Cardiovascular Disease Packet - Cardiovascular bronchitis

Name: Carly Lauraine

Cardiovascular and respiratory Clinical Packet

Please answer all questions in your own words.

list the applicable references at the end of each section.

A.) Cardiovascular and Respiratory Diseases and Conditions

1. Define the following as they relate to cardiovascular or respiratory function or disease.

a. Aneurism – A weakened portion of the blood vessel wall

b. Angina, differentiate stable versus variant – Chest pain caused when there is an oxygen deficit to the heart. Stable: Increased oxygen demand

c. Angiostenosis – Narrowing of one or more blood vessels.

d. Aortic stenosis – Decrease in vlood flow from the heart due to the aortic valve not opening fully.

e. Arteriosclerosis – Cholsterol, fat, and other substances build up to create plaque in the arteries causing them to harden.

f. Arrhythmia – Any change from the normal sequence of electrical impulses.

g. Atrial fibrillation – Very irregular and fast contraction of the heart due to 3

h. Bradycardia -

i. Tachycardia -

j. Endocarditis -

k. Anasarca -

l. Cyanosis -

m. Dyspnea -

n. Electrocardiogram -

o. Endotracheal intubation -

p. Hemochromatosis -

q. Ischemia -

r. Orthopnea -

s. Pericardium -

t. Phlebitis -

u. Atelectasis -

v. Pneumothorax -

w. Pleural effusion -

x. Pulmonary effusion -

y. Pulmonary embolism -

z. Thoracentesis -

aa. Thrombosis -

ab. Tracheostomy -

ac. Sputum -

ad. Transient Ischemic Attack (TIA) -

ae. Aphasia -

References:

| |

|For each of the following cardiovascular or respiratory diseases and conditions: |

|I am giving you the definition of the disease or condition |

|I am giving you the causes (etiologies) |

|You describe the physical changes specific to the disease process and progression (pathogenesis). |

|You explain how the disease impacts the patient’s nutritional status (in some cases there will be no impact.) |

|You tell me - is a modified diet recommended for this condition? If so what is the diet prescription? |

| | |

|2. |Coronary artery disease / Atherosclerosis |

| |a. |Definition: CAD is a generalized term for heart disease characterized by a narrowing of the vessels supplying blood to the |

| | |heart. More specifically, atherosclerosis is the narrowing of blood vessels caused by thickening of the vessel wall due to the |

| | |presence of plaque |

| |b. |Etiology: |

| | |The three primary hypotheses: |

| | |A response to serum lipid levels – lipid insudation – currently held to be the most important factor in the pathogenesis of |

| | |atherosclerosis |

| | |Reaction to injury of the vessel wall, including chronic hemodynamic stress, which may explain the typical localization of |

| | |plaques at arterial branch points |

| | |Cellular transformation |

| | |Risk factors – modifiable and nonmodifiable |

| | |Modifiable – smoking, elevated blood pressure, glucose intolerance, elevated cholesterol and LDL’s, physical inactivity, |

| | |obesity, weight fluctuations, ineffective stress management |

| | |Nonmodifiable – age, gender ( male gender is a risk factor for earlier development), ethnicity, heredity |

| | |Other risk factors include infections and inflammatory agents |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|3. |Myocardial Infarction |

| |a. |Definition: Heart attack. Localized area of cardiac necrosis and/or tissue damage as a result of oxygen deprivation due to |

| | |impeded blood flow. Most often associated with coronary heart disease. May result in sudden death. |

| |b. |Etiology: prolonged or total disruption of blood flow to the myocardium causes irreversible cell death of the myocardial |

| | |tissue. |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|4. |Cardiomyopathy |

| |a. |Definition: progressive disorder that impairs both structure and function of the muscular walls of the heart. There are three |

| | |main types of cardiomyopathy: dilated, hypertrophic, and restrictive; or these can be combined. |

| | | |

| | | |

| | | |

| | | |

| | | |

| |b. |Etiology: |

| | |Dilated cardiomyopathy is most frequently caused by extensive CAD. It may also result from an acute infection and inflammation |

| | |of the heart muscle – viral cardiomyopathy is most often from the coxsackie B virus. Other causes include poorly controlled DM |

| | |or thyroid, abuse of alcohol (esp with malnutrition), cocaine or antidepressants. |

| | |Hypertrophic cardiomyopathy may be caused by an inherited genetic defect and present at birth. Acquired hypertrophic |

| | |cardiomyopathy may be caused by such disorders as acromegaly (excessive growth due to overproduction of growth hormone), a |

| | |pheochromocytoma (a tumor that overproduces the hormone epinephrine) or a neurobibromatosis (an inherited disorder). |

| | |Restrictive cardiomyopathy is less common and the cause is not known. |

| |c. |Dilated Cardiomyopathy - |

| | |Hypertrophic Cardiomyopathy - |

| | |Restrictive Cardiomyopathy - |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|5. |Cerebral vascular accident / Stroke |

| |a. |Definition: Sudden onset of neurologic dysfunction due to cerebrovascular disease. |

| |b. |Etiology: |

| | |Ischemic Stroke |

| | |Blood flow occlusion r/t thrombus of the cerebral arteries |

| | |Thrombotic strokes are associated with athersclerosis |

| | |Left-sided embolism |

| | |Emboli usually are from a cardiac source |

| | |Risk factors include age, HTN, smoking, heart disease, atrial fibrillation, diabetes, birth control pills |

| | |Hemorrhagic Stroke |

| | |Severe and long-standing hypertension |

| |c. |Ischemic Stroke - |

| | |Hemorrhagic stroke - |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|6. |Hypertension, differentiate essential and secondary |

| |a. |Definition: |

| | |Essential: blood pressure persistently elevated above 140 mm Hg systolic, 90 mm Hg diastolic, or both when secondary causes |

| | |(renovascular disease, aldosteronism, pheochromocytoma, renal failure) are not present |

| | |Secondary: hypertension of known cause, can be explained by a specific disease |

| |b. |Etiology: |

| | |Essential: |

| | |Obesity – |

| | |Inadequate potassium and magnesium intake – both reduce blood pressure so deficiency can promote hypertension |

| | |ANY MENTION OF SODIUM NEEDS AN EXPLANATION OF THE CONTROVERSY |

| | |Diabetes mellitus |

| | |Hyperinsulinemia and insulin resistance without diagnosis of DM2 account for approximately 50% of individuals with essential |

| | |hypertension |

| | |Genetics – influenced by environmental factors: |

| | |Environmental factors such as stress, moderate alcohol intake, smoking, sedentary lifestyle |

| | |Race and gender |

| | |Increased sensitivity to angiontensin II and the associated effects on nitric oxide |

| | |Secondary: |

| | |Renal artery stenosis, renal failure, hypersecretion of aldosterone or catecholamines, hyperthyroidism, increased intracranial |

| | |pressure, drugs |

| | |It is the most common cause of high blood pressure in children |

| | |Early hyperinsulinemia, hyperlipidemia, and obesity may have a role in the development of hypertension in children |

| |c. |Essential |

| | | |

| | |Secondary |

| | | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|7. |Hypotension |

| |a. |Definition – a drop in systolic blood pressure greater than 20 mm Hg and/or a pulse increase of 20 beats/min or more signifies |

| | |orthostatic hypotension |

| |b. |Etiology – |

| | |Orthostatic – |

| | |Loss of blood volume (hypovolemia) |

| | |Clinical dehydration |

| | |Prolonged bed rest |

| | |Impaired cardiovascular response (beta-blockers may increase) |

| | |Peripheral neuropathy (as occurs in diabetics) |

| | |Some medications including diuretics, antihypertensive meds, and pain meds |

| | |Impaired baroreceptor reflex – adrenergic blocking drugs, peripheral neuropathy, and spinal cord injury can interrupt the normal|

| | |pathway |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|8. |Edema |

| |a. |Definition: an excess of fluid in the interstitial compartment. Edema is a sign of an underlying disease process which needs to|

| | |be treated. |

| |b. |Etiology: Generalized edema is due to increases in both total body water and sodium. If just water is retained, it distributes|

| | |throughout the total body water compartment (60% of body weight) and edema will not usually form. However, if sodium is |

| | |retained as well, it is confined to the extracellular spaces. The increased osmolality due to sodium retains water in the ECF. |

| | |Generalized edema can occur with low, normal, or high serum sodium concentration. Serum sodium concentration, per se, does not|

| | |reflect total body sodium. Increased total body sodium can occur with a low, normal or high serum sodium concentration. |

| | |Causes of generalized edema |

| | |Decreased oncotic pressure |

| | |Nephrotic syndrome |

| | |Cirrhosis |

| | |Malnutrition |

| | |Increased vascular permeability to proteins |

| | |Angioneurotic edema (usually allergic) – anaphylactic shock |

| | |Increased hydrostatic pressure |

| | |Congestive heart failure |

| | |Cirrhosis |

| | |Obstruction of lymph flow |

| | |Congestive heart failure |

| | |Inappropriate renal sodium and water retention |

| | |Renal failure |

| | |Nephrotic syndrome |

| | | |

| | |Except for increased vascular permeability to proteins, virtually every clinical situation in which edema is manifest requires |

| | |the kidneys to reabsorb supranormal amounts of sodium and water. |

| |c. |Decompensated CHF - |

| | |Cirrhosis - |

| | |Nephrotic Syndrome - |

| | |Generalized Pathogenesis - |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|9. |Congestive Heart Failure (CHF) |

| |a. |Definition: dysfunctional cardiac pumping that results in congestion of blood behind the dysfunctional cardiac pump. |

| | |Right-sided heart failure is associated with systemic venous congestion. Left-sided heart failure is associated with pulmonary |

| | |congestion. |

| |b. |Etiology: |

| | |The majority of cases of CHF are associated with ischemic cardiomyopathy due to coronary artery disease and hypertension |

| | |Less common causes of CHF include dilated cardiomyopathy, congenital heart defects, valvular disorders, respiratory diseases, |

| | |anemia, and hyperthyroidism |

| | |Regardless of specific cause, the pathophysiologic state of heart failure results from impaired ability of myocardial fibers to |

| | |contract (systolic failure), relax (diastolic failure), or both |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|10. |Hyponatremia |

| |a. |Definition: water excess in the body |

| |b. |Etiology: |

| | |Gain of Relatively More Water Than Salt |

| | |Excessive antidiuretic hormone |

| | |Barbiturate overdose |

| | |Hyptonic irrigating solutions |

| | |Excessive intravenous infusion of 5% dextrose in water |

| | |Tap water enemas |

| | |Psychogenic polydipsia (compulsive water drinking) |

| | |Forced excessive water ingestion (child abuse or club initiation) |

| | |Excessive beer ingestion (beer potomania) |

| | |Near-drowning in fresh water |

| | |Loss of Relatively More Salt Than Water |

| | |Diuretics |

| | |Salt-wasting renal disease |

| | |Replacement of water but not salt lost through emesis, diarrhea, gastric suction, diaphoresis, or burns |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|11. |Hypernatremia |

| |a. |Definition – water deficit; hypertonic syndrome; hyperosmolality – a deficit of water to salt in the extracellular fluid |

| |b. |Etiology – |

| | |Gain of Relatively More Salt Than Water |

| | |Tube feeding |

| | |Intravenous infusion of hypertonic solution |

| | |Near-drowning in salt water |

| | |Overuse of saltables |

| | |Food intake with reduced fluid intake |

| | |Difficulting swallowing fluids |

| | |No access to water |

| | |Inability to respond to thirst |

| | |Loss of Relatively More Water Than Salt |

| | |Diabetes insipidus (deficient antidiuretic hormone) |

| | |Tube feeding (causes obligate water loss in urine) |

| | |Osmotic diuresis |

| | |Prolonged diarrhea or diaphoresis without water replacement |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|12. |Hypokalemia |

| |a. |Definition – a decreased potassium concentration in the extracellular fluid |

| |b. |Etiology – |

| | |Decreased Potassium Intake: |

| | |Anorexia |

| | |NPO and intravenous solutions without potassium |

| | |Fasting |

| | |Unbalanced diet |

| | |Shift of Potassium from Extracellular Fluid (ECF) to Cells (ICF) |

| | |Alkalosis |

| | |Rapid correction of acidosis |

| | |Excess insulin (e.g., during TPN) |

| | |Excess beta-adrenergic stimulation |

| | |Hypokalemic familial periodic paralysis |

| | |Increased Potassium Excretion Through Renal Routes |

| | |Corticosteroid therapy |

| | |Potassium-wasting diuretics |

| | |Parenteral carbenicillin or similar agents |

| | |Hypomagnesemia |

| | |Cushing disease |

| | |Hyperaldosteronism |

| | |Excessive ingestion of black licorice (contains aldosterone-like chemicals) |

| | |Amphortericin B, cisplatin, and many other drugs |

| | |Increased Excretion Through Fecal Routes |

| | |Diarrhea (includes laxative abuse) |

| | |Increased Excretion Through Skin Route |

| | |Excessive diaphoresis |

| | |Loss of Potassium Through Abnormal Routes |

| | |Emesis |

| | |Gastric suction |

| | |Fistula drainage |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|13. |Hyperkalemia |

| |a. |Definition – serum potassium concentration rises above 5.0 mEq/L; denotes an elevation of potassium concentration in the |

| | |extracellular fluid |

| |b. |Etiology |

| | |Increased Potassium Intake |

| | |Excessive or too-rapid intravenous potassium infusion |

| | |Insufficiently mixed intravenous potassium |

| | |Large transfusion of stored blood |

| | |Massive doses of potassium penicillin G |

| | |Shift of Potassium from Cells to Extracellular Fluid |

| | |Acidosis caused by mineral acids |

| | |Insufficient insulin |

| | |Crushing injury |

| | |Cytotoxic drugs (tumor lysis syndrome) |

| | |Hyperkalemic periodic paralysis |

| | |Beta-adrenergic blockade |

| | |Decreased Potassium Excretion |

| | |Oliguria (such as in hypvolemia or renal failure) |

| | |Potassium-sparing diuretics |

| | |Adrenal insufficiency |

| | |Angiotensin-converting enzyme (ACE) inhibitors |

| | |AngiotensinII receptor antagonists |

| | |Nephrotoxic drugs |

| | |Renin-deficient states |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|14. |Pneumonia |

| |a. |Definition – from pneuma, “breath”, refers to an inflammatory reaction in the alveoli and interstitium of the lung, usually |

| | |caused by an infectious agent |

| |b. |Etiology |

| | |aspiration of oropharyngeal secretions composed of normal bacterial flora and/or gastric contents |

| | |inhalation of contaminants (virus, Mycoplasma) |

| | |bacterial, atypical, and viral |

| | |community-acquired or hospital acquired |

| | |contamination from the systemic circulation |

| | |community-acquired pneumonia occurs when defense mechanisms are compromised |

| | |patients with chronic illness, those who are immobile or immunosupressed are at highest risk |

| | |other patients at risk are those who have undergone thoracic or abdominal surgery or anesthesia |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|15. |Aspiration Pneumonia |

| |a. |Definition – pneumonia caused by the inadvertent entry of particles, food substances, liquids or gastric contents into the |

| | |respiratory system. |

| |b. |Etiology |

| | |Patient’s gag or cough reflex is decreased or their level of consciousness is impaired, such as with alcohol intoxication or the|

| | |effects of some drugs |

| | |Patients who have difficulty chewing and swallowing are at risk |

| | |May occur with gastric tube feedings |

| | |Aspiration of gastric contents may occur with vomiting and subsequent inhalation of vomitus |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|16. |COPD – Emphysema |

| |a. |Definition – an obstructive airway disorder that results from destruction of alveoli and small airways without fibrosis and |

| | |abnormal enlargement of the distal air sacs. Also known as “pink puffer”. |

| |b. |Etiology |

| | |Occurs primarily in cigarette smokers and is often see in association with chronic bronchitis |

| | |Also associates with air pollution and certain occupations (welding, mining, and working with or near asbestos) |

| | |Develops over a long period and is seen more frequently in persons older than 50 |

| | |Smoking leads to inflammation in the lung tissue, |

| | |Genetic deficiency of alpha-antitrypsin is an uncommon cause of emphysema |

| | |May follow bacterial lung infections (e.g., staphylococcal) which involves secretion of proteases that destroy the elastin |

| | |responsible for the normal elasticity of the lung tissue. |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|17. |COPD – Bronchitis |

| |a. |Definition – hypersecretion of bronchial mucus and a chronic or recurrent productive cough of more than 3 months duration and |

| | |occurring each year for two successive years in patients in whom other causes have been excluded. Also referred to as “blue |

| | |bloater”. |

| |b. |Etiology |

| | |Acute bronchitis results from: |

| | |Temporary inflammation of the tracheobronchial tree. |

| | |Inflammation may be due to viral, bacterial, fungal, or chemical irritants. |

| | |Chronic bronchitis is an inflammatory disorder of the airways that results from: |

| | |Most commonly, long-term cigarette smoking. |

| | |Repeated airway infections |

| | |Genetic predisposition |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

| | |

|18. |Cystic Fibrosis |

| |a. |Definition – autosomal recessive disorder of the exocrine glands. It is the most common genetic lung disease in the US. |

| |b. |Etiology – genetic; passed on when both parents carry the recessive gene. |

| |c. | |

| |d. | |

| |e. | |

| | |Reference: |

B.) Nutrition Prescriptions:

1. For each of the following:

a. Describe the diet as it pertains to cardio or respiratory conditions. Your description should be specific and detailed – think about the directions you would give to a patient about restrictions, etc.

b. Explain the expected physiological response to the diet (how should the diet improve the condition)?

|Description |

| |

| |

|Response |

| |

| |

|Low Fat |

|Description |

| |

| |

|Response |

| |

| |

|Low Cholesterol |

|Description |

| |

| |

|Response |

| |

| |

|Low Saturated Fat |

|Description |

| |

| |

|Response |

| |

| |

|Low Trans-Fat |

|Description |

| |

| |

|Response |

| |

| |

|High Monounsaturated Fat |

|Description |

| |

| |

|Response |

| |

| |

|No Added Salt |

|Description |

| |

| |

|Response |

| |

| |

|3 gram Sodium |

|Description |

| |

| |

|Response |

| |

| |

|2 gram Sodium |

|Description |

| |

| |

|Response |

| |

| |

|1 gram Sodium |

|Description |

| |

| |

|Response |

| |

| |

|Include Salt Substitutes |

|Description |

| |

| |

|Response |

| |

| |

|High Potassium |

|Description |

| |

| |

|Response |

| |

| |

|Low Carbohydrate |

|Description |

| |

| |

|Response |

| |

| |

|Vitamin K-Stable |

|Description |

| |

| |

|Response |

| |

| |

|DASH |

|Description |

| |

| |

|Response |

| |

| |

|Therapeutic Lifestyle Changes - TLC |

|2. |Discuss the role of alcohol in cardiovascular disease. |

| | |

References for this section:

C.) Nutrition Related Topics:

|1. |Discuss the metabolism and function of the major lipoproteins as well as their role in the pathogenesis of disease. Use the format as|

| |provided in the example. |

| |Example: |

| |Triglycerides: |

| |a. |Metabolism - Dietary triglycerides are catabolized in the small intestine into mono-glycerides and free fatty acids which are |

| | |carried via micelles across the brush border where the fragments are reassembled into triglycerides, packaged into chylomicrons |

| | |for transport through the lymph system and into the blood for transport to the tissues of the body. |

| | |Endogenous triglycerides are also metabolized as a result of a high-carbohydrate intake. Insulin is released, and in addition |

| | |to stimulating glucose uptake by body tissues, insulin stimulates the production of glycogen and fat synthesis (in the form of |

| | |triglycerides) in an effort to restore blood glucose levels to a normal range. |

| |b. |Function – |

| | |provide fuel for muscle tissue at rest |

| | |an efficient form of stored energy |

| | |carriers of nutrients such as fat-soluble vitamins |

| | |insulate the body and protect organs. |

| |c. |Role in pathogenesis of disease - Elevated triglycerides are an independent risk factor for cardiovascular disease. High |

| | |triglycerides are usually accompanied by low HDLs. Excess calories and carbohydrates increase the production of triglycerides |

| | |and VLDLs; this may be caused or compounded by insulin resistance and/or obesity. (See metabolism above). Alcohol intake |

| | |aggravates high triglycerides. |

| | |

| |VLDL: |

| |a. |Metabolism - |

| |b. |Function - |

| |c. |Role in pathophysiology of disease - |

| | |

| |LDL: |

| |a. |Metabolism - |

| |b. |Function - |

| |c. |Role in pathophysiology of disease - |

| | |

| |HDL: |

| |a. |Metabolism - |

| |b. |Function - |

| |c. |Role in pathophysiology of disease - |

| | |

| |Apolipoprotein A: |

| |a. |Metabolism - |

| |b. |Function - |

| |c. |Role in pathophysiology of disease - |

| | |

| |Apolipoprotein B: |

| |a. |Metabolism - |

| |b. |Function - |

| |c. |Role in pathophysiology of disease - |

| | |

| |References for this section: |

|2. |Why can manufacturers state that a product is “trans-fat free” when hydrogenated fats are listed in the product’s ingredient list? |

| |List the ways manufacturers can legally meet the labeling requirements for trans fatty acids. |

| | |

| | |

|3. |Discuss the role of each of the following as it relates to cardiac disease (what happens and how). Include recommendations and any |

| |current controversy in your discussion. |

| |a. |High sodium diets |

| | | |

| |b. |B-6, Folate (hint: homocystine mechanism) |

| | | |

| |c. |Plant stanols |

| | | |

| |d. |Omega-3 fatty acids (include sources) |

| | | |

| |e. |Soy protein |

| | | |

| |f. |Soluble fiber |

| | | |

| |References for this section: |

|4. |Outline the inflammation response. How does it relate to cardiac disease? Your answer should include a detailed discussion of the |

| |roles of omega-3 and omega-6 fatty acids, and C-reactive protein. |

| |The Inflammation Response |

| | |

| | |

| |Omega 6 Fatty Acids |

| | |

| | |

| |Omega 3 Fatty Acids |

| | |

| | |

| |Summary of Omega Fatty Acids |

| | |

| | |

| |C-Reactive Protein |

| | |

| |References: |

|5. |Discuss the relationship between blood pressure and each of the following: calcium, sodium, potassium, and chloride |

| |CALCIUM: |

| | |

| |SODIUM: |

| | |

| |POTASSIUM: |

| | |

| |CHLORIDE: |

| | |

| |References: |

|6. |The following is a list of procedures/surgeries frequently performed in the assessment of cardiovascular diseases. Describe the |

| |procedure and risks associated with each procedure. What nutrition interventions, if any, are typically recommended with each? |

| |Angioplasty |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |Coronary Artery Bypass Graft (CABG) |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |Stent |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |Mechanical ventilation |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |Pacemaker |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |Cardiac Catheterization |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

| |ECG |

| |a. |Description - |

| |b. |Risks - |

| |c. |Nutrition interventions - |

| | |

|7. |Describe how the metabolic cart assesses resting energy expenditure. |

| | |

| | |

|8. |Define respiratory quotient (RQ) and describe how it is affected by carbohydrate, protein and fat intake. |

| | |

References for this section:

................
................

In order to avoid copyright disputes, this page is only a partial summary.

To fulfill the demand for quickly locating and searching documents.

It is intelligent file search solution for home and business.

Literature Lottery

Related download

Related searches