Smart Balance Creamy Cheddar Flavor Slices by GFA Brands, Inc.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Dyspepsia. Oral olive leaf extract has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small study in healthy adults shows that taking a specific combination product containing olive leaf extract 24% and prickly pear cactus 33% (Mucosave, Bionap S.R.L.) 400 mg daily for 8 weeks seems to improve dyspepsia and other gastrointestinal symptoms when compared with placebo (105904). It is unclear if this benefit would occur in patients with clinically diagnosed dyspepsia.
• Exercise-induced respiratory infections. It is unclear if oral olive leaf extract is beneficial for reducing respiratory infections from exercise. Details: A small clinical study in high school athletes shows that taking one tablet of olive leaf extract providing eleuropein 100 mg daily for 2 months during training season does not reduce the incidence of the common cold when compared with placebo. While it may reduce the number of sick days by 28%, a sub-group analysis suggests that this reduction is only evident in female athletes (101860).
• Gastroesophageal reflux disease (GERD). Although there is interest in using oral olive leaf for GERD, there is insufficient reliable information about the clinical effects of olive for this condition.
• Herpes zoster (shingles). Although there is interest in using oral olive leaf for shingles, there is insufficient reliable information about the clinical effects of olive for this condition.
• Influenza. Although there is interest in using oral olive leaf for influenza, there is insufficient reliable information about the clinical effects of olive for this condition.
• Metabolic syndrome. It is unclear if oral olive leaf extract is beneficial for improving body composition and cardiovascular risk factors in patients with metabolic syndrome. Details: A small clinical trial in overweight, middle-aged males at risk for metabolic syndrome shows that taking four capsules of olive leaf extract providing oleuropein 51.1 mg and hydroxytyrosol 9.7 mg daily for 12 weeks improves insulin sensitivity by 15% when compared with placebo. However, body composition, blood pressure, cholesterol levels, and other cardiovascular risk factors were not improved (92245).
• Osteoarthritis. It is unclear if oral olive fruit or leaf extract is beneficial for improving osteoarthritis. Details: Preliminary clinical research shows that taking a freeze-dried aqueous extract of olive fruit 400 mg daily for 8 weeks decreases pain and increases mobility in people with osteoarthritis (14844). Other preliminary clinical research in adults with knee osteoarthritis shows that taking olive leaf extract 50.1 mg daily for 4 weeks improves overall pain measurements by 14%, compared to only 4% in the placebo group. However, many individual measurements of pain are not improved (92252).
• Osteoporosis. It is unclear if oral olive leaf extract is beneficial for osteoporosis. Details: Clinical research shows that taking olive leaf extract (Bonolive, BioActor BV) 250 mg daily for 12 months, along with elemental calcium 400 mg daily, increases osteocalcin levels by about 32% when compared to baseline; this increase was significant when compared to those taking calcium 400 mg plus placebo, who showed a 6% decrease in osteocalcin levels. However, taking olive leaf extract does not significantly increase bone mineral density of the lumbar spine or femur neck when compared with placebo (92247).
• Rheumatoid arthritis (RA). It is unclear if oral olive fruit extract is beneficial for improving RA symptoms. Details: Preliminary clinical research in adults with RA shows that taking an aqueous freeze-dried extract of olive fruit 400 mg daily for 8 weeks does not improve symptoms when compared with control (14844). More evidence is needed to rate the effectiveness of olive for these uses.

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LIKELY EFFECTIVE

• Vitamin A deficiency. Oral palm oil is likely effective for preventing or treating vitamin A deficiency. Details: Clinical studies in pregnant individuals and in children in developing countries shows that dietary supplementation with red palm oil reduces the risk of developing vitamin A deficiency and treats existing vitamin A deficiency (14030,14031,14032,34466,34474,67509,67510,67511,67534,67571). A meta-analysis of these and other clinical studies primarily involving children or those who are pregnant or lactating shows that taking red palm oil increases levels of serum retinol, a marker of vitamin A status, by 0.09 mcmol/L and reduces the rate of vitamin A deficiency by 45% when compared with placebo. Intake of red palm oil appears to be comparable to taking vitamin A supplements for preventing vitamin A deficiency. Red palm oil in doses of about 3-8 grams daily seems to be most beneficial; higher intake does not appear to have additional benefit (97572).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Cardiovascular disease (CVD). Although there has been interest in using oral palm oil for CVD, including atherosclerosis, hypercholesterolemia, and hypertension, there is insufficient reliable information about the clinical effects of palm oil for these conditions.
• Malaria. It is unclear if oral palm oil is beneficial in children with malaria. Details: Dietary consumption of palm oil by children under 5 years of age in developing countries where malaria is endemic does not seem to be associated with a reduced severity of malaria (14034). More evidence is needed to rate the effectiveness of palm oil for this use.

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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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POSSIBLY EFFECTIVE

• Breast cancer. High dietary intake of soy might be beneficial for the prevention of breast cancer and breast cancer recurrence in some patients. However, soy supplements do not seem to be beneficial. Details: For prevention, most population research has found that higher dietary intake of soy is associated with up to a 26% reduced odds of developing breast cancer when compared with a lower intake (7335,7336,11038,11807,75377,75587,90955,108251). One meta-analysis of population research found that patients who consumed more than 15 mg soy isoflavones daily made up about 25% of all cases of breast cancer, compared with 75% of cases in the group of patients consuming less than 15 mg daily (108251). The effects appear to vary depending on the ethnicity of the patient. Population research has consistently found that a high-soy diet in Asian and Asian-American females is associated with a significantly reduced risk of breast cancer (7335,7336,11038,11807,75377,75587,90955). However, the amount of soy consumed in a Western diet, even among those who consume the highest amounts of soy, was not found to have a preventative effect (11391,17109,90955,90967). The reason for the disparate findings are unknown but may be related to genetic differences or differences in quantification of soy intake (7663,94153). Also, the prophylactic benefit seems to apply regardless of whether high amounts of soy are consumed during adolescence or later in life (7335,7336,9674). Limited population research has also found that consuming a diet high in soy is associated with up to a 25% reduced risk of breast cancer recurrence; however, it is unclear whether there is an association with reduced mortality in breast cancer patients (90956,90969,94154). The effect appears to be greater for certain subgroups of breast cancer patients. Increased dietary soy intake is associated with a 28% to 36% risk reduction in patients with estrogen receptor (ER)-negative tumors, a 30% risk reduction in patients with ER-positive/progesterone receptor (PR)-positive tumors, and a 25% to 36% risk reduction in postmenopausal patients (90956). Some small clinical studies have also evaluated the use of soy isoflavone extract . One small clinical study in patients with breast cancer shows that taking a soy isoflavone extract 200 mg daily for 2 weeks prior to surgery does not seem to affect cancer cell growth when compared with a historical control (11042). Another small clinical study in patients at high risk for breast cancer or with a history of breast cancer shows that taking a soy tablet containing 50 mg soy isoflavones (Novasoy, Archer Daniels Midland Co.) daily for 12 months does not alter mammographic or breast tissue density when compared with placebo (95999).
• Chronic kidney disease (CKD). Oral soy protein seems to improve some measures of disease severity in patients with CKD. Details: Clinical research shows that consuming soy protein seems to reduce proteinuria in people with kidney disease (2286,2287,2288,75249,75634). Also, a meta-analysis of clinical research in patients with CKD who are not on dialysis shows that soy protein intake reduces serum levels of creatinine by 0.07 mg/dL, phosphorus by 2.5 mg/dL, and triglyceride by 18 mg/dL when compared with placebo or control (90989).
• Diabetes. Diets high in soy seem to reduce the risk of type 2 diabetes. Also, oral soy protein, but not soy isoflavones, seems to modestly improve glycemic indices. It is unclear if soy is beneficial for lowering blood lipid levels or reducing cardiovascular (CVD) mortality risk in adults with type 2 diabetes. Details: A meta-analysis of observational studies has found that higher dietary intake of tofu, soy protein, or soy isoflavones is associated with an 8% to 16% lower risk of developing diabetes when compared with a lower dietary intake (105608). In menopausal patients without diabetes, a meta-analysis of clinical research shows that intake of soy isoflavones 40-161 mg daily seems to improve glycemic indices when compared with control (96423). Some research shows that soy can modestly improve glycemic indices in patients with diabetes. A meta-analysis of small low-quality clinical studies in patients with diabetes or metabolic syndrome shows that taking various formulations of soy protein modestly reduces fasting plasma glucose and insulin levels, as well as insulin resistance, when compared with control (96001). An older meta-analysis assessing both healthy patients and patients with diabetes shows that a whole soy diet reduces fasting blood glucose by about 4 mg/dL when compared with control (75493). Small clinical studies also suggest that an extract of the fermented soybean product, Touchi, acts as an alpha-glucosidase inhibitor. It seems to modestly lower blood glucose, glycated hemoglobin (HbA1c), and triglycerides in patients with type 2 diabetes (11762,75205). However, some conflicting evidence exists. A meta-analysis of small, low-quality clinical studies in patients with type 2 diabetes shows that taking soy isoflavones does not improve glycemic indices when compared with control (105610). Also, another meta-analysis of clinical research in patients with type 2 diabetes shows that taking soy protein and/or soy isoflavones for 6-12 weeks does not improve glycemic indices when compared with either soy protein without isoflavones, other protein, or placebo (105610). Reasons for these conflicting results are unclear but may relate to differences in baseline blood glucose levels, the formulation of soy, or the duration of treatment. Some research shows that soy may modestly improve the lipid profile in patients with diabetes. A meta-analysis of clinical research in patients with diabetes shows that taking soy protein and/or soy isoflavones for 6-12 weeks modestly reduces levels of total and low-density lipoprotein (LDL) cholesterol, but not high-density lipoprotein (HDL) cholesterol or triglycerides, when compared with control (105610). Consuming soy foods might reduce the risk of mortality related to CVD in patients with diabetes. Population research suggests that consuming soy foods at least four days each week is associated with a 23% reduced risk of CVD mortality when compared with never consuming soy foods. Consuming soy foods less than four times weekly is not associated with CVD mortality risk (108242). Soy is also of interest in the prevention or treatment of gestational diabetes. Population research has found that consumption of less than 40 grams of soy daily in the second trimester is associated with a 2.1-fold increased risk of gestational diabetes when compared with daily soy intake of 40 grams or more (108241). Also, a small clinical trial in patients with gestational diabetes shows that consuming a diet containing about 0.3 grams/kg soy protein for 6 weeks, beginning at 24-28 weeks' gestation, reduces blood glucose levels, insulin resistance, and triglyceride levels when compared with consuming a non-soy control diet (95993).
• Diarrhea. Oral soy fiber seems to reduce acute diarrhea in infants, although it may not be beneficial in adults. Details: Giving soy fiber-supplemented formula orally, either alone or in combination with oral rehydration solution, seems to reduce the duration of acute diarrhea in infants when compared with cow's milk formula or oral rehydration solution alone (2291,2292,75474,75517,75523,75531,75572). However, in some studies, a reduction in the duration of acute diarrhea was not observed when compared with cow's milk formula (75522,75542). In adult patients receiving nutrition via intubation, preliminary clinical research suggests that treatment with soy-polysaccharide fiber does not improve the incidence of diarrhea when compared to control (75508).
• Galactosemia. Oral soy protein can be used in infant formula to prevent symptoms of galactosemia. Details: Soy does not contain the sugar galactose. Some research suggests that giving oral isolated soy protein-based formula in place of milk-based formula to infants seems to be helpful for preventing symptoms of galactosemia (3400).
• Hyperlipidemia. Oral soy protein seems to modestly reduce lipid levels. However, purified soy isoflavone may not have the same benefit. Details: Consuming soy protein orally, in place of other dietary protein, seems to modestly reduce total cholesterol and low-density lipoprotein (LDL) cholesterol by about 3% to 4% when compared with control (842,2293,2294,2296,2585,3402,4755,6412,7346,7803)(8530,10459,42059,75356,105598,105604). Additionally, some research shows that soy protein might be more effective in patients with more severe hyperlipidemia (75497). The FDA has approved labeling for specific soy products that states that they may be used for cholesterol reduction in combination with a diet low in saturated fat and cholesterol. To be eligible for this labeling, soy products must provide at least 6.25 grams of soy protein per serving, which is 25% of the effective daily intake (3977). However, not all evidence is positive. Some studies have shown no benefit of soy protein or isoflavones on LDL cholesterol levels when compared to control (8521,9679,12034,17105,53771,75236)(75242,75274,75276). Furthermore, although a few clinical trials have shown significant decreases in triglycerides following supplementation with soy or soy protein isolate (75258,75365), most studies suggest that soy protein does not decrease triglycerides when compared to control (2293,6412,8530,12034,17105). The effect of soy protein on high-density lipoprotein (HDL) cholesterol is inconsistent. Most studies suggest that it does not increase HDL levels (2293,6412,8530,12034,75286)(75524), although some analyses of clinical research suggest that soy might increase HDL cholesterol levels by up to 4% when compared to control (75480,75497). Doses of soy protein have ranged from 25-135 grams daily, providing 40-318 mg daily of isoflavones; however, higher doses do not seem to be more effective (17106,105598). Some evidence suggests that soy protein providing more isoflavones, or supplemented with isoflavones, might be more effective (3402,6413,10459), but this has not been consistently found in studies (3402). Most studies evaluating soy protein products containing little to no isoflavones suggest that these products are not effective (3402,7346,9679); however, purified soy isoflavone supplements alone do not seem to decrease LDL cholesterol (851,4738,7345,8502,10459,14066). In addition to soy protein, limited evidence suggests that soy fiber alone might reduce total cholesterol, LDL cholesterol, and triglyceride levels when compared with placebo (75686,75689). There is also some evidence that ultra-high temperature (UHT) treatment of soy milk destroys any cholesterol-lowering activity (17106).
• Hypertension. Oral soy seems to modestly reduce blood pressure in some patients. Details: A meta-analysis of the available clinical research shows that consuming soy products modestly lowers systolic and diastolic blood pressure by an average of 1.6 mmHg and 1.2 mmHg, respectively, when compared with control (105605). This analysis is limited by high risk of bias and the lack of a dose-response relationship. An older meta-analysis, as well as individual clinical studies, in patients with prehypertension or mild hypertension show that consuming soy protein 18-40 grams, providing 118-143 mg of isoflavones, daily or black soy peptide 4.5 grams daily for 8 weeks reduces systolic blood pressure by about 4-8 mmHg and diastolic blood pressure by about 3-5 mmHg when compared with control (1313990962,90965). In normotensive patients, soy protein does not seem to reduce systolic or diastolic blood pressure (90965).
• Lactose intolerance. Oral soy protein can be used in infant formula to prevent symptoms of lactose intolerance. Details: Providing isolated soy protein-based formula orally to infants is an acceptable alternative to milk-based formulas, especially for infants with symptoms of lactose intolerance (3400).
• Menopausal symptoms. Oral soy seems to reduce hot flashes in patients with menopausal symptoms. Details: Consuming soy protein 15-60 grams, providing 34-100 mg of isoflavones, daily seems to modestly decrease the frequency and severity of hot flashes in some menopausal adults. Improvement seems to be greater in those with a higher frequency of hot flashes at baseline (2296,2297,3978,3986,3987,7653,9917,11805,15220,17110,75478)(75486,75649,92661,95997). Taking concentrated soy isoflavone extracts, providing 35-200 mg of isoflavones, daily seems to have similar effects (4751,6455,7802,9916,10460,11805,11993,11994,13209,15220)(15850,75478,90950,90979,92661). Higher doses of 100-200 mg of isoflavones daily and higher frequency of dosing intervals seem to have greater benefit (90950). Furthermore, the amount of the specific isoflavone genistein contained in a soy product may influence outcomes. According to one analysis, studies using products that provide at least 15 mg of genistein daily consistently show positive outcomes. Studies using products containing a lower concentration of genistein have produced inconsistent findings (15133). Not all research has found that soy extracts reduce hot flashes (7801,11806,14062,15038,15851,16762); some experts speculate that this is due to a high placebo response (9916). Some clinical research has compared soy isoflavone extracts to conventional estrogen replacement. In one study, a concentrated soy isoflavone extract of genistein 54 mg daily reduced hot flashes by 22% to 29%, compared to 54% in those taking 17beta-estradiol as 1 mg daily plus norethisterone acetate 0.5 mg daily (11994). Additional preliminary research suggests that taking a soy isoflavone extract providing 60 mg isoflavones twice daily is comparable in efficacy to conjugated estrogens 0.625 daily for reducing menopausal symptoms. Conjugated estrogens seem to work more quickly; it seems to take up to 2 months to achieve the full effect of soy isoflavones (13209). One clinical trial compared soy isoflavones 10-40 mg daily to S-equol, a soy isoflavone metabolite. Soy isoflavones were less effective for reducing hot flash frequency when compared with S-equol (90960). This has led to some speculation that the effectiveness of soy in relieving hot flashes is influenced by a patient's ability to convert daidzen, a soy isoflavone, to S-equol (90950). It is theorized that patients who are S-equol producers are more likely to achieve symptom relief from soy. However, observational and clinical research does not support this theory (90990,94162). Soy has also been evaluated for the management of other symptoms of menopause. Some clinical research in menopausal patients with depression suggests that taking soy 100 mg, providing 50 mg of soy isoflavones, in combination with sertraline 50 mg daily for three months improves depression severity when compared with sertraline or soy alone (90958). An analysis of two small clinical trials shows that supplemental soy providing 50-118 mg of isoflavones can reduce vaginal dryness scores by 0.26 when compared with control (92661). Also, an open-label study suggests that drinking a specific beverage (ViveSoy) containing soy protein 15 grams and soy isoflavones 50 mg orally daily for 12 weeks reduces overall urogenital symptoms when compared with a control group (95997). However, one small clinical study in perimenopausal patients shows that a soy-rich diet does not relieve urogenital symptoms, including vaginal dryness, itching, and urinary incontinence, when compared with a soy-free diet (75285).
• Metabolic syndrome. Oral soy protein seems to improve glycemic control and other markers of metabolic syndrome. Details: A meta-analysis of clinical research in patients with diabetes or metabolic syndrome shows that following a diet high in soy protein can decrease fasting plasma glucose and insulin levels, as well as insulin resistance, when compared with a control diet. Furthermore, dietary intake of soy protein modestly decreases diastolic blood pressure and low-density lipoprotein (LDL) cholesterol by a small amount in this population, although there is no effect on systolic blood pressure, high-density lipoprotein (HDL) cholesterol, or triglycerides (96001). Other clinical research shows that consuming a soy nut diet or a soy protein diet reduces fasting plasma glucose and LDL cholesterol levels when compared to baseline in postmenopausal adults with metabolic syndrome; however, the soy nut diet seems to more beneficial than either the soy protein diet or a Dietary Approaches to Stop Hypertension (DASH) diet (75378).
• Muscle strength. Oral soy protein seems to increase muscle strength. Details: Overall, soy protein combined with resistance training seems to increase muscle strength when compared with placebo (16748,75246,96942,98871). A meta-analysis of three clinical studies shows that consuming soy protein in addition to resistance training improves strength and lean body mass in untrained athletes (98871). Other clinical research shows that soy also improves muscle strength in trained athletes and postmenopausal adults (75246,96942). One study in Olympic endurance athletes shows that consuming isolated soy protein (Supro) 1.5 grams/kg daily for 8 weeks increases body mass and strength indices and reduces fatigue when compared with no protein supplementation (75246). Clinical research in postmenopausal adults undergoing resistance training 3 days weekly shows that taking soy protein 25 grams daily in skim milk for 16 weeks increases the maximum amount of weight lifted in one repetition by over 80% for both bench press and knee extension when compared to a maltodextrin placebo (96942). Soy protein has also been compared with other protein supplements. A meta-analysis of preliminary clinical studies and other clinical research show that soy protein seems to work as well as whey, beef, and dairy (casein and whey) protein for improving muscle strength (75404,85941,98871,105591). However, the validity of these findings is limited by the small size and high heterogeneity of the studies.
• Osteoporosis. Oral soy isoflavones seem to improve bone density and reduce the risk of osteoporosis in post-menopausal adults. Details: Most clinical research suggests that soy protein or soy extract containing 75-90 mg of isoflavones can increase bone mineral density (BMD), or slow BMD loss, and improve biochemical markers of bone turnover in peri- and postmenopausal adults when compared with control (842,4951,6449,9775,11082,90972,90980). Lower doses of isoflavones do not seem to be as beneficial. However, some observational research in postmenopausal Japanese adults and Chinese females aged 30-40 years has found that consuming about 50 mg dietary soy isoflavones daily is associated with a higher BMD when compared with lower soy isoflavone intake (7342,11081). An observational study in postmenopausal Asian patients has found that consuming higher dietary soy protein is associated with a lower risk of developing fractures when compared with lower amounts (13181). However, not all research has been positive. Some conflicting evidence suggests that soy protein does not improve BMD in some postmenopausal adults. The discrepancy in findings may be due to differences in soy formulations, concomitant treatments, or variable patient populations (4952,12034,14064,90978). For example, most evidence shows that soy does not affect BMD in premenopausal patients or bone turnover in adolescents (7660,8532,9684,11086). It is theorized that only people who can convert daidzein, a soy isoflavone, to S-equol might obtain benefits from soy (4952). However, clinical research suggests that there is no difference in bone calcium retention between equol producers and nonproducers (95995).

POSSIBLY INEFFECTIVE

• Benign prostatic hyperplasia (BPH). Oral soy does not seem to reduce BPH symptoms. Details: Clinical research in patients with BPH shows that taking soy isoflavones 40 mg (Soylife 40, Acatris) daily for 12 months does not improve peak urine flow rate, residual urine volume, symptoms of BPH, or general quality of life when compared with placebo (90983).
• Breast cancer-related hot flashes. Oral soy does not seem to reduce the risk for breast cancer-related hot flashes. Details: Clinical research shows that consuming a soy beverage providing soy isoflavones 90 mg daily or taking a soy extract providing soy isoflavones 50 mg three times daily does not reduce hot flashes in breast cancer survivors (3991,7658,8499). Observational research in breast cancer survivors has also found no association between hot flash incidence and soy isoflavone consumption (105602).
• Colorectal cancer. Oral soy does not seem to reduce the risk for colorectal cancer. Details: Some observational research from China and Japan has found that intake of soy protein or soy isoflavone is not associated with the risk of developing colorectal cancer (105601). Furthermore, some clinical research shows that soy protein powder 58 grams containing isoflavones 83 mg, taken daily for 12 months, does not reduce the proliferation of colorectal epithelial cells in patients with adenomatous polyps when compared to control (75282).
• Exercise-induced muscle soreness. Oral soy does not seem to reduce muscle soreness after exercise. Details: Some clinical research shows that taking soy isoflavone extract 120 mg orally for 30 days prior to exercise doesn't ameliorate muscle soreness caused by exercise when compared with placebo (8524).

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Alzheimer disease. It is unclear if oral soy improves cognition in patients with Alzheimer disease. Details: Preliminary clinical research in patients with Alzheimer disease shows that taking soy isoflavones (Novasoy, Archer Daniels Midland Co.) 100 mg daily for 6 months does not improve cognition when compared with placebo (96424).
• Androgen deprivation therapy (ADT)-associated hot flashes. One small clinical study in patients with prostate cancer receiving ADT shows that taking soy protein powder 20 grams, providing 160 mg of isoflavones, alone or along with venlafaxine 75 mg, once daily for 12 weeks does not improve the severity of hot flash symptoms when compared with milk protein, with or without venlafaxine (90981).
• Asthma. It is unclear if oral soy reduces asthma symptoms. Details: One population study has found that people with asthma who consume soy foods providing more than 250 mcg of genistein for every 1000 kcal consumed (e.g., 500 mcg/day for 2000 kcal diet) daily have increased lung function, as measured by FEV1 scores, when compared to those who consume less (11084). However, clinical research in adult and pediatric patients with poorly controlled asthma shows that taking soy isoflavones 50 mg twice daily for 24 weeks does not improve FEV1 scores, reduce the number of asthma episodes, or improve asthma symptoms when compared with placebo (90977).
• Cardiovascular disease (CVD). It is unclear if soy consumption reduces the risk for CVD or CVD-related mortality. More research is needed to determine whether certain populations may benefit from increased soy intake. Details: Due to mixed findings, it is unclear if consuming soy is associated with a reduced risk of CVD events. One population study has found that consuming at least 60 grams of soy daily over a 12-month period is associated with a 14% reduced risk of having a CVD event over the next 5 years, as well as a reduced risk of stroke, when compared with consuming less than 15 grams daily (108253). A study in Japan has found that consuming soy five or more times per week over a 10-year period is associated with fewer adverse cardiovascular outcomes in only a certain subset of patients when compared with consuming soy twice a week or less. Postmenopausal adults with the highest consumption had a 36% lower risk of stroke, a 45% lower risk of myocardial infarction, and a 65% lower risk of CVD mortality. However, risk was not significantly reduced in males or premenopausal adults (17108). In contrast, a study in Korea has found that consuming a median of 16.5 servings of soy per week is associated with a 64% reduced risk of CVD incidence in premenopausal, but not postmenopausal, adults when compared with a median of 4.7 servings per week. A subgroup analysis has found that the highest intake of tofu, but not soybeans, fermented soy paste, or soy milk, is associated with a reduced incidence of CVD (108243). Additionally, higher dietary intake of soy does not seem to be associated with a reduced risk of cardiovascular events in Western females (13040). The amount of phytoestrogens typically consumed in Western diets is significantly lower than the amount typically consumed in Asian diets. The form of soy food and isoflavone content might play a role in these discrepancies. Any association between consumption of soy-containing foods and CVD mortality is also unclear. A meta-analysis of observational studies conducted in China or Japan has found that the highest intake of soy-containing foods is not associated with a lower risk of CVD-related mortality when compared with the lowest intake (96941). A population study in patients with or without a prior history of CVD has also found that soy-containing food consumption is not associated with a lower risk of CVD-related mortality when compared with the lowest intake (108244). However, some research has found a positive effect of soy consumption on CVD mortality risk. A subgroup analysis of a meta-analysis has found that the highest intake of fermented soy products is associated with a 16% reduced risk of CVD mortality; higher intake of non-fermented soy is not associated with CVD mortality (96941). Population research in patients without a prior history of CVD has found that soy-containing food consumption is associated with a lower risk of myocardial infarction-related mortality when compared with the lowest intake (108244). Also, one population study in adults with type 2 diabetes has found that consuming soy-containing foods at least four days each week is associated with a 23% reduced risk of CVD mortality when compared with never consuming soy foods. Consuming soy foods less than four times weekly is not associated with CVD-related mortality (108242).
• Cervical cancer. It is unclear if oral soy reduces the risk for cervical cancer. Details: Population research has found that the highest dietary intake of soy over approximately 17 years is associated with a 57% decreased risk of cervical cancer when compared to the lowest intake of soy in females who also drank green tea. However, neither soy intake nor green tea intake alone was associated with a decreased risk of cervical cancer. Additionally, other population research has not confirmed an association between soy intake and cervical cancer (101800).
• Child growth. It is unclear if oral soy protein enhances child growth. Details: Preliminary clinical research in Colombian children 2-7 years of age shows that consuming a soy protein supplement dissolved in fruit juice on 6 days of every week for 1 year does not improve body mass index, body composition, weight, or height when compared with consuming fruit juice and whole milk. A sub-analysis shows that children consuming the soy protein supplement had an increase in weight-for-age when compared with the control group, indicating that the supplement may be beneficial for ensuring adequate weight and nutritional status during prepubertal growth (100320). However, the children in this study had normal or below average weight-for-age at baseline, limiting the applicability of these findings to other patient populations.
• Cognitive function. It is unclear if oral soy improves cognitive function; research is conflicting. Details: Some research shows that college students who increase consumption of soy foods providing isoflavones 100 mg daily have improved short- and long-term memory (9671). Postmenopausal patients aged 50-65 years who take a soy extract supplement providing isoflavones 60 mg daily also seem to have some improvement in some measures of cognitive function (12048). There is also evidence in postmenopausal patients aged 55-75 years that taking a soy extract supplement providing isoflavones 110 mg daily might improve verbal memory scores (12040). However, another study in this population shows that consuming 25.6 grams daily of soy protein providing 99 mg of isoflavones does not improve cognitive function (12034). Similarly, population research in females aged 42-52 years has found that increasing dietary intake of the isoflavones genistein and daidzein is not associated with improved measures of cognitive function (15042). These differing findings might be explained by variations in study design and soy formulations.
• Cognitive impairment. Oral soy has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in adults 55 years of age and older with mild cognitive impairment shows that taking a specific combination product (DW2009) containing fermented soybean powder and Lactobacillus plantarum daily for 12 weeks modestly improves composite cognitive function when compared with placebo (100319). It is not clear if this effect is due to soy, lactobacillus, or the combination.
• Colic. It is unclear if oral soy is beneficial in infants with colic. Details: Preliminary clinical research shows that consuming soy-based formula might reduce the duration of colic symptoms in infants with cows' milk intolerance (75509,75543). However, other clinical research shows that consuming soy-based formula does not improve crying in infants with colic when compared with dicyclomine hydrochloride 3 mg/kg daily (75573). Also, a meta-analysis of only high quality clinical research shows that soy milk formula does not improve the persistence of colic or the duration of crying in infants with colic when compared with control (75611).
• Crohn disease. It is unclear if oral soy improves symptoms of Crohn disease. Details: A small observational study in patients with inactive Crohn disease has found that taking oral soy-derived protein in combination with enteral treatment for 4 weeks is associated with increased bowel movements, improved symptoms such as fatigue and mental strain, and increased body weight when compared with standard enteral treatment alone (75175).
• Diabetic nephropathy. It is unclear if oral soy improves kidney function in patients with diabetic nephropathy. Details: A meta-analysis of small clinical trials in patients with diabetic nephropathy shows that consuming soy products, such as soy protein and soy milk, modestly reduces proteinuria and blood urea nitrogen (BUN), as well as levels of total and low-density lipoprotein (LDL) cholesterol, triglycerides, and fasting blood glucose, when compared with animal protein or cow's milk. However, there was no effect on any measures of kidney function (108247). Some individual small clinical trials show that replacing dietary animal protein with soy protein reduces urinary albumin excretion in patients with diabetic nephropathy (7348,12555,12556). However, one small clinical study shows that consuming soy milk 240 mL daily for 4 weeks does not affect urinary creatinine, blood urea nitrogen, proteinuria, or glomerular filtration rate in patients with diabetic nephropathy (90966).
• Dyspepsia. Oral soy protein has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: A small clinical study in adults with mild or moderate dyspepsia shows that consuming 1 gram of toasted soy flour fermented with Lactobacillus delbrueckii up to three times daily for 3 weeks does not improve heartburn severity or frequency when compared with placebo (105599).
• Endometrial cancer. It is unclear if oral soy protein reduces the risk for endometrial cancer. Details: Most epidemiological research has found that increased soy intake is associated with a lower risk of endometrial cancer. Endometrial cancer incidence is lower in Japan, China, and other Asian countries where the typical diet is low in calories and high in soy, whole grain foods, vegetables, and fruits (7338,11036,90954). Also, a large meta-analysis of population research has found that the highest total and fermented soy intake is associated with a 17% to 19% reduced risk of developing endometrial cancer when compared to the lowest intakes in postmenopausal adults (96002). However, one clinical study shows that taking soy protein 25 grams daily providing 91 mg of aglycon equivalents of isoflavones and glycosides for three years does not reduce the risk of endometrial hyperplasia or cancer when compared with placebo in postmenopausal adults. However, this study may not have been adequately powered to detect small differences in the low rates of endometrial hyperplasia (90971).
• Fibromyalgia. It is unclear if oral soy reduces fibromyalgia symptoms. Details: Clinical research shows that consuming a shake containing soy protein 20 grams and soy isoflavone 160 mg once daily for 6 weeks does not improve physical functioning or symptoms of depression in patients with fibromyalgia when compared with placebo (75451).
• Gastric cancer. It is unclear if oral soy reduces the risk for gastric cancer. Details: Meta-analyses of population research have found that the highest intake of soy-containing foods and nonfermented soy products is associated with a 21% to 37% decreased risk of gastric cancer when compared with the lowest intake (95998,108246). Intake of at least 100 grams daily of nonfermented soy foods was found to be the most protective (95998). However, a high intake of fermented soy products is associated with an increased risk of gastric cancer, and intake of 1-5 cups daily of the fermented soy product miso soup is associated with an increased risk of gastric cancer in males (95998,108246).
• Hepatitis C. It is unclear if oral soy is beneficial for hepatitis C. Details: Preliminary clinical research in patients with hepatitis C shows that taking soy protein 32 grams daily for 12 weeks reduces the number of cases of steatosis by 47% and reduces alanine aminotransferase (ALT) levels by 13% when compared to baseline. However, it is no different than taking casein protein (90970).
• Irritable bowel syndrome (IBS). A small study suggests that oral soy isoflavones might reduce IBS symptoms. Details: A small clinical study in females with IBS shows that taking soy isoflavones 40 mg daily for 6 weeks improves symptoms of IBS, such as abdominal distention and abdominal pain severity and duration, by approximately 27% when compared with placebo. Quality of life is also improved. Some symptoms are also improved when soy isoflavones are taken in combination with vitamin D; however, the combination of soy isoflavones and vitamin D does not seem to improve symptoms better than soy isoflavones alone (96425).
• Lung cancer. It is unclear if dietary soy reduces the risk for lung cancer. Details: A meta-analysis of epidemiological research has found that although increased soy intake is not associated with a reduced risk of lung cancer overall, it is associated with a slightly reduced risk in nonsmoking adults (90985).
• Mastalgia. It is unclear if oral soy is beneficial for mastalgia. Details: A small clinical study suggests that soy milk providing 34 grams soy protein daily might reduce cyclical breast pain when compared with no intervention (2428).
• Migraine headache. Oral soy has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research shows that taking a combination of soy isoflavones 60 mg, dong quai 100 mg, and black cohosh 50 mg daily for 24 weeks reduces the frequency of menstrual-associated migraine attacks when compared with placebo (35797). It is not clear if this effect is due to soy, the other ingredients, or the combination.
• Neonatal jaundice. It is unclear if oral soy reduces the risk of neonatal jaundice. Details: Clinical research shows that patients with gestational diabetes who consume a diet containing soy protein along with other plant and animal proteins for 6 weeks beginning at 24-28 weeks' gestation have a 73% reduced risk for newborn hyperbilirubinemia when compared with those consuming a control diet containing only non-soy plant and animal proteins (95993).
• Nonalcoholic fatty liver disease (NAFLD). It is unclear if oral soy is beneficial for the treatment or prevention of NAFLD. Details: Observational research in a Chinese population has found that increased frequency of dietary soy consumption is associated with a lower incidence of NAFLD when compared with lower consumption (105612). A meta-analysis of three small clinical trials in patients living in Iran with NAFLD shows that consuming soy milk, soy foods, or a genistein supplement for 8 weeks might reduce some liver transaminase levels when compared with control (105611). Another meta-analysis of small clinical trials in patients with NAFLD shows that consuming soy milk, soy foods, or a genistein supplement for 8 or 24 weeks modestly improves insulin resistance but does not improve body mass index, cholesterol levels, or liver transaminase levels (108239). These analyses are limited by their generally small population size and the heterogeneity of interventions.
• Obesity. It is unclear if consuming oral soy protein as part of a calorie-restricted diet improves weight loss; research is conflicting. Details: Some clinical research shows that consuming soy protein in conjunction with calorie restriction for 2-6 months helps reduce weight in those who are obese and overweight when compared with calorie restriction alone (11085,75397). Other clinical research shows that consuming soy protein for 16 weeks improves weight loss in overweight females when compared with consuming protein from meat (75620). Also, consuming black soy peptide 4.5 grams daily for 12 weeks reduces body weight and body fat mass more than placebo in overweight and obese adults (90961). In addition, some clinical evidence shows that eating biscuits supplemented with soy fiber 100 grams daily for 12 weeks reduces body weight, body mass index (BMI), and low-density lipoprotein (LDL) cholesterol when compared to control in overweight and obese patients (90960). However, contradictory evidence exists. Some clinical research shows that following a calorie-restricted diet and consuming soy-based meal replacements 3-5 times daily for 12-16 weeks, or eating soy protein-rich foods in place of animal protein for 2-12 weeks, does not improve weight loss in overweight or obese individuals when compared to a calorie-restricted diet alone (75277,75372,75376,90968). Also, in overweight and obese females following a free-choice diet, soy protein 56 grams daily for 23 weeks does not appear to improve weight loss when compared to eating an isoenergetic amount of carbohydrates (86077). Finally, a subgroup analysis of six preliminary clinical trials shows that soy products do not improve weight loss in postmenopausal adults (98870). The reason for these disparate findings is unclear but may be due to differences in the soy products used or differences in patient population. For example, a meta-analysis of clinical research shows that phytoestrogen consumption reduces weight in healthy postmenopausal adults but not in those with comorbid conditions (98870). However, the clinical validity of this analysis is limited because it did not evaluate the effect of soy-only phytoestrogens. Soy protein has also been compared with whey protein. One small clinical study in overweight and obese adults shows that patients taking soy protein isolate 52 grams for 23 weeks had similar overall weight and fat loss as those taking whey protein concentrate 52 grams daily (86077). In contrast, another small clinical study in overweight males shows that taking soy isolate 60 grams before lunch daily for 12 weeks is less effective for weight loss when compared with taking whey protein concentrate 65 grams (91801).
• Osteoarthritis. It is unclear if oral soy protein reduces osteoarthritis pain. Details: Preliminary clinical research shows that taking soy protein 40 grams daily for three months improves range of motion, pain, and quality of life in osteoarthritis patients, particularly males, when compared to baseline. However, these beneficial effects seem to also be observed following supplementation with milk-based protein, indicating that the benefits may have resulted from a placebo effect (75266).
• Overall mortality. It is unclear if dietary soy reduces overall mortality; the available research is conflicting. Details: A meta-analysis of observational studies has found that the highest intake of soy products is not associated with a lower risk of overall mortality, mortality from cardiovascular disease, or mortality from cancer when compared with the lowest intake (96941). However, a more recent population study has found that consuming at least 60 grams of soy daily over a 12-month period is associated with a 17% reduced risk of overall mortality over the next 5 years when compared with consuming less than 15 grams daily (108253). Also, an observational study in Japanese patients followed over 14.8 years has found that although overall soy intake is not associated with any benefit, increased intake of fermented soy products, such as natto and miso, was found to be associated with a slightly reduced risk of mortality (105600).
• Polycystic ovary syndrome (PCOS). It is unclear if oral soy reduces PCOS symptoms. Details: Clinical research shows that taking soy isoflavones 50 mg daily for 12 weeks improves insulin levels and insulin resistance by a small amount when compared with placebo in patients with PCOS. Furthermore, taking soy isoflavones improves the free androgen index by approximately 25% and triglyceride levels by 14% when compared to baseline. However, taking soy isoflavones does not improve low- or high-density lipoprotein (LDL or HDL) cholesterol levels or markers of inflammation (95994).
• Postmenopausal conditions. It is unclear if oral soy is beneficial for postmenopausal conditions. Details: A meta-analysis of generally small clinical trials in postmenopausal adults shows that taking soy protein with isoflavones or soy isoflavones, usually for 3-24 months, has modest beneficial effects on total cholesterol, and possibly high-density lipoprotein (HDL) cholesterol, when compared with milk protein, soy protein without isoflavones, or placebo. However, there was no effect on low-density lipoprotein (LDL) cholesterol or triglyceride levels. Subgroup analyses show that reductions in LDL cholesterol levels occur when soy is used for less than 6 months, in individuals older than 55 years, and when the soy protein contains isoflavones (108249).
• Preterm labor. It is unclear if oral soy reduces the risk for preterm labor. Details: Clinical research in patients with gestational diabetes shows that consuming a diet containing soy protein along with other plant and animal proteins for 6 weeks, beginning at 24-28 weeks' gestation, does not reduce the likelihood for caesarean section, preterm delivery, or maternal hospitalization when compared with a control diet containing only non-soy plant and animal proteins (95993).
• Premenstrual syndrome (PMS). It is unclear if oral soy reduces PMS symptoms. Details: Preliminary clinical research in patients with PMS shows that taking isolated soy protein containing soy isoflavones 68 mg daily for two menstrual cycles reduces cramps and swelling when compared with placebo (75279).
• Prostate cancer. It is unclear if oral soy is beneficial for the treatment or prevention of prostate cancer; research is conflicting. Details: Observational and clinical research has evaluated the effects of soy intake on prostate cancer risk. Observational research has found that consuming an Asian diet, which contains 10 times more soy than the average American diet, is associated with a lower risk of prostate cancer; however, it is unclear whether it is the soy content of the diet or if genetic differences or environmental factors such as fat ingestion are responsible for this correlation (2298,12884,12886,12887). A meta-analysis of observational trials from North America, Europe, and Asia has found that highest intake of total soy foods, unfermented soy foods, or soy isoflavones is associated with a reduced risk of prostate cancer when compared with the lowest intakes. However, higher intake of fermented soy foods is not associated with a reduced risk (96939). Furthermore, some observational research in Japanese males has found a weak association between increased prostate cancer mortality and a higher dietary intake of soy isoflavones when compared with a lower intake (105607). Research evaluating the use of soy supplements is also conflicting. One clinical study shows that taking soy protein 40 grams daily for 6 months reduces the development of prostate cancer six-fold in those at risk of prostate cancer when compared with milk protein (75432). However, another clinical study in healthy adults aged 50-80 years shows that taking soy protein, providing 83 mg isoflavones, daily for a year does not affect PSA levels when compared with a soy protein drink without isoflavones (12888). Soy products have also been evaluated in patients with prostate cancer. One clinical study shows that consuming a specific bread containing 50 grams of soy, providing 117 mg isoflavones, reduces PSA levels after about 3 weeks of treatment when compared with control (13140). Other preliminary clinical research in patients with rising PSA levels following prior therapy for prostate cancer shows that consuming 8 ounces of soy milk, standardized to contain 47 mg isoflavones, three times daily for 12 months slows the increase in PSA levels from 56% to 20% when compared with baseline (75435). However, one clinical study shows that taking soy protein 40 grams daily for 6 months does not reduce prostate size or improve PSA levels in those diagnosed with prostate cancer when compared with milk protein (75432). Also, in those with early stage prostate cancer, consuming a soy beverage daily providing genistein 60 mg does not seem to affect risk factors for progression of prostate cancer, including testosterone, estradiol, PSA, and sex hormone binding globulin (SHBG) levels (11033). Furthermore, consuming soy protein isolate 20 grams standardized to contain approximately 70 mg isoflavones daily for two years does not prevent prostate cancer recurrence following radical prostatectomy when compared with placebo (90953). Reasons for the discrepancies are not entirely clear, but may include the relatively short trial durations (up to 12 months) and heterogeneity of soy preparations and dosing regimens.
• Rheumatoid arthritis (RA). It is unclear if oral soy reduces RA symptoms. Details: Preliminary clinical research in patients with RA shows that consuming a liquid diet containing hydrolyzed soy protein (Top Up) daily for 4 weeks does not improve pain intensity, morning stiffness, or joint swelling and tenderness when compared to consuming a normal daily diet (75619).
• Sarcopenia. It is unclear if oral soy reduces age-related muscle loss; evidence is conflicting. Details: Some clinical research in postmenopausal adults shows that consuming soy protein containing isoflavones 99 mg daily for 12 months does not improve hand grip strength or physical performance when compared with a milk protein placebo (75283). However, another small clinical study in older adults with low muscle mass living in China shows that taking soy, or a whey-soy blended protein, 16 grams daily for 6 months, slightly attenuates muscle loss when compared with no intervention (105603).
• Stroke. It is unclear if oral soy improves outcomes and overall function in people who have had a stroke. Details: One small clinical study shows that older adults with a history of stroke who consumed soy milk 500 mL daily while participating in a rehabilitation program had greater improvements in hand grip strength, 8-feet walking speed, walking performance, and 6-minute walk test after 8 weeks when compared with placebo. However, consuming soy milk did not lead to greater improvements in lean mass or overall short physical performance battery (SPPB) scores when compared with placebo (100321).
• Thyroid cancer. It is unclear if dietary soy reduces the risk for thyroid cancer. Details: Epidemiological research has found that high dietary intake of soy is associated with a reduced risk of thyroid cancer when compared with lower intake (7662,12041).
• Vaginal atrophy. It is unclear if topical soy improves vaginal atrophy. Details: A small clinical study in postmenopausal adults with vaginal atrophy shows that applying one gram of soy extract 4% vaginal gel daily for 12 weeks reduces vaginal dryness and pain during sexual intercourse and improves vaginal endometrial thickness when compared with placebo (90964).
• Wrinkled skin. Small studies suggest that oral and topical soy might reduce wrinkles. Details: A small clinical study in middle-aged females shows that consuming soy isoflavone 40 mg daily for 12 weeks improves skin elasticity and the appearance of fine wrinkles when compared with placebo (75388). Another small clinical study in females with photodamaged skin shows that applying a soy moisturizer containing soybean trypsin inhibitor and Bowman-Birk protease inhibitor (Aveeno Positively Radiant Daily Moisturizer, Johnson & Johnson CCI) twice daily for 12 weeks improves skin pigmentation, fine lines, texture, tone, and appearance when compared with a placebo moisturizer (75410). More evidence is needed to rate soy 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 olive fruit is used orally and appropriately in amounts commonly found in foods.

POSSIBLY SAFE ...when olive leaf extract is used orally and appropriately. Olive leaf extract providing 51-100 mg oleuropein daily has been used with apparent safety for 6-8 weeks (92245,92247,101860). There is insufficient reliable information available about the safety of olive fruit extract when used in amounts greater than those found in foods.

PREGNANCY AND LACTATION:
Insufficient reliable information available; stick with amounts commonly found in foods.

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LIKELY SAFE ...when used orally in food amounts. Palm oil can be safely consumed as a component of the diet (14031,14032). However, palm oil should not be considered a healthy alternative to other saturated fats. Palm oil contains more saturated fat than animal-based fats, including lard and butter, and increased consumption of palm oil has been associated with a higher risk for mortality from ischemic heart disease (14021,17739,94918,94920). Therefore, like all saturated fats, palm oil should be used in moderation.

POSSIBLY SAFE ...when used orally and appropriately in medicinal amounts, short-term. Palm oil has been used with apparent safety in clinical studies at doses of about 7-12 grams daily for up to 6 months (14030,14032,97572).

CHILDREN: POSSIBLY SAFE
when used orally and appropriately in medicinal amounts. Palm oil has been used with apparent safety in clinical studies in children under 5 years of age at doses of 6 grams daily for up to 6 months and in children 5 years of age and older at doses of 9 grams daily for up to 12 months (14032,34466,67509,67534,67571,97572).

PREGNANCY: POSSIBLY SAFE
when used orally and appropriately in medicinal amounts. Diets rich in palm oil or supplemented with palm oil have been used safely during the third trimester of pregnancy (14030,14031,14032).

LACTATION:
There is insufficient reliable information available about the safety of palm oil when used in medicinal amounts during lactation; avoid amounts in excess of those found in foods.

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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 soy protein is used orally and appropriately. Soy protein products in doses up to 60 grams, providing up to 185 mg isoflavones, daily have been safely used in studies lasting up to 16 weeks (842,2293,2294,2296,3025,3402,3977,4755,6412,8530)(10372,11805).

POSSIBLY SAFE ...when soy extracts are used orally and appropriately, short-term. Soy extracts containing concentrated isoflavones in doses of 35-120 mg daily have been used with apparent safety for up to 6 months (4751,6455,7802,12040,12048,13209,95994,95999).

CHILDREN: LIKELY SAFE
when consumed in amounts commonly found in foods or as a component of infant formula (3400,4912,7331). Soy milk that's not designed for infants should not be used as a substitute for infant formula. Regular soy milk can lead to nutrient deficiencies (12045). Most evidence shows that exposure to soy formula or other soy products in infancy does not cause early onset of puberty or health or reproductive problems later in life (7331,11080,108245). However, some small cohort studies have suggested that higher soy intake during childhood may be associated with an increased risk of precocious puberty (108240) and may be weakly correlated with the development of breasts in children less than 2 years of age (75520). This is in contrast to an observational study in Chinese children ages 7-9 years which suggests that higher soy intake is associated with delayed puberty (108252). One small cohort study has also found that use of soy infant formula may be associated with an increased risk of endometriosis in adulthood, although endometriosis was also correlated with prematurity, which may have confounded the findings (101803).

CHILDREN: POSSIBLY UNSAFE
when used orally as an alternative to cow's milk in children with severe milk allergy (75359). Although soy protein-based infant formulas are often promoted for children with milk allergy, children with a severe allergy to cow's milk are also frequently sensitive to soy protein (9883). There is insufficient reliable information available about the safety of soy products when used in amounts higher than typical food quantities for children.

PREGNANCY: LIKELY SAFE
when used orally in amounts commonly found in foods (4912).

PREGNANCY: POSSIBLY UNSAFE
when used orally in medicinal amounts. Soy contains mildly estrogenic constituents (3373,3988,3989,3990,3994,6029,75303). Theoretically, therapeutic use of soy might adversely affect fetal development; avoid using.

LACTATION: LIKELY SAFE
when used orally in amounts commonly found in foods (4912). A single 20-gram dose of roasted soybeans, containing 37 mg isoflavones, produces four to six times less isoflavones in breast milk than provided in a soy-based infant formula (2290). There is insufficient reliable information available about the safety of long-term use of therapeutic amounts of soy during lactation.

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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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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, palm oil might decrease the effectiveness of antiplatelet or anticoagulant drugs.  Details The palm olein constituent in palm oil seems to increase platelet aggregation (14037).

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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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ANTIBIOTIC DRUGS Interaction Rating = Minor Be watchful with this combination. Severity = Mild •  Occurrence = Possible •  Level of Evidence = D Theoretically, antibiotics may decrease the activity of soy isoflavones.  Details Intestinal bacteria are responsible in part for converting soy isoflavones into their active forms. Antibiotics may decrease the amount of intestinal bacteria and decrease its ability to convert isoflavones (7657).

ANTIDIABETES DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = A Soy can lower blood glucose and have additive effects with antidiabetes drugs.  Details Clinical research shows that whole soy diets and soy-based meals reduce fasting glucose levels in diabetic and non-diabetic individuals (75268,75296,75378,75493,96001). Also, individuals following a soy-based meal replacement plan seem to require lower doses of sulfonylureas and metformin to manage blood glucose levels when compared with individuals following a diet plan recommended by the American Diabetes Association (75268).

ANTIHYPERTENSIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = A Theoretically soy protein may have additive effects with antihypertensive drugs and increase the risk of hypotension.  Details Although some contradictory research exists (14254), most clinical evidence suggests that consuming soy protein modestly reduces systolic and diastolic blood pressure in individuals with prehypertension or hypertension (13139,75482).

CAFFEINE Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, soy might reduce the clearance of caffeine.  Details Soy contains genistein. Taking genistein 1 gram daily for 14 days seems to inhibit caffeine clearance and metabolism in healthy females (23582). This effect has been attributed to inhibition of the cytochrome P450 1A2 (CYP1A2) enzyme, which is involved in caffeine metabolism. It is unclear if this effect occurs with the lower amounts of genistein found in soy.

CYTOCHROME P450 2C9 (CYP2C9) SUBSTRATES Interaction Rating = Minor Be watchful with this combination. Severity = Moderate •  Occurrence = Unlikely •  Level of Evidence = D Soy might modestly induce CYP2C9 enzymes. However, this effect does not seem to be clinically significant.  Details In vitro research suggests that an unhydrolyzed soy extract might induce CYP2C9. However, the significance of this interaction is likely minimal. In healthy females taking a specific extract of soy (Genistein Soy Complex, Source Naturals), blood levels of losartan, a CYP2C9 substrate, were not significantly affected (16825).

DIURETIC DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, soy might have additive effects when used with diuretic drugs.  Details Animal research suggests that genistein, a soy isoflavone, increases diuresis within 6 hours of subcutaneous administration in rats. The effects seem to be similar to those of furosemide (75604). This effect has not been reported in humans.

ESTROGENS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, soy might competitively inhibit the effects of estrogen replacement therapy.  Details Soy contains phytoestrogens and has been shown to have estrogenic activity in some patients (3860). Although this has not been demonstrated in humans, theoretically, concomitant use of soy with estrogen replacement therapy might reduce the effects of the estrogen replacement therapy.

LEVOTHYROXINE (Synthroid, others) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = B Soy products might reduce the absorption of levothyroxine in some patients.  Details Preliminary clinical research and a case report suggest that soy-based formulas inhibit the absorption of levothyroxine in infants with congenital hypothyroidism (20636,20637,75548,90959). A levothyroxine dosage increase may be needed for infants with congenital hypothyroidism while using soy-based formulas, and the dose may need to be reduced when soy-based formulas are no longer administered. However, in postmenopausal adults, clinical research shows that taking a single dose of soy extract containing isoflavones 60 mg along with levothyroxine does not affect the oral bioavailability of levothyroxine (95996).

MONOAMINE OXIDASE INHIBITORS (MAOIs) Interaction Rating = Major Do not take this combination. Severity = High •  Occurrence = Likely •  Level of Evidence = C Taking soy products containing high amounts of tyramine along with MAOIs can increase the risk of hypertensive crisis.  Details Fermented soy products such as tofu and soy sauce contain tyramine, a naturally occurring chemical that affects blood pressure regulation. The metabolism of tyramine is decreased by MAOIs. Consuming more than 6 mg of tyramine while taking an MAOI can increase the risk of hypertensive crisis (15649). The amount of tyramine in fermented soy products is usually less than 0.6 mg per serving; however, there can be significant variation depending on the specific product used, storage conditions, and length of storage. Storing one brand of tofu for a week can increase tyramine content from 0.23 mg to 4.8 mg per serving (15649,15701,15702). Advise patients taking MAOIs to avoid fermented soy products that contain high amounts of tyramine.

PROGESTERONE Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = A Theoretically, combining soy isoflavones with transdermal progesterone may worsen bone density.  Details Clinical research suggests that significant bone loss may occur in females with osteoporosis who receive a combination of transdermal progesterone with soy milk containing isoflavones when compared with placebo, soy milk alone, or progesterone alone (69859).

TAMOXIFEN (Nolvadex) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Theoretically, estrogenic soy isoflavones might alter the effects of tamoxifen.  Details Laboratory research suggests that genistein and daidzen, isoflavones from soy, can antagonize the antitumor effects of tamoxifen under some circumstances (7072,14362,8966); however, soy isoflavones might have different effects when used at different doses. A relatively low in vitro concentration of soy isoflavones such as 1 microM/L seems to interfere with tamoxifen, whereas high in vitro concentrations such as those >10 microM/L might actually enhance tamoxifen effects. People on a high-soy diet have soy isoflavones levels ranging from 0.1-6 microM/L. Until more is known, advise patients taking tamoxifen to avoid therapeutic use of soy products.

WARFARIN (Coumadin) Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, soy might interfere with the effects of warfarin.  Details Soy milk has been reported to decrease the international normalized ratio (INR) in a patient taking warfarin. The mechanism of this interaction is not known (9672). However, animal and in vitro research suggests that soy may also inhibit platelet aggregation (3992). Dosing adjustments for warfarin may be necessary.

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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, olive fruit is well tolerated when used in typical food amounts. Olive leaf extract seems to be well tolerated.
Most Common Adverse Effects:
Orally: Headache and stomach discomfort.

Dermatologic ...Orally, one patient in one clinical trial reported bad skin and acne after using olive leaf extract (101860).

Gastrointestinal ...Orally, three patients in one clinical trial reported stomach ache after using olive leaf extract (101860).

Neurologic/CNS ...Orally, three patients in one clinical trial reported headache after using olive leaf extract (101860).

Psychiatric ...In one case report, a 67-year-old female experienced irritability, anger, a lack of control, and feelings of sadness and negativity after consuming a multi-ingredient product containing olive leaf extract 5 grams, horseradish root, and eyebright daily for 38 days. All psychiatric symptoms disappeared within days of stopping the combined product. It is hypothesized that the hydroxytyrosol component of olive leaf extract contributed to these symptoms due to its chemical similarity to dopamine; however, it is not clear if these symptoms were due to the olive leaf extract or to the other ingredients (96245).

Pulmonary/Respiratory ...Olive tree pollen can cause seasonal respiratory allergy (1543).

(Read more about OLIVE)

General ...Orally, palm oil is well tolerated.

Cardiovascular ...In population research, increased dietary intake of palm oil has been associated with a higher risk for mortality from ischemic heart disease, but not stroke (94920). The effect of oral palm oil on blood lipid levels differs depending on the diet to which it is compared and the patient population being studied. Some research suggests that diets rich in palm oil can increase levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol when compared with diets rich in monounsaturated and/or polyunsaturated fatty acids (106719). When substituted for other saturated fats in the diet, palm oil reduces total, HDL, and LDL cholesterol levels better than myristic and lauric acids, but increases these when compared with stearic acid (67533,67569,94913,94919). However, meta-analyses of studies in healthy individuals show that palm oil has no significant effects on total or LDL cholesterol or triglycerides when compared with unsaturated fatty acids, although it may increase HDL cholesterol in these individuals (103847,103848). If substituted for trans fatty acids, palm oil increases HDL cholesterol levels, with no impact on total or LDL cholesterol levels. When substituted for hydrogenated vegetable oils, the effect of palm oil on cholesterol levels is neutral. The effect of palm oil on cholesterol levels, regardless of the comparator fat source, appears to be more pronounced with older age, higher total intake of fat in the diet, and higher baseline cholesterol levels (94913).

Dermatologic ...Orally, red palm oil may cause carotenosis (also called carotenoderma), which is a yellow to yellow-orange discoloration of the skin caused by increased serum carotenoids and their subsequent deposition in the outermost layer of skin (14053). Due to the lipophilic nature of the carotenoids, the onset may be delayed and persist for up to 5 months after ceasing red palm oil consumption (67547).

Musculoskeletal ...In one clinical study, infants fed formula containing palm olein oil (a palm oil derivative) had reduced bone mineral content and bone mineral density at 3 and 6 months when compared with infants fed milk-based formula. However, this reduction is not considered clinically significant, as the values for all infants were within the normal range (14033).

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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, soy is well tolerated.
Most Common Adverse Effects:
Orally: Bloating, constipation, diarrhea, and nausea.
All ROAs: Allergic reactions.

Endocrine ...In the 1950s and 1960s, cases of altered thyroid function, particularly goiter, were reported in children taking soy formula. However, adding iodine to soy formula or replacing soy flour in formula with soy protein isolate has nearly eliminated the risk of altered thyroid function in most infants (75353,75651).
In adults, there is some evidence that soy intake can alter thyroid function. Results from one clinical trial suggests that consuming soybeans 30 grams daily for as little as one month can increase thyroid-stimulating hormone (TSH) and decrease thyroxine, causing diffuse goiters, constipation, fatigue, and lethargy in some Japanese men. Recovery was achieved by discontinuing soybean intake (75206,75353). There is also some evidence that soy inhibits thyroid hormone synthesis resulting in increased secretion of TSH in some postmenopausal patients (7806). However, this seems to only occur in people with iodine deficiency (6466,75311). In postmenopausal patients with normal levels of iodine, taking a soy extract for 6 months does not seem to significantly affect thyroid hormone levels (13010).
Evidence from a single case-control study suggests that consumption of soy-based formulas may be associated with an observed three-fold increase in the risk of breast development in Puerto Rican children less than 2 years-old (75520). The correlation has been attributed to the estrogenic activity of soy. However, other risk factors, including a maternal history of ovarian cysts and consumption of meat products were also associated with the increased risk of breast development prior to 2 years of age. Also, the investigators noted that in over half of the cases, the child had not been exposed to soy or any of the other risk factors. Therefore, factors other than soy consumption may be more strongly associated with the increased risk of breast development prior to 2 years of age.

Gastrointestinal ...Gastrointestinal upset, such as constipation, diarrhea, bloating, and nausea are the most common side effects of soy (2297,11033,11082,15851,75491,95999). Reports of "bad taste" and taste intolerance have also been documented in clinical research (15851,39007,75491). Firmer stools, diarrhea, colitis, and intestinal mucosal damage has been reported in infants fed soy protein formula (75161,75448,75516,75525).

Genitourinary ...Orally, soy might increase discomfort during menstrual periods. Evidence from a small, retrospective cohort study has found that consuming soy formula as an infant may slightly increase the duration and discomfort of menstrual periods later in life. However, the investigators noted that these differences may not be clinically significant (7331).
Orally, frequent soy consumption might be a risk factor for uterine leiomyoma, an estrogen-dependent benign tumor located on the uterus. Observational research found that consumption of soy milk or soybean at least four times weekly is associated with a 7-fold increased odds of uterine leiomyoma (98869).
There is some concern that use of soy-based formulas in infants might result in long-term health complications. However, results from a retrospective cohort study has found that intake of soy-based formula as an infant does not affect height, weight, body mass index, pubertal maturation, menstrual history, or pregnancy history, nor does it increase the risk of reproductive organ disorders, hormonal disorders, libido dysfunction, or birth defects in the offspring of adults who received soy formula as infants (7331,11080). Additionally, research in adults shows that urinary phytoestrogens are not associated with endometriosis risk (101804). However, some population research has found that regular exposure to soy-based formulas during infancy is associated with an increased risk for endometriosis (101803).

Immunologic ...Orally, soy can cause allergic reactions such as skin rash and itching in some people (6412). In an 11-year-old female, allergy to soy protein resulting in a delayed itching papular rash was thought to be responsible for the reaction to injected benzathine benzylpenicillin containing possible soy protein-contaminated soy lecithin (96422).
Topically, soy-based ingredients were responsible for the development of hand atopic dermatitis in a young female using cosmetic lotions in the workplace. Percutaneous sensitization resulted in the development of anaphylaxis to oral soy (96000).

Neurologic/CNS ...Orally, one clinical study showed that insomnia was more common in postmenopausal adults taking soy isoflavone supplements when compared with those receiving placebo (9917). Some research suggests that dietary consumption of tofu during midlife might decrease cognitive function in later years. Evidence from one retrospective cohort study suggests that males who consume at least two servings of tofu weekly during midlife have increased risk of cognitive impairment in late life (19% vs. 4%) compared to those who consume tofu less frequently. Although the effect of tofu was considered to be marginal compared to other factors such as age, education, or history of stroke, results from the study suggest that the effect of significant midlife consumption of tofu is comparable to the effect of an age difference of 4 years or an education difference of 3 years. However, numerous other factors, such as lifestyle and health, could be involved (6415,6416). Therefore, these findings are too preliminary to be used as a basis for clinical recommendations.

Oncologic ...There is controversy about the role of soy in breast cancer. Population studies suggest that soy is protective against breast cancer. Asian females who eat a traditional diet high in soy seem to have a lower risk of developing breast cancer (4590,5939,9674). Early exploratory studies have suggested that soy stimulates proliferation of normal human breast tissue (3980,3981). However, taking a soy tablet containing 50 mg soy isoflavones daily for 12 months does not alter mammographic or breast MRI tissue density in adults at high risk of breast cancer, with non-endocrine treated breast cancer, or previously treated for breast cancer and without evidence of recurrence (95999).
There is some concern that soy supplements, but not soy foods, might increase the risk of endometrial hyperplasia due to its estrogenic effects. Population and clinical research suggests that soy foods do not have a proliferative effect on endometrial cells (7358,2429,7654,9676,9917), and increased dietary soy and phytoestrogens are associated with reduced endometrial cancer risk (7338,10372). However, the effects seem to be different with concentrated soy isoflavone extract. While taking products providing isoflavones 120 mg daily for 6 months does not increase endometrial thickening (13209), taking higher doses such as isoflavones 150 mg daily for 5 years might increase the risk of simple endometrial hyperplasia (12105). However, there is no evidence that soy isoflavones increase the risk of atypical hyperplasia which has a much higher risk of developing into endometrial cancer than simple endometrial hyperplasia (12105,90973).
There is also concern that increased soy intake increases the risk for other types of cancer. Some observational research has found that higher dietary intake of soy is associated with a higher risk for bladder cancer and pancreatic cancer (9677,105609).
A meta-analysis of results from cohort and case-control studies evaluating the risk of stomach cancer related to consumption of fermented soy products is unclear and inconclusive. The highest quality data from cohort studies suggests that these products have no significant effect on stomach cancer (7340,7341). More research is required to determine if soy products have any correlation with stomach cancer.

Pulmonary/Respiratory ...Inhaled soy dust and soy hull aeroallergen can trigger symptoms of asthma and allergic rhinitis (5084,5085,5086).

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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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