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By F. Umbrak. Black Hills State University.

Dicobalt edetate 600 mg followed by sodium thiosulphate – very toxic therapy and least ideal of the three buy sildigra 120mg amex statistics of erectile dysfunction in india. Mustard gas can also cause suppression of the bone marrow order 50 mg sildigra impotence male; if this occurs in an austere situation death is likely from infection cheap 50 mg sildigra with amex erectile dysfunction at the age of 30. Unroof large blisters ( remove the loose overlying skin) and irrigate frequently with water and soap cheap 120 mg sildigra fast delivery erectile dysfunction icd 9 2014. Eyes should be irrigated with copious amounts of saline initially then daily irrigations. For mustard gas there is a specific decontamination powder but it is not readily available. Certainly this can be effective but like anything it carries a risk if not done properly; poor healing, infection, and reactions to the suture material. Many wounds that we currently suture will heal very well without any intervention, and suturing is mostly done to speed up wound healing and for cosmetic reasons. However, suturing isn’t hard and only requires adherence to a few basic principles. A number of the books listed in the reference section provide detailed instruction on suture techniques. An area which is poorly covered and where there is a great deal of inaccurate information is regarding suture materials and needles. In a pinch your fishing line and a normal sewing needle may be ok, but they are far from ideal. The manufacturers of suture material have a wealth of material available on their websites: Ethicon: http://www. Absorption is how long it takes for the suture material to be absorbed by the body. Sutures are classified as: Absorbable natural or synthetic Or Non-absorbable natural or synthetic And Monofilaments – suture made of a single strand Or Braided – suture made of several filaments twisted together • Natural absorbable: Surgical Gut: Collagen material derived from the submucosal layer of sheep or the serosal layer of cattle intestines. Several types: - 128 - Survival and Austere Medicine: An Introduction Plain gut: Tensile strength for 5-7 days, absorption within 42 days. Versatile material commonly used for closing bowel, uterus, and episiotomy/tear repairs; ok for skin but not first choice. Much better products available Surgical linen: Braided multifilament obtained from flax; not commonly used. Stainless steel: commonly used either as staples for the skin, for wiring the sternum following cardiac surgery, or for tendon repairs • Synthetic Absorbable: Most are synthetic protein polymers. Exact names vary with which company has produced them but each company has equivalent products. Very versatile suture, useful for most things: Skin, internal tissues, episiotomy/tear repairs. Most versatile general purpose needle o Cutting: Triangular-shaped needle point with a cutting edge on the inside curvature of the needle. If the area is under a lot of stress such as the abdominal wall or over a joint or active muscle then 7-10 days. Alternative methods: Staples: Staples can be used interchangeably with sutures for closing skin wounds. Their main drawback is that from a cosmetic standpoint they are inferior to sutures. Glue: Glue is useful for small, superficial skin lacerations; lacerations only partial thickness or just into the subcutaneous layer. It should not be used around the eyes or mouth, and it is less effective in hairy areas. The wound should be cleaned, and hair along the edges of the wound formed into bundles, and then opposite bundles tied across the wound to bring the edges together. Alternative suture material: A number of materials can be substituted for commercial suture material in austere situation. Possible suture materials include – fishing and sewing nylon, dental floss, and cotton, and in an absolute worse case horse hair or home made “gut” sutures. If you only have improvised suture material available - 130 - Survival and Austere Medicine: An Introduction you should seriously consider if suturing is the right thing to do. Anything which is organic has a much greater chance of causing tissue irritation and infection. Alternative needles: Consider small sail makers, glove makers or upholsters needles. In theory any sewing needle can be used – but curved ones are obviously easier to use. Summary: Our view is that the most versatile material is a synthetic absorbable suture like Vicryl (or an equivalent), in a variety of sizes with a 1/3 circle taper needle. If Vicryl is unobtainable or too expensive then we recommend stocking nylon and simple gut in a variety of sizes. It is also worth considering disposable staplers if your finances stretch to that. It is limited in the details of its coverage of dental anaesthesia and modern filling material, but, otherwise, is an excellent and easy to understand introduction to dental care. There are several other good web-based resources: Common Dental Emergencies: http://www. Much of this information is useless without detailed anatomical knowledge and instruction in actual techniques. We are not trying to teach dentistry here but are providing an overview of what is possible in austere situation, and helping you focus your preparations, and further education. The basics of dentistry can simplistically be broken down into 7 areas: Preventive dentistry: Like preventive medicine the importance of preventive dentistry cannot be over emphasised. Before finding yourself in an austere environment get in the habit of daily brushing, and flossing, and regular dental check-ups, and appropriate treatments. When access to regular dental care is no longer possible then continuing with daily flossing and brushing is vital. High sugar foods and drinks particularly between main meals should be discouraged. While regular cleaning and flossing will minimise and slow plaque build-up it will still occur. This takes the form of mineralised deposits at the edges of the teeth and the gums, and just below the gum margins. Scaling is the process where this material is scraped off using a scaler or dental pick. The tooth is usually not sensitive to percussion or palpation but maybe sensitive to heat, cold, sweets. Management is by symptom control with oral antiinflammatories, and pain medications, local nerve blocks, cold packs, saline gargles, and soft diet. This management is standard for a number of conditions and will be referred to as “standard dental first aid” in the rest of this chapter. Periapical Inflammation – Inflammation, but not infection, at the apex (root base) The involved tooth is usually is easily located. Usually there is no obvious external swelling as is the usual case with infection. Aphthous Ulcers – Lesion on oral mucus membranes, cause unclear There are often multiple ulcers lasting 7 – 15 days. Topical steroids may shorten course of healing Muscle Pain & Spasm – chewing muscle dysfunction due to teeth grinding, jaw clenching, heavy chewing, etc. Other Causes Infections (discussed below), facial nerve pain, herpes zoster, vascular pain-migraine, sinus pain, referred pain. Infections: Herpes Labialis (viral) = cold sores on lips, tongue, gingiva, palate - 133 - Survival and Austere Medicine: An Introduction Often triggered by sunburn, stress, and trauma. Mouth rinse of equal parts Maalox, Benadryl liquid, and Viscous Lidocaine may be soothing, swish & spit out, use every 2 hours as needed. Oral Candidiasis (fungal) = Thrush; caused by overgrowth of yeast normally found in the mouth Often seen in the very ill, immunocompromised, or those on/recently taking antibiotics. It looks like white spots or patches throughout mouth, may have a “cottage cheese” appearance, can be rubbed off, the patient’s mouth and throat often very sore & red. It is managed by eliminating source of re-infection (toothbrushes washed in boiling water & air dried, etc. A good substitute is any sort of vaginal yeast cream rubbed into mouth & gums 4x/day. Oral antifungals like Diflucan 100 mg tablets 2x/day until it clears can also be used Bacterial Infections Many different organisms can cause infections often mixed aerobic and anaerobic bugs that are normally in the oral cavity. Infections can be life threatening if the infection spreads to deep tissues or into the brain. Apical Abscess/Cellulitis – Infection of the pulp extending down to the bone & gum. This is an infection at the very apex of the roots that has eaten through the thin bone of the jaw. Notable for fever, pain, often an abscess/pus pocket, or swelling will form where the gum tissue joins the lip, no sensitivity to heat or cold. A small improvised drain such as a portion of rubber band or cotton wick, will speed healing – remove when no longer draining. Pericoronitis – Infection of the gum overlying a partially erupted tooth such as a wisdom tooth. It can mimic a peritonsillar abscess or pharyngitis although there usually is no drainage or purulence with this. It is managed by cleaning out between the tooth & gum and dental first aid measures. Immediate incision & drainage is required along with aggressive antibiotic therapy and supportive care. This is a potentially life-threatening emergency, and you should try to get help if you possibly can. When to use antibiotics: Dental abscesses are best treated by drainage of any collection present. Antibiotics should be used in patients who are systemically unwell – high temperatures, chills or shakes, nausea, vomiting, or gross local swelling. Penicillin 500 mg 4x/day or Erythromycin 500 mg 3x/day are usually acceptable antibiotics. For patients who are very unwell the addition of the drug metronidazole 400 mg 3 times daily or Tinidazole 2 gm once daily to cover anaerobic bacteria may be helpful. Drilling and Filling: Cavities on teeth cause pain either because they allow infection into the inside of the tooth or they expose nerve endings in the pulp of the tooth which is stimulated by exposure to temperature extremes or extreme sweetness. It is very straightforward to provide a temporary filling which covers the hole and protects the exposed nerve endings. This can be done with a number of temporary filling materials available on the market.

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Harker sildigra 120mg lowest price most effective erectile dysfunction pills, at al (2008) also suggests that it is 25 important to have prevention programmes that attempt to engage the minds of the youth to avoid boredom quality sildigra 50 mg erectile dysfunction drugs australia. Such activities include life skills programmes generic 50mg sildigra with visa xylometazoline erectile dysfunction, vocational training services buy 100mg sildigra visa impotence support group, youth sport and recreational activities. Thwala (2005), highlights the following key elements for successful prevention programmes:  Balancing negative and positive effects of substance abuse  Improve social skills,  Provide healthy alternatives to drugs,  Focusing on harm reduction to those already affected,  Emphasise quality of life changes  Have interactive programmes and include peers and parents. As young people spend most their time at school, school-based programmes are essential. At school Harker, Myers and Parry (2008) caution against once-off training sessions by specialists as these may have perverse outcomes. They note that once off lectures have proved to be ineffective and instead stimulate more interests on substance abuse. Scare tactics, where inducing fear among substance abusers and immediate families by exaggerating the risks and relative dangers of illegal drugs, or misusing statistics to drive scare messages home, should also be avoided as they have rarely influenced behaviours in a positive way (United Nations Office on Drugs and Crime for Southern Africa 2004). When adolescents discover that they have been misled they subsequently reject any information on drugs from official channels Microsystem: Literature is clear that successful interventions are those that target the youth concurrently with their peers, parents and families. Improving parenting skills and behaviours is essential when trying to address a youth’s immediate toxic environment. The training for parents should ideally focus on  The importance of nurturing one’s children. This could be done through regulatory interventions; decreasing access to alcohol via increased taxes; brief interventions for high risk drinkers; regulation of unlicensed outlets, and removing outlets from residential areas; advertisement restrictions; community mobilisation; and product related strategies such as appropriate labelling. A study by Griffin and Botvin, (2011) has documented various evidence based successful approaches to dealing with youth drug abuse problems. The study reviews tried and tested approaches that include school based, family-based and community-based prevention approaches Many policies address an individual, but miss the point that many individuals exist in a family context. Literature has shown that policies that seek to strengthen families are essential in addressing the substance abuse problem. In South Africa, one single most important initiative that seeks to address a family unit as key to building an individual is the 26 Green Paper on Families. It deals with how to promote family life, and how to strengthen families and what family strengthening programmes can be pursued. Societal/Community level and Drug use campaigns At the level of society or community, interventions should ideally focus on reducing youth’s access to drugs, and modifying societal norms that promote indulgence in these substances. Regulations and stricter enforcement of laws play a key role in reducing drug abuse. Harker, at al (2008) also recommends:  Community mobilization to counter the sale of legal and illegal drugs. In 2003 the Department of Social development launched the campaign “Ke moja, I’m fine without drugs”. In line with the National Drug Master Plan, “Ke moja I’m fine without drugs” main focus is on the primary prevention. The programme further works towards the protection and upliftment of all people and communities by promoting well-being and encouraging and supporting people to take pro- health decisions. In 2010, the Department of Social Development launched an Anti-substance abuse campaign popularized through the name ‘No place for drugs in my community’. The campaign focused on awareness raising and promoting rehabilitation amongst those affected. One of the objectives of the campaign was to promote debate and action around drug abuse. The last of these was launched by the minister in 2015 under the banner ‘Vulnerable populations in emergencies’. Many of these seasonal campaigns are often overshadowed by many others from different stakeholders – which are aimed specifically at alcohol abuse. As a result of this, substance abuse, other than alcohol does not get the desired prominence. Recently, the government launched a national campaign, known as Operation Fiela/Reclaim. Operation Fiela-Reclaim is a multidisciplinary interdepartmental operation aimed at eliminating criminality and general lawlessness in communities. The ultimate objective of the 27 operation is to create a safe and secure environment for all in South Africa through the prevention and combating of various crime types and addressing the safety concerns of the citizens of the country. Although no formal evaluation of the campaign has been conducted – there is anecdotal evidence of success particularly in its other areas of focus such as confiscating counterfeit goods and unlicensed fire arms. Its focus in dealing with the criminal aspect of possession, with no specific education is another limitation. Through the ‘Be Alert’ campaign, drug awareness has been prioritized – giving information on different drugs, their effects and dangers of addiction. Several civil society organizations have also developed and implemented drug abuse related campaigns. National Youth Development Agencies has been involved in Anti-drug awareness campaign. At community level, these organizations tend to mushroom in high drug use communities, many of them emphasizing harm reduction – through promoting rehabilitation programmes. Whilst these tend to have some microsomal success – they often lack adequate support from law enforcement and exist in isolation from those aimed at addressing supply of drugs. Indeed, they are often overwhelmed by the continued supply of the drugs, resulting in addiction relapses. The program has not been formally evaluated but continues to inspire private sector involvement in the fight against drugs. On a daily basis, these prosecutors noticed that many of the young people filtering through the criminal justice system shared this history and were in trouble as a direct result of it. They embarked on a carefully structured campaign, which addressed substance abuse and revealed how children were being led into a life of crime due to addiction. They are a safe place for children between the ages of 14 and 17 who are in conflict with the law. The children at the Mogale Youth Centre, along with social workers, use drama as a vehicle to promote change within drug-stricken communities. The campaign was introduced to a wide range of schools where the children performed this drama production for their peers. It quickly became evident that telling others about their circumstances – for example, criminal charges and living in a detention centre – had a strong impact on many who saw the campaign. Other private sector initiatives include the Addiction Harm Reduction Compliancy, which is a value that commits individuals and companies to a set of Principles, Compliancy Solutions and Processes, which reduce the harm that addiction causes to society. This calls for greater efforts and effective strategies in dealing with the drug problem. It also calls for a multi pronged approach targeting demand, supply and harm reduction. The following recommendations are made for different campaigns: Social Mobilisation Campaigns The following general recommendations are in order:  Use the ecological framework as a basis for designing programmes and interventions to combat drug abuse. Evidence in literature suggests that there is a need for more structured and evidence based campaigns which will be able to advocate increased focus and resources to combating drug use. The effort should be maintained throughout the course of the year, with campaign renewals at peak high recreational periods. These campaigns need to adopt the framework outlined in the South African Drug Prevention Master Plan in order for them to be easily monitored against the 3 pillars. In addition, the campaign should be multi disciplinary with a range of stakeholders as suggested in Table 5 below. Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. School violence and adolescent mental health in South Africa: Implications for school health programs. Sociological Practice: A Journal of Clinical and Applied Sociology, 1(4), 285-303. Adolescent multiple risk behaviour: an asset approach to the role of family, school and community. National strategy for the prevention and management of alcohol and drug use amongst learners in schools. Prevalence patterns and predictors of alcohol use and abuse among secondary school students in Southern KwaZulu-Natal, South Africa: Demographic factors and the influence of parents and peers. Botvin, (2011), Evidence-Based Interventions for Preventing Substance Use Disorders in Adolescents, Child Adolesc Psychiatr Clin. Audit of prevention programmes targeting substance use among young people in Greater Cape Town Metropole. Jacobs, L and Steyn, N (2013) commentary: If You Drink Alcohol, Drink Sensibly: Is This Guideline Still Appropriate? The experience review of interventions and programmes dealing with youth violence in urban schools in South Africa. Factors associated with substance use among orphaned and nonorphaned youth in South Africa. Sikkema (2014), The Impact of methamphetamine (“tik”) on a peri-urban community in Cape Town, South Africa, International Journal of Drug Policy, Mar; 25(2): 219–225. Morojele and L Ramsoomar, (2016), Addressing adolescent alcohol use in South Africa, S Afr Med J 2016;106(6):551-553. Perceptions of sexual risk behaviours and substance abuse among adolescents in South Africa: a qualitative investigation. A qualitative study of home-brewed alcohol use among adolescents in Mankweng District, Limpopo Province, South Africa. Alcohol consumption and non-communicable diseases: Epidemiology and policy implications. A prospective study of metaphetamine use as a predictor of high school non-attendance in Cape Town, South Africa. Women’s discourses about secretive alcohol dependence and experiences of accessing treatment. Unpublished dissertation presented for the degree of Doctor of Philosophy in the Department of Psychology at the University of Stellenbosch; Pretorius, C. Umthente Uhlaba Usamila – The 2 nd South African Youth Risk Behaviour Survey 2008. Umthenthe uhlaba usamila – the 1st South African youth risk behaviour survey 2002. The comparative risk assessment for alcohol as part of the global burden of disease 2010 study: What changed from the last study? Alcohol consumption as a risk factor for pneumonia: A systematic review and meta-analysis. Setlalentoa M, Elma Ryke and Herman Strydom (2015) Intervention strategies used to address alcohol abuse in the North West province, South Africa Social work (Stellenbosch. Religious activity and risk behavior among African American adolescents: Concurrent and developmental effects. Evaluation of a Primary Prevention of Substance Abuse Programme Amongst Young people at Tembisa. Baseline study of the liquor industry including the impact of the national liquor act 59 of 2003. Conducting effective Substance abuse prevention work among the youth in South Africa.

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Long-term data in Westernized popula- tions purchase 120 mg sildigra overnight delivery erectile dysfunction occurs at what age, which could determine the minimal amount of carbohydrate com- patible with metabolic requirements and for optimization of health 100mg sildigra with visa iief questionnaire erectile function, are not available trusted 100mg sildigra erectile dysfunction causes divorce. This amount of glucose should be sufficient to supply the brain with fuel in the absence of a rise in circulating aceto- acetate and β-hydroxybutyrate concentrations greater than that observed in an individual after an overnight fast (see “Evidence Considered for Estimating the Average Requirement for Carbohydrate”) buy 120 mg sildigra otc erectile dysfunction organic. This assumes the consumption of an energy-sufficient diet containing an Acceptable Macronutrient Distribution Range of carbohydrate intake (approximately 45 to 65 percent of energy) (see Chapter 11). Data on glucose consumption by the brain for various age groups using information from Dobbing and Sands (1973) and Dekaban and Sadowsky (1978) were also used, which corre- lated weight of the brain with body weight. The average rate of brain glucose utilization in the postabsorptive state of adults based on several studies is approximately 33 µmol/100 g of brain/min (5. Based on these data, the brain’s requirement for carbohydrate is in the range of approximately 117 to 142 g/d (Gottstein and Held, 1979; Reinmuth et al. Regardless of age and the associated change in brain mass, the glucose utilization rate/100 g of brain tissue remains rather constant, at least up to age 73 years (Reinmuth et al. In 351 men (aged 21 to 39 years), the average brain weight at autopsy was reported to be 1. There was excellent correlation between body weight and height and brain weight in adults of all ages. Therefore, the overall dietary carbohydrate requirement in the presence of an energy-adequate diet would be approximately 87 (117 – 30) to 112 (142 – 30) g/d. This amount of carbohydrate is similar to that reported to be required for the prevention of ketosis (50 to 100 g) (Bell et al. The carbohydrate requirement is modestly greater than the potential glucose that can be derived from an amount of ingested protein required for nitrogen balance in people ingesting a carbohydrate-free diet (Azar and Bloom, 1963). This amount of carbohydrate will not provide sufficient fuel for those cells that are dependent on anaerobic glycolysis for their energy supply (e. That is, the cyclic interconversion of glucose with lactate or alanine occurs without a net loss of carbon. The amount of dietary protein required approaches the theoretical maximal rate of gluconeogenesis from amino acids in the liver (135 g of glucose/24 h) (Brosnan, 1999). This amount should be sufficient to fuel central nervous system cells without having to rely on a partial replacement of glucose by ketoacids. Although the latter are used by the brain in a concentration-dependent fashion (Sokoloff, 1973), their utilization only becomes quantitatively significant when the supply of glucose is considerably reduced and their circulating concentra- tion has increased several-fold over that present after an overnight fast. Never- theless, it should be recognized that the brain can still receive enough glucose from the metabolism of the glycerol component of fat and from the gluconeogenic amino acids in protein when a very low carbohydrate diet is consumed. It is well known that the overall rate of energy metabolism decreases with aging (Roberts, 2000a). In adults 70 years of age or older, the glucose oxidation rate was only about 10 percent less than in young adults between 19 and 29 years of age (Robert et al. This decrease is similar to that reported from autopsy data in Japan (mean 1,422 to 1,336 g) (Yamaura et al. Whether glucose oxidation changes out of proportion to brain mass remains a controversial issue (Gottstein and Held, 1979; Leenders et al. In any case, the decrease in brain glucose oxidation rate is not likely to be substantially less. There is no evidence to indicate that a certain amount of carbohydrate should be provided as starch or sugars. However, most individuals do not choose to eat a diet in which sugars exceed approximately 30 percent of energy (Nuttall and Gannon, 1981). This increased fuel requirement is due to the establish- ment of the placental–fetal unit and an increased energy supply for growth and development of the fetus. It is also necessary for the maternal adapta- tion to the pregnant state and for moving about the increased mass of the pregnant woman. This increased need for metabolic fuel often includes an increased maternal storage of fat early in pregnancy, as well as suffi- cient energy to sustain the growth of the fetus during the last trimester of pregnancy (Knopp et al. In spite of the recognized need for increased energy-yielding substrates imposed by pregnancy, the magnitude of need, as well as how much of the increased requirement needs to be met from exogenous sources, remains incompletely understood and is highly variable (Tables 5-23 through 5-27). There is general agreement that the additional food energy requirement is relatively small. Several doubly labeled water studies indicate a progres- sive increase in total energy expenditure over the 36 weeks of pregnancy (Forsum et al. The mean difference in energy expenditure between week 0 and 36 in the studies was approximately 460 kcal/d and is proportional to body weight. The fetus does not utilize significant amounts of free fatty acids (Rudolf and Sherwin, 1983). As part of the adaptation to pregnancy, there is a decrease in maternal blood glucose concentration, a development of insulin resistance, and a tendency to develop ketosis (Burt and Davidson, 1974; Cousins et al. A higher mean respiratory quotient for both the basal metabolic rate and total 24-hour energy expenditure has also been reported in pregnant women when compared to the postpartum period. The increased glucose utilization rate persists after fasting, indicating an increased endogenous production rate as well (Assel et al. Thus, irrespective of whether there is an increase in total energy expenditure, these data indicate an increase in glucose utilization. Earlier, it was reported that the glucose turnover in the overnight fasted state based on maternal weight gain remains unchanged from that in the nonpregnant state (Cowett et al. The fetus reportedly uses approximately 8 ml O2/kg/min or 56 kcal/ kg/d (Sparks et al. The transfer of glucose from the mother to the fetus has been estimated to be 17 to 26 g/d in late gestation (Hay, 1994). If this is the case, then glucose can only account for approximately 51 percent of the total oxidizable substrate transferred to the fetus at this stage of gestation. The mean newborn infant brain weight is reported to be approximately 380 g (Dekaban and Sadowsky, 1978). Assuming the glucose consumption rate is the same for infants and adults (approximately 33 µmol/100 g of brain/min or 8. This is greater than the total amount of glucose transferred daily from the mother to the fetus. Data obtained in newborns indicate that glucose oxidation can only account for approximately 70 percent of the brain’s estimated fuel require- ment (Denne and Kalhan, 1986). In addition, an increase in circulating ketoacids is common in pregnant women (Homko et al. Taken together, these data suggest that ketoacids may be utilized by the fetal brain in utero. If nonglucose sources (largely ketoacids) supply 30 percent of the fuel requirement of the fetal brain, then the brain glucose utilization rate would be 23 g/d (32. These data also indicate that the fetal brain utilizes essentially all of the glucose derived from the mother. There is no evidence to indicate that a certain portion of the carbohydrate must be consumed as starch or sugars. The lactose content of human milk is approximately 74 g/L; this concentration changes very little during the nursing period. Therefore, the amount of precursors necessary for lactose synthesis must increase. Lactose is synthe- sized from glucose and as a consequence, an increased supply of glucose must be obtained from ingested carbohydrate or from an increased supply of amino acids in order to prevent utilization of the lactating woman’s endogenous proteins. However, the amount of fat that can be oxidized daily greatly limits the contribution of glycerol to glucose production and thus lactose formation. For extended periods of power output exceeding this level, the dependence on carbohydrate as a fuel increases rapidly to near total dependence (Miller and Wolfe, 1999). Therefore, for such individuals there must be a corre- sponding increase in carbohydrate derived directly from carbohydrate- containing foods. Additional consumption of dietary protein may assist in meeting the need through gluconeogenesis, but it is unlikely to be con- sumed in amounts necessary to meet the individual’s need. A requirement for such individuals cannot be determined since the requirement for carbohydrate will depend on the particular energy expenditure for some defined period of time (Brooks and Mercier, 1994). They are composed of various proportions of glucose (dextrose), maltose, trisaccharides, and higher molecular-weight products including some starch itself. These syrups are also derived from cornstarch through the conversion of a portion of the glucose present in starch into fructose. Other sources of sugars include malt syrup, comprised largely of sucrose; honey, which resembles sucrose in its composition but is composed of individual glucose and fruc- tose molecules; and molasses, a by-product of table sugar production. With the introduction of high fructose corn sweeteners in 1967, the amount of “free” fructose in the diet of Americans has increased consider- ably (Hallfrisch, 1990). Department of Agriculture food consumption survey data, nondiet soft drinks were the leading source of added sugars in Americans’ diets, accounting for one-third of added sugars intake (Guthrie and Morton, 2000). This was followed by sugars and sweets (16 percent), sweetened grains (13 percent), fruit ades/drinks (10 percent), sweetened dairy (9 percent), and breakfast cereals and other grains (10 percent). Together, these foods and beverages accounted for 90 percent of Ameri- cans’ added sugars intake. Gibney and colleagues (1995) reported that dairy foods contributed 31 percent of the total sugar intakes in children, and fruits contributed 17 percent of the sugars for all ages. The majority of carbohydrate occurs as starch in corn, tapioca, flour, cereals, popcorn, pasta, rice, potatoes, and crackers. Between 10 and 25 percent of adults consumed less than 45 percent of energy from carbohydrate. Less than 5 percent of adults consumed more than 65 percent of energy from carbohydrate (Appendix Table E-3). Median carbohydrate intakes of Canadian men and women during 1990 to 1997 ranged from approximately 47 to 50 percent of energy intake (Appendix Table F-2). More than 25 percent of men consumed less than 45 percent of energy from carbohydrate, whereas between 10 and 25 per- cent of women consumed below this level. Less than 5 percent of Canadian men and women consumed more than 65 percent of energy from carbo- hydrate. Data from the Third National Health and Nutrition Examination Survey shows that the median intake of added sugars widely ranged from 10 to 30 tsp/d for adults, which is equivalent to 40 to 120 g/d of sugars (1 tsp = 4 g of sugar) (Appendix Table D-1). Potential adverse effects from consuming a high carbohydrate diet, including sugars and starches, are discussed in detail in Chapter 11. Behavior The concept that sugars might adversely affect behavior was first reported by Shannon (1922). The notion that intake of sugars is related to hyperactivity, especially in children, is based on two physiological theories: (1) an allergic reaction to refined sugars (Egger et al. A number of studies have been conducted to find a correlation between intake of sugars and adverse behavior; some have been reviewed by White and Wolraich (1995). Most of the intervention studies looked at the behavior effects of sugars within a few hours after ingestion, and therefore the long-term effects are unclear. A meta-analysis of 23 studies conducted over a 12-year period concluded that sugar intake does not affect either behavior or cognitive performance in children (Wolraich et al. Dental Caries Sugars play a significant role in the development of dental caries (Walker and Cleaton-Jones, 1992), but much less information is known about the role of starch in the development of dental caries (Lingstrom et al. Early childhood dental caries, also known as baby-bottle tooth decay or nursing caries, affects about 3 to 6 percent of children (Fitzsimons et al. This is associated with frequent, prolonged use of baby bottles containing fermentable sugars (e.