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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EOur preference for sweetness is not new, but over the past 20 years there has been a remarkable increase in the consumption of refined sugars around the globe. Of particular interest to anyone interested in cardiometabolic risk is the fact that the growing use of high-fructose corn syrup between 1970 and 1990 has paralleled the rising trend of the prevalence of obesity.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiometabolic Disorder\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENursing\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EOur preference for sweetness is not new, but over the past 20 years there has been a remarkable increase in the consumption of refined sugars around the globe. Of particular interest to anyone interested in cardiometabolic risk is the fact that the growing use of high-fructose corn syrup between 1970 and 1990 has paralleled the rising prevalence of obesity in the period between 1970 and 2000 [Bray GA. CMR\u003Cem\u003Ee\u003C\/em\u003Ejournal. \u003Ca href=\u0022http:\/\/www.cardiometabolic-risk.org\/cmrejournal\/\u0022\u003Ehttp:\/\/www.cardiometabolic-risk.org\/cmrejournal\/\u003C\/a\u003E].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe main source of this increase in refined sugar consumption has been from sugar-sweetened beverages, including soft drinks, fruit drinks, energy drinks, and vitamin and other functional beverage waters (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). \u201cFor reasons that we do not fully understand,\u201d said Barry Popkin, PhD, University of North Carolina, Chapel Hill, NC, \u201chumans do not reduce food intake when we consume calorie-containing liquids.\u201d Thus, this lack of compensation for caloric intake creates a shift in our net energy balance that plays a major role in the global increase in abdominal obesity and metabolic conditions [Wolf A et al. \u003Cem\u003EObes Rev\u003C\/em\u003E 2008]. This effect is worsened when combined with an accelerated shift toward inactivity and poor diet.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Relative Contribution of Sugar from Desserts, Fruit Drinks, and Soda: 1965 to 2004.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-637699656\u0022 data-figure-caption=\u0022Relative Contribution of Sugar from Desserts, Fruit Drinks, and Soda: 1965 to 2004.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11448\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ERelative Contribution of Sugar from Desserts, Fruit Drinks, and Soda: 1965 to 2004.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ESource: Duffy KJ \u0026amp; Popkin BM. \u003Cem\u003EAm J Clin Nutr\u003C\/em\u003E 2008;88(Suppl):1722S.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EAs with tobacco, sugar-sweetened beverages are associated with no health benefits and high health costs. A few countries, most notably Mexico, are attempting to shift beverage consumption back to healthier options through taxation. Other countries have banned vending machines from schools, and from media to which children and teens are exposed. There is evidence that such programs work, especially when combined with the provision of inexpensive healthy alternatives, such as potable water.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThe deleterious effects of overconsumption of sugar-sweetened beverages have been well documented. In a study that examined the metabolic effects of fructose in healthy men (n=8) and women (n=8), Couchepin and colleagues found that short-term (6 days) fructose overfeeding produces significant (p\u0026lt;0.05) increases in fasting triglyceride levels (71% increase), endogenous glucose production (12%), alanine aminotransferase (38%), and fasting insulin concentrations (14%) in men. The effects were less pronounced in women, although significant (p\u0026lt;0.05) changes were observed in fasting glucose (4%) and triglycerides (16%). The investigators suggested either that the difference in response was related to the effect of estrogen on fructose metabolism or that women may remove triglyceride-rich particles from circulation more efficiently than men [Couchepin C et al. \u003Cem\u003EDiab Care\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EWhen Raben and colleagues investigated the role of artificial sweeteners in body weight regulation, they found that overweight subjects (n=21) who consumed fairly high levels of sucrose, mostly as beverages, had increased total energy (by 1.6 MJ\/d), body weight (1.6 kg), fat mass (1.3 kg), and blood pressure (3.8 mm Hg and 4.1 mm Hg, systolic and diastolic, respectively) after 10 weeks. These effects were not observed in a similar group of subjects who consumed artificial sweeteners (n=20) [Raben. \u003Cem\u003EAm J Clin Nutr\u003C\/em\u003E 2002]. A further analysis of data from this study showed increases in several markers of inflammation in the sucrose group (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Sorensen LB et al. \u003Cem\u003EAm J Clin Nutr\u003C\/em\u003E 2005].\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11454\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11454\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11454\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EChanges in Concentrations of Inflammatory Markers Associated with Sugar-Sweetened Beverages.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EOf particular relevance to the metabolic syndrome, fructose appears to have a much greater effect on increases in visceral fat than other sugars [Stanhope KL et al. \u003Cem\u003EJ Clin Invest\u003C\/em\u003E 2009]. Other studies have shown a potential connection between the consumption of soft drinks and gout [Choi HK \u0026amp; Curhan G. \u003Cem\u003EBMJ\u003C\/em\u003E 2008], as well as diabetes and the metabolic syndrome [Johnson RJ et al. \u003Cem\u003EEndocr Rev\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EAfter reviewing the literature, Dr. Bray said he has concluded that, \u201cIn the amounts now ingested, fructose is hazardous to the health of some people.\u201d\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003ESoft drinks are an important source of glycemic load in the diet of United States residents, and epidemiological studies have reported that a higher glycemic load, especially combined with low intake of cereal fiber, significantly elevates long-term risk of type 2 diabetes and coronary heart disease (CHD) [Hu FB \u0026amp; Willett WC. \u003Cem\u003EJAMA\u003C\/em\u003E 2002].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EEight-year data from the Nurses\u0027 Health Study II showed that increased consumption of sugar-sweetened beverages was associated with a significant (p\u0026lt;0.001) trend for an increased risk for diabetes, regardless of whether the data were controlled for body mass index (BMI; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Schulze MB et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2004]. These results suggest that the detrimental effects of soft drinks on type 2 diabetes are not completely mediated through energy balance or body weight.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Sugar-Sweetened Soft Drinks and Type 2 Diabetes; Data from the Nurses\u0027 Health Study II for 1991 to 1998.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-637699656\u0022 data-figure-caption=\u0022Sugar-Sweetened Soft Drinks and Type 2 Diabetes; Data from the Nurses\u0027 Health Study II for 1991 to 1998.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/5\/26\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11451\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ESugar-Sweetened Soft Drinks and Type 2 Diabetes; Data from the Nurses\u0027 Health Study II for 1991 to 1998.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003ESource: Adapted from Schulze MB. \u003Cem\u003EJAMA\u003C\/em\u003E 2004;292:927.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EData from the Black Women\u0027s Health study also showed a significant relationship between sugar-sweetened soft drink consumption and the risk for diabetes among 43,960 African-American women who were followed from 1995 to 2001 [Palmer JR et al. \u003Cem\u003EArch Int Med\u003C\/em\u003E 2008]. There were 2713 incident cases of type 2 diabetes during the follow-up period. The RR (adjusted for confounding variables) for \u22652 soft drinks\/day was 1.24 (95% CI, 1.06 to 1.45) and 1.31 (95% CI, 1.13 to 1.52) for fruit drinks. The association of diabetes with soft drinks was primarily mediated by BMI; the fruit drink association was independent of body weight.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EUsing data from the Framingham Heart Study, Dhingra and colleagues found that in middle-aged adults, consumption of \u22651 soft drink\/day is associated with increased odds of developing metabolic syndrome (OR, 1.44; 95% CI, 1.20 to 1.74), obesity (OR, 1.31; 95% CI, 1.02 to 1.68), increased waist circumference (OR, 1.30; 95% CI, 1.09 to 1.56), impaired fasting glucose (OR, 1.25; 95% CI, 1.05 to 1.48), higher blood pressure (OR, 1.18; 95% CI, 0.96 to 1.44), hypertriglyceridemia (OR, 1.25; 95% CI, 1.04to1.51), and low high-density lipoprotein cholesterol (OR, 1.32; 95% CI, 1.06 to 1.64) [Dhingra R et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EIn a recent study, women from the Nurses\u0027 Health Study (n=88,520) were followed for 24 years (1980 to 2004), during which time there were 3105 incident cases of CHD. Regular soft drink consumption was shown to be associated with a significantly (p for trend \u0026lt;0.001) increased risk of CHD, even after adjusting for unhealthy lifestyle or dietary factors (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E). Additional adjustments for BMI, energy intake, and incident diabetes attenuated the associations, but they remained significant. Artificially sweetened beverages were not associated with CHD [Fung TT \u003Cem\u003EAm J Clin Nutr\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11458\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11458\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11458\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-17\u0022 class=\u0022first-child\u0022\u003ERelative Risk for CHD Based on Sugar-Sweetened Beverage Consumption.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-18\u0022\u003E\u201cThe detrimental effects of sugar-sweetened beverages stem from both increased caloric intake and glycemic load,\u201d said Dr. Hu.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003ECommenting on the presentations, Jean-Pierre Despr\u00e9s, PhD, Scientific Director, International Chair on Cardiometabolic Risk, said, \u201cA robust action plan should be put into place to battle the epidemic of obesity underlying the huge prevalence of type 2 diabetes that is limiting our ability to successfully combat cardiovascular disease. Although the question is complex, it would appear that a focus on limiting the consumption of sugar-sweetened beverages may represent a simple initial step to reduce caloric intake and help to prevent or manage obesity and its related complications.\u201d\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/5\/26.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmic1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmic1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmic1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}