Anuhs Meal Plan: Managing Prediabetes, Lactose Intolerance and Weightloss

http://stocksonwallstreet.net/wp-content/uploads/2010/12/vietnam-flag.gif Accessed November 26, 2012

http://flagspot.net/images/u/us.gif Accessed November 26, 2012

Espada D. Steamed sea bass. D Magazine Web Site. http://directory.dmagazine.com/restaurants/Malai_Kitchen/52201. Accessed November 27, 2012.

Alexis Beltran, Jessica Salgado, Karina Navarro, Lauren Doherty, Stephanie Wharton Nutrition 304: Nutrition Throughout the Life Span Instructor: Mee Young Hong November 28, 2012

Introduction
The on campus clinic at the University of California Los Angeles decided to perform a voluntary study to determine the prevalence of prediabetes and type-two diabetes among the student population. The study was open to all volunteers who exhibited any of the risk factors for type 2 diabetes. According to Jacquelin V. Deatcher those risks include but are not limited to having a BMI greater than 25 kg/m2, leading a sedentary lifestyle, genetic predisposition from family history, elevated blood pressure, elevated triglyceride levels, etc.(1). Anuh Ngyuen is a twenty-seven year old female college student attending UCLA. She chose to volunteer for the clinical study because she had gradually been gaining weight throughout the last five years, was now noticeably overweight and had become increasingly uncomfortable with her appearance. As a result of the study, Anuh discovered that she has prediabetes and must take action in order to prevent the development of type-two diabetes along with lifelong health impairments. To treat her prediabetes, Anuh opted to consult the Registered Dietician on her UCLA campus. Prediabetes, according to Vivian A. Fonseca, is a condition that usually precedes type-two diabetes and is characterized by both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). It is important to identify patients with prediabetes in order to treat them and therefore effectively delay or prevent the onset of diabetes which is associated with more serious and life threatening complications. Along with pharmacologic interventions, appropriate lifestyle modifications such as diet and exercise regimens can reduce the incidence of diabetes in patients with prediabetes (2). Anuh was born and raised in Los Angeles, California where there is a subtropicalMediterranean climate throughout the year. Currently temperatures in Los Angeles range between 68 degrees Fahrenheit to 71degrees Fahrenheit during the winter. She was raised by her mother and father who emigrated from Vietnam in 1976 to Los Angeles, California. Her parents brought her up with traditional Vietnamese values and beliefs. Anuhs parents, although not very religious, also raised her as a Buddhist and instilled Buddhist ideals in her from a very young age. While Anuh lived with her parents she lived a well-rounded and active life and was not employed for her first four years of college. While living at home she mostly ate only the foods her mother prepared. Her diet consisted mainly of traditional Vietnamese wholesome foods such as rice noodles, spring rolls, white rice, fish, fish sauces, coconut milk, a variety of soups like crab and asparagus soup, in addition to typical Vietnamese herbs and spices added to each dish. Since she moved out of her parents home her diet has drastically changed. Anuh has lived on her own since she transferred to UCLA at the age of twenty-two years old. Currently Anuh is working part-time as an assistant manager at a bed and breakfast in Los Angeles near her home and UCLA campus. She gets paid a total of $18 dollars per hour and works a total of 27 hours per week. Her work schedule during the semester consists of working Friday through Sunday from 9:00 am to 7:00 pm. She is also a full time student at UCLA where she is studying to get her Masters Degree in Hospitality & Hotel Management and that takes up most of her time. Anuhs school schedule consists of class Monday through Thursday. Every Monday and Wednesday she attends classes from 12:00 pm to 7:00 pm and Tuesday and Thursday she has classes from 9:00 am to 5:00 pm. With an overwhelming work, school, and study schedule, she has developed a sedentary lifestyle which has likely led to her gradual weight

gain over the last several years. During Anuhs clinical evaluation with the Registered Dietitian, she expressed that she feels she doesnt have enough time in her daily schedule to cook healthy foods and doesnt pay attention to her daily vitamin, macronutrient, or kcal intake. Also, Anuh explained to the dietician that she is lactose intolerant. According to Anh et al, the Vietnamese traditional diet lacks dairy, thus Vietnamese people are likely to develop lactose intolerance which means they have a very hard time digesting lactose (3). Although she is aware of the intolerance however, she still chooses to eat foods containing dairy products. While she lived with her family she ate a healthy diet but because her mother did most of the cooking. Anuh never acquired many cooking skills and that led her to practice an unhealthy lifestyle. Anuhs current usual diet consists of skipping breakfast most days of the week unless she stops at the nearest Starbucks and grabs a 16oz or larger Frappuccino with a muffin or scone. On the weekends she goes out to eat breakfast with her friends at a restaurant like Dennys where she might order something like French toast with sausage. During the week Anuh tends to be an on-the-go individual with many of her food choices being very similar. Her typical lunch consists of two servings of orange chicken, chow mien, and egg rolls from Panda Express or what she considers a healthy lunch of a fiesta taco salad with beef from Taco Bell. For dinner Anuh either grabs something from her favorite take-out places that offer curbside to-go like Chilis and Applebees or she will heat up an easy microwavable TV dinner. On the weekends or after late nights at work she enjoys getting drinks with friends or coworkers. Since she tends to get off work at 7 pm Anuh is usually hungry and rushing off to meet her friends and ends up grabbing food wherever they meet, perhaps a restaurant or a bar where she will order menu items such as fried chicken tenders, french fries, mozzarella breaded and fried cheese sticks, nachos platter with beef and extra cheese, or a large cobb salad with a hefty serving of ranch dressing. Anuh weighs 175 pounds (79.37kg) and she measures 55 (165.1cm) tall. These values make her BMI 29.1kg/m2, which is overweight. Her ideal body weight is 125 pounds (56.699kg; formula used - women 100 pounds for 5 feet and 5 pounds for each 1 inch after) thus she is currently at 140% of her ideal body weight. Anuhs lab test results from her initial evaluation for the clinical research study were fine with the exception of the following; fasting blood glucose 113mg/dL (elevated/prediabetic range) and Triglyceride (TG) level of 211mg/dL (high). Normal values from blood glucose (BG) and TG respectively are 70-110mg/dL and <150mg/dL. These lab test results reflect the usual dietary intake that Anuh reported. On her 24-hr recall Anuh reported a breakfast that consisted of a maple oat scone and a grande (16oz) mocha frappuccino, lunch was a beef fiesta taco salad, an afternoon snack of a milkshake, and a jalapeno burger. Based on the information Anuh gave, in one day, Anuh consumed roughly 4150 kcals which included 235g of fat, 166g sugar, and 5620mg of sodium. This is double and triple her recommend dietary intake of kcals, fat, and her sugar intake was roughly 16% of the total caloric intake which is 6% more than the World Health Organization recommends according to Madeleine Greey(4). Based on Anuhs anthropometric measurements her recommended kcal intake is 1,871.1 kcal/day based on her adjusted body weight of 145.2 pounds (62.37kg) and 30kcal/kg/day.

Appendix A
Anthropometric Measurements BMI 29.1kg/m2 (overweight) IBW 125lbs, 56.7kg %IBW 140% (obese) ABW 137.5lbs, 62.37kg Macronutrients EER Sedentary lifestyle = 30kcal/kg/day 1,871.1kcal/day Protein/day = 0.8g/kg/day 1g/kg/day 49.89g/day 62.37g/day Carbohydrate = 50% or less of kcals/day <233.89g/CHO/day Fat = 30% or less of kcals/day <62.37 g/fat/day Fiber = 14g/1,000kcals 26.2g/day

Macro/Micronutrient
Calories (kcal) Fat (g) Protein (g) Carbohydrate (g) Vitamin A (IU) Vitamin C (mg) Sodium/NA (mg) Zinc (mg) Folate/Folic Acid (mg) Vitamin D (IU) Calcium/Ca (mg) Iron/Fe (mg) Fiber (g)

DRI
1,871.1 <62.37 49.89 62.37 <233.89 5,000 75 2,300 6.8 400 600 1,000 18 26.2

Menu Plan
Monday
Breakfast 1 C light soy milk 1 Whole egg & 1 white scrambled 2 Tbs salsa 1 cup orange Juice

Tuesday
1 Medium whole wheat bagel 1 Tbs low fat cream cheese choice of fortified beverage

Wednesday
2 Slices whole wheat high fiber French toast C Sugar free 1 C black coffee

Thursday
1 Whole wheat high fiber tortilla 2 egg whites 2 Tbs salsa 1 Tbs sour cream

Friday
1 C raw rolled oats unsweetened 1 C blueberries 1 tsp no calorie sweetener 1 C soy milk

Saturday
1 Packet Kashi GoLean Hot Cereal 1 C. Unsweetened Soy Milk 1/2 C. Blueberries

Sunday
1 slice whole wheat high fiber 1 Tbs low fat peanut butter 1 C mixed berries 1 C black coffee 2 C Broccoli and carrots raw 2 Tbs

Snack Daily: 12 oz water or tea Lunch

C popcorn (kernels) 1tsp cinnamon 1 Tbs Margarine 3/4 C Spicy tuna salad 2 C raw spinach C raw tomato raw avocado C onion

1 C dried strawberries 1 small piece of chocolate

1 Sugar free pudding 1 low sugar granola bar

3 C carrots 2 Tbs low fat ranch 1 bag low fat baked chips 1 Recipe chicken salad 1oz lactose free cheese 1 Tbs olive oil C Dried Apricots 3 C lettuce 1/2 Tomato 1 Tbs pine nuts

1 C mixed dehydrated fruit C peanuts

1 Luna Bar Nuts Over Chocolate

Single serve recipe; salmon salad: 1 sprig dill 1 stalk large celery 1/2 head red leaf lettuce 1/2 oz sweet onion 4 oz grilled salmon

1 Chicken wrap Whole wheat tortilla 4oz chicken 1Tbs Light Mayo 2 slices tomato C spinach

4 oz turkey 2 slices whole wheat bread 1 tsp low fat mayo 1 Tbs chile sauce tsp lime juice 2 slices onion 1 tsp cilantro salt & pepper to taste

1 C Cabbage 1 small tomato 1/4 C onion 2 Tbs Kraft Italian Dressing RF 1 fillet of Tilapia 87 g

1 large green pepper stuffed with C lean ground turkey 1 Tbs jalapeo medium tomato diced C olives

Daily: 22 oz water Snack

Med Baked Potato

1 Lactose free Greek yogurt

2 C steamed edamame

3 stalks of celery 2 Tbs peanut butter 1 small pack raisins

1/3 C unsalted peanuts 12 oz water or tea

Mon Fri: 12 oz water or tea Dinner 1 Tbsp Canola 3/4 Broccoli 3/4 celery ribs 4 oz Mushrooms 1/2 garlic clove 1/2 Tbs low NA Soy sauce 1/8 tsp ginger Tbs corn starch C chicken broth tsp pepper C tofu C brown rice 2 Chicken fajitas 2 whole wheat high fiber tortillas 3oz chicken each 1oz sauted onions and peppers each 2 Tbs sour cream 2 Tbs salsa (to taste) 3/4 C gnocchi steamed 3oz chicken 1 light garlic and herb cheese wedge C light alfredo sauce 1 C frozen broccoli steamed 1 grilled eggplant tsp pepper 1 tsp salt 1 Tbs olive oil 1 C whole wheat pasta C spaghetti sauce parmesan cheese to taste (side dish) 1 Baked tilapia fillet (87g) 1 C cauliflower puree garlic salt and pepper to taste 1 C steamed carrots

1 Cup Raw Mango 2 Tbs fat free ranch dress 1/2 avocado 1 C no sugar Soy Milk 12 oz water or diet soda 1/6 C. uncooked jasmine rice 3oz. chicken 3 pieces fresh ginger root 1 stalk lemon grass 1/4 Cup chopped fresh chives 1 /8 lime wedge

2C Strawberry, blueberry, & 1 C no sugar smoothie 12 oz water or diet soda

Daily: 24 oz water

2 C Pho beef noodle stew 1 C broth C noodles C beef cilantro & onion to taste 1 C sauted carrots, baby corn, broccoli, and celery

Dessert Choice of beverage

1 Plain sugar doughnut

1 Plain sugar doughnut

Nutrient Analysis Day 1:

Nutrients
Calories Carbohydrates Protein Fat Zinc Sodium Iron Calcium Vitamin A Vitamin C Vitamin D Folacin Fiber

DRI Standard
1871.1 < 233.8 62.37 < 62.37 6.8 2300 18.1 1,000 5,000 75 600 400 26.2

Monday Nutrient Intake

1494 181.9 62.3 56.6 7.68 1703 10.92 997.5 5,221 171 452 335.5 23.9

% of DRI Met
79% 77% 99% 90% 112% 75% 60% 99% 104% 228% 75% 83% 91%

Monday's Intake: Macronutrients

Protein 17% Carbohydrate 48% Fat 35%

Total Calorie Intake: 1494

Day 2:

Nutrients
Calories (kcal) Carbohydrates (g) Protein (g) Fat (g) Zinc (mg) Sodium (mg) Iron (mg) Calcium (mg) Vitamin A (IU) Vitamin C (mg) Vitamin D (IU) Folacin (mcg) Fiber (g)

DRI Standard
1871.1 < 233.89 62.37 < 62.37 6.8 2300 18 1,000 5,000 75 600 400 26.2

Saturday Nutrient Intake

1585.21 183.67 78.16 56.03 8.2 2367 18.39 1235.25 5162.25 164.6 430 558 31.74

% of DRI Met
85% 78.5% 125% 90% 120% 102% 102% 124% 103% 219% 72% 139% 121%

Saturday's Intake: Macronutrients

Fat 33% Carbohydrates 47%

Protein 20%

Total Calorie Intake: 1585

Menu Costing

USDA Food Cost Plan: October 2012 Budgeted amount for one week: $46.80 Budgeted amount for one day: $6.69
Brand Name Silk Eggland Herdez Casera Bumble Bee Delish Pantry Essentials Safeway Safeway The Snack Artist Newstar Vine Ripe Purchase Size (2) Half Gallons 18 count 70 oz. 5 oz. 8 oz. 0.7 oz. 1 unit 24 fl. Oz. 32 fl. Oz. 30 oz. 13.25 oz. 1 unit 1 unit 1 unit Safeway 48 fl. Oz. 1 lb. 1 lb. 1 lb. 1 unit Safeway Its Delish Swanson Safeway Delish O Organics Safeway Shoppers Value Gold n Soft Its Delish 40 oz. 7 oz. 14 oz. 16 oz. 8 oz. 14 oz. 80 oz. 128 oz. 1 head 45 oz. 8 oz. 5 lb Purchase Price Serving Size Cost Per Serving $0.48 $0.44 $0.09 $0.50 $0.05 $0.02 $0.06 $0.03 $0.02 $0.36 $0.50 $0.27 $0.27 $0.20 $0.12 $0.12 $0.32 $0.40 $0.03 $0.04 $0.02 $0.12 $0.01 $0.01 $0.43 $0.22 $0.24 $0.43 $0.03 $0.11 $0.30

Food Item Soy Milk Eggs Salsa Tuna Paprika Cayenne Pepper Jalapeno Relish Light Mayonnaise Popcorn kernels Spinach Tomatoes Avocado Red Onion Canola Oil Broccoli Celery White Mushrooms Garlic Soy Sauce Ground Ginger Chicken Broth Cornstarch Black Pepper Tofu Logn Grain Brown Rice Orange Juice Iceburg Lettuce Margarine Cinnamon Russet Potatoe

$7.69 1 Cup $3.99 2 eggs $6.59 1 oz. $1.00 2.5 oz. $4.89 1/2 tsp. $1.39 1/2 tsp. $0.11 1/2 unit $3.59 1/3 tbsp. $2.99 1/3 tbsp. $5.49 1/4 Cup $3.29 2 Cups $0.55 1/2 unit $1.07 1/4 unit $0.82 1/4 unit $3.33 1 tbsp $0.99 3/4 Cup $1.29 3/4 Cup $3.99 4 oz. $0.50 1/2 clove $5.59 1/2 tbsp $5.29 1/8 tsp $0.88 2 oz. $1.69 1/4 tbsp. $4.39 1/4 tsp. $1.50 1/2 Cup $5.49 1/2 Cup $4.79 1 Cup $1.09 2 cups $3.29 1 tbsp $5.09 1 tsp $1.49 1 unit

Total for one day: $6.24

Discussion and Summary

Anuh Nguyen, a 27 year old Vietnamese female, recently discovered that she has prediabetes and that she must treat it if she hopes to improve her overall health and avoid more serious complications in the future. Prediabetes puts Anuh at a high risk of developing type 2 diabetes within the next few years but this early diagnosis also allows her to take appropriate measures in treating her prediabetes to prevent type 2 diabetes. According to Vivian A. Fonseca, appropriate lifestyle modifications have been found to be effective for individuals with prediabetes. Lifestyle interventions that reduce the incidence of diabetes in prediabetes patients include both diet and exercise regimens (2). Anuh currently lives a sedentary lifestyle and that, coupled with her poor eating habits, has contributed to her progressive weight gain in the past 5 years. She is now considered overweight due to her increased BMI and is at risk for developing type 2 diabetes due to both her prediabetes and her overweight status. She is also lactose intolerant but does not eat a diet that is appropriate for her condition. Some basic lifestyle changes could help Anuh improve her quality of life and she is just now realizing it. Anuh decided to take action by consulting the Registered Dietician on her college campus of UCLA. Anuh attends UCLA as a full time student to obtain her masters degree and she also works part-time at a bed and breakfast near the college campus. She has a very busy schedule and between school, work and study time, she admits that her health has not been a priority. The majority of her meals are eaten out and they are chosen based more on convenience than on nutrient quality. She eats a lot of fast food because it is the easiest to obtain and when she does have some free time she spends it at bars with her friends and she will order high fat food accompanied by alcoholic beverages. Her lifestyle has changed drastically since she moved out of her parents house to live on her own. Her parents provided her with traditional Vietnamese meals and brought her up within the Buddhist religion which both emphasize a mostly vegetarian diet and a diet high in nutrients but she never acquired the cooking skills to follow these practices. Because of Anas risk of diabetes, it is important that she finds time to exercise in her busy schedule. The RDA for exercise is 30 minutes of Moderate/Vigorous physical activity 5 days each week. According to Tremblay, all systems of the body, including metabolism, bone mineral content, and vascular health, are all dependent on the level of physical activity an individual receives. Maintaining metabolism is a priority for Ana in order to keep her weight down and prevent the development of diabetes. Also, because she is lactose intolerant, she must ensure her bones remain as strong as possible while she may not be meeting her needs for calcium. Low activity levels are linked to decreased insulin sensitivity as well as high triglyceride levels and low high-density lipoprotein (5). Sedentary lifestyle also increases the risk for cardiovascular disease (6). Not only does exercise help in lowering and maintaining weight, it also improves mental functioning (5). As a busy college student, eating a balanced diet and exercising regularly will help her focus in class and will reduce any stress she is feeling. By

adding a 30 minute walk at a quick pace for her, she can take advantage of these benefits. Even by engaging in 2 walks of 15 minutes, she will see the same benefits. The menu that was created for Anuh took into account a wide variety of factors. It was made primarily to improve her health status but at the same time still incorporates and combines the foods and flavors that she enjoys. The first factor that was looked at when making the menu was the fact that Anuh has prediabetes and is overweight. This signaled that the menu had to decrease the total number of calories that Anuh was consuming on a daily basis. She was also going to have to make a serious reduction in her fat intake since that was a major contributor of her total calories. Some of the menu items that reflect this reduction in fat and calories include products like low fat peanut butter and low fat mayo and food items that are baked and grilled instead of fried. Anuh is also lactose intolerant which means that her menu now includes foods like soy milk, lactose free cheese and lactose free greek yogurt so that she does not have to endure the discomfort and pain that lactose products cause her. The menu plan also includes various on-the-go snacks like pudding and granola bars to accommodate Anuhs busy schedule and the long hours she must endure at school and work without a break for a formal meal. These will help keep her hunger down, even though her calories will be reduced, so that she does not reach the points of extreme hunger that prompt her to go for the quick and easy fast food. At the same time this menu is very attractive to Anuh because it has a great variety of foods and flavors that she enjoys such as traditional Vietnamese ingredients and dishes, American meals that are easy for her to prepare even at her low skill level, and a semi-vegetarian diet because she wishes to implement some Buddhist practices back into her life. The DRI charts show Anuhs Dietary Reference Intake specific for her anthropometrics, pre-diabetic, and overweight status. The macronutrients were calculated specifically for her based on her ideal body weight and the micronutrient values are the standard recommended values. The seven-day meal plan will provide Anuh with adequate nutrients using these values as a guideline. Each day will fulfill at least 75% of Anuhs DRIs and provide her with a healthy balance of carbohydrates, fats, and proteins. All of the DRIs were met from the menu plan to a minimum of 75% of the DRIs and some were exceeded. The nutrient analysis of the menu and the % DRI that was met was calculated using the USDA database (7). Vitamin A was obtained in Anuhs diet through her consumption of various vegetables such as carrots, lettuce, and tomatoes. She received the highest amount of Vitamin A in carrots and avocado. The adequate levels of vitamin D were obtained from fortified soy milk and orange juice, tuna, and tilapia. It is also important for Anuh to consume an adequate amount of folacin. In order to reach the DRI for this vitamin her menu consists of whole grains such as whole wheat bread, cereals, and brown rice and she also received adequate amounts from spinach. To obtain an adequate amount of calcium, Anuhs diet includes fortified soy milk and orange juice, whole wheat bread, and eggs. The zinc levels were adequate in Anuhs diet by including grains in the menu. The fact that Anuh will now be incorporating a moderate exercise plan means that there are some days when she will be allowed to go over her recommended carbohydrate, fat, or protein intake

percentages. Her new exercise routine will allow her to get Vitamin D from the sun and that will make up for the days with a relatively low Vitamin D intake from her diet. The total cost for one day of food for our individual was $6.24. According to the USDA, the maximum amount for the low income budget for a woman 27 years of age is $6.69/day (7). In order to meet this requirement and still provide adequate nutrients, our individual has been given the lowest priced items as well as given lower cost options. When deciding on a protein source, the lowest cost meat was chosen. Vegetables that are nutrient dense, such as spinach, were used to provide more nutritional value with fewer ingredients. By adding spices, not only can flavor be enhanced, but they contain beneficial nutrients that can be increased with small amounts of product. Not only were the foods low cost, but easy to prepare. As a busy college student, it is not feasible to spend a lot of time cooking. Using simple ingredients, our individual can make nutritious meals that are in her food budget. The snacks are items that she can easily pack and take with her to eat during the day and the meals require little effort in cooking. The table above (Menu Costing) represents all the food items eaten in one day. It shows that each food item is not required in large amounts, but buying in bulk lowers the cost per ounce and so it is more affordable to our individual. By taking time to compare costs of various brands, it is possible to meet the low income grocery budget and still obtain the required nutrients to maintain health. In conclusion, Anuhs menu plan meets all of the proposed objectives agreed upon between her and her Registered Dietician. The menu manages to decrease the fat in her daily diet and decrease her total calorie intake therefore working towards lowering her body weight and ultimately her BMI to get her out of the overweight category. The menu introduces more vegetables, fruits and homemade meals. This eliminates the need for fast food, microwaveable TV dinners and the restaurant to-go dinners that she became so accustomed to. The menu leaves out the alcohol that was contributing to her weight gain and instead substitutes it with beverages that provide useful nutrients. This menu is a perfect balance for Anuh who wishes to have variety, flavor and simplicity in her dishes but also a sufficient intake of nutrients and a reduced intake of fats and calories for her modified lifestyle towards a healthier life.

References
1. Deatcher JV. Prediabetes. The American journal of nursing. 2008;108:77-79. Available at: http://ovidsp.tx.ovid.com.libproxy.sdsu.edu/sp3.7.1b/ovidweb.cgi?QS2=434f4e1a73d37e8cdd8fbc96f8f18d4b0c6bc9a42907db3d7b297 6e4a38a3dca748b058a24a3987c1c1314cadb071ca6b4e87b7582334cc5e0a0904af4ab3c0 68e83f6f45c85dd880c9b9e951895694ca949d18ddb29acca645fc63dd89af203d4b5a017ce 36af7ba945bc69137ed5ab10748e5ede8803eeb4c8bb1c6c58c8713ad577ae165f614b39cc 54a9fb1041eecb0314d325ab48591ae7f97b04b631d34c75fc0e5267bfbc55cabc99c45bca1 6e943c86213609dc6e03bb2a45a0d84388abfa215baa0d7a29c6a0b7e52a402664d71a692c 5dd4abb0ee7f7747f9f32b33cca9b8e7a775019ec666cbaf54545194cd7bcbbdcc02cca12f7 97546a8bef7fdfdaeb97b48841ccb85b47c9958607a77eb1cb0d0b2a1ab440bd19dfccb9c45 d9dbe01ad6683f5ae438db7a0c16908a14bd92af4377130fa6afe8b0d2ab5a1d42bc9d5e294 76db1e03d01c2257b620600d21025b7ca073987f9da6cc29ca78b29310a66c184e3c67725 8324f233178f072d4dcf9d3d6bf925957166895e8f3eb446098036c230c33a63364e1da343 98f740bc9a5cc991c2346d199d9147ef4be7c0040597b8ea9cc91d82c21e414d61b31aba65 12da6700cb3ac5a3db0b68d2a68e5b640edcc3a5b849db832befbae659c3eaaf6d01e4fa365 dc23a29ba6d7c65d207faeef61b13eeebafa5dda225b719783daf4788dd7da4e2cbc41d11b8 5955a1e681c2cef242fb6b86cf469a85e58fce838fca0f01c3d1070b6365b0f9f914c51f9b6b 0a8eaf6. Accessed November 27, 2012. 2. Fonseca VA. Identification and treatment of prediabetes to prevent progression to type 2 diabetes. Clinical Cornerstone. 2007;8:10-20. Available at http://dx.doi.org/10.1016/S1098-3597(09)60004-1. Accessed November 27, 2012. 3. Anh NT, Thuc TK, Welsh JD. Lactose malabsorption in Vietnamese adults. The American Journal of Clinical Nutrition. 1977;30:468. Available at http://ajcn.nutrition.org/content/30/4/468.full.pdf+html. Accessed November 27, 2012. 4. Greey M. Sugar in disguise. Today's Parent. 2010;27:62. Available at http://search.proquest.com/docview/863488483?accountid=13758. Accessed November 27, 2012. 5. Tremblay MS, Healy GN, Colley RC, Saunders TJ, Owen N. Physiological and health implications of a sedentary lifestyle. Applied Physiology, Nutrition, and Metabolism. 2010;35:725-740. 6. Daray LA, Henagan TM, Zanovec M, Earnest CP, Johnson LG, Winchester J, Tuuri G, Stewart LK. Endurance and resistance training lowers c-reactive protein in young, healthy females. Applied Physiology, Nutrition, and Metabolism. 2011;36:660-670. 7. US Department of Agriculture. The USDA national nutrient database for standard reference. Available at http://ndb.nal.usda.gov/. Accessed November 27, 2012.