Does The Menstrual Cycle Affect Exercise Performance?

Jesse Oswald • February 24, 2024

Menstrual Cycle And Exercise Key Points:

  • The menstrual cycle is a biological process that supports reproduction.
  • The three main phases of the cycle are the follicular, ovulatory, and luteal phases.
  • During each phase, the fluctuations of two primary sex hormones, estrogen and progesterone, might impact exercise performance in women.
  • However, any detrimental effects of menstruation on exercise are trivial at best during the different phases.
  • Instead, it is recommended that women track their cycles and training and combine them to develop an individualized approach to exercise and nutrition.

 

Over the last 30 years, there has been a significant rise in the number of women participating in exercise. However, research on female athletes and those interested in general fitness has yet to keep pace with this exponential rise in participation.

 

One area of research on women that has been neglected is the effects of the menstrual cycle on exercise performance, specifically, how menstruation might affect strength, aerobic and anaerobic capabilities, and muscle recovery.

 

Before we discuss how the menstrual cycle might affect exercise performance, we first need to understand:

 

  • What is the menstrual cycle?
  • The phases of the menstrual cycle.
  • The main hormones found in each cycle and their fluctuations.

 

Let’s Dive in!

What Is The Menstrual Cycle?

You can think of the menstrual cycle as an essential biological process with significant changes in a woman’s sex hormones. The primary purpose of these fluctuations is to support reproduction, BUT they also might exert various effects on the cardiovascular, respiratory, metabolic, and neuromuscular systems. These effects might affect exercise performance.

What Are The Different Phases?

The menstrual cycle can be divided into six separate phases. In order, these are:


  1. Early follicular - Days 1-5.
  2. Late follicular - Days 6-12.
  3. Ovulation - Days 13-15.
  4. Early luteal - Days 16-19.
  5. Mid-luteal - Days 20-23.
  6. Late luteal - Days 24-28.


Next, let’s discuss the two primary hormones found in each phase and how their levels fluctuate.

Hormonal Changes During The Different Phases Of Menstruation

Estrogen and progesterone are essential hormones that fluctuate during the menstrual cycle. Let’s briefly discuss each before moving on to how they rise and fall during each menstruation phase.

What Is Estrogen, And What Does It Do?

Estrogen plays various roles in the body, but one of its primary functions is to help develop and maintain both the reproductive system and female characteristics. Furthermore, estrogen can be broken down into three different types.


  • Estrone is present in the body after menopause. It is a weaker form of estrogen that can be converted to other forms as necessary.
  • Estradiol is the most common type of estrogen during a female's reproductive years. This type of estrogen might have the most significant effect on exercise performance.
  • Estriol levels rise during pregnancy and peak just before birth. It functions to help the uterus grow.


It’s also important to know that estrogen is a very anabolic (muscle-building) hormone and may help increase glycogen storage while increasing fat utilization. All of which could have important implications for exercise performance.


Next, let’s discuss estrogen’s counterpart, progesterone.

What Is Progesterone?

Progesterone is the other primary hormone involved in the menstrual cycle. Its purpose is to prevent the fertilization of more than one egg and strengthen the pelvic muscle walls in preparation for labour.


Progesterone can also be thought of as the ying to estrogens yang. Meaning as progesterone levels rise during menstruation, estrogen levels fall. 


This is important to remember as we move on to the next section of this article. How this rise and fall of estrogen and progesterone during each menstrual cycle phase might positively or negatively affect exercise.

The Follicular Phase And Exercise

Early Follicular

During this phase, concentrations of both estrogen and progesterone are low. 


As mentioned earlier, estrogen is a potent anabolic hormone that helps protect against exercise-induced muscle damage while reducing inflammatory responses. When levels are low, there is a possibility of adverse effects on muscular performance or maximal and submaximal intensity exercise performance.


On the flip side, during the follicular phase (and due to low estrogen), the body might be able to utilize more glucose/glycogen. This can be highly advantageous for exercise, especially for longer duration/higher intensity training and events. It can also benefit those who strength train as working muscles use creatine phosphate and muscle glycogen as primary fuel sources.


In sum, even though muscle performance and performance might be slightly reduced during the early follicular phase due to low estrogen, the increased utilization of glycogen by the body might help offset it.



Late Follicular

Estrogen concentrations (anabolic hormone) rise during the late follicular phase while progesterone levels remain low. Compared to the early follicular phase, this may be ideal for focusing on strength training where the environment is primed.


High weight (75-85% of 1 repetition max), medium reps, and medium rest periods should be emphasized during this period. This may lead to more significant gains in strength and quicker recovery times when combined with the higher estrogen levels. 


For example, one could perform four sets of 8 reps of compound exercises (bench press, deadlift, shoulder press, squat) with 75 seconds of rest between sets and 2 minutes of rest between exercises.


Cardio-wise, high-intensity interval training would improve cardiorespiratory fitness during the late follicular phase.


However, it must be stressed that more research is needed to verify this theory.

The Ovulation Phase And Exercise

Estrogen will continue to rise (progesterone remains low) and hit its highest level during this phase. This has the potential to impact substrate metabolism. More specifically, your body can store and use carbohydrates as energy.


Carbohydrates act as the primary fuel source when exercise intensity increases and moves from more aerobic to anaerobic. Anaerobic metabolism (think strength training, intervals, or HIIT) can only be fueled by carbohydrates. Without carbs, high-intensity exercise cannot be maintained.


During this phase, it may be recommended to focus on lower intensity exercise as your body utilizes more fat as an energy source during this phase.

The Luteal Phase And Exercise

During the luteal phase, both estrogen and progesterone levels are high. A 2019 study suggests that bloating and fatigue are common symptoms that make exercise uncomfortable during this phase.


Heart rate and core body temperature may also increase during the luteal phase, which may alter performance when exercising in the heat and humidity.


Lastly, central nervous system fatigue is higher in this phase, and the increased progesterone levels can contribute to sodium loss. 


Considering all the above, it may be advisable to adjust training schedule to include more lower-intensity exercise during this phase while minimizing exercise in hot conditions.

The Bottom Line On Menstruation And Exercise

From the available research, knowing menstruation's effects (positive and negative) on exercise might help a woman develop a training program where certain performance variables are focused on during each phase.


For example:


  • During the early follicular phase, the focus should be on higher intensity, more prolonged duration cardio activities due to the body utilizing glycogen more efficiently. Strength training can also be done but should be conducted at a medium intensity as muscle recovery may be affected by the lower circulating estrogen levels.
  • Due to higher estrogen levels, the body is primed for intense strength and high-intensity interval training during the late follicular phase. 
  • During the ovulatory phase, estrogen levels peak and may affect the body’s ability to utilize muscle glycogen. Therefore, low-intensity training like long, slow cardio is recommended as the body uses more fat as fuel.
  • During the luteal phase, estrogen and progesterone levels increase. Exercise in hot, humid environments should be avoided. Low-intensity cardio and strength training should be the primary focus.


In addition to the above information, It is also recommended that women track their cycles and training and combine them to develop an individualized approach to exercise and nutrition. Certain apps like FitrWoman may help with this. 


References:

  • McNulty, K. L., Elliott-Sale, K. J., Dolan, E., Swinton, P. A., Ansdell, P., Goodall, S., ... & Hicks, K. M. (2020). The effects of menstrual cycle phase on exercise performance in eumenorrheic women: a systematic review and meta-analysis. Sports Medicine, 50(10), 1813-1827.
  • Dasa, M. S., Kristoffersen, M., Ersvær, E., Bovim, L. P., Bjørkhaug, L., Moe-Nilssen, R., ... & Haukenes, I. (2021). The female menstrual cycles’ effect on strength and power parameters in high-level female team athletes. Frontiers in Physiology, 12, 164.
  • de Jonge, X. A. (2003). Effects of the menstrual cycle on exercise performance. Sports medicine, 33(11), 833-851.
  • Thompson, B., & Han, A. (2019). Methodological recommendations for menstrual cycle research in sports and exercise. Medicine and science in sports and exercise, 51(12).

An Ounce of Prevention - Hyperion Health Blog

A woman is helping an older woman do exercises on an exercise ball in a gym.

What is a Kinesiologist?

By Jesse Oswald • January 29, 2025
What is a Kinesiologist?
A woman is wearing an oxygen mask while running on a treadmill.

Predicting Medical Costs with VO2max

By Jesse Oswald • January 20, 2025
Highlights Healthcare expenses are skyrocketing, with consumers and employers facing the significant brunt. Identifying those likely to get sick is critical as our resource-strapped healthcare system should focus on those likely to become the most significant burden to the system. VO2 max is a crucial longevity indicator that can also accurately predict healthcare expenses. The rampant chronic disease epidemic and the resulting surge in medical expenses is one of the most dire problems of modern societies, probably only second to climate change. Healthcare inflation is on a meteoric rise, and for those with limited or no healthcare coverage, a medical emergency is the equivalent of personal bankruptcy. A dire problem for employers In the US, employers and consumers who face rising health insurance premiums and astronomical out-of-pocket medical expenses feel the brunt of rising healthcare costs. Such is the problem that even large, well-capitalized corporations choose to send employees overseas for specific medical procedures since the cost of traveling and treatment in a foreign country is lower than the cost of care in the US. Another startling example is the infamous "northern caravan," a term that describes people with diabetes in the northern states who travel to Canada to secure their insulin supply. According to McKinsey , a survey conducted among over 300 employers highlighted that the average increase in the cost of health benefits over the past three years has been within the range of 6 to 7 percent. This survey also indicated that any rate increases exceeding 4 to 5 percent were deemed unsustainable. Interestingly, 95 percent of the surveyed employers expressed willingness to contemplate reducing benefits if costs surged by 4 percent or more. The primary cost-control measures that these employers indicated they might explore included elevating the portion of premium costs covered by employees and a potential transition to high-deductible health plans. Why is Breath Analysis relevant? Vis-a-vis this problem, the early and accurate estimation of who will get sick and how much they will cost is as critical as the treatment itself. The reason is that no other method of accurately identifying at-risk populations exists; it helps focus our scarce prevention resources and attention on those most in need. Breath analysis, AKA VO2max or metabolic testing, is an assessment that reveals two key biomarkers that provide significant predictive value for one's likelihood of developing costly chronic conditions. These two biomarkers are VO2max and the Respiratory Exchange Ratio. In this article, we will dive into VO2max to understand why it's a critical reflection of our overall health and, consequently, a window into our future healthcare spend. What is VO2max? Let's start with the basics. What is VO2max? VO2 max is the maximum amount of oxygen the human body can absorb. It is measured in terms of milliliters of oxygen consumed per kilogram of body weight. The below formula below indicates how VO2max is calculated: The numerator indicates the volume of oxygen your heart, lungs, and cells can absorb, expressed in milliliters per minute. The denominator indicates the weight of the individual represented in kilograms. 
There are many different types of fats in this picture.

Dietary Fat: An Essential Dietary Component Rather than the root of all Nutritional Health Issues

By Jesse Oswald • January 13, 2025
Key points A total fat intake between 20-35% ensures sufficient intake of essential fatty acids and fat-soluble vitamins Omega-6 PUFAs are primarily found in vegetable oils, while omega-3 PUFAs are primarily found in fatty fish and fish oils Both omega-3 PUFAs and MUFAs have established benefits for cardiovascular disease TFAs are the only dietary lipids that have a strong positive relationship with cardiovascular disease Omega-3 PUFA supplementation increases the beneficial bacteria of the human microbiome Over the last three decades, there has been a great revolution against fat due to its suspected association with several nutritional health issues, especially cardiovascular disease. There was a tremendous amount of evidence that indicated dietary cholesterol and saturated fat as the main culprits of cardiovascular disease, thus morbidity and mortality. It was when all the low-fat and no-fat dairy products started to launch, promising even complete substitution of the cholesterol-lowering heart medication if these products were exclusively consumed. Let’s start from the beginning. Dietary fat intake can vary significantly and still meet energy and nutrient needs. International guidelines suggest a total fat intake between 20% and 35% of the daily caloric consumption. This range ensures sufficient intake of essential fatty acids and fat-soluble vitamins. Not only does the quantity of the ingested fat matter, but most importantly, its quality. Some dietary fats have beneficial effects, with a significant role in maintaining good health, while others may threaten it. Which are, after all, the dietary fats? Dietary fats is a rather heterogeneous group of organic compounds, including four main types of fat, which are elaborately described in the following sections of this article. Polyunsaturated fatty acids (PUFAs) Polyunsaturated fatty acids (PUFAs) have two or more carbon-carbon double bonds. Omega-6 PUFAs and omega-3 PUFAs are the main types of PUFAs and are classified according to the location of the first unsaturated bond (sixth and third carbon atom, respectively). Alpha-Linolenic acid (ALA), docosahexaenoic acid (DHA), docosapentaenoic acid (DPA), and eicosapentaenoic acid (EPA) are the most important omega-3 PUFAs. ALA is an essential fatty acid that can only be obtained from diet and can be converted into EPA and then to DHA, but the rate of this conversion is finite, approximately 7.0%–21% for EPA and 0.01%–1% for DHA. In the same way, the most important omega-6 PUFAs are linoleic acid (LA) and arachidonic acid (ARA). LA is an essential fatty acid that, in order to give rise to ARA, needs to be ingested through the diet as the human body cannot synthesize it. The recommended intake for total PUFA ranges between 5% and 10% of the total energy intake, while a total omega-3 PUFA intake of 0.5%–2% and a total omega-6 PUFA intake of 2.5%-5% is suggested. A dietary ratio of omega−6/omega−3 PUFA is recommended to be 1:1–2:1 to balance their competing roles and achieve health benefits. Omega-6 and omega-3 PUFAs Omega-6 PUFAs, in the form of LA, are plentiful in most crop seeds and vegetable oils, such as canola, soybean, corn, and sunflower oils. In contrast to omega-6 PUFAs, omega-3 PUFAs are obtained from a limited range of dietary sources. Flax, chia, and perilla seeds are rich in ALA, with significant amounts also detected in green leafy vegetables. The consumption of fatty fish, such as salmon, sardines, tuna, trout, and herring, provides high amounts of EPA and DHA. Besides fish and their oils, small amounts of omega-3 PUFAs are also detected in red meat like beef, lamb, and mutton. All the above dietary sources provide EPA, DPA, DHA, LA, and ARA in different amounts, and their intake is necessary for normal physiological function. PUFAs play a critical role in many chronic diseases, affecting human cells by regulating inflammation, immune response, and angiogenesis. Omega-3 PUFAs’ role against hypertriglyceridemia has been clarified, and research indicates that systematically consuming oily fish can contribute to general heart protection. Supplementation with omega-3 PUFAs could potentially lower the risk of several cardiovascular outcomes, but the evidence is stronger for individuals with established coronary heart disease. Moreover, adequate EPA and DHA levels are necessary for brain anatomy, metabolism, and function. Although the mechanisms underlying omega-3 PUFAs' cardioprotective effects are still poorly understood, several studies have been conducted in this direction. Unfortunately, that does not hold true for their omega-6 counterparts, for which controversial emerging data tend to show anti-inflammatory behavior that needs to be further studied. Monounsaturated fatty acids (MUFAs) In contrast to PUFAs, monounsaturated fatty acids (MUFAs) are easily produced by the liver in response to the ingestion of carbohydrates. The main MUFA is oleic acid, found in plant sources, such as olive oil, olives, avocado, nuts, and seeds, while minimal amounts are also present in meat, eggs, and dairy products. Specific guidelines around MUFAs’ dietary consumption do not exist. Therefore, MUFAs are recommended to cover the remaining fat intake requirements to reach the total daily fat intake goal. A growing body of research shows that dietary MUFAs reduce or prevent the risk of metabolic syndrome, cardiovascular disease (CVD), and hypertension by positively affecting insulin sensitivity, blood lipid levels, and blood pressure, respectively. Moreover, olive oil contains several bioactive substances, possessing anti-tumor, anti-inflammatory, and antioxidant qualities. According to a meta-analysis, consuming olive oil was linked to a lower risk of developing any sort of cancer, especially breast cancer and cancer of the digestive system. Another study found that an isocaloric replacement of 5% of the energy from saturated fatty acids (SFAs) with plant MUFAs led to an 11% drop in cancer mortality over a 16-year follow-up period. Therefore, including MUFAs in the everyday diet offers multifaceted benefits in chronic disease prevention and management, including cancer and general health promotion.  Saturated fatty acids (SFAs) Saturated fatty acids (SFAs) form a heterogeneous group of fatty acids that contain only carbon-to-carbon single bonds. Whole-fat dairy, (unprocessed) red meat, milk chocolate, coconut, and palm kernel oil are all SFA-rich foods. These fatty acids have distinct physical and chemical profiles and varying effects on serum lipids and lipoproteins. Stearic, palmitic, myristic, and lauric acids are the principal SFAs found in most natural human diets. Dietary practice and guidelines recommend limiting SFA intake to <10% of the total energy (E%), while the American Heart Association suggests an even lower intake of <7 E% because total saturated fat consumption and LDL-C levels are positively correlated. However, the role of SFAs in CVDs is quite complex, and the evidence is heterogeneous. In a recent study with a 10.6-year follow-up period, which included 195,658 participants, there was no proof that consuming SFAs was linked to developing CVD while replacing saturated fat with polyunsaturated fat was linked to an increased risk of CVD. Moreover, according to 6 systematic reviews and meta-analyses, cardiovascular outcomes and total mortality were not significantly impacted by substituting saturated fat with polyunsaturated fat. Even if these analyses were to be challenged, due to heterogenous evidence, the possible reduction in CVD risk associated with replacing SFAs with PUFAs in several studies may not necessarily be an outcome of SFAs’ negative effect but rather a potential positive benefit of PUFAs. Regarding SFAs' effect on different types of cancers, associations of their intake with an increased risk of prostate and breast cancer have been indicated. Conversely, a meta-analysis showed no link between SFA intake and a higher risk of colon cancer; similarly, consuming MUFAs, PUFAs, or total fat did not affect colon cancer risk. Hence, the role of SFA consumption in preventing, promoting, or having a neutral role in serious chronic diseases has not been fully elucidated yet. Trans fatty acids (TFAs) Trans fatty acids (TFAs) are created industrially by partially hydrogenating liquid plant oils or can be naturally derived from ruminant-based meat and dairy products. TFAs are highly found in commercial baked goods, biscuits, cakes, fried foods, etc. Guidelines regarding TFAs are stringent and limit TFA intake to <1% of energy or as low as possible. In 2015, the US Food and Drug Administration declared that industrial TFAs are no longer generally recognized as safe and should be eliminated from the food supply as their consumption is strongly linked to various CVD risk factors. Specifically, TFA intake raises triglycerides and increases inflammation, endothelial dysfunction, and hepatic fat synthesis, leading to a significantly increased risk of coronary heart disease (CHD). A meta-analysis suggested that increased TFA intake led to an increase in total and LDL-cholesterol and a decrease in HDL-cholesterol concentrations. Data also indicates that TFAs may influence carcinogenesis through inflammatory pathways, but the reported data are debatable. A recent study investigated the effects of all types of dietary fat intake on CVD risk. While PUFA, MUFA, and SFA intake were not linked to higher CVD risk, dietary TFA intake showed a strong association with CVD risk. Analysis indicated PUFA intake and CVD risk were inversely correlated, and the relative risk of CVD was reduced by 5% in studies with a 10-year follow-up. Dietary lipids and the human microbiome Dietary lipids also affect human microbiota composition. Studies have identified a close association between the human microbiome and metabolic diseases, including obesity and type 2 diabetes. Diets with a high omega-6 PUFA, SFA, and TFA intake increase the amount of many detrimental bacteria in the microbiome and reduce the amount of the beneficial ones, altering the microbiota composition and inducing inflammation via the secretion of pro-inflammatory cytokines. These bacteria may disrupt the gut barrier function, allowing lipopolysaccharides (LPS) translocation, which are bacterial toxins. This condition is linked to metabolic perturbations such as dyslipidemia, insulin resistance, non-alcoholic fatty liver disease (NAFLD), and CVD. On the contrary, omega-3 PUFA (EPA and DHA) supplementation increases beneficial bacteria and limits harmful ones, enhancing intestinal barrier functioning and preventing LPS translocation and its implications. Omega-3 PUFA supplementation has also been studied as a means of mental health disorders management, but the evidence is still controversial. A possible protective impact of fish consumption on depression has been suggested by various studies, as well as a possible protective effect of dietary PUFAs on moderate cognitive impairment. A recent review of meta-analyses indicated that omega-3 PUFA supplementation might have potential value in mental health disorders, but data credibility is still weak. Dietary lipids and obesity Last but not least, obesity and its management is another field that dietary lipids intake seems to impact with their mechanisms. A diet high in PUFA has been shown to lower the total mass of subcutaneous white adipose tissue (the predominant fat type in human bodies), reduce blood lipid levels, and improve insulin sensitivity. In a study comparing PUFA and MUFA isocaloric intake, PUFA was more advantageous and lowered visceral adiposity in patients with central obesity. By stimulating brown adipose tissue, which aids energy expenditure through its elevated thermogenic activity, omega-3 PUFAs seem to elicit these positive effects in fat tissue, thus being useful in preventing and/or managing obesity. Another related study compared PUFA to SFA overfeeding in dietary surplus conditions that aimed to increase weight by 3%. While SFA overfeeding led to weight gain, primarily through the expansion of the visceral adipose tissue, PUFA overfeeding also led to weight gain, but because of a greater expansion of lean tissue mass. To sum up, dietary fats are an essential part of the human diet with many important physiologic functions, including cell function, hormone production, energy, and nutrient absorption. Moreover, dietary fat consumption is associated with positive outcomes in regard to cardiovascular disease, metabolic syndrome, cancer, and depression. Therefore, there is no reason to demonize this valuable dietary component, incriminating it for irrelevant adverse health outcomes, primarily weight loss failure and obesity. References 1. Astrup A, Magkos F, Bier DM, Brenna JT, de Oliveira Otto MC, Hill JO, King JC, Mente A, Ordovas JM, Volek JS, Yusuf S, Krauss RM. Saturated fats and health: A reassessment and proposal for food-based recommendations: JACC State-of-the-Art review. J Am Coll Cardiol. 2020;76(7):844-857. DOI: 10.1016/j.jacc.2020.05.077 2. Bojková B, Winklewski PJ, Wszedybyl-Winlewska M. Dietary fat and cancer-Which is good, which is bad, and the body of evidence. Int J Mol Sci. 2020;21(11):4114. DOI: 10.3390/ijms21114114 3. Custers, Emma EM, Kiliaan, Amanda J. Dietary lipids from body to brain. Prog Lipid Res. 2022;85:101144. DOI: 10.1016/j.plipres.2021.101144 4. de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, Uleryk E, Budylowski P, Schünemann H, Beyene J, Anand SS. Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies. BMJ. 2015;351:h3978. DOI: 10.1136/bmj.h3978 5. Gao X, Su X, Han X, Wen X, Cheng C, Zhang S, Li W, Cai J, Zheng L, Ma J, Liao M, Ni W, Liu T, Liu D, Ma W, Han S, Zhu S, Ye Y, Zeng F-F. Unsaturated fatty acids in mental disorders: An umbrella review of meta-analyses. Adv Nutr. 2022;13(6):2217-2236. DOI: 10.1093/advances/nmac084 6. Liu AG, Ford NA, Hu FB, Zelman KM, Mozaffarian D, Kris-Etherton PM. A healthy approach to dietary fats: understanding the science and taking action to reduce consumer confusion. Nutr J. 2017;16(1):53. DOI: 10.1186/s12937-017-0271-4 7. Poli A, Agostoni C, Visioli F. Dietary fatty acids and inflammation: Focus on the n-6 series. Int J Mol Sci. 2023;24(5):4567. DOI: 10.3390/ijms24054567 8. Saini RK, Keum Y-S. Omega-3 and omega-6 polyunsaturated fatty acids: Dietary sources, metabolism, and significance-A review. Life Sci. 2018;203:255-267. DOI: 10.1016/j.lfs.2018.04.049 9. Saini RK, Prasad P, Sreedhar RV, Naidu KA, Shang X, Keum Y-S. Omega-3 polyunsaturated fatty acids (PUFAS): Emerging plant and microbial sources, oxidative stability, bioavailability, and health benefits-A review. Antioxidants (Basel). 2021;10(10):1627. DOI: 10.3390/antiox10101627 10. Zhao M, Chiriboga D, Olendzki B, Xie B, Li Y, McGonigal LJ, Maldonado-Contreras A, Ma Y. Substantial increase in compliance with saturated fatty acid intake recommendations after one year following the American Heart Association diet. Nutrients. 2018;10(10):1486. DOI: 10.3390/nu10101486 11. Zhu Y, Bo Y, Liu Y. Dietary total fat, fatty acids intake, and risk of cardiovascular disease: a dose-response meta-analysis of cohort studies. Lipids Health Dis. 2019;18:91. DOI: 10.1186/s12944-019-1035-2
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