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This method provides a more accurate estima- American Society of Nephrology American Society of Nephrology 3 Table 2 cheap clindamycin 150mg otc. Therapeutic drug monitoring Drug Name Therapeutic Range When to Draw Sample How Often to Draw Levels Aminoglycosides Gentamicin and Trough: immediately before Check peak and trough with third dose (conventional dosing) tobramycin: dose Trough: 0 buy discount clindamycin on line. Repeat drug level in 1 wk or if dosing) gentamicin generic 150 mg clindamycin with mastercard, 12 h after dose renal function changes tobramycin buy clindamycin with amex, amikacin Carbamazepine 4–12 g/ml Trough: immediately before Check 2–4 days after first dose or change in dosing dose Cyclosporin 150–400 ng/ml Trough: immediately before Daily for first week and then weekly. Repeat drug levels if renal function changes Peak: 25–40 mg/L Peak: 60 min after a 60-min infusion 4 American Society of Nephrology American Society of Nephrology tion of renal function in patients with low muscle mass, high portant to know the exact dose given, the route of administra- protein intake, or geriatric populations and is subject to less tion, time of administration, and time since the last dose. In dialysis patients, with a residual renal levels are meaningful for only few drugs. Peak drug levels rep- function, the residual renal function may to a large extent con- resent the highest drug concentration achieved after initial tribute to the elimination of drugs and their active metabolites. For most drugs, trough levels are obtained The effect of residual renal function on drug elimination in immediately before the next dose, represent the lowest serum dialysis patients with urine output 500 ml/d is very difficult concentration, and predict drug toxicity. In ample, aminoglycoside antibiotics can accumulate in tissues patients with normal renal function, steady-state drug concen- such as the inner ear and renal tubules. The half- ity can occur after a single dose or in some cases without asso- life of drugs that are excreted renally may be significantly pro- ciated high plasma concentrations. For example, in dialysis patients, the loading dose of binding is altered significantly. For highly protein-bound digoxin should be reduced by 25 to 50% to avoid toxicity. An increase in unbound drug is plasma concentration should be monitored very closely. Free phenytoin levels provide better therapeutic drug Step 4: Maintenance Dose Determination monitoring in older patients with renal impairment. In general, cording to the renal function for most drugs, a combined approach using both the dose re- • Dosage modification can be accomplished by dose reduction, dosing interval prolongation, or both methods duction and interval prolongation methods is often used. Am Fam Physician 75: 1487–1496, 2007 supplements among older adults in the United States. Pollock B, Forsyth C, Bies R: The critical role of clinical pharmacology 1999 in geriatric psychopharmacology. All of the above American Society of Nephrology American Society of Nephrology 7 . Until now, Life Extension could cite only isolated statistics to make its case about the dangers of conventional medicine. A group of researchers meticulously reviewed the statistical evidence and their findings are absolutely shocking. This fully referenced report shows the number of people having in-hospital, adverse reactions to prescribed drugs to be 2. The number of unnecessary antibiotics prescribed annually for viral infections is 20 million per year. The number of unnecessary medical and surgical procedures performed annually is 7. The most stunning statistic, however, is that the total number of deaths caused by conventional medicine is an astounding 783,936 per year. The article uncovered so many problems with conventional medicine however, that it became too long to fit within these pages. We placed this article on our website to memorialize the failure of the American medical system. By exposing these gruesome statistics in painstaking detail, we provide a basis for competent and compassionate medical professionals to recognize the inadequacies of today’s system and at least attempt to institute meaningful reforms. Natural medicine is under siege, as pharmaceutical company lobbyists urge lawmakers to deprive Americans of the benefits of dietary supplements. Drug-company front groups have launched slanderous media campaigns to discredit the value of healthy lifestyles. These attacks against natural medicine obscure a lethal problem that until now was buried in thousands of pages of scientific text. In response to these baseless challenges to natural medicine, the Nutrition Institute of America commissioned an independent review of the quality of “government-approved” medicine. The startling findings from this meticulous study indicate that conventional medicine is “the leading cause of death” in the United States. The Nutrition Institute of America is a nonprofit organization that has sponsored independent research for the past 30 years. What you are about to read is a stunning compilation of facts that documents that those who seek to abolish consumer access to natural therapies are misleading the public. A definitive review of medical peer-reviewed journals and government health statistics shows that American medicine frequently causes more harm than good. Besser spoke in terms of tens of millions of unnecessary antibiotics prescribed annually. By comparison, approximately 699,697 Americans died of heart in 2001, while 553,251 died of cancer. Any invasive, unnecessary medical procedure must be considered as part of the larger iatrogenic picture. The figures on unnecessary events represent people who are thrust into a dangerous health care system. Simply entering a hospital could result in the following: In 16. Working with the most conservative figures from our statistics, we project the following 10-year death rates. Table 3: Estimated 10-Year Death Rates from Medical Intervention 10-Year Condition Author Deaths Adverse Drug Reaction 1. Our projected figures for unnecessary medical events occurring over a 10-year period also are dramatic. Medical science amasses tens of thousands of papers annually, each representing a tiny fragment of the whole picture. To look at only one piece and try to understand the benefits and risks is like standing an inch away from an elephant and trying to describe everything about it. Each specialty, each division of medicine keeps its own records and data on morbidity and mortality. We have now completed the painstaking work of reviewing thousands of studies and putting pieces of the puzzle together. Because of the extraordinarily narrow, technologically driven context in which contemporary medicine examines the human condition, we are completely missing the larger picture. Medicine is not taking into consideration the following critically important aspects of a healthy human organism: (a) stress and how it adversely affects the immune system and life processes; (b) insufficient exercise; (c) excessive caloric intake; (d) highly processed and denatured foods grown in denatured and chemically damaged soil; and (e) exposure to tens of thousands of environmental toxins. Instead of minimizing these disease-causing factors, we cause more illness through medical technology, diagnostic testing, overuse of medical and surgical procedures, and overuse of pharmaceutical drugs. The huge disservice of this therapeutic strategy is the result of little effort or money being spent on preventing disease. Underreporting of Iatrogenic Events As few as 5% and no more than 20% of iatrogenic acts are ever reported. In 1994, Leape said his figure of 180,000 medical mistakes resulting in death annually was equivalent to three jumbo-jet crashes every two days. What we must deduce from this report is that medicine is in need of complete and total reform—from the curriculum in medical schools to protecting patients from excessive medical intervention. It is obvious that we cannot change anything if we are not honest about what needs to be changed. We are fully aware of what stands in the way of change: powerful pharmaceutical and medical technology companies, along with other powerful groups with enormous vested interests in the business of medicine. They fund medical research, support medical schools and hospitals, and advertise in medical journals. Such funding can sway the balance of opinion from professional caution to uncritical acceptance of new therapies and drugs. You have only to look at the people who make up the hospital, medical, and government health advisory boards to see conflicts of interest. Erik Campbell, the lead author, said, "Our previous research with faculty has shown us that ties to industry can affect scientific behavior, leading to such things as trade secrecy and delays in publishing research. Marcia Angell struggled to bring greater attention to the problem of commercializing scientific research. In June 2002, the New England Journal of Medicine announced that it would accept journalists who accept money from drug companies because it was too difficult to find ones who have no ties.
In many institutions purchase 150 mg clindamycin mastercard, physician mistrust of hospital motivations and strategies is a dominant theme 150 mg clindamycin free shipping. Mistrust Although competitive tensions between physician-sponsored enter- prises and hospitals have contributed to this problem buy clindamycin 150 mg cheap, many physi- cians view the hospital as a battleship whose wake is sufﬁcient to swamp the small boats it operates 150 mg clindamycin with visa. The fact that hospitals and physi- cians have completely separate information domains complicates the ability to implement new clinical information systems. The Hospital as Potential Information Source Hospitals are presently committing major capital resources to com- puterize both operations and clinical services. As argued above, physician practices, even many large groups, are capital poor and thus lag in automating their processes and services. It is entirely possible given the present course that hospitals will complete this Physicians 85 process a decade or more ahead of physicians, leaving what physi- cians “know” about their patients locked up in paper records and their memories. When physicians do automate, if no compatibility standards are set in advance, they will use incompatible software and be unable to move clinical information between their systems and those of the hospital. Optimal patient care would require that the clinical team be able to access important clinical information about a patient at any place and at any time. Because hospitals have capital, and physicians, generally speaking, do not, hospitals could be a potential source for modern digital clinical information systems, as well as patient care support tools like disease management, for their physicians. If hospitals could help bring about a shared record format across their medical staffs, it would be easier for physicians to send patient information to one another for consultative purposes. Historically, physicians have been extremely reluctant to permit hospitals access to their private practices. Many experiments by hos- pitals during the 1990s with salaried employment of physicians and with practice management support ended in costly failure. Physi- cians resisted installing inexpensive software that enabled them to perform remote order entry or retrieval of test results from hospi- tals because they thought it opened a portal that enabled hospital executives to understand their practice’s economics. Legal and Regulatory Barriers Besides the mistrust discussed above, legal and regulatory barriers make linking hospitals and physicians difﬁcult. Federal Medicare regulations forbid hospitals from offering physicians anything of value (including software and services) if it would inﬂuence their patterns of hospital utilization. These statutes were intended to pre- vent hospitals from, in effect, bribing physicians to bring their pa- tients in. If compatible clinical software made it easier for physicians 86 Digital Medicine with a choice to use the facility that provided them the software, it might trigger fraud and abuse investigations. Tax laws provide another barrier to the sharing of clinical soft- ware between hospitals and physicians. The Internal Revenue Code and state laws forbid not-for-proﬁt hospitals (recall that 85 percent of all community hospitals are not-for-proﬁt) from giving physicians (or anyone else) anything of value. Competitive advantage for speciﬁc providers could be eliminated by regulation that requires clinical information systems developed by different vendors to interoper- ate (that is, to use common record formats, coding conventions, messaging standards, etc. This would mean that, once installed, physicians could use their clinical software in conjunction with any of the available local hospitals or retrieve information about their patients from any of them. The fact that software and services could be provided on a dial- in basis without signiﬁcant capital expenditures by hospitals on the physicians’ behalf could help change some of the equation as well. The most expensive part of a physician ofﬁce’s digital conversion is transferring all of its existing patient records to digital form so they can be used by the information system. If these costs can be surmounted and physicians can obtain password-protected access to computerized patient records and clinical decision support from their ofﬁces, it would be a major boost to overall computerization. Hospitals and Physicians Digitizing Patient Records Together Ideally, hospitals and physicians should move together to digitize patient records. Technical opportunities exist for hospitals to create Physicians 87 virtual private networks that segregate the physician’s clinical records from those of the hospital (as well as the rest of the Internet), protect the physician’s business autonomy and privacy, and still provide the transparency of information ﬂow that is needed for optimal patient care. Physicians have to be willing to wade into the battle over how digital medicine is organized and be assured that their concerns about autonomy and privacy are recognized. When you sum the potential impact of various information tech- nologies across the physician’s world, the aggregate impact is im- pressive. Speed the ﬂow of new knowledge to physicians and store it efﬁciently so physicians don’t have to rely on their memories 2. Guide and assist in patient care itself, wherever the physician or patient may be at the moment 3. Free physicians from paper records and bills, reducing their prac- tice expenses 4. Facilitate collaboration between physicians both in consultation and in learning As with hospitals, this progress will not come easily, quickly, or cheaply. Moreover, not all physicians will be able to realize all of these beneﬁts at the same time. Physicians practicing in larger groups and clinic settings will ﬁnd these tools become available to them sooner simply because their organizations have the ﬁnancial resources and personnel to make them happen and the capability 88 Digital Medicine of experimenting with these tools before adopting them wholesale. Physicians in private practice will have to overcome mistrust of their hospitals and each other and work with their colleagues to build data systems they can use from the ofﬁce or from home. However, what ails physicians stretches far beyond the curable logistical difﬁculties of medical practice itself. At the root of medicine’s midlife crisis is the nagging feeling on physicians’ part that patients and society no longer trust them. Consumers are sending physicians a message: be more available to us when we need your help, do not patronize us, and give us the information we need to help us manage our own health. The physicians who hear these messages develop new relationships with consumers and may ﬁnd their practices acquire more meaning. Physicians who grasp this capability effectively will also ﬁnd that they can grow their practices and, by making more efﬁcient use of their own time, still devote more time to the patients who need the personal contact. Information technology can extend the power of the physician’s mind, a most valuable and fragile tool, and can help strengthen the doctor-patient relationship. As this relationship is improved, it may help lay the groundwork for a newer, more conﬁdent medicine. Although they may not believe it, physicians retain extraordinary power in our health system. All too often, they have used that power to retard needed changes in health policy and management. With information technology, however, physicians have a marvelous op- portunity to lead the transformation. Because they remain strategic actors, not only in health systems, but also in the lives of patients, physicians hold the key to “birthing” the digital transformation of the health system. For further, in-depth readings on the beneﬁts of digitization on physicians, I recommend Digital Doctors by Marshall de Graffenried Rufﬁn, Jr. Trails Other English Speaking Countries in Use of Electronic Medical Records and Electronic Prescribing. Measured against this end point, the contem- porary health system in the United States has become increasingly user-unfriendly. The institutions of medical practice—hospitals, health plans, and physician organizations—have grown so large and become so intimidating that many of them dwarf those who give and receive care. As mechanisms for transmitting knowledge, healthcare organizations have become riddled with bureaucracy and institutional processes that impede the free ﬂow of communication between patients and caregivers. Moreover, as discussed in Chapter 1, healthcare institutions have become prisons of vital medical knowledge. The knowledge and wisdom that all the actors in healthcare seek from medical institu- tions is imprisoned in paper, in indecipherable notes and images, in journals and professional reports that are often written in a private language few can understand, and in the overtaxed memories of caregivers. New knowledge is ﬂooding into the health system at an accelerating pace, but ensuring that this vital new knowledge actually reaches the practitioners and consumers who need it is an urgent piece of unﬁnished business. The health system is there to serve them, and through their taxes and forgone salaries, they pay most of its bills. Managing consumer expectations for compassionate and responsive advice and care is the central challenge facing our health system. How we describe people in our health system is important and has signiﬁcant consequences for how we think about them. In describing the role users play in the health system, traditional vocabulary and medical culture constrain us.
It may originate from an organ located in the chest or be referred from another part of the body best buy for clindamycin. Signs and symptoms • History: Ask about the following factors o Duration: Constant (likely not cardiac) vs buy clindamycin 150 mg on-line. Causes • Low contractility o Cardiomyopathy o Myocarditis • Poor heart filling o Arrhythmias o Mitral stenosis o Pericardial tamponade • Other valvular heart disease o Examples include acute mitral regurgitation or aortic regurgitation from acute rheumatic fever or endocarditis Signs and symptoms • History o Depends on etiology clindamycin 150mg without a prescription; may have slowly progressing or acute symptoms o Dyspnea generic 150mg clindamycin with amex, syncope, weakness, confusion/coma • Exam o Low blood pressure alone should not make the diagnosis. These patients are in shock because their heart is not squeezing well (contractility problem). Once goal is reached, the infusions should be lowered slowly as blood pressure tolerates (do not turn off completely at once). This may need to be reduced with Captopril or nitroglycerin once above pressors have been started and blood pressure is raised. Be aware that this may further lower their blood pressure, therefore, may need to start pressors prior to or just after intubation. Cardiogenic shock secondary to mitral stenosis and rapid heart rate o These patients are in shock because their left ventricle is unable to fill adequately during diastole (preload problem). If they are in rapid atrial fibrillation, defibrillate o If defibrillation does not work, give Amiodarone or Digoxin ■ Amiodarone 150 mg over 10 minutes ■ Digoxin 0. According to data from three district hospital outpatient clinics with access to echocardiography, the leading causes are cardiomyopathy (41%), rheumatic heart disease (33%), hypertensive heart disease (8%), and congenital heart disease (2%). Ischemic heart disease as a cause of heart failure is thought to remain relatively uncommon in Rwanda, particularly in more rural settings. If anything other normal or cardiomyopathy, should be referred for formal echocardiogram (possible candidates for cardiac surgery) Management: Initial approaches to heart failure the same in all patients. Severe heart failure may require aggressive airway management with positive pressure ventilation or intubation. Heart failure secondary to high afterload) o Need to rapidly decrease afterload to allow the left side of the heart to empty ■ N itroglycerin0. Heart failure secondary to poor heart filling: Main causes in Rwanda include tamponade and mitral stenosis o Tamponade ■ Iflargeeffusionandinshock,performimmediatebedside pericardiocentesis (see pericardial effusion chapter for information on procedure) o Mitral stenosis: ■ Look for and treat rapid atrial fibrillation, including anticoagulation. Recommendations • Heart failure is a common presentation in Rwanda, but very difficult to manage in a resource limited environment. If one is not immediately available, use blood pressure measurements (very high or very low will have different treatments as above), renal function (high Cr has worse prognosis), diuresis, and palpation of extremities (cold extremities=shock) to guide your management. Aggressive management is needed early in order to ensure good outcome for patient. Bradycardia may reflect a primary cardiac problem or may be a marker of disease in another system. Tachycardia may reflect a primary cardiac problem or may be a marker of disease in another system. Causes • Sinus tachycardia: The rhythm is a marker of a disease and not a disease itself. When this fluid collection impairs cardiac filling, it is considered pericardial tamponade. Causes • Trauma with a hemopericardium • Infection (Tuberculosis most common; viruses also can cause) • Cancer (often metastatic and often bloody) • Renal failure Signs and symptoms • Pericardial effusion can mimic symptoms of pericarditis including chest pain (often pleuritic and positional), palpitations, malaise, weakness and shortness of breath. Circumferential effusions causing right atrium and/ or right ventricular collapse during diastole. Must urgently reduce pericardial effusion to allow heart to fill by performing a pericardiocentesis (see Appendix). Recommendations • Tuberculosis most important and reversible cause of pericardial effusion in our setting. Hypertensive Emergency Definition • Hypertension: A chronic, usually asymptomatic disease defined as persistently elevated blood pressure > 140/90 in adults. See Chapter on Non-traumatic Headache for guidance on whether a headache needs further investigation • Exam: Look for signs and symptoms of end organ damage o Neurologic: Altered mental status, focal neurologic deficits, papilledema, reduced visual acuity o Cardiac: Acute pulmonary edema, ischemia o Be sure that you are measuring blood pressure with an appropriately sized cuff Consider formal echo and renal ultrasound if working up secondary causes of hypertension. Be careful of rapid drops in blood pressure with Nifedipine and Hydralazine, as this can cause end organ damage. Infective Endocarditis Definition: Infection of the endocardium (valves and/ or mural endocardium). Risk increased greatly with rheumatic or prosthetic heart valves or with history of congenital heart disease. More subtle findings include vascular phenomenon (Janeway lesions, splinter hemorrhages, other systemic emboli) and immune phenomenon (splenomegaly, nephritis, Osier nodes, Roth spots) • Bedside ultrasound should be used to look for clear evidence of vegetation. Management • It is impossible to treat endocarditis unless you consider it in your differential diagnosis! Consider in any patient with a fever and either new murmur or signs of thrombotic emboli (gangrene limb, stroke). Treat according the heart failure algorithms (see heart failure chapter) • Many patients will require surgical intervention and should be transferred immediately to referral center with cardiology available. Recommendations • All patients with suspected endocarditis should be referred to center capable of performing echocardiography and cardiology review. But if the patient is very sick, do not delay antimicrobial therapy Syncope Definition: Syncope is a transient loss of consciousness followed by complete recovery of neurologic function without resuscitative efforts. It is caused by either lack of blood flow to both cerebral hemispheres or to the reticular activating systems. Pre-syncope is transient near loss of consciousness and is treated the same as syncope. Other causes include obstructive lesions (hypertrophic cardiomyopathy, pericardial tamponade, stenotic valve lesions), very large pulmonary embolism. However, given lack of resources to address an identified problem, should not be routinely recommended. The emergency provider must attempt to differentiate a "surgical abdomen" from a non-surgical abdomen. Patients require aggressive, early treatment and often early transfer to referral hospital. Liver disorders are divided into two categories - acute or chronic - depending on the duration of the illness. However, it is appropriate to transfer these patients if there is a possibility for another diagnostic cause of confusion (i. Transfer patients with continued fever, tachycardia, low blood pressure, or other signs of acute illness not getting better with antibiotics. Recommendations • Complications from chronic liver disease can be complicated and life- threatening. Providers must recognize gallbladder infections and treat with appropriate antibiotics. Appendicitis Definition: Inflammation or infection of the appendix caused by acute obstruction of appendiceal lumen and eventual ischemia of the bowel wall. Care must be taken to exclude alternative etiologies of abdominal pain, particularly in women of child-bearing age. Imaging: none Management • Acute Diarrheal Illness: The goal of management is to provide appropriate fluid resuscitation, determine cause, and initiate specific antimicrobial therapies where appropriate. Pylori treatment o Consider early referral for endoscopy in patients with weight loss, vomiting after eating, dysphagia. Abdominal Mass Definition: Any abnormal collection of tissue in the abdominal region. Cancers that are recognized early have much better prognoses as treatments are more feasible. Testicular torsion is an emergency- surgery can correct the problem and save the testis if done within six hours. Signs and symptoms • Timing of onset of pain- if less than six hours, transfer immediately without work up o Torsion: sudden onset scrotal, inguinal, or abdominal pain. If clinical diagnosis is suspicious for torsion and less than 6hr since onset of symptoms, refer immediately for ultrasound and surgical evaluation without delay. Management: The general goal is to decide whether there is a high likelihood of testicular torsion based on exam and history If immediate transfer not possible or if arrival to urology will be more than 6hr after onset of pain, attempt manual detorsion. Use an ultrasound, when available, to verify a full bladder and ensure no bowel is present.
As with other planning examples clindamycin 150 mg visa, food waste and to what extent the amount of energy offered would need to exceed the target median intake need to be consid- ered generic clindamycin 150mg with visa. Assessing the plan following its implementation would lead to further refinements cheap clindamycin 150mg on line. Assessing Energy Intakes As was true for planning buy clindamycin 150 mg fast delivery, the approach to assessing the adequacy of energy intakes differs from that described for other nutrients. Perhaps more importantly though, it is related to the fact that for energy, unlike most nutrients, a readily observable, accurate biological indicator—body weight—can be used to assess the long-term adequacy of energy intake. The availability of a biological indicator to assess the adequacy of energy intake becomes particularly critical because of the effect of dietary underreporting on the assessment of adequacy. It is now widely accepted, and supported by a large body of literature, that underreporting of food intake is pervasive in dietary surveys (Black et al. Underreporters can constitute anywhere from 10 to 45 percent of the total sample, depend- ing on the age, gender, and body composition of the sample. Under- reporting tends to increase in prevalence as children age (Livingstone et al. Both the prevalence and severity of underreporting is greater among obese individuals compared with lean individuals (Bandini et al. In addition, those of low socioeconomic status (characterized by low incomes, low educational attainment, and low literacy levels) are more likely to report low energy intakes (Johnson et al. Theoretically, one could compare the usual energy intake of an individual to his or her requirement to maintain current weight and activity level, as estimated using the equations developed to estimate energy expenditure. Accordingly, comparing the individual’s intake to the calculated average expenditure is essentially meaningless. If the woman’s actual energy intake averaged 2,200 kcal, her actual intake could be inadequate, adequate, or excessive. Excessive intake must be interpreted as being excessive in relation to energy expenditure. In many cases, intake may not be excessive in absolute terms; instead, inadequate energy expenditure may be the primary factor in con- tributing to long-term positive energy balance. This has important implica- tions for how this issue is best addressed at the population level. There are a number of reasons why increased energy expenditure may be a more appropriate solution than decreased energy intake to long-term positive energy balance (i. First, restricting energy intake also decreases the ability to meet requirements of many nutrients. Increasing physical activity, thereby improving fitness, improves health outcomes of overweight individuals irrespective of changes in relative weight (Blair et al. In addition to the major impact of underreporting on assessment of the adequacy of energy intake, it also has potential implications for other macronutrients. If it is assumed that underreporting of macronutrients occurs in propor- tion to underreporting of energy intake, macronutrients expressed as a percentage of energy would be relatively accurate. Underreporting would, however, overestimate the prevalence of dietary inadequacy for protein, indispensable amino acids, and carbo- hydrate. It could also lead to an overestimate of the percentage of energy derived from carbohydrate. Added Sugars Added sugars are defined as sugars and syrups that are added to foods during processing or preparation. Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn-syrup solids, high-fructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, anhydrous dextrose, and crystal dextrose. Since added sugars provide only energy when eaten alone and lower nutrient density when added to foods, it is suggested that added sugars in the diet should not exceed 25 percent of total energy intake. Usual intakes above this level place an individual at potential risk of not meeting micronutrient requirements. To assess the sugar intakes of groups requires knowledge of the distri- bution of usual added sugar intake as a percent of energy intake. Once this is determined, the percentage of the population exceeding the maximum suggested level can be evaluated. Dietary, Functional, and Total Fiber Dietary Fiber is defined in this report as nondigestible carbohydrates and lignin that are intrinsic and intact in plants. Instead, it is based on health benefits asso- ciated with consuming foods that are rich in fiber. Fiber consumption can be increased by substituting whole grain or products with added cereal bran for more refined bakery, cereal, pasta, and rice products; by choosing whole fruits instead of fruit juices; by con- suming fruits and vegetables without removing edible membranes or peels; and by eating more legumes, nuts, and seeds. For example, whole wheat bread contains three times as much Dietary Fiber as white bread, and the fiber content of a potato doubles if the peel is consumed. For most diets (those that have not been fortified with Functional Fiber that was isolated and added for health purposes), the contribution of Functional Fiber is minor relative to the naturally occurring Dietary Fiber. Because there is insufficient evidence of deleterious effects of high Dietary Fiber as part of an overall healthy diet, a Tolerable Upper Intake Level has not been established. Thus, when planning diets for individuals, it is necessary to first calculate the individual’s esti- mated energy expenditure, determine 20 and 35 percent of this number in kilocalories, and then divide by 9 kcal/g to get the range of fat intake in grams per day. For example, a person whose energy expenditure was 2,300 kcal/day should aim for an energy intake from fat of 460 to 805 kcal/ day. Likewise, when assessing fat intakes of individuals, the goal is to deter- mine if usual energy intake from total fat is between 20 and 35 percent. As illustrated above, this is a relatively simple calculation assuming both usual fat intake and usual energy intake are known. However, because dietary data are typically based on a small number of days of records or recalls, it may not be possible to state with confidence that a diet is within this range. If planning is for a confined population, a procedure similar to the one described for individuals may be used: determine the necessary energy intake from the planned meals and plan for a fat intake that pro- vides between 20 and 35 percent of this value. If the group is not confined, then planning intakes is more complex and ideally begins with knowledge of the distribution of usual energy intake from fat. Then the distribution can be examined, and feeding and education programs designed to either increase, or more likely, decrease the percent of energy from fat. Assessing the fat intake of a group requires knowledge of the distribution of usual fat intake as a percent of energy intake. Thus, there are several consider- ations when planning and evaluating n-3 and n-6 fatty acid intakes. However, with increasing intakes of either of these three nutrients, there is an increased risk of coronary heart disease. Chapter 11 provides some dietary guidance on ways to reduce the intake of saturated fatty acids, trans fatty acids, and cholesterol. For example, when planning diets, it is desirable to replace saturated fat with either monounsaturated or polyunsaturated fats to the greatest extent possible. This implies that requirements and recommended intakes vary among indi- viduals of different sizes, and should be individualized when used for dietary assessment or planning. However, this method requires a number of assump- tions, including that the individual requirement for the nutrient in question has a symmetric distribution. Planning the Diet When planning a diet for an individual, recommended intakes can be determined on the basis of the individual’s body weight. Thus, determining a recommended protein intake based on current body weight may not be appropriate for those who are signifi- cantly underweight or overweight. For example, a medical professional might choose to specify a protein intake for a malnourished, underweight patient based on what the patient’s body weight would be if he were healthy. A patient weighing 40 kg, whose body weight when healthy was 55 kg, could thus have a recommended protein intake of 44 g/day (55 kg × 0. Conversely, protein intakes recommended for individuals who are morbidly obese could be based on the amounts recommended for those with more normal body weights. In other words, it was not necessary to assess or plan for intakes of indispensable amino acids. The simplest scenario for answering this question relates to dietary planning for individuals. Data in Table 13-2 suggest that although most protein sources provide recommended amounts of threonine, tryptophan, and sulfur-containing amino acids, this is not true for lysine. Even then, diets could be marginal, as the data in Table 13-2 regarding amino acid compo- sition do not account for the apparent lower digestibility of some plant protein sources. Thus, it appears that, in addition to assessing and planning total protein intakes, it is also necessary to assess and plan for intakes of the amino acid lysine in individuals consuming proteins with low levels of lysine.