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Tsilas CS, de Souza RJ, Mejia SB, Mirrahimi A, Cozma AI, Jayalath VH, Ha V, Tawfik R, Di Buono M, Jenkins AL, Leiter LA, Wolever TMS, Beyene J, Khan T, Kendall CWC, Jenkins DJA, Sievenpiper JL. Relation of total sugars, fructose and sucrose with incident type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies. CMAJ 2017; 189:E711-E720. [PMID: 28536126 DOI: 10.1503/cmaj.160706] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sugar-sweetened beverages are associated with type 2 diabetes. To assess whether this association holds for the fructose-containing sugars they contain, we conducted a systematic review and meta-analysis of prospective cohort studies. METHODS We searched MEDLINE, Embase, CINAHL and the Cochrane Library (through June 2016). We included prospective cohort studies that assessed the relation of fructose-containing sugars with incident type 2 diabetes. Two independent reviewers extracted relevant data and assessed risk of bias. We pooled risk ratios (RRs) using random effects meta-analyses. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Fiffeen prospective cohort studies (251 261 unique participants, 16 416 cases) met the eligibility criteria, comparing the highest intake (median 137, 35.2 and 78 g/d) with the lowest intake (median 65, 9.7 and 25.8 g/d) of total sugars, fructose and sucrose, respectively. Although there was no association of total sugars (RR 0.91, 95% confidence interval [CI] 0.76-1.09) or fructose (RR 1.04, 95% CI 0.84-1.29) with type 2 diabetes, sucrose was associated with a decreased risk of type 2 diabetes (RR 0.89, 95% CI 0.80-0.98). Our confidence in the estimates was limited by evidence of serious inconsistency between studies for total sugars and fructose, and serious imprecision in the pooled estimates for all 3 sugar categories. INTERPRETATION Current evidence does not allow us to conclude that fructose-containing sugars independent of food form are associated with increased risk of type 2 diabetes. Further research is likely to affect our estimates. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01608620.
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Affiliation(s)
- Christine S Tsilas
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Russell J de Souza
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Sonia Blanco Mejia
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Arash Mirrahimi
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Adrian I Cozma
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Viranda H Jayalath
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Vanessa Ha
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Reem Tawfik
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Marco Di Buono
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Alexandra L Jenkins
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Lawrence A Leiter
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Thomas M S Wolever
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Joseph Beyene
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Tauseef Khan
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - Cyril W C Kendall
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - David J A Jenkins
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask
| | - John L Sievenpiper
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask.
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