(Circulation. 1996;94:2720-2727.)
© 1996 American Heart Association, Inc.
Articles |
Intake of Dietary Fiber and Risk of Coronary Heart Disease in a Cohort of Finnish Men
The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study
the Department of Nutrition (P.P., P.K., J.V.), National Public Health Institute, Helsinki, Finland; Departments of Nutrition and Epidemiology (E.B.R., W.C.W.), Harvard School of Public Health, Boston, Mass; and Division of Cancer Prevention and Control (A.M.H., D.A.), National Cancer Institute, Bethesda, Md.
Correspondence to Dr Pirjo Pietinen, Department of Nutrition, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland. E-mail Pirjo.Pietinen ktl.fi.
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Abstract |
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Background Even though dietary fiber has been hypothesized to reduce the risk of coronary heart disease, few large epidemiological studies have examined this relation with good methodology.
Methods and Results The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study was a randomized, double-blind, placebo-controlled trial with daily supplementation of 
-tocopherol and/or beta-carotene. Of the participants, 21 930 smoking men aged 50 to 69 years who were free of diagnosed cardiovascular disease and had completed a validated dietary questionnaire at baseline were followed for 6.1 years. We monitored the incidence of major coronary events (a combination of first nonfatal myocardial infarction and coronary heart disease death; n=1399) and mortality from coronary heart disease (n=635). Both entities had a significant inverse association with dietary fiber, but the association was stronger for coronary death. For men in the highest quintile of total dietary fiber intake (median, 34.8 g/d), the relative risk for coronary death was 0.69 (95% confidence interval, 0.54 to 0.88; P<.001 for trend) compared with men in the lowest quintile of intake (median, 16.1 g/d). With an adjustment for known cardiovascular risk factors, intake of saturated fatty acids, beta-carotene, vitamin C, and vitamin E did not materially change the result. Water-soluble fiber was slightly more strongly associated with reduced coronary death than water-insoluble fiber, and cereal fiber also had a stronger association than vegetable or fruit fiber.
Conclusions These findings suggest that independent of other risk factors, greater intake of foods rich in fiber can substantially reduce the risk of coronary heart disease, and particularly coronary death, in middle-aged, smoking men.
Key Words: coronary disease • diet • epidemiology
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Introduction |
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An apparently protective effect of dietary fiber intake against coronary heart disease has been observed in several prospective studies.1 2 3 4 5 6 7 Also, the intake of complex carbohydrates8 9 10 and consumption of vegetables and fruit11 12 have been inversely associated with risk of coronary heart disease. Collectively, these findings suggest that dietary fiber or foods rich in fiber may protect against coronary heart disease.
Despite these reports, however, the effect of dietary fiber on coronary heart disease risk remains unclear because the definition of fiber has varied in these studies, energy intake was not always considered, and information on different fiber fractions was not reported. Water-soluble fiber has been thought to be particularly important because of its cholesterol-lowering effect.13 Based on a meta-analysis of 20 studies in which oat bran was fed, however, the effect of soluble fiber on serum cholesterol appears relatively modest14 and could not account for a substantial effect of fiber on coronary heart disease incidence. Other possible mechanisms for fiber include reduced blood pressure, better glycemic control, and lower triglyceride levels.15
We examined the relations between intake of dietary fiber and risk of coronary heart disease in a cohort of middle-aged smoking Finnish men, who typically consume a diet relatively high in fiber. In addition to total dietary fiber, we measured intakes of water-soluble and water-insoluble fiber, the chemically distinct fractions of insoluble fiber as well as different sources of fiber.
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Methods |
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The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study
The Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study was a randomized, double-blind, placebo-controlled primary prevention trial undertaken to determine whether supplementation with
-tocopherol, beta-carotene, or both would reduce the incidence of lung cancer in male smokers. The rationale, design, and methods of the study as well as the characteristics of the participants have been previously described in detail.16 The main results indicated no reduction in lung cancer incidence after 5 to 8 years of supplementation with either -tocopherol or beta-carotene.17
Participants were male smokers who were 50 to 69 years of age at entry. They were recruited from the total male population of this age group in southwestern Finland (n=290 406). To be eligible, men had to be smokers (five or more cigarettes per day at entry) and willing to give written consent. The exclusion criteria included history of cancer or other serious disease that would limit participation; the use of vitamin E, vitamin A, or beta-carotene supplements in excess of predefined doses; and treatment with anticoagulant agents. After these exclusions, 29 133 men were randomly assigned to one of four supplementation regimens: -tocopherol (50 mg/d) alone, beta-carotene (20 mg/d) alone, -tocopherol and beta-carotene, or placebo. Follow-up continued for 5 to 8 years (median, 6.1 years) until death or April 30, 1993, when the trial ended.
Diet was assessed at baseline using a self-administered modified dietary history method.18 This questionnaire was satisfactorily completed by 27 111 (93%) participants. We excluded men who reported at baseline any prior diagnosis of myocardial infarction, angina, stroke, or diabetes (n=4346), after which we also excluded men with typical exercise-related chest pain (Rose angina classes 1 and 2) as well as men with missing data on cardiovascular risk factors (n=835). After these exclusions, 21 930 men remained for the present analyses.
Baseline Measurements
At baseline, the men provided information on general characteristics and medical, smoking, and occupational history. Educational level was categorized as <7 years of school, 7 to 11 years, or >11 years. Frequency of leisure time physical activity (at least slightly strenuous activity for a minimum of 30 minutes at a time) was categorized as less than once a week, once or twice per week, or three or more times per week. Height and weight were measured, and body mass index was calculated as weight (kg) divided by height (m2). Blood pressure was measured from the right arm with a mercury sphygmomanometer under standardized conditions. The lower of two measurements at least 1 minute apart was recorded. Serum samples were collected and stored at -70°C for later analysis. Serum total and HDL cholesterol levels were determined enzymatically (CHOD-PAP methods, Boehringer-Mannheim).19 HDL cholesterol was measured after precipitation of VLDL and LDL with dextran sulfate–magnesium chloride.20
Dietary Assessment
The diet questionnaire included 276 food items and mixed dishes and was used together with a portion size picture booklet of 122 photographs of foods, each with three to five different portion sizes. Each subject was asked to report his usual frequency of consumption and the usual portion size of foods during the previous 12 months. The frequencies were reported as number of times per month, week, or day. At the first visit, the questionnaire together with the picture booklet were given to the subject to be filled in at home. At the second baseline visit, 2 weeks later, the questionnaire was returned, and a nurse checked and completed it, spending on average 30 minutes interviewing the subject about possible discrepancies.
The fiber content of foods was based on the analyses of Finnish foods using a modification of the analytical scheme developed by Englyst.21 The method measures the total carbohydrate composition as the following fractions: soluble sugars, starch, and dietary fiber as cellulose; water-soluble and water-insoluble noncellulosic polysaccharides; and lignin. Water-soluble noncellulosic polysaccharides are the same as water-soluble fiber, and the total amount of water-insoluble fiber is the sum of water-insoluble noncellulosic polysaccharides, lignin, and cellulose. Total dietary fiber is the sum of water-soluble and water-insoluble fiber. The fiber content of Finnish foods analyzed with the use of this methodology has been published.22 23 In addition to these chemically different fiber fractions, we separately calculated total dietary fiber intake from cereals, vegetables, and fruit.
The dietary method was validated in a pilot study carried out among 190 men before the ATBC study.18 The men filled in the questionnaire first and then maintained 24 days of food records spread over 6 months as the reference method; they filled in the questionnaire again at the end. At that time, only the preliminary data on total dietary fiber were available and were reported. However, the data set has been updated with all fiber fractions. The correlations between the first questionnaire and the food records were .62 for dietary fiber, .65 for water-soluble fiber, .67 for water-insoluble fiber, .65 for water-insoluble noncellulosic polysaccharides, .66 for lignin, and .64 for cellulose. Adjustment for energy did not materially change the correlations.
Ascertainment of End Points
The end points of this study were major coronary event and coronary death. The major coronary event (n=1399) included the first nonfatal myocardial infarction (alive on day 28 from the onset of the attack) during the study (n=818) or death due to coronary heart disease (n=581). Data on nonfatal myocardial infarction were obtained from the National Hospital Discharge Register. Men who had a hospital discharge with International Classification of Diseases (ICD; eighth revision) codes 410.00 or 410.99 through December 31, 1986, or ICD codes 4100- (ninth revision) since January 1, 1987, were considered to have had an acute myocardial infarction. Deaths were identified through the Central Population Register. The death certificates were reviewed by one study physician, and a coronary death was assigned when coronary heart disease was described as the underlying cause of death (ICD codes 410 through 414). In addition, the validity of the diagnosis of major coronary events was evaluated in 408 cases on whom all relevant information on the attack was collected from hospitals and pathology departments. The cases were reviewed according to the MONICA criteria,26 and 94% of them were then diagnosed as either definite or possible myocardial infarctions.
There were 54 men who had survived their first myocardial infarction but died from coronary heart disease later during the study. Thus, there are 635 coronary deaths in the analysis on the associations between fiber intake and coronary mortality.
Statistical Analysis
The participants contributed follow-up time from the date of randomization until an end point, death, or April 30, 1993. Men were grouped in quintiles of energy-adjusted intakes of nutrients as calculated from the dietary questionnaire. All nutrients were log-transformed before the energy adjustment, which was done by the residual method.24
Proportional hazards models were used to estimate the relative risks (with 95% confidence interval) of coronary heart disease associated with intakes of fiber fractions and selected foods, with simultaneous adjustment for age and treatment group first and then for cardiovascular risk factors. Adjustment for treatment group was done because the main results of the trial showed that there were fewer deaths due to coronary heart disease in the -tocopherol–supplemented group than in the group not receiving -tocopherol but more coronary deaths in the beta-carotene–supplemented group than in the group not receiving beta-carotene.17 Test for the linearity of the trend was done by treating the energy-adjusted values of nutrients as continuous variables in the proportional hazards model. The main results were corrected for measurement error in assessing dietary fiber using the method developed by Prentice.25 All P values are two-tailed. The main analyses were also repeated in the placebo group of the trial cohort.
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Results |
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An increase in the number of cigarettes per day, years of smoking, blood pressure, body mass index, and serum cholesterol increased the risk of both major coronary events and coronary deaths, whereas HDL cholesterol, education, and physical activity were inversely associated with risk of coronary heart disease (data not shown). Alcohol was inversely but nonsignificantly related to risk of major coronary events but had a U-shaped relation with coronary deaths. There was no association between energy intake and the risk of coronary heart disease.
There was more than a twofold difference in the median total fiber intake between the highest and lowest quintiles of the population (34.8 versus 16.1 g/d; Table 1
). Men who consumed more fiber had a lower intake of saturated fatty acids, cholesterol, and alcohol and a higher intake of beta-carotene, vitamin C, and vitamin E. They also consumed more rye products (161 g/d in the highest quintile of fiber intake versus 28 g/d in the lowest quintile). There were no differences in age, smoking, body mass index, serum total or HDL cholesterol, or blood pressure across quintiles of fiber intake. However, high fiber intake was associated with increased physical activity.
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The correlations between different fiber fractions, fiber sources and foods rich in fiber showed that in the Finnish diet, water-soluble and water-insoluble fibers are highly correlated (r=.88, Table 2). Dietary fiber is mostly cereal fiber, predominantly from the high rye bread consumption. Because rye flour contains both water-soluble and water-insoluble fiber, all the fiber fractions are strongly correlated with each other.
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In age- and treatment group–adjusted analysis (Table 3), water-soluble fiber, cellulose and vegetable fiber, and fruit fiber were significantly inversely associated with the risk of major coronary events (P<.05 for trend). After further adjustment for cardiovascular risk factors, total energy, alcohol, saturated fatty acids, and total dietary fiber were inversely associated with risk of major coronary events. However, further adjustment for intakes of beta-carotene, vitamin C, and vitamin E attenuated these associations, and only soluble fiber remained significantly protective; the relative risk for coronary heart disease was 0.83 (95% confidence interval, 0.68 to 1.01) in the highest quintile of intake compared with the lowest quintile. The attenuation of the results in this last model was, however, expected because the vitamins are derived from the same sources.
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We further examined the associations between fiber and fatal and nonfatal coronary events. Because the inverse associations for fiber were strongest for fatal events, we present the detailed analysis only for coronary deaths. In a model that adjusts only for age and treatment group, total dietary fiber as well as all fiber fractions and types of fiber were significantly inversely related to risk of coronary death (Table 4). Adjustment for coronary risk factors did not materially change the results. Further adjustment for intakes of beta-carotene, vitamin C, and vitamin E did not change the results for total dietary fiber or fiber fractions, but the association between vegetable and fruit fiber and coronary death became nonsignificant. In this final multivariate model, the relative risk of coronary death for men in the highest quintile of total dietary fiber intake compared with the lowest quintile was 0.73 (95% confidence interval, 0.56 to 0.95). A 10-g greater daily intake of fiber appeared to lower the risk of coronary death by 17% (relative risk, 0.83; 95% confidence interval, 0.80 to 0.86). Measurement error correction for dietary fiber as well as all of the other dietary factors in the model (ie, energy, alcohol, saturated fatty acids, beta-carotene, vitamin C, vitamin E) made this association even stronger (relative risk, 0.69; 95% confidence interval, 0.60 to 0.81).
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The relative risk in the highest quintile of soluble fiber intake compared with the lowest was 0.68 (95% confidence interval, 0.50 to 0.92), and that of insoluble fiber was 0.75 (95% confidence interval, 0.58 to 0.98). The results for the subfractions of insoluble fiber, insoluble noncellulosic polysaccharides, lignin, and cellulose were very similar. Further adjustment for serum total and HDL cholesterol did not change the relative risks in any of the previous tables. The relative risk of coronary death between the extreme quintiles was 0.72 (95% confidence interval, 0.55 to 0.95) for dietary fiber and 0.67 (95% confidence interval, 0.49 to 0.90) for soluble fiber after controlling for these serum lipids.
Simultaneous adjustment for each of the three main sources of fiber (cereal, vegetable, and fruit fiber) showed that only the inverse association between cereal fiber and coronary death remained significant in the model, including vitamins (relative risk, 0.71; 95% confidence interval, 0.64 to 0.92).
The analyses were repeated in the placebo group of the trial cohort, and they showed similar results. For example, the relative risk of coronary death for men in the highest quintile of dietary fiber intake compared with the lowest was 0.70 (95% confidence interval, 0.40 to 1.23; P=.13 for trend). The confidence intervals are larger because of the smaller number of cases.
In the food group analyses, intake of rye products or other cereals, potatoes, or fruit was not associated with major coronary events (data not shown). The only food group significantly inversely related to risk of major coronary events was vegetables (relative risk in the highest quintile of intake versus the lowest, 0.73; 95% confidence interval, 0.60 to 0.88). Intake of rye products, potatoes, vegetables, and fruit were, however, all inversely associated with coronary death (Table 5). The relative risk in the highest quintile of vegetable consumption compared with the lowest was 0.60 (95% confidence interval, 0.45 to 0.79). A 100-g greater daily intake of vegetables was associated with a 26% lower risk of coronary death.
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Discussion |
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In this large cohort of middle-aged men, we found consistent evidence of an inverse association between the intake of dietary fiber and risk of coronary heart disease. This association was stronger for coronary deaths than for major coronary events; apparent protective effects were seen for all fiber fractions, especially for soluble and cereal fiber. Adjustment for serum cholesterol did not change the results.
The food content of dietary fiber and its fractions was based on relatively recent analyses of Finnish foods and not on values reported in foreign food composition tables. In a substudy of the dietary questionnaire, the correlations between the intake of dietary fiber and its fractions based on the questionnaire and those based on the reference method (24 days of food recording) varied between 0.62 and 0.67, indicating a relatively high degree of validity.
Men in this study consumed more dietary fiber than any of the previously reported cohorts, except for another Finnish cohort.12 The mean intake of dietary fiber was 26.7 g/d. This compares well with Finnish national survey data from 1992 showing a mean fiber intake of 25 g/d in men27 but is substantially greater than the mean intake of dietary fiber in men in the United States (17 g/d), as based on the Third National Health and Nutrition Examination Survey.28
The most important contributor to the high content of dietary fiber in the Finnish diet is rye bread and other whole-grain breads. Typical sourdough rye bread is made of full-grain rye flour and contains 9.9 g of dietary fiber per 100 g.22 Even though most of the fiber in rye bread is water insoluble (6.1 g of noncellulosic polysaccharides, 0.9 g of cellulose, and 1.2 g of lignin per 100 g), there also is more soluble fiber (1.7 g per 100 g) than in oat bread (1.2 g per 100 g). Many of the breads, however, contain a variety of grains: rye, wheat, oats, and barley. This explains the high correlations among the intake of different fiber fractions and why all fiber fractions had similar inverse associations with coronary heart disease. Because the intake of vegetables was relatively low, vegetable and fruit fibers, which are mainly soluble fibers, contribute less to the total intake of soluble fiber than cereal fiber, which may explain why cereal fiber had an apparently stronger protective effect than vegetable or fruit fiber. The situation may be quite different in populations in which the diet is based more on vegetables than the Finnish cereal-based diet.
Most previous prospective studies of fiber and coronary heart disease are limited by a small number of events, differences in the validity of the fiber measurements, and the inability to account for other dietary factors. The strongest dose-response relation found so far was in the Health Professionals Follow-up Study,7 which is comparable to our study in its large size and good methodology. In the 6-year follow-up, an inverse association between total myocardial infarctions and total dietary fiber intake was found; it was strongest for fatal events. The relative risk for fatal myocardial infarction was 0.45 among men in the highest quintile of fiber intake (median, 28.9 g/d) compared with men in the lowest quintile (median, 12.4 g/d). Cereal fiber was more strongly associated with risk of coronary heart disease than was vegetable or fruit fiber.
The only other Finnish prospective study on diet and risk of chronic diseases among men and women is the mobile clinic study of the Social Insurance Institution, which was begun in the late 1960s. There was a suggestion of an inverse association between intake of dietary fiber and coronary mortality in women but not in men.12 There was, however, a strong inverse association between vegetable and fruit consumption and coronary mortality in men and a similar but weaker association in women. An apparent protective effect of vegetable and fruit consumption was also seen in an Italian case-control study of coronary heart disease.11 Vegetable consumption was also associated with a substantially lower risk of coronary death in our study even though fiber intake from vegetables was quite low. This may result, in part, because vegetables are good sources of many vitamins, minerals, and antioxidants; attenuation of our results with vegetables and fruit by vitamin C, vitamin E, and beta-carotene supports this premise.
Water-soluble fiber is known to lower serum LDL cholesterol, but the magnitude of the effect is small. Based on a recent meta-analysis of 20 trials in which high doses of oat bran, which is rich in soluble fiber, were fed to volunteers, 3 g/d of soluble fiber from oat products lowered the total cholesterol level by 0.13 to 0.16 mmol/L (5 to 6 mg/dL).14 In our cohort, the mean intake of soluble fiber was 5.4 g/d, and the mean intake of insoluble fiber was 18.9 g/d. Based on our data, an increase in daily soluble fiber intake by 3 g reduced the risk of coronary death by 27%. Adjustment for serum cholesterol did not change the result. Thus, the effect of soluble fiber on serum cholesterol does not explain our results. This is consistent with other prospective studies in which fiber intake was not related to serum cholesterol, and cholesterol adjustment did not attenuate the association between fiber intake and risk of coronary heart disease.1 6
Several other mechanisms have been suggested to explain an inverse association between dietary fiber and coronary heart disease. These involve postprandial lipid response, glucose tolerance factors, and hemostatic factors. Anderson et al29 30 demonstrated that dietary fiber can inhibit 1-hour plasma glucose, insulin, and triglyceride responses. The reduction in postprandial lipid response has been repeatedly shown in healthy adults.31 32 The literature is vast on the effects of dietary fiber on glucose metabolism of diabetic patients,33 and similar beneficial effects have been seen in healthy adults.34 In the LRCCPT trial, an inverse association of postchallenge glucose with both coronary heart disease event and fiber quintile was found.6 The authors speculated that higher postprandial glucose levels in subjects with lower fiber intake were probably accompanied by higher levels of insulin. In the Zutphen study, fiber intake was inversely associated with hyperinsulinemia and insulin resistance, giving further support to this hypothesis.35 Hyperinsulinemia has been found to be a risk factor for coronary heart disease in many population studies.36 37 Another possible pathway could be through an influence on hemostatic factors.38 Low dietary fiber intake has been associated with high plasminogen activator inhibitor–1 levels.39 Unfortunately, we do not have data on glucose tolerance or hemostatic factors in our study.
Our results provide further evidence that an increase in dietary fiber intake may be protective against coronary heart disease, particularly coronary death. Although all types of fiber appear to be related to coronary heart disease in this way, water-soluble fiber and cereal fiber seemed to have the strongest effects. In practice, high consumption of all fiber-containing foods, cereals, vegetables, and fruit is recommended to prevent coronary heart disease.
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Acknowledgments |
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This study was supported by contract NO1-CN-45165 with the National Cancer Institute and a fellowship from the Academy of Finland.
Received April 1, 1996; revision received August 5, 1996; accepted August 7, 1996.
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References |
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1. Morris JN, Marr JW, Clayton DG. Diet and heart: a postscript. Br Med J. 1977;2:1307-1314.
2. Kromhout D, Bosschieter EB, de Lezenne Coulander C. Dietary fiber and 10-year mortality from coronary heart disease, cancer and all causes: the Zutphen Study. Lancet. 1982;2:518-521.[Medline] [Order article via Infotrieve]
3. Kushi LH, Lew RA, Stare FJ, Ellison CR, el Lozy M, Bourke G, Daly L, Graham I, Hickey N, Mulcahy R, Kevaney J. Diet and 20-year mortality from coronary heart disease: the Ireland-Boston Diet-Heart Study. N Engl J Med. 1985;312:811-818.[Abstract]
4.
Khaw KT, Barrett-Connor E. Dietary fiber and reduced ischemic heart disease mortality rates in men and women: a 12-year prospective study. Am J Epidemiol. 1987;126:1093-1102.
5. Fehily AM, Yarnell JWG, Sweetnam PM, Elwood PC. Diet and incident ischemic heart disease: the Caerphilly Study. Br J Nutr. 1993;69:303-314.[Medline] [Order article via Infotrieve]
6. Humble CG, Malarcher AM, Tyroler HA. Dietary fiber and coronary heart disease in middle-aged hypercholesterolemic men. Am J Prev Med. 1993;9:197-202.[Medline] [Order article via Infotrieve]
7.
Rimm EB, Ascherio A, Giovannucci E, Spiegelman D, Stampfer M, Willett WC. Vegetable, fruit and cereal fiber intake and risk of coronary heart disease among men. JAMA. 1996;275:447-451.
8.
Garcia-Palmieri MR, Sorlie P, Tillotson J, Costas R Jr, Cordero E, Rodriquez M. Relationship of dietary intake to subsequent coronary heart disease incidence: the Puerto Rico Heart Health Program. Am J Clin Nutr. 1980;33:1818-1827.
9.
Yano K, Rhodes GG, Kagan A, Tillotson J. Dietary intake and the risk of coronary heart disease in Japanese men living in Hawaii. Am J Clin Nutr. 1978;31:1270-1279.
10.
Gordon T, Kagan A, Garcia-Palmieri M, Kannel WB, Zukel WJ, Tillotson J, Sorlie P, Hjortland M. Diet and its relation to coronary heart disease and death in three populations. Circulation. 1981;63:500-515.
11. Gramenzi A, Gentile A, Fasoli M, Negri E, Parazzini F, La Vecchia C. Association between certain foods and risk of acute myocardial infarction in women. Br Med J. 1990;300:771-773.
12.
Knekt P, Reunanen A, Jarvinen R, Seppanen R, Heliovaara M, Aromaa A. Antioxidant vitamin intake and coronary mortality in a longitudinal population study. Am J Epidemiol. 1994;139:1180-1189.
13. Anderson JW, Siesel AE. Hypocholesterolemic effects of oat products. In: Furda I, Brine CJ, eds. New Developments in Dietary Fiber. New York, NY: Plenum Press; 1990:17-36.
14.
Ripsin CM, Keenan JM, Jacobs DR, Elmer PJ, Welch RR, Van Horn L, Liu K, Turnbull WH, Thye FW, Kestin M, Hegsted M, Davidson D, Davidson MH, Dugan LD, Demark-Wahnefried W, Beling S. Oat products and lipid lowering: a meta-analysis. JAMA. 1992;267:3317-3325.
15. Anderson JW, Tietyen-Clark J. Dietary fiber: hyperlipidemia, hypertension, and coronary heart disease. Am J Gastroenterol. 1986;81:907-919.[Medline] [Order article via Infotrieve]
16. The ATBC Cancer Prevention Study Group. The Alpha-Tocopherol, Beta-Carotene Lung Cancer Prevention Study: design, methods, participant characteristics, and compliance. Ann Epidemiol. 1994;4:1-10.[Medline] [Order article via Infotrieve]
17.
The Alpha-Tocopherol Beta Carotene Cancer Prevention Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med. 1994;330:1029-1035.
18.
Pietinen P, Hartman AM, Haapa E, Rasanen L, Haapakoski J, Palmgren J, Albanes D, Virtamo J, Huttunen JK. Reproducibility and validity of dietary assessment instruments, I: a self-administered food use questionnaire with a portion size picture booklet. Am J Epidemiol. 1988;128:655-666.
19. Katterman R, Jaworek D, Moller G. Multicentre study of a new enzymatic method of cholesterol determination. J Clin Chem Clin Biochem. 1984;22:245-251.[Medline] [Order article via Infotrieve]
20. Kostner GM. Enzymatic determination of cholesterol in high density lipoprotein fractions prepared by polyanion precipitation. Clin Chem. 1976;22:695.
21. Englyst H. Determination of carbohydrate and its composition in plant materials. In: James WPT, Theander O, eds. The Analysis of Dietary Fiber in Food. New York, NY: Marcel Decker; 1981:71-93.
22. Varo P, Laine R, Veijalainen K, Pero K, Koivistoinen P. Dietary fiber and available carbohydrates in Finnish cereal products. J Agric Sci Finl. 1984;56:39-48.
23. Varo P, Laine R, Veijalainen K, Espo A, Wetterhoff A, Koivistoinen P. Dietary fiber and available carbohydrates in Finnish vegetables and fruits. J Agric Sci Finl. 1984;56:49-59.
24.
Willett W, Stampfer MJ. Total energy intake: implications for epidemiologic analyses. Am J Epidemiol. 1986;124:17-27.
25. Prentice RL. Covariate measurement errors and parameter estimation in a failure regression model. Biometrika. 1987;69:331-342.
26.
Tuomilehto J, Arstila M, Kaarsalo E, Kankaanpaa J, Ketonen M, Kuulasmaa K, Lehto S, Miettinen H, Mustaniemi H, Palomaki P, Puska P, Pyorala K, Salomaa V, Torppa J, Vuorenmaa T. Acute myocardial infarction (MI) in Finland: baseline data from the MONICA AMI register in 1983-1985. Eur Heart J. 1992;13:577-587.
27. Kleemola P, Virtanen M, Pietinen P. The 1992 Dietary Survey of Finnish Adults. Helsinki, Finland: National Public Health Institute, publication No. B2, 1994.
28. Alaimo K, McDowell MA, Briefel RR. Dietary intake of vitamins, minerals, and fiber of persons ages 2 months and over in the United States: the Third National Health and Nutrition Examination Survey, Phase 1, 1988-1991. Adv Data. 1994;258:1-26.
29. Anderson JW, Chen WL. Plant fiber: carbohydrate and lipid metabolism. Am J Clin Nutr. 1979;23:346-363.[Abstract]
30. Anderson JW, Chen WL, Sieling B. Hypolipidemic effects of high-carbohydrate, high-fiber diets. Metabolism. 1980;29:551-558.[Medline] [Order article via Infotrieve]
31.
Cara L, Dubois C, Borel P, Armand M, Senft M, Protugal H, Pauli A-M, Bernard P-M, Lairon D. Effects of oat bran, rice bran, wheat fiber, and wheat germ on postprandial lipemia in healthy adults. Am J Clin Nutr. 1992;55:81-88.
32.
Dubois C, Armand M, Senf M, Portugal H, Pauli A-M, Bernard P-M, Lafont H, Lairon D. Chronic oat bran intake alters postprandial lipemia and lipoprotein in healthy adults. Am J Clin Nutr. 1995;61:325-333.
33. Riccardi G, Rivellese AA. Effects of dietary fiber and carbohydrate on glucose and lipoprotein metabolism in diabetic patients. Diabetes Care. 1991;14:1115-1125.[Abstract]
34.
Hallfrisch J, Scholfield DJ, Behall KM. Diets containing soluble oat extracts improve glucose and insulin responses of moderately hypercholesterolemic men and women. Am J Clin Nutr. 1995;61:379-384.
35.
Feskens EJM, Loeber JG, Kromhout D. Diet and physical activity as determinants of hyperinsulinemia: the Zutphen Elderly Study. Am J Epidemiol. 1994;140:350-360.
36. Stout RW. Insulin and atheroma: 20-year prospective. Diabetes Care. 1990;13:631-654.[Abstract]
37. Fontbonne A, Charles MA, Thibult N, Richard JL, Claude JR, Warnet JM, Rosselin GE, Eschewege E. Hyperinsulinemia as a predictor of coronary heart disease mortality in a healthy population: the Paris prospective study, 15-year follow-up. Diabetologia. 1991;34:356-361.[Medline] [Order article via Infotrieve]
38. Simpson HCR, Mann JI, Chakrabarti R. Effect of high-fiber diet on hemostatic variables in diabetes. Br J Med. 1982;284:1608-1615.
39. Boman K, Hellsten G, Bruce A, Hallmans G, Nilsson TK. Endurance physical activity, diet and fibrinolysis. Atherosclerosis. 1994;106:65-74.[Medline] [Order article via Infotrieve]
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H. Kan, J. Stevens, G. Heiss, R. Klein, K. M Rose, and S. J London Dietary fiber intake and retinal vascular caliber in the Atherosclerosis Risk in Communities Study Am. J. Clinical Nutrition, December 1, 2007; 86(6): 1626 - 1632. [Abstract] [Full Text] [PDF]
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 L. Djousse and J. M. Gaziano Breakfast Cereals and Risk of Heart Failure in the Physicians' Health Study I Arch Intern Med, October 22, 2007; 167(19): 2080 - 2085. [Abstract] [Full Text] [PDF]
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 A. Andersson, S. Tengblad, B. Karlstrom, A. Kamal-Eldin, R. Landberg, S. Basu, P. Aman, and B. Vessby Whole-Grain Foods Do Not Affect Insulin Sensitivity or Markers of Lipid Peroxidation and Inflammation in Healthy, Moderately Overweight Subjects J. Nutr., June 1, 2007; 137(6): 1401 - 1407. [Abstract] [Full Text] [PDF]
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 E. K. Kabagambe, A. Baylin, and H. Campos Nonfatal Acute Myocardial Infarction in Costa Rica: Modifiable Risk Factors, Population-Attributable Risks, and Adherence to Dietary Guidelines Circulation, March 6, 2007; 115(9): 1075 - 1081. [Abstract] [Full Text] [PDF]
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 B. Halliwell Dietary polyphenols: Good, bad, or indifferent for your health? Cardiovasc Res, January 15, 2007; 73(2): 341 - 347. [Abstract] [Full Text] [PDF]
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L. Dauchet, P. Amouyel, S. Hercberg, and J. Dallongeville Fruit and Vegetable Consumption and Risk of Coronary Heart Disease: A Meta-Analysis of Cohort Studies J. Nutr., October 1, 2006; 136(10): 2588 - 2593. [Abstract] [Full Text] [PDF]
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L. M Steffen, C. H Kroenke, X. Yu, M. A Pereira, M. L Slattery, L. Van Horn, M. D Gross, and D. R Jacobs Jr Associations of plant food, dairy product, and meat intakes with 15-y incidence of elevated blood pressure in young black and white adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study Am. J. Clinical Nutrition, December 1, 2005; 82(6): 1169 - 1177. [Abstract] [Full Text] [PDF]
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E. K. Kabagambe, A. Baylin, E. Ruiz-Narvarez, X. Siles, and H. Campos Decreased Consumption of Dried Mature Beans Is Positively Associated with Urbanization and Nonfatal Acute Myocardial Infarction J. Nutr., July 1, 2005; 135(7): 1770 - 1775. [Abstract] [Full Text] [PDF]
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K. L. Tucker, J. Hallfrisch, N. Qiao, D. Muller, R. Andres, and J. L. Fleg The Combination of High Fruit and Vegetable and Low Saturated Fat Intakes Is More Protective against Mortality in Aging Men than Is Either Alone: The Baltimore Longitudinal Study of Aging J. Nutr., March 1, 2005; 135(3): 556 - 561. [Abstract] [Full Text] [PDF]
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U. A. Ajani, E. S. Ford, and A. H. Mokdad Dietary Fiber and C-Reactive Protein: Findings from National Health and Nutrition Examination Survey Data J. Nutr., May 1, 2004; 134(5): 1181 - 1185. [Abstract] [Full Text] [PDF]
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M. A. Pereira, E. O'Reilly, K. Augustsson, G. E. Fraser, U. Goldbourt, B. L. Heitmann, G. Hallmans, P. Knekt, S. Liu, P. Pietinen, et al. Dietary Fiber and Risk of Coronary Heart Disease: A Pooled Analysis of Cohort Studies Arch Intern Med, February 23, 2004; 164(4): 370 - 376. [Abstract] [Full Text] [PDF]
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H. Wu, K. M Dwyer, Z. Fan, A. Shircore, J. Fan, and J. H Dwyer Dietary fiber and progression of atherosclerosis: the Los Angeles Atherosclerosis Study Am. J. Clinical Nutrition, December 1, 2003; 78(6): 1085 - 1091. [Abstract] [Full Text] [PDF]
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L. A. Bazzano, J. He, L. G. Ogden, C. M. Loria, and P. K. Whelton Dietary Fiber Intake and Reduced Risk of Coronary Heart Disease in US Men and Women: The National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study Arch Intern Med, September 8, 2003; 163(16): 1897 - 1904. [Abstract] [Full Text] [PDF]
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D. R Jacobs Jr and L. M Steffen Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy Am. J. Clinical Nutrition, September 1, 2003; 78(3): 508S - 513. [Abstract] [Full Text] [PDF]
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 D. Mozaffarian, S. K. Kumanyika, R. N. Lemaitre, J. L. Olson, G. L. Burke, and D. S. Siscovick Cereal, Fruit, and Vegetable Fiber Intake and the Risk of Cardiovascular Disease in Elderly Individuals JAMA, April 2, 2003; 289(13): 1659 - 1666. [Abstract] [Full Text] [PDF]
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G. H McIntosh, M. Noakes, P. J Royle, and P. R Foster Whole-grain rye and wheat foods and markers of bowel health in overweight middle-aged men Am. J. Clinical Nutrition, April 1, 2003; 77(4): 967 - 974. [Abstract] [Full Text] [PDF]
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 V. Mai, A. Flood, U. Peters, J. V Lacey Jr, C. Schairer, and A. Schatzkin Dietary fibre and risk of colorectal cancer in the Breast Cancer Detection Demonstration Project (BCDDP) follow-up cohort Int. J. Epidemiol., April 1, 2003; 32(2): 234 - 239. [Abstract] [Full Text] [PDF]
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F. B. Hu and W. C. Willett Optimal Diets for Prevention of Coronary Heart Disease JAMA, November 27, 2002; 288(20): 2569 - 2578. [Abstract] [Full Text] [PDF]
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 J. Stevens, K. Ahn, Juhaeri, D. Houston, L. Steffan, and D. Couper Dietary Fiber Intake and Glycemic Index and Incidence of Diabetes in African-American and White Adults: The ARIC Study Diabetes Care, October 1, 2002; 25(10): 1715 - 1721. [Abstract] [Full Text] [PDF]
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 G. P. Jarvik, N. T. Tsai, L. A. McKinstry, R. Wani, V. H. Brophy, R. J. Richter, G. D. Schellenberg, P. J. Heagerty, T. S. Hatsukami, and C. E. Furlong Vitamin C and E Intake Is Associated With Increased Paraoxonase Activity Arterioscler Thromb Vasc Biol, August 1, 2002; 22(8): 1329 - 1333. [Abstract] [Full Text] [PDF]
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A. Adam, V. Crespy, M.-A. Levrat-Verny, F. Leenhardt, M. Leuillet, C. Demigne, and C. Remesy The Bioavailability of Ferulic Acid Is Governed Primarily by the Food Matrix Rather than Its Metabolism in Intestine and Liver in Rats J. Nutr., July 1, 2002; 132(7): 1962 - 1968. [Abstract] [Full Text] [PDF]
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 P. J. Jones Clinical nutrition: 7. Functional foods -- more than just nutrition Can. Med. Assoc. J., June 1, 2002; 166(12): 1555 - 1563. [Full Text] [PDF]
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M. A Pereira, D. R Jacobs Jr, J. J Pins, S. K Raatz, M. D Gross, J. L Slavin, and E. R Seaquist Effect of whole grains on insulin sensitivity in overweight hyperinsulinemic adults Am. J. Clinical Nutrition, May 1, 2002; 75(5): 848 - 855. [Abstract] [Full Text] [PDF]
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 S. Liu, J. E. Buring, H. D. Sesso, E. B. Rimm, W. C. Willett, and J. E. Manson A prospective study of dietary fiber intake and risk of cardiovascular disease among women J. Am. Coll. Cardiol., January 2, 2002; 39(1): 49 - 56. [Abstract] [Full Text] [PDF]
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L. A. Bazzano, J. He, L. G. Ogden, C. Loria, S. Vupputuri, L. Myers, and P. K. Whelton Legume Consumption and Risk of Coronary Heart Disease in US Men and Women: NHANES I Epidemiologic Follow-up Study Arch Intern Med, November 26, 2001; 161(21): 2573 - 2578. [Abstract] [Full Text] [PDF]
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 T.D. Barringer Dietary fats in the prevention of coronary heart disease: the need for more clinical trials Eur. Heart J. Suppl., June 1, 2001; 3(suppl_D): D79 - D84. [Abstract] [PDF]
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E. Saltzman, S. K. Das, A. H. Lichtenstein, G. E. Dallal, A. Corrales, E. J. Schaefer, A. S. Greenberg, and S. B. Roberts An Oat-Containing Hypocaloric Diet Reduces Systolic Blood Pressure and Improves Lipid Profile beyond Effects of Weight Loss in Men and Women J. Nutr., May 1, 2001; 131(5): 1465 - 1470. [Abstract] [Full Text]
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I. Suh, K. W. Oh, K. H. Lee, B. M Psaty, C. M. Nam, S. I. Kim, H. G. Kang, S. Y. Cho, and W. H. Shim Moderate dietary fat consumption as a risk factor for ischemic heart disease in a population with a low fat intake: a case-control study in Korean men Am. J. Clinical Nutrition, April 1, 2001; 73(4): 722 - 727. [Abstract] [Full Text] [PDF]
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R. M. Krauss, R. H. Eckel, B. Howard, L. J. Appel, S. R. Daniels, R. J. Deckelbaum, J. W. Erdman Jr, P. Kris-Etherton, I. J. Goldberg, T. A. Kotchen, et al. AHA Scientific Statement: AHA Dietary Guidelines: Revision 2000: A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart Association J. Nutr., January 1, 2001; 131(1): 132 - 146. [Full Text]
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 R. M. Krauss, R. H. Eckel, B. Howard, L. J. Appel, S. R. Daniels, R. J. Deckelbaum, J. W. Erdman Jr, P. Kris-Etherton, I. J. Goldberg, T. A. Kotchen, et al. AHA Dietary Guidelines : Revision 2000: A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart Association Stroke, November 1, 2000; 31(11): 2751 - 2766. [Full Text] [PDF]
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R. M. Krauss, R. H. Eckel, B. Howard, L. J. Appel, S. R. Daniels, R. J. Deckelbaum, J. W. Erdman Jr, P. Kris-Etherton, I. J. Goldberg, T. A. Kotchen, et al. AHA Dietary Guidelines : Revision 2000: A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart Association Circulation, October 31, 2000; 102(18): 2284 - 2299. [Full Text] [PDF]
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B. Halliwell Lipid peroxidation, antioxidants and cardiovascular disease: how should we move forward? Cardiovasc Res, August 18, 2000; 47(3): 410 - 418. [Full Text] [PDF]
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 S.D. Oliver The long-term safety and tolerability of ispaghula husk Perspectives in Public Health, June 1, 2000; 120(2): 107 - 111. [Abstract] [PDF]
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 J. W. Anderson, T. J. Hanna, X. Peng, and R. J. Kryscio Whole Grain Foods and Heart Disease Risk J. Am. Coll. Nutr., June 1, 2000; 19(90003): 291S - 299. [Abstract] [Full Text] [PDF]
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L. H Kushi, K. A Meyer, and D. R Jacobs Jr Cereals, legumes, and chronic disease risk reduction: evidence from epidemiologic studies Am. J. Clinical Nutrition, September 1, 1999; 70(3): 451S - 458. [Abstract] [Full Text] [PDF]
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D. C Nieman Physical fitness and vegetarian diets: is there a relation? Am. J. Clinical Nutrition, September 1, 1999; 70(3): 570S - 575. [Abstract] [Full Text] [PDF]
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 M. Segasothy and P.A. Phillips Vegetarian diet: panacea for modern lifestyle diseases? QJM, September 1, 1999; 92(9): 531 - 544. [Abstract] [Full Text] [PDF]
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A. Wolk, J. E. Manson, M. J. Stampfer, G. A. Colditz, F. B. Hu, F. E. Speizer, C. H. Hennekens, and W. C. Willett Long-term Intake of Dietary Fiber and Decreased Risk of Coronary Heart Disease Among Women JAMA, June 2, 1999; 281(21): 1998 - 2004. [Abstract] [Full Text] [PDF]
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L. H Kushi Vitamin E and heart disease: a case study Am. J. Clinical Nutrition, June 1, 1999; 69 (6): 1322S - 1329S. [Abstract] [Full Text] [PDF]
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 M. Law, N. Wald, M. Stampfer, E. Rimm, D J P Barker, J. P Mackenbach, and A. E Kunst Why heart disease mortality is low in France: the time lag explanation • Commentary: Alcohol and other dietary factors may be important • Commentary: Intrauterine nutrition may be important • Commentary: Heterogeneity of populations should be taken into account • Authors' response BMJ, May 29, 1999; 318(7196): 1471 - 1480. [Full Text]
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M. H. Davidson, L. D. Dugan, J. Stocki, M. R. Dicklin, K. C. Maki,, F. Coletta, R. Cotter, M. McLeod, and K. Hoersten A Low-Viscosity Soluble-Fiber Fruit Juice Supplement Fails to Lower Cholesterol in Hypercholesterolemic Men and Women J. Nutr., November 1, 1998; 128(11): 1927 - 1932. [Abstract] [Full Text]
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A. Ascherio, E. B. Rimm, M. A. Hernan, E. L. Giovannucci, I. Kawachi, M. J. Stampfer, and W. C. Willett Intake of Potassium, Magnesium, Calcium, and Fiber and Risk of Stroke Among US Men Circulation, September 22, 1998; 98(12): 1198 - 1204. [Abstract] [Full Text] [PDF]
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 J. I Mann, P. N Appleby, T. J Key, and M. Thorogood Dietary determinants of ischaemic heart disease in health conscious individuals Heart, November 1, 1997; 78(5): 450 - 455. [Abstract] [Full Text] [PDF]
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K. C. Maki, M. H. Davidson, A. McDonald, and K. C. Malik Fiber Intake and Risk of Developing Non--insulin-dependent Diabetes Mellitus JAMA, June 11, 1997; 277(22): 1761 - 1761. [Abstract] [PDF]
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D. R. Labarthe Dietary Fiber: Further Epidemiological Support for a High-Intake Dietary Pattern Circulation, December 1, 1996; 94(11): 2696 - 2698. [Full Text]
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