Fighting the Push-Pull on Banana Wall

Moving onto the headwall of Banana Wall XII,12 Photo: Calum Muskett

On Friday, Calum Muskett and myself made 2nd and 3rd ascents of Banana Wall XII,12 on Cairngorm. This route was put up by Greg Boswell and Masa Sakano in 2015. Greg had a few onsight attempts on the climb ending not that far into the difficulties. He returned and abseiled down the route, but because of its grossly overhanging nature, he didn’t gain much knowledge other than sight of enough cracks/features to commit to push on beyond the highpoint. Returning in 2015, he made a very impressive attempt, getting close to the belay but taking a large fall on the thin and delicate headwall. Even more impressively, he lowered back down and had another go on the same day, finishing the climb. Even with the gear in place from the previous attempt, that takes an immense amount of fitness and I always thought this was impressive. His efforts were nicely documented by Masa on his blog.

For several years I’ve been interested in taking a look at it, but I never actually made the decision to try it. Once, perhaps in 2016 or so, I did drive over with a friend to get on it, but the ski road was blocked with snow and we went for a cup of tea and drove home. After that, I became more interested in focusing on bouldering during the winters and only did a handful of winter routes per season. I have tried a few extremely hard new winter routes on Ben Nevis over the last few seasons, but all have been failures, albeit still good experiences. I have never posted any photos of them obviously. Maybe I’ll go back on at least two of them?

I would say there is a push-pull effect that drew me towards more bouldering and less frequent winter climbing. The main one is just that the difficulty of my boulder projects just keeps going up as I complete more of them. In the early 2000s, I could just about manage to go winter climbing every week and project Font 8A. When I got a bit stronger in 2016, I managed to raise this to maybe 8B. But at 8B+ or especially harder than that, I start to struggle. It’s okay if I just stick to an ‘off the couch’ grade of VIII or IX. But if trying harder winter routes than this, I find I start to turn more towards an endurance phenotype/burly mountain man and can’t also do the moves on 8B+/8C boulders. Possibly this is just an excuse and I do try to remain aware of that. But surely at some point there is a trade off and it does feel like I’m bumping into it. Ultimately, if forced to choose, I prefer bouldering. That’s the pull.

The push has a few components. One is that my ankles sometimes get quite sore on winter walk-ins, especially walking in crampons. I’m usually fine once actually climbing, it’s just the walks. To be fair though, I sometimes find myself carrying so many mats to boulders that this becomes almost as bad. Another aspect is just a tinge of sadness at the lack of snow these days with global warming. The thing that first sparked an attraction to winter mountains in Scotland was the sheer amount of snow. Vast piling quantities of it. The sad truth is, I have never seen as much snow as in that very first winter I became interested in mountains (1993/94). There have been a few winters that have still been very good, but most are a reminder than winters are warmer and leaner.

Another issue is that the Scottish winter discipline has an odd scene, in that the culture is a bit harsh at times. I think a few (certainly far from all) climbers worry that the elements that make it unique may become diluted. I have been reading articles suggesting that its ethics of climbing in wintry conditions and focusing on onsight climbing are under threat for about 30 years. If anything, I think it may have the opposite problem. It defends the ideals so hard, it is actually off putting, to me at least. There is always someone ready to tell you that your Scottish winter climbs ‘should be’ this or that. It should be a long route because short routes are too short, or should be icy because hooking is too dry, or should be done in one attempt because [reason needed]. You shouldn’t post your routes on social media because that doesn’t fit with the dark horse image, but you should post on social media so that everyone know the details of your ascents!

I think it’s totally fine for people to dictate what their climbing should be, but if that morphs into dictating what my climbing should be, I tend to just stop listening. For this reason, I’ve tended to pay less attention to Scottish winter climbing culture and a bit distracted from winter climbing itself. Instead, I’ve become more inspired by and connected to bouldering culture. Overall, I just found it more appealing to pull on grippy crimps in the cold months.

Then I got a text from Calum the other week, asking if I wanted to try Banana Wall.

I tried writing an explanation of the above, then deleted it and said ‘yes’.

A good as I am at lining up reasons not to try Banana Wall, it is still kind of hard wired that when a friend asks if you want to try a hard route, yes is usually the correct answer.

I did make a caveat in my message that I was not sure how I would fare with a sore ankle. That was my way of saying ‘I’ll belay you’, but this message was too subtle. Claire is constantly telling me this. When I arrived at the foot of Banana Wall with Calum, he suggested I tie into the lead ropes. Sadly, that is the other thing that is hard wired. If someone asks you to lead; lead.

After two months of attempts to string more than one move together on my boulder project, I had absolutely zero chance of improving my onsight winter grade by three grades in a single jump. But I could at least go up a bit and begin a ground up ascent. I went up, went the wrong way, got pumped and hung around until it was time to down climb. Often on the harder mixed climbs a deciding factor is protection. If cam placements are needed, it’s important the cracks are not coated in verglas. This isn’t such a big deal with wires which you can tap in to seat them even in icy cracks. A few years ago I did the IX two metres right of Banana Wall ‘Bavarinthia’. The whole time I was looking across at Banana Wall and remembered seeing breaks under the overlaps and thinking ‘that’s going to need dry cracks’. They were coated in verglas and so without gear I was happy to fall onto, I climbed down. Calum didn’t go any higher.

I knew that all I would need to do would be to go on Banana Wall once and I’d get the bug for it. When I got home I looked up the picture of Greg on the FA and realised I’d gone slightly off route at my highpoint, missing an important wire placement. I also decided that it was kind of inevitable I’d try it again, so might as well forget my boulder project for a week or three and do some work on my tools. So I started with daily rounds of 3x20 minute circuits on the tools for a week. Of course this is not enough to actually get fit. But the curve of improvement from zero endurance is not linear, so a week of steady work certainly does get you a few rungs up the fitness ladder.

Helen joined me for another day on Banana Wall. Conditions were a lot worse. I had a double rack of cams on my harness which again were completely useless. The route was really far too plastered for a serious try. I did get much further though. With all the cam slots useless, basically all the gear I was getting was peckers in blind seams. After grinding to a halt, I rested on peckers and went a few more moves, finding an in-situ nut, presumably left from Greg’s ascent. It was very well jammed and I wondered if this may have held his fall. In grim weather and with still unfit arms, I lowered from this, leaving behind a few peckers to back it up.

The next week I came back with Calum, yet again finding totally verglassed cracks. With peckers in place and the nut to aim for, I climbed past my previous highpoint but again found the icy cracks made it feel too dangerous (for me at least) to justify running it out while pumped. The cam placements before the two crux sections would be totally reliable runners and without them ended up resting on my ice tool and wondering what to do. Beyond the in-situ nut, the headwall above was vertical but looked thin. I got back on and gingerly climbed to the belay, again only finding a couple of pecker/terrier runners where in better conditions there would be decent cams. Calum also went up the pitch on my gear with some rests.

The next morning we were back and finally had a break from stormy weather. We had left our gear in from the previous day since it didn’t make much sense to hammer the peckers out and then back in again the next morning. This time Calum lead first. He was saying he felt he had a very low chance of success but nonetheless climbed with conviction, as he tends to do very well. Calum has always been excellent at just battling his was up pitches without hesitation. He appears to accept that a hard route is not going to give in with a tentative or conservative approach. The higher he got, the more pumped he looked but also the more committed to going all the way. He moved out of sight for some time on the headwall and there was mumbling. Shortly afterwards the tell tale sign of falling rime (being cleared off the belay ledge) told me he’d made it.

Calum lowering after his try.

He quickly lowered down so that I could also try to lead it before we tackled the easier, but still important second pitch. I was also unsure I could do it. The main difficulty of Banana Wall I would say is that several of the hooks are very thin to the point they may rip with the slightest movement of a tool. You can certainly make your own luck by being careful and ‘tight’ with your movement, but this is easier said than done when sketching about above aid climbing protection I’d really rather not fall onto. After watching Calum’s fine effort, there was no way I was going to do hesitate and miss my opportunity to finish the route, so just focused on neither rushing it nor hanging around longer than needed. I’d had 8 days in a row of board circuits, followed by two days rest and finally could feel I was just maintaining a steady pump that wasn’t any worse after I got through the hardest moves. For a brief moment on the headwall, on the one hook I’d actually call decent, I briefly enjoyed being there at the time. Normally enjoyment tends to be retrospective on such routes.

Suspended enjoyment soon returned when teetering onward towards a fluffy clump of turf on the skyline above, tempting you on for an even bigger whipper onto that pecker below. It was really too late to care and so I went all in by taking top handle on a thin hook and stretching straight for the turf. Thunk! It was really good turf. Calum followed and then led the top pitch quickly while I marvelled at the total lack of wind that seems to perpetually rasp Coire an Lochain.

Overall I’m pleased that I decided to finally bite the bullet and get on this route, even if was really Calum’s bullet! Protecting it was a little worrying at times and I’d recommend trying to catch it with verglas free cracks which will make a difference for protection. It was hard work trying to place peckers and terriers on lead on steep terrain and would be rather cleaner to use cams since you can just take them out and place them again easily if you end up falling off the onsight attempt. It was an excellent effort from Greg on the first ascent and his ascent inspired me, despite my draw towards bouldering in recent winters.

The question is, boulder project or something else on the tools next. I’ll need to think about that.

Banana Wall on the morning of our ascent. Ideal apart from the verglas.

Crescents and Stars video

A music video made by myself, Claire and my daughter Freida recently. It comes from a new album by Aaron Jones and Rachel Walker called Despite the Wind and Rain, which celebrates influential women in Scottish history. Check out the album here https://rachelwalkerandaaronjones.bandcamp.com/album/despite-the-wind-and-rain

This song is about Mary Somerville, a scientist who spent her youth exploring the outdoors in Scotland and cultivating a gift for observation that eventually led to the discovery of Neptune as well as many books and papers on mathematics, astronomy, geography, ecology and anthropology. We thought it would be nice to represent that magic of exploring the outdoors early in life, observing, learning and finding inspiration that can take your life off on some exciting path whether that is science, sport, art or just enjoyment.

Tope rope self belay

A video on the logistics I use for top rope self belay climbing, which I have used for countless hours over the past twenty years to work on hard route projects. Note that I use the Petzl Shunt which is specifically not recommended for this purpose and I’m not recommending it either, merely showing how I use it since people ask me frequently.

Hangboard 30 min follow along

I made a follow along hang board workout, 30 minutes long and pitched for beginner/intermediate climbers (two handed hangs). In the rests in between the hangs I discuss various aspects of adjusting the hang board loading depending on your level and climbing goals. Enjoy the workout!

This is very similar to the basic workout I used when I started fingerboarding and went from 8b+ to 9a in a couple of years.

Agag's Groove free solo with Kev Shields

The other day myself and Kev Shields went for a morning’s solo on Buachaille Etive Mor in Glen Coe. We climbed an easy classic, Agag’s Groove, that is a first mountain route for many new climbers. I decided to take a few cameras and film the climb. Soloing and filming at the same time is not all that easy. But its nice to show off the route and I hope it encourages more folk to go and climb mountain routes like this.

Can you quantify climbing technique?

Coaches and sport scientists are often trying to quantify aspects of sport and there’s good reasons for this. But climbing technique is hopelessly complex with endless variation in movement. How could we go about quantifying it, or even thinking about it in any kind of structured manner? With difficulty. In this video I introduce some simple ideas for the way I think about technique that helps me to learn it and monitor my learning.

Oban sport crags topo

Over the past few years I’ve been involved along with others in developing low-mid grade sport routes at the conglomerate crags just south Oban. The crags are only a couple of minutes drive from Oban town centre at Gallanach, near the ferry to Kerrera. They are roadside, quick to dry, don’t seep much at all and provide great friendly sport climbing.

I’ve been really enjoying developing the crags. It’s also been a lot of work and expense. For all my routes, I’ve used Titanium glue-in bolts (from Titan Climbing in Sheffield) and pure epoxy resin so that they should last many decades if not hundreds of years in this coastal environment. The downside of this is the cost which adds up to nearly £10 per single bolt. Early on I received a small grant from the Scottish Mountaineering Trust which really helped get the ball rolling and fund a handful of routes. Some of you have donated for bolts via my Patreon (link here and I greatly appreciate the help), but the majority of the bolts I’ve self-funded.

The crags are laid out along the roadside over a mile or so, with five main buttresses. Below I’ve made topos and descriptions for the buttresses I’ve been involved in developing. I’m thinking of making a small paper guidebook that is more complete with all the routes, once the development is further on. There are still a number of lines I’d like to bolt yet. The crags take little drainage and seem to dry very quickly and some of the routes can even be climbed in light rain. Give the seaside location, they take any breeze that’s going, but in the forest at the foot of the routes, it still can be midday in summer. Year round climbing is possible here and the routes get the sun from mid afternoon.

Park on the grass verges near or at the parking for the Kerrera ferry. Don’t park in the passing places. If coming by public transport, you can walk to the crags from Oban town centre, or hire foldable bikes from a vending machine outside Oban train station.

HELMETS ARE ESSENTIAL at the crag as they are new conglomerate routes that have not had much traffic. Loose chunks of rock will break off. Don’t stand directly below your climbing partner while belaying. If you’ve not climbed on this rock type before, it takes a little getting used to. It follows that grades of the routes are approximate and will likely shift a bit as these routes get traffic and lose the odd hold or foothold. Let me know your grade opinions in the comments. Most of the routes are equipped with Ramshorn lower-offs which means you don’t need to re-thread or leave karabiners behind when stripping the routes. The buttresses are described below, running left to right.

The Riches

The first crag reached from Oban, situated well hidden in the trees above Dungallan Terrace, just north east of the old Kilbowie Outdoor Centre. Approach from a Lay-by opposite a house called Ardcuan. Please don’t park in the lay-by though, you’ll have to walk along the road from the parking near the Kerrera Ferry as for the other buttresses which only takes a few minutes. The buttress is 50m directly above Ardcuan. Routes described right to left.

1 Potato Hack 10m 6c

Steep burly climbing up the prominent arête.

2 First News 12m 4**

The pleasant corner and slab above.

3 Glitterati 12m 6a**

Nice climbing on some of the best rock at the Gallanach crags.

4 Ultra Rosa 12m 6c+

Technical climbing leads rightwards to better holds up the right arête of the wall.

5 Mango Loco 15m 7a+*

Good climbing left of the blue streak leads to a break and an easier finish above.

6 Mango Maxx 18m 7b/7b+*

Follow Mango Loco to just past its crux, swing left to cross the headwall of Super Rich and continue left to reach the finishing holds of Coming from You.

7 Super Rich 15m 7b*

Thin technical climbing leads to a good rest at the ledge and an easier headwall.

8 Coming from You 10m 6c*

Start from the ledge below the Offwidth and climb the left side of the wall.

9 Ill Wind 10m 6c

An unusual route bridging and laybacking up the edge of the off width crack. There is a tricky move rightward at the top to reach the anchor.

10 Ripper Ramp 10m 6c

A bouldery move off the ground (stick clip useful) leads to easier climbing following the hanging ramp. Would be much improved another quick clean.

Oakley

Topo and descriptions soon

Sigma Buttress

This is the most extensive buttress of the Gallanach crags with long and interesting climbs on open walls and grooves. The central routes are long and a few longer draws are useful.

1 Kilbowie 25m 6c**

The left-hand line of bolts up the vertical wall. Good climbing with some useful pockets


2 Thin White Teuch 25m 7a*

The right-hand line. Move left at the crux in the middle of the wall to follow pockets, then step back right with a couple of thin moves to reach the finishing slab.


3 Arran Victory 30m 6b+*

The leftmost line. Follow the crack in the slab then a left-facing groove. Where this peters out, move left (crux) to gain the upper cracked groove.


4 Pink Eye 30m 6c**

Follow the crack in the slab as for Arran Victory but break rightwards from the steep groove to reach an overlap. Pull through this to gain the upper steep left-facing groove.


5 Skerry Champion  35m 6c+**

Aims for the rightmost of the three left facing crack/grooves at the top left of the buttress. Follow the pocketed slab and corner of Sigma then continue up and left following a flake-crack to the spiky ledge. Crank between good holds up the overhanging wall to reach the crack.


6 Cream of the Crop 35m 7a+***

Follow Skerry Champion to the spiky ledge. The smooth headwall directly above gives good sustained climbing, trending rightwards to join Electra at the last bolt.


7 Electra 35m 7b***

Climb to a few moves along the right-slanting ramp of Sigma. Tackle the bulging overhang above with burly laybacking up the undercut flange.


8 Sigma 35m 6a***

The central snaking line of weakness, weaving its way through the steep wall. Climb the white pocketed wall and short corner above. Step slightly right and climb another white wall trending rightwards to gain a big right-slanting ramp. Move along this and then continue into the steep finishing groove (crux) of Miss Blush. A few long quickdraws are useful to avoid rope drag.


9 Irish Cobbler 35m 7a*

Start up Miss Blush but step back left on the pillar and follow a flaky crack to the right end of the ramp of Sigma. Attack the groove steep bulge above, just right of Electra. The slab above is easy.


10 30m Miss Blush 35m 6c**

A steep start through a bulging right-facing corner, followed by a blunt prow trending rightwards to the top of the pinnacle. Step right into the overhanging groove and follow it to the top.


11 15m Melody Grooves 35m 6b*

Climb the bulging right-facing corner and blunt prow but move rightwards onto grass ledges and a lower-off. Belay here if you want to climb it in two pitches, other wise use a few long quickdraws moving right onto the grass ledges. From the lower-off gain the open groove near the right edge of the crag and follow it to the top.


Roadside


Mission Creep 6a+** 35m

Start in a scoop near the left end of the wall. Climb up then left through a bulge on good holds and through the gap in the first overhang on good holds to the bottom edge of the slab above(rams horn here to redirect the rope when stripping the route). Balance leftwards on good foot ledges to a big hold in the left facing groove. Bridge up the groove to the lower-off.



The Towers


The large buttress right above the parking verge, featuring prominent arêtes.


1 Vomitorium 30m 6b***

The original line on the crags. Left of the deep roofed corner is a vertical wall with two lines. This takes the left-hand line, moving through a deep crack at half height.


2 International Kidney 30m 6b+**

The right hand line on the wall, moving past the big detached flake at half height with a crux moving left on undercuts at the last bolt to the same lower-off as Vomitorium.


3 Herbie Mhor 30m 7b*

The steep right wall of the deep corner.


4 Majestic 30m 6c***

Excellent climbing and positions on the flying arête right of Herbie Mhor. Good pockets where needed.


5 Tabula Rasa 30m 6b**

The grooves and walls just right of the flying arête.

Dave MacLeod Comments
How strong am I really?

Maddy and Ollie at Lattice Training recently invited me to their HQ in Chesterfield for their finger strength and endurance testing protocol. It was fun and interesting to see how I compare to their ever growing database of high level climbers for these basic measures of strength and endurance. As you can see in the video, it yielded a couple of surprising results for me and a little food for thought for my general approach to climbing goals in the future.

Lexicon, 3rd ascent

Setting up for the crux of Lexicon, a lunge out right to a slot. Photo: Chris Prescott

My first route in the Lake District was Breathless, John Dunne’s E10 7a on Gable in 2005. I’ve always been absolutely fascinated by hard trad routes and before I could try them, I built up a huge debt of curiosity about the hard routes I’d read about, that I’d need to pay back at some point. I wanted to know what the holds were like, to understand what level of physical and mental prowess you’d need to dare to start up them. I remember seeing a picture of Lakes climbing legend Dave Birkett in a climbing magazine, looking very much the honed athlete. For me, that combination of athletic ability and competence to put it to use on serious mountain trad was inspiring. I can’t remember why I chose to go at Breathless first. Maybe it was just the nice picture of John Dunne on the first ascent. Maybe Birkett’s testpiece If Six Was Nine E9 6c sounded way too dangerous.

I was otherwise occupied in 2006 but came back to the Lakes with Claire in 2007 and went straight for If Six Was Nine. It was a spicy lead and I was glad to have a decent amount of experience behind me before I went near it. I had only just turned onto the M6 to drive back north and my phone went. It was Dave Birkett ringing just to say well done, a gesture I appreciated a lot. Around the same time, I had a nice weekend with Kev and Steve and repeated another gnarly E8 of Dave’s, Caution on Gillercombe buttress. A benchmark at that grade and again not one to do for your first E8. The following day I persuaded the guys to go up to Pavey Ark to try Impact Day. It was originally given E9 6c but settled out at E8. The rock on that wall was beautiful and I just could not resist leading it that day. 

Repeating Impact Day E8 6c on Pavey Ark in 2007. Photo: Steven Gordon

Since then I’ve only visited the Lakes a few times, once in 2016 to do Return of the King E8 6c up on Scafell, also a route with lovely rock. Last September I glanced at my feed and saw that Neil Gresham had climbed a new E11 on Pavey Ark. I stopped what I was doing and read the whole article about Neil’s new route Lexicon instantly. There was no point kidding myself on, I might as well decide right now that I would be travelling to the Lakes next week.

There are some things in life that you know you’re just going to have to go and do. Might as well get on and do them. I recalled the lovely rock on the wall and so the prospect of a route here with such a massive grade would surely present a brilliant climbing challenge. Aside from that, I was also highly impressed with Neil’s effort to climb the route. I interviewed Neil on my Youtube channel a while ago and in that piece, I asked him about his continued significant improvement in climbing throughout his 40s and into his 50s. I’ve spent many years studying physiology and so of course I know that this is possible. But possible and actually doing it are two very different things. Almost no-one does it because discarding habits, forcing new ones, breaking glass ceilings of your own making and essentially reinventing yourself is not easy. You need to be driven by something to make this happen. I suspected that perhaps the quality of the climbing on this wall might have been a significant driver for Neil. If it was as good as it sounded, I too could let myself become locked in to the one-way journey of obsession, starting with the M6 south.

Repeating Return of the King E8 6c on Scafell in 2016. Photo: Steve Ashworth

A week after Neil made the big lead of Lexicon, E11 7a, I pulled up in the ever packed car park in Langdale and slogged up to the top of the crag. I flung my rope over the edge and sat down for a cup of tea in the sunshine when I noticed two guys on the shoulder across from the crag, soon recognising their two distinctive accents carried across the gully on the breeze. Neil Gresham and Steve McClure. They were up with Alastair Lee, finishing off a bit of filming on Lexicon and Steve was keen to try the route. It was great to sit and chat with them about the climb and life in general.

We got on the route and I did do all the moves straight away. It was an okay start but doesn’t mean all that much on a steep sustained route like this. At first I used a similar sequence to Steve. But a terrible pinch hold he seemed to use without a bother felt like the living end to me. Steve is just so strong on tiny fingery holds like this, it’s incredible to watch, desperate to emulate. Neil explained his sequence. For starters, I couldn’t do the first crux as Neil had done, with a foot still on the girdle break. Neil’s high step move from this position is an awesome thing to behold. No wonder he did ballet lessons for it. Thankfully there were other footholds and I could do in four foot moves what he did in one. As I sat at the top talking to Neil, Steve appeared over the top with a look of ‘Oh shit I’m going to have to lead it’ written all over his face. Sure enough, he announced that he’d linked the moves. Although he said nothing about leading, it was quite obvious that was what would be happening. 

It was far too hot for a Scotsman and I had no skin left to try again, so headed down to the shoulder and sat with Alastair as we watched Steve go for his ‘look’. He ‘looked’ his way smoothly up most of the massive runout up the headwall. As he locked off and took the crimp in the little groove before the redpoint crux at the last few moves, it was crunch time. I don’t get to watch many other people do this. It’s normally me feeling the fear as the commitment suddenly hits you. I couldn’t help but relate to what he must be feeling. Being Steve, he looked controlled, although I detected just a note of tension in his movement. It’s reassuring to know that perhaps he feels it too, when way out on a limb. Just then, his foot popped off during a balancy move, pulling in on a tiny nubbin for the right foot. If it had been a split second later, it might not have mattered, but he didn’t quite have his right hand in a shallow pocket. His body wobbled for a fraction of a second and then he just dropped. He shot essentially the full height of the crag, coming to rest with a stiff bounce about three metres off the deck. Silence. Both Neil and Steve sounded a bit shocked. No shit.

Steve McClure’s monster fall from before the crux. Montage: Alastair Lee

After they absorbed the events and set about de-rigging in the gathering dusk, I jogged off down the path and drove back to Roy Bridge, also absorbing the events. That day I had learned that I am no ballet dancer, I cannot move statically off ‘nothing’ pinches like Steve McClure and I did not like the look of that fall. Yet I still wanted to do the route. Steve returned a few days later and finished the job, as one would expect. He commented that he had to replace his usual psychological tactic of pretending he was just going up for a top rope try and then ‘sneaking up’ on the decision to lead before the prospect became scary. This time he knew he would be leading and he wondered how folk like myself deal with this. I have only one strategy to throw at this challenge; thorough preparation.

I resolved to return to Lexicon with thorough preparation in mind, taking my time and aiming at an incident free ascent with no falls. Slips notwithstanding, the most likely place to fall off the route would be the very last hard move, higher than where Steve fell. That would be uncomfortably close to the ground and obviously, twenty five metre ground falls tend to be fatal. Thankfully, there were some things under my control to avoid this scenario and I set about controlling them.

First, as I played back my video of Steve’s fall, I could see that the top cam had ripped, causing Steve to drop onto the next one which was on a longer quickdraw. On my next visit, the route was kind of wet and so I focused on sorting out the gear. The slot looked like a bomber placement. Had it just ripped because of the sheer length of the fall? Probably. But I noted that the slot had a film of soft dusty lichen in the back. With a good brush it had a bit more friction. A slightly different cam fitted a little better and I could squeeze a C3 into the same placement. A slight improvement perhaps?

Above on the headwall, I’d noticed a little slot. Surely that would take a nut? I had mentioned it to Neil and Steve but they did not seem impressed with the placement and didn’t want to bother with it. I found that a BD nut seemed pretty bomber, the only issue was that the ‘crystally’ rock around it could break. But there was also a good skyhook right beside it. Perhaps both of these on a screamer each could actually hold? I think it’s plausible. Even if not, they might prevent the belayer being pulled up so far and give you that crucial extra metre or so if you did take the full ride. Even if none of those things were true, it looked good to have something clipped to the rope. I would almost certainly feel less lonely up on that headwall. This all came with a major downside in that stopping to place these two runners mid crux adds nearly a grade to the physical difficulty of the route. That headwall is very much a power endurance sprint. Adding another 20 or 30 seconds of hanging off a thin sidepull, gradually barndooring off poor footholds while faffing with skyhooks was not ideal. I resolved to pre-clip them to the lead rope and velcro them to my harness to avoid having to do any clipping. At least I could make it a 10 second penalty rather than 20.

Taking a key sloper with my left hand. Neil and Steve used this with the right.

My biggest weapon by far is the ability to work out a good sequence. I made countless changes to it over two days in early October, ending up using some holds with the opposite hand to Neil and Steve, as well as a couple of holds they don’t use at all. One of these allowed me to shake my left arm before taking the crucial crimp in the groove where Steve fell. With this sequence, I linked the climb completely on the shunt six times across two sessions and knew the route was possible. A summer of various mishaps in 2021 had left me a bad case of tennis elbow and this was really limiting me. I couldn’t try the route for long before it hurt too much, and I was not in anywhere near good enough shape to lead it. October was pretty wet anyway and most of the time I’d tried it there were wet holds.

I was working on the assumption I’d just get it all as sussed as possible before winter and then come back the following spring. Task number one was to recover from the tennis elbow to even begin training again. The elbow recovered steadily and I could tentatively start on my 45 board in early November. Even just a few sessions on the board gave me some confidence and in late November I optimistically went down with Iain Small to lead Lexicon. Sadly, the overnight rain had been heavier than expected and it was seepy. At least it drew a definite line under proceedings for the autumn and I could move on.

I planned my winter training as such; December - board. January - boulder projects outside, February and March - endurance training on the board. Training plans rarely survive real life intact, but this one seemed to roughly hold up and as March progressed I had many boulders between 8A and 8B+ under my belt, plus a reasonable amount of endurance work, for me at least. There were niggles; a tweaked finger joint and my usual ankle issues that suddenly seemed to flare. Could I even walk in?!

On the stellar late March forecast I went to find out. I was indeed a bit hobbly but could get to the crag. It was lovely and dry but the wind was raging and I could not warm up. Yet I could link it with my big belay jacket on and numb, glassy fingers. A good sign. I just needed that one confirmatory session in more reasonable conditions. After a rest day, I got it and linked the moves repeatedly, placing all the gear and trailing a lead rope, sussing out exactly how to extend all the runners. Game on. Chris messaged, keen to take pictures if I was trying it. I said it was ready to go and so Natalie and Chris joined me in Ambleside a couple of days later.

On our day on the hill, that keen March wind had died completely and I now was back to the opposite problem of ‘too warm’. Your fingers have to bite those rhyolite crystals. If it is too warm, my skin just rolls off them. This did not fit within my ‘thorough protocol’. How would I feel if I greased off the last move and dropped the length of the crag, for the sake of waiting for a breezy day? And yet, the fact I’ve arranged a climbing partner does weigh on me. I felt bad enough dragging Iain up there and felt silly as we sat about in 4 degrees looking at a dripping crag. If I could just get a half hour of wind, I could see it off. I also had a hunch that I was in good enough shape to just scrap my way up it even in less than perfect conditions. Why not just finish it?

Unfinished climbs have always been a source of chronic pain to me, an ache I can tolerate for long periods when there is no other option. But the minute I can change the picture, I’ll do anything I can to resolve it. When I say ache, I mean that in a good way, like the ache of burning muscles in training. It’s good pain! The minute I resolve it, I’m almost instantly looking to cause it again and have lived this way for 25 years. There is an expression that pain is the cost of being alive and as far as I’m concerned, it’ll stop when I’m dead.

Little bits of breeze came and went and so I continued with preparations. Final bits of velcro were attached to screamers, the rack was laid out on the grass and then attached to my harness in order and we abseiled down. At the absolute minimum, I wanted to force myself to climb to the nut and skyhook on the headwall, no matter the conditions. I could have the opportunity for a confidence building fall from the sloper where Neil did his super high step. If I got to the skyhook and nut, I could test exactly how efficiently I could get them in on the lead. It’s always more of a faff than you would like. If the breeze suddenly picked up and I could hang that wee side pull long enough to get the hook in, maybe I could just commit? Delaying this decision right to the last moment is a classic psychological tactic. It nearly always works, as long as you have the experience to be able to deal with hitting the ‘go’ button when the moment comes.

Committing to the runout on Lexicon. Photo: Chris Prescott

I worked my way up the E6 lower wall and arranged the gear at an awkward kneebar. I hate the delay of lingering on rests on trad routes. Where the rest is purely about putting off the inevitable, I tend to just rally and want to force the outcome. I committed by vocalising a little announcement to Natalie; ‘climbing’ and pulled up on the little undercut. As I took the hold after the sloper, a little sidepull right in front of your face, I clocked the sweat on my fingertips. ‘Don’t go any higher’. The nut went in okay, but I was barn-dooring badly while trying to detach the skyhook from fresh velcro. ‘Get it in and then just grab it’. With the runners in, I relieved the left hand and chalked up, noting that to my surprise the left arm was not pumped. A distracted thought flashed across my mind ‘training fucking works!, that’s cool!’ Back in the present, my feet were somehow already built up level with the skyhook and I was leaving it behind. ‘What are you doing? Don’t go any higher. Grab that skyhook’. ‘Oh fuck sake Dave as if you were ever going to grab the bloody runner. Forget that. Feel that breeze. You’re here, you’ve got a partner to belay and you’ve linked it ten times. Just climb another ten moves and don’t let go of that slot at the end’.

Leaving behind the skyhook and deciding to commit.

By the time that little conversation was over I had the crimp in the groove and was carefully stuffing the back three fingers into the shallow pocket where Steve fell. ‘Oh yes, this spot feels just as high and lonely as I thought it would. Might as well enjoy the mad position, it’s too late for doing anything else. Regardless of the outcome, you’re only going to be here for a second or two’. Setting up for the lunge to the slot, I felt all in the wrong place, my feet were numb and body too tense. I felt like all my weight was on the tiny crimps and was pulling like hell on them. But I also felt I had a lot of power on them. Time to use it! It wasn’t pretty, but I grabbed the slot with a deep grunt. ‘Massive neural drive’ as my muscle physiology lecturer used to say. It worked, with the consequence of a bit of shakiness as the neural drive spilled over on the easier last couple of moves. The security of the huge spiky jug at the top was so comforting, an unquestionable finish line from which you can finally let go of the ache.

I have not climbed all the hard trad routes in England or Wales by any means, but I have climbed quite a few and Lexicon is harder than any of them. Neil’s effort climbing the first ascent is exceptional in my opinion. There are plenty of climbers who could do the moves on it, but I suspect the number who would actually lead it is rather small, at the moment at least. At 43 I’m delighted to be the youngest person to climb it by some margin. Watching both Neil and Steve destroy such a hard piece of trad climbing is a great example that I would like to emulate as my climbing progresses. Age is a funny thing, it can work in multiple ways. The battle scars that come with it can weigh on you, if you don’t just decide to work around them. On the other hand, it can give you an appreciation that if you don’t go and get on the route and get yourself in finishing shape, the time will pass and you’ll never do it. That mindset can put you in a powerful position.

Taking the wee pocket where Steve fell from. Photo: Chris Prescott

Fast recovery from my elbow injury

My annoying tennis elbow improved enough to start bouldering regularly again a month ago. Since then I feel like its stronger every session. A good feeling. In this session I keep on with working through the established problems on my board, building up to starting on the projects. At the end I’m getting close to my Pjs on the fingerboard, which is kind of surprising to me, but great! I also go through some of your questions about training from my last full session vlog episode. If you have more, leave a comment here on my YouTube.

BTW Did you subscribe to my YouTube channel yet? Lots more videos sharing climbing, training, nutrition and nice routes and mountains coming in 2022.

Keystone

A new film on my YouTube channel now which I made with the John Muir Trust. It's about me making the first free ascent of Keystone (E8) in Glen Nevis in the summer. But although Glen Nevis is somewhere I thought I knew quite well and have spend a lot of time in, I also explore the reasons why this corner of the glen seems so different from the rest of the Glen, and the hills in general. That story is one of land, money and power.

If you would like to know a bit more about the trees I’m talking about in the film, there is more info about them at https://www.johnmuirtrust.org/mountainwoodland

The ketogenic diet in sport performance - 6 years of experiments and scientific evidence

The ketogenic diet had a large impact on my life and my climbing. Here is a detailed discussion of 6 years of my own experiences with the keto diet for sport performance as a pro rock climber, with references to 150 scientific papers on the performance, health and other effects of the diet. You can find all the references below.

I’ve also published an audio version of the piece on my Patreon page as a thanks to my Patreon supporters. I thought that might be useful for folk to listen to it on the move since it’s a long and detailed piece.

Bibliography

1. Hyppönen, E. and C. Power, Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. The American Journal of Clinical Nutrition, 2007. 85(3): p. 860-868. https://doi.org/10.1093/ajcn/85.3.860

2. Nixon, R., Comparisons of aspects of Glasgow’s 56 neighbourhoods. 2016: G.C.f.P. Health. https://www.gcph.co.uk/assets/0000/5492/Comparisons_of_aspects_of_Glasgows_56_neighbourhoods.pdf

3. Price, W.A., Nutrition and physical degeneration. 1998, New Canaan, Conn.: Keats. https://amzn.to/39gxhkG

4. Weiser, M.J., C.M. Butt, and M.H. Mohajeri, Docosahexaenoic Acid and Cognition throughout the Lifespan.Nutrients, 2016. 8(2): p. 99-99. https://pubmed.ncbi.nlm.nih.gov/26901223

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772061/

5. Careau, V., et al., Energy compensation and adiposity in humans. Current Biology. https://doi.org/10.1016/j.cub.2021.08.016

6. Pontzer, H., et al., Hunter-gatherer energetics and human obesity. PloS one, 2012. 7(7): p. e40503-e40503. https://pubmed.ncbi.nlm.nih.gov/22848382

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405064/

7. Pontzer, H., et al., Energy expenditure and activity among Hadza hunter-gatherers. Am J Hum Biol, 2015. 27(5): p. 628-37. https://pubmed.ncbi.nlm.nih.gov/25824106/

8. Pontzer, H., et al., Constrained Total Energy Expenditure and Metabolic Adaptation to Physical Activity in Adult Humans. Curr Biol, 2016. 26(3): p. 410-7. https://pubmed.ncbi.nlm.nih.gov/26832439/

9. Pontzer, H., B.M. Wood, and D.A. Raichlen, Hunter-gatherers as models in public health. Obes Rev, 2018. 19 Suppl 1: p. 24-35. https://pubmed.ncbi.nlm.nih.gov/30511505/

10. Cowley, J., J. Kiely, and D. Collins, Unravelling the Glasgow effect: The relationship between accumulative bio- psychosocial stress, stress reactivity and Scotland's health problems. Preventive medicine reports, 2016. 4: p. 370-375. https://pubmed.ncbi.nlm.nih.gov/27512652

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979043/

11. Alvheim, A.R., et al., Dietary linoleic acid elevates endogenous 2-AG and anandamide and induces obesity.Obesity (Silver Spring), 2012. 20(10): p. 1984-94. https://pubmed.ncbi.nlm.nih.gov/22334255/

12. Naughton, S.S., et al., Fatty Acid modulation of the endocannabinoid system and the effect on food intake and metabolism. Int J Endocrinol, 2013. 2013: p. 361895. https://doi.org/10.1155/2013/361895

13. Naughton, S.S., et al., The Acute Effect of Oleic- or Linoleic Acid-Containing Meals on Appetite and Metabolic Markers; A Pilot Study in Overweight or Obese Individuals. Nutrients, 2018. 10(10): p. 1376. https://www.ncbi.nlm.nih.gov/pubmed/30261617

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213143/

14. Clark, T.M., et al., Theoretical Explanation for Reduced Body Mass Index and Obesity Rates in Cannabis Users.Cannabis and cannabinoid research, 2018. 3(1): p. 259-271. https://www.ncbi.nlm.nih.gov/pubmed/30671538

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340377/

15. Deol, P., et al., Soybean Oil Is More Obesogenic and Diabetogenic than Coconut Oil and Fructose in Mouse: Potential Role for the Liver. PLOS ONE, 2015. 10(7): p. e0132672. https://doi.org/10.1371/journal.pone.0132672

16. Deol, P., et al., Dysregulation of Hypothalamic Gene Expression and the Oxytocinergic System by Soybean Oil Diets in Male Mice. Endocrinology, 2020. https://doi.org/10.1210/endocr/bqz044

17. Benani, A., et al., Role for Mitochondrial Reactive Oxygen Species in Brain Lipid Sensing. Diabetes, 2007. 56(1): p. 152. http://diabetes.diabetesjournals.org/content/56/1/152.abstract

18. López, S., et al., Distinctive postprandial modulation of β cell function and insulin sensitivity by dietary fats: monounsaturated compared with saturated fatty acids. The American Journal of Clinical Nutrition, 2008. 88(3): p. 638-644. https://doi.org/10.1093/ajcn/88.3.638

19. Harvey, C.J.d.C., et al., Effects of differing levels of carbohydrate restriction on the achievement of nutritional ketosis, mood, and symptoms of carbohydrate withdrawal in healthy adults: A randomized clinical trial. Nutrition: X, 2019: p. 100005. http://www.sciencedirect.com/science/article/pii/S2665902619300056

20. Stellingwerff, T., Case Study: Body Composition Periodization in an Olympic-Level Female Middle-Distance Runner Over a 9-Year Career. Int J Sport Nutr Exerc Metab, 2018. 28(4): p. 428-433. https://pubmed.ncbi.nlm.nih.gov/29140157/

21. Holt, S.H.A., et al., A Satiety Index of common foods. European journal of clinical nutrition, 1995. 49: p. 675-90. https://pubmed.ncbi.nlm.nih.gov/7498104/

22. Edwards, K.H., B.T. Elliott, and C.M. Kitic, Carbohydrate intake and ketosis in self-sufficient multi-stage ultramarathon runners. J Sports Sci, 2020. 38(4): p. 366-374. https://pubmed.ncbi.nlm.nih.gov/31835963/

23. Baar, K. and T. Stellingwerff, Maximising power to weight ratio. Peak Performance, 2015(337): p. 1-5. https://fliphtml5.com/mrom/hiie/basic

24. Koutnik, A., D. D'Agostino, and B. Egan, Anticatabolic Effects of Ketone Bodies in Skeletal Muscle. Trends in Endocrinology and Metabolism, 2019. 30: p. 227-229. https://pubmed.ncbi.nlm.nih.gov/30712977/

25. Paoli, A., et al., Ketogenic Diet and Skeletal Muscle Hypertrophy: A Frenemy Relationship? Journal of human kinetics, 2019. 68: p. 233-247. https://pubmed.ncbi.nlm.nih.gov/31531148

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724590/

26. Impey, S.G., et al., Fuel for the Work Required: A Theoretical Framework for Carbohydrate Periodization and the Glycogen Threshold Hypothesis. Sports Med, 2018. 48(5): p. 1031-1048. https://pubmed.ncbi.nlm.nih.gov/29453741/

27. Wallace, I.J., et al., Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proceedings of the National Academy of Sciences, 2017. 114(35): p. 9332. http://www.pnas.org/content/114/35/9332.abstract

28. Goldberg, E.L., et al., Ketogenic diet activates protective γδ T cell responses against influenza virus infection.Science Immunology, 2019. 4(41): p. eaav2026. http://immunology.sciencemag.org/content/4/41/eaav2026.abstract

29. Pardo, A.C., Ketogenic Diet: A Role in Immunity? Pediatr Neurol Briefs, 2020. 34: p. 5. https://pubmed.ncbi.nlm.nih.gov/32174748/

30. Entrenas Castillo, M., et al., “Effect of calcifediol treatment and best available therapy versus best available therapy on intensive care unit admission and mortality among patients hospitalized for COVID-19: A pilot randomized clinical study”. The Journal of Steroid Biochemistry and Molecular Biology, 2020. 203: p. 105751. https://www.sciencedirect.com/science/article/pii/S0960076020302764

31. Antonio, J., et al., The effects of consuming a high protein diet (4.4 g/kg/d) on body composition in resistance-trained individuals. J Int Soc Sports Nutr, 2014. 11: p. 19. http://www.ncbi.nlm.nih.gov/pubmed/24834017

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022420/pdf/1550-2783-11-19.pdf

32. Berrazaga, I., et al., The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review. Nutrients, 2019. 11(8). 

33. Carmen, M., et al., Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series. Journal of Eating Disorders, 2020. 8(1): p. 2. https://doi.org/10.1186/s40337-020-0278-7

34. SACN, Saturated Fats and Health. 2019: SACN. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/814995/SACN_report_on_saturated_fat_and_health.pdf

35. Ness, A.R., et al., Diet in childhood and adult cardiovascular and all cause mortality: the Boyd Orr cohort. Heart, 2005. 91(7): p. 894-8. https://pubmed.ncbi.nlm.nih.gov/15958357/

36. Mente, A., et al., A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med, 2009. 169(7): p. 659-69. https://pubmed.ncbi.nlm.nih.gov/19364995/

37. Skeaff, C.M. and J. Miller, Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised controlled trials. Ann Nutr Metab, 2009. 55(1-3): p. 173-201. 

38. Siri-Tarino, P.W., et al., Saturated fat, carbohydrate, and cardiovascular disease. Am J Clin Nutr, 2010. 91(3): p. 502-9. https://www.ncbi.nlm.nih.gov/pubmed/20089734

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824150/pdf/ajcn9130502.pdf

39. Siri-Tarino, P.W., et al., Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. The American Journal of Clinical Nutrition, 2010. 91(3): p. 535-546. https://doi.org/10.3945/ajcn.2009.27725

40. Kuipers, R.S., et al., Saturated fat, carbohydrates and cardiovascular disease. Neth J Med, 2011. 69(9): p. 372-8. https://pubmed.ncbi.nlm.nih.gov/21978979/

41. Hooper, L., et al., Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev, 2012(5): p. Cd002137. https://pubmed.ncbi.nlm.nih.gov/22592684/

42. Chowdhury, R., et al., Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med, 2014. 160(6): p. 398-406. 

43. Schwingshackl, L. and G. Hoffmann, Dietary fatty acids in the secondary prevention of coronary heart disease: a systematic review, meta-analysis and meta-regression. BMJ Open, 2014. 4(4): p. e004487. http://bmjopen.bmj.com/content/4/4/e004487.abstract

44. Hooper, L., et al., Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev, 2015(6): p. Cd011737. https://pubmed.ncbi.nlm.nih.gov/26068959/

45. de Souza, R.J., et al., 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: p. h3978. https://pubmed.ncbi.nlm.nih.gov/26268692/

46. Harcombe, Z., J.S. Baker, and B. Davies, Evidence from prospective cohort studies does not support current dietary fat guidelines: a systematic review and meta-analysis. Br J Sports Med, 2016. https://www.ncbi.nlm.nih.gov/pubmed/27697938

http://bjsm.bmj.com/content/early/2016/10/03/bjsports-2016-096550.long

47. Ramsden, C.E., et al., Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73). Bmj, 2016. 353: p. i1246. https://pubmed.ncbi.nlm.nih.gov/27071971/

48. Dehghan, M., et al., Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet, 2017. 390(10107): p. 2050-2062. https://doi.org/10.1016/S0140-6736(17)32252-3

49. Hamley, S., The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials. Nutrition Journal, 2017. 16(1): p. 30. https://doi.org/10.1186/s12937-017-0254-5

50. Dehghan, M., et al., Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE): a prospective cohort study. The Lancet, 2018. 392(10161): p. 2288-2297. http://www.sciencedirect.com/science/article/pii/S0140673618318129

51. DuBroff, R. and M. de Lorgeril, Fat or fiction: the diet-heart hypothesis. BMJ Evidence-Based Medicine, 2019: p. bmjebm-2019-111180. http://ebm.bmj.com/content/early/2019/07/10/bmjebm-2019-111180.abstract

52. Heileson, J.L., Dietary saturated fat and heart disease: a narrative review. Nutrition Reviews, 2019. https://doi.org/10.1093/nutrit/nuz091

53. Khan, S.U., et al., Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes: An Umbrella Review and Evidence Map. Annals of Internal Medicine, 2019. 171(3): p. 190-198. https://doi.org/10.7326/M19-0341

54. Zhu, Y., Y. Bo, and Y. Liu, Dietary total fat, fatty acids intake, and risk of cardiovascular disease: a dose-response meta-analysis of cohort studies. Lipids in Health and Disease, 2019. 18(1): p. 91. https://doi.org/10.1186/s12944-019-1035-2

55. Astrup, A., et al., Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review. Journal of the American College of Cardiology, 2020. http://www.sciencedirect.com/science/article/pii/S0735109720356874

56. Sendra, E., Dairy Fat and Cardiovascular Health. Foods, 2020. 9(6). https://pubmed.ncbi.nlm.nih.gov/32604766/

57. Keys, A., Atherosclerosis: a problem in newer public health. J Mt Sinai Hosp N Y, 1953. 20(2): p. 118-39. https://pubmed.ncbi.nlm.nih.gov/13085148/

58. Yerushalmy, J. and H.E. Hilleboe, Fat in the diet and mortality from heart disease; a methodologic note. N Y State J Med, 1957. 57(14): p. 2343-54. https://pubmed.ncbi.nlm.nih.gov/13441073/

59. Grasgruber, P., et al., Food consumption and the actual statistics of cardiovascular diseases: an epidemiological comparison of 42 European countries. Food Nutr Res, 2016. 60: p. 31694. https://www.ncbi.nlm.nih.gov/pubmed/27680091

60. Young, S.S. and A. Karr, Deming, data and observational studies. Significance, 2011. 8(3): p. 116-120. https://doi.org/10.1111/j.1740-9713.2011.00506.x

61. Appleby, P.N., et al., Mortality in vegetarians and comparable nonvegetarians in the United Kingdom. The American journal of clinical nutrition, 2016. 103(1): p. 218-230. https://www.ncbi.nlm.nih.gov/pubmed/26657045

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691673/

62. Mihrshahi, S., et al., Vegetarian diet and all-cause mortality: Evidence from a large population-based Australian cohort - the 45 and Up Study. Prev Med, 2017. 97: p. 1-7. https://pubmed.ncbi.nlm.nih.gov/28040519/

63. Archer, E., G. Pavela, and C.J. Lavie, The Inadmissibility of What We Eat in America and NHANES Dietary Data in Nutrition and Obesity Research and the Scientific Formulation of National Dietary Guidelines. Mayo Clin Proc, 2015. 90(7): p. 911-26. 

64. Archer, E., M.L. Marlow, and C.J. Lavie, Controversy and debate: Memory-Based Methods Paper 1: the fatal flaws of food frequency questionnaires and other memory-based dietary assessment methods. J Clin Epidemiol, 2018. 104: p. 113-124. http://www.sciencedirect.com/science/article/pii/S0895435617313756

65. Ioannidis, J.A., The challenge of reforming nutritional epidemiologic research. JAMA, 2018. http://dx.doi.org/10.1001/jama.2018.11025

66. Ioannidis, J., Why Most Published Research Findings Are False. PLoS medicine, 2005. 2: p. e124. https://doi.org/10.1371/journal.pmed.0020124

67. Ornish, D., et al., Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 1990. 336(8708): p. 129-33. https://pubmed.ncbi.nlm.nih.gov/1973470/

68. Howard, B.V., et al., Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA, 2006. 295(6): p. 655-66. https://www.ncbi.nlm.nih.gov/pubmed/16467234

69. Beresford, S.A., et al., Low-fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA, 2006. 295(6): p. 643-54. https://www.ncbi.nlm.nih.gov/pubmed/16467233

70. Prentice, R.L., et al., Low-fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA, 2006. 295(6): p. 629-42. https://www.ncbi.nlm.nih.gov/pubmed/16467232

71. Taubes, G., Good calories, bad calories : challenging the conventional wisdom on diet, weight control, and disease. 1st ed. 2007, New York: Knopf. xxv, 601 p. Table of contents only http://www.loc.gov/catdir/toc/ecip0711/2007006794.html

72. Ramsden, C.E., et al., Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis. BMJ : British Medical Journal, 2013. 346: p. e8707. http://www.bmj.com/content/346/bmj.e8707.abstract

73. Khaw, K.-T., et al., Randomised trial of coconut oil, olive oil or butter on blood lipids and other cardiovascular risk factors in healthy men and women. BMJ Open, 2018. 8(3): p. e020167. http://bmjopen.bmj.com/content/8/3/e020167.abstract

74. Creighton, B.C., et al., Paradox of hypercholesterolaemia in highly trained, keto-adapted athletes. BMJ Open Sport & Exercise Medicine, 2018. 4(1). http://bmjopensem.bmj.com/content/4/1/e000429.abstract

75. Phinney, S.D., et al., The transient hypercholesterolemia of major weight loss. Am J Clin Nutr, 1991. 53(6): p. 1404-10. 

76. Hockley, T.G., M, European Cholesterol Guidelines Report. 2017: P.A. Centre. https://policy-centre.com/wp-content/uploads/2017/04/European-Cholesterol-Guidelines07.pdf

77. Bartlett, J., et al., Is Isolated Low High-Density Lipoprotein Cholesterol a Cardiovascular Disease Risk Factor? New Insights From the Framingham Offspring Study. Circ Cardiovasc Qual Outcomes, 2016. 9(3): p. 206-212. https://pubmed.ncbi.nlm.nih.gov/27166203/

78. Assmann, G. and H. Schulte, Relation of high-density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (the PROCAM experience). Prospective Cardiovascular Münster study. Am J Cardiol, 1992. 70(7): p. 733-7. 

79. Kawamoto, R., et al., Low density lipoprotein cholesterol and all-cause mortality rate: findings from a study on Japanese community-dwelling persons. Lipids in Health and Disease, 2021. 20(1): p. 105. https://doi.org/10.1186/s12944-021-01533-6

80. Feinman, R.D. and J.S. Volek, Low carbohydrate diets improve atherogenic dyslipidemia even in the absence of weight loss. Nutrition & metabolism, 2006. 3: p. 24-24. https://www.ncbi.nlm.nih.gov/pubmed/16790045

https://www.ncbi.nlm.nih.gov/pmc/PMC1488852/

81. Volek, J.S., et al., Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Progress in Lipid Research, 2008. 47(5): p. 307-318. http://www.sciencedirect.com/science/article/pii/S0163782708000167

82. Hallberg, S.J., et al., Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther, 2018. 9(2): p. 583-612. https://pubmed.ncbi.nlm.nih.gov/29417495/

83. Borén, J., et al., Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel. European Heart Journal, 2020. 41(24): p. 2313-2330. https://doi.org/10.1093/eurheartj/ehz962

84. Penson, P.E., et al., Associations between very low concentrations of low density lipoprotein cholesterol, high sensitivity C-reactive protein, and health outcomes in the Reasons for Geographical and Racial Differences in Stroke (REGARDS) study. Eur Heart J, 2018. 39(40): p. 3641-3653. https://pubmed.ncbi.nlm.nih.gov/30165636/

85. Willeit, P., et al., Low-Density Lipoprotein Cholesterol Corrected for Lipoprotein(a) Cholesterol, Risk Thresholds, and Cardiovascular Events. J Am Heart Assoc, 2020. 9(23): p. e016318. https://pubmed.ncbi.nlm.nih.gov/33222611/

86. Noto, H., et al., Low-Carbohydrate Diets and All-Cause Mortality: A Systematic Review and Meta-Analysis of Observational Studies. PLOS ONE, 2013. 8(1): p. e55030. https://doi.org/10.1371/journal.pone.0055030

87. Mazidi, M., et al., P5409Low-carbohydrate diets and all-cause and cause-specific mortality: a population-based cohort study and pooling prospective studies. European Heart Journal, 2018. 39(suppl_1). https://doi.org/10.1093/eurheartj/ehy566.P5409

88. Seidelmann, S.B., et al., Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. The Lancet Public Health, 2018. 3(9): p. e419-e428. http://www.sciencedirect.com/science/article/pii/S246826671830135X

https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(18)30135-X.pdf

89. Lagiou, P., et al., Low carbohydrate-high protein diet and mortality in a cohort of Swedish women. J Intern Med, 2007. 261(4): p. 366-74. https://pubmed.ncbi.nlm.nih.gov/17391111/

90. Trichopoulou, A., et al., Low-carbohydrate-high-protein diet and long-term survival in a general population cohort. Eur J Clin Nutr, 2007. 61(5): p. 575-81. https://pubmed.ncbi.nlm.nih.gov/17136037/

91. Fung, T.T., et al., Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med, 2010. 153(5): p. 289-98. https://pubmed.ncbi.nlm.nih.gov/20820038/

92. Nilsson, L.M., et al., Low-carbohydrate, high-protein score and mortality in a northern Swedish population-based cohort. Eur J Clin Nutr, 2012. 66(6): p. 694-700. https://www.nature.com/articles/ejcn20129.pdf

93. Johnston, B.C., et al., Comparison of Weight Loss Among Named Diet Programs in Overweight and Obese Adults: A Meta-analysis. JAMA, 2014. 312(9): p. 923-933. https://doi.org/10.1001/jama.2014.10397

94. Buga, A., et al., Extended Ketogenic Diet and Physical Training Intervention in Military Personnel. Military Medicine, 2019. 184(9-10): p. e538-e547. https://dx.doi.org/10.1093/milmed/usz046

95. Chawla, S., et al., The Effect of Low-Fat and Low-Carbohydrate Diets on Weight Loss and Lipid Levels: A Systematic Review and Meta-Analysis. Nutrients, 2020. 12(12). https://pubmed.ncbi.nlm.nih.gov/33317019/

96. Falkenhain, K., et al., Keyto App and Device versus WW App on Weight Loss and Metabolic Risk in Adults with Overweight or Obesity: A Randomized Trial. Obesity, 2021. https://pubmed.ncbi.nlm.nih.gov/34124856/

97. Aamodt, S., Why Diets Make Us Fat: The Unintended Consequences of Our Obsession with Weight Loss. 2016. 204. https://amzn.to/3CptAFM

98. Fothergill, E., et al., Persistent metabolic adaptation 6 years after "The Biggest Loser" competition. Obesity (Silver Spring), 2016. 24(8): p. 1612-9. https://pubmed.ncbi.nlm.nih.gov/27136388/

99. McKenzie, A.L., et al., Type 2 Diabetes Prevention Focused on Normalization of Glycemia: A Two-Year Pilot Study. Nutrients, 2021. 13(3): p. 749. https://www.mdpi.com/2072-6643/13/3/749

100. Murphy, N.E., C.T. Carrigan, and L.M. Margolis, High-Fat Ketogenic Diets and Physical Performance: A Systematic Review. Advances in Nutrition, 2020. https://doi.org/10.1093/advances/nmaa101

101. Gardner, C.D., et al., 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: The DIETFITS Randomized Clinical Trial.JAMA, 2018. 319(7): p. 667-679. https://doi.org/10.1001/jama.2018.0245

102. Ludwig, D.S., et al., The carbohydrate-insulin model: a physiological perspective on the obesity pandemic.The American Journal of Clinical Nutrition, 2021. https://doi.org/10.1093/ajcn/nqab270

103. Aronica, L., et al., Examining differences between overweight women and men in 12-month weight loss study comparing healthy low-carbohydrate vs. low-fat diets. International Journal of Obesity, 2020. https://doi.org/10.1038/s41366-020-00708-y

104. Lindeberg, S., et al., Age relations of cardiovascular risk factors in a traditional Melanesian society: the Kitava Study. The American Journal of Clinical Nutrition, 1997. 66(4): p. 845-852. https://pubmed.ncbi.nlm.nih.gov/9322559/

105. Lindeberg, S., et al., Low serum insulin in traditional Pacific Islanders--the Kitava Study. Metabolism, 1999. 48(10): p. 1216-9. https://www.metabolismjournal.com/article/S0026-0495(99)90258-5/pdf

106. Sacks, F.M., et al., Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association. Circulation, 2017. 136(3): p. e1-e23. https://pubmed.ncbi.nlm.nih.gov/28620111/

107. Blasbalg, T.L., et al., Changes in consumption of omega-3 and omega-6 fatty acids in the United States during the 20th century. Am J Clin Nutr, 2011. 93(5): p. 950-62. https://pubmed.ncbi.nlm.nih.gov/21367944/

108. Alvheim, A.R., et al., Dietary linoleic acid elevates endogenous 2-arachidonoylglycerol and anandamide in Atlantic salmon (Salmo salar L.) and mice, and induces weight gain and inflammation in mice. Br J Nutr, 2013. 109(8): p. 1508-17. https://pubmed.ncbi.nlm.nih.gov/22883314/

109. Alvheim, A.R., et al., Dietary linoleic acid elevates the endocannabinoids 2-AG and anandamide and promotes weight gain in mice fed a low fat diet. Lipids, 2014. 49(1): p. 59-69. https://pubmed.ncbi.nlm.nih.gov/24081493/

110. Desmarchelier, C., et al., Diet-induced obesity in ad libitum-fed mice: food texture overrides the effect of macronutrient composition. British Journal of Nutrition, 2013. 109(8): p. 1518-1527. https://www.cambridge.org/core/article/dietinduced-obesity-in-ad-libitumfed-mice-food-texture-overrides-the-effect-of-macronutrient-composition/725D71275CF7399332CEC8C9C76BE23F

111. Hall, K.D., et al., Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metab, 2019. 30(1): p. 67-77.e3. https://pubmed.ncbi.nlm.nih.gov/31105044/

112. Heaton, K.W., et al., Particle size of wheat, maize, and oat test meals: effects on plasma glucose and insulin responses and on the rate of starch digestion in vitro. The American Journal of Clinical Nutrition, 1988. 47(4): p. 675-682. https://doi.org/10.1093/ajcn/47.4.675

113. Juntunen, K.S., et al., Postprandial glucose, insulin, and incretin responses to grain products in healthy subjects. The American Journal of Clinical Nutrition, 2002. 75(2): p. 254-262. https://doi.org/10.1093/ajcn/75.2.254

114. Juntunen, K.S., et al., Structural differences between rye and wheat breads but not total fiber content may explain the lower postprandial insulin response to rye bread. The American Journal of Clinical Nutrition, 2003. 78(5): p. 957-964. https://doi.org/10.1093/ajcn/78.5.957

115. Sumithran, P., et al., Ketosis and appetite-mediating nutrients and hormones after weight loss. Eur J Clin Nutr, 2013. 67(7): p. 759-64. https://www.ncbi.nlm.nih.gov/pubmed/23632752

116. Phinney, S.D., et al., The human metabolic response to chronic ketosis without caloric restriction: preservation of submaximal exercise capability with reduced carbohydrate oxidation. Metabolism, 1983. 32(8): p. 769-76. https://pubmed.ncbi.nlm.nih.gov/6865776/

117. Hill, J.C. and I.S. Millan, Validation of musculoskeletal ultrasound to assess and quantify muscle glycogen content. A novel approach. Phys Sportsmed, 2014. 42(3): p. 45-52. https://pubmed.ncbi.nlm.nih.gov/25295766/

118. Greene, J., et al., State-of-the-Art Methods for Skeletal Muscle Glycogen Analysis in Athletes - The Need for Novel Non-Invasive Techniques. Biosensors, 2017. 7. https://www.ncbi.nlm.nih.gov/pubmed/28241495

119. Hettinga, F.J., A.M. Edwards, and B. Hanley, The Science Behind Competition and Winning in Athletics: Using World-Level Competition Data to Explore Pacing and Tactics. Frontiers in Sports and Active Living, 2019. 1(11). https://www.frontiersin.org/article/10.3389/fspor.2019.00011

120. Burke, L.M., Re-Examining High-Fat Diets for Sports Performance: Did We Call the 'Nail in the Coffin' Too Soon? Sports Med, 2015. 45 Suppl 1(Suppl 1): p. S33-49. https://pubmed.ncbi.nlm.nih.gov/26553488/

121. Stellingwerff, T., et al., Decreased PDH activation and glycogenolysis during exercise following fat adaptation with carbohydrate restoration. American Journal of Physiology - Endocrinology And Metabolism, 2006. 290(2): p. 380-388. https://pubmed.ncbi.nlm.nih.gov/16188909/

122. Peters, S.J., Regulation of PDH activity and isoform expression: diet and exercise. Biochemical Society Transactions, 2003. 31(6): p. 1274-1280. http://www.biochemsoctrans.org/content/ppbiost/31/6/1274.full.pdf

123. Wood, T., Lost Metabolic Machinery During Ketosis? Depends Where You Are Looking. Strength & Conditioning Journal, 2017. 39(5). https://journals.lww.com/nsca-scj/Fulltext/2017/10000/Lost_Metabolic_Machinery_During_Ketosis__Depends.13.aspx

124. Burke, L.M., et al., Low carbohydrate, high fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers. J Physiol, 2017. 595(9): p. 2785-2807. https://pubmed.ncbi.nlm.nih.gov/28012184/

125. Shaw, D.M., et al., Effect of a Ketogenic Diet on Submaximal Exercise Capacity and Efficiency in Runners.Med Sci Sports Exerc, 2019. 51(10): p. 2135-2146. https://pubmed.ncbi.nlm.nih.gov/31033901/

126. Burke, L.M., et al., Crisis of confidence averted: Impairment of exercise economy and performance in elite race walkers by ketogenic low carbohydrate, high fat (LCHF) diet is reproducible. PLoS One, 2020. 15(6): p. e0234027. https://pubmed.ncbi.nlm.nih.gov/32497061/

127. Burke, L.M. and J.A. Hawley, Swifter, higher, stronger: What’s on the menu? Science, 2018. 362(6416): p. 781. http://science.sciencemag.org/content/362/6416/781.abstract

128. Miller, V.J., et al., A ketogenic diet combined with exercise alters mitochondrial function in human skeletal muscle while improving metabolic health. American Journal of Physiology-Endocrinology and Metabolism, 2020. https://doi.org/10.1152/ajpendo.00305.2020

129. Lane, N., A unifying view of ageing and disease: The double-agent theory. Journal of theoretical biology, 2004. 225: p. 531-40. https://pubmed.ncbi.nlm.nih.gov/14615212/

130. Miller, V.J., F.A. Villamena, and J.S. Volek, Nutritional Ketosis and Mitohormesis: Potential Implications for Mitochondrial Function and Human Health. Journal of nutrition and metabolism, 2018. 2018: p. 5157645-5157645. https://pubmed.ncbi.nlm.nih.gov/29607218

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828461/

131. San-Millán, I. and G.A. Brooks, Assessment of Metabolic Flexibility by Means of Measuring Blood Lactate, Fat, and Carbohydrate Oxidation Responses to Exercise in Professional Endurance Athletes and Less-Fit Individuals.Sports Medicine, 2018. 48(2): p. 467-479. https://doi.org/10.1007/s40279-017-0751-x

132. Cipryan, L., et al., Effects of a 4-Week Very Low-Carbohydrate Diet on High-Intensity Interval Training Responses. Journal of Sports Science & Medicine, 2018. 17(2): p. 259-268. https://www.ncbi.nlm.nih.gov/pubmed/29769827

https://www.ncbi.nlm.nih.gov/pmc/PMC5950743/

133. Prins, P.J., et al., High Rates of Fat Oxidation Induced by a Low-Carbohydrate, High-Fat Diet, Do Not Impair 5-km Running Performance in Competitive Recreational Athletes. J Sports Sci Med, 2019. 18(4): p. 738-750. 

134. McSwiney, F.T., et al., Keto-adaptation enhances exercise performance and body composition responses to training in endurance athletes. Metabolism, 2018. 81: p. 25-34. https://pubmed.ncbi.nlm.nih.gov/29208366/

135. Mirtschin, J.G., et al., Organization of Dietary Control for Nutrition-Training Intervention Involving Periodized Carbohydrate Availability and Ketogenic Low-Carbohydrate High-Fat Diet. International Journal of Sport Nutrition and Exercise Metabolism, 2018. 28(5): p. 480-489. https://journals.humankinetics.com/view/journals/ijsnem/28/5/article-p480.xml

136. Dostal, T., et al., Effects of a 12-Week Very-Low Carbohydrate High-Fat Diet on Maximal Aerobic Capacity, High-Intensity Intermittent Exercise, and Cardiac Autonomic Regulation: Non-randomized Parallel-Group Study.Frontiers in Physiology, 2019. 10(912). https://www.frontiersin.org/article/10.3389/fphys.2019.00912

137. Volek, J.S., et al., Metabolic characteristics of keto-adapted ultra-endurance runners. Metabolism, 2016. 65(3): p. 100-110. http://www.sciencedirect.com/science/article/pii/S0026049515003340

138. Areta, J.L. and W.G. Hopkins, Skeletal Muscle Glycogen Content at Rest and During Endurance Exercise in Humans: A Meta-Analysis. Sports Med, 2018. 48(9): p. 2091-2102. https://pubmed.ncbi.nlm.nih.gov/29923148/

139. Brooks, G.A., The Science and Translation of Lactate Shuttle Theory. Cell Metab, 2018. 27(4): p. 757-785. https://pubmed.ncbi.nlm.nih.gov/29617642/

140. Greene, D.A., et al., A Low-Carbohydrate Ketogenic Diet Reduces Body Mass Without Compromising Performance in Powerlifting and Olympic Weightlifting Athletes. J Strength Cond Res, 2018. 32(12): p. 3373-3382. https://pubmed.ncbi.nlm.nih.gov/30335720/

141. Hetlelid, K.J., et al., Rethinking the role of fat oxidation: substrate utilisation during high-intensity interval training in well-trained and recreationally trained runners. BMJ Open Sport & Exercise Medicine, 2015. 1(1). http://bmjopensem.bmj.com/content/1/1/e000047.abstract

142. Cahill, G.F., Jr., Fuel metabolism in starvation. Annu Rev Nutr, 2006. 26: p. 1-22. https://pubmed.ncbi.nlm.nih.gov/16848698/

143. Cox, P., et al., Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes. Cell Metabolism, 2016. 24. https://pubmed.ncbi.nlm.nih.gov/27475046/

144. Sherman, W.M., et al., Effect of exercise-diet manipulation on muscle glycogen and its subsequent utilization during performance. Int J Sports Med, 1981. 2(2): p. 114-8. https://pubmed.ncbi.nlm.nih.gov/7333741/

145. MacLeod, D., et al., Physiological determinants of climbing-specific finger endurance and sport rock climbing performance. J Sports Sci, 2007. 25(12): p. 1433-43. 

146. Ortega, J.O., et al., Muscle force, work and cost: a novel technique to revisit the Fenn effect. J Exp Biol, 2015. 218(Pt 13): p. 2075-82. https://pubmed.ncbi.nlm.nih.gov/25964423/

147. Hargreaves, M. and L.L. Spriet, Skeletal muscle energy metabolism during exercise. Nature Metabolism, 2020. https://doi.org/10.1038/s42255-020-0251-4

148. Baker, J.S., M.C. McCormick, and R.A. Robergs, Interaction among Skeletal Muscle Metabolic Energy Systems during Intense Exercise. Journal of nutrition and metabolism, 2010. 2010: p. 905612-905612. https://pubmed.ncbi.nlm.nih.gov/21188163

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3005844/

149. Newcomer, B.R., M.D. Boska, and H.P. Hetherington, Non-Pi buffer capacity and Initial phosphocreatine breakdown and resynthesis kinetics of human gastrocnemius/soleus muscle groups using 0.5 s time-resolved 31P MRS at 4.1 T. NMR in Biomedicine, 1999. 12(8): p. 545-551. https://pubmed.ncbi.nlm.nih.gov/10668047/

150. Artioli, G.G., et al., Determining the contribution of the energy systems during exercise. J Vis Exp, 2012(61). https://pubmed.ncbi.nlm.nih.gov/22453254/