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Just Keep Esterifying

I’ve had many of my patients and followers on social media ask about my continued use of the hashtag #JustKeepEsterifying.  Well, here is the answer.  Check out the short 4 minute video below to get the answer:

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“Keep the carbs low and the fat high.”
#DrAdamNally #DocMuscles #DocMusclesLive #DocTalk #DocsWhoLift #LiftRunShoot #DocMusclesLife  #PicoSure #Icon #SculpSure #TempSure
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The Shovel will Fail You in Obesity, Finances & Life

A few years ago, my family and I set out to build a pond.

I have always loved Koi and the serenity of a Koi pond in my own back yard was very enticing. I spent about a year planning my design and the location.  I dreamed of a serene evening after a very long, hectic day seeing patients relaxing beside the pond.  The sound of trickling water, the occasional splash from fish, the cool breeze passing over the mist from a water-fall would sooth my soul after a busy day in the office.

I envisioned the perfect area.  An unused access path, previously worn by the previous owner with truck and trailer traffic, beside my now expanded patio. Twenty feet wide, thirty feet long and four feet deep. . . that seems just perfect.

I pulled out my shovel and set about digging. Eager to begin and filled with the energy of the final product, I set to digging.  What could be so hard about digging my own pond?  Think of the exercise I will be getting.  Thoughts spurred me on.

Minutes later, chest heaving, face glistening with sweat, I stared in dismay at the ground. All I had to show for my wild digging was a small 1/2 inch dent in the dusty Arizona top soil.

Sonoran Clay

Over time, calcium-carbonate, along with other minerals, accumulates and dissolves into the topsoil of the very arid regions of Arizona Sonoran Desert.  It forms a two to three-foot layer of soil called “caliche.” Periodic rains carry the calcium as far as three feet down into the soil, then the water rapidly evaporates in the blistering Arizona heat.  This often forms two to three feet of soil that is “literally” harder than concrete.

With tremendous zeal, a great deal of sweat and a round of painful blisters, I broke my third shovel on this impenetrable ground.  I realized this was much more difficult than I thought.  I pulled out the back-hoe attachment for my small farm tractor.  After a few hours and few gallons of diesel fuel later, still very little progress occurred.

Multiple weekends and evenings of digging in the Arizona caliche left me with three broken shovels, a ruptured hydrolic line in my tractor, anger that my expensive back-hoe attachment didn’t work, and only a small dent in the ground near my patio.  Even the brute force from the tractor would not budge the clay.  I wondered if dynamite would be effective?  (My wife would have none of this idea).

With my exuberance quashed, I concluded that this would require much more measured exhuming.

Escape From the Prison

We often imagine, with great delight, the removal or destruction of that which enslaves or imprisons us.  We dream that just a little sweat, exertion of a few shovel scoops of dirt and the foundation to our prison of obesity, addiction, debt, and depression are exposed.  A few extra scoops and we imagine freedom from that prison cell.

If only I had a jack hammer and a bigger, more powerful scoop, I imagine . . . I could make short work of these manacles that bind me.

But, our manacles and prison cells do not so easily give way.

The failings of our sharpened spades and powerful back-hoes form a new, even stronger fetter – the belief that our prison cell is unbreakable, that our challenge is just too great. These failings usually leave a person cured of any further desire to break free.  It quashs the dream and solidifying the depression of stagnation.

The in-fecundity of my shovel, no matter the strength and effort put behind it, was not cause to quit.  It was life’s lesson that prisons and shackles often only need a simple tool.

Enter the pick-axe.  During this process my wife said, “Honey, why don’t you use the pick in the garage?”

“If my shovel and the back-hoe didn’t work, there was no way I was going to break through this clay with a pick axe.” That was absurd, I thought.

Yet when I humbled myself to try, it was simple.  The pick-axe was unpretentious.  This simple tool allowed for an almost effortless stroke to a small area of weakness in the caliche.  A large flake of soil would pop free with each stroke. The process was repeated.

Scale by scale, the dragon’s flank was exposed. Careful work of the pick-axe began to loosen layer after layer, section after section, pellicle after pellicle.  Yes, it was slow work. But, each swing was a small victory.

At each little victory, my heart would leap, the dream would become ever clearer.

Working this magic again and again until finally the specter was weakened enough to pull out the shovel.  And, further work, allowed for bringing back the powerful back-hoe, in gratifying scoops.

The excavation that I thought would take two months took me fourteen.  But, it was gratifying.

I learned a powerful lesson. Wherever life has pinned you, fettered you or barred you in, put down the shovel, and pick up the pick-axe.  Second, if you really listen, your spouse may point out the tool you really need. Don’t be afraid to chip away at it a piece at a time.

Finances

Stop waiting for the sharper shovel or the bigger back-hoe to dig yourself out of your harrowing debt, mega mortgage, or your income dwarfing spending. The jackpot or financial windfall won’t come. While others await the jackpot, put down your shovel and shoulder your pick-axe.

  1. Pick one small debt and begin to pick at it by applying just a little extra each month until it is gone.
  2. Cancel your extra cable, sell the motorcycle and payoff the 21% interest credit card.
  3. If you must, pick up a side-hustle for extra to sharpen the pick.

Once you’ve lifted one flake, chip away at the next. Making progress will make it easier to continue.  It doesn’t matter how long it takes, just keep at it.

Marriage

You long for resolution of the apathy, progressive resentment and mutual stalemate that permeates your relationship.  You look in vain for the bigger shovel that will uncover the treasure that years of apathy have buried. You long to uncover your dreams and needs that have been covered and hardened under the clay of resentment.  The shovel and the back-hoe won’t help you here.

Drop the shovel.  Shoulder your pick-axe.

  1. Kiss your wife every time you leave, even if it’s just for a ten minutes to run to the convenience store.
  2. Hold her for five seconds longer every time you hug.
  3. Find a gift you can give her once a week, just because.
  4. Put down your phone and look her in the eyes when she talks to you and listen. Really listen and the flakes of hard clay will unveil the beauty of her soul.
  5. Find a way to praise her every day, even if it is through a simple text.

Health

You long to rid yourself of your addiction to sugar, bread, stress, and sleep deprivation.  You’ve tried to scoop them out of your life.  You even hired a trainer with some muscle to force you to change.  You’ve tried in vain to save yourself from yourself.

Trying to use the shovel here is like trying to use the shovel on steel forged walls of your life’s prison fortress.  Forget the shovel.  Shoulder your pick-axe.

  1. Start with one meal and make some substitutions.  My dietary plan can help you with this.
  2. Go to bed an hour earlier. Really, you’ll be surprised that the focus you have will more than compensate for the hour of lost time in the evening.
  3. Add a quality vitamin to your morning routine.
  4. Take ten minutes and do 20 push-ups and 20 sit-ups, then take a 10-minute walk.
  5. Simply remove the “white stuff” from your meals. You will be amazed at the results.
  6. Put down your phone for 30 minutes and read that book you’ve been meaning to read, instead of surfing Facebook.

Grand-standing with your back-hoe doesn’t help you.  Just swing the pick-axe once or twice.  Simple daily picking with the sharp point weakens the hardest of ground and the prison walls in our lives.  It takes time, so be patient.

Find the weak point, apply the pick.  Day by day, little by little you will be free.

I’ve been there.  I’m with you.  Keep me posted on your journey.

If you’re looking for a program that teaches you how to do this, check out my membership site.

Long-term weight loss

Long-Term Weight Loss: Why So Many Fail

Over fifty years of data have demonstrated that creating energy deficit through the reduction in caloric intake is effective in reducing weight. . . However, it is only for the short term (1, 2).  The biggest challenge physicians face in the treatment of obesity is that calorie restriction fails when it comes to long-term weight loss.

Isn’t Fasting Effective in Long-Term Weight Loss?

With the craze and popularity of intermittent fasting, some have claimed that intermittent fasting is more effective in weight reduction.  Recent results demonstrate that this may also be incorrect.  In the short term evaluation of caloric restriction and intermittent fasting, reduction in 15-20 lbs of weight is effectively seen and the highly publicized Biggest Loser’s losing ~ 120 lbs.  Intermittent fasting and alternate day fasting have been shown to be more effective in lowering insulin levels and other inflammatory markers in the short term.

There is, however, controversy over maintaining weight loss beyond 12 months in the calorie restriction, intermittent and alternate day fasting groups. Forty different studies in a recent literature review, thirty-one of those studies looking at forms of intermittent fasting, demonstrate that the majority of people regain the weight within the first 12 months of attempting to maintain weight loss(3, 5).  This is, also, what I have seen for over 18 years of medical practice.

Is Calorie Restriction the Only Way to Lose Fat?

Numerous “experts” claim that the only way to reduce fat is “caloric deficit.”  Variations through the use of intermittent, long-term or alternate day fasts can be found all over the internet.   In regards to calorie restriction, these “experts” with nothing more than a personal experience and a blog to back their claims preach this louder than the “televangelists” preach religion.  Based on the faith that many place in this dogma, it could be a religion.  What causes belief in this dogma is that weight and fat loss actually does occur with caloric restriction to a point.  The average person will lose 20-25 lbs, however, within 12 months of achieving this goal, most people regain all the weight.  (No one ever mentions the almost universal problem with long-term weight loss, especially those “experts.”)

Prolonged calorie restricted fasts, intermittent fasts, and alternate day fasts are often grouped together into the fasting approach, causing significant confusion among those that I speak to and counsel in my office.  There is great data that alternate day fasts do not have the reduction in resting energy expenditure that prolonged fasting, intermittent fasting and calorie restriction cause.  However, none of these approaches appears to solve the problem of weight re-gain after long-term (12-24 months into maintenance) weight loss (3).  And, a recent study of 100 men participating in alternate day fasting showed that there was a 38% dropout rate, implying that without close supervision and direction, maintenance of this lifestyle is not feasible for over 1/3rd of those attempting it.

Long-Term Weight Loss Failure Brings Tears

Failure on calorie restricted diets, low fat diets, and intermittent fasting diets with weight regain at twelve to twenty-four months is the most common reason people end up in my office in tears.  They’ve fasted, starved themselves, calorie restricted, tried every form of exercise, and still regained the weight.  Trainers, coaches and “experts” have belittled them for “cheating” or just not keeping to the diet.  Yet, we know that calorie restriction and intermittent fasting cause a rebound in leptin, amilyn, peptid YY, cholecystikinin, insulin, ghrelin, gastric inhibitory peptide and pancreatic poly peptide by twelve months causing ineffective long-term weight loss (6).  The dramatic rise in these hormones stimulates tremendous hunger, especially from ghrelin and leptin.

Hormones after weight loss
N Eng J Med 27 Oct 2011. Mean (±SE) Fasting and Postprandial Levels of Ghrelin, Peptide YY, Amylin, and Cholecystokinin (CCK) at Baseline, 10 Weeks, and 62 Weeks.

Although less problematic in alternate day fasting, these calorie restricted approaches also cause dramatic slowing of the metabolism at the twelve month mark.  In many cases, the metabolic rate never actually returns to baseline, creating even more difficulty in losing further weight or even maintaining weight (6).

Weight rebound after loss
N Engl J Med 27 Oct 2011. Mean changes is weight from 0 – 62 weeks.

Is Gastric Bypass or Gastric Sleeve the Solution?

Gastric bypass and the gastric sleeve procedures have been touted as the solution to this problem, as they decrease ghrelin, however, 5-10 years later, these patients are also back in my office.  They find that 5-10 years after these procedures the weight returns, cholesterol and blood pressure rise, and diabetes returns.  These hormones kick into high gear, stimulating hunger in the face of a slowed metabolism, that to date, has been the driver for weight regain in the majority of people.  People find it nearly impossible to overcome the hunger. You may have experienced this, I know I have.

It’s the Hormones, Baby!

So, what is the answer?  It’s the hormones.  (WARNING – You’ll hear that when your wife is pregnant, too, gentlemen).  We are hormonal beings, both in weight gain, and in pregnancy.  Trying to preach calorie control to a hormonal being is like showing up at the brothel to baptize the staff. You might get them into the water, but you’re probably not getting them returning weekly to church or pay a tithe.

Respect My HormonesSo, how do you manipulate the hormones in a way to control the rebounding hunger and suppression of metabolism?  This is where we put a bit of twist on the knowledge we’ve gained from alternate day fasting.  Recent research shows that “mild” energy deficit in a pulsatile manner, that has the ability to mimicking the body’s normal bio-rhythm’s is dramatically effective in reducing weight and maintaining normal hormonal function without cause of rebound metabolic slowing (4).

Pulsed Mild Energy Restriction

What does this mean in layman’s terms?  It means that if we provide a diet that maintains satiety hormones while providing a period of baseline total energy expenditure needs and a period of mildly reduce caloric intake in a pulsed or cyclic manner, greater weight loss occurs and there is no rebound of weight 1-2 years later.

The main reason I’ve not jumped on the intermittent fasting band wagon is the shift in leptin, amylin, ghrelin and GLP-1 signaling that regularly occurs at the 6-12 month mark.  The rebound of these hormones causes weight re-gain and is what prevents successful long-term weight loss.  A number of people come to my office and tell me they couldn’t follow a ketogenic diet, so they’re doing intermittent fasting and it works . . . for a while.  Then, they end up in my office having hit a plateau or fallen off the wagon and regained all the weight.  They are completely confused and don’t understand what happned.  Most of them are convinced it’s their thyroid or cortisol and they’ve seen every naturopath and functional medicine doctor in town.

What people really need is a simple approach to long-term weight loss without having to spend the night in the physiology lab every two weeks sleeping under a ventilated hood system.

The Ketogenic Lifestyle is a Pulsed Energy Lifestyle

  • First, it is essential to turn off the insulin load. Insulin is the master hormone.  This is done by a ketogenic lifestyle that restricts carbohydrates.
  • Second, providing adequate protein to supply maintenance of muscle and testosterone is key.
  • Third, providing adequate fat is the simple way to maintain leptin, ghrelin, amylin, GLP-1 (among the others) and long-term weight loss.  Can you eat too much fat?  Of course you can.  But, because each of us have differing levels of stress and activity each day, this fat intake becomes the lever for hunger control.
  • Fourth, the use of exogenous ketones ensures easily accessible ketone (short chain fatty acids) to modulate adipose (white fat) signaling of the liver without large caloric intake through the portal vein by first pass of liver metabolism.  The ketones also help stabilize the gut bacteria.  The combination of hormone balance between the liver and fat cells and improvement of gut bacteria suppresses key hunger hormones and aids glucose regulation between the fatty tissues and the liver.  Ketones, both endogenous and exogenous, suppress production of TNF-alpha, IL-6, resistin, and stabilize production of adiponectin and leptin from the adipose cells (7, 8, 9).

In my office, once we calculate the basic protein needs daily, we start with a 1:1 ratio of protein to fat.  Then, the fat is adjusted up or down based on hunger. Remember, hunger occurs, because your body produces hormones.  The addition of fat to a diet that is not stimulating large amounts of insulin resets the hormone patterns back to normal without causing weight gain.

Give Obese People Fat Ad Libitum?

“Sure, Dr. Nally, but what about those people who don’t know if they are hungry, bored, stressed or just have a bacon fixation?  You can’t just give them all the fat they want?!”

Why not?  Implying that people aren’t smart enough to know when they are full is a bit of a fascist philosophy, don’t you think?

Do people over eat?  Sure they do.  But, I’ve found that when you give people an antidote to hunger (using fat intake in the presence of stabilized insulin levels) over a few months, people begin to recognize true hunger from other forms of cravings.  This is especially true when they keep a diet journal.  This gives people the ability to begin listening to their own bodies, responding accordingly and governing their stress, eating, exercise and activity.  Keeping a diet journal is key to long-term weight loss.  And, isn’t helping people use their own agency to improve their health really what we’re trying to do?

Interestingly, doing this over the years seems to line up with the findings of this year’s MATADOR study in the International Journal of Obesity.  They found that mild intermittent energy restriction of about 30-33% for two weeks, then interrupting this with two weeks of a diet that was energy balanced for needs improved both short and long-term weight loss efficiency (4).  In looking at my, and my patient’s diet journals, this energy restriction of about 1/3 of needed calories cyclically seems to happens naturally with a ketogenic lifestyle, without even counting calories.  (Calories are a swear-word in my office).

What does the correct long-term wight loss program look like in a diet or meal plan?  Well, you’ll have to join the Ketogenic Lifestyle 101 Course to see what that really means to you individually.  I look forward to seeing you there.

Want to find out more about the Ketogenic Lifestyle 101 course?  CLICK HERE.

 

Have you read my book The Keto Cure?  Get a signed copy from me by clicking HERE.

References:

  1. Bronson FH, Marsteller FA. “Effect of short-term food deprivation on reproduction in female mice.” Biol Reprod. Oct 1985; 33(3): 660-7. https://www.ncbi.nlm.nih.gov/pubmed/4052528?dopt=Abstract&holding=npg
  2. Connors JM, DeVito WJ, Hedge GA. “Effects of food deprivation on the feedback regulation of the hypothalamic-pituitary-thyroid axis of the rat.” Endocrinology. Sep 1985. 117(3): 900-6. https://www.ncbi.nlm.nih.gov/pubmed/3926471?dopt=Abstract&holding=npg
  3. Seimon RV, Roekenes JA, Zibellini J, Zhu B, Gibson AA, Hills AP, Wood RE, King NA, Byrne NM, Sainsbury A. “Do intermittent diets provide physiological beneftis over continuous diets for weight loss? A systematic review of clinical trials.” Mol Cell Endo. 15 Dec 2015. 418(2): 153-172. https://www.sciencedirect.com/science/article/pii/S0303720715300800
  4. Byrne NM, Sainsbury A, King NA, Hills AP, Wood RE. “Intermittent energy restriction improves weight loss efficiency in obese men: the MATADOR study.” Int J Obes. 2018. 42:129-138.  https://www.nature.com/articles/ijo2017206
  5. Trepanowski JF, Kroeger CM, Barnosky A. “Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults.” JAMA Intern Med. Jul 2017. 177(7): 930-938. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2623528?redirect=true
  6. Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. “Long-term persistence of hormonal adaptations to weight loss.” N Engl J Med. 27 Oct 2011. 365: 1597-1604. http://www.nejm.org/doi/full/10.1056/NEJMoa1105816
  7. Asrih M et al., “Ketogenic diet impairs FGF21 signaling and promotes differential inflammatory responses in the liver and white adipose tissue.” PlosOne. 14 May 2015. Open Access. https://doi.org/10.1371/journal.pone.0126364
  8. Veniant MM et al. “FGF21 promotes metabolic homeostasis via white adipose and leptin in mice.” PlosOne.  Jul 2012. Open access. https://doi.org/10.1371/journal.pone.0040164
  9. Whittle AJ, “FGF21 conducts a metabolic orchestra and fat is a key player.” Endocrinology. 1 May 2016. 157(5): 1722-1724.

The Dreaded Seven . . . (Seven Detrimental Things Caused by High Insulin Loads)

85% of the people that walk through my office doors have some degree of insulin resistance.

What is “insulin resistance?”  It is an over production of insulin in response to ANY form of carbohydrate intake (yes, even the “good carbs” cause an insulin over-response in a person with insulin resistance.)

How do I know this? Because I routinely check insulin levels (I check them every three months) and the down stream markers of insulin on a large number of the patients that I see.  I have been fascinated by the fact that a diet high in both sugar and fat [like the Standard American Diet, (SAD) diet]  turn on the genetics leading to insulin resistance.  Starch and sugar load the genetic gun.

Insulin acts like a key at the glucose doorway of every cell in your body.  In many people, the insulin signal is blocked by hormones produced in the fat cell and the the insulin, acting like a “dull or worn out key” – can’t open the glucose doorway as efficiently.

So, the body panics, and releases extra insulin in response to the same load of carbohydrate or glucose.  People with insulin resistance will produce between 2-20 times the normal amount of insulin in response to a simple carbohydrate load.  Recent studies(1, 2) reveal high cholesterol and diets high in both fat and carbohydrate cause insulin resistance to progress or worsen.

So, instead of producing enough insulin to accommodate the one slice of bread or the one apple that you might eat, the insulin resistant person produces enough insulin for an entire loaf of bread or an entire bushel of apples.  This excess insulin then stimulates one or all of the following:

  1. Weight Gain – Insulin directly stimulates weight gain by activating lipoprotein lipase to take up triglycerides into the fat cells.  This causes direct storage of fat and increases your waistline. (3)  weight tape measure
  2. Elevated Triglycerides – Insulin directly stimulates production of free fatty acids and triglycerides through hepatic gluconeogenesis and is even more notably amplified by the broken signaling mechanism of the FOX-01 phosphorylation mechanism in patients with insulin resistance. (4)triglycerides homer simpson
  3. Increased number of Small Dense LDL (sdLDL) particles – Low density lipoprotein (LDL, or “bad cholesterol”) is actually comprised of various sized lipoproteins including small, medium and large.  As triglycerides increase, the small dense LDL particle numbers increase.  Research points to the fact that it is the small dense particle that is highly atherogenic (leading to the formation of vascular plaques within the arteries). (5, 8)
  4. Elevated Uric Acid – Leptin resistance and insulin resistance syndromes are often found together and are suspected to have significant influence on each other.  High insulin loads lead to “sick adipose cells” causing leptin resistance.  This has a dramatic effect on hepatic fructose metabolism increasing the production of uric acid.  Excess insulin suppresses urinary excretion of uric acid and dramatically increases serum content of uric acid and the risk of kidney stones and gout. (6, 7)gout-pain
  5. Increased Inflammation – Increased levels of circulating insulin have a direct correlation on raising many of the inflammatory markers and hormones including TNF-alpha and IL-6 in the body (9).  Any disease process that is caused by chronic inflammation can be amplified by increased circulating levels of insulin including asthma, acne, eczema, psoriasis, arthritis, inflammatory bowel and celiac disease, etc.
  6. Elevated Blood Pressure – Increased uric acid production from insulin resistance as noted above directly suppresses production of nitric oxide within the vasculature and increases blood pressure (7). This completes the triad of metabolic syndrome (elevated triglycerides & cholesterol, weight gain, and elevated blood pressure) found in patients with insulin resistance.Blood-pressure
  7. Water Retention – We have known for many years that insulin affects the way the kidney uses sodium in the distal nephron.  Insulin has a direct effect on sodium retention in the kidney.  As insulin levels rise, the kidney retains increased levels of sodium (10).  Water follows sodium and thereby causes fluid retention.  This is the reason that many of my insulin resistant patients who have struggled with leg swelling and edema suddenly improve when they correct their diet and their high circulating insulin levels fall.  It is also the reason that many of my patients show up in my office after the holidays with swollen legs and amplified swelling in their varicose veins after cheating on their ketogenic diets.

swollen feet

If you are plagued by any or all of these, my first suggestion is to see your doctor and get screened for insulin resistance.  I treat patients with these every day and have reversed these effects in thousands of patients with the correct diet and/or medications.  Having seen these signs and patterns over the last 20 years of medical practice, I am still astonished every day by the dramatic effect our diet plays on the hormonal changes within the body. Remember that the food you eat is actually the most powerful form of medicine . . . and the slowest form of pernicious poison.

A ketogenic or carnivorous diet is your first step.

We take most insurances, however, check out my concierge program or my Direct Primary Care program if you are interested in an alternative to insurance.

References:

  1. Cholesterol Elevation Impairs Glucose-Stimulated Ca2+Signaling in Mouse Pancreatic β-Cells, Endocrinology, June 2011, Andy K. Lee, Valerie Yeung-Yam-Wah, Frederick W. Tse, and Amy Tse; DOI: http://dx.doi.org/10.1210/en.2011-0124
  2. Glucose-Stimulated Upregulation of GLUT2 Gene Is Mediated by Sterol Response Element–Binding Protein-1c in the Hepatocytes, DIABETES, VOL. 54, JUNE 2005; Seung-Soon Im, Seung-Youn Kang, So-Youn Kim, Ha-il Kim, Jae-Woo Kim, Kyung-Sup Kim and Yong-Ho Ahn
  3. Obesity and Insulin Resistance. J Clin Invest. 2000 Aug;106(4):473-81.Kahn BB, Flier JS
  4. Selective versus Total Insulin Resistance: A Pathogenic Paradox, Cell Metabolism, Volume 7, Issue 2, 6 February 2008, Pages 95–96, Michael S. Brown, Joseph L. Goldstein
  5. Association between small dense LDL and early atherosclerosis in a sample of menopausal women, Department of Clinical Medicine and Surgery, University “Federico II” Medical School, Naples, Italy Division of Cardiology, Moscati Hospital, Aversa, Italy A. Cardarelli Hospital, Naples, Italy, Gentile M, Panico S, et al., Clinica Chimica Acta, 2013
  6. Sugar, Uric Acid and the Etiology of Diabetes and Obesity. Diabetes. 2013;62(10):3307-3315, Richard J. Johnson; Takahiko Nakagawa; L. Gabriela Sanchez-Lozada; Mohamed Shafiu; Shikha Sundaram; Myphuong Le; Takuji Ishimoto; Yuri Y. Sautin; Miguel A. Lanaspa
  7. Fructose: metabolic, hedonic, and societal parallels with ethanol. J Am Diet Assoc. 2010 Sep;110(9):1307-21. doi: 10.1016/j.jada.2010.06.008. Lustig RH
  8. Cardiovascular Risk in Patients Achieving Low-Density Lipoprotein Cholesterol and Particle Targets. Atherosclerosis. Vol 235; 585-591, May 2014, Peter P. Toth, Michael Grabner, Rajeshwari S. Punekar, Ralph A. QuimboMark J. Cziraky c, Terry A. Jacobson
  9. Chronic Subclinical Inflammation as Part of the Insulin Resistance Syndrome The Insulin Resistance Atherosclerosis Study (IRAS), Circulation, July 2000, 102:42-47; Andreas Festa, MD; Ralph D’Agostino, Jr, PhD; George Howard, DrPH; Leena Mykka¨nen, MD, PhD; Russell P. Tracy, PhD; Steven M. Haffner, MD
  10. The Effect of Insulin on Renal Sodium Metabolism. Diabetologia. September 1981, Volume 21, Issue 3, pp 165-171. R. A. DeFronzo