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[26] A complication of severe chronic PA is subacute combined degeneration of spinal cord, which leads to distal sensory loss (posterior column), absent ankle reflex, increased knee reflex response, and extensor plantar reflex response

Each meal should contain no more than 45 grams of carbohydrates (accounting for 40% of total calories), which should be evenly distributed across the three meals to prevent excessive fluctuations in blood glucose and increased oxidative stress (153)

Some varieties of flavored sparkling water are sweetened, either with natural sugar or artificial sweeteners

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