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These agents have been shown to be have been suggested and developed to address the high- extremely efficacious in high-turnover osteoporosis [43] purchase cheap tadora line men's health erectile dysfunction pills. Although calcium and vitamin D They increase bone mass at all measurable sites and de- are not considered anti-resorptive agents cheap tadora 20mg on-line beer causes erectile dysfunction, approximately crease fracture incidence by 50% buy 20mg tadora with mastercard erectile dysfunction age 35, including in the spine half of patients presenting at hospitals with hip fractures and the hip [7 generic 20mg tadora fast delivery erectile dysfunction cancer, 18, 57]. Reported side effects of oral bis- in the elderly population, primarily by reversing secondary phosphonates include esophagitis and indigestion, but the hyperparathyroidism [19. Intravenous shown to increase bone mass while effecting a decrease of therapies, while not tested specifically for treatment in os- vertebral fracture incidence by approximately 50% [54, teoporosis, appear to be efficacious, and once yearly zole- 60]. Unfortunately, estrogen in combination with proges- dronate (Zometa) infusions appear to be just as effective terone therapy is associated with increased cardiovascular as the oral dose of alendronate regarding bone mass [22]. As a consequence, estrogen is mainly Bisphosphonates decrease bone turnover, and in very used in the early post-menopausal period to treat post- high dosages in canine models have been shown to cause menopausal symptomatology, and then lowered to the least fatigue fractures that are not actively repaired. It is no indicate that patients on alendronate for 10 years have an longer recommended by the US Federal Government for 8. Patients stopping alendronate therapy after agents which have a significant anti-estrogen effect on 5 years retain the decreased fracture risk. However, osteoblasts are preferentially stim- that bisphosphonates remain active for extended periods ulated by SERMs and upregulate the rate of bone forma- once the bone surface has been coated. The half-lives of 68 alendronate and risedronate are at least 10 years and 1. Therapeu- somewhat delayed, the ultimate mechanical strength of the tic medications do not completely eliminate fractures, and repaired bone was unchanged compared to the controls [84]. Overall, bisphosphonates are critical factor in fracture prevention [81, 98]. Fall history extremely effective in the prevention of osteoporotic fragility can be determined through a complete patient interview, fractures. In addition, bisphosphonates are just as efficacious as can the inability to rise from a chair without using the in men as in women [1, 35, 78], and are particularly effec- hands, poor eye sight and neuromuscular impairment. Another easily administered and highly informative protection is afforded by the avoidance of significant bone test is the heel-toe straight line walk. However, in low-turnover osteoporosis, the pri- the etiology for increased falls, a wide variety of factors mary disturbance is ineffective osteoblast activity. Anabolic must be considered, including neurologic, metabolic, oph- agents lead to bone mass accretion at a high rate. The inter- roid hormone (PTH 1–34) has been recently released for the play of these factors to cause increased falling may best be treatment of osteoporosis. It can lead to up to a 13% in- evaluated in the hands of a neurologist, physiatrist, or a crease in bone mass within a year of therapy, and appears to clinician with similar interests. PTH While therapeutic exercises for bone mass accretion focus is given by a self-administered subcutaneous dose. Appro- on load bearing exercises [95], balance training utilizes a priate serum levels of PTH stimulate osteoblasts preferen- different array of activities. Enhancement of muscle coor- tially, and do not lead to increased osteoclastic resorption. Tai Chi programs for fall Several articles report on the possible benefits of PTH on prevention were first described by Wolf et al. Its efficacy has been confirmed liferation and differentiation of osteoprogenitor cells and more recently [53, 101]. At the Hospital for Special Sur- increases in production of bone matrix proteins [72]. There gery, our Tai Chi program has been extremely well re- are no data at this time answering the question of whether ceived, and 1-year follow-up has indicated that the major- PTH will play a role in enhancing spine fusion, though ity of patients continue to perform Tai Chi after they grad- similar mechanisms may be involved. Regarding the fracture risk with exer- states, controversy exists as to the indications of PTH ver- cise programs, as bone mass decreases, loads applied an- sus the bisphosphonates. Currently, we recommend bis- terior to the center of gravity become more deleterious. Patients with low-turnover states, patients patients with osteoporosis, and sit-ups or crunches should who have been on bisphosphonates and have further be avoided. Patients should rely on isometric exercises to fragility fractures, or patients who have radiographic evi- strengthen abdominal musculature. The characteristics of surfaces are extremely important, Parathyroid hormone is acceptable in women of child-bear- as many vertebral fractures occur with falls. Concerns of osteogenic sarcoma have been voiced soft surfaces are suggested for individuals with a predis- regarding PTH due to PTH-like receptors on osteosarcoma position for falling. Therefore, PTH is not recommended for patients with dementia or who are otherwise disoriented, floor sur- with higher rates of osteoblast activity, such as children, faces adjacent to their beds must be closely scrutinized. Future interventions Fall prevention Recent investigations have suggested several local and systemic procedures that may lead to rapid restoration of Patients with osteoporosis who sustain one or more falls vertebral body bone mass and architecture. The first group within a year have a 25-fold higher risk of fracture [33]. Potential bone formation in vivo, a family of biodegradable ceram- agents include the bone morphogenetic proteins (BMPs), ics has been established that can lead to mechanical bone which have been demonstrated to lead to rapid bone aug- augmentation. They may be injected into vertebral bodies, mentation, specifically BMP-2 and its analog receptor ag- and because the size of their trabecular structure is similar onists[82, 102]. These agents may be placed directly in to human bone, they are gradually resorbed and replaced trabecular bone and can rapidly lead to enhanced bone by native bone over time [52, 97]. The mechan- tri-calcium phosphate classes are more resorbable than bone ical properties of this bone, however, will be shaped by cements such as polymethylmethacrylate, but will still the mechanical load applied to that vertebral body in the lead to mechanical protection for a period of years. Local bone regeneration using Osteoporotic vertebral fractures occur commonly and this technique can be maintained by systemic agents, in- lead to long-term morbidity and mortality. There are diagnostic tools available growth factors and medications, even with slow release, which allow the clinician to recognize osteoporosis and to are metabolized and excreted within a relatively short pe- further classify the underlying etiologies. Lieberman and others have demonstrated that and Drug Administration (FDA) approved agents now ex- the utilization of a BMP gene can continue the production ist to address either the high-resorptive rate or the low- of BMP-2 over a long period of time, controlled by the formation state successfully, and have been shown to de- promoters within the inserted gene [56]. Patients presenting with is ideally transduced through a viral vector or through ex- a fragility vertebral fracture require osteoporosis evalua- vivo insertion into appropriate cells is uncertain, but this tion and treatment, because further fractures in both the technique appears promising [88, 99]. It may be possible spine and the hip will occur in the majority of individuals to insert cells containing gene therapeutics which will pref- who remain untreated. New methodologies on the horizon erentially direct bone metabolism in osteoporotic vertebral include local and systemically administered substances, sites. There is preliminary evidence in animal models that including cements, proteins and genes which may rapidly intravenous injection of specialized cells can be targeted augment vertebral bone quality. Alendronate for the treatment J, Holden J, Hock J (1996) Parathy- (1992) New approaches for interpret- of osteoporosis in men. Calcif Tissue roid hormone regulates the expression ing projected bone densitometry data. Int 69:239–241 of rat osteoblast and osteosarcoma J Bone Miner Res 7:137–145 2. Black DM, Cummings SR, Karpf DB, mortality following clinical fractures.

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Cloning makes it possible to identify the DNA sequence in a gene and produce the pro- A new drug is protected by patent for 14 years buy tadora 20 mg line xylometazoline erectile dysfunction, during which tein product encoded by a gene order tadora paypal erectile dysfunction psychogenic causes, including insulin and sev- it can be marketed only by the pharmaceutical manufacturer eral other body proteins effective tadora 20mg erectile dysfunction kidney stones. However purchase tadora 20mg online erectile dysfunction treatment tablets, for new drugs DRUG CLASSIFICATIONS that are popular and widely used, other companies often pro- AND PROTOTYPES duce similar drugs, with different generic and trade names. For example, the marketing of fluoxetine (Prozac) led to the Drugs are classified according to their effects on particular introduction of similar drugs from different companies, such body systems, their therapeutic uses, and their chemical as citalopram (Celexa), fluvoxamine (Luvox), paroxetine characteristics. For example, morphine can be classified as (Paxil), and sertraline (Zoloft). Prozac was approved in 1987 a central nervous system depressant, a narcotic or opioid and went off patent in 2001, meaning that any pharmaceuti- analgesic, and as an opiate (derived from opium). The names cal company could then manufacture and market the generic of therapeutic classifications usually reflect the conditions for formulation of fluoxetine. Generic drugs are required to be which the drugs are used (eg, antidepressants, antihyperten- therapeutically equivalent and are much less expensive than sives, antidiabetic drugs). Official drugs must meet standards of purity and strength as determined by chemical analysis or Pharmacoeconomics involves the costs of drug therapy, in- animal response to specified doses (bioassay). The Durham- cluding those of purchasing, dispensing (eg, salaries of Humphrey Amendment designated drugs that must be pre- pharmacists, pharmacy technicians), storage, administra- scribed by a physician and dispensed by a pharmacist. The tion (eg, salaries of nurses, costs of supplies), laboratory Food and Drug Administration (FDA) is charged with en- and other tests used to monitor client responses, and losses forcing the law. Length of illness or hospitalization is also lates vaccines and other biologic products, and the Federal considered. Trade Commission can suppress misleading advertisements Costs are increasingly being considered a major factor in of nonprescription drugs. Title II of studies is to define drug therapy regimens that provide the de- this law, called the Controlled Substances Act, regulates the sired benefits at the least cost. For drugs or regimens of simi- manufacture and distribution of narcotics, stimulants, depres- lar efficacy and toxicity, there is considerable pressure on sants, hallucinogens, and anabolic steroids. These drugs are prescribers (eg, from managed care organizations) to prescribe categorized according to therapeutic usefulness and potential less costly drugs. The Drug Enforcement Administration (DEA) is charged PRESCRIPTION AND with enforcing the Controlled Substances Act. Individuals NONPRESCRIPTION DRUGS and companies legally empowered to handle controlled sub- stances must be registered with the DEA, keep accurate Legally, American consumers have two routes of access to records of all transactions, and provide for secure storage. One route is by prescription or order from Physicians are assigned a number by the DEA and must in- a licensed health care provider, such as a physician, dentist, clude the number on all prescriptions they write for a con- or nurse practitioner. Prescriptions for Schedule II drugs cannot (OTC) purchase of drugs that do not require a prescription. Nurses are respon- Both of these routes are regulated by various drug laws. American Drug Laws and Standards In addition to federal laws, state laws also regulate the sale and distribution of controlled drugs. These laws may be Current drug laws and standards have evolved over many more stringent than federal laws; if so, the stricter laws usu- years. Canadian Drug Laws and Standards the Food, Drug, and Cosmetic Act of 1938 was especially important because this law and its amendments regulate the Canada and its provinces have laws and standards that paral- manufacture, distribution, advertising, and labeling of drugs. Indicate the controlled substance category for each (usually conducted or sponsored by a pharmaceutical com- drug. From the information you obtained in researching the drug, pany) about proposed new drugs; the organization does not reflect on why each drug was placed in the assigned category. How did the resources you used differ in the organization and Before passage of the Food, Drug, and Cosmetic Act, depth of information provided about drugs? BOX 1–1 CATEGORIES OF CONTROLLED SUBSTANCES Schedule I drogens and anabolic steroids, some CNS stimulants (eg, benzphet- Drugs that are not approved for medical use and have high abuse amine), and mixtures containing small amounts of controlled sub- potentials: heroin, lysergic acid diethylamide (LSD), peyote, stances (eg, codeine, barbiturates not listed in other schedules). Schedule IV Schedule II Drugs with some potential for abuse: benzodiazepines (eg, diazepam, Drugs that are used medically and have high abuse potentials: lorazepam, temazepam), other sedative-hypnotics (eg, phenobarbi- opioid analgesics (eg, codeine, hydromorphone, methadone, tal, chloral hydrate), and some prescription appetite suppressants meperidine, morphine, oxycodone, oxymorphone), central nervous (eg, mazindol, phentermine). Included are antidiarrheal drugs, but abuse may lead to psychological or physical dependence: an- such as diphenoxylate and atropine (Lomotil). One such effort involves contracts with some been extensively tested before being marketed for general commercial companies that provide access to databases use. Testing containing information on the actual use of prescription usually proceeds if there is evidence of safety and effective- drugs in adults and children. Examples of information in- ness but may be stopped at any time for inadequate effec- clude how long nonhospitalized patients stay on prescribed tiveness or excessive toxicity. Many potential drugs are medications, which combinations of medications are being discarded and never marketed; some drugs are marketed but prescribed to patients, and the use of prescription drugs in later withdrawn, usually because of adverse effects that be- hospitalized children. Individual patients are not identified come evident only when the drug is used in a large, diverse in these databases. Food and Drug Administration Approval Testing and Clinical Trials the FDA approves many new drugs annually. In 1992, pro- the testing process begins with animal studies to determine cedures were changed to accelerate the approval process, es- potential uses and effects. The next step involves FDA re- pecially for drugs used to treat acquired immunodeficiency view of the data obtained in the animal studies. Since then, new drugs are categorized according to undergoes clinical trials in humans. Most clinical trials use a their review priority and therapeutic potential. Most newly approved drugs are 1S pre- In Phase I, a few doses are given to a few healthy volun- scription drugs. In Phase II, ing the transfer of drugs from prescription to OTC status, and a few doses are given to a few subjects with the disease or may require additional clinical trials to determine safety and symptom for which the drug is being studied, and responses effectiveness of OTC use. Numerous drugs have been trans- are compared with those of healthy subjects. In Phase III, ferred from prescription to OTC status in recent years and the the drug is given to a larger and more representative group trend is likely to continue. In double-blind, placebo-controlled designs, for use may be different, and recommended doses are usually half the subjects receive the new drug and half receive a lower for the OTC formulation. For example, for OTC ibupro- placebo, with neither subjects nor researchers knowing who fen, which is available under its generic and several trade receives which formulation. In crossover studies, subjects names (eg, Advil) in 200-mg tablets and used for pain, fever, serve as their own controls; each subject receives the ex- and dysmenorrhea, the recommended dose is usually 200 to perimental drug during half the study and a placebo during 400 mg three or four times daily. Other research methods include control stud- Motrin is the common trade name and dosage may be 400, 600, ies, in which some clients receive a known drug rather than or 800 mg three or four times daily. Phase III studies help evaluation of evidence that the consumer can use the drug to determine whether the potential benefits of the drug out- safely, using information on the product label, and shifts pri- weigh the risks. With OTC drugs, the may become evident during the postmarketing phase as the client must make these decisions, with or without consulta- drug is more widely used. Questions to be answered in- in recent years, partly or mainly because of the increased post- clude the following: marketing surveillance. Can consumers accurately self-diagnose the condition to streamline the approval process have allowed unsafe drugs for which a drug is indicated?

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The effect of de-efferentation on the responses to stretch and shortening of a primary ending in the relaxed peroneus longus muscle discount 20mg tadora with mastercard erectile dysfunction causes premature ejaculation. De-efferentation was achieved by complete nerve block with lignocaine proximal to recording site (horizontal double-headed dashed line in (a)) purchase tadora 20mg visa erectile dysfunction after age 50. Responses of the ending are identical before (b ) and during (c ) the nerve block tadora 20 mg without a prescription impotence may be caused from quizlet. How- (PSTH in the second trace) generic 20 mg tadora with visa erectile dysfunction medication covered by insurance, but produced no EMG ever, when subjects were performing an appropriate in the silent tibialis anterior. The stimuli produced a task (active standing), muscle spindle endings could reflexresponse insoleus (fourthtrace)anda forward be activated by the same volleys without producing body sway (fifth and six traces) but this would have EMG activity. The tibialis anterior spindle ending in unloadedthespindleending,andcannotexplainthe Fig. Findings such as this suggest that subject was standing without support and with eyes fusimotor reflexes are task-dependent, only active closed, and was therefore activated by steady pres- when subjects are performing an appropriate motor sure applied to the tendon. A train of five non-painful stimuli to the the moment-to-moment control of movement (see ipsilateral sural nerve activated the spindle ending p. Poststimulus increase in discharge of a muscle spindle ending in tibialis anterior after non-painful trains of stimuli to the sural nerve during unsupported standing with eyes shut. Recording with a microelectrode in the common peroneal nerve (CPN) from a TA muscle spindle ending. Traces are, from above, CUSUM of the PSTH with the onset of the increase in discharge indicated by the arrow at the 84 ms latency; PSTH of spindle discharge; stimulus-triggered averages of rectified surface EMG of TA, of rectified surface EMG of soleus, of force and of ankle-joint angle. It is likely that, in the upper limb, such reflexes may be In these muscles cutaneous afferents can change active even at rest. More importantly, the decreased the muscle spindle response to tendon percussion, response to percussion of two spindle endings though this has been demonstrated for only four suggests that there must have been some back- afferents – for two, the discharge increased and ground fusimotor drive to the resting muscles, in 130 Muscle spindles and fusimotor drive this case d activity. Contrary to the hypothesis that, Relaxed muscles because of temporal and spatial facilitation, natural Primary endings cutaneous volleys would have more powerful effects on motoneurones than artificially synchronised the dominant input produced by vibration of a ten- electrically evoked volleys, natural activity of cuta- don will be from primary spindle endings in the neousafferentsevokedbyskinstrokingortapsfailed vibrated muscle. The majority of human primary to affect spindle discharge in these studies. However, the discharge is often at subhar- monics of the vibration frequency, particularly if the Motor cortex stimulation using single transcranial amplitude of tendon vibration is kept small in order magnetic or electrical stimuli can alter the discharge to make it as selective as possible. A frequency of of muscle spindle endings, presumably through ∼80 Hz seems the optimal frequency for most effects on and probably motoneurones (Roth- vibration-induced perceptual and motor effects (see well, Gandevia & Burke, 1990). However, it does not Roll & Vedel, 1982;Roll, Vedel & Ribot, 1989), do so at a lower threshold than that required to pro- whether the vibration is applied using an eccentri- duce the MEP, and these findings suggest that an cally weighted motor or as high-frequency tendon effective discharge cannot be generated by cor- taps (using, e. Again, this depends on Muscle vibration has been employed extensively in the amplitude of vibration (Roll & Vedel, 1982;Roll, humansubjectstoproducereflexeffectsortodistort Vedel & Ribot, 1989). It has been used to pro- it should be possible to avoid activating secondary duce reflex contractions (the tonic vibration reflex, endings, but the lower the amplitude the less secure TVR), to suppress the H reflex or tendon jerk, and to the driving of primary endings. For these reasons the specificity of vibration for primary spin- Tendon organs dle endings needs to be addressed. There are many fallacious or over-interpreted reports in the litera- Some tendon organs can respond to tendon vibra- turebasedontheassumptionthattransversetendon tion in relaxed muscles and many do so during vol- vibration in intact human subjects can be a selec- untary contractions. Indeed, all three tendon organs tive stimulus for primary spindle endings, driving in the study of Burke et al. That all did so may be the result of a sam- intact subject, vibration is commonly not selective pling bias of microneurography towards stretch- for muscle spindle receptors and, in intact human responsive receptors (see p. Further studies subjects, it may not excite only the primary spindle isolating Ib afferents during a voluntary contrac- ending. Nevertheless, response of the primary ending switches off during the data in Figs. Responses during voluntary Cutaneous mechanoreceptors movements will not be accurately predictable, par- Most cutaneous mechanoreceptors respond to ticularlyifthevibratorisnotservo-controlledsothat vibration. Ribot-Ciscar, Vedel & Roll, 1989), and there is a constant force of application to the mov- it is probable that Ruffini endings in joints do so as ing tendon (Cordo et al. Motor tasks and physiological Contracting muscles implications In contractingmuscles,fusimotordrivecanenhance the spindle response to vibration (Burke et al. First, the application of the vibra- Remote contractions may be of limited functional tor to the tendon is not exactly the same as in the significance, but the mechanisms responsible for relaxed state, secondly, the spread of the vibration the widespread reflex enhancement accompanying wave to the muscle belly is altered when the mus- such contractions have long been a matter of dis- cle contracts and the tendon stiffens, and thirdly, the pute, and the manoeuvre is important in the clin- contraction may not be associated with a sufficient ical examination. It was previously thought that per- increase in drive to offset these effects. Indeed, if formance of the Jendrassik manoeuvre potentiated thecontractionisareflexcontractiontothevibration tendonjerksinuninvolvednon-contractingmuscles (tonic vibration reflex, TVR), unloading is the rule, in duetowidespreadactivationofdynamic motoneu- human subjects (Burke et al. Similarly, the reflex potentiation accompany- (Clark, Matthews & Muir, 1981). These problems are ing other alerting stimuli, such as a warning cue, has even greater if overt movement occurs at the joint, been attributed to the same mechanism. However, because movement can displace the vibrator and attractive as it may be, this hypothesis is seriously because the responses of different endings are not flawed for a number of reasons. For (i) It is based on the belief that the H reflex is not example, the response of primary endings is maxi- potentiated to the same extent by the reinforcement malduringthestretchingphaseofpassiveoscillating manoeuvre. The effects of alternating passive movements on the spindle response to vibration. The response increases more gradually through subharmonics during the stretching phase to 1:2. With shortening, the response gradually decreases again through subharmonics. If a mechanism was responsible Increased spindle discharge for the reflex reinforcement, one would expect the during contraction effects on spindle activity to be large, not small, not restricted to a few afferents, and one would expect Evidence for activation of γ motoneurones all studies to have no difficulty demonstrating this When movement is prevented so that contractions same finding. Panel (b ) plots the size sure block experiments suggest that this increase in of the muscle afferent volley from soleus against the spindle discharge is mediated, at least in part, by the intensity of tendon percussion. The round symbols activation of motoneurones (Burke, Hagbarth & represent data when the subject was at rest and the Skuse,1979). Theunloadingreflexprovidesevidence triangles when the subject performed the Jendrassik that muscle afferent feedback (presumably mainly manoeuvre. There is no difference in the relation- of spindle origin) contributes to the maintenance ships. However, the manoeuvres were effective re- of motor firing during a tonic isometric contrac- inforcing manoeuvres because a tendon jerk tion. When a muscle is pulling against a fixed resis- occurred (filled symbols) with weaker percussion tancethatsuddenlygivesway,asilentperiodappears and a lesser afferent volley. Panel (c ) plots, for the in the EMG of the contracting muscle at a latency same data, the size of the reflex response against the appropriate for the withdrawal of Ia afferent support intensity of the afferent volley. Jendrassikmanoeuvre(triangles),thereflexresponse Thus, overall the fusimotor-driven inflow from pri- was obtained at lower threshold than at rest (circles) maryandsecondaryendingsduringavoluntarycon- and was larger for any given size of afferent volley. Decreased presynaptic inhibition of Ia terminals has been suggested (Zehr & Stein, 1999), but, if any- Spindle acceleration after the onset of EMG thing,presynapticinhibitionofIaterminalstosoleus motoneurones is slightly increased at the onset of With brisk phasic contractions, the increase in spin- abrisk ECR contraction (Meunier & Morin, 1989; dle discharge follows the appearance of EMG in the Chapter8,p.

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Worse, some research indicates that sugar substitutes create the same surge in insulin, the fat storage hormone, as the real thing. It become abundantly clear to me as we spoke that she was consuming too much fruit. In the maintenance chapter (Chapter 7), you will learn which fruits can be reintroduced into your diet. Instead, all your protein will be lean: skinless chicken breast, egg whites, fresh roasted turkey breast, turkey bacon, wild salmon, fresh tuna, halibut, and striped bass, to name a few. These foods are not regulated by the FDA, and many of them con- tain more carbs than you bargain for. Nuts are good and satisfying, and the Ultimate Body Plan prescribes 7 to 10 raw almonds a day. Not only will you be getting a great supply of fiber (which will help keep you regular), but almonds have a higher concentration of vitamin E than any other food. You can also use up to a teaspoon of olive oil a day, as a dressing for your salad. For these two weeks, you will stay away from additional unsaturated fats such as avocados, olives, peanut butter, and egg yolks. Although all these foods are healthy, they all contain high amounts of calories. In addition to staying away from the banned foods I have named, you also will be making your own meals for the next two weeks. That means brown- bagging it to work, cooking dinner, and making breakfast. Cooking your own food is the surest way to guarantee that your food complies with your nutri- tion plan. If you must eat out, be mindful of how and why you are eating, and you will be able to eat out intelligently and safely. Finally, I recommend you give up any flavored beverage, including diet soda, and switch to water. THE ULTIMATE BODY NUTRITION PLAN 121 TLFeBOOK Make sure to drink one or two glasses before each meal. As much as I know that you love that morning jolt, it may be doing some not so beneficial things to your body. The caffeine in coffee raises the cortisol levels in your blood, causing your insulin to rise and your blood sugar to spike. Green tea contains enough caffeine to wake you up, but not so much that it spikes cortisol lev- els. It also delivers a healthy dose of anticarcinogenic polyphenols, which, science shows, boost metabolism. A TYPICAL DAY OF ULTIMATE EATING So now you know what you are not going to eat during the next few weeks. On the Ultimate New York Body Plan, you will eat every three hours, ideally at 7 A. This will prevent you from getting too hungry, thus preventing cravings and bingeing, and will keep your metabolic furnace burning. This will help you to stick with the Ultimate New 122 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK York Body Plan for the rest of the day. In a study of 37 obese children, those who ate low-glycemic foods for breakfast—such as high protein meals—con- sumed fewer calories during the rest of the day, compared to children who ate high-glycemic foods for breakfast. Although you may be used to start- ing the day with carbs, possibly in the form of a doughnut or, maybe slightly better, in the form of cold breakfast cereal, the sounder choice is nutritious protein. Whereas you probably feel hun- gry an hour or so after eating a breakfast high in carbohydrate, this high-pro- tein breakfast will keep you satisfied for most of the morning. It will also turn up your metabolic rate because your body burns more calories to digest pro- tein than it does to digest carbohydrates. To keep your metabolism humming along, your body needs regular doses of calories, about every three hours. After sleeping for eight hours, you need to get your metabolism moving, and the only way to do that is to eat. When you deny your body the breakfast that it needs, you start the day with a slower than normal metabolism. Your body senses that a famine is approaching, and it turns down your metabolic rate in order to conserve calories and fat. Also, skipping breakfast allows your blood sugar to plummet, which increases hunger and cravings throughout the day. Nutritionists have long known that people who tend to binge at night, eating the majority of their calories after 7 P. If you want to sabotage your suc- cess on this program, then go ahead and skip breakfast. To keep your metabolism on the go, you must feed it fuel about every three hours. For staying power, make this snack high in pro- tein, such as 3 ounces of canned tuna (packed in water) or a serving of my low-fat egg salad. Ingesting protein will keep your metabolic rate up and pre- vent you from feeling the crash (or low) of carb. Lunch might consist of a lean source of protein, such as 6 ounces of chicken breast or fish, along with half a plate to a full plate of your favorite vegetable such as steamed broccoli or spinach. Anything goes to make up this salad as long as you stay away from carrots (because of their high carbohydrate content). Add a source of protein to your salad, such as a piece of salmon or tuna, sliced, skinless, grilled chicken breast, or sliced hard-boiled egg whites.