Patricia B. Crawford DrPH, RD

• Adjunct Professor

https://publichealth.berkeley.edu/people/patricia-crawford/

Key aspects to emphasize include choosing potassium-rich fruits and vegetables type 2 diabetes symptoms joint pain losartan 50mg for sale, prioritizing seafood diabetes insipidus neurogenic vs nephrogenic buy 25mg losartan visa, making whole grains the predominant type of grains offered diabetes mellitus uncontrolled icd 9 discount 25mg losartan amex, and choosing oils over solid fats diabetes prevention natural remedies cheap losartan 25 mg without a prescription. A Pattern also was Scientific Report of the 2020 Dietary Guidelines Advisory Committee 7 Part A metabolic disease hyperparathyroidism generic losartan 50 mg without prescription. Executive Summary established for toddlers ages 12 to 24 months who are fed lacto-ovo vegetarian diets and neither human milk nor infant formula diabetes symptoms glucose in urine cheap losartan 50 mg. The modeling exercises revealed the importance of prioritizing nutrient-rich food groups and making careful food choices within food groups. This gives families substantial flexibility to accommodate cultural preferences and cost considerations, and provides opportunities to introduce children to a wide variety of healthy foods that are important in shaping healthy dietary patterns. Dietary Patterns People eat foods and drink beverages for many reasons, including, but certainly not limited to , nourishment. Common characteristics of dietary patterns associated with positive health outcomes include higher intake of vegetables, fruits, legumes, whole grains, low- or nonfat dairy, lean meat and poultry, seafood, nuts, and unsaturated vegetable oils and low consumption of red and processed meats, sugar-sweetened foods and drinks, and refined grains. In addition, the Committee found that negative (detrimental) health outcomes were Scientific Report of the 2020 Dietary Guidelines Advisory Committee 8 Part A. Executive Summary associated with dietary patterns characterized by higher intake of red and processed meats, sugar-sweetened foods and beverages, and refined grains. The healthy patterns the Committee examined in its review comprised various combinations of foods and were identified with many different names. This suggests that a healthy diet that promotes optimum growth and development while minimizing risk factors for chronic diseases can be created and tailored to suit cost considerations and a wide variety of personal and cultural preferences. Dietary Fats and Seafood Fats are an important component of the American diet, contributing about one-third of the total calories consumed after infancy. The types and food sources of fats consumed have distinct metabolic and health effects. Replacing saturated with unsaturated fats in the diet also reduces serum total and low-density lipoprotein cholesterol in all adults and some children, especially boys. However, the benefits of replacing saturated fat with carbohydrates are less clear. The recommended shift from saturated to unsaturated fats occurs best within the context of a healthy dietary pattern consisting of higher intakes of vegetables, fruits, legumes, whole grains, nuts and seeds, with some vegetable oils, low-fat dairy, lean meat and poultry, and fatty fish and lower intakes of red and processed meats, sugar-sweetened foods and drinks, and refined grains. Beverages Beverages are broadly defined as any type of energy or non-energy-yielding drink. They contribute substantially to the dietary patterns of Americans in both favorable and adverse ways. Executive Summary the Committee reviewed available data on the relationships between beverage consumption and achieving nutrient and food group recommendations. It also examined evidence on the relationship between beverage consumption and growth, size, body composition, and risk of overweight and obesity for children and adults. All beverages contribute to hydration needs, and many beverages, such as milk and 100% juice, can help people attain recommended nutrient intake goals. Sweetened beverages, not including coffee and tea with added sugar, account for approximately one-third of total beverage consumption and contribute approximately 30 percent, 50 percent, and 60 percent of added sugars to the diet of young children, adolescents, and adults, respectively. Limited evidence suggests that low- or no-calorie sweetened beverage consumption is associated with reduced adiposity in adults. Alcohol consumption and binge drinking are increasing in the United States, and excessive alcohol consumption is a leading behavioral risk factor for a variety of morbidity and mortality outcomes, social harms, and economic costs. Binge drinking is consistently associated with increased risk compared to not binge drinking, and more frequent binge drinking is associated with increased risk compared to less binge drinking. Similarly, among those who drink, consuming higher average amounts of alcohol is associated with increased mortality risk compared to drinking lower average amounts. The Committee concurred with the recommendation of the 2015-2020 Dietary Guidelines for Americans that those who do not drink should not begin to drink because they believe alcohol would make them healthier. Although alcohol can be consumed at low levels with relatively low risk, for those who choose to consume alcohol, evidence points to a general rule that drinking less is better for health than drinking more. Therefore, the focus should remain on reducing consumption among those who drink, particularly among those who drink in ways that increase the risk of harms. The Committee concluded that no evidence exists to relax current Dietary Guidelines for Americans Scientific Report of the 2020 Dietary Guidelines Advisory Committee 10 Part A. Executive Summary recommendations, and there is evidence to tighten them for men such that recommended limits for both men and women who drink would be 1 drink per day on days when alcohol is consumed. As with previous editions of the Dietary Guidelines, recommended limits pertain to days on which alcohol is consumed. Added Sugars As part of its focus on healthy dietary patterns that include nutrient-dense foods consumed at appropriate energy levels, the 2015-2020 Dietary Guidelines for Americans recommended that Americans consume less than 10 percent of energy from added sugars. It also examined the impact of added sugars on achieving nutrient recommendations and considered how much added sugars could be accommodated in a healthy dietary pattern. For Americans ages 1 year and older, average consumption of added sugars represent 13 percent of daily energy intake, meaning that most Americans consume diets that exceed current Dietary Guidelines recommendations. Nearly 70 percent of added sugars intake comes from 5 food categories: sweetened beverages, desserts and sweet snacks, coffee and tea (with their additions), candy and sugars, and breakfast cereals and bars. Reducing the amount of added sugars in the diet, either through changes in consumer behavior or in how food is produced and sold, is an achievable objective that could improve population health. After considering the scientific evidence for the potential health impacts of added sugars intake, along with findings from model-based estimations of energy available in the dietary pattern after meeting nutrient requirements, the Committee suggests that less than 6 percent of energy from added sugars is more consistent with a dietary pattern that is nutritionally adequate while avoiding excess energy intake from added sugars than is a pattern with less than 10 percent energy from added sugars. Frequency of Eating Eating is a behavior that provides humans with nutrients for growth, function, and body maintenance. Eating behaviors can support or weaken health and strongly influence the quality and length of life. The Scientific Report of the 2020 Dietary Guidelines Advisory Committee 11 Part A. Although the Committee was unable to find adequate evidence to answer the questions on the relationship between eating frequency and health outcomes, its analysis of eating frequency in the United States revealed a wide variety of eating frequency patterns that varied by socioeconomic and demographic factors. Diet quality was higher when self-reported meal intake increased from 2 meals per day to 3, whereas latenight eating often contained food components recommended to be consumed in moderation. Despite the importance of this topic, the available evidence for many questions was insufficient to form conclusion statements, highlighting the critical need for additional research. The Food Patterns are updated every 5 years and are presented to the Committee for its assessment of how well the Patterns align with the most current evidence on diet, health, and nutrient adequacy. Based on its review of the evidence, the Committee confirmed that these Food Patterns represent healthy dietary patterns in that they provide the majority of energy from plant-based foods, such as vegetables, fruits, legumes, whole grains, nuts and seeds; provide protein and fats from nutrient-rich food sources; and limit intakes of added sugars, solid fats, and sodium. The Committee noted that the types of foods that individuals should eat are remarkably consistent and that these Patterns can be applied across life stages, even taking into account specific nutrient needs at particular life stages. Integrating the evidence reviewed for the topics addressed in this report, the 2020 Committee concludes that every life stage provides an opportunity to make food choices that promote health and wellbeing, achieve and maintain appropriate weight status, and reduce risk of diet-related chronic disease. In summarizing the findings of the dietary patterns reviews, the Committee also noted that a powerful aspect of using a dietary patterns approach is that it enables multiple adaptations to fit cultural, personal, and individual needs and preferences in food choices. The Committee also identified several resource needs for the next Dietary Guidelines Advisory Committee (such as updates to the Dietary Reference Intakes for macronutrients, for birth to age 24 months, and for pregnancy and lactation), and pointed to the need for additional research on the birth to age 24 months life stage. Finally, the Committee suggested ways to incorporate its major findings into updates of the 2015-2020 Dietary Guidelines for Americans overarching principals for achieving an overall healthy dietary pattern. Early editions focused on healthy members of the general public but, recognizing the growing prevalence of diet-related chronic diseases, such as heart disease, type 2 diabetes, obesity, and some forms of cancer, more recent editions have covered individuals with increased risk of chronic disease as well. The 2020 Dietary Guidelines Advisory Committee was established for the single, time-limited task of examining the evidence on specific nutrition and public health topics and scientific questions and of providing independent, science-based advice and recommendations to the Federal government. Unhealthy dietary intakes, tobacco use, and not enough physical activity, among other risk factors, are related to the leading causes of deaths in the United States. Up-to-date nutrition advice in the Dietary Guidelines can help improve the health of Americans by encouraging food and beverage choices that are affordable, enjoyable, promote health, and help prevent chronic disease, taking into account that availability and access to nutritious food is important for all Americans, including those who are food insecure. Data from 2018 show that food insecurity and lack of access to affordable healthy food affect more than 37 million people, including 6 million children, Scientific Report of the 2020 Dietary Guidelines Advisory Committee 1 Part B. The earliest focus of dietary guidance was on food groups in a healthy diet, food safety, food storage, and ensuring that people got enough vitamins and minerals to prevent deficiency diseases. As nutrition science evolved, researchers learned that diet also played a role in disease prevention and health promotion, and dietary guidance also evolved to reflect the rapidly growing knowledge base about the relationships between diet and health. Since 1980, the Dietary Guidelines, and the science on which they have been based, have been remarkably consistent on the majority of components that make up a healthy diet, but they also have evolved in several substantial ways. Expanding to New Populations Historically, the Dietary Guidelines for Americans focused on nutrition and food-based recommendations for health promotion and disease prevention for individuals ages 2 years and older. Over the years, however, a growing body of evidence made it increasingly clear that proper nutrition during the earliest stages of life was critical to support healthy growth and development during childhood and help promote health and prevent chronic disease through adulthood, that is, across the lifespan. In February 2014, Congress passed the Agricultural Act of 2014, which mandated that, beginning with the 2020-2025 edition, the Dietary Guidelines for Americans expand to include dietary guidance for infants and toddlers (from birth to age 24 months) as well as women who are pregnant. The project was tasked with conducting comprehensive systematic reviews on diet and health that are of public health importance for women who are pregnant and infants and toddlers from birth to 24 months of age. Chapter 1: Introduction in recent editions, dietary guidance for these populations in the 2020-2025 Dietary Guidelines for Americans. Evolving from Nutrients to Dietary Patterns Previous Dietary Guidelines Advisory Committees focused on evidence that looked at the relationships between individual nutrients, foods, and food groups and health outcomes. Although this science base continues to be substantial, researchers and public health experts began to consider a broader perspective. Science was acknowledging that just as nutrients are not consumed in isolation, foods and beverages are not consumed separately either. The evolving evidence showed that components of a dietary pattern could have interactive, synergistic, and potentially cumulative relationships, such that they could predict overall health status and disease risk more fully than could individual foods or nutrients. The 2010 Committee acknowledged the importance of dietary patterns and recommended additional research in this area. The 2015 Committee made dietary patterns a central focus of its evidence review and concluded that a healthy diet could be attained with many dietary patterns adaptable to personal and cultural preferences. The 2020 Committee continues this same focus with an even deeper examination of the relationships between dietary patterns and specific health outcomes. Future Committees will continue to address the evolving public health concerns and nutrition needs of the U. Government uses the Dietary Guidelines for Americans as the basis of its food assistance programs, nutrition education efforts, and decisions about national health objectives. For example, the National School Lunch Program and the Elderly Nutrition Program incorporate the Dietary Guidelines in menu planning, the Special Supplemental Nutrition Program for Scientific Report of the 2020 Dietary Guidelines Advisory Committee 3 Part B. The Dietary Guidelines also provides a critical framework for state and local health promotion and disease prevention initiatives. In addition, it provides foundational evidencebased nutrition guidance for use by individuals and those who serve them in public and private settings, including health professionals, public health and social service agencies, health care and educational institutions, researchers, and business. The Committee also hopes that the 2020-2025 Dietary Guidelines for Americans will encourage the food industry to grow, manufacture, and sell foods and beverages that promote health and contribute to the U. Part C describes the methodology the Committee used to conduct its work and review the evidence on diet and health. The Report concludes with a number of Appendices, including a glossary; a summary of the process used to collect public comments; biographical sketches of Committee members; a list of Subcommittee and Working Group members; and Acknowledgments. A lifespan approach highlights the importance of implementing dietary patterns that are most associated with nutrition adequacy, energy balance, and reduced risk of diet-related chronic health conditions starting at the earliest life stages. This orientation further emphasizes the importance of adhering to these nutrient-dense dietary patterns throughout each subsequent life stage to meet nutritional needs appropriate to each life stage and to maintain health and wellbeing. As opposed to a focus on weight status at one point in life, the recommended dietary intakes support healthy weight trajectories at each stage of life, including healthy growth and development from infancy through adolescence, appropriate weight gain during pregnancy, energy needs during pregnancy and lactation, weight stability during mid-life, and healthy body composition late in life. The recommended dietary intakes can help prevent excess weight gain at every life stage, and support health even apart from considerations of energy intake. Of substantial concern is the increasing prevalence of overweight and obesity beginning at younger ages that can be carried into later life stages and worsen in adulthood. These high rates are a driver for diet-related chronic disease risk and are strongly associated with adverse maternal and fetal outcomes, including pregnancy outcomes and initiation and duration of breastfeeding. More than 70 percent of American adults are overweight or obese and the prevalence of severe obesity has increased over the past two decades. The Committee included evidence from studies that included people with overweight and obesity to reflect this reality of our current population. Prominent among these are poor nutrition, lack of physical activity, and excessive alcohol use. The consequences of these chronic conditions affect all Americans, given their impact on quality of life, vulnerability to emerging infectious diseases, and the cost burden to society, particularly the health care system. The 2010 Committee introduced the importance of dietary patterns in understanding the relationship between food choices and risk of chronic diseases. The 2020 Committee has further expanded this approach, using a growing body of evidence. The 2015-2020 Dietary Guidelines3 recommended a healthful eating pattern for ages 2 years and older based on food groups to include as well as food groups and related food components to limit. The underconsumption of these food groups leads to less than recommended intake of specific nutrients and increased disease risk. Additionally, the food components of added sugars, solid fats, and sodium, which are highlighted as components to limit, are consumed in excess of recommendations. These components are derived primarily through consumption of sweetened beverages (including coffee and tea), desserts and sweet snacks, candy and sugars, breakfast cereals and bars, burgers and sandwiches, higher fat dairy products, food items that are predominantly fat. Across all life stages, many of these foods also contribute to total grain consumption that is predominantly refined grains rather than whole grains. These and additional nutritional considerations exist at each life stage (see Part D. The 2015-2020 Dietary Guidelines for Americans did not include recommendations specific to the ages of birth to 24 months to enable a similar comparison for this age group. Chapter 5: Foods and Beverages Consumed During Infancy and Toddlerhood and Part D. Overall, the diet quality is higher in young children and tends to decline with age.

As a consequence diabetes type 1 early symptoms order losartan 25mg free shipping, the school nurse needs to consider carefully issues of documentation and confidentiality blood glucose 74 discount losartan 50mg mastercard. Recognizing the complexity of these issues diabetes symptoms in women over 50 buy losartan 25mg mastercard, both state and national agencies are beginning to address the many questions raised by the schools diabetes 2 symptoms diet order losartan 25mg otc. Depending upon how information is documented xceed blood glucose meter instructions generic losartan 50mg online, it may be subject to differing maintenance and confidentiality requirements diabetes insipidus life expectancy cheap 25mg losartan fast delivery. This information includes medication administration, nursing care/treatments, special diet, and impaired vision or hearing - provided such information is not of a type that should be protected from disclosure (see the discussion below on private notes). Relevant student health information may be disclosed to public health officials if warranted by an outbreak of a serious disease in the school or community. The school nurse, whether employed by the school committee or board of health, is responsible for keeping these records. For written records, the school should have policies regarding safe storage (locked cabinets) and a protocol for accessing the records. If the student health record is maintained electronically, the record should be protected by security measures, such as the use of passwords, limiting access to authorized school health personnel. Communication of Student Health Record Information to Other Authorized School Personnel There may be circumstances in which there is a need to share information in the student health record with authorized school personnel - either to enhance the educational progress of the student or protect his/her safety or well-being. For example, staff may need to be alerted to signs or symptoms of a medical problem and offered a course of action. This type of disclosure should be made only to those authorized school personnel who work directly with the student in an instructive, administrative, or diagnostic capacity. It is important to stress that only the minimum necessary information should be disclosed to other school personnel under these circumstances. For example, this information should not be shared in a public written list that is posted or circulated to all educators. Finally, authorized school personnel should be instructed not to re-disclose the information. If there is any question about the sensitivity of the information in the student health record, the permission of the parent/guardian and student, if appropriate, should be sought prior to disclosure to authorized school personnel. Ultimately, however, federal regulations permit information in the student health record to be seen by authorized school personnel, and the basis for such sharing seems even more compelling when necessary to protect the well-being or safety of the student. While it is appropriate practice for a nurse or other health professional to document observable facts with respect to a health condition, health needs, treatment plan, and the care provided, some information is not sufficiently related to the educational progress of a student to be appropriate for documentation in the student record. In addition, health professionals may have an ethical and legal duty to protect certain medical information which they possess. Placement of medical information in the school record, where persons other than the school nurse may see it, may violate this duty. Most of these statutes do not specifically address the duty of nurses or the provision of care in a school setting. The statutes do indicate a legislative intent to encourage minors to promptly seek certain types of medical diagnosis and treatment, in part by their being assured that information related to that treatment will be protected as confidential. For example, a minor who believes s/he has been exposed to a dangerous disease. In such cases, the statute requires that the information be held confidential between the treating physician and the minor. Such information may be released only with consent of the minor or a judicial order; it must be disclosed if the life or limb or the minor is endangered. The wording of the statute suggests that there must be a solid justification for disclosure of personal information, particularly if it is of a sensitive nature. Such information may be shared with the student, parent, or a temporary substitute of the maker of the record but otherwise should be released only with proper consent or court order. The statute provides that school staff shall immediately notify the school department or person in charge of the school. This approach seems consistent with a decision of the Massachusetts Supreme Judicial Court, Alberts v. The court, however, recognized an exception allowing (but not requiring) disclosure when there is a "serious danger to the patient or to others. Impact of Computerized Systems on Health Record: Benefits and Additional Confidentiality Issues Computerization of school health data improves management of school health records in a number of ways. Because computerized school health information systems make the collection and sharing of data much easier, they also raise many issues related to the privacy and security of school health information. However, schools developing computerized school health information systems should conduct a thorough analysis of system-specific privacy and security concerns. This would include an analysis of the regulations affecting collecting and sharing information. Data on the number and types of diagnoses of children with special health care needs have implications for staffing and program development. These include information on the number and type of health encounters, as well as the specific interventions performed by the school nurse. These data are essential for defining the role of school nurses in the provision of student health services. The number of students who lack a primary care provider or regular source of medical care may have implications for the types of services offered by the school. These include variables such as race/ethnicity, number of siblings and family structure, air and water quality indexes, and neighborhood characteristics. These include indicators on smoking, alcohol and drug use, seatbelt usage, sexual behavior, and nutritional intake, among others. Accurate and timely data are critical to reflect the nature of school health services and document the impact of these services on the student population. Program Monitoring and Surveillance Program monitoring is a crucial aspect of a school health program and involves the systematic collection of data for the purpose of determining the quantity of service provision. This information is essential for documenting need and also contributes to the evaluation process. Program monitoring and surveillance are frequently used interchangeably, and both assess the activities of the school health program. Program monitoring usually deals with what is being done, whereas surveillance usually tracks health status indicators for populations of children. Computerized Systems and School Health Data School health data can quantify the scope and extent of health services provided in schools. It also provides information about the make-up and health of the ever-changing school-age population. It may demonstrate the extent to which environmental factors (such as air quality) and school and community influences (such as the availability of healthy nutrition and physical activity choices) impact student health. The primary method for collecting school health data is the use of computerized data collection systems. In addition to school health data, there are other sources of data that computerized systems make accessible and that nurses may find useful for purposes of program planning, development, and implementation. Census, Hospital discharge data, and the Behavioral Risk Factor Surveillance System. The Youth Risk Behavior Survey and the Massachusetts Youth Health Survey provide statewide (and, in some cases, regional) estimates of levels of risk behaviors such as smoking, alcohol and drug use, seatbelt usage, sexual behavior, and nutritional intake. While data collection and analysis may prove useful for purposes of program planning and development, school nurses should consider the cost of collecting and using data, including equipment, training, maintenance, and human resources. It is preferable to collect fewer pieces of data and conserve resources to carry out the proper analysis and reporting steps. The technology is still evolving, but the direction of development is clearly toward more complex and integrated systems that allow for greater data sharing and manipulation. This is inevitable, because capturing more and better information about student health status and school nursing services requires increasing the quantity of data elements. Making efficient and effective use of the information collected also requires integration of the multiple, overlapping systems used by different schools, governmental offices, and agencies. For example, district-wide health reporting and maintenance of information relating to individual students throughout their school years could be greatly simplified by all the schools in a district using standardized network software. One method involves increasing the capability to exchange data across different systems. Some school districts do this by using a "modular" administrative information system that includes school health data as one module. The continued evolution of these systems could eventually lead to a further integration of school health data across various local and state agencies, perhaps through a single point of entry (such as a Web application). Identifying all of the factors one should consider in the selection of a school health software package is beyond the scope of this manual. School nurses should be involved in the selection of software and need to be informed about the issues involved. Sources of information about selecting school health software include the School Health Data Systems Resource Guide (Massachusetts Department of Public Health, 1999) and contact with other local school nurses who have used various data systems. The greatest challenge to developing and maintaining local school health information systems is the availability of technical expertise for ongoing support and development. School nurses should be an integral part of the development of screening and reporting design as their local system is developed. Computer coordinators should be knowledgeable concerning hardware and software acquisitions and locally sited to provide technical assistance and consultation, as needed. Because each community is unique, strategies that are effective in one community may need to be altered dramatically in another. The following recommendations address various community stakeholders and focus on developing "connectivity," which the Harvard Center for Public Health Preparedness defines as the development of "a seamless web of organizations, people, resources, and information" across the community to promote positive outcomes. It is important for school health personnel to share school health data, including service data, with school committee members on a regular basis, highlighting health trends and issues in the school population. The committee offers a structure for discussing youth health issues in depth and obtaining advice from community members. In addition, schools need to share aggregate information such as asthma surveillance data. Parent/Teacher Organizations and School Site Councils: Parents can be the greatest supporters of quality school health programs. Regular presentations about the issues can be a vehicle for securing their support. Public Safety and Emergency Medical Services: Schools need to form working relationships with public safety services on a variety of issues, such as response to individual and group emergencies and prevention of violence. Coalitions and Committees Addressing Health Issues Affecting the Student Population: A school nurse or other member of the school health program can assist these groups by offering unique insights into such areas as teen pregnancy, violence, tobacco use, behavioral health, or drug abuse. Representatives of Local Hospitals and Community Health Centers: Collaborations and communication systems developed with local hospitals and community health centers are mutually beneficial in many ways. Presentations by school personnel at hospital rounds may emphasize that the school health program is an extension of health care into the community. Primary Care Providers: Inviting local pediatricians and other medical providers to visit the school and learn about the health program may enhance collaboration and lead to development of effective communication systems. Schools have used a variety of methods to improve collaboration, such as inclusion of providers on the health advisory committee, sharing the names of school nurses who cover each building, and holding an annual breakfast for local primary care providers. Dental Providers: As oral health is increasingly recognized as critical to health and wellbeing, school health programs have established creative collaborations to address this issue. In some communities, local dentists and dental hygienists have contributed time for oral health education, assessments, application of dental sealants, and treatment of children who lack dental providers. Local Universities and Schools of Medicine and Nursing: School health programs offer clinical practice opportunities for educating nurses and physicians. Collaborations with these institutions also may provide the impetus for much-needed research into the outcomes of school health programs. In addition, as schools expand the use of technology, they are developing comprehensive websites accessible to a large percentage of the population. The purpose of program evaluation is to assess whether or not the goals and objectives of the school health program are being met. School Nursing Research Agenda and Desired Outcomes Many priorities around school nursing research and desired outcomes for school nursing practice have been identified over the years. Following are a few examples that may be useful to schools as they determine design and implementation of appropriate evaluation plans. The National Nursing Coalition for School Health has developed a school nursing research agenda (Edwards, 2002). Ten broad categories of desired outcomes for school nursing practice have been identified and prioritized by a group of school nurses representing all regions of the country (Selekman & Guilday, 2003). Types of Evaluation Ongoing data collection and evaluation are central to promoting responsiveness in programs, staffing, funding, and resources. The results and recommendations that come from an evaluation then become input for subsequent planning. This feedback loop allows plans to be revised as needed in order to keep programs appropriate, realistic, and effective.

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However diabete 200 generic losartan 25mg overnight delivery, conditions occasionally arise that may prevent the body from maintaining this optimum internal environment; such conditions may lead to health complications early warning signs diabetes type 2 losartan 25 mg otc. External environmental extremes diabetes test glasgow cheap 50mg losartan with mastercard, such as heat and cold-particularly in damp or windy conditions-are among those conditions that may create health problems for athletes in the course of routine practice or competitive play diabetes back pain buy generic losartan 25mg on line. Heat is an important product of chemical activities constantly taking place inside the body diabetes medication buy losartan 50mg with amex, such as the metabolic process that converts food into energy diabetes type 2 explained simply order losartan 50mg line. Muscle contractions also produce heat through the burning of calories-another chemical activity. Thus, when the body is exercising and the muscles are working, heat is constantly generated within the cells. Even when the body is at rest, the slight involuntary contraction of skeletal muscles generates heat. In normal circumstances this shivering produces enough heat to warm the body back to normal temperature. The heat-regulating center of the body, known as the hypothalamus, lies within the brain. By monitoring nerve impulses from temperature receptors in the skin and the flow of blood to the brain, the hypothalamus tracks and controls the amount of body heat lost. In many ways, the hypothalamus does the same thing for the body that a thermostat does when it controls the temperature in a room. When the blood temperature rises, the hypothalamus sends signals via nerve impulses to dilate (expand) the blood vessels in the skin. In order for its various temperature-regulating mechanisms to function properly, the body must be well fed, hydrated, rested, and kept in good physical condition through regular exercise. Should the body temperature fall outside of the optimum range, a variety of complications may result, some of which can be fatal. In high humidity the body cannot cool itself as well as it can in less-humid conditions because perspiration does not easily evaporate-one of the primary ways in which cooling takes place. However, fluid absorption is limited by evaporation a method of heat loss in which a liquid changes from a liquid to vapor, as with perspiration. It has been found that cold drinks leave the stomach quicker and do not cause stomach cramping. Sweat becomes an insulating factor when it cannot evaporate, such as when humidity is high. On days with high humidity and heat, t-shirts might be changed halfway through practice. This will cool athletes by removing the insulation and letting their bodies cool down. When the humidity exceeds 70%, players should be more closely monitored for heat-related problems. Refer to Figure 19-2 for precautions that should be taken when certain temperature/humidity thresholds are reached. Relative humidity is a figure that is based on the difference between the amount of water vapor in the air and the maximum amount the air could contain at the same temperature and is used to calculate the Heat Index. Devised by the National Weather Service, the Heat Index (also referred to as "apparent temperature") is an accurate measure of how hot it really feels when the relative humidity is combined with the actual air humidity moisture in the air. Clothing should be changed when it becomes wet because dampness becomes an insulator under these conditions. Relative Humidity (%) psychrometer an instrument used to measure relative humidity. The Heat Index combines air temperature and humidity to determine how hot it actually feels. Sunburn Sunburn is a potential hazard for anyone who participates in outdoor activities without proper protection. Symptoms of sunburn include red and painful skin and may appear 2 to 8 hours after exposure. For example, skin damaged by a previous burn is more susceptible to sunburns than undamaged skin. Likewise, lightly pigmented skin is more susceptible to sun damage than skin with dark pigmentation. Certain medications can increase sensitivity to the sun, so individuals who take medication should check the labels for potential side effects. Immediate Treatment: Treat a sunburn like any burn, based on the severity of the injury. Applied topically, cold compresses and 1% hydrocortisone or aloe vera products can provide relief to mild burns. Follow-up Treatment: If symptoms do not improve in four days or if signs of infection or blood poisoning are present, refer the athlete to a physician. Prevention: Individuals who participate in outdoor activities should wear adequate sunscreen. Sunscreen should be applied to all exposed skin at least 20 to 30 minutes before exposure. Swimmers and athletes prone to excessive sweating should use a waterproof sunscreen. Hats and proper clothing are also good methods of sun protection, as is gradual exposure to the sun. Heat problems can be caused by inadequate heat acclimatization, inadequate fitness level, higher body fat, dehydration, illness or fever, presence of gastrointestinal distress, salt deficiency, inadequate meals or insufficient energy intake, skin conditions. Heat Cramps Heat cramps (muscle cramps) are painful spasms of skeletal muscle, most commonly occurring in the gastrocnemius, or calf muscle, but possibly in the abdominals as well. When one or more athletes complain of cramping and the weather is warm or humid, suspect heat (dehydration) rather than activity as the source of the problem. Heat cramps are caused by a lack of fluid volume and in most cases can be heat cramps muscle spasms resulting from dehydration. Therefore, it is better to let athletes drink as much water or sports drinks as they would like during practice and not schedule hydration breaks. Make sure there is an unlimited supply of cool water or sports drinks available to the athletes. Each athlete should have a separate water/sports drink bottle to prevent the spread of illness. Follow-up Treatment: If the athlete is in the sun, move the athlete to a shaded area and have the person drink water or a sports drink until the cramping stops. Prevention: the best ways to prevent heat cramps and other heat-related disorders are described in the guidelines on the following pages. Heat Exhaustion heat exhaustion a physical reaction to heat exposure resulting from dehydration and characterized by profuse sweating and extreme weakness or fatigue; can lead to heatstroke. Heat exhaustion is a condition in which the body becomes dehydrated from water and/or electrolyte loss. Symptoms of this condition include extreme weakness, exhaustion, and sometimes unconsciousness. Additional symptoms may include headache, dizziness, hyperventilation, dilated pupils, nausea, vomiting, clammy skin, and profuse sweating. Immediate Treatment: Individuals affected by heat exhaustion should replenish lost fluid by drinking water or a sports drink. The athlete should lie down in a cool, shaded place with feet elevated and should be withdrawn from further activity for the remainder of the day. If the athlete does not recover fully within 30 minutes, send the athlete to a physician. The amount of fluid lost can be determined by weighing athletes before and after practice. It may occur suddenly without any other symptoms, or it may arise from heat exhaustion. An athlete suffering from heatstroke may become disoriented, collapse, and lose consciousness. The symptoms of heat exhaustion, with the exception of sweating, will also likely be present. The most important symptom differentiating heat exhaustion from heat stroke is that an individual experiencing heatstroke stops sweating. The absence of perspiration is a sign of serious dehydration, which is a major medical emergency. Fan the athlete and apply cold packs or cloths to areas with a rich blood supply, such as the groin, armpits, and head. The objective is to lower the body temperature as quickly and safely as possible to prevent death or serious brain damage, which can occur in minutes. Prevention: All heat-related illnesses can be prevented using the guidelines on the following pages. Athletes who lose more than 3% of their body weight during practices should be observed for signs of heat exhaustion because of excessive water loss. If an athlete loses more than 7% body weight during one practice or game, the athlete should be sent to a physician. Athletes who have a low percentage of body fat will be more likely to experience heat cramps because of the lower level of fluids in their body. Athletes should be symptom-free, fully hydrated, and cleared by a physician before returning to play. Return to Play Once all signs and symptoms are gone and the athlete is able to move at a preinjury pace, the athlete may return to competition. Two good Internet sources of weather information are the Weather Channel at. Be aware of the duration and intensity of practice in hot or humid weather (see Figure 19-6). Use the Temperature/ Humidity Training Guidelines and the Heat Index to make decisions about athletic participation in hot or humid weather. If practice is held in hot or humid weather, look out for symptoms of overheating, which are not always easy to identify. Moving practice indoors during hot days can be a possible solution if conditions are better inside. Use acclimatization strategies to help the athletes become accustomed to temperature and environmental conditions that may change between inand off-season. For example, if the athletes practice during the off-season in a cool, climate-controlled environment, and practice during the season in an outside environment with heat and humidity, the athletes will not be properly acclimatized to the type of environment in which they will be expected to compete. It can take up to two weeks to become properly acclimatized; make sure all athletes are aware of this. Some areas of the country provide challenges with acclimatization because of environmental differences within a region. For example, a competition may be in a desert region, whereas school and practice sessions for the athletes may be in the mountains where it is cooler. Select practice clothing and summer or winter uniforms in accordance with the temperature and the humidity of that particular day. Black or darkcolored, thick fabrics absorb heat; so light-colored, lightweight, or vented fabrics are preferred for hot or humid weather. Therefore, never let an athlete practice or perform while wearing plastic or rubber clothes. Make sure athletes change shirts that become soaked with sweat, because these sweat-soaked shirts become insulators in hot weather and do not allow sweat to evaporate and cool the body. In this situation, it is best to have the athletes change shirts and put on dry ones. Be sure athletes drink f luids before exercising: 17 to 20 ounces 2 to 3 hours before, and 7 to 10 ounces 10 to 20 minutes before. During exercise, have athletes drink 7 to 10 ounces of f luid every 10 to 15 minutes; always keep water available. Remind athletes that water from cold f luids empties from the stomach faster than water from warm fluids. If the urine is dark yellow and has a strong odor, the athlete needs to drink more fluids. Note that taking a large number of vitamins can change both the color and odor of the urine. Make sure athletes drink plenty of water or sports drinks before, during, and after exercise to replace lost fluid (see Figure 19-7). During intense exercise or activities, such as football, the rate of fluid loss can be even greater. Note: the fluids athletes are given to drink during practice should also be provided at competitions. If athletes are not given sports drinks during practice, sports drinks should not be provided during sporting events. Some sports drinks provide an advantage over water because they contain important electrolytes as well as water. Both water and electrolytes, such as sodium, potassium, and chloride, are lost from the body when an athlete perspires. In solution, these electrolytes conduct electrical charges important to nerve conduction, muscle contraction, and fluid level regulation. Since electrolytes are so important to proper body function, many athletes choose to rehydrate with a sports drink containing these vital substances.

It also was noted that the pupil of the right eye Answers and Explanations to Clinical Problem Solving 421 was constricted blood sugar drop after eating buy cheap losartan 50 mg, and there was drooping of the right upper eyelid diabetes type 1 incidence purchase losartan 25mg otc. The skin of the right cheek felt warmer and drier and was redder in color than the left cheek diabetic hands quality 50mg losartan. A 3-year-old boy with a history since infancy of chronic constipation and abdominal distention was taken to a pediatrician blood glucose chart mg dl buy cheap losartan 50mg on line. It was not responding to laxatives blood glucose up after exercise 25mg losartan for sale, and she was finding it necessary to give her son an enema once a week to relieve his abdominal distention diabetes mellitus type 2 factors safe losartan 25 mg. Following an enema and repeated colonic irrigation with saline solution, the patient was given a barium enema followed by a radiographic examination. The radiograph showed a grossly distended descending colon and an abrupt change in lumen diameter where the descending colon joined the sigmoid colon. It was interesting to note that the child failed to empty the colon of the barium. Using your knowledge of the autonomic nerve supply to the colon, what is the diagnosis A nervous 25-year-old woman attended her physician because she was experiencing attacks of painful discoloration of the fourth and fifth fingers of both hands. She said that her symptoms had started 2 years previously, during the winter, and affected her right hand first and, in subsequent attacks, her left hand as well. Initially, her fingers turned white on exposure to cold and then became deep blue. The color change was confined to the distal half of each finger and was accompanied by an aching pain. Holding her hands over a hot stove or going into a hot room was the only treatment that relieved the pain. She told her physician that she had noticed that her fingers were moist with sweat during some of the attacks. An obese 45-year-old mother of six children was examined by her physician because her symptoms were suggestive of gallbladder disease. She complained of having severe attacks of colicky pain beneath the right costal margin, which often radiated through to the back beneath the right scapula. The physician turned to a medical student and said,"Note that the patient complains of referred pain to the back. Explain the phenomenon of referred pain to the back and sometimes the right shoulder in gallbladder disease. Examination of a patient with neurosyphilis indicated that the pupil of her left eye was small and fixed and did not react to light but contracted when she was asked to look at a near object. Using your knowledge of neuroanatomy,state where you believe the neurologic lesion would be situated to account for these defects. A 36-year-old man was admitted to the emergency department following a gunshot wound to the lower back. Radiographic examination revealed that the bullet was lodged in the vertebral canal at the level of the third lumbar vertebra. A complete neurologic examination revealed the symptoms and signs that indicate a complete lesion of the cauda equina. On routine medical examination, a 40-year-old black man was found to have essential hypertension. What is the action of the various types of drugs that are commonly used in the treatment of hypertension What transmitter substances are liberated at the following nerve endings: (a) preganglionic sympathetic, (b) preganglionic parasympathetic, (c) postganglionic parasympathetic, (d) postganglionic sympathetic fibers to the heart muscle,and (e) postganglionic sympathetic fibers to the sweat glands of the hand As a result of holding onto the moving truck with the right hand, this man had sustained a severe traction injury of the eighth cervical and first thoracic roots of the brachial plexus. The various paralyzed forearm and hand muscles together with the sensory loss were characteristic of Klumpke paralysis. In this case, the pull on the first thoracic nerve was so severe that the white ramus communicantes to the inferior cervical sympathetic ganglion was torn. This effectively cut off the preganglionic sympathetic fibers to the right side of the head and neck, causing a right-sided Horner syndrome (preganglionic type). This was exemplified by (a) constriction of the pupil, (b) drooping of the upper lid,and (c) enophthalmos. The arteriolar vasodilatation, due to loss of sympathetic vasoconstrictor fibers, was responsible for the red, hot cheek on the right side. The dryness of the skin of the right cheek also was due to the loss of the sympathetic secretomotor supply to the sweat glands. This 3-year-old boy has Hirschsprung disease, a congenital condition in which there is a failure of development of the myenteric plexus (Auerbach plexus) in the distal part of the colon. The proximal part of the colon is normal but becomes greatly distended due to the accumulation of feces. Thus, this segment of the bowel had no peristalsis and effectively blocked the passage of feces. Once the diagnosis had been confirmed by performing a biopsy of the distal segment of the bowel, the treatment was to remove the aganglionic segment of the bowel by surgical resection. The disease is much more common in women than in men, especially those who have a nervous disposition. The cyanosis that follows is due to local capillary dilatation due to accumulation of metabolites. Since there is no blood flow through the capillaries, deoxygenated hemoglobin accumulates within them. It is during this period of prolonged cyanosis that the patient experiences severe, aching pain. On exposing the fingers to warmth, the vasospasm disappears, and oxygenated blood flows back into the very dilated capillaries. There is now a reactive hyperemia and an increase in the formation of tissue fluid that is responsible for the swelling of the affected fingers. The sweating of the fingers during the attack probably is due to the excessive sympathetic activity, which may be responsible in part for the arteriolar vasospasm. The preganglionic fibers originate from the cell bodies in the second to the eighth thoracic segments of the spinal cord. They ascend in the sympathetic trunk to synapse in the middle cervical, inferior cervical, and first thoracic or stellate ganglia. The postganglionic fibers join the nerves that form the brachial plexus and are distributed to the digital arteries within the branches of the brachial plexus. The patient should be reassured and told to keep her hands warm as much as possible. However, should the condition worsen, the patient should be treated with drugs, such as reserpine, that inhibit sympathetic activity. This would result in arterial vasodilatation with consequent increase in blood flow to the fingers. The visceral pain originated from the cystic duct or bile duct and was due to stretching or spasm of the smooth muscle in its wall. The pain afferent fibers pass through the celiac ganglia and ascend in the greater splanchnic nerve to enter the fifth to the ninth thoracic segments of the spinal cord. Referred pain to the right shoulder in gallbladder disease is discussed on page 420. This patient has an Argyll Robertson pupil, which is a small fixed pupil that does not react to light but contracts with accommodation. The neurologic lesion in this patient interrupted the fibers running from the pretectal nucleus to the parasympathetic nuclei of the oculomotor nerve on both sides. The urinary bladder is innervated by sympathetic fibers from the first and second lumbar segments of the spinal cord and by parasympathetic fibers from the second, third, and fourth sacral segments of the spinal cord. In this patient,the cauda equina was sectioned at the level of the third lumbar vertebra. This meant that the preganglionic sympathetic fibers that descend in the anterior roots of the first and second lumbar nerves were left intact, since they leave the vertebral canal to form the appropriate spinal nerves above the level of the bullet. The preganglionic parasympathetic fibers were, however,sectioned as they descended in the vertebral canal within the anterior roots of the second, third, and fourth sacral nerves. The patient would, therefore, have an autonomous bladder and would be without any external reflex control. Micturition could be activated by powerful contraction of the abdominal muscles by the patient, assisted by manual pressure on his anterior abdominal wall in the suprapubic region. Nevertheless, the objective of the treatment is to lower the blood pressure and keep it, if possible, within normal limits before the complications of cerebral hemorrhage, renal failure, or heart failure develop. The best way to accomplish this in patients with mild hypertension is to reduce the plasma fluid volume by the use of diuretics. These reduce the rate and force of contraction of the cardiac muscle and lower the cardiac output. The following statements concern the autonomic nervous system: (a) the enteric nervous system is made up of the submucous plexus of Meissner and the myenteric plexus of Auerbach. The following statements concern the autonomic nervous system: (a) An Argyll Robertson pupil indicates that the accommodation reflex for near vision is normal but that the light reflex is lost. The following general statements concern the autonomic nervous system: (a) the hypothalamus has little control over the autonomic nervous system. Directions: Each of the numbered items or incomplete statements in this section is followed by answers or completions of the statement. Anticholinesterase drugs act at synapses by: (a) mimicking the action of acetylcholine at its receptor sites (b) preventing the release of acetylcholine (c) increasing the secretion of acetylcholine (d) blocking the breakdown of acetylcholine (e) preventing the uptake of acetylcholine by the nerve ending Atropine has the following effect on the autonomic nervous system: (a) It is an anticholinesterase drug. The sympathetic outflow: (a) arises from nerve cells that are situated in the posterior gray column (horn) of the spinal cord (b) has preganglionic nerve fibers that leave the spinal cord in the posterior roots of the spinal nerves (c) is restricted to the T1-L2 segments of the spinal cord (d) receives descending fibers from supraspinal levels that pass down the spinal cord in the posterior white column (e) has many preganglionic nerve fibers that synapse in the posterior root ganglia of the spinal nerves 6. Norepinephrine is secreted at the endings of the: (a) preganglionic sympathetic fibers (b) preganglionic parasympathetic fibers (c) postganglionic parasympathetic fibers (d) postganglionic sympathetic fibers (e) preganglionic fibers to the suprarenal medulla 7. The parasympathetic innervation controlling the parotid salivary gland arises from the: (a) facial nerve. The following statements concern autonomic innervation of the urinary bladder: (a) the parasympathetic part brings about relaxation of the bladder wall muscle and contraction of the sphincter vesicae. The following statements concern the autonomic innervation of the heart: (a) the parasympathetic part causes dilation of the coronary arteries. Directions: Match the numbered glands with the most appropriate lettered autonomic ganglion listed below. Superior mesenteric ganglion (b) Vermiform appendix (c) Constrictor pupillae (d) Descending colon (e) None of the above Match the numbered cranial nerves with the appropriate lettered nuclei listed below. Facial nerve Oculomotor nerve Glossopharyngeal nerve Hypoglossal nerve (a) Inferior salivatory nucleus (b) Edinger-Westphal nucleus (c) Lacrimatory nucleus (d) None of the above 14. Submandibular gland Lacrimal gland Nasal glands Parotid gland Sublingual gland (a) (b) (c) (d) (e) Otic ganglion Submandibular ganglion Pterygopalatine ganglion Ciliary ganglion None of the above the following questions apply to Figure 14-19. Match the numbered areas of referred pain with the appropriate lettered viscus originating the pain listed below. Match the numbered autonomic ganglia with the most appropriate lettered viscus or muscle listed below. Number 1 Number 2 Number 3 Number 4 (a) Heart (b) Appendix (c) Gallbladder (d) Stomach (e) None of the above 19. Celiac ganglion (a) Levator palpebrae superioris (smooth muscle only) 2 3 1 4 Figure 14-19 Areas of referred pain. The enteric nervous system is made up of the submucous plexus of Meissner and the myenteric plexus of Auerbach (see p. The nerve cells and the nerve fibers in the enteric nervous system are surrounded by neuroglialike cells that closely resemble astrocytes (see p. The activities of the parasympathetic part of the autonomic nervous system aim at conserving and restoring energy (see p. The parasympathetic part of the autonomic system contains both afferent and efferent nerve fibers (see p. An Argyll Robertson pupil indicates that the accommodation reflex for near vision is normal but that the light reflex is lost (see p. White rami communicantes are found in the thoracic and first and second lumbar parts of the sympathetic trunk (see p. The lesser splanchnic nerves arise from the 10th and 11th ganglia of the thoracic part of the sympathetic trunks (see p. A patient with Adie tonic pupil syndrome has a decreased or absent light reflex and a slow or delayed pupillary contraction to near vision and a slow or delayed dilatation in the dark (see p. Visceral pain frequently is referred to skin areas that are innervated by the same segment of the spinal cord as the painful viscus (see p. In Horner syndrome, the patient has vasodilation of the facial skin arterioles (see p. The sympathetic outflow is restricted to T1L2 segments of the spinal cord. Norepinephrine is secreted at the endings of most postganglionic sympathetic fibers (see p. The parasympathetic innervation controlling the parotid salivary gland is the glossopharyngeal nerve (see p. The parasympathetic part of the autonomic nervous system produces effects that are local and discrete due to preganglionic neurons synapsing with few postganglionic neurons (see p.