Wrestling hope from the fog of pain

april 2011

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vol 92

arthritis mother and baby A big bouncy baby business

business Barriers to e-health uptake australian journal of pharmacy

achieve weigh-less-ness?

Turn To page 14 To discover pharmacy’s new weighT-loss soluTion

in side

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VLED 4764 Pharmacy Covers AJP Front.indd 1

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Weight loss how to achievit

®

The new achievit® VLED range from iNova offers pharmacists an additional support in their role to help overweight and obese customers lose weight in a healthy and successful manner .

D

espite increasing focus on weight loss by health professionals, including community pharmacists, the number of Australians who are overweight or obese is at epidemic proportions, with 7.4 million Australians classified as overweight or obese according to the 2004–05 National Health Survey.1 Overweight and obesity can have serious health consequences such as heart disease, diabetes, musculoskeletal disorders and some cancers. More recently, obesity has

been found to be an independent risk associated with fatal coronary heart disease in middle-aged men.2,3 Because of the growing magnitude of being overweight or obese as a major public health issue, the role of healthcare professionals such as pharmacists is vital to customers who seek weight loss solutions. For this increase in demand, now more than ever is a time to open conversation with pharmacy customers. While there are many weight loss solutions available, sustained weight loss requires professional

New scientifically formulated VLED from iNova

The achievit VLED range The achievit VLED range of soups and

of fibre. Fibre is a key requirement

Low GI carbohydrates

shakes are scientifically formulated and

for the management of obesity as

Each sachet of achievit contains a low

nutritionally complete, which can be used

it improves digestive health and

glycaemic index carbohydrate. Sweet

to replace some or all daily meals without

helps customers to feel fuller for

whey powder is the source of low GI

the need for further supplementation

longer and be less tempted to snack.

lactose. A low GI diet supports effective

with fibre or vitamins. The achievit VLED

Additionally, fibre is recognised for

weight loss.10

shakes and soups can be used as

its ability to help stabilise cholesterol

part of a healthcare supervised weight

and glucose levels.7,8,9

management plan involving diet, exercise

Each sachet of achievit contains

and behaviour modification and where

Oat beta-glucan

flaxseed oil, which is a rich source

appropriate, with pharmacotherapy.

Each sachet of achievit contains oat

of omega-3 and omega-6 fatty

beta-glucan, which has been shown to

acids and associated with improved

Fibre

reduce cholesterol re-absorption and

cardiovascular outcomes and

Each sachet of achievit contains 7g

reduce blood glucose levels.7

hyperlipidemia.11

The Australian journal of Pharmacy vol.92 april 2011

14

Flaxseed oil

assessment, behaviour modification, customer support, self-monitoring and reducing the amount of energy consumed in relation to the energy expended. Very low energy diets (VLEDs) are an effective and convenient way to lose weight. Very low energy diets Very low energy diets (VLEDs), also called very low calorie diets (VLCDs) restrict energy intake to about 1,700– 3,300kJ per day. VLEDs are nutritionally balanced to replace all meals and are indicated for short-term treatment of severely obese people, or obese people with life-threatening co-morbidities.4 VLEDs may also be used by overweight people looking for diet restriction, such as pre-surgery or pre-IVF. VLEDs produce greater initial weight loss than other forms of energy restriction (9 to 26kg over 4–20 weeks) and are very effective in initiating early weight loss.5,6 According to accredited practising dietitian, Dr Naras Lapsys, pharmacists are crucial to his efforts with overweight

cover advertorial

or obese patients, especially in supporting the use of VLEDs. ‘If I see a client and refer them to get a VLED, I want them to use a product that is more appropriate than may be found on a supermarket shelf such as meal replacements. ‘VLEDs, usually found in pharmacies, tend to have a higher grade nutritional profile than products found on supermarket shelves and I ask the patient to speak to the pharmacist about the most appropriate VLED; I don’t specify a brand. This is essentially a referral and it’s up to the pharmacist to help the individual make such decisions. ‘It’s important that the pharmacist considers the customer’s expectations of their frequency in using the product. If it’s for aggressive weight loss and to be used exclusively, then the pharmacist should consider the complete nutritional profile of VLED choices, of which there are very few. ‘If the customer expects to use such weight-loss support products on a more sporadic basis, then the pharmacist should consider other issues across a range of products, including flavour options, because it’s not being used to replace all meals.’

Weight management practice points 1. Identify people at

2. Measuring BMI and waist

of weight, waist circumference and

increased risk of

circumference5

eating habits provide a realistic

overweight/obesity5

• BMI and waist circumference can

• Many factors can place customers at an increased risk of excessive weight gain. These include: genetic pre-disposition, endocrine and metabolic disorders,

propose increased metabolic risks, comorbidities and consequences. • BMI of 25–29.9kg/m2 is overweight,

approach to weight management. • Behaviour: people find it easier to make small changes at first. • Support Groups: encouragement by others has many benefits.

BMI >30kg/m2 is obese.

• Self-monitoring: Recording body

• Waist circumference of ≥94 cm

pregnancy, menopause,

in men and ≥80cm in women, or

weight, with a written food record

psychological stress, some

considered at risk from CVD.

and logging steps taken provide objective feedback.

medicines and quitting smoking. • Other factors can include lower socio-economic groups, people with low education levels and people from rural areas or different ethnic groups.

3. Goals of weight loss • Achievable goals should be set for a loss of 5–10% of initial weight.5 • Maintaining modest weight loss

5. Pharmacotherapy • Pharmacological therapies, initiated or prescribed by healthcare professionals, which

has clinical benefits.12

suppress appetite or fat absorption

• Obesity is a topic which requires sensitivity when discussing with

4. Behavioural and

can be recommended for

the customer.

lifestyle management13

appropriate patients.

• Initial assessment: measurements

Comorbidities help direct choice Dr Lapsys, who specialises in supporting weight loss efforts of patients from his Sydney-based practice, The Body Doctor, said it was always important for the pharmacist to also consider whether their customer

Web-based achievit support with livinglite program Successful weight management requires ongoing counselling and support, which is why pharmacists can feel confident in recommending achievit, which is supported by the Livinglite web based support program. Customers who use achievit soups and shakes gain access to the website which offers further support via weight loss advice, goal-setting, tips to help customers stay motivated and other caloriecontrolled diet suggestions. For more information visit www.livingliteprogram.com.au

had comorbidities to their overweight or obese condition. ‘While some pharmacists may only be comfortable offering a certain level of advice to an overweight customer, many will have potentially significant comorbidities and require a higher level of care. VLED products offer properties that lend themselves to support certain comorbidities such as higher fibre for those with cardiovascular disease or a low glycaemic index profile for those with diabetes.’ For customers who do require a higher level of care, Dr Lapsys said motivational counselling was an effective tool in helping them to overcome addiction behaviours related to their overweight or obese conditions. ‘Motivational counselling should be offered along with VLED products to

obese customers with comorbidities. These people have often displayed addictive behaviours from a young age and can require compelling motivation—more than numbers on a scale—to successfully lose weight in a healthy manner. By actively listening, you can pick up clues as to what lifestyle motivations are most compelling.’

iNova Pharmaceuticals, 9–15 Chilvers Rd, Thornleigh NSW 2120

www.livingliteprogram.com.au www.inovapharma.com achievit is a registered trademark of iNova Pharmaceuticals (Australia) Pty Limited

REFERENCES: 1. Overweight and obesity in adults, Australia, 2004–05 www.abs.gov.au; Release: 4719.0; Accessed 14/02/11; 2. Obesity and overweight: Fact Sheet No:311. World Health Organisation. Updated February 2011. http://www. who.int/mediacentre/factsheets/fs311/en/index.html; Accessed 14/02/11; 3. Logue J, et al. Obesity is associated with fatal coronary heart disease independently of traditional risk factors and deprivation (WOSCOPS). Heart 2011 Doi:10.1136/ hrt.2010.211201; 4. Management of overweight and obesity [revised June 2009. Amended October 2009, Feb 2010]. In: eTG complete [CD-ROM]. Melbourne: Therapeutic Guidelines Limited; 2010 March; 5. NH&MRC Clinical practice guidelines for the management of overweight and obesity in adults. 2003; 6. Caterson ID. Weight management. Aust Prescr 2006;29:43–7; 7. Chen J and Raymond K. Beta-glucans in the treatment of diabetes and associated cardiovascular risks. Vascular Health and Risk Management 2008:4(6);1265–72; 8. Nutrient reference values for Australia and New Zealand – including recommended dietary intakes. NH&MRC. 2005; 9. Brown L, et al. Cholesterol-lowering effects of dietary fiber: metaanalysis 1999 Am J Clin Nutr;69:30–42; 10. McMillan-Price J, et al. Comparison of four diets of varying glycemic load on weight loss and cardiovascular risk reduction in overweight and obese young adults: a randomized controlled trial.Arch Intern Med 2006;166(14):1466–75; 11. Simopoulos AP. The importance of the omega-6/omega-3 fatty acid ratio in cardiovascular disease and other chronic diseases. Exp Biol Med 2008, 233:674–88; 12. Klein S, et al. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies. Diabetes Care 2004: 27(8);2067–73; 13. Freedman DH. How to fix the obesity crisis. Scientific American February 2011 p20–27.

The Australian journal of Pharmacy vol.92 april 2011

15

education s p e c i a lt y p r a c t i c e s e r i e s

Dr Naras Lapsys, BSc (Hons), MSc (Nutr& Diet), PhD (Med). Accredited practising dietitian, The Body Doctor Pty Ltd

Very low energy diets for weight loss and health management Very low energy diets offer pharmacists a means of supporting weight loss and health goals of people who are overweight and obese and contributing to reducing the burden of overweight and obesity on society. After reading the article, the reader should be able to: • discuss the role of very low energy diets in weight loss; • explain the difference between very low energy diets and meal replacement products; • identify customers for whom very low energy diets are appropriate and useful in supporting weight loss. Competencies addressed: 1.3; 1.5; 6.1; 6.2; 6.3; 7.1; 7.2

O

ver the past 20 years, the prevalence of obesity has increased to the point that many consider it to be a public health epidemic. In 2008, the World Health Organization reported that, globally, 1.5 billion adults were overweight and, of these, more than 200 million men and 300 million women were obese.1 In 2004–2005, the National Health Survey reported that 7.4 million Australians were classified as overweight or obese. The proportion of men in these

categories was significantly higher than that for women and this difference was most evident in the overweight category, where 43% of men were overweight compared to 28% of women.2,3 As a result of these alarming trends, numerous obesity management models have evolved, presenting new opportunities and challenges to pharmacists and to the services they provide. Health risks associated with overweight and obesity Both overweight (body mass index (BMI) > 25kg/m2) and obesity (BMI > 30kg/m2) are associated with increased mortality.4 Furthermore, obesity causes or is associated with a range of serious health conditions including: cardiovascular disease, hyperinsulinaemia, dyslipidaemia, hypertension and diabetes. See Table One.

Meal replacements for weight loss and management The use of low energy meal replacement products for the treatment of obesity is a strategy recommended in the clinical guidelines from the National Health and Medical Research Council.6 Recent meta analyses have identified the use of meal replacement products for effective weight loss.7,8 As a result, meal replacement products may be an effective tool for pharmacists to administer to the obese patient, as their protocols are well defined, they are easy to supervise and they are cost-effective to the patient. The difference between meal replacements and VLEDs Food Standards Australia New Zealand (FSANZ) defines meal replacements as ‘a single food or pre-packaged selection of foods that is sold as a replacement for one or more of the daily meals, but not as a total diet replacement’.9 Meal replacements are designed to be used for one or two meals a day, with at least one usual meal consumed as part of a reduced calorie diet. They are not nutritionally complete.9 On the other hand, very low energy diets (VLEDs, also termed very low calorie diets or VLCDs), are a specially formulated form of meal replacement that may be used in place of all meals and are designed to be nutritionally complete for minerals, vitamins, trace

The articles in this ongoing series are written by experts in their field and reviewed for their value to pharmacists as continuing professional education resources by the Australian College of Pharmacy Practice and Management and the Pharmaceutical Society of Australia. The AJP appreciates the support of inova pharmaceuticals in providing unbiased quality information for the education of its readers.

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education

AJPCPD

s p e c i a lt y p r a c t i c e s e r i e s

CONTINUING PROFESSIONAL DEVELOPMENT

elements and essential fatty acids. VLEDs aim to provide at least 0.8g protein/kg of ideal bodyweight per day in order to preserve lean body mass. Up to 10g of total fat per day is also recommended to stimulate gall bladder contraction and approximately 50g carbohydrate daily is suggested to maintain normal glycaemic control and to prevent the loss of proteins and electrolytes.10 A comparison of the caloric and nutritional requirements for these two types of meal replacements are presented in Table Two.

Table One: Health risks associated with obesity adapted from Australian Prescriber 19995

Mechanical Osteoarthritis Sleep apnoea Varicose veins Metabolic/Endocrine Dyslipidaemia Hyperinsulinaemia Impaired glucose tolerance and type 2 diabetes mellitus Infertility Hirsutism

clinical use and safety VLEDs are generally used in medically supervised weight reduction programs for patients with a BMI>30kg/m2, or for those requiring rapid weight loss, such as patients about to undergo bariatric surgery. Such patients need rapid weight loss to reduce the size of their liver prior to surgery.11 In the United States, VLEDs are usually administered as part of a coordinated and medically supervised intervention program that includes a physician and associated allied health professionals.12,13 In Australia, VLEDs are frequently used under less medical supervision. However, they can be purchased from a pharmacist and a prescription is not required. Meal replacements, on the other hand, can be purchased from supermarkets in addition to some pharmacies. The duration of treatment usually varies from 8–16 weeks, however there is one report of the safe weight loss treatment with a VLED spanning a 12-month period.14,15 VLEDs are considered to be safe and effective when used appropriately. Common minor side effects associated with VLEDs include: increased risk of gallstones, hair loss, headache, dry skin, fatigue and dizziness, muscle cramps and constipation.16,17 These side effects are usually mild and transient.

Cardiovascular Hypertension Heart disease Gastrointestinal Fatty liver Gall stones Other Certain cancers Psychosocial difficulties

Table Two: A Comparison of meal replacements and very low energy diets Meal Replacement (minimum requirements per meal (FSANZ) 12g protein 850kJ 25% of the recommended daily intake of 16 prescribed vitamins and minerals Very Low Energy Diets (VLEDs) (FSANZ draft requirements) 1.7–3.3MJ per day 50g carbohydrate per day 50g protein per day Minimum and maximum levels for 24 prescribed vitamins and minerals

It has been generally advised that patients starting VLED weight loss programs have liver function tests, lipid profile analyses, full blood counts and iron studies. Levels of electrolytes, creatinine and uric acid levels should also be measured.18 It has also been advised that if the VLED is to be continued for more than 12 weeks, baseline tests should be repeated every two months.19 VLEDs and weight loss Studies have identified that patients who adhere to a VLED program that includes lifestyle modification—in the form of behaviour change that affects eating habits in the long-term and increases physical activity to correct the energy imbalance20—can expect to lose 15–25% of their initial weight over a 3–4 month period.21,22,23 A 2001 meta-analysis identified that subjects who used VLEDs for weight loss maintained a significantly greater weight loss at 4.5 years than after a hypocaloric balanced diet.24 The partial use of VLEDs and meal replacements has also been shown to be effective for long-term weight loss and subsequent weight maintenance.25,26 A comparison of commercially available VLEDs in Australia In Australia, VLEDs are currently available to customers through community pharmacies. A comparison of daily intakes for total energy and key nutrients for each of these products are shown in Table Three. All four products satisfy the (FSANZ) draft guidelines for VLEDs. Due to advances in food technology, the quality and mix of nutrients in VLEDs is high and well balanced. For example, combinations of high quality proteins such as whey and soy protein concentrate and casseinate are used in all commercially available VLEDs. The use of higher quality proteins for the preservation of muscle mass in weight loss programs

is well documented.27,28 Dietary fibre is a key contributor to weight loss management as it associated with increased satiety29 Studies have also identified that dietary fibre can impart significant improvements in cholesterollowering and improvements in blood glucose levels.30,31,32 In a recent study, it was shown that the intake of 6g of the soluble fibre oat beta-glucan per day for six weeks significantly reduced total and LDL cholesterol in subjects with elevated cholesterol.33 Increased dietary intake of dietary fibre has also been associated with improvements in constipation.34 Two VLED product ranges contain higher levels of total dietary fibre. It must be noted though, that the nutrient values in Table Three reflect only one type of VLED (chocolate shake) and that other flavours and formulations may contain additional or differing amounts of fibre and/or other nutrients. Two VLCDs also list the inclusion of omega-3 and omega-6 essential fatty acids in their nutritional profile. Dietary intake of these fatty acids has been associated with improved outcomes for hyperlipidaemia and for reduced cardiovascular risk.35 The regular consumption of omega-3 fatty acids have also been linked to improvements of a number of health issues such as asthma, depression, diabetes and inflammatory health issues. Summary In conclusion, VLEDs may be an effective tool for initiating early and rapid weight loss in appropriately selected individuals. They offer the convenience of a nutritionally complete meal replacement and they do not require the need for further supplementation with vitamins and minerals. In addition to the benefits of weight loss alone, VLEDs may also improve certain obesityrelated comorbidities by reducing

The Australian journal of Pharmacy vol.92 april 2011

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education s p e c i a lt y p r a c t i c e s e r i e s

Table Three: Comparison of commercially available very low energy diets (VLEDs) in Australia Product

Achievit®

KicStart™

Optifast VLCD®

Optislim 2000®

(Chocolate) 52g

(Chocolate Deluxe) 55g

(Chocolate) 40g

(Expresso Coffee) 52g

Energy (kJ)

20. Egger G. Helping patients lose weight: what works. Aust Family Physician 2008;37(1/2):20–3. 21. Wadden TA, Frey DL. A multicenter evaluation of a proprietary weight loss program for the treatment of marked obesity:

2,175kJ

2,583kJ

1,905kJ

1,884kJ

51.3g

54.3g

45.0g

50.7g

48.3g

43.2g

27.6g

46.8g

Protein (g)

50.1g

69.6g

51.9g

49.98g

Fat

8.97g

10.8g

6.9g

6.0g

1.65g

6.3g

1.2g

2.7g

Yes

Yes

Not listed

Not listed

loss to cardiovascular risk factors in morbidly

21.27g

9.6g

10.8g

Not listed

obese individuals. J Am Coll Nutr 1994 Jun;

3.0g

Not listed

Not listed

Not listed

684mg

1,083mg

996mg

1,158mg

24

24

26

23

Carbohydrates, Total – Sugars component

– Saturated fat component Omega 3-6 fatty acids Total Dietary Fibre Oat Beta-glucan Sodium No. Vitamins and Minerals

a five-year follow-up. Int J Eat Disord 1997 Sep;22(2):203–12. 22. Anderson JW, et al . Food-containing hypocaloric diets are as effective as liquidsupplement diets for obese individuals with NIDDM. Diabetes Care 1994; 17:602–4. 23. Anderson JW, et al. Relationship of weight

13(3):256–61. 24. Anderson JW. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001;74(5):579–84.

• Figures are based on a total of 3 single serve sachets daily. This comparison is for illustration purposes and is not definitive as characteristics vary across product range

25. Rothacker DQ. Five-year self-management

variants and brands. All values are correct at the time of printing, March 2011. Source: Product Labels. (Achievit® – iNova Pharmaceuticals, Sydney NSW; Kicstart™ –

of weight using meal replacements:

Pharmacy Health Solutions, Sydney NSW; Optifast® VLCD™ – Reg. Trademark of Société des Produits Nestlé S.A; Optislim – Optipharm, Melbourne VIC). ®

comparison with matched control in rural Wisconsin. Nutrition 2000;16:344–8. 26. Egger G. Are meal replacements an

cholesterol levels and improving glycaemic control. With the incidence of obesity escalating, the role of the pharmacist in offering supervised weight loss solutions is of significant importance. n 1. Obesity and Overweight: Fact Sheet No:311. World Health Organisation. Updated February 2011. www.who.int/mediacentre/factsheets/ fs311/en/index.html. Accessed 14/02/11. 2. Overweight and Obesity in Adults, Australia, 2004–05 www.abs.gov.au. Release 4719.0. Accessed 28/02/11. 3. Global Database on Body Mass Index: Australian National Statistics. http://apps.who. int/bmi/index.jsp. Accessed 18/02/11. 4. Berrington de Gonzalez A, Phil D, Hartge P. Body-mass index and mortality among 1.46 million white adults. N Engl J Med 2010; 363:2211–19. (2 Dec 2010) 5. Caterson, ID. Obesity and its management, Australian Prescriber 1999; 22:12–16. 6. National Health and Medical Research Council. National clinical guidelines for weight control and obesity management. Canberra: Commonwealth Department of Health and Ageing, 2002. 7. Tsai AG, Wadden TA. The evolution of verylow-calorie diets: an update and meta-analysis. Obesity 2006;14:1283–93. 8. Brown T, et al. Systematic review of longterm lifestyle interventions to prevent weight gain and morbidity in adults. Obes Rev 2009 Nov;10(6):627–38. Epub 2009 Sep 14.

9. www.foodstandards.gov.au/_srcfiles/ Standard_2_9_3_Supplem_Foods_v109.pdf. 10. Saris, WH. Very low calorie diets and sustained weight loss. Obes Res 2001;2:61–72. 11. Brancatisano R, Brancatisano T. Bariatric surgery for weight loss. Weight Management in Review 2008, iNova on file. 12. National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health. Very low-calorie diets. JAMA. 1993; 270:967–74. 13. National Heart Lung and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health/National Heart Lung and Blood Institute. Obes Res 1998;6: 51–209S. 14. Mustajoki P, Pekkarinen T. Very low energy diets in the treatment of obesity. Obes Rev 2001;2:61–72. 15. Sumithran P, Proietto J. Safe year-long use of a very-low-calorie diet for the treatment of severe obesity. MJA 2008;188/6: 366–8. 16. Saris WH. Very-low-calorie diets and sustained weight loss. Obes Res 2001;9:295–301S. 17. Wadden TA, Stunkard AJ, Brownell KD. Very low calorie diets: their efficacy, safety, and future. Ann Intern Med 1989;99:675–84. 18. Sumithran P and Proietto J. Safe year-long use of a very-low-calorie diet for the treatment of severe obesity. MJA 2008;188/6:366–8. 19. Delbridge E, Proietto, J. State of the science: VLED (very low energy diet) for obesity. Asia Pac J Clin Nutr 2006; 15 suppl: 49–54.

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effective clinical tool for weight loss? MJA 2006;184(2):52–3. 27. Laymen DK, et al. A moderate protein diet produces sustained weight loss and long-term changes in body composition and blood lipids

VLEDs may also improve certain obesity-related comorbidities by reducing cholesterol levels and improving glycaemic control

in obese adults. J Nutr 2009:514–21. 28. Flechtner-Mors M. Enhanced weight loss with protein-enriched meal replacements in subjects with the metabolic syndrome. Diabetes Metab Res Rev 2010 Jul; 26(5):393–405. 29. Slavin J, Green H. Dietary fibre and satiety. Nutr Bull 2007;32:32–42. 30. Chen J and Raymond K. Beta-glucans in the treatment of diabetes and associated cardiovascular risks. Vascular Health and Risk Management 2008;4(6);1265–72. 31. Nutrient Reference Values for Australia and New Zealand–Including Recommended Dietary Intakes. NH&MRC, 2005. 32. Brown L et al. Cholesterol-lowering effects of dietary fibre: meta-analysis. Am J Clin Nutr 1999;69:30–42. 33. Queenan KM, et al. Concentrated oat betaglucan, a fermentable fibre, lowers serum cholesterol in hypercholesterolemic adults in a randomized controlled trial. Nutr J 2007; Mar 26(6):6. 34. Lennard-Jones JE. Clinical management of constipation. Pharmacology 1993 Oct;47 Suppl 1:216–23. 35. Simopoulos AP. The importance of the omega-6/omega-3 fatty acid ratio in cardiovascular disease and other chronic diseases. Exp Biol Med 2008;233:674–88.