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General Recommendations for Diabetes Diet
Low-Carb and Low-Fat Diets
The two major forms of diabetes are type 1, previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, and type 2, previously called non-insulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes.
Both type 1 and type 2 diabetes share one central feature: elevated blood sugar (glucose) levels due to absolute or relative insufficiencies of insulin, a hormone produced by the pancreas. Insulin is a key regulator of the body's metabolism. It normally works in the following way:
In type 1 diabetes, the pancreas does not produce insulin. Onset is usually in childhood or adolescence. Type 1 diabetes is considered an autoimmune disorder.
Patients with type 1 diabetes need to take insulin. Dietary control in type 1 diabetes is very important and focuses on balancing food intake with insulin intake and energy expenditure from physical exertion.
Type 2 diabetes is the most common form of diabetes, accounting for 90 - 95% of cases. In type 2 diabetes, the body does not respond normally to insulin, a condition known as insulin resistance. Over time, some patients also run out of insulin. In type 2 diabetes, the initial effect is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia).
Patients whose blood glucose levels are higher than normal, but not yet high enough to be classified as diabetes, are considered to have pre-diabetes. It is very important that people with pre-diabetes control their weight to stop or delay the progression to diabetes.
Obesity is common in patients with type 2 diabetes, and this condition appears to be related to insulin resistance. The primary dietary goal for overweight type 2 patients is weight loss and maintenance. With regular exercise and diet modification programs, many people with type 2 diabetes can minimize or even avoid medications. Weight loss medications or bariatric surgery may be appropriate for some patients.
Lifestyle changes of diet and exercise are extremely important for people who have pre-diabetes, or who are at high risk of developing type 2 diabetes. Lifestyle interventions can be very effective in preventing or postponing the progression to diabetes. These interventions are especially important for overweight people. Even moderate weight loss can help reduce diabetes risk.
The American Diabetes Association recommends that people at high risk for type 2 diabetes eat high-fiber (14g fiber for every 1,000 calories) and whole-grain foods. High intake of fiber, especially from whole grain cereals and breads, can help reduce type 2 diabetes risk.
Patients who are diagnosed with diabetes need to be aware of their heart health nutrition and, in particular, controlling high blood pressure and cholesterol levels.
For people who have diabetes, the treatment goals for a diabetes diet are:
Overall Guidelines. There is no such thing as a single diabetes diet. Patients should meet with a professional dietitian to plan an individualized diet within the general guidelines that takes into consideration their own health needs.
For example, a patient with type 2 diabetes who is overweight and insulin-resistant may need to have a different carbohydrate-protein balance than a thin patient with type 1 diabetes in danger of kidney disease. Because regulating diabetes is an individual situation, everyone with this condition should get help from a dietary professional in selecting the diet best for them.
Several good dietary methods are available to meet the goals described above. General dietary guidelines for diabetes recommend:
Several different dietary methods are available for controlling blood sugar in type 1 and insulin-dependent type 2 diabetes:
Tests for Glucose Levels. Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. It is important, therefore, to monitor blood glucose levels carefully. Patients should aim for the following measurements:
Hemoglobin A1C Test. Hemoglobin A1C (also called HbA1c or HA1c) is measured periodically every 2 - 3 months, or at least twice a year, to determine the average blood-sugar level over the lifespan of the red blood cell. While fingerprick self-testing provides information on blood glucose for that day, the A1C test shows how well blood sugar has been controlled over the period of several months. For most people with well-controlled diabetes, A1C levels should be at around 7%.
Other Tests. Other tests are needed periodically to determine potential complications of diabetes, such as high blood pressure, unhealthy cholesterol levels, and kidney problems. Such tests may also indicate whether current diet plans are helping the patient and whether changes should be made. Periodic urine tests for microalbuminuria and blood tests for creatinine can indicate a future risk for serious kidney disease.
Food Labels. Every year thousands of new foods are introduced, many of them advertised as nutritionally beneficial. It is important for everyone, most especially people with diabetes, to be able to differentiate advertised claims from truth. Current food labels show the number of calories from fat, the amount of nutrients that are potentially harmful (fat, cholesterol, sodium, and sugars) as well as useful nutrients (fiber, carbohydrates, protein, and vitamins).
Labels also show "daily values," the percentage of a daily diet that each of the important nutrients offers in a single serving. This daily value is based on 2,000 calories, which is often higher than what most patients with diabetes should have, and the serving sizes may not be equivalent to those on diabetic exchange lists. Most people will need to recalculate the grams and calories listed on food labels to fit their own serving sizes and calorie needs.
Weighing and Measuring. Weighing and measuring food is extremely important to get the correct number of daily calories.
Timing. Patients with diabetes should not skip meals, particularly if they are taking insulin. Skipping meals can upset the balance between food intake and insulin and also can lead to low blood sugar and even weight gain if the patient eats extra food to offset hunger and low blood sugar levels.
The timing of meals is particularly important for people taking insulin:
Diabetes can lead to kidney disease and failure. People with early-stage kidney failure need to follow a special diet that slows the build-up of wastes in the bloodstream. The diet restricts protein, potassium, phosphorus, and salt intake. Fat and carbohydrate intake may need to be increased to help maintain weight and muscle tissue.
People who have late-stage kidney disease usually need dialysis. Once patients are on dialysis, they need more protein in their diet. Patients must still be very careful about restricting salt, potassium, phosphorus, and fluids. Patients on peritoneal dialysis may have fewer restrictions on salt, potassium, and phosphorus than those on hemodialysis.
Compared to fats and protein, carbohydrates have the greatest impact on blood sugar (glucose). Except for dietary fiber, which is not digestible, carbohydrates are eventually broken down by the body into glucose. Carbohydrate types are either complex (as in starches) or simple (as in fruits and sugars).
One gram of carbohydrates provides 4 calories. The current general recommendation is that carbohydrates should provide between 45 - 65% of the daily caloric intake. Carbohydrate intake should not fall below 130 grams/day.
Complex carbohydrates are broken down more slowly by the body than simple carbohydrates. They are more likely to provide other nutritional components and fiber.
Simple carbohydrates, or sugars (either as sucrose or fructose), adds calories, increases blood glucose levels quickly, and provides little or no other nutrients.
People with diabetes should avoid products listing more than 5 grams of sugar per serving, and some doctors recommend limiting fruit intake. You can limit your fructose intake by consuming fruits that are relatively lower in fructose (cantaloupe, grapefruit, strawberries, peaches, bananas) and avoiding added sugars such as those in sugar-sweetened beverages. Fructose is metabolized differently than other sugars and can significantly raise triglycerides.
In addition, avoid processed foods with added sugars of any kind. Pay attention to ingredients in food labels that indicate the presence of added sugars. These include terms such as sweeteners, syrups, fruit juice concentrates, molasses, and sugar molecules ending in “ose” (like dextrose and sucrose).
The Carbohydrate Counting System. Some people plan their carbohydrate intake using a system called carbohydrate counting. It is based on two premises:
In other words, the amount of carbohydrates eaten (rather than fats or proteins) will determine how high blood sugar levels will rise. There are two options for counting carbohydrates: advanced and simple. Both rely on collaboration with a doctor, dietitian, or both. Once the patient learns how to count carbohydrates and adjust insulin doses to their meals, many find it more flexible, more accurate in predicting blood sugar increases, and easier to plan meals than other systems.
The basic goal is to balance insulin with the amount of carbohydrates eaten in order to control blood glucose levels after a meal. The steps to the plan are as follows:
The patient must first carefully record a number of factors that are used to determine the specific requirements for a meal plan based on carbohydrate grams:
The patient works with the dietitian for two or three 45 - 90 minute sessions to plan how many grams of carbohydrates are needed. There are three carbohydrate groups:
One serving from each group should contain 12 - 15 carbohydrate grams. (Patients can find the amount of carbohydrates in foods from labels on commercial foods and from a number of books and web sites.)
The dietitian creates a meal plan that accommodates the patient's weight and needs, as determined by the patient's record, and makes a special calculation called the carbohydrate to insulin ratio. This ratio determines the number of carbohydrate grams that a patient needs to cover the daily pre-meal insulin needs. Eventually, patients can learn to adjust their insulin doses to their meals.
Patients who choose this approach must still be aware of protein and fat content in foods. These food groups may add excessive calories and saturated fats. Patients must still follow basic healthy dietary principles.
The Glycemic Index. The glycemic index helps determine which carbohydrate-containing foods raise blood glucose levels more or less quickly after a meal. The index uses a set of numbers for specific foods that reflect greatest to least delay in producing an increase in blood sugar after a meal. The lower the index number, the better the impact on glucose levels.
There are two indices in use. One uses a scale of 1 - 100 with 100 representing a glucose tablet, which has the most rapid effect on blood sugar. [See Table: "The Glycemic Index of Some Foods," below.] The other common index uses a scale with 100 representing white bread (so some foods will be above 100).
Choosing foods with low glycemic index scores often has a significant effect on controlling the surge in blood sugar after meals. Many of these foods are also high in fiber and so have heart benefits as well. Substituting low- for high-glycemic index foods may also help with weight control.
One easy way to improve glycemic index is to simply replace starches and sugars with whole grains and legumes (dried peas, beans, and lentils). However, there are many factors that affect the glycemic index of foods, and maintaining a diet with low glycemic load is not straightforward.
No one should use the glycemic index as a complete dietary guide, since it does not provide nutritional guidelines for all foods. It is simply an indication of how the metabolism will respond to certain carbohydrates.
Low-Carbohydrate Diets. Low carb diets generally restrict the amount of carbohydrates but do not restrict protein sources. Popular low-carb diet plans include Atkins, South Beach, The Zone, and Sugar Busters.
According to the American Diabetes Association (ADA), low-carb diets may help reduce weight in the short term (up to 1 year). However, because these diets tend to include more fat and protein, the ADA recommends that people on these diet plans have their blood lipids, including cholesterol and triglycerides, regularly monitored. Patients who have kidney problems need to be careful about protein consumption, as high-protein diets can worsen this condition.
Fiber is an important component of many complex carbohydrates. It is found only in plant foods such as vegetables, fruits, whole grains, nuts, and legumes (dried beans, peanuts, and peas). Fiber cannot be digested. Instead, it passes through the intestines, drawing water with it, and is eliminated as part of feces content. The following are specific advantages from high-fiber diets (up to 50 grams a day):
The Glycemic Index of Some Foods
Based on 100 = a Glucose Tablet
Kidney (dried and boiled, not canned)
Spaghetti (boiled 5 minutes)
Spaghetti (boiled 15 minutes)
Note. These numbers are general values, but they may vary widely depending on other factors, including if and how they are cooked and foods they are combined with.
Replacing fats and sugars with substitutes may help some people who have trouble maintaining weight.
Fat Substitutes. Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat but do not add as many calories. They cannot be eaten in unlimited amounts. Fat substitutes include:
Artificial Sweeteners. Artificial sweeteners use chemicals to mimic the sweetness of sugar. These products do not contain calories and do not affect blood sugar. Artificial sweeteners approved by the FDA include:
Sugar alcohols (which include xylitol, mannitol, and sorbitol) are often used in “sugar-free” products, such as cookies, hard candies, and chewing gum. Sugar alcohols can slightly increase blood sugar levels. The American Diabetes Association recommends against consuming large amounts of sugar alcohol as it can cause gas and diarrhea, especially in children.
Protein intake in diabetes is complicated and depends on various factors. These factors include whether a patient has type 1, type 2, or pre-diabetes. There are additional guidelines for patients who show signs of kidney damage (diabetic nephropathy).
In general, diabetes dietary guidelines recommend that proteins should provide 12 - 20% of total daily calories. This daily amount poses no risk to the kidney in people who do not have kidney disease. Protein is important for strong muscles and bones. Some doctors recommend a higher proportion of protein (20 - 30%) for patients with pre- or type 2 diabetes. They think that eating more protein helps people feel more full and thus reduces overall calories. In addition, protein consumption helps the body maintain lean body mass during weight loss.
Patients with diabetic kidney problems need to limit their intake of protein. A typical protein-restricted diet limits protein intake to no more than 10% of total daily calories. Patients with kidney damage also need to limit their intake of phosphorus, a mineral found in dairy products, beans, and nuts. (However, patients on dialysis need to have more protein in their diets.) Potassium and phosphorus restriction is often necessary as well.
One gram of protein provides 4 calories. Protein is commonly recommended as part of a bedtime snack to maintain normal blood sugar levels during the night, although studies are mixed over whether it adds any protective benefits against nighttime hypoglycemia. If it does, only small amounts (14 grams) may be needed to stabilize blood glucose levels.
Good sources of protein include fish, skinless chicken or turkey, nonfat or low-fat dairy products, soy (tofu), and legumes (such as kidney beans, black beans, chick peas, and lentils).
Fish. Fish is probably the best source of protein. Evidence suggests that eating moderate amounts of fish (twice a week) may improve triglycerides and help lower the risks for death from heart disease, dangerous heart rhythms, blood pressure, a tendency for blood clots, and the risk for stroke.
The most healthy fish are oily fish such as salmon, mackerel, or sardines, which are high in omega-3 fatty acids. Three capsules of fish oil (preferably as supplements of DHA-EPA) are about equivalent to one serving of fish.
Women who are pregnant (or planning on becoming pregnant) or nursing should avoid fish that contains high amount of mercury. These high-mercury fish include swordfish, tuna, bass, and mackerel.
Soy. Soy is an excellent food. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soy proteins have more vitamins and minerals than meat or dairy proteins. They also contain polyunsaturated fats, which are better than the saturated fat found in meat. The best sources of soy protein are soy products (such as tofu, soy milk, and soybeans). Soy sauce is not a good source. It contains only a trace amount of soy and is very high in sodium.
For many years, soy was promoted as a food that could help lower cholesterol and improve heart disease risk factors. Recent studies have found that soy protein and isoflavone supplement pills do not have major effects on cholesterol or heart disease prevention. The American Heart Association still encourages patients to include soy foods as part of an overall heart healthy diet but does not recommend using isoflavone supplements.
Meat and Poultry. Lean cuts of meat are the best choice for heart health and diabetes control. Saturated fat in meat is the primary danger to the heart. The fat content of meat varies depending on the type and cut. For patients with diabetes, skinless chicken or turkey is a better choice than red meat. (Fish is an even better choice.)
Dairy Products. A high intake of dairy products may lower risk factors related to type 2 diabetes and heart disease (insulin resistance, high blood pressure, obesity, and unhealthy cholesterol). Some researchers suggest the calcium in dairy products may be partially responsible for these benefits. Vitamin D contained in dairy may also play a role in improving insulin sensitivity, particularly for children and adolescents. However, because many dairy products are high in saturated fats and calories, it’s best to choose low-fat and nonfat dairy items.
Some fat is essential for normal body function. Fats can have good or bad effects on health, depending on their chemistry. The type of fat is more important than the total amount of fat when it comes to reducing heart disease. Monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) are “good” fats that help promote heart health, and should be the main type of fats consumed. Saturated fats and trans fats (trans fatty acids) are “bad” fats that can contribute to heart disease, and should be avoided or limited.
Current dietary guidelines for diabetes and heart health recommend that:
All fats, good or bad, are high in calories compared to proteins and carbohydrates. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (1 fat gram provides 9 calories, whether it's oil or fat) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats contains about 5 grams of fat. All fats, no matter what the source, add the same calories. The American Heart Association recommends that fats and oils have fewer than 2 grams of saturated fat per tablespoon.
Try to replace saturated fats and trans fatty acids with unsaturated fats from plant and fish oils. Omega-3 fatty acids, which are found in fish and a few plant sources, are a good source of unsaturated fats. Generally, two servings of fish per week provide a healthful amount of omega-3 fatty acids. Fish oil dietary supplements are another option. Fish and fish oil supplements contain docosahexaenoic (DHA) and eicosapentaenoic (EPA) acids, which have significant benefits for the heart. Discuss with your doctor whether you should consider taking fish oil supplements.
Low-Fat Diets. The American Diabetes Association states that low-fat diets can help reduce weight in the short term (up to 1 year). Low-fat diets that are high in fiber, whole grains, legumes, and fresh produce can offer health advantages for blood sugar and cholesterol control.
Animal-based food products contain cholesterol. High amounts occur in meat, dairy products, egg yolks, and shellfish. (Plant foods, such as fruits, vegetables, nuts, and grains, do not contain cholesterol.) The American Heart Association recommends no more than 300 mg of dietary cholesterol per day for the general population and no more than 200 mg daily for those with high cholesterol or heart disease.
Research has shown that vitamin supplements have no benefit for heart disease and diabetes. Because of the lack of scientific evidence for benefit, the American Diabetes Association does not recommend regular use of vitamin supplements, except for people who have vitamin deficiencies.
Patients with type 2 diabetes who take metformin (Glucophage) should be aware that this drug can interfere with vitamin B12 absorption. Calcium supplements may help counteract metformin-associated vitamin B12 deficiency.
It is important for everyone to restrict their sodium (salt) intake. People with diabetes should reduce sodium intake to less than 1,500 mg daily. Limiting or avoiding consumption of processed foods can go a long way to reducing salt intake. Simply eliminating table and cooking salt is also beneficial.
Salt substitutes, such as Nusalt and Mrs. Dash (which contain mixtures of potassium, sodium, and magnesium) are available, but they can be risky for people with kidney disease or those who take blood pressure medication that causes potassium retention. Similarly, while eating more potassium-rich foods is helpful for achieving healthy blood pressure, patients with diabetes should check with their doctors before increasing the amount of potassium in their diets. [For more information on potassium, see “Other Minerals,” below.]
Calcium. Calcium supplements may be important in older patients with diabetes to help reduce the risk for osteoporosis, particularly if their diets are low in dairy products.
Potassium and Phosphorus. Potassium-rich foods, and potassium supplements, can help lower systolic and diastolic blood pressure. Current guidelines encourage enough dietary potassium to achieve 3,500 mg per day for people with normal or high blood pressure (except those who have risk factors for excess potassium levels, including kidney disease and the use of certain medications). This goal is particularly important in people who have high sodium intake.
The best source of potassium is from the fruits and vegetables that contain them. Potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados.
No one should take potassium supplements without consulting a doctor. Kidney problems can cause potassium overload, and medications commonly used in diabetes (such as ACE inhibitors or potassium-sparing diuretics) also limit the kidney's ability to excrete potassium. Patients with diabetic nephropathy (kidney disease) and kidney failure need to restrict dietary potassium, as well as phosphorus. Phosphorus-rich foods that should be avoided include meats, dairy products, beans, whole foods, and nuts. In addition, many processed and fast foods contain high amounts of phosphorus additives.
Magnesium. Magnesium deficiency may have some role in insulin resistance and high blood pressure. Research indicates that magnesium-rich diets may help lower type 2 diabetes risk. Whole grain breads and cereals, nuts (such as almonds, cashews, and soybeans), and certain fruits and vegetables (such as spinach, avocados, and beans) are excellent dietary sources of magnesium. Dietary supplements do not provide any benefit. Persons who live in soft water areas, who use diuretics, or who have other risk factors for magnesium deficiency may require more dietary magnesium than others.
Chromium. Most studies have indicated that chromium supplements have little or no effect on glucose metabolism and may cause adverse side effects.
Selenium. Selenium, a trace mineral, may increase diabetes risk. An average healthy diet supplies adequate amounts of selenium. There is no need to take dietary supplements.
Zinc. More studies are needed to establish the benefits or risks of taking zinc supplements. Large doses of zinc can have toxic side effects.
Alcohol. The American Diabetes Association recommends limiting alcoholic beverages to 1 drink per day for non-pregnant adult women and 2 drinks per day for adult men.
Coffee. Many studies have noted an association between coffee consumption (both caffeinated and decaffeinated) and reduced risk for developing type 2 diabetes. Researchers are still not certain if coffee protects against diabetes.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.
Traditional herbal remedies for diabetes include bitter melon, cinnamon, fenugreek, and Gymnema sylvestre. Few well-designed studies have examined these herbs’ effects on blood sugar, and there is not enough evidence to recommend them for prevention or treatment of diabetes.
Various fraudulent products are often sold on the Internet as “cures” or treatments for diabetes. These dietary supplements have not been studied or approved. The FDA warns patients with diabetes not to be duped by bogus and unproven remedies.
The American Diabetes Association recommends that patients aim for a small but consistent weight loss of ½ - 1 pound per week. Most patients should follow a diet that supplies at least 1,000 - 1,200 kcal/day for women and 1,200 - 1,600 kcal/day for men.
Even modest weight loss can reduce the risk factors for heart disease and diabetes. There are many approaches to dieting and many claims for great success with various fad diets. They include calorie restriction, low-fat/high-fiber, or high protein and fat/low carbohydrates.
Here are some general weight-loss suggestions that may be helpful:
Even repeated weight loss failure is no reason to give up.
Calorie restriction has been the cornerstone of obesity treatment. Restricting calories in such cases also appears to have beneficial effects on cholesterol levels, including reducing LDL and triglycerides and increasing HDL levels.
The standard dietary recommendations for losing weight are:
Aerobic exercise has significant and particular benefits for people with diabetes. Regular aerobic exercise, even of moderate intensity (such as brisk walking), improves insulin sensitivity. People with diabetes are at particular risk for heart disease, so the heart-protective effects of aerobic exercise are especially important.
Exercise Precautions for People with Diabetes. The following are precautions for all people with diabetes, both type 1 and type 2:
The objective of using diabetic exchange lists is to maintain the proper balance of carbohydrates, proteins, and fats throughout the day. Patients should meet with a dietician or diabetes nutrition expert for help in learning this approach.
In developing a menu, patients must first establish their individual dietary requirements, particularly the optimal number of daily calories and the proportion of carbohydrates, fats, and protein. The exchange lists should then be used to set up menus for each day that fulfill these requirements.
The following are some general rules:
The following are the categories on exchange lists:
Starches and Bread. Each exchange under starches and bread contains about 15 grams of carbohydrates, 3 grams of protein, and a trace of fat for a total of 80 calories. A general rule is that a half-cup of cooked cereal, grain, or pasta equals one exchange. One ounce of a bread product is 1 serving.
Meat and Cheese. The exchange groups for meat and cheese are categorized by lean meat and low-fat substitutes, medium-fat meat and substitutes, and high-fat meat and substitutes. Use high-fat exchanges a maximum of 3 times a week. Fat should be removed before cooking. Exchange sizes on the meat list are generally 1 ounce and based on cooked meats (3 ounces of cooked meat equals 4 ounces of raw meat).
Vegetables. Exchanges for vegetables are 1/2 cup cooked, 1 cup raw, and 1/2 cup juice. Each group contains 5 grams of carbohydrates, 2 grams of protein, and 2 - 3 grams of fiber. Vegetables can be fresh or frozen; canned vegetables are less desirable because they are often high in sodium. They should be steamed or cooked in a microwave without added fat.
Fruits and Sugar. Sugars are included within the total carbohydrate count in the exchange lists. Sugars should not be more than 10% of daily carbohydrates. Each exchange contains about 15 grams of carbohydrates for a total of 60 calories.
Milk and Substitutes. The milk and substitutes list is categorized by fat content similar to the meat list. A milk exchange is usually 1 cup or 8 ounces. Those who are on weight-loss or low-cholesterol diets should follow the skim and very low-fat milk lists -- while avoiding the whole milk group. Others should use the whole milk list very sparingly. All people with diabetes should avoid artificially sweetened milks.
Fats. A fat exchange is usually 1 teaspoon, but it may vary. People, of course, should avoid saturated and trans fatty acids and choose polyunsaturated or monounsaturated fats instead.
Number of Exchanges per Day for Various Calories Levels
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.