case report generalized anxiety disorder and hypoglycemia

Case ReportGeneralized Anxiety Disorder and Hypoglycemia SymptomsImproved with Diet Modification

Monique Aucoin and Sukriti Bhardwaj

Canadian College of Naturopathic Medicine 1255 Sheppard Avenue E Toronto ON Canada M2K 1E2

Correspondence should be addressed to Monique Aucoin maucoinccnmedu

Received 14 March 2016 Accepted 26 June 2016

Academic Editor Fabrice Jollant

Copyright copy 2016 M Aucoin and S Bhardwaj This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Observational evidence suggests that a relationship may exist between high glycemic index diets and the development of anxietyand depression symptoms however as no interventional studies assessing this relationship in a psychiatric population have beencompleted the possibility of a causal link is unclear AB is a 15-year-old female who presented with concerns of generalized anxietydisorder and hypoglycemia symptoms Her diet consisted primarily of refined carbohydrates The addition of protein fat andfiber to her diet resulted in a substantial decrease in anxiety symptoms as well as a decrease in the frequency and severity ofhypoglycemia symptoms A brief return to her previous diet caused a return of her anxiety symptoms followed by improvementwhen she restarted the prescribed diet This case strengthens the hypothesis that dietary glycemic index may play a role in thepathogenesis or progression of mental illnesses such as generalized anxiety disorder and subsequently that dietary modification asa therapeutic intervention in the treatment of mental illness warrants further study

1 Introduction

Generalized anxiety disorder (GAD) is a common and oftendisabling disease It is characterized by fear tension andexcessive worries regarding common events or problemsfor a minimum of six months [1] and is accompanied byphysical symptoms such as heart palpitationsmuscle tensionand chest tightness Patients may experience nonspecificsymptoms such as irritability and difficulty concentrating inaddition to deterioration in the quality of their social workand personal experiences [1 2] Traumatic life experiencesdysfunctional serotonin and epinephrine neurotransmittersystems and pernicious genetic influences are potentiallyinvolved in the development of GAD [3] It is estimated thatthe lifetime prevalence is between 43 and 59 [1 3] and40ndash67 of patients experience comorbid depression [3]

Conventional treatment of anxiety involves cognitivebehavioural therapy in combination with pharmacologicinterventions such as serotonin-norepinephrine reuptakeinhibitors (SNRI) selective serotonin reuptake inhibitors(SSRI) or benzodiazepines [2 3] Despite appropriate treat-ment many GAD patients cannot successfully achieve shortterm or long term remission After five years remission

rates may remain as low as 38 [2] Thus the need fornonpharmacological approaches is evident [4]

Several studies suggest a relationship between improvednutrition and better mental health outcomes both in generaland adolescent populations Epidemiological studies includ-ing a recent meta-analysis have shown that a diet includingfruits vegetables fish olive oil nuts and legumesmay reducethe chance of developing depression [4 5] A prospectivestudy found that a Mediterranean dietary pattern at baselinereduced the risk of depressive episodes 165 years later [6]

Despite evidence correlating a healthy diet with themaintenance of mental health a trend towards a reduction inthe quality of adolescent diets has been observed at the globallevelThis trend is characterized by an increased intake of fastfoods fried foods sweets refined grains processedmeat anda reduction of fruitvegetable intake [7] The consumptionof this Western-style diet has been independently associatedwith a greater risk for the development of anxiety anddepression [7] and associated with a decline in the mentalhealth status of adolescents [6] Another study found anincreased likelihood of psychological problems in adolescentsassociated with diets high in unhealthy foods [7]

Hindawi Publishing CorporationCase Reports in PsychiatryVolume 2016 Article ID 7165425 4 pageshttpdxdoiorg10115520167165425

2 Case Reports in Psychiatry

A number of possible mechanisms have been proposedfor the effect of diet on mental health including a role ofinflammation and oxidation [6] deficiency ofmicronutrientssuch as folate zinc and magnesium [7] and glycemicbalance

The increase in global consumption of refined foods suchas sweetened beverages pastries and refined carbohydratesimpacts dietary glycemic index (GI) a measurement of therate of blood glucose generation from specific food itemsGlycemic load (GL) reflects both the glycemic index valueand the total carbohydrate content of the food Foods witha higher GI or GL create greater increases in blood sugar [8]

A recent cohort study showed that increasing oddsof depression and anxiety have been associated with theconsumption of foods that have a progressively higher GI andthis relationship is maintained after controlling for micronu-trients known to play a role in mental health [8] Cross-sectional studies have demonstrated a correlation betweenthe occurrence of depressionstress andhigher intake of sweetfoods [9] and a large prospective cohort study showed apositive correlation between a diet high in sweet desserts andrefined grains and the risk for depression Conversely it wasfound that high consumption of fruits and vegetables whichcontain fiber that lowers GI was associated with a lower riskfor depression [9]

In addition to the observational studies a limited numberof interventional studies have explored a potential relation-ship between blood sugar balance and emotional and cog-nitive health One clinical trial assigned healthy overweightsubjects to high or low GI diets and found that the highGI diet resulted in worsening mood scores [10] Two studiesassessed the impact of high and low GI meals on cognitiveperformance in adults with type 2 diabetes and childrenrespectively and found that the higher GI meal was relatedto poorer cognitive function [11 12] Conversely two otherintervention studies comparing high and low GI diets inpatients with diabetes did not find a change in subclinicaldepression or cognitive function [9] Despite this evidencethat a relationship between dietary GI and emotional andcognitive functioning may exist no interventional studieshave assessed the impact of a low GI or low GL dietaryintervention in psychiatric patient populations in order toassess causality of the relationship

2 Case Presentation

AB is a 15-year-old female student of south-Asian descentShe presented with concerns of anxiety and symptoms ofhypoglycemia as well as difficulty concentrating fatigueheadaches asthma and frequent urinary and vaginal infec-tions

Her anxiety met criteria for GAD and she rated theintensity of anxiety as 810 with 10 being the highest level ofanxiety possibleThe anxiety started threemonths prior to theinitial appointment and hadworsened in the previousmonthShe described excessiveworry that was difficult to control andimpacted her daily functioning by causing her to be absentfrom school on several occasions She experienced a numberof somatic symptoms including heart palpitations shakiness

discomfort in her stomach and muscle tension In responseto the anxiety symptoms she would eat foods like chocolatechips or fruit AB was working with a counsellor to managethe anxiety symptoms and was finding some benefit

AB had experienced episodes suggestive of hypoglycemiasince 12 years of age The symptoms included muscle weak-ness and shaking headaches nausea anxiety and loss ofconcentration Her symptoms were ameliorated by eatingsweet foods AB reported that her hypoglycemia was at itsworst at 12 years of age when she had to eat a granola barhourly in order to concentrate

21 Clinical Findings A diet history revealed the followingtypical daily food intake

(i) Breakfast fruit smoothie containing fruit fruit juiceand water

(ii) Morning snack bagel with margarine(iii) Lunch pasta or white rice with vegetables(iv) Afternoon snack granola bar or cookies or gummy

candies(v) After school meal white pasta it may include meat(vi) Dinner white rice or spaghetti it may include meat(vii) Evening snack cookies and toast(viii) Beverages 2 liters of water 1 cup of juice 1 cup of

lactose-free milk and 1 cup of tea

22 PastMedical History Due to her difficulty concentratingAB was prescribed dextroamphetamine 5mg While shefound that it improved concentration this medication causedher to lose weight As the patientrsquos weight was initially on thelower end of normal (weight 115 lb height 51015840610158401015840 and BMI186) the dose was reduced to 2 to 3 times per week as needed

23 Psychosocial History AB lives with her mother fatherand sister ABrsquos sister experienced mental health concerns inthe previous years which created elevated stress levels in thefamily home

24 Diagnostic Focus and Assessment Repeated assessmentsof random and fasting blood glucose and screening physicalexamination were within normal range

25 Therapeutic Approach At the initial visit the followingdietary plan was prescribed

(i) Breakfast it includes a smoothie containing fruitwater 1 scoop of protein powder and 1 tablespoon offlax seeds or olive oil

(ii) Lunch and dinner they include a serving of protein(meat legume and soy) and a serving of vegetables

(iii) Snacks they include protein when possible (egapple with sunflower seed butter vegetable sticks withhummus and pumpkin seeds)

Case Reports in Psychiatry 3

(iv) Continue to eat carbohydrate-containing snacks asneeded for the management of hypoglycemia symp-toms

She was asked to follow these dietary guidelines daily untilthe follow-up visit While eggs nuts and fish would havenormally been recommended as well the patient had ananaphylactic allergy to these foods

26 Follow-Up and Outcomes At the first follow-up fourweeks later AB reported that she had complied with thedietary plan since the previous visit She reported a significantdecrease in anxiety (4 to 510) as well as improved energyless-frequent and less intense hypoglycemia symptoms andfewer headaches (once per week compared to daily) inaddition to improved concentration and mood She requiredfewer snacks during the day and decreased her intake ofgranola bars cookies and candies (1-2 servings per day) Shealso reported a cessation of chronic vaginal discharge Thesubstantial improvement in her anxiety symptoms promptedAB to temporarily discontinue her counselling sessions

At a subsequent follow-up visit four weeks later ABreported that she had briefly reverted back to her originaldiet for a period of one week and experienced a worseningof anxiety symptoms within one day After returning tothe dietary intervention prescribed her anxiety symptomsdecreased within two days

3 Discussion

This case illustrates an example of improved anxiety andhypoglycemia symptoms in response to changes in themacronutrient composition of the diet It suggests thatdietary GI and blood sugar balance within a physiologicrange may play a role in the development or clinical progres-sion of anxiety Subsequently modifying the diet by reducingthe consumption of refined carbohydrates and includingmore protein fat and fiber may be beneficial

The proposed relationship is supported by observationalstudies demonstrating a relationship between higher GIGLand increased incidence of mental illness as well as apotential mechanism High GI foods result in an increase inblood glucose levels however a large compensatory insulinrelease may result in reactive hypoglycemia Hypoglycemia isassociated with an acute increase in epinephrine [13] whichcontributes to neuropsychiatric symptoms including anxiety[14] and symptoms associated with anxiety such as shakinesssweating and heart palpitations Induction of hypoglycemiain a laboratory setting has a negative impact on moodhedonic tone and energy levels as well as an increase in tensearousal [15] The presence of both anxiety and hypoglycemiasymptoms in ABrsquos case along with their concurrent responseto treatment lends support to the hypothesis that theseconditions may be related

However it is unclear if other macronutrient or micronu-trient changes were at least in part responsible for thepatientrsquos symptom improvement as she had made severalchanges concurrently A recent study found that the individu-als in the highest third of GI had lower intake of magnesium

vitamin B6 vitamin B12 omega-3 fatty acids and proteinEvidence shows that all of these nutrients may play a role inthe prevention of mental illness [9]

Evidence suggests that adequate intake of protein maybe required in the maintenance of mental health Dietaryprotein provides amino acids eight of which are essentialThey cannot be synthesized by the body and must besupplied through the diet Amino acids form the buildingblocks of neurotransmitters For example the synthesis ofserotonin requires the essential amino acid tryptophan anddopamine synthesis requires tyrosine which is producedfrom the essential amino acid phenylalanine The lack oftyrosine and tryptophan leads to deficiencies of the respectiveneurotransmitters and has been associated with psychiatricdisturbances [16]

Micronutrient factors are also involved in neurotrans-mitter synthesis and may be involved in the development ofmood and anxiety disorders As in this case a diet low inmeatmay be low in vitamin B12 and a diet low in green vegetablesmay lack folate Because both nutrients are important forneurotransmitter synthesis [17] dietary intake may play arole in the development or progression of mood and anxietydisorders

Dietary fat may also play a role in mental health Thedry weight of the brain is 60 percent fat [18] and low levelsof omega-3 fats and cholesterol are significant risk factorsfor major depression and suicide [19] Omega-3 fats whichcannot be produced endogenously and must be obtainedfrom the diet affect the serotonergic system [19] and aninverse relationship between dietary omega-3 fatty acids andanxiety disorders has been demonstrated [7] Preliminaryevidence suggests that omega-3 supplementation may bebeneficial in the treatment of anxiety [20]

Despite these other potential factors the concomitantimprovement in both anxiety and hypoglycemia symptomssuggests that blood sugar balancemay have been contributingto ABrsquos anxiety disorder and that improvement in blood sugarmanagement as seen in the reduction of hypoglycaemicsymptoms may have been a significant factor in the responseto treatment In conjunction with the observational data [13]this may strengthen our understanding of the relationshipbetween suboptimal blood sugar regulation GIGL andmental illness

One strength of this case report is that the dietarymodifications were the only intervention initiated at the timeduring which the improvement in symptoms was observedAs well the brief return to the patientrsquos previous diet andsubsequent worsening of symptoms lends support to thelikelihood of a causal relationship

Some limitations exist as well No validated assessmenttool was used to monitor change in anxiety symptoms onlythe patientrsquos subjective report Additionally the patient wasreceiving counselling concurrently

Blood sugar balance and dietary GIGL appear to beimportant factors in a number of chronic illnesses A recentmeta-analysis found significant positive associations betweenhigher GI or GL and higher incidence of diabetes coronaryheart disease gallbladder disease breast cancer and alldiseases combined [21] As such implementing a diet lower


in refined carbohydrates in the treatment of anxietymay havesubstantial additional benefit with respect to risk of chronicdisease

4 Conclusion

Dietary carbohydrates may be significantly related to emo-tional and cognitive symptoms such as anxiety and difficultyconcentrating Further research into the potential role ofGI in the pathogenesis and progression of mental healthconcerns in addition to the utility of dietary interventions inthe treatment of these conditions is warranted

Competing Interests

The authors declare that they have no competing interests

References

[1] J L R Martin M Sainz-Pardo T A Furukawa E Martin-Sanchez T Seoane and C Galan ldquoReview benzodiazepines ingeneralized anxiety disorder heterogeneity of outcomes basedon a systematic review and meta-analysis of clinical trialsrdquoJournal of Psychopharmacology vol 21 no 7 pp 774ndash782 2007

[2] C D Lalonde andR J Van Lieshout ldquoTreating generalized anx-iety disorder with second generation antipsychoticsrdquo Journal ofClinical Psychopharmacology vol 31 no 3 pp 326ndash333 2011

[3] B Bandelow R J Boerner S Kasper M Linden H-UWittchen and H-J Moller ldquoThe diagnosis and treatmentof generalized anxiety disorderrdquo Deutsches Arzteblatt Interna-tional vol 110 no 17 pp 300ndash310 2013

[4] R SOpie AOrsquoNeil C Itsiopoulos andFN Jacka ldquoThe impactof whole-of-diet interventions on depression and anxiety a sys-tematic review of randomised controlled trialsrdquo Public HealthNutrition vol 18 no 11 pp 2074ndash2093 2014

[5] J S Lai SHiles A Bisquera A J HureMMcEvoy and J AttialdquoA systematic review and meta-analysis of dietary patterns anddepression in community-dwelling adultsrdquoAmerican Journal ofClinical Nutrition vol 99 no 1 pp 181ndash197 2014

[6] A Ruusunen S M Lehto J Mursu et al ldquoDietary patterns areassociated with the prevalence of elevated depressive symptomsand the risk of getting a hospital discharge diagnosis ofdepression in middle-aged or older Finnish menrdquo Journal ofAffective Disorders vol 159 pp 1ndash6 2014

[7] A A Kulkarni B A Swinburn and J Utter ldquoAssociationsbetween diet quality and mental health in socially disadvan-taged New Zealand adolescentsrdquo European Journal of ClinicalNutrition vol 69 no 1 pp 79ndash83 2015

[8] J E Gangswisch L Hale L Garcia et al ldquoHigh glycemic indexdiet as a risk factor for depression analyses from the WomenrsquosHealth Initiativerdquo The American Journal of Clinical Nutritionvol 102 no 2 pp 454ndash463 2015

[9] F Haghighatdoost L Azadbakht A H Keshteli et alldquoGlycemic index glycemic load and common psychologicaldisordersrdquo The American Journal of Clinical Nutrition vol 103no 1 pp 201ndash209 2016

[10] R A Cheatham S B Roberts S K Das et al ldquoLong-termeffects of provided low and high glycemic load low energy dietson mood and cognitionrdquo Physiology and Behavior vol 98 no3 pp 374ndash379 2009

[11] J Ingwersen M A Defeyter D O Kennedy K A Wesnesand A B Scholey ldquoA low glycaemic index breakfast cerealpreferentially prevents childrenrsquos cognitive performance fromdeclining throughout the morningrdquo Appetite vol 49 no 1 pp240ndash244 2007

[12] Y Papanikolaou H Palmer M A Binns D J A Jenkins andC E Greenwood ldquoBetter cognitive performance following alow-glycaemic-index compared with a high-glycaemic-indexcarbohydrate meal in adults with type 2 diabetesrdquoDiabetologiavol 49 no 5 pp 855ndash862 2006

[13] A-S Sejling T W Kjaeligr U Pedersen-Bjergaard et alldquoHypoglycemia-associated changes in the electroencephalo-gram in patients with type 1 diabetes and normal hypoglycemiaawareness or unawarenessrdquo Diabetes vol 64 no 5 pp 1760ndash1769 2015

[14] N J Paine L L Watkins J A Blumenthal C M Kuhn andA Sherwood ldquoAssociation of depressive and anxiety symp-toms with 24-hour urinary catecholamines in individuals withuntreated high blood pressurerdquo PsychosomaticMedicine vol 77no 2 pp 136ndash144 2015

[15] A EGold KMMacLeod BM Frier and I J Deary ldquoChangesin mood during acute hypoglycemia in healthy participantsrdquoJournal of Personality and Social Psychology vol 68 no 3 pp498ndash504 1995

[16] T Sathyanarayana Rao M R Asha B N Ramesh and KS Jagannatha Rao ldquoUnderstanding nutrition depression andmental illnessesrdquo Indian Journal of Psychiatry vol 50 no 2 pp77ndash82 2008

[17] G I Papakostas T Petersen D Mischoulon et al ldquoSerumfolate vitamin B12 and homocysteine in major depressivedisorder part 2 Predictors of relapse during the continuationphase of pharmacotherapyrdquo Journal of Clinical Psychiatry vol65 no 8 pp 1096ndash1098 2004

[18] C-Y Chang D-S Ke and J-Y Chen ldquoEssential fatty acids andhuman brainrdquo Acta Neurologica Taiwanica vol 18 no 4 pp231ndash241 2009

[19] M Huan K Hamazaki Y Sun et al ldquoSuicide attempt and n-3fatty acid levels in red blood cells a case control study in ChinardquoBiological Psychiatry vol 56 no 7 pp 490ndash496 2004

[20] K-P Su Y Matsuoka and C-U Pae ldquoOmega-3 polyunsatu-rated fatty acids in prevention of mood and anxiety disordersrdquoClinical Psychopharmacology andNeuroscience vol 13 no 2 pp129ndash137 2015

[21] A W Barclay P Petocz J McMillan-Price et al ldquoGlycemicindex glycemic load and chronic disease riskmdashameta-analysisof observational studiesrdquo The American Journal of ClinicalNutrition vol 87 no 3 pp 627ndash637 2008

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


A number of possible mechanisms have been proposedfor the effect of diet on mental health including a role ofinflammation and oxidation [6] deficiency ofmicronutrientssuch as folate zinc and magnesium [7] and glycemicbalance

The increase in global consumption of refined foods suchas sweetened beverages pastries and refined carbohydratesimpacts dietary glycemic index (GI) a measurement of therate of blood glucose generation from specific food itemsGlycemic load (GL) reflects both the glycemic index valueand the total carbohydrate content of the food Foods witha higher GI or GL create greater increases in blood sugar [8]

A recent cohort study showed that increasing oddsof depression and anxiety have been associated with theconsumption of foods that have a progressively higher GI andthis relationship is maintained after controlling for micronu-trients known to play a role in mental health [8] Cross-sectional studies have demonstrated a correlation betweenthe occurrence of depressionstress andhigher intake of sweetfoods [9] and a large prospective cohort study showed apositive correlation between a diet high in sweet desserts andrefined grains and the risk for depression Conversely it wasfound that high consumption of fruits and vegetables whichcontain fiber that lowers GI was associated with a lower riskfor depression [9]

In addition to the observational studies a limited numberof interventional studies have explored a potential relation-ship between blood sugar balance and emotional and cog-nitive health One clinical trial assigned healthy overweightsubjects to high or low GI diets and found that the highGI diet resulted in worsening mood scores [10] Two studiesassessed the impact of high and low GI meals on cognitiveperformance in adults with type 2 diabetes and childrenrespectively and found that the higher GI meal was relatedto poorer cognitive function [11 12] Conversely two otherintervention studies comparing high and low GI diets inpatients with diabetes did not find a change in subclinicaldepression or cognitive function [9] Despite this evidencethat a relationship between dietary GI and emotional andcognitive functioning may exist no interventional studieshave assessed the impact of a low GI or low GL dietaryintervention in psychiatric patient populations in order toassess causality of the relationship

2 Case Presentation

AB is a 15-year-old female student of south-Asian descentShe presented with concerns of anxiety and symptoms ofhypoglycemia as well as difficulty concentrating fatigueheadaches asthma and frequent urinary and vaginal infec-tions

Her anxiety met criteria for GAD and she rated theintensity of anxiety as 810 with 10 being the highest level ofanxiety possibleThe anxiety started threemonths prior to theinitial appointment and hadworsened in the previousmonthShe described excessiveworry that was difficult to control andimpacted her daily functioning by causing her to be absentfrom school on several occasions She experienced a numberof somatic symptoms including heart palpitations shakiness

discomfort in her stomach and muscle tension In responseto the anxiety symptoms she would eat foods like chocolatechips or fruit AB was working with a counsellor to managethe anxiety symptoms and was finding some benefit

AB had experienced episodes suggestive of hypoglycemiasince 12 years of age The symptoms included muscle weak-ness and shaking headaches nausea anxiety and loss ofconcentration Her symptoms were ameliorated by eatingsweet foods AB reported that her hypoglycemia was at itsworst at 12 years of age when she had to eat a granola barhourly in order to concentrate

21 Clinical Findings A diet history revealed the followingtypical daily food intake

(i) Breakfast fruit smoothie containing fruit fruit juiceand water

(ii) Morning snack bagel with margarine(iii) Lunch pasta or white rice with vegetables(iv) Afternoon snack granola bar or cookies or gummy

candies(v) After school meal white pasta it may include meat(vi) Dinner white rice or spaghetti it may include meat(vii) Evening snack cookies and toast(viii) Beverages 2 liters of water 1 cup of juice 1 cup of

lactose-free milk and 1 cup of tea

22 PastMedical History Due to her difficulty concentratingAB was prescribed dextroamphetamine 5mg While shefound that it improved concentration this medication causedher to lose weight As the patientrsquos weight was initially on thelower end of normal (weight 115 lb height 51015840610158401015840 and BMI186) the dose was reduced to 2 to 3 times per week as needed

23 Psychosocial History AB lives with her mother fatherand sister ABrsquos sister experienced mental health concerns inthe previous years which created elevated stress levels in thefamily home

24 Diagnostic Focus and Assessment Repeated assessmentsof random and fasting blood glucose and screening physicalexamination were within normal range

25 Therapeutic Approach At the initial visit the followingdietary plan was prescribed

(i) Breakfast it includes a smoothie containing fruitwater 1 scoop of protein powder and 1 tablespoon offlax seeds or olive oil

(ii) Lunch and dinner they include a serving of protein(meat legume and soy) and a serving of vegetables

(iii) Snacks they include protein when possible (egapple with sunflower seed butter vegetable sticks withhummus and pumpkin seeds)






3 Discussion














4 Conclusion


Competing Interests


References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















3 Discussion














4 Conclusion


Competing Interests


References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















4 Conclusion


Competing Interests


References



























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















case report generalized anxiety disorder and hypoglycemia

Documents