creatine with protein and carbohydrates can have a greater effect than creatine combined with either protein or carbohydrates alone. While generally considered safe, long-term or excessive consumption of creatine may have an adverse effect on the kidneys, liver, or heart and should be avoided if any pre-existing conditions affecting these organs exist. β-Hydroxy β-methylbutyrate When combined with an appropriate exercise program, dietary supplementation with β-hydroxy β-methylbutyrate (HMB) has been shown to dose-dependently augment gains in muscle hypertrophy (i.e., the size of a muscle), muscle strength, and lean body mass, reduce exercise-induced skeletal muscle damage, and expedite recovery from high-intensity exercise. HMB is believed to produce these effects by increasing muscle protein synthesis and decreasing muscle protein breakdown by various mechanisms, including activation of the mechanistic target of rapamycin (mTOR) and inhibition of the proteasome in skeletal muscles. The inhibition of exercise-induced skeletal muscle damage by HMB is affected by the time that it is used relative to exercise. The greatest reduction in skeletal muscle damage from a single bout of exercise appears to occur when calcium HMB is ingested 1–2 hours prior to exercise. Controversy Mislabeling and adulteration While many of the claims are based on scientifically-based physiological or biochemical processes, their use in bodybuilding parlance is often heavily colored by bodybuilding lore and industry marketing and, as such, may deviate considerably from traditional scientific usages of the terms. In addition, ingredients listed have been found at times to be different from the contents. In 2015, Consumer Reports reported unsafe levels of arsenic, cadmium, lead and mercury in several of the protein powders that were tested. In the United States, the manufacturers of dietary supplements do not need to provide the Food and Drug Administration with evidence of product safety prior to marketing. As a result, the incidence of products adulterated with illegal ingredients has continued to rise. In 2013, one-third of the supplements tested were adulterated with unlisted steroids. More recently, the prevalence of designer steroids with unknown safety and pharmacological effects has increased. In 2015, a CBC investigative report found that protein spiking (i.e., the addition of amino-acid filler to manipulate analysis) was not uncommon; however, many of the companies involved challenged these claims. Health problems The US FDA reports 50,000 health problems a year due to dietary supplements and these often involve bodybuilding supplements. For example, the "natural" best-seller Craze, 2012's "New Supplement of the Year" by