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Healthful Eating
As Lifestyle
(HEAL)
Integrative Prevention for
Non-Communicable Diseases
Healthful Eating
As Lifestyle
(HEAL)
Integrative Prevention for
Non-Communicable Diseases
Edited by
Shirin Anil
Boca Raton London New York
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Library of Congress Cataloging‑in‑Publication Data
Names: Anil, Shirin, editor.

Title: Healthful eating as lifestyle (HEAL) : integrative prevention for
non-communicable diseases / edited by Shirin Anil.
Other titles: HEAL
Description: Boca Raton : CRC Press, 2016. | Includes bibliographical
references and index.
Identifiers: LCCN 2016028349| ISBN 9781498748681 (hardback : alk. paper) |
ISBN 9781315368511 (ebook)
Subjects: | MESH: Diet Therapy | Chronic Disease--prevention & control |
Attitude to Health | Life Style
Classification: LCC RM216 | NLM WB 400 | DDC 615.8/54--dc23
LC record available at https://lccn.loc.gov/2016028349
Visit the Taylor & Francis Web site at

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and the CRC Press Web site at

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Dedicated to His Highness Prince Karim Aga Khan—the founder
and chairman of the Aga Khan Development Network, my idol
and inspiration to bring about a positive change and improve the
quality of lives for all humans. This is my humble contribution, like
a star in the galaxy of your work impacting the lives of millions.
Contents
Editor ........................................................................................................................ix
Contributors ..............................................................................................................xi
Chapter 1 HEAL for Non-Communicable Diseases .............................................1

Shirin Anil
Chapter 2 HEAL for Hypertension ..................................................................... 27

Saman Tahir, Sara Habib, and Romaina Iqbal
Chapter 3 HEAL for Obesity .............................................................................. 49

Ayesha Salem Al Dhaheri and Leila Cheikh Ismail
Chapter 4 HEAL for Hyperlipidemia ................................................................. 71

Bart Kay
Chapter 5 HEAL for Diabetes ............................................................................ 89

Chunling Wang, Zhizhong Dong, Zhe Yi, Jian Ying, and
Geng Zhang
Chapter 6 HEAL for Heart Diseases ................................................................ 115

Ioanna Bakogianni, Dimitra Karageorgou, Muna Ibrahim
Atalla Al Baloushi, and Antonis Zampelas
Chapter 7 HEAL for Stroke .............................................................................. 141

Claudia Stefani Marcilio, Antonio Cordeiro Mattos, Gustavo
B.F. Oliveira, and Alvaro Avezum
Chapter 8 HEAL for Asthma ............................................................................ 159

Zaid Kajani, Sivakumar Sudhakaran, and Salim Surani
Chapter 9 HEAL for Cancers ........................................................................... 179

Shirin Anil and Redhwan Al Naggar
vii
viii Contents
Chapter 10 HEAL for Mental Health Issues....................................................... 203

Karen M. Davison, Ann S. Hatcher, and David Benton
Chapter 11 HEAL and Physical Activity ............................................................ 231

Ranjit Mohan Anjana, Vaidya Ruchi, Vasudevan Sudha,
Unnikrishnan Ranjit, and Rajendra Pradeepa
Chapter 12 HEAL and Smoking Cessation ........................................................ 247

Shirin Anil and Redhwan Al Naggar
Index ...................................................................................................................... 267

Editor
Shirin Anil, MBBS, MSc, is a medical doctor, an
epidemiologist and biostatistician, and an Endeavour
Executive Fellow in nutritional epidemiology, with
extensive experience in the fields of global health,
nutrition, non-communicable diseases (NCDs), infec-
tious diseases, and mother and child health in devel-
oped and developing countries. She has conducted and
presented more than 50 research projects in Australia,
the United States, the United Kingdom, Spain, France,
China, Pakistan, Malaysia, Saudi Arabia, and the
United Arab Emirates, with publications in peer-reviewed journals including Lancet,
BMC Gastroenterology, BMC Pregnancy and Childbirth, the British Journal of
Surgery, Frontiers of Medicine, Global Health Action, and the Journal of Human
Hypertension. Her major projects include project LIFE (Lifestyle Interventions For
Eradication of NCDs), a community-led intervention for the control of diabetes, obe-
sity, hypertension, and hypercholesterolemia, dietary patterns associated with high
blood pressure, smoking in the general population, preventive medicine education
for chronic diseases, complementary and alternative medicine in cancer patients,
the association of artificial night light and cancer in 158 countries globally, factors
associated with nonalcoholic fatty liver disease, hepatocellular cancer, nutrition in
celiac disease in children, randomized control trials for the early screening and man-
agement of diabetes, hypertension, chronic respiratory diseases, and early childhood
development interventions in primary health-care settings.
Dr. Anil manages the Victorian Congenital Anomalies Register, with more than
3,000 notifications of congenital anomalies in over 75,000 births per year at the
Department of Health and Human Services in Victoria, Australia. She is a consulting
epidemiologist and statistician at the Association for Social Development, Pakistan.
In an honorary capacity, she serves on the True Health Initiative Council, a coali-
tion of more than 250 global health experts from 30 countries, and also as the team
leader for NCD prevention and control at the Aga Khan Development Network (a
community health team) in Australia and the UAE. Dr. Anil is also a reviewer of
many journals, including the Journal of the American College of Nutrition, SAGE
Open Medicine, the Saudi Journal of Gastroenterology, the Journal of Patient
Safety, and the Journal of Royal Society of Medicine. She is on the editorial board of
MOJ Public Health, and was an advisor to the editorial board for the International
Journal of Medical Students and a regional advisor for Lancet Student.
ix
Contributors
Muna Ibrahim Atalla Al Baloushi Zhizhong Dong
Department of Nutrition and Health COFCO Nutrition and Health Research
College of Food and Agriculture Institute
United Arab Emirates University Beijing, China
Al Ain, UAE
Sara Habib
Ayesha Salem Al Dhaheri Aga Khan University
Department of Nutrition and Health Karachi, Pakistan
College of Food and Agriculture
United Arab Emirates University Ann S. Hatcher
Al Ain, UAE Center for Addiction Studies
Department of Human Services
Redhwan Al Naggar Metropolitan State University–Denver
Faculty of Medicine Denver, Colorado
Universiti Teknologi MARA (UiTM)
Shah Alam, Malaysia Romaina Iqbal
Aga Khan University
Ranjit Mohan Anjana Department of Community Health
Madras Diabetes Research Foundation Sciences
Chennai, India Karachi, Pakistan
Alvaro Avezum Leila Cheikh Ismail

Research Division Nuffield Department of Obstetrics and
Dante Pazzanese Institute of Cardiology Gynaecology
São Paulo, Brazil University of Oxford
Oxford, United Kingdom
Ioanna Bakogianni
Department of Food Science and Zaid Kajani
Human Nutrition Columbia University
Agricultural University of Athens New York, New York
Athens, Greece
Dimitra Karageorgou
David Benton Department of Food Science and
Department of Psychology Human Nutrition
Swansea University Agricultural University of Athens
Swansea, Wales, United Kingdom Athens, Greece
Karen M. Davison Bart Kay

School of Nursing School of Allied Health Sciences
University of British Columbia de Montfort University
Vancouver, Canada Leicester, United Kingdom
xi
xii Contributors
Claudia Stefani Marcilio Salim Surani

Research Division Texas A&M University
Dante Pazzanese Institute of Cardiology Houston, USA & University of North
São Paulo, Brazil Texas
Houston, Texas
Antonio Cordeiro Mattos
Research Division Saman Tahir
Dante Pazzanese Institute of Department of Community Health
Cardiology Sciences
São Paulo, Brazil Aga Khan University
Karachi, Pakistan
Gustavo B.F. Oliveira
Research Division Chunling Wang
Dante Pazzanese Institute of COFCO Nutrition and Health Research
Cardiology Institute
São Paulo, Brazil Beijing, China
Rajendra Pradeepa Zhe Yi

Madras Diabetes Research COFCO Nutrition and Health Research
Foundation Institute
Chennai, India Beijing, China
Unnikrishnan Ranjit Jian Ying

Madras Diabetes Research COFCO Nutrition and Health Research
Foundation Institute
Chennai, India Beijing, China
Vaidya Ruchi Antonis Zampelas

Madras Diabetes Research Department of Food Science and
Foundation Human Nutrition
Chennai, India Agricultural University of Athens
Athens, Greece
Vasudevan Sudha and
Madras Diabetes Research Department of Nutrition and Health
Foundation College of Food and Agriculture
Chennai, India United Arab Emirates University
Al Ain, UAE
Sivakumar Sudhakaran
Texas A&M University Health Science Geng Zhang
Center COFCO Nutrition and Health Research
Houston Methodist Hospital Institute
Houston, Texas Beijing, China
1 HEAL for
Non-Communicable
Diseases
Shirin Anil
CONTENTS
1.1 Non-Communicable Diseases: Global Health Challenge ................................. 2
1.2 Prevention of Non-Communicable Diseases ....................................................2
1.3 Healthful Eating As Lifestyle (HEAL) ............................................................3
1.4 Dietary Guidelines ............................................................................................4
1.4.1 WHO’s Dietary Recommendations ......................................................4
1.4.2 Dietary Guidelines for Americans........................................................5
1.4.3 Eating Well with Canada’s Food Guide................................................ 5
1.4.4 United Kingdom: The Eatwell Guide ...................................................7
1.4.5 Australian Dietary Guidelines—Eat for Health ................................... 7
1.5 Impact of Food-Based Dietary Guidelines on Non-Communicable Diseases ..... 8
1.5.1 WHO Dietary Guidelines and NCDs ...................................................8
1.5.2 Dietary Guidelines for Americans and NCDs ......................................9
1.5.3 Eat Well with Canada’s Food Guide and NCDs ................................. 10
1.5.4 The Eatwell Guide and NCDs ............................................................ 11
1.5.5 Australian Dietary Guidelines and NCDs .......................................... 11
1.6 Dietary Patterns to Prevent Non-Communicable Diseases ............................ 12
1.6.1 Mediterranean Diet ............................................................................. 12
1.6.2 Dietary Approaches to Stop Hypertension (DASH)........................... 12
1.7 Home Remedies to Prevent Non-Communicable Diseases ............................ 13
1.7.1 Remedies for Diabetes ........................................................................ 13
1.7.2 Remedies for Hypertension ................................................................ 13
1.7.3 Remedies for Hypercholesterolemia ................................................... 14
1.7.4 Remedies for Cardiovascular Disease (Heart Disease and Stroke) .... 14
1.7.5 Remedies for Obesity.......................................................................... 15
1.7.6 Remedies for Asthma ......................................................................... 15
1.7.7 Remedies for Cancers ......................................................................... 16
1.8 Nutritional Counseling for Non-Communicable Diseases ............................. 16
1.9 Case Studies .................................................................................................... 19
1.9.1 Case Study 1 ....................................................................................... 19
1.9.2 Case Study 2 ....................................................................................... 19
References ................................................................................................................ 19
1
2 Healthful Eating As Lifestyle (HEAL)
1.1 NON-COMMUNICABLE DISEASES:

GLOBAL HEALTH CHALLENGE
Non-communicable diseases (NCDs)—diseases that are chronic in nature, slow
in progression, cannot be transmitted from one person to another, yet can be
inherited—are a global public health challenge. NCDs caused 38 million (68%) of
56 million deaths worldwide in 2012, of which 28 million (approximately three-
quarters) occurred in lower- and middle-income countries, and 16 million (more
than 40%) premature deaths—that is, the death of people less than 70 years of age
(World Health Organization [WHO] 2014). Four major diseases that account for 82%
of NCD deaths are (1) cardiovascular disease (CVD) (e.g., heart disease and stroke;
17.5 million deaths), (2) cancer (8.2 million deaths), (3) chronic respiratory diseases
(e.g., asthma and chronic obstructive pulmonary disease [COPD]; 4 million deaths),
and (4) diabetes (1.5 million deaths) (WHO 2014). If the same trend continues, CVD
deaths are expected to rise to 23.3 million and cancer deaths to 11.5 million in the
year 2030 (Mathers and Loncar 2006).
In addition to mortality, NCDs are responsible for worldwide morbidity. Global
disability-adjusted life years (DALYs) due to NCDs increased from 43% in 1990 to
54% in 2010. Ischemic heart disease is the leading cause of DALYs, showing a 29%
increase in 10 years, and stroke is the fifth leading cause, claiming 19% more DALYs
in 2010 compared with that in 1990 (Murray et al. 2013).
NCDs are a threat to economic and human development. The economic growth
rate is expected to decrease by half a percent for every 10% rise in NCD mortality in
the working-age population (Stuckler 2008). It has been estimated that heart disease,
stroke, and diabetes have led to an economic loss of USD 84 billion in the 23 lower- and
middle-income countries with a high burden of NCDs from 2006 to 2015, spanning a
duration of 10 years alone (Abegunde et al. 2007). If this goes unchecked without any
interventions to decrease the burden of NCDs, it will not only widen the economic gap
between developing and developed countries, but will also hamper the achievement of
the Millennium Development Goals (MDGs) (Beaglehole et al. 2011a).
1.2 PREVENTION OF NON-COMMUNICABLE DISEASES

NCDs can be prevented by controlling their risk factors. These diseases can be attrib-
uted to four major risk factors: unhealthy diet, insufficient physical activity, smoking,
and alcohol consumption, which contribute to the development of metabolic risk
factors such as high blood pressure, obesity, high blood lipids, and high glucose
level (Beaglehole et al. 2011b; Wagner and Brath 2012). People with ≥3 of these risk
factors (abdominal obesity [>40 in. in males, >35 in. in females]; fasting glucose
≥100 mg/dl or on pharmacological treatment [Rx]; triglycerides ≥150 mg/dl or on
Rx; HDL cholesterol <40 mg/dl in males or <30 mg/dl in females or on Rx; systolic
blood pressure >130 mm Hg or diastolic blood pressure >85 mm Hg or on Rx) are
labeled as having metabolic syndrome (MetS), according to the National Cholesterol
Education Program’s Adult Treatment Panel III (ATP III) (Grundy et al. 2005).
These risk factors interact with each other to impact morbidity or mortality due
to NCDs. Meta-analysis of 87 studies with 951,083 participants showed that MetS
HEAL for Non-Communicable Diseases 3
increases the risk of CVD twofold (relative risk [RR] 2.35; 95% confidence interval
[CI] 2.02–2.73), CVD mortality (RR 2.40; 95% CI 1.87–3.08), all-cause mortality
(RR 1.58; 95% CI 1.39–1.78), stroke (RR 2.27; 95% CI 1.80–2.85), and myocardial
infarction (RR 1.99; 95% CI 1.61–2.46) (Mottillo et al. 2010).
When the individual effects of the risk factors are added together, the attribut-
able risk of a disease in the population (population attributable fraction [PAF]) may
account for more than 100%, but their combined effect is less than the individual
effect added together, as these risk factors overlap in disease causation (Danaei et al.
2005; WHO 2009). For example, the PAFs of smoking and unsafe sex for cervical
cancer uteri are 2% and 100%, respectively, but their combined PAF is 100%, as the
cancer patient may have the presence of both the risk factors, which leads to disease
causation (Danaei et al. 2005). The interrelation of the risk factors also means that
various interventions can be used for disease prevention depending on the resources
available (Danaei et al. 2005). The intervention emphasized in this book is “health-
ful eating,” the impact of which will be discussed on the prevention and control of
NCDs as well as the risk factors mentioned previously.
1.3 HEALTHFUL EATING AS LIFESTYLE (HEAL)

Healthful eating can be described as choosing food that makes a person healthy.
“Healthful” here refers to something that “creates good health,” while “Healthy”
refers to someone or something that “enjoys good health.” The WHO defines health
as a “state of complete physical, mental and social well being, and not merely the
absence of disease or infirmity” (1948).
People perceive healthful eating as the consumption of fruits and vegetables and
meat; less intake of sugar, salt, and fat; and a fresh, unprocessed, homemade, natural,
balanced diet composed of a variety of foods in moderation (Paquette 2005). It is
important to make healthful eating a lifestyle throughout the life course to enjoy
good health and prevent NCDs (Figure 1.1).
Dietary
patterns
Food-based
Home
dietary
remedies
guidelines
Prevention of
Non-
Communicable
Diseases (NCDs)
FIGURE 1.1 Healthful eating approaches for the prevention of non-communicable diseases.
1.4 DIETARY GUIDELINES

Food-based dietary guidelines (FBDGs) are defined as “simple messages on
healthy eating, aimed at the general public. They give an indication of what a
person should be eating in terms of foods rather than nutrients, and provide a
basic framework to use when planning meals or daily menus” (European Food
Information Council 2009). WHO emphasizes that FBDGs should be food based
rather than nutrient based as people enjoy eating food, not nutrients. FBDGs should
account for dietary patterns and the prevalence of deficiency disorders and NCDs
(WHO 2003b).
WHO has given dietary recommendations for the prevention of NCDs (WHO
2015c). Many countries have developed their FBDGs specifically to their national
context: for example, Dietary Guidelines for Americans (DGA) in the United States
(U.S. Department of Health and Human Services 2015), Eating Well with Canada’s
Food Guide (Health Canada 2011a), the Eatwell Guide in the United Kingdom (NHS
Choices 2016), and the Eat for Health Australian Dietary Guidelines (NHMRC
2013a). All these dietary guidelines have a primary focus of maintaining a balanced
diet and healthy weight and preventing NCDs. The salient features of these guide-
lines are as follows.
1.4.1 WHO’s Dietary recOmmenDatiOns

Though FBDGs vary in different parts of the world, WHO has given the follow-
ing guidelines for healthful eating to prevent and control NCDs in adults (WHO
2015c):
• The consumption of fruits and vegetables (at least 400 g—5 portions
a day, excluding starchy roots such as potatoes, sweet potatoes, and
cassava) (WHO 2003a), legumes (e.g., lentils and beans), whole grains
(e.g., brown rice, millet, oats, and unprocessed maize), and nuts is
recommended.
• Sugar intake should be less than 10% of total energy (approximately 50 g or
12 teaspoons for a person with healthy body weight requiring 2000 cal/day)
(WHO 2003a, 2015b) and less than 5% for additional health benefits (WHO
2015b). It should be taken into consideration that sugars are naturally pres-
ent in fruits, fruit juice and fruit concentrates, honey, and added by manu-
facturers in many packaged foods and drinks.
• Fat intake should be less than 30% of total energy (WHO 2003a; Food and
Agricultural Organization 2010; Hooper et al. 2012). Saturated fats (e.g.,
those present in butter, coconut and palm oil, cream, cheese, ghee and lard,
and fatty meat) should be avoided, and unsaturated fats (e.g., those pres-
ent in avocado, nuts, canola, olive and sunflower oils, and fish) should be
preferred. Trans fats (e.g., those present in processed foods, snacks, fast
foods, fried food, pies, cookies, frozen pizza, margarines, and spreads) do
not form a part of healthful eating.
• Salt should be restricted to 5 g/day (approximately 1 teaspoon) and iodized

salt used (WHO 2012).
WHO gives a similar guideline for healthful eating in children to that in adults,
with the following additions:
• Exclusive breast-feeding should be done in the first 6 months of life.

• Breast-feeding should continue in children up to 2 years of age and beyond.
• Breast milk should be complemented by a variety of safe and healthy foods
from 6 months of age onward. Do not add salt or sugar to the complemen-
tary foods given to infants and children.
1.4.2 Dietary GuiDelines fOr americans

DGA is released by the secretaries of the U.S. Department of Health and Human
Services (HHS) and the U.S. Department of Agriculture (USDA) every 5 years, the
first edition being published in the year 1980 and the eighth in 2015. It is based on
the latest/current scientific evidence and is for children and adults aged 2 years and
older, including those who are at risk of developing NCDs. DGA will cover all age
groups, including children less than 2 years, from the year 2020. Five major guide-
lines of DGA 2015–2020 (U.S. Department of Health and Human Services and U.S.
Department of Agriculture 2015) are
• A healthy eating pattern consisting of appropriate calorie levels in order to

maintain healthy weight supporting nutrient adequacy should be followed
throughout the lifespan.
• Consume nutrient-dense foods and beverages: fruits, fruit juices, veg-
etables, whole grains, seafood, and fat-free and low-fat milk and milk
products.
• Foods containing sodium (salt), saturated fats, trans fats, cholesterol, added
sugars, and refined grains should be restricted in the diet.
• Choose healthier foods and beverages.
• Support others to have healthy eating patterns.
Table 1.1 shows the foods to decrease and increase according to DGA 2015.
1.4.3 eatinG Well WitH canaDa’s fOOD GuiDe

Eating Well with Canada’s Food Guide gives recommendations for the number of
servings of four groups of foods—namely, “vegetable and fruits,” “grain products,”
“milk and alternatives,” and “meat and alternatives”—to be consumed by different
age groups starting from 2 years of age in males and females, separately (Health
Canada 2011a). By following these recommendations, one can meet his/her require-
ment of vitamins, minerals, and other nutrients, reduce the risk of obesity, heart dis-
ease, type 2 diabetes, certain types of cancers, and osteoporosis, and lead a healthy
TABLE 1.1
Foods to Be Reduced and Increased in Consumption According to the
Dietary Guidelines for Americans (2010)
Reduce Consumption of Increase Consumption of

• Salt: Less than 2300 mg, further reduction to • Fruits
1500 mg in people aged >51 years and in • Vegetables: Especially dark green, red, and
those of any age with hypertension, diabetes, orange vegetables; beans, and peas
or chronic kidney disease, or who are African • Whole grains: Replace refined grains with
Americans whole grains
• Saturated fatty acids: Restrict to less than • Low-fat and fat-free milk and milk products
10% of total calorie intake by saturated fatty • Proteins: Seafood, lean meat and poultry,
acids; replace with poly- and eggs, beans, peas, soy products, and unsalted
monounsaturated fatty acids nuts and seeds; replace protein foods
• Cholesterol: Less than 300 mg/day containing solid fats with those containing
• Trans fats lower solid fats and/or which are sources of
• Sugars: Less than 10% calories per day from oils
added sugars • Oil to replace solid fats
• Refined grains • Foods containing potassium, dietary fiber,
• Alcohol: Restrict to one drink per day for calcium, and vitamin D
women, two drinks per day for men of legal
drinking age
Source: USDA and U.S. HHS, Dietary Guidelines for Americans, Washington, DC, 2015.
life (Health Canada 2011a). Canada’s Food Guide gives the following basic recom-
mendations (Health Canada 2011b):
• At least one dark green and one orange vegetable to be consumed every day.
• Fruits and vegetables should be chosen such that they have little or no added
sugar, salt, and fat.
• Fruits and vegetables should be preferred to juices.
• Half of the grain products should be whole grains.
• Consume grain products low in salt, sugar and fats.
• Consume 1% or 2% skim milk every day.
• Lower-fat alternative milk products should be preferred.
• Meat alternatives such as beans, tofu and lentils should be consumed more.
• At least 2 food guide servings of fish to be consumed every week.
• Lean meat and its alternatives should be cooked with less or no added salt
and fats.
• Unsaturated fats should be restricted to 30–45 mL (2–3 tbsp) each day.
Vegetable oils should be used and butter, hard margarine, shortening and
lard should be avoided.
• Drink plenty of water.
1.4.4 uniteD KinGDOm: tHe eatWell GuiDe

The Eatwell Plate was developed by the Food Standards Agency and released in
2007, to guide people toward a balanced diet and healthful eating in the United
Kingdom (Food Standards Agency 2007). The Eatwell Plate has now been replaced
by the Eatwell Guide (NHS Choices 2016). It is a pictorial representation of five
food groups—namely, “fruits and vegetables,” “bread, rice, potatoes, pastas and
other starchy foods,” “meat, fish, eggs, beans and other nondairy sources of protein,”
“milk and dairy foods,” and “foods and drinks high in fats and/or sugar”—in the
proportions they should be consumed on a plate (Food Standards Agency 2007). It
emphasizes the consumption of a diet low in energy-dense food and high in fruits
and vegetables (Evans 2015). As a general rule, the meal should be comprised of
one-third carbohydrates, one-third fruits and vegetables, and one-third dairy, non-
dairy protein food, and only a little of fatty and sugary food. It applies to most
people of all ethnic groups irrespective of their weight. As children less than 2 years
have different nutritional needs, the Eatwell Plate is not applicable to them (Food
Standards Agency 2007). The Eatwell Guide recommends the following:
• Fruits and vegetables—at least five portions a day. Limit fruit juices and
smoothies to no more than 150 ml per day.
• Meals should be based on breads, rice, pasta, potatoes, or other starchy
carbohydrates. Whole grains should be chosen where possible.
• Dairy or diary alternatives (soya drinks or yogurts) should be consumed,
preference should be given to lower-fat and lower-sugar options.
• Beans, pulses, fish, eggs, meat, and other protein should be added to the
diet. Consume at least two portions of fish per week, one of which should
be oily fish such as salmon or mackerel.
• Fats—unsaturated oils and spreads should be chosen and should be con-
sumed in small amounts.
• Saturated fats and sugars should be reduced in the diet.
• Plenty of fluids—consume at least 6–8 cups/glasses of fluid a day.
1.4.5 australian Dietary GuiDelines—eat fOr HealtH

The Australian Dietary Guidelines aim at promoting health and well-being, reduce
the risk of NCDs, and reduce the risk of diet-related conditions (NHMRC 2013a).
These guidelines apply to healthy Australians of all age groups and also to those who
are overweight. It does not apply to people with medical conditions requiring dietary
adjustment, nor to the frail elderly. The five guidelines (NHMRC 2013b) outlined are
• Maintain a healthy weight. Consume calories according to individual need

and burn calories through physical activity.
• Choose nutritious foods from the five food groups and plenty of water.
• Vegetables and legumes/beans
• Fruits
• Grains, mostly whole grains with high fiber content such as bread, rice,
pasta, oats, quinoa, noodles, and barley
• Lean meat and poultry, eggs, fish, and nuts and seeds
• Reduced-fat dairy such as milk, cheese, and yogurt
• Limit the consumption of saturated fats, added sugar, and salt. Low-fat diets
should not be considered in children less than 2 years of age.
• Breast-feed infants; breast-feed exclusively for the first 6 months of life.
• Care for food; store and prepare it safely.
The Australian Dietary Guidelines explain the servings of the food groups to be
consumed according to age and gender, and give examples of daily dietary patterns
for healthful eating and well-being (NHMRC 2013b).
1.5 IMPACT OF FOOD-BASED DIETARY GUIDELINES

ON NON-COMMUNICABLE DISEASES
Researchers have studied the impact of FBDGs on the prevention and control of
NCDs. The association of the dietary guidelines outlined previously with NCDs is
highlighted as follows.
1.5.1 WHO Dietary GuiDelines anD ncDs

The healthy diet indicator (HDI) is a measure based on WHO’s dietary guidelines for
the prevention of NCDs. HDI, which is used to assess adherence to the WHO dietary
guidelines of 1990 (WHO 1990), was originally developed in 1997 (Huijbregts et al.
1997). Later, when WHO revised its guidelines (WHO 2003a), HDI was adapted
accordingly (Berentzen et al. 2013; Stefler et al. 2014).
The Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE)
cohort study measured the association of HDI with all-cause mortality and CVD
specific to a sample of 18,559 Central and Eastern European populations, 45–
69 years of age, without major NCDs at the baseline. HDI had a statistically sig-
nificant inverse association with CVD mortality (hazard ratio [HR] 0.90, 95% CI
0.81–0.99) and mortality due to chronic heart disease (CHD) (HR 0.85, 95% CI
0.74–0.97), and a marginally significant association with all-cause mortality (HR
0.95, 95% CI 0.89–1.00) (Stefler et al. 2014). An analysis of 21,142 randomly selected
adults in the HAPIEE study found that HDI was significantly inversely related to
metabolic syndrome, defined by the ATP III criteria (Grundy et al. 2005), in the
Czech Republic (odds ratio [OR] of MetS for a 10 unit rise in HDI score 0.91, 95% CI
0.83–1.00) and Poland (OR 0.92, 95% CI 0.85–0.99) (Huangfu et al. 2014).
A meta-analysis of 11 cohort studies with 396,391 participants, 60 years or older,
from Europe and the United States showed that adherence to the WHO dietary recom-
mendations can lead to longevity in both men and women: pooled adjusted HR was
0.90 (95% CI 0.87–0.93), 0.89 (95% CI 0.85–0.92), and 0.90 (95% CI 0.85–0.95) for
both genders, males, and females, respectively. According to the authors, this trans-
lates to an increase in life expectancy by 2 years at the age of 60 (Jankovic et al. 2014).
A cross-sectional study of 433 Japanese males measured the association of HDI

with untreated hypertension. It found that low adherence to the WHO dietary guide-
lines was statistically significantly associated to the high prevalence of untreated
hypertension (OR 3.33, 95% 1.39–7.94), after adjusting for age, energy consump-
tion, physical activity, smoking, alcohol drinking, and salt intake (Kanauchi and
Kanauchi 2015).
The Dutch European Prospective Investigation into Cancer and Nutrition
(EPIC-NL), with 35,355 males and females with a mean follow-up of 12.7 years,
explored the relation of adherence to the WHO dietary guidelines with overall can-
cer incidence. It found no association of HDI with overall cancer (HR 0.96, 95% CI
0.89–1.03 in males; HR 1.00, 95% CI 0.96–1.04 in females), smoking-related cancer
(HR 0.94, 95% CI 0.84–1.04 in males; HR 1.00, 95% CI 0.94–1.07 in females), nor
with alcohol-related cancer (HR 1.02, 95% CI 0.87–1.20 in males; HR 1.03, 95% CI
0.98–1.08 in females) (Berentzen et al. 2013).
A British cohort of 33,731 females with a mean follow-up of 9 years could not
find significant association between adherence to the WHO dietary guidelines as
assessed by HDI and risk of breast cancer (Cade et al. 2011).
1.5.2 Dietary GuiDelines fOr americans anD ncDs

Two measures have been developed by researchers to assess diet quality and adher-
ence to DGA. These are the Healthy Eating Index (HEI) (Guenther et al. 2008) and
the Dietary Guidelines Adherence Index (DGAI) (Fogli-Cawley et al. 2006). These
have been revised from time to time following revision of DGA (Guenther et al.
2013; Troy and Jacques 2012).
The Health Professionals Follow-Up Study (HPFS), a cohort of 51,529 U.S. male
doctors aged 40–75 years, assessed the association of HEI, calculated from a vali-
dated food frequency questionnaire (HEI-f) measuring adherence to DGA 1995,
with major chronic diseases (defined as incident CVD [stroke and myocardial infarc-
tion], cancer, and nontrauma-related deaths) in 38,622 participants with a mean fol-
low-up of 8 years (McCullough et al. 2000a). HEI-f had inverse association that was
marginally significant with major chronic diseases (RR 0.89, 95% CI 0.79–1.00) and
statically significant with CVD (RR 0.72, 95% CI 0.60–0.88), while no significant
association with cancer (RR 1.12, 95% CI 0.95–1.31) was observed (McCullough
et al. 2000a).
The Nurses’ Health Study in the United States, a cohort of 121,700 female nurses
aged 30–55 years, analyzed the association of HEI-f to assess adherence to DGA 1995
with major chronic diseases (fatal or nonfatal CVD including stroke and myocardial
infarction, cancer and nontraumatic deaths) in 67,272 females with a mean follow-up
of 12 years (McCullough et al. 2000b). It found no association of HEI-f with major
chronic diseases (RR 0.97, 95% CI 0.89–1.06), neither with CVD (RR 0.86, 95% CI
0.72–1.03) nor with cancer (RR 1.02, 95% CI 0.93–1.12) (McCullough et al. 2000b).
The third phase of the Tehran Lipid and Glucose Study in Iran randomly selected
2540 adults (1384 females and 1120 males) aged 19–70 years and measured their
adherence to DGA 2005 with the help of DGAI 2005. It found that the people more
adherent to DGA 2005 had a low prevalence of MetS risk factors and a significantly
lower prevalence of hyperglycemia, hypertension, and low high-density lipoprotein

(HDL) cholesterol (Hosseini-Esfahani et al. 2010).
The Framingham Heart Study Offspring Cohort measured the association of
DGAI 2005 and MetS risk factors in 3177 adults. Participants more adherent to DGA
2005 had lower waist circumference, triacylglycerol concentration, diastolic and sys-
tolic blood pressure, abdominal adiposity, hyperglycemia, and a lower prevalence of
MetS. These associations of DGA and MetS were more pronounced in those younger
than 55 years of age (Fogli-Cawley et al. 2007).
The Estrogen Replacement and Atherosclerosis Study in the United States studied
the association of adherence to DGA 2005 with atherosclerotic progression in 224
postmenopausal females with already established coronary artery disease (Imamura
et al. 2009). DGAI in which each component was weighted pertaining to its relation
to atherosclerotic progression (wDGAI) was found to be inversely associated to the
narrowing of the coronary arteries (0.049 mm less narrowing with 1 standard devia-
tion [SD] difference in wDGAI, standard error [SE] 0.017, p value 0.004), adjusting
for age, study site, education, smoking, frequency of walking, energy intake, systolic
blood pressure, glucose concentration, self-reported intake of cholesterol-lowering
drugs, and self-reported chest pain (Imamura et al. 2009).
The Southern Community Cohort Study studied the association of HEI 2010 and
HEI 2005 with all-cause and case-specific mortality in low-income populations from
the Southeastern United States, including 50,434 African Americans, 24,054 white
individuals, and 3,084 individuals from other racial/ethnic groups, 40–79 years of
age, followed up for a mean duration of 6.2 years (Yu et al. 2015). The authors
reported that a higher adherence to DGA 2010 was associated with lower risk of
all-cause mortality (HR 0.80, 95% CI 0.73–0.86), CVD mortality (HR 0.81, 95%
CI 0.70–0.94), cancer mortality (HR 0.81, 95% CI 0.69–0.95), and other disease
mortality (HR 0.77, 95% CI, 0.67–0.88), comparing the highest quintile of the HEI
2010 score with the lowest. These significant inverse associations existed even after
adjustment for age, gender, and income. HEI 2005 also depicted significant inverse
association with all-cause mortality in this study population (Yu et al. 2015).
1.5.3 eat Well WitH canaDa’s fOOD GuiDe anD ncDs

Various measures are available to measure adherence to Canada’s Food Guide,
including the Canadian Healthy Eating Index (HEI-C or CHEI) (Nkondjock and
Ghadirian 2007; Woodruff et al. 2008), adapted from the American HEI to suit
to the dietary recommendations by Canada’s Food Guide, and the Canada’s Food
Guide (CFG) index (Hajna et al. 2012).
A cross-sectional survey conducted in school settings in the Niagara region
(Ontario, Canada) studied the association of adherence to Canada’s Food Guide as
measured by the CFG index and anthropometric measures in 1570 children (782 girls
and 788 boys) with a mean age of 12.4 years (Hajna et al. 2012). The researchers found
a significant inverse association of the CFG index with waist-to-height ratio (β −0·001,
95% CI −0·002, −0·0004), waist-to-hip ratio (β −0·001, 95% CI −0·002, −0·001), and
waist girth (β −0·18, 95% CI −0·30, −0·07) in girls (Hajna et al. 2012). No significant
association was observed in boys.
A case control study among 80 French Canadian families—with 250 people com-
posed of 89 BRCA gene carriers who had breast cancer (cases), 48 BRCA gene car-
riers without breast cancer (control 1), and 46 participants not carrying the BRCA
gene and not having breast cancer (control 2)—studied the association of adherence
to Canada’s Food Guide measured by CHEI with the risk of developing breast cancer.
It showed a significant inverse relationship between CHEI and BRCA-associated
breast cancer risk (OR 0.18, 95% CI 0.05–0.68, p value .006 for trend) when compar-
ing the highest tertile of CHEI with the lowest tertile, controlling for age, physical
activity, and total energy intake (Nkondjock and Ghadirian 2007).
The data from 33,664 respondents from the Canadian Community Health
Survey—Nutrition showed that CHEI was significantly higher in nonsmokers com-
pared with smokers, lower in people consuming alcohol, and had a statistically sig-
nificant positive association with the level of physical activity (Garriguet 2009).
1.5.4 tHe eatWell GuiDe anD ncDs

Data on the association of adherence with the Eatwell Guide (previously Eatwell
Plate) and NCDs and its risk factors is scarce. This may be due to the fact that
very few people strictly adhere to the consumption of all the five food groups in the
proportions recommended by the Eatwell Guide. An analysis of 807 adults aged
19–64 years, included in the National Diet and Nutrition Survey (NDNS) rolling
program, showed that only 4% of them adhered to the five dietary targets of the
Eatwell Guide, and with the exception of protein intake, 51% did not follow any of
the recommendations (Harland et al. 2012). Those who achieved the targets for fats,
saturated fatty acids, and fruits and vegetables intake (12%) were more likely to
be nonsmokers (a significant difference); no statistically significant difference was
observed in terms of waist circumference or body mass index (BMI) in this group
compared with people who did not achieve these three targets (Harland et al. 2012).
While working out the cost of a healthy diet, using data from the UK Women’s
Cohort Study, researchers from the University of Leeds in the United Kingdom devel-
oped a healthiness index, an increasing score of which shows increased adherence to
the food groups of the Eatwell Guide (Morris et al. 2014). The healthiness index score
was positively associated with physical activity levels. It also showed a significant asso-
ciation with BMI: the lowest BMI with the vegetarian dietary pattern and the highest
with the traditional meat, chips, and pudding dietary pattern (Morris et al. 2014).
1.5.5 australian Dietary GuiDelines anD ncDs

Adherence to the Australian Dietary Guidelines in adults can be measured by a
dietary guideline index (DGI), a higher value of which shows greater adherence
(McNaughton et al. 2008). The Dietary Guideline Index for Children and Adolescents
(DGI-CA) is a tool to measure adherence to the Australian Dietary Guidelines in
children aged 4–16 years (Golley et al. 2011).
Data from the Australian National Nutritional Survey (ANNS) 1995, including
10,851 adults ≥19 years of age, was utilized to explore the association between adher-
ence to the Australian Dietary Guidelines and health status, including blood pressure,
smoking status, physical activity, and BMI (McNaughton et al. 2008). It found that
DGI was positively associated to physical activity levels. Higher DGI scores were
inversely related to systolic and diastolic blood pressure. There were more smokers and
ex-smokers among adults with lower DGI scores than those with higher DGI scores.
The Australian National Children’s Nutrition and Physical Activity Survey 2007,
which included 3416 children and adolescents aged 4–16 years, studied the relation-
ship of DGI-CA with anthropometric measures (Golley et al. 2011). Researchers
observed a weak positive association between DGI-CA and BMI and waist circum-
ference z-scores in children aged 4–10 years and 12–16 years.
Analyses of 7441 males and females aged ≥25 years who participated in the
Australian Diabetes, Obesity and Lifestyle (AusDiab) study showed the association
between DGI and NCDs (McNaughton et al. 2009). It was found that less adherence
to the Australian Dietary Guidelines (low DGI scores) was positively associated with
waist circumference in males. DGI scores were inversely related to systolic and dia-
stolic blood pressure in males, systolic blood pressure in females, and total choles-
terol, triglycerides, and fasting blood sugar level in both genders.
1.6 DIETARY PATTERNS TO PREVENT NON-

COMMUNICABLE DISEASES
“Dietary pattern” refers to the pattern or combination in which nutrients or food
groups are consumed. It represents a broader picture of food consumption. As nutri-
ents interact with one another to complement or inhibit each other in the foods we
eat, our dietary pattern is more predictive of the risk of NCDs (Hu 2002). Dietary
patterns can be predefined, such as the summation of recommendations in the dietary
guidelines mentioned previously or specific food models historically linked to health
(e.g., the Mediterranean diet), or can be extracted from the population’s eating behav-
iors by statistical techniques such as factor analysis, cluster analysis, and reduced
rank regression (Tucker 2010). Two famous dietary patterns and their associations
with NCDs are elaborated as follows.
1.6.1 meDiterranean Diet

The Mediterranean diet is characterized by an abundance of plant foods (vegetables,
fruits, breads, cereals, beans, nuts, and seeds); olive oil; fresh fruits consumed as
desserts; dairy products, principally yogurt and cheese; fish and poultry in moderate
amounts; red meat in low amounts; zero to four eggs weekly; and wine in low-to-
moderate amounts, normally with meals (Willett et al. 1995). The Mediterranean
diet has been shown to reduce overall mortality, decrease the risk of CVD incidence
and mortality, reduce cancer incidence and mortality, and reduce neurodegenerative
diseases (Sofi et al. 2010). It also reduces the risk of stroke, depression, and cognitive
impairment (Psaltopoulou et al. 2013).
1.6.2 Dietary apprOacHes tO stOp HypertensiOn (DasH)

The DASH diet is rich in fruits and juices, vegetables, grains, and low-fat dairy prod-
ucts; small amounts of meat, poultry and fish; nuts, seeds, and legumes; and very
small amounts of sugar and snacks (Appel et al. 1997). The DASH diet plays a role
in the reduction of systolic and diastolic blood pressure (Appel et al. 1997) and the
reduction of the risk of CVD, chronic heart disease, stroke, and heart failure (Salehi-
Abargouei et al. 2013). It has also been shown to reduce the risk of type 2 diabetes
in whites (Liese et al. 2009).
1.7 HOME REMEDIES TO PREVENT NON-

COMMUNICABLE DISEASES
Many home remedies have been suggested to prevent individual NCDs. Precaution
should be taken due to safety concerns as food ingredients, like medicines, interact
with each other to inhibit or exacerbate each other’s effects and disease conditions.
Also, NCDs tend to occur in clusters; for example, a person with type 2 diabetes may
also have hypertension, and hence may not be able to use the remedy for one disease
that might adversely affect the other. Evidence regarding home remedies is scarce
and needs more rigorous research, taking safety concerns into consideration. Some
scientifically proven remedies are as follows.
1.7.1 remeDies fOr Diabetes

The following foods/food ingredients have been shown to reduce blood sugar levels:
• Cinnamon has been found to have a modest lowering effect on blood sugar
(Pham et al. 2007).
• Ginger, administrated at 2 g/day for at least 12 weeks, has been shown to
decrease fasting blood sugar and hemoglobin A1c levels compared with
placebo in type 2 diabetes patients (Khandouzi et al. 2015).
• Green tea extract consisting of 544 mg of polyphenols (456 mg of cate-
chins) taken daily for a duration of at least 2 months can reduce hemoglobin
A1c levels in borderline diabetics aged 32–73 years (Fukino et al. 2008).
• Bitter gourd, also known as bitter melon or karla, has been shown to
reduce blood sugar levels in rats without causing nephrotoxicity and hepa-
totoxicity (Virdi et al. 2003). In a concentration of at least 2000 mg/day for
4 weeks, it can reduce the levels of fructosamine in newly diagnosed type 2
diabetes patients compared with 1000 mg/day of metformin (Fuangchan
et al. 2011).
1.7.2 remeDies fOr HypertensiOn

The following food/food ingredients have been reported to reduce blood pressure
levels:
• Garlic: A meta-analysis of 11 studies has reported that garlic significantly

reduces systolic blood pressure compared with placebo; its effect on the
reduction of diastolic blood pressure is marginally significant (Ried et al.
2008).
• Dark chocolate: A meta-analysis of 13 studies showed that cocoa chocolate

reduces systolic and diastolic blood pressure in prehypertensive and hyper-
tensive patients, having no significant lowering effect on blood pressure in
normotensive subjects (Ried et al. 2010).
• Tea: Green tea and British tea have been shown to reduce the risk of hyper-
tension in Singaporean Chinese adults ≥40 years of age (Li et al. 2015).
1.7.3 remeDies fOr HypercHOlesterOlemia

Research shows evidence of the following foods to be effective in the lowering of
serum lipid levels:
• Garlic: A meta-analysis of 39 clinical trials indicates that if people with

high total cholesterol level (>200 mg/dL) use garlic for more than 2 months,
it reduces total serum cholesterol by 17 ± 6 mg/dL and low-density lipopro-
tein (LDL) by 9 ± 6 mg/dL (Ried et al. 2013).
• Coriander: The intake of two tablets of coriander seed powder per day for
6 weeks has been shown to significantly lower serum lipid levels in type 2
diabetes patients (Parsaeyan 2012).
• Cinnamon: Meta-analysis of 10 trials shows that the consumption of 0.12–
6.0 g of cinnamon per day for 4–18 weeks can reduce total cholesterol by
15.6 mg/dL, LDL by 9.42 mg/dL, and triglycerides by 29.59 mg/dL and
increases high-density lipoprotein (HDL) by 1.66 mh/dL in patients with
type 2 diabetes (Allen et al. 2013).
• Oatmeal: 100 g of instant oatmeal per day for 6 weeks has been found to be
effective in reducing total cholesterol, LDL, and triglyceride, and increas-
ing HDL compared with those consuming 100 g of wheat flour–based noo-
dles everyday for 6 weeks (Zhang et al. 2012).
• Onions: Researchers have reported a marked decrease in serum triglyceride
levels after consumption of 200 mL/day of onion extract, corresponding to
500 g of onions/day for 8 weeks (Nam et al. 2007).
1.7.4 remeDies fOr carDiOvascular Disease (Heart Disease anD strOKe)

Studies have reported the following to be effective in the prevention of cardiovascu-
lar diseases:
• Pomegranate: Due to its antioxidant properties, pomegranate has been

found to attenuate atherosclerosis and cardiovascular events related to it.
The consumption of 240 mL of pomegranate juice per day for 1 year can
increase arterial elasticity (Aviram and Rosenblat 2013).
• Aged garlic extract: 4 mL/day of aged garlic extract for 1 year was found to
decrease the rate of progression of coronary artery calcification compared
with the placebo (Budoff et al. 2004).
• Vinegar: In a large cohort study of women it was found that those who con-
sumed vinegar and oil salad dressing ≥5–6 times/week had a lower risk of
fatal ischemic heart disease compared with those who rarely consumed it
(RR 0.46, 95% CI 0.27–0.76) (Hu et al. 1999).
• Fish: The Health Professionals Follow-Up Study in men reported that eat-
ing fish once a month or more decreases the risk of ischemic stroke (He
et al. 2002). A meta-analysis of cohort studies found that increased fish
consumption is inversely related to the risk of stroke, especially ischemic
stroke (He et al. 2004).
• Ginger: Pharmacologists have suggested that ginger extract can reduce the
risk of stroke (Chang et al. 2011).
1.7.5 remeDies fOr Obesity

Obesity, one of the risk factors for NCDs, can be prevented and controlled by the
following remedies:
• Lemons: Lemon phenol has been shown to suppress weight gain and body
fat accumulation in animal models (Fukuchi et al. 2008). The lemon detox
program has been reported to reduce body fat in premenopausal Korean
women (Kim et al. 2015).
• Green tea: 379 mg of green tea extract daily for 3 months has been shown
to decrease waist circumference and BMI in male and female obese patients
30–60 years of age (Suliburska et al. 2012).
• Kanuka honey with cinnamon, chromium, and magnesium: In a random-
ized crossover trial, it was found that a kanuka honey formula with cinna-
mon, chromium, and magnesium at a dose of 53.5 g for 40 days decreased
weight significantly by an average of 2.2 kg compared with kanuka honey
alone in type 2 diabetes patients (Whitfield et al. 2015). Some types of
honey contain toxic substances and hence precaution should be taken to
avoid these (Islam et al. 2014).
1.7.6 remeDies fOr astHma

Some natural remedies for asthma in scientific literature are as follows:
• Licorice root and turmeric root: In patients with bronchial asthma, licorice
root and turmeric root combined have been found to reduce leukotriene
C4, nitric oxide, and malondialdehyde significantly compared with those
receiving placebo (Houssen et al. 2010).
• Caffeine (contained in coffee and other beverages): A systematic Cochrane
review of six randomized controlled trials reported that even low doses of
caffeine (5 mg/kg body weight) can improve lung functions in asthmatic
patients for up to 4 h (Welsh et al. 2010).
• Fish oil: Fish oil is rich in polyunsaturated fatty acids. The consumption of
fish oil from the 30th week of gestation to pregnancy can reduce the risk of
asthma in children by 63% and of allergic asthma by 87% compared with
olive oil intake during the same period in pregnancy (Olsen et al. 2008).
1.7.7 remeDies fOr cancers

The following have been researched as a part of healthful eating for the prevention
of cancers:
• Green tea: Green tea extract has been shown to inhibit tumor development
in animal models at sites including the skin, oral cavity, esophagus, lung,
stomach, intestine, colon, mammary gland, bladder, and prostate (Yang and
Wang 2010). Green tea consumption has also been found to decrease over-
all cancer incidences in a population cohort study in Japan with 8552 par-
ticipants (Nakachi et al. 2000).
• Olive oil: Researchers from Italy, through a large case control study, have
reported that increased olive oil consumption is inversely related to the risk
of breast cancer in a dose–response way (La Vecchia et al. 1995).
• Tomatoes: A meta-analysis of observational studies has shown that raw and
cooked tomatoes can reduce the risks of prostate cancer (Etminan et al.
2004).
• Grapes: The resveratrol present in grapes can reduce the risk of breast can-
cer in women (Levi et al. 2005).
Hence, a variety of home remedies in the form of foods can be used for the pre-
vention and control of NCDs.
1.8 NUTRITIONAL COUNSELING FOR

NON-COMMUNICABLE DISEASES
Nutritional counseling starts with asking the patient/client about the symptoms, such
as heaviness in the head, headache, blurred vision, increased thirst, frequent urina-
tion, vertigo, numbness in the extremities, and the like in patients with hypertension,
diabetes, or CVD. Asthma presents with a cough, especially at night, during exer-
cise, or when laughing, shortness of breath, chest tightening, and wheezing. COPD
usually presents with a chronic cough that produces a lot of mucus, often referred
to as a smoker’s cough. Cancers present with lumps, weight loss, tiredness, blood in
stools or any orifice of the body, pale skin, and localized symptoms depending on
the site involved. Mental health disorders such as depression present with a lack of
interest in daily activities, a sense of hopelessness, changes in eating and sleeping
patterns, anger or irritability, and reckless behavior. Sometimes no symptom might
be present and an NCD might be detected as an incidental finding.
Health professionals, including medical students, nurses, doctors, nutritionists,
and community health workers should advise their clients and the general population
to be screened for NCDs. Some routine tests that should be performed in screening
for NCDs are
• Weight and height: BMI should be calculated by dividing weight in kg by

height in m2. Obesity should be identified by the following cutoff values, as
suggested by WHO (WHO 2015a):
Another random document with
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I was fortunate enough to get some interesting sketches of the cavalry crossing
the river under fire (see page 238)
To face page 246
It was just the sort of night to engender depth of thought, and we

were both in poetic vein, and soliloquizing on the iniquity of warfare
while nature was always so beautiful, when the loud report of a gun
rang out in the stillness of the night and brought us back to stern
reality. It was so close that had it not been for the wall in front of us
we could have seen where it came from.
There were a few seconds of dead silence, and then there broke
out the most terrific fusillade it would be possible to imagine;
machine gun and rifle fire mixed up in one long hellish tatoo; whilst,
as though to punctuate the unearthly music, at intervals one heard
the isolated bang of trench mortars and the sharp detonation of
hand-grenades.
The extraordinary suddenness of it all was so remarkable that it
was as if it had been timed to commence at a certain minute.
All quietude was now at an end, and although the firing varied in
intensity it never ceased. At moments there would be a lull, and it
appeared as though about to die out, and then it would recommence
with renewed violence.
It could certainly not have been more than a few hundred yards
away, so near in fact that now and again one heard shouts and yells,
and several stray bullets actually struck the upper part of the hotel.
The fighting was still continuing when our companions returned.
They told us that they had found out that this was the
commencement of the expected counter-attack, but that so far it was
not developing to any serious extent, though what the night might
bring forth might alter matters considerably; anyhow, the Italians
were not being taken unawares as the Austrians were discovering.
This was interesting news, and made one feel that we were not
spending the night in Gorizia for nothing, and that we might have an
exciting time before the morning. For the moment, however, since
there was nothing to be seen, we thought the best thing to do was to
lie down and have a rest for an hour or so.
Our companions had had an extra bit of luck whilst they were out,
in the shape of a whole candle which had been given them, so we
ran no further risk of being left in darkness.
Of course we all lay down in our clothes, boots and all, ready for
any emergency; when big “counter-attacks” are on the tapis it is as
well to take no chances.
The beds looked very comfortable, and had clean sheets and
pillow cases, but although I was very tired, I could not somehow get
to sleep for a long while. I felt a sensation of discomfort which was
almost unbearable, and had it not been that I did not wish to disturb
my companions, I should have got up and walked about the room.
It is not pleasant lying on a soft bed with all your clothes on,
including field boots, on a hot night, and I put my restlessness down
to this. However, I managed to doze off fitfully after a while, though
for what appeared to be hours I was being continually woke up by
what I took to be the noise made by men wearing heavy boots
running down the stone stairs and slamming the street door.
This at last woke me completely, when I realized that the noise
came from the trenches, and was caused by the rattle of machine
guns and rifles and the booming of mortars. I managed to get to
sleep after this; the monotony of the noise ended by exercising a
sedative effect on my nerves.
When I awoke it was quite early, but to my surprise I had the
rooms to myself, my companions having already gone out. I found
them downstairs, and learned that they had passed the night seated
in the car; they had decided that anything was preferable to the
“comfortable” beds of the hotel.
I then comprehended the cause of my “restlessness.” It was a
striking instance of “Where ignorance is bliss,” etc., for I had
managed to have a good sleep in spite of it all.
Gorizia, in the early morning sunshine, looked delightful, and
everybody we met seemed bright and cheerful like the weather; and
quite indifferent to the bombardment which still continued at
intervals. An officer told me that one often ended by trying mentally
to calculate what all this senseless waste of ammunition was costing
per hour.
Nothing had come of the counter-attack, except to give the Italians
a chance of further consolidating their front here, and as there
appeared no likelihood of anything important happening that day we
arranged to return to Udine forthwith.
Instead, however, of going via Grafenberg, we took the road which
follows the left bank of the Isonzo and goes through Savogna,
Sdraussina, and Sagrado, as Bacci was anxious to shake hands with
a doctor friend of his who was with a field hospital somewhere this
way.
This gave us an opportunity of seeing the wonderful cantonments
of the troops waiting to advance on the Carso.
From Savogna right on to Sagrado, a distance of, roughly
speaking, six miles, was one continuous encampment on either side
of the road. A whole army corps must have been gathered here,
cavalry, artillery, infantry, motor transport, cyclists and motor
ambulances, in endless encampments.
It was as interesting a panorama of military activity as I had seen
anywhere on the Italian Front, and was alone worth coming here to
see. The troops were fully protected from shell fire, as the road all
the way is sheltered by Monte San Michele and the adjacent hills,
which tower above the route, so it was possible to construct
permanent huts on the slopes of the hill, and also to take advantage
of the many caves which are a feature of this region, to quarter the
men in.
Monte San Michele, as I shall describe in my next chapter, was
captured simultaneously with Gorizia, and one saw from here the
formidable series of trenches the Italians, with a courage which will
pass into history, constructed and gradually pushed forward up the
hill, under the fire of the Austrian guns, until the final assault, when
the whole position was taken.
Unless this operation had been successful, no troops would have
been here now, as this road was, prior to the victory, a “No man’s
land.”
One saw every phase of soldier life along this interesting road, and
one could not fail to be deeply impressed by the extraordinary
“completeness,” I can think of no other word, of the arrangements on
all sides, and the business-like air of readiness to go anywhere at a
moment’s notice of every unit. Certain it is that the Austrians had no
conception of what was ready for them behind these hills.
It was like looking for a needle in a bundle of hay to find any
particular field ambulance amongst such a multitude, and the more
specially as these ambulance stations are continually being shifted
as necessity arises. So, after trying for some time and going
backwards and forwards up and down the road in the vicinity of
Sdraussina, where we hoped to come across it, we had to give it up
as a bad job.
A somewhat striking feature of this vast camping area were the
military cemeteries, where hundreds of soldiers’ graves were
crowded together in serried lines. Of course there is no sentiment in
warfare, and soldiers live in the midst of death, but it struck me as
somewhat unnecessary putting this burial ground alongside a road
so frequently traversed by the troops when there is so much space
elsewhere.
The Isonzo, which here is a broad, pelucid and swiftly running
stream much divided up with gravel islets, presented a scene of
much animation; hundreds of soldiers were taking advantage of a
few hours peaceful interregnum to have a bath and do a day’s
washing.
We continued on past Sagrado, crossing the river lower down by a
newly-placed pontoon bridge below San Pietro dell Isonzo. Here
there was no regular road, but merely a rough track leading to the
river, and it was only by the skilfulness of our chauffeur friend that
the car was got through at all without accident.
Round about here were many Austrian trenches that had been
hastily abandoned, so we had a good opportunity for examining
them.
They struck me as being constructed on the most approved
principles, and were finished in elaborate style with wicker work
lining to the walls and along the floors. None of these trenches,
however, had ever been used, so it was only possible to hazard
conjectures as to their utility.
Just here we met the cavalry division advancing dismounted in
Indian file. A fine lot of well-equipped men with very serviceable
looking horses.
It may be of interest to mention here that most of the Italian
cavalry officers who, as is well known, are magnificent horsemen,
ride thoroughbreds of Irish descent.
When we got back to Udine we learned that Gorizia was being
heavily shelled from Monte Santo, so it looked as if the Austrians
were attempting to destroy it by degrees, as the Huns are doing with
Rheims in revenge for losing it.
CHAPTER XVIII
Big operations on the Carso—General optimism—No risks taken—

Great changes brought about by the victory—A trip to the new lines
—Gradisca and Sagrado—A walk round Gradisca—Monte San
Michele—Sagrado—Disappearance of Austrian aeroplanes and
observation balloons—Position of Italian “drachen” as compared with
French—On the road to Doberdo—Moral of troops—Like at a picnic
—A regiment on its way to the trenches—The Italian a “thinker”—
Noticeable absence of smoking—My first impression of the Carso—
Nature in its most savage mood—The Brighton downs covered with
rocks—Incessant thunder of guns—Doberdo hottest corner of the
Carso—No troops—Stroll through ruins of street—Ready to make a
bolt—A fine view—The Austrian trenches—Shallow furrows—Awful
condition of trenches—Grim and barbarous devices—Austrian
infamies—Iron-topped bludgeons, poisoned cigarettes, etc.—Under
fire—A dash for a dug-out—The imperturbable Carabinieri—Like a
thunderbolt—A little incident—Brilliant wit—The limit of patience—
The Italian batteries open fire—No liberties to be taken—On the way
back—Effect of the heavy firing—Motor ambulances—Magnified
effect of shell fire on Carso—Rock splinters—Terrible wounds.
CHAPTER XVIII
All the big operations were now taking place on the Carso, and
scarcely a day passed without news of progress in that direction.
The official communiqués were, therefore, of the most cheery
description, and their cheerfulness was reflected all over the town.
Everybody was optimistic, and one was continually hearing
rumours of the surprises in store for the Austrians during the next
few weeks.
That many of these rumours materialised was undeniable, but it
was soon realised that the conquest of the Carso is a very tough job,
and will require a lot of patience and necessitate much hard fighting
for every yard of ground; which obviously also meant much great
sacrifice of gallant lives unless the advance is carried out
methodically and without undue haste. In this respect General
Cadorna may be relied on, and also to take no risks of failure.
The Carso, therefore, presented the chief point of interest after the
fall of Gorizia, as every advance there means progress towards the
main objective, Trieste. Scarcely a day passed now without a car
from the Censorship going in the direction of the fighting line. I was
therefore constantly able to make excursions, and was gradually
filling up my sketch book with interesting subjects.
I may mention that no difficulty whatever was put in my way, and
so long as I could find a car to take me, I was at liberty to go where I
chose and stay away as long as I liked; it would have been
impossible to have been treated with greater courtesy and regard,
and I shall never be sufficiently grateful for it.
The changes brought about by the victory and the brilliant strategy
of General Cadorna were so widespread that they would have been
unbelievable if one had not seen it all for oneself a few days after the
battle. In fact, it was almost at once that the results were
discernable. You realized it yourself as soon as you reached certain
well-known points which had hitherto been inside the danger zone.
The sense of relief at being able to move about freely and without
having to keep your ears cocked all the time, listening for shells
coming over, was very pleasant.
With a little party of confrères I motored out to the new Italian lines
within a few hours of their re-adjustment.
Most of the places we went through in order to get close up to the
fighting had only become accessible since the fall of Gorizia, whilst
others, as for instance Sagrado, and Gradisca, were now almost
peaceful after months of constant bombardment.
Gradisca interested me very particularly, as I had lively
recollections of the flying visit I had paid to it the preceding year
when, as I have described in a previous chapter, our cars to get
there had to run the gauntlet of the fire of the batteries on Monte San
Michele.
Now the Austrian guns were well out of range, and the little town
was quite delightfully peaceful in comparison, and you could wander
as you pleased under the big trees in the park, round the bandstand,
and fancy you were waiting for the music to commence; or through
the grass-grown, deserted streets and take note of the wanton
damage done by the Austrians to their own property.
Monte San Michele, at the back of the town, was now but a very
ordinary and unpicturesque hill in the distance, and from the military
standpoint no longer of any importance whatever.
The town itself was rapidly being occupied, and inhabited; several
of the big buildings were being transformed into first line hospitals,
and the General of the division had already fixed up his
headquarters here.
All these changes conveyed more to me than any communiqués
had done; I saw for myself what had been accomplished since I was
last there, and there was no doubting the evidence of my own eyes.
At Sagrado, on the lower Isonzo, a similar condition of affairs
existed; but here it was my first visit, as it was inaccessible the
previous year. A one-time beautiful little town, I should say, typically
Austrian, it is true, but nevertheless from all accounts a very pleasant
place to live in.
All the river frontage at the present time is nothing but a shapeless
heap of ruins; the magnificent bridge and the elaborate system of
locks are irreparably damaged.
Fortunately a considerable portion of the town escaped damage
by the shells, and this was now crowded with troops. Yet, barely a
week before, it was practically uninhabitable except at enormous
risk.
Not the least significant of changes one noticed on the way to the
lines was the complete disappearance of Austrian aeroplanes. There
had been a few over Gorizia on the great day, but here there
appeared to be none at all, and the “Caproni” now held undisputed
sway in the air.
As to the observation balloons, the “Drachen,” they had all along
been noticeable by their absence; as a matter of fact, I don’t recollect
ever seeing any of these aerial look-outs over the Austrian lines at
any time, the reason for this deficiency being perhaps that they were
not found to sufficiently fulfil their purpose.
The Italians evidently thought differently, and their “drachen” were
to be seen everywhere, and along this front in particular.
In this connection I could not fail to note how much further behind
the lines they are stationed here as compared with their usual
position on the French Front. There may be some very simple
explanation of this, but it appeared to me as a layman that they lost a
lot of their utility by being always so distant from the Austrian lines.
We were bound for Doberdo, the village on the Carso that was
being mentioned every day in the communiqués. From Sagrado we
went by way of Fogliano, the road skirting the railway most of the
way. We were now on the confines of a region of universal havoc
and desolation.
War had swept across the country-side with the devastating effect
of a prairie fire. Nothing had escaped it. All the villages we passed
through were only names now, and nothing remained but ruins to
indicate where they had been; of inhabitants, of course, there was
not so much as a trace.
In spite, however, of the general devastation, troops were to be
seen everywhere, and numbers were camping even among the ruins
with the utmost unconcern; in fact, you couldn’t fail to notice that the
moral of the men was wonderful, and that they seemed as cheerful
as if at a picnic.
The Italian soldier struck me as having a happy faculty for making
the best of everything, so hardships do not seem to trouble him, and
the equivalent of “grousing” is, as I have already stated, an unknown
word in his vocabulary.
This was particularly observable here, though, of course, the
glorious weather may have had some thing to do with it; but the fact
remained that they were supporting exceptional hardships with a
stoicism that was quite remarkable, I thought.
The only difficulty the officers experienced was in getting them to advance with
caution (see page 273)
To face page 258
Along the road at one place we passed a regiment halted on its

way to the trenches. The men, all apparently very young, were sitting
or lying about on either side of the road. We had to slow down in
order to get past, so I had an opportunity to take a mental note of the
scene.
It was the more interesting to me as I knew that these men were
fully aware that in a couple of hours or so they would be in the thick
of the hottest fighting. Nevertheless, I could see no trace of any
nervous excitement, though the guns were booming in the distance;
they might have all been case-hardened old warriors, so far as you
could outwardly judge from their stolid demeanour.
Many were taking advantage of the halt to snatch a few minutes
sleep, whilst others were writing letters. There was very little of the
grouping together or chatting one would have expected to see. The
Italian of to-day is becoming a “thinker.”
But what struck me perhaps most of all was the quite noticeable
absence of smoking. Probably every other man in an English or
French regiment under the circumstances would have had a pipe or
a cigarette in his mouth, and would have considered the hardships
increased tenfold if he hadn’t been able to enjoy a smoke. Here the
men in the field don’t seem to look upon tobacco as an absolute
necessity; so far as I could judge; and one seldom sees them
smoking on the march, like the French poilu, or the English Tommy.
About a mile and a half past Fogliano we took a road that went by
an archway under the railway embankment, and brought us a few
hundred yards on to a heap of rubble that had once been a little
village named Redipuglia, if I remember rightly.
On our right was the much talked of Monte Cosich, a hill that had
been the scene of innumerable desperate fights, and facing us was
the commencement of the Carso.
I shall never forget my first impression of this shell-swept waste;
for what I had already seen of it was only from a distance, and
though through powerful binoculars, one was not really able to form
any conception of what it is like in reality. I had been prepared to see
Nature in its most savage mood, but the scene before me was so
terrible in its utter desolation as to inspire a sense of awe.
Imagine the Brighton downs covered from end to end with
colourless stones and rock instead of turf; no sign of vegetation
anywhere; ribbed in every direction with trenches protected by low,
sand-bagged walls; bristling with wire entanglements, and
everywhere pitted with huge shell-craters.
Even then you have only a faint conception of what war means on
the Carso, and the awful character of the task the Italians have had
before them for the past eighteen months.
There is certainly nothing to compare with it on any of the other
Fronts; for here nature appears to have connived at the efforts of
man, and every hollow and every hummock form as it were potential
bastions. The incessant thunder of the guns in the distance seemed,
as it were, to be in keeping with the utter desolation of the scene.
The road gradually ascended for about a couple of miles, till we at
last arrived on the plateau of Doberdo, and close to all that remains
of the village.
Fighting was going on only a short distance away in the direction
of Nova Vas, so we were under fire here, as shrapnel was bursting
all round the village, and at times in amongst the ruins as well.
Doberdo was then reputed to be the hottest corner of the Carso,
and one literally took one’s life into one’s hands when going there.
But it was, nevertheless, so absorbingly interesting that it
compensated for the risk one was taking, and there was a weird sort
of fascination in listening to the booming of the guns and watching
the shells bursting.
There were no troops here, only some officers and a few soldiers,
for the village was far too much exposed for actual occupation; but it
was on the road to the trenches, so it was to a certain extent
“occupied” for the moment. There was also a Field Dressing Station,
where a few devoted Red Cross men were working under conditions
of ever-present peril.
Every yard almost of the ground had been shelled, and it was
pock-marked with craters of all sizes. In fact, the wonder was that
even a particle of the village was left standing.
We left the car under the shelter of the remnant of a wall, and
strolled along what had evidently been the main street; but it was not
altogether what one would term a pleasant stroll, for the stench of
unburied dead was in the air, and horrible sights faced you on all
sides.
We proceeded very gingerly and ready to make a bolt for cover
whenever we heard the warning screech of an approaching shell.
There was really not more to see at one end of the street than the
other, but one feels just a little bit restless standing still under fire, so
we started off on a look round.
At the end of the village there was a fine view looking towards
Oppachiasella on the left, and Monte Cosich and the road by which
we had come up on the right. One was, therefore, able to judge for
oneself what fighting in this arid wilderness means.
You had the impression of gazing on the scene of an earthquake,
so little semblance to anything recognizable was there in sight. Here
and there a black and gaping hole on the hillside indicated the
entrance to one of the famous Carso caves, which are so
characteristic a feature of the region.
What was left of the Austrian trenches after the Italian artillery had
done with them was sufficient to convey an idea of the awful time
their occupants must have passed through; you had the idea that
any human beings who survived after being in such an inferno
deserved peace and quietude to the end of their days.
In many cases these trenches were only a few yards apart, so the
courage necessary to take them by direct assault must have been
extraordinary. One could see the dead lying in between them. The
peculiar rock formation of the whole area precludes any making of
actual trenches except with enormous labour; to obviate this shallow
furrows are formed and protected with stone parapets, finished with
sand-bags (or rather bags of small stones, as, of course, there is no
sand here).
The condition of these parapets and “trenches” after continual
pounding with high explosives may be left to the imagination. A
gruesome detail must be mentioned: so difficult is it to excavate the
ground here that the dead are not being “buried” but simply covered
over with stones.
Many grim and barbarous devices for causing death in the most
horrible and unexpected form were discovered in the Austrian
trenches here on the Doberdo plateau, and the mere sight of them
was often sufficient to rouse the Italian soldiers to a pitch of frenzy.
One is apt to forget at times that the Austrian is by nature quite as
callous and inhuman a creature as the Hun, but here one had ample
reminder of what he is capable of when he realises that he is up
against a better man than himself.
It is of historic interest in this connection to recount a few of the
new infamies these apt disciples of the Hun have introduced: the
poisoned cigarettes and shaving brushes left in the trenches; the
bombs under dead bodies; explosive bullets; baccilli of typhoid
dropped from aeroplanes; and the iron-topped bludgeons.
The latter instrument of torture, for it is nothing less, is quite one of
the latest devices of Austrian “Kultur” for putting a wounded
adversary to death. The iron head is studded with jagged nails, and
has a long spike let into the end. No South Sea cannibal ever
devised a more awful weapon.
I was lucky enough to get one and brought it back to London,
where it makes a fitting pendant in my studio to another barbaric
“souvenir” of the war, one of the Hun “proclamations” put on the
walls in Rheims before the battle of the Marne.
However, to revert to Doberdo. We stood for some little while at
the end of the village endeavouring to grasp the import of the various
strategic points we could discern from here, when all of a sudden the
Austrian batteries started a furious bombardment in our direction
with apparently no object whatever, except perhaps that our car had
been seen, and they hoped to stop any further movement on the
road.
We could see shell after shell bursting with wonderful precision on
either side, and in the centre, of the road. Then they must have
spotted our little group, for the range was shortened and we found
ourselves apparently receiving the polite attention of all the guns.
My two companions made a dash for a sort of dug-out which was
close by, and I was about to follow them when I happened to glance
round and saw a carabinieri standing right out in the road a few
yards away, as imperturbably as though it was a slight shower of rain
passing over. He was looking in my direction, and I fancied I caught
a twinkle of amusement in his eyes at my hurry.
In an instant the thought flashed through my mind: if it doesn’t
matter to him remaining in the open why should it to me? So I
climbed back on to the road, trying the while to appear as though I
had never really intended to take shelter.
I had scarcely regained my feet when I heard the wail of an
approaching shell, and then the peculiar and unmistakable sound of
a big shrapnel about to burst overhead.
I only just had time to put my arm up to protect my eyes when it
exploded. It was like a thunderbolt, and so close that I heard pieces
of metal strike the ground all round me.
A moment elapsed and footsteps approached. Turning round I saw
a soldier I had not noticed before; he was fumbling with something in
his hands which appeared too hot to hold easily.
Then to my astonishment he said to me with a laugh, and in
perfect English: “I think this was addressed to you, Sir,” at the same
time handing me a jagged little piece of shell.
I was so taken aback at hearing English spoken just at that
particular moment that all I found to say to him in reply to his brilliant
wit was the idiotic commonplace “Thanks very much,” as I took the
interesting fragment.
It occurred to me afterwards that he must have thought me a very
taciturn and phlegmatic Englishman, but I had just had a very narrow
escape and felt a bit shaken up, as may be imagined, so was
scarcely in the mood for conversational effort.
We had hoped to have a look at the trenches round the lake of
Doberdo, about three-quarters of a mile away from the village, but
with the firing so intense and showing every sign of increasing rather
than diminishing, it would have been madness to have attempted to
get there, as it was right out in the open. In fact, there was
considerable doubt as to the advisability of starting on the return
journey yet, as the road was in the thick of it.
We had only just been remarking on the extraordinary quiescence
of the Italian guns which had not fired a shot since we had been up
here, when scarcely were the words out of our mouths than
suddenly, as though the limit of patience had been reached, with a
terrifying crash, all the batteries near us opened fire.
The result was positively magnificent, and roused one to the pitch
of enthusiasm. We could see the shells bursting along the crest of a
hill some two thousand yards away with such accuracy of aim that in
a few moments there was probably not a yard of the ground that had
not been plastered with high explosives; and anything living that was
there must have been battered out of existence.
The Italian Commander had no intention of wasting ammunition,
however; he only wished to show he was allowing no liberties to be
taken with him; for in less than a quarter of an hour the Italian fire
ceased with the same suddenness it had started, and
notwithstanding that the Austrian guns were still going it as hard as
ever.
There was no use waiting indefinitely for the chance of getting
away in quietude, so we started off on our return to Sagrado. We
had extra passengers in the car now, three officers having asked us
to give them a lift part of the way. One could not very well refuse, but
it made it a very tight fit.
The road was downhill all the way, and there were one or two
awkward turns. The effect of the heavy firing was visible all the way.
There were big shell-holes and stones everywhere, so it was
impossible to go at any speed, much as we should have liked it.
The only thing to do, therefore, was to sit still and trust to luck.
One or two shells burst quite close by us, but we managed to get out
of range safely.
We passed some motor ambulances full of serious casualties from
the plateau round Doberdo. Even when there was no actual battle
proceeding never a day passed I learned without a constant stream
of wounded coming down. The promiscuous shell fire of the
Austrians continually taking toll somewhere and helping to keep the
ambulances busy and the hospitals full.
I was told in Udine that the wounded coming in from the Carso are
usually found to be more seriously injured than those from any other
Front; the explanation of this being that owing to the peculiar
character of the rocky surface the effect of a shell exploding is, as it
were, magnified several times.
Wounds, therefore, are caused as often by the splinters of rock
flying upwards, and ricochets, as from the actual fragments of the
projectile itself. It is certain that the majority of the terrible facial
injuries are more frequently caused by re-percussion than by direct
hits.
As will have been gathered, therefore, the soldiers of Italy in this
region of desolation are fighting against two enemies, the Austrians
and the Carso.
CHAPTER XIX
Difficulties Italians have still to contend with on way to Trieste—

Italian superior in fighting quality—Dash and reckless courage—
Success reckoned by yards—Total number of prisoners taken—A
huge seine net—The “call of the wild”—A visit to San Martino del
Carso—My companion—Our route—The attraction of the road—
Early morning motoring—On our own—The unconventional quarters
of the divisional general—The Rubbia-Savogna railway station.—
The signalman’s cabin—An interesting chat with the General—At our
own risk—The big camp on Monte San Michele—The desolate
waste of the Carso—An incident—Nothing to sketch—“Ecco San
Martino del Carso”—Shapeless dust-covered rubble—The Austrian
trenches amongst the ruins—Under fire—Back to Udine—A pleasant
little episode—Déjeuner to Colonel Barbarich at Grado—A “day’s
outing”—The little “Human” touch—The “funk-holes” in the dining
room—A trip in a submarine chaser—Things quiet in Udine—A
period of comparative inactivity.

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Textbook Healthful Eating As Lifestyle Heal Integrative Prevention For Non Communicable Diseases 1St Edition Shirin Anil Ebook All Chapter PDF

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Healthful eating as lifestyle (HEAL):

integrative prevention for

An introduction to population-level prevention of non-

Social Determinants of Health in Non communicable

Role of Herbal Medicines: Management of Lifestyle

Nutrition and Lifestyle in Neurological Autoimmune

High-Density Lipoproteins as Biomarkers and Therapeutic

Personalized Nutrition as Medical Therapy for High-Risk

Fostering Recovery and Well-being in a Healthy

Health IT as a Tool for Prevention in Public Health

Boca Raton London New York

CRC Press is an imprint of the

© 2017 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-4868-1 (paperback)

Library of Congress Cataloging‑in‑Publication Data

Names: Anil, Shirin, editor.

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

Chapter 1 HEAL for Non-Communicable Diseases .............................................1

Chapter 2 HEAL for Hypertension ..................................................................... 27

Chapter 3 HEAL for Obesity .............................................................................. 49

Chapter 4 HEAL for Hyperlipidemia ................................................................. 71

Chapter 5 HEAL for Diabetes ............................................................................ 89

Chapter 6 HEAL for Heart Diseases ................................................................ 115

Chapter 7 HEAL for Stroke .............................................................................. 141

Chapter 8 HEAL for Asthma ............................................................................ 159

Chapter 9 HEAL for Cancers ........................................................................... 179

Chapter 10 HEAL for Mental Health Issues....................................................... 203

Chapter 11 HEAL and Physical Activity ............................................................ 231

Chapter 12 HEAL and Smoking Cessation ........................................................ 247

Index ...................................................................................................................... 267

Alvaro Avezum Leila Cheikh Ismail

Karen M. Davison Bart Kay

Claudia Stefani Marcilio Salim Surani

Rajendra Pradeepa Zhe Yi

Unnikrishnan Ranjit Jian Ying

Vaidya Ruchi Antonis Zampelas

1.1 NON-COMMUNICABLE DISEASES:

1.2 PREVENTION OF NON-COMMUNICABLE DISEASES

1.3 HEALTHFUL EATING AS LIFESTYLE (HEAL)

1.4 DIETARY GUIDELINES

1.4.1 WHO’s Dietary recOmmenDatiOns

• Salt should be restricted to 5 g/day (approximately 1 teaspoon) and iodized

• Exclusive breast-feeding should be done in the first 6 months of life.

1.4.2 Dietary GuiDelines fOr americans

• A healthy eating pattern consisting of appropriate calorie levels in order to

1.4.3 eatinG Well WitH canaDa’s fOOD GuiDe

Reduce Consumption of Increase Consumption of

1.4.4 uniteD KinGDOm: tHe eatWell GuiDe

1.4.5 australian Dietary GuiDelines—eat fOr HealtH

• Maintain a healthy weight. Consume calories according to individual need

1.5 IMPACT OF FOOD-BASED DIETARY GUIDELINES

1.5.1 WHO Dietary GuiDelines anD ncDs

A cross-sectional study of 433 Japanese males measured the association of HDI

1.5.2 Dietary GuiDelines fOr americans anD ncDs

lower prevalence of hyperglycemia, hypertension, and low high-density lipoprotein

1.5.3 eat Well WitH canaDa’s fOOD GuiDe anD ncDs

1.5.4 tHe eatWell GuiDe anD ncDs

1.5.5 australian Dietary GuiDelines anD ncDs

1.6 DIETARY PATTERNS TO PREVENT NON-

1.6.1 meDiterranean Diet