Recommendations Summary
AWM: Medical Nutrition Therapy 2014
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
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Recommendation(s)
AWM: Medical Nutrition Therapy
Medical nutrition therapy (MNT) provided by a registered dietitian nutritionist (RDN) is recommended for overweight and obese adults. MNT provided by an RDN results in both statistically significant and clinically meaningful weight loss in overweight and obese adults, as well as reduced risk for diabetes, disorders of lipid metabolism and hypertension.
Rating: Strong
Imperative-
Risks/Harms of Implementing This Recommendation
None.
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Conditions of Application
Weight loss may be beneficial for other health conditions as well. In addition, the RDN should assess for appropriateness of weight management in certain populations (eating disorders, pregnancy, receiving chemotherapy, etc.).
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Potential Costs Associated with Application
Costs of MNT sessions vary, however MNT sessions are essential for improved outcomes.
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Recommendation Narrative
Recommendation Narrative from MNT Effectiveness
- MNT provided by an RDN results in both statistically and clinically significant weight loss in otherwise healthy overweight and obese adults
- Four studies regarding the effectiveness of MNT for under six months reported significant weight losses of approximately one to two pounds per week (Holm et al, 1983; Richardson et al, 2005; Schneider et al, 2005; Raatz et al, 2008)
- Four studies regarding the effectiveness of MNT from six to 12 months reported significant mean weight losses of up to 10% of body weight (Eilat-Adar et al, 2005; Feigenbaum et al, 2005; Dengel et al, 2006; Digenio et al, 2009)
- Four studies report maintenance of this weight loss beyond one year. In these studies, both individual and group sessions were employed with weekly and monthly sessions (Melin et al, 2003; Willaing et al, 2004; Ashley et al, 2007; Sacks et al, 2009).
Recommendation Narrative from Diabetes
- In randomized clinical trials, approximately half report improvement in A1C values with weight loss; whereas, approximately half report no improvement in A1C values despite fairly similar weight losses
- A total of 12 studies with more than one diet arm (Hollander et al, 1998; Manning et al, 1998; Hanefeld et al, 2002; Miles et al, 2002; Kelley et al, 2003; Redmon et al, 2003; Brinkworth et al, 2004; Metz et al, 2004; Wolf et al, 2004; Li et al, 2005; Berne et al, 2005; Redmon et al, 2005) reported weight loss and A1C values at 12 months
- Seven studies in diet arms reported no improvement in A1C (Hollander et al, 1998; Manning et al, 1998; Redmon et al, 2003; Brinkworth et al, 2004; Wolf et al, 2004; Li et al, 2005; Redmon et al, 2005) despite weight loss (range, -0.8kg to -4.4kg) in all but one study, which reported no weight loss (Manning et al, 1998)
- Five studies in diet arms reported improvement in A1C ranging from -0.2% to -0.6% (Hanefeld et al, 2002; Miles et al, 2002; Kelley et al, 2003; Mertz et al, 2004; Berne et al, 2005) with fairly similar weight losses (range, -1.3kg to -5.1kg)
- Studies using weight loss medications (orlistat and lifestyle, sibutramine) report consistent improvement in A1C. Six studies with an orlistat arm (Hollander et al, 1998; Hanefeld et al, 2002; Miles et al, 2002; Kelley et al, 2003; Derosa et al, 2004; Berne et al, 2005) reported improvements in A1C values (range, -0.3% to -1.1%) with orlistat and lifestyle intervention with weight loss (range, -3.9kg to -6.2kg).
- Five studies (McNulty et al, 2003; Redmon et al, 2003; Derosa et al, 2004; Sanchez-Reyes et al, 2004; Redmon et al, 2005) reported improvements in A1C values (range, -0.3% to -6.0%) with sibutramine with weight loss (range, -4.1kg to -8.0kg)
- A total of 10 studies reported significant improvements in at least one lipid value, generally in triglycerides and HDL-cholesterol from weight loss either by diet alone or with weight loss medications (Hollander et al, 1998; Hanefeld et al, 2002; Miles et al, 2002; Paisey et al, 2002; Ash et al, 2003; Kelley et al, 2003; McNulty et al, 2003; Metz et al, 2004; Berne et al, 2005; Li et al, 2005)
- Seven studies reported improvement in blood pressure with weight loss (Miles et al, 2002; Redmon et al, 2003; Brinkworth et al, 2004; Derosa et al, 2004; Metz et al, 2004; Li et al, 2005; Redmon et al, 2005), however one study using sibutramine reported increases in blood pressure (McNulty et al, 2003) and one study using sibutramine reported no change in blood pressure (Derosa et al, 2004).
Recommendation Narrative from Disorders of Lipid Metabolism- A total of 10 studies provide evidence that:
- An increased BMI and waist circumference are associated with increased risk of metabolic syndrome
- In the metabolic syndrome patient, a cardioprotective dietary pattern (low in saturated fat, trans fat and cholesterol, limited in simple sugar intake and increased in consumption of fruits, vegetables and whole grains) provides the background for modifying the energy balance to achieve weight loss. Extremes in intakes of carbohydrate or fats should be avoided.
- Physical activity at any level, light, moderate or vigorous, is associated with reduced incidence of metabolic syndrome
- Food patterns emphasizing a diet high in fruits and vegetables and whole grains is associated reduced incidence of metabolic syndrome
- Lifestyle modification resulting in weight reduction and increased physical activity has been shown to improve risk factors associated with metabolic syndrome. Caloric restriction combined with daily activity of at least 30 minutes at moderate intensity resulted in weight loss of at least 7% and improved components of the metabolic syndrome.
- Studies included two positive-quality cross-sectional studies (Ford et al, 2003; Irwin et al, 2002), one positive-quality systematic review/evidence report (Adult Treatment Panel III, 2002), two positive-quality cohort studies (Case et al, 2002; Lakka et al, 2003), one positive-quality case-controlled study (Pitsavos et al, 2003), one positive-quality before/after study (Katzmarzyk et al, 2003), one neutral-quality cross-sectional study (Panagiotakos et al, 2004) and two negative-quality consensus statements (Grundy, Brewer et al, 2004; Grundy, Hansen et al, 2004):
- One positive-quality retrospective cohort study (Case et al, 2002) found weight loss obtained by calorie restriction and physical activity improved risk factors of the metabolic syndrome
- One positive-quality before/after study (Katzmarzyk et al, 2003) of Caucasian and black men and women found an aerobic exercise training program improved risk factors of the metabolic syndrome
- Five epidemiological studies [(four positive-quality (Ford et al, 2003; Irwin et al, 2002; Lakka et al, 2003; Pitsavos et al, 2003) and one neutral-quality (Panagiotakos et al, 2004)] support an inverse relationship between physical activity (and inactivity) and the metabolic syndrome. One study included three different ethnic groups (Irwin et al, 2002).
- Reports of the American Heart Association, the National Heart, Lung, and Blood Institute and the American Diabetes Association (Grundy, Brewer et al, 2004; ATP III, 2002; Grundy, Hansen, et al, 2004) concluded that lifestyle modification leading to weight reduction and increased physical activity represent first-line clinical therapy for the metabolic syndrome. Nutritional therapy calls for a low intake of saturated fat, trans-fatty acids and cholesterol; reduced consumption of simple sugars; and increased fruits and vegetables and whole grains. Extremes in intakes of either carbohydrate or fats should be avoided.
Recommendation Narrative from Hypertension
Based on the JNC 7 report, a weight loss of as little as 10 lbs (4.5kg) reduces blood pressure and prevents hypertension in a large proportion of overweight persons. -
Recommendation Strength Rationale
Recommendation Strength Rationale from MNT Effectiveness
Conclusion statement in support of the recommendation received Grade I.Recommendation Strength Rationale from Diabetes
Conclusion statement from diabetes in support of the recommendation received Grade II.Recommendation Strength Rationale from Disorders of Lipid Metabolism- Research findings were across men and women of different ethnic groups residing in the United States
- This recommendation is supported by a consensus of three organizations interested in the prevention and treatment of metabolic syndrome
- Conclusion statements are Grade II, except conclusion statement on Dietary Pattern to Achieve Weight Loss and Reduce Components of the Metabolic Syndrome, which is a Grade IV
- Conclusion statements were based on:
- Two positive-quality cross-sectional studies
- One positive-quality systematic review/evidence report
- Two positive-quality cohort studies
- One positive-quality case-control study
- One positive-quality before/after study
- One neutral-quality cross-sectional study
- Two negative-quality consensus statements.
Recommendation Strength Rationale from Hypertension
The ADA Hypertension Expert Work Group concurs with the recommendations from the JNC 7 regarding weight management. -
Minority Opinions
Consensus reached.
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Risks/Harms of Implementing This Recommendation
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Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the evidence to support effectiveness of MNT provided by a Registered Dietitian for overweight/obesity in otherwise healthy adults?
What is the long-term effect (1 year or greater) of weight management on metabolic outcomes in persons with type 1 and type 2 diabetes?
Is obesity associated with the metabolic syndrome?
In metabolic syndrome patients, what dietary pattern will achieve weight loss and reduce components of the metabolic syndrome?
Is physical activity associated with the metabolic syndrome?
What food patterns are associated with reduced incidence of metabolic syndrome?
In patients with the metabolic syndrome, what lifestyle practices have reduced the risk factors and components of the metabolic syndrome?-
References
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Ash S, Reeves MM, Yeo S, Morrison G, Carey D, Capra S. Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial. International Journal of Obesity. 2003; 27:797-802.
Berne C, for the Orlistat Swedish Type 2 Diabetes Study Group. A randomized study of orlistat in combination with a weight management programme in obese patients with Type 2 diabetes treated with metformin. Diabetic Medicine 2005;22: 612-618.
Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with Type 2 diabetes: one-year follow-up of a randomized trial. Diabetologia 2004; 47:1677-1686.
Brown SA, Upchurch S, Anding R, Winter M, Ramirez G. Promoting weight loss in type 2 diabetes. Diabetes Care. 1996;19(6):613-624.
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Hanefeld M, Sachse G. The effects of orlistat on body weight and glycaemic control in overweight patients with type 2 diabetes: a randomized, placebo-controlled trial. Diabetes, Obesity and Metabolism 2002; 4:415-423.
Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T, Weiss SR, Crockett SE, Kaplan RA, Comstock J, Lucas CP, Lodewick PA, Canovatchel W, Chung J, Hauptman J. Role of orlistat in the treatment of obese patients with type 2 diabetes. Diabetes Care. 1998;21:1288-1294.
Kelley DE, Bray GA, Pi-Sunyer FX, Klein S, Hill J, Miles J, Hollander P. Clinical efficacy of orlistat therapy in overweight and obese patients with insulin-treated type 2 diabetes: a 1-year randomized controlled trial. Diabetes Care 2002;25:1033-1041.
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Manning RM, Jung RT, Leese GP, Newton RW. The Comparison of Four Weight Reduction Strategies Aimed at Overweight Patients with Diabetes Mellitus: Four-year Follow-up. Diabetic Medicine 1998;15:497-502.
Mayer-Davis EJ, D'Antonio AM, Smith SM, Kirkner G, Martin SL, Parra-Medina D, Schultz R. Pounds off with Empowerment (POWER): a clinical trial of weight management strategies for black and white adults with diabetes who live in medically underserved rural communities. Am J Public Health. 2004;94:1736-1742.
McNulty SJ, Ur E, Williams G; for the Multicenter Sibutramine Study Group. A randomized trial of sibutramine in the management of obese type 2 diabetic patients treated with metformin. Diabetes Care. 2003; 125-131.
Metz JA, Stern JS, Kris-Etherton P, Reusser ME, Morris CD, Hatton DC, Oparil S, Haynes RB, Resnick LM, Pi-Sunyer FX, Clark S, Chester L, McMahon M, Snyder GW, McCarron DA. A randomized trial of improved weight loss with a prepared meal plan in overweight and obese patients: impact on cardiovascular risk reduction. Arch Intern Med. 2000; 160: 2,150-2,158.
Miles JM, Leiter L, Hollander P, Wadden T, Anderson JW, Doyle M, Foreyt J, Aronne L and Klein S. Effect of orlistat in overweight and obese patients with type 2 diabetes treated with metformin. Diabetes Care 2002;25(7):1123-1128.
Norris SL, Zhang X, Avenell A, Gregg E, Bowman B, Serdula M, Brown TJ, Schmid CH and Lau J. Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004 Nov 15;117(10):762-74.
Paisey RB, Frost J, Harvey P, Paisey A, Bower L, Paisey RM, Taylor P, Belka I. Five-year results of a prospective very low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet 2002;15(2):121-7.
Redmon JB, Raatz SK, Reck KP, Swanson JE, Kwong CA, Fan Q, Thomas W and Bantle JP. One-year outcome of a combination of weight loss therapies for subjects with type 2 diabetes: a randomized trial. Diabetes Care 2003;26(9):2505-2511.
Redmon JB, Reck KP, Raatz SK, Swanson JE, Kwong CA, Ji H, Thomas W, Bantle JP. Two-year outcome of a combination of weight loss therapies for Type 2 diabetes. Diabetes Care 2005;28:1311-1315.
Sanchez-Reyes L, Fanghanel G, Yamamoto J, Martinez-Rivas L, Campos-Franco E, Berber A. Use of sibutramine in overweight adult Hispanic patients with type 2 diabetes mellitus: A 12-month, randomized, double-blind placebo-controlled clinical trial. Clinical Therapeutics. 2004; 26(9):1,427-1,435.
Vettor R, Serra R, Fabris R, Pagano C and Federspil G. Effect of sibutramine on weight management and metabolic control in type 2 diabetes: A meta-analysis of clinical studies. Diabetes Care. 2005; 28(4): 942-949.
Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D. Long-term effects of modest weight-loss in type II diabetic patients. Arch Intern Med. 1987;147:1749-1753.
Wolf AM, Conaway MR, Crowther JQ, Hazen KY, Nadler JL, Oneida B, Bovbjerg VE. Translating Lifestyle Intervention to Practice in Obese Patients with Type 2 Diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care, 2004; 27 (7): 1,570-1,576.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002
Ford ES, Mokdad AH, Giles WH, Brown DW. The metabolic syndrome and antioxidant concentrations: findings from the Third National Health and Nutrition Examination Survey. Diabetes. 2003 Sep; 52 (9): 2,346-2,352.
Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004;109:433-438.
Grundy SM, Hansen B et.al. Clinical Management of Metabolic Syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association Conference on scientific Issues Related to Management. Circulation. 2004;109:551-556.
Irwin ML, Ainsworth BE, Mayer-Davis EJ, Addy CL, Pate RR, Durstine JL.Physical activity and the metabolic syndrome in a tri-ethnic sample of women. Obes Res. 2002 Oct; 10 (10): 1,030-1,037.
Lakka TA, Laaksonen DE, Lakka HM, Männikkö N, Niskanen LK, Rauramaa R, Salonen JT. Sedentary lifestyle, poor cardiorespiratory fitness, and the metabolic syndrome. Med Sci Sports Exerc. 2003 Aug; 35 (8): 1,279-1,286.
Panagiotakos DB, Pitsavos C, Chrysohoou C, Skoumas J, Tousoulis D, Toutouza M, Toutouzas P, Stefanadis C. Impact of lifestyle habits on the prevalence of the metabolic syndrome among Greek adults from the ATTICA study. Am Heart J. 2004 Jan; 147 (1): 106-112.
Pitsavos C, Panagiotakos DB, Chrysohoou C, Papaioannou I, Papadimitriou L, Tousoulis D, Stefanadis C, Toutouzas P. The adoption of Mediterranean diet attenuates the development of acute coronary syndromes in people with the metabolic syndrome. Nutr J. 2003 Mar 19; 2: 1.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002
Case CC, Jones PH, Nelson K, O'Brian Smith E, Ballantyne CM. Impact of weight loss on the metabolic syndrome. Diabetes Obes Metab. 2002 Nov; 4 (6): 407-414.
Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004;109:433-438.
Grundy SM, Hansen B et.al. Clinical Management of Metabolic Syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association Conference on scientific Issues Related to Management. Circulation. 2004;109:551-556.
Katzmarzyk PT, Leon AS, et al. Targeting the Metabolic Syndrome with Exercise: Evidence from the HERITAGE Family Study. Medicine & Science in Sports & Exercise. 35:1703-1709, 2003.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002
Ford ES, Mokdad AH, Giles WH, Brown DW. The metabolic syndrome and antioxidant concentrations: findings from the Third National Health and Nutrition Examination Survey. Diabetes. 2003 Sep; 52 (9): 2,346-2,352.
Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004;109:433-438.
Grundy SM, Hansen B et.al. Clinical Management of Metabolic Syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association Conference on scientific Issues Related to Management. Circulation. 2004;109:551-556.
Irwin ML, Ainsworth BE, Mayer-Davis EJ, Addy CL, Pate RR, Durstine JL.Physical activity and the metabolic syndrome in a tri-ethnic sample of women. Obes Res. 2002 Oct; 10 (10): 1,030-1,037.
Lakka TA, Laaksonen DE, Lakka HM, Männikkö N, Niskanen LK, Rauramaa R, Salonen JT. Sedentary lifestyle, poor cardiorespiratory fitness, and the metabolic syndrome. Med Sci Sports Exerc. 2003 Aug; 35 (8): 1,279-1,286.
Panagiotakos DB, Pitsavos C, Chrysohoou C, Skoumas J, Tousoulis D, Toutouza M, Toutouzas P, Stefanadis C. Impact of lifestyle habits on the prevalence of the metabolic syndrome among Greek adults from the ATTICA study. Am Heart J. 2004 Jan; 147 (1): 106-112.
Pitsavos C, Panagiotakos DB, Chrysohoou C, Papaioannou I, Papadimitriou L, Tousoulis D, Stefanadis C, Toutouzas P. The adoption of Mediterranean diet attenuates the development of acute coronary syndromes in people with the metabolic syndrome. Nutr J. 2003 Mar 19; 2: 1.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002
Ford ES, Mokdad AH, Giles WH, Brown DW. The metabolic syndrome and antioxidant concentrations: findings from the Third National Health and Nutrition Examination Survey. Diabetes. 2003 Sep; 52 (9): 2,346-2,352.
Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004;109:433-438.
Grundy SM, Hansen B et.al. Clinical Management of Metabolic Syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association Conference on scientific Issues Related to Management. Circulation. 2004;109:551-556.
Irwin ML, Ainsworth BE, Mayer-Davis EJ, Addy CL, Pate RR, Durstine JL.Physical activity and the metabolic syndrome in a tri-ethnic sample of women. Obes Res. 2002 Oct; 10 (10): 1,030-1,037.
Lakka TA, Laaksonen DE, Lakka HM, Männikkö N, Niskanen LK, Rauramaa R, Salonen JT. Sedentary lifestyle, poor cardiorespiratory fitness, and the metabolic syndrome. Med Sci Sports Exerc. 2003 Aug; 35 (8): 1,279-1,286.
Panagiotakos DB, Pitsavos C, Chrysohoou C, Skoumas J, Tousoulis D, Toutouza M, Toutouzas P, Stefanadis C. Impact of lifestyle habits on the prevalence of the metabolic syndrome among Greek adults from the ATTICA study. Am Heart J. 2004 Jan; 147 (1): 106-112.
Pitsavos C, Panagiotakos DB, Chrysohoou C, Papaioannou I, Papadimitriou L, Tousoulis D, Stefanadis C, Toutouzas P. The adoption of Mediterranean diet attenuates the development of acute coronary syndromes in people with the metabolic syndrome. Nutr J. 2003 Mar 19; 2: 1.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002
Case CC, Jones PH, Nelson K, O'Brian Smith E, Ballantyne CM. Impact of weight loss on the metabolic syndrome. Diabetes Obes Metab. 2002 Nov; 4 (6): 407-414.
Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C, for the Conference Participants. Definition of the Metabolic Syndrome, Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004;109:433-438.
Grundy SM, Hansen B et.al. Clinical Management of Metabolic Syndrome: Report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association Conference on scientific Issues Related to Management. Circulation. 2004;109:551-556.
Katzmarzyk PT, Leon AS, et al. Targeting the Metabolic Syndrome with Exercise: Evidence from the HERITAGE Family Study. Medicine & Science in Sports & Exercise. 35:1703-1709, 2003. -
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Chobanian AV1, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. JAMA. 2003; 289: 2, 560-2, 571.
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References