By E. Bufford. Mount Olive College.

Underreporting would purchase 5 mg fincar visa, however generic 5mg fincar free shipping, 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.

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Trans Fatty Acids Trans fatty acids are unsaturated fatty acids that contain at least one double bond in the trans configuration order fincar 5mg without prescription. The trans double-bond configura- tion results in a larger bond angle than the cis configuration buy fincar 5 mg otc, 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.

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The patient must have a physi- cian who can be honest and forthright in a sensitive buy fincar 5mg amex, empathic and caring fashion buy 5 mg fincar visa. The physician must be careful that their own personal beliefs and perspectives do not interfere with effective care. Coping with an adverse event, complaint or litigation Canadian Medical Protective Association Objectives Physicians invest inordinate amounts of time and energy This chapter will in their work, and their self-image is often centred on their • discuss the effects of medical errors, complaints and litiga- status as a physician. Legal allegations and patient complaints tion on physicians in training and throughout their career frequently depict doctors as callous, negligent or incompetent; in medicine, and physicians may feel this is a direct assault on their essence as • present an approach to dealing with errors and complaints a person. The legal claim is made by the family coverage of the clinical event, their trial, or college hearing. Internal emotions • sorrow The physician scans the document quickly but has to get • guilt back to work. The physician has diffculty completing the • loss of self-esteem shift and experiences feelings of insecurity bordering on • shame panic. Although the physician believes his family will be • fear supportive, the physician is ashamed to tell them about External pressures the legal action and the mistakes the physician presumes • social isolation from friends and family to have made in the case. Physicians are also susceptible to feelings of isolation during Approximately two per cent of physicians are named in a legal diffcult moments in their career. Far more are involved in a wide variety of it hard to maintain a social network of friends and colleagues other medico-legal diffculties. Patients or other parties may with whom they can commiserate and share experiences. They complain about a physician to a regulatory authority (college), may also feel shame or embarrassment about presumed medi- hospital or privacy commissioner or to the Human Rights cal errors. Physicians may be referred for college disciplin- as a failure, they may be inclined to keep the matter from their ary hearings or have their practice reviewed. Maintaining perspective Although it is impossible to erase a physician’s sadness and Medico-legal diffculties are stressful for physicians for several regret associated with a poor patient outcome, feelings of reasons. In some cases, the problem arises from a clinical out- guilt, inadequacy or fear can be greatly attenuated by keeping come that is unexpected and even disastrous to the patient. Physicians may be consoled by the is normal for a doctor to feel distressed when a patient dies following facts and observations. Physicians ex- perience empathy and sorrow for the patient and family when A poor patient outcome, even if unexpected, does not signify a tragic clinical outcome occurs. Doctors may beat up on themselves and won- sis or a surgical complication does not equate with negligence. They may be tormented have determined that the clinical standard of care by which a by doubts and second thoughts, even if their management of claim is judged is not one of perfection, but rather one that the case, viewed prospectively, had appeared reasonable at the might reasonably be expected from a normal, prudent health time. In spite of a deep commitment to patient care counsel, so as to maintain legal privilege. Provincial and university- or community-based physician health programs are available to provide support and assistance to Doctors often work in suboptimal conditions; they may be physicians going through diffcult moments. Contact informa- overloaded with work and may suffer from fatigue or sleep tion is available in Chapter 12-B of this guide. A physician may be loath to use fatigue as an excuse for a poor outcome, but the reality is that fatigue and Practical considerations other system and organizational issues often contribute to the Most physicians do cope reasonably well with adverse events occurrence of adverse events. Many come to realize that a medico- legal diffculty is not the cataclysmic event they may have All colleagues and most patients are aware that any physician, imagined. A medico-legal diffculty may induce a physician to even the most competent and knowledgeable among them, may appraise their practice and lifestyle and to implement construc- encounter a medico-legal diffculty at one time or another. Doctors should endeavour to achieve a satisfying unusual for patients to leave a physician’s practice because of work–life balance, and if a phase of practice becomes par- another patient’s complaint or legal action. Colleagues, patients, ticularly stressful they may wish to modify their practice to other health professionals, family and friends are appreciative allow for more time to invest in and take care of themselves. It can also be helpful to engage the services cian are rarely affected by a medico-legal diffculty. Physicians’ worries about the effect of a lawsuit or patient complaint on their career are often exaggerated. However, Positive practice changes can enhance patient safety, but physi- even when the medico-legal problem is reported in the me- cians should also avoid the urge to practise overly defensive dia, in most cases it is quickly forgotten by all but the parties medicine with excessive and clinically unwarranted investiga- involved. Above all, physicians should strive to do their best, to be thorough and conscientious, and to realize that perfection There is, of course, no magic remedy for the regret and sadness is unattainable. Case resolution The physician’s spouse is also a family physician and is Managing the stress unwavering in their support during the legal process. Kind Physicians should not be ashamed to seek help when facing a words from colleagues and patients helped to restore the medico-legaldiffculty. CanadianMedicalProtectiveAssociation physician’s confdence in themselves and the system. They express the concern that values, if physicians were allowed to “opt out,” it would inevitably • outline the professional and legal standards that frame happen that some patients would not be able to fnd a physi- the options physicians have in dealing with value conficts cian in their area who is willing to provide a given service, thus with a patient, and preventing them from accessing legitimate treatments.

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