Low Carb is Attacked by the Media

...Again

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Study finds Low Carb diets can lower lifespan...if they had actually studied Low Carb​

…We did not update carbohydrate exposures of participants that developed heart disease, diabetes, and stroke before Visit 3, to reduce potential confounding from changes in diet that could arise from the diagnosis of these diseases… The expected residual years of survival were estimated…

Hello, my lovelies,


First and foremost, a shout out to Belinda Fettke and Zoë Harcombe for their fantastic contributions to the people in setting things straight with logical, evidence-based critiques. Their work, plus many others, is pivotal in making better standards in scientific article publication, as well as bringing unbiased fact to the public.


This is long, so bear with me if you want to read through!


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In one of the most blatantly unscientific methods that could ever be applied to the scientific world, an epidemiological study (see: Food Frequency Questionnaire) was placed into circulation as fact with manipulated statistics. The paper: Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. The verdict of this paper? They found that Low Carb lowered lifespan and there was a curve of carbohydrate “need”, placing carbohydrate around 50%-55% of the dietary necessity to be healthy, with below 30% and above 65% found to be the most detrimental to health (1).

Headlines ensued (2-6):
BBC: “Low-carb diets could shorten life, study suggests”
CNN: “Low and high carb diets increase risk of early death, study finds”
The Guardian: “Both low- and high-carb diets can raise risk of early death, study finds”
New Scientist: “Eating a low-carb diet may shorten your life – unless you go vegan too”
The Sydney Morning Herald: “People on low-carb diets die younger, says science”

 

Pretty hefty claims there, guys.

The biggest problem with this false news? Not to beat a dead horse, but there were zero Low Carb participants in this study. It’s not about Low Carb at all. At a whopping 37% as the average, and the lowest a whopping 26%, none of these subjects could be classified Low Carb, and given the specifics of a Low Carb lifestyle, their dietary practices absolutely cannot compare to those following a specified regimen unless they were actually on the regimen and following it to a T or as much as possible. Low Carb lifestyles, or “diets” (what one eats, not a fad diet), have rules, ones which were blatantly ignored in this study when it accused all Low Carb as causing shortened lifespan. I’ll get to this later. As pointed out by Zoë Harcombe, Ph.D., Low Carb was mentioned 40 times, making the paper wrong 40 times, in retrospect (7).


Read up on her evaluation for full details on a very poorly done paper.


I would also like to bring up an interesting point: It takes newspapers a relatively longer time to catch wind of studies, and usually it’s a cascade after one initial report and subsequent reports from all others. Take note almost all headlines are exactly one day after—the vegan one from New Scientist is on the same day; Herald was two days. This paper was planted. Reporting simply does not happen like this unless there is advertisement to the journalists, and it was set up at a time when Low Carb is coming around with ample positive evidence. Desperate move.


An example is this: How many times have you heard about statins leading to heart disease and failure? How about the connection with low cholesterol and neurodegenerative disease? No? Never? That’s because it wasn’t a paid promotion, but the data in randomized control trials exists (8).


In another blunder by this paper laced with bias, all credible, well-done empirical data about actual Low Carb was ignored. What does the empirical data from randomized control trials tell us about all-cause mortality? It says the exact opposite, and actual data from randomized control trials, case studies, meta-analyses, et cetera, are predominantly showing specific types of carbohydrate and refined plant fats (PUFA/Trans fats) increasing all-cause mortality, having a direct link to atherosclerosis (or artery-clogging, as it’s so lovingly dubbed), causing fatty liver and hypertension, being detrimental to lungs, being directly causal with diabetes and other diseases, among many other things (9-33).


Further, the empirical data stacking up for the Low Carb Spectrum of Carnivore, Ketogenic, and Primal have been gathering much support over the years as evidence mounts in the positive and healing effects of these lifestyles, least of all weight loss—that’s just a nice bonus—but expanding to disease control of neurological disorders/diseases, heart disease, strokes, cancer, and many other things which plague us today (34-52).


Never you mind the fact carbohydrate isn’t essential to human nutrition (53-56).


Further, this study clumped meat consumption in with “foods” like sweets, baked goods (cakes, bread, etc), cereal, misc, as though meat has any connection at all. Studies show no correlation whatsoever, only in processed meats—which are cured with sugar or are processed/cooked with carbohydrate-rich ingredients (57-78).


Some epidemiological studies can be applied well if done correctly. These ones, even observational, can provide a good backdrop to perform a randomized control trial or RCT, the gold standard of science. What they cannot do is provide a definite answer to a problem, especially when there is no evidence being used and it’s all conjecture:

So, this is telling me that they did not actually perform a study, they’re taking a wild swing at a ball while equipped with a blindfold and hoping to hit a home run. This is science? You, good sirs and/or madams, have officially defecated on the very foundations and principals of what makes science what it is supposed to be.


Learn how to science before you science, please.

Shout out:


Belinda Fettke’s critique


Zoë Harcombe’s critique

 

References

The Study:
1. Seidelmann SB, Walter C Willet, MD, et al. Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. The Lancet Public Health, 16 August 2018; DOI:https://doi.org/10.1016/S2468-2667(18)30135-X

 

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Headlines:
2. BBC News, 17 August 2018. Website. Low-carb diets could shorten life, study suggests. Accessed on 25 August 2018 from https://www.bbc.co.uk/news/health-45195474

 

3. CNN News, 17 August 2018. Website. Low and high carb diets increase risk of early death, study finds. Accessed on 25 August 2018 from https://edition.cnn.com/2018/08/17/health/low-carb-high-carbohydrate-diet-risk-of-death-intl/index.html


4. The Guardian, n.d. Website. Both low- and high-carb diets can raise risk of early death, study finds. Accessed on 25 August 2018 from https://www.theguardian.com/lifeandstyle/2018/aug/16/both-low-and-high-carb-diets-can-raise-risk-of-early-death-study-finds


5. New Scientist, 16 August 2018. Website. Eating a low-carb diet may shorten your life – unless you go vegan too. Accessed on 25 August 2018 from https://www.newscientist.com/article/2176933-eating-a-low-carb-diet-may-shorten-your-life-unless-you-go-vegan-too/


6. The Sydney Morning Herald, 19 August 2018. People on low-carb diets die younger, says science. Accessed on 25 August 2018 from https://www.smh.com.au/lifestyle/health-and-wellness/people-on-low-carb-diets-die-younger-says-science-20180819-p4zye3.html
 

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Zoë Harcombe’s review:
7. Zoë Harcombe, Ph.D. Low carb diets could shorten life (really?!). Website. 23 August, 2018. Retrieved from http://www.zoeharcombe.com/2018/08/low-carb-diets-could-shorten-life-really/

 

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Cholesterol Research:
8. Critical Analysis of Cholesterol and Statins. From Grove of Wisdom at (coming soon; hang in there, this paper is taking a lot of my time)


Carbohydrate and PUFA/Trans Fats Data:
9. Meenakshi Ravichandran, et al. Dietary Carbohydrates Impair Healthspan and Promote Mortality. Cell Metabolism; Volume 26, Issue 4, P585-587, October 03, 2017; https://doi.org/10.1016/j.cmet.2017.09.011


10. Dariush Mozaffarian, et al. Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. The American Journal of Clinical Nutrition, Volume 80, Issue 5, 1 November 2004, Pages 1175–1184; https://doi.org/10.1093/ajcn/80.5.1175


11. Metin Basaranoglu, et al. Carbohydrate intake and nonalcoholic fatty liver disease: fructose as a weapon of mass destruction. Hepatobiliary Surg Nutr. 2015 Apr; 4(2): 109–116; doi:  10.3978/j.issn.2304-3881.2014.11.05


12. James J DiNicolantonio. The cardiometabolic consequences of replacing saturated fats with carbohydrates or Ω-6 polyunsaturated fats: Do the dietary guidelines have it wrong? Open Heart. 2014; 1(1): e000032; Published online 2014 Feb 8. doi:  10.1136/openhrt-2013-000032


13. Ian Spreadbury. Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity. Diabetes Metab Syndr Obes. 2012; 5: 175–189; Published online 2012 Jul 6. doi:  10.2147/DMSO.S33473


14. Karin de Punder and Leo Pruimboom. The Dietary Intake of Wheat and other Cereal Grains and Their Role in Inflammation. Nutrients. 2013 Mar; 5(3): 771–787; Published online 2013 Mar 12. doi:  10.3390/nu5030771


15. Tommy Jönsson, et al. Agrarian diet and diseases of affluence – Do evolutionary novel dietary lectins cause leptin resistance? BMC Endocr Disord. 2005; 5: 10; Published online 2005 Dec 10. doi:  10.1186/1472-6823-5-10


16. Eric C Westman and Mary C Vernon. Has carbohydrate-restriction been forgotten as a treatment for diabetes mellitus? A perspective on the ACCORD study design. Nutr Metab (Lond). 2008; 5: 10; Published online 2008 Apr 9. doi:  10.1186/1743-7075-5-10


17. Yunsheng Ma, MD, PhD, et al. Association between Carbohydrate Intake and Serum Lipids. J Am Coll Nutr. 2006 Apr; 25(2): 155–163.


18. Brittanie M. Volk, et al. (2014) Effects of Step-Wise Increases in Dietary Carbohydrate on Circulating Saturated Fatty Acids and Palmitoleic Acid in Adults with Metabolic Syndrome. PLoS ONE 9(11): e113605. https://doi.org/10.1371/journal.pone.0113605


19. Siri PW and Krauss RM. Influence of dietary carbohydrate and fat on LDL and HDL particle distributions. Curr Atheroscler Rep. 2005 Nov;7(6):455-9.


20. Elizabeth J. Parks. Effect of Dietary Carbohydrate on Triglyceride Metabolism in Humans. The Journal of Nutrition, Volume 131, Issue 10, 1 October 2001, Pages 2772S–2774S, https://doi.org/10.1093/jn/131.10.2772S


21. Pavel Grasgruber, et al. Food consumption and the actual statistics of cardiovascular diseases: an epidemiological comparison of 42 European countries. Food Nutr Res. 2016; 60: 10.3402/fnr.v60.31694; Published online 2016 Sep 27. doi:  10.3402/fnr.v60.31694


22. S. D. Pointer, et al. Dietary carbohydrate intake, insulin resistance and gastro‐oesophageal reflux disease: a pilot study in European‐ and African‐American obese women. AT&P, Volume 44, Issue 9, Pages 976-988, 01 September 2016; https://doi.org/10.1111/apt.13784


23. Wolfe RR, et al. (2002). Dietary fat composition alters pulmonary function in pigs. Nutrition. 2002 Jul-Aug;18(7-8):647-53.


24. Marla Paul. (May 20, 2014). Vitamin E in Canola and Other Oils Hurts Lungs. Retrieved from https://news.northwestern.edu/stories/2014/05/vitamin-e-in-canola-and-other-oils-hurts-lungs/ Original study: [https://respiratory-research.biomedcentral.com/track/pdf/10.1186/1465-9921-15-31?site=respiratory-research.biomedcentral.com]


25. Helmut Bartsch, et al. (1999). Dietary polyunsaturated fatty acids and cancers of the breast and colorectum: emerging evidence for their role as risk modifiers. Carcinogenesis, Volume 20, Issue 12, 1 December 1999, Pages 2209–2218, https://doi.org/10.1093/carcin/20.12.2209


26. Marian L. Neuhouser , et al. (2007). (n-6) PUFA Increase and Dairy Foods Decrease Prostate Cancer Risk in Heavy Smokers. The Journal of Nutrition, Volume 137, Issue 7, 1 July 2007, Pages 1821–1827, https://doi.org/10.1093/jn/137.7.1821


27. Sonestedt E, et al. (2008). Do both heterocyclic amines and omega-6 polyunsaturated fatty acids contribute to the incidence of breast cancer in postmenopausal women of the Malmö diet and cancer cohort? Int J Cancer. 2008 Oct 1;123(7):1637-43. doi: 10.1002/ijc.23394.


28. MG Enig. 1995. Trans Fatty Acids in the Food Supply: A Comprehensive Report Covering 60 Years of Research, 2nd edition. (Enig Associates; MD)


29. Willett, W. C., et al. 1993. Intake of trans fatty acids and risk of coronary heart disease among women. Lancet 341: 581.


30. Ascherio, A., Willet, W. C. Health effects of trans fatty acids. Am J Clin Nutr 66( 4): 1006S-1010S.


31. Mensink, R. P., Katan, M. B. 1990. Effect of Dietary trans Fatty Acids on High-Density and Low-Density Lipoprotein Cholesterol Levels in Healthy Subjects. N Engl J Med 323: 439-445.


32. Lopez-Garcia, E., et al., 2005. Consumption of Trans Fatty Acids Is Related to Plasma Biomarkers of Inflammation and Endothelial Dysfunction. J. Nutr. 135( 3): 562-566


33. Lichtenstein, A. H. 1997. Trans Fatty Acids, Plasma Lipid Levels, and Risk of Developing Cardiovascular Disease: A Statement for Healthcare Professionals From the American Heart Association. Circulation 95: 2588-2590

 

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Low Carb Data:
34. Gary D Foster, et al. A Randomized Trial of a Low-Carbohydrate Diet for Obesity. May 22, 2003; N Engl J Med; 348:2082-2090; DOI: 10.1056/NEJMoa022207


35. Stern L, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med. 2004 May 18;140(10):778-85.


36. Lydia A. Bazzano, et al. Effects of Low-Carbohydrate and Low-Fat Diets. Ann Intern Med. 2014 Sep 2; 161(5): 309–318; doi:  10.7326/M14-0180


37. MJ Sharman, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutr Metab (Lond). 2004 Nov 8; 1: 13; doi:  10.1186/1743-7075-1-13


38. Rachel M Gregory, et al. A Low-Carbohydrate Ketogenic Diet Combined with 6-Weeks of Crossfit Training Improves Body Composition and Performance. Int J Sports Exerc Med. ISSN: 2469-5718; DOI: 10.23937/2469-5718/1510054


39. Volek JS. Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Prog Lipid Res. 2008 Sep;47(5):307-18. doi: 10.1016/j.plipres.2008.02.003.


40. Trinity College Dublin. (2017, May 30). Not such a 'simple' sugar: Glucose may be important in the fight against cancer. ScienceDaily. Retrieved August 22, 2018 from www.sciencedaily.com/releases/2017/05/170530115125.htm


41. Joslin Diabetes Center. (2017, May 1). Connecting the dots between insulin resistance, unhealthy blood vessels and cancer: Animal studies examine risk factors that may overlap between colorectal cancer and cardiovascular disease. ScienceDaily. Retrieved August 21, 2018 from www.sciencedaily.com/releases/2017/05/170501131655.htm


42. William S Yancy, Jr, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab (Lond). 2005 Dec 1; 2: 34; doi:  10.1186/1743-7075-2-34


43. Tendler, D., Lin, S., Yancy, W.S. et al. The Effect of a Low-Carbohydrate, Ketogenic Diet on Nonalcoholic Fatty Liver Disease: A Pilot Study. Dig Dis Sci (2007) 52: 589. https://doi.org/10.1007/s10620-006-9433-5


44. Laura R. Saslow, et al. A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes. PLoS One. 2014 Apr 9; 9(4): e91027; doi:  10.1371/journal.pone.0091027


45. Yamada Y, et al. A non-calorie-restricted low-carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes. Intern Med. 2014;53(1):13-9.


46.  Austin, G.L., Thiny, M.T., Westman, E.C. et al. A Very Low-Carbohydrate Diet Improves Gastroesophageal Reflux and Its Symptoms. Dig Dis Sci (2006) 51: 1307. https://doi.org/10.1007/s10620-005-9027-7


47. Ken Peeters, Frederik Van Leemputte, et al. Fructose-1,6-bisphosphate couples glycolytic flux to activation of Ras. Nature Communications, volume 8, Article number: 922; 13 Oct 2017


48. The Lancet. The link between cancer and obesity. Volume 390, Issue 10104, P1716, October 14, 2017; DOI:https://doi.org/10.1016/S0140-6736(17)32659-4


49. Klement, R.J. Beneficial effects of ketogenic diets for cancer patients: a realist review with focus on evidence and confirmation. Med Oncol (2017) 34: 132. https://doi.org/10.1007/s12032-017-0991-5


50. Peggy P. Hsu and David M. Sabatini. Cancer Cell Metabolism: Warburg and Beyond. Volume 134, Issue 5, P703-707, September 05, 2008; DOI:https://doi.org/10.1016/j.cell.2008.08.021


51. Willem H. Koppenol, Patricia L. Bounds and Chi V. Dang. Otto Warburg’s contributions to current concepts of cancer metabolism. Nature Reviews Cancer volume 11, pages 325–337 14 April 2011; doi:10.1038/nrc3038


52. Kearns CE, Apollonio D, Glantz SA (2017) Sugar industry sponsorship of germ-free rodent studies linking sucrose to hyperlipidemia and cancer: An historical analysis of internal documents. PLoS Biol 15(11): e2003460. https://doi.org/10.1371/journal.pbio.2003460

 

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Necessity of Carbohydrate:
53. Eric C Westman. Is dietary carbohydrate essential for human nutrition? The American Journal of Clinical Nutrition, Volume 75, Issue 5, 1 May 2002, Pages 951–953, https://doi.org/10.1093/ajcn/75.5.951a


54. Owen OE, et al. Protein, fat, and carbohydrate requirements during starvation: anaplerosis and cataplerosis. Am J Clin Nutr. 1998 Jul;68(1):12-34.


55. Walter S. McClellan and Eugene F. Du Bois. Prolonged Meat Diets with a Study of Kidney Function and Ketosis. The Journal of Biological Chemistry; 01 July 1930: 87, 651-668.


56. Weston Andrew Price. Nutrition and Physical Degeneration. 1939-45.

 

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Meat, animal fat, and disease:
57. Sabine Rohrmann, et al. Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition. BMC Med. 7 Mar 2013; 11: 63; doi:  10.1186/1741-7015-11-63 [After correction for measurement error, higher all-cause mortality remained significant only for processed meat.]


58. D. D. Alexander and C. A. Cushing. Red meat and colorectal cancer: a critical summary of prospective epidemiologic studies. Volume12, Issue5, May 2011, Pages e472-e493; https://doi.org/10.1111/j.1467-789X.2010.00785.x 


59. Marije Oostindjer, Jan Alexander, Gro V. Amdam, et al. The role of red and processed meat in colorectal cancer development: a perspective. Volume 97, Issue 4, August 2014, Pages 583-596; https://doi.org/10.1016/j.meatsci.2014.02.011


60. Micha R1, Wallace SK, Mozaffarian D. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation. 2010 Jun 1;121(21):2271-83. doi: 10.1161/CIRCULATIONAHA.109.924977.


61. Eunyoung Cho and Stephanie A. Smith-Warner. Meat and fat intake and colorectal cancer risk: A pooled analysis of 14 prospective studies. Proc Amer Assoc Cancer Res, Volume 45, 2004; Volume 64, Issue 7


62. Yamagishi K, et al. Dietary intake of saturated fatty acids and mortality from cardiovascular disease in Japanese: the Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC) Study. Am J Clin Nutr. 2010 Oct;92(4):759-65. doi: 10.3945/ajcn.2009.29146.


63. Russell J de Souza, 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 doi: https://doi.org/10.1136/bmj.h3978 (Published 12 August 2015)


64. Aseem Malhotra, Rita F Redberg, Pascal Meier. Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions. BJSports, Volume 51, Issue 15; http://dx.doi.org/10.1136/bjsports-2016-097285


65. Patty W Siri-Tarino, et al. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 535–546, https://doi.org/10.3945/ajcn.2009.27725


66. Michele Drehmer, et al. (2016). Total and Full-Fat, but Not Low-Fat, Dairy Product Intakes are Inversely Associated with Metabolic Syndrome in Adults. The Journal of Nutrition, Volume 146, Issue 1, 1 January 2016, Pages 81–89, https://doi.org/10.3945/jn.115.220699


67. Mario Kratz, et al. (2013). The relationship between high-fat dairy consumption and obesity, cardiovascular, and metabolic disease. Eur J Nutr (2013) 52: 1. https://doi.org/10.1007/s00394-012-0418-1


68. Berkey CS, et al. (2005). Milk, dairy fat, dietary calcium, and weight gain: a longitudinal study of adolescents. Arch Pediatr Adolesc Med. 2005 Jun;159(6):543-50.


69. Patty W Siri-Tarino, et al. (2010). Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. The American Journal of Clinical Nutrition, Volume 91, Issue 3, 1 March 2010, Pages 535–546, https://doi.org/10.3945/ajcn.2009.27725


70. Hamley S. (2017). The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials. Nutr J. 2017 May 19;16(1):30. doi: 10.1186/s12937-017-0254-5.


71. C.V. Felton, et al. (1994). Dietary polyunsaturated fatty acids and composition of human aortic plaques. The Lancet, Volume 344, Issue 8931, P1195-1196, 29 October 1994; DOI: 10.1016/S0140-6736(94)90511-8


72. Nina Teicholz; Eric Thorn, MD. (2017). Saturated Fats and CVD: AHA Convicts, We Say Acquit. Retrieved from https://www.medscape.com/viewarticle/882564


73. Brittanie M. Volk, et al. (2014). Effects of Step-Wise Increases in Dietary Carbohydrate on Circulating Saturated Fatty Acids and Palmitoleic Acid in Adults with Metabolic Syndrome. PLoS ONE 9(11): e113605. https://doi.org/10.1371/journal.pone.0113605


74. STACHOWSKA Ewa, et al. (2004). Dietary trans fatty acids and composition of human atheromatous plaques. European journal of nutrition (Print) A. 2004, vol. 43, n° 5, pp. 313-318 [6 pages] [bibl. : 32 ref.]; Retrieved from http://www.refdoc.fr/Detailnotice?cpsidt=16144789


75. Sarah K. Gebauer, et al. (2011). Effects of Ruminant trans Fatty Acids on Cardiovascular Disease and Cancer: A Comprehensive Review of Epidemiological, Clinical, and Mechanistic Studies. Advances in Nutrition, Volume 2, Issue 4, 1 July 2011, Pages 332–354, https://doi.org/10.3945/an.111.000521


76. Sinéad Weldon, et al. (2004). Conjugated linoleic acid and atherosclerosis: no effect on molecular markers of cholesterol homeostasis in THP-1 macrophages. June 2004, Volume 174, Issue 2, Pages 261–273; DOI: https://doi.org/10.1016/j.atherosclerosis.2004.02.007


77. Miner JL, et al. (2001). Conjugated linoleic acid (CLA), body fat, and apoptosis. Obes Res. 2001 Feb;9(2):129-34.


78. Arion Kennedy, et al. (2011). Antiobesity Mechanisms of Action of Conjugated Linoleic Acid. J Nutr Biochem. 2010 Mar; 21(3): 171–179; Published online 2009 Dec 1. doi:  10.1016/j.jnutbio.2009.08.003

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