Tips On Improving Your Cholesterol Profile

The beneficial effects on the heart and circulatory system of a having a low blood level (below 130) of LDL cholesterol and a high blood level (above 55) of HDL cholesterol are well established. It is also good to have a ratio of total cholesterol to HDL cholesterol of no more than 4.0. If your levels don’t meet these criteria, you might benefit from the recommendations listed in an online Men’s Health Magazine article by Bill Phillips dated September 13, 2011. It presents the following ways, purportedly based on scientific studies, of improving your cholesterol profile without drugs:

Raise Your HDL Level

• Eat at least 2 oz (57 gm) of nuts per day.
• Do endurance exercise at least 20 min/day
• Do 3 sets of 6-8 reps of the half squat, leg extension, and leg press, with 2 min max rest between sets, 2x/wk
• Take a 1000 mg calcium supplement daily with 400 IU of Vitamin D-3
• Eat fresh, not processed, white fish (e.g. cod, sole, flounder)
• Take a daily 10-20 mg polycosanol supplement
• Drink cranberry juice
• Eat 2.5 oz of dark chocolate daily

Lower Your LDL Level

• Eat a grapefruit daily
• Eat several small meals a day
• Eat food fortified with oat bran
• Switch from a margarine containing trans fats to a spread that doesn’t
• Drink Concord grape juice
• Take phytosterol or phytostanol supplements in pills or margarine form
• Add whole grains, nuts, and beans to your diet

Bottom Line

These seem like good recommendations. Just observe the following precautions:

• Don’t overdo the calories by adding these items to your diet. Remove other items when you add these.
• Endurance exercise is important for everyone. Weight training alone is not optimal for health.
• Do not exceed 1000 mg of calcium/day from all sources (1200 mg/day if you're over 70) because of a possible increased risk of prostate cancer.
• Don’t eat only white fish, because darker, fattier fish like salmon and mackerel are high in beneficial omega-3 fish oil.
• Don’t overdo the juice because even natural juices contain a lot of sugar, especially fructose, which can increase fatty deposits in the liver and around the midsection.
• Look for brands of dark chocolate without added milk fat.
• Several small meals means SMALL.
• The margarine brands that contain phytosterols and phytostanols contain some trans fats that are not listed because they're less than 0.5 mg per serving. So you may prefer getting these supplements in tablet form.

　

Important Information About Vitamins

An article in the September 2011 issue of the Nutrition Action Health Letter, published by the Center for Science in the Public Interest, examined research data on the value of taking multivitamins. Key points of the articles are:

Three major studies with a total of 426,000 study subjects over the age of 40 showed no difference between those who took and those who didn’t take multi-vitamins as to lifespan or the incidence of cardiovascular disease, cancer, or stroke.

Other studies showed no effect of multi-vitamin use on the incidence of colds, other infections, length of illness, or absence from school, work or other planned activities.

Cognitive performance was not improved in various study groups that took multi-vitamins for 6-12 months

However, the U.S. Dietary Guidelines Advisory Committee found that the following nutrients that are deficient among a large number of Americans:

• Vitamin D
• Folic acid
• Vitamin B-12
• Iron (among women due to menstruation)
• Calcium

Most brands of multivitamins do not provide large enough doses to cause harm. However, there is concern that some people may be ingesting enough of the following to increase their risk of health problems:

• Folic acid: Too little folic acid can increase the risk of colorectal cancer, and pregnant women who are deficient in folic acid are at risk for having babies with neural tube defects. That is why the U.S. government now mandates that folic acid be added to grain products. However, there is some evidence that too much folic acid taken over several years can increase the risk of having colorectal pre-cancerous growths (adenomous polyps) as well as prostate cancer. Thus, it is prudent not to ingest more than 1,000 micrograms a day of folic acid. Some breakfast cereals contain 400 micrograms per serving, and many people eat more than the standard serving size. Eating such cereals every day as well as taking a multivitamin and eating fortified bread, pasta, or rice can easily lead to exceeding 1,000 micrograms. This can be prevented by avoiding multivitamins with more than 400 micrograms of folic acid and limiting consumption of cereals that are fortified with 400 micrograms of folic acid per serving (e.g. Kashi Heart to Heart, Total, Multigrain Cheerios, Kellog’s Mueslix, Product 19, Smart Start, and Special K Original).
• Selenium: Although there is marginal evidence that selenium may lower the risk of certain types of cancer, a study showed that people who took 200 micrograms of selenium daily for 8 years were almost 3 times as likely to be diagnosed with diabetes than those who didn’t take the supplement. So it is best to avoid multivitamins that contain more than 100 micrograms of selenium.
• Vitamin A: While a Vitamin A deficiency can cause various health problems, very few Americans are deficient in the vitamin. However, a study showed that excess Vitamin A (more than 1667 IU/day) doubled the risk of hip fracture among women. The safest alternative is to take a multivitamin that contains beta-carotene rather than Vitamin A. Beta carotene is converted to Vitamin A as needed by the body and doesn’t cause any harm itself.

Bottom Line

• Unless you feel you can get all your needed nutrients from your food, take a multivitamin that has 100% of the recommended daily value of each vitamin, rather than taking megadoses.
• It is advisable not to exceed 1000 micrograms per day of folic acid by avoiding multivitamins with over 400 micrograms per serving and limiting intake of breakfast cereals containing more than 200 micrograms per serving.
• Limit selenium in supplements to 100 micrograms per day.
• Limit Vitamin A in supplements to 100% of daily value (5000 IU). Or, even better, take a supplement that contains beta-carotene rather than Vitamin A.

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Are dairy products healthy?

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Many books and articles contain health recommendations based on little or no scientific evidence. So when making personal decisions about how to maintain and improve one’s health, it is important to look for books and articles based on solid studies, especially large, well-controlled ones. A good example of science-based health information can be found in the July/August 2011 issue of the Nutrition Action Health Letter, published by the Center for Science in the Public Interest. It evaluates the pros and cons of consuming dairy products, Some of its key points:

Bones
We all know that milk is a major source of dietary calcium, which is needed to maintain bone density. Recently however, some health writers have contended that eating animal protein lowers bone density. Because protein contains amino acids, the alleged mechanism is increased acidity of the blood, prompting the body to respond by leaching calcium from the bones to neutralize the acid. Since milk is a protein source, it is implicated in bone loss. However, scientific study has refuted this contention. In actuality, bone mineral density is higher among people who eat more protein and lower among people who eat less protein. Radio isotope studies that tracked actual deposition and depletion of calcium have verified that consumption of dairy foods does not increase bone loss as we age.

Colon Cancer
A major analysis by the Harvard School of Public Health of 10 studies conducted in 5 countries, involving over 500,000 people concluded that people who drank at least one cup of milk per day had a 15% lower risk of colon cancer than those who drank less than 2 cups per week. Similarly, people treated for colon cancer who took 1200 mg of calcium per day and who had an above-average Vitamin D level had 15% less chance of recurrent colon cancer than those who didn’t take the calcium. Twenty-five percent of experimental animals fed a high-fat diet low in fiber, calcium, Vitamin D, and folic acid, developed colon tumors, but those supplemented with calcium and Vitamin D got none.

Prostate Cancer
There is some inconsistent evidence that high calcium consumption (in excess of 1500 mg/day) may increase the risk of prostate cancer. Milk increases the body’s level of insulin-like growth factor-1 (IGF-1), a hormone that stimulates the growth of both muscle and bone, but may also stimulate prostate-cancer growth. Even though a study of men receiving a 1200 mg calcium supplement daily showed no prostate cancer increase, the article recommended that men limit their calcium intake from food and supplements combined to 1000 mg/day if under 70 years of age and 1200 mg/day if over 70.

Blood Pressure
Adding 2 servings per day of low-fat dairy foods to a diet rich in fruits and vegetables, lowered blood pressure even further. In addition, a study of 28,000 women over 10 years showed that those consuming at least 2 cups/day of low-fat dairy foods reduced their risk of high blood pressure by 10%.

Weight Loss
When restricted to the same number of calories per day, women consuming more dairy products showed no difference in weight loss than those who consumed less dairy. However, when allowed to eat all they wanted at the end of the study, the dairy group consumed fewer calories. The implication is that dairy may help control appetite. While the weight-loss results were equivocal, the women in the low-dairy group lost bone density in their hips, while the high-dairy group did not. This is an important finding, considering that dangerous loss in bone density is common among both women and men as they age.

Lactose Intolerance
Lactose is the sugar found in milk. The following is the lactose content of some dairy products:

• 8 oz cup of milk: 12 grams
• 6 oz cup of yogurt - 10 grams
• 1 oz hard cheese or cream cheese - 1 gram or less
• ½ cup cottage cheese - 4-5 grams
• ½ cup ice cream - 4-5 grams

Many people think they are lactose-intolerant, However, the article cites evidence that between one-third and three-quarters of people who think they are lactose-intolerant are actually not so. Many of them show none of the typical symptoms of gas or diarrhea when lactose is put in their non-dairy drinks without their knowledge. Many people’s digestive systems can adjust to lactose by building up intestinal bacteria over a period of time. So the authors recommend that people who think they are lactose intolerant try to adjust to lactose by:

• Limiting lactose to 12 grams at a time (the amount in one 8 oz glass of milk).
• Consuming lactose along with other foods to give it more time to be digested
• Eating dairy foods regularly to maintain lactose-digesting bacteria
• Other Health Issues Related to Dairy Products

Diabetes
A study of 200,000 people over 20 years showed that those consuming 3-5 servings per day of dairy products had a 14% lower risk of Type II diabetes than those consuming less than 1.5 servings per day. However, it is not known whether that is an effect of the dairy products or another factor common to people who consume more dairy products.

Breast and Ovarian Cancer
Eight studies of 350,000 women in several countries did not find any link between milk consumption and breast cancer. However, research on 500,000 women in the U.S. and Europe did show a weak and marginally significant increased risk of ovarian cancer for women who consumed more than 30 grams of lactose per day. However, two major cancer research organizations did not feel the evidence was conclusive.

Bottom Line
Dairy products made from skim or one-percent milk can be considered health-promoting foods. They contain large quantities of calcium necessary for maintaining bone-density as we age. Also, most are excellent sources of protein (except products made primarily from milk fat, such as cream cheese and butter). Milk appears to help control blood pressure and avoid colon cancer, and may also help control appetite. However, high milk consumption may increase the risk of prostate cancer among men and ovarian cancer among women. Therefore, men should limit calcium consumption from food and supplements combined to 1000 mg/day below age 70 and 1200 mg/day above age 70. Adequate Vitamin D intake is essential for healthy bone mineralization, even if calcium intake is adequate. Many people are deficient in Vitamin D because of low sun exposure. Current recommendations for daily Vitamin D supplementation are in the neighborhood of 1,000-2,000 IU.

Additional Note
The main type of saturated fat found in milk (myristic acid) is particularly potent in raising blood cholesterol, specifically the harmful low-density variety (LDL). Because of that, consumption of milk fat should be very limited. High proportions of milk fat are found in cream, butter, ice cream, cheese (especially cream cheese and soft cheeses like Brie), whole milk, and 2% milk. That is why non-fat and 1% fat milk products are preferable. Unfortunately, many dishes popular in the U.S., such as cheese burgers cheese ravioli, macaroni and cheese, and pizza, contain large amounts of cheese. The evidence indicates that the cardiovascular health of Americans would benefit from a reduction in cheese consumption.

How to Avoid Inflammation of Your Arteries

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Inflammation of the blood vessels and other bodily tissue has become increasingly recognized as being complicit in heart disease, arthritis, and decline of mental capacity. Fortunately, the choices we make concerning what and how much we eat and drink, and how much exercise we do, can dramatically influence the degree of inflammation we experience. The information presented herein concerning lifestyle factors that affect inflammation, comes from a review article by O’Keefe, Gheewala, and O’Keefe in the Journal of the American College of Cardiology (vol. 51, no. 3, 2008).

Meals that are high in calories, and/or contain easily digestible, quickly absorbable, calorie-dense processed food and drink result in spikes in blood glucose and triglycerides (blood-borne fats), overwhelming the body’s ability to process them. Oxidative free radicals are then produced which attack the lining of the arteries (endothelium), inflaming them, causing them to constrict, and building up fatty deposits (atherosclerosis). In contrast, smaller meals containing ingredients that digest more slowly (e.g. fiber) produce smaller surges in blood sugar and triglycerides, and are thus not inflammatory.

Even a single meal high in saturated fat results in an increase of triglycerides, oxidative free radicals and inflammation, which negatively affects the function of the endothelium, causing constriction of the arteries, and raising systolic blood pressure.

A high glycemic meal is one that causes a spike in blood glucose. The Glycemic Index rates foods in comparison to glucose. Foods scoring closer to 100 cause relatively large spikes in blood sugar, while foods scoring closer to zero produce relatively small spikes. See a table listing the glycemic index of various foods from Harvard medical school. The body often responds to high glycemic index foods with insulin surges that remove sugar from the blood and can actually result in low blood sugar (hypoglycemia), an ebb in energy, and hunger. Regularly eating this way predisposes one to excess fat on and around the organs below the abdominal muscles (visceral fat) which, in turn, leads to inflammation and insulin resistance and raises the risks of diabetes, high blood pressure, and cardiovascular disease.

Dietary changes that reduce the magnitude of the triglyceride spike following meals by 20% and 40% respectively have been shown to reduce the risk of coronary artery disease by 30% and 40%. In addition to avoiding foods with a high glycemic index, adding certain foods to the diet can slow down digestion and reduce the spikes in glucose, insulin, and triglycerides. For example, nuts eaten along with a high-carbohydrate meal slow digestion and reduces blood sugar spikes by 30-50%. This both reduces oxidative stress, and provides antioxidants that combat such stress. In fact, a Mediterranean diet supplemented with either 30 grams of nuts or olive oil was found to reduce systolic blood pressure, blood sugar, and biomarkers of inflammation significantly better than a low-fat diet. Eating nuts 5 times per week was found to reduce risk of diabetes and cardiovascular disease by 20-50%. Quality protein sources low in saturated fat have a similar beneficial effect. These include egg-whites, lean meats, fish, casein, and whey protein, among others. Fish oil lowers triglyceride levels by 16-40%.

As expected, physical exercise has a positive effect, reducing post-meal spikes in blood sugar and triglycerides. Exercise is most beneficial in this regard if it is done within 2 hours before or after a large meal. Loss of body fat by diet control and/or exercise can also reduce post-meal spiking of blood sugar and triglycerides.

Alcohol consumption shows a J-shaped relationship with inflammation and blood sugar spiking, in addition to various other health problems such as coronary artery disease, diabetes, stroke, dementia, and all-cause death, with the lowest levels of these problems at 1-2 drinks per day for men and 0.5-1 drink a day for women. The J-shape means that drinking no alcohol increases the risk of these problems somewhat, while drinking in excess greatly increases the risks of these problems.

Characteristics of Inflammatory Meals

• High in calories
• High in calorically-dense foods
• High in saturated fat
• High in refined carbohydrates
• Contain foods with high glycemic index

Characteristics of Diets That are Not Inflammatory

• Smaller meals spread over the day
• Low in saturated fat
• Low in, or free of trans fats
• Low in processed carbohydrates
• Low in foods with high glycemic index
• High in unprocessed fruits and vegetables rich in antioxidants
• High in nuts, seeds, and whole grains
• Contain vinegar (1-2 tbsp eaten with a meal high in refined carbohydrates reduces the blood sugar spike by 25-35% and reduces hunger)
• Moderate amounts of lean animal protein
• Moderate amounts of beneficial fats such as fish oil and monounsaturated oils (e.g. olive,canola)

The following Foods High in Antioxidants Help Prevent Oxidative Damage to the Endothelium

• Berries
• Red wine
• Chocolate
• Tea
• Pomegranates
• Cinnamon (also reduces glucose spike caused by high-glycemic-index meal)

If you are concerned about the possibility of inflammation in your arteries, you can ask your doctor about testing the C-reactive protein level in your blood when you get a checkup. However, if your total cholesterol level is below 200 and your HDL level is above 55, it is very unlikely that you have a problem with arterial inflammation. If your C-reactive protein level is above 1.0 or the ratio of your total cholesterol level to your HDL level is above 4.0, you would likely benefit from following an anti-inflammatory diet and exercising regularly.

Updated List of the Most-Contaminated Fruits and Vegetables

We have all been well-informed that eating plenty of fruits and vegetables is good for our health. Yet there is a continuing problem with pesticide contamination. It is recommended that we avoid pesticide exposures that are more than a thousandth of the levels known to be toxic. Yet, a 2009 study by the Environmental Protection Agency found that about 40% of U.S. children have levels of at least one pesticide well above this limit.

The nonprofit organization, Environmental Working Group, while reaffirming that eating a lot of fruits and vegetables is good for our health, suggested that by avoiding the most pesticide-contaminated fruits and vegetables, and choosing the least-contaminated ones, we can lower pesticide residues in our bodies. To assist us in making such choices, the organization just published a list of the dozen most pesticide-contaminated fruits and vegetables, based on testing done in 2009 by the U.S. Department of Agriculture and the Food and Drug Administration. It also published a list of the 15 least-contaminated fruits and vegetables to provide us with healthy alternatives. The group estimates that by avoiding the “Dirty Dozen” (or buying organic versions of these items) and selecting from the “Clean 15” we can cut our pesticide exposure by 92%.

The Dirty Dozen - Most Contaminated Fruits and Vegetables (number 1 is the worst)

1. Apples
2. Celery
3. Strawberries
4. Peaches
5. Spinach
6. Nectarines (imported)
7. Grapes (imported)
8. Sweet bell peppers
9. Potatoes
10. Blueberries (domestic)
11. Lettuce
12. Kale/collard greens

The Clean 15 - Least Contaminated Fruits and Vegetables (Number 1 is the best)

1. Onions
2. Sweet corn
3. Pineapples
4. Avocados
5. Asparagus
6. Sweet peas
7. Mangoes
8. Eggplant
9. Cantaloupe (domestic)
10. Kiwi
11. Cabbage
12. Watermelon
13. Sweet potatoes
14. Grapefruit
15. Mushrooms

Bottom Line
Obviously, buying all organic produce is the best alternative for health. However, most of us cannot or choose not to incur the major budget hit it would entail. So the next best alternative is to avoid the “dirty dozen” while selecting more items from the “clean 15 “ list. Going organic for selected items can still keep our food budgets from skyrocketing.

Omega-3 Fats from Fish Oil Raise Risk of High-Grade Prostate Cancer

It has been increasingly evident that there are trade-offs in the quest to get and stay healthy. In other words, there are actions we can take that will reduce the risk of one health problem, but increase the risk of another. One example is playing high-impact sports such as basketball, which is great for improving and maintaining physical fitness while having fun, but also increases the risk of sprains, strains and other musculoskeletal problems. Now, an article by Brasky et al. in the American Journal of epidemiology (published online April 24, 2011)  points up a trade-off involved in taking fish-oil supplements, which have been widely recommended for reducing the risk of cardiovascular diseases and other health problems.

The researchers analyzed blood samples of 3,461 men to measure levels of omega-3 fats (DHA and EPA from fish consumption), omega-6 fats (from common vegetable oils), and trans-fats (from hydrogenated oils in margarine, shortening, and processed foods). The men were then followed over a 7-year period in order to see the association of the different fat types to the incidence of prostate cancer. The hypotheses were that:

• Because of the anti-inflammatory effect of the omega-3 fats, men with the highest blood levels of them would have a lower incidence of prostate cancer
• Because of the inflammatory effect of the trans- fats, men with the highest blood levels of them would have a higher incidence of prostate cancer

Results
The statistical analysis produced the following surprising results:

   > There were no effects of any of the fat types on overall incidence of prostate cancer.
   > When looking at the high-grade form of prostate cancer that progresses rapidly and is the most lethal:

• Those men with the highest blood levels of DHA from fish oil had more than twice the risk of contracting high-grade prostate cancer as men with the lowest blood levels of DHA.
• EPA from fish oil had no effect on the incidence of high-grade prostate cancer.
• Those men with the highest blood levels of trans-fats had about half the risk of contracting high-grade prostate cancer as men with the lowest blood levels of trans-fats
• Blood levels of the type of omega-3 fat from vegetable sources (e.g. flax seeds, walnuts) had no effect on the incidence of high-grade prostate cancer.

Bottom Line
The results of highly surprising, given the widespread view of fish oil as all-good and trans-fats as all-bad. Here is a clear case of trade-off. There is considerable evidence that fish-oil is good for the heart and cardiovascular system and reduces the incidence of heart attacks. Yet, here we see that it increases the risk of high-grade prostate cancer. Eating omega-3 fats from flax-seeds or other vegetable sources is not a solution because that type of omega-3 fat has not been proven to reduce the risk of cardiovascular disease. The good news is that most prostate cancer is of the low-grade variety. Given that heart disease remains the number one killer of both men and women, it doesn’t appear that fish and fish-oil be abandoned as a health-promoting dietary elements. Yet men must be aware of the trade-off in risk of eating fatty fish or taking fish-oil supplements in order to make an informed decision about how best to promote their health.

Update (May 8, 2011):
Consumerlab.com, a company that tests the quality of supplements from various companies, contacted Dr. Theodore Brasky, the lead author of the study described herein. He stated that the blood levels of DHA and EPA measured in the study were largely based on fish consumption rather than fish-oil supplements. However, a recent study of his, soon to be published, shows no link between fish oil supplementation and risk of prostate cancer. He also noted another study (Szymanski, Am J Clin Nutr 2010) that found fish consumption associated with a large reduction in late state or fatal prostate cancer.

Our Changing Eating Patterns

The U.S. Department of Agriculture recently published information on the sources of our daily caloric intake between 1970 and 2008, a time period in which our daily caloric consumption increased by 23.2% from 2,169 cals to 2,672 cals, and rates of overweight and obesity have risen sharply. An interactive graphic was created from the data that allows users to scroll along a time-line to see how the amount of daily calories in each food category has changed over time. The following are the percentage changes in calories coming from each food category:

meat, eggs, and nuts: +4.1%
fruit:                         +22.9%
added fat:                 +56.3%
dairy:                          -3.7%
grains:                      +44.7%
vegetables                   -2.4%
added sugar              +14.2%

Some Observations on the Data

In Terms of Absolute Calories

• The biggest contributors by far to our increased daily caloric intake are added fat (231 cals) and grains (193 cals).
• Much more modest contributors to our increased daily caloric intake are added sugar (57 cals), meat/eggs/nuts (19 cals), and fruit (16 calories).
• Our daily consumption of dairy actually decreased by 10 calories and of vegetables by 3 calories.

In Terms of Percentage of Daily Calories

• The only foods that increased as percentages of our diet from 1970 to 2008 are added fats (from 18.9% to 24.0% of daily calories) and grains (from 19.9 % to 23.4% of daily calories).
• Caloric consumption from fruit was steady at 3.2 % of calories.
• All other foods declined as percentages of our daily calories including meat/nuts/eggs (from 21.3% to 18.0% of daily calories), dairy (from 12.3% to 9.6% of daily calories), added sugar (from 18.5% to 17.2% of daily calories), and vegetables (from 5.8% to 4.6% of daily calories).

Bottom Line
The greatest contributors to our increase in caloric consumption are grains and added fat. While we have increased our intake of all other foods except vegetables, grains and fat together account for 84% of our increase in caloric consumption and should therefore be the prime focus of cutting back calories. This makes it clear that the low-fat and low-carb diets are both missing something because the intake of both must be reduced. Any diet that emphasizes what you eat rather than how much you eat is bound to fail. Overweight and obese people who seek to attain a healthy body weight must face the reality that total intake must be lessened. Focusing on eating both fewer grain-based foods and fewer added fats is a good start.

Maintaining Strength and Muscle Mass As We Age

An article entitled, “Staying Strong: How exercise and diet can help preserve your muscles” appeared in the April 2011 issue of the Nutrition Action Health Letter, a publication of the Center for Science in the Public Interest. The article stated some interesting facts, including:

• Starting in their late 30s and early 40s, most people lose a quarter pound of muscle per year.
• Several studies have shown that resistance exercise can restore and preserve strength and power, even at an advanced age.
• Resistance exercise also helps prevent loss in bone density and may even reverse age-related loss.
• People with Type II diabetes can lower their blood sugar by doing resistance exercise.
• After a large protein feeding (~ 30 grams, the quantity in 4 ounces of cooked meat) both younger and older people show equivalent protein synthesis (muscle-building) responses.
• After a small protein feeding (~ 14 grams, the quantity in an egg plus a glass of  milk) younger people synthesize about half the protein they synthesized in the large feeding BUT PEOPLE OVER 60 SHOW ALMOST NO PROTEIN SYSTHESIS. In other words, the larger protein portions are necessary for the older people to synthesize any protein at all. However, anything above 30 grams of protein in a meal is either burned off as energy or stored as fat. So extremely large protein meals do not aid in muscle-building.
• Of the 9 essential amino acids that our bodies can’t manufacture and must ingest, leucine is by far the most important for muscle development, especially for older individuals. Researchers recommend a minimum of 3 grams of leucine per meal, in addition to other amino acids. Animal products generally have relatively high percentages of leucine. Protein from whey (a byproduct of cheese-making) is relatively high in leucine and makes a good protein supplement.
• Plant protein contains a smaller percentage of leucine, but soy is the best of the common plant proteins in regard to leucine content.
• According to researchers, ingesting protein shortly after exercise provides the greatest boost for muscle building. Two hours is the longest one should wait before ingesting protein after resistance exercise.
• While the U.S. Institute of Medicine set a Recommended Daily Allowance (RDA) of 0.36 grams of protein per pound bodyweight per day, researchers feel that about 0.50 grams of protein per pound bodyweight per day can best promote muscle building and minimize muscle loss as we age.

Bottom Line
Regular resistance exercise and adequate protein intake are essential for increasing and maintaining strength and muscle mass, especially as we age. A daily protein intake of half a gram per pound bodyweight is recommended (e.g. a 200 lb person should take in 100 grams of protein daily). The protein should not be concentrated in one meal but should be distributed over the day in meals containing about 30 grams of protein.

Fatty Liver Disease: Another Reason to Avoid Obesity

An article in the January 2011 issue of the Harvard Health Letter reveals that the epidemic of obesity has increased the occurrence of fatty liver disease. Previously, most cases of fatty liver disease were related to excess alcohol consumption, but now, many cases are related to excess body fat, which can lead to Type II diabetes. Fatty liver disease affects 70-90% of those who are obese and/or have diabetes.

Abdominal obesity can lead to metabolic syndrome (elevated blood pressure and levels of triglycerides and blood sugar, and low HDL (good cholesterol). Overfilled fat cells become resistant to insulin (which lowers blood sugar by storing it in the cells) resulting in excess fatty acids in the blood. Fat then accumulates in liver cells, which can lead to inflammation and liver tissue damage.  This can in turn bring about liver fibrosis (buildup of fibrous tissue) or cirrhosis (buildup of scar tissue). Cirrhosis increases the risk of liver cancer.

Fatty liver disease increases the risk of heart attack and stroke because a fatty liver produces inflammatory factors that can promote the deposition of plaque in the arteries, leading to arterial narrowing.

The only effective treatment for fatty liver disease is to lose weight.

Bottom Line
If you want to avoid or reverse fatty liver disease, avoid gaining unnecessary body fat or lose existing excess body fat through a program of good nutrition and exercise. Both caloric restriction and exercise are essential parts of any weight-loss program.

New Insights into Obesity

The December 2010 issue of the Nutrition Action Health Letter, published by the Center for Science in the Public Interest, featured an interview with Eric Ravussin, head of the Nutrition Obesity Research Center of the highly regarded Pennington Biomedical Research Center in Baton Rouge, LA. The discussion centered on new clues as to why we gain weight, and revealed the following:

• Leptin, a hormone discovered in 1994, is produced by fat cells and  tells the brain when the cells are full.
• When people diet and lose weight, leptin levels drop sharply, causing food cravings and weight regain.
• Loss of 10-20% of body weight slows the metabolism and rate of caloric burn.
• Injecting leptin can bring the metabolism back up.
• However, most overweight people are resistant to leptin, just as Type II diabetics are resistant to insulin.
• Using drugs to shut down hunger mechanisms doesn’t work well because the human body has developed several redundant systems to stimulate eating as protection against starvation.
• People have natural ranges of body fat depending on their genes that control energy intake and expenditure.
• Nutrition in the womb and infancy can affect propensity for overweight and obesity by switching different genes on and off.
• Brown adipose tissue, which burns calories to produce body heat, previously thought to exist only in infants, was recently discovered in adults.
• By maintaining homes at a steady comfortable temperature throughout the year, we don’t burn calories via brown fat to keep warm in winter, and we miss the appetite-suppressing effect of heat in the summer.
• A common cold virus (adenovirus-36) makes experimental animals gain a lot of weight. Antibodies to this virus, an indication of exposure, are much more common in obese than in normal-weight people.
• Gut bacteria can be a factor. Transplanting feces from a fat animal to a lean one results in weight gain for the latter, while transplanting from the lean to the fat animal makes the fatter one leaner. Similar transplants in humans have reduced insulin-resistance of people with metabolic syndrome, a set of symptoms indicative of heart-disease risk characterized by excess fat around the waist, low HDL, and elevated blood pressure, blood triglycerides, and fasting blood glucose.

Ravussin feels that we should tax soft drinks and other unhealthy foods while subsidizing healthy foods, create areas where kids can safely play, and make physical education mandatory so that everyone, not only the athletically-gifted, engages in physical activity,

Eating Nuts Provides Several Health Benefits

An article in the January 2011 Harvard Health Letter listed several health benefits of eating nuts. Although the calories in nuts come mainly from fat, the type of fat is largely of the unsaturated healthful variety. The article cited a study done at the Beth Israel Deaconess Medical Center showing that walnuts eaten at breakfast made subjects feel more full before lunch, potentially reducing caloric consumption. Other health benefits include favorable effects on blood cholesterol, blood pressure, and inflammatory factors. Studies on large populations have linked high nut consumption with lower heart disease rates. Nuts also contain little or no carbohydrate so they do not cause spikes in blood sugar and may even blunt blood sugar spikes caused by carbohydrates eaten along with the nuts. Peanuts, almonds, and pistacios have the highest protein content, while brazil nuts, cashews, hazelnuts, and walnuts have intermediate protein content, and pecans and macadamias have the lowest protein content. Walnuts have the additional benefit of being high in omega-3 fatty acids, which are widely considered the most healthful kind.

Are There Hidden Causes of the Overweight Epidemic?

In the December 20, 2010 issue of Newsweek magazine, Sharon Begley, the magazine’s science columnist, wrote that there are some little-known factors that may contribute to the continued increase in the prevalence of overweight and obesity. Her main argument is that it must be more than a matter of exercising more and eating better because, among animals that have contact with human beings, such as pets, lab animals and rodent pests, 23 of the 24 species studied since 1940 have shown significant increases in the percentages of overweight and obese animals, a statistic that could have occurred by chance only once in 8 million. Yet changes in diet and exercise don’t appear to be the reason, as these factors haven’t changed much for these animals over the years.

Begley cites some possible reasons other than diet and exercise for the weight gain of animals and, by extension, us:

• The type of bacteria in our gut - more efficient bacteria wring more calories out of our food than do less efficient bacteria. In this case, efficiency is not our friend.
• Lack of sleep, which increases the appetite-stimulating hormone ghrelin, and decreases the hormone leptin that suppresses our appetite when we’ve eaten enough.
• Environmental chemicals such as BPA that stimulate fat-cell production.
• Home heating, which lessens the need for the body’s calorie-consuming heat production.
• Home air conditioning, which lessens the appetite-suppressing effect of environmental heat.
• Infection with adenovirus-36, which causes obesity in  lab animals and is correlated with obesity in humans.

In addition, I feel that there may be another contributor to obesity:

• The lack of internal parasites due to modern sanitary practices. If parasites eat some of our food, less of it can be packed on as fat. If they partake of our bodies, then energy must be consumed for repair. This assumes the kind of parasites that are relatively harmless other than consuming some of our food or body tissue.

Bottom Line
There is no doubt that our health benefits from exercising regularly and eating a healthy diet without excess calories. However, we must continue to look for other contributing factors in order to effectively deal with and counteract the continued rise in overweight and obesity that threatens to undermine the gains we’ve made in improving our health and increasing our lifespan.

You May Not Be Getting Enough of These Nutrients

An article in the September 2010 issue of the Nutrition Action Health Letter contains a cover story entitled, “Getting Enough? What you don‘t eat can hurt you.” The article states that many of us are not getting enough potassium, magnesium, Vitamin D, or Vitamin B-12, with possible negative health consequences.

Potassium

• A third of Americans have high blood pressure, which increases the risk of heart attack and stroke. Over age 65, two-thirds of us have high blood pressure. More than half of those afflicted don’t have it under control.
• Potassium can help regulate blood pressure. Major studies have shown that people with higher potassium intake have lower blood pressure.
• A low potassium level is a predictor of stroke. A study of 43,000 subjects showed that those consuming the most potassium had 38 percent fewer strokes that those who consumed the least. The beneficial effect of potassium is the greatest for those who consume the most sodium. It is thought to work by increasing the flexibility of arteries and widening the tiny blood vessels.
• While blood pressure typically rises as one gets older, 4 weeks on a low sodium, high potassium diet can totally reverse the effect of age on blood pressure. The DASH Diet (Dietary Approaches to Stop Hypertension), which minimizes added salt and includes 11 daily servings of fruit and vegetables as well as 2 servings of low-fat dairy products and low quantities of saturated fats, refined sugar, and refined grains, provides plentiful potassium while keep sodium down to recommended levels.
• Potassium citrate is the form of potassium found in fruits and vegetables and it is considered more effective for blood-pressure reduction and safer than potassium supplements (usually potassium chloride), which can cause heart problems if taken in excess. Potassium citrate also reduces the risk of kidney stones by 50% and may help prevent bone loss.

 Vitamin D

• This nutrient seems more important than calcium for protecting bones and preventing osteoporosis, a  bone-thinning disease that causes bone fractures in 25% of men and 50% of women over age 50.
• Among Navy recruits, supplementation of 2,000 mg of calcium along with 800 IU of vitamin D per day reduced stress fractures by 20%.
• Evidence suggests that Vitamin-D also protects against colon cancer, heart atacks, stroke, diabetes, falls, autoimmune disease, and all-cause mortality.
• The article recommends taking a Vitamin-D supplement, as it is difficult to get the recommended amount from food. The recommended dosage is 400 IU per day for people under 60 and 800-1000 IU per day for people over 60.
• Recommended calcium intake is 1000 mg/day for people under 50, and 1200 mg/day for people over 50.

Magnesium

• Many Americans have Type II diabetes, including 25% of people over 60.
• Diabetes greatly increases the risk of stroke, heart disease, blindness, kidney failure, nervous system damage, and limb amputations.
• While excess body fat, lack of exercise, and poor eating habits are the major risk factors for Type II diabetes, a lack of magnesium can be a contributing factor. Large studies have shown that high magnesium intake is associated with reduced incidence of diabetes.
• Fruits, vegetables, whole grains, nuts and beans are plentiful in magnesium. 

Vitamin B-12

• Low levels of Vitamin B-12 are associated with poorer memory and mental ability. Yet the ability to absorb this vitamin from food decreases as we age.
• A low Vitamin B-12 level in combination with a high levels of folic acid is strongly associated with cognitive impairment.
• The article recommends taking a multivitamin containing at least 6 micrograms of Vitamin B-12 or a B-12 supplement containing up to 100 micrograms of B-12, and being careful not to get too much folic acid from vitamins and fortified cereals.

Heart Attack Deaths in the U.S. Have Dropped Sharply

In the Harvard Health Letter, vol 35, no. 10, August 2010, and article appeared entitled, "Is the heart attack going out of style?". It stated that, based on Medicare data, the U.S. heart-attack hospitalization rate declined by 23% from 2002 to 2007. Also, a study based on 3 million members of a northern California health plan showed a 24% drop in heart attack hospitalizations between 1999 and 2008. While an increasing number of people are diagnosed with heart disease, fewer are dying from it - heart attack deaths have been declining in the U.S. for the past 40 years.

The article conjectures that, "Maybe decades of efforts to eat right and exercise more, stop smoking, lower LDL cholesterol levels, and control blood pressure are working." This appears only partially true. Yes, fewer Americans smoke, and Lipitor, a medication for reducing LDL and total cholesterol, is the most prescribed drug in the U.S. Many people are also taking blood pressure medication. Yet, there is little evidence that people are "eating right" as fast-food consumption and obesity continue to increase. Also, various national campaigns, such as the American College of Sports Medicine's Healthy People 2000, have failed dismally to get people to exercise more. Thus, it appears that the reduction in heart attacks is less due to anything that requires will power than to modern medicine. Another possible factor is reduced stress, as the economy was doing well over the study period. It remains to be seen what the recession and high unemployment rate will do to the heart attack rate. Hopefully, and emphasis on family and personal fulfillment and relationships will help keep stress to a minimum, even in the face of economic difficulties.

The reduction in heart attacks is encouraging, yet it would be even better if people became healthier through lifestyle changes such as exercise and good nutrition.

Should You Skip Breakfast to Burn More Fat During a Workout?

An Associated Press article suggesting that, because skipping breakfast before a workout burns more fat, such a practice may be effective for body fat loss. Yet, the study on which the article is based provides absolutely no evidence that such a practice would result in a stable loss of body fat. Sure, if your body is depleted of stored carbohydrates in the form of muscle and liver glycogen, you will burn more fat during exercise. However, a close look at the article reveals that the fat burned is in the muscle, and not around the waist or other parts of the body where people generally want to lose fat. Thus, exercising in a fasted state merely depletes intramuscular fat that is replenished upon eating. So there is no net body fat loss unless one consumes fewer calories than are used, which requires dietary control. So we can’t escape from the truism that the only way to lose weight is to burn more calories than you take in.

The following are additional reasons not to exercise in a fasted state:

• You will feel less energetic and more lethargic
• The quality of your workout will diminish
• Your motivation to exercise will be reduced
• You will cannibalize muscle to convert protein into needed carbohydrates

The only advantage to running in a fasted state might be for long-distance runners who wish to train their bodies to preferentially burn fat, thereby sparing muscle and liver glycogen to avoid “hitting the wall” late in a race. However, training with long-distance runs accomplish the same goal.

Limiting Your Fruit and Vegetable Pesticide Exposure

The Environmental Working Group, a nonprofit organization whose purpose is to promote public health, reviewed nearly 100,000 reports on fruit and vegetable pesticide residue from the U.S. Food and Drug Administration and the Department of Agriculture. After being washed with a USDA high-pressure water system, many of the fruits and vegetables still contained high pesticide residues. The following were the worst.

• Celery
• Peaches
• Strawberries
• Apples
• Domestic blueberries
• Nectarines
• Sweet bell peppers
• Spinach, kale and collard greens
• Cherries
• Potatoes
• Imported grapes
• Lettuce

 In contrast, the following were found to have little or no pesticide residue.

• Onions
• Avocados
• Sweet corn
• Pineapples
• Mango
• Sweet peas
• Asparagus
• Kiwi fruit
• Cabbage
• Eggplant
• Cantaloupe
• Watermelon
• Grapefruit
• Sweet potatoes
• Sweet onions

Bottom Line
Obviously, buying organic fruit and vegetables is the simplest and most direct way to avoid pesticide exposure. Unfortunately, organic produce is usually a lot more expensive than the non-organic variety and most people balk at the price difference. A reasonable compromise is to limit consumption of the most pesticide-tainted fruits and vegetables and preferably buy them in organic form, while buying other fruits and vegetables in non-organic form. The Environmental Working Group states that switching to the organic version of just the produce from the worst-offender list would reduce total dietary pesticide consumption by 80%.

Avoiding or Lessening the Effects of a Stroke

An article in the May 2010 issue of the NIH (National Institutes of Health) News in Health describes how to avoid a stroke or, if you have one, how to recognize it and take immediate action to completely avoid, or at least lessen any lasting effects.

A stroke is a failure of normal blood flow to the brain, which can damage and destroy brain cells. There are two types of stroke:

• Ischemic Stroke - the arteries feeding the brain are blocked, usually by a blood clot
• Hemorrhagic stroke - broken or leaking blood vessels fail to supply oxygen to brain cells

Ischemic stroke accounts for about 80%, and hemorrhagic stroke about 20% of cases. Unfortunately, the treatment for the two types of stroke are opposite, so treating for the wrong kind of stroke can actually increase the damage to brain cells.

Signs of an ischemic stroke include sudden weakness or numbness of the face, arm, or leg, especially if it occurs on one side of the body, and/or difficulty in walking, talking, seeing and thinking. If you have any of these symptoms, it is important to be taken to an emergency room immediately (don’t drive yourself) because clot-busting drugs, if taken within 3 hours of the onset of symptoms, can stop brain damage. Unfortunately, only 2% of stroke victims actually get this effective treatment within the optimal time window. If given too late, the drug can actually increase damage. It is also important to get prompt treatment even if symptoms disappear quickly, because mini-strokes, also called transient ischemic attacks (TIAs), are a sign that a major stroke may occur soon afterwards.

The most common symptom of hemorrhagic stroke is a very sudden and painful headache, and prompt surgery may be required to repair a damaged blood vessel feeding the brain.
 
Some cases of partial or complete paralysis on one side of the face are not caused by stroke but by Bell’s Palsy, a nerve disorder that is, in most cases, temporary. However, only a medical professional can distinguish between Bell’s Palsy and a stroke. In both illnesses, immediate treatment produces the best outcome, so an emergency room visit is required in either case.

A healthy lifestyle can lessen your risk of a stroke. By exercising, eating healthfully (especially limiting foods high in saturated fat, cholesterol, and sodium), not smoking, and keeping your weight under control you can dramatically reduce your risk of a stroke. Our web site has more specific details on avoiding a stroke.
 
Bottom Line
To greatly reduce your risk of a stroke, follow a healthy lifestyle. But if you do develop stroke symptoms, seek immediate medical attention to avoid permanent damage and long-term disability.

The Bagel Dilemma

What could be more simple than a bagel? It would appear to have simple ingredients like flour and water and, when flavored, ingredients like cinnamon, raisins, sesame seeds, onion, and garlic. All seem fairly wholesome. What could be a better snack or source of energy when a meal is several hours away or an exercise session is planned within 2-4 hours?

Just to check on the ingredients in fresh bagels available to me, I did a web search on their ingredients, and found the following counts for plain bagels:

• Stop and Shop: calories 290, sodium 520 mg, sugars 4 mg
• Finagle a Bagel: calories 290, sodium 410 mg, sugars 8 mg
• Dunkin Donuts calories 320, sodium 660 mg, sugars 6 mg
• Bruegger’s: calories 300, sodium 530 mg, sugars 7 mg
• Starbucks: calories 300, sodium 460 mg, sugars 8 mg

I have nothing against the calories. We all need them to survive. And when carbo loading for athletic activity, healthy calories are what we’re looking for. It’s the sodium that’s the problem. Based on average caloric intake and recommended sodium limits, we should be taking in very roughly about one milligram of sodium per calorie consumed. That means that any food containing significantly more milligrams of sodium than calories should be considered a high-sodium food. Thus, all of the bagels listed above are high in sodium. If a plain bagel can’t be low to moderate in sodium, what can? Anything you put on top of the bagel is likely to be high in sodium as well. One slice of cheese contains about 300 mg, 2 slices of cold-cuts have 600-800 mg. But the real dilemma is, if even a plain bagel is high in sodium, how can we possibly keep our sodium levels under control?

The best we can do is to carry our own snacks and energy foods that have healthy ingredients and low to moderate sodium levels. That means either using fresh fruits or buying products whose ingredient labels pass muster. And when we prepare dinner, we can use as many fresh ingredients as possible and use processed products like sauces and salad dressings that have reasonable sodium levels listed on their labels. Fruit juices are not recommended as a major energy source because of their high sugar content. The same goes for chocolate milk, which has recently been touted as a good recovery drink. Skim or 1% milk isn’t a bad alternative if one prefers a liquid rather than solid snack. A glass of 1% milk contains 102 calories, 107 mg of sodium, and 13 mg of natural sugars.

The Difficulty of Eating Lunch Without Getting Socked by Sodium

Recommendations for daily sodium intake have been made by various health organizations such as the National Academy of Sciences' Institute of Medicine. They generally agree on a range of 1,500 to 2,300 mg/day for normal people but lower limits for those with congestive heart failure, liver cirrhosis, or kidney disease. One teaspoon of salt contains 2,300 gm of sodium.

Unfortunately, without ever picking up a salt shaker, it is very difficult to keep within the recommended sodium limits range if one either eats in restaurants or uses processed foods at home.

While people frequently eat dinner at home, and thus may control the amount of sodium they take in by using fresh ingredients, many of us find it convenient to eat lunch in a fast-food or table-served restaurant. Some examples from popular restaurants below show how difficult it is to find a restaurant meal that does not contain excess sodium.

McDonald's

• Big Mac®: 1040 mg
• Premium Grilled Chicken Ranch BLT Sandwich: 1190 mg
• Premium Bacon Ranch Salad with Grilled Chicken: 1010 mg

 Burger King

• Whopper®with cheese: 1450 mg
• Angus Steak Burger®: 1260 mg
• TenderGrill™ Chicken: 1180 mgs
• BK Big Fish®: 1450 mgs

Wendy's

• Double w/Everything and Cheese: 1440 mg
• Homestyle Chicken Fillet Sandwich: 1120 mg

Dunkin’ Donuts

• Egg and cheese on a bagel: 1160 mg
• Bagel and cream cheese: 910 mg

Panera Bread

• Chipotle chicken sandwich on artisan French: 2370 mg
• Cuban chicken Panini: 1900 mg
• Turkey artichoke Panini on focaccia: 2340 mg

Pizza Hut

• Half of a 12” medium cheese pan pizza: 2120 mg
• 2 slices of large 14” meat lover’s pan pizza: 2360 mg

Chipotle

• Chicken burrito in 13” tortilla with rice, black beans, tomato salsa, guacamole and lettuce: 2100 mg
• Steak burrito in 13” tortilla with rice, red beans, tomato salsa, cheese, guacamole and lettuce: 2160 mg

Bottom Line
These amounts of sodium are way over the top. And don’t think that table-served restaurants are any better. They vary widely as to the amount of salt added to their food, but most use a lot of salt. Why? Because most people like the taste. It’s obvious that any large restaurant chain would do extensive taste tests to see what people like best. So high salt foods must be what people prefer. Salt levels in food are thus market-driven. However, it is difficult to tell whether we have just gotten used to high-salt foods because of their prevalence or whether we have some instinctive salt craving that dates back to hunting and gathering days, when salt in the diet was difficult to obtain. Whatever the case, medical authorities widely agree that we are getting too much of it. Pending possible legislation to limit the sodium count in foods, the best we can do is to prepare our own food from fresh ingredients as much as possible and to consult nutritional information at restaurants or on their web sites to make selections without excessive sodium content, however difficult that is. It would also be helpful if large companies received e-mail or other messages from consumers asking to reduce the sodium content in their foods.

Is Fructose Unhealthy?

There has recently been some concern from various sources that fructose might be unhealthy. The focus on fructose has likely been prompted by the widely increased use of high-fructose corn syrup to sweeten various foods and drinks such as sodas, iced tea, yogurt, and snacks. Yet fructose can also be found in relatively high amounts in fruits, especially apples, pears, grapes (including raisins), and pineapples, and even in vegetables such as tomatoes, cabbage and squash. Table sugar (sucrose) is a 50/50 amalgam of fructose and glucose, while high-fructose corn syrup is 55% free fructose and 45% free glucose, industrially manufactured from corn starch,

There is some fairly solid evidence supporting the negative health effects of fructose on mice, but the evidence concerning humans is much less conclusive. In human studies, fructose intake has been positively correlated with obesity (1, 2), especially fatty deposits around the waist, which is thought to be the most dangerous to health and, of course, detrimental to the 6-pack look. Fructose also increases blood triglycerides, a recognized risk factor for heart disease (3). All cells in the body can metabolize glucose, but only the liver can metabolize fructose, and high fructose consumption appears to load the liver with fatty deposits (4, 5). Also, fructose tends to suppress insulin and leptin, both of which are hormones that decrease appetite, while increasing ghrelin, which raises appetite (6, 7), thus possibly contributing to excess weight gain. However, there is little evidence that the fructose in high-fructose corn syrup is more damaging than the fructose in table sugar (typically sucrose from sugar cane).

Bottom Line
While more studies must be done to solidify the evidence on the effects of fructose on human health, it appears wise to avoid excessive intake of fructose. This can be accomplished by:

• Completely avoiding foods and drinks containing high-fructose corn syrup
• Limiting consumption of table sugar and any product with a high sugar content
• Limiting fruit juice consumption, especially juice from apples and grapes

References:
1. Lustig RH (2006). "Childhood obesity: behavioral aberration or biochemical drive? Reinterpreting the First Law of Thermodynamics". Nature clinical practice. Endocrinology & metabolism 2 (8): 447–58. doi:10.1038/ncpendmet0220. PMID 16932334.

2. Isganaitis E, Lustig RH (2005). "Fast food, central nervous system insulin resistance, and obesity". Arterioscler. Thromb. Vasc. Biol. 25 (12): 2451–62. doi:10.1161/01.ATV.0000186208.06964.91. PMID 16166564.

3. Bantle JP, Raatz SK, Thomas W, Georgopoulos A (2000). "Effects of dietary fructose on plasma lipids in healthy subjects". Am. J. Clin. Nutr. 72 (5): 1128–34. PMID 11063439.

4. Forristal, Linda (Fall 2001). "The Murky World of High-Fructose Corn Syrup". Weston A. Price Foundation. http://www.westonaprice.org/motherlinda/hfcs.html.

5. Ouyang X, Cirillo P, Sautin Y, et al. (June 2008). "Fructose consumption as a risk factor for non-alcoholic fatty liver disease". J. Hepatol. 48 (6): 993–9. doi:10.1016/j.jhep.2008.02.011. PMID 18395287.


6. Teff, KL; Elliott SS, Tschöp M, Kieffer TJ, Rader D, Heiman M, Townsend RR, Keim NL, D'Alessio D, Havel PJ (June 2004). "Dietary fructose reduces circulating insulin and leptin, attenuates postprandial suppression of ghrelin, and increases triglycerides in women". J Clin Endocrinol Metab. 89 (6): 2963–72. doi:10.1210/jc.2003-031855. PMID 15181085.

7. Swan, Norman; Lustig, Robert H. "ABC Radio National, The Health Report, The Obesity Epidemic". http://www.abc.net.au/rn/healthreport/stories/2007/1969924.htm. Retrieved 2007-07-15.