Chapter 18. Nutritional Issues

Threats to Health

Chronic Diseases

Chronic diseases are ongoing, life-threatening, and life-altering health challenges. They are the leading cause of death worldwide. Chronic conditions are increasing in frequency. They cause significant physical and emotional suffering and are an impediment to economic growth and vitality. It is important, now more than ever, to understand the different risk factors for chronic disease and to learn how to prevent their development.

The Risk Factors of Chronic Disease

A risk factor is a signal that your chances for acquiring a chronic disease may be increased. You might liken a risk factor to the flags that lifeguards sometimes set up at beaches. When you see these flags, you know immediately that swimming within the marked areas could be hazardous, and that if you choose to swim within these parameters anyway, you are doing so at your own risk. But, if you heed the warnings, you are taking the necessary step to protect your safety and health. Similarly, risk factors are warning signs that coincide with the development and progression of disease. However, risk factors are not a 100-percent guarantee that a person will develop a chronic disease, only that the conditions are right. For example, if a person gets sick with the flu, we can say with certainty that the illness was caused by a virus. However, we cannot say that a sedentary lifestyle caused the onset of cardiovascular disease in a patient, because a risk factor indicates a correlation, not a causation.

Chronic disease usually develops alongside a combination of the following risk factors: genetics, a prior disease such as obesity or hypertension, dietary and lifestyle choices, and environmental problems. Risk factors such as genetics and age cannot be changed. However, some risk factors can be altered to promote health and wellness,such as diet. For example, a person who continuously eats a diet high in sugars, saturated fats, and red meat is at risk for becoming obese and developing Type 2 diabetes, cardiovascular disease, or several other conditions. Making more healthy dietary choices can greatly reduce that risk. Being a woman over age sixty-five is a risk factor for developing osteoporosis, but that cannot be changed. Also, people without a genetic predisposition for a particular chronic illness can still develop it. Not having a genetic predisposition for a chronic disease is not a guarantee of immunity.

Identifying Your Risk Factors

To estimate your own risk factors for developing certain chronic diseases, search through your family’s medical history. What diseases do you note showing up among close blood relatives? At your next physical, pay attention to your blood tests and ask the doctor if any results are out of normal range. It is also helpful to note your vital signs, particularly your blood pressure and resting heart rate. In addition, you may wish to keep a food diary to make a note of the dietary choices that you make on a regular basis and be aware of foods that are high in saturated fat, among other unhealthy options. As a general rule, it is important to look for risk factors that you can modify to promote your health. For example, if you discover that your grandmother, aunt, and uncle all suffered from high blood pressure, then you may decide to avoid a high sodium diet. Identifying your risk factors can arm you with the information you need to help ward off disease.

The Crisis of Obesity

Excessive weight gain has become an epidemic. According to the National Institutes of Health, over two-thirds of American adults are overweight, and one in three is obese. Obesity in particular puts people at risk for a host of complications, including Type 2 diabetes, heart disease, high cholesterol, hypertension, osteoarthritis, and some forms of cancer. The more overweight a person is, the greater his or her risk of developing life-threatening complications. There is no single cause of obesity and no single way to treat it. However, a healthy, nutritious diet is generally the first step, including consuming more fruits and vegetables, whole grains, and lean meats and dairy products.[1]

Cardiovascular Disease

Throughout the remainder of this section, we will examine some of the more prevalent chronic diseases, their risk factors, and the choices that can help to discourage their development or progression. Let’s begin with cardiovascular disease. According to the Centers for Disease Control and Prevention (CDC), heart disease is the leading cause of death in the United States.[2]

The disease generally starts with atherosclerosis, or a hardening of the arteries, a chronic condition so common that most people show signs of it by the time they turn thirty. Arteries start to narrow and harden when fats accumulate along their inner walls and form plaques. A plaque is made of fat, cholesterol, calcium, and other substances found in blood.

Plaque formation causes arteries to narrow and harden, which elevates blood pressure because the vessels can’t expand effectively to accommodate blood pulses. Higher blood pressure strains the heart and causes more damage. Arterial walls can become so weakened due to high blood pressure that they balloon and form what is known as an aneurysm. If the aneurysm bursts, it becomes a life-threatening event. The plaques themselves can also rupture due to a spike in blood pressure or a tremor along an arterial wall, and the body responds to this perceived injury by forming blood clots. These clots are serious health threats, whether they are stationary (a thrombus) or moving (an embolus). A stable clot can slowly kill off surrounding tissue, or grow so big that it blocks blood circulation and causes thrombosis. When a moving clot becomes stuck in an artery too small for its passage, it cuts off blood flow and causes cell death. This is referred to as an embolism. Blood clots in heart and brain arteries can cause heart attacks or strokes.

Table 18.2 The Risk Factors for Cardiovascular Disease

Unmodifiable Risk Factors Modifiable Risk Factors
  • Age. Risk increases for men at forty-five, and for women at fifty-five.
  • Sex. Men have a higher risk than women, though the risk for women steeply rises after menopause.
  • Family history. The more family members who have heart disease, the greater the risk.
  • Cigarette smoking. Nicotine constricts blood vessels, and carbon monoxide damages their inner lining, which increases the risk of atherosclerosis.
  • Obesity. Excess weight worsens other risk factors.
  • Diabetes. This condition is associated with an increased risk of heart disease. Both types have certain risk factors in common, including obesity and high blood pressure.
  • Physical inactivity. Lack of exercise is associated with heart disease.
  • Cholesterol levels. High levels of blood cholesterol can increase the risk. A high level of low-density lipoprotein (LDL), or the “bad” cholesterol, is a common contributing factor. However, a low level of high-density lipoprotein (HDL), or “good” cholesterol, can also promote atherosclerosis.

Steps to Reducing the Risk of Cardiovascular Disease

Diet and nutrition can play a significant role in reducing the risk of cardiovascular disease. It is helpful to lower sodium intake, increase consumption of dietary fiber, and limit consumption of saturated fat, which promotes plaque formation. In addition, it is important to replace refined starches and added sugar, which can boost triglycerides, with whole grains, fruits, and vegetables. Eating foods rich in omega-3 fatty acids, especially fish, using alcohol in moderation, and opting for low or no-fat dairy products can all help reduce your cardiovascular disease risk. Emphasizing vegetable-based sources of protein, such as beans and legumes, can be beneficial, as well as consuming more soy products. It is also important to maintain a healthy weight and avoid smoking or chewing tobacco.


Chronic high blood pressure, also known as hypertension, is a significant health hazard affecting one out of three adults in the United States.[3] This chronic condition is a major cause of heart attacks and strokes, yet it has no symptoms until blood pressure reaches very high levels, which is why it is known as “the silent killer.” The only way to find out if you have high blood pressure is to get an accurate reading of your resting blood pressure rate, which is best done by a medical professional and should be monitored regularly.

High blood pressure is such an important factor in cardiovascular disease, that keeping it within a healthy range is vitally important. Blood pressure readings consist of two numbers. The top number measures systolic pressure (when the heart contracts) and the bottom number measures diastolic pressure (when the heart is at rest). The key blood pressure numbers to keep in mind are:

  • Ideal. 120 over 80 or below
  • Prehypertension. Higher than 120 over 80 and lower than 139 over 89
  • Hypertension. Greater than 139 over 89

Table 18.3 The Risk Factors for Hypertension

Unmodifiable Risk Factors Modifiable Risk Factors
  • Age. After fifty-five, the risk of developing high blood pressure is 90 percent.
  • Race. African-Americans are more likely to develop hypertension, manifest it at a younger age, and have higher blood pressure readings.
  • Family history. There is a strong genetic component to high blood pressure, and an individual’s risk goes up along with the number of family members who have hypertension.
  • Weight. Roughly 60 percent of people with hypertension are obese.
  • Sodium consumption. The more salt in a person’s diet, the more likely they are to have high blood pressure.
  • Alcohol. Drinking more than two drinks per day for men and one drink for women increases the likelihood of hypertension.
  • Diet. In addition to salt and alcohol consumption, other dietary factors increase chances of developing hypertension.

Steps to Reducing the Risk of High Blood Pressure

Although it is not possible to change one’s age or genetics, there are actions that people can take to decrease their risk of hypertension. Techniques to reduce blood pressure include becoming physically active, maintaining a healthy weight, reducing sodium intake below 2,400 milligrams per day (or below 1,500 milligrams if you are in a high-risk group or already have been diagnosed with hypertension), using alcohol moderately, and following the DASH diet. Additionally, vitamin C, calcium, and potassium have all been shown to promote healthy blood pressure. It is also vital to monitor your blood pressure levels on a regular basis. Prompt intervention when readings rise above the ideal level (120 over 80) can save lives, which is why everyone should know the status of their blood pressure.


More than one hundred diseases are classified as different forms of cancer, all of them characterized by the uncontrolled growth of abnormal cells. Cancer is triggered by mutations in a cell’s genetic material. The cause of these changes may be inherited, or it may result from exposure to carcinogens, which are agents that can cause cancer. Carcinogens include chemicals, viruses, certain medical treatments such as radiation, pollution, or other substances and exposures that are known or suspected to cause cancer.[4] The National Institutes of Health has classified fifty-four different compounds as known cancer-causing agents in humans.[5]

Under normal conditions, a healthy cell will either repair any damage that has been done or self destruct so that no future cells will be affected. Cells become cancerous when their DNA is damaged, but they do not self-destruct or stop reproducing as normal cells would. As these abnormal cells continue their rapid growth, in most cancers they coalesce in a mass called a tumor. Cancer cells can overwhelm healthy cells and interfere with the healthy functioning of the body. They can also invade other organs and spread throughout the body in a process known as metastasis. Scientists and the medical community are giving considerable attention to the early stages of cancer, from the moment a healthy cell is exposed to a carcinogen to the point where cells with damaged DNA are replicating out of control. Intervention at any of these early stages could prove to be quite beneficial, because it is thought that most cancers are the result of lifestyle choices and environmental exposure.

The risk factors for different cancers can vary. For example, exposure to ultraviolet radiation from the sun and from tanning beds is a risk factor for skin cancer, while exposure to asbestos is a risk factor for mesothelioma cancer. Table 18.4 “The Risk Factors for Cancer” shows some common risk factors for a number of different types of cancer.

Table 18.4 The Risk Factors for Cancer

Unmodifiable Risk Factors Modifiable Risk Factors
  • Age. Most cancers occur in people over the age of sixty-five. However, people of all ages, including children, can get cancer.
  • Family history. Certain types of cancer have a genetic link. However, environmental factors may also play a part.
  • Tobacco. Smoking or chewing tobacco greatly increases the risk for certain cancers, including cancer of the lungs, bladder, cervix, kidneys, mouth, and pancreas.
  • Alcohol. Drinking alcohol is linked to cancers of the mouth, throat, esophagus, and breast, as well as to cancers of the neck and head.
  • Obesity. Linked to cancers of the colon, uterus, pancreas, esophagus, kidney, and breast.
  • Cooking techniques. Grilling, smoking, and preparing meat at high temperatures forms carcinogens.
  • Red meat. The risk of colon cancer seems to increase with the consumption of red meat and processed meat.
  • Cured meats. According to a recent study, there is a mild risk of pancreatic cancer with the consumption of cured meats, such as sausage, pepperoni, bacon, ham, smoked turkey, salami, and hot dogs.
  • Physical inactivity. Linked to colon, breast, and other cancers.
  • Exposure to chemicals. People who have jobs that expose them to chemicals on a regular basis, such as construction workers and painters, have an increased risk of cancer.
  • Viruses or bacteria. Certain viruses or bacteria may increase the risk of developing cancer. For example, human papillomaviruses, which are sexually transmitted, are the primary cause of cervical cancer.

Steps to Reducing the Risk of Cancer

According to the American Cancer Society, half of all American men and one-third of American women will be diagnosed with some form of cancer in their lifetime.[6] Although cancer is one of the leading causes of death worldwide, ongoing research and innovations in treatment have improved the outlook for cancer patients to the point where millions now survive or live with cancer, making it a chronic disease.

The American Institute for Cancer Research (AICR) has published guidelines for preventing cancer and staying healthy. They include several dietary and lifestyle choices, such as participating in physical activity for thirty minutes per day or more, and maintaining a healthy weight. In addition, AICR recommends consuming a plant-based diet.[7]

Several epidemiological studies have found a link between eating plenty of fruits and vegetables and a low incidence of certain cancers. Fruits and vegetables containing a wide variety of nutrients and phytochemicals may either prevent or reduce the oxidative damage to cell structures. Cruciferous vegetables, such as cauliflower, broccoli, and Brussels sprouts, may also reduce the risk of certain cancers, such as endometrial, esophageal, and others. Also, studies have shown that the more fiber you have in your diet, the lower your risk of colon cancer.

Supplementation may also be helpful to a limited degree. Vitamin D and antioxidants have been linked to lowering the risk of some cancers (however taking an iron supplement may promote others), but, obtaining vital nutrients from food first is the best way to help prevent or manage cancer. In addition, regular and vigorous exercise can lower the risk of breast and colon cancers, among others. Also, wear sunblock, stay in the shade, and avoid the midday sun to protect yourself from skin cancer, which is one of the most common kinds of cancer.[8]


What Is Diabetes?

Diabetes is one of the top three diseases in America. It affects millions of people and causes tens of thousands of deaths each year. Diabetes is a metabolic disease of insulin deficiency and glucose over-sufficiency. Like other diseases, genetics, nutrition, environment, and lifestyle are all involved in determining a person’s risk for developing diabetes. One sure way to decrease your chances of getting diabetes is to maintain an optimal body weight by adhering to a diet that is balanced in carbohydrate, fat, and protein intake. There are three different types of diabetes: Type 1 diabetes, Type 2 diabetes, and gestational diabetes.

Type 1 Diabetes

Type 1 diabetes is a metabolic disease in which insulin-secreting cells in the pancreas are killed by an abnormal response of the immune system, causing a lack of insulin in the body. Its onset typically occurs before the age of thirty. The only way to prevent the deadly symptoms of this disease is to inject insulin under the skin.

A person with Type 1 diabetes usually has a rapid onset of symptoms that include hunger, excessive thirst and urination, and rapid weight loss. Because the main function of glucose is to provide energy for the body, when insulin is no longer present there is no message sent to cells to take up glucose from the blood. Instead, cells use fat and proteins to make energy, resulting in weight loss. If Type 1 diabetes goes untreated individuals with the disease will develop a life-threatening condition called ketoacidosis. This condition occurs when the body uses fats and not glucose to make energy, resulting in a build-up of ketone bodies in the blood. It is a severe form of ketosis with symptoms of vomiting, dehydration, rapid breathing, and confusion and eventually coma and death. Upon insulin injection these severe symptoms are treated and death is avoided. Unfortunately, while insulin injection prevents death, it is not considered a cure. People who have this disease must adhere to a strict diet to prevent the development of serious complications. Type 1 diabetics are advised to consume a diet low in the types of carbohydrates that rapidly spike glucose levels (high-GI foods), to count the carbohydrates they eat, to consume healthy-carbohydrate foods, and to eat small meals frequently. These guidelines are aimed at preventing large fluctuations in blood glucose. Frequent exercise also helps manage blood-glucose levels. Type 1 diabetes accounts for between 5 and 10 percent of diabetes cases.

Type 2 Diabetes

The other 90 to 95 percent of diabetes cases are Type 2 diabetes. Type 2 diabetes is defined as a metabolic disease of insulin insufficiency, but it is also caused by muscle, liver, and fat cells no longer responding to the insulin in the body (Figure 18.4 “Healthy Individuals and Type 2 Diabetes” . In brief, cells in the body have become resistant to insulin and no longer receive the full physiological message of insulin to take up glucose from the blood. Thus, similar to patients with Type 1 diabetes, those with Type 2 diabetes also have high blood-glucose levels.

Figure 18.4 Healthy Individuals and Type 2 Diabetes

For Type 2 diabetics, the onset of symptoms is more gradual and less noticeable than for Type 1 diabetics. The first stage of Type 2 diabetes is characterized by high glucose and insulin levels. This is because the insulin-secreting cells in the pancreas attempt to compensate for insulin resistance by making more insulin. In the second stage of Type 2 diabetes, the insulin-secreting cells in the pancreas become exhausted and die. At this point, Type 2 diabetics also have to be treated with insulin injections. Healthcare providers is to prevent the second stage from happening. As with Type 1 diabetes, chronically high-glucose levels cause big detriments to health over time, so another goal for patients with Type 2 diabetes is to properly manage their blood-glucose levels. The front-line approach for treating Type 2 diabetes includes eating a healthy diet and increasing physical activity.

The Centers for Disease Control Prevention (CDC) estimates that as of 2010, 25.8 million Americans have diabetes, which is 8.3 percent of the population.[9] In 2007 the cost of diabetes to the United States was estimated at $174 billion.[10] The incidence of Type 2 diabetes has more than doubled in America in the past thirty years and the rise is partly attributed to the increase in obesity in this country. Genetics, environment, nutrition, and lifestyle all play a role in determining a person’s risk for Type 2 diabetes. We have the power to change some of the determinants of disease but not others. The Diabetes Prevention Trial that studied lifestyle and drug interventions in more than three thousand participants who were at high risk for Type 2 diabetes found that intensive lifestyle intervention reduced the chances of getting Type 2 diabetes by 58 percent.[11]

Gestational Diabetes

During pregnancy some women develop gestational diabetes. Gestational diabetes is characterized by high blood-glucose levels and insulin resistance. The exact cause is not known but does involve the effects of pregnancy hormones on how cells respond to insulin. Gestational diabetes can cause pregnancy complications and it is common practice for healthcare practitioners to screen pregnant women for this metabolic disorder. The disorder normally ceases when the pregnancy is over, but the National Diabetes Information Clearing House notes that women who had gestational diabetes have between a 40 and 60 percent likelihood of developing Type 2 diabetes within the next ten years.[12] Gestational diabetes not only affects the health of a pregnant woman but also is associated with an increased risk of obesity and Type 2 diabetes in her child.


As the term infers, prediabetes is a metabolic condition in which people have moderately high glucose levels, but do not meet the criteria for diagnosis as a diabetic. Over seventy-nine million Americans are prediabetic and at increased risk for Type 2 diabetes and cardiovascular disease.[13] The National Diabetes Information Clearing House reports that 35 percent of adults aged twenty and older, and 50 percent of those over the age of sixty-five have prediabetes.[14]

Long-Term Health Consequences of Diabetes

The long-term health consequences of diabetes are severe. They are the result of chronically high glucose concentrations in the blood accompanied by other metabolic abnormalities such as high blood-lipid levels. People with diabetes are between two and four times more likely to die from cardiovascular disease. Diabetes is the number one cause of new cases of blindness, lower-limb amputations, and kidney failure. Many people with diabetes develop peripheral neuropathy, characterized by muscle weakness, loss of feeling and pain in the lower extremities. More recently, there is scientific evidence to suggest people with diabetes are also at increased risk for Alzheimer’s disease.

Diabetes Treatment

Keeping blood-glucose levels in the target range (70–130 mg/dL before a meal) requires careful monitoring of blood-glucose levels with a blood-glucose meter, strict adherence to a healthy diet, and increased physical activity. Type 1 diabetics begin insulin injections as soon as they are diagnosed. Type 2 diabetics may require oral medications and insulin injections to maintain blood-glucose levels in the target range. The symptoms of high blood glucose, also called hyperglycemia, are difficult to recognize, diminish in the course of diabetes, and are mostly not apparent until levels become very high. The symptoms are increased thirst and frequent urination. Having too low blood glucose levels, known as hypoglycemia, is also detrimental to health. Hypoglycemia is more common in Type 1 diabetics and is most often caused by injecting too much insulin or injecting it at the wrong time. The symptoms of hypoglycemia are more acute including shakiness, sweating, nausea, hunger, clamminess, fatigue, confusion, irritability, stupor, seizures, and coma. Hypoglycemia can be rapidly and simply treated by eating foods containing about ten to twenty grams of fast-releasing carbohydrates. If symptoms are severe a person is either treated by emergency care providers with an intravenous solution of glucose or given an injection of glucagon, which mobilizes glucose from glycogen in the liver. Some people who are not diabetic may experience reactive hypoglycemia. This is a condition in which people are sensitive to the intake of sugars, refined starches, and high GI foods. Individuals with reactive hypoglycemia have some symptoms of hypoglycemia. Symptoms are caused by a higher than normal increase in blood-insulin levels. This rapidly decreases blood-glucose levels to a level below what is required for proper brain function.

The major determinants of Type 2 diabetes that can be changed are overnutrition and a sedentary lifestyle. Therefore, reversing or improving these factors by lifestyle interventions markedly improve the overall health of Type 2 diabetics and lower blood-glucose levels. In fact it has been shown that when people are overweight, losing as little as nine pounds (four kilograms) decreases blood-glucose levels in Type 2 diabetics. The Diabetes Prevention Trial demonstrated that by adhering to a diet containing between 1,200 and 1,800 kilocalories per day with a dietary fat intake goal of less than 25 percent and increasing physical activity to at least 150 minutes per week, people at high risk for Type 2 diabetes achieved a weight loss of 7 percent and significantly decreased their chances of developing Type 2 diabetes.[15]

The American Diabetes Association (ADA) has a website that provides information and tips for helping diabetics answer the question, “What Can I Eat”. In regard to carbohydrates the ADA recommends diabetics keep track of the carbohydrates they eat and set a limit. These dietary practices will help keep blood-glucose levels in the target range.

Figure 18.5 Metabolic Syndrome: A Combination of Risk Factors Increasing the Chances for Chronic Disease

Having more than one risk factor for Type 2 diabetes substantially increases a person’s chances for developing the disease. Metabolic syndrome refers to a medical condition in which people have three or more risk factors for Type 2 diabetes and cardiovascular disease. According to the International Diabetes Federation (IDF) people are diagnosed with this syndrome if they have central (abdominal) obesity and any two of the following health parameters: triglycerides greater than 150 mg/dL; high density lipoproteins (HDL) lower than 40 mg/dL; systolic blood pressure above 100 mmHg, or diastolic above 85 mmHg; fasting blood-glucose levels greater than 100 mg/dL.[16] The IDF estimates that between 20 and 25 percent of adults worldwide have metabolic syndrome. Studies vary, but people with metabolic syndrome have between a 9 and 30 times greater chance for developing Type 2 diabetes than those who do not have the syndrome.[17]

Everyday Connection

In 2010, the Pacific Islands Health Officers Association declared a regional state of health emergency for the epidemic of chronic diseases in the United States Affiliated Pacific (USAP). Due to the high risk factors that many of these Pacific Islanders, the leading cause of mortality of adults in the USAP from chronic diseases. To learn more about this declaration, visit

Disease Prevention and Management

Eating fresh, healthy foods not only stimulates your taste buds, but also can improve your quality of life and help you to live longer. As discussed, food fuels your body and helps you to maintain a healthy weight. Nutrition also contributes to longevity and plays an important role in preventing a number of diseases and disorders, from obesity to cardiovascular disease. Some dietary changes can also help to manage certain chronic conditions, including high blood pressure and diabetes. A doctor or a nutritionist can provide guidance to determine the dietary changes needed to ensure and maintain your health.

  1. Overweight and Obesity Statistics.National Institute of Diabetes and Digestive and Kidney Diseases. Accessed April 15, 2018.
  2. Leading Causes of Death. Updated March 17, 2017. Accessed April 15, 2018.
  3. High Blood Pressure Facts. Center for Disease Control and Prevention. Updated April 5, 2018. Accessed April 15, 2018.
  4. Known and Probable Human Carcinogens. American Cancer Society. -human-carcinogens. Updated November 3, 2016. Accessed April 15, 2018.
  5. Israel B. How Many Cancers Are Caused by the Environment?. Published May 10, 2010. Accessed April 15, 2018.
  6. What Is Cancer? American Cancer Society. Updated December 8, 2015. Accessed April 15, 2018.
  7. Cancer Prevention and Early Detection Facts and Figures 2013. American Cancer Society. Published 2013. Accessed April 15, 2018.
  8. Cancer Prevention: 7 Steps to Reduce Your Risk. Mayo Clinic. -prevention/CA00024. Updated November 29, 2017. Accessed April 15, 2018.
  9. Diabetes Research and Statistics.Centers for Disease Control and Prevention. Updated March 14, 2018.  Accessed April 15, 2018.
  10. Diabetes Quick Facts. Centers for Disease Control and Prevention. Updated July 24, 2017. Accessed April 15, 2018.
  11. Knowler WC. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. The New England Journal of Medicine. 2002; 346(6), 393–403. Accessed April 15, 2018.
  12. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. Accessed April 15, 2018.  
  13. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. Accessed April 15, 2018.  
  14. Diabetes Overview. National Institute of Diabetes and Digestive and Kidney Disease. Accessed April 15, 2018.  
  15. Knowler WC. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. The New England Journal of Medicine. 2002; 346(6), 393–403. Accessed April 15, 2018.
  16. The IDF Consensus Worldwide Definition of the Metabolic Syndrome. International Diabetes Federation. Accessed April 15, 2018.   
  17. The IDF Consensus Worldwide Definition of the Metabolic Syndrome. International Diabetes Federation. Accessed April 15, 2018.


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