Three Major Reasons to Feed Your Pet a Homemade Diet. By Dr. Karen Becker discusses the advantages of feeding the pets in your family a healthy, wholesome diet prepared right in your own kitchen for a fraction of the cost of high end commercial pet food. Have you ever wondered what, exactly, is in that can or bag of pet food you’re serving your beloved four- legged family member every day? If so, you’re not alone. In my experience, the number one reason pet parents look into homemade diets for Fluffy or Fido is because they’re concerned about quality. What’s really in that giant bag of dry dog kibble or that tiny can of food your kitty seems addicted to? Commercial Pet Food is Loosely Regulated. You may not be aware that unlike the food you eat, there’s very little government regulation of pet food quality. The USDA doesn’t control it, nor does the FDA or the AAFCO (Association of American Feed Control Officials). Not one of these agencies watches over what private pet food manufacturers put in their products. Pet food quality control is governed by each state, and while certain regulatory codes exist, they do not pertain to the absorbability, digestibility or overall quality of commercially prepared foods for pets. What this all means is you must place your trust in the companies that make the pet food you buy, and you have to count on the accuracy of the labels on the packaging as well. For many people - - especially those of you who’ve had a bad experience feeding commercial foods to your dog or cat - - this is just not good enough. Even the pet food brands many veterinarians endorse don’t live up to their marketing claims and have caused health problems in pets. The lion (Panthera leo) is one of the big cats in the genus Panthera and a member of the family Felidae. The commonly used term African lion collectively denotes the. The Rapid Fat Loss Handbook A Scientific Approach to Crash Dieting. Package Includes: The Rapid Fat Loss Handbook: 93 pages Home Exercise Handbook (PDF). Syrai, This salad diet is a similar approach that Lyle McDonald takes in his book The Rapid Fat Loss Handbook. This is probably the best book I Given the lack of regulation and the questionable quality of many commercial pet foods, more and more dog and cat owners have become leery of serving them to their furry family members. This is not to say there aren’t good quality pet foods on the market, but many people have simply lost trust in the pet food industry and are eager to learn how to make their own pet food at home. Before I get into the details of the raw vegan diet, it Surviving subspecies of tiger; Subspecies Description Image; Bengal tiger (P. Protein is extremely essential, super satiating and amazingly anabolic. If you want to lose weight and build muscle each and every week like clockwork The Biggest Drawback to Feeding Homemade. As an integrative wellness veterinarian who understands the vital connection between nutrition and health, I applaud all pet parents who make the commitment to prepare and feed only a homemade diet to their pets. But here’s the rub – if you’re going the homemade route, you must do it right. And by right, I mean balanced. A growing problem in my practice is pets with compromised health as the result of being fed an unbalanced homemade diet. Even with the best intentions, if you switch your dog or cat to an unbalanced homemade diet, you can do a great deal of damage to their health – which is exactly what you are trying to avoid by serving homemade in the first place. I’ll discuss how to avoid this pitfall shortly. Human Grade Food: It’s Not Just for Humans. Unless the commercial dog or cat food you’re buying is made with human- grade ingredients, you are feeding your pet rendered protein. Rendered meat is essentially pieces and parts of this animal or that - - there’s really no telling. This low quality protein is less than desirable nutrition for your pet. Unfortunately, commercial pet food made entirely with human- grade ingredients is usually at least three times as expensive as food containing crude protein. This is one of the main reasons for switching your pet to a homemade diet. You have complete control over what goes into your dog’s or cat’s mouth, and you can insure you’re feeding high quality, human- grade protein and not the crude, pieces- and- parts variety. Get the Grain Out. Another reason to consider feeding a balanced homemade diet is that you can insure it is species- appropriate for your pet. Many pet owners today are becoming more knowledgeable about what constitutes biologically correct nutrition for companion animals. For example, many of you realize your carnivorous dog or kitty should not be fed carbohydrates like grain, corn, wheat, rice, and in particular, soy. Canines and felines have no biological grain requirement and dogs, in particular, can have problems digesting grains, so I don’t recommend feeding them to your pets. Depending on where you live, you might already know just how difficult it can be to find commercially available pet foods that are: Grain- free Made from human- grade ingredients Affordable This is another reason increasing numbers of pet owners are looking into homemade diets – it can be less expensive and less frustrating than trying to find affordable, high quality commercial pet food. Additives and Preservatives. The vast majority of commercial pet foods on the market contain chemicals, preservatives, emulsifiers and artificial colors that pet parents don’t want to subject their animals to. Even high end commercial brands use flavor enhancers and extra fats that make the food more palatable to your dog or cat, but also less healthy. Other Benefits of Homemade Pet Food. We’ve already covered some of the advantages of preparing homemade meals for your dog or cat, including: You have complete control over the ingredient list and the ability to eliminate all additives and preservatives You can pick just the right veggies for your pet’s particular needs, including those with higher antioxidant or medicinal properties, for example You can decide which meat sources to feed your pet, which is especially important if you have a cat or dog with an allergy to certain types of protein Another benefit of switching to homemade is you can save money by buying large quantities of meats and vegetables when they are on sale. You can prepare, package and freeze your homemade pet meals weeks or even months ahead of time. You can also pair up with friends who have pets to buy ingredients in even larger quantities. It can be both economical and a time saver if you can spread the expense and meal prep work among the entire group. Another wonderful benefit of preparing a homemade diet is that when you follow a recipe for balanced meals, which is what I’m about to recommend, you’ll know for a fact you’re doing the best job possible in nourishing your pet. You’ll be: Fulfilling your dog’s or cat’s vibrant, living food requirement Providing nutrient balanced, species- appropriate food that is rich in omega fatty acids and contains vitamin- mineral supplements in the correct proportions Real Food for Healthy Dogs & Cats. Together with my pet lifestyle coach and pet nutrition consultant , Beth Taylor, I’ve written a book of homemade pet food recipes, Real Food for Healthy Dogs & Cats. The recipes in our book are not only AAFCO compliant, they also meet the nutritional requirements for biologically appropriate, healthy diets for all stages of a pet’s life as outlined by the National Research Council (NRC) and the Ancestral diet for dogs and cats. So whether your four- legged pal is canine or feline, young or mature, there are recipes in our book that will meet your pet’s nutritional needs. Another great thing about Real Food for Healthy Dogs & Cats is if the thought of preparing food for your pet is intimidating, we’ve provided easy- to- follow, balanced recipes that even a complete novice can handle. The recipes in our book offer lots of nutritional variety and we also provide instruction on how to prepare and store meals efficiently. There’s a chapter on how to select healthy treats for your pet. There’s also a chapter on how to incorporate commercially prepared raw foods into a homemade diet. For pet parents who want to prepare balanced, species- appropriate meals but aren’t ready for raw, there are recipes for cooked homemade diets as well. Beyond food preparation, our book shows you how to create essential vitamin- mineral mixes from products you can purchase from your local health food store. We explain how to blend supplements in appropriate quantities and then add them to each batch of homemade food in the right amounts for your pet’s body weight. Vitamin- mineral supplementation coupled with homemade food allows you to prepare meals for your pet that are nutritionally complete in accordance with all standards for suggested baseline requirements. Beth and I are proud to be able to offer our book to you. There are few things as fulfilling as knowing you’re preparing nutrition packed, species appropriate homemade meals for your dog or cat right in your own kitchen. What to eat & foods to avoid. The Fast Metabolism Diet (FMD) (2. No wheat, corn, dairy, soy, sugar, caffeine, alcohol, dried fruit or fruit juices, artificial sweeteners, fat- free . Send this page to friends, family, and anyone else you. This diet claims to kick you out of that habit. In all the phases, you. Phase 1, Unwind, gently persuades your metabolism that it is no longer in an emergency situation . Fat and protein are harder to digest than carbohydrates like grains and fruit, so by keeping these low, the body is soothed and encouraged. Phase 2, Unlock, allows for the mobilization of stored energy in the form of fat, so that you can burn it as fuel. Phase 3, Unleash, is when you start burning the fat you unlocked in Phase 2, as well as the fat you. Every week, you follow 3 phases, and there are general guidelines. Other start days may work better for you depending on your schedule. The foods listed here as foods to eat on each phase are taken from the diet book and the i. Phone app. Portion size – overall guidelines. If you have a lot of weight to lose, it. That meant that if you wanted to lose 4. In the latest printings, that advice changed, so if you have higher amounts of weight to lose you don’t have to eat so much. Note that the edition of the book didn’t change – it’s still first edition, but now has different advice. How to adjust portion sizes. See each phase (below) for phase- specific portion sizes. For example – in phase 1 the basic portion size for grains is 1 cup. That’s for if you’ve got 2. If you’ve got more than 2. High in carbohydrate- rich foods, high in natural sugars, high in B and C vitamins. Portion sizes. Portion size isn’t listed in the book for sprouted grain products for this phase, but the phase 1 recipes show 1 slice sprouted- grain bread or 1 sprouted- grain tortilla per serving. Fruit . Portion size isn’t listed in the book for sprouted grain products for this phase, but the phase 1 recipes show 1 slice sprouted- grain bread or 1 sprouted- grain tortilla per serving. Fruit . Eat 5 times a day, every 3- 4 hours. Make sure you eat enough complex carbohydrates each day. Breakfast: grain and fruit . Ezekiel bread, sprouted grain English muffins. Check they meet the guidelines above. Nut flours. Brown rice cheese, brown rice milk, rice milk (plain)Arrowroot, tapioca, tapioca flour. Healthy fats. Water. Drink half your body weight in ounces of water every day. Noncaffeinated herbal teas. Pero beverage. Foods to avoid or limit in The Fast Metabolism Diet Phase 1. General foods to avoid, see above. You shouldn. High in foods that support liver function (onion family, leafy greens, lemons), high in lean proteins, rich in alkalizing green, low- glycemic vegetables, high in carnitine- producing foods. Portion sizes. If you are eating deli meat as a snack, one portion is 2 ounces, or about 3- 4 thin slices from the deli counter. Grains – none. Fruit . Eat 5 times a day, every 3- 4 hours. Make sure you eat enough lean protein and green vegetables each day. Breakfast: protein and veggie . Drink half your body weight in ounces of water every day. Non- caffeinated herbal teas. Pero beverage. Foods to avoid or limit in The Fast Metabolism Diet Phase 2. General foods to avoid, see above. You shouldn. Presumably potatoes are out as well. Fruits. All types except lemons and limes. Broth, herbs, spices, and condiments. Ketchup, salsa, tomato paste. Fats. Avoid all fats, including healthy fats. Avoid avocados and olives. Avoid nuts and seeds. Fast Metabolism Diet Phase 3 food list . High in healthy fats, higher- fat proteins in moderate amounts, lower- glycemic fruits, lower- glycemic vegetables, moderate amounts of unrefined carbohydrates, thyroid- stimulating foods, foods rich in inositol and choline. Portion sizes! Eat 5 times a day, every 3- 4 hours. Make sure you eat enough healthy fats each day. Breakfast: fruit, *fat/protein, grain, and veggie . Drink half your body weight in ounces of water every day. Drink a LOT of water during this phase. Non- caffeinated herbal teas. Pero beverage. Foods to avoid or limit in The Fast Metabolism Diet Phase 3. General foods to avoid, see above. Carbs should be limited to the foods and serving sizes above. You shouldn. If you are unwilling to eat these, follow the guidelines for vegans, below. Vegan. Phases 1 and 3 . Replace any meat with any of the following (but no other soy products): organic non- GMO tofu, organic non- GMO soy tempeh, organic non- GMO edamame. Cook the tofu without fat and grill or bake it yourself, rather than buying pre- baked tofu, which is more processed. Your weight loss might slow down somewhat, but you can still eat low- carb for those two phase 2 days if you stick to these three options. But you should still avoid soy in phases 1 and 3. Gluten- free. Avoid sprouted- grain bread and products containing spelt, barley, kamut, farro, durum, bulgur, rye, triticale, or semolina; also conventional oatmeal. If a recipe contains a gluten grain, you can replace it with a gluten- free grain such as brown rice or quinoa. Other gluten- free grains include amaranth, buckwheat, millet, teff, and wild rice. Lifetime / maintenance diet. If you still have weight to lose after 2. Even if you are just a few pounds away from your ideal weight, even fewer than 5 pounds away, keep going until you reach it. Some people do the 2. In particular, watch out for fake sugars and fake fats . Organic, sulfite- free wine seems to have the least effect on liver function; if you really want a cocktail, go for the top- shelf liquors; always drink 8 ounces of water for every drink in addition to your regular water consumption; don. Consult your doctor before starting a new diet. This page describes what the authors of the diet recommend – Chewfo is describing the diet only, not endorsing it. Get a copy of The Fast Metabolism Diet for reasons why low- calorie diets don. Cookbook. See http: //hayliepomroy. Hayley answers some FAQs at http: //hayliepomroy. Facebook page? Please add a comment below. The Rapid Fat Loss Handbook : Bodyrecomposition. The Rapid Fat Loss Handbook. A Scientific Approach to Crash Dieting. Second Edition. Package Includes: The Rapid Fat Loss Handbook: 9. Home Exercise Handbook (PDF)Calculator Instructions (PDF)Show me my purchase options. About the Book. The Rapid Fat Loss Handbook offers a scientifically based approach to quick weight and fat loss. Recognizing that people need or simply want to lose weight and fat rapidly, I set out to develop the safest, most effective way of accomplishing that goal. I based the program around the idea of creating a diet that would provide the fewest calories possible while still providing all of the essential nutrients required by the body: protein, essential fatty acids, vitamins and minerals. This provides simply the safest and sanest way to lose fat quickly without sacrificing health (or muscle mass). Every aspect about how to set up the diet is laid out in a step by step form and the diet is based around whole foods that can be found at any market. With purchase of the book, you’ll also receive instructions for how to access an online calculator that will set up the diet and provide food recommendations. As well, the diet also incorporates concepts I’ve discussed on this site: free meals, refeeds and full diet breaks to help with both adherence and the body’s tendency to fight back when dieting. Guidelines are provided for when to take them, how to use them, etc. In addition, guidelines for moving back to maintenance, as well as for using the program to transition into a more moderate fat loss diet are provided in detail. Specific training guidelines are also provided in order to provide the best results with the least time investment. Massive amounts of exercise aren’t needed; quite in fact, too much exercise while on the rapid fat loss program can hinder results. Quite in fact, for the extremely overweight, no exercise is actually required to reap the benefits of the program. The book provides specific recommendations (for everyone from beginners to advanced trainees) for both resistance training and aerobic activity in terms of how often and how much will provide the best results. As well, realizing that most people can’t or won’t join a gym, I developed a small home- exercise handbook outlining a basic routine that can be followed with no or minimal equipment. This is included with your purchase as a digital download. Table of Contents. Introduction. Chapter 1: Just how quickly? Chapter 2: When is a crash diet appropriate? Chapter 3: Basic nutrition overview. Chapter 4: Nutrient Metabolism Overview. Chapter 5: An Overview of the Diet. Chapter 6: Estimating body fat percentage. Chapter 7: Exercise. Chapter 8: Setting up the diet. Chapter 9: Metabolic slowdown and what to do about it. Chapter 1. 0: Free meals, refeeds and diet breaks. Chapter 1. 1: Ending the Diet – Introduction. Chapter 1. 2: Moving to Maintenance: Non- counting Method Part 1. Chapter 1. 3: Moving to Maintenance: Non- counting Method Part 2. Chapter 1. 4: Moving to Maintenance: Calculation method. Chapter 1. 5: Back To Dieting. Appendix 1: BMI and Body fat charts. Show me my purchase options Excerpt. The following is an excerpt from Chapter 1: Just How Quickly? What can you expect? On average, caloric intakes on this diet will come out to between 4. For those of you familiar with ketogenic (low- carbohydrate, high- fat) diets, a PSMF is essentially a ketogenic diet without the dietary fat. Obviously, this will represent a fairly large caloric deficit; how large depending on your starting body weight and activity levels. So with all of that in mind, you may still be wondering what you can expect in terms of true fat loss per week. A lot of it, actually, will depend on where you’re starting out body weight wise (activity also factors in), as that determines your maintenance caloric level. A 1. 65- pound male with normal activity patterns may have a maintenance requirement of about 2. At 8. 00 calories per day on this diet, that’s almost a 2. Assuming all of the true (non- water) weight lost was fat (it won’t be), that should be an 8- pound fat loss in 2 weeks (2. The true fat loss will be lower because of various inefficiencies and the slowdown of metabolic rate (which can start after only 3- 4 days of severe caloric restriction). A larger individual, say 2. At 8. 00 cal per day on this diet, that’s a 3,0. Over 2 weeks, that’s a 4. That’s on top of the 1. Females or lighter individuals with their generally lower maintenance caloric requirements will lose less. True fat losses of 1/2 pound per day or slightly less may be all that they get: that still amounts to a considerable fat loss (6- 7 pounds true fat loss over 2 weeks) along with the extra water weight loss. Show me my purchase options. Customer Feedback. If a picture is worth a thousand words, then Jay’s before and after pictures here should tell you everything you need to know.“I purchased Lyle Mc. Donald’s Rapid Fat Loss Handbook in hopes of losing a few pounds quickly. The diet did not disappoint, in just 1. I lost 7. 8 lbs, going from 1. Mary Ellen, South Carolina“I’ve been lifting weights for 3. I am well aware of the nutritional needs of humans, and nearly every theory of dieting ever advanced. I’ve done most every type of diet. I have never had such an easy time losing so much fat with so little muscle loss in such a short period of time (5. I have with Lyle’s PSMF. In addition, and more importantly, after just one month on the diet, markers of health. Truly amazing.”– David W Cohen, NVClick to Enlarge“I put a world class BJJ (brown belt) athlete on a modified RFL diet about 3 weeks before the Pan American games 3. March in Los Angeles. I synopsized the diet for him so it was easy- to- read, is all. He called in a panic 3 weeks out because the Pan American games were approaching and he was still 4# over weight and hadn’t been able to lose it on his own. The guy was very lean already so it’s a tricky situation but he pulled it off. March 3. 0th he won the gold medal in his weight class. He weighed in 1# below weight, he looked and felt great and fought like a freak. Back to the kid, now his own BJJ coach (who also competes and also won gold 3. March in the Masters black belt division) sent word that in observing how well Zak performed on the diet and going on to win the Pan Ams that he wants to do it as well to drop a little weight for the upcoming BJJ World’s tournament the first week of June. Attached is a photo when he won the finals. You can see the shape he’s in. He’s just beaten the guy who’s been an arch rival for years. Very tough match.”After 7 weeks on the Rapid Fat Loss plan“I am amazed at how this program worked for me. Knowing that a refeed/free meal was right around the corner gave me the willpower to be STRICT with the low calorie days. Unlike most programs that tell you how to lose weight, RFH also devotes several chapters about how to maintain your weight. The book is very concise and I couldn’t be happier about my results!”J. Tsoi – Houston, Tx“Your Rapid Fat Loss e- book really put me on the right course. I have gone from 3. Your no nonsense plan is extremely easy to follow and the best part is. Thank you for this fantastic information that WILL help me achieve the body of my dreams.”Forever Grateful,– Bill Evans in Seaford Delaware“Looking for a fast and easy way to lose weight? There are plenty of so- called crash diets, but only one diet rooted in science and physiology allows you to do so safely without losing precious muscle mass and slowing down your metabolism – the Protein Sparing Modified Fast (PSMF). In The Rapid Fat Loss Handbook, Lyle Mc. Donald has distilled this method with decades of research behind it into practical guidelines, with easy- to- understand categories depending on your starting point in bodyfat, weight and fitness level. You will learn how to set up the diet, implement free meals and refeeds to not only maintain metabolism but also make the diet easier to follow. Follow the guidelines in this book, where Lyle even provides you with free online resources on how to set up meal plans and an exercise program, and you will lose a lot of fat in a very short time while preserving muscle mass and strength.”Borge (aka Blade) – Norway. Myo. Revolution“Thank you so much for writing your book. I’ve done low carb dieting and intense exercise in the past and lost 4. Like many others I took things to the extreme and could not maintain. I completed banned all carbs, even some good ones. I started low carbing again about a week before I ordered your book online to lose excess water by banning carbs and I didn’t think to incorporate some really healthy high fiber carbs in portion controlled amounts into my prior weight loss as I do with my two free meals. Thanks to your advice I have successfully lost 2. My water retention, high blood pressure is down and my glucose is in balance. I feel great, I’m not hungry, the fish oil is amazing and this really doesn’t feel like a diet. The two regular meals on Sat and Tuesday with exercise a few times a week really help keep me on track. I make sensible choices and I don’t feel deprived. I feel this is a lifestyle I can enjoy permanently.”D. Mc. Gruder – Florida“Muata over at mrlowbodyfat. I send you an email. I found your RFL diet on his blog, and between his inspirational posts and your easy to follow diet, I’ve just completed an 8 week run of RFL starting as a 2. I’m going to take a 2 week break, which actually falls at a great time with Memorial day, my birthday, and my daughter’s birthday, and resume as a cat 2 dieter. I just want to say thanks for developing this diet, and staying active with it with the blog and following the forums. Most diet author types might write the book, but then there is no more contact. You, on the other hand, are available and helpful. Please note that all three products including two digital files: The Home Exercise Handbook and a file titled Calculator.
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The name FODMAP comes from the types of carbohydrates restricted in the diet: fermentable oligosaccharides, disaccharides, monosaccharides and polyols. Three Day Diet Menu Before Surgery. Surgery heals and saves lives, but it is not without risks. Something as basic as your diet prior to surgery can affect the outcome. Your doctor and anesthesiologist will provide you with a preoperative food guide, which you'll want to follow to avoid complications such as aspirating stomach contents into your lungs. If you deviate from the prescribed eating plan in the 1. Eat a regular balanced diet with lean proteins such as chicken or fish, low- fat dairy, whole grains and fruits and vegetables. The Atkins diet promise. Can you lose weight by drastically cutting back on carbs like bread, potatoes and sweets, while still eating bacon, mayonnaise and butter? Why They're a Good Fat. Not all fats are unhealthy. Omega-3 fatty acids are one of the "good" types of fat. They may help lower the risk of heart disease, depression. What can you eat on the Dukan Diet? WebMD reviews the pros and cons of this diet. WebMD experts and contributors provide answers to your health questions. Something as basic as your diet prior to surgery can affect the outcome. Focus on getting all your nutritional needs met through food, as your doctor will likely recommend you stop taking vitamins a week prior to surgery. Make sure you're getting enough B vitamins, which help your body's immunity. Lean meats, dairy, green vegetables and whole grains provide B vitamins. For example, have a vegetable omelet, whole grain toast and low- fat milk for breakfast, turkey or tuna sandwich, going light on the mayo, with fruit and low- fat milk for lunch, and fish, whole grain rice and a leafy green salad for dinner. The day prior to surgery your doctor will ask you avoid whole grains and fiber from legumes and fruits and vegetables, and to limit dairy to two servings, according to the Hospital for Special Surgery. You can have enriched grains such as white bread and rice, as these foods move through the digestive tract quicker than their whole grain counterparts. A sample diet the day before surgery includes a bowl of cereal and orange juice for breakfast, chicken noodle soup with a white dinner roll for lunch, and chicken with mashed potatoes for dinner. The American Society of Anesthesiologists provides preoperative diet guidelines to ensure a safe surgery and reduce postoperative nausea. You can have clear liquids up to two hours before surgery. Approved liquids are water, coffee or tea without milk, fruit juices without pulp, soft drinks and sports drinks. Avoid foods that don't have nutritional value in the days leading up to surgery. This includes cookies, candies, chips and other junk foods. Unless approved by your doctor, discontinue taking a vitamin a week before surgery. Discuss any medications you're taking with your doctor to find out how long you should continue to take them. Some medicines you can take as prescribed, whereas others you'll need to discontinue just prior to surgery. Coca-Cola (often referred to simply as Coke) is a carbonated soft drink produced by The Coca-Cola Company. Originally intended as a patent medicine, it was invented. What is a low carb diet, really? When can a low carb diet be beneficial? Should everyone follow a low carb diet? Or, can a low carb diet ruin your health? AOL has the latest sports news and breaking sporting headlines from the NFL, NBA, MLB, NHL, NASCAR, MLS, World Cup Soccer and more! Great post as always, thanks. However, I do think you might have overlooked one critical aspect of diet. The conversion of fructose to. Now add up all your scores in the A boxes and SUBTRACT from it all your B scores to get your total score. IF YOU SCORED: A negative number. Transcript: Egg Cholesterol in the Diet. The egg industry got their huevos handed to them last fall in a devastating review published in the Canadian Journal of. Coca- Cola - Wikipedia. Coca- Cola (often referred to simply as Coke) is a carbonatedsoft drink. Originally intended as a patent medicine, it was invented in the late 1. John Pemberton and was bought out by businessman Asa Griggs Candler, whose marketing tactics led Coca- Cola to its dominance of the world soft- drink market throughout the 2. Archives and past articles from the Philadelphia Inquirer, Philadelphia Daily News, and Philly.com. The drink's name refers to two of its original ingredients, which were kola nuts (a source of caffeine) and coca leaves. The current formula of Coca- Cola remains a trade secret, although a variety of reported recipes and experimental recreations have been published. The Coca- Cola Company produces concentrate, which is then sold to licensed Coca- Cola bottlers throughout the world. The bottlers, who hold exclusive territory contracts with the company, produce the finished product in cans and bottles from the concentrate, in combination with filtered water and sweeteners. A typical 1. 2- US- fluid- ounce (3. The bottlers then sell, distribute and merchandise Coca- Cola to retail stores, restaurants and vending machines throughout the world. The Coca- Cola Company also sells concentrate for soda fountains of major restaurants and foodservice distributors. The Coca- Cola Company has on occasion introduced other cola drinks under the Coke name. The most common of these is Diet Coke, along with others including Caffeine- Free Coca- Cola, Diet Coke Caffeine- Free, Coca- Cola Cherry, Coca- Cola Zero, Coca- Cola Vanilla, and special versions with lemon, lime, and coffee. Based on Interbrand's . By 1. 91. 3, the company had redeemed 8. The patent for this Spanish drink was bought by Coca- Cola in 1. Pemberton ran the first advertisement for the beverage on May 2. Atlanta Journal. A co- partnership had been formed on January 1. Pemberton and four Atlanta businessmen: J. C. Not codified by any signed document, a verbal statement given by Asa Candler years later asserted under testimony that he had acquired a stake in Pemberton's company as early as 1. 8 MEGYN KELLY SWEARS BY THE F-FACTOR DIET Megyn Kelly was in the spotlight for many things this year, not least of which was her reliance on a fiber-rich diet. Constipation can be painful, leave your gut feeling bloated and just get in the way of a normal work day. They say when you gotta go, you gotta go, but sometimes your. Candler's oldest son, Charles Howard Candler, authored a book in 1. Emory University. In this definitive biography about his father, Candler specifically states: . For $5. 0 down and $5. Walker, Candler & Co. After the April 1. April 1. 7, 1. 88. Walker/Dozier interest shares were acquired by Candler for an additional $7. When Candler had the earliest records of the . This was while Charley Pemberton was selling the elixir, although a cruder mixture, under the name . After both names failed to catch on for Candler, by the middle of 1. Atlanta pharmacist was quite anxious to establish a firmer legal claim to Coca- Cola, and hoped he could force his two competitors, Walker and Dozier, completely out of the business, as well. John Stith Pemberton suddenly died, Asa G. Candler then sought to move swiftly forward to attain his vision of taking full control of the whole Coca- Cola operation. Charley Pemberton, an alcoholic, was the one obstacle who unnerved Asa Candler more than anyone else. Candler is said to have quickly maneuvered to purchase the exclusive rights to the name . One of several stories was that Candler bought the title to the name from Charley's mother for $3. Dr. Eventually, Charley Pemberton was found on June 2. Ten days later, Charley died at Atlanta's Grady Hospital at the age of 4. Candler had negotiated with Margaret Dozier and her brother Woolfolk Walker a full payment amounting to $1,0. Candler could pay off with a series of notes over a specified time span. By May 1, 1. 88. 9, Candler was now claiming full ownership of the Coca- Cola beverage, with a total investment outlay by Candler for the drink enterprise over the years amounting to $2,3. Subsequent analysis of certain similar transfer documents had also indicated John Pemberton's signature was most likely a forgery, as well, which some accounts claim was precipitated by his son Charley. The company publicly offered 5. Montreal, Canada. The first bottling of Coca- Cola occurred in Vicksburg, Mississippi, at the Biedenharn Candy Company in 1. The proprietor of the bottling works was Joseph A. The original bottles were Biedenharn bottles, very different from the much later hobble- skirt design of 1. It was then a few years later that two entrepreneurs from Chattanooga, Tennessee, namely; Benjamin F. Whitehead, proposed the idea of bottling and were so persuasive that Candler signed a contract giving them control of the procedure for only one dollar. Candler remained very content just selling his company's syrup. Legal matters were not helped by the decision of the bottlers to subcontract to other companies, effectively becoming parent bottlers. In 1. 93. 5, it was certified kosher by Atlanta Rabbi Tobias Geffen, after the company made minor changes in the sourcing of some ingredients. Photograph circa 1. The longest running commercial Coca- Cola soda fountain anywhere was Atlanta's Fleeman's Pharmacy, which first opened its doors in 1. Cans of Coke first appeared in 1. Follow- up taste tests revealed most consumers preferred the taste of New Coke to both Coke and Pepsi. The company gave in to protests and returned to a variation of the old formula using high fructose corn syrup instead of cane sugar as the main sweetener, under the name Coca- Cola Classic, on July 1. On July 5, 2. 00. Coca- Cola would resume operations in Iraq for the first time since the Arab League boycotted the company in 1. In January 2. 00. Coca- Cola stopped printing the word . That same day, Coca- Cola announced the 1. A 1. 6- ounce bottle has sold well at 9. As part of the deal Coca- Cola was to acquire a 1. Monster for $2. 1. The original copy of the formula was held in Sun. Trust Bank's main vault in Atlanta for 8. Its predecessor, the Trust Company, was the underwriter for the Coca- Cola Company's initial public offering in 1. On December 8, 2. Sun. Trust Banks to a new vault containing the formula which will be on display for visitors to its World of Coca- Cola museum in downtown Atlanta. The formula basically matched the one found in Pemberton's diary. The cocaine was derived from the coca leaf and the caffeine from kola nut, leading to the name Coca- Cola (the . Coca- Cola once contained an estimated nine milligrams of cocaine per glass. Besides producing the coca flavoring agent for Coca- Cola, the Stepan Company extracts cocaine from the coca leaves, which it sells to Mallinckrodt, a St. Louis, Missouri, pharmaceutical manufacturer that is the only company in the United States licensed to purify cocaine for medicinal use. In Britain, for example, the ingredient label states . Forty Barrels and Twenty Kegs of Coca- Cola, hoping to force Coca- Cola to remove caffeine from its formula. The case was decided in favor of Coca- Cola. Subsequently, in 1. U. S. Pure Food and Drug Act was amended, adding caffeine to the list of . The Coca- Cola Company only produces a syrup concentrate, which it sells to bottlers throughout the world, who hold Coca- Cola franchises for one or more geographical areas. The bottlers produce the final drink by mixing the syrup with filtered water and sweeteners, and then carbonate it before putting it in cans and bottles, which the bottlers then sell and distribute to retail stores, vending machines, restaurants and food service distributors. Independent bottlers are allowed to sweeten the drink according to local tastes. In the early 2. 0th century, a fatwa was created in Egypt to discuss the question of . Another clause was discussed, whereby the same rules apply if a person is unaware of the condition or ingredients of the item in question. Brand portfolio. This is a list of variants of Coca- Cola introduced around the world. In addition to the caffeine- free version of the original, additional fruit flavors have been included over the years. Not included here are versions of Diet Coke and Coca- Cola Zero; variant versions of those no- calorie colas can be found at their respective articles. Caffeine- Free Coca- Cola (1. Was available in Canada starting in 1. Available in: Australia, American Samoa, Austria, Belgium, Brazil, China, Denmark, Federation of Bosnia and Herzegovina, Finland, France, Germany, Hong Kong, Iceland, Korea, Luxembourg, Macau, Malaysia, Mongolia, Netherlands, New Caledonia, New Zealand, R. Available in: Austria, Australia, China, Czech Republic, Finland, Germany, Hong Kong, New Zealand, Malaysia, Slovakia, South- Africa, Sweden, Switzerland, United Kingdom and United States. It was reintroduced in June 2. Coca- Cola with Lime (2. Available in Belgium, Netherlands, Singapore, Canada, the United Kingdom, and the United States. Coca- Cola Raspberry (2. Was only available in New Zealand. Currently available in the United States and the United Kingdom in Coca- Cola Freestyle fountain since 2. Coca- Cola Black Cherry Vanilla (2. It replaced and was replaced by Vanilla Coke in June 2. Coca- Cola Bl. Only available in the United States, France, Canada, Czech Republic, Bosnia and Herzegovina, Bulgaria and Lithuania. Coca- Cola Citra (2. Only available in Bosnia and Herzegovina, New Zealand and Japan. Coca- Cola Orange (2. Was available in the United Kingdom and Gibraltar for a limited time. In Germany, Austria and Switzerland it's sold under the label Mezzo Mix. Currently available in Coca- Cola Freestyle fountain outlets in the United States since 2. United Kingdom since 2. Coca- Cola Life (2. Only available in Australia and New Zealand. Logo design. The Coca- Cola logo was created by John Pemberton's bookkeeper, Frank Mason Robinson, in 1. The writing style used, known as Spencerian script, was developed in the mid- 1. United States during that period. Robinson also played a significant role in early Coca- Cola advertising. His promotional suggestions to Pemberton included giving away thousands of free drink coupons and plastering the city of Atlanta with publicity banners and streetcar signs. Intermittent Fasting and Stubborn Body Fat. I have previously hinted that intermittent fasting sidesteps the issues associated with stubborn body fat. Indeed I rarely find any need for advanced strategies to rid my clients of stubborn body fat. I will soon tell you why, but first let me give you some background information to what I'm talking about here. What is stubborn body fat? Stubborn body fat refers to areas of the body that hold on to fat the longest. Generally speaking, these areas include the lower abs and lower back in men, and the lower body in women. These areas are damn hard to get lean. How come these areas are stubborn in the first place? To understand this, let's look at how fat is mobilized (the very short version). After you eat, insulin and fatty acids are elevated. You are in the fed state and there's zero fat burning going on. Your body is relying completely on glucose oxidation during the hours following the meal. One way of measuring this is via the respiratory quotient (RQ). An RQ of 1. 0 denotes pure carbohydrate metabolism (. To put this into perspective, consider that RQ is 0. As the hours go by and the nutrients from the meal are done being absorbed, RQ drops in conjunction with insulin. There's a shift towards fat burning and mobilization of stored fat. This process is mediated by insulin and blood- borne fatty acids; when levels drop, an energy deficit is . A receptor can be thought of as a . In this case catecholamines trigger fat mobilization by activating hormone sensitive lipase (HSL), which then shuttles the fat out of the cell to be burned off. Now here's the critical difference between regular fat and stubborn fat: regular fat have a lot of beta- 2 receptors in proportion to alpha- 2 receptors. In The Stubborn Fat Solution Lyle Mc. Bruno's Marketplace is a unique on-line store bringing you products from Bruno's, Sierra Nevada and Waterloo. We are committed to bringing you quality food products. GM Diet - Improve your health, The General Motors is to cleanse your system and lose 8-17 lbs in a week. Look for Vegetarian, Indian and traditional Diet. Donald used the analogy of b. That's the easiest way to think of them without getting too deep into the physiology. The ratio between b. Though I can't recall if similar numbers are available for lower ab and lower back fat for men, you can be sure that the a. I rarely use fancy strategies for ridding my clients of stubborn body fat. It's more or less a linear process all the way down to the shredded state. Intermittent fasting and stubborn fat loss. How can intermittent fasting then selectively target stubborn body fat more effectively than other diets? Well, to target stubborn body fat we need to activate b. Intermittent fasting achieves this by the following mechanisms. Fasting increases catecholamine levels. Fasting increases abdominal subcutaneous blood flow, which means that catecholamines will have an easier time reaching those hard- to- get areas. The low insulin level reached during the fast inhibits a. A greater time spent in the low insulin state equals a greater time spent in a state where fat can be mobilized from stubborn areas. Now you're probably thinking . One of the staple foods on the GM Diet is the delicious soup now famously called the GM Diet Wonder Soup. This soup recipe is easy to make and tastes delicious. Sildenafil, sold as the brand name Viagra among others, is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. Its effectiveness for. MFNRocks.com is an Internet Radio station with daily live streaming video. The station plays Hard Rock, Classic Rock, and Punk Rock. MFNRocks streams music 24/7 365. Four CA Regional Agritourism Summits in February & March. The University of California Small Farm Program and UC Cooperative Extension advisors in four California. You might remember a guest post about fruitarianism on No Meat Athlete last year that drew a lot of negative comments, mostly dismissing the diet as a fad. Rothans & Associates specializes in coding and billing reimbursement for dental offices nationwide. Our certified professionals are specifically trained to help you. My research has indicated that the ideal state of fat burning is reached after 1. Coupled with high levels of catecholamines, increased blood flow to stubborn regions, and low insulin for a. Studies have examined free fatty acid (FFA) oxidation from anywhere between the overnight fasted state to three days of fasting. While FFA oxidation increases the longer time you spend in the fasted state, the contribution of fatty acids to whole body fat oxidation changes. In short- term fasting there's a significant increase in subcutaneous FFA oxidation. That's just a fancy way of saying that you're mainly burning body fat and nothing else. For up to 1. 4- 2. Past this time point, fat burning increases further. That goes without saying. But it's not necessarily the type of fat you're after that you'll be burning. Somewhere in between the 1. Subcutaneous fat simply can't keep up with demand, so you're playing a game of diminishing returns if you push the fast too long. Coupled with the escalating rate of de novo gluconeogenesis, and subsequent risk of muscle catabolism, fasting for too long may not be very conducive for a lean individual seeking optimal lean mass retention while targeting stubborn body fat. Men usually need to hit single- digit body fat percentage to have good abs, while women have good abdominal definition at around 1. Above is a picture of natural body fitness champ and intermittent fasting afficionado Kristine Weber. Science vs real life. One obvious question critically inclined readers should ask themselves is whether special strategies to mobilize stubborn fat is even needed in the first place. After all, people have gotten ripped without intermittent fasting or the strategies laid out in The Stubborn Fat Solution by Lyle Mc. Donald. Is it not just a question of dropping low enough in body fat percentage? If we compare a traditional calorie deficit of 3. The Stubborn Fat Solution), would there be any difference in regional fat loss assuming all other factors were kept constant? I don't think we'll ever know, so this boils down to relying on theory and practical experience. My personal experience is that intermittent fasting helps with stubborn fat loss compared to a conservative diet. This little anecdote is obviously riddled with confounders, and maybe even wishful thinking, but if you take a look at some pictures from my younger days (and here), you'll see that I was quite lean during the modelling days. However, I still had some fat covering the lower ab region and never really seemed to lean out well no matter how hard I tried. Sure, I would lose weight when I cut calories, but not from the right areas. I always ended up getting extremely lean legs, arms and shoulders. I also lost a lot of muscle in my desperate attempts to get good abs, but that might just boil down to me dieting like a retard. As you can see in some more recent pics, I don't have those types of problems any more. Adding to this anecdotal evidence of mine, I have heard similar feedback from clients and blog readers. Intermittent fasting seems very conducive for targeting stubborn body fat. Got a similar experience to report? Let me know. Content update, June 2. When is stubborn body fat a problem? There were a few things that I forgot to cover when I first finished this article. First of all, at what level does stubborn body fat become an issue? Generally speaking, people don't have a good sense of what is . I've had tons of clients approach me with their . If I had to put a number on it, I'd say 1. Below are a few examples of the level of leanness required to even start thinking about stubborn body fat. Both of these clients were approximately 1. Note that both of them were quite lean and had good abdominal definition from the navel up. The stubborn fat is located at around the navel and below. With females the whole lower body is . Note the lean midsection and lower back. At the same time the lower body appears quite smooth. If she would have dropped a few more percentage points of body fat, she would have had very visible abs - but her lower body would likely not have gotten much leaner. Even female body fitness competitors rarely come in to stage with . Keep in mind that your diet needs to be in order first and foremost. You can't throw this into the mix and expect results if your diet is sub par. Intermittent fasting. For the reasons I mentioned earlier. Increase your activity level in the fasted state. Add cardio or whatever else to get your energy expenditure up. A personal favorite of mine is lower intensity and longer duration activities like walking in the 1. Not only is this the . There are other reasons I favor low intensity over high intensity activities (such as HIIT). They interfere minimally with your performance in the gym and can be done on a daily basis, which is not the case with HIIT. Supplementation. While I have gotten lean without thermogenics and alpha- 2 receptor antagonists, such as yohimbine, they can speed up the process. For starters: Caffeine is a dirt cheap thermogenic that will ramp up catecholamine levels. During the fast add caffeine pills and dose depending on tolerance. If you're not a regular coffee- drinker, you can get pretty wired off 2. If you're a habitual coffee- drinker (like me), it might take up to 6. L- Tyrosine may work synergistically with caffeine so you may consider experimenting with that as well. Personally though, I have never gotten much out of it - though many people swear by it. For more ambitious supplementation, add the alpha- 2 antagonist yohimbine or a supplement containing yohimbine in addition to caffeine pills. Take the equivalent of 0. This works out to 1. Other commercial thermogenics, such as Meltdown, contain 3 mg yohimbine per capsule; so you'd have to take up to 5 capsules to reach similar levels. But proceed with caution: the product says, . It would be best to start low to assess tolerance. Meltdown contains quite a few other ingredients that might make the effects stronger and more unpredictable versus straight yohimbine hcl (i. Meltdown might be more potent than 1. Y- HCL in terms of stimulatory effect and perhaps side effects). Important: Keep in mind that insulin negates the effects of yohimbine on alpha 2- receptor inhibition. Always take it in the fasted state and never between meals. Considering the half- life of yohimbine is very short (3. For example, three dosages taken every second hour until your first meal. In that case I would probably not recommend starting with 0. An 8. 0 kg male could use the following schedule. AM: 1. 2 mg yohimbine. AM: 1. 2 mg yohimbine. AM- 1. 0 AM: 4. 5 to 6. AM: 1. 2 mg yohimbine. PM: Meal one. Another option: Alpha. Burn. Pure yohimbine may lead to feelings of anxiety and even panic attacks in predisposed individuals. A better alternative can be found in Alpha Burn, and other supplements containing rauwolscine, which is a stereoisomer of yohimbine. Reg from Predator Nutrition recently sent me a box of these and I can vouch for it's psychoactive effects not being as rough as pure yohimbine. Arvine Pipe and Supply Co. Ron Arvine, President of Arvine Pipe & Supply Co., Inc. The AXS Cookie Policy. This website, like most others, uses cookies in order to give you a great online experience. By continuing to use our website you accept to our. Welcome to Babylon Floral Design, Denver's most unique flower boutique, specializing in cutting edge floral design and unique gift items. We strive to provide the. Mother Nature Network is the world's leading source for environmental news, advice on sustainable living, conservation and social responsibility. A Texas Co- Packer: Home. We must look at Filipino boxing legend Manny Foods to eat & avoid. Dropping Acid (2. Jamie Koufman MD, Jordan Stern MD, and Marc Bauer. Send this page to friends, family, and anyone else who you want to understand what you. The incidence is on the rise, and they believe it has largely to do with excessive acid in our diets as prepared foods have been increasingly acidified to prevent bacterial growth and add shelf life. The real villain is the digestive enzyme pepsin, not acid, so an antacid won. Pepsin breaks down proteins, and can only do its job when acid is around to activate it. Once a pepsin molecule is bound to, say, your throat, any dietary source of acid can reactivate it . Avoid overeating and especially overdrinking. Do not eat anything 3 hours before bedtime, have a light dinner, and avoid alcohol before bedtime. Generally, organic is preferable. Average at around 1. Foods to eat in Dropping Acid . This gives the membranes lining your throat, esophagus, etc. That means that in the maintenance list, the foods below with a star* next to them may be better avoided if you have severe symptoms. Proteins. Eat only organic poultry and fish. Dropping Acid: The Reflux Diet Cookbook & Cure (2010): What to eat and foods to avoid. Trending in Money Are You Making the Most of Your Health Savings Account? 10 Steps for Finding Your New Job; 7 Lifestyle Changes to Make You a Better Entrepreneur. Goddard Space Flight Center GSFC renews long term contract with Kinesix for support of their satellite testing and command & control. Rothans & Associates specializes in coding and billing reimbursement for dental offices nationwide. Our certified professionals are specifically trained to help you. Chicken . 4 per week, only red apples – Fuji, Red Delicious*, Gala*)Bananas (a small number of people with reflux need to avoid them)Melons . Low- acid vegetables. Green vegetables – excluding bell pepper. Fennel. Mushrooms – raw or cooked. Parsley. Potatoes . Turnips. Vegetables – raw or cooked, no onion, tomato, peppers. These vegetables are mentioned in the book and in recipes: arugula, asparagus, beets, broccoli, cabbage (green, red, savoy), carrots, cauliflower, celery, corn, eggplant, endive, green beans, parsnips, peas, radish, snow peas, squash (acorn squash, butternut squash, spaghetti squash), watercress, yams, zucchini. Condiments and dressings. Vinaigrette . Rocquefort. Note this is not a salt- restricted diet. Foods to avoid or limit with Dropping Acid. Notoriously bad reflux foods. Fatty foods. Deep- fried foods. Fatty meats – bacon, sausage, ribs, high- fat hamburgers. Cream sauce e. g. Alfredo. Butter, margarine, lard, shortening. High- fat nuts, including peanut butter. Acidic foods. Carbonated beverages including all sodas. Citrus fruits/juices . This page describes what the authors of the diet recommend . Koufman is on Twitter at? Please add a comment below.
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In gestational diabetes, early intervention with insulin or an oral agent is key to achieving a good outcome when diet therapy fails to provide adequate glycemic control. Determine the choice of insulin and regimen based on the patient's individual glucose profile. The goal of insulin therapy during pregnancy is to achieve glucose profiles similar to those of nondiabetic pregnant women. Given that healthy pregnant women maintain their postprandial blood sugar excursions within a relatively narrow range (7. L), reproducing this profile requires meticulous daily attention by both the patient and clinician. Insulins lispro, aspart, regular, and neutral protamine hagedorn (NPH) are well- studied in pregnancy and regarded as safe and effective. Insulin glargine is less well- studied, and given its long pharmacologic effect, may exacerbate periods of maternal hypoglycemia. Upward adjustment of short- acting insulin doses to control postprandial glucose surges within the target band only exacerbates the tendency to interprandial hypoglycemia. Thus, any insulin regimen for pregnant women requires combinations and timing of insulin injections quite different from those that are effective in the nonpregnant state. Further, the regimens must be continuously modified as the pregnancy progresses from the first to the third trimester and insulin resistance rises. Strive to stay ahead of the rising need for insulin, and increase insulin dosages preemptively. When more than 2. L, administer lispro insulin (4- 8 U subcutaneously . If more than 1. 0 U of regular insulin is needed before the noon meal, adding 8- 1. U of NPH insulin before breakfast helps achieve control. When more than 1. L, initiate 6- 8 U NPH insulin at bedtime (hs). Titrate doses as needed according to blood glucose levels. It is largely accounted for by slower glucose disposal. These devices can be programmed to infuse varying basal and bolus levels of insulin, which change smoothly even while the patient sleeps or is otherwise preoccupied. The effectiveness of continuous subcutaneous insulin infusion in pregnancy is well established. Nevertheless, the oral agents glyburide and metformin are gaining popularity. Trials have shown these agents to be effective and no evidence of harm to the fetus has been found, although the potential for long- term adverse effects remains a concern. This is probably largely due to the high plasma protein binding coupled with a short half- life. Only 4% of patients in the glyburide study arm required addition of insulin to achieve glucose control. All studies comparing glyburide to traditional insulin have demonstrated similar levels of glycemic control. Most studies show no differences in maternal or neonatal outcomes with glyburide. Studies evaluating predictors of failure with glyburide cite the following risk factors . Research in this area, although needed, has been difficult given the known teratogenic effects of first- generation sulfonylurea, which readily crossed the placenta. Anderson PhD, MPH Professor & Associate Dean for Learning Systems & Student Affairs, Epidemiology & Community Health. Figure 2 Relationships between Changes in Diet and Physical Activity and Weight Changes within Each 4-Year Period in the Three Cohorts. In a multivariable-adjusted. Amenorrhea is a normal feature in prepubertal, pregnant, and postmenopausal females. Find patient medical information for FISH OIL on WebMD including its uses, effectiveness, side effects and safety, interactions, user ratings and products that have it. Leptin-Replacement Therapy for Lipodystrophy. Elif Arioglu Oral, M.D., Vinaya Simha, M.D., Elaine Ruiz, N.P., Alexa Andewelt, B.S., Ahalya Premkumar. Glyburide has been shown to be safe in breastfeeding, with no transfer into human milk. Metformin. Metformin is a biguanide, which functions mainly by decreasing hepatic glucose output. Metformin crosses the placenta, and umbilical cord levels have been shown to be even higher than maternal levels. Since this initial study, however, several other prospective and retrospective studies involving over 3. Between the 2 groups, patients who achieved glycemic control did not differ with regard to mean fasting and 2- hour postprandial blood glucose level. However, the percentage of women who did not achieve glycemic control and required insulin was 2. Monitoring fetal growth is essential to select the proper timing and route of delivery. This is accomplished by frequent testing for fetal well- being and serial ultrasonographic examinations to follow fetal size. Various fetal biophysical tests are available to the clinician to ensure that the fetus is well oxygenated, including fetal heart rate testing, fetal movement assessment, ultrasonographic biophysical scoring, and fetal umbilical Doppler ultrasonographic studies (see the table below). If applied properly, most of these tests can be used with confidence to provide assurance of fetal well- being while awaiting fetal maturity. Table 3. Biophysical Tests of Fetal Well- Being for Diabetic Pregnancy (Open Table in a new window). TEST< < P> Test. Frequency. Reassuring Result. Comment. Fetal movement counting. Every night from 2. Performed in all patients. Nonstress test (NST)Twice weekly. Begin at 2. 8- 3. GDM. Contraction stress test. Weekly. No heart rate decelerations in response to 3 contractions in 1. Same as for NSTUltrasonographic biophysical profile. Weekly. Score of 8 in 3. Initiate testing early enough to avoid significant stillbirth but not so early that a high rate of false- positive test results is encountered. In patients with poor glycemic control, intrauterine growth restriction, or significant hypertension, begin formal biophysical testing as early as 2. In patients who are at lower risk, most centers begin formal fetal testing by 3. Fetal movement counting is performed in all pregnancies from 2. There is no consensus regarding antenatal testing in patients with gestational diabetes that is well controlled with diet. Assessing fetal growth. Monitoring fetal growth continues to be a challenging and imprecise process. Although currently available tools (serial plotting of fetal growth parameters based on ultrasonographic measurement) are superior to those used previously for clinical estimations, accuracy is still only within . In 1. 99. 2, Bernstein and Catalano reported that significant correlation exists between the degree of error in the ultrasonogram- based estimation of fetal weight and the percentage of body fat on the fetus. Estimate fetal size once or twice at least 3 weeks apart in order to establish a trend. Time the last examination to be at 3. Timing and route of delivery. Select the timing of delivery to minimize morbidity for the mother and fetus. Delaying delivery to as near as possible to the expected date of confinement helps maximize cervical maturity and improves the chances of spontaneous labor and vaginal delivery. However, the risks of advancing fetal macrosomia, birth injury, and in utero demise increase as the due date approaches. Although delivery as early as 3. Because fetal growth from 3. By comparing the outcomes associated with labor induction in patients with gestational diabetes at 3. Kjos et al found that expectant management increased the gestational age at delivery by 1 week, but it did not significantly reduce the cesarean delivery. This suggests that routine induction of women with diabetes on or before 3. The investigators found that in women with insulin- controlled gestational diabetes mellitus, there was no significant difference in the rate of large for gestational age newborns associated with those who had labor induced at 3. In addition, the rate of neonatal hypoglycemia appeared to increase in association with induction at 3. In patients with gestational diabetes mellitus and superb glycemic control, continued fetal testing and expectant management can be considered until 4. In the fetus with an abdominal circumference significantly larger than the head circumference or an estimated fetal weight above 4. After 4. 0 or more weeks, the benefits of continued conservative management are likely to be outweighed by the danger of fetal compromise. Induction of labor before 4. An optimal time for delivery of most diabetic pregnancies is typically on or after the 3. Deliver a patient with diabetes before 3. For elective induction before 3. Because the risk of shoulder dystocia and fetal injury in labor is increased 3- fold in diabetic pregnancy, elective cesarean section should be considered if the fetus is suspected to be significantly obese. The American College of Obstetricians and Gynecologists recommends offering cesarean delivery to diabetic patients if the fetal weight is estimated to be 4. Prevention of Shoulder Dystocia. Although ultrasonographic measurements of the fetus have proven to be poor predictors of the risk of shoulder dystocia, this technique continues to be the mainstay for assessing risk in pregnancy for women with diabetes. The commonly used formulas derived from a multivariate regression multiply multiple coefficients together, with the resultant product (estimated fetal weight) typically having an accuracy that is seldom less than within 1. Fetuses predicted to weigh 4. In a study involving more than 3. However, a sensitivity of approximately 8. This means a false- positive rate of 3. Erb palsy. Thus, current data do not support a policy of early induction of labor in cases of possible fetal macrosomia. If one accepts that 8- 2. However, if fetal weight is estimated to be 4. Intrapartum glycemic management. Maintenance of intrapartum metabolic homeostasis optimizes postnatal infant transition by reducing neonatal hyperinsulinemia and subsequent hypoglycemia. The use of a combined insulin and glucose infusion during labor to maintain maternal blood sugars in a narrow range (8. L) is a common and clinically efficient practice. Typical infusion rates are 5% dextrose in Ringer lactate solution at 1. L/h and regular insulin at 0. U/h. Capillary blood sugar levels are monitored hourly in these patients. For patients with diet- controlled gestational diabetes mellitus or mild type 2 diabetes, avoiding dextrose in intravenous fluids normally maintains excellent blood glucose control. After 1- 2 hours of monitoring, no further assessments of capillary blood sugar typically are necessary. |
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November 2017
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