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By J. Kent. Texas Christian University. 2019.

Worryingly cheap hyzaar 12.5 mg mastercard, approximately 22 million children under the age of five years are obese cheapest hyzaar. While affecting every country discount 50 mg hyzaar amex, overweight and obesity in children are particularly common in North America 50mg hyzaar visa, the United Kingdom, and south-western Europe. In Malta and the United States, over a quarter of children aged 10–16 years are overweight. In the United Kingdom, the prevalence of overweight in children aged 2 to 10 years rose from 23% to 28% between 1995 and 2003. The first cases of type 2 diabetes in young people were recognized in the United States in the 1970s. Fifteen years ago, they accounted for less than 3% of all cases of new-onset diabetes in children and adolescents, whereas today they account for up to 45% of new-onset cases. Subsequent studies con- ducted in Asia and Europe have revealed a similar pattern, and, more recently, reports on type 2 diabetes in children and adolescents have begun to mount worldwide (3). A key lesson from many wealthy countries is Accumulation ofAccumulation of that it is possible to delay deaths chronic disease riskchronic disease risk from chronic diseases by sev- eral decades, thereby avoiding deaths among middle-aged people. Successful interven- tions in middle and older age will Age reap major short-term benefits. In the longer term, interventions early in life have the potential to reduce substantially the chronic disease pandemic. Globalization refers to the increasing interconnectedness of countries and the openness of borders to ideas, people, commerce and financial capital. Globalization drives chronic disease population risks in complex ways, both directly and indirectly. The health-related advantages of glo- balization include the introduction of modern technologies, such as infor- mation and communication technologies for health-care systems. The negative health-related effects of globalization include the trend known as the “nutrition transition”: populations in low and middle income countries are now consuming diets high in total energy, fats, salt and sugar. The increased consumption of these foods in these countries is driven partly by shifts in demand-side factors, such as increased income and reduced time to prepare food. Supply-side determinants include increased production, promotion and marketing of processed foods and those high in fat, salt and sugar, as well as tobacco and other products with adverse effects on population health status. A significant proportion of global marketing is now targeted at children and underlies unhealthy behaviour. The widespread belief that chronic diseases are only “diseases of afflu- ence” is incorrect. Chronic disease risks become widespread much earlier in a country’s economic development than is usually realized. For example, population levels of body mass index and total cholesterol increase rapidly as poor countries become richer and national income rises. They remain steady once a certain level of national income is reached, before eventually declining (see next chapter) (4). In the second half of the 20th century, the proportion of people in Africa, Asia and Latin America living in urban areas rose from 16% to 50%. Urbanization creates conditions in which people are exposed to new products, technologies, and marketing of unhealthy goods, and in which they adopt less physically active types of employment. Unplanned urban sprawl can further reduce physical activity levels by discouraging walking or bicycling. As well as globalization and urbanization, rapid population ageing is occurring worldwide. The total number of people aged 70 years or more worldwide is expected to increase from 269 million in 2000 to 1 billion 51 in 2050. High income countries will see their elderly population (defined as people 70 years of age and older) increase from 93 million to 217 million over this period, while in low and middle income countries the increase will be 174 million to 813 million – more than 466%. The general policy environment is another crucial determinant of popula- tion health. Policies by central and local government on food, agricul- ture, trade, media advertising, transport, urban design and the built environment shape opportunities for people to make healthy choices. In an unsupportive policy environment it is difficult for people, especially those in deprived populations, to benefit from existing knowledge on the causes and prevention of the main chronic diseases. Chronic disease risk factors are a leading cause of the death and dis- ease burden in all countries, regardless of their economic development status. The leading risk factor globally is raised blood pressure, followed by tobacco use, raised total cholesterol, and low fruit and vegetable consumption. The major risk factors together account for around 80% of deaths from heart disease and stroke (5). Further analyses using 2002 death estimates show that among the nine selected countries, the proportion of deaths from all causes of disease attributable to raised systolic blood pressure (greater than 115 mm Hg) is highest in the Russian Federation with similar patterns in men and women, representing more than 5 million years of life lost. Chronic diseases: causes and health impacts Percent attributable deaths from raised blood pressure by country, all ages, 2002 40 35 30 25 20 15 10 5 0 Brazil Canada China India Nigeria Pakistan Russian United United Federation Kingdom Republic of Tanzania The proportion of deaths attributed to raised body mass index (greater than 21 kg/m2) for all causes is highest in the Russian Federation, accounting for over 14% of total deaths, followed by Canada, the United Kingdom, and Brazil, where it accounts for 8–10% of total deaths. Percent of attributable deaths from raised body mass index by country, all ages, 2002 16 14 12 10 8 6 4 2 0 Brazil Canada China India Nigeria Pakistan Russian United United Federation Kingdom Republic of Tanzania The estimates of mortality and burden of disease attributed to the main modifiable risk factors, as illustrated above, show that in all nine countries raised blood pressure and raised body mass index are of great public health significance, most of all in the Russian Federation. Maps of the worldwide prevalence of overweight in adult women for 2005 and 2015 are shown opposite. If current trends continue, average levels of body mass index are projected to increase in almost all countries. The largest 20052005 20102010 20152015 70 increase is projected to 60 be in women from upper 50 middle income countries. The highest 0 projected prevalence of Brazil Canada China India Nigeria Pakistan Russian United United overweight in women in Federation KingdomKingdom Republic of Tanzaniaof Tanzania the selected countries * Body mass index in 2015 will be in Brazil, followed by the United Kingdom, the Russian Federation and Canada. In general, deaths from chronic diseases are projected to increase between 2005 and 2015, while at the same time deaths from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies combined are projected to decrease. The projected increase in the burden of chronic diseases worldwide is largely driven by population ageing, supplemented by the large numbers of people who are now exposed to chronic disease risk factors. There will be a total of 64 million deaths in 2015: » 17 million people will die from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies combined; » 41 million people will die from chronic diseases; » Cardiovascular diseases will remain the single leading cause of death, with an estimated 20 million people dying, mainly from heart disease and stroke; » Deaths from chronic diseases will increase by 17% between 2005 and 2015, from 35 million to 41 million. There is abundant evidence of how the use of existing knowledge has led to major improvements in the life expectancy and quality of life of middle-aged and older people. Yet as this chapter has shown, approximately four out of five chronic disease deaths now occur in low and middle income countries. People in these countries are also more prone to dying prematurely than those in high income countries. The results presented in this chapter suggest that a global goal for preventing chronic disease is needed to generate the sustained actions required to reduce the disease burden. The target for this proposed goal is an additional 2% reduction in chronic disease death rates annually over the next 10 years to 2015. The indicators for the measurement of success towards this goal are the number of chronic disease deaths averted and the number of healthy life years gained. This target was developed based on the achievements of several coun- tries, such as Poland, which achieved a 6–10% annual reduction in cardiovascular deaths during the 1990s (8). Similar results have been realized over the past three decades in a number of countries in which comprehensive programmes have been introduced, such as Austra- lia, Canada, New Zealand, the United Kingdom, and the United States (9–11). This global goal aims to reduce death rates in addition to the declines already projected for many chronic diseases – and would result in 36 million chronic disease deaths averted by 2015. This represents an increase of approximately 500 million life years gained for the world over the 10-year period. Cardiovascular diseases and cancers are the diseases for which most deaths would be averted. Most of the deaths averted from specific chronic diseases would be in low and middle income countries as demonstrated by the top figure, opposite (12). Chronic diseases: causes and health impacts Projected cumulative deaths averted by achieving the global goal, by World Bank income group, 2006–2015 40 Low and middle income countries High income countries 35 30 25 20 15 10 5 0 Chronic Cardiovascular Cancer Chronic Diabetes diseases diseases respiratory diseases Every death averted is a bonus, but the goal contains an additional positive feature: almost half of these averted deaths would be in men and women under 70 years of age (see figure below). Extending their lives for the benefit of the individuals concerned, their families and communities is in itself the worthiest of goals. It also supports the overall goal of chronic disease prevention and control, which is to delay mortality from these diseases and to promote healthy ageing of people everywhere. Chronic disease deaths, projected from 2005 to 2015 and with global goal scenario, for people aged 70 years or less 20 2005 2015 baseline 2015 global goal 18 16 14 12 10 8 6 4 2 0 Chronic Cardiovascular Cancer Chronic Diabetes diseases diseases respiratory diseases This goal is ambitious and adventurous, but it is neither extravagant nor unrealistic.

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Various saturated fatty acids are also associated with proteins and are necessary for their normal function hyzaar 50mg online. Fats in general generic 50 mg hyzaar otc, including saturated fatty acids order hyzaar 12.5mg without a prescription, play a role in providing desirable texture and palatability to foods used in the diet safe 50 mg hyzaar. Palmitic acid is particularly useful for enhancing the organoleptic properties of fats used in commercial products. Stearic acid, in contrast, has physical properties that limit the amount that can be incorporated into dietary fat. Monounsaturated fatty acids are present in foods with a double bond located at 7 (n-7) or 9 (n-9) carbon atoms from the methyl end. Monounsaturated fatty acids that are present in the diet include: • 18:1n-9 Oleic acid • 14:1n-7 Myristoleic acid • 16:1n-7 Palmitoleic acid • 18:1n-7 Vaccenic acid • 20:1n-9 Eicosenoic acid • 22:1n-9 Erucic acid Oleic acid accounts for about 92 percent of dietary monounsaturated fatty acids. Monounsaturated fatty acids, including oleic acid and nervonic acid (24:1n-9), are important in membrane structural lipids, particularly nervous tissue myelin. Other monounsaturated fatty acids, such as palmitoleic acid, are present in minor amounts in the diet. Linoleic acid is the precursor to arachidonic acid, which is the substrate for eicosanoid production in tissues, is a component of membrane structural lipids, and is also impor- tant in cell signaling pathways. Dihomo-γ-linolenic acid, also formed from linoleic acid, is also an eicosanoid precursor. Arachidonic acid and other unsaturated fatty acids are involved with regulation of gene expression resulting in decreased expres- sion of proteins that regulate the enzymes involved with fatty acid synthesis (Ou et al. This may partly explain the ability of unsaturated fatty acids to influence the hepatic synthesis of fatty acids. This group includes: • 18:3 α-Linolenic acid • 20:5 Eicosapentaenoic acid • 22:5 Docosapentaenoic acid • 22:6 Docosahexaenoic acid α-Linolenic acid is not synthesized by humans and a lack of it results in adverse clinical symptoms, including neurological abnormalities and poor growth. Trans Fatty Acids Trans fatty acids are unsaturated fatty acids that contain at least one double bond in the trans configuration. The trans double-bond configura- tion results in a larger bond angle than the cis configuration, which in turn results in a more extended fatty acid carbon chain more similar to that of saturated fatty acids rather than that of cis unsaturated, double-bond– containing fatty acids. The conformation of the double bond impacts on the physical properties of the fatty acid. Those fatty acids containing a trans double bond have the potential for closer packing or aligning of acyl chains, resulting in decreased mobility; hence fluidity is reduced when compared to fatty acids containing a cis double bond. Partial hydrogena- tion of polyunsaturated oils causes isomerization of some of the remaining double bonds and migration of others, resulting in an increase in the trans fatty acid content and the hardening of fat. Hydrogenation of oils, such as corn oil, can result in both cis and trans double bonds anywhere between carbon 4 and carbon 16. In addition to these isomers, dairy fat and meats contain 9-trans 16:1 and conjugated dienes (9-cis,11-trans 18:2). The trans fatty acid content in foods tends to be higher in foods containing hydrogenated oils (Emken, 1995). There is limited evidence to suggest that the trans-10,cis-12 isomer reduces the uptake of lipids by the adipocyte, and that the cis-9,trans-11 isomer is active in inhibiting carcino- genesis. Similarly, there are limited data to show that cis-9,trans-11 and trans-10,cis-12 isomers inhibit atherogenesis (Kritchevsky et al. Dietary fat undergoes lipolysis by lipases in the gastro- intestinal tract prior to absorption. Although there are lipases in the saliva and gastric secretion, most lipolysis occurs in the small intestine. The hydrolysis of triacylglycerol is achieved through the action of pancreatic lipase, which requires colipase, also secreted by the pancreas, for activity. In the intestine, fat is emulsified with bile salts and phospholipids secreted into the intestine in bile, hydrolyzed by pancreatic enzymes, and almost completely absorbed. Pancreatic lipase has high specificity for the sn-1 and sn-3 positions of dietary triacylglycerols, resulting in the release of free fatty acids from the sn-1 and sn-3 positions and 2-monoacylglycerol. These products of digestion are absorbed into the enterocyte, and the triacyl- glycerols are reassembled, largely via the 2-monoacylglycerol pathway. The triacylglycerols are then assembled together with cholesterol, phospholipid, and apoproteins into chylomicrons. Following absorption, fatty acids of carbon chain length 12 or less may be transported as unesterified fatty acids bound to albumin directly to the liver via the portal vein, rather than acylated into triacylglycerols. Dietary phospholipids are hydrolyzed by pancreatic phospholipase A2 and cholesterol esters by pancreatic cholesterol ester hydrolase. The lyso- phospholipids are re-esterified and packaged together with cholesterol and triacylglycerols in intestinal lipoproteins or transported as lysophospholipid via the portal system to the liver. These particles enter the circulation and within the capillaries of muscle and adipose tissue. Chylomicrons come into contact with the enzyme lipo- protein lipase, which is located on the surface of capillaries. Most of the fatty acids released in this process are taken up by adipose tissue and re-esterified into triacylglycerol for storage. Triacylglycerol fatty acids also are taken up by muscle and oxidized for energy or are released into the systemic circulation and returned to the liver. Most newly absorbed fatty acids enter adipose tissue for storage as triacylglycerol. However, in the postabsorptive state or during exercise when fat is needed for fuel, adipose tissue triacylglycerol under- goes lipolysis and free fatty acids are released into the circulation. Hydrolysis occurs via the action of the adipose tissue enzyme hormone-sensitive lipase. When plasma insulin concentrations fall in the postabsorptive state, hormone-sensitive lipase is activated to release more free fatty acids into the circulation. Thus, in the postabsorptive state, free fatty acid concentrations in plasma are high; conversely, in the postprandial state, hormone-sensitive lipase activity is suppressed and free fatty acid concentrations in plasma are low. When free fatty acid concen- trations are relatively high, muscle uptake of fatty acids is also high. As in liver, fatty acids in the muscle are transported via a carnitine-dependent pathway into mitochondria where they undergo β-oxidation, which involves removal of two carbon fragments. These two carbon units enter the citric acid cycle as acetyl coenzyme A (CoA), through which they are completely oxidized to carbon dioxide with the generation of large quantities of high- energy phosphate bonds, or they condense to form ketone bodies. However, the uptake of fatty acids in excess of the needs for oxidation for energy by muscle does result in temporary storage as triacylglycerol (Bessesen et al. High uptake of fatty acids by skeletal muscle also reduces glucose uptake by muscle and glucose oxidation (Pan et al. Oxidation of fatty acids containing up to 18 carbon atoms occurs mainly in the mito- chondria. Oxidation of excess fatty acids in the liver, which occurs in pro- longed fasting and with high intakes of medium-chain fatty acids, results in formation of large amounts of acetyl CoA that exceed the capacity for entry to the citric acid cycle. During starvation or prolonged low carbohy- drate intake, ketone bodies can become an important alternate energy substrate to glucose for the brain and muscle. High dietary intakes of medium-chain fatty acids also result in the generation of ketone bodies. This is explained by the carnitine-independent influx of medium-chain fatty acids into the mitochondria, thus by-passing this regulatory step of fatty acid entry into β-oxidation. Fatty acids of greater than 18 carbon atoms require chain shortening in peroxisomes prior to mitochondrial β-oxidation. The major pathway for triacylglycerol synthesis in liver is the 3-glycerophosphate pathway, which shows a high degree of specificity for saturated fatty acids at the sn-1(3) position and for unsaturated fatty acids at the sn-2 position. Fatty acids are generally catabolized entirely by oxidative processes from which the only excretion products are carbon dioxide and water. Small amounts of ketone bodies produced by fatty acid oxidation are excreted in urine. Fatty acids are present in the cells of the skin and intestine, thus small quantities are lost when these cells are sloughed. When saturated fatty acids are ingested along with fats con- taining appreciable amounts of unsaturated fatty acids, they are absorbed almost completely by the small intestine. In general, the longer the chain length of the fatty acid, the lower will be the efficiency of absorption. Studies with human infants have shown the absorption to be 75, 62, 92, and 94 percent of palmitic acid, stearic acid, oleic acid, and linoleic acid, respectively, from vegetable oils (Jensen et al. The absorption of palmitic acid and stearic acid from human milk is higher than from cow milk and vegetable oils (which are commonly used in infant formulas) because of the specific positioning of these long-chain saturated fatty acids at the sn-2 position of milk triacylglycerols (Carnielli et al. The intestinal absorption of palmitic acid and stearic acid from vegetable oils was 75 to 78 percent compared with 91 to 97 percent from fats with these fatty acids in the sn-2 position (Carnielli et al.

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Interestingly discount 50 mg hyzaar with amex, he asserts that it is women who say they ‘‘have their womb in their stomach’’ or in their throat or at their heart order hyzaar paypal. It was a gen- eral medical assumption throughout most of the medieval period that women needed regular sexual activity in order to remain healthy cheap 50 mg hyzaar mastercard. Indeed order hyzaar 50 mg free shipping, Soranus’s distinctive views on sexu- ality were suppressed when Muscio’s Gynecology was twice readapted to new uses in or before the eleventh century. Johannes Platearius went farther than Conditions of Women in reincorporating the traditional Hippocratic recommendation of sex and marriage as suitable, even preferable cures: ‘‘If [the disease] occurs because of corrupt semen, let her know her husband. This is, nevertheless, one of the first acknowledgments by a medical writer of a category of Christian women who were chaste not by force of circumstance but by individual choice. Although not produced at the same time as the Trotula text found within this manuscript, these images do offer vivid evidence of how medical theory and practice may have been played out. First, on the top of the recto side of folio , we see the woman falling in a seizure; the dog with her signifies that she is of noble status, though it perhaps also indicates that she has only her pet to keep her company. In the upper half of the verso page, we see her as if dead, already laid out on a bier while her servants, apparently, mourn her death. The bowl on her chest points to an amplification that Platearius made on the Viaticum’s text when he suggested that the woman’s condition could be determined by either a flock of wool placed to the nose or a glass bowl placed on the chest. Just as the wool would move slightly with her breath, so the water in the bowl would, by its slight vibrations, show that she was still alive. Illustrations of a case of uterine suffocation from a late thirteenth- century English manuscript. The final frame depicts the kinds of women most susceptible to uterine suffocation: widows (note the prayer- book falling from the hand of the veiled woman) and virgins who have just reached the age of marriage. Here we also get an additional mode of treat- ment: the female attendant is holding a bone to the nose of the older woman. Although burnt bones were mentioned in neither Conditions of Women nor Platearius, various kinds of burnt substances—because of their stench—were usually recommended for application to the nose. Odoriferous therapy was still the basis of treatment for uterine suffoca- tion, and the associative links it had with the notion of uterine movement seem to have been strong. As we saw earlier, Soranus had vehemently rejected odor- iferous therapy as nonsensical and harmful, and his views, even if somewhat attenuated, were carried into Latin in the late antique Latin translations. Yet use of odoriferous therapy persisted in almost all other gynecological texts in the early Middle Ages, so much so that it is not really surprising to find that the compiler who abbreviated Muscio’s Gynaecia in the eleventh century or so put odoriferous therapy back into the text. The inclusion of odor- iferous therapy for prolapse is particularly notable, since it was not found in the Viaticum. Indeed, the author of Conditions of Women thought it so impor- tant that, uncharacteristically, he situated it before the therapies offered by Ibn al-Jazzār. The notion of ‘‘revulsion’’ dictated that blood was to be drawn off from a vein quite distant from the affected part. The objective was to force the flow of blood in a direction in which it was not accustomed to flowing. In all three Introduction  cases, blood is drawn from the saphenous vein under the arch of the foot in order to reorient the body’s bloodflowdown toward the uterus,which is where it normally should flow. The employment of cupping glasses—used for exces- sive menstruation (¶) and suffocation (¶)—has a similar rationale as that of phlebotomy. In both cases, the suction created on the surface of the skin by the cupping glass pulls blood toward that area. In the first instance, however, cupping glasses are applied near the breasts in order to encourage bloodflow away from the uterus, since it is clearly in excessive abundance there. In the sec- ond case, cupping glasses are applied to the groin to encourage menstrual flow downward. Finally, scarification (the superficial incision of the skin) works on the same principle, though, like cupping glasses, it produces a less intensive effect than phlebotomy. It is mentioned only once in Conditions of Women,as an alternate therapy for menstrual retention (¶). These were not simply used to di- rect odors to thevagina and womb, but were also a means of introducing medi- cations for menstrual retention (¶), a retained afterbirth (¶), and uterine pain (¶). The variety of fumigation pots and stools depicted in a fifteenth- century Dutch translation of the Trotula (fig. Again, the late medieval Dutch manuscripts are the only ones to offer us depictions of pessaries (fig. The late twelfth- or early thirteenth-century writer Roger de Baron gives a particu- larly well-articulated rationale for the use of pessaries: ‘‘Just as. For to the degree that the former organs are remote from the organs of nutrition and to the degree that substances coming to the bowels are weak- ened in strength in proportion to their remoteness, not only by the length of the distance [they have to travel] but also by the narrowness of the passages, to thatdegreetheyhavenoefficacy. We have seen in this extended analysis of menstrual disorders and uterine Figures  and . Depictions of fumigation pots and pessaries from a fifteenth-century Dutch translation of the Trotula. These same principles of physiology, pathology, and appro- priate therapeutic intervention guide the rest of the text. Aside from a brief discussion of excessive heat in the womb (¶), the next group of chapters —swellings or tumors (apostemes) from various humoral causes (¶¶–), wounds of the womb and vagina (¶¶–), and itching of the vagina (¶¶– )—derive their substance from the Viaticum. The man’s seed, in turn, may itself be too thin and liquidy, or his testicles may be so cold that he cannot generate seed. A test is then offered to determine whether the cause lies with the man or the woman (¶). Inter- estingly, infertility in either partner is considered incurable; it is only if neither partner is found to be sterile that medical aids are deemed to be in order. Five recipes are then provided, sometimes for the woman alone, sometimes for the man and woman together. Neither here nor in the vast majority of medieval medical texts are there any explicit instructions on how to conceive females. Those that this author advocates, interestingly, all rely on amulets or sympa- thetic magic (¶¶–), which derive from the author’s alternate source, the Book on Womanly Matters. It is notable that there is no reference here to any of the many herbs of presumed contraceptive or abortifacient properties de- scribed in a variety of readily available pharmacological texts. From the Viati- cum the author draws discussions of the causes of miscarriage (¶), care of the pregnant woman (¶a; ¶ in the present edition), common disorders of pregnancy (¶¶b and c; in the present edition, ¶¶ and , respectively), followed by a brief statement on the process of birth itself (¶), then aids for difficult birth (¶¶–). Then, perhaps referring to Muscio’s Gynecology,the author adds the specific instruction that ‘‘the women who assist her ought not look her in the face, for many women are ashamed to be looked upon dur- ing birth’’ (¶). These, in turn, are followed by twelve remedies for ex- tracting the fetus that has died in utero (¶¶–). Recipes for removing the afterbirth (¶¶– and –) and treating postpartum pain (¶) follow, while a test to determine the sex of the fetus closes the text (¶¶–). Some of these obstetrical remedies derive from the Viaticum, though many of the rest reflect traditional practices, some of them magical, some strictly herbal. These consisted of both prenatal procedures and instruc- tions for attendance at the birth itself. Sneezing is to be induced; potions are to be prepared; a magnet is to be held in the hand; coral is to be suspended from the neck; the white substance found in the dung of a hawk is to be drunk, as are the washings from the nest and a stone found in the belly of a swallow. Here, too, we find the explicit statement that ‘‘the womb follows sweet smells and flees foul ones. The Book on the Conditions of Women is very much the offspring of Greco- Roman and Arabic medicine. Although by no means slavish in its adherence to the Viaticum or its other sources, the points on which it diverges from its textual models are for the most part themselves reflections of the survival of certain ancient medical notions (the concept of uterine movement being the most prominent) through a probable combination of oral and literate trans- mission. The only distinctive indication that Conditions of Women is the prod- uct of a Christian culture is the prologue (¶¶–). A recasting of the creation story of Genesis (:– and :) into Galenic physiological terms, the pro- logue explains how woman’s subjugation to man allows reproduction to take place, which in turn is the chief cause of illness in the female body. The au- thor recasts Galen’s original view of man as the perfect standard (from which women then deviate) into a case of equal divergence of both men and women from a temperate mean. Lest the man tend too strongly toward his natural state of hotness and dryness,God desired that the male’s excess be restrained by the opposite qualities of the female, coldness and wetness. The author nevertheless leaves no doubt that this mutual ‘‘tempering’’ is not really a balancing out of equal oppo- sites: the man is ‘‘the more worthy person’’; heat and dryness are ‘‘the stronger qualities. A  charm from a fifteenth-century medical amulet (bottom row, left of center).

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Soft drink intake was negatively associated with achieving rec- ommended vitamin A intake in all age groups cheap hyzaar 12.5 mg with mastercard, calcium in children younger than 12 years of age order hyzaar overnight, and magnesium in children 6 years of age and older buy hyzaar 12.5mg with visa. Others have shown that children who consumed milk at the noon meal had the highest daily intakes of vitamin A purchase hyzaar with amex, vitamin E, calcium, and zinc, whereas the opposite was true for children who consumed soft drinks and tea (Johnson et al. Hence, beverages that are major contributors of the naturally occurring sugars, such as lactose and fructose, in the diet (e. The findings from three surveys on the relationship between total sugars intake and micronutrient intake in children are mixed (Table 11-6). Gibson (1993) did not observe reduced micronutrient intakes when total sugars intake exceeded 25 percent of energy. A linear reduction in several micronutrients was observed with increasing total sugars intake (Farris et al. High Fat, Low Carbohydrate Diets of Children Risk of Obesity In the United States and Canada, there is evidence that children are becoming progressively overweight (Flegal, 1999; Gortmaker et al. Furthermore, Serdula and coworkers (1993) reviewed a number of longitudinal studies with vary- ing cut-off levels for obesity and concluded that 26 to 41 percent of obese preschool children and 42 to 63 percent of obese school-age children became obese adults. Clinical evidence of disease associated with excess body weight, reduced physical activity, or high dietary fat intakes, however, are generally absent. The evidence for a role of dietary fat intakes in pro- moting higher energy intakes and thus promoting obesity in young chil- dren is conflicting. A positive trend in energy intake was associated with an increased percent of energy from fat for children up to 8 years of age (Boulton and Magarey, 1995). A positive correlation between fat intake and fat mass has been reported for boys 4 to 7 years of age (Nguyen et al. However, several studies showed a positive correlation between dietary fat intake and body fatness in children 8 to 12 years of age (Maffeis et al. The average fat intake of nonobese children was measured to be 31 to 34 percent for children 9 to 11 years old, whereas the average fat intake of obese children was 39 percent of energy (Gazzaniga and Burns, 1993). A positive association between fat intake and several adiposity indices were observed, but only for up to 35 percent of energy (Maillard et al. Furthermore, a significant positive association between fat intake and total cholesterol con- centration was observed in only two of five countries (Knuiman et al. The prevalence of aortic fatty streaks differs only slightly among children and adolescents of all populations studied, regardless of the fre- quency of atherosclerosis and coronary artery disease in adults of the respective population (Holman et al. The absence of a relation between aortic fatty streaks and the clinically relevant lesions of atherosclerosis in epidemiological and histological studies has thus raised questions on the clinical significance of fatty streaks in the aorta of young children (Newman et al. The Pathobiological Deter- minants of Atherosclerosis in Youth Study, however, has provided evidence that an unfavorable lipoprotein pattern (i. These findings are consistent with the hypothesis of the progression of fatty streaks to fibrous plaques under the influence of the prevailing risk factors for coronary artery disease (McGill et al. In addition, there are still pivotal issues that must be examined further, including the relationship between fatty streaks found in the arteries of young children and the later appearance of raised lesions associated with coronary vascular disease, the effects of dietary total fat modification on predictive risk factors in children, the safety of the diet with respect to total energy and micronutrients for the general population, and the long- term health benefit of establishing healthy dietary patterns early in childhood. It can been seen from these tables that as the level of carbohydrate intake decreases, and therefore the level of fat increases, certain nutrients such as folate and vitamin C markedly decrease. Furthermore, with increasing levels of fat intake, the intake of saturated fat relative to linoleic acid intake markedly increases. Dietary fat provides energy, which may be important for younger children with reduced food intakes, particularly during the transition from a diet high in milk to a mixed diet. The ranges of fat intake include intakes of saturated fat that should be consumed at levels as low as possible while consuming a nutritionally adequate diet. Maximal Intake Level for Added Sugars As for adults, no more than 25 percent of energy from added sugars should be consumed by children to ensure adequate micronutrient intakes. For those children whose intake is above this level, added sugars intake can be reduced by consuming sugars that are primarily naturally occurring and present in foods such as milk, dairy products, and fruits, which also contain essential micronutrients. Monounsaturated fatty acids are not essential fatty acids, but they may have some benefit in the prevention of chronic disease. Other reports indicate that mono- unsaturated fatty acids have a neutral or beneficial effect on risk (Hu et al. Much work has been conducted and is ongoing to identify the ideal substitute for saturated fat in a blood cholesterol- lowering diet. The effects of a high monounsaturated fatty acid versus a low fat, high carbohydrate diet on serum lipid and lipoprotein concentrations have been a focus of considerable scientific inquiry. Eighteen well- controlled clinical studies that compared the effects of substituting mono- unsaturated fatty acids versus carbohydrate for saturated fat in a blood cholesterol-lowering diet have recently been reviewed (Kris-Etherton et al. In these studies, when on both high monounsaturated fat and low fat, high carbohydrate diets, saturated fatty acids contributed to 4 to 12 percent of energy and dietary cholesterol varied from less than 100 up to 410 mg/d. Diets high in monounsaturated fatty acids provided 17 to 33 percent of energy from monounsaturated fatty acids and contained more total fat (33 to 50 percent energy) than the low fat, high carbohy- drate diets (18 to 30 percent energy). The low fat, high carbohydrate diets provided 55 to 67 percent of energy from carbohydrate. Compared to baseline values, serum total cholesterol concentrations changed from –17 to +3 percent on the low fat, high carbohydrate diet, whereas it changed from –20 to –3 percent on the high monounsaturated fatty acid diet. The change in serum triacylglycerol concentrations ranged from –23 to +37 percent for individuals consuming the low fat, high carbo- hydrate diets and from –43 to +12 percent for diets high in monounsaturated fatty acids. Similarly, some intervention studies showed no effect of monounsaturated fatty acid intake on indicators for risk of diabetes (Fasching et al. Uusitupa and coworkers (1994), however, reported a significantly lower area under the curve for plasma glucose concentration and a greater glucose disappearance rate when healthy women consumed a diet rich in monounsaturated fatty acids (19 to 20 percent) compared with a diet rich in saturated fatty acids. Risk of Cancer Bartsch and colleagues (1999) reported a protective effect of oleic acid on cancer of the breast, colon, and possibly the prostate. A few epide- miological studies have reported an inverse relationship between mono- unsaturated fatty acid intake and risk of breast cancer (Willett et al. Increased consumption of olive oil was associated with significantly reduced breast cancer risk (La Vecchia et al. A diet high in monounsaturated fatty acid-rich vegetable oils, includ- ing olive, canola, or peanut oils, has been associated with a protective effect or no risk of prostate cancer (Norrish et al. Some speculate that the apparent protective effects of olive oil (and other vegetable oils) reflect constituents other than monounsaturated fatty acids including squalene (Newmark, 1999), phenolic compounds, antioxidants, and other com- pounds (Owen et al. No significant association has been reported for monounsaturated fatty acid intake and risk of colorectal cancer (Giovannucci et al. Risk of Nutrient Inadequacy In the United States, monounsaturated fatty acids provide 12 to 13 per- cent of energy intake. About 50 percent of these fatty acids are consumed via animal products, primarily meat fat (Jonnalagadda et al. Although the major sources of monounsaturated fatty acids (animal fat and vegetable oils) are not required to supply essential nutrients, very low intakes of monounsaturated fatty acids would require increased intakes of other types of fatty acids to achieve recommended fat intakes. Consequently, intakes of saturated and n-6 polyunsaturated fatty acids would probably exceed a desirable level of intake (see “n-6 Poly- unsaturated Fatty Acids” and Chapter 8). High n-9 Monounsaturated Fatty Acid Diets There are limited data on the adverse health effects from consuming high levels of n-9 monounsaturated fatty acids (see Chapter 8, “Tolerable Upper Intake Levels”). Acceptable Macronutrient Distribution Range n-9 Monounsaturated fatty acids are not essential in the diet, and the evidence relating low and high intakes of monounsaturated fatty acids and chronic disease is limited. Many populations of the world, such as in Crete and Japan, have low total intakes of n-6 polyunsaturated fatty acids (e. However, high intakes of n-6 polyunsaturated fats have been associated with blood lipid profiles (e. An inverse association between linoleic acid intake and risk of coronary death was observed in several prospective studies (Arntzenius et al. Controlled trials have examined the effects of sub- stituting n-6 fatty acids in the diet to replace carbohydrate or saturated fatty acids (Mensink et al. Risk of Diabetes A number of epidemiological studies have been conducted to ascer- tain whether the quality of fat can affect the risk for diabetes. An inverse relationship was reported for vegetable fats and polyunsaturated fats and risk of diabetes (Colditz et al. One study reported a positive association between 2-hour glucose concentrations and polyunsaturated fatty acid intake (Mooy et al. A review of epidemiological studies on this relationship concluded that higher intakes of polyunsaturated fats could be beneficial in reducing the risk for diabetes (Hu et al. Risk of Nutrient Inadequacy Dietary n-6 polyunsaturated fatty acids have been reported to contrib- ute approximately 5 to 7 percent of total energy intake of adults (Allison et al.

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