





































Clinical Medicine Insights
Received 25 Jul 2021 | Revised 22 Aug 2021 | Accepted 18 Sept 2021 | Published Online 01 Oct 2021

DOI: https://doi.org/10.52845/CMI/2021-2-4-1 
CMI JOURNAL 2 (4), 201−223 (2021) ISSN (O) 2694-4626 

REVIEW ARTICLE

Diet and Non-Communicable Diseases: Part I Cardiovascular Diseases, 
Respiratory Diseases, Obesity, Depression, Liver Diseases

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902, USA

Abstract
Diet is involved in the development and progression of several chronic
diseases. These include diseases that are responsible for a major health
burden globally, such as cancer, cardiovascular diseases, obesity, di-
abetes mellitus, and depression. The scientific world is replete with
studies on the impact of dietary factors and common diets on these
ailments. Prudent dietary habits sever both preventive and therapeutic
roles in several non-communicable diseases. Healthy diets are primarily
plant-based, and low in red and processed meats and sugar-sweetened
beverages.
This manuscript discusses our understanding of the modulation of
diet in order to mitigate cardiovascular diseases, respiratory diseases,
obesity, depression, and liver diseases.
Keywords: diet, non-communicable diseases, cardiovascular diseases,
respiratory diseases, obesity, depression, liver diseases

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

I t is estimated that almost 10% of the global
burden of disease is related to poor diet1. The
influence of diet has been noted with several

ailments, including cardiovascular diseases2,3, di-
abetes mellitus4,5, cancer6,7, lung diseases8,9, gas-
trointestinal diseases10−12, kidney diseases13,14, neu-
rological diseases15,16, mental disorders17−19, and
arthritis20,21, and many others22−25. A poor diet re-
duces the quality of life26. It is also one of the

leading causes of accelerated aging27, disability28,
and excess mortality29. The seven countries study,
reevaluated in 2017, highlighted the substantial in-
fluence of diet on health30. Dietary interventions
have become a core aspect of primary and secondary
prevention of the most common non-communicable
diseases (NCDs)31. Besides caloric restriction to
avoid overweight and obesity (a body mass index
below 25 kg/m2)32, a healthy diet is well balanced
and consists of high consumption of non-starchy
vegetables, fruits, whole grains, and legumes, a lim-

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ited to moderate consumption of nuts, seafood lean
meats, low-fat dairy products, and vegetable oil rich
in mono and polyunsaturated fats, and limitation or
elimination of trans-fats, saturated fats, fried foods,
sodium, red meat, refined carbohydrates, and sugar-
sweetened beverages33−35.
Several diets have become popular for their bene-
ficial health effects36−38. The most common ones
are the Mediterranean39, Dietary Approaches to Stop
Hypertension (DASH)40, and vegetarian41 diets. The
Mediterranean diet is commonly followed in the
olive-growing areas of the Mediterranean region.
These residents have a high intake of vegetables,
whole grains, legumes, fresh fruit, non-refined ce-
reals, nuts, and extra virgin olive oil. They have a
moderate consumption of fish, poultry, and dairy,
and a low intake of red meats (usually reserved
for special occasions only) and sweets. Their intake
of alcohol is moderate and usually limited to red
wine consumed during their main meals36,39. Meta-
analysis of cohort studies on this diet revealed a 10%
reduction in cardiovascular events and 8% reduction
in mortality39. The DASH diet is low in sodium (<
2300mg/day) and has been promoted by theNational
Institutes of Health to treat hypertension. It also
encourages consumption of fruits and vegetables
of different colors, fat-free or low-fat dairy prod-
ucts, whole grains, and various protein sources (e.g.,
seafood, lean meats, eggs, legumes, nuts, seeds, and
soya) while limiting added sugars (< 10% of calories
per day), saturated fats (< 10% of calories per day),
and alcohol (≤ 1 drink per day for women and ≤
2 drinks per day for men). Besides effects on blood
pressure, it also helps in improving other risk factors
for CVD and diabetes mellitus37,40. A vegetarian diet
is a plant-based diet, rich in whole grains, cereals,
legumes, fruits, leafy ground vegetables, nuts, seeds,

Supplementary information The online version 
of this article (10.52845/CMI/2021-2-4-1) contains 
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902,USA
Email: usacardiologist@gmail.com

and sea vegetables38,41. The term semi-vegetarians
is sometimes used to describe individuals who con-
sume meat up to or less than once a week. Lacto-
vegetarians eat dairy products, ovo-vegetarians eat
eggs, lacto-ovo vegetarians eat both dairy products
and eggs, while a pesco-vegetarian eats fish, in ad-
dition to the plants42. A vegan usually consumes
no food from animal sources43. The nature of veg-
etarianism often varies between different cultures
and regions44−46. Most European and North Amer-
ican vegetarians eat dairy products and eggs and
are therefore lacto-ovo-vegetarians44. Asian Indian
vegetarians are mainly lacto-vegetarians45. Dairy in-
take is much less in Chinese vegetarians when com-
pared to Western vegetarians46. Vegetarian diets are
specifically linked to a lower risk of coronary artery
disease and type 2 diabetes43,47, while vegan diets, in
addition, also help in losing weight43.
The impact of diet on common chronic medical
conditions is discussed in this two-part manuscript.
Part I discusses the relationship between diet and
cardiovascular diseases (CVD), chronic obstructive
pulmonary disease (COPD), obesity, depression,
and liver diseases. Part II discusses its impact on
cancer, diabetes mellitus (DM), kidney diseases,
Alzheimer’s disease, and arthritis.

2 DISCUSSION

CDC defines chronic diseases as “conditions that
last 1 year or more and require ongoing medical
attention or limit activities of daily living or both”48
Most chronic diseases are NCDs, and their incidence
and prevalence is growing all over the world49. Diet
is an important modifiable risk factor for chronic
diseases development and progression50−52. Cardio-
vascular diseases (CVDs) are a heterogeneous group
of diseases of the heart and the circulatory system53.
CVDs are associated with extremely high morbid-
ity and continue to be the leading cause of pre-
mature mortality worldwide54. It is estimated that
by the year 2030, 23.6 million people will die of
CVDs per year55. The underlying cause is usually
atherosclerosis56. Chronic respiratory diseases are
common non-communicable diseases57 and include
chronic obstructive pulmonary disease (COPD),

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mailto:usacardiologist@gmail.com


DIET AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
RESPIRATORY DISEASES, OBESITY, DEPRESSION, LIVER DISEASES
asthma, interstitial lung diseases, pulmonary sar-
coidosis, and pneumoconiosis such as silicosis and
asbestosis58. It is estimated that 545 million peo-
ple in the world suffered from chronic respiratory
diseases in 201759. They remain a leading cause
of death and disability worldwide60. They caused
more than 3.8 million deaths in 2017, which ac-
counted for 7% of all global deaths and 9% of
all NCD deaths61. Obesity is an increasing public
health problem worldwide62. Besides its epidemic
influence in adults, it is increasingly affecting chil-
dren and adolescents63. Obesity leads to a wide
array of illnesses such as type 2 diabetes mellitus
(DM)64, hepatic steatosis65, gallbladder diseases66,
osteoarthritis67, and several cancers (such as those
of the endometrium, breast, ovary, prostate, liver,
gallbladder, kidney, and colon)68, in addition to the
diseases discussed in this manuscript. Even modest
weight loss—5%decrease in bodyweight—has been
shown to lower the risk of chronic disease69,70. Its
etiology is multifactorial, but diet plays an important
role71. Obesity increases mortality72. Depressive dis-
orders are the leading cause of global disability73.
It is usually associated with a low mood, sadness,
lack of energy, and an inability to enjoy life74. It also
affects physical health75. Overall, depression leads to
a considerable reduction in the quality of life, med-
ical comorbidity, and mortality76,77. Chronic liver
diseases have become a major international pub-
lic health concern78−80. It is estimated that non-
alcoholic fatty liver disease (NAFLD) has a preva-
lence of around 25% of the general population81.
Diet also plays a major role in alcoholic liver dis-
ease (ALD)82 . Diet also is associated with liver
cancer83. Chronic liver diseases cause more than 2
million deaths per year57. These diseases and their
relationship with diet are discussed below.

2.1 CARDIOVASCULAR DISEASES

Poor eating habits are a major modifiable risk factor
for cardiovascular diseases (CVD)84−86. A plethora
of scientific studies indicates that red and processed
meat87, fried foods88, sugar-sweetened beverages89,
excess alcohol intake90 and obesity91 have detrimen-
tal effects on CVDs, while fruits and vegetables92,93,
whole grains94, fiber95, tree nuts96, chocolate97, and

coffee98 are cardioprotective.
The most effective dietary intervention is probably
salt restriction99. This leads to blood pressure (BP)
reduction, which is associated with a substantial re-
duction in morbidity and mortality from CVDs100.
According to major US cardiology associations, a
reduction of salt intake to <1500 mg/d101 should
bring the BP down by about -5/6 mm Hg systolic
and -2/3 mm Hg diastolic102. Obesity is closely re-
lated to hypertension (HTN)103, and weight reduc-
tion in obese individuals, via calorie restriction, or
other dietary changes, is also associated with BP
reduction104. The AHA estimates that every 1 Kg
(2.2 lbs) weight reduction is associated with about a
1mmHg reduction in systolic BP105. A change in the
quality of diet also helps105,106. A diet rich in fruits,
vegetables, whole grains, low-fat dairy products and
with a reduction in saturated and total fat has also
been estimated to reduce systolic BP by -11 mm Hg
and diastolic BP by – 3mm Hg105. Both the DASH
diet107 and theMediterranean diet108, help reduce BP
in patients with HTN. Controlling HTN helps reduce
several CVDs, including stroke109, heart failure110,
and cardiac arrhythmias111. The major beneficial
impact of a drop in BP is, however, on coronary
artery disease112,113. In a recent longitudinal study
of 153,082 US veterans, the DASH diet was in-
versely associated with the incidence of coronary
artery disease (CAD)114. Another study, a meta-
analysis of cohort studies determined that adherence
to the DASH diet resulted in a 21% reduced risk of
CAD115. The Lyon Diet Heart Study, which evalu-
ated the impact of the Mediterranean diet on CAD,
found a reduction in coronary mortality of 65%
after 46 months116. Benefits of a healthy diet have
also been recorded with stroke117, heart failure118,
peripheral arterial disease119, and vasculogenic erec-
tile dysfunction120. A high-fat diet has also been
linked to an increase in cardiac arrhythmias121, and
SCD122. A cardiovascular healthy diet also helps
reduce hypercholesterolemia123, DM124, and chronic
kidney disease125 – all major risk factors for CVDs.

2.2 RESPIRATORY DISEASES

The adverse association between obesity and COPD
is well known126,127. Obesity risks increase with the

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consumption of an energy-dense, high fat, and low-
fiber diet, resulting in excess caloric intake128. The
quality of diet also appears to influence COPD129,130.
Several diets appear to reduce the development of
COPD from 25% to 54%131−133. The most impor-
tant beneficial component of these diets appears to
be a higher intake of fruits and vegetables134. con-
sumption of fish135, and a lower intake of processed
meats136. A diet rich in a higher intake of meat and
potatoes, and a lower intake of soy and cereal has
been associated with lower forced expiratory volume
in one second (FEV1) and an increased prevalence
of COPD137. In patients with diagnosed COPD, pa-
tients on a diet with high consumption of fruits and
vegetables demonstrated an annual increase in their
FEV1 while those on a usual diet showed a decrease
in FEVI during 3 years of followup138. Several recent
studies have confirmed the beneficial effects of fruits
and vegetables in retarding the development and
progression of COPD139−141. Several micronutrients
are present in high amounts in fruits and vegeta-
bles, are associated with better lung parameters and
their presence may explain their beneficial effect
in patients with COPD142,143. These include vita-
min C142, alpha-tocopherol140, and beta-carotene143.
Their benefits have been attributed to a reduction in
inflammation and oxidative stress144. Fish oils are
anti-inflammatory and are protective against the de-
velopment of COPD145. Micronutrients like calcium,
phosphorus, iron, potassium, and selenium also ap-
pear to be beneficial in these patients146. Vitamin D
supplementation, especially in those with severe de-
ficiency, also helps in reducing the number of COPD
exacerbations147. Diet also influences COPD-related
mortality148. Walda et al noted an inverse trend for
20-year COPD mortality, and a 100 g increase in
fruit intake at baseline resulted in a 24% lower COPD
mortality risk149.
Obesity, which is usually associated with an energy-
dense, low fiber, and high-fat diet, is common in
asthma patients150 with harmful effects151,152. Ex-
cess body weight is associated with reduced lung
volumes, poorer asthma control and outcomes, and
poorer quality of life151,152. Excess adipose tissue
induces immunometabolism disarray, increased ox-
idative stress, and decreased bioavailability of nitric
oxide, producing or aggravating airway disease153.

Reduction in weight helps, as has been demonstrated
by bariatric surgery studies that have resulted in
dramatic improvements in asthma control and lung
function154. A weight-reducing diet is therefore ben-
eficial in asthma patients155. Asthma is an inflam-
matory disease156, and the latter can be beneficially
modulated with a judicious diet157. In adults with
severe asthma, higher fat and lower fiber intake
have been associated with increased eosinophilic
airway inflammation158. Reduction of dietary sat-
urated fat intake reduces this inflammation159. In
contrast, fruits, vegetables, and their antioxidants
help lower airway inflammation160,161. A study from
Mexico demonstrated that fruit and vegetable in-
take was inversely associated with IL-8 protein in
nasal lavage of asthmatic children, indicating re-
duced inflammation162. In asthmatic adults, intake
of tomato juice, which is abundant in the antioxi-
dant lycopene, reduced airway neutrophil influx and
sputum neutrophil elastase activity after just seven
days of supplementation157. On the other hand, a diet
characterized by highly processed foods, with high
intakes of refined grains, processed and red meats,
desserts and sweets, fried foods, and high-fat dairy
products, with low intake of fruits and vegetables has
harmful effects on asthma in children163−165.
Several case–control studies indicate that a diet rich
in vegetables and fruits, may exert some protective
effect against lung cancer166,167. Cruciferous vegeta-
bles, such as broccoli, are rich in isothiocyanates,
and these have cancer-preventive activity166. A high
intake of total or saturated fat does not appear to
increase the risk of lung cancer, as a pooled analysis
of eight cohort studies showed168. However, high
levels of nitrosamines (formed during cooking) in
fried or well-done red meat, appear to increase lung
cancer risk169,170.

2.3 OBESITY

Excess caloric intake without corresponding energy
burn results inweight gain171. An imbalance between
energy intake and expenditure, results in an increase
in the number (hyperplasia) and size (hypertrophy)
of adipocytes172,173. In other words, individuals con-
suming more calories than the recommended daily
allowance according to the METs expended, are

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RESPIRATORY DISEASES, OBESITY, DEPRESSION, LIVER DISEASES
likely to become overweight or obese171. Excess
calories are easier to consume with food rich is
fats and sugars, and low in fiber174. Ultra-processed
foods are typical examples - they are highly pro-
cessed foods high in total energy, free sugars, sat-
urated fats, sodium, and additives, and low in fiber,
protein, phytochemicals, and micronutrients – with
additives primarily to increase their shelf life without
increasing their cost175. The foods include chips, car-
bonated soft drinks, sweet or savory snacks, confec-
tionary, mass-produced packaged bread, buns, pas-
tries, cakes, biscuits and desserts, prepacked break-
fast cereals, preprepared meals, including pies, pasta
and pizza dishes, reconstituted meat and meat prod-
ucts, ‘instant’ soup, and noodle dishes175. Ultra-
processed foods account for about 50–60 % of the
energy content in the usual diet of the average US,
Canadian, or British consumer176−178.
Several epidemiological studies have examined dif-
ferences in body weight based on dietary patterns.
Findings from AHS, EPIC and the Swedish Mam-
mography Cohort studies found that omnivores had
the highest prevalence of overweight and obesity
compared to individuals eating less meat, such as
plant-based diets179. The EPIC-PANACEA study
showed that an increase in 250 g/day of meat led
to a 2 kg weight gain after 5 years180. In a study
examining a cohort of 49,098 Taiwanese adults, the
percentage of participants with a BMI ≥ 27 kg/m2
was significantly lower among those following a
vegetarian diet (10.9%) as compared to those fol-
lowing a non-vegetarian diet (15.4%)181. The Ad-
ventist Health Study also demonstrated that BMI
increases as the number of animal foods in the diet
increased182. In this study, vegans had the lowest
BMI, followed by vegetarians, pesco-vegetarians,
semi-vegetarians, and omnivores182. The European
Prospective Investigation into Cancer and Nutri-
tion (EPIC-Oxford) study found that vegans gain
significantly less weight as they age compared to
omnivores183. Plant-based diets also help in weight
loss184,185, Huang et al in ameta-analytic study found
significant weight loss with plant based diets184,
while Barnard et al reported in another meta-analysis
that plant-based diets were associated with a mean
weight loss of −3.4 kg to 4.6 kg185. Several sub-
sequent clinical trials, including the New DIETs

study186, HER Health Study187, and the VA BEACH
Diet Study188, have also confirmed the weight loss
benefit associated with plant-based diets. A prudent
diet – plant based or restricted in calories, should ide-
ally include 60% carbohydrate intake, 25% protein
intake, and 15% fat intake189. Weight loss in these
patients is enhanced by combining exercise190 - reg-
ular moderate-intensity aerobic exercise for at least
150 min per week or more than 300 min per week.
Resistance exercises at moderate intensity two times
per week with 10 to 15 resistance exercise repetitions
should also be part of this exercise regimen.

2.4 DEPRESSION

Diet is a well-known factor associated with
depression191−194. As mentioned before, a calorie-
rich diet may result in obesity128. Obesity is harmful
to depression195. The prevalence of depression
in obese individuals is twice as high as in those
of normal weight196,197. An improvement in the
diet, especially with calorie restriction resulting
in weight loss may help with an improvement
in depression symptoms198,199. Depression can
also lead to obesity, indicating that there is a
bidirectional causality200−202. The quality of diet
also has a major impact on depression203. Lassale
et al. in a review and analysis of 20 longitudinal
and 21 cross-sectional studies, concluded that
an inverse association between healthy diet and
depression204. A recent meta-analysis confirmed
that ‘healthy’ dietary patterns (regardless of the
type) may contribute to the prevention of depressive
symptoms205 . and this appears to be related in
a linear dose-response fashion198. Diets low in
fruit and vegetables206, fish207, or legumes208,
are associated with an increase in depression.
Diets rich in sugar, sodium, saturated fat209,210,
meat, and eggs211,212 are associated with more
depression. A diet with lower intakes of low-calorie
foods is similarly harmful213. An unhealthy diet
is often poor in several micronutrients, including
tryptophan, inositol, magnesium, fiber, folate, and
omega-3 fatty acids which are important for proper
mental wellbeing214. However, dietary supplements
do not appear to be very effective in reducing
depression215. Improper diet and obesity result

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SHASHI K. AGARWAL, MD

in HPA axis dysregulation216. They also increase
inflammation, oxidative stress, and other endocrine
dysfunctions217.

2.5 LIVER DISEASES

Nonalcoholic fatty liver disease (NAFLD) is a pro-
gressive disease of the liver that ranges from hep-
atic steatosis (liver fat >5% of liver weight) to
more severe steatohepatitis, (NASH, hepatocellular
inflammation}, with progression to fibrosis and end-
stage cirrhosis218. Weight loss via caloric restriction
remains the most viable option in the treatment of
NAFLD and fibrosis219. Reducing body weight by 7-
10%with hypocaloric diets is the most efficacious in
the treatment of NAFLD/NASH and fibrosis220,221,
with greater weight loss (≥10%) being associated
with the highest rates of NAFLD/NASH resolution
and fibrosis regression222. However, histological im-
provements are also observed with as little as 3-
5% weight loss223,224. A healthy diet, besides a diet
that prevents excess body weight, is also impor-
tant. Several diets, including the Mediterranean Pa-
leolithic, ketogenic, high-protein, plant-based, low-
carbohydrate, and intermittent fasting approaches
all have shown beneficial health outcomes in these
patients225. Dietary ingredients that are beneficial
include soluble and insoluble fiber, monounsaturated
or polyunsaturated fatty acids, several micronutri-
ents, vitamins E, C, and D, and several polyphenols
(e.g., resveratrol, curcumin, caffeine, quercetin) are
also helpful in NAFLD226,227. On the other hand,
fructose and saturated fatty acids contribute to the
pathogenesis of NAFLD228. Alcohol intake in ex-
cess induces hepatic damage resulting in alcohol
liver disease, which includes liver steatosis, fibrosis,
cirrhosis, and alcoholic hepatitis229. These can be
prevented by alcohol abstinence and the damaged
liver can be helped with nutritional support. Patients
with ALD usually suffer from malnutrition230, and
this exacerbates the severity of the liver disease231.
These patients may either have an intake of an
unhealthy diet with too few essential nutrients or
the alcohol may prevent the body from digesting
and utilizing essential nutrients232. Many ALD pa-
tients suffer from protein-calorie malnutrition233
which increases complications. The American Col-

lege of Gastroenterology and the American As-
sociation for the Study of Liver Diseases guide-
lines recommend 1.2 to 1.5 g/kg per day of pro-
tein intake and 35 to 40 kcal/kg per d of body
weight for energy intake in patients with ALD82 Be-
sides these macronutrients, ALD patients need sev-
eral micronutrients to protect liver toxicity and dis-
tant complications include zinc234, magnesium235,
selenium236, vitamins D237, vitamin E238, folate239,
niacin240, and thiamine241. A proper nutritional sup-
port in patients with ALD helps reduce infectious
complications and improves 1-year mortality in such
patients242,243. There is a strong association between
obesity and hepatocellular carcinoma244,245 .The re-
sults show that diet plays an important role in HCC
occurrence246. Several diets have been noted to lower
the risk of hepatocellular carcinoma247,248. These di-
ets are usually rich in foods such as vegetables249,250,
poultry251, fish252, wholegrains253, nuts254, tea255,
and caffeinated coffee256,257. Micronutrients such
as vitamin E, vitamin B9, β-carotene, manganese,
and potassium may help in reducing the develop-
ment of HCC258. Some fats, including monoun-
saturated fats259, may also have beneficial effects.
However, data indicates that processed red meat
consumption260 high-fat dairy foods261, and in-
gestion of sugar-sweetened beverages262 may in-
crease HCC risk. Heavy alcohol intake is also
harmful263,264.

3 CONCLUSION

A healthy diet should provide adequate macro and
micronutrients, and avoid harmful saturated fat, pro-
cessed meats, sugar-sweetened drinks, excess salt,
and excess alcohol. The beneficial effects of a pru-
dent diet on several NCDs are strong. Water is also
an important component of diet265. It comprises from
75%bodyweight in infants to 55% in the elderly. Be-
sides providing adequate hydration, plain water in-
take is associated with a decrease in sugar-sweetened
beverages, and a decrease in caloric intake. Water
intake should not be forgotten as a beneficial com-
ponent of a healthy diet.
Acknowledgment: None
Funding: None

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DIET AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
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Conflict of interest: None

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How to cite this article: Agarwal S.K, MD DIET 
AND NON-COMMUNICABLE DISEASES: 
PART I Cardiovascular Diseases, Respiratory 
Dis-eases, Obesity, Depression, Liver Diseases. 
Clin-ical Medicine Insights. 2021;201−223. 
https://doi. org/10.52845/CMI/2021-2-4-1

CMI JOURNAL 2 (4), 201−223 (2021) MEERP LTD 223


	Introduction
	Discussion
	CARDIOVASCULAR DISEASES 
	RESPIRATORY DISEASES
	OBESITY
	DEPRESSION
	LIVER DISEASES

	CONCLUSION
	 REFERENCES



