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Underground Fat Loss Manual

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Mechanism Linking Obesity and PCOS

The mechanisms linking obesity and PCOS are unclear but may be related to insulin resistance and hyperandrogenism, both of which are commonly documented in lean and obese women with this condition. Insulin resistance is a common but not universal feature of PCOS, although women with insulin resistance appear to be more clinically affected (2). Because insulin resistance is strongly influenced by obesity in non-PCOS subjects, it was initially debated whether insulin resistance and hyperinsulinemia are a primary metabolic disturbance of PCOS or a symptom of the obesity commonly observed in PCOS. Hyperandrogenemia and insulin resistance appear to be independent features of PCOS, with hyperinsulinemia enhancing the expression of hyperandrogenemia by increasing bioavailability of androgens (4) (Fig. 1). Obese women with PCOS show decreased insulin sensitivity and hyperinsulinemia to an extent greater than can be explained by obesity alone (4,5). A synergistic interaction appears to exist...

Weight control the role of exercise

Weight control towards optimal levels yields considerable health benefits to all, notably in this context to those who have the combined disadvantages of being overweight and having Type 2 diabetes. Exercise has a central role in weight reduction and health improvement. The proven benefits include reduced insulin resistance (hence enhanced insulin sensitivity) leading to better glycaemic control which may even be independent of actual weight reduction. Risk factors for cardiovascular disease,

Nutrition and Weight Management

American Obesity Association 1250 24th St. NW, Suite 300 Washington, DC 20037 (202) 776-7711 www.obesity.org Office of Dietary Supplements National Institutes of Health Bethesda, MD 20892 2005 Dietary Guidelines available at Nutrition.gov The 2005 Revised Food Pyramid (sponsored by the USDA) www.mypyramid.gov

Dietary Interventions

Epidemiologic observations of large international differences in the incidence of breast cancer have provided a basis for formulating hypotheses on a possible relation between diet and the development of cancer. The age-adjusted incidence of breast cancer varies from 22 per 100,000 in Japan to 68 per 100,000 in the Netherlands.116 The ratio of breast cancer mortality between the United States and Japan is 3 1 for premenopausal women and 8 1 for postmenopausal women.117 These important differences may possibly be related to fat intake and total calories in the diet. Clinical data collected from case-control studies have demonstrated a positive correlation between diets high in fat and meat and breast cancer.118-122 Experimental studies have shown that omega-6 polyunsaturated fatty acids (PUFAs) contained in high-fat diets promote both mammary tumorigenesis and cell proliferation in chemically induced mammary tumors, whereas omega-3 PUFAs, contained in fish oil, can inhibit these...

Dietary Protein And Amino Acids

It is not possible to establish recommendations for cancer prevention based upon dietary protein level or source. Dietary protein can increase, decrease, or have no effect on tumorigenesis in various tumor models, suggesting that protein may exert very specific mechanisms of action that are unique to each target tissue and initiating agent (42,147-149). Very little research has focused on the role of dietary protein or amino acids in tumor angiogenesis. One mechanism whereby dietary protein intake may influence angiogen-esis is via dietary intake of the amino acid L-arginine, and subsequent modulation of nitric oxide (NO) production. NO is synthesized from L-arginine by the enzyme family, NO synthase (NOS). Recent investigations revealed that the NOS pathway is frequently upregulated in solid tumors of experimental animals (150-153), and the expression of different isoforms of NOS has been characterized in several tumor systems (150152,154). The synthesis of NO by endothelial cells is...

Extracting Dietary Patterns from the Nutritional Data

We return now to the subset of the EPIC database describing dietary habits of 4852 French women. Figure 17.2 summarizes the Kohonen SOM analysis of the data based on a 10 x 10 sheet. Because one bin is empty, 99 distinct regimens were identified. Both a standard ascending algorithm Murthag (1995) and a conceptual clustering algorithm Chavent (1998) applied to the microregimens, suggest four, six, or nine classes or dietary patterns. The results of the six-class analysis are summarized in Figure 17.4 which shows the first factorial plane of the CA representing the relationship between centers and dietary pattern Figure 17.4, which shows the Zoom Star graphs Noirhomme-Fraiture and Rouard (1998) of the eight most discriminating variables describing dietary patterns and Table 17.4 which gives a rough estimate of the proportions of subjects following the six dietary patterns, overall and by center.

Dietary Lipids And Fatty Acid Patterns

The role of dietary lipid concentration, sources of fat, and specific fatty acid patterns on the incidence and progression of many cancers has been the source of much specula tion and investigation (6,7,21). The human and laboratory evidence is most convincing for a stimulatory effect of dietary lipid concentration, particularly a diet rich in saturated fats, on cancers of the colon and rectum (6,7,21). Less certain, but supported by many studies, are the positive relationships between diets rich in fat and cancers of the prostate, breast, lung, ovary, and endometrium (6,7,21). The possibility that diets rich in omega-3 fatty acids from marine sources have inhibitor properties for cancers has been postulated, and is currently an area of active investigation (6,7,21,109-114). Dietary lipid intake is primarily in the form of triacylglycerols (triglycerides), with one molecule of glycerol bound to three fatty acids. Dietary fatty acids vary in chain length (typically even numbered, 4-22...

Dietary Recommendations

Dietary protein restriction has been advocated for years for patients with hepatic encephalopathy. However, protein intakes of less than 40 g d generally result in negative nitrogen balance and gradual malnutrition. This chain of events worsen as many of these patients undergo periodically large-volume paracentesis with considerable protein losses. We recommend protein restriction during the actual episode of encephalopathy, in a manner proportional to the severity of the mental impairment (see Table 114-1). Thus, for patients with mild to moderate, stage I or II encephalopathy, 30 to 40 g protein per day are temporarily adequate. Severe encephalopathy, stages III or IV, requires further restriction, down to 0 to 20 g daily during the stay in intensive care unit. However, once recovered from the episode of encephalopathy, the daily amount of dietary protein should be gradually titrated upwards according to the patient's neurological tolerance. The underlying concept is to maintain a...

Effects of dietary polyunsaturated fatty acids PUFA

As a result of the benefits of dietary intake of w-3 PUFA to human health, there has been increased interest in elevating the w-3 PUFA content of cultured fish with specialized diets. It is now clear that experimental diets enriched with w-3 PUFA can alter the muscle lipid composition of cultured salmonids (Bell et al., 1991a Higgs et al., 1995). It is equally clear that these w-3 PUFA enriched diets also have important physiological effects that are beneficial to the fish. In particular, there can be considerable shifts in the membrane phospholipid fatty acid compositions and the eicosanoids produced from them (Bell et al., 1991a,b, 1992). One of the remarkable effects of an insufficient dietary intake of w-3 PUFA (i.e. a low w-3 w-6 ratio diet produced by using a sunflower oil rather than a fish oil dietary supplement) was that heart size was significantly reduced in cultured post-smolt Atlantic salmon (Bell et al, 1991a). In severe cases a marked depletion in the amount of compacta...

Influence of dietary calcium and calcium phosphorus ratio on the effectiveness of phytase

The response to a given level of supplemental phytase will be influenced by dietary Ca level and or Ca P ratio, dietary P level and dietary phytate level (Lei et al., 1994 Dungelhoef and Rodehutscord, 1995 Kornegay, 1996b). A high molar ratio of Ca to phytate in the diet can lead to the formation of extremely insoluble Ca phytate complexes under intestinal conditions, making the phytate molecule inaccessible to phytase. The presence of such strong complexes could explain the apparent inactivity of phytase in calcium-rich diets rather than a direct inhibition of the enzyme by Ca2+ (Wise, 1983 Bos, 1988). The importance of maintaining a narrow ratio of total Ca to total P (or for that matter available Ca to available P) has recently been demonstrated in broilers (Qian et al., 1997), turkeys (Qian et al., 1996b) and pigs (Qian et al, 1996a Liu et al., 1998). A Ca nP (weight weight) ratio of 2 1 is suggested for poultry with the exception of laying birds (NRC, 1994). A high level of...

The Role of Obesity

Weight loss is generally recognized as an important lifestyle measure to observe in the treatment of GERD, and obesity is felt to be a significant risk factor for GERD. Until fairly recently, this approach was based only on the logical assumption that increased girth promotes an increase in intra-abdominal pressure, thereby facilitating the retrograde flow of gastric contents into the esophagus. In more carefully analyzing the relationship between obesity and GERD, the relationship between GE reflux per se and the symptoms of GERD must be taken into account. For example, it is now well-established that 50 or fewer of reflux events are associated with a symptom such as heartburn or regurgitation, and the relationship between 24-hour esophageal pH measures of esophageal acid contact and the presence or absence of esophagitis is relatively poor. Therefore, any indictment of weight loss simply because it does not reduce the absolute percent of esophageal acid contact time is probably not...

Obesity

Lished that hyperinsulinemia, insulin resistance, and other obesity-related metabolic abnormalities are significantly associated with overall accumulation of fat in the body, there is now substantial evidence that the specific distribution of fat is important as outlined in Chapter 3. Excessive accumulation of fat in the upper body's so-called truncal region, or central obesity, is a better predictor of morbidity than excess fat in the lower body, the so-called lower body segment obesity10,12,13.

Healthy eating

Healthy eating is the cornerstone of diabetic treatment, and control of the diet should always be the first treatment offered to Type 2 diabetic patients before drugs are considered. Eliminating sugar (sucrose and glucose) lowers blood glucose concentrations in both Type 1 and Type 2 diabetic patients, and although recent dietary recommendations suggest that eating small amounts of sugar is of little consequence, this practice is not recommended. Artificial sweeteners can be used. Good dietary advice is essential to the proper care of diabetic patients ill considered advice can be very damaging or else it is ignored. I recall one patient who kept to the same sample menu for many years before she reported it to be rather boring. The diet needs to be tailored to the patient's age and weight, type of work, race, and religion. Recommendations for Type 2 diabetic patients Diets for overweight Type 2 diabetic patients should aim to eliminate all forms of sugar and restrict the total energy...

Severe Obesity

In severe ( morbid ) obesity, corresponding to a BMI of 40 kg m2 or more, the only practical diet for most patients is a VLCD or other highly restricted diet with careful medical monitoring and long-term follow-up. It should be noted, however, that even a modest weight loss can yield substantial health benefits for morbidly obese patients. Sleep apnea often disappears with as little as a 10 loss in weight, and hypertension, diabetes, and gastroesophogeal reflux may also improve significantly. I do not view, nor let my patients view, modest weight loss as a failure or a waste of time. The same is true for patients with lesser degrees of obesity.

Caloric Restriction

A starvation diet appears to be the only sure way to increase the mean life span of a mammal. It has been shown to work in mice and rats, and there is at present a very large caloric restriction (CR) study being conducted at the University of Wisconsin on 76 rhesus monkeys. This study will not be concluded until 2005, but the research team released some preliminary results in December 2000. The most notable effect in the CR group is a reduction in the amount of low density lipoprotein (LDL), a macromolecule that is associated with the onset of age-related cardiovascular disease. The CR group has retained a lower body weight and a more youthful appearance but are less active than the control group. Caloric restriction is important from a theoretical point of view, but it is never likely to form a practical therapy. North Americans in general find it difficult maintaining even modest shifts in eating habits. The typical CR diet, which reduces caloric intake to one-third of normal...

Dietary Modification

A trial of dietary modification is a reasonable first choice in the treatment of the IBS. Patients should be encouraged to keep a diary of food intake and symptoms allowing the identification and exclusion of symptom-causing foods. Dietary modification may be useful because most IBS patients complain of symptom exacerbation after intake of certain food groups. There is a separate and highly detailed chapter on dietary-induced symptoms (Chapter 56). Some patients may benefit from avoiding or limiting intake of caffeine, alcohol, fatty foods, gas-producing vegetables, and or sorbitol-containing products such as sugarless gum and dietetic candy. Avoiding constipating foods and the addition of fiber either in the diet or in the form of supplements, such as bran, polycarbophil or a psyllium derivative, equal to 20 to 30 g per day may be helpful in treating patients with constipation. In patients with diarrhea, a trial of a lactose free diet should be instituted in the event of a...

Dietary Sources

The animal proteins of meat, eggs, and dairy products closely match human proteins in amino acid composition. Thus animal products provide high-quality complete protein, whereas plant proteins are incomplete. Nevertheless, this does not mean that your dietary protein must come from meat indeed, about two-thirds of the world's population receives adequate protein nutrition from diets containing very little meat. We can combine plant foods so that one provides what another lacks beans and rice, for example, are a complementary combination of legume and cereal. Beans provide the isoleucine and lysine lacking in grains, while rice provides the tryptophan and cysteine lacking in beans.

Dietary Counseling

Input from our dietitians not only serves to reinforce dietary advice we have given patients, but also gives the patients and families another source of expertise they can draw from. Generally speaking, children with active disease are placed on fiber- and residue-restricted diets. To avoid the common misperception that the patient is condemned to this diet for life, we emphasize to our patients early on that the diet can be liberalized as they improve. Lactose intolerance is another issue and is fairly common in children with CD and is included in discussions with our patients. The ethnic distribution of lactose intolerance and management in children, and adults, is discussed in a separate chapter (see Chaper 62, Lactose Intolerance ). The main emphasis in children is to insure adequate nutrition for growth.

Dietary Assessment

Although most aspects of diet are more properly characterized as behaviors, the need remains to understand patients' tastes and the macronutrient composition of their usual array of food choices. This information is a tool for suggesting behavioral changes that will comport with the patient's preferences and lifestyle. Although the physician can and should get some idea of these things in talking with the patient, a formal dietary assessment is best done by a dietitian using either a prospective or retrospective food diary. Recommend scouring the supermarket aisles (at a time when the patient is not hungry) for tasty, low fat, or fat-free alternatives to favored foods. Encourage the patient to explore the wide variety of foods now available and to focus on the good taste of the new choice rather than comparing it with the real thing. The presentation of nutritional information on food labels is becoming more and more useful, listing not just g of fat, for example, but also the...

Dietary Factors

The definition of dietary factors is far ranging, and any attempts to characterize individual diets are fraught with confounding factors. On the other hand, it is becoming well accepted that diet can make considerable contributions to the multifactorial nature of diseases such as prostate cancer. To this end, a number of dietary components have been examined. It appears that there are two main possibilities that could explain the differences in prostate cancer risk observed between North Americans and Asians. The first possibility is that something in the Western diet predisposes Westerners to a higher risk for prostate cancer. Data continue to support the idea that total fat intake (especially animal fat derived from red meat) contributes to prostate cancer risk. The Chinese diet is well recognized to be low in meat consumption and enriched for the consumption of vegetables, especially as a source of protein. cancer. Micronutrients such as zinc, selenium, vitamin E, lycopene,...

Preface To The Series

The business of dietary supplement in the Western World has expanded from the Health Store to the pharmacy. Alternative medicine includes plant based products. Appropriate measures to ensure the quality, safety and efficacy of these either already exist or are being answered by greater legislative control by such bodies as the Food and Drug Administration of the USA and the recently created European Agency for the Evaluation of Medicinal Products, based in London. In the USA, the Dietary Supplement and Health Education Act of 1994 recognised the class of phytotherapeutic agents derived from medicinal and aromatic plants. Furthermore, under public pressure, the US Congress set up an Office of Alternative Medicine and this office in 1994 assisted the filing of several Investigational New Drug (IND) applications, required for clinical trials of some Chinese herbal preparations. The significance of these applications was that each Chinese preparation involved several plants and yet was...

James T McCarthy Rajiv Kumar

In the presence of normal renal function, magnesium retention and hypermagnesemia are relatively uncommon. Hypermagnesemia inhibits magnesium reabsorption in both the proximal tubule and the loop of Henle. This inhibition of reabsorption leads to an increase in magnesium excretion and prevents the development of dangerous levels of serum magnesium, even in the presence of above-normal intake. However, in familial hypocalciuric hypercalcemia, there appears to be an abnormality of the thick ascending limb of the loop of Henle that prevents excretion of calcium. This abnormality may also extend to Mg. In familial hypocalciuric hypercalcemia, mild hypermagnesemia does not increase the renal excretion of magnesium. A similar abnormality may be caused by lithium 1,2,6,10 . The renal excretion of magnesium also is below normal in states of hypomagnesemia, decreased dietary magnesium, dehydration and volume depletion, hypocalcemia, hypothyroidism, and hyperparathyroidism 1,2,6,10 .

Malabsorption Syndrome

Oral manifestations of malabsorption may be seen as mucosal and gingival pallor, angular cheilitis, and atrophic or a beefy-red glossitis. Additionally, as previously described, oral manifestations of anemia, may occur, particularly in undiagnosed or poorly controlled disease. Nutritional deficiencies are directly related to the section of the bowel affected by the GI disease. Persistent malnutrition is often a problem and the dentist can assist the physician in monitoring compliance with recommended dietary supplementation.

Radiographic Endoscopic Examinations

In addition to defining the functional abnormality, this procedure also allows for evaluation of the efficacy of various compensatory dietary modifications, postures, and swallowing maneuvers in improving swallowing dysfunction. Intraluminal manometry can complement videoflu-oroscopy by providing information on the strength of pharyngeal contraction, the completeness of UES relaxation, and the relative timing of these events. This may provide useful information regarding UES dysfunction and may help distinguish impaired UES function from weak pharyngeal contractions.

Fredrick V Osorio Stuart L Linas

Potassium, the most abundant cation in the human body, regulates intracellular enzyme function and neuromuscular tissue excitability. Serum potassium is normally maintained within the narrow range of 3.5 to 5.5 mEq L. The intracellular-extracellular potassium ratio (Kj Ke) largely determines neuromuscular tissue excitability 1 . Because only a small portion of potassium is extracellular, neuromuscular tissue excitability is markedly affected by small changes in extracellular potassium. Thus, the body has developed elaborate regulatory mechanisms to maintain potassium homeostasis. Because dietary potassium intake is sporadic and it cannot be rapidly excreted renally, short-term potassium homeostasis occurs via trans-cellular potassium shifts 2 . Ultimately, long-term maintenance of potassium balance depends on renal excretion of ingested potassium. The illustrations in this chapter review normal transcellular potassium homeostasis as well as mechanisms of renal potassium excretion.

Supplemental Reading

Diet, obesity and reflux in the etiology of adenocarcinomas of the esophagus and gastric cardia in humans. J Nutr 2002 3467S-70S. Nilsson M, Johnsen R, Ye W, et al. Obesity and estrogen as risk factors for gastroesophageal reflux symptoms. JAMA 2003 290 66-72. Wilson L, Wenzhou M, Hirschowitz B. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol 1999 94 2840-4.

Prevention of Type 2 diabetes

Lifestyle changes in those prone to Type 2 diabetes can effectively delay the onset of this disease. Several studies in different countries have demonstrated the feasibility of achieving this by a programme of weight reduction, improved diet (less fat, less saturated fat, and more dietary fibre) and increased physical activity. Recent investigations show that the development of diabetes can be approximately halved if these lifestyle changes are maintained over four years.

Diabetic complications

The illustration of an islet cell is reproduced from Gepts W Insulin islet pathology, islet function, insulin treatment, Loft R, ed. Nordisk Insulinlaboratorium. The bar chart showing relative risk of type 2 diabetes according to body mass index in US women uses data from Colditz GA, et al. Ann Intern Med 1995 122 461-86. The figure showing a family with dominantly inherited Type 2 diabetes is adapted from Fajans SS, et al. History, genetics and pathogenesis of HNF-4a MODY1 a 40-year prospective study of the RW pedigree. In Frontiers in Diabetes. Basel Karger, 2000. The age of onset chart is adapted from Diabetes in Epidemiological perspective, Mann JI, et al, eds. Churchill Livingstone, 1983. The bar chart showing number of people over 20 years estimated to have Type 2 diabetes in developed and developing countries is adapted from King H, Rogtic G. Global status of diabetes and recommendations for international action. International Diabetes Monitor Copenhagen IFDOR (Novo Nordisk)....

Treatment of Heart Disease

If atherosclerotic buildup increases, the arteries narrow and restrict blood flow. The formation of a clot can completely stop blood flow, causing an MI or cerebral vascular accident (CVA or stroke). Atherosclerosis is a life-long process, partially controlled by inherited genetic factors such as metabolism. Although humans have no influence over their genes, our physiological factors affecting atherosclerosis include blood cholesterol, blood pressure, and obesity. These physiological factors and CVD risk are partially Regular physical activity may reduce blood pressure by reducing obesity, increasing aerobic fitness, and reducing the blood levels of certain stress-related chemicals such as adrenalin. In individuals who already have hypertension, exercise significantly reduced resting blood pressure in most studies. Other studies have examined the effect of activity interventions on individuals who do not yet have hypertension, but who are at high risk for developing it (e.g., people...

Patient Assessment and Perioperative Considerations

Antireflux surgery should be approached more cautiously in certain groups of patients. Obese patients have a high failure rate with fundoplication therefore, we recommend obese patients lose weight before proceeding with an operation. The alternative for morbidly obese individuals (body mass index 40) with GERD is a Roux-en-Ygastric bypass. This operation not only aids in weight loss (thus providing other health benefits), but it is an extremely effective antireflux procedure. Patients with multiple comorbidities and previous upper abdominal operations should be approached more cautiously. Patients with severe cardiopulmonary disease may not tolerate general anesthesia or the pneumoperitinum required to do the operation laparoscopically. Former upper Gi or gastric surgery may preclude safe or effective access to the hiatus or make the use of the stomach to construct the wrap more difficult, and sometimes impossible. The most important factor is probably the experience and comfort of...

Potential Side Effects

Surgery is not without potential side effects, the most common being dysphagia, bloating, diarrhea, and early satiety. Inappropriate geometry of the wrap, tightness of the crural closure, and esophageal peristaltic function are all variables that may lead to difficulties swallowing after an operation. The reported incidence varies from 2 to 5 (Anvari and Allen, 2003 Atwood et al, 1992). Although some degree of dysphagia is common immediately after surgery, it generally resolves quickly with expectant management alone. The need for postoperative dilation is unusual, and the need to take down the fundoplication is even less so. Gas bloating can occur and is the result of swallowed air that cannot escape by belching secondary to the new wrap. Early satiety may result because the gastric volume has been reduced with construction of the wrap. Fortunately, these are also generally short lived and require little or no intervention. Diarrhea can occur after surgery and may have several...

What is moderate drinking

While it is generally agreed that we should do all things in moderation 58 , there is less agreement about the precise definition of 'moderate' drinking. Use of different sets of drinking categories in different reports has resulted in different interpretations, and the number and boundaries of categories appears to be determined by the sample size available in the study. Classification of moderate alcohol consumption ranges from a half a drink per day (or less) in some studies, up to six drinks a day in others 59 , Data from the National Health Interview Survey 52 demonstrated that people with different drinking habits perceived 'moderate' drinking differently. Only 25 of men who drink 3 or more drinks per day, in comparison to 56 of other men, considered 2 or fewer drinks per occasion as moderate. Likewise, only 6 of the women who drink at least 2 drinks per day (vs. 27 of other women) perceived moderate drinking as 1 drink or less per occasion. The National Health and Medical...

Measurement Of Insulin Resistance And Clinical Assessment

Furthermore, even at similar levels of body mass index (BMI), there appear to be ethnic differences in the degree of insulin sensitivity (Figure 2.5)8. Therefore, it is very difficult to distinguish between non-diabetic and diabetic individuals on the basis of insulin resistance.

Triple reuptake inhibitors

Triple reuptake inhibitors (TRIs), which increase DA levels in addition to serotonin and NE, are expected to be as efficacious as monoamine oxidase inhibitors (MAOIs) without being limited by the same side effects and dietary restrictions that accompany MAOI use. The rationale for including DAT inhibition is partially based on the well-established role of dopaminergic systems in motivation and reward. Anhedonia and lack of interest, which are core symptoms of MDD, result from dopaminergic impairment in corticolimbic areas, and depressed patients have been shown to have decreased DA release by nerve terminals in the mesolimbic system

Establishing Pneumoperitoneum

Establishing Pneumoperitoneum Open

Pneumoperitoneum can be established using a Veress needle or by an open approach. The open technique is generally preferred, as it minimizes the risks of inherent lesions to the small bowel. However, in obese patients, the Veress needle is used, as the thick subcutis does not allow visualization of the fascia through a 1-2cm incision.

Plotting Your Personal Problems Profile

Tyler, a middle-aged engineer, doesn't consider himself depressed or plagued with any emotional problems. But when he sees his primary care doctor, Tyler complains of fatigue, recent weight gain, and a noticeable loss in his sex drive. After ruling out physical causes, the doctor suggests that he may be depressed. Funny, Tyler says, my girlfriend just bought me the Anxiety & Depression Workbook For Dummies and said she thought I was depressed too. Maybe I'll take a look at it.

Nutritional and Vitamin Deficiency

Tropical populations subsisting on diets deficient in protein and vitamins are prone to leg ulceration, if the limb is injured and infected with bacteria, especially Bacillus fusiformis. In the 18th century, these conditions sometimes affected sailors deprived of a balanced diet and most notably prisoners of war in Japanese camps of the tropical zone during the Second World War. Without a suitable dietary intake, skin injuries of the lower limbs failed to heal and becoming infected, progressed to involve bone and threaten life, often precipitating amputation in rudimentary operating conditions.46

Moshe Levi Mordecai Popovtzer

Major determinants of serum phosphorus concentration are dietary intake and gastrointestinal absorption of phosphorus, urinary excretion of phosphorus, and shifts between the intracellular and extracellular spaces. Abnormalities in any of these steps can result either in hypophosphatemia or hyperphosphatemia 3-7 . The kidney plays a major role in the regulation of phosphorus homeostasis. Most of the inorganic phosphorus in serum is ultrafil-terable at the level of the glomerulus. At physiologic levels of serum phosphorus and during a normal dietary phosphorus intake, approximately 6 to 7 g d of phosphorous is filtered by the kidney. Of that (type I and type II Na-Pj cotransport proteins). Most of the hormonal and metabolic factors that regulate renal tubular phosphate reabsorption, including alterations in dietary phosphate content and parathyroid hormone, have been shown to modulate the proximal tubular apical membrane expression of the type II Na-Pj cotransport protein 11-16 .

Clinical Markers of CAD

Similar to surgery-specific considerations, clinical markers of CAD have been identified that correlate with both perioperative and long-term cardiac complications. Identification of these markers using multivariate analysis led to development of a number of clinical scoring systems that can estimate perioperative cardiac risk based on clinical evaluation (history, physical, and ECG). The most notable scoring system, the Goldman Multifactorial Index,5 has been useful for estimating risk of a broad-based population of general surgical patients, but is less effective in estimating risk for a more homogeneous but higher-risk subset of patients, such as those undergoing major vascular procedures. Moreover, 15 ofvascular patients will harbor occult CAD and will not demonstrate major markers of CAD such as recent MI, unstable or new onset angina, or poorly controlled left ventricular (LV) dysfunction. Accordingly, Eagle and coworkers analyzed cardiac events occurring in 200 consecutive...

Other Psychotropic Agents

Mirtazapine (Remeron) is a novel quadricyclic antidepressant agent that blocks pre- and postsynaptic a-2 receptors, as well as the serotonin receptors 5-HT2 and 5-HT3 (see Table 43-2). It also has the potentially beneficial 5-HT3 receptor antagonist effect on peripheral GI symptoms and should be considered in patients who complain of poor sleep, nausea, inability to gain weight, and diarrhea. In contrast to TCAs, it has low affinity for a1 receptor blockade. Mirtazapine has little interaction with acetylcholine receptors, but is a potent blocker of histamine receptors.

Ductal Drainage Operation

No risk of diabetes because little if any pancreatic tissue is resected. Pain is relieved in 85 of patients for the first several years. Most patients gain weight because they no longer experience pain with eating, although the degree of malabsorption does not change. The major drawback of this operation is that within 5 years, pain recurs in as many as 40 to 50 of patients. In a small number, this may be due to stricturing of the anastomosis, but in most, it is probably associated with disease progression or the development of a complication. Recurrence of pain may also herald the appearance of pancreatic cancer.

Screening and Referral

1 Age patient first became preoccupied with losing weight or feeling fat 2 Age of first dieting behavior At what weight BMI 8 Type of restricting (skipping meals, small meals, or narrowing food repertoire) Diet Pills BMI body mass index. BMI body mass index. tory should include careful questions about dieting and eating behavior, and screening for comorbid mood and substance abuse problems, because these often complicate the presentation of patients with eating disorders (see Table 381 for eating disorder-related questions we ask during an initial examination). Besides standard questions used to screen for eating disorder symptoms, we have found the following three questions to be sensitive in cases marked by denial of illness (1) How much would you like to weigh (desired weight) (2) Exactly what (and how much) did you eat yesterday and (3) in the case of excessive exercisers, If exercise did not burn calories how much time would you spend exercising Although emaciated anorectics will...

Postoperative Considerations

To 3 days after surgery, and enteral nutrition is begun as soon as tolerated. Feeding intolerance and vomiting usually indicate delayed gastric emptying, which may be functional (unknown etiology) or mechanical (reduced-size left lobe grafts impinge on the stomach). Problems with gastric emptying may respond to prokinetic medications or may require nasojejunal feeding. Diarrhea and failure to gain weight despite adequate caloric intake indicate malabsorption owing to a secondary digestive insufficiency, such as exocrine pancreatic insufficiency and hypoplastic villous atrophy. Some infants require immense amounts of formula ( 160 kcal kg d) to initiate weight gain. Finally, watery diarrhea, often with perianal irritation, can indicate carbohydrate malabsorption, which can be corrected by reducing the amount in the formula. More often, it indicates bile acid malabsorption. For posttransplantation diarrhea, we empirically administer a bile acid binding substance (aluminum hydroxide...

Normal Requirements Volume

Much is spoken about normal fluid requirements, although in truth there is no such thing. We are all aware as adults that if we drink little we do not get dehydrated and if we drink excessively we merely diurese. Healthy children's kidneys are just as capable of maintaining fluid balance. Fluids in neonates are often prescribed upon the basis of 150 ml kg day but this is not related to fluid needs but is merely the volume of standard formula milk required to give an adequate protein and calorie intake. What is required clinically is a simple means of prescribing fluid such that patients are maintained well

How Many Genes

What about the genes in worms or flies which increase longevity At first sight, they seem to play a critical role in the ageing process, because changing one gene can increase lifespan by as much as 50 . This is very much like taking a complex machine, changing one component, and then finding the machine lasts twice as long as before. With regard to organisms, all sorts of possibilities exist. For instance, we know that reducing calorie intake extends lifespan in rodents. It is fairly easy to imagine a mutation which simply reduces the efficiency of digestion, thereby decreasing the intake of calories, and thereby having the long term effect of increasing lifespan. Alternatively, we can easily envisage genes which reduce fertility, and allow more resources to be diverted to maintenance. There could be genes that slow down metabolic rate, reduce the production of ROS, and as a consequence there is less damage inflicted on proteins and DNA. All these possible changes, and probably many...

Secondary prevention of peripheral vascular disease

Effective reduction of the risk of cardiovascular disease depends on coordinated and stringent modification of identifiable risk factors to prevent progression or new disease and the use of drugs to correct existing abnormalities. Stopping smoking, correction of hyperlipidaemia and hypertension, and optimisation of diabetic control are the cornerstones of secondary prevention of cardiovascular disease. Lesser benefits are also likely to accrue through weight reduction in obese patients, the institution of regular exercise, and dietary modification. Additional risk factors have been identified but are uncommon and their treatment is of unproved value. Obesity

Relief of Foreign Body Airway Obstruction

Chest thrusts should be used for obese patients if the rescuer is unable to encircle the victim's abdomen (Class Indeterminate). If the choking victim is in the late stages of pregnancy, the rescuer should use chest thrusts instead of abdominal thrusts (Class Indeterminate). Because abdominal thrusts can cause injury,251-272 victims of FBAO who are treated with abdominal thrusts should be encouraged to undergo an examination by a physician for injury (Class IIb).

Behavioral Assessment

It is critical to gain a sense of the behavioral, as well as the medical aspects, of the patient's situation. This can be accomplished by referral to an appropriately skilled behavioral psychologist and or through your own discussions with the patient. First, it is important to assess not only specific behaviors, but also the impact of these behaviors and the obesity itself, on the patient's level of functioning and quality of life. It may only emerge with inquiry that the patient has withdrawn from all unnecessary social interactions, or is no longer able to enjoy certain activities or interests because of weight gain, or has suffered job discrimination, to name a few examples. Also related to quality of life are the patient's expectations about what changes will occur with successful weight control. Although it may be motivating for the patient to believe that life will improve with weight loss, disappointment may follow unless the changes likely to occur have been placed in proper...

Free Transverse Rectus Abdominis Myocutaneous Flap

And fat necrosis, and are inherent to the procedure's secondary blood supply and volume constraints.57'66'73-76'84-86 These complications may impose prolonged wound healing and considerable delay in the therapeutic sequence. Although the free TRAM procedure requires greater technical proficiency and a slightly longer operating time, the flap has unparalleled vascular reliability and versatility, and is the flap of choice in high-risk patients. These include obese patients, smokers, and those patients with prohibitive scars or who have had prior radiation treatment.73-76

Growth of Outpatient Surgery

Economic benefits aside, the major issue in the movement of surgical activities out of the hospital and into a more convenient and economical environment is how best to ensure that patients continue to receive safe, high-quality care. This consideration must in all circumstances be the primary issue underlying the planning of elective surgery. More and more, third-party payors expect surgical care to be provided to their clients (patients, to us) in a cost-effective environment. On the whole, this is not a bad thing. If, however, they also expect that surgical care can be provided just as cost-effectively to diabetic patients, morbidly obese patients, and patients with serious cardiac or respiratory disease, there is a real danger that patients' welfare could be compromised. Accordingly, it is crucial that all third parties who are not directly involved in the care of the patient permit the surgeon and the anesthesiologist to exercise sound medical judgment in regard to what type of...

Investigation of Venous Aetiology in Pseudotumor Cerebri Syndrome

Venous pressures should be measured for all segments of the venous sinuses including the SSS, torcular, transverse and sigmoid sinuses, jugular bulb, internal jugular vein and right atrium. Where a morphological obstruction has been demonstrated, the pressures proximal to, at and immediately distal to the stenosis are recorded. By pulling the catheter back across the stenosis under radiological control and recording the pressure simultaneously, a sudden fall in venous pressures is often recorded demonstrating the functional significance of the stenosis. By measuring right atrial pressures non obstructive venous hypertension can be demonstrated and is particularly relevant in the grossly obese patients.

Exercise and weight loss

BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters) BP, blood pressure HDL, high-density lipoprotein LDL, low-density lipoproteins mo, months. SI conversions to convert glucose to mmol L, multiply by 0.0555 HDL, LDL, and total cholesterol to mmol L, multiply by 0.0259 insulin to pmol L, multiply by 6.945 and triglycerides to mmol L, multiply by 0.0113. *For Atkins group, the actual numbers of records available were 31 at 2 months, 22 at 6 months, and 21 at 12 months for Zone group, 33 at 2 months, 26 at 6 months, and 26 at 12 months for Weight Watchers group, 33 at 2 months, 30 at 6 months, and 26 at 12 months for Ornish group, 29 at 2 months, 21 at 6 months, and 20 at 12 months. BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters) BP, blood pressure HDL, high-density lipoprotein LDL, low-density lipoproteins mo, months. SI conversions to convert glucose to mmol L, multiply by 0.0555 HDL, LDL,...

Alexandra L B WebbMD and Aaron S Fink Md Facs

This illness is more frequent in females the female to male ratio is 3 1 for patients under the age of 50 years and decreases to 1.5 1 after the age of 50 years. Acute cholecystitis is most common in the fourth to eighth decades of life and occurs with increased frequency in overweight patients as well as in those who are multiparous. Most patients who develop acute cholecystitis have a prior history of symptomatic cholelithiasis.

Interactions Between Food Energy Consumption Tumor Growth And Angiogenesis

A strong positive correlation between energy intake and the incidence or growth of tumors has been reported in virtually every animal model system evaluated (6,10,40,41). Many studies have shown that an imposed restriction of total food intake or energy inhibits tumorigenesis (Fig. 1 12). In addition, groups of mice or rats with free access to food, which is typical in most rodent studies, also show a striking positive correlation between self-selected energy intake and risk of cancer (Fig. 2 40,42,43). Recent examination of data derived from the National Toxicology Program shows that chemicals reducing body weight, and presumably reducing self-selected energy intake, are associated with a lower cancer risk (44). Subsequent studies show that energy intake can have a profound influence upon the sensitivity of the bioassays used to identify health risks from environmental chemicals and define regulatory policy (45). Fig. 1. The effects of high-fat or low-fat diets fed at controlled...

Lifestyle Modification in the Infertile Patient With PCOS

Obesity is a very common feature of women with PCOS, with an estimated prevalence of 35-63 among women with the disorder (3). Ghrelin homeostasis and measures of hunger and satiety are significantly impaired in subjects with PCOS, although not affected by dietary composition (4). Abdominal obesity, characterized by a waist-to-hip ratio of more than 0.8, has been reported in 63 of women with PCOS whether they are obese or not (5,6). Obesity, particularly abdominal, is often associated with insulin resistance and hyperinsulinemia, which stimulates the biosynthesis of androgens and the decreased hepatic production of sex hormone-binding globulin (SHBG). Other factors such as increased estrogen production rate, increased activity of the opioid system and of the hypothalamic-pituitary-adrenal axis, and, possibly, high dietary lipid intake may be mechanisms by which obesity worsens the degree of hyperandrogenism and ovulatory function in PCOS (7). Obesity is associated with a reduced chance...

Future Avenues Of Investigation

Address the alternative approaches to achieve and maintain weight loss in obese women with PCOS. It is also important to determine the predictors of response to lifestyle modification. The success rate of insulin-sensitizing agents for short-term reproductive outcomes is promising. Large, preferably multicenter randomized controlled studies investigating possible direct effects, optimal dose-finding studies, and treatment regimens under different conditions in different types of patients are warranted to optimize the efficacy of insulin-sensitizing agents and tailor treatment strategies to individual needs. Finally, the use of newer ovulatory agents, such as aromatase inhibitors, requires further study in large prospective randomized trials.

DNA Structure Inspires New Theories

However, many investigators were quick to realize that even though induced errors in protein synthesis had no effect on the rate of aging, other errors, involving replication or the repair of the DNA molecule, could still be an important, if not primary, cause of the aging process. Testing the revised catastrophe theory required detailed information about the gene, but at the time, there was no way to sequence DNA or to infer the sequence of messenger RNA. Throughout the 1960s, physicists were busy perfecting the electron microscope, which offered unparalleled resolution of cellular organelles and tissue ultrastructure. Consequently, many gerontologists turned their attention to refining the structural and biochemical analysis of age-related changes that was begun by scientists of the first epoch. These studies, carried out on the housefly, Drosophila, and mouse, introduced methods for modulating the life span of the organism. The life span of houseflies, for example, was tripled when...

Exposure and dissection of the splenic vein

The splenic vein is initially identified by a combination of palpation and vision. In an obese patient the vein may not be readily seen on the posterior surface of the pancreas, but it can always be felt. Initial dissection of the splenic vein is started where it is most easily seen or palpated. The goal is to mobilize all the overlying adventitia along the inferior and posterior surface of the splenic vein from the superior mesenteric vein to the splenic hilus.

Laparoscopic Cholecystectomy for Expanded Indications

With growing experience, surgeons are now successful in performing laparoscopic cholecystectomy on the majority of patients regardless of presentation. However, several clinical scenarios continue to provide challenging settings for the laparoscopic technique and controversies with regard to methods of treatment. Acute cholecystitis, gallstone pancreatitis, choledocholithiasis, hepatitis or cirrhosis with portal hypertension, previous abdominal surgery, severe obesity, sepsis, and pregnancy are areas where dramatic improvements have occurred. Patients with cirrhosis and portal hypertension remain a challenge for the surgeon to perform any surgical procedure. However, laparoscopic cholecystectomy can be performed safely and effectively in patients with Child's A or B cirrhosis. In addition, increased experience with laparo-scopic lysis of adhesions allows surgeons to successfully complete laparoscopic cholecystectomy in patients who have had previous surgical procedures. Obesity is no...

Does this patient have cachexia

A history and physical examination are probably the most useful tools in making the diagnosis and assessing response to therapy. Weight loss in the past six months should be recorded. Symptoms associated with reduced food intake (for example, loss of appetite, early satiety, nausea or vomiting, and alterations in taste or smell) are key warning signals. Weight should be measured and recorded along with height. Oedema and ascites are common and should be documented because fluid retention may mask the severity of underlying weight loss. Body mass index (weight (kg) height (m)2) should be calculated. A BMI

Managing Age Related Disorders

CARDIOVASCULAR DISEASE Cardiac output and the response of the heart to exercise decreases with age. Ventricular contractions become weaker with each decade, a problem that is compounded by the age-related reduction in blood vessel elasticity. Hardening of the arteries is the prime cause of hypertension in the elderly, but it is not an unavoidable consequence of aging. The first stage in managing hypertension and cardiovascular disease is a change in lifestyle. Clinical trials have shown that even the very old can benefit by this approach, which involves maintaining an ideal body weight, no smoking, regular aerobic exercises, and a diet consisting of fruits, vegetables, and low-fat dairy products (all of which are rich in essential potassium, calcium, and magnesium). If these procedures fail to reduce blood pressure, drugs such as thiazide, beta-blockers, or calcium channel blockers may be used, but the diet and exercise regimen should be maintained.

Restoration of Nutrition

Many patients with gastroparesis are nutritionally impaired by the time the diagnosis is firmly established. Even if the reduction in body mass index (BMI) is modest, dietary measures are usually tried first. A low fat, low fiber, soft diet with frequent small meals should be initiated and high caloric liquid supplements are often needed to maintain weight. Sometimes patients may have already adapted to their condition by adopting a mostly liquid diet. This can result in less vomiting than a normal diet would and cause the clinician to underestimate the severity of the disorder. If BMI continues to decline despite dietary measures with adequate medical therapy, the patient is having recurrent hospital admissions, not functioning outside the home, or is unable to maintain hydration, a jejunal feeding tube (jejunostomy or J -tube) may be required. These can be placed surgically, endoscopically, or radiologically, depending upon local expertise. J-tubes allow for nocturnal

Alcohol intake type of drink and risk of CHD events and mortality

+ adjusted for age, social class, smoking, physical activity, body mass index, lung function evidence of CHD on questionnaire, diabetes and regular medication. + adjusted for age, social class, smoking, physical activity, body mass index, lung function evidence of CHD on questionnaire, diabetes and regular medication.

Puncture wound with delay in presentation of wet necrotic foot

A 38-year-old male Afro-Caribbean patient with type 2 diabetes mellitus of 2 years' known duration, and a body mass index of 31, who had been lost to follow-up after his initial diagnosis, trod on a tin tack. This penetrated the sole of his shoe during his work as a school caretaker. He visited his general practitioner who prescribed a 5-day course of 250 mg amoxicillin tds. After 5 days the patient thought the foot had healed.

Prognostic Assessment

Include signs of peritonitis, shock, coma, and respiratory insufficiency. An admission hematocrit of 47 or pleural effusions may be a poor prognostic signs. Ranson's prognostic criteria are often used (Table 136-3). A score of a 6 is correlated with 60 mortality. Drawbacks include that it requires all 11 measures, takes 48 hours to evaluate and has a sensitivity and specificity for severe disease of 60 to 80 . The APACHE-II (Acute Physiological and Chronic Health Evaluation) is commonly used to score disease severity and uses 14 routinely measured parameters. It predicts severity in acute pancreatitis with a sensitivity and specificity of 70 to 80 (Wilson et al, 1990). A score 8 predicts severe disease. A major shortcoming is its complexity. Contrast enhanced CT dynamic scan is useful to document necrosis and fluid collections. Because necrosis progresses during the first 3 days of disease, we usually wait 48 to 72 hours after disease onset to perform a contrast-enhanced study. The CT...

Applied Epidemiology Sample Size and Power Estimation

Height, weight, body-mass index, blood pressure, cholesterol 4. Consider a cohort sampling approach for individual participants. As discussed earlier, this is a multifaceted trade-off that involves issues besides statistical power. But for outcomes that are relatively stable within individuals over time (such as body-mass index and serum cholesterol) and for study settings and durations that would yield low attrition in panels of individuals followed over time, cohort samples can offer significant power advantages (McKinlay 1994).

Concommitant Cocaine And Ethanol Consumption

20-32 years of age) of varied socioeconomic status in 1987, and then to evaluate the relationship between lifetime cocaine use in 1987 and cardiovascular disease risk factors 5 years later. The longitudinal design, the cardiovascular focus of CARDIA, and the inclusion of essentially healthy individuals at baseline, provided a unique opportunity to assess the cardiotoxicity of chronic cocaine use. Results of the CARDIA study indicate that lifetime cocaine use experience in 1987, after adjustment for age, ethnicity, daily alcohol intake, cigarettes smoked per day, body mass index, sum of skinfolds, physical activity, and other illicit drug use, was not related to blood pressure, blood pressure difference, heart rate, or hypertension prevalence in cross-sectional analysis in either men or women. Regarding the long-term, multivariate relationships between lifetime cocaine use experience in 1987 and blood pressure, blood pressure difference, and heart rate in 1992, the data from CARDIA...

Jnc Vi Life Style Modifications

Lose weight if overweight (2.4 g sodium or 6 g sodium chloride) Maintain adequate intake of dietary potassium (approximately 90 mmol d) Maintain adequate intake of dietary calcium and magnesium for general health Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

Influence of phytase on zinc bioavailability

Zinc is probably the most vulnerable mineral to phytate complexation. In early research in chicks, swine, rats and other species it was observed that dietary Zn requirement was affected by dietary phytate (Prasad, 1966). Oberleas and Harland (1996) suggest that it is imperative that much of the endogenously secreted minerals needs to be reabsorbed lest perpetual deficiencies result. Oberleas and Harland (1996) reported results that clearly showed that phytate was a significant factor in the development of zinc deficiency. The presence of Ca aggravated the effect of phytate on zinc utilization, probably through an insoluble Ca phytate Zn complex that is formed which prevents the absorption of Zn.

Post Surgery Syndromes

Post-surgery syndromes are another fruitful area for dietary therapy. No surgical intervention on the gut is without the potential for disturbing function, and when the disturbance is severe enough to produce symptoms, careful dietary management can improve matters substantially. Conditions in which food intolerance may aggravate symptoms include postvagotomy or postgastrectomy dumping syndrome, short bowel syndrome, ileostomy diarrhea, postresection diarrhea, and ileoanal pouch dysfunction. There are separate chapters on some of those situations.

Factors influencing phytase response

The dietary level of P influences the response to phytase (Dungelhoef and Rodehutscord, 1995 Kornegay and Qian, 1996 Kornegay, 1996a,b). Results of studies in pigs (Kornegay and Qian, 1996 Yi etal., 1996a), broilers (Denbow etal., 1995 Kornegay et al., 1996a) and turkeys (Ravindran et al., 1995a) clearly demonstrate that the response to microbial phytase is influenced by dietary levels of available or non-phytate P, and that digested P per unit of phytase decreases as the amount of phytase increases per unit of diet. Extremely high and low levels of dietary P should be avoided, to optimize the response to phytase.

Are there any medications that are available without a prescription to treat osteoporosis

Vitamins, minerals, and dietary supplements can be sold over the counter (OTC), that is, without a prescription. These products can be purchased in drug stores, health food stores, some department stores, and over the Internet. The FDA does not regulate OTC products as they do prescription medications. Because of this, certain claims can be made without clinical trials or scientific evidence to support the claims. Therefore, you should be aware of what you're buying and do some research in advance. The Consumer Labs Web site (www.consumerlabs.com) provides an excellent resource for the contents of many products containing vitamins, minerals, herbals, and dietary supplements. The Consumerlabs.com site reports the results of independent testing to evaluate manufacturer's claims and the presence of amounts of ingredients in the tested products.

Bulk Forming Laxatives

Dietary fiber and bulk laxatives with adequate fluid intake are the most physiologic and safest of medical therapies. However, they may be counterproductive in patients with idiopathic slow transit constipation or with constipation associated with irritable bowel syndrome (IBS) because they often worsen bloating and abdominal distension in these populations. Dietary Fiber Dietary fiber in cereals contain cell walls that resist digestion and retain water within their cellular structures, whereas those found in citrus fruits and legumes stimulate the growth of colonic flora and increase fecal mass. Wheat bran is the most effective fiber laxative with a clear dose response on fecal output. Patients with poor dietary habits may add 2 to 4 tablespoons of bran to each meal, followed by a glass of water or another beverage. A laxative effect may not be observed for 3 to 5 days. Patients should be cautioned that large amounts of bran can cause abdominal bloating or flatulence therefore, they...

Performance and carcass characteristics

Performance is the most important criterion from a practical point of view. It correlates more or less with fat digestibility but reflects also the described interactions between fat type and enzyme supplementation. In most experiments, liveweight gain and feed-to-gain ratio were improved to a greater extent by carbohydrase addition in broilers fed diets containing animal-originated fats (Table 9.5, Fig. 9.10). Although the interactions were not always significant they should not be neglected, since the tendency is obvious in most cases. As already shown for fat digestibility, carbohydrase effects depend on dietary concentration of soluble NSP (Fig. 9.5). Enzyme effects can be expected to be greater in birds fed animal fat and at higher concentrations of dietary soluble NSP. Total mortality (including losses by culling) depends also on fat type, carbohydrase addition and rye proportion (D nicke et al., 1999d). Mortality increased significantly with the introduction of rye into the...

Digestibility of protein and amino acids

The effect of intestinal viscosity on protein and amino acid digestibility is generally less dramatic than on digestibility of fat and fatty acids (Table 9.5). Digestibility of crude protein and that of some amino acids at the terminal ileum was decreased as dietary pentosan content was increased and significantly improved by xylanase addition (Fig. 9.9). No fat effect or interactions were detected at this site. In contrast, measurements made over the whole gastrointestinal tract showed significantly lower protein and amino acid digestibility values for tallow-fed birds, and significant greater enzyme effects in tallow-containing diets, especially in diets with higher pentosan concentrations (Fig. 9.9). Langhout et al. (1997) reported the Fig. 9.9. Praecaecal and faecal protein digestibility as influenced by rye proportion, dietary fat type and xylanase supplementation (D nicke et al., 1999e). Without xylanase,-- with xylanase,----- praecaecal, faecal, o. improvement in faecal...

Phytase and organic acids

The use of organic acids in combination with phytase to enhance the effectiveness of phytase has produced mixed results. It is known that the inclusion of organic acids in the diet will generally lower dietary pH (Kirchgessner and Roth, 1982 Giesting and Easter, 1985 Risley et al., 1992) with a resultant smaller effect on lowering the stomach pH (Risley et al., 1992 Radcliffe et al., 1998b). Also, it is well documented that there are two optimal pH values for maximizing microbial phytase activity 2.5 and 5.5 (Shieh etal., 1969 Simons etal., 1990) -with the activity about 50 greater at pH 5.5. Organic acids (fumaric and citric) have been reported to promote some improvement in the total tract apparent digestibility ofminerals (Hohler and Pallauf, 1993 Ravindran and Kornegay, 1993). Complexes are known to be formed between organic acids and various cations such as minerals, and these may result in increased intestinal absorption of minerals (Ravindran and Kornegay, 1993). Valencia and...

Management of constipation

The most important causes of constipation are immobility, poor fluid and dietary intake, and drugs, particularly opioids. Good general symptom control will minimise the first three of these, but most patients will require laxatives. The aim of laxative therapy is to achieve comfortable defecation, rather than any particular frequency of bowel movement. The choice of laxative depends on the nature of the stools, acceptability to the patient, and cost. Dose should be titrated against individual response. Clinically it is useful to divide laxatives into two groups

A twolevel statistical model

Xr ) has as distribution a mixture of k multivariate normal distributions, each corresponding to a macroregimen, or dietary pattern in our example. Thus the density can be written as A more complex model would include dependence of the s and the As on c. The interest of such a model is limited, although it could eventually be used to check the adequacy of the one we propose. The simpler model is of greater interest, especially for our dietary data example, because it allows identification of general patterns that are to be found in all centers albeit in different proportions. For instance, we may expect that the Mediterranean diet is not an exclusive characteristic of Mediterranean regions although more frequently encountered in these regions, it can be chosen as a way of eating normally, perhaps for health reasons, by people living in all areas of France, and indeed, of Europe.

Methionine And Cysteine

There have been several attempts to estimate the dietary requirements for methionine (Table 3) and each estimate has methodological limitations. The values for adults by Rose (1957) and Leverton et al. (1959) were based on early studies of essential amino acids and are derived from balance study data. Estimates were provided for methionine and combined methionine plus cysteine. The World Health Organization values (WHO, 1985) are more recent and give a single value for methionine plus cysteine. The National Research Council (NRC, 1989) adopted the WHO recommendations for their 1989 dietary guidelines. In the absence of adequate dietary cysteine, methionine must also provide the sulfur for cysteine synthesis. The presence of an adequate level of cysteine in the diet will reduce or spare about 30 of the requirement for methionine (NRC, 1989). However, cysteine cannot completely replace methionine and about 60 of the total requirement for methionine cysteine must be provided as...

Nutritional Deficiency

Patients with SB CD often develop specific nutritional deficits in addition to overall malnutrition. The use of EN or PN as CD therapy or nutritional support was discussed earlier. The most common problem is anemia, which is often multifactorial in etiology. Deficiency in iron, vitamin B12, and folate may contribute to the development of anemia. Etiologies for these deficiencies include chronic GI blood loss, inadequate dietary iron intake or absorption, vitamin Bi2 malabsorption secondary to terminal ileal disease or resection, and folate deficiency as a result of proximal SB disease or sulfasalazine therapy. These nutritional deficiencies should be sought out and appropriately supplemented. Another common nutritional problem in patients with SB CD is calcium and vitamin D deficiency. Calcium deficiency is usually caused by a combination of malabsorption from the SB disease and low dietary intake. Factors contributing to the development of vitamin D deficiency include inadequate...

Sources of information

Most research in the UK has focused on touch and mind-body therapies. Cancer organisations and charities have information on these therapies. There is little information available, however, on medicinal and nutritional approaches such as vitamin use and dietary supplements. Patients do use these products, often without the knowledge of their health professionals. Their use may be intended as complementary but the effects may not be. Further attention needs to be given to this issue with consideration of possible drug interactions and interference with orthodox treatment and educating patients to make informed decisions about their use.

Nutritional Management

A major complication of oral and esophageal diseases is decreased food intake. Dietary consultation with creative diet planning and choice may be quite beneficial in milder cases. Caloric supplementation with formula diets also may be helpful. In patients with local lesions that cannot be treated successfully or in refractory cases of anorexia, some form of nonvolitional feeding is required. Nutritional repletion has been reported in response to total parenteral nutrition (TPN) and to enteral feeding regimens. Nasoenteric tubes can be used, though there are problems with cooperation in long term use and there is the possibility of precipitating or exacerbating sinus disease. Percutaneous endoscopic gastrostomy feedings are efficacious and well tolerated by AIDS patients, and can be continued indefinitely.

Minerals and Vitamins

Minerals are inorganic elements that plants extract from soil or water and introduce into the food web. Vitamins are small dietary organic compounds that are necessary to metabolism. Neither is used as fuel, but both are essential to our ability to use other nutrients. With the exception of a few vitamins, these nutrients cannot be synthesized by the body and must be included in the diet. They are, however, required in relatively small quantities. Mineral RDAs range from 0.05 mg of chromium and selenium to 1,200 mg of calcium and phosphorus. Vitamin RDAs range from about 0.002 mg of vitamin B12 to 60 mg of vitamin C. Despite the small quantities involved, minerals and vitamins have very potent effects on physiology. Indeed, excessive amounts are toxic and potentially lethal.

Capsaisin Caffeine and Others

Other dietary components that may induce GI symptoms include capsaisin, caffeine, and various minerals. Capsaisin is the active ingredient in hot peppers and reacts with specific receptors in the mucosa that activate enteric sensory nerves. The physiological purpose of these receptors is not clear at the present time. Caffeine and other bioactive amines have pharmacological effects when ingested in milligram amounts. In addition to central nervous system effects, the co-editor of this text and his colleagues have shown that caffeine can increase intestinal chloride secretion by inhibiting phosphodiesterase, which may exaggerate diarrhea in patients with ileostomies and in those with IBS (Wald et al, 1976). Minerals such as calcium, aluminum, and iron tend to be constipating, whereas magnesium may cause diarrhea. Many patients ingest dietary supplements containing these elements and may not be aware of their effects on bowel fUnction. Finally, many patients ingest health foods which...

Gut morphology and microbial implications

Dietary fat type might also contribute to changes in intestinal morphology, as shown by Sagher et al. (1991), who found that feeding of maize oil and olive oil significantly increased villus height compared with a low-fat control diet, whereas feeding of butterfat significantly decreased villus height. The question of whether changes in intestinal viscosity interact with such a response remains unanswered. Table 9.3. Effects of dietary fat type (S, 10 soybean oil T, 10 beef tallow) and enzyme supplementation (-, without +, with 1 g Avizyme 1300 kg-1 diet) in a rye-based diet (56 dietary inclusion) on protein metabolism in male broilers (D nicke etal., 2000a,b). Table 9.3. Effects of dietary fat type (S, 10 soybean oil T, 10 beef tallow) and enzyme supplementation (-, without +, with 1 g Avizyme 1300 kg-1 diet) in a rye-based diet (56 dietary inclusion) on protein metabolism in male broilers (D nicke etal., 2000a,b). Table 9.4. Tissue-associated bacterial counts in different segments...

Management of Refractory Ascites

Refractory ascites is defined as ascites that cannot be mobilized by dietary sodium restriction and intensive diuretic treatment. The term refractory ascites includes two different subtypes (1) diuretic-resistant ascites and (2) diuretic-intractable ascites. Diuretic-resistant ascites cannot be mobilized because of a lack of response to dietary sodium restriction and intensive diuretic treatment. Diuretic-intractable ascites cannot be mobilized because of diuretic-induced complications precluding the use of an effective diuretic dosage. Diuretic-induced complications include hepatic encephalopathy, renal insufficiency, hyponatremia, and potassium disturbances (Arroyo et al, 1996). As discussed above, LVP results in rapid resolution of tense ascites. Serial LVP sessions remain the first line therapy for patients with refractory ascites. Albumin infusion is optional for LVP of over 5 L, but is not needed for paracentesis of lesser volume. Assuming serum and ascitic fluid sodium...

Conclusions And Research Needs

The impact of dietary Se status on As metabolism is of interest from both the standpoint of exposure potential and toxicity. Numerous studies have investigated As and Se interactions at the level of both effects on metabolism and toxicity in laboratory animals, but generally focusing on the effect of arsenic on Se-induced toxicities. Studies in humans have primarily focused on the correlation of As and Se levels in tissues and excreta in both apparently healthy populations and patients suffering from As-induced peripheral vascular disease (Lin and Yang, 1988 Wang, 1996 Del Razo et al., 2000). Relatively few investigations have been conducted in which dietary Se status has been examined as a potential modifier of As metabolism and toxicity in laboratory animals or humans. known to be important in the maintenance of intracellular redox balance, including TR and GPx (Hill, 1994 Holben and Smith, 1999). This is relevant to As in that oxidative stress is one of the hypothesized mechanisms...

Effects of phytase on improving the bioavailability of phosphorus

Phosphorus digestibility response equations were generated using 52 pig experiments representing 32 references in a review reported by Kornegay et al. (1998a). Also, 23 poultry experiments representing 13 references were used to generate P retention equations (Kornegay, 1999). Studies that had very high dietary P levels (NRC or above) for the negative control diets were excluded. Because of limited data, no attempt was made to separate and evaluate data by commercial inorganic phosphorus sources. Several equations were generated for the pig and poultry data sets with the upper levels of phytase varying from 600 to 800, 1000, 1200 or 1500 U kg-1 of diet. An evaluation was made of estimates of digestibility (or retention) of P calculated using each of these equations. Within the range of 100-600 U kg-1 for pigs and 200-800 U kg-1 for poultry, similar values were generally obtained for the various equations. It was decided to use the wider range of data, but equations for the upper level...

Triglyceride structure fatty acid positional effects

Another important point that adversely influences the digestibility of dietary fats is the positional distribution of the fatty acids at the glycerol molecule. Generally, high proportions of the LCSFAs at the 2-position are associated with an increased micellar solubility of these fatty acids in the form of the respective monoglycerides compared with their relative solubility when released as free fatty acids from the 1- and 3-positions by the action of the lipase. It has been shown that a relatively high proportion of the LCUSFAs in beef tallow (mainly oleic acid) are bound to the

Weight loss and anorexia

Simple dietary measures such as encouraging smaller, more frequent, meals may be helpful and a wide variety of nutritional supplements are available. Appetite stimulants such as megestrol acetate may be beneficial but weight gain is usually modest. Recombinant human growth hormone, although expensive, may partially reverse HIV-associated weight loss. In patients unable to tolerate oral feeding, enteral and parenteral feeding are alternative forms of nutrition but their efficacy and place in management are still being evaluated. Enteral nutrition offers a safer and cheaper alternative to total parenteral nutrition which is perhaps most useful in patients with severe diarrhoea, nausea, and vomiting, in whom fluid balance and control of symptoms has been difficult.

Inflammatory Bowel Disease

IBD is frequently associated with malnutrition. These patients are often hypermetabolic and may have anorexia due to nausea and abdominal pain. Dietary therapy in IBD has always been considered important. However, no one specific diet can be recommended. Fat restriction may be important in patients with ileal disease or those who have undergone an ileal resection. The use of EN is an important component of IBD therapy for those patients who cannot eat. EN has not proven superior to TPN or drug therapy in inducing remissions in IBD (Lochs et al, 1990). It is, however, less costly and associated with fewer complications. The use of PN in IBD should be restricted to those who have not responded to conservative medical therapy (EN and medications) or in whom EN cannot be delivered.

Enhancement of Absorption

Remaining segment is the provision of enteral feeding as soon as possible postoperatively. The presence of growth factors, such as epidermal growth factor in the salivary glands and esophagus, makes oral feeding preferable. However, except for certain patient groups, as discussed below, there is no need for either special diets or dietary restrictions. what is important is that the patient consume as much energy and nitrogen as they can. This may mean upwards of 4,000 to 6,000 kcal and 150 g of nitrogen daily psychological training to induce such hyperphagia may be required. Bolus feedings should always be avoided, and the patient should be instructed to graze throughout the day. Although initial nonblinded studies of glutamine and growth hormone use suggested improved adaptation and absorption, two recent double-blinded, placebo-controlled studies cast doubt on whether either has any potential influence on bowel adaptation in humans. Studies with glucagon-like peptide II are...

Diarrhea Unrelated to the Pouch

Thus, any of the infectious diarrheas must always be considered and excluded in patients with IPAA diarrhea. Moreover, patients lacking a colon are more sensitive to the fluid losses that accompany any common infectious diarrhea which increase fecal volumes. Thus, consideration must always be given to small bowel diseases, such as celiac sprue, lactase deficiency, CD of the proximal bowel, and bacterial overgrowth. If a positive diagnosis of a pouch-related cause cannot be made, etiologies outside the pouch must be sought. Chapter 56, Dietary-Induced Symptoms, has additional clues.

Constipation in Pregnancy

Dietary modifications, such as increased fluid and fiber intake, are the most physiologic and safest approachs to constipation during pregnancy. As with all patients, pregnant women should be warned that fiber can cause abdominal bloating or flatulence and that sufficient amounts of fluid should be consumed daily. Fiber supplements should be started with small amounts and gradually increased as tolerated.

Interview And Clinical Examination

Each participant was asked questions about the various symptoms, socioeconomic status, the dietary habits, addiction, past history of major illness, and history of parasitic infestation. A thorough clinical examination of each participant was carried out taking special care to detect skin pigmentation and keratosis, and enlargement of the liver. Specific symptoms like weakness, abdominal pain or nausea (suggesting affection of the alimentary system), tingling and numbness (paresthesia, suggestive of nervous system disorder) were also recorded.

Effectiveness of Microbial Phytase in Fish Diets

Feed ingredients of plant origin are being used in greater amounts in intensive fish farming. Like pigs and poultry, several species of fish utilize only one-third of the phytate P in plant feedstuffs. The addition of inorganic P is necessary to meet the P needs of the fish for normal growth. It has also been observed that high dietary phytate levels lead to depressed growth, feed intake and protein utilization, which may be a result ofphytate complexing with cations in the gastrointestinal tract so that Zn, protein and energy bioavailability are reduced (Spinelli etal., 1983 Richardson et al, 1985, 1986 McClain and Gatlin, 1988). In summary, microbial phytase is very effective in improving P availability of diets based on plant ingredients and can significantly reduce P excretion and accumulation in the water when dietary P levels are reduced. Because of very limited data where multiple levels of phytase were fed, it is not possible to derive a response curve for any measurement so...

Clinical Evidence of Cross Talk between Dyslipidemia and RAS Activation

O'Callaghan et al. 38 examined the effects of pravastatin in the setting of background antihypertensive therapy with ACE inhibitors and calcium antagonists. They treated 25 hypertensive hypercholesterolemic patients with 12 weeks of either pravastatin or placebo in this double-blind, placebo-controlled parallel group study. Placebo treatment did not alter plasma lipids, whereas 12 weeks of treatment with pravastatin reduced total cholesterol by 27 and LDL cholesterol by 35 . There was no change in systolic or diastolic blood pressure following 12 weeks of treatment or 3 weeks of withdrawal of pravastatin. Sposito et al. 39 demonstrated an additional effect of statins on blood pressure reduction by comparing patients receiving ACE inhibitors alone with those receiving these medications plus statins after 3 months of dietary intervention. Although blood pressure was similarly reduced at week 4, the statin-treated group had a greater reduction in blood pressure and total cholesterol...

Practical Aspects Of Radioactive Iodine Imaging And Therapy

Preparation of patients with thyroid hormone withdrawal and dietary iodine restriction is essential for optimal 131I imaging or therapy. For patients currently on thyroid hormone suppression therapy, the T4 is withdrawn for 4 to 6 weeks with a substitution of triiodothyronine (T3) for 2 to 3 weeks. Then T3 is discontinued and the patient is placed on a low-iodine diet ( 50 pg d) for 1 to 2 weeks prior to the 131I uptake and scan study. This regimen will allow 90 of patients to achieve a serum TSH concentration 30 mU L to stimulate iodide uptake by residual thyroid tissue. It usually takes 6 to 12 months after initial therapy for 131I to achieve maximal effects. Serum TSH and Tg concentrations may be measured every 3 months during this period. The 131I diagnostic scan is repeated at the end of the year after adequate thyroid hormone withdrawal and dietary iodine restriction. If there is uptake in the neck or the body or if serum Tg is 5 ng mL when the patient is hypothyroid, a repeat...

In the cardiovascular system

Much evidence has accumulated from various lines of inquiry that indicates that the dietary fatty acid intake and lipid acyl composition of tissues is a determinant of many of the chronic diseases prominent in the Western World, notably cardiovascular disease. It has been appreciated since the 1950s that when dietary polyunsaturated fat intake is increased, a decrease in the total serum and lipoprotein cholesterol levels results 1 . Bang and Dyerberg, in their study of the Greenland Eskimos, a group in which CVD had an extremely low incidence, made the ground breaking inference that the high dietary intake of the long chain polyunsaturated fatty acids, eicosapentanoate and docosahexaenoate was responsible for this protection from disease 2 , More recently, several epidemiological studies have reported a relationship between dietary n-3 polyunsaturates and the risk of CVD 3-8 , For example, Dolechek et al. found an inverse relationship between alpha-linolenate and mortality from CVD,...

Management of Patients with Cirrhosis and Ascites

Positive sodium balance causes ascites formation. To achieve negative sodium balance, sodium output must exceed intake. in the absence of diuretics, many patients with cirrhosis and ascites have almost no urinary sodium excretion. Reducing dietary sodium intake below total output leads to a reduction in fluid volume and weight in these patients. Instituting a low-sodium diet maximizes urinary excretion and fluid loss. Thus, sodium restriction to 2 g (ie, 88 mmol) d is warranted in all patients with cirrhosis and ascites (Bernardi et al, 1993). Ascites may improve with discontinuation of the precipitating agent, such as saline infusions given perioperatively or as resuscitative measures during gastrointestinal (GI) bleeding. loss and a negative sodium balance in approximately 90 of patients. In contrast, patients who are gaining fluid weight during treatment may either be noncompliant with the diet or diuretic-resistant. Monitoring urinary sodium excretion allows assessment of dietary...

The Mediterranean Diet Meltdown

The Mediterranean Diet Meltdown

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