#Carbohydrate -last meal pattern lowers postprandial glucose and insulin excursions in type 2 #diabetes
http://drc.bmj.com/content/5/1/e000440
There are limited data regarding the timing of carbohydrate ingestion during a meal and postprandial glucose regulation
The incremental areas under the curve for glucose (iAUC0–180) and incremental glucose peaks were 53% and 54% lower, respectively, when carbohydrate was consumed last compared with carbohydrate consumed first (3124.7±501.2 vs 6703.5±904.6 mg/dL×180min, p<0.001; 34.7±4.1 vs 75.0±6.5 mg/dL, p<0.001) and 44% and 40% lower, respectively, compared with the all components together condition (3124.7±501.2 vs 5587.1±828.7 mg/dL×180min, p=0.003; 34.7±4.1 vs 58.2±5.9 mg/dL, p<0.001). Postprandial insulin excursions were lower (iAUC0–180: 7354.1±897.3 vs 9769.7±1002.1 µU/mL×min, p=0.003) and GLP-1 excursions higher (iAUC0–180: 3487.56±327.7 vs 2519.11±494.8 pg/mL×min, p=0.019) following the carbohydrate-last meal order compared with carbohydrate first.
Conclusion The carbohydrate-last meal pattern may be an effective behavioral strategy to improve postprandial glycemia
http://drc.bmj.com/content/5/1/e000440
There are limited data regarding the timing of carbohydrate ingestion during a meal and postprandial glucose regulation
The incremental areas under the curve for glucose (iAUC0–180) and incremental glucose peaks were 53% and 54% lower, respectively, when carbohydrate was consumed last compared with carbohydrate consumed first (3124.7±501.2 vs 6703.5±904.6 mg/dL×180min, p<0.001; 34.7±4.1 vs 75.0±6.5 mg/dL, p<0.001) and 44% and 40% lower, respectively, compared with the all components together condition (3124.7±501.2 vs 5587.1±828.7 mg/dL×180min, p=0.003; 34.7±4.1 vs 58.2±5.9 mg/dL, p<0.001). Postprandial insulin excursions were lower (iAUC0–180: 7354.1±897.3 vs 9769.7±1002.1 µU/mL×min, p=0.003) and GLP-1 excursions higher (iAUC0–180: 3487.56±327.7 vs 2519.11±494.8 pg/mL×min, p=0.019) following the carbohydrate-last meal order compared with carbohydrate first.
Conclusion The carbohydrate-last meal pattern may be an effective behavioral strategy to improve postprandial glycemia
BMJ Open Diabetes Research & Care
Carbohydrate-last meal pattern lowers postprandial glucose and insulin excursions in type 2 diabetes
Background There are limited data regarding the timing of carbohydrate ingestion during a meal and postprandial glucose regulation.
Methods Sixteen subjects with type 2 diabetes mellitus (T2DM) consumed the same meal on 3 days in random order: carbohydrate…
Methods Sixteen subjects with type 2 diabetes mellitus (T2DM) consumed the same meal on 3 days in random order: carbohydrate…
Effect of Low- #Fat vs Low-#Carbohydrate Diet on 12-Month #Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion
https://jamanetwork.com/journals/jama/article-abstract/2673150
Among 609 participants randomized (mean age, 40 SD, 7 years; 57% women; mean body mass index, 33 SD, 3; 244 40% had a low-fat genotype; 180 30% had a low-carbohydrate genotype; mean baseline INS-30, 93 μIU/mL), 481 (79%) completed the trial. In the HLF vs HLC diets, respectively, the mean 12-month macronutrient distributions were 48% vs 30% for carbohydrates, 29% vs 45% for fat, and 21% vs 23% for protein. Weight change at 12 months was −5.3 kg for the HLF diet vs −6.0 kg for the HLC diet (mean between-group difference, 0.7 kg 95% CI, −0.2 to 1.6 kg). There was no significant diet-genotype pattern interaction (P = .20) or diet-insulin secretion (INS-30) interaction (P = .47) with 12-month weight loss. There were 18 adverse events or serious adverse events that were evenly distributed across the 2 diet groups.
Conclusions and Relevance In this 12-month weight loss diet study, there was no significant difference in weight change between a healthy low-fat diet vs a healthy low-carbohydrate diet, and neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss. In the context of these 2 common weight loss diet approaches, neither of the 2 hypothesized predisposing factors was helpful in identifying which diet was better for whom
https://jamanetwork.com/journals/jama/article-abstract/2673150
Among 609 participants randomized (mean age, 40 SD, 7 years; 57% women; mean body mass index, 33 SD, 3; 244 40% had a low-fat genotype; 180 30% had a low-carbohydrate genotype; mean baseline INS-30, 93 μIU/mL), 481 (79%) completed the trial. In the HLF vs HLC diets, respectively, the mean 12-month macronutrient distributions were 48% vs 30% for carbohydrates, 29% vs 45% for fat, and 21% vs 23% for protein. Weight change at 12 months was −5.3 kg for the HLF diet vs −6.0 kg for the HLC diet (mean between-group difference, 0.7 kg 95% CI, −0.2 to 1.6 kg). There was no significant diet-genotype pattern interaction (P = .20) or diet-insulin secretion (INS-30) interaction (P = .47) with 12-month weight loss. There were 18 adverse events or serious adverse events that were evenly distributed across the 2 diet groups.
Conclusions and Relevance In this 12-month weight loss diet study, there was no significant difference in weight change between a healthy low-fat diet vs a healthy low-carbohydrate diet, and neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss. In the context of these 2 common weight loss diet approaches, neither of the 2 hypothesized predisposing factors was helpful in identifying which diet was better for whom
!!
Dietary #carbohydrate intake and #mortality: a prospective cohort study and meta-analysis
https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30135-X/fulltext
During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50–55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (<40%) and high carbohydrate consumption (>70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09–1·32 for low carbohydrate consumption; 1·23, 1·11–1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08–1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78–0·87).
Interpretation
Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50–55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut but butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality.
Dietary #carbohydrate intake and #mortality: a prospective cohort study and meta-analysis
https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30135-X/fulltext
During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50–55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (<40%) and high carbohydrate consumption (>70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09–1·32 for low carbohydrate consumption; 1·23, 1·11–1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08–1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78–0·87).
Interpretation
Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50–55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut but butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality.
!!
Effects of a low #carbohydrate diet on energy expenditure during #weight loss maintenance: randomized trial.
https://www.ncbi.nlm.nih.gov/pubmed/30429127
Total energy expenditure differed by diet in the intention-to-treat analysis (n=162, P=0.002), with a linear trend of 52 kcal/d (95% confidence interval 23 to 82) for every 10% decrease in the contribution of carbohydrate to total energy intake (1 kcal=4.18 kJ=0.00418 MJ). Change in total energy expenditure was 91 kcal/d (95% confidence interval -29 to 210) greater in participants assigned to the moderate carbohydrate diet and 209 kcal/d (91 to 326) greater in those assigned to the low carbohydrate diet compared with the high carbohydrate diet. In the per protocol analysis (n=120, P<0.001), the respective differences were 131 kcal/d (-6 to 267) and 278 kcal/d (144 to 411). Among participants in the highest third of pre-weight loss insulin secretion, the difference between the low and high carbohydrate diet was 308 kcal/d in the intention-to-treat analysis and 478 kcal/d in the per protocol analysis (P<0.004). Ghrelin was significantly lower in participants assigned to the low carbohydrate diet compared with those assigned to the high carbohydrate diet (both analyses). Leptin was also significantly lower in participants assigned to the low carbohydrate diet (per protocol).
CONCLUSIONS:
Consistent with the carbohydrate-insulin model, lowering dietary carbohydrate increased energy expenditure during weight loss maintenance. This metabolic effect may improve the success of obesity treatment, especially among those with high insulin secretion.
Effects of a low #carbohydrate diet on energy expenditure during #weight loss maintenance: randomized trial.
https://www.ncbi.nlm.nih.gov/pubmed/30429127
Total energy expenditure differed by diet in the intention-to-treat analysis (n=162, P=0.002), with a linear trend of 52 kcal/d (95% confidence interval 23 to 82) for every 10% decrease in the contribution of carbohydrate to total energy intake (1 kcal=4.18 kJ=0.00418 MJ). Change in total energy expenditure was 91 kcal/d (95% confidence interval -29 to 210) greater in participants assigned to the moderate carbohydrate diet and 209 kcal/d (91 to 326) greater in those assigned to the low carbohydrate diet compared with the high carbohydrate diet. In the per protocol analysis (n=120, P<0.001), the respective differences were 131 kcal/d (-6 to 267) and 278 kcal/d (144 to 411). Among participants in the highest third of pre-weight loss insulin secretion, the difference between the low and high carbohydrate diet was 308 kcal/d in the intention-to-treat analysis and 478 kcal/d in the per protocol analysis (P<0.004). Ghrelin was significantly lower in participants assigned to the low carbohydrate diet compared with those assigned to the high carbohydrate diet (both analyses). Leptin was also significantly lower in participants assigned to the low carbohydrate diet (per protocol).
CONCLUSIONS:
Consistent with the carbohydrate-insulin model, lowering dietary carbohydrate increased energy expenditure during weight loss maintenance. This metabolic effect may improve the success of obesity treatment, especially among those with high insulin secretion.
!!
#Carbohydrate quality and human #health: a series of systematic reviews and meta-analyses
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31809-9/fulltext
Observational data suggest a 15–30% decrease in all-cause and cardiovascular related mortality, and incidence of coronary heart disease, stroke incidence and mortality, type 2 diabetes, and colorectal cancer when comparing the highest dietary fibre consumers with the lowest consumers
Clinical trials show significantly lower bodyweight, systolic blood pressure, and total cholesterol when comparing higher with lower intakes of dietary fibre. Risk reduction associated with a range of critical outcomes was greatest when daily intake of dietary fibre was between 25 g and 29 g. Dose-response curves suggested that higher intakes of dietary fibre could confer even greater benefit to protect against cardiovascular diseases, type 2 diabetes, and colorectal and breast cancer. Similar findings for whole grain intake were observed.
Findings from prospective studies and clinical trials associated with relatively high intakes of dietary fibre and whole grains were complementary, and striking dose-response evidence indicates that the relationships to several non-communicable diseases could be causal.
Implementation of recommendations to increase dietary fibre intake and to replace refined grains with whole grains is expected to benefit human health. A major strength of the study was the ability to examine key indicators of carbohydrate quality in relation to a range of non-communicable disease outcomes from cohort studies and randomised trials in a single study. Our findings are limited to risk reduction in the population at large rather than those with chronic disease.
#Carbohydrate quality and human #health: a series of systematic reviews and meta-analyses
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31809-9/fulltext
Observational data suggest a 15–30% decrease in all-cause and cardiovascular related mortality, and incidence of coronary heart disease, stroke incidence and mortality, type 2 diabetes, and colorectal cancer when comparing the highest dietary fibre consumers with the lowest consumers
Clinical trials show significantly lower bodyweight, systolic blood pressure, and total cholesterol when comparing higher with lower intakes of dietary fibre. Risk reduction associated with a range of critical outcomes was greatest when daily intake of dietary fibre was between 25 g and 29 g. Dose-response curves suggested that higher intakes of dietary fibre could confer even greater benefit to protect against cardiovascular diseases, type 2 diabetes, and colorectal and breast cancer. Similar findings for whole grain intake were observed.
Findings from prospective studies and clinical trials associated with relatively high intakes of dietary fibre and whole grains were complementary, and striking dose-response evidence indicates that the relationships to several non-communicable diseases could be causal.
Implementation of recommendations to increase dietary fibre intake and to replace refined grains with whole grains is expected to benefit human health. A major strength of the study was the ability to examine key indicators of carbohydrate quality in relation to a range of non-communicable disease outcomes from cohort studies and randomised trials in a single study. Our findings are limited to risk reduction in the population at large rather than those with chronic disease.
!!
The Effect of Low- #Carbohydrate and Low-Fat Diets on Pain in Individuals with Knee #Osteoarthritis
https://academic.oup.com/painmedicine/advance-article-abstract/doi/10.1093/pm/pnz022/5380130?redirectedFrom=fulltext
(low-carbohydrate [LCD], low-fat [LFD]) or continue to eat as usual (control [CTRL]) over 12 weeks.
Osteoarthritis is the most prominent form of arthritis, affecting approximately 15% of the population in the United States. Knee osteoarthritis (KOA) has become one of the leading causes of disability in older adults. Besides knee replacement, there are no curative treatments for KOA, so persistent pain is commonly treated with opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs. However, these drugs have many unpleasant side effects, so there is a need for alternative forms of pain management. We sought to test the efficacy of a dietary intervention to reduce KOA.
We present evidence suggesting that oxidative stress may be related to functional pain, and lowering it through our LCD intervention could provide relief from pain and be an opioid alternative.
The Effect of Low- #Carbohydrate and Low-Fat Diets on Pain in Individuals with Knee #Osteoarthritis
https://academic.oup.com/painmedicine/advance-article-abstract/doi/10.1093/pm/pnz022/5380130?redirectedFrom=fulltext
(low-carbohydrate [LCD], low-fat [LFD]) or continue to eat as usual (control [CTRL]) over 12 weeks.
Osteoarthritis is the most prominent form of arthritis, affecting approximately 15% of the population in the United States. Knee osteoarthritis (KOA) has become one of the leading causes of disability in older adults. Besides knee replacement, there are no curative treatments for KOA, so persistent pain is commonly treated with opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs. However, these drugs have many unpleasant side effects, so there is a need for alternative forms of pain management. We sought to test the efficacy of a dietary intervention to reduce KOA.
We present evidence suggesting that oxidative stress may be related to functional pain, and lowering it through our LCD intervention could provide relief from pain and be an opioid alternative.
OUP Academic
Effect of Low-Carbohydrate and Low-Fat Diets on Pain in Individuals with Knee Osteoarthritis
AbstractObjective. Osteoarthritis is the most prominent form of arthritis, affecting approximately 15% of the population in the United States. Knee osteoarthri
Short-Term Consumption of #Sucralose with, but Not without, #Carbohydrate Impairs Neural and Metabolic Sensitivity to Sugar in Humans
https://2medical.news/2020/03/14/short-term-consumption-of-sucralose-with-but-not-without-carbohydrate-impairs-neural-and-metabolic-sensitivity-to-sugar-in-humans/
There is a general consensus that overconsumption of sugar-sweetened beverages contributes to the prevalence of obesity and related comorbidities such as type 2 diabetes (T2D). Whether a similar relationship exists for no- or low-calorie “diet” drinks is a subject of intensive debate and controversy. Here, we demonstrate that consuming seven sucralose-sweetened beverages with, but not without, a carbohydrate over 10 days decreases insulin sensitivity in …
https://2medical.news/2020/03/14/short-term-consumption-of-sucralose-with-but-not-without-carbohydrate-impairs-neural-and-metabolic-sensitivity-to-sugar-in-humans/
There is a general consensus that overconsumption of sugar-sweetened beverages contributes to the prevalence of obesity and related comorbidities such as type 2 diabetes (T2D). Whether a similar relationship exists for no- or low-calorie “diet” drinks is a subject of intensive debate and controversy. Here, we demonstrate that consuming seven sucralose-sweetened beverages with, but not without, a carbohydrate over 10 days decreases insulin sensitivity in …
Low #carbohydrate diet and all cause and cause-specific #mortality
https://2medical.news/2020/09/29/low-carbohydrate-diet-and-all-cause-and-cause-specific-mortality/
Evidence is limited regarding the association between low-carbohydrate diet (LCD) score and mortality among Asians, a population that consumes a large amount of carbohydrates.. ..A U-shaped association was observed between LCD score and total mortality: the multivariable-adjusted hazard ratios (HRs) (95% CI) of total mortality for lowest through highest scores were 1.00, 0.95 (0.91, 1.01), 0.93 (0.88, 0.98), 0.93 (0.88, 0.98), and 1.01 (0.95, 1.07) …
https://2medical.news/2020/09/29/low-carbohydrate-diet-and-all-cause-and-cause-specific-mortality/
Evidence is limited regarding the association between low-carbohydrate diet (LCD) score and mortality among Asians, a population that consumes a large amount of carbohydrates.. ..A U-shaped association was observed between LCD score and total mortality: the multivariable-adjusted hazard ratios (HRs) (95% CI) of total mortality for lowest through highest scores were 1.00, 0.95 (0.91, 1.01), 0.93 (0.88, 0.98), 0.93 (0.88, 0.98), and 1.01 (0.95, 1.07) …
A randomized controlled trial of 130 g/day low-#carbohydrate diet in type 2 #diabetes with poor glycemic control
https://2medical.news/2021/01/22/a-randomized-controlled-trial-of-130-g-day-low-carbohydrate-diet-in-type-2-diabetes-with-poor-glycemic-control/
The usefulness of low-carbohydrate diet (LCD) for Japanese patients with type 2 diabetes mellitus (T2DM) has not been fully investigated. Therefore, we compared the effectiveness and safety of LCD with calorie restricted diet (CRD). This prospective, randomized, open-label, comparative study included 66 T2DM patients with HbA1c >7.5% even after receiving repeated education programs on CRD. They were randomly allocated to either the 130g/day LCD group …
https://2medical.news/2021/01/22/a-randomized-controlled-trial-of-130-g-day-low-carbohydrate-diet-in-type-2-diabetes-with-poor-glycemic-control/
The usefulness of low-carbohydrate diet (LCD) for Japanese patients with type 2 diabetes mellitus (T2DM) has not been fully investigated. Therefore, we compared the effectiveness and safety of LCD with calorie restricted diet (CRD). This prospective, randomized, open-label, comparative study included 66 T2DM patients with HbA1c >7.5% even after receiving repeated education programs on CRD. They were randomly allocated to either the 130g/day LCD group …
The #carbohydrate-insulin model: a physiological perspective on the #obesity pandemic
https://2medical.news/2021/09/20/the-carbohydrate-insulin-model-a-physiological-perspective-on-the-obesity-pandemic/
https://2medical.news/2021/09/20/the-carbohydrate-insulin-model-a-physiological-perspective-on-the-obesity-pandemic/
2Medical.News
The #carbohydrate-insulin model: a physiological perspective on the #obesity pandemic
According to a commonly held view, the obesity pandemic is caused by overconsumption of modern, highly palatable, energy-dense processed foods, exacerbated by a sedentary lifestyle. However, obesit…
Dietary #Carbohydrate and #Fat Intakes and Risk of #Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative Cohort Study
https://2medical.news/2023/09/15/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study/
https://2medical.news/2023/09/15/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study/
2Medical.News
Dietary #Carbohydrate and #Fat Intakes and Risk of #Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative…
BackgroundPrevious cohort studies have yielded contradictory findings regarding the associations of dietary carbohydrate and fat intakes with risks of mortality.ObjectivesWe examined long-term asso…
Dietary #Carbohydrate and #Fat Intakes and Risk of Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative Cohort Study
https://2medical.news/2023/09/23/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study-2/
https://2medical.news/2023/09/23/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study-2/
2Medical.News
Dietary #Carbohydrate and #Fat Intakes and Risk of Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative…
BackgroundPrevious cohort studies have yielded contradictory findings regarding the associations of dietary carbohydrate and fat intakes with risks of mortality.ObjectivesWe examined long-term asso…
#Almonds vs. #carbohydrate snacks in an energy-restricted diet: Weight and cardiometabolic outcomes from a randomized trial
https://2medical.news/2023/09/25/almonds-vs-carbohydrate-snacks-in-an-energy-restricted-diet-weight-and-cardiometabolic-outcomes-from-a-randomized-trial/
https://2medical.news/2023/09/25/almonds-vs-carbohydrate-snacks-in-an-energy-restricted-diet-weight-and-cardiometabolic-outcomes-from-a-randomized-trial/
2Medical.News
#Almonds vs. #carbohydrate snacks in an energy-restricted diet: Weight and cardiometabolic outcomes from a randomized trial
ObjectiveThis study evaluated weight and cardiometabolic outcomes after a 3-month energy-restricted diet (−30%) containing almonds (almond-enriched diet [AED]) or containing carbohydrate-rich snack…
Dietary #Carbohydrate and #Fat Intakes and Risk of Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative Cohort Study
https://2medical.news/2023/09/30/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study-3/
https://2medical.news/2023/09/30/dietary-carbohydrate-and-fat-intakes-and-risk-of-mortality-in-the-japanese-population-the-japan-multi-institutional-collaborative-cohort-study-3/
2Medical.News
Dietary #Carbohydrate and #Fat Intakes and Risk of Mortality in the Japanese Population: the Japan Multi-Institutional Collaborative…
BackgroundPrevious cohort studies have yielded contradictory findings regarding the associations of dietary carbohydrate and fat intakes with risks of mortality.ObjectivesWe examined long-term asso…