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“Y. Kawakami, H. Yamanaka-Okumura, Y. Naniwa-Kuroki and M. Sakuma, “Flaxseed oil intake reduces serum small dense low-density lipoprotein concentrations in Japanese men: a randomized, double blind, crossover study,” Nutrition Journal, vol. 14, no. 36, 2015. (https://www.ncbi.nlm.nih.gov/…”
Never lived, Merely survived. A scripted life full of sighs, and sugar coated lies, Read the epitaph of the young old man, Who died. ---Anonymous
An unusual question
DS1 asked an unexpected question, “AC, which of the two sayings is more true in your opinion? The meek shall inherit the earth or Veer bhogya vasundhara?”
I looked at him. The question was bizarre. He was not known for asking philosophical questions.
The first saying was a quotation from the Holy Bible “Blessed are the meek: for they shall inherit the earth“.2 The second was from Shrimad Bhagwat Gita, which meant “only the brave will enjoy this earth.”3
DS was my classmate who had left India to settle in the USA. He is a cardiologist by profession and was visiting his ailing parents in India. During this visit, he himself suffered from a Myocardial Infarction. Fortunately, he had reached a private hospital in time to have primary PTCA.4 He was currently recuperating in the hospital.
I had gone to look him up and to wish him a quick recovery. It was early morning and his hospital was on my way to work. When I entered his room, I found him busy devouring breakfast. On his tray were two fried eggs with sunny side up, a single buttered toast and black coffee.
A long lost friend
We had met after nearly 40 years. I decided to remain quiet about all that bright yellow yolk in the spoon moving towards his mouth. In college, we used to have long and frank discussions about what was right and what was wrong.
His decision to leave India was also the subject of one of our discussions. He was very clear that it was the only way he could improve the financial state of his family.
During his breakfast we caught up on the lost time. Overall, he appeared very disconsolate that day.
“AC, I have not lived for myself even a single day.” There was a regret in his voice, “And everyone I have tried to help has exploited me.”
I asked him, “Why do you say that?”
He said, “I guess, I have never talked about it to anyone in my life so far. It started very innocently when I was very young. We were a very poor family. My parents were busy making ends meet and I studied in a ‘Sun & Sand’ school.”
I smiled at his use of a fancy term for a village open air school where there is ‘sun above and sand below.’ He added, “For the secondary level, I was placed in a Government school, where the fee was merely 81 paise per month and none of the boys were interested in studies.”
I was aware that many brilliant students come out of such schools because of strong motivation. He carried on, “One day, our class-teacher Tripathi sir, called me and said – DS, if you do your maths well, I will let you pluck mangoes from the school tree!”
“What happened then?” I asked.
“Forbidden fruit was a big temptation for the young me. I worked hard and topped in maths. Tripathi sir, as promised, allowed me to pluck five mangoes every day during the season. Of the five, he used to keep four and give me one. And I would proudly take that mango home as a trophy to share with everyone.”
“Everyone?” I asked
“My parents and my two younger sisters. And the look of pleasure on their faces was addicting too.” He reminisced. “It changed my attitude to work. It led me into the habit of trying to remain in the good books of my teachers/parents.”
“So that is why you were so committed?” I observed.
“I used to get depressed if I did badly in any subject or if I could not do any chore at home as asked.” He replied.
“Good for you! No wonder you did so well.” I tried to cheer him up.
“Yes, it did work well for me till I reached the USA.” he sighed.
“As far as I know, you have done extremely well there too!” And that was the truth.
“In a way that is right. However, the guilt of leaving them was there. I used to feel compelled to share a major part of my scholarship money with my parents. Later it was from my pay. My sisters started taking their new found affluence for granted.” He said.
“Ohh.” there was nothing for me to say.
“With time, the demands from home kept increasing. My parents also now wanted to buy a flat and I felt obliged to help them as much as I could by staying away from all conveniences or luxuries for myself.”
I could sense that he was regretting it at some level now. He continued after a brief pause.
“You see, I never tried to have a good time as all my colleagues did. Never drank, never bought anything expensive for myself. I pushed myself to remain busy with my work. There was always something to be done for the family. Sisters’ education, marriage and then post marriage rituals; problems with brothers-in-law and so on. My focus on my parents and sisters was one of the reasons that my wife left with our kids. I was left alone with my work.”
I tried to console him, “Your work is formidable. Your research has made you a legend. Everyone admires you.”
I saw his eyes tearing up. He said,”That is the main problem!”
“Why?’ I was astonished.
“It’s a long story.” He was reluctant to go any further.
“I have time. And It will be better for you to take it out.” I tried to be helpful.
He thought for some time and then said, “You see, when I finished my cardiology, my mentor was working on coronary heart disease (CHD) due to atherosclerosis. My thesis was also on the same subject.”
“Naturally! That’s the subject dominating research the world over.” I interjected.
Cholesterol at the centerstage
He stated further, “Our team had done a lot of work on the risk factors for CHD, which included obesity, physical inactivity, raised blood glucose, raised blood pressure, raised total cholesterol, and high salt intake.5 I was asked to focus mainly on the cholesterol.”
I could understand that,”Yes it has been in the centerstage!”
“In 1950s, it was thought that saturated fat in diet is the principal cause of elevated serum cholesterol and CHD. American Heart Association (AHA) by 1960s, had accepted that Americans should lower their intake of saturated fat.”6
He was giving me the background of his research work. “I continued work in this area and some of our work led to the U.S. federal government formulating a document ‘new dietary goals’ and recommended reducing fat intake in diet (1977).7 My mentor was a part of that national document largely because of my research.”
I was impressed, “That shows the caliber of your work!.”
“At that time, we were aware of an alternative theory by a British physiologist, John Yudkin, who said that sugar was closely related to CHD incidence and mortality.8 My mentor saw his work as a competition and we debunked it. We proposed that cholesterol was the main thing.”
He was talking of a time when we had just discovered that cholesterol was carried in the blood with some proteins as tiny vesicles called lipoproteins. Some classes of these lipoproteins, for example, low-density lipoproteins (LDL) were linked to higher risk of CHD. That’s why we called it bad cholesterol. This was in contrast to high density lipoproteins (HDL) which was known as good cholesterol.
Good and bad cholesterol
He elaborated further, “Our research later showed that it was incorrect to blame total cholesterol or LDL for heart disease. CHD risk depended on a special component of LDL called ‘small dense LDL’ which was more readily oxidized.11,12 The remaining large, buoyant or fluffy LDL could even be anti-atherogenic.”13,14
“You mean the remaining large, fluffy LDL behaved like good cholesterol?” I asked.
“There were some indications that it does. The research also showed that eating saturated fat led to reduction in small-dense LDL and increased large buoyant LDL.15,16 It meant that saturated fats protect against CHD, although we called these conclusions controversial.17,18
“You mean eating saturated fat protects one against heart disease?” I repeated what he had said.
He took no notice of my remark and went on, “Something more came to light around the same time. Some saturated fatty acids increased LDL and HDL levels while others did not.19 For example, saturated fatty acids – streate and laureate, seemed to reduce heart disease risk.”
I recalled one report which had generated a lot of discussion among lay people, “Would that explain the normal cholesterol levels in an 88 years old man, so called ‘Cool Hand Luke,’ who ate 25 eggs a day for the last 15 years?”20
He replied nonchalantly, “I am not sure. That was a freak case. There must have been some genetic protection there.”
Why cut down fat?
I looked at him sideways and remarked, “But the hospitals are now allowing eggs to patients with heart disease!”
He understood that I was referring to his breakfast and said defensively, “Yes, thanks to the efforts of the egg-industry, the restrictions on eggs have now been eased.”21
“Tell me in simple term, what should one eat?” I asked
He was ready with the answer, “If one wants to reduce really bad cholesterol, one may be advised to eat low carbohydrate diet with reasonable amount of fat/saturated fat (including nuts, avocados, flax seed oil and fish oils).22,[ref]V. Guay, L. B. A. Charest, A. Tremblay and C. P. , “Effect of short-term low- and high-fat diets on low-density lipoprotein particle size in normolipidemic subjects.,” Metabolism, vol. 61, no. 1, pp. 76-83, 2012. (https://www.ncbi.nlm.nih.gov/pubmed/21816443)[/ref],23,[ref]Y. Kawakami, H. Yamanaka-Okumura, Y. Naniwa-Kuroki and M. Sakuma, “Flaxseed oil intake reduces serum small dense low-density lipoprotein concentrations in Japanese men: a randomized, double blind, crossover study,” Nutrition Journal, vol. 14, no. 36, 2015. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4409715/)/ref],24,25,[ref]M. Pedersen, C. Mølgaard, L. Hellgren and L. Lauritzen, “Effects of fish oil supplementation on markers of the metabolic syndrome.,” J Pediatr, vol. 157, no. 3, pp. 395-400, 2010.(https://www.ncbi.nlm.nih.gov/pubmed/20472253)[/ref] One should exercise more and avoid sugars particularly fructose.”26,[ref]S. Rizkalla, “Health implications of fructose consumption: A review of recent data,” Nutrition & Metabolism, vol. 82, no. https://doi.org/10.1186/1743-7075-7-82, p. 7, 2010.(https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-7-82)[/ref]
“Is that what current guidelines say?” I wanted to be sure.
“Current guidelines suggest that saturated fats as well as sugars, each should not form more than 10% of total calories.27 He continued his narrative, “When we first recommended that fat intake should be reduced, we had not realised that it will be replaced by carbohydrates!”
What does one eat in low fat diet?
“And what was the impact?” I asked.
“Clearly unfavourable! If carbohydrate intake was increased, total cholesterol automatically rose,28 In addition, HDL levels fell with increased risk for CHD!”29 He said. “Consuming even moderate amounts of sugar led to an increase in CHD risk significantly.30,31,32,33 Most of the evidence was coming from our competitors.”
“So your recommendations went to prove your competitors right?” I could not hide my smile.
Look at carbohydrates
He sighed. “In a way, yes. High sugar in diet led to increased risk for CHD, insulin resistance and other vascular diseases.34,[ref]Szanto S, Yudkin J. Dietary sucrose and platelet behaviour. Nature 1970;225:467-8.[/ref],35 Among the sugars too, fructose, and sucrose, seemed to be more harmful than others.”36
I asked, “Common cane sugar is sucrose. Isn’t fructose the sugar that is present in fruit juices, honey, corn syrup and mayonnaise?”
Sugar, honey and fruits?
“I asked, “So, is carbohydrate worse than fat?”
“More and more studies are finding that dietary fat has no significant impact on risk of CHD.43,44,45 Thus, there was no scientific evidence to support our recommendations of 1977. But the same theme was copied in many subsequent guidelines in the USA and also 1983 Dietary Fat Guidelines of the UK.46,47
“What happened when people followed your older guidelines and reduced saturated fat in the diet? Was it not beneficial?” I asked.
Sugar is the poison!
“I give you bitter pills, in a sugar coating. The pills are harmless - the poison's in the sugar” ― James St. James, Party Monster: A Fabulous But True Tale of Murder in Clubland
He answered, “Results depended on what the ‘saturated fat‘ calories were replaced with! Many replacements such as trans-fats or omega-6 polyunsaturated oil were worse and lead to higher deaths.48,49,50 If we replaced it with refined carbohydrates or sugars, the risk of CHD is increased.51,52,53 Replacing saturated fats with whole grains could be beneficial for CHD though.”54
“You are equating carbohydrates and sugar.” I interjected.
I tried to console him, “Lets forget all research for a moment. Even if your competitors were proven right, science was richer. You should be happy!”
“AC, you have missed the real point!” He appeared alarmed.
“Which point?” I asked.
“What did that paper say?” I asked.
“It was devastating. It started with Sugar Research Foundation (SRF or the research front of sugar industry) president Henry Hass’s 1954 speech, on What’s New in Sugar Research.”63
“What did he say?” I was puzzled.
“In his speech, he quoted from one of my mentor’s papers that reducing 20% calories from fat can reduce blood cholesterol. And asked his men to try to fill that 20% gap with energy giving sugars. The sugar industry then went on to spend $600,000 (Around $ 6 billion in today’s value) to orchestrate a disinformation campaign. It taught lay people that sugar keeps us alive and gives us energy to face daily problems.”64
“Ooh,” I saw his point.
A learned fool is more a fool than an ignorant fool
DS further said, “When Yudkin’s research started getting attention, SRF (Sugar Reseach Foundation) financed a program to change society’s negative attitude towards sugar.65 Project 226 was born,66 which resulted in the famous 2-part review in NEJM on Dietary Fats, Carbohydrates and Atherosclerotic Disease.67,68
I added, “NEJM is one of the most reputable medical journals in the US.”
“This paper did not disclosed funding and participation of SRF. It concluded that there was ‘no doubt’ that the only dietary intervention required to prevent CHD was to reduce dietary cholesterol and substitute polyunsaturated fat for saturated fat in the American diet.”
“That’s a biased conclusion, ignoring contemporary knowledge.” I exclaimed.
I asked, “Is there more?”
“The sugar industry also commissioned yet another review, “Sugar in the Diet of Man,” and several other papers aimed at favourably influencing the 1976 US Food and Drug Administration evaluation of the safety of sugar.73,74,75 It appears that the industry has a long history of influencing scientific minds and federal policy using its financial muscle.”
Doctors are gullible
I asked, “I guess, the pharmaceutical industry is not the only one doctoring medical science.76 Are you depressed because you were unknowingly manipulated to mislead people?”
“More than depressed. I learnt later that my mentor had received major funding from SRF. My own scholarship was sponsored by SRF money. My mentor in the USA, just like Tripathy sir, allowed me to keep one mango, while he took home four! All my initial research was not only funded by SRF money, but was also analysed by SRF paid statistician. My lifetime of hard work appears a deception to me now, because it was used to mislead the world!”
I stared at his stern face and said nothing
After a pregnant pause, DS asked an unexpected question, “AC, which of the two sayings is more true in your opinion? The meek shall inherit the earth! or Veer Bhogya Vasundhara?”
The meek may be disinherited!
I did not answer his question. Obviously he identified with the meek. One who followed all the rules and tried to please everyone. He regretted that he could not be a ‘veer’ or a brave one who lives by one’s own rules.
I said, “DS, you can not blame yourself. The credit or discredit belongs entirely to your mentor, who orchestrated everything!”
DS spoke in a low voice, “I was the proverbial good boy. Very conscientious, obedient and well meaning. I did all I could for everyone in my life. Two days back, when I was having an MI, I thought, my end had come. My whole life scrolled past in front of my eyes. I felt cheated and exploited! Maybe self centered people are better off.”
I tried to console him. “You are a good man DS. You did everything an ideal son, brother or student should have done. Let the world live by the values it has.”
After some time I wished him a quick recovery, and came out. I was wondering how can one escape being exploited by the big businesses? The word ‘business ethics’ is an oxymoron and goes way beyond the contradiction in terms.77
In the Treta yug, assiduous and dutiful Ram, who had followed every rule in the moral book, was worshipped as God because his conduct was exemplary for his time. In Dwapar yug, ingenious Krishan had to bend every other rule to succeed!
For Kaliyug, what kind of conduct would be appropriate for Kalki?
Just ponder over this question. Happy Deepawali.
|↑1||Names of the characters in this conversation are imaginary, though every fact stated is real|
|↑4||Percutaneous transluminal coronary angioplasty|
|↑5||Sharma M, Kishore A, Roy D, Joshi K. A comparison of the Indian diet with the EAT-Lancet reference diet. BMC Public Health. 2020 May 29;20(1):812. doi: 10.1186/s12889-020-08951-8. PMID: 32471408; PMCID: PMC7260780.|
|↑6||Dietary fat and its relation to heart attacks and strokes. Report by the Central Committee for Medical and Community Program of the American Heart Association. JAMA 1961;175:389-91.|
|↑7||Dietary Goals for the United States, Nutrition Reviews, Volume 35, Issue 5, May 1977, Pages 122–125, https://doi.org/10.1111/j.1753-4887.1977.tb06563.x|
|↑8||Yudkin J. DIETARY FAT AND DIETARY SUGAR IN RELATION TO ISCHAEMIC HEART-DISEASE AND DIABETES. Lancet 1964;2:4-5.|
|↑9||Mensink RP, Zock PL, Kester AD, et al. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a metaanalysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146-55.|
|↑10||Robinson F, Hackett AF, Billington D, et al. Changing from a mixed to self-selected vegetarian diet–influence on blood lipids. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association 2002;15:323-9.|
|↑11||Verhoye E, Langlois MR. Circulating oxidized low-density lipoprotein: a biomarker of atherosclerosis and cardiovascular risk? Clin Chem Lab Med 2009;47:128-37.|
|↑12||Wraith KS, Magwenzi S, Aburima A, et al. Oxidized low-density lipoproteins induce rapid platelet activation and shape change through tyrosine kinase and Rho kinase-signaling pathways. Blood 2013;122:580-9.|
|↑13||Fernandez ML. Rethinking dietary cholesterol. Curr Opin Clin Nutr Metab Care 2012;15:117-21.|
|↑14||Lamarche B, Tchernof A, Moorjani S, et al. Small, dense low-density lipoprotein particles as a predictor of the risk of ischemic heart disease in men. Prospective results from the Quebec Cardiovascular Study. Circulation 1997;95:69-75.|
|↑15||Dreon DM, Fernstrom HA, Campos H, et al. Change in dietary saturated fat intake is correlated with change in mass of large low-density-lipoprotein particles in men. Am J Clin Nutr 1998;67:828-36.|
|↑16||Ramsden CE, Faurot KR, Carrera-Bastos P, et al. Dietary fat quality and coronary heart disease prevention: a unified theory based on evolutionary, historical, global, and modern perspectives. Curr Treat Options Cardiovasc Med 2009;11:289-301.|
|↑17||Campos H, Moye LA, Glasser SP, et al. Low-density lipoprotein size, pravastatin treatment, and coronary events. JAMA 2001;286:1468-74.|
|↑18||Mora S, Szklo M, Otvos JD, et al. LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2007;192:211-7.|
|↑19||Ramsden CE, Faurot KR, Carrera-Bastos P, et al. Dietary fat quality and coronary heart disease prevention: a unified theory based on evolutionary, historical, global, and modern perspectives. Curr Treat Options Cardiovasc Med 2009;11:289-301|
|↑20||Kern F Jr. Normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day. Mechanisms of adaptation. N Engl J Med. 1991 Mar 28;324(13):896-9. doi: 10.1056/NEJM199103283241306. PMID: 1953841.|
|↑21||McNamara DJ. The Fifty Year Rehabilitation of the Egg. Nutrients. 2015;7(10):8716-8722. Published 2015 Oct 21. doi:10.3390/nu7105429|
|↑22||R. Krauss, P. Blanche, R. Rawlings, H. Fernstrom and T. Williams, “Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia,” American Journal of Clinical Nutrition, vol. 83, no. 5, pp. 1025-1031, 2006 .(http://ajcn.nutrition.org/content/83/5/1025.long)|
|↑23||J. DiNicolantonio, S. Lucan and J. O’Keefe, “The Evidence for Saturated Fat and for Sugar Related to Coronary Heart Disease,” Prog Cardiovasc Dis., vol. 58, no. 5, pp. 464-472, 2016. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856550/)|
|↑25||L. Wang, P. Bordi, J. Fleming, A. Hill and P. Kris-Etherton, “Effect of a Moderate Fat Diet With and Without Avocados on Lipoprotein Particle Number, Size and Subclasses in Overweight and Obese Adults: A Randomized, Controlled Trial,” J Am HEart Assoc, vol. 4, no. 1, p. e001355., 2015. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330060/)|
|↑26||P. Siri-Tarino, P. Williams, H. Fernstrom, R. Rawlings and R. Krauss, “Reversal of Small, Dense LDL Subclass Phenotype by Normalization of Adiposity,” Obesity (Silver Spring), vol. 17, no. 9, pp. 1768-1775, 2010. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2837149/)|
|↑28||Naismith DJ, Stock AL, Yudkin J. Effect of changes in the proportions of the dietary carbohydrates and in energy intake on the plasma lipid concentrations in healthy young men. Nutr Metab 1974;16:295-304.|
|↑29||Yudkin J, Kang SS, Bruckdorfer KR. Effects of high dietary sugar. Br Med J 1980;281:1396.|
|↑30||Albrink MJ, Meigs JW, Man EB. Serum lipids, hypertension and coronary artery disease.Am J Med 1961;31:4-23.|
|↑31||Szanto S, Yudkin J. The effect of dietary sucrose on blood lipids, serum insulin, platelet adhesiveness and body weight in human volunteers. Postgrad Med J 1969;45:602-7.|
|↑32||Szanto S, Yudkin J. Dietary sucrose and platelet behaviour. Nature 1970;225:467-8.|
|↑33, ↑34||Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014 Jul;100(1):65-79. doi: 10.3945/ajcn.113.081521. Epub 2014 May 7. PMID: 24808490.|
|↑35||Barua RS, Ambrose JA. Mechanisms of coronary thrombosis in cigarette smoke exposure. Arterioscler Thromb Vasc Biol 2013;33:1460-7|
|↑36||Reiser S, Michaelis OEt, Cataland S, et al. Effect of isocaloric exchange of dietary starch and sucrose in humans on the gastric inhibitory polypeptide response to a sucrose load. Am J Clin Nutr 1980;33:1907-11.|
|↑37||Vasselli JR, Scarpace PJ, Harris RB, et al. Dietary components in the development of leptin resistance. Advances in nutrition (Bethesda, Md) 2013;4:164-75.|
|↑38||Stanhope KL. Sugar consumption, metabolic disease and obesity: The state of the controversy. Crit Rev Clin Lab Sci. 2016;53(1):52-67. doi: 10.3109/10408363.2015.1084990. Epub 2015 Sep 17. PMID: 26376619; PMCID: PMC4822166.|
|↑39||Lim JS, Mietus-Snyder M, Valente A, et al. The role of fructose in the pathogenesis of NAFLD and the metabolic syndrome. Nature reviews Gastroenterology & hepatology 2010;7:251-64.|
|↑40||Schwarz JM, Noworolski SM, Wen MJ, et al. Effect of a High-Fructose Weight-Maintaining Diet on Lipogenesis and Liver Fat. J Clin Endocrinol Metab 2015;100:2434-42.|
|↑41||Brown CM, Dulloo AG, Yepuri G, et al. Fructose ingestion acutely elevates blood pressure in healthy young humans. Am J Physiol Regul Integr Comp Physiol 2008;294:R730-7.|
|↑42||Young JB, Landsberg L. Stimulation of the sympathetic nervous system during sucrose feeding. Nature 1977;269:615-7.|
|↑43||Leosdottir M, Nilsson PM, Nilsson JA, et al. Dietary fat intake and early mortality patterns–data from The Malmo Diet and Cancer Study. J Intern Med 2005;258:153-65.|
|↑44||Siri-Tarino PW, Sun Q, Hu FB, et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 2010;91:535-46.|
|↑45||Hooper L, Summerbell CD, Higgins JP, et al. Dietary fat intake and prevention of cardiovascular disease: systematic review. BMJ 2001;322:757-63.|
|↑46||Harcombe Z, Baker JS, Cooper SM, et al. Evidence from randomised controlled trials did not support the introduction of dietary fat guidelines in 1977 and 1983: a systematic review and meta-analysis. Open Heart 2015;2:e000196.|
|↑47||Harcombe Z, Baker JS, DiNicolantonio JJ, Grace F, Davies B. Evidence from randomised controlled trials does not support current dietary fat guidelines: a systematic review and meta-analysis. Open Heart. 2016 Aug 8;3(2):e000409. doi: 10.1136/openhrt-2016-000409. PMID: 27547428; PMCID: PMC4985840|
|↑48||de Souza RJ, Mente A, Maroleanu A, et al. Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ 2015;351:h3978.|
|↑49||Ramsden CE, Hibbeln JR, Majchrzak SF, et al. n-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr 2010;104:1586-600.|
|↑50||Ramsden CE, Zamora D, Leelarthaepin B, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ 2013;346:e8707.|
|↑51||Jakobsen MU, O’Reilly EJ, Heitmann BL, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009;89:1425-32.|
|↑52||Liu S, Willett WC, Stampfer MJ, et al. A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr 2000;71:1455-61.|
|↑53||Hu FB. Are refined carbohydrates worse than saturated fat? Am J Clin Nutr 2010;91:1541-2.|
|↑54||Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared With Unsaturated Fats and Sources of Carbohydrates in Relation to Risk of Coronary Heart Disease: A Prospective Cohort Study. J Am Coll Cardiol 2015;66:1538-48.|
|↑55||Basu S, Yoffe P, Hills N, et al. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One 2013;8:e57873.|
|↑56||Goran MI, Ulijaszek SJ, Ventura EE. High fructose corn syrup and diabetes prevalence: a global perspective. Global public health 2013;8:55-64.|
|↑57||Lapidus L, Bengtsson C, Blohme G, et al. Blood glucose, glucose tolerance and manifest diabetes in relation to cardiovascular disease and death in women. A 12-year follow-up of participants in the population study of women in Gothenburg, Sweden. Acta Med Scand 1985;218:455-62.|
|↑58||Garcia MJ, McNamara PM, Gordon T, et al. Morbidity and mortality in diabetics in the Framingham population. Sixteen year follow-up study. Diabetes 1974;23:105-11.|
|↑59||Venkataraman K, Khoo CM, Leow MK, et al. New measure of insulin sensitivity predicts cardiovascular disease better than HOMA estimated insulin resistance. PLoS One 2013;8:e74410.|
|↑60||Gast KB, Tjeerdema N, Stijnen T, et al. Insulin resistance and risk of incident cardiovascular events in adults without diabetes: meta-analysis. PLoS One 2012;7:e52036.|
|↑61||Journal of American Medical Association|
|↑62||Kearns CE, Schmidt LA, Glantz SA. Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents. JAMA Intern Med. 2016 Nov 1;176(11):1680-1685. doi: 10.1001/jamainternmed.2016.5394. Erratum in: JAMA Intern Med. 2016 Nov 1;176(11):1729. PMID: 27617709; PMCID: PMC5099084.|
|↑63, ↑64||Hass HB. What’s new in sugar research.Proceedings of the American Society of Sugar Beet Technologists. 1954. http://digitalcollections.qut.edu.au/1407/5/American_Society_of_Sugar_Beet_Technologists_1954_Part_1.pdf.|
|↑65||Hickson JL. Memoranda to Neil Kelly regarding possible activities of the Sugar Association Inc (December 14, 1964). Papers of Roger Adams at the University of Illinois Archives, 1889-1971. Urbana: University of Illinois. Record Series No. 15/5/23. Quoted by 56 ibid.|
|↑66||Hegsted DM. Letter to John L. Hickson, Sugar Research Foundation (July 23, 1965). D. Mark Hegsted papers, 1952-1999 (inclusive), 1960-1978 (bulk). Boston, MA: Harvard Medical Library, Francis A. Countway Library of Medicine. HMS c54. Quoted by 56 ibid.|
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