Phenomics, genomics of oil palm (Elaeis guineensis Jacq.): way forward for making sustainable and high yielding quality oil palm.

Oil palm (Elaeis guineensis Jacq.) is a heterogeneous, perennial crop having long breeding cycle with a genome size of 1.8 Gb. The demand for vegetable oil is steadily increasing, and expected that nearly 240-250 million tons of vegetable oil may be required by 2050. Genomics and next generation technologies plays crucial role in achieving the sustainable availability of oil palm with good yield and high quality. A successful breeding programme in oil palm depends on the availability of diverse gene pool, ex-situ conservation and their proper utilization for generating elite planting material. The major breeding methods adopted in oil palm are either modified recurrent selection or the modified reciprocal recurrent selection method. The QTLs of yield and related traits are chiefly located on chromosome 4, 10, 12 and 15 which is discussed in the current review. The probable chromosomal regions influencing the less height increment is observed to be on chromosomes 4, 10, 14 and 15. Advanced genomic approaches together with bioinformatics tools were discussed thoroughly for achieving sustainable oil palm where more efforts are needed. Major emphasis is given on oil palm crop improvement using holistic approaches of various genomic tools. Also a road map given on the milestones in the genomics and way forward for making oil palm to high yielding quality oil palm.

Genome-wide association study (GWAS) of major QTLs for bunch and oil yield related traits in Elaeis guineensis L.

Oil palm (Elaeis guineensis Jacq.) is a long breeding cycle perennial crop with a genome size of 1.8 Gb. This is the first report of GWAS on large number of 310 African germplasm using 400 SSR markers till date. Highly significant correlation was found between leaf area (LA) and rachis length (RL) (0.75) followed by bunch weight (BW) and bunch index (BI) (0.65), whereas negative correlation was observed between bunch number (BN) and average bunch weight (ABW). First two principal component analysis (PCA) together explained maximum amount of variation (84.5 %). The PCA1 revealed that group 2 (Guinea Bissau and Cameroon) and group 4 (Zambia and Cameroon) genotypes are best suitable for BN, BI and BW traits. GWAS of six bunch yield and seven bunch oil yield traits with SSRs resulted in the identification 43 significant quantitative trait loci (QTLs) by mixed linear model (MLM) approach. Seven SSR loci were found to be linked to oil to dry mesocarp (ODM) on chromosomes 1,4,7,10,12 and 15. The SSR locus mEgCIR1753 for ODM was significantly linked at a p of ≤0.05 which explained 34.6 % of phenotypic variance. The important parameters like ODM, OWM and OB were located on 4, 10, 11 and 15 chromosomes. The leaf area and ODM were associated with candidate genes representing of low-temperature-induced 65 kDa proteins. The identified markers can be effectively used for marker assisted selection of high yielding oil palm genotypes.

Identification of QTLs in oil palm (Elaeis guineensis Jacq.) using SSR markers through association mapping.

Oil palm (Elaeis guineensis Jacq.) is a perennial vegetable and a high oil-yielding crop (4-6 t/ha). There is a large scope for increasing the oil yield by selecting elite planting material for breeding programme in germplasm evaluation, characterization and utilization. In the present study, a diverse range of 150 oil palm genotypes were characterized using 12 quantitative variables with 54genomic microsatellite markers. A wide variation was observed in the morphological traits among indigenous populations. Highly significantand positive correlations were observed between vegetative dry matter (VDM) and total dry matter (TDM) (0.862), and height and height increment (0.838). The first two principal component analyses explained 67.7% of total variation among morphological traits. The genotypes IC0610001-59 (Pune-2) and IC0610001-60 (Pune-2) were found highly promising based on less height increment, more TDMwith high yield. For the mapping study, general linear model (GLM) approach, quantitative-trait loci (QTL) for annual height increment, number of bunches, bunch yield and bunch index were linked to simple-sequence repeat (SSR) loci mEgCIR3649 with phenotypic variance of 15.08, 10.43, 11.74, 15.39. TDM and VDM were linked to mEgCIR0192 (27.34 and 24.19%), mEgCIR3684 (16.84 and 18.30%), SPSC00163 (18.8 and 15.39%) and mEgCIR0555 (16.47 and 18.81%), with at a significant threshold (P) level of B0.001 and by mixed linear model (MLM) approach. TDM was linked to mEgCIR0555 with phenotypic variance of 20.72%, bunch yield and bunch index were linked to mEgCIR2813 at phenotypic variance of 17.11% and 12.88%, respectively, at a significant threshold (P) level of B0.01.

Genome wide association study (GWAS) and identification of candidate genes for yield and oil yield related traits in oil palm (Eleaeis guineensis) using SNPs by genotyping-based sequencing.

The genotyping-based sequencing (GBS) method used for GWAS of four yield and seven oil yield related traits on highly diverse African oil palm germplasm. GBS generated 325 million-reads covering 50.78Gb of sequence data, with an average of 3.4 million-reads per sample. Finally, 4031 fully informative SNPs with a range between 157 on chromosome 15 to 455 on chromosome 1 were used for GWAS. Association mapping resulted in identification of 40 highly significant loci, where more genetic loci were found to be associated with oil to bunch (OB), followed by average bunch weight (ABW). The loci, SGI|593,593|linked to QTNOB3 explained high amount of phenotypic variance (25.3%). The nucleotide sequences of linked genetic loci for OB were found to be similar to mitogen activated protein kinase-5 (MAPK-5) protein which is an early flowering protein. The significant loci identified can be used to select desirable palms at early stage through marker assisted selection.

Genome-wide association study for leaf area, rachis length and total dry weight in oil palm (Eleaeisguineensis) using genotyping by sequencing.

The marker-trait association for complex traits using genotyping by sequencing (GBS) method is being widely spread in plants. The study aimed to identify significant single nucleotide polymorphism (SNP) associations for rachis length (RL), leaf area (LA) and total dry weight (TrDW) in oil palm among diverse African germplasm. The Illumina NextSeq platform has been used for SNP genotyping and retained 4031 fully informative SNPs after applying the filter criterion. These 4031 SNPs were used for genome wide association study for the above three traits. The LD decay rates of the African germplasm using GBS data of SNP is observed to be 25 Kb at 0.45 of average pair wise correlation coefficient (r2). Association mapping led to the identification of seven significant associations for three traits using MLM approach at a P value of ≤ 0.001. Three associations were identified for total dry weight, two each for leaf area index and rachis length. The qtlLA1 was found to be highly significant at a P value of 7.39E-05 (18.4% phenotypic variance) which is located on chromosome 4. Two QTLs (qtlLA2 and qtlRL1) were located on chromosome 1, which explained 11.9% and 12.4% of phenotypic variance respectively. Three QTLs for total dry weight were located on chromosome 2, 14 and 16, all-together explained 40% phenotypic variance. The results showed that the SNP-trait associations identified in the present study could be used in selection of elite oil palm germplasm for higher yields.

Development and validation of whole genome-wide and genic microsatellite markers in oil palm (Elaeis guineensis Jacq.): First microsatellite database (OpSatdb).

The availability of large expressed sequence tag (EST) and whole genome databases of oil palm enabled the development of a data base of microsatellite markers. For this purpose, an EST database consisting of 40,979 EST sequences spanning 27 Mb and a chromosome-wise whole genome databases were downloaded. A total of 3,950 primer pairs were identified and developed from EST sequences. The tri and tetra nucleotide repeat motifs were most prevalent (each 24.75%) followed by di-nucleotide repeat motifs. Whole genome-wide analysis found a total of 245,654 SSR repeats across the 16 chromosomes of oil palm, of which 38,717 were compound microsatellite repeats. A web application, OpSatdb, the first microsatellite database of oil palm, was developed using the PHP and MySQL database ( https://ssr.icar.gov.in/index.php ). It is a simple and systematic web-based search engine for searching SSRs based on repeat motif type, repeat type, and primer details. High synteny was observed between oil palm and rice genomes. The mapping of ESTs having SSRs by Blast2GO resulted in the identification of 19.2% sequences with gene ontology (GO) annotations. Randomly, a set of ten genic SSRs and five genomic SSRs were used for validation and genetic diversity on 100 genotypes belonging to the world oil palm genetic resources. The grouping pattern was observed to be broadly in accordance with the geographical origin of the genotypes. The identified genic and genome-wide SSRs can be effectively useful for various genomic applications of oil palm, such as genetic diversity, linkage map construction, mapping of QTLs, marker-assisted selection, and comparative population studies.

Development, identification and validation of CAPS marker for SHELL trait which governs dura, pisifera and tenera fruit forms in oil palm (Elaeis guineensis Jacq.).

The oil palm fruit forms (dura, pisifera and tenera) governed by the shell thickness gene (Sh) plays a major role in identification of fruit type and also influences palm oil yield. Identification of desired fruit type is a major asset to the breeders and oil palm workers for applications in breeding, seed certification and to reduce time, space and money spent on identification of fruit form. In the present study, we developed Sh gene specific primer pairs and bulk segregant analysis was done using 300 genomic and 8 genic SSR markers. We identified one cleaved amplified polymorphic site (CAPS) marker for differentiation of oil palm fruit type which produced two alleles (280 and 250bp) in dura genotypes, three alleles in tenera genotypes (550, 280, and 250bp) and one allele in pisifera genotypes (550bp). The shell allele sequencing results showed that two SNPs were present, of which SNP2 contributed for variation of fruit forms. The nucleotide 'A' was present in only dura genotypes, where as 'T' was present only in pisifera genotypes, which in turn led to the change of amino acid lysine to aspargine. The identified CAPS marker was validated on 300 dura, 25 pisifera and 80 tenera genotypes, 80 dura/ pisifera cross progenies and 60 lines of tenera/ tenera cross progeny. Association mapping of marker data with phenotypic data of eight oil yield related traits resulted in identification of seven significant QTLs by GLM approach, four by MLM approach at a significant threshold (P) level of 0.001. Significant QTLs were identified for fruit to bunch and oil to bunch traits, which explained R2 of 12.9% and 11.5% respectively. The CAPS marker used in the present study facilitate selection and timely distribution of desirable high yielding tenera sprouts to the farmers instead of waiting for 4-5 years. This saves a lot of land, time and money which will be a major breakthrough to the oil palm community.

Low-level laser therapy as an adjunct to conventional therapy in the treatment of diabetic foot ulcers.

Foot ulcers are serious complications of diabetes mellitus (DM) and are known to be resistant to conventional treatment. This study was conducted to evaluate the efficacy of low-level laser therapy (LLLT) for the treatment of diabetic foot ulcers in a tertiary care centre (Department of Surgery, Mahatma Gandhi Memorial Medical College and Maharaja Yashwantrao Hospital, A.B. Road, Indore). A total of 30 patients with type 2 DM having Meggitt-Wagner grade I foot ulcers of more than 6 weeks duration with negative culture were studied. Patients were randomized into two groups of 15 each. Patients in study group received LLLT (660 ± 20 nm, 3 J/cm2) along with conventional therapy and those in control group were treated with conventional therapy alone. The primary outcome measure was the absolute and relative wound size reduction at 2 weeks compared to the baseline parameter. Percentage ulcer area reduction was 37 ± 9% in the LLLT group and 15 ± 5.4% in the control group (p < 0.001). For ∼75% of wounds of the treatment group, wound area reduction of 30-50% was observed. In contrast, for the control group, ∼80% of wounds showed a wound area reduction of <20% on day 15. Further, the wounds with initial wound area 1000-2000 mm2 seems to have better final outcome than the groups with larger areas. The treated groups showed higher amount of granulation than the control group. The results suggest that LLLT is beneficial as an adjunct to conventional therapy in the treatment of diabetic foot ulcers.

Epidemiological trends of pediatric trauma: A single-center study of 791 patients.

AIM: To assess the various epidemiological parameters that influence the causation of trauma as well as the consequent morbidity and mortality in the pediatric age group. MATERIALS AND METHODS: A prospective study of 791 patients of less than 12 years age, was carried out over a period of 1 year (August 2009 to July 2010), and pediatric trauma trends, with regards to the following parameters were assessed: Age group, sex, mode of trauma, type of injury, place where the trauma occurred and the overall mortality as well as mortality. RESULTS: Overall trauma was most common in the school-going age group (6-12 years), with male children outnumbering females in the ratio of 1.9:1. It was observed that orthopedic injuries were the most frequent (37.8%) type of injuries, whereas fall from height (39.4%), road traffic accident (27.8%) and burns (15.2%) were the next most common modes of trauma. Home was found out to be the place where maximum trauma occurred (51.8%). Maximum injuries happened unintentionally (98.4%). Overall mortality was found out to be 6.4% (n = 51). CONCLUSIONS: By knowing the epidemiology of pediatric trauma, we conclude that majority of pediatric injuries are preventable and pediatric epidemiological trends differ from those in adults. Therefore, preventive strategies should be made in pediatric patients on the basis of these epidemiological trends.

A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture.

OBJECTIVE: To compare the intensity of pain and duration of return to normal activity in patients with rib fractures treated with surgical stabilization with plating versus conventional treatment modalities. PATIENTS AND METHODS: This study was conducted over a 12 month period. Patients with rib fractures were assessed by numerical pain scale. Patients having pain scale less than 5 were excluded from study. Patients having pain scale of 5 or more than 5 were treated with conventional treatment for next 10 days. On 11th day patients were again assessed by numerical pain scale and patients having score less than 5 were excluded from study. Patients having pain scale of 5, 6, and 7 were treated with conventional treatment and patients having pain scale of 8, 9, and 10 were selected for operative management. Operative and control group were compared on basis of intensity of pain and duration of return to normal activity. Follow up was done on 5, 15, and 30 post operative day. RESULTS: There was less pain in operative group as compared to control group. Mean rib fracture pain in operative group was 9.15, 2.31, 1.12 as compared to 6.25, 5.96, 4.50 in control group on 5, 15 and 30 post operative days. Also there was early return to normal activity in operative group. CONCLUSION: Surgical stabilization of rib fracture, an underutilized intervention is better than conventional conservative management in terms of both, decrease in intensity of pain and early return to normal activity.

Tube sigmoidostomy: a valuable alternative to sigmoidopexy for sigmoid volvulus.

OBJECTIVE: To compare the effectiveness of tube sigmoidostomy and sigmoidopexy as effective treatment options for patients with acute uncomplicated sigmoid volvulus. METHODS: The records of 72 patients with acute uncomplicated sigmoid volvulus with obstruction who were treated by tube sigmoidostomy (Group I: n=32) and sigmoidopexy (Group II: n=40) were reviewed retrospectively. Follow-up period was 22 months (range: 6-51 months). RESULTS: Results show significant improvement in postoperative tachycardia, respiratory distress and urine output in Group I patients as compared to those in Group II. Most of the clinical parameters of Group I patients normalized by day 3, while it took up to 7 days in Group II patients. Intraabdominal hypertension caused by persistent colonic dilatation after sigmoidopexy was found to be an important determinant of postoperative morbidity. As compared to tube sigmoidostomy, the sigmoidopexy group had delayed recovery, more chances of abdominal fascial dehiscence, and longer hospital stay, as well as more prolonged abdominal discomfort, constipation, and recurrent volvulus rates during follow-up. CONCLUSION: Tube sigmoidostomy provides both fixation and decompression of the redundant sigmoid colon in the postoperative period while allowing time to recover from massive dilatation and edema caused by prolonged volvulus. Compared with sigmoidopexy for the treatment of uncomplicated sigmoid volvulus, tube sigmoidostomy leads to lesser rates of morbidity and recurrence. Thus, it can be considered as a definitive alternative treatment option for uncomplicated sigmoid volvulus.

Total urogenital sinus mobilization in common cloaca: experience of 25 cases.

OBJECTIVE: Common cloaca is a complex anorectal and genitourinary malformation in which the rectum, vagina and urinary tract are fused to form a single channel. Surgical treatment is complicated especially when the channel is long. Our aim was to emphasize the importance of joint mobilization of the urogenital sinus after separation from the rectum. This maneuver avoids separation of the urinary tract from the genital tract, and reduces operating time by more than 60%. The functional and cosmetic results are also excellent. PATIENTS AND METHODS: We retrospectively reviewed all consecutive cases of persistent cloaca managed by total urogenital mobilization via a posterior sagittal approach during 2005-2009. There were 25 patients, with a median age of 18 months (10 months-3 years). Two patients with a long common channel required additional maneuvers after mobilization to complete the reconstruction. Each patient had a primary covering colostomy. After distal loop colograms, genitograms, renal ultrasound and genitoscopy, patients were planned for definitive surgery at 1-3 years of age. CONCLUSION: Total urogenital sinus mobilization in cases of common cloaca represents a surgical advance, and is a promising procedure with reasonably good results for this complex anomaly.

Paediatric pancreatic problems: a five-year experience.

BACKGROUND: To analyse a tertiary care experience with various pancreatic problems in the paediatric age group and clarify the frequency of various pancreatic diseases in the same patient population as well as the role of surgical or conservative management in their treatment. PATIENTS AND METHODS: All patients with clinical suspicion of disease pertaining to the pancreas, substantiated by laboratory investigations or imaging modalities over a period of five years are included in our study. RESULTS: Of the total 228 patients with various pancreatic problems, who presented to us, mostly with acute pancreatitis and pancreatic trauma, 64 needed surgical interventions. The total mortality rate encountered was a meagre 3.5%. CONCLUSION: Paediatric pancreatic disorders are not so infrequent; and a high index of suspicion aided by the newer modalities of investigation greatly helps in the appropriate and timely management.

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients.

To compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: 'honey group' and 'SSD group'. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Treatment of keloids and hypertrophic scars using bleom.

BACKGROUND: Numerous treatments have been attempted with unsatisfactory results using either single or combination modalities for treatment of keloids and hypertrophic scars. The aim of our study was to determine the effectiveness and safety of bleomycin in the treatment of hypertrophic scars and keloids. METHODS: This study included 50 patients with keloids and hypertrophic scars. Bleomycin was administered through multiple superficial puncture technique. Three applications were given at intervals of 15 days each, followed by a fourth and final application 2 months after the last application. Final results were read 2 months after the last application. Results were evaluated according to change in size as follows: Group Response. a. Complete flattening (100% regression). b. Significant flattening (75-99% regression). c. Adequate flattening (50-74% regression). d. Inadequate flattening (less than 50%). Patients were assessed for any complication of bleomycin (systemic as well as local) and recurrence of keloids and hypertrophic scars. Regular follow-up for side-effects was done for 18 months. RESULTS: Out of 50 patients, complete flattening was observed in 22 cases (44%); significant flattening in 11 cases (22%); and adequate flattening was observed in 7 cases (14%). Only 10 cases (20%) did not show any satisfactory flattening. Pruritus was relieved completely in 40 patients (88.88%). Recurrence was seen in seven patients. CONCLUSION: Bleomycin is easy to administer, is cheap, shows high regression rate, and has minimum complication and recurrence. Thus, it can be used as the first-line treatment modality for management of keloids and hypertrophic scars.

Estimation of BCL-2 protein in carcinoma of the breast and its clinical correlation in locally advanced breast cancer.

UNLABELLED: The change in expression of apoptotic markers (Bcl-2 and Bax proteins) brought about by various chemotherapeutic regimens is being used for its predictive value for assessing response to neoadjuvant chemotherapy (NACT) in locally advanced breast carcinoma (LABC). AIMS: (1) Estimation of Bcl 2 expression in LABC, (2) Any change in Bcl 2 expression following chemotherapy in LABC, (3) Any relation of Bcl 2 estimation to changes in size of tumor, nodal status, age, and menopausal status. SETTINGS AND DESIGN: This was a prospective study of 120 cases of LABC. MATERIALS AND METHODS: All cases were subjected to biopsy and the tissue was evaluated immunohistochemically for apoptotic marker Bcl-2 family protein. Three cycles of NACT were given at three-weekly intervals. Modified radical mastectomy was performed and the specimens were re-evaluated for any change in the Bcl-2 family protein. The clinical response and immunohistochemical response were correlated and compared. STATISTICAL ANALYSIS: Coefficient of correlation was calculated by Pearson correlation coefficient (P-value). RESULTS: Clinical response, as measured by reduction in the tumor size, was observed in 81 (67.5%) patients while immunohistochemical response was observed in 67 (55.8%) patients. Correlation between immunohistochemical and clinical response was found to be statistically significant (P = 0.02). Nodal response was seen in 72 (60%) patients. There were no patients in the N o group; 22 (53.7%) of the N 1 patients were down-staged to N o , while 19 (46.3%) remained N 1 . In patients with N 2 disease, 11 (13.9%) were down-staged to N o status, 39 (49.4%) were down-staged to N 1 status, and 29 (36.7%) did not show any response. Immunohistochemical response was observed in 67 (55.8%) patients. Correlation between immunohistochemical and nodal responses was also found to be statistically significant (P = 0.03). CONCLUSIONS: This significant positive correlation between clinical and immunohistochemical responses highlights the importance of apoptotic marker Bcl-2 family protein in predicting the response of LABC to NACT.

A rare case of incidentally diagnosed primary papillary carcinoma of thyroglossal duct cyst.

Thyroglossal duct cysts are the most common congenital abnormality of thyroid development. Seventy percent of thyroglossal duct cysts are diagnosed during childhood and 7% are diagnosed in adulthood. Less than 1% of these cases are malignant with most being papillary in nature. It is often diagnosed incidentally after surgical excision. Incidentally discovered, well-differentiated thyroid carcinoma of the thyroglossal duct, in the presence of a clinically and radiologically normal thyroid gland, can be managed adequately by the Sistrunk operation. We present a rare case of primary papillary carcinoma of thyroglossal duct cyst, with normal thyroid gland, in a 28-year-old female that was diagnosed incidentally on histopathological examination. A Sistrunk procedure was performed on the patient to remove the thyroglossal duct cyst and patient is doing well at regular follow up.

Isolated left lung aplasia with bronchial asthma.

Congenital lung anomalies are categorised as pulmonary agenesis, aplasia and hypoplasia with distinct clinical implications. An 8-year-old boy was referred for an opaque left hemithorax for which he had received antituberculous therapy. A detailed evaluation including flowing contrast computed tomography of the thorax and fiberoptic bronchoscopy led to a diagnosis of left lung aplasia. He also had wheezing dyspnea, which was confirmed as bronchial asthma. Congenital lung defects with associated asthma was reported only twice till date. A high index of suspicion is required to recognise such a patient.

The role of hyperosmolal food in the development of atherosclerosis.

Hyperosmolality of ingested food causes excessive thermogenesis in humans. And when this heat does not find a way to dissipate or expelled from body it causes the blood circulatory system to build an insulator wall by depositing fat in aorta resulting in atherosclerosis. The mechanism of excessive thermogenesis is presently unknown. It seems that the hyperosmolal food stimulates intestinal osmoreceptors and raises plasma osmolality. However, the dissipation of this heat is less likely to occur in obese people than skinny people because there is an extra layer of fat in obese people. In addition, the climatic conditions do not affect the development of atherosclerosis. Therefore, hyperosmolality of ingested food is the primary factor in the development of atherosclerosis and obesity is only secondary. In addition, the ingestion of fat has practically no effect on the development of atherosclerosis because it does not cause thermogenesis like amino acids, sugars, and NaCl do. Thus, both skinny as well as obese people are at risk of developing atherosclerosis if they habitually consume hyperosmolal foods irrespective of what part of the world they live in.