Eight documented botanical failures each trace to a missing control, at identity, contamination, legal status or dose
What happened, what the primary record counted, what changed, and which control would have caught it, from a Brussels slimming clinic in 1993 to kratom actions in 2025 and 2026. Harms are described as published.
Status. EUTECNIQ was not involved in any case on this page. The controls named are proposals for a company that has no laboratory or products. Nothing here is medical advice.
Thirty-three years of failures and responses: harm signals, investigations and the rules or rulings that followed
Text version: all 25 events in date order
- 1993 Nine women with rapidly progressive kidney fibrosis after one slimming regimen Two index cases and seven more women under 50 in terminal or preterminal renal failure (1991–1992) had all followed the same slimming treatment at a Brussels clinic, which added two Chinese herbs in May 1990. Vanherweghem JL et al. Lancet 1993;341:387–391.
- October 25, 1994 DSHEA enacted The Dietary Supplement Health and Education Act created the notification duty for new dietary ingredients not marketed before October 15, 1994. Pub. L. 103-417; 21 U.S.C. 350b.
- June 1997 FDA proposes a dose limit for ephedrine alkaloids The proposal would have deemed a supplement adulterated at 8 mg or more of ephedrine alkaloids per serving; FDA withdrew that provision in April 2000. As described in 69 FR 6788 (Feb. 11, 2004).
- June 8, 2000 Urothelial carcinoma in 18 of 39 patients Aristolochia fangchi had replaced Stephania tetrandra in the slimming pills through a manufacturing error. Every tissue sample analyzed carried aristolochic acid–DNA adducts, and cumulative doses above 200 g carried higher risk. Nortier JL et al. N Engl J Med 2000;342:1686–1692.
- December 21, 2000 Causality review of 140 ephedra adverse-event reports 31% were judged definitely or probably related and 31% possibly related; 10 events were deaths and 13 caused permanent disability. Haller CA, Benowitz NL. N Engl J Med 2000;343:1833–1838.
- February 11, 2004 FDA declares ephedrine-alkaloid supplements adulterated The final rule found that they present an unreasonable risk of illness or injury; it took effect on April 12, 2004. 69 FR 6788 (Docket 1995N-0304).
- August 17, 2006 Appeals court upholds the ban at every dose Reversing a 2005 district ruling that had blocked enforcement at 10 mg a day or less, the Tenth Circuit held that FDA reasonably concluded "there is no recommended dose of EDS that does not present an unreasonable risk." Nutraceutical Corp. v. Von Eschenbach, 459 F.3d 1033 (10th Cir. 2006).
- June 25, 2007 Supplement cGMP rule requires identity testing 21 CFR Part 111 requires at least one appropriate test or examination to verify the identity of every dietary ingredient before use. 72 FR 34752; 21 CFR 111.75(a)(1)(i).
- April 2012 Warning letters to ten DMAA marketers Letters dated April 24, 2012 opened FDA's DMAA actions; its list grew to 18 firms by October 2017. FDA calls DMAA an amphetamine derivative that can raise blood pressure. FDA, DMAA in Products Marketed as Dietary Supplements (content current as of Feb. 22, 2023).
- 2013 DMAA formulations detained and destroyed FDA administratively detained OxyElite Pro and Jack3d after the distributor initially refused voluntary compliance; the products were destroyed. FDA DMAA page.
- October 11, 2013 Hepatitis cluster in Hawaii 29 cases of acute hepatitis of unknown cause, May 10 to October 3, 2013; 24 had used OxyELITE Pro. Eleven were hospitalized, two received liver transplants and one died. The product was recalled later in 2013. MMWR 2013;62(40):817; U.S. Department of Justice release, Mar. 13, 2019.
- February 2015 State attorney general halts sales after DNA tests The New York attorney general ordered four national retailers to stop selling certain herbal supplements after DNA barcoding failed to detect the labeled botanical in about 80% of products tested. As summarized in Wu DT et al. Sci Rep 2017;7:7792. The attorney general's release could not be retrieved for this page.
- 2016 Review: universal DNA barcodes cannot identify processed botanicals alone The authors do not recommend universal-primer DNA barcoding as the sole identification of processed plant material; they recommend combining specific DNA primers with chemical, microscopic and macroscopic methods. Parveen I et al. Planta Med 2016;82:1225–1235.
- March 13, 2019 Guilty pleas in the OxyELITE Pro and Jack3d case The distributor pleaded guilty to conspiracy involving mislabeled food. The indictment alleged that DMAA was imported with false certificates of analysis and sold as a natural plant extract. U.S. Department of Justice, Office of Public Affairs, Mar. 13, 2019.
- 2019 DMAA is not a dietary ingredient, a court affirms The Eleventh Circuit affirmed that "DMAA is not a dietary ingredient and is not generally recognized as safe"; the seized products were destroyed on November 12, 2020. FDA DMAA page.
- Current version, December 10, 2020 Import Alert 54-10 FDA detains, without physical examination, bulk and finished dietary supplements containing aristolochic acid. FDA Import Alert 54-10.
- February 2023 Ten turmeric liver-injury cases in a national network All ten were enrolled since 2011; five were hospitalized and one died. Seven carried HLA-B*35:01, an allele frequency of 0.450 against 0.056 to 0.069 in controls. Halegoua-DeMarzio D et al. Am J Med 2023;136:200–206.
- October 28, 2023 FDA alert on cinnamon applesauce pouches The distributor recalled the product the next day; the recall was expanded and reached 2,998,088 pouches. MMWR 2025;74(14):239–244.
- February 29, 2024 The source was lead chromate FDA reported that the lead and chromium in the recalled products and cinnamon came from lead chromate. MMWR 2025;74(14):239–244.
- January 7, 2025 Lead action levels for baby food Final guidance sets 10 ppb for fruits, most vegetables, mixtures, yogurts, custards and single-ingredient meats, and 20 ppb for single-ingredient root vegetables and dry infant cereals. 90 FR 1135; Docket FDA-2022-D-0278.
- April 24, 2025 566 cases in 44 States, DC and Puerto Rico 130 confirmed, 401 probable and 35 suspected; 96% were children under 6. Pouches from affected homes held 1.9 to 3.0 ppm lead. MMWR 2025;74(14):239–244.
- May 2025 Tianeptine: "not a dietary ingredient" FDA reports poison-center cases rising from 4 in 2013 to about 350 in 2024 and says it has issued import alerts to detain tianeptine shipments. FDA consumer update (content current as of May 9, 2025).
- July 29, 2025 FDA recommends scheduling 7-OH The recommendation targets concentrated 7-hydroxymitragynine products, "not natural kratom leaf products"; DEA rulemaking would follow. HHS press release, July 29, 2025.
- Current version, August 17, 2026 Import Alert 54-15 on kratom Supplements and bulk ingredients that are or contain Mitragyna speciosa are detained without physical examination as adulterated new dietary ingredients. FDA Import Alert 54-15.
- October 19, 2026 Final guidance on NDI identity and safety information Finalizes FDA's recommendations on identity, history of use and the safety narrative in a new dietary ingredient notification. 91 FR 66336; Docket FDA-2025-D-6501.
Five of the eight signals came from clinicians, a case registry, adverse-event reports or poison centers, after people had been exposed.
The primary records count very different things, from 9 patients to 566 children
Data table
| Case | What was counted | Number |
|---|---|---|
| Cinnamon applesauce | Cases (blood lead ≥ 3.5 µg/dL within 3 months of eating a recalled product) | 566 |
| Ephedra | Adverse-event reports reviewed, June 1997 to March 1999 | 140 |
| Aristolochia, Belgian cohort | Patients who had prophylactic removal of kidneys and ureters | 39 |
| OxyELITE Pro period | Acute hepatitis cases, Hawaii, May–October 2013 (24 used OxyELITE Pro) | 29 |
| Turmeric | Adjudicated DILIN cases, 2004–2022 | 10 |
| Aristolochia, first report | Women with rapidly progressive interstitial renal fibrosis after the same slimming regimen (2 index cases and 7 found by survey) | 9 |
The bars show the size of each investigation; none of them is an incidence rate, so they do not rank the risk of one botanical against another.
A substituted root caused kidney failure and urothelial cancer; an identity test that cannot read extracts produced a disputed verdict
Data table
| Finding | Patients |
|---|---|
| Urothelial carcinoma, ureter or renal pelvis (or both) | 17 |
| Urothelial carcinoma, bladder (papillary tumor) | 1 |
| Mild-to-moderate urothelial dysplasia | 19 |
| Normal urothelium | 2 |
| Total | 39 |
An identity test fit for the material, run on every lot before use, is the control that would have stopped the substitution.
Explanation, details and sources
In Brussels, a slimming clinic changed its regimen in May 1990 to include two Chinese herbs; by 1992 nine young women were in renal failure (Vanherweghem 1993). The pills' alkaloid profiles differed from those expected. Nortier and colleagues later reported that Aristolochia fangchi, which is nephrotoxic and carcinogenic, had been supplied in place of Stephania tetrandra by a manufacturing error. FDA now detains imported supplements containing aristolochic acid without physical examination (Import Alert 54-10).
Identity has a second failure mode: the test itself. In February 2015 the New York attorney general halted sales of certain store-brand herbal supplements after DNA barcoding failed to find the labeled plant in most products tested. Reviewers noted that extraction and processing can destroy DNA, so its absence is not proof of substitution (Wu et al. 2017; Ivanova et al. 2016, who called the move premature), and Parveen et al. (2016) advised against universal-primer barcoding as the sole identification of processed material. Since 2007, 21 CFR 111.75(a)(1)(i) has required at least one appropriate identity test of each dietary ingredient before use.
Lead chromate in cinnamon reached 566 people, almost all young children, through pouches at about 190 to 300 times FDA's action level
Data table
| Group | Cases | Share |
|---|---|---|
| Confirmed (venous test, no other significant lead source) | 130 | 23.0% |
| Probable (venous test; other sources possible or not assessed) | 401 | 70.8% |
| Suspected (capillary or unspecified test) | 35 | 6.2% |
| Under 2 years | 311 | 55.2% of 563 with age reported |
| 2 to 5 years | 231 | 41.0% of 563 |
| 6 years and older | 21 | 3.7% of 563 |
| Age not reported | 3 | – |
Case-status shares are of all 566 cases; age shares are of the 563 cases with age reported, as in the MMWR table. Children under 6 were 542 (96% of 566).
Testing incoming spice lots for lead and qualifying the spice supplier were the missing controls; highest venous blood lead in a case was 39.3 µg/dL.
Explanation, details and sources
FDA issued a public health alert on October 28, 2023; the distributor recalled the product the next day, and the recall was later expanded to 2,998,088 pouches. On February 29, 2024 FDA reported that the lead and chromium came from lead chromate. A case had a blood lead level of 3.5 µg/dL or more within three months of eating a recalled product. The within-person maximum venous level ranged from 3.5 to 39.3 µg/dL (median 7.2). The MMWR authors write that "increased product testing is essential to identifying contaminated products."
Green-tea EGCG raised liver enzymes at 800 mg a day in supplement trials, and turmeric injury clustered in one genotype
Dose and exposure data: EGCG and curcumin dose–exposure studies · benchmark-dose explorer
A safe history in one form and dose does not transfer to a concentrated extract, a higher dose or a susceptible person.
Explanation, details and sources
EFSA estimated mean EGCG intake from green tea infusions at 90 to 300 mg a day and up to 866 mg for high-level consumers, while supplements supply 5 to 1,000 mg. It concluded that tea prepared traditionally is generally safe at reported intakes, but that interventional trials show a statistically significant rise in serum transaminases at 800 mg EGCG a day or more taken as a supplement.
Dose was also the legal question for ephedra. A 2005 district court blocked enforcement of the ban for products at 10 mg a day or less; the Tenth Circuit reversed in 2006, holding that FDA "reasonably concluded that there is no recommended dose of EDS that does not present an unreasonable risk." In the aristolochia cohort, cumulative doses above 200 g were associated with a higher risk of urothelial carcinoma.
In the turmeric series, three of seven products tested also contained piperine (black pepper); the authors suggest the rise in cases may reflect use patterns or combination with black pepper.
Substances that are not dietary ingredients, from DMAA to tianeptine, were sold as supplements until warning letters, import alerts and prosecutions intervened
A legal-status review before purchase, and a certificate of analysis checked against an independent test, address both failure routes. Recall counts: drug recalls of supplements, supplement food recalls.
Explanation, details and sources
FDA states that "DMAA is not a dietary ingredient" and considers it an unsafe food additive in supplements; an appeals court affirmed in 2019. In the OxyELITE Pro and Jack3d case, the indictment alleged that DMAA was imported with false certificates of analysis and represented to some retailers as a natural plant extract; the distributor pleaded guilty in 2019 to conspiracy involving mislabeled food. A separate 2013 hepatitis cluster in Hawaii, in which 24 of 29 patients had used OxyELITE Pro, led to a recall that year.
Tianeptine is not approved by FDA for any medical use, and FDA states it "is not a dietary ingredient." For kratom, FDA's Import Alert 54-15 treats supplements that are or contain Mitragyna speciosa as adulterated because they contain a new dietary ingredient without adequate safety information; in July 2025 FDA recommended scheduling concentrated 7-hydroxymitragynine products, excluding natural leaf products.
Recall records show the same pattern at scale: see FDA drug recall records for products sold as supplements on Legal status and food recall records described as dietary supplements on the Regulatory overview.
By this page's assessment, identity testing or adverse-event surveillance would directly have caught seven of the eight cases; claims review, none
The proposed EUTECNIQ quality system would put identity, contaminant and legal-status checks before purchase and release, and monitor adverse events after.
Explanation, details and sources
Identity testing addresses substitution (aristolochia), undeclared synthetic substances (DMAA) and unsuitable methods (DNA barcoding of extracts). Supplier qualification with independent verification of certificates addresses falsified certificates (DMAA) and adulterated spice (lead chromate). Element testing addresses lead. Legal-status review addresses substances that are not dietary ingredients. Adverse-event surveillance is how the ephedra, OxyELITE Pro, turmeric and tianeptine signals were found. These controls would be designed and run by a company that does not yet exist; they describe intent, not performance.
Four large randomized trials of widely used botanicals found no benefit over placebo on their primary outcomes
Data table
| Trial | Participants, dose, duration | Primary result |
|---|---|---|
| Ginkgo biloba (GEM) | 3,069 aged 75+; 120 mg twice daily; median 6.1 years | Dementia HR 1.12 (95% CI 0.94–1.33; P = .21) |
| Saw palmetto (CAMUS) | 369 men; 320, 640, then 960 mg/day; 72 weeks | AUASI change −2.20 vs −2.99 placebo; difference 0.79 favoring placebo (1-sided P = .91) |
| Echinacea angustifolia | 399 volunteers challenged with rhinovirus; three extracts | No statistically significant effect on infection rate or symptom severity |
| Black cohosh (HALT) | 351 women; 160 mg/day; 1 year | No difference from placebo in vasomotor symptoms (herbal arms within 0.55 symptoms per day on average), except worse symptom intensity at 12 months with multibotanical plus soy; hormone therapy −4.06 (95% CI −5.93 to −2.19) |
Long use shows that people chose a plant; a randomized trial measures whether a defined product did what was claimed.
Explanation, details and sources
Each trial tested one characterized product, at a stated dose, in one population, against placebo. The echinacea trial compared three root extracts made by supercritical CO₂, 60% ethanol and 20% ethanol; none differed from placebo. In CAMUS, tripling the saw palmetto dose did not separate it from placebo. A null result applies to the product, dose and population tested. Safety and efficacy are separate questions: a clean safety record says nothing about benefit, and a benefit claim needs human evidence. Trial design is covered on Clinical research.
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