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While initial studies sought to reveal if nutrient antioxidant supplements might promote health, one meta-analysis concluded that supplementation with vitamins A and E and beta-carotene did not convey any benefits and may in fact increase risk of death. Another cultural phenomenon in the Soviet Union linked with the Gulag was the forced migration of many artists and other people of culture to Siberia. Where rates are severe, early action is critical see Table We DO need fat in our diet. Deficiencies of folates or folic acid , vitamin B 12 and protein may also cause anaemia. Dehydration and over-hydration - too little and too much water, respectively - can have harmful consequences.

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However, research now indicates that iron deficiency has very important implications, including poorer learning ability and behavioural abnormalities in children, lower ability to work hard and poor appetite and growth. To maintain good iron nutritional status each individual needs to have an adequate quantity of iron in the diet. The iron has to be in a form that permits a sufficient amount of it to be absorbed from the intestines. The absorption of iron may be enhanced or inhibited by other dietary substances.

Human beings have the ability both to store and to conserve iron, and it must also be transported properly within the body. The average male adult has 4 to 5 g of iron in his body, most of it in haemoglobin, a little in myoglobin and in enzymes and around 1 g in storage iron, mainly ferritin in the cells, especially in the liver and bone marrow. Losses of iron from the body must not deplete the supply to less than that needed for manufacture of new red blood cells.

To produce new cells the body needs adequate quantities and quality of protein, minerals and vitamins in the diet. Protein is needed both for the framework of the red blood cells and for the manufacture of the haemoglobin to go with it.

Iron is essential for the manufacture of haemoglobin, and if a sufficient amount is not available, the cells produced will be smaller and each cell will contain less haemoglobin than normal.

Copper and cobalt are other minerals necessary in small amounts. Folates and vitamin B 12 are also necessary for the normal manufacture of red blood cells.

If either is deficient, large abnormal red blood cells without adequate haemoglobin are produced. Ascorbic acid vitamin C also has a role in blood formation.

Providing vitamin A during pregnancy has been shown to improve haemoglobin levels. Of the dietary deficiency causes of nutritional anaemias, iron deficiency is clearly by far the most important. Good dietary sources of iron include foods of animal origin such as liver, red meat and blood products, all containing haem iron, and vegetable sources such as some pulses, dark green leafy vegetables and millet, all containing non-haem iron.

However, the total quantity of iron in the diet is not the only factor that influences the likelihood of developing anaemia. The type of iron in the diet, the individual's requirements for iron, iron losses and other factors often are the determining factors. Iron absorption is influenced by many factors. In general, humans absorb only about 10 percent of the iron in the food they consume.

The adult male loses only about 0. On an average monthly basis, the adult pre-menopausal woman loses about twice as much iron as a man. Similarly, iron is lost during childbirth and lactation. Additional dietary iron is needed by pregnant women and growing children.

The availability of iron in foods varies greatly. In general, haem iron from foods of animal origin meat, poultry and fish is well absorbed, but the non-haem iron in vegetable products, including cereals such as wheat, maize and rice, is poorly absorbed.

These differences may be modified when a mixture of foods is consumed. It is well known that phytates and phosphates, which are present in cereal grains, inhibit iron absorption. On the other hand, protein and ascorbic acid vitamin C enhance iron absorption. Recent research has shown that ascorbic acid mixed with table salt and added to cereals increases the absorption of intrinsic iron in the cereals two- to fourfold.

The consumption of vitamin C-rich foods such as fresh fruits and vegetables with a meal may therefore promote iron absorption. Egg yolk impairs the absorption of iron, even though eggs are one of the better sources of dietary iron. Tea consumed with a meal may reduce the iron absorbed from the meal.

The normal child at birth has a high haemoglobin level usually at least 18 g per ml , but during the first few weeks many cells are haemolysed. The iron liberated is not lost but is stored in the body, especially in the liver and spleen. As milk is a poor source of iron, this reserve store is used during the early months of life to help increase the volume of blood, which is necessary as the baby grows.

Premature infants have fewer red blood cells at birth than full-term infants, so they are much more prone to anaemia. In addition, iron deficiency in the mother may affect the infant's vital iron store and render the infant more vulnerable to anaemia.

A baby's store of iron plus the small quantity of iron supplied in breastmilk suffice for perhaps six months, but then other iron-containing foods are needed in the diet. Although it is desirable that breastfeeding should continue well beyond six months, it is also necessary that other foods containing iron be introduced into the diet at this time.

Although most solid diets, both for children and adults, provide the recommended allowances for iron, the iron may be poorly absorbed. Many people have increased needs because of blood loss from hookworm or bilharzia infections, menstruation, childbirth or wounds. Women have increased needs during pregnancy, when iron is needed for the foetus, and during lactation, for the iron in breastmilk.

It is stressed that iron from vegetable products, including cereal grains, is less well absorbed than that from most animal products. Anaemia is common in premature infants; in young children over six months of age on a purely milk diet; in persons infected with certain parasites; and in those who get only marginal quantities of iron, mainly from vegetable foods.

It is more common in women, especially pregnant and lactating women, than in men. In most of the world, both North and South, the greatest attention to iron deficiency anaemia is directed at women during pregnancy, when they have increased needs for iron and often become anaemic.

Pregnant women form the one group of the healthy population who are advised to take a medicinal dietary supplement, usually iron and folic acid. Pregnant and lactating women are a group at especially high risk of developing anaemia. It is only in recent years that the prevalence and importance of iron deficiency apart from anaemia has been widely discussed.

Clearly, however, if the causes of iron deficiency are not removed, corrected or alleviated then the deficiency will lead to anaemia, and gradually the anaemia will become more serious. Increasing evidence suggests that iron deficiency as manifested by low body iron stores, even in the absence of overt anaemia, is associated with poorer learning and decreased cognitive development.

International agencies now claim that iron deficiency anaemia is the most common nutritional disorder in the world, affecting over 1 million people. In females of child-bearing age in poor countries prevalence rates range from 64 percent in South Asia to 23 percent in South America, with an overall mean of 42 percent Table Prevalence rates are usually considerably higher in pregnant women, with an overall mean of 51 percent. Thus half the pregnant women in these regions, whose inhabitants represent 75 percent of the world's population, have anaemia.

Unlike reported figures for PEM and vitamin A deficiency, which are declining, estimates suggest that anaemia prevalence rates are increasing. In most of the developing regions, and particularly among persons with anaemia or at risk of iron deficiency, much of the iron consumed is non-haem iron from staple foods rice, wheat, maize, root crops or tubers.

In many countries the proportion of dietary iron coming from legumes and vegetables has declined, and rather small quantities of meat, fish and other good sources of haem iron are consumed. In some of the regions with the highest prevalence of anaemia the poor are not improving their dietary intake of iron, and in some areas the per caput supply of dietary iron may even be decreasing year by year. In many parts of the world where iron deficiency anaemia is prevalent it is due as much to iron losses as to poor iron intakes.

Whenever blood is lost from the body, iron is also lost. Thus iron is lost in menstruation and childbirth and also when pathological conditions are present such as bleeding peptic ulcers, wounds and a variety of abnormalities involving blood loss from the intestinal or urinary tract, the skin or various mucous membrane surfaces.

Undoubtedly one of the most prevalent and important causes of blood loss is hookworms, which can be present in very large numbers. The worms suck blood and also damage the intestinal wall, causing blood leakage. Some million people in the world are infested with hookworms. Other intestinal parasites such as Trichuris trichiura may also contribute to anaemia. Schistosomes or bilharzias, which are of several kinds, also cause blood loss either into the genito-urinary tract in the case of Schistosoma haematobium or into the gut.

Malaria, another very important parasitic infection, causes destruction of red blood cells that are parasitized, which can lead to what is termed haemolytic anaemia rather than to iron deficiency anaemia. In programmes to reduce anaemia actions may be needed to control parasitic infections and to reduce blood loss resulting from disease as well as to improve dietary intakes of iron. Anaemia resulting from folate deficiency is less prevalent than that from iron deficiency or iron loss.

It occurs when folate intakes are low and when red cells are haemolysed or destroyed in conditions like malaria. The anaemia of both folate and vitamin B 12 is macrocytic, with larger than normal red blood cells. Folic acid or folates are present in many foods including foods of animal origin e. Iiver and fish and of vegetable origin e. Vitamin B 12 is present only in foods of animal origin.

In most countries vitamin B 12 deficiency is uncommon. Haemoglobin in the red blood cells is necessary to carry oxygen, and many of the symptoms and signs of anaemia result from the reduced capacity of the blood to transport oxygen. The symptoms and signs are: These symptoms and signs are not confined to iron deficiency anaemia but are similar in most forms of anaemia. Most occur also in some other illnesses and thus are not specific to anaemia. Because none of the symptoms seem severe, dramatic or life threatening, at least in the early stages of anaemia, the disorder tends to be neglected.

An experienced health worker can sometimes make a preliminary diagnosis by examining the tongue, the conjunctiva of the lower eyelid and the nailbed, which may all appear paler than normal in anaemia.

The examiner can compare the redness or pinkness below the nail of the patient with the colour beneath his or her own nails. Enlargement of the heart may result and can be detected in advanced severe anaemia. Oedema usually occurs first in the feet and at the ankles.

There may also be an increased pulse rate or tachycardia. Occasionally the nails become relatively concave rather than convex and become brittle. This condition is termed koilonychia. Anaemia is also reported to lead both to abnormalities of the mouth such as glossitis and to pica abnormal consumption of earth, clay or other substances.

What is surprising is that many persons with very low haemoglobin levels, especially women in developing countries, appear to function normally.

With chronic anaemia they have adapted to low haemoglobin levels. They may indeed do reduced work, have fatigue and walk more slowly, but they still give the appearance of performing their normal duties even though severely anaemic. Severe anaemia can progress to heart failure and death. Anaemia, as well as producing the symptoms and signs discussed above, also leads to a reduced ability to do heavy work for long periods; to slower learning and more difficulty in concentration by children in school or elsewhere; and to poorer psychological development.

A very important aspect of anaemia in women is that it markedly increases the risk of death of the mother during or after childbirth. The woman may bleed severely, and she has low haemoglobin reserves.

There is also an increased risk for her infant. The diagnosis of anaemia requires a laboratory test.

In this respect it differs from the serious manifestations of PEM, vitamin A deficiency and IDD; kwashiorkor, nutritional marasmus, advanced xerophthalmia, goitre and cretinism can all be diagnosed with some degree of certainty by skilled clinical observation.

Consequently, whereas few district hospitals and practically no health centres have laboratories set up to test, for example, levels of serum vitamin A or urinary iodine, most are able to do haemoglobin or haematocrit determinations. These tests require quite cheap apparatus and can be performed by a trained technician, nurse or other health worker. Determinations of haemoglobin or haematocrit levels are the most widely used in the diagnosis of anaemia. It is now realized that although these tests provide information on the absence, presence or severity of anaemia, they do not provide information on the iron stores of the individual.

In terms of nutritional assessment to guide nutrition planning and interventions, or for research, it may be important to know more about the iron status of an individual than can be gained from haemoglobin and haematocrit determinations. Many methods are used to measure haemoglobin levels. These range from simple colorimetric tests to more advanced tests which require a proper laboratory. Some new portable colorimeters can be used in the field; they are simple to use and provide reasonably accurate measurements.

In the laboratory of even a moderate-sized hospital the so-called cyanmethaemoglobin method is frequently used; it is accurate and can be used to test blood collected by finger prick in the field. The different methods and their advantages are discussed in various books, of which some are included in the Bibliography.

Haematocrit level or packed cell volume PCV , i. Blood also obtained from a finger prick is placed in a capillary tube and centrifuged, usually at 3 rpm. The centrifuge can be electric run if necessary from a vehicle battery or hand operated. A thin blood film examined under the microscope can be used to judge if the red blood cells are smaller microcytic or larger macrocytic than normal normo cytic.

In iron deficiency they are microcytic and in folate or vitamin B 12 deficiency they are macrocytic. Pale cells are termed hypochromic. Cut-off points taken from the World Health Organization WHO suggestions for the diagnosis of anaemia based on haemoglobin and haematocrit determinations are given in Table Certain other laboratory tests are useful in judging iron nutritional status rather than for diagnosing anaemia or its severity. In recent years it has been increasingly recognized that iron status is important because mild or moderate iron deficiency, prior to the development of anaemia, may adversely influence human behaviour, psychological development and temperature control.

A person whose diet is low in iron or who is losing iron goes through a period when body iron stores which are mainly in the liver are gradually depleted before he or she develops anaemia as judged by low haemoglobin or haematocrit levels see Figure 7. Anaemia is the end stage after iron stores have been depleted. To monitor iron stores it is useful to determine serum ferritin levels, because they are the first to decline.

This is not a simple or cheap test to do, and few small or medium-sized hospitals in developing countries have the ability to do it, but teaching hospitals and nutrition research laboratories sometimes can.

Unfortunately serum ferritin levels are influenced by infections, which are common in developing countries. Other determinations that may be done to evaluate iron status and which are described in textbooks include free erythrocyte protoporphyrin FEP and transferrin saturation TS Figure 7.

Suggested criteria for diagnosis of anaemia using haemoglobin Hb and haematocrit PCV determinations. Changes in body iron compartments and laboratory parameters of iron status during development of iron deficiency due to a continuous negative iron balance. The treatment of anaemia depends on the cause. Iron deficiency anaemia is relatively easy and very cheap to treat.

There are many different iron preparations on the market; ferrous sulphate is among the cheapest and most effective. The recommended dose of ferrous sulphate is usually mg providing 60 mg of elemental iron twice daily between meals for adults. Iron tends to make the stools black. Because side-effects can occur, particularly involving the intestinal tract, sometimes people do not take their iron tablets regularly.

Slow-release iron capsules have become available and seem to be associated with fewer side-effects. Most capsules contain ferrous sulphate in small pellets, so the iron is slowly released. Only one capsule or dose needs to be taken each day, but the capsules cost much more than ferrous sulphate tablets. Therefore it is unlikely that slow-release preparations will replace standard ferrous sulphate tablets for use in clinics in developing countries.

New research conducted in China suggests that ferrous sulphate is as effective when given once every week as when given once a day. If further trials confirm this observation, the finding will alter both the treatment of anaemia and the efforts to prevent it using medicinal iron supplements in prenatal clinics. In Indonesia, where vitamin A deficiency is a problem, it has been shown recently that giving vitamin A as well as iron improves the haemoglobin levels of pregnant women more than iron tablets alone.

In all cases the underlying cause of the anaemia should be sought and treated if possible. Iron dextran is the injectable preparation most commonly used. Intravenous injection is preferable. The standing rule is to give a very small test dose initially and to wait for five minutes for any sign of an anaphylactic reaction. If there is no reaction, then mg can be given from a syringe over a period of five to ten minutes.

These injections may be given at intervals over a few days. Alternatively, a total dose infusion can be provided at one time.

This procedure must be employed only by doctors experienced in the technique and in calculating dosage levels. It is common during pregnancy to provide folate as well as iron, or combined with iron, as part of the treatment of or prophylaxis against anaemia.

For prevention, where anaemia is prevalent, doses of mg of iron and 5 mg of folate daily are recommended. For treatment of established anaemia, doses of mg of iron and 10 mg of folate are suggested. Successful treatment usually leads to a response in haemoglobin levels within four weeks. Persons with iron deficiency anaemia on very poor diets should be advised to consume more fresh fruits and vegetables at mealtimes.

These foods contain vitamin C, which enhances the absorption of non-haem iron in cereals, root crops and legumes. They also contain folic acid and an array of other vitamins and minerals. If it is feasible and in line with the anaemic patient's budget and culinary habits, he or she could also be advised to consume, even in small quantities, more foods rich in haem iron such as meat, especially liver or kidney.

Creating awareness of the nutritional needs of different family members and helping household decision-makers to understand how these needs can best be met from available resources are important steps in preventing iron deficiency. Iodine deficiency is responsible not only for very widespread endemic goitre and cretinism, but also for retarded physical growth and intellectual development and a variety of other conditions.

These conditions together are now termed iodine deficiency disorders IDD. They are particularly important because: In fact, as H. Labouisse wrote in when he was Executive Director of the United Nations Children's Fund UNICEF , "Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for this reason" quoted in Hetzel, Nonetheless this crime persists. Endemic goitre and severe cretinism are the exposed part of the IDD iceberg.

These are abnormalities that are visible to the populations where they are prevalent, and they can be diagnosed relatively easily by health professionals without the use of laboratory or other tests. The submerged and larger part of the iceberg includes smaller, less visible enlargements of the thyroid gland and an array of other abnormalities. In many areas of Latin America, Asia and Africa iodine deficiency is a cause of mental retardation and of children's failure to develop psychologically to their full potential.

It is also associated with higher rates of foetus loss including spontaneous abortions and stillbirths , deaf-mutism, certain birth defects and neurological abnormalities. For several decades the main measure used to control IDD has been the iodization of salt, and when properly conducted and monitored it has proved extremely effective in many countries. It is also relatively cheap. Several international meetings, including the International Conference on Nutrition held in Rome in , called for the virtual elimination of IDD by the year This goal is achievable, provided the effort receives international support and real national commitment in each of the many countries where the disorders remain prevalent.

The most important cause of endemic goitre and cretinism is dietary deficiency of iodine. The amount of iodine present in the soil varies from place to place and this influences the quantity of iodine present in the foods grown in different places and in the water. Iodine is leached out of the soil and flows into streams and rivers which often end in the ocean. Many areas where endemic goitre is or has been highly prevalent are plateau or mountain areas or inland plains far from the sea.

A less important cause of IDD is the consumption of certain foods which are said to be goitrogenic or to contain goitrogens. Goitrogens are "antinutrients" which adversely influence proper absorption and utilization of iodine or exhibit antithyroid activity. Foods from the genus Brassica such as cabbage, kale and rape and mustard seeds contain goitrogens, as do certain root crops such as cassava and turnips.

Unlike goitrogenic vegetables, cassava is a staple food in some areas, and in certain parts of Africa, for example Zaire, cassava consumption has been implicated as an important cause of goitre. Areas of the world where iodine deficiency is prevalent.

Any enlargement of the thyroid gland is called a goitre. The thyroid is an endocrine gland centrally situated in the lower front part of the neck. It consists of two lobes joined by an isthmus. In an adult each lobe of the normal thyroid gland is about the size of a large kidney bean. In areas of the world or communities where only sporadic goitre occurs or where health workers see only an occasional patient with an enlarged thyroid gland, the cause is not likely to be related to the individual's diet.

Sporadic goitre may for example be due to a thyroid tumour or thyroid cancer. However, if goitre is common or endemic in a community or district, then the cause is usually nutritional. Endemic goitre is almost certainly caused by iodine deficiency, and where goitre is endemic other iodine deficiency disorders can also be expected to be prevalent. Where goitre is endemic, often large numbers of people have an enlargement of the thyroid gland, and some have enormous unsightly swellings of the neck.

The condition is usually somewhat more prevalent in females, especially at puberty and during pregnancy, than in males. The enlarged gland may be smooth colloid goitre or lumpy adenomatous or nodular goitre. The iodine content of foods varies widely, but the amount of iodine present in common staple foods such as cereals or root crops depends more on the iodine content of the soil where the crop is grown than on the food itself.

Because the amount of iodine in foods such as rice, maize, wheat or legumes depends on where they are grown, food composition tables cannot provide good figures for their iodine content. Foods from the ocean, including shellfish, fish and plant products such as seaweed, are generally rich in iodine. In many populations, particularly in the industrialized countries of the North and among affluent groups almost everywhere, diets do not depend mainly on locally grown foods.

As a result many of the foods purchased and consumed may contribute substantially to iodine intakes. For example, persons living in the Rocky Mountains of North America, where goitre used to be endemic, now do not rely much on locally produced foods; they may consume bread made from wheat grown in the North American central plains, rice from Thailand, vegetables from Mexico or California, seafood from the Atlantic coast and so on.

Similarly, affluent segments of society in La Paz, Bolivia consume many foods not grown in the altiplano, and these imported foods will have adequate quantities of iodine. In contrast, the poor in the Bolivian highlands eat mainly locally grown foods and do develop goitre. Many countries of Asia, Africa and Latin America have major iodine deficiency problems, although some countries have made great progress in reducing the prevalence of IDD.

China and India, with their vast populations, still have a high prevalence of IDD. In the Americas, endemic goitre has been largely controlled in the United States and Canada, but many Andean countries including Bolivia, Colombia, Ecuador and Peru still have relatively high endemic goitre and cretinism rates.

During a survey conducted by the author in the s in the Ukinga Highlands of Tanzania, 75 percent of the people examined had goitre. This was the highest prevalence yet reported in Africa. Prevalence rates of over 60 percent have been reported from communities in many African, Asian and Latin American countries.

Generally goitre prevalence rates of 5 to But even with rates of 10 to 15 percent the need for action is important. Where prevalence rates are moderate, urgent action is needed. Where rates are severe, early action is critical see Table Enlargement of the thyroid gland is the most frequently described and most obvious clinical manifestation of iodine deficiency.

Where there is a chronic dietary deficiency of iodine the thyroid often begins to enlarge during childhood, and it becomes more markedly enlarged around the time of puberty, particularly in girls.

In many areas where goitre is endemic the majority of people have some evidence of thyroid enlargement. The thyroid gland secretes hormones vital to metabolism and growth. The gland is made mainly of follicles called acini, minute sacs filled with colloid. Each sac manufactures thyroid hormones, stores them and secretes them into the bloodstream as needed. The main thyroid hormone is thyroxine.

The amount of thyroxine secreted is controlled by another endocrine gland, the anterior pituitary, and its hormone, called thyroid stimulating hormone TSH or thyrotrophic hormone. The function of the thyroid gland is somewhat similar to that of the thermostat of the heating system in a house. It controls the rate of metabolism and influences the Basal metabolic rate BMR , to some extent the heart rate and also growth in children.

The normal adult thyroid gland contains about 8 mg of iodine. In simple goitres the total iodine content might be only 1 or 2 mg even though the gland is larger than normal.

Thyroxine contains 64 percent iodine. A lack of dietary iodine makes it increasingly difficult for the thyroid to manufacture enough thyroxine. The gland enlarges to try to compensate and make more thyroxine. This enlargement is described by pathologists as a hyperplasia of the gland. It is triggered by increased production of TSH by the pituitary gland. Microscopic examination of a gland undergoing hyperplasia shows ingrowths or invaginations of the lining epithelium into the normal architecture of the colloid-containing acini.

There is an intense multiplication of cells, with an excess of colloid. This compensatory reaction is an attempt to trap more iodine, and it is partly successful. Many people with colloid goitres show no evidence of poor thyroid function. Investigation of goitre prevalence is one of the most important means of assessing whether there is an IDD problem of public health importance.

Examination of well-chosen samples of schoolchildren has often been recommended as the first step; this survey is relatively easy because schoolchildren are collected together in one place and are usually disciplined, so large numbers can be examined over a short time.

To get a full picture of the prevalence in the area, however, it is important at some stage to examine a representative sample of community members of all ages and both sexes. The thyroid gland of each person should be examined both visually and by palpation to judge its size. Visual examination informs the examiner whether a goitre is visible with the head in normal position or with the head tilted back. Palpation is usually done with the examiner sitting or standing facing the person being examined; the examiner's eyes should be level with the person's neck.

By placing and rolling the thumbs on either side of the trachea below the Adam's apple or voice box, the examiner can feel the gland and judge its size. A normal thyroid gland is considerably smaller than the last joint terminal phalanx of the thumb. In fact a normal thyroid lobe is perhaps one-fifth that size. If each lobe is larger than this joint, then there is a goitre. Palpation from behind is recommended by some because the fingertips are then used to determine gland size, and they are more sensitive than the tips of the thumbs.

It is useful to classify the goitre size using an accepted classification system. Use of the system assures reasonable comparisons by different observers and in different regions. The main use of grading goitres is for survey purposes and to allow comparisons of goitre prevalence rates between areas. It is not possible to be completely objective, and there will seldom be complete agreement between two examiners, but there will be a reasonable measure of agreement.

Persons with goitre are more likely than others to have manifestations of poor thyroid function, especially hypothyroidism. A large goitre, and especially one that enlarges behind the upper part of the sternum, may cause pressure on the trachea and oesophagus, which may interfere with breathing, cause an irritative cough or voice changes and occasionally affect swallowing. A mass in the neck that is consistent with an enlarged thyroid that is palpable but not visible when the neck is in normal position.

It moves upwards in the neck as the subject swallows. Nodular alteration s can occur even when the thyroid is not visibly enlarged. A swelling in the neck that is visible when the neck is in normal position and is consistent with an enlarged thyroid when the neck is palpated.

Moderate and large goitres also create an undesirable appearance and possibly difficulty with wearing certain clothes.

It has been reported that in some areas where endemic goitre is highly prevalent, goitres may be accepted as the normal condition or as a sign of beauty and people without a goitre may be considered abnormal. However, in the Ukinga Highlands of Tanzania, where prevalence was over 70 percent, the author found that the people were not pleased to have large neck swellings.

Many people had symmetrical small scars in the skin covering the goitre, which was clear evidence that they had sought local medical treatment; in East Africa treatment frequently consists of cuts and scarification of the offending area, sometimes with herbal medicines rubbed into the cuts.

Clearly these people hoped their goitres would disappear. If for any reason too little thyroid hormone is produced, the BMR goes down and a condition called hypothyroidism develops, which may lead to the clinical condition called myxoedema.

In the adult this condition is characterized by coarsened features, dry skin and sometimes puffiness of the face. The person is often somewhat overweight, has a slow pulse and feels sluggish. Testing would reveal a low BMR and low levels of thyroid hormones in the blood. In contrast, an overactive thyroid gland producing more thyroid hormone than necessary produces a condition known as hyperthyroidism or Graves' disease. The adult with this condition tends to be thin and asthenic, to be nervous and to have a rapid pulse rate, particularly during sleep.

Tests reveal high thyroid hormone levels and high BMR. As stated above, persons with endemic goitre often have good compensation and do not have evidence of either hypothyroidism or hyperthyroidism. They are said to be euthyroid, which means that they have normal thyroid function despite thyroid enlargement. However, in endemic areas rates of hypothyroidism are elevated.

In many cases the hypothyroidism is mild and not as obvious as classical myxoedema, but thyroid hormone levels are low, and low BMR, lower productivity and slower mental functioning may be chronic. It is hypothyroidism in children, however, that is of most concern for developing countries, because of the strong evidence that it causes both mental retardation and slowing of physical growth.

Mental retardation ranges from very severe, which is easy to recognize, to mild, which may be difficult to diagnose. In areas with a high prevalence of IDD large numbers of children may fail to reach their intellectual potential because of impaired school performance and lower IQ than in matched groups from areas without iodine deficiency.

These children may later, as adults, fail to make as great a contribution to society and to national development as they would have made if they and their mothers had always consumed adequate amounts of iodine.

Endemic cretinism, including deaf-mutism and mental retardation, begins in infancy. Iodine deficiency in a woman during pregnancy can lead to the birth of a cretinous child. The infant may appear normal at birth but is slow to grow and to develop, small in size, mentally dull, slow to learn and retarded in reaching normal development milestones.

Many of these children are deaf mutes. As the child gets older he or she may have the typical appearance of a cretin, which includes a thick skin, coarse features, a depressed nose, a large protruding tongue and frequently strabismus the medical term for eyes that look in different directions, cross-eye or squint.

It will also hurt like hell, make you sweat buckets, scream, and toughen you mentally. All in 30 minutes a day. If you take my word for it, I say what are you waiting for? Theres a lot of crap out there that is really just Advertising disguised as review, and it took me a while to find this.

Looking forward to another update from you as you get through the program. I started today and maxed out at 7 mins… it was bloody hard!

I love how Max makes you chase the impossible. I find it hard to progress at equal pace with my maxing out time though. Some days I can push even two minutes further than before, and then there are those when I cannot match my previous threshold.

Will update the review these days around too. What programme do you recommend after completing Insanity? Insanity Asylum Vol 1 or Insanity Max 30? It all depends on what are you aiming at- if you would like to get even more ripped and add some muscle too, then go with Asylum.

Max, although being very hard, is designed mostly for weight loss. So, if you want to drop even more pounds of fat tissue, Max out: Im still deciding between T25 or insanity max: Im 21 and overweight at the moment but have done sports all my life and love to push myself sometimes too much where i need to be real and stop i wanna loose the weight fast, but im a flight attendant and im traveling all the time, i wanna know which u think will be better for traveling and taking into different places.

Should i start with T25? In max 30 its using your own body weight, its hard but great. The modifier in max 30 is a lot better as well as you can choose to split screen between shaun and the modifier.

Hey Rob how are things going so far? Any tips to share? How is your Max time- progressing fast enough? As Rob said, Focus T25 requires weights in its second month. Having said that it is very hard with regards to practical considerations. Max, though harder a lot harder, in fact takes use of the modifier and can be done even by someone who struggles with elementary fitness though I recommend it only to those who are ready to give in their best.

While others require to be fit in order to even have a chance to enter Asylum , Max can take you there in no time. Resistance bands are OK to leave behind, though I cannot say the same thing about dumbbells. Here is the thing though- there is only one video where you use the dumbbells, the strength video, and all the others are bodyweight only. Whatever you do before stepping into the asylum, make sure it is easy and gives you enough room to prepare, and moreover rest. To answer your question about dumbbells again- you will have great results nonetheless, only maybe a bit less in terms of strength and muscle mass.

I have been scanning the web for reviews and impressions and this report and reflection of Insanity Max 30 is just spot on, good job! The tips section is gold and so true. Calm and smile, exactly the right attitude for this crazy package.

The concept really is phenomenal. I use a sports tracker app to write in my max out time and make notes of the workout, it has really helped me advance and reach the next level.

Are you planning to do a retrospective on the whole thing? I really hope you will. Cheers and thanks for a great review. Finished and now taking a weekly dose of two or three workouts. Still loving the challenge. Glad to hear that you are having a great time.

And congrats for the results so far. I finished month two at the end of February. I have also gone back and sporadicly re-visited some of the P90X3 and T25 workouts and even a few of the previous seasons of Insanity. They are fine and all but I have to say they fade in comparison. I keep coming back to Max: I maxed out at I think I eat pretty well and always get hours sleep a night.

Does anyone have any suggestions how I can reduce the aches? Do I need to add in a stretch or will my muscles just ache less the more they get used to the workouts? Congrats for sticking with when it gets hard. A massage sometimes makes all the difference, so that might be a plus.

Your max out time is fantastic, so it might be that you are pushing yourself too much- always a good thing, and usually an indicator that you are going to have great results. Hey Andy For me week one was no doubt the hardest in terms of aches. Especially my thighs, had to skip one day in week 1 because of that. Thank you for both of the replies.

You were both right the aches are much less severe now although still there. Although yeah a massage is a good idea my legs especially are still sore especially after sweat and Friday Fight. I am also trying to maintain weight as much as possible I dont want to reduce my weight just tone up what I have. Hope you guys all keep having great success with it too.

I am about to start max 30 and love reading all these great reviews! I just started Max 30 this week and my daughter started on Tuesday as well. We are keeping each other accountable and motivated during the workouts. I have done Insanity in the past but always had problems with my knees and was never able to complete it. The modifiers that are available are great and really help out a lot. My goals for this are to loose about 25 pounds and gain some definition in my muscles.

I will keep you all posted how my 43 year old body holds up to the workout! The body will eventually adjust. The P90X formula, as other people say, is great, though I use whey protein only and it seems just about enough.

The modifiers are really something when compared to the Insanity workout, and they allow you to go strategically step by step. The best thing is how your body slowly starts to adjust to the challenge. Great work so far Amy, congrats! And nice finding someone you can keep each other accountable with. I really needed this while I was going through Insanity Max, and it makes a lot of a difference.

Could you please help me to decide what to do? Hi Maria, I would personally start with the first day of the program. Have in mind that losing one day is not that big of a deal as long as you intend to follow through most of the time. Besides, it can be easier for you to step into the workout with only four consecutive days of training for starters. This might be even better. I am 39 soon hitting 40 and I have decided to do this program. A friend of mine is a coach and convinced me to start working out.

I signed up and ordered the material. In the mean time I have two questions. Any advised on preparing before I get my package?

Question 2 I have convinced my girlfriend to do the program with me. Any suggestion on motivators for couples that are starting the program together? No need to prepare other than some resistance moves or light jogging here and there if you can. You can start Max even without preparation though. You will catch up in less than a week. Looking forward to the challenge! Shalom, thanks for the great review and feedback that people have posted. I have done insanity, Brazilian Buttlift, T25 and had great results.

I am now looking to do Max 30 to drop off the extra pounds that I added with our second baby who is 7 months. My question is what pre and post drinks do you recommend? How effective is it with toning loose skin? I have not ordered the program yet because I wanted to see review first. Looking forward to reading some more. To answer your question, pre and post workout drinks are not entirely necessary.

Sure, they will help with speeding up muscle recovery, and somewhat of muscle growth, but you can just as well go without them. If you consume enough protein throughout the day, then there is no need for additional supplementation.

A simple whey protein shake will suffice. Take one after the workout and it will help with muscle recovery and growth. The ideal there is weight lifting, but this type of training comes very close. I recently started using Beachbody Energy and Endurance formula about minutes before I workout.

I have definitely noticed a difference! I know my times probably would improve a little anyways but the biggest difference is in the way I feel. I do my workouts in the morning and have a hard time waking up and getting started.

This is the first supplement I have ever tried and am not disappointed! My main reason for doing insanity max 30 was so I could be rid of the belly fat I have. I finished the program half a month ago and did not lose the fat at all.

Although my stamina did increase. Can you write more about yourself- current weight, weight before the workout, describe your sleeping schedule roughly, and a thing or two about how your usual day diet plan looked like… This way I- as much as I can- will try to give any advice in some of these verticals, or objectively point where things are going wrong. Also, tell me more about the intensity with which you were doing the workouts rest time, max out time, whether or not you were paying attention to correct form….

Insanity Max 30, as well as other workouts from Beachbody, give room for taking things lightly. You are the judge of your form, intensity… and some of us want to rush it through, not paying attention to the form of the exercises my brother did the same thing, figuring, at the end of a single session, that these workouts are very easy… next time I tried watching his form only to find out that he was doing everything half the way it should be done.

If this is the case, my advice is to slow down and focus more on form than anything else. Gutting but hopefully if I modify with max I can make it 60 days before they play up…fingers crossed…and by the way wow you look amazing! I only hope I could one day have a stomach like yours. Day in and day out with Max 30 and you will see amazing results as well. One week of extra modifying and less-than-clean diet is nothing when compared to the two months you will definitely going to endure if you ease your start into it.

Hey Jodie, Great work, you will enjoy the results. Thank you for this review. It helped me alot in making the choice in buying Insanity Max: Im a martial artist and I like to push my body to its limits, and beyond.

Looking forward to getting my ass kicked again by Shaun T. Keep up the good work. Been playing around with Max for a while, it might be time to give it a full go. I choose insanity max 30 for the time, having done insanity and T I have put on weight on my stomach due to lack of trainning.

So I choose max 30 to do this. Because with Insanity my I started to see my abs after 3 weeks. Completed my 8 weeks today, and I am fitter and able to do the moves better. I found this impossible in the beginning, but I could not be beaten.

I am going back to Insanity,on Monday. When finish back to Insanity max Insanity is my all time favourite. I just started max: Eating clean and balanced is all that it takes. Take the calorie suggestion as a general guidance but nothing more. Using only the principles of healthy eating outlined in the guide, along with some recipes is really enough. You will figure it along the way that is, adding or subtracting calories. Oh, and another thing when it comes to diet.

I always try to tweak things a bit and lower or raise my calorie intake depending to how content I am with the progress I say progress cause it is not only looks, but rather energy level and performance as well. Sandra had some trouble logging in, so I posted her comment. Forgot to change the name, will ediit itt later.

Hi quick question — your MAX out time…I assume you note this, catch your breath, and then jump back in right? You write your time down, and then continue with the workout as soon as you catch your breath. From there till the end of the workout it is no holds barred- do the moves, as many of them as you can, trying not to rest.

If you must, take a few seconds to catch your breath, and go for it again. The max out time is designed to track how far can you go without taking a break, measuring from the beginning of the workout.

After that, it is on and off according to your ability. I was used to working out about 2,5 hours every morning before I started this program. So, this is an improvement actually: At the end of each workout, I write down how long this specific workout took me to complete and, next time, I try to beat that time.

Just an idea for some of you who might actually have more time to work out than only 30 minutes…. Especially since you say there is not a lot of weight for you to lose. Makes sense to move more slowly and thoroughly, and make sure you complete the complex movements the way they were meant.

This is way more important for muscle definition and growth, since you are encouraging correct form all the way- targeting the muscles way more. At the end of the day, we all prefer a certain way of working out and react differently to different methods of training. I finished month 1 of Insanity Max 30 last Friday. Sorry Slavko I forgot to mention that putting back some weight back on has discouraged me from doing month 2 of Max This sounds very illogical.

I cannot tell, honestly. How was month one? Intensity wise, nutrition, results? It is quite unusual to get some of your old weight back in only a couple of days. One intensity session with Max 30 and you will lose that again. I did Max Sweat two days ago and thought I was going to throw up in my living room…one arm burpees, people, one arm burpees!!. The results are amazing. I bought this to lose some fat, get leaner and get more muscle definition.

Insanity Max 30 is doing that and then some. Keep it up, ultimately you end up enjoying the madness more by the day: I still have to say this is the best dvd workout set I have ever done. My body has definitely changed for the good but not as much as my fitness. Just thought I would check back in with you all.

As a follow up to that I am all done now. I was definitely wrong about how much my body has changed. Before and after pics almost look like a different person. I will say it again…this workout is awesome!!! Does this give helpful nutrition advice? I am currently doing T starting beta on Monday: Would max 30 be a good choice for me? Also I still have trouble with the T workouts…. I find them hard…lol. Guess I am just not as fit as all you guys: Only 3 simple rules: NO sugar especially sweet drinks , no junk, no fat food sauces included.

There are recipes of healthy meals in internet, just do some research. Love this work out! Let the video keep running and join back in when I can? Pause and play, pause and play…? Help me out here. Note the 1max out time, catch your breath and get back into it. Next time you do the same workout be sure to have the max out time memorized it will help you to push further and beat yourself.

Diet is my real issue and one I definitely plan to resolve. Anyway my question is should I be diving in in my first week and maxing out possibly in three to five minutes or should I see how week 1 goes with the modifier and take it from there?

Hi Great review and excellent tips. I have recently completed Insanity and Insanity Max 30 has arrived today, very excited about getting started. I lost 22lbs with Insanity and looking to loose another 28 with Insanity Max. I need to really up my game with regards to nutrition to make sure I get the best results. Do you know anywhere I can get some weekly meal plan ideas to give me a helping hand with getting started with the routine.

So, let me know. How did things went for you? I hope you already know this by now though: Hi,my name is abel and am Sweat intervals, though different from these other two workouts is somehow in a similar ballpark. Tabata strength though, is entirely different. To answer your question then, it will be quite OK, though you may not have the same results in terms of strength, and muscle definition. It will also affect your result at the end in terms of weight loss as well.

Not by a huge margin, but still. Hi I have a question, i just finished insanity max 30 and i wanted to know if you have any recommandation of beachbody programm to do after that? My goal is to weight loss and define muscle. I played basketball throughout HS so i did mostly cardio. I run every morning but I need a workout plan to tell me what to do so I can follow it. I really just want to gain some visible muscle, lose weight,and gain back my cardio.

Max 30 sounds intense but I find it very interesting. Or what workout plan should I try? Max 30 is great for muscle definition, and it will get you ripped. Every bit of muscle in your body will show up. If you want more bulk though, you can simply add more intensity by resistance to your workouts less speed, more range of motion, correct form, and slower reps while paying the most attention to correct form, and tightening your muscles throughout each move.

You should also add more protein to your diet. However, Max 30 is not intended for giving you a bulky appearance, so if you want that you should maybe try Insanity Asylum Vol. I need to understand something: When you max out the first time, you simply write down the time.

Then, you continue with the workout, though only within your own limits- meaning, if you need to take a break, you take a break. As many times necessary be that 5,6,7, 20…. The goal is to take less breaks and make them shorter. You know your body best, so it is up to how you feel. However, try not to limit yourself mentally, and push harder every now and then. Tell you what- every time you need to take a break, just go ahead and see if you can do one or two repetitions more.

My son and I just finished week one of Max There are a couple of exercises I cannot do at all, even using the modified version. Would doing a similar exercise be just as effective?

Here are my concerns with Max 30 but hopefully you will be able to aleviate them. To be honest about the modifications, there is something that most are not taking in consideration. The program is designed to be done as it is- no modifications, no nothing. That is, if you want to have the optimum results. However though, many people find it extremely hard, next to impossible to follow the pace.

In the light of this, the modifiers are placed there as an alternative, and their primarily reason is to keep you into the zone, keep your muscles active preferably the same muscle groups that the original move is targeting but with lower intensity.

The only thing I can say is push yourself more every chance you get. The point of it is that once you spend enough time with the program- less modifiers or more- you will increase your strength, endurance, flexibility… Sensing this on daily basis, you will do the right modifiers where need be, or skip them altogether.

As for the water breaks, the program is simply following the intended intensity curve. When people fail to catch up, they usually quit- allow that to say something about you because you are still pushing forward congrats!

Proper form- go slower and make sure you are doing it right. It is far more important than going faster, or doing more reps. I believe that all the attention should be pointed towards listening to your own body and learning its capacity. Monitoring is, at least for me, a sort of a distraction from that. However, you can slow down a bit just when you are checking form and do an extra check on that as well.

Over time though, believe me, you will have more intuitive understanding on when is time to stop, slow down or speed up. I started to do Max Insanity 30… And I plan to do it for 8 weeks according to the workout plan… I feel great so far, but my question is: You can either repeat the program and do the modifiers more in order to step down on intensity while still keeping your shape. Or, you can do one day and rest the other. Thanks for your awesome review — you look amazing!

Anyway, when I went off of birth control last year, I found that it was harder for me to lose the extra fat around my tummy very frustrating. I eat very clean and take in about grams of protein per day — my problem? Max can definitely help you with those stubborn areas of fat, and I will even go ahead and suggest you try Asylum Vol. As for nutrition, try and slightly up your protein and see what happens.

Preferably right after workout. Same goes for healthy fats- a spoon or a half spoon of peanut butter, along with your protein intake right after workout. Add only that and see what happens. Also, try and eat more greens, tricking the body in that way. I have a lot of free time ……. You will cause your body shorts bursts of stress throughout the day- not advised for the results I think many people are hoping for. You need one session of intense and targeted stress to your muscles, and a healthy diet and long hours of rest throughout the day afterwards for the body to recuperate, and hence grow your msucle tissue while draining fat.

If you cannot manage to go through the whole workout, try the modifiers throughout. If still not- it is better to cut the workout in half, and do the stretching in full at the end and beginning.

Max out, write down your time, and then do as much as you can while taking breaks where need be. If you feel you cannot continue stop, and then do the modifiers if that helps. Take many of them if need be, and longer ones as well. Get back to it when you can get back to it be that 10 seconds or a full minute or two, but leave the video rolling.

Then, stop with the workout even if it is mid way or sooner. The day after, you will try again, and again, and again… Eventually you will get there, and see that all the while you were pushing, the results kind of took place. If you are doing Max 30 only, then it is a very good transition, and you will achieve your goals most def. Hi, thanks for your very comprehencive review.

Would you recommend that for me? Depends on how hectic your day becomes suddenly afterwards. If you are finishing your workout only to run to the shower and dresser and right out of home, then this may cause unpleasant levels of stress for the day ahead.

If not, there is nothing inherently wrong with doing your exercise in the morning, regardless of how intense it is.

As the second week comes, you will have more awareness over how to pace yourself. I want to lose only 25 pounds.. Do you recommend this to me? However depending on your fitness level you will have to chose between the two. Also, much depends on your diet and lifestyle in general you will need hours of sleep. Having said that, these workout are your best bet of achieving your goal within the shortest time frame. Hey, i start insanity max 30 2 weeks before.

Seeing how Max 30 is an intense workout program, and you only have 6 hours of sleep available, I will recommend trying another program for starters.

Maybe go with Focus T25, or P As for food, it is not entirely the main issue right now, though you must have the best diet regimen possible if you want to somehow endure Max 30 with only 6 hours of sleep and still get results, or even function throughout the day. Here, if this helps, try reading these other two reviews of mine, of two programs I feel will be more suitable for your circumstances.

I carry almost all of my weight in my thighs and butt. The more you workout with the Max 30, the leaner your body looks. You will drain fat tissue, all the while promoting muscle definition. Any extra muscle mass created, will drain even more fat from your thighs. And muscle mass, by all definition, is very lean, and occupies less space than fat tissue. Im Dayana and I came across this review. I would like to gain strenght and body muscle but without having to go to a gym, which I have before.

I love sports but I dont know what option would be best for me to build up muscle and get stronger. You will get stronger with Max 30, and there is no doubt about that. As far as muscle mass goes, you will not bulk up significantly, but only build slightly more muscle mass than what you have now, and define your body more muscle, less fat tissue.

If however, you up the protein intake slightly, and increase the intensity of the workouts, you will gain more muscle mass and get even stronger. I have 2 children an 3 yr old and a 1 yr old. I would like to lose the weight on my upper body especially the babyfat and gain some muscle on my lower body like legs and butt.

I want your opinion. Sorry for being so late with my reply. This program can help you achieve exactly what you want. Only thing is, you will have to fight very hard for it. As a beginner, and not knowing your history with fitness, I will assume that you cannot start on a fast pace initially.

This program has a modified set of moves for each workout, so can start slowly and build strength and cardio condition. And having in mind that you are having a family and kids, the fact that Max 30 is taking only 30 minutes per day, kinda makes the most suitable program for what you have described. Pardon me,does the program DVD package able to ship to international country other than in USA or Canada after i buy it from online website?

So after a few months of t25 gamma to add a little muscle and climbing a mountain I am going to start this again today. I hope I enjoy it as much as last time. I think my cardio has dropped since I stopped doing this. So hopefully after a few weeks I will be feeling super fit again like last time! Just keep pushing through the first couple of days, it gets much easier after that. I too sometimes forget how on Earth was I able to complete the program last year.

But then, few of the modifications during the first couple of days, and I quickly get back in shape to test my metal. Hello I have done insanity and lost 20 kgs in three rounds..

I am not eating clean.. Glad that you started Max If you enjoyed the results with Insanity, you will love this one. And yes, as far as being a vegan goes, you can make awesome abs as well- just need to know your way around the kitchen and pack enough protein. Anyway, the formula will tell you a rough estimate. Though you can try and balance things out all by yourself.

Belive me it is not that hard. Just start eating clean and healthy, and portion your food as much as your body needs. When hungry, attack the vegetables, no extra calories there.

Ab attack comes with the cardio workouts, and you can do it as you please. If you however go with the ab maximizer program additional kit, sold separately from Max 30 there is a schedule included and two extra ab workouts as well. For now, do the ab attack as you see fit. I am very interested in starting this program, definitely time to get back in shape! The variation training offered by P90X helps continuously change and improve the body, culminating in a lean, strong, built physique.

P90X is offered in three different packages. The difference in each package is the equipment that is included in each and, of course, also the cost. The Insanity Workout Program is considered more basic than the P90X program because there is little to no equipment necessary to complete the workouts. With P90X, there is a need for various pieces of equipment, such as a chin up bar and weights. With Insanity, however, there is nothing else needed besides a DVD player. The cost for the three different packages offered with P90X are as follows: There is only one option offered when purchasing the plan since not much more than a DVD player and workout attire are needed to complete the program.

The high cost of P90X versus Insanity can be attributed to the equipment necessary to complete each of the 12 workouts in the P90X series. When comparing the two workouts, not including the additional equipment, the cost is the same. Equipment to do the P90X workouts can be purchased through Beachbody or at your local sporting goods store. Either way, however, it is necessary and brings the cost of the P90X program far above that of Insanity.

When deciding to take on the P90X challenge, you can expect to workout virtually every day of the week with workouts lasting between 60 to 90 minutes. The seventh day will be the Stretch workout and is substantially easier than the other workouts in the series.

It is considered more of a rest day but, since you are still expected to complete the Stretch DVD, it is still considered a workout day. The workouts are intense and will require various pieces of equipment that may or may not accompany the DVDs. Some of the equipment necessary is a pull-up or chin-up bar, various resistance bands, small dumbbells and a yoga or exercise mat.

As you can see from the list above, the P90X workouts tend to focus on specific areas of the body. Instead of whole body workouts, P90X splits its workouts in order to work different parts each day of the week and usually with a different discipline.

With P90X, you will be doing yoga, martial arts, kick boxing and weigh training all in the same week. Some workouts include plenty of cardio work as opposed to strength training and others are the opposite. P90X is extremely varied and, as previously mentioned, this is intentional in order to continuously shock the body and bring about constant change.

The Insanity plan involves six days per week of workouts lasting from 30 to 60 minutes each. Each DVD features a workout that combines very high, medium and low intensity activity with high intensity segments lasting approximately three minutes each.

There are very short rest periods in between that last approximately 30 seconds. Most of the rest periods are not really rest periods at all.

They involve slower paced exercises to help you catch your breath and start the high intensity segments all over again. Insanity is based on extreme cardio workouts that include plyometrics, core exercises, and strength training with your own body weight and balance work. Most Insanity workouts are about 45 minutes to an hour long, with some lasting up to 90 minutes.

One main difference between Insanity and P90X is that Insanity workouts tend to target the entire body. When you do an Insanity workout, you will feel sore all over the next day. The P90X workouts target specific body parts each day and, by the end of the week, each body part will be worked to the extreme. The main reason behind this is that these programs are two very different types of fitness regimens. P90X is more of a strength workout and strength training requires rest days for each muscle group.

Insanity is cardio based and cardio can safely be done every day, as long as it is followed by proper stretching. The P90X Nutrition Plan is made up of three phases.

Introduction to P90X