Saturday, July 13, 2019

Does skipping breakfast make it harder to lose weight?


The Study
For decades, people trying to lose weight have been told that skipping breakfast will seriously hurt their efforts. A recently published meta-analysis put this theory to the test. A meta-analysis combines the findings from several trials and produces a summary estimate of the results. This particular meta-analysis included 13 randomized trials. The results were both interesting and surprising. There was a slight weight loss benefit to skipping breakfast. Subjects randomized to a breakfast skipping group lost about 1 pound more than subjects randomized to a breakfast eating group. The breakfast skippers also had an average of 260 fewer calories consumed per day. British Medical Journal 2019; 346:142.

Take Home Message
Before we all start skipping breakfast, lets take a deep breath. While this study is interesting, the trials only lasted between 24 hours and 16 weeks. This is a very short time for weight loss studies. If there was a drop in resting metabolic rate with skipping breakfast, it may not appear until after this amount of time. In fact, this paper mentions that longer term observational studies have shown a weight loss benefit to eating breakfast.

Despite these interesting results, I still recommend eating breakfast for the following reasons:

-If you eat dinner at 6 in the evening, skip breakfast the next morning and have lunch at noon, you have gone 18 hours without food. My concern with this amount of time fasting is that your body will go into starvation mode and start to reduce resting metabolic rate. There is evidence in the research literature that fasting can decrease resting energy expenditure, as well as have a number of other effects that decrease weight loss efficacy. (Take a look at some of this research here)

-If you are only eating twice per day, it is really hard to get enough protein, healthy fats, fruits, vegetables, vitamins and minerals.

-Your mood, focus, energy and attention will be better if you eat breakfast. 

There are lots of good reasons to eat breakfast. Although this is a very interesting study, I wouldn’t let it change your mind about the importance of this meal.

Is snacking a good idea if you are trying to lose weight?


The Study
Many of my weight loss clients ask me if they are permitted to snack if they get hungry in between meals. A recent study published in the American Journal of Clinical Nutrition examined the impact of snacking on total daily calories. In this investigation, 3,777 men and women from the National Health and Nutrition Examination Survey were studied. These subjects each filled out two 24-hour dietary recalls. In one of the recalls, the subject reported snacking in between meals. In the other, they did not. Total calories were compared between the two days.

On the days that the men snacked, they consumed an extra 239 calories. The women consumed an extra 219 calories on the day that they snacked. Added sugars and sodium were significantly higher on the days that included snacking. American Journal of Clinical Nutrition 2019;109:1145-53.

Take Home Message
I have never been a big fan of snacking for my weight loss clients. If you are eating 3 good, blood sugar stabilizing meals each day, there is really no need to snack. You should not be at all hungry in between meals. The additional calories that snacking adds can have a dramatic impact on body weight. The 200 plus extra calories found in this study would result in nearly two pounds gained each month. 

Eat three balanced meals that include a healthy source of fat, protein and low glycemic carb. You won’t be hungry in between meals and it will be much easier to lose weight.

New research on eggs and cardiovascular disease


Eggs are back in the news in a big way after a meta-analysis published in April in the Journal of the American Medical Association showed an increased risk of cardiovascular disease with only ½ egg consumed per day. Should this study lead us to alter our consumption of eggs? Let’s take a closer look.

The Article
The meta-analysis included 29,615 participants from 6 prospective U.S. cohorts that were followed for roughly 18 years (Reference 1). Each additional half egg consumed per day was associated with a 6% higher risk of cardiovascular disease and an 8% higher risk of mortality.

Limitations And Other Research
While this is definitely an interesting study and we must consider the findings, there are two reasons not to go completely overboard and swear off eggs completely.

#1: There are some methodological issues with this study. To start with, only a single measure of egg consumption was taken and then subjects were followed for 18 years. There is a really good chance that egg consumption changed during this time. Very few of us eat the same way for 18 consecutive years. This study did not account for changes in diet over the follow-up.

Another methodological issue is that the control of confounders was not ideal. A confounder is a variable that may impact risk of cardiovascular disease. To deal with a confounder, you measure it and then control for it in statistical models. Similar to egg consumption, confounders in this study were not updated, just a baseline measure was used. This leaves the door open for residual confounding. Further, certain confounders were left out of the models, including family history of cardiovascular disease, menopausal status and supplement use.

#2: Other studies that were better executed do not show an increased risk of cardiovascular disease with a high consumption of eggs. For example, in an analysis of the Nurses’ Health Study and the Health Professional Follow-up Study that included 117,933 men and women, no significant association was found between consumption of one egg per day and risk of heart disease or stroke (Reference 2). In this study, both egg consumption and confounders were repeatedly updated during the follow-up period. There was also a more complete control of confounders.

Another very large meta-analysis was conducted a few years back (Reference 3). This analysis included subjects taken from 22 cohorts with a follow-up of up to 20 years. When comparing subjects who consumed one or more eggs per day to subjects consuming less than 1 egg per week, there was no increased risk of heart disease, stroke or total cardiovascular disease.

Conclusions And Recommendations
While the results of this new study need to be considered, a lot of other well-designed research has shown that eggs are safe to consume. If you are otherwise healthy, a moderate consumption of eggs can be considered part of a healthy diet. Keep in mind that eggs are a really good source of protein, healthy fat, vitamins and minerals. The yolks are very much like a multivitamin pill.

If you have diabetes, talk to your doctor about how many eggs you should consume, as some research has shown an increased risk of cardiovascular disease with high egg consumption in diabetics.

References
1) Zhong VW, et al. Association of dietary cholesterol or egg consumption with incident cardiovascular disease and mortality. Journal of the American Medical Association 2019; 321:1081-95.

2) Hu FB, et al. A prospective study of egg consumption and risk of cardiovascular disease in men and women. Journal of the American Medical Association 1999; 281:1387-94.

3) Shin, et al. Egg consumption in relation to risk of cardiovascular disease and diabetes: A systematic review and meta-analysis. American Journal of Clinical Nutrition 2013; 98:146-59.

Tuesday, May 14, 2019

Can I drink alcohol if I am trying to lose weight?


This is a question I get all the time from new clients.  The answer is yes you can, but in moderation. Alcohol has been associated with weight gain in the research literature. Scientists from Harvard combined subjects from 3 separate cohorts into a giant study on individual foods and weight gain (1). Over 120,000 men and women were followed for up to 20 years. Increases in alcohol, even just one drink a day, were significantly and consistently associated with modest weight gain. There are several reasons why this may be true:

-Alcohol is calorie dense, it contains 7 calories per gram. A typical beer has 150 calories, a glass of wine has 85 calories and 1.5 ounces of hard liquor generally has 100 calories. Have 2 or 3 of these a day and trust me, the calories begin to add up.

- Liquid calories generally don’t register with the body. In other words, if you eat a solid food snack in the late afternoon, you would compensate by eating a little less at dinner. The body does not seem to recognize liquid calories in the same way. So, if you have a drink or two before dinner, you don’t eat any less food. In this way, alcohol calories are simply added on rather than substituted.

               - Alcohol can’t be stored in the body, so it becomes a priority for oxidation. Because of this fact, alcohol consumption suppresses fat oxidation. Therefore, you are burning less of your body fat when you drink.

               - In my experience and that of my clients, when you have a few drinks and start to get a bit of a buzz, your discipline goes out the window. After 3 or 4 drinks, the dessert menu becomes harder to resist and the late night fast food/diner stop seems to become all but inevitable!

You don’t necessarily have to give up alcohol here. If you have a few drinks a week, say four or less, you’ll be fine. If you’re drinking every day, this can really slow your rate of weight loss. A good strategy that several of my successful clients have used is to drink only on the weekends and avoid alcohol completely during the week.

References
1) Mozaffarian D, et al. Changes in diet and lifestyle and long-term weight gain in women and men. New England Journal of Medicine 2011; 364:2392-404.

Multivitamin use and your health


The Study
The health benefits of multivitamin use remain controversial. In this recent investigation, 30,899 adults identified through the National Health and Nutrition Examination Survey (NHANES) had their multivitamin use measured and then were followed for over 6 years. Multivitamin use had no association with risk of mortality in either direction. A few other interesting findings:

-Adequate intake of Vitamin A, K, magnesium, zinc and copper were associated with a reduce risk of all cause mortality. However, this was only true when these nutrients were obtained from foods, not from supplements.

-Excess intake of calcium was associated with an increased risk of cancer death. This association was mostly from supplemental calcium, not calcium obtained from food.

Annals of Internal Medicine doi:10.7326/M18-2478

Take Home Message
It appears that multivitamins don’t do much harm or much good. There really is no reason to take them. I always recommend getting your vitamins and minerals from your food. Make sure to include a variety of fruits and vegetables, whole grains, and nuts each day. The findings concerning calcium are disturbing. If you are taking a high dose of calcium, you may want to talk to your doctor about the pro’s and con’s of doing so.

Monday, May 13, 2019

Fruits And Vegetables And Your Health


The Study
Blood levels of vitamin C, carotenoids and alpha-tocopherol are biomarkers for fruit and vegetable consumption. In a meta-analysis of 69 prospective cohort studies, the association between these biomarkers and health were examined. In addition to blood levels, this study also examined dietary intake of these nutrients. The results were impressive. Blood levels/and or dietary intake of these nutrients were associated with a statistically significant lower risk of coronary heart disease, stroke, cardiovascular disease, cancer and all-cause mortality. American Journal of Clinical Nutrition 2018: 108: 1069-91.

Take Home Message
We have all heard it many times before- fruits and vegetables are good for you. Well, they still are. Fruits and vegetables are among the most healthy things that we can eat. Load up on them. I have my clients shoot for at least 5 servings per day of fruits and vegetables. More is better. 

Just a few notes:

-Limit dried fruits, like raisins and dried cranberries. These are higher glycemic can spike your blood sugar.

-Limit fruit and vegetable juices. These are also high glycemic.

-Try to vary your sources of fruits and vegetables. Get as many colors on your plate as possible.


Product Review: Lose it! Food Tracking App


If you are trying to drop a few pounds, keeping track of what you are eating is essential. It provides accountability and gives you a sense of control over the healthy changes you are trying to make. I always have a new client write down their food for the critical first few weeks of our work together. 

That is why the Lose it! app is next up for review. This is an app for your smart phone that allows you to track your food. It is available for both Android and iPhones.

Pros
1) The lite version is free, which is great. 

2) It is really easy to use. It takes about 2 minutes to get comfortable with how it works.

3) There are 7 million foods in the database. Every single food I tried to look up was there.

4) It is convenient. Being able to log your food on your phone makes it really easy.

5) There is a macronutrient breakdown that shows you the percentage of your diet that is fat, protein and carbohydrate. This is very useful.

6) You can scan the bar code of a food item in the app to add it to your meal. This really increases the accuracy of your logging.

Cons
1) There are constant reminders to upgrade to the premium version. I don’t begrudge anyone trying to make money, but it does get a little annoying.

2) There is not a lot of nutrition information available in the lite version. Nutrients such as saturated fat, grams of sugar, sodium, etc, are not available.

3) There are lots of links to other things you don’t really need that clutter up the interface.

Do I Recommend the Lose it! food tracking app?
Absolutely. This is a great app that will help you keep track of your diet. It is convenient, free, easy to use and has a comprehensive food database. Lose it! makes logging your diet a snap. I do not know if upgrading to the premium version is a good value as I, personally, did not see the need to do that. Give this one a try. It is available at the Google Play Store or the App Store for Apple products.

Disclosure: I am not affiliated with the company that makes the Lose it! food tracking app and make no money if you use it.


Wednesday, March 13, 2019

Exercise and inflammation


The Study
In this investigation, 10 subjects who exercised regularly for up to 5 hours per week added 17.5 miles of running to their weekly fitness routine. The researchers were trying to see the impact of intense exercise on the subject’s ability to absorb dietary iron. By the end of follow-up, the subjects had a significant increase in Interleukin-6 levels, which is a biomarker of inflammation. American Journal of Clinical Nutrition 2018;108:1324-1333.

Take Home Message
Inflammation plays a central role in the progression of many chronic diseases, including heart disease, cancer, type 2 diabetes and Alzheimer’s disease. This study is interesting because it provides further evidence that too much exercise is not great for our body. In this investigation, adding 17.5 miles of running to a moderate fitness routine significantly increased body wide inflammation. Moderate exercise has been shown to decrease inflammation, which is one of the many reasons why it is good for you. However, this study shows us that if you do too much, exercise can actually have the opposite effect.

Don’t go overboard with your cardio. Thirty to forty minutes of moderate intensity cardiovascular exercise each day is about as high as I would go. This is the perfect amount to maintain your weight, improve your energy, improve your mood and strengthen your immune system. This amount will also help decrease your risk of today’s most deadly diseases. When it comes to exercise, more is not necessarily better.

Carbohydrate intake and energy expenditure after weight loss


The Study
Following weight loss, resting energy expenditure drops significantly. This is a big reason why so many dieters quickly regain their lost weight. A recently published randomized trial examined if the ratio of carbohydrate to fat impacts resting energy expenditure post weight loss. After a 12% weight loss, 164 overweight subjects were randomized to one of three diets for a period of 20 weeks:

-High Carbohydrate: 60% carbohydrate, 20% fat, 20% protein.

-Moderate Carbohydrate: 40% carbohydrate, 40% fat, 20% protein.

-Low Carbohydrate: 20% carbohydrate, 60% fat, 20% protein.

The primary outcome was total energy expenditure, which was measured by doubly labeled water. The results were fascinating. Subjects consuming the higher levels of carbohydrates had greater decreases in total energy expenditure. Subjects on the moderate carbohydrate diet burned 91 more calories per day when compared to subjects on the high carbohydrate diet. Subjects on the low carbohydrate diet burned 209 more calories per day when compared to the high carbohydrate diet. British Medical Journal 2018;363:k4583.

Take Home Message
This is a really interesting study. The differences in energy expenditure found in this study are highly relevant. Compared to the high carb diet, the extra calories burned in the moderate and low carb diets could prevent 10-20 lbs. of weight regain in a year. 

The researchers believed that the differences in energy expenditure could be due to a lower glycemic index, a lower glycemic load, thermic effects, brown adipose activity, autonomic tone, nutrient cycling, changes in ghrelin levels and/or changes in leptin sensitivity.  

The low carb subjects were found to have lower levels of ghrelin. Ghrelin has been shown to lower energy expenditure and promote fat deposition. The low carb group also had lower levels of leptin. Previous research has shown that lower levels of leptin after weight loss predict less weight regain.

Although more research is needed in this area, going lower carb may make it a lot easier to keep lost weight off permanently. This study provides further evidence that low-fat high carbohydrate diets do not seem to be the path to permanent weight loss.

Does intermittent fasting improve rate of weight loss?


Intermittent fasting has become a popular weight loss strategy in recent years. Many best-selling diet books advocate intermittent fasting as an efficient and natural way to lose weight that is more effective than conventional methods. A randomized controlled trial was recently published that compared an intermittent fasting protocol to a standard weight loss diet where calories where slightly reduced on a daily basis.

The Article
This randomized trial was conducted in Germany and was recently published in The American Journal of Clinical Nutrition (Reference 1). In this investigation, 150 overweight and obese men and women were randomized to one of two weight loss diet groups. The intermittent calorie restriction group (ICR) had a weekly schedule of 5 days without energy restriction and 2 days with an energy restriction that was 75% of usual calories. The goal of the continuous calorie restriction group (CCR) was to reduce calories by 20% each day.

There was a 12 week intervention phase, a 12 week weight maintenance phase, and an additional 26 week follow period for a total of 50 weeks of follow-up. By the end of the 12 week intervention, there was no significant difference in weight loss between the two groups. By the end of the 50 week follow-up, there was still no significant difference between groups in the amount of weight lost.

There were a few other notable findings:
-Physical activity was measured by means of an accelerometer at the start of the study and in Week 12. Levels of physical activity increased by .2% in the continuous calorie restriction group but decreased by 13.4% in the intermittent calorie restriction group.

-By the end of Week 12, fasting glucose had been reduced more in the continuous calorie restriction group than in the intermittent calorie restriction group (-7.6% vs. -2.9%). This difference was statistically significant.

-Five times as many subjects reported uncomfortable side effects in the fasting group compared to the daily calorie restriction group.

Other Research
Several other research publications I have covered in my blog showed negative outcomes with diets using intermittent fasting. These include: an increased LDL cholesterol, glucose dysregulation, increased inflammation, increased hunger and a decreased energy expenditure. If you want to reference these studies, please refer to my review of the Obesity Code (click here).

Conclusions And Recommendations
Despite its recent popularity, intermittent fasting does not appear to be a better weight loss strategy than moderate daily calorie restriction. In fact, it appears to have some real negatives. There is no reason to starve yourself in order to lose weight. I have found that the combination of a blood sugar stabilizing low glycemic load Mediterranean diet, adequate cardiovascular exercise and resistance training is absolutely the way to go if you want to lose weight, feel great and reduce your risk of today’s most deadly diseases.

References
1) Schubel R, et al. Effects of intermittent and continuous calorie restriction on body weight and metabolism over 50 weeks: A randomized controlled trial. American Journal of Clinical Nutrition 2018; 108:933-45.

Monday, January 14, 2019

Is whole wheat any better for you than refined wheat?


The Study
Whole grains are really important to include in your diet. They are high in fiber, high in micronutrients and have an easier impact on your blood sugar than their refined counterparts. However, are they all equally beneficial? This study is a meta-analysis that compared the blood glucose response of whole wheat vs. refined wheat and whole grain rice vs. refined white rice. Twenty randomized trials were included in this investigation. Whole grain rice resulted in a significantly lower post-prandial blood sugar when compared to white rice. Unexpectedly, whole wheat did not significantly lower blood sugar in subjects when compared to refined wheat.
American Journal of Clinical Nutrition 2018;108:759-74.

Take Home Message
I have recommended whole grains in place of refined grains to my clients since day one for many reasons. In the research literature, a high consumption of whole grains has been associated with a reduced risk of heart disease, stroke, type 2 diabetes, cancer and total mortality. For those looking to lose weight, replacing refined grains with whole grains reduces the swings in blood sugar and insulin that tend to increase hunger and promote fat storage. 

However, I noticed that when my clients ate whole wheat, they were still just as hungry as if they were eating refined wheat. For this reason, I have always had my clients limit whole wheat and focus on other whole grains such as brown rice, quinoa and old fashioned oats. This study shows that whole wheat raises blood sugar in a similar fashion to refined wheat. This is the first time I have seen this in the literature but it makes total sense to me. My initial recommendations are confirmed, limit whole wheat and instead focus on brown rice, quinoa and old fashioned oats for your all-important sources of whole grains.

Drop in resting energy expenditure with weight loss


The Study
There is evidence that after weight loss, resting energy expenditure (REE) drops to levels lower than predicted. This is a major reason why so many people quickly regain lost weight. In this case-control study, three different groups of subjects had their resting energy expenditure measured. The first group included 34 subjects that had lost over 30 lbs. and kept the weight off for 1 year. The second group included 35 normal weight subjects. The third group included 33 overweight and obese subjects. Resting energy expenditure was predicted by standardized formulas and then precisely measured with indirect calorimetry. There were several interesting results:

-In the subjects that lost at least 30 lbs., there was no significant difference between predicted and measured resting energy expenditure.

-However, in the 34 subjects that had lost over 30 lbs. and kept it off for a year, there was a lot of variability. When comparing the expected to the actual resting energy expenditure, the range was -257 to +163 calories per day.

-In the weight loss maintainers, a lower than predicted REE was positively correlated with maximum weight, maximum BMI and maximum weight lost. American Journal of Clinical Nutrition 2018; 108:658-66.

Take Home Message
There are 3 really interesting things about this study:

1) The more weight that a subject had to lose, the more severe the reduction in resting energy expenditure. This supports the idea that the more weight you lose, the harder it is to keep it off.

2) Even though these subjects lost a lot of weight, their REE did not drop all that much from what would be expected given their new weight. This is somewhat surprising given previous results.

3) There was a lot of variability in resting energy expenditure after weight loss. The range was 257 calories per day lower than expected to 163 calories higher than expected. It is encouraging that even subjects who had a serious drop in REE were able to maintain their weight loss for over a year. It has been previously argued that a drop in REE makes it impossible to keep lost weight off.

The REE response to weight loss is a fascinating topic that we need to learn more about in order to increase weight loss success. The fact that it varies so much at the individual level is a new concept to me.  Is this because of exercise habits, genetics or something else? We’ll have to stay tuned as further research evolves on this topic.



Does eating organic foods reduce risk of cancer?


Organic produce is really expensive. The majority of people who purchase organic instead of conventionally grown produce believe that it is superior from a health and nutrition standpoint. However, there is surprisingly little research that tests this hypothesis. You may have heard in the news of a study on this topic recently published in JAMA Internal Medicine.

The Article
This study followed 68,946 French men and women for an average of 4½ years (Reference 1). Subjects were asked in a questionnaire how often they purchased organic foods for 16 different food groups. Subjects who reported the highest consumption of organic foods had a 25% lower risk of cancer when compared to subjects who reported the lowest consumption of organic foods.

Limitations
While this research is interesting, there are some limitations that need to be mentioned before considering how these results fit into the context of prior research. 

First off, there is a strong possibility of residual confounding in this study that may account for the results. A confounder is a variable that is associated with the outcome of a study and may influence the relationship between the independent variable and the outcome. In this study, subjects reporting a higher organic food score were less likely to smoke, drank less, had a lower body weight and a much healthier diet (higher fiber, lower processed meat and less red meat). Each of these variables reduces risk of cancer. While the authors of the study attempted to measure these variables and control for them in the statistical analyses, they may not have captured them completely. If this was the case, the reduction in risk of cancer seen in these subjects may have been due to their healthier lifestyle and not the organic produce consumption.

Secondly, and more importantly, the organic food score was not validated. This was discussed in an invited commentary to the French study by Harvard nutrition researchers, including the Department Chair, Dr. Frank Hu (Reference 2). When a self-reported variable is supposed to measure something, it is critical to prove that it measures what it is supposed to. For example, you could take a subset of the cohort, measure their self-reported organic food consumption and then test their urine or serum for pesticide residues. You could then see if those who had a high self-reported organic food score had a low pesticide residue and vice versa. This was not done in the new study and is a major limitation of this research. The truth is that we don’t know what the organic food score measured, if anything. It may have just been an indicator of a healthy lifestyle, which would completely explain the reduction in cancer risk found in this investigation.

In fact, in the invited commentary, Hu cites a reference from the Environment and Reproductive Health Study showing that self-reported organic produce was not significantly related to urinary pesticide residues (Reference 3).

Other Research
There are a couple of other important studies to mention on this topic. In 2014, a study was published in the British Journal of Cancer that followed over 628,000 British women from the Million Women Study for 9 years (Reference 4). By the end of follow-up there was no relationship between self-reported organic food consumption and risk of cancer. Interestingly, there was a significant increase in breast cancer in subjects consuming the most organic produce. Keep in mind that this study had a much longer follow-up and many more subjects than the more recent French study.

Another really important study was a systematic review of the health effects of organic food published in the journal Annals of Internal Medicine in 2012 by Stanford University researchers (Reference 5). Here are some of the more important findings of this study:

-The majority of conventionally grown produce (62%) that was tested contained no detectable pesticide residues.

-7% of organic produce contained detectable pesticide residues.

-The researchers found 3 studies that tested if pesticide residues exceeded maximum limits. One of these studies found that neither the organic or conventionally grown produce exceeded maximum limits. One study found that 1% of both the organic and conventionally grown produces tested exceeded maximum limits. The other study ironically found that 6% of organic produce tested exceeded maximum limits while only 2% of conventionally grown produce exceeded maximum limits.

-Four of five studies analyzed found that organic produce had a higher risk of bacterial contamination than conventionally grown produce.

Here is the major conclusion of this well-done study:

“In summary, our comprehensive review of the published literature on the comparative health outcomes, nutrition, and safety of organic and conventional foods identified limited evidence for the superiority of organic foods. The evidence does not suggest marked health benefits from consuming organic versus conventional foods…” (Reference 5).

Conclusions And Recommendations
The jury is still out on whether or not choosing organic produce improves health in comparison to conventionally grown produce. More research is needed here. However, to date, there is not much evidence that this is the case. In fact, much of the evidence suggests that there is no difference. We’ll keep our eye out for further research in this area. 

In the meantime, conventionally grown fruits and vegetables are a wonderful addition to a healthy diet. There is no need to limit them. If you like organically grown produce and can afford the higher price tag, feel free to buy it. If your major reason for doing so is that you think you will be much healthier, keep in mind that this very likely may not be true.

While the evidence is not quite there for organic produce, there is strong evidence that you can reduce your cancer risk by not smoking, maintaining a healthy weight, exercising regularly and eating a healthy diet. These are the important areas to focus on for all of us.

References
1) Baudry J, et al. Association of frequency of organic food consumption with cancer risk. JAMA Internal Medicine 2018; doi:10.1001/jamainternmed.2018.4357.

2) Hemler EC, et al. Invited commentary: Organic foods for cancer prevention-Worth the investment?
JAMA Internal Medicine 2018; doi:10.1001/jamainternmed.2018.4363.

3) Chiu YH, et al. Comparison of questionnaire based estimation of pesticide residue intake from fruits and vegetables with urinary concentrations of pesticide biomarkers.  J Expo Sci Environ Epidemiol 2018; 28:31-39.

4) Bradbury KE, et al. Organic food consumption and the incidence of cancer in a large prospective study of women in the United Kingdom. British Journal of Cancer 2014; 110:2321-2326.

5) Smith-Spangler C, et al. Are organic foods safer or healthier than conventional alternatives? A systematic review. Annals of Internal Medicine 2012; 157:348-66.