Side effects can mask improper use of medications.  They can furthermore be misinterpreted as a symptom of disease, and result in more medication(s) being prescribed.

Side effects can mask improper use of medications. They can furthermore be misinterpreted as a symptom of disease, and result in more medication(s) being prescribed.

Medications undoubtedly save millions of lives, yet, medication side effects hospitalize many patients and are a major cause of death in the United States.  Trends of medication use continue to rise as we progress through the years and, understandably, so do the number of reported cases of side effects.  Polypharmacy (or having four or more prescriptions) is especially more common, specifically in the elderly.  Many studies have found polypharmacy to have additional negative health outcomes.   Doctors and scientists speculate whether this trend is due to more medications on the market, more sophisticated means of diagnosing disease, increased knowledge and awareness, more access to healthcare or a combination therein.  Whatever the case, the increased use of medications by default poses an increased risk of adverse side effects.   Preventable side effects of medications (otherwise known as adverse drug reactions) cause tens of thousands of hospitalizations yearly, and hundreds of deaths.  One observational study included 18820 patients > 16 years old over a six month period.  1665 patients were admitted for adverse drug reactions, with a median hospital stay of eight days and an annual cost of $847 million dollars.  This same study found that almost all medication related side effects that resulted in hospitalization were preventable.

Medical experts are eluding to some side effects possibly being misinterpreted as an underlying disease, and consequently, diagnosing a patient with another disease state or more severe condition.  This may also, unfortunately, result in the prescribing more medication(s).  For instance, bupropion is a common antidepressant medication that is stimulating by nature (similar to caffeine).   If a patient were to take bupropion at night or in the late afternoon, they may have trouble sleeping.  This is clearly noted by its increased risk of insomnia on the prescription label.  If the patient is unaware that bupropion is best taken in the morning or at least eight hours before bed time, they may report this newfound insomnia to their prescriber.  The trouble is, insomnia is also a common finding in depression………so the prescriber may mistakenly take this new found complaint as worsening depression and prescribe another antidepressant or a sleep aid.  This of course could lead to further side effects from the addition of those secondary prescriptions.  This is turning out to be a fairly common occurrence, and underreported.   Remember, polypharmacy (or having four or more prescriptions) is especially common in the elderly.  This population is also at greater risk for accidental overdose and death from prescription medications.  Is the literature telling us that we are past a tipping point?  Are health care professionals are no longer treating disease but instead treating medication side effects, with more meds?

Polypharmacy and misdiagnosis happen, arguably too frequently, considered most (and in theory, all) cases of side effects are preventable with a little bit of knowledge and a keen clinical suspicion.  But we all make mistakes, to err is human after all.  Most people don’t want the mistake their prescriber is making to take away from their quality of life, and at worst, their life itself!  Pharmacists are there to help educate patients on how to take their medications appropriately, including amount of medication (dose) and times of day.  We are the “front line” and accessible 24 hours a day in most cases.  However, the dark reality is a significant amount of pharmacists report challenging time constraints in community and hospital settings.  It may be very well impossible to educate EVERY patient that goes to a pharmacy on the possible side effects and proper use of each drug.  Especially considering their physician may have not told them anything about the prescription besides the medication name, and the patient may be bringing it to pharmacists who is verifying over 400 prescriptions in a shift, all the while answering phone calls, patient questions, filling prescriptions, calling doctors offices and giving vaccinations and blood pressure readings.

So, in order to help those folks who visit our page and may be on or know someone who may be on some prescription meds, I decided to list a few of the most common prescription side effects and/or improper use of medications, that frequently get mistaken as a second symptom or disease state when in fact it is more so related to a side effect or improper use of a prescription medication.

 

ANTIDEPRESSANTS

Examples: Bupropion (WELLBUTRIN), paroxitine (PAXIL) and venlafaxine (EFFEXOR)

Issue: Insomnia.  Stimulating antidepressants can lead to trouble falling asleep.  This may be misdiagnosed as insomnia, a common symptom in depression, and that person may be prescribed additional sleep aids.  No bueno.

Solution:  Take all doses of stimulating antidepressants like bupropion and paroxitine at least 8 hours before bed time.  If you take two to three doses a day, consider speaking with your doctor about doubling up a morning dose, which does not effect treatment outcomes.

Details:  Bupropion, paroxitine and venlafaxine are antidepressants that are stimulating.  Think cup of caffeinated coffee.  Ironically, some of them are prescribed twice or three times daily……and the directions on the bottle might just be “Take one twice a day”.  This commonly is interpreted as one in the morning and one at bedtime.  You may be surprised how many physicians are unaware that these meds can cause insomnia if taken too close to bedtime on a daily basis.  These two a day doses are best had within a six to eight hour period, like 7am and 2pm, or something of that nature.  By having all doses at least eight hours before bed time, a patient can significantly reduce the chances of experiencing insomnia from taking these antidepressants.  Are you on one of these antidepressants?  Are you also on a sleep aid like zolpidem (Ambien) or eszopiclone (Lunesta)?  Was the sleep aid prescribed shortly after the antidepressants??  Do you take all your doses of antidepressant right before bedtime??  If you answered yes to all of these questions, this probably is you.

 

SLEEP AIDS (Used for insomnia, trouble sleeping)

Examples: Zolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL), Diazepam (VALIUM)

Issue:  Dependence.  Sleep aids are commonly prescribed for trouble sleeping due to stressful events.  If they are not tapered appropriately, they can become habit forming.

Solution:  Lifestyle modifications.  Certain habits may hinder ones ability to stimulate the bodies natural sleep cycle.  Learning how to avoid stimulating activities before bed is a natural way to cope with trouble sleeping.

Details:  Having a sleep aid on board may help falling or staying asleep, but does effect that natural sleep cycles a person experiences.  Some sleep aids cut out certain parts of the sleep cycle.  This could ultimately affect the quality of the sleep a person experiences.  Sometimes insomnia is brought on by big life stressors like a move, a new job, a death in the family or similar accident.  In these cases, short term use of sleep aids is good in that any sleep is better than no sleep.  Usually these short term stressors go away and the medication is only used for  a few weeks to months.  Again, if you have a legitimate case of insomnia, undoubtedly having a sleep aid is likely a good idea if you have exhausted all non-drug methods of improving sleep.  To do this, you will want to get to the root cause of the insomnia.

Many cases of insomnia or trouble sleeping are based on a persons lifestyle choices  versus an actual organic cause.  Sleep is brought on by a shift in brain chemistry and the production of a chemical called melatonin.  Our bodies experience an increase in the production of melatonin before bed time.  Some common lifestyle habits may disrupt the natural production of melatonin, and consequently put people at risk of insomnia.  These lifestyle habits include: Diet (sugary foods throughout the day and late at night), Stress (little down time throughout the day), Electronics exposure (using phones, computers, or watching TV within 2 hours before bed without blue-blocking eye protection), Stimulants (having caffeinated beverages or stimulating prescription medications in the afternoon and evening), work (doing stressful work late in the evening or exercising close to bed time).   Some lifestyle modification that may help cope with trouble sleeping are a wholesome natural foods diet (eating protein rich breakfast and vegetables and fruits with moderate protein at lunch and dinner), or taking 10-20 minutes out of their day to do something relaxing and unwinding (meditation/yoga/relaxing music), or by reading a magazine or book before bed instead of watching TV (or wearing blue blocker glasses a few hours before bed).  Black out out rooms are a must, any forms of light could offset the natural chemical release.  In fact, just laying in a dark room for an hour (no light, not even from an alarm clock) will have many people falling asleep.  If you are partaking in any of these risky behaviors, you may want to consider making small adjustments to your evening ritual to improve your chances of falling asleep naturally.  Making these lifestyle adjustments will likely help in falling asleep naturally.

If you are on sleep aids already, these adjustments may help you eventually be able to taper off your sleep medication and ward off any side effects in due case (under the watchful care of a health professional of course!).  Sometimes, occupations prevent us from getting enough sleep or consistent sleep schedules (like multiple shift work occupations such as medical or first responders, military, pilots and flight attendants, etc.) in these cases, things like blue-blocker glasses or sleep masks with ear plugs are a great option for helping fall and stay asleep.  Wearing blue-blocker glasses for an hour or two before bed, and wearing a sleep mask  before bed, may help in aiding the natural production of melatonin and consequently, sleep.

 

INHALERS

Examples: Albuterol (PROAIR) and fluticasone/salmenterol (ADVAIR) 

Issue:  Improper inhaler technique and consequent misdiagnosis of asthma severity.

Solution:  See your local pharmacist for a tutorial on appropriate use of inhalers.

Details:  Improper use of inhalers has been well established.  In fact, inhalers are probably one of the most misused medications out there.  There are many different types of inhalers and techniques for proper dosing of medication with each.  For whatever reason, people find a very unique, albeit incredibly wrong, way to use inhalers.  Although spraying albuterol mist behind a fan and putting your face in front of the drafting particles and wind is creative, it is most likely not getting you the proper dose of medication.  Furthermore, the frequent early fills are not helping and may not be a misinterpreted as a sign that things are getting worse rather than a clue into misuse of the inhaler.   Albuterol in itself is stimulating to cardiac muscle, and over-use of albuterol can lead to serious cardiac events and even death (from heart attack).  Making sure you are using the inhalers as prescribed is uber important to improving the respiratory condition being treated.  Misusing inhaler is unfortunately all too common.  Most misuse involves practices that prevent enough medication getting into the lungs for appropriate treatment doses.  This may result in further prescriptions for short term oral steroid tapers of prednisone, or adding on a long acting steroid inhalers like ADVAIR.  If the misuse isn’t caught, and the person is prescribed yet another inhaler, you can imagine where this may start going.  Seeing as how some reports indicate up to 50% percent of inhaler use is wrong, this is a good bet.  You can simply ask your pharmacist how to properly use the inhaler, or check out these videos:

Albuterol inhalers, courtesy of Utah health – https://www.youtube.com/watch?v=Rdb3p9RZoR4

Corticosteroid inhaler, proper use – https://www.youtube.com/watch?v=Kr02is6jVUk

*remember to rinse your mouth out with water after using corticosteroid inhalers and spit out the water (into a sink) afterwords.

It is also important to note that if you smoke, you are likely not making your condition any better.  Smoking anything, tobacco or marijuana, will worsen asthma or inflammatory lung conditions.  Yes, it is established that any type of smoke, including marijuana smoke, is harmful to lung function.

 

ANTI-HYPERTENSIVES (or HIGH BLOOD PRESSURE/CARDIAC MEDS)

Beta-blockers 

Examples: metoprolol (TOPROL), atenolol (TENORMIN), carvedilol (COREG), etc.

Issue:  Missed doses lead to “rebound” hypertensive episode and increase risk of heart attack or stroke.

Solution:  Try a diuretic, ACE inhibitor or ARB.  Especially if you have diabetes (the ACE and ARB are recommended) or know you are one to forget doses of medication frequently.

Details:  Beta-blockers are commonly used to treat conditions like high blood pressure.  They have been researched and used in the treatment of high blood pressure for some decades now.  Technically, in most cases, they are NOT considered “first-line” agents, or to be given before trying other agents like diuretics (hydrochlorothiazide, chlorthalidone) or ACE-inhibitors (lisinopril, ramipril, etc) or ARBs (valsartan, olmesartan, etc).  Beta-blockers can sometimes cause shortness of breath, especially the non-selective beta-blockers.  More importantly, beta-blockers have a rebound hypertensive effect when they are missed, meaning, if you miss a few doses of your metoprolol or atenolol your blood pressure could increase dramatically in a short period to counteract the missed dose.  This is the cause of some heart attacks, simply missing a few doses of a beta-blocker could get you there if you aren’t careful and have been taking them for a while.  If you know you are a person who misses doses of medications frequently, or in the least a few times a week, or can’t take them exactly on time every time, beta-blockers are not a good choice for you.  Try an ARB or and ACE inhibitor or diuretic first.  If you are on a beta-blocker and have high blood pressure AND have diabetes, you definitely want to be on an ACE or an ARB to help avoid long term diabetic complications like diabetic induced nephropathy.     Beta-blockers have been shown by some reports to worsen thyroid conditions, too, so if you have some underlying issues, are on a beta-blocker, haven’t been tried on the other blood pressure meds, you get the picture.  Some folks may have been prescribed beta-blockers before any of the ACE inhibitors or ARBs ever hit the market.  Again, as long as you don’t have issues missing your doses or have any shortness of breath or thyroid symptoms, or diabetes or metabolic syndrome, you are probably alright.  If you miss doses frequently, keep seeing your thyroid doses and beta-blocker doses going up, or have blood sugar issues, it may be a good idea to try a diuretic, ACE inhibitor or ARB if you haven’t yet done so.

High blood pressure and many other cardiac diseases may be reversed or at least prevented from further damaging and inflammation through diet an exercise.  As always, this is not the easiest option for most of us; but, over the long term, small changes to diet and lifestyle can go a long way.  It can not be stressed enough how much healthy eating and exercise improve heart health.  Try something simple like drinking water with lemon instead of sodas or juices.   Or, substitute greens, vegetables and fruits for grains and cereals.  Avoiding starchy foods like rice, noodles, greasy chips and breads many of us to better regulate insulin, lower inflammation, normalize blood sugar and improve blood pressure.  Also, try to get some lean meats in and especially fatty, sustainably wild caught fish.  Drink broths from slow cooked grass-fed beef and meats, they are loaded with potassium and essential nutrients and fats like omega-3.  These methods have all shown to have some possible benefit in cases of high blood pressure.

 

MOOD STABILIZERS

Examples: Quetiapine (SEROQUEL), Risperidone (RISPERDAL), Olanzapine (ZYPREXA), etc.

Issue: Weight Gain.

Solution:  Eat Quality Foods!  Lean meats and vegetables, nuts and seeds, some fruits, little starch, no sugar, healthy fats.

Details:  Mood stabilizers, sometimes termed antipsychotics, are used in multiple psychiatric conditions ranging from depression, to schizophrenia, to bipolar and agitation.  Sometimes, these meds are also used to help people sleep considering they are very sedating.  They come with a cost though, weight gain, and lots of it.  This weight gain is associated with increased risk of metabolic syndrome (high blood pressure, obesity or large waist line, high triglycerides and low HDL or good cholesterol).  The result of getting a diagnosis of metabolic syndrome after using one of the mood stabilizers is arguably preventable.  Some reports indicate these meds are associated with weight gain.  They tend to give people the “munchies” and consequently, the natural response is to eat more food.  Given most people in America are accustomed to the Wester diet (high intake of refined carbohydrates, industrial fats and sugars) this likely makes weight gain matters even worse.  It may not be the case that the meds increase ones risk of getting fat as much  as they just make someone who eats triple bacon burgers with large fries and soda, more hungry.  If you want to prevent yourself from getting four to five additional prescriptions for blood pressure, diabetes and cholesterol meds a few years down the line, consider changing your diet as a first priority if you are on these psych meds.  Not only that, some reports indicate that psychiatric conditions greatly improved with sound diet and exercise, the gut-brain connection can not be underestimated!  This approach sounds like a win, win to me.

 

CHOLESTEROL MEDS

Statins

Examples: Atorvastatin (LIPITOR), simvistatin (ZOCOR), rosuvastatin (CRESTOR)

Issue:  Muscle cramping, depression, alzheimer’s and rhabdomyolysis.

Solution:  Supplementing with Co-Enzyme Q10, focusing on regulating blood sugars and eating plenty of non-starchy vegetables and low-sugar fruits.

Details:  Statins are the top drugs prescribed in America ever since their release.    The new statin guidelines, which recommend their use to even more patients (like double the patients) is only adding to their reign.   They are probably going to beat out vicodin and penicillin for sure.  JAMA reported these new guidelines need to be placed under serious scrutiny and with good cause.  Lets face it, diet and exercise trump statins for reversing cholesterol issues and arguably make statin treatments for high “bad” cholesterol look like a bandaid for a gangrenous limb.   Yet, it just seems easier to spend ten dollars a month and pop a pill nightly for most people, given these drugs outsell all other meds in comparison.  Lets face it , not everyone is ready revamp their pantry and cookbook collection, and start prepping meals daily, completely understandable.  Plus, you can imagine how many fast food corporations and diners would be would totally support that.

 It is ironic that these medications are known to decrease concentrations of ubiquinone, or co-enzyme Q10, which is chemical involved in the production of energy in cells, especially heart cells.  This is also speculated as being the main cause of the rhabdomyolysis side effect sometimes seen with these medications (muscle cramping, vomitting, death, nothing big, etc.).  It’s hard to imagine that depleting peoples ability to provide cardiac muscle with energy is a good thing, but the drug company funded studies seemed to state otherwise otherwise.  Also, recent reports have shown that cholesterol may have a protective effect on overall risk of death.  Also, people with incredibly low chlesterol numbers (sometimes brought about by statin treatments) seem to be at increased risk of depression, Alzheimer’s and suicide according to some reports!  

It is important to note that LDL alone or cholesterol alone are not good indicators of possible risk of developing heart disease.  Authors like cardiologist Stephen Sinatra, MD  (“The Cholesterol Myth”) and Gary Taubes (“Why We Get Fat” and “Good Calories Bad Calories”) elude to this in their books.  We now know the relationship of LDL, HDL, Cholesterol and Triglycerides and more specifically the ratios of their relationships, have more to do with  a persons risk of developing heart disease.  Also, things like LDL particle size (there are big and small LDL particles), and the ratio of their concentrations, may be better predictors of heart disease than LDL or cholesterol alone, too.

If you are on a statin, consider diet and exercise as a long term goal for wellness.  Science is telling us the artery blocking effects of cholesterol are probably not completely related to cholesterol intake or even cholesterol levels.  In fact, higher cholesterol numbers (higher in the accepted range of normal) seem to have a protective effect on mortality according to some reports.  Most artherosclerosis (or cholesterol clogging artery formations) are caused by hyperglycemia (high blood sugar) and the aftermath of hyperinsulinemia and insulin resistance.  Start with simple steps,  like drinking water with lemon instead of sodas or juices.   Or, substitute greens, vegetables and fruits for grains and cereals.  Avoiding starchy foods like rice, noodles, greasy chips and breads helps lots of folks better regulate insulin, lower inflammation and improve their blood pressure.  Get some lean meats in and especially fish and other great sources of naturally occurring essential omega-3 fats.

Talk to your doctor about possibly also using Co-Enzyme Q10 while on a statin, especially if you feel tired more often on a day to day basis, or experience muscle soreness more frequently.  Co-enzyme Q10 is necessary for healthy heart function.  Reports show significant improvements in patients with congestive heart failure, and other cardiac conditions, with co-enzyme Q10 supplementation.  I think it is interesting that the media likes to focus on how intense exercise is a risk of rhabodomyolysis, when one arguably has (maybe even a greater) risk  of developing this condition by using statins and not exercising.

 

THYROID MEDICATIONS

Examples: Levothyroxine (LEVOXYL, SYNTHROID)

Issue: Food sensitivity induced thyroid dysfunction.  Our autoimmune systems can be stimulated by ingesting foods we are sensitive too.  The most common food sensitivities include gluten, dairy, grains/cereals, soy and legumes (beans).

Solution: Avoid gluten, grains, soy and dairy.  At least for 30 and more so ideally for 60 days.  Any seed based product you can not eat raw, like a grain or a bean, may be a culprit, considering their outer shells are highly concentrated in chemicals to deter insects and rodents.

Details:  Thyroid medications are commonly prescribed for hypothyroidism, or low thyroid function.  Most people believe that this is a genetically hereditary condition.   However, many patients find incredible benefit through lifestyle modifications.  Thyroid medications do not “fix” the thyroid, they only provide synthetically derived thyroid hormones into the blood to substitute for what is missing.  The thyroid itself still goes on, unchecked and, if the root cause for the thyroid function disturbances are diet or exercise related, the damage will inevitably go on if these lifestyle factors are not addressed.  One common issue is gluten and/or soy-derived thyroid dysregulation.  Some reports indicate gluten, a protein found in wheat, barley and rye, can have some negative impact on thyroid function (read Dr. William Davis’s “Wheat Belly” for the details).  Specifically, the proteins are structured in so that they may trick the thyroid into thinking there is more or less thyroid hormone in circulation than actually is the case.   Not to mention possible gut conditions and malabsorption issues related to ingesting gluten and other grains.   Try eliminating gluten, soy, grains and cereals in general for thirty to sixty days days.  Replace these foods with greens, vegetables and fruits instead.  Observe how you feel and get a thyroid test.  Any benefits?  Weight loss?  Energy improvements?  If yes, consider this a likely possible lifestyle factor to your thyroid dysfunction.   As always, discuss these issues with a licensed health professional.

 

ACID SUPPRESSING MEDICATIONS

Examples: Calcium Carbonate (TUMS), Omeprazole (PRILOSEC), etc

Issue: Incomplete digestion of foods, increased risk of infections.

Solution:  Eating smaller meals of “good stuff” more frequently throughout the day, slowly.  Using digestive aids like digestive enzymes and betaine HCl.   These solutions especially apply to people who are self-treating with over the counter proton pump inhibitors like omperazole (Prilosec).  If you have never had an endoscopy (where the put a tube down your throat into your stomach with a camera and/or have had a pH test, you may want to try the non-drug methods of acid reflux firstly.

Details:  Your stomach produces acid in order to break down the foods you eat and help in absorbing the proteins, vitamins, minerals, fats, and other nutrients needed for the body to process and survive.  Within the last century there has been a major shift in the idea behind “acid reflux” .  Within the last half century, medical experts have went from treating this condition as “hypochlorydria” or the underproduction of stomach acid, to categorizing it as caused by hyperchlorydria, or the over production of stomach acid.  The latter diagnosis is usually called GERD or “gastroesophogeal reflux disease”.  It is incredibly common for people to be prescribed these super-powerful acid inhibiting drugs for acid reflux symptoms like burning chest, coughing, trouble sleeping, stomach ache, etc.  The scary thing is how many people are prescribed these meds without any testing of their stomach acid.

If you are over the age of forty, and especially over the age of sixty, you are at increased risk of UNDERPRODUCING stomach acid.  The results are the same symptoms seen in GERD, but the treatment is changing your diet and lifestyle.  Eating smaller meals, more frequently throughout the day, at a slower rate, in smaller bites, with more chewing, helps a lot of people overcome these symptoms.  Also, using digestive aids like digestive enzymes and betaine HCl have been shown to improve acid reflux symtpoms as well.  If you in fact do produce more stomach acid than the average individual, it may also benefit form these same lifestyle modifications.

Acid inhibitors, especially proton pump inhibitors, long term are being reported as putting people at increased risk of vitamin malabsorption, anemia, protein malabsorption, stomach and intestinal infections, and lung infections like pneumonia.  Granted, having acid reflux is also putting people at risk of some of these conditions.  But, changing your diet and lifestyle for the better and using digestive aids is probably a safer bet long term.  Consider this, stomach acid, when it does its job and stays in the stomach, protects your stomach, esophagus and lungs from infections and helps you digest your food.  Granted, some people have a malfunctioning flap that sits on top of the stomach and help to close the opening of the stomach and prevent stomach acid from gushing out into your throat.  Fixing this flap is another issue, but having smaller meals more frequently in smaller portions may lower the amount of stomach acid needed to digest a meal and consequently a persons risk of getting acid reflux.

If you were prescribed or are taking an over the counter acid blocking medication like TUMs, Ranitidine (ZANTAC) or Omeprazole (PRILOSEC), frequently and have been for some time, you need to ask yourself a few questions.  Did you ever get an endoscopy exam (where they put a tube down your throat into your stomach) and have your acid levels checked?  If you didn’t, you probably should see your doctor and let them know if you are taking over the counter acid reducing medications.  You also may want to try smaller, more frequent meals and digestive aids, instead.  If you did get an endoscopy and your acid levels were high, you may want to try smaller more frequent meals and digestive enzymes and talk to your doctor about coming off your acid reducing medications for a short trial to see if things improve by improving your diet and lifestyle.  Whenever stopping these medications, your acid reflux gets much worse.  This typically lasts for several days.  Some physicians recommend using deglycyrrhizinated licorice (DGL) to offset this rebound acid reflux, a half an hour before meals.

“Stomach Acid Is Good For You” by Jonathan Wright, MD is an incredible resource for GERD patients.

 

CONCLUSION

This list is short and the details, maybe a little lengthy, but hopefully this provides a good reference point and some helpful points to watch out for and some good references to go to and learn more.  Sharing is caring.  Be well, stay fit.

 

 SOME REFERENCES and FURTHER READINGS:

Hajjar et al. Polypharmacy in Elderly Patients.  Am J Geriatr Pharmacother. 2007; 5:345-351).

Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenride AM.  Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients.  BMJ 2004; 329: 15.

Yach D, Hawkes C, Gould CL, Hofman KJ.  The global burden of chronic diseases: Overcoming Impediments to prevention and control.  JAMA 2004; 291(21):2616-2622.

Centers for Disease Control. 2010. www.cdc.gov/chronicdisease/resources/publications/AAG/chronic.htm

American Heart Association Heart Disease and Stroke Statistics Writing Group. Circulation: Journal of the American Heart Association. 2011;123:e18-e209.

Yusuf S, Hawken S, Ounpuu S, on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952.

Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA 2003;290(14): 1884-1890.

Trust for America’s Health.  Report. “F as in Fat: How Obesity Threatens America’s Future”. 2012.  accessed April 2, 2014.  http://healthyamericans.org/report/100/

 

 

 

 

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