findings is limited by the lack of a comparator group.
• Obesity. It is unclear if oral whey protein is beneficial for weight loss when used without dietary modifications. Adding whey protein to a calorie-restricted diet or an exercise regimen does not seem to improve weight loss. Details: Most research in overweight and obese individuals shows that taking whey protein along with a low-calorie diet and/or in addition to an exercise program does not further increase weight loss when compared with the low-calorie diet or exercise alone (85897,86069,86130,91794,91798,91802,96027,102172). However, a small clinical study in patients who have regained weight after bariatric surgery shows that following a low-calorie diet and taking whey protein 0.5 grams/kg daily for 16 weeks reduces body weight by about 2 kg and fat mass by about 3 kg when compared with following a low-calorie diet alone (96022). When whey protein is taken without diet modifications, studies have yielded conflicting results. One small clinical study in overweight and obese adults shows that taking whey protein isolate 27 grams twice daily for 12 weeks does not reduce body weight when compared with a glucose control (86011). However, another small clinical study in overweight and obese adults shows that taking whey protein concentrate 52 grams daily for 23 weeks reduces weight by 1.8 kg and fat by 2.4 kg when compared with a carbohydrate control, but is no better than taking soy protein isolate 52 grams (86077). In contrast, a small clinical study in overweight males shows that taking whey protein concentrate 65 grams before lunch daily for 12 weeks decreases calorie intake and reduces weight by about 1 kg when compared with taking soy protein isolate 60 grams (91801). In contrast to adults, supplementation with whey protein might increase weight in adolescents. A clinical study in overweight adolescents shows that consuming 1 liter of a milk-based whey protein drink daily for 12 weeks increases weight and body mass index when compared with a water control (86144).
• Parkinson disease. It is unclear if oral whey protein improves symptoms of Parkinson disease. Details: Clinical research in a small group of patients shows that taking a specific type of whey protein isolate (HMS 90/Immunocal) 10 grams twice daily for 6 months does not improve symptoms of Parkinson disease when compared with placebo (96026). However, this study may have been inadequately powered to detect a difference between groups.
• Polycystic ovary syndrome (PCOS). It is unclear if oral whey protein improves symptoms and metabolic effects of PCOS. Details: One small clinical study in patients with PCOS shows that taking 240 kcal as a nutritional supplement containing pure whey protein 96% daily, in addition to a calorie-restricted diet for 2 months, reduces body weight, fat mass, and cholesterol and apolipoprotein B levels when compared with a simple sugar control supplement. However, the whey protein supplement does not improve glucose or insulin levels, and seems to decrease high-density lipoprotein (HDL) cholesterol levels (85912). The validity of this study is limited by its small size and a significant dropout rate.
• Polymyalgia rheumatica. It is unclear if oral whey protein improves muscle function in patients with polymyalgia rheumatica. Details: A small clinical study in patients with polymyalgia rheumatica shows that taking a whey protein-enriched dairy product twice daily for 8 weeks does not improve lower limb muscle function, walking speed, chair stand test performance, peak jump power, or peak jump force when compared with a regular dairy product (Play, Valio Ltd.) (86075).
• Psoriasis. It is unclear if oral whey protein improves psoriasis. Details: A small clinical study in patients with stable psoriasis shows that taking a specific whey protein extract product (Dermylex, Advitech, Inc.) 5 grams daily for 8 weeks modestly decreases symptom severity when compared with placebo (85885).
• Sarcopenia. Research on the use of oral whey protein in older adults with sarcopenia is conflicting. Details: Small clinical studies in trained older females show that consuming whey protein 35 grams three times weekly for 12 weeks, either before or after resistance training, modestly increases skeletal muscle mass, strength, and functional capacity when compared with resistance training and insufficient protein intake (98887,98890). Research on the use of whey supplementation without exercise is conflicting. A small clinical study in older adults with low muscle mass living in China shows that taking whey, or a whey-soy protein blend, 16 grams daily for 6 months slightly attenuates muscle loss when compared with no intervention (105603). However, a clinical study in healthy, active older adults living in Denmark shows that taking whey protein hydrolysate 20 grams twice daily does not increase muscle size or strength when compared with a carbohydrate control (105593). This finding may not be generalizable to frail adults or those with existing sarcopenia. Whey protein with or without exercise has shown benefit when used in combination with other nutrients. Specifically, whey protein 60 grams has been used with creatine 5 grams, calcium 800 mg, vitamin D 1000 IU, and omega-3 fatty acids 3 grams (Infinit Nutrition) for 6 weeks (96016). A beverage with leucine-enriched whey protein 20 grams has been used in combination with vitamin D 800 IU (Nutricia Advanced Medical Nutrition) daily for 6 weeks (96017). Another beverage containing whey protein 20 grams and vitamin D 800 IU has been used daily for 6 months (98882).
• Sepsis. It is unclear if oral whey protein is beneficial in children with sepsis. Details: A very small clinical study in long-term intensive care pediatric patients shows that taking a specific whey protein supplement (Beneprotein) 0.3 grams/kg daily for up to 28 days has a similar effect on the time to onset and the rate of hospital-acquired infection or sepsis when compared with taking a combination of zinc, selenium, glutamine, and metoclopramide. It is not clear how these results compare to patients receiving no supplementation (86095). More evidence is needed to rate whey protein for these uses.

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LIKELY SAFE ...when used in the amounts commonly found in food.

POSSIBLY SAFE ...when the leaves are applied topically and appropriately (93456). There is insufficient reliable information available about the safety of the other parts of the banana plant when used orally or topically as a medicine.

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using 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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LIKELY SAFE ...when used orally and appropriately. Whey protein up to 30 grams has been safely used in clinical trials for up to 6 months (4930,16728,16729,105587).

CHILDREN: LIKELY SAFE
when used orally and appropriately as a dietary protein in food or infant formula. Hydrolyzed whey protein-based formula has been safely used in infants for up to 6 months in clinical trials (4927,105585,105594).

PREGNANCY AND LACTATION:
Insufficient reliable information available; avoid using.

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LEVODOPA Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Taking banana may reduce the effectiveness of levodopa.  Details A case report describes apparent wearing off in a patient with Parkinson disease after eating a banana every day. The wearing off subsided after removing dietary bananas (110618).

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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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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D In vitro and animal research suggests that strawberry extract can inhibit platelet aggregation due to its phenolic content (76472,76488). Theoretically, strawberry might increase the risk of bleeding when used with antiplatelet or anticoagulant drugs.  Details Some anticoagulant or antiplatelet drugs include aspirin, clopidogrel (Plavix), dalteparin (Fragmin), enoxaparin (Lovenox), heparin, ticlopidine (Ticlid), warfarin (Coumadin), and others.

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D In vitro research suggests that strawberry extract can inhibit p-glycoprotein efflux (76474,76476). Theoretically, strawberry might inhibit p-glycoprotein mediated drug efflux and potentially increase levels of drugs that are substrates of p-glycoprotein. Until more is known, strawberry should be used cautiously in people taking p-glycoprotein substrates.  Details Drugs that might be affected include some chemotherapeutic agents (etoposide, paclitaxel, vinblastine, vincristine, vindesine), antifungals (ketoconazole, itraconazole), protease inhibitors (amprenavir, indinavir, nelfinavir, saquinavir), H2 antagonists (cimetidine, ranitidine), some calcium channel blockers (diltiazem, verapamil), corticosteroids, erythromycin, cisapride (Propulsid), fexofenadine (Allegra), cyclosporine, loperamide (Imodium), quinidine, and others.

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BISPHOSPHONATES Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = D Theoretically, whey protein might reduce the absorption of bisphosphonates.  Details Whey protein contains minerals such as calcium that bind bisphosphonates in the gut (9,12937). Advise patients to take bisphosphonates at least 30 minutes before whey protein, but preferably at a different time of day.

LEVODOPA Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Probable •  Level of Evidence = D Theoretically, whey protein might decrease levodopa absorption.  Details Small clinical studies show that concomitant ingestion of protein or high doses of leucine or isoleucine (100 mg/kg) and levodopa can exacerbate tremor, rigidity, and the "on-off" syndrome in patients with Parkinson disease (3291,3292,3293,3294,4944).

QUINOLONE ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = D Theoretically, whey protein might decrease quinolone absorption.  Details Whey protein contains minerals, such as calcium, that can bind to quinolones in the gut (9,10339). To avoid this interaction, advise patients to take oral quinolones at least 2 hours before or 4-6 hours after whey protein.

TETRACYCLINE ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Probable •  Level of Evidence = D Theoretically, whey protein might decrease tetracycline absorption.  Details Whey protein contains minerals, such as calcium, that bind to tetracyclines in the gut (9,1843). To avoid this interaction, advise patients to take oral tetracyclines at least 2 hours before or 4-6 hours after whey protein.

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General ...Orally, bananas are well tolerated when consumed as food.
Most Common Adverse Effects:
Orally: Bloating, cramping, gas.
Topically: Urticaria.
Serious Adverse Effects (Rare):
Orally: Anaphylaxis, intestinal obstruction.

Endocrine ...In one case report, an adolescent girl who consumed nothing other than 20 bananas daily developed hyperkalemia and hyperdopaminemia. These changes in the blood resulted in pseudoaldosteronism and dysthymia (93780).

Gastrointestinal ...Orally, banana starch isolated from green bananas has resulted in bloating, gas, cramping, and softer feces (93448,93449,110619). When consumed prior to exercise, fullness and bloating during exercise have been reported (93459). In children, nausea, vomiting, and abdominal distension have been reported when banana is used in the treatment of diarrhea (93461). Cases of intestinal obstruction due to banana seeds have been reported (93777).
In one case report, food protein-induced enterocolitis syndrome (FPIES) has been associated with banana consumption (93778).

Immunologic ...Orally, banana has been reported to cause allergic reaction, including urticaria and redness, abdominal pain and nausea, dyspnea (93779,93781,93782,93797,93798,93803), and anaphylaxis (93783,93793,93802,93803). Topically, contact urticara has also been reported (93784). Skin testing is not always accurate, even for patients with severe banana allergy (93793).

Psychiatric ...Orally, high banana consumption has been associated with a higher likelihood of depressive symptoms in females, but not males, in a cross-sectional study of the general Chinese adult population (106471).

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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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General ...Orally, strawberry is well tolerated when taken in the amounts commonly found in food. When taken in medicinal amounts, strawberry seems to be generally well tolerated (100109,100113,100116,100119). Rarely, strawberry has been reported to cause nausea and allergic reactions, including oral allergy syndrome and skin reactions (100113,100119,103880).
Topically, strawberry can cause contact dermatitis (13637).

Gastrointestinal ...Orally, taking freeze-dried strawberry powder 50 grams daily has been reported to cause nausea in clinical trials (100113,100119).

Immunologic ...Orally, consuming strawberry has been reported to cause allergic reactions, including oral allergy syndrome and skin reactions, in some patients. (103880). Topically, strawberry has caused contact urticaria in one case report (13637). Overall, allergy to strawberry appears to be rare (103880).

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General ...Orally, whey protein is generally well tolerated.
Most Common Adverse Effects:
Orally: Acne, bloating, cramps, diarrhea, fatigue, headache, nausea, reflux, reduced appetite, and thirst. Most adverse effects are dose-related.

Cardiovascular ...In one case report, use of an unclear quantity of whey protein over one month was thought to be probably responsible for the development of coronary embolism in three coronary arteries in a 33-year-old male with no history of atherosclerosis risk factors. The patient required treatment with intravenous glycoprotein IIb/IIIa inhibitor and heparin (96023).

Dermatologic ...Orally, whey protein has been reported to trigger the onset or worsening of acne. Multiple case reports in teenagers and young adults have associated intake of whey protein with the development of acne or the worsening of existing acneiform lesions. In these reports, the discontinuation of whey protein was typically associated with the clearance of acne lesions. In some cases, patients who were unresponsive to acne treatments while using whey protein became responsive after whey protein discontinuation (103965,103970,103971). Cow's milk, which is comprised of 20% whey protein, is also thought to exacerbate acne. It is theorized that this effect may be due to the growth factor and alpha-lactalbumin content of whey protein (103971,103982).

Gastrointestinal ...Orally, whey protein, especially in higher doses of 2. 3-6.5 grams/kg daily, may cause increased bowel movements, nausea, thirst, bloating, esophageal reflux, cramps, and reduced appetite (2640,85961,85702,86043,86074,86075,86084,86089,86095).

Hepatic ...In two case reports, acute cholestatic liver injury occurred after consumption of the combination of whey protein and creatine supplements (46701,90319).

Musculoskeletal ...In one case report, a 26-year-old male experienced fasciitis, or swelling of the forearms, hands, and legs, after consuming the supplement Pure Whey (85895).

Neurologic/CNS ...Orally, high doses of whey protein may cause tiredness or fatigue and headache (2640). Mild drowsiness has also been reported (86089,86092,86124).

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