There is ample evidence that eating more fruits and vegetables can reduce the risk of developing Alzheimer's Disease. But what can be done to improve the mental functioning of people who already have the disease?
The simple sugar glucose, derived from starch and from other sugars, is the brain's main source of energy. Recent studies, though, show that the brains of people developing Alzheimer's Disease cannot utilize the glucose as well as the brains of other people do. Further, it has been found that beta-hydroxybutyrate, formed in the liver as a breakdown product of medium chain triglycerides (fats), can serve as an alternative to glucose as fuel for the brain. Two recent studies provide some evidence that feeding people afflicted with Alzheimer's Disease a supplement containing such medium chain triglycerides may bring about mild cognitive improvement.
In its June 29, 2009, issue, The Medical Letter, which usually adopts a conservative stance with regard to new treatments, concludes that the evidence at this point "is insufficient, and the long-term effects" of taking this physician-prescribed supplement "are unknown." Nevertheless, it is probable that the supplement will be widely used even at this point. The reason is that caregivers for Alzheimer's Disease patients are desperate to try anything that carries even a glimmer of hope. We see this with the drugs currently being prescribed for the disease: in general, there is only about a 30% chance they will have a demonstrable beneficial effect, although such an effect, if it occurs, is only modest. Patients who are started on one of these drugs, which are expensive and which can cause a variety of side effects, should be monitored and continued on the drug only if there is strong evidence the drug is helping them. But what usually happens is that, even without such evidence, they remain on the drug indefinitely because of the need on the part of physicians and caregivers to feel they are "doing something."
New avenues of research into the prevention and treatment of Alzheimer's Disease are greatly needed, and we can only hope that future studies on the use of "medical foods" bear fruit.
By now, most people have heard about some of the relatively healthful regional diets such as the Mediterranean diet and the Japanese diet. There are some significant differences between these two diets, to be sure. For example, the Japanese diet is much lower in fat. One possible consequence of this difference is that the Japanese are slimmer and longer-lived than people of the Mediterranean region. But the most important common feature of the two diets is the fact that they are plant-based.
The Greek segment of the European Prospective Investigation Into Cancer and Nutrition (EPIC) has just published a report describing the relative contribution of the individual components of the Mediterranean diet to reduced mortality (Trichopoulou A et al. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ 2009;338:b2337 - Online First). The most important components contributing to lower mortality were moderate alcohol consumption (in the form of wine), low consumption of meat and meat products, high vegetable, fruit, and legume consumption, and use of olive oil as opposed to oils containing more saturated fat. Low as opposed to high dairy consumption had a very small beneficial effect. Interestingly, high fish consumption was not protective. In fact, there was a small, non-significant increase in mortality ratio associated with higher consumption of fish. It was noted that fish intake for this population as a whole was low. The authors also noted that a large proportion of this Greek population was overweight or obese and a high proportion of the men were either current or former smokers.
This study confirms once more the well established health benefits associated with high intake of plant foods and low intake of animal products. Although it is clear that olive oil consumption is greatly preferable to intake of animal fats or tropical oils, reducing the fat intake would probably alleviate the serious overweight problem in the Greek population by reducing caloric intake. The other important point is that fish consumption did not affect mortality in a positive way and may even have had a negative effect.
Among the large segment of the public that still relies on the news media for medical information, confusion reigns as to the ideal dietary approach toward maintaining a normal weight and reducing the risk of chronic disease. Many overweight people have "eaten up" the concept that "carbs" are the culprit, because it is easier to have a scapegoat than it is to assume personal responsibility for overeating. In reality, overweight is caused by an overly high caloric intake, regardless of the source of those calories. Studies comparing one diet with another are of limited value because people assigned to a diet that seems strange to them are often poorly motivated to adhere to the diet.
A new report from the Adventist Health Study-2 shed some important light on the subject. All participants in this prospective study are Seventh-Day Adventist church members, whose religion strongly encourages, although does not require, vegetarian diets. Religious or ethical motivation increases the likelihood of compliance. This study by Serena Tonstad, M.D., and her colleagues was titled "Type of Vegetarian Diet, Body Weight, and Prevalence of Type II Diabetes" and was published in the May, 2009, issue of the medical journal Diabetes Care.
They found that the more animal products were present in the diet the greater the prevalence of overweight and of diabetes. With regard to weight, vegans (total vegetarians who consume no dairy, eggs, or animal flesh) had, on average, the lowest BMI (body mass index, a measure of weight relative to height) of all. Lacto-ovo vegetarians were heavier, followed by pesco-vegetarians (fish plus a vegetarian diet), semi-vegetarians (small quantities of all kinds of animal products), and omnivores. Thus, even adding just fish to a vegetarian diet is associated with a higher BMI (26.3 in pesco-vegetarians vs. 23.6 in vegans). A similar relationship was seen with regard to diabetes prevalence. When the researchers controlled for BMI, the vegetarians still had the lowest risk of having diabetes. Thus, lower weight is not the only way in which vegetarian diets protect against diabetes. Higher fiber and magnesium content as well as other characteristics of vegetarian diets may add to the protective effect.
Whether any health benefits would accrue from adding fish to a vegetarian diet remains to be determined, but this study, which builds upon previous studies, provides evidence that in some respects, at least, it may be better not to eat fish.
You can't eat your cake and have it, too, but can you eat your meat and still have it all?
For years, many figures in the medical industrial complex have made the claim that consuming more fruits and vegetables rather than reducing meat consumption is the key to a healthful diet. One question raised by that position is: "How do you increase the consumption of one food product without reducing the consumption of another?" Otherwise, your caloric intake will be higher, and that is certainly not a good thing. Getting back to the point, though, is it true that meat consumption per se has no deleterious effects?
A study just published in the Archives of Internal Medicine provides evidence that high meat consumption may indeed be harmful to your health (Sinha R, Cross AJ, Graubard BI, Leitzmann MF, and Schatzkin A. Meat intake and mortality. Arch Int Med 2009;169:562-571). This was a prospective study of over half a million people and was performed under the auspices of the National Institutes of Health. It found that intake of both red and processed meats was significantly associated with total mortality and with mortality from cancer and from cardiovascular disease in both men and women. The researchers attempted to adjust for such confounding factors as smoking and fruit and vegetable consumption.
The news media, as usual, got the story wrong when some reported that higher white meat consumption reduced the mortality in men and in women. True, there was an inverse relationship between white meat consumption and total mortality, meaning that the lower the intake the higher the mortality. But an association found in any observational study such as this one does not prove a cause and effect relationship. The authors reported that those study participants who ate the most red meat tended to consume less white meat than those who ate the least red meat. The researchers did not adjust for red meat consumption when they reported the mortality figures for different levels of white meat consumption. Thus, the lower mortality reported for those with higher white meat consumption may have represented a "substitution effect," that is to say, those who were eating more white meat were also eating less red meat, and the lower red meat consumption may, therefore, account for the lower mortality. Furthermore, when the researchers looked at mortality stemming only from cardiovascular disease, they found that higher intake of white meat was actually associated with higher mortality!
An accompanying editorial supported the idea of reducing meat consumption for the world's health, and I found it interesting that the journal found the necessity to state under "Financial Disclosure" that the author is not a vegetarian. Nevertheless, the author made some comments that require a response. One statement made was that "numerous studies have shown that adding small amounts of red meat to the diets of most populations consuming a vegetarian or very low meat diet provide [sic] nutritional benefits." The two references cited in support of that claim involved studies of Kenyan school children, such as those in rural areas. While animal products may indeed improve nutrient intake in children consuming deficient diets in Third World countries, there is no good evidence that any benefit from supplementing with animal products accrues to people consuming healthful vegetarian diets in Western countries, where a good variety of plant foods is present in abundance.
For many years, people have often tried to claim that adding animal products to a vegetarian diet is beneficial. In 1996, results of a World Health Organization-supported study of Tanzanian Bantu villagers appeared in the respected British journal The Lancet. One group of villagers was said to consume a diet consisting almost exclusively of plant foods. The other group, which lived by a lake, consumed fish as well. The cholesterol concentrations and the blood pressures of the fish-eating group were lower, and these findings were presented in support of the notions that fish oils have these beneficial effects and that a fish-containing diet is, therefore, superior to a vegetarian diet. These results were picked up by a variety of journal and nutrition newsletters, which trumpeted recommendations to increase fish consumption.
When I first read this report, it seemed familiar. I went through my files and found a previous report from this study that had been published in a journal with much more limited circulation, Advances in Prostaglandin, Thromboxane, and Leukotriene Research. I found that, contrary to the impression given in The Lancet article, the plant food portions of the diets of these two groups of villagers were actually quite different. The fish-eating group was said to have derived almost have its calories from a cassava root preparation, similar to what we know as tapioca. It turns out that there is experimental evidence that cassava root, by virtue of its fiber content, can lower cholesterol in the blood and, by virtue of a neurotoxin it contains called scopoletin, can lower blood pressure! My response, which I felt refuted the conclusions of The Lancet article, was published in a later issue.
It is instructive with regard to the politics of the nutrition establishment that, after my letter appeared in The Lancet, the groups that reported initially on the results of this study did not offer any modifications. The desire to extol the consumption of fish (and other animal products) and to deprecate vegetarian diets appears to be fairly well ingrained.
Another statement made in the editorial related to meat and mortality was that "a large number of recent clinical trials show either a low-fat, low-fat and high-complex carbohydrate diet, or a high-protein-low carbohydrate diet are equally healthy." The references given relate primarily to obesity. It is quite true that the number of calories consumed is the primary factor that determines weight gain or loss irrespective of the composition of the diet. But the healthfulness of a diet relates both to caloric intake and to its composition. "Healthfulness" means producing health, and "health" is defined by the presence or absence of disease and not to markers or risk factors for disease. We know from caloric restriction studies that cutting calories in itself may not only allow maintenance of a normal weight but may also have a favorable impact on blood pressure, cholesterol concentrations, and other factors. But, in terms of health, intakes of both beneficial and detrimental substances play an equally important role. The traditional Japanese diet typifies the high-carbohydrate plant-based diet, and the Japanese are the longest-lived people in the world.
In summary, a very important prospective study has shown an association between red/processed meat consumption and mortality. The findings are consistent with the conception of the ideal diet as one that maximizes the consumption of plant foods and minimizes the consumption of animal products.
A growing body of evidence implicates degenerative changes in the mitochondria of our cells as a major cause of aging. Mitochondria are organelles - specialized parts of our cells that function in a manner similar to the way in which organs serve our bodies. Mitochondria are the powerhouses of the cell. They generate stored forms of energy from the nutrients we consume. When we consume too much food, containing energy beyond our needs, free radicals and other compounds promoting oxidation may form in the mitochondria. This represents one theory as to why calorie (dietary) restriction diets increase longevity in almost all species of animals studied.
An important antioxidant enzyme is mitochondrial superoxide dismutase. Some experimental data suggest that having higher activity levels of this enzyme may help protect against chronic disease processes such as diabetic retinopathy and Alzheimer's disease. Mitochondrial superoxide dismutase requires the mineral manganese as a cofactor, so this enzyme is usually abbreviated MnSOD. If a person is deficient in manganese, there will be less superoxide dismutase activity in the mitochondria. The best dietary sources of manganese include whole grains, legumes, nuts, and tea. Leafy vegetables and fruit contain moderate amounts. It is difficult to determine whether a person is mildly deficient, however, because most of the manganese in the body is concentrated in organs, such as the liver, kidneys, and pancreas. It would require a biopsy to determine the manganese content of these organs. There is some manganese in the blood, although the concentration there does not necessarily reflect its concentration in the organs. For minerals like this, checking the activity of enzymes that require manganese is sometimes the best way to determine adequacy or deficiency.
A study has been reported in the British Journal of Nutrition (2008) that examines just this issue. It is titled, "Epigenetic Regulation of Human Buccal Mucosa Mitochondrial Superoxide Dismutase Gene Expression by Diet." Forty young adult vegetarians were compared with a group of nonvegetarians, and some elderly people were studied as well. The important finding was that the vegetarian group had "a 3-fold increase in the expression of the MnSOD gene" as compared with the nonvegetarian group. Although we cannot be certain of the reason, the most likely explanation is the better manganese status of the vegetarians because of the foods they consume. The superior manganese status of vegetarians has been documented in the past. This may explain some of the health benefits associated with a plant-based diet.
It is important to note, though, that simply following a vegetarian diet is not enough to insure adequate manganese intake. It must be a healthful diet, rich in the whole plant foods mentioned previously. For example, whole wheat flour contains over five times as much manganese as refined flour. Consuming a good variety of unrefined plant foods and avoiding the high fat/salt/sugar "immediate gratification" trap represent the keystones of the ideal diet.
Many doctors recommend calcium supplementation in the range of 1,000 to 1,500 mg a day to women who are developing or who are at risk for osteoporosis. Because calcium supplementation has been shown to have a favorable effect on blood lipids (fats), raising the ratio of HDL (good) cholesterol to LDL (bad) cholesterol in postmenopausal women, some have speculated that this may lower their risk of heart disease and stroke.
A randomized, controlled clinical trial in New Zealand examined this possibility (Bolland MJ, Barber PA, Doughty RN, et al. Vascular events in healthy older women receiving calcium supplementation: randomized controlled trial. BMJ 2008; Online First). The women in the experimental group took 1,000 mg of calcium citrate a day: 400 mg in the morning and 600 mg in the evening. Surprisingly, these researchers from the University of Auckland found a significantly increased risk of heart attack and stroke in the group receiving the calcium. The fact that calcium often forms part of atherosclerotic plaques (hardening of the arteries) suggests a possible mechanism for the observed result.
This illustrates a number of important points:
Following a report from The Women's Healthy [sic] Eating and Living (WHEL) Study, 1 news articles bearing blaring headlines declared that fruits and vegetables do not help women with breast cancer and that there was no need for such women to increase their consumption of such foods. It is obvious to scientifically-minded individuals that conclusions of this nature can hardly ever be drawn from the results of a single study, but it is not at all obvious to the general public. Such irresponsible journalism feeds the mindset that nutritional scientists are always flip-flopping on their recommendations and that their advice is best ignored. Scientists from all disciplines lament the increasingly poor scientific knowledge of news reporters and science writers, who often seem to be more interested in sensationalism than in getting the story right - even if their misstatements hurt people. No, the medical writers generally don't pore the scientific literature to find studies of interest. They are fed stories from the public relations departments of academic institutions. Once upon a time, there were ethical scientists who published their findings and allowed them to be subjected to the scrutiny of others. Now, they have public relations people to promote themselves and inflate the significance of their results. So much for reputation.
The WHEL study was a controlled trial in which one (intervention) group of women with breast cancer were to consume at least 5 vegetable servings, 3 fruit servings, and 1 pint of vegetable juice each day, all in the context of a moderately low-fat diet (15-20% of calories from fat). They received phone calls from "dietary counselors," and attended a few cooking classes, mainly in the first year of the study. A control group was asked to consume at least five servings of fruits and vegetables a day. Here's the rub, though. At baseline (before the study began), the women in both groups were consuming, on average, more than 7 servings of fruit and vegetables a day. Consider that the average American consumes about 1 serving of vegetables a day, which includes potatoes, such as French fries (the WHEL study excluded white potatoes)! Therefore, if the study participants were already consuming a diet so rich in fruits and vegetables, how much of an effect could one expect to see by increasing fruit and vegetable consumption by such a small amount?
In any study such as this, compliance is a major problem. Poor dietary habits are difficult to change when they're so much a part of our culture. Compliance was measured by phone calls in which the women were asked about their eating habits. Now if they've been told they're supposed to follow such and such a diet, what do you think they're going to say? Of course, many are going to lie and say they ate more fruits and vegetables than they did and that they consumed a lower fat and lower calorie diet than they did because they know what was expected of them and they're ashamed to admit the truth. It is well established that overweight people especially tend to underestimate the amount of food they actually eat. Therefore, the results of such telephone interviews cannot be trusted. The intervention and control groups gained similar amounts of weight during the study.
To overcome the aforementioned problem, the researchers in this study measured the concentrations in the blood plasma of a number of carotenoids - pigments present in most fruits and vegetables. These included beta-carotene, alpha-carotene, lutein and zeaxanthin, lycopene, and beta-cryptoxanthin. In a prior publication from this study, the researchers reported no significant changes in the laboratory results from the control group, but the intervention group showed a 223% increase in plasma alpha-carotene and an 87% increase in beta-carotene but only a 29% increase in lutein, a 17% increase in lycopene, and no significant change in beta-cryptoxanthin. The authors of this study claimed that these results provided objective evidence of the compliance of the women in the intervention group. But do they really? The main dietary sources of alpha-carotene are carrots, pumpkins, and, to a minor degree, winter squash. Since most people eat little pumpkin and squash, it's reasonable to assume that carrot consumption caused the large increase in plasma alpha-carotene. Because carrots are also rich in beta-carotene, they could be largely responsible for the 87% increase there. Considering that it is much easier to comply with drinking a pint of vegetable juice each day than it is to change one's whole dietary lifestyle, I would strongly suggest that the higher carotenoid concentrations seen in the intervention group were largely the result of consuming carrot-rich juice each day. Thus, I do not feel that the carotenoid data establishes the compliance of the intervention group.
Comments of some of the co-authors of this study also bear mentioning. One of the lead authors was quoted as saying that the women were placed on a "tough diet." Tough? What is so tough about following a diet moderately low in fat and rich in fruits and vegetables? The comment betrays the mindset of so many in the nutrition field. They're so entrenched in our culture of "If it feels good, eat it" that they're loath to recommend truly healthful, low-fat diets because of their own prejudice that such diets are not very palatable. How can we expect the population-at-large to adopt healthful eating habits if they're given the perception that such diets are "tough?" In reality, the intervention group should have been placed on a much more restricted diet, one not only rich in whole vegetables and fruits but also eliminating the animal products and the bulk of the saturated fat. They may actually have found it easier to comply with such a diet. It's much easier to backslide from a half-hearted dietary regimen than it is from one in which some foods are permitted while others are totally off-limits.
Another of the lead authors, a dietitian, was quoted in a press release (naturally) as claiming that this study showed how successful telephone counseling is in bringing about large differences in dietary lifestyle. I don't think so. The only thing this study should teach us is that we should be wary of anything we read in the news media.
There is a growing body of evidence that healthful plant-based diets, low in fat (especially saturated fat, derived mainly from animal products), can improve the quality of life and survival of women with breast cancer. Telephone calls by "trained counselors" are not enough to overcome the resistance to "regimen change" in our society. We need a system where physicians, aided by dietitians, can work with patients and provide the continuing support they need.
1Pierce JP, Natarajan L, Caan BJ, et al. Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer. JAMA 2007;298:289-298.
Looking at 17th century Dutch paintings, with the succulent table spreads and the plump visages of Jan Steen and his contemporaries, one might expect to get in Dutch with one's doctor if one followed a Dutch diet. But a study 1 just published in The American Journal of Clinical Nutrition indicates that "it ain't necessarily so." Over 5,400 women in their sixties were studied, and the relationship between their dietary patterns and their longevity was determined. These dietary patterns included a Traditional Dutch dietary pattern (high consumption of meat, potatoes, other vegetables, and alcoholic beverages); a Mediterranean-like pattern (high consumption of vegetables, grains, sauces, fish, and wine); and what the authors call a Healthy Traditional Dutch pattern (high consumption of vegetables, fruits, nonalcoholic beverages, and dairy products in general but low in butter and in alcoholic beverages). They found a 30% reduction in mortality risk (chance of dying) for those women following the Healthy Traditional Dutch diet as compared with those following either the Traditional Dutch or Mediterranean style diets.
Let us now put these results into context by comparing the Healthy Traditional Dutch diet with two other relatively healthful dietary patterns, the Mediterranean diet and the traditional Japanese diet. The Mediterranean diet is rich in vegetables, grains, olive oil, and red wine, with modest amounts of dairy and other animal products, whereas the Japanese diet is rich in vegetables and grains but low in fat and in all animal products. The Mediterranean diet receives the most publicity even though the Japanese are the longest-lived people in the world, most likely because the higher fat Mediterranean diet comes closer to the taste preferences of people used to the standard Western diet. But what components of the Mediterranean diet contribute to its reputed benefits? Is it the olive oil and the red wine as we are often led to believe? There is a certain plausibility to this claim, because both olive oil and red wine contain phytochemicals, the beneficial chemical compounds found throughout the plant kingdom. However, the common denominator of all of these diets is the high consumption of plant foods, in particular, vegetables.
Two other recent articles in this journal underscore the important of vegetable and fruit consumption. One Italian study,2 a meta-analysis of the results of sixteen previously performed studies, showed a very sharp reduction in the risk of oral cancer associated with both fruit and vegetable consumption. The other study3 showed a lower risk of non-Hodgkin's lymphoma, one of our major causes of death due to cancer, with higher consumption of vegetables, especially the dark leafy greens like kale, spinach, collards, chard, and mustard and turnip greens, which are rich in the carotenoid lutein.
The moral of the story, then, is that eating multiple servings of vegetables and fruit a day keeps the doctor away, the benefit from which should not be underestimated.
1Waijers PMCM, OckŽ MC, van Rossum CTM, et al. Dietary patterns and survival in older Dutch women. Am J Clin Nutr 2006;83:1170-1176.
2Pavia M, Pileggi C, Nobile CGA, Angelillo IF. Association between fruit and vegetable consumption and oral cancer: a meta-analysis of observational studies. Am J Clin Nutr 2006;83:1126-1134.
3Kelemen LE, Cerhan JR, Lim U, et al. Vegetables, fruit, and antioxidant-related nutrients and risk of non-Hodgkin lymphoma: a National Cancer Institute-Surveillance, Epidemiology, and End Results population-based case-control study. Am J Clin Nutr 2006;83:1401-1410.
Inflammation in the body is now believed to play a causative role in a number of chronic diseases, not just in obviously inflammatory conditions such as rheumatoid arthritis. It is now well established that inflammation serves as a risk factor for heart disease, stroke, and other blood vessel disease in the body. It may be related to adult-onset diabetes, and a growing body of evidence links inflammation with Alzheimer's disease and with the "wet" form of age-related macular degeneration, the main cause of poor vision among the elderly. Obesity carries with it an inflammatory tendency, but it hasn't always been clear to what degree it is the obesity itself rather than the overeating associated with the obesity that leads to the problem. As mentioned on the Dietary Restriction page, people who consume a low-calorie diet tend to have very low concentrations of biochemical markers of inflammation, such as C-reactive protein (CRP), in their blood. Theoretically, plant foods in and of themselves should be helpful. Fruit and vegetables are rich in phytochemicals with anti-inflammatory properties. A plant-based diet is also low in arachidonic acid, a pro-inflammatory omega-6 fatty acid that comes mainly from animal products.
Recent studies have added to our knowledge regarding the connection between diet and inflammation. When people are instructed to follow a low-fat, high-carbohydrate diet but are made to maintain the same intake of calories as before, nothing much happens. But when they aren't required to take in a certain minimum amount of food, their calorie intake drops, and so do their markers of inflammation.1 This study provides support for the role of caloric intake in inflammation.
Another study showed that the more fiber people consume, the lower their levels of CRP in their blood. 2 As with other studies involving fiber, it isn't clear whether the fiber itself is beneficial or whether it is just a marker for a healthful, plant-based diet, which tends to be lower in calories than the average diet and which is rich in fruits and vegetables with their potentially beneficial properties.
Still another study just out linked higher plasma vitamin C concentrations with evidence of reduced inflammation in the body. 3 As with fiber, vitamin C may just be a marker here for a plant-based diet.
Finally, although a high glycemic load, that is, the tendency of the foods one eats to raise one's blood sugar, has been linked with higher levels of CRP by some, it is premature to recommend avoiding foods with a high glycemic index (tendency to raise one's blood sugar). Glycemic load may just be a marker for an unhealthful diet in general. Indeed, a recent clinical trial showed that when sugar (sucrose) consumption was increased by 151% in one group of patients and reduced by 42% in another group, there was no significant effect on CRP levels.4
In summary, the flurry of recent studies supports the concept that the best way to minimize any inflammatory tendency in the body is to consume a high-fiber, low-fat, plant-based diet, which generally results in a lower intake of calories than the standard Western diet.
1Kasim-Karakas SE, Tsodikov A, Singh U, Jialal I. Responses of inflammatory markers to a low-fat, high-carbohydrate diet: effects of energy intake. Am J Clin Nutr 2006:83:774-779.
2Ma Y, Griffith JA, Chasan-Taber L, et al. Association between dietary fiber and serum C-reactive protein. Am J Clin Nutr 2006;83:760-766.
3Wannamethee SG, Lowe GDO, Rumley A, Bruckdorfer KR, Whincup PH. Associations of vitamin C status, fruit and vegetable intakes, and markers of inflammation and hemostasis. Am J Clin Nutr 2006;83:567-574.
4Sorensen LB, Raben A, Stender S, Astrup A. Effect of sucrose on inflammatory markers in overweight humans. Am J Clin Nutr 2005;82:421-427.