An evaluation of the relative contributions of exposure to sunlight and of diet to the circulating concentrations of 25-hydroxyvitamin D in an elderly nursing home population in Boston insomnia disorder cheap sominex 25mg online. The dose-dependent reduction in blood pressure through administration of magnesium sleep aid reviews purchase 25mg sominex amex. Reduction of blood pressure with oral magnesium supplementation in women with mild to moderate hypertension sleep aid commercial sominex 25 mg. Thirteenweek toxicity study of d-alpha-tocopheryl acetate (vitamin E) in Fischer 344 rats insomnia janet jackson no sleep sominex 25mg cheap. Nomenclature policy: Generic descriptors and trivial names for vitamins and related compounds insomnia unspecified generic sominex 25 mg without prescription. Changes in human milk vitamin E and total lipids during the first twelve days of lactation insomnia or sleep apnea order 25mg sominex free shipping. Amiel J, Maziere J, Beucler I, Koenig M, Reutenauer L, Loux N, Bonnefont D, Feo C, Landrieu P. Correlations of vitamin A and E intakes with the plasma concentrations of carotenoids and tocopherols among American men and women. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. Detection and localization of lipid peroxidation in selenium- and vitamin E-deficient rats using F2isoprostanes. Effect of supplementary antioxidant vitamin intake on carotid arterial wall intima-media thickness in a controlled clinical trial of cholesterol lowering. Plasma lipid response and nutritional adequacy in hypercholesterolemic subjects on the American Heart Association Step-One Diet. Hepatic concentrations of zinc, copper and manganese in infants with extrahepatic biliary atresia. Gamma-tocopherol: Metabolism, biological activity and significance in human vitamin E nutrition. Intestinal absorption and thoracic-duct lymph transport of dl-alpha-tocopheryl-3,4-14C2 acetate dl-alpha-tocopheramine-3,4-14C2 dl-alpha-tocopherol-(5-methyl-3H) and N(methyl-3H)-dl-gamma-tocopheramine. Monitoring erythrocyte free radical resistance in neonatal blood microsamples using a peroxyl radical-mediated haemolysis test. Vitamin E, lipid fractions, and fatty acid composition of colostrum, transitional milk, and mature milk: An international comparative study. The pecking order of free radicals and antioxidants: Lipid peroxidation, alpha-tocopherol, and ascorbate. The antioxidant activity of vitamin E and related chain-breaking phenolic antioxidants in vitro. Vitamin E: Application of the principles of physical organic chemistry to the exploration of its structure and function. Is vitamin E the only lipid-soluble, chainbreaking antioxidant in human blood plasma and erythrocyte membranes? The influence of antioxidant nutrients on platelet function in healthy volunteers. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Ataxia with isolated vitamin E deficiency: Heterogeneity of mutations and phenotypic variability in a large number of families. Vitamin E up-regulates arachidonic acid release and phospholipase A2 in megakaryocytes. Vitamin E up-regulates phospholipase A2, arachidonic acid release and cyclooxygenasein endothelial cells. Inhibition of smooth muscle cell proliferation and protein kinase C activity by tocopherols and tocotrienols. Relative bioavailabilities of natural and synthetic vitamin E formulations containing mixed tocopherols in human subjects. The effect of alpha-tocopherol on the synthesis, phosphorylation and activity of protein kinase C in smooth muscle cells after phorbol 12-myristate 13-acetate down-regulation. Platelet function in type I diabetes: Effects of supplementation with large doses of vitamin E. Serum retinol, beta-carotene, vitamin E, and selenium as related to subsequent cancer of specific sites. The risk of developing lung cancer associated with antioxidants in the blood: Ascorbic acid, carotenoids, alpha-tocopherol, selenium, and total peroxyl radical absorbing capacity. Davi G, Ciabattoni G, Consoli A, Mezzetti A, Falco A, Santarone S, Pennese E, Vitacolonna E, Bucciarelli T, Costantini F, Capani F, Patrono C. In vivo formation of 8-iso-prostaglandin F2a and platelet activation in diabetes mellitus. Effect of wheat fiber and vitamins C and E on rectal polyps in patients with familial adenomatous polyposis. Decreased lipid oxidation, interleukin 1b secretion, and monocyte adhesion to endothelium. Plasma concentrations and urinary excretion of the antioxidant flavonols quercetin and kaempferol as biomarkers for dietary intake. Effect of oral supplementation with d-alpha-tocopherol on the vitamin E content of human low density lipoproteins and resistance to oxidation. Plasma alpha-tocopherol concentrations after supplementation with water- and fat-soluble vitamin E. The effect of vitamin C, either alone or in the presence of vitamin E or a water-soluble vitamin E analogue, upon the peroxidation of aqueous multilamellar phospholipid liposomes. Relationships of serum carotenoids, retinol, alpha-tocopherol, and selenium with breast cancer risk: Results from a prospective study in Columbia, Missouri (United States). The influence of smoking and diet on the hypoxanthine phosphoribosyltransferase (hprt) mutant frequency in circulating T lymphocytes from a normal human population. Prediction of male cancer mortality by plasma levels of interacting vitamins: 17-year followup of the prospective Basel study. Dietary antioxidants and cigarette smoke-induced biomolecular damage: A complex interaction. Nitrogen oxides are important contributors to cigarette smoke-induced ascorbate oxidation. Alpha-tocopherol inhibits agonistinduced monocytic cell adhesion to cultured human endothelial cells. Serum alpha-tocopherol status in the United States population: Findings from the Third National Health and Nutrition Examination Survey. Alpha-tocopherol inhibits aggregation of human platelets by a protein kinase C-dependent mechanism. Determinants of the nutritional status of vitamin E in a non-smoking Mediterranean population. Analysis of the effect of vitamin E intake, alcohol consumption and body mass index on the serum alpha-tocopherol concentration. Effect of vitamin E supplementation on platelet thromboxane A2 production in type I diabetic patients. Adult-onset spinocerebellar dysfunction caused by a mutation in the gene for the alpha-tocopherol-transfer protein. Establishing the significance and optimal intake of dietary antioxidants: the biomarker concept. Human adipose alpha-tocopherol and gamma-tocopherol kinetics during and after 1 y of alpha-tocopherol supplementation. Spinocerebellar degeneration associated with a selective defect of vitamin E absorption. Absorption of different doses of fat soluble and water miscible preparations of vitamin E in children with cystic fibrosis. Syndrome in premature infants associated with low plasma vitamin E levels and high polyunsaturated fatty acid diet. Prostate cancer and supplementation with alpha-tocopherol and beta-carotene: Incidence and mortality in a controlled trial. Effects of vitamin E on the aggregation and the lipid peroxidation of platelets exposed to hydrogen peroxide. Serial coronary angiographic evidence that antioxidant vitamin intake reduces progression of coronary artery atherosclerosis. Effects of limited tocopherol intake in man with relationships to erythrocyte hemolysis and lipid oxidations. Erythrocyte survival time and reticulocyte levels after tocopherol depletion in man. Relationship between tocopherol and serum lipid levels for determination of nutritional adequacy. Affinity for alpha-tocopherol transfer protein as a determinant of the biological activities of vitamin E analogs. Vitamin E remains the major lipid-soluble, chain-breaking antioxidant in human plasma even in individuals suffering severe vitamin E deficiency. Ishizuka T, Itaya S, Wada H, Ishizawa M, Kimura M, Kajita K, Kanoh Y, Miura A, Muto N, Yasuda K. Differential effect of the antidiabetic thiazolidinediones troglitazone and pioglitazone on human platelet aggregation mechanism. Alpha-tocopherol enrichment of monocytes decreases agonist-induced adhesion to human endothelial cells. Vitamin C nutriture has little short-term effect on vitamin E concentrations in healthy women. Effect of modest vitamin E supplementation on blood glycated hemoglobin and triglyceride levels and red cell indices in type I diabetic patients. The effect of modest vitamin E supplementation on lipid peroxidation products and other cardiovascular risk factors in diabetic patients. Relationship of blood thromboxane-B2 (TxB2) with lipid peroxides and effect of vitamin E and placebo supplementation on TxB2 and lipid peroxide levels in type 1 diabetic patients. Relationship of prolonged pharmacologic serum levels of vitamin E to incidence of sepsis and necrotizing enterocolitis in infants with birth weight 1,500 grams or less. The measurement of nanograms of tocopherol from needle aspiration biopsies of adipose tissue: Normal and abetalipoproteinemic subjects. Impairment of glucose and glutamate transport and induction of mitochondrial oxidative stress and dysfunction in synaptosomes by amyloid beta-peptide: Role of the lipid peroxidation product 4-hydroxynonenal. Biodiscrimination of alpha-tocopherol stereoisomers in humans after oral administration. Generation of the isoprostane 8-epi-prostaglandin F2alpha in vitro and in vivo via the cyclooxygenases. Identification of alpha-, beta-, gamma-, and delta-tocopherols and their contents in human milk. A treatable familial neuromyopathy with vitamin E deficiency, normal absorption, and evidence of increased consumption of vitamin E. Human plasma phospholipid transfer protein accelerates exchange/ transfer of alpha-tocopherol between lipoproteins and cells. Acute toxicity, subchronic feeding, reproduction, and teratologic studies in the rat. Identification and purification of a human liver cytosolic tocopherol binding protein. Normalization of diacylglycerol-protein kinase C activation by vitamin E in aorta of diabetic rats and cultured rat smooth muscle cells exposed to elevated glucose levels. Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. Alpha tocopherol, total lipid and linoleic acid contents of human milk at 2, 6, 12, and 16 weeks. A progressive neurological syndrome associated with an isolated vitamin E deficiency. Increased indices of free radical activity in the cerebrospinal fluid of patients with tardive dyskinesia. Vitamin E and vitamin C supplement use and risk of all-cause and coronary heart disease mortality in older persons: the Established Populations for Epidemiologic Studies of the Elderly. The absorption of alpha-tocopherol in control subjects and in patients with intestinal malabsorption. Quercetin is recovered in human plasma as conjugated derivatives which retain antioxidant properties. Dietary intake and plasma concentrations of vitamin E, vitamin C, and beta carotene in patients with coronary artery disease. Vitamin E inhibits low-density lipoprotein-induced adhesion of monocytes to human aortic endothelial cells in vitro. Supplemental therapy in isolated vitamin E deficiency improves the peripheral neuropathy and prevents the progression of ataxia. A randomized trial of vitamins C and E in the prevention of recurrence of colorectal polyps. Influence of age, sex, strain of rat and fat soluble vitamins on hemorrhagic syndromes in rats fed irradiated beef. Postprandial changes in the plasma concentration of alpha- and gammatocopherol in human subjects fed a fat-rich meal supplemented with fatsoluble vitamins. Assessment of the safety of supplementation with different amounts of vitamin E in healthy older adults. Vitamins E, C and lipid peroxidation in plasma and arterial tissue of smokers and non-smokers. Peroxidative stress and in vitro ageing of endothelial cells increases the monocyte-endothelial cell adherence in a human in vitro system. Increase in circulating products of lipid peroxidation (F2-isoprostanes) in smokers. Free radical generation by early glycation products: A mechanism for accelerated atherogenesis in diabetes.
At surgery for the biopsy sleep aid long term use cheap 25 mg sominex otc, a locator needle is inserted into the region of macrocalcification and the position confirmed by mammography melatonin sleep aid 3 mg cheap sominex 25 mg on line. The pathology report indicates ductal carcinoma with microinvasion necessitating surgery insomnia 4 weeks pregnant 25mg sominex fast delivery. Both patient and surgeon agree that a modified radical mastectomy offers the best prognosis in her case sleep aid lendormine purchase sominex 25mg visa. At surgery for mastectomy sleep aid videos purchase 25mg sominex otc, the surgeon carries the dissection along the major pathway of lymphatic drainage from the mammary gland insomnia 1997 trailer purchase sominex 25 mg with amex. Subcutaneous venous networks to the contralateral breast and abdominal wall Tributaries of the axillary vessels to the axillary nodes Tributaries of the intercostal vessels to the parasternal nodes Tributaries of the internal thoracic (mammary) vessels to the parasternal nodes Tributaries of the thoracoacromial vessels to the apical (subscapular) nodes 332. A 48-year-old woman underwent a complete mastectomy, including removing several axillary lymph nodes. However, the patient is found to have winging of the scapula when her flexed arm is pressed against a fixed object. A firefighter, age 34, who is a nonsmoker, complains of bouts of dizziness at times of intense exertion. His history reveals having been exposed to intense smoke 6 months ago when his breathing apparatus malfunctioned during a job. A decrease in the anterior-posterior diameter of the chest No movement at the costovertebral joints An increase in the superior-inferior diameter of the chest A primary change in the anterior-posterior diameter of the chest A primary change in the transverse diameter of the chest Thorax 461 334. When you ask a patient to exhale forcibly and maximally, the volume of expiration is constant, but the rate of flow is diminished compared to normal, indicating airway constriction likely due to bronchospasm. The smooth muscle of the bronchial airways is innervated by which of the following? Your order an echocardiogram because you suspect your patient has which of the following? Tetralogy of Fallot Pulmonary valve stenosis Atherosclerosis Aortic valve stenosis Defective tricuspid valve 336. Pain referred to the right side of the neck and extending laterally from the right clavicle to the tip of the right shoulder is most likely to involve which of the following? Cervical cardiac accelerator nerves Posterior vagal trunk Right intercostal nerves Right phrenic nerve Right recurrent laryngeal nerve 462 Anatomy, Histology, and Cell Biology 337. An elderly woman visits the hospital emergency room with the recent onset of grotesque swelling of the right arm, neck, and face. Her right jugular vein is visibly engorged and her right brachial pulse is diminished. A left cervical rib A mass in the upper lobe of the right lung Aneurysm of the aortic arch Right pneumothorax Thoracic duct blockage in the posterior mediastinum 338. A 3-year-old child suspected of aspirating a small, cloth-covered metal button is seen in the emergency room. In both lungs In the lingula of the left inferior lobe In the right inferior lobe In the left superior lobe In the right superior lobe 339. He also reports some left side chest pain and points to the inferior portion of his ribs. You listen to his lung sounds and there seems to be reduced breath sounds in the inferior half of his left plural cavity. You wish to determine the nature of the fluid accumulating in the left pleural cavity, since that will dictate the appropriate treatment. What structures will your 19 g needle penetrate as you pass from skin to fluid at the midaxillary line below the sixth rib? Skin, subcutaneous tissue, external intercostal muscle, internal intercostal muscle, innermost intercostal muscle, parietal pleura b. Skin, subcutaneous tissue, external intercostal muscle, internal intercostal muscle, parietal pleura, innermost intercostal muscle c. Skin, subcutaneous tissue, parietal pleura, external intercostal muscle, internal intercostal muscle, innermost intercostal muscle d. Skin, parietal pleura, external intercostal muscle, internal intercostal muscle, innermost intercostal muscle, subcutaneous tissue. Skin, subcutaneous tissue, innermost intercostal muscle, internal intercostal muscle, external intercostal muscle, parietal pleura Thorax 463 340. An otherwise healthy married 25-year-old female medical student is referred to your cardiology practice by her primary care physician for consultation and evaluation. She has told her primary care physician that she is thinking of starting a family. The pregnancy adds significant additional resistance to the peripheral venous system because of the size of the placenta. This will cause a left to right atrial shunt, which will cause hypertrophy of the left ventricle. The pregnancy adds significant additional resistance to the peripheral venous system because of the size of the fetal circulatory system. This will cause a right to left shunt, which will cause hypertrophy of the left atrium. This will cause a left to right shunt, which will cause hypertrophy of the right atrium. In addition, now that she is older the risks of open-heart surgery are significantly reduced compared to surgery as a child because the heart is much larger 341. Cardiothoracic surgeons must be familiar with bronchopulmonary segments since individual segments of the lung can be removed, leaving the rest of the lung intact and functional. Which of the following is a correct characterization of bronchopulmonary segments? They are arranged with their bases directed toward the hilum of the lung They are separated by parietal pleura the arterial supply is located in the periphery of each segment Each segment is supplied by a secondary or lobar bronchus Veins may be used to localize the planes between segments 464 Anatomy, Histology, and Cell Biology 342. A 28-year-old woman comes into the emergency room exhibiting dyspnea and mild cyanosis, but no signs of trauma. The most obvious abnormal finding in the inspiratory posteroanterior chest x-ray of this patient (viewed in the anatomic position) is a left pneumothorax (collapsed lung) as indicated by the dark appearance of the left lung and the shifting of the heart to the right. Bilateral expansion of the pleural cavities above the first rib Grossly enlarged heart Aortic arch Pulmonary trunk Left ventricle Thorax 465 343. A 23-year-old, semiconscious man is brought to the emergency room following an automobile accident. The right lower anterolateral thoracic wall reveals a small laceration and flailing. Air does not appear to move into or out of the wound, and it is assumed that the pleura have not been penetrated. After the patient is placed on immediate positive pressure endotracheal respiration, his cyanosis clears and the abnormal movement of the chest wall disappears. Radiographic examination confirms fractures of the fourth through eighth ribs in the right anterior axillary line and of the fourth through sixth ribs at the right costochondral junction. There is no evidence that bony fragments have penetrated the lungs or of pneumothorax (collapsed lung). The small superficial laceration, once it is ascertained that it has not penetrated the pleura, is sutured and the chest bound in bandages; positive pressure endotracheal respiration is maintained. The right side of the thorax is found to be more expanded than the left, yet moves less during respiration. A B 466 Anatomy, Histology, and Cell Biology Which of the following is the most obvious abnormal finding in the inspiratory posteroanterior and lateral chest x-ray of this patient (viewed in the anatomic position)? Flail chest Right hemothorax Right pneumothorax Paralysis of the right hemidiaphragm 344. A negative pressure drain (chest tube) must be inserted into the pleural space in order to remove either fluid or air that normally is not present. Apex between the clavicle and first rib Costomediastinal recess on the left, adjacent to the xiphoid process Right fourth intercostal space in the midclavicular line (just below the nipple) Right sixth intercostal space in the midaxillary line Right eighth intercostal space in the midclavicular line (about 4 in. The intercostal neurovascular bundle is particularly vulnerable to injury from fractured ribs because it is found in which of the following locations? Above the superior border of the ribs, anteriorly Beneath the inferior border of the ribs Between external and internal intercostal muscle layers Deep to the posterior intercostal membrane Superficial to the ribs, anteriorly 346. The miscarriage rate in humans is estimated to be as high as 15% of all pregnancies. These most often occur very early in pregnancy due to major defects in vital organs. Failure of the sixth aortic arch arteries to form would lead to loss of blood supply to which of the following essential organs? Right side of the heart Face Thyroid gland Lungs Upper digestive tract Thorax 467 347. A 62-year-old man reports to you that at times he has some chest pain and thinks that his heart is not beating at an appropriate rate, mainly too slowly, but occasionally too quickly. Which of the following is the best description of the blood supply for the sinoatrial nodal artery? About 60% of the time blood comes from the right coronary artery and about 40% of the time blood comes from the left circumflex artery d. About 60% of the time blood comes from the right marginal artery and 40% of the time from the left marginal artery. Blood usually comes from the posterior interventricular artery regardless of whether that has originated from the right or left coronary artery 348. The major venous return system of the heart, the coronary sinus, empties into which of the following structures? Inferior vena cava Left atrium Right atrium Right ventricle Superior vena cava 349. A 36-year-old male bartender is brought by ambulance to your emergency room because a patron jumped over the bar, grabbed an ice pick, and stabbed him in the chest rather than pay his bar tab at the end of the night. The ice pick entered the chest about 2 cm to the left of the sternum in between the fourth and fifth rib. Upon examining the bartender, you note very little blood is coming from the puncture wound and normal lung sounds from both the right and left lung. However, his heart is beating rapidly at 100 beats per minute, his external jugular veins are bulging, and you have difficulty hearing his heart sounds. Hemothorax Pneumothorax Cardiac tamponade Aortic valve stenosis Deep venous thrombosis 468 Anatomy, Histology, and Cell Biology 350. He is brought to the emergency room because he can no longer walk due to weakness, and he is feeling faint. All his heart sounds are distant and muffled and his blood pressure is low despite a very rapid pulse. Insert it just under the left tip of the xiphoid process in an effort to remove blood from the pericardial cavity b. Insert it at the second intercostal space on the left side of the sternum in an effort to inject nitroglycerine in an effort to increase the strength of cardiac contractions. Insert it at the ninth intercostal space at the left midclavicular line in an effort to remove blood from the pleural cavity d. Insert it at the fourth intercostal space on the right side in an effort to remove blood from the right pulmonary artery. Insert it just under the left clavicle in an effort to remove blood from the right cephalic vein Thorax 469 351. Your patient reports he spent two weeks on a desert island as part of a television survival show. Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe 470 Anatomy, Histology, and Cell Biology 352. A 36-year-old male office worker comes to the clinic complaining of general weakness and shortness of breath. Cardiac auscultation reveals a diastolic rumbling murmur attributable to the mitral valve. Left side adjacent to the sternum in the second intercostal space Left side adjacent to the sternum in the fifth intercostal space Left side in the midclavicular line in the fifth intercostal space Right side adjacent to the sternum in the second intercostal space Right side adjacent to the sternum in the fourth intercostal space 353. While listening to her lungs, which do sound congested, you also listen to her heart. While three of the valves sound normal the valve sound at the second intercostal space just to the right of the sternum sounds stenotic. In addition to mild pneumonia, which one of the following other conditions should be further evaluated for potential treatment? Pneumothorax Ventricular septal defect Aortic valve stenosis Pulmonary valve stenosis Mitral valve prolapse 354. The girl has just joined a recreational soccer team for the first time and she is not as fast as most of the girls her age and both of her legs hurt all over during and after soccer practices. The nurse checked her blood pressure upon arrival and was shocked at how high it was, 150/90. Upon physical exam, you reconfirm the hypertension in both arms and feel a weak femoral pulse just below her inguinal ligament. A patent ductus arteriosus Tetralogy of Fallot Transposition of the great arteries Grooving of the inferior surface of the ribs An enlarged right heart border Thorax 471 355. In angina pectoris, the pain that is often referred down the left arm, is mediated by increased activity in the c-fibers in which of the following nerves? Carotid branch of the glossopharyngeal nerves Greater splanchnic nerves Phrenic nerves Cardiac plexus Vagus nerve and recurrent laryngeal nerves 356. The sonographer, who immediately performs the echo study, is convinced that the baby girl has transposition of her great vessels. Which of the following is the most likely additional heart defect that is present in the newborn girl? Overriding aorta Ventricular septal defect Ligamentum arteriosum Coarctation of the aorta Aortic aneurysm 357. To improve the blood flow to the interventricular septum, a coronary bypass procedure is elected.
However quietude sleep aid review order 25 mg sominex with amex, for group planning insomnia 79th and amsterdam sominex 25 mg generic, this chapter presents a new approach sleep aid 2012 buy sominex 25mg low price, one based on considering the entire distribution of usual nutrient intakes insomnia gaming festival 2016 discount 25 mg sominex with mastercard, rather than focusing on the mean intake of a group insomnia or sleep apnea 25 mg sominex with amex. Variability exists because not all individuals in a group have the same requirements for a nutrient raf fender insomnia 01 25mg sominex, even if the individuals belong to the same life stage and gender group. Prevalence of inadequacy: the percentage of a group with intakes that fall below requirements. These concepts are explained in greater detail later in this chapter, beginning with a short review of the statistical foundation underlying the concept of a distribution. A distribution is an arrangement of data values showing their frequency of occurrence throughout the range of the various possible values. One of the most common distributions is a "normal" distribution, which is a symmetrical bell-shaped curve that has most of the values clustered in the center of the distribution and a few values falling out in the tails (see Figure 1). Important measures that describe a distribution are the mean, median, and standard deviation. It is calculated by adding all the data values and then dividing by the number of data values. It is the point at which half the data values are below and half the data values are above. In a symmetrical/normal distribution, the mean and median occur in the same place. One important use of the normal distribution is the way it can be used to convert scores into percentile ranks, or probabilities. This score can be related directly to the normal distribution and the associated percentage probability of nutrient adequacy or inadequacy, as seen in Figure 2. By making use of this property of the normal distribution, the probability (or prevalence) of adequacy or inadequacy can be estimated. For example, a "skewed" distribution is one where the curve has one tail longer than the other end. If the data do not form a normal distribution, then the properties of the normal distribution do not apply. Variability exists because not all individuals have the same requirement for a nutrient. A 24-hour recall is a detailed description of all foods and beverages consumed in the previous 24-hour period. When more than one 24-hour recall is collected, intake data can reflect the day-to-day variability within an individual that occurs because different foods are eaten on different days. When working with groups, statistical procedures should be used to adjust the distribution of observed intakes by partially removing the day-to-day variability in individual intakes so that the adjusted distribution more closely reflects a usual intake distribution. It is seldom possible to accurately measure long-term usual intake due to day-to-day variation in intakes as well as measurement errors. Therefore, mean observed intakes (over at least two non-consecutive days or three consecutive days) are used to estimate usual intake. Overlap of the Requirement Distribution and the Intake Distribution the requirement and intake distributions can overlap to varying degrees. In some cases, the two distributions will barely intersect, if at all (see Figure 3, Panel A), and in others there may be a lot of overlap between intakes and requirements (see Figure 3, Panel B). In dietary planning, efforts are made to ensure that the distribution of intakes is adequate relative to the distribution of requirements. Ideally, intake data are combined with clinical, biochemical, or anthropometric information to provide a valid assessment of nutritional status. Recognizing the inherent limitations and variability in dietary intakes and requirements is a major step forward in nutrition. Thus, assessment of dietary intakes should be used as only one part of a nutritional assessment, and the results must be kept in context. Nutrient intake data should always be considered in combination with other information, such as anthropometric measurements, biochemical indices, diagnoses, clinical status, and other factors. Dietary adequacy should be assessed and diet plans formulated based on the totality of evidence, and not on dietary intake data alone. Estimation of Usual Intake Obtaining accurate information on dietary intakes is challenging for a number of reasons, including the accuracy of dietary assessment techniques, as well as the challenges related to variability in intakes. The strongest methods for dietary assessment of nutrient adequacy are 24-hour recalls, diet records, or quantitative diet histories. Even so, the literature indicates that a sizeable proportion of individuals systematically misreport their dietary intakes, with the tendency toward underreporting (particularly for energy and percentage of energy from fat). It is unclear how this affects the accuracy of self-reported intakes of nutrients. Well-accepted, validated methods to statistically correct for the effects of underreporting are presently lacking. Thus, observed dietary intake is probably not the same as the long-term usual intake of an individual. However, the observed mean intake is still the best available estimate of dietary intake, and can still be used providing that it is recognized there is an amount of variability associated with that best estimate. It is important to note that there is variation in nutrient requirements between different individuals, and this needs to be taken into account when conducting an assessment. When conducting this type of descriptive assessment, it is important to keep in mind the limitations associated with the estimation of both intakes and requirements. The equations developed for the assessment of individuals are based on the principles of hypothesis testing and levels of confidence based on a normal distribution curve. The equations proposed here are not applicable to all nutrients because they assume a normal distribution of daily intakes and requirements. For nutrients for which a distribution is skewed (such as iron requirements of menstruating women, or dietary intakes of vitamin A, vitamin B12, vitamin C, and vitamin E), a different methodology needs to be developed. For these nutrients, individual assessment should continue to place emphasis on other types of information available. As illustrated in Box 2, the equation solves for a z-score on the normal distribution curve. The numerator of the equation is the difference between the estimated intake and the estimated requirement. It can intuitively be seen that the higher an intake is compared to the requirement, the larger the numerator will be. The denominator of the equation is the term that incorporates all the variability. Note that an increase in the number of days of records will lead to a decrease in the amount of variability. The question is whether this observed mean intake of 320 mg/ day indicates that her usual magnesium intake is adequate. The shortcoming of the qualitative method is that it does not incorporate any variability at all. If the variability in magnesium intake was even larger than 86 mg/day, the probability that an intake of 320 mg is adequate for this woman would be even lower than 85 percent, but the result of the qualitative assessment would not change at all. For this reason it is strongly encouraged that the statistical method be the method of choice when assessing nutrient adequacy, because even an intake that looks as though it is at the upper end of the distribution. Second, the diet developed should be one that the individual can afford and will want to consume. Special guidance should be provided for those with greatly increased or decreased needs. Figure 4 is a flow chart that describes decisions that need to be made during the planning process. The likelihood of the benefit must be weighed against the cost, monetary and otherwise, likely to be incurred by increasing the intake level. However, the approach to planning for energy differs substantially from planning for other nutrients. The situation for energy is quite different because for individuals who consume energy above their requirements and needs over long periods of time, weight gain will occur. They are only a starting point because energy expenditures vary from one individual to another even though their characteristics may be similar. These errors in estimation would eventually lead to a gain or loss in body weight, which would be undesirable when the goal is to maintain a healthy weight. Developing Dietary Plans for an Individual Once appropriate nutrient intake goals have been identified for the individual, these must be translated into a dietary plan that is acceptable to the individual. This is most frequently accomplished using nutrient-based food guidance systems such as national food guides. The requirement for zinc may be as much as 50 percent greater for vegetarians, particularly for strict vegetarians whose major food staples are grains and legumes. Average requirements for iron may range from 30 to 70 percent above those for normally active individuals. Vitamin B12 for those older than 50 years of age Smoking Vitamin C Bioavailability in vegetarian diets Iron Zinc Age of menstruation Iron (it is assumed that girls younger than 14 years do not menstruate and that girls 14 years and older do menstruate) Athletes engaged in regular intense exercise Iron Recommendation set according to reference weight Recommendation set per 1,000 kcal Protein Fiber Recommendation is 14 g/1,000 kcal. In all cases, individual assessments should be cautiously interpreted, preferably in combination with other information on factors that can affect nutritional status, such as anthropometric data, biochemical measurements, dietary patterns, lifestyle habits, and the presence of disease. Examples of such groups include nursing home residents, research study participants, and children attending residential schools. How to Assess the Nutrient Intakes of a Group the goal of assessing the nutrient intakes of groups is to determine the prevalence of inadequate (or excessive) nutrient intakes within a particular group of individuals (see Box 1 for definitions). To accurately determine the proportion of a group that has a usual intake of a nutrient that is less than their requirement, information on both the distribution of usual intakes and the distribution of requirements in the group is needed. Several characteristics of dietary intake data make estimating the distribution of usual intakes for a group challenging. When single 24-hour recalls or diet records are obtained from members of a group, the variability of the nutrient intakes will reflect both differences between individuals as well as differences within individuals. To obtain a distribution of usual intakes for a group, the distribution of observed intakes. To do this, at least two 24-hour recalls or diet records obtained on nonconsecutive days (or at least three days of data from consecutive days) are needed from a representative subsample of the group. If intake distributions are not properly adjusted, the prevalence of nutrient inadequacy will be incorrectly estimated and is usually overestimated (see Figure 5). Although these methods will adjust for variability in day-to-day intakes, they do not make up for inaccuracies in reported or observed intakes. This method depends on two key assumptions: that intakes and requirements are independent and thus no correlation exists between usual intakes and requirements (this is thought to be true for most nutrients, although it is not known to be true for energy) and that the distribution of requirements for the nutrient in question is known. This method then uses statistical equations to estimate the prevalence of inadequacy. Case studies one and two at the end of the chapter illustrate the use of the probability approach. Blood (and therefore iron) losses during menstrual flow greatly vary among women, and some women have unusually high losses. Note, however, that the assumption that intakes are more variable than requirements might not hold for groups of similar individuals who were fed similar diets. When the requirement distribution is symmetrical, when intakes are more variable than requirements, and when intakes and requirements are independent, the proportion of the group described in item 1 cancels out the proportion described in item 2. For example, as shown in Box 3, women 51 to 70 years of age had a median dietary vitamin B6 intake of 1. For this reason, it is simply not possible to determine the proportion of a group with intakes below requirements. Accordingly, only limited inferences can be made about the adequacy of group intakes. The distribution has been adjusted for individual variability using the method developed by the National Research Council. For some nutrients, such as fluoride, phosphorus, and vitamin C, the distribution of usual intakes would need to include intake from all sources. For others, such as magnesium, folate, niacin, and vitamin E, only the distribution of usual intakes from synthetic sources added to foods and from supplements (and in the case of magnesium, medications) would be needed. If significant proportions of the population fall outside the range, concern could be heightened for possible adverse consequences. This is because empirical evidence indicates a strong correlation between energy intake and energy requirement. This correlation most likely reflects either the regulation of energy intake to meet needs or the adjustment of energy expenditure to be consistent with intakes. This can be challenging because the amount and selection of foods that group individuals eat will vary, even if the same meal is offered. Situations where group planning occurs include residential schools, prisons, military garrisons, hospitals, nursing homes, child nutrition programs, and food assistance programs. When planning for groups, a practitioner should aim for a low prevalence of inadequate intakes.
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