My Healthy Living Program
Rosa Maurino 
healthyliving.pdf
i
Alters & Schi! ESSENTIAL CONCEPTS FOR
Healthy Living
EIGHTH EDITION
Je! Housman, PhD, MCHES Assistant Professor in Department of
Health & Human Performance Texas State University, San Marcos, Texas
Mary Odum, PhD, CHES Texas State University
San Marcos, Texas
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Library of Congress Cataloging-in-Publication Data
Names: Housman, Je#, author. | Odum, Mary, author. Title: Alters & Schi# essential concepts for healthy living / Je# Housman and Mary Odum. Other titles: Alters & Schi# essential concepts for healthy living | Essential concepts for healthy living Description: Eighth edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2020] | Preceded by Alters & Schi# essential concepts for healthy living / Je# Housman, Mary Odum. 7th ed. 2015. | Includes bibliographical references. Identi!ers: LCCN 2018024740 | ISBN 9781284152791 (pbk.) Subjects: | MESH: Healthy Lifestyle | Health Education | Health Behavior | Hygiene | United States | Popular Works Classi!cation: LCC RA776.5 | NLM QT 210 | DDC 613–dc23 LC record available at https://lccn.loc.gov/2018024740
6048
Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1
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Brief Contents
1 Health: !e Foundation for Life 2
2 Psychological Health 38
3 Stress and Its Management 72
4 Violence and Abuse 98
5 Reproductive Health 124
6 Romantic Relationships and Sexuality 168
7 Drug Use and Abuse 204
8 Alcohol and Tobacco 238
9 Nutrition 278
10 Body Weight and Its Management 320
11 Physical Fitness 350
12 Cardiovascular Health 388
13 Cancer 422
14 Infection, Immunity, and Noninfectious Disease 464
15 Aging, Dying, and"Death 512
16 Environmental Health 546
v
Focus on Critical Thinking xiv
Reviewers xxi
About the Authors xxii
C H A P T E R 1 Health: !e Foundation for Life 2
What Is Health? 5 Health and Wellness 6 The Components of Health 6
The Nation’s Health 8 Tracking the Nation’s Health 8 Health Promotion: Development of
Healthy People 2020 10 Minority Health Status 11
Genetics and Genomics 11
Understanding Health Behavior 13 Changing Health Behavior 13 Making Positive Health-Related
Decisions 16
The Goal of Prevention 18 Can Good Health Be Prescribed? 18
Analyzing Health Information 20 Becoming a Wary Consumer of
Health Information 20 Assessing Information on the Internet 23
Applying What You Have Learned 24
Contents
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 24
Analyzing Health-Related Information 25 Herbs as Medicines 27 CAM Therapies in Perspective 29 Choosing Conventional Medical
Practitioners 31
CHAPTER REVIEW 34
C H A P T E R 2 Psychological Health 38 The Basics of Psychological Health 40
Personality Development 41 Theories of Personality Development 43
Adjustment and Growth 45 Self-Esteem 46 Improving Your Psychological Health 47
Understanding Psychological (Mental) Illness 48
The Impact of Psychological Illness 49 What Causes Psychological Disorders? 50 Treating Psychological Disorders 51
Common Psychological Disorders 52 Anxiety Disorders 52 Trauma- and Stressor-Related Disorders 53 Obsessive-Compulsive and Related
Disorders 54 Neurodevelopmental Disorders 54 Substance-Related and Addictive Disorders 55
vi Contents
Major Types of Violence and Abuse 102 Sexual Violence 102 Family Violence 105 Sexual Harassment 107 Stalking 107 Community Violence 109 Institutional Violence 110 Workplace Violence 110 Terrorism 111
Assessing Your Risk of Violence 111
Preventing and Avoiding Violence 112 Home Security Measures 113 Community Security Measures 113 Reducing the Risk of Violence
While in a Car 114 Workplace Safety Measures 114 Self-Protection 114
Reporting Violence 115 Analyzing Health-Related Information 119
CHAPTER REVIEW 120
C H A P T E R 5 Reproductive Health 124 The Male Reproductive System 126
The Internal Organs of Sexual Reproduction 126
The External Organs of Sexual Reproduction 128
The Female Reproductive System 128 The Internal Organs of Sexual
Reproduction 128 The External Organs of Sexual
Reproduction 130
The Menstrual Cycle 132 Premenstrual Syndrome 132 Toxic Shock Syndrome 133
Pregnancy and Human Development 134 Prepregnancy and Prenatal Care 134 Determining If You Are or
Your Partner Is Pregnant 138
Mood Disorders 55 Feeding and Eating Disorders 59 Schizophrenia 62
Suicide 63 Preventing Suicide 63 Analyzing Health-Related Information 67
CHAPTER REVIEW 68
C H A P T E R 3 Stress and Its Management 72 What Is Stress? 74
Stressors 74
Stress Responses 75 Physical Responses 75 Psychological Responses 77
The Impact of Stress on Health 79 Stressful Life Events 79 The Mind–Body Relationship 80 Personality and Stress 82 Stress and Chronic Health Problems 82
Coping with Stress 86 Problem-Focused Strategies 86 Analyzing Health-Related Information 87 Journal Writing 88 Emotion-Focused Strategies 88 Social Support Strategies 89
Relaxation Techniques 90 Deep Breathing 90 Progressive Muscular Relaxation 90 Meditation and the Relaxation Response 91 Imagery 92 Self-Talk 92 Physical Exercise 92
CHAPTER REVIEW 95
C H A P T E R 4 Violence and Abuse 98 How Violence Affects Health 100
What Causes Violent Behavior? 101
Contents vii
Solitary Sexual Behavior 188 Celibacy 188
Romantic Relationships 188 Defining Love 188 Psychologists’ Theories About Love 189
Love Attachments 190 Establishing Romantic Commitments 192 Love Changes over Time 192 Types of Romantic Commitments 193
Communication in Relationships 195 Analyzing Health-Related Information 198
CHAPTER REVIEW 200
C H A P T E R 7 Drug Use and Abuse 204 Drug Use, Misuse, and Abuse 206
Psychoactive Drugs: Effects on the Mind and Body 208
How Psychoactive Drugs Affect the Brain 208
What Happens to Drugs in the Body? 209
Illicit Drug Use in the United States 209 Why Do People Use Psychoactive
Drugs? 210 Patterns of Psychoactive Drug Use 210
Drug Dependence 212 Physiologic and Psychological
Dependence 212 Risk Factors for Drug Dependency 212
Stimulants 213 Amphetamines and
Methamphetamines 213 Cocaine 216 Caffeine 217
Depressants 218 Sedatives and Tranquilizers 219 Rohypnol 219 GHB and GBL 219
Pregnancy and Fetal Development 139 The Birth Process 140 Circumcision 144 The Postpartum Period 145
Infertility 146 Factors That Affect Fertility 146 Treating Infertility 147
Contraception 148 Abstinence and Natural Methods 148 Chemical Methods 151 Barrier Methods 151 Hormonal Methods 154 Intrauterine Devices 156 Emergency Contraception 157 Sterilization 157
Abortion 158 Analyzing Health-Related Information 164
CHAPTER REVIEW 165
C H A P T E R 6 Romantic Relationships and Sexuality 168
Human Sexual Behavior 171 The Biology of Sexual Behavior 171 The Psychology of Sexual Behavior 172
The Sexual Response 172
Sexual Dysfunctions 175 Erectile Dysfunction (Impotence) 175 Premature (Rapid) Ejaculation 176 Hypoactive Sexual Desire Disorder 177 Female Sexual Arousal Disorder 177 Vaginismus 177
Culture, Gender, and Sexuality 180 Gender Identity and Roles 180 Sexual Orientation 184 Nature or Nurture? 185 Sexual Orientation and Society 186
viii Contents
Diagnosis and Treatment of Alcoholism and Alcohol Abuse 255
Tobacco 257 Who Uses Tobacco and Why? 258 Nicotine Addiction 259 The Health Effects of Tobacco Use 260 Environmental Tobacco Smoke 266 Quitting 266 Prevention 270
CHAPTER REVIEW 274
C H A P T E R 9 Nutrition 278 Basic Nutrition Principles 281
What Are Nutrients? 281 What Are Non-nutrients? 281 Natural, Health, Organic, and
Functional Foods 282 What Happens to the Food You Eat? 284
Energy-Supplying Nutrients 286 Carbohydrates 286 Lipids 291 Proteins 294
Non-Energy-Supplying Nutrients 299 Vitamins 299 Minerals 301 Water 304
The Basics of a Healthful Diet 305 Nutrient Requirements and
Recommendations 305 The Dietary Guidelines 306 MyPlate 307 Using Nutritional Labeling 308 What About Foods Sold in
Restaurants? 310 Do You Need Vitamin or Mineral
Supplements? 310 Malnutrition: Undernutrition and
Overnutrition 311 Analyzing Health-Related Information 315
CHAPTER REVIEW 316
Opiates 220 Opium and Heroin 221 OxyContin and Vicodin 221
Marijuana 222
Hallucinogens 223 LSD 223 Mescaline 223 Psilocybin 224 PCP 224 Ketamine 224
Inhalants 224
Designer Drugs: Drugs with Mixed Effects 225
Ecstasy 226 K2 226 Bath Salts 227
Over-the-Counter Drugs 227 Look-Alike Drugs 227 Weight-Loss Aids 228 Ephedrine/Ephedra 228
Drug Treatment and Prevention 229 Treating Drug Dependency 229 Antidrug Vaccines 230 Preventing Drug Misuse and Abuse 230 Analyzing Health-Related Information 234
CHAPTER REVIEW 235
C H A P T E R 8 Alcohol and Tobacco 238 Alcohol Use, Abuse, and Dependence 241
Factors Related to Alcohol Abuse and Dependence 242
Alcohol and College Students 244 How the Body Processes Alcohol 246 Consequences of Alcohol Abuse and
Dependence 248 Analyzing Health-Related Information 249 Prevention 253 How to Manage Alcohol Consumption 255
Contents ix
The Health-Related Components of Physical Fitness 355
Cardiorespiratory Fitness 356 Muscular Strength 359 Muscular Endurance 360 Flexibility 361 Body Composition 363 Analyzing Health-Related Information 365
Athletic Performance 367 The Sports-Related Components
of Fitness 367 Diet and Performance 367 Ergogenic Aids 367
Exercising for Health 370 The Exercise Session 372 Exercise Danger Signs 373
Preventing and Managing Common Exercise Injuries 373
Strains and Sprains 373 Dislocation 373 Temperature-Related Injuries 374
Developing a Personal Fitness Program 376
Active for a Lifetime 378
CHAPTER REVIEW 384
C H A P T E R 1 2 Cardiovascular Health 388 The Cardiovascular System and How It Works 390
Cardiovascular Diseases 393 Atherosclerosis 393 Coronary Artery Disease 394 Stroke 400
Risk Factors for Cardiovascular Disease 402 Family Health History 403 Abnormal Blood Lipid Levels 403 Cigarette Smoking 405 High Blood Pressure 405 Physical Inactivity 406
C H A P T E R 1 0 Body Weight and Its Management 320 Overweight and Obesity 322
Body Mass Index 322 The Prevalence of Obesity 324 How Does Excess Body Fat Affect Health? 325
The Caloric Cost of Living 325 Energy for Basal (Vital) Metabolism 325 Energy for Physical Activity 326 Energy for the Thermic Effect of Food 328 The Basics of Energy Balance 328
Body Composition 328 How Much Body Fat
Is Healthy? 329 Estimating Body Fat 329
What Causes Obesity? 332 Biological Influences 332 Environmental, Social, and
Psychological Influences 335
Weight Management 336 Weight Reduction Diets 336 Physical Activity 338 Surgical Procedures 339 Medications 339 Alternative Therapies 340 Strategies for Successful Weight Loss 340 Analyzing Health-Related Information 343
Weight Gain 343
CHAPTER REVIEW 347
C H A P T E R 1 1 Physical Fitness 350 Principles of Physical Fitness 352
The Body in Motion 352 The Circulatory and Respiratory Systems 352 Defining Physical Activity and Exercise 354
Physical Activity and Health 354
x Contents
Reducing Your Risk for Cancer 458
CHAPTER REVIEW 460
C H A P T E R 1 4 Infection, Immunity, and Noninfectious Disease 464 Noninfectious Diseases 466
Genetic Diseases 466 Noninfectious Disease and the Interaction
of Genetic Factors with the Environment 469
Noninfectious Conditions with Environmental or Unknown Causes 471
Trends in Infectious Disease 472
The Chain of Infection 473 Pathogens 473 Transmission 476 The Host 478
Immunity 479 Nonspecific Immunity 479 Specific Immunity 482 Interactions Between Nonspecific and
Specific Immunity 484
Protection Against Infectious Diseases 484
Drugs That Combat Infection 485
Sexually Transmitted Infections 488
Sexually Transmitted Infections Caused by Viruses 489
Human Immunodeficiency Virus 489 Genital Herpes 494 Genital Warts 495 Analyzing Health-Related Information 497
Sexually Transmitted Infections Caused by Bacteria 498
Syphilis 498 Gonorrhea 499 Chlamydial Infections 501
Obesity 407 Diabetes Mellitus 407 Anxiety and Stress 407 Elevated C-Reactive Protein 409
Maintaining Cardiovascular Health 409 Smoking Cessation 410 Maintaining a Healthy Weight 410 Regular Exercise 410 Lowering Blood Pressure 410 Reducing Blood Cholesterol 411 Aspirin Therapy 412 Hormone Replacement Therapy 412 Analyzing Health-Related Information 414
CHAPTER REVIEW 418
C H A P T E R 1 3 Cancer 422 What Is Cancer? 424
How Cancers Develop and Spread 424 Genes and Cancer Development 425 Metastasis 425
Cancer Detection and Staging 428
Cancer Treatment 429 Surgery 433 Radiation 433 Chemotherapy 433 Laser and Photodynamic Therapy 434 Targeted Therapies 434 Bone Marrow and Peripheral Blood
Stem Cell Transplants 435
Prevalent Cancers in the United States 435 Cancers Caused by or Related to Tobacco 435 Cancers Related to Diet 443 Cancers Related to Hormone Function 445 Cancers Related to Viral Infection:
Cervical Cancer 449 Cancers Related to Ultraviolet Radiation:
Skin Cancers 451 Analyzing Health-Related Information 453 Cancers with Unknown Causes 454
Contents xi
C H A P T E R 1 6 Environmental Health 546 Environmental Health in and Around the Home 548
Poisoning 549 Inhalation of Asbestos Fibers 554 Electromagnetic Radiation 555 Analyzing Health-Related Information 556 Irradiation of Food 557
Environmental Health in the Workplace 558
Pesticide Poisoning 558 Exposure to and Inhalation of Other Toxic
Chemicals 559 Indoor Air Pollution 560
Environmental Health in the Outdoors 561 Water Pollution 561 Air Pollution 562 Noise Pollution 564
CHAPTER REVIEW 567
Appendix A !e Mission, Vision, and Goals of Healthy People 2020 571
Appendix B Injury Prevention and Emergency Care 575
Appendix C Food Intake Patterns Based on MyPlate Recommendations 583
Student Workbook 589
Glossary 692
Index 702
Other Sexually Transmitted Infections 502
Trichomonas Vaginalis Infections 502 Yeast Infections 502 Pubic Lice 502 Scabies 503
Protecting Yourself Against STIs 503
CHAPTER REVIEW 508
C H A P T E R 1 5 Aging, Dying, and"Death 512 Aging 514
Life Expectancy 516 The Characteristics of Aged
Americans 516 Why Do We Age? 518 The Effects of Aging on Physical
Health 519 Analyzing Health-Related Information 524 The Effects of Aging on Psychological
Health 526 The Effects of Aging on Social
Health 527 Successful Aging 527
Dying 529 The Spiritual Aspects of Dying 529 The Emotional Aspects of Dying 530 Terminal Care: The Options 531
Death 533 What Is Death? 533 Euthanasia and the Right to Die 534 Preparing for Death 535 Some Final Thoughts on Death 537
Grief 538
CHAPTER REVIEW 542
xii
Features
Minority Health Status in the United States 14 American Indians and Psychological Health 42 Stress and Asian Americans 78 Spouse Abuse: An International Problem 108 Menopause 161 The Perceived Virtue of Virginity 178 Common Sexual Practices Between Partners 187 Khat 214 Tobacco Drinking? 263 Asian American Food 295 The Plight of the Pima 333 New Interest in an Ancient Approach
to Fitness 382 The Italian Gene: A Hope for Reversing
Atherosclerosis? 407 Stomach Cancer: Variation in Mortality
Among Countries 441 Sickle Cell Disease: Why Does This
Deleterious Gene Persist? 467 Hunting for Supercentenarians 515 Hunger, the Environment, and the
World’s Population 566
Diversity in Health
Consumer Health
Consumer Protection 21 Locating and Selecting Mental Health
Therapists 50
Managing Your Health
Routine Health Care for Disease Prevention: Adult Recommendations 19
Resolving Interpersonal Conflicts Constructively 47
A Technique for Progressive Muscular Relaxation 91
Sexual Assault: Safety and Prevention 103 Genetic Counseling and Prenatal Diagnosis 136 Enlargement of the Prostate 162 Minding Your Sexual Manners 192 Falling Asleep Without Prescriptions 219
Healthy Technology and Social Media Consumption 85
Natural Defense: Pepper Spray 115 Home Pregnancy Tests 139 Ginseng and Sexual Prowess 174 Over-the-Counter Medicines: Safety
and the FDA 228 Electronic Cigarettes or E-Cigarettes 262 Dietary Supplements 312 Dietary Supplements: Weight-Loss Aids 342 Choosing a Fitness Center 380 Vitamin Pills for a Healthier Heart? 408 Alternative Cancer Therapies 432 CAM Products and Colds 486 Choosing a Long-Term Care Facility 532 Carbon Monoxide Detectors: Are
They Reliable? 554
Features xiii
Across the Life Span
Health 32 Psychological Health 65 Stress 94 Violence and Abuse 117 Sexual Development 160 Sexuality 196 Drug Use and Abuse 231 The Effects of Alcohol and Tobacco Use 272 Nutrition 313 Weight Management 345 Physical Fitness 381 Cardiovascular Health 412 Cancer 458 Infectious and Noninfectious Diseases 505 Dying and Death 540 Environmental Health 565
Drinking and Date-Rape Drugs: Safety Tips 247
Guidelines for Safer Drinking 255 How to Say No to Secondhand Smoke 269 Tips for Quitters 271 Trimming Unhealthy Fats from Your Diet 296 General Features of Reliable Weight
Reduction Plans 344 Assessing the Intensity of Your Workout:
Target Heart Rates 357 Heart Attack and Stroke (Brain Attack)
Symptoms: What to Do in an Emergency 401 Screening Guidelines for the Early
Detection of Cancer in Average-Risk Asymptomatic People 430
Breast Self-Examination 446 Testicular Self-Examination 456 Reducing Your Risk for Cancer 458 Cancer’s Seven Warning Signs 459 Eliminating or Reducing Your Risk of
HIV Infection and Other STIs 493 After the Death of a Loved One 539 Tips to Prevent Poisonings 552 Avoiding ELF Radiation 557 Reducing Pesticide Levels in the Food
You Eat 560
As the title suggests, Alters & Schiff Essential Concepts for Healthy Living was written to provide students with cur- rent information on how to live and age well. Our text- book combines evidence-based information with critical thinking activities to guide students toward healthy living through analysis of their own health behavior. We challenge students to think seriously about health- related information by using critical-thinking strategies.
What Is Critical Thinking? What Does a Critical-Thinking Textbook Do? Critical thinking encompasses a variety of cognitive skills, such as:
• Synthesizing
• Analyzing
• Applying
• Evaluating
Throughout the textbook, a critical-thinking icon identi- fies features that focus specifically on these skills. In the health sciences, critical-thinking skills are necessary to understand and evaluate health information as well as apply it to daily life. This book teaches critical thinking skills that help students develop expertise in important cognitive functions:
• Differentiating between verifiable facts and value statements
• Distinguishing relevant information from irrelevant information
• Determining the factual accuracy of health claims
• Making responsible health-related decisions
To think critically, students need a solid foundation of personal health information. Alters & Schiff Essential Concepts for Healthy Living has been developed from the latest scientific and medical research, relying heavily on primary sources, which are cited in the text. Because understanding health involves understanding science, this text includes basic scientific information that relates to health and presents it in an easy-to-under- stand manner.
Focus on Critical !inking What Is New and Improved in This Edition? The eighth edition is updated to provide the most cur- rent statistical data on a comprehensive array of health and wellness topics and issues. Updates to the new edi- tion include:
• Extensive changes to Chapter 4, “Violence and Abuse”
• The Managing Your Health box, Sexual Assault: Safety and Prevention, has been heavily revised to avoid victim blaming.
• The definitions for key words such as sexual harassment have been updated.
• The section on Community Violence has new information to include gang violence.
• A new table, Safety Planning, has been added (Table 4.3).
• Chapter 6, “Romantic Relationships and Sexuality,” has also been heavily revised.
• The section on Culture, Gender, and Sexuality was completely rewritten to reflect the evolving understanding of nontraditional gender identities.
• A new table lists Common Gender Identity Terms as well as Outdated, Inaccurate, or Offensive Gender Identity Terms (Table 6.1).
• The subsection Sexual Orientation now includes new definitions for various types of sexual orientation, including asexual, pansexual, and so on.
• The chapter “Nutrition” (Chapter 9) includes updated Dietary Guidelines for Americans 2015–2020.
• Table 13.3 in the chapter “Cancer” (Chapter 13) has been updated with 2018 estimates on new cancer cases and deaths.
• A new Workbook activity for Chapter 6 has been added: the Couples Satisfaction Index.
• New features appear throughout, including:
• Consumer Health: Healthy Technology and Social Media Consumption in Chapter 3, “Stress and Its Management”
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• Figure 4.3, Community Violence, is a photo of the memorial following the Las Vegas mass shooting (Chapter 4, “Violence and Abuse”).
How to Use This Book Analyzing Health-Related Information activities included throughout the text provide students with examples of common advertisement techniques and other forms of media and ask them to determine whether the infor- mation presented is valid. Because health information is readily available through many forms of media, we believe it is important for students to be able to dis- tinguish evidence-based information from unreliable health information.
We believe that students will find these activities and tools easy to use. If students read each chapter carefully and complete each activity thoroughly, they will gain a good understanding of major concepts of healthy liv- ing that can be applied to their personal lives as well as future health-related careers.
Key Features Alters & Schiff Essential Concepts for Healthy Living focuses on teaching behavior change, personal deci- sion making, and up-to-date personal health concepts. The critical-thinking approach encourages students to consider their own behaviors in light of the knowledge they are gaining. The pedagogical aids that appear in the chapters are described in the following pages.
Focus on Critical Thinking xv
Chapter-Opening Pedagogy Each chapter-opening spread shows students the orga- nization of the chapter using a chapter overview and a list of the special boxed features. It also lists activities in the companion Student Workbook (included at the back of this text).
The organization of ideas is an integral part of learning comprehension. The chapters are struc- tured with a consistent format throughout the text. Each chapter begins and ends with a section that points out the key concepts and ties the information together.
xvi Focus on Critical Thinking
Healthy Living Practices Unique to this text, these short lists of bulleted state- ments throughout the chapters summarize key points and concisely state concrete yet simple actions students can take to improve their own health.
Managing Your Health This feature contains short essays or lists of tips that focus on ways to live a healthier life.
Chapter Summaries Research says that students learn how to identify the key ideas of stories in elementary school, but they often have difficulty identifying key ideas in textbooks in their later schooling. Chapter summaries help students with this task. The chapter summaries follow the organization of the chapter.
How to Use This Book to Adopt Healthier Lifestyles Alters & Schiff Essential Concepts for Healthy Living, Eighth Edition, encourages students to adopt healthier lifestyles, and the boxed features throughout the text recommend practical ways to do so.
Focus on Critical Thinking xvii
Consumer Health These commentaries and tips provide practical infor- mation and suggestions to help students become more careful consumers of health-related goods and ser- vices. In addition to being highlighted in this feature, consumer topics are integrated throughout the book and are the subject of scrutiny in the Analyzing Health- Related Information activities.
Diversity in Health This feature cultivates an interest in and an apprecia- tion for the health status and practices of various ethnic, cultural, and racial groups in the United States, as well as people around the world. Although the diversity essays focus specifically on multiculturalism, additional multicultural information is woven throughout the book.
How to Use This Book to Enforce Critical Thinking The focus of education today is not simply to give students information but to teach them how to acquire and evaluate information. Unlike other personal health textbooks, the critical-thinking features in this text teach stu- dents higher order thinking skills and give them ways to practice these skills in every chapter.
xviii Focus on Critical Thinking
Analyzing Health-Related Information This innovative feature teaches students the critical- thinking skill of analysis. Students use this skill and the model provided to determine the reliability of health- related information in articles, advertisements, websites, and other sources. Learning such a skill and practicing it helps students become knowledgeable consumers of health-related information and products.
Applying What You Have Learned This unique end-of-chapter feature is a series of ques- tions and activities that require critical thinking— application, analysis, synthesis, and evaluation. Each question is labeled with what type of critical thinking is required, and a key provides a brief explanation of the process students need to follow to complete the ques- tion or activity.
Reflecting on Your Health This end-of-chapter journal-writing activity stimulates students to consider what they have learned and to understand how their thoughts and feelings about health might have changed as a result of their new knowledge. Compiling these activities and reviewing them from time to time, especially at the end of the semester, can offer tangible evidence of changes and psychological and intellectual growth.
Focus on Critical Thinking xixFocus on Critical Thinking xix
The Integrated Teaching and Learning Package Integrating the text and ancillaries is crucial to deriving their full benefit. Based on feedback from instructors and students, the following supplements are offered with Alters & Schiff Essential Concepts for Healthy Living, Eighth Edition.
Instructor Resources Qualified instructors will receive a full suite of instructor resources, including the following: • A robust test bank, including chapter review
questions, a midterm, and a final
• Slides in PowerPoint format
• Image bank
• An updated instructor’s manual
• Sample syllabus
• Lecture outlines
Student Resources • An interactive eBook
• Warm-up activities
• Animations, now with audio and captions
• Revised Student Workbook with various health- related activities such as: Would a Behavior Change Improve Your Relationship? and How Much Energy Do You Use Daily?
Student Workbook In addition, the eighth edition contains a built-in critical thinking workbook that allows students to assess and improve their health-related behaviors and attitudes. (See the Student Workbook at the end of this text for more information.)
xxi
Regina M. Kay Mercer County Community College West Windsor Township, New Jersey Donna McGill-Cameron Woodland Community College Woodland, California Tony Monahan Queensborough Community College Bayside, New York J. Dirk Nelson West Texas A&M University Canyon, Texas David J. Pearson Baptist University Riverside, California Grace Pokorny Long Beach City College Long Beach, California Mikel Stone Shawnee University Portsmouth, Ohio Renee M. D. Swain Saint Augustine’s University Raleigh, North Carolina Nanette Tummers Eastern Connecticut State University Willimantic, Connecticut Julia VanderMolen Davenport University Grand Rapids, Michigan
Many health teachers and researchers have made signi!cant contributions to the development of this book. Our gratitude goes to the following reviewers whose expertise gave invaluable direction to the development of the% eighth edition of Alters & Schi! Essential Concepts for Healthy Living:
Brandy Hancock Adelsberger Fontbonne University St. Louis, Missouri Liza Allen Mesa Community College Mesa, Arizona Leigh Poirier Ball Orange Coast College Costa Mesa, California Amanda L. Divin Western Illinois University Macomb, Illinois Chris Eisenbarth Weber State University Ogden, Utah Bruce E. Ferguson Ta$ College Ta$, California Jacqueline M. Franz Mercer County Community College West Windsor Township, New Jersey Linda J. Ho#man Community College of Allegheny County Pittsburgh, Pennsylvania Waltert Hook Eastern University St. Davids, Pennsylvania
Reviewers
xxii
Jeff Housman Je# Housman holds a doctorate degree in health education and a master’s degree in kinesiology and is a tenured associate professor in health and
human performance at Texas State University, where he teaches courses in community and public health, health behav- ior theory, and behav- ioral research and statistics. Understanding the importance of research, as well as remaining cur- rent with the industry, Dr.
Housman’s research interests include health behav- ior, substance use, and program evaluation. He has authored multiple peer-reviewed articles and several textbook chapters, in addition to Alters & Schi! Essen- tial Concepts for Healthy Living. He has also contrib- uted to several professional publications, including A Competency-Based Framework for Health Education Specialists for the National Commission for Health Education Credentialing, Inc., and he has served as a consulting editor for the Journal of American College Health and "e Health Educator. Dr. Housman is a member of multiple professional organizations, including the Eta Sigma Gamma Health Education Honorary, the American College Health Association, and the Society for Public Health Education. As the lead author on Alters & Schi! Essential Concepts for Healthy Living, Eighth Edition, Dr. Housman brings his education expertise, background in community and public health, exercise science, and health behav- ior, as well as his extensive writing experience, to this best-selling product and author team.
Mary Odum Mary Odum holds a doctorate degree in health education, a master’s degree in health, exercise, and sport sciences, and a bachelor’s degree in psychol- ogy. She is an assis- tant professor in health and human performance at Texas State Univer- sity, where she currently teaches courses in health education and promo- tion, program planning and evaluation, health behavior theory, and scienti!c writing. Dr. Odum’s research interests include health behavior, community-based health programs, and prepar- ing students as writers, and she serves as a review editor for several academic journals, including the American Journal of Health Behavior. Dr. Odum is a member of multiple professional organizations, including the Eta Sigma Gamma Health Education Honorary, the Society for Public Health Educators, and the American Academy of Health Behavior.
A lters & Schi! Essential Concepts for Healthy Living, Eighth Edition, was written by an author team with extensive credentials and backgrounds in health, exercise science, human sexuality, nutrition, health behavior, and education.
About the Authors
Garden path: © Simon Marlow / EyeEm /Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/Getty Images.
Across the Life Span Health
Managing Your Health Routine Health Care for Disease Prevention
Consumer Health Consumer Protection
Diversity in Health Minority Health Status in the United States
Chapter Overview How the dimensions of health influence your well-being
The major health concerns of our nation
How your decisions affect your health
How to analyze health-related information
The differences between conventional and alternative treatment methods
Student Workbook Self-Assessment: Healthstyle | Personal Health History
Changing Health Habits: Model Activity for Better Health
Do You Know? How your lifestyle affects your health?
How to make responsible health-related decisions?
How to analyze health-related information?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © aricvyhmeister/Shutterstock.
Health: !e Foundation for Life
© EyeEm
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Learning Objectives “A higher percentage of American adults report exercising during their leisure time …”
After studying this chapter, you should be able to:
1. Identify trends in U.S. population health. 2. Describe the impact of lifestyle choices on one’s health. 3. Discuss different perspectives on health and wellness. 4. Describe the six components of health and discuss how
each component affects one’s health. 5. Identify major causes of death for members of various
age groups. 6. Explain why Americans’ life expectancy increased
dramatically during the twentieth century. 7. Identify the purpose and four main goals of Healthy
People 2020. 8. Describe factors that influence health behavior and health behavior change. 9. Describe the steps of the decision-making model and the stages of the behavior change model. 10. Explain how to analyze health information and assess information on the Internet. 11. Differentiate between conventional and complementary and alternative medicine. 12. Describe how to choose a conventional medical practitioner.
CHAPTER 1
3
In the United States, there are some encourag-ing signs that more people are concerned about improving and protecting their health than in the past. A higher percentage of American adults met physical activity guidelines for aerobic physical activ- ity (i.e., at least 150 minutes or more a week) in 2015 than in previous years.1 In 1995, 71% of adults reported that their blood cholesterol level had been checked. By 2015, that percentage had increased to 81.5% of adults.2 Between 1988 and 2016, the percentage of Americans wearing seat belts while riding in motor vehicles increased dramatically.3 In some respects, Americans have also improved their eating habits. Between 2005 and 2014, on average, adolescents consumed more than 16% of their total calories from added sugar, slightly above the recommended 15%. Most adults aged 20 or older, however, met recommended sugar consumption guidelines. In addition, Americans are consuming more calcium and more dietary !ber.4,5 In 2014, fewer Americans died of cancer than in 1999.6 Finally, Americans are living longer than in the 1980s. Life expectancy is the average number of years that an individual of a particular age can expect to live. In 1990, the life expectancy of an infant in the United States was 75.4 years.7 By 2010, Americans’ life expectancy at birth had increased to 76 years for males and 81 years for females; however, life expectancy at birth decreased slightly between 2014 and 2016.7
Other !ndings about Americans’ current health status and health-related behaviors, however, are less encouraging. Although the overall rate of ciga- rette smoking has decreased slightly, consumption of cigars and loose-leaf tobacco (e.g., pipe tobacco) increased from 2000 to 2015. "e greatest increase in loose-leaf tobacco consumption occurred a$er the federal tobacco excise tax increased in 2009, making cigarettes more expensive than loose-leaf tobacco.8 Recently, some laws aimed at tax avoidance strate- gies have resulted in a slight reduction in loose-leaf tobacco use. Additionally, alcohol abuse is a wide- spread behavior, particularly among young people. Tobacco use remains the leading cause of preventable illness and death in the United States. In 2015, adults smoked fewer cigarettes than in 1985, but about 18% of Americans who were 18 years of age and older smoked cigarettes.8 U.S. public health o&cials are also concerned about Americans who use alcohol irresponsibly. In 2013, excessive alcohol consumption
was the third leading cause of preventable deaths in the United States, including tra&c-related fatalities.9 Approximately 17% of adult Americans reported binge drinking in 2016,10 and 18% of high school stu- dents reported that they engaged in binge drinking in 2015.11 Binge drinking is de!ned as consuming !ve or more alcoholic drinks per occasion for males and four or more drinks per occasion for females. Americans who are 18–24 years of age are more likely to binge drink than other members of the population. Accord- ing to the results of one study, about one in four col- lege students indicated that their drinking behaviors contributed to serious academic problems, including missing classes, performing poorly on exams, and lowering their grade point averages.12 "e typical American does not meet the federal government’s recommendations concerning healthy food choices. "e majority of the U.S. population does not eat enough vegetables, whole grains, fruits, milk, and oils (“healthy” fats).13 An important sign of Americans’ poor nutritional practices is the high prevalence of obesity in the United States. Between 1988 and 1994, 10% of children14 and almost 23% of adults14 were obese. By 2014, 17% of American children and more than 38% of American adults were obese.15 Between 1994 and 2014, the prevalence of obesity increased dramatically among all groups of Americans regard- less of their age, sex, race, ethnicity, socioeconomic status, region of the country, and education level. Excess body fat is associated with the development of many serious diseases, including high blood pressure, heart disease, certain cancers, and type 2 diabetes, a serious disorder characterized by the body’s inability to regulate blood sugar normally.
Although Americans are living longer than in the past, living longer is not always a sign that people are living better. Many older adults su#er from condi- tions that reduce their ability to enjoy life and per- form important daily activities such as bathing and dressing. Heart disease, stroke, cancer, Alzheimer’s disease, impaired vision, hearing loss, osteoporo- sis, and depression create much misery not only for millions of older adults but also for the family mem- bers who struggle to care for their disabled relatives.
"e results of many studies show that exercising regularly, eating a more nutritious diet, and avoiding smoking and excess alcohol consumption promote good health. Incorporating these and other healthy habits into your lifestyle while you are still young can improve your health and well-being and increase your chances of living a longer and healthier life than your parents and grandparents.
life expectancy The average number of years that an individual of a particular age can expect to live.
4 Chapter 1 Health: The Foundation for Life
constitution de!ned health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or in!rmity.”16 Some, however, consider this de!nition too limited and suggest that health cannot be a state because our health is ever changing. Consider the people in Figure 1.1. Although they are in wheelchairs, they are able to compete as athletes. If you judged their state of health using WHO’s 1948 de!nition, you might conclude that they are unhealthy. Many physically disabled people are able to function adequately in society and do not consider them- selves ill or in!rm.
"e Ottawa Charter for Health Promotion de!nes health as “a resource for everyday life . . . a positive concept emphasizing social and personal resources, as well as physical capabilities.”17 According to this charter, health requires “peace, shelter, educa- tion, food, income, a stable ecosystem, sustainable resources, social justice and equity.” In addition to these conditions, most healthy adults want to func- tion independently; enjoy eating, sexual, and physi- cal activities; feel good about themselves; and enjoy being with family and friends.
Lifestyle is a way of living. As a college student, your lifestyle includes a variety of behaviors that pro- mote or impair good health and longevity. Although you may be unable to prevent severe birth defects or inherited disorders from a#ecting your health, you can modify many health risk factors, reducing the likeli- hood that you will develop serious medical problems. A risk factor is a characteristic that increases an indi- vidual’s chances of developing a health problem. For example, physical inactivity, tobacco use, emotional stress, and obesity are risk factors for heart disease, hypertension (persistent high blood pressure), and certain types of cancers. You can dramatically lower your chances of developing these conditions by incor- porating exercise into your daily schedule, choosing not to use tobacco products, practicing relaxation techniques, and eating a more nutritious diet.
Are you concerned about your health? What are you doing to protect it? What steps can you take to enhance your state of health so that you can enjoy life more fully? Where can you !nd reliable information concerning health? "is text presents !ndings from current scienti!c research for you to use in making choices that will improve your health.
What Is Health? Most people can describe how it feels to be healthy or ill, but trying to de!ne health is not an easy task. In 1948, the World Health Organization (WHO)
lifestyle A way of living, including behaviors that promote or impair good health and longevity.
risk factor A characteristic that increases an individual’s chances of developing a health problem.
Figure 1.1 Wheelchair Athletes. Many physically disabled people do not consider themselves ill or infirm because they can function well in society. According to Hochbaum’s definition of health, individuals with physical disabilities can be healthy and enjoy life. © Marek Slusarczyk/Shutterstock.
What Is Health? 5
one end of this continuum, and the highest level of functioning (optimal well-being) is at the other end. Many people accept responsibility for the quality of their health and well-being. "ese people are willing to take various steps to improve their health, achiev- ing a higher degree of wellness in the process.
Most health professionals agree that health and wellness are holistic; that is, they involve all aspects of the individual. "us, the holistic concept of health encompasses not only the physical, psychological, and social aspects but also the intellectual, spiritual, and environmental dimensions of a person. Each dimension is an integral part of a person’s health, and any change in the quality of one component of health a#ects the others. For example, individuals who exer- cise with others to increase their level of physical health o$en report a sense of improved psychological and social health.
The Components of Health Physical Health Physical health refers to the overall condition of the organ systems, such as the cardio- vascular system (heart and blood vessels), respiratory system (lungs), reproductive system, and nervous system. A healthy person’s systems function properly; the individual feels well and is free of disease. When organs do not function adequately, a person has various signs and symptoms of illness. Signs are the observable and measurable features of an illness, such as fever, rash, and abnormal behavior. Symptoms are the subjective complaints of an illness, such as reports of fatigue, headaches, and numbness. An acute condition or illness, such as the common cold or a foodborne infection, tends to develop quickly and resolve within a few days or weeks. A chronic condition or disease o$en takes months or years to develop, progresses in severity, and can a#ect a per- son over a longer period—in some cases, throughout his or her lifetime.
Behavioral scientist Godfrey Hochbaum proposed a simple de!nition for health: “Health is what helps me be what I want to be . . . do what I want to do .%.%. [and] live the way I would like to live.”18 Using Hochbaum’s de!nition, you might conclude that the wheelchair-bound athletes in Figure 1.1 are as healthy as people who are capable of running. In this text, we use concepts from all of these perspectives and de!ne health as “a dynamic state or condition of the human organism that is multidimensional (i.e., physical, emotional, social, intellectual, spiritual, and occupational) in nature, a resource for living, and results from a person’s interactions with and adapta- tions to his or her environment.”19
Health and Wellness Health and wellness are related concepts. Good health enables one to function adequately and inde- pendently in a constantly changing environment; optimal wellness is a sense that one is functioning at one’s best level. Figure 1.2 illustrates the concept of health as a continuum; there are degrees of health. "e absence of functioning (premature death) is at
good health The ability to function adequately and independently in a constantly changing environment.
optimal wellness A sense that one is functioning at his or her best level.
holistic (hole-IS-tic) A characteristic involving all aspects of the person.
signs Observable and measurable features of an illness.
symptoms Subjective complaints of illness.
acute A condition or illness that tends to develop quickly and resolve within a few days or weeks.
chronic A condition or disease that often takes months or years to develop, progresses in severity, and can affect a person over a long period.
Personal Adjustment
Personal Growth
Enthusiasm for Living
Optimal Well-Being
Premature Death
Loss of Interest in Living
Loss of Function
Signs and Symptoms of Illness
No Disease
Figure 1.2 A Health Continuum. Some people view health as a continuum; that is, there are degrees of health. Premature death is at one end of this continuum, and optimal well-being is at the other end. Modi!ed from Ebersole, P., & Hess, P. (1994). Toward healthy aging (4th ed.). St. Louis: Mosby.
6 Chapter 1 Health: The Foundation for Life
having religious beliefs in'uence the spiritual health of many people. However, spirituality is not con!ned to those who belong to organized religious groups or have religious beliefs. People can develop spirituality without practicing a particular religion or believing in the power of a supreme being. Whatever the nature of their spirituality, many individuals achieve a sense of inner peace and harmony, as well as emotional ful- !llment, by believing that their lives have a purpose. As in the other wellness dimensions, a breakdown in spiritual health can have a negative impact on one’s well-being.
Environmental Health Nothing a#ects the qual- ity of wellness components as much as the state of the environment—the conditions in which people live, work, and play. Environmental concerns that in'uence wellness include the provision of clean water and air, the management of wastes, and the control of distressing social problems such as crime and family violence. Humans cannot achieve a high degree of wellness if their environment is polluted or unsafe (Figure 1.3).
Figure 1.4 is a model that illustrates how these six components of health are related and integrated into a holistic approach to understanding wellness. "is model has the physical and psychological health components at the core of the larger environmental component. "e social, intellectual, and spiritual components involve thought processes; therefore, they are found in the psychological health dimension. Note how the physical and psychological spheres
Psychological Health Psychological (mental) health involves the ability to deal e#ectively with the psy- chological challenges of life. Psychologically healthy people accept responsibility for their behavior, feel good about themselves and others, are comfortable with their emotions (feelings), and have positive, realistic outlooks on life. Although experiences such as losing a job or a family member cause stress or grief, psychologically healthy people are able to limit the extent to which crises a#ect their lives.
Social Health Social health is the sense of well- being that an individual achieves by forming emo- tionally supportive and intellectually stimulating relationships with family members, friends, and associates. Living in communities rather than in iso- lation, identifying with social groups, and belonging to organizations strengthen the social dimension of health. When social networks break down, health declines.
Intellectual Health Intellectual health is the abil- ity to use problem-solving and other higher order thinking skills to deal e#ectively with life’s challenges. Healthy people analyze situations, determine alter- native courses of action, and make decisions. A$er making decisions, intellectually healthy individuals are able to judge the e#ectiveness of their choices and learn from their experiences. E#ective intellectual skills enable people to feel in control of their lives.
Spiritual Health Spiritual health is the belief that one is a part of a larger scheme of life and that one’s life has purpose. Identifying with a religion and
Figure 1.3 Environmental Health. The state of the environment in which people live, work, and play affects the quality of their health. People cannot achieve a high degree of wellness if their environment is polluted or unsafe. © Hung Chung Chih/Shutterstock.
What Is Health? 7
of the gross domestic product.20 Americans gener- ally rely on themselves and their employers, as well as private and public health insurance programs, to pay for some of their health care; approximately 10% of Americans younger than 65 years of age were not covered by health insurance in 2015.20 A major ill- ness, serious accident, or hospitalization can quickly exhaust a person’s !nancial resources and create enor- mous personal debt; therefore, it is important to have adequate health insurance to cover such expenses. "e A#ordable Care Act is projected to reduce the num- ber of uninsured Americans by 30 million by 2022.20
Tracking the Nation’s Health "e U.S. government, particularly the Public Health Service of the Department of Health and Human Services, monitors the nation’s health in a variety of ways. One way is by recording cases of certain dis- eases and causes of death. Table 1.1 shows data for the 10 leading causes of death for all Americans in
overlap to illustrate how the body and mind are closely integrated. When the components of health function well together, the individual has a sense of well-being.
!e Nation’s Health Health involves more than just personal health— health is a national concern, too. Many of the cru- cial social, political, and economic issues facing this country are health related, such as domestic violence, terrorism, care of the aged, and access to health care and insurance.
Lack of health insurance and the high cost of health care are major barriers to obtaining routine preventive medical care and proper treatment. "e United States spends more on health-related care per person than any other country.7 According to the U.S. Department of Health and Human Services, total healthcare costs reached $3.2 trillion in 2015, or 17.8% of the United States gross domestic product. By, 2025, healthcare costs are expected to increase by an annual average rate of 5.6%, or approximately 20%
Figure 1.4 The Components of Health. The components of health are interrelated. According to this model, the social, intellectual, and spiritual components of health are in the larger spheres of physical and psychological health, which are in the largest sphere of environmental health.
Intellec tu
al
Spiritual
Social
Environmental
Physical Psychological
Rank Cause
Approx. Percentage of Deaths
1 Heart disease 23.4
2 Cancer 22.0
3 Chronic lower respiratory diseases
5.7
4 Accidents/unintentional injuries
5.4
5 Stroke 5.2
6 Alzheimer’s disease 4.1
7 Diabetes mellitus 2.9
8 Pneumonia/influenza 2.1
9 Nephritis 1.8
10 Suicide 1.6
— Other causes 25.8
Modified from Murphy, S. L., Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015. National Vital Statistics Reports, 66(6), 1–74.
Table 1.1
The 10 Major Causes of Death in the United States (2017)
8 Chapter 1 Health: The Foundation for Life
longer lives. "is progress occurred largely because various government agencies provided greater access to health care, promoted preventive health- care e#orts, funded health education and research programs, and regulated the safety of the envi- ronment. For example, childhood vaccination programs have removed the threat of polio and con- trolled other infectious diseases such as measles, diphtheria, rubella, and tetanus. Food forti!cation programs have nearly eliminated nutritional de!- ciency diseases such as goiter, rickets, and pellagra. E#orts to educate the public concerning the impor- tance of early and routine prenatal care (medical care for pregnant women) have helped reduce the infant death rate.
Although the life expectancy of Americans has increased, many people still die prematurely, that is, before they reach 75 years of age. According to health experts at the Centers for Disease Control and Prevention in Atlanta, actual causes of death are the underlying reasons that are not reported on death certi!cates. In 2015, for example, about 17% of all deaths were the result of drug use, and alcohol and !rearm-related incidents accounted for about 20% of deaths.21 However, tables that list leading causes of death, such as Table 1.1, integrate those deaths with the number of deaths resulting primarily from heart disease, cancer, chronic lower respiratory diseases, and stroke. Health experts predict that the combi- nation of poor diet and physical inactivity will soon replace tobacco use as the leading actual cause of death in the United States. In many instances, actual causes of death are associated with lifestyle choices, such as tobacco use or physical inactivity. By chang- ing these and other health-related behaviors, people may avoid dying prematurely.
2015. In the United States, heart disease was the lead- ing cause of death, followed by cancer, chronic lower respiratory disease, and stroke.21
"e major causes of death di#er for members of various age groups. Table 1.2 shows preliminary data concerning the leading causes of death in two age cat- egories: 15–24 years and 25–44 years. In 2009, unin- tentional injuries (accidents), homicide, and suicide were the top three leading causes of death of people between 15 and 24 years of age. Note that uninten- tional injuries, cancer, and heart disease were the top three leading causes of death of people between 25%and 44 years of age.
Over the past 100 years, Americans made great progress toward improving their health, well- being, and longevity. In 1900, the life expectancy of a newborn baby was less than 50 years. Compared to people who lived in the !rst half of the twentieth century, many Americans can now expect to live
Ages 10–24
Rank Cause
1 Unintentional injuries
2 Suicide
3 Homicide
4 Cancer
5 Heart disease
Ages 25–44
Rank Cause
1 Unintentional injuries
2 Cancer
3 Heart disease
4 Suicide
5 Homicide
Modified from Murphy, S. L., Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015. National Vital Statistics Reports, 66(6), 1–74.
Table 1.2
Causes of Death: All Races, Selected Age Groups of Americans (Preliminary Data, 2017)
Co ur
te sy
of Ja
m es
G at
ha ny
/Ju dy
Sc hm
id t/C
DC .
The Nation’s Health 9
areas,” including “physical activity” and “injury and violence prevention,” as well as nearly 600 health objectives. An objective identi!es target populations and a speci!c health concern. One of the physical activity objectives, for example, is, “Increase the pro- portion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle strengthening activity.”
Sta# of various federal, state, and local agencies are responsible for developing and implementing health education e#orts, such as community and
Health Promotion: Development of Healthy People 2020 Health promotion is the practice of helping people become healthier by encouraging them to take more control over their health and change their lifestyles. Health promotion e#orts strive to prevent rather than treat disease and injury. Federal, state, and local gov- ernments can help the population develop healthy lifestyles by funding and providing educational pro- grams and preventive medical care services. When planning e#ective health promotional programs, public health experts and government o&cials need to identify which aspects of the population’s health should receive the most attention. How does the fed- eral government identify serious health concerns and monitor the health of its citizens? What is being done to improve the nation’s health?
In the late 1980s, a team of concerned health experts, health educators, and U.S. government o&cials ana- lyzed the results of reports, recommendations, and studies that provided data concerning the health status of Americans. In 1991, these experts published their !ndings in a report called Healthy People 2000.22
Healthy People 2000 had three general goals: increase the healthy life span of Americans, improve the health status of American minorities, and extend the accessibility of preventive health services to all Americans. Healthy People 2000 also established numerous health-related objectives that related to each goal, such as increasing the percentage of chil- dren who engaged in 20 minutes or more of vigorous physical activity at least 3 days a week. "e overall aim was for Americans to achieve the health objectives by the year 2000; as more Healthy People 2000 objec- tives were met, the overall health status of Americans would improve. By 2000, public health experts had collected and analyzed information about the popu- lation’s progress toward achieving the health objec- tives, and the data were used for the publication of a revised set of goals and objectives. "is process would be repeated approximately every 10 years. In 2000, the federal government released the second edition of the plan, Healthy People 2010. "e analysis of data obtained from Healthy People 2010 led to the publication of Healthy People 2020, the third and lat- est edition of the national health goals and objectives.
Table 1.3 indicates the four main goals of Healthy People 2020 and factors that will be measured to monitor progress toward meeting those goals. Healthy People 2020 identi!es 42 “objective topic
Main Goals of Healthy People 2020 Measures of Progress
General Health Status Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Life expectancy; healthy life expectancy
Years of potential life lost Physically and mentally
unhealthy days Self-assessed health
status Limitation of activity Chronic disease
prevalence
Disparities and Inequity Achieve health equity, eliminate disparities, and improve the health of all groups
Race/ethnicity Socioeconomic factors Natural and built
environments Policies and programs
Social Determinants of Health Create social and physical environments that promote good health for all
Social and economic factors
Natural and built environments
Policies and programs
Health-Related Quality of Life and Well-Being Promote quality of life, healthy development, and healthy behaviors
Self-reports of well-being and satisfaction
Quality of life Participation in common
activities
Modified from U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). Healthy People 2020. Available at: http://www.healthypeople.gov/2020/about /Foundation-Health-Measures.
Table 1.3
Healthy People 2020: Foundation Health Measures
10 Chapter 1 Health: The Foundation for Life
school-based programs to reduce the prevalence of childhood obesity, that support Healthy People 2020 objectives. In addition, sta# will monitor Americans’ progress in meeting these health objectives. You can learn more about Healthy People 2020 by visiting the government’s web site: www.healthypeople.gov/2020 /default.aspx.
Minority Health Status For hundreds of years, immigrants from around the world have been changing the face of the United States as they settle in this country. Each new group of immigrants brings di#erent cultural traditions and various ethnic identities with them (Figure 1.5). Cul- ture consists of the unique social characteristics of a population, such as its customs, rituals, and health beliefs and practices, which are passed down from generation to generation. An ethnic group is one in which members share a common national, religious, racial, or ancestral identity. According to the U.S. Department of Health and Human Services, the major
American racial/ethnic subpopulations are Cauca- sians (Whites), African Americans (Blacks), Latinos (Hispanics), American Indian/Alaska Natives, and Asian/Paci!c Islanders. "e same terms, however, are not used by all agencies. "roughout this text, terms such as Caucasian may be used in one context and Whites in another when reporting statistics or results of research studies; the text re'ects the language of the agency or researcher.
In the United States, the majority of Americans have European ancestry, particularly northern European. "e National Center for Health Statistics refers to this population as “White, non-Hispanic.” In 2017, 61.3% of the U.S. population identi!ed itself as “White, not His- panic”; 13.3% identi!ed as Black or African American; and 17.8% identi!ed as Hispanic or Latino.23
Di#erences in death and illness rates between the nation’s men and women, as well as among its diverse ethnic and racial groups, are major public health con- cerns. For example, American men generally do not live as long as American women and are more likely to die from each of the 10 leading causes of death. More African Americans die of cancers and diseases of the heart and blood vessels than do members of other ethnic and racial groups. "e reasons for these di#erences are unclear, but socioeconomic status, environmental conditions, and lifestyle choices are major contributing factors. "e term minority, how- ever, is not strictly limited to race or ethnicity. In the United States, minority groups also include religious minorities (e.g., Mormons, Muslims), sexual minori- ties (e.g., lesbian, gay, bisexual, and transgender), age minorities (e.g., the very young or very old), and peo- ple with disabilities (e.g., those with autism).
"e Diversity in Health essay addresses topics that concern a variety of populations in the United States and around the world. "e Diversity in Health essay in this chapter, “Minority Health Status in the United States,” discusses di#erences in the overall health of major minority groups in the United States.
Genetics and Genomics Your lifestyle and environment in'uence your health status, but your genes also play a role in determining your health. With the exception of red blood cells, all cells in your body contain genes. Genes are segments
Figure 1.5 An American Family. Culture consists of the unique social characteristics of a population, such as its customs, rituals, and health practices. Immigrants who settle in the United States contribute much to the racial, ethnic, and cultural diversity of the population. © digitalskillet/Shutterstock.
genes Segments of DNA that code for specific proteins.
Genetics and Genomics 11
genetic component. Unlike cases of rare genetic con- ditions, these common chronic diseases generally develop partly as a result of multiple genes interact- ing with behavioral and environmental risk factors, such as poor food choices, lack of physical activity, and exposure to tobacco smoke.
Genomics is the study of all of a person’s genes (genome), including the complex ways the genes interact with each other and the environment to in'uence the individual’s health. A person’s genome can provide medical researchers with important biological clues about the individual’s health status, disease risk, and responses to treatments. Scienti!c analysis of individual genomes may help explain why people who share similar environments or health- related behaviors do not always develop the same health conditions.
Genes play roles in a person’s ability to achieve and maintain good health. Medical researchers use genetics to learn more about diseases that are caused by genes. Researchers use genomics to understand how multiple genes contribute to the development of complex diseases and how these particular genes interact with other factors, such as lifestyle and environment. As a result of such analyses, medical researchers can develop better ways to prevent, diag- nose, and treat diseases.
Genomics is a relatively new science, and genomic testing, which involves combinations of biochemi- cal and molecular methods to analyze a cell’s genes, has the potential to improve the health of individu- als. However, the value of genomic testing for diag- nosing, predicting, and treating common chronic diseases has not been established. Public health experts are concerned about personal genomic tests that are directly marketed to consumers through the Internet and other media outlets. At present, very little scienti!c evidence supports the validity and usefulness of the results of such direct-to-consumer genomic tests.
More research is needed to establish the useful- ness of adding information obtained by genomic testing to the standard medical history that health- care practitioners routinely collect from their patients. Maintaining a record of your health history can help you make a positive contribu- tion to your medical care. How? When you share this information with your physicians, the medi- cal practitioners can consider inherited factors to predict your risk of certain chronic diseases and develop ways (interventions) to help you prevent or forestall those diseases.
of DNA, a complex chemical compound that codes for the production of proteins. Cells use proteins for a variety of functions, including building, maintain- ing, and repairing structures, such as bones and other tissues. Mistakes in the genetic code can result in the production of faulty proteins that can cause disease and even death. Genes are inherited, that is, their coded instructions for protein synthesis are passed on to subsequent generations.
Genetics is the scientific study of genes and the way they pass certain traits, such as the risk of breast cancer, or medical conditions, such as birth defects, from one generation to another. Thus, genetics can help people understand how cer- tain life-threatening medical conditions, includ- ing sickle cell anemia and cystic fibrosis, tend to “run in families.” Scientists have developed tests to identify the gene or genes for hundreds of diseases, most of which are rare genetic disorders, such as Duchenne muscular dystrophy and certain breast and ovarian cancers.
Most of the 10 leading causes of death in the United States, particularly heart disease, cancer, stroke, diabetes, and Alzheimer’s disease, have a
genomics (JEE-nom-iks) The scientific study of an organism’s entire set of genes.
A gene is a segment of DNA. © Hemera/Thinkstock.
12 Chapter 1 Health: The Foundation for Life
quit smoking than someone who doesn’t believe he or she has time to attend. Various barriers, such as poor education or lack of support from family mem- bers, can interfere with self-e&cacy development and reduce someone’s motivation to change or modify their behavior.
Knowledge about risky behaviors and the serious- ness of a health condition is another important factor for behavior change. Someone who smokes cigarettes and does not know smoking causes lung cancer will not usually be motivated to quit. On the other hand, someone who smokes and understands health risks associated with smoking may have a di#erent attitude toward smoking and may be motivated to quit. As we’ve seen, however, many other factors also in'u- ence our health behavior. For example, many people know that seat belts reduce the possibility of a serious injury in an automobile accident and that most states require them to wear seat belts in a car. Nevertheless, some people cite discomfort, restricted movement, and individual choice as reasons for not wearing seat belts regularly. Many students enrolled in personal health classes can correctly identify behaviors that promote optimal health, yet they do not regularly practice these behaviors. Acquiring knowledge about health is important, but many additional factors inform one’s motivation to adopt a healthier lifestyle.
Taking an active role in achieving and maintain- ing good health depends on certain personal factors: degree of perceived vulnerability, attitude, sense of control, and perceived value of the behavior. Health behavior research indicates some people are moti- vated to take action if they feel that a su&cient threat to their health exists and that the consequences of changing the behavior are worthwhile. Furthermore, people tend to be more likely to attempt a behavior if they value the behavior (i.e., the behavior is impor- tant to them), they believe the behavior (e.g., regular exercise) will lead to desired outcomes (e.g., weight loss), and they believe they have control over the behavior (i.e., “I can exercise regularly if I want to”).
Assume, for example, that diabetes a#ects several members of your family. You have heard that diabe- tes may be inherited; therefore, you are aware that you have a good chance of developing this condition
Understanding Health Behavior
Regardless of their cultural and ethnic background, not all Americans share the same level of concern for their health. How many times have you heard a smoker say, “I can stop smoking whenever I want to; now is just not a good time,” or “You’ve got to die of something; it might as well be lung cancer.” You may know people who eat too many fatty foods, do not exercise regularly, drink too much alcohol, and smoke cigarettes. You may know other people who follow a nutritious diet, walk at a brisk pace for 45% minutes nearly every day, and avoid drugs such as alcohol and tobacco. Why do some people adopt more positive health behaviors than others do?
Changing Health Behavior “I wish I could just stop smoking.” “I just can’t seem to !nd the motivation to exercise more o$en.” Do these statements sound familiar? What motivates people to adopt healthier behaviors? Can people will themselves into adopting healthy behaviors?
Professionals who study health behavior o$en use the term motivation to describe what is commonly referred to as willpower. Willpower implies that peo- ple can simply engage in a behavior if they try hard enough; however, engagement in a behavior is o$en motivated by many di#erent factors. Motivation is the combination of all the forces or drives, both inter- nal and external, that lead people to take action or not. Internal factors, such as past experiences, per- ceived needs and barriers, and personal beliefs and values are part of one’s motivation. For example, a person who has tried unsuccessfully to stop smoking several times and claims to enjoy smoking may have little motivation to make another attempt to quit. In this case, the enjoyment a person gets from smoking outweighs potential risks or concerns for his or her health. Additionally, external factors, such as one’s environment (e.g., access to health care, recreational areas, drugs) and social and cultural norms (what is considered “normal” in one’s social circle and com- munity), also in'uence one’s behavior; therefore, these factors are also part of one’s motivation.
Self-efficacy, an individual’s belief in his or her ability to perform a behavior that will lead to the desired outcome, is also an important factor in health behavior. For example, someone who believes he or she has the ability to attend smoking cessa- tion counseling sessions is more likely to attempt to
motivation The forces or drive that leads people to take action.
self-efficacy (EF-fih-ka-see) Regarding health education, the belief that one is capable of changing his or her behavior.
Understanding Health Behavior 13
Diversity in Health Minority Health Status in the United States Did you know that African Americans are more likely to die of cancer than are Whites? Did you know that His-
panics are more likely to die in accidents than as the result of strokes? The differences in death and illness rates for various population subgroups reflect numer- ous factors, such as socioeconomic status and access to health insurance and medical care. By investigating reasons for these differences, medical researchers have learned a great deal about the health of American minor- ities. A major goal of the U.S. Department of Health and Human Services is improving the health of all Ameri- cans through research, education, and better access to health care.
Hispanic or Latino People Hispanic, or Latino, people have immigrated to the United States or have ancestors from countries in which Spanish is the primary language, especially Mexico, Puerto Rico, Central and South America, and Cuba. Hispanics are the largest minority group in the United States, making up 17.8% of the population in 2016.23
In 2015, the leading causes of death for Hispanics were cancer, heart disease, accidental injuries, stroke, and diabetes.21 Some Hispanic/Latino population groups have a high prevalence of asthma, obesity, chronic lung diseases, HIV infection, tuberculosis (TB), and diabetes.
Poverty, lack of health insurance, and poor education are barriers to good health for many Hispanics. About 25% of this minority lives in poverty.24 Health disor- ders associated with poverty, such as tuberculosis and obesity, are more common in certain Spanish-speaking subgroups. In 2015, almost 21% of Hispanic Americans did not have health insurance.25 Hispanic persons, espe- cially those of Mexican ancestry, are more likely to be uninsured than are non-Hispanic Whites. Regardless of one’s ethnic/racial background, not having health insur- ance is a major obstacle to obtaining good health care in the United States.
African or Black Americans In the United States, African Americans comprised 13.3% of the population in 2016; they are the second largest minority group.23 Despite recent improvements, the health status of Black Americans is generally poorer
than that of other minorities. The life expectancies of Whites and Blacks reflect their health status. In 2015, the life expectancy of African American females was 78.1 years; the life expectancy of White American females was 81.1 years. At the same time, the life expectancy of African American males was 71.8 years and that of White males was 76.3 years.21
The major causes of death of Black Americans are similar to those of non-Hispanic Whites. Although Black Americans are less likely to die from chronic lung dis- eases, Alzheimer’s disease, and suicide, members of this minority are more likely to die of homicide, cancer, stroke, diabetes, HIV infection, and heart disease than are White Americans.21 Black women are more likely to die of breast, cervical, colon, and stomach cancers than White women are, and Black men are more likely to die of lung, prostate, colon, and stomach cancers than White men are.21 Simi- lar to Hispanic populations, disparities in disease rates and treatment are partially explained by economic factors; approximately 25% of African Americans live in poverty.26
Childbearing is riskier for an African American woman; in 2015, African American women were almost three times more likely to die during pregnancy or childbirth than were White women.21 In addition, Black infants are more likely to die during the first month of life than other babies are; in 2015, the infant death rate among Black infants was more than twice that of White babies.21
In 2015, African Americans were more likely to have hypertension than non-Hispanic White Americans or Mexican Americans.26 The reason for this high prevalence is unclear, but scientists think diet, genetics, stress, and smoking play roles. Overweight also increases the risk of hypertension. African Americans are more likely to have excess body fat than are other Americans. In 2015, approximately 48% of non-Hispanic African Americans were obese, compared to 42% and 34% of Hispanic and White Americans, respectively.27
Asian and Pacific Islanders As one of the fastest growing minority groups, Asian Americans and Pacific Islanders (APIs) are a diverse group of people who immigrated to the United States from China, Japan, Vietnam, Korea, India, the Philip- pines, and other Pacific Islands. In 2016, Asian Ameri- cans made up about 6% of the U.S. population.23 Asian Americans generally have lower age-adjusted death rates for the 10 major causes of death than do Whites and members of other minority groups.21 This means that an average 30-year-old Asian American is less likely to die of any major cause of death, including heart disease and cancer, than is an average 30-year-old American who is a
14 Chapter 1 Health: The Foundation for Life
White person or a member of another minority popula- tion. Compared to other minority groups of Americans, Asian American women have the highest life expec- tancy.21 Asian American women, however, are more likely to die from stomach cancer than other American women are.21 People who immigrated recently from Asia and the Pacific Islands are more likely to suffer from hepatitis, a serious liver disease, and tuberculosis than are people who have lived in the United States for longer periods of time. Factors that contribute to the poor health status of some Asian Americans include language and cultural barriers; social disgrace (stigma) associated with certain conditions, especially mental illness; and lack of health insurance.28
American Indians and Alaska Natives American Indian and Alaska Natives (AI/ANs) are a diverse group of people comprising only about 1.5% of the American population in 2016.23 About 22% of this minority population live in designated areas such as res- ervations or reservation trust areas, whereas 60% live in metropolitan areas. AI/ANs generally have more health problems than do non-Hispanic White Americans. Geo- graphic isolation, poverty, inadequate sewage disposal, and cultural barriers are some of the reasons that health among AI/ANs is poorer than it is among other groups of Americans.29
American Indian/Alaska Native infants and children are more likely to die than are other American infants and children.29 AI/ANs are more likely to be smokers than are members of other racial/ethnic groups, and binge drink- ing is a serious health concern of AI/ANs. Diabetes poses a health threat for many members of this minority. The rate of diabetes among AI/ANs is twice as high as the rate among White Americans.29 In addition to diabetes, mental health problems and alcohol-related deaths such as accidents, homicides, and suicides are major health concerns for AI/ANs.
The Impact of Social Conditions on Health Status Although genetic factors may be the primary cause of many health problems, income level, health insurance coverage, educational attainment, and years living in the United States play major roles in determining a par- ticular group’s state of health. Many chronic diseases, such as tuberculosis and malnutrition, are associated with poor standards of living. Other health threats often associated with poverty include substance abuse, homicide, and lead poisoning. Poverty, however, is not limited to any single population group in the United States. Regardless of their racial or ethnic background, individuals who achieve a higher level of education usually have higher incomes and better health than do those with less education.
In the United States, many chronic diseases are associated with poor standards of living. © DenisTangneyJr/iStock/Getty Images Plus/Getty Images.
Understanding Health Behavior 15
realize or admit tobacco use is unhealthy, and they intend to quit smoking in the next 6 months. In the preparation stage of change, smokers may have made unsuccessful attempts to quit smoking, yet they express
(vulnerability). You know that family mem- bers who have diabetes su#er from kidney damage, blindness, and premature heart dis- ease. Because you want to avoid these conse- quences, you are motivated to change certain behaviors (motivation). Moreover, you believe that your actions in'uence the quality of your health (sense of control). Concerned, you decide to learn more about diabetes and determine what actions can reduce your risk of developing the disease. You now have a reason to take action because you believe it is important (value) to prevent this disease, even if it means making lifestyle changes now while you are still healthy.
Making Positive Health-Related Decisions How I Quit Smoking About a month ago, I%was a smoker—about 10 cigarettes a day dur- ing the week and up to a pack a day on week- ends. A$er thinking about quitting for about a year, it happened. Without even giving it any consideration, I was able to not buy a pack for 2 days. On day 3, I realized my success and told myself I would never buy a pack again. I miss it, especially a$er a drink or a meal, but I’m glad I’ve gone this far. "ere have been times when I’ve really wanted one, but that’s when you real- ize how powerful of a drug it is. At least that’s how I talk myself out of having one. Before, I never thought of myself as being addicted—too harsh of a word— but I was just like all of the other smokers out there. It’s a !lthy habit—I’m glad I stopped.
Although this college student smoked less than a pack of cigarettes a day, he took about a year to quit smoking. He made the !nal decision to stop smok- ing while listening to other students’ habit-breaking experiences in his health class. Some people take less time to make health-related decisions than others do, and some people have less di&culty making life- style changes than others do. Figure 1.6 illustrates the complex process of decision making.
According to many health education experts, the process of changing behaviors involves the !ve stages shown in Figure 1.7.30 We use the example of smoking to illustrate this process. "e !rst stage is precontem- plation. In this stage, smokers show no interest in quit- ting tobacco use, do not see a need to quit, and may avoid discussing their smoking behavior with others. Smokers move into the contemplation stage when they
Figure 1.6 Decision-Making Model. Decision making can be a complex process. Information, personal attitudes, and personal experiences influence your decision-making process. To change health-related behaviors, you must recognize the need to change, that the change has personal value, and that it is consistent with your beliefs.
Evaluate Choices
Consider Pros and Cons
Analyze Outcomes
Consider Benefits
and Harms
Receive Information
(Cues)
Environment
Media
Institutions
FriendsFamily
Peers
Feedback
Health Practitioners
Recognize the Need to Change
Behavior
Change Has Value
Make Decision
Formulate Attitudes
and Beliefs
Figure 1.7 Stages of Behavior Change. According to many health education experts, the process of changing behaviors involves these five stages.
Precontemplation
Contemplation
Preparation
Action
Maintenance
16 Chapter 1 Health: The Foundation for Life
fruit, or drinking a glass of water whenever you feel the urge to smoke may also reduce the craving.
Rewards are incentives for positive behaviors. Some former smokers keep a jar in which they save the money that would have been used to buy ciga- rettes. At the end of a week or two, they spend that money on something fun such as a movie or another type of reward to help maintain the new behavior. Other former tobacco users are rewarded by the return of their sense of taste or the praise they receive from nonsmokers for adopting a smoke-free lifestyle.
Obtaining social support by enlisting the help of others is very important for changing a negative behavior and maintaining a positive one. If you are a smoker in the contemplation stage of change and most of your friends are smokers in the precontem- plation stage, they are not likely to support your e#orts to quit. "erefore, you may have to associate with nonsmokers or people in later stages of change to provide the help, encouragement, and positive reinforcement you need to quit tobacco use.
A systematic model for the decision-making pro- cess can help you improve your health and well-being. A model is a plan or pattern that can be used as a guide.
"e !rst part of the decision-making process involves identifying a problem behavior that you want to change, a goal that you would like to reach, or a question that you would like to answer. For example, you might want to quit smoking, lose 20 pounds, or determine whether you are ready to end an abusive relationship. Because the process of altering a behav- ior can have its unpleasant aspects, particularly if you have to overcome side e#ects or cravings, it is important to determine your level of commitment. To determine if you are ready to change a behavior or situation, it is helpful to make a list of the bene!ts, or pros, as well as the harms, or cons, of changing. A$er you make the list, think about each pros and cons value or importance to you. Assign a point value from 1 to 5 to each pro and con; a rating of 5 points would
the desire to stop within the next month. Smokers in the action stage of change take steps to quit smoking, such as “going cold turkey” or using a nicotine patch. "ey succeed in quitting for up to 6 months. Finally, smokers in the maintenance stage develop practices to avoid relapsing into using tobacco. Former smok- ers, for example, might socialize with nonsmokers or use exercise as a substitute for smoking. According to health education researchers, 40% of people who engage in risky behaviors such as smoking or being physically inactive are in the precontemplation stage, 40% are in the contemplation stage, and the remaining 20% are preparing to change the unhealthy behaviors.31
When people relapse, they return to an earlier stage of change and usually feel like failures as a result of their inability to maintain the new behaviors. In the case of smokers, they may even return to the precontempla- tion stage in which they stop thinking about quitting. However, the majority of people who relapse eventually decide to stop smoking again, and they tend to try a dif- ferent method of quitting. People who seriously want to quit smoking, for example, typically make three to four e#orts to stop before they actually succeed.31
When changing a behavior, people use various strategies to increase their chances of success, includ- ing stimulus control, counterconditioning, rewards, and social support. Stimulus control involves alter- ing cues to modify responses (behaviors). Cues can be sensory triggers, such as seeing a billboard adver- tisement for cigarettes or smelling someone else’s cigarette smoke. Cues can also be emotional states or thoughts. For example, a person may smoke to relieve stress or because he or she associates smoking with celebrities or sophisticated people. As a result, this person is likely to light up a cigarette when tense or in certain social situations.
If you are a smoker who wants to quit, you may need to identify and eliminate the various cues that signal this unhealthy behavior. You may realize, for example, that seeing ashtrays and lighters are your smoking cues. "rowing out or giving away your ashtrays and lighters are ways of avoiding these cues. If feeling tense triggers your desire to smoke, then learning and practicing relaxation techniques when- ever you feel stressed out may help you resist the urge to buy a pack of cigarettes.
Counterconditioning involves replacing unhealthy behaviors with less destructive or healthier ones. When you desire a cigarette, you may be able to elim- inate the craving by exercising, taking a warm bath, or calling someone who supports your e#orts to quit. Chewing sugarless gum, eating raw vegetables or
Cues are sensory triggers for behaviors, such as seeing cigarette butts as a cue for smoking. © AbleStock.
Understanding Health Behavior 17
be the highest value. "en, !nd the sums of each list. If the sum of the cons list is greater than that of the pros list, you are probably in the precontemplation stage and not ready to make the change. On the other hand, if the sum of your pros is higher, you are likely in the contemplation stage and ready to make the change.
"e second part of the process used in the decision-making model describes steps you can take to implement the change and evaluate your progress. A$er you decide to make a change, set a target date to begin the new behavior, reach the goal, or modify the situation. Mark that date on a calendar that is in an obvious place for you to notice, such as by your computer monitor or on your refrigerator or mir- ror. "en, make a list of factors that will increase the chances that you will be successful in making the change, such as enlisting the help of friends or obtain- ing advice from a medical expert. Because there are o$en barriers to making changes, make another list of factors that will hinder your chances for success, such as having little time to practice new behaviors or friends who will not support your decision to change.
"e third major step in the process involves pre- paring an action plan that provides speci!c steps you will take to change your behavior or situation. You should be able to identify more than one way to reach your goal. To quit smoking, for example, you might quit “cold turkey,” gradually reduce the number of cigarettes smoked over a 4-week period, or use a medically approved nicotine-containing product. At this point, it is important to learn about the pros and cons of each method and consider the factors that can help or hinder your e#ort to change. How are you going to handle cravings or social situations that pro- mote the behavior you are trying to change? Now you are ready to make the change by implementing your action plan. Keep a daily record of your progress, including helping strategies and your feelings about the process. When you reach the goal date, analyze your success in attaining the goal. How well did your plan work? What can you learn from the experience?
To enjoy a long, healthy, and productive life, it is important for you to make numerous health-related decisions every day. It may be more di&cult to engage in healthy behavior and avoid less healthy behaviors if you base decisions on cues or momentary emo- tions. However, you are more likely to engage in healthy behaviors if you follow a systematic method of decision making such as the one described in this text. Changing habits o$en requires learning new information, gaining new skills, and planning for the new behavior(s).
!e Goal of Prevention A primary focus of health promotion is prevent- ing diseases, infections, injuries, birth defects, and other serious health conditions. Preventing a health problem is typically better for long-term health and it is o$en less costly than treatment. In addition to adopting healthy lifestyle practices, serious health problems can also be prevented by having routine physical examinations. "e Managing Your Health box that follows provides recommendations for the frequency of routine screening procedures such as blood pressure and cholesterol screenings, mammo- grams, prostate exams, and Pap smears (cervical can- cer detection). Some examinations, such as testicular and breast self-exams, can be done in the privacy of your home. Some college students do not believe routine physical evaluations are important; however, having regular medical checkups enables you and your physician to monitor your physical and psycho- logical health status. Furthermore, your physician may be able to identify a problem before it results in serious damage to your health and well-being.
Can Good Health Be Prescribed? No one has a crystal ball that predicts future health, and neither can anyone guarantee good health. Numer- ous factors contribute to an individual’s chances of enjoying a long and productive lifetime of good health. Several of these factors are the result of daily lifestyle behaviors to prevent or delay disease. You may know someone or have heard about individu- als who did not exercise, smoked a pack of ciga- rettes a day, and consumed a six-pack of beer each night, yet lived to a ripe old age. Such behavior de!es
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18 Chapter 1 Health: The Foundation for Life
Managing Your Health
The following recommendations apply to adults who have low risks of disease. People who have higher risks may need more frequent testing and to begin testing at
an earlier age. Consult your personal physician for advice about routine test- ing and immunization schedules.
Medical Test/Preventive Measure Recommended Frequency
Blood pressure At least every 2 years
Cholesterol (fasting lipoprotein profile)
Men aged 20–35 and women over 20 with increased heart disease risk; all men aged 35 and older
Glucose Asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg
PSA and digital rectal exam (detects prostate cancer)
Men aged 50–75
Testicular exam Some physicians recommend regular exams; discuss need for exam with physician
Skin exam (detects skin cancer)
Have physician check skin during routine general exams
Breast exam (detects breast cancer)
American Cancer Society recommends annual screen and clinical breast exams for healthy women aged 45 years and older; women should have the choice to begin annual mammograms at age 40
Pap test (detects cervical cancer)
Begin screening within 3 years of first sexual intercourse or by 21st birthday; yearly Pap test, or every 2 years if liquid form of test is used. Beginning at age 30 years, include human papillomavirus (HPV) test
Routine Health Care for Disease Prevention: Adult Recommendations
Medical Test/Preventive Measure Recommended Frequency
Colon/rectal examination (detects cancer)
Have flexible sigmoidoscopy or colonoscopy at age 50 years; physician can decide which test is appropriate and how often testing should be repeated
Sexually transmitted infections
Sexually active people who are 24 years of age or younger should be tested for chlamydial infection; older women should be tested if they have new or multiple sex partners. All adolescents and adults aged 15–65 years should be tested for HIV.
Immunizations
Rubella One or two doses from ages 19 to 59
Influenza Annually for adults aged 19 and older
Tetanus Every 10 years
Hepatitis B Three doses
Recommendations vary among medical organizations.
Data from U.S. Centers for Disease Control and Prevention. (2017). Recommended immunization schedule for adults aged 19 years and older, United States. Retrieved from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf; Agency for Healthcare Research and Quality. (2014). Guide to Clinical and Preventive Services, 2014. Retrieved from http://www.ahrq.gov/professionals/clinicians -providers/guidelines-recommendations/guide/section1.html#ref12; American Cancer Society. (2018). American Cancer Society breast cancer screening guideline. Retrieved from https://www.cancer.org/latest-news/special-coverage/american-cancer-society-breast-cancer-screening -guidelines.html.
The Goal of Prevention 19
nearly every reasonable prescription for good health. Perhaps these people inherited genes that foster the hardiness to withstand the e#ects of their risky life- styles. You might wonder if these people enjoyed good health throughout their lives, or if they spent their last years in poor health. Would their lives have been even longer and healthier if they had followed more health-conscious behaviors?
Analyzing Health Information
“Take antioxidants to live longer.” “Drink red wine to prevent heart attacks.” “Improve your memory with ginkgo.” Every day, Americans are barraged with a confusing array of health-related information in newspapers, magazines, television and radio shows, commercials, and infomercials. Family members, friends, medical professionals, and the Internet also supply information about health and health-related products. Are these sources reliable? Not necessarily. No laws prevent anyone from making statements or writing books about health, even if their information is false. "e First Amendment to the U.S. Constitu- tion protects freedom of speech and freedom of the press. "is protection extends to talk show hosts and guests, authors, and salespeople in health food stores who might provide health misinformation.
Companies and individuals can make consider- able amounts of money by selling untested remedies, worthless cures, unnecessary herbal supplements, and books !lled with misinformation. Health frauds include the promotion or sale of substances or devices that are touted as being e#ective to diagnose, pre- vent, cure, or treat health problems, but the scienti!c evidence to support their safety and e#ectiveness is lacking.
Despite the regulatory activities of the Food and Drug Administration (FDA) and Federal Trade%Com- mission (FTC), the sale of fraudulent products and services and the circulation of false or misleading health information continue to be concerns for med- ical experts. For information about the roles of the FDA and FTC in regulating health-related informa- tion, see the Consumer Health feature that follows.
Becoming a Wary Consumer of Health Information Maybe you have read an article or an ad about the health bene!ts of an herbal supplement or a weight- loss device that you might buy. Perhaps you watched a physician promote his “antiaging, high-energy” diet on a TV show. How do you know if health-related information and claims that are in the media and from other sources are true? Will the supplement, device, product, or diet do what its promoters claim? Or will you merely be wasting your money?
As shown in Figure 1.6, information is a crucial element of decision making. Although health infor- mation from some sources is based on scienti!c evi- dence and can be extremely useful, that from other sources may be unreliable. Relying on 'awed infor- mation can waste time and money and can even be dangerous. To be a wary consumer of health infor- mation, you need to learn how to analyze it.
Analysis Model Analyzing something simply means breaking it down into its component parts for study. Analyzing information is easier to do if you follow a particular model of analysis. "e following model is a series of questions that will help you evaluate health information and determine if it is reliable, regardless of its source.
anecdotes Personal reports of individual experiences.
testimonials Individual claims about the value of a product.
4To change your health-related behaviors, you must determine that you need to change and that you value the change.
4Use a decision-making plan as a tool to help you make responsible decisions.
4Take charge of your health by having regular physical examinations and monitoring your health.
Healthy Living Practices
1. Which statements are veri!able facts, and which are unveri!ed statements or value claims? In the context of this model, veri#able facts are con- clusions drawn from scienti!c research. Unveri- #ed statements are conclusions that have no such support. Value claims are statements suggesting that something is useful, is e#ective, or has other worthwhile characteristics. Look for unveri!ed statements and value claims; such information
20 Chapter 1 Health: The Foundation for Life
2. What are the credentials of the person who makes health-related claims? Does this person have the appropriate background and edu- cation in the topic area? What can you do to check the person’s credentials? O$en it is di&- cult to tell if a health “expert” is quali!ed to make claims. Articles and books usually include the name and credentials of the author, but the cre- dentials may be fraudulent. Anyone can call him- self or herself a “nutritionist,” “doctor,” or “health expert.” "erefore, a PhD or the title “Certi!ed%. . .” a$er someone’s name is no guarantee that this
may or may not be true. Also, be wary of claims that “sound too good to be true.”
Look for red-$ag terms, expressions that indicate the possibility of irrelevant information or misinformation, such as “patented formula,” “all-natural,” “no risk,” “chemical-free,” “clini- cally tested,” “scienti!cally proven,” or “every- one is using.” Claims that the product or service provides “quick,” “painless,” “e#ortless,” or “guar- anteed” cure or other desirable results are also red 'ags.
Ignore anecdotes and testimonials. Anecdotes are personal reports of individual experiences, such as “I take vitamin C and zinc pills, and I never get colds.” Testimonials are claims indi- viduals make concerning the value of a product. Advertisers o$en rely on paid celebrities to pro- vide testimonials. Anecdotes may be interesting and testimonials may be persuasive, but these sources of information re'ect the experiences of individuals and may not be true for most people. More compelling evidence, on the other hand, involves results of studies of hundreds or thou- sands of people. Such !ndings are more likely to be generalized to a wide population.
Look for disclaimers on product labels or in advertisements, such as “"is statement has not been evaluated by the FDA,” “"is product is not intended to diagnose, treat, cure, or prevent dis- ease,” or “Results are not typical.” In televised or written ads, disclaimers usually appear in small print near the end of the ad. Disclaimers may provide important information to consider.
Consumer Health Consumer Protection The U.S. government has laws and agencies to protect consumers against health fraud.
The federal agencies that enforce consumer protection laws include the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC). The FDA protects consumers by regulating the information that manufac- turers can place on food or drug product labels. In addi- tion, FDA personnel alert consumers about fraudulent health practices and can seize untested or unsafe medical devices and drugs. The manufacturers of such products can be punished (usually fined) for their illegal practices. The FTC regulates claims made in advertisements for
products and services. Both agencies reg- ulate only products and services involved in interstate commerce. The FDA’s web site is www.fda.gov, and the FTC’s web site is www.ftc.gov.
To avoid being victims of health frauds, people must take the initiative and be very critical when judging the reli- ability of health-related information. If you suspect fraudu- lent activity, you can file a complaint with the local office of the FDA or your state’s attorney general. You can also file a lawsuit if you have been injured as a result of following the advice or using the services or products of unscrupulous practitioners and manufacturers.
Disclaimer on a dietary supplement label. Courtesy of Wendy Schi".
Analyzing Health Information 21
person has had extensive training in a health or science !eld from an accredited educational institution. Individuals can buy certain doctorate degrees through the mail or Internet from unac- credited colleges called “diploma mills.” To deter- mine if a college or university is accredited, visit the U.S. Department of Education’s web site (www .ed.gov).
One way to investigate an author’s medical or scienti!c expertise is to see if his or her work has been published in reputable journals. To conduct a literature search, use a site such as PubMed, which is sponsored by the National Library of Medicine (www.ncbi.nlm.nih.gov/pubmed/).
Quackery is the practice of medicine with- out having the proper training and credentials. Quackwatch is a web site operated by retired psy- chiatrist Stephen Barrett, vice president of the Institute for Science and Medicine and a fellow of the Committee for Skeptical Inquiry. Quack- watch (www.quackwatch.org) provides informa- tion about health-related frauds as well as people, popular books, and organizations that are sources of questionable health information.
3. What might be the motives and biases of the person making the claims? Motive is the incen- tive, purpose, or reason for which someone pro- motes health misinformation. People pro!t from the sales of books as well as bogus treatments and products. "us, ads are always written to moti- vate the consumer to buy the treatment, product, or service. A bias is the tendency to have a partic- ular point of view. "e author of a book or article, for example, may present information that sup- ports his or her bias and ignores opposing views or research !ndings that do not support the bias. When analyzing health-related information, it is important to take into account the motives and biases of the people providing the information as you draw conclusions from it.
4. What is the main point of the article, ad, or claim? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant? "e main point may be to provide practical information, but in many instances, it is to encourage you to buy a product or service. Ignore terms and information that are
not pertinent or to the point; they will only con- fuse your analysis.
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the bene!ts and risks of the product? Look for sup- porting or more in-depth information in scien- ti!c or medical journals because their articles are written and reviewed by scientists or medical experts. Articles in reputable scienti!c journals have been peer reviewed, meaning their content was critiqued by experts in that !eld before it was accepted for publication. If peer reviewers think a study was poorly designed or provides question- able conclusions, the article describing the study is likely to be rejected by the journal’s editor.
Be wary of sources, such as magazines, books, and journals, that look like bona !de providers of health information but may not be. In many instances, they are actually designed to sell prod- ucts or services. Such publications have articles about the bene!ts of healthcare products and include advertisements and instructions for order- ing these products, o$en in the article or next to it.
Be skeptical of promoters, articles, or ads that do not present the risks along with the bene!ts of using a health product or service. For example, a reliable article about taking bee pollen supple- ments should present scienti!c evidence from peer-reviewed journals to support as well as refute health claims. Moreover, reliable sources of information o$en caution people about the hazards of using treatments, and they may include recommendations to seek the advice of more than one medical expert.
6. Does the source of information attack the cred- ibility of conventional scientists or medical authorities? In some instances, people making health claims try to confuse readers by imply- ing that evidence-based medicine is unreliable. For example, an ad for a treatment to relieve back pain may include claims that the technique is “unknown to Western medicine” or “used for centuries in China.” Such claims suggest that conventional medical practitioners, including physicians, dietitians, and nurse practitioners, lag behind ancient systems of health care in !nd- ing cures or treatments. Statements that attack the reliability of conventional (scienti!c) medi- cal practitioners are usually indications that the information is unreliable.
quackery The practice of medicine without having the proper training and credentials.
22 Chapter 1 Health: The Foundation for Life
Although HON monitors the web sites it certi!es, no organization regulates the quality and truthful- ness of all the health information on the Internet. Many web sites are sources of inaccurate and poten- tially harmful information. "erefore, you need to analyze the reliability of health information from web sites as critically and carefully as you analyze health information from other sources. In addition, when researching a health topic, seek information from more than one Internet source and consult a medical professional before following advice from the Web.
When using a web site as a source of health-related information, determine answers to the following questions to help you establish credibility of the site.
• What is the source of the information? Web sites sponsored by individuals may give questionable advice that is based on personal experiences, biases, or opinions rather than medical expertise and scienti!c evidence, unless the individuals are credentialed experts. Commercial sites (.com) may or may not contain misinformation, but keep in mind that their purpose is generally commercial, not educational. As with any commercial endeavor, the focus is usually selling products, so what is stated is meant to entice the buyer. Web sites sponsored by organizations (.org) may or may not provide credible information as well. However, there are many good .com and .org sources of health-related information. Asking yourself the next questions will help you determine which of those sites likely provides reliable health-related information.
• Is the site sponsored by a nationally known health or medical organization or a"liated with a well-known medical research institution or major university? If not, is the site sta#ed by well-respected and credentialed experts in the !eld? Such sites usually provide accurate and timely health information. Some have independent review boards to ensure that the site maintains accuracy and timeliness. Web sites providing credible health-related information usually include documentation of the expertise of the sta# and the background of the institution or organization.
• Does the site include up-to-date references from well-known, respected medical or scienti!c journals or links to reputable web sites, such as nationally recognized medical organizations? Such information generally helps support the claims or information on the site and provides
Finding reliable sources of health-related informa- tion can be challenging. You can usually obtain reli- able answers to your questions from experts at state and local health departments, universities and col- leges, local hospitals, and federal health agencies.
Assessing Information on the Internet "e Internet can be a valuable source of health-related information. "e U.S. government maintains web sites for health-related information, including the sites of the Centers for Disease Control and Prevention (www.cdc.gov), the Food and Drug% Administra- tion (www.fda.gov), and the National Institutes of Health (www.nih.gov). Additionally, the Depart- ment of Health and Human Services sponsors www .health!nder.gov, a general health information site that provides links to reliable sources, including gov- ernment agencies, universities, and nonpro!t health organizations.
Web sites that are accredited by the Health on the Net (HON) Foundation (www.healthonnet.org /pat.html) are reliable sources of health-related or medical information. "is nonpro!t organization is headquartered in Switzerland and provides a widely recognized and accepted code of ethics. Web sites can become certi!ed by adhering to the HONcode. "e HON site also provides a search engine to research trustworthy sources of health information (www .healthonnet.org/HONsearch/Patients/index.html).
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Analyzing Health Information 23
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine
Conventional medicine (scienti!c medicine) relies on modern scienti!c principles, modern technolo- gies, and scienti!cally proven methods to prevent, diagnose, and treat health conditions. "e notion that certain agents of infection such as bacteria and viruses cause many health disorders is accepted by conventional medical practitioners. To practice in their professions, conventional healthcare practi- tioners, such as physicians, nurses, dietitians, and dentists, must meet established national and/or state standards concerning their education and pass licensing examinations. To maintain their profes- sional certi!cation or licensing, many types of con- ventional healthcare practitioners must update their medical backgrounds regularly by participating in continuing education programs. Most Americans use the services of conventional medical practitioners.
Before adopting a method of treatment, conven- tional medical practitioners want to know if it is safe and e#ective. To determine the safety and e#ec- tiveness of a treatment, medical researchers usually conduct studies on animals before testing humans in clinical studies. A clinical study should contain at least 30 subjects, preferably hundreds or thousands if possible. "e greater the number of participants in the study, the more likely the !ndings did not occur by chance and are the result of the treatment.
In designing clinical studies, researchers take a group of volunteers with similar characteristics and randomly divide them into two groups: a treatment group and a control group. Subjects in the treatment group receive the experimental treatment; members of the control group are given a placebo. A placebo, o$en referred to as a “sugar pill,” is a sham treatment that has no known physical e#ects. Because a person’s positive expectations can result in positive !ndings, placebos help rule out the e#ects of such wishful thinking.
Researchers give subjects placebos to compare their responses to responses of subjects who receive the actual treatment. In double-blind studies, subjects and researchers are unaware of the identity of those taking placebos. Placebos can temporarily relieve sub- jective complaints, such as pain, lack of energy, and poor mood. "us, subjects who are given placebos
ways to research the claims in-depth. Providing such references also shows that the information is based on published research.
• Is the information at the web site current? Health information is constantly changing; the site should indicate when the information was posted and updated.
Applying What You Have Learned
"e Analyzing Health-Related Information feature in this text provides examples of ads, articles, and web sites to help you determine the value of health-related information. To sharpen your critical thinking skills, analyze the information in these features using the six points of the analysis model. When you analyze a web site, use the questions posed in the previous section. If you determine that the web site is highly credible, your analysis is completed. If, however, you are unsure of the credibility of the site a$er answering the Web analysis questions, then continue with the six Analyzing Health-Related Information questions. Additionally, the Consumer Health feature provides tips to help you become a better consumer of health information.
To obtain reliable answers for your health-related questions, consult experts at clinics or hospitals, state and local health departments, universities and col- leges, federal health agencies, and nationally recog- nized health associations and foundations.
conventional medicine The form of medicine that relies on modern scientific principles, modern technologies, and scientifically proven methods to prevent, diagnose, and treat health conditions.
placebo A sham treatment that has no known physical effects; an inactive substance.
4Use the model for analyzing health-related information and the questions for analyzing web sites to evaluate information from the media and other sources.
Healthy Living Practices
24 Chapter 1 Health: The Foundation for Life
Critical Thinking
Analyzing Health-Related Information
SwayCon Pharmaceuticals has developed a capsule that contains everything you need to reduce suffering, enhance health, and regain youthful vigor.
A team of medical experts from three major medical schools in the United States have clinical proof that the ingredients of Panacea are effective! Panacea contains a chemical-free mixture of natural enzymes and exotic herbs that • relieve up to 80% more arthritis pain than
aspirin; • lower blood pressure by up to 20%; • lower cholesterol by up to 45%; • reduce lung cancer risk by as much as 50%,
even in smokers; • and reduce the risk of heart attack by 75%.*
Other remarkable findings Taking Panacea for a few months can improve
intelligence. R.P., a college student at a large East Coast university, reports, “At the beginning of the fall semester, I started taking three capsules of Panacea a day. My G.P.A. went from a 1.8 to a 3.4! Panacea has helped me get all A’s!”
Reports are coming into our offices that Panacea acts as a sexual stimulant, increasing potency. S.D., a computer programmer in St. Louis, writes, “Thanks for saving my marriage. Before taking Panacea, my husband complained about my lack of interest in sex. One of my friends told me that Panacea can help. Just a few days after taking the capsules, our marriage turned into a perpetual honeymoon.”
Panacea is only available in fine health food stores. Order a three-month supply now,
while supplies last
For centuries, doctors in the Orient have known
about the wonders of herbal medicines—
nature’s botanical cures for human ailments.
Finally, American scientists are recognizing the healthful benefits
of these herbs.
A PANACEA PILL A DAY KEEPS THE EXPENSIVE DOCTORS AWAY!
This suggests that American scientists do not understand that medicines can be derived from plant sources, when, in fact, American researchers often rely on plants as sources of chemicals that have medicinal uses. No scientific evidence is cited to show that the herbs in Panacea have the touted properties. These two sentences, then, contain only value claims; thus, the information may be unreliable.
This statement has value claims that are not supported with scientific evidence.
No treatment contains everything each person needs to improve his or her health.
“Clinical proof” is a red flag. The medical experts and medical schools where their research has been conducted are not identified. Objective testing could show the product is neither safe nor effective. The ad should cite the specific effects of the product, including negative ones.
“Chemical-free” is a red flag; all matter, including herbs and other plants, is comprised of chemicals. Furthermore, scientific studies should be cited to provide evidence for these value claims.
A testimonial from an individual is not scientific evidence. This student’s G.P.A. may have risen for a variety of reasons. Studies conducted to show that a treatment is useful should contain at least 30 subjects.
“Potency” is a vague and unfounded red-flag term. Again, this testimonial is a value claim that is unsupported by scientific evidence.
No scientific evidence is cited that a daily Panacea pill prevents serious illness. Additionally, this statement attacks conventional medical practitioners by implying that they are interested only in making money, which suggests that physicians can’t be trusted.
This is irrelevant information. Where the product is sold has nothing to do with its quality or characteristics. The authors of the ad are simply trying to make their product look superior to other similar products.
Conclusion: This ad is merely a collection of value claims that are not supported by scientific research. The ad further attempts to encourage the reader to purchase the product by suggesting that it is better (and less expensive) than conventional therapies. It claims to relieve a wide range of health conditions. The red-flag phrases and testimonials, lack of scientific evidence, and failure to caution consumers about potential hazards of the product all suggest the ad is an unreliable source of health-related information.
* These statements have not been evaluated by the FDA.
This statement gives the impression that consumers have no time to investigate the product thoroughly. It is intended to make consumers think that the product will sell out if they wait, and they will miss out on a good thing. Again, this information is irrelevant.
Disclaimer
Finally, American scientists are ecognizing the healthful benefit Finally Ameerican scientists areerican
human ailmen
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 25
information about popular CAM practices, including homeopathy and re'exology.
Promoters of certain CAM practices claim dis- eases can be prevented or cured by “cleansing” tissues, “eliminating toxins” from the body, and “balancing chi.” To support claims of their method’s e#ectiveness, promoters o$en use anecdotal reports and testimonials. Nevertheless, the e#ectiveness of most CAM therapies is not supported by results of well-designed clinical studies.
Conventional medicine focuses on the “disease- oriented” approach, which seeks to diagnose and treat illnesses. Many physicians practice integrative medicine, which emphasizes personalized health
o$en report feeling better even though the placebo did not provide any known physical e#ects. Scientists refer to these reports as the placebo e!ect. "e placebo e#ect may be responsible for many claims of bene!cial results from using unconventional medical therapies.
Complementary and alternative medicine (CAM) is an unconventional and diverse system of preventing, diagnosing, and treating diseases that emphasizes spirituality, self-healing, and harmonious interaction with the environment.32 A treatment is complemen- tary when it is used along with scienti!c medical care. A young man with liver cancer, for example, may use yoga and meditation to accompany the conventional medical treatments prescribed by his physician. An alternative therapy replaces conventional medical therapy. If the patient with liver cancer stops his pre- scribed treatments and substitutes fasting and co#ee enemas in hopes of a cure, he is relying on alternative forms of medical care.
CAM can be classi!ed as follows:
• Alternative medical systems, such as Ayurveda, traditional Chinese medicine, homeopathy, and naturopathy
• Manipulative therapies, such as spinal manipulation (chiropractic), osteopathy, re'exology, rol!ng, and therapeutic massage
• Mind–body interventions, such as meditation, biofeedback, prayer, and creative arts healing (music therapy, for example)
• Biologically based treatments, such as aromatherapy, special foods (probiotic yogurt, for example), herbal teas, and large doses of vitamins
• Energy therapies, such as acupuncture, acupressure, and use of magnets
Certain CAM therapies have positive e#ects on the body and mind. For example, acupuncture (Figure"1.8) can relieve the nausea and vomiting that o$en occur a$er surgery or that are associated with early preg- nancy and lower back pain.33 Although di&cult to test scienti!cally, aromatherapy and therapeutic mas- sage can be soothing and relaxing. Table 1.4 provides
integrative medicine A system of medical care that emphasizes personalized health care and disease prevention.
dietary supplement A product that is consumed to add nutrients, herbs, or other plant materials to a person’s diet.
Figure 1.8 Acupuncture. Some physicians combine acupuncture with conventional forms of medical care. Acupuncture may stimulate the body to release natural pain-relieving compounds, but its effectiveness is difficult to test scientifically. © Stuart Pearce/Pixtal/age footstock.
26 Chapter 1 Health: The Foundation for Life
Type Claims and Principles of Practice Results of Scientific Research
Acupuncture Used to treat a variety of common ailments. Based on an ancient Chinese medical practice in which thin needles are inserted into the skin or underlying muscles at specific places and stimulated to regulate the flow of “chi,” the life force.
Testing acupuncture scientifically is difficult. It may relieve nausea and vomiting associated with “morning sickness,” recovery from surgery, and cancer chemotherapy. Acupuncture may stimulate the body to release natural pain-relieving compounds.
Ayurvedic medicine
According to ancient Hindu religious beliefs, one achieves good health by meditating; eating grains, ghee (a form of butter), milk, fruits, and vegetables; and using herbs. Lack of balance between “energies” causes health problems.
Fasting and enemas are used to treat severe ailments.
Meditation relieves stress; fruits, vegetables, and dairy products are nutritious foods; and some herbs have medicinal value. Ghee, however, can be fattening, and fasting can be dangerous for unhealthy people. Enemas are unnecessary for good health and should be used only under a physician’s instructions.
Chiropractic medicine
According to some chiropractors, misaligned spinal bones cause disease. Spinal manipulation prevents or cures disease by correcting the spine.
Other practitioners use spinal manipulation but accept the germ theory of disease.
Can be effective in treating certain types of back pain, but some spinal conditions require medications and surgery that only a physician can provide. There is no scientific evidence that any disease can be treated by spinal adjustment.*
Homeopathy Use of extremely dilute solutions of natural substances to treat specific illness symptoms.
Studies do not indicate that homeopathy is effective.
Naturopathy or natural medicine
Practice based on natural healing. Practitioners believe diseases occur as the body rids itself of wastes and toxins. Treatments include fasting, enemas, acupuncture, and “natural” drugs.
Lack of standardized medical training for practitioners called “neuropaths.”
Therapeutic massage, reflexology, or zone therapy
Specific areas of the body correspond to certain organs. To alleviate pain or treat certain diseases, practitioners massage or press on the area that is related to the affected tissues.
The practice may stimulate the body to release pain-relieving compounds, but testing “touch” therapies scientifically is difficult. In general, scientific evidence does not indicate that pressing on body parts is an effective method of diagnosing or treating ailments.
*Data from: Ernst, E. (2008). Chiropractic: A critical evaluation. Journal of Pain and Symptom Management, 35(5), 544–562. Ernst, E., & Posaszki, P. (2011). An independent review of NCCAM-funded studies of chiropractic. Clinical Rheumatology, 30(5), 593–600.
Common Alternative Medical Practices
Table 1.4
care and disease prevention. Integrative medical prac- titioners focus on ways to encourage people to take greater responsibility for achieving and maintaining good health and well-being. Such practitioners also recognize the potential value of incorporating forms of alternative medicine that have scienti!c support into their preventive healthcare practices.
Herbs as Medicines Many Americans ingest pills or teas made from herbs and other plants because they think these products
are natural and harmless ways to cure various disor- ders or achieve optimal health and well-being. "e U.S. government classi!es herbal products as dietary supplements. A dietary supplement is a product that is consumed to add nutrients, herbs, or other plant materials to a person’s diet. Dietary supplements are not regulated by the FDA like medications are. As a result, the FDA does not require dietary supplement manufacturers to register their products and submit clinical evidence indicating that the products have been tested for safety and e#ectiveness before being
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 27
pennyroyal, kava, birthwort, snakeroot, and ger- mander, contain chemicals that can be harmful and even deadly when consumed. Ingesting kava, an herb that is promoted for relieving anxiety, can result in serious liver damage.39 In 2004, the FDA banned the sale of most dietary supplements that contained ephedra, a naturally occurring stimulant drug that is o$en called ma huang. Traditional Chi- nese remedies and herbal teas that contain ephedra were exempt from the ban. Consuming ephedra can result in stroke, heart attack, and death.40 In 2003, a weight-loss supplement that contained the toxic herb contributed to the sudden death of Steve Bechler, a 23-year-old professional pitcher for the Baltimore Orioles baseball team.
Consumers should be aware that medicinal herbs may interact with prescription medications or other herbs, producing serious side e#ects. "ese products may also be contaminated with pesticides or highly toxic metals. Many dietary supplements are expensive and do little to promote good health. Table 1.5 includes information about the safety and e#ectiveness of some popular herbal supplements. For reliable information about herbs and other dietary supplements, check the following government web sites: http://nccam.nih.gov /health/atoz.htm and www.ods.od.nih.gov.
Some herbal supplement manufacturers claim their products have been clinically tested and shown to provide health bene!ts. "e reliability of these claims may be questionable, however, because they are o$en based on results obtained from animal research or few, poorly designed human studies. Given the lack of scienti!c evidence that most medicinal herbs are safe and e#ective, the amount of money consum- ers pay for these products is astonishing. In% 2016,
marketed. In 2007, the FDA established a new rule that required manufacturers of dietary supplements to test the purity, strength, and composition of their products before marketing them to consumers. As a result, dietary supplements sold in the United States should be accurately labeled, contain the ingredients listed on the label, and provide standard amounts of the substances.
When the FDA determines that an ingredient contained in dietary supplements is dangerous, the agency can ban its use. Furthermore, the FDA can remove a dietary supplement from the market if its label states claims about the product’s health ben- e!ts that are not supported by scienti!c evidence. "e FDA permits herbal supplement manufacturers to include certain structure/function claims on the product’s label. For example, the claims “maintains a healthy circulatory system” and “improves urine 'ow” describe how supplements can a#ect body functions. Unless given prior approval by the FDA, herbal supplement manufacturers cannot indicate on the label that a supplement can prevent, diagnose, treat, improve, or cure diseases. Results of clinical studies indicate that speci!c herbs can provide mea- surable health bene!ts. St. John’s wort, for example, can relieve symptoms of mild to moderate depres- sion and appears to be relatively safe when not com- bined with prescription medications.34 Ginseng is a top-selling dietary supplement in the United States. People use the herb for a variety of purposes, includ- ing as a sedative, antidepressant, and aphrodisiac. "ere is scienti!c evidence that taking American gin- seng before meals may improve blood sugar values of people with type 2 diabetes.35 Ingesting an extract made from the herb regularly may reduce the risk of respiratory tract infections, such as the common cold. Although evidence that ginseng provides other healthful bene!ts is lacking, scientists continue to investigate the herb’s potential uses.
Not every herbal product has measurable ben- e!cial e#ects on health. Ginkgo is a popular dietary supplement, but scienti!c evidence to support claims that extracts made from ginkgo leaves improve mem- ory is weak or inconsistent.36 Many people take echi- nacea to prevent or treat the common cold, but the usefulness of this practice does not have widespread scienti!c support.36,37,38 More research is needed to determine whether taking ginkgo, echinacea, and many other dietary supplements has measureable health bene!ts.
A “natural” therapy is not necessarily a safe one. Many plants, including comfrey, chaparral,
St. John’s wort. © iStockphoto/Thinkstock.
28 Chapter 1 Health: The Foundation for Life
Research Findings
Supplement Common Claims Uses Risks
St. John’s wort Relieves depression May reduce mild to moderate depression symptoms; no value for major depression
Can interfere with birth control pills and other prescribed medicines, increase sensitivity to sunlight, and cause stomach upset
Saw palmetto Improves urine flow May reduce symptoms of prostate enlargement that are not caused by cancer
May interfere with prostate-specific antigen (PSA) test to detect prostate cancer
Feverfew Relieves headaches, fever, arthritis pain
Contains a chemical that may prevent migraines or reduce their severity
May cause dangerous interactions with aspirin or Coumadin (warfarin, a prescribed drug)
Echinacea Prevents colds and influenza
Does not prevent colds or reduce their severity
May cause allergic response and be a liver toxin
Ginkgo biloba Enhances memory and sense of well-being; prevents dementia
Weak or inconsistent scientific evidence to support claims
May interfere with normal blood clotting, cause intestinal upset, and increase blood pressure
Ginseng Enhances sexual, mental, and exercise performance; increases energy; relieves stress and depression
Has no mood-enhancing effects. May reduce risk of respiratory infections and improve blood sugar values of people with diabetes
Can cause “jitters,” insomnia, hypertension, and diarrhea and can be addictive; can be contaminated with pesticides and the toxic mineral lead
Yohimbe Enhances muscle development and sexual performance
Dilates blood vessels but has no beneficial effects on muscle growth or sex drive of humans
Can produce abnormal behavior, high blood pressure, and heart attacks
Guarana Boosts energy and enhances weight loss
Acts as a stimulant drug May cause nausea, anxiety, and irregular heartbeat
Kava Relieves anxiety and induces sleep
Acts as a depressant drug May cause serious liver damage; do not use when driving
Popular Herbal Supplements
Table 1.5
for% example, Americans spent more than $7% billion on herbal supplements.41
CAM Therapies in Perspective National surveys provide estimates of the extent to which Americans use unconventional medical thera- pies. According to the National Health Interview Survey, 38% of adults used forms of CAM in 2007.42 Other commonly used CAM treatments were natural products, deep breathing exercises, meditation, and chiropractic care. In most cases, CAM was used to treat back, neck, and joint problems; colds; anxiety; and depression.
"e natural or exotic nature of many alternative therapies such as herbal pills and teas, co#ee enemas, shark cartilage, and re'exology may appeal to people who distrust modern technology or have lost faith in conventional medical care. Others use alternative therapies to prevent or treat ailments because they want to take more control over their health. Con- ventional medical practitioners are concerned when persons with serious conditions forgo or delay con- ventional treatments and rely instead on questionable alternative therapies. "ese could be life-threaten- ing decisions. Many forms of cancer, for example, respond well to conventional treatments, particularly
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 29
research to determine the safety and e#ectiveness of alternative medical practices. Until supportive data are available from well-designed studies, consumers should be wary of CAM practices.
Before using alternative therapies, discuss your options with your physician and consider taking the following steps to protect yourself:
• Contact a variety of reliable sources of information to determine the risks and bene!ts of the treatment. For example, ask people who have used the treatment to describe its e#ectiveness and side e#ects. Conduct a review of medical literature, and recognize that popular sources of information such as health magazines and the Internet may be unreliable. Look for articles in medical journals or news magazines that have information concerning the usefulness of conventional as well as alternative medical approaches to care.
• Ask people who administer the treatment to provide proof of their medical training. Investigate the validity of their educational credentials. People who promote certain alternative medical practices o$en have little or no medical and scienti!c training.
• Determine the cost of treatment and whether your health insurance covers the particular alternative therapy. If it does not, !nd out why. You may !nd that your health insurer considers the treatment risky or ine#ective.
• Ask your primary care physician for his or her opinion of the treatment. If you still have questions about the treatment, seek a second opinion from one or more other physicians.
• If you decide to use an alternative therapy, do not use it along with conventional therapy or abandon conventional treatment for any medical problem without consulting your physician.
• Investigate the possibility that the alternative medicine or herbal supplement can interact with conventional medications that you take and produce serious side e#ects. Investigate the possibility that taking combinations of herbal supplements can be harmful.
• If you are pregnant or breastfeeding, do not use herbal supplements or alternative therapies without consulting your physician.
• Do not give herbal supplements or alternative therapies to children.
if the disease is in an early stage. Many adults who use alternative medical therapies choose them to comple- ment rather than replace conventional treatments.41
Regardless of treatment, people su#ering from acute conditions such as low back pain, common colds, and gastrointestinal disturbances generally recover with time. Individuals with chronic health problems such as osteoarthritis and multiple sclerosis o$en report remissions, times when their conditions improve. If people use alternative therapies when they are recovering or their illnesses are in remission, they are likely to think the nonconventional treat- ment cured or helped them. Additionally, people who combine alternative therapies with conventional medical care may attribute any improvement in their health only to the alternative treatments.
Conventional medical practitioners are likely to be skeptical of CAM techniques if they have not been shown scienti!cally in large-scale clinical studies to be safe or more helpful than placebos. "e National Center for Complementary and Alternative Medi- cine within the National Institutes of Health funds
Echinacea. © Zina Seletskaya/Shutterstock.
30 Chapter 1 Health: The Foundation for Life
Choosing Conventional Medical Practitioners Scienti!c research, technological advancements, and a systematic approach to medical education make the conventional healthcare system in the United States among the best in the world. Conventional medicine, however, has its limitations; not every condition can be prevented, managed, or cured.
Americans generally consider conventional medi- cal care practitioners, such as physicians, dentists, nurses, and dietitians, to be experts in their !elds. How do you choose the best medical professionals? A good way is to ask family and friends for their rec- ommendations. If you are enrolled in certain health insurance plans, you generally must select from approved lists of providers. A$er you obtain some names of physicians or other conventional practi- tioners, check your health insurance plan’s list of healthcare providers to determine whether the rec- ommended individuals are listed.
To help ensure high-quality conventional health care, consumers should choose physicians who have certain personal and professional characteristics, including appropriate training and excellent medi- cal credentials (Table 1.6). For example, a physician who is board certi#ed or board eligible in a specialty, such as internal medicine, is well trained in that par- ticular !eld of practice. In addition to considering a prospective physician’s quali!cations, you should evaluate his or her personality and o&ce conditions. Make an appointment to meet with the physician and prepare a list of questions to ask him or her. For example, which health insurance plans are accepted? Where did the practitioner receive his or her medi- cal training? With which hospitals does the physician have a&liations? When you are in the practitioner’s waiting room, observe its cleanliness and the sta# ’s attitude and friendliness. When you interview the physician, observe his or her body language and judge the person’s verbal responses to your questions.
4Before using an herbal supplement or alternative therapy, obtain reliable information concerning the pros and cons of the treatment and discuss your options with your physician.
Healthy Living Practices
A good personal physician:
• Is intelligent and well qualified in his or her field of practice
• Spends adequate time with patients and listens to patients’ concerns
• Is willing to modify treatment to meet patients’ concerns and values
• Is caring and sympathetic • Enlists patients’ active participation in health-
related decisions • Is willing to admit when his or her medical
knowledge is lacking • Recognizes the limitations of his or her expertise
and is willing to refer patients to other medical professionals when necessary
• Provides thorough physical examinations and orders appropriate testing, such as blood tests or X-rays
• Is available for telephone consultations when necessary
• Is available to handle emergencies or has a competent backup physician take care of such situations
• Does not delay in seeing patients with urgent care needs
• Is on staff at one or more nearby accredited hospitals
• Keeps up to date by attending professional educational meetings or reading medical journals
• Has a well-managed, well-equipped office with friendly, courteous staff
Table 1.6
Characteristics of Good Personal Physicians
A$er the interview, evaluate the physician’s level of comfort with you, his or her answers to your ques- tions, and o&ce conditions. Was the physician friendly and interested in you and your health his- tory? Did he or she provide satisfactory answers to your questions? Was the o&ce clean and sta# courte- ous? If you answered “yes” to these questions, you are likely to enjoy a good relationship with this physician and receive good medical care.
Ideally, people should be able to form a trusting relationship with their conventional medical practi- tioners, including physicians. To develop these rela- tionships, patients need to acknowledge that they are largely responsible for their health status. For example, patients should adopt healthy lifestyles, obtain regular checkups, and seek medical attention
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 31
HEALTH Although the focus of this text is adult health, the Across the Life Span feature brie'y describes health concerns that are speci!c to other stages of life, such as infancy, childhood, adolescence, and the older adult years. Table 1.7 indicates the approximate age groupings for these life stages.
Why should college students learn about health conditions that can a#ect very young or very old members of the population? "is information is rel- evant because many college students have younger siblings, some students have children, and those who are not parents may have children in the future. Many college students are middle aged or have elderly par- ents and grandparents. "e following information highlights some major life cycle health concerns of Americans.
In the United States in 2015, about 6 babies in 1,000 died during the !rst year a$er birth.21 Most of these deaths were due to birth defects, low birth weights, and breathing di&culties that arose from prematurity—being born too early (Figure 1.9). Pub- lic health e#orts aimed at educating and providing medical care for pregnant women can reduce the number of infant deaths.
for ailments that do not improve within a few days or have serious signs or symptoms. Moreover, patients should follow their healthcare practitioners’ advice and communicate with them should concerns about their medical care arise.
Healthcare practitioners can foster positive rela- tionships with patients by spending adequate time with them, listening to their concerns carefully, and showing an interest in knowing more about them, not just their physical signs and symptoms. In addition, it is important for practitioners to be caring, sensitive, and understanding; to modify treatment to meet the patient’s concerns and values; and to enlist the patient’s active participation in health-related decisions.
Stage Approximate Age
Infants and toddlers 0–3 years
Children 4–11 years
Adolescents and teens 12–19
Adults 20–64
Older adults 65 or older
Table 1.7
Life Stages Across THE LIFE SPAN
Figure 1.9 Premature Newborns. Infants born prematurely have a greater risk of serious health problems than do healthy full-term infants. © iStockphoto/Thinkstock.
32 Chapter 1 Health: The Foundation for Life
15%to 24. In 2015, motor vehicle accidents accounted for almost two-thirds of deaths resulting from unin- tentional injuries for Americans in this age group.21
In 2015, the teenage birth rate declined to its low- est level in nearly 70 years of recordkeeping in the United States.44 However, sexually transmitted infec- tions (STIs) continue to be a major health concern for adolescents. In 2016, people between 20 and 29 years of age contracted about 40% of all new cases of HIV.45 AIDS is primarily a sexually transmitted infection; therefore, sexually active adolescents are at greater risk of becoming infected with HIV, the virus that causes AIDS.
In 2016, people 65 years of age and older made up nearly 15% of the U.S. population. "e percentage of older adults in the population is expected to increase rapidly over the next 40 years.23
Unintentional injuries are the major health threat to children between 1 and 14 years of age. Most deaths from unintentional injuries, such as deaths due to motor vehicle crashes, drownings, and house !res, are preventable.
Adolescence is a time when youngsters establish behaviors that may last a lifetime and when experi- mentation with risky behaviors usually begins. In 2015, about 8% of high school students reported driving a car or other vehicle a$er consuming alco- hol, and 16.2% had carried a weapon on at least one day during the 30 days preceding the survey.43 About 10% reported that they had been physically abused intentionally by a boyfriend or girlfriend, and 30% of these students reported being overweight or obese. Unintentional injuries (accidents), homicide, and suicide are major causes of death for people aged
Conventional Medicine, Complementary and Alternative Medicine, and Integrative Medicine 33
CHAPTER REVIEW
1. Develop a plan to improve your health by selecting a health behavior you’d like to change. Appli cation
2. Select a health-related advertisement from the Internet and evaluate the validity of its informa- tion. Use the information provided in the “Ana- lyzing Health Information” section to help you answer the following questions. Analysis
3. Identify several sources of health information that you have used in the past year. Using the criteria from the “Analyzing Health Information”
section, explain why you think each source is reliable or unreliable. Synthesis
4. "ink of a health-related decision that you made recently. For example, did you decide to turn down an o#er to use a mind-altering drug, wear a helmet while riding a motorcycle, lose a few pounds, or use an herbal product to treat a condi- tion? When you made this decision, did you use the decision-making process described in this chapter, or did you act impulsively? Explain why you would or would not make the same decision today. Evaluation
Applying What You Have Learned
Summary Lifestyle includes behaviors that promote or deter good health and well-being. Optimal wellness is an optimal degree of health. "e holistic approach to health integrates physical, psychological, social, intellectual, spiritual, and environmental dimen- sions. Contemporary de!nitions of health re'ect not only how an individual functions but also what that person can achieve, given his or her circumstances.
Heart disease and cancer are the major killers of Americans. Lifestyle choices contribute to the devel- opment of these and many other life-threatening diseases. "e distribution of health problems di#ers among the various ethnic and racial groups in the United States. Poverty and cultural di#erences are o$en barriers to good health care.
Experiences, knowledge, needs, and values a#ect one’s motivation to change health-related behaviors. People are motivated to take action if they feel that a su&cient threat to their health exists and that the results of changing their behavior will be worthwhile.
Although no one can guarantee good health, many factors contribute to one’s chances of enjoying a long and productive lifetime of good health. Several of these factors are the result of lifestyle choices that people can make, while they are still young, to prevent or delay disease. Responsible health-related lifestyle choices involve a systematic approach to decision making.
People can become more careful consumers of health-related information, products, and services by learning to recognize misinformation. To obtain reli- able health-related information, check with experts in federal, state, and local agencies and organizations.
Conventional medicine relies on modern scien- ti!c principles, modern technologies, and scienti!- cally proven methods to prevent, diagnose, and treat health conditions. Complementary and alternative medicine (CAM) is an unconventional and diverse system of preventing, diagnosing, and treating dis- eases that emphasizes spirituality, self-healing, and harmonious interaction with the environment. Con- ventional medical practitioners are likely to be skep- tical of CAM techniques that have not been shown scienti!cally to be safe and e#ective. Until support- ive data are available, consumers should be wary of CAM practices.
"roughout the life span, health concerns vary. "e most common causes of infant deaths are birth defects, low birth weights, and prematurity. Prevent- able injuries are the major causes of death for chil- dren and youth. Additional serious public health concerns for adolescents are suicide, homicide, drug abuse, obesity, pregnancy, and sexually transmitted infections (including HIV).
34 Chapter 1 Health: The Foundation for Life
Key
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
A re'ective journal is a personal record of your thoughts and expressions of your feelings. "e pur- poses of keeping this journal are to stimulate your thinking about what you have learned about health and to help you understand how your thoughts and feelings about your health might have changed over the semester. "inking about new information can help you determine its usefulness, which can in'u- ence your attitudes and behaviors.
"e Re'ecting on Your Health questions at the end of each chapter are designed to guide your think- ing. If you want to write about something else that is related to the contents of the chapter, feel free to do so, but make sure to identify the topic in your opening sentence. Write your journal entries in the !rst person, using “I” statements to express your thoughts, as though you were talking to a close friend. Do not worry about your spelling, punctuation, or grammar—just let your thoughts 'ow.
Some instructors make journal writing an optional activity; others require that you respond to all of the questions, and they grade journals. Still other
instructors simply check to see if students are doing the assignment. Refer to the course syllabus or ask your instructor about his or her grading practices and other instructions concerning the journal.
1. What does the term health mean to you? Which of the de!nitions of health provided in this chap- ter best “!ts” with your thoughts on health?
2. Do you think everyone should strive to achieve optimal health? Provide a rationale for your response.
3. What impact does spiritual health have on your sense of well-being? If spiritual health is impor- tant to you, describe the role it plays in your life.
4. Do you agree with the idea presented in the chapter that social health in'uences your physi- cal health? Why or why not?
5. Select a current behavior that you believe is your worst health behavior. Identify three factors that in'uence this speci!c behavior, and explain how each factor in'uences your behavior.
6. Under what circumstances would you consider using alternative therapies?
Reflecting on Your Health
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CHAPTER REVIEW
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13. Krebs-Smith, S. (2010). Americans do not meet federal dietary recommendations. Journal of Nutrition, 140(10), 1832–1838.
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15. Fryar, C., Carroll, M. D., & Ogden, C. (2016). Health E-Stat: Prev- alence of overweight, obesity, and extreme obesity among adults: United States, trends 1960–1962 through 2013–2014. Retrieved from https://www.cdc.gov/nchs/data/hestat/obesity_adult_13_14 /obesity_adult_13_14.htm
16. World Health Organization. (1948). O%cial records of the World Health Organization, no. 2. Proceedings and #nal acts of the international health conference held in New York from 19 June to 22 July& 1946. New York, NY: United Nations WHO Interim Commission.
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18. Hochbaum, G. M. (1979). An alternative approach to health educa- tion. Health Values, 3, 197–201.
19. McKenzie, J. F., Pinger, R. R., & Kotecki, J. E. (2012). An intro- duction to community health (7th ed.). Burlington, MA: Jones & Bartlett Learning.
20. U.S. Department of Health and Human Services, Centers for Medi- care and Medicaid Services. (2017). National health expenditure projections 2016–2025, forecast summary. Retrieved from https:// www.cms.gov/Research-Statistics-Data-and-Systems/Statistics -Trends-and-Reports/NationalHealthExpendData/Downloads /proj2016.pdf
21. Murphy, S. L, Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015. National Vital Statistics Reports, 66(6). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_06.pdf
22. U.S. Department of Health and Human Services, Public Health Ser- vice. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: Government Print- ing O&ce.
23. U.S. Census Bureau. (2017). Quick Facts, United States. Retrieved from https://www.census.gov/quickfacts/fact/table/US/PST045217
24. U.S. Centers for Disease Control and Prevention. (2017). Hispanic health. Retrieved from https://www.cdc.gov/vitalsigns/hispanic -health/index.html
25. U.S. Centers for Disease Control and Prevention, O&ce of Minor- ity Health and Health Disparities. (2017). Pro#le: Hispanic/Latino Americans. Retrieved from https://minorityhealth.hhs.gov/omh /browse.aspx?lvl=3&lvlid=64
26. U.S. Centers for Disease Control and Prevention, O&ce of Minority Health and Health Disparities. (2017). Pro#le: Black/African Ameri- cans. Retrieved from https://minorityhealth.hhs.gov/omh/browse .aspx?lvl=3&lvlid=61
27. U.S. Centers for Disease Control and Prevention. (2017). Obesity & overweight: Adult obesity facts. Retrieved from https://www.cdc .gov/obesity/data/adult.html
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3. U.S. Centers for Disease Control and Prevention. (n.d.). Behavioral Risk Factor Surveillance System. Prevalence and trends data: Seatbelt use—2016. Retrieved from https://nccd.cdc.gov/BRFSSPrevalence/ rdPage.aspx?rdReport=DPH_BRFSS.ExploreByLocation&rdProce ssAction=&SaveFileGenerated=1&irbLocationType=States&islLoc ation=99&islState=&islCounty=&islClass=CLASS12&islTopic=TO PIC50&islYear=2016&hidLocationType=States&hidLocation=99& hidClass=CLASS12&hidTopic=TOPIC50&hidTopicName=Seatbel t+Use&hidYear=2016&irbShowFootnotes=Show&rdICL-iclIndica- tors=_RFSEAT2&iclIndicators_rdExpandedCollapsedHistory=&ic lIndicators=_RFSEAT2&hidPreviouslySelectedIndicators=&Dashb oardColumnCount=2&rdShowElementHistory=divTopicUpdating %3dHide%2cislTopic%3dShow%2cdivYearUpdating%3dHide%2ci slYear%3dShow%2c&rdScrollX=0&rdScrollY=200&rdRnd=51873
4. Ervin, R. B., & Ogden, C. L. (2013). Consumption of added sugars among U.S. adults, 2005–2010 (NCHS Data Brief No. 122). Hyatts- ville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db122.pdf
5. U.S. Department of Agriculture, Agricultural Research Service. (2017). Data tables from What We Eat in America, NHANES 2013– 2014. Nutrient intakes: Mean amounts consumed per individual, by gender and age, in the United States, 2013–2014. Retrieved from https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1314 /Table_1_NIN_GEN_13.pdf
6. U.S. Centers for Disease Control and Prevention. (n.d.). U.S. cancer statistics: An interactive atlas. Retrieved from http://apps.nccd.cdc .gov/DCPC_INCA/DCPC_INCA.aspx
7. U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. (2017). Health, United States, 2016. Retrieved from https://www.cdc.gov/nchs/data/hus/hus16.pdf#015
8. U.S. Centers for Disease Control and Prevention. (2016). Con- sumption of cigarettes and combustible tobacco—United States, 2000–2015. Morbidity and Mortality Weekly Report, 65(48), 1357– 1363. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr /mm6548a1.htm
9. National Highway Tra&c Safety Administration (2014). Tra%c safety facts: Alcohol-impaired driving 2013. Table 1112. Retrieved from https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication /812102
10. U.S. Centers for Disease Control and Prevention. (n.d.). Behav- ioral Risk Factor Surveillance System 2016. Prevalence and trends data: Binge drinking—2016. Retrieved from https://nccd.cdc.gov /BRFSSPrevalence/rdPage.aspx?rdReport=DPH_BRFSS.ExploreB yLocation&rdProcessAction=&SaveFileGenerated=1&irbLocation Type=States&islLocation=99&islState=&islCounty=&islClass=CL ASS01&islTopic=TOPIC07&islYear=2016&hidLocationType=Stat es&hidLocation=99&hidClass=CLASS01&hidTopic=TOPIC07&h idTopicName=Binge+Drinking&hidYear=2016&irbShowFootnote s=Show&rdICL-iclIndicators=_RFBING5&iclIndicators_rdExpan dedCollapsedHistory=&iclIndicators=_RFBING5&hidPreviouslyS electedIndicators=&DashboardColumnCount=2&rdShowElement History=divYearUpdating%3dHide%2cislYear%3dShow%2c&rdSc rollX=0&rdScrollY=0&rdRnd=28019
11. U.S. Centers for Disease Control and Prevention. (2017). Current and binge drinking among high school students—United States, 1991– 2015. Morbidity and Mortality Weekly Report, 66(18), 474–478. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/mm6618a4.htm
36 Chapter 1 Health: The Foundation for Life
38. Karsch-Volk, M., et al. (2014). Echinacea for preventing and treating the common cold. "e Cochrane Database of Systematic Reviews, 20(2), 1–90.
39. U.S. National Institutes of Health, National Center for Complemen- tary and Alternative Medicine. (2016). Kava. Retrieved from http:// nccam.nih.gov/health/kava/
40. U.S. National Institutes of Health, National Center for Complemen- tary and Alternative Medicine. (2016). Ephedra. Retrieved from http://nccam.nih.gov/health/ephedra/
41. American Botanical Council. (2017). US sales of herbal supplements increase by 7.7% in 2016. Retrieved from http://cms.herbalgram.org /press/2017/USSalesofHerbalSupplementsIncreaseby77percentin 2016.html?t=1504734295&ts=1504734303&signature=d764fdbd5f cd4e7a55eda008335e0c73
42. Barnes, P. M., et al. (2008). Complementary and alternative medi- cine use among adults and children: United States, 2007. National Health Statistics Reports, No. 12. Hyattsville, MD: National Center for Health Statistics.
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44. Martin, J. A., et al. (2016). Births: Final data for 2015. National Vital Statistics Reports, 66(1), 1–70. Retrieved from https://www.cdc.gov /nchs/data/nvsr/nvsr66/nvsr66_01.pdf
45. U.S. Centers for Disease Control and Prevention. (2017). HIV in the United States: At a glance. Retrieved from https://www.cdc.gov/hiv /statistics/overview/ataglance.html
28. U.S. Centers for Disease Control and Prevention, O&ce of Minor- ity Health and Health Disparities. (2017). Pro#le: Asian Ameri- cans. Retrieved from https://minorityhealth.hhs.gov/omh/browse .aspx?lvl=3&lvlid=63
29. U.S. Centers for Disease Control and Prevention, O&ce of Minor- ity Health and Health Disparities. (2017). Pro#le: American Indian /Alaskan Native. Retrieved from https://minorityhealth.hhs.gov /omh/browse.aspx?lvl=3&lvlid=62
30. Norcross, J. C., & Prochaska, J. O. (2002). Using the stages of change. Harvard Mental Health Letter, 18(11), 5–7.
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33. Vanderploeg, K., & Yi, X. (2009). Acupuncture in modern society. Journal of Acupuncture and Meridian Studies, 2(1), 26–33.
34. U.S. National Institutes of Health, National Center for Complemen- tary and Alternative Medicine. (2017). St. John’s wort. Retrieved from http://nccam.nih.gov/health/stjohnswort
35. U.S. National Institutes of Health, National Library of Medicine, MedlinePlus. (2017). American ginseng. Retrieved from https:// medlineplus.gov/druginfo/natural/967.html
36. Fransen, H. P., Pelgrom, S. M., Stewart-Knox, B., de Kaste, D., & Verhagen, H. (2010). Assessment of health claims, content, and safety of herbal supplements containing Ginkgo biloba. Food & Nutrition Research, 54, 5221.
37. Barrett, B., et al. (2010). Echinacea for treating the common cold. A randomized trial. Annals of Internal Medicine, 153(12), 769–777.
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow / EyeEm/Getty Images.
CHAPTER REVIEW
References 37
Across the Life Span Psychological Health
Managing Your Health Resolving Interpersonal Conflicts Constructively
Consumer Health Locating and Selecting Mental Health Therapists
Diversity in Health American Indians and Psychological Health
Chapter Overview How your nervous system affects your psychological health
How biological, social, and cultural forces interact to mold personality
How psychological adjustment leads to psychological growth
How to identify common psychological disorders
How to recognize suicidal behavior and prevent suicide
Student Workbook Self-Assessment: Self-Esteem Inventory
Changing Health Habits: Are You Ready to Improve Your Psychological Health?
Do You Know? If you are psychologically healthy?
Why emotions are useful?
How to resolve conflicts in a healthy manner?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Lolostock/Shutterstock.
Psychological Health
© EyeEm
/Getty Im ages.
Learning Objectives “Each newborn is a unique person.”
After studying this chapter, you should be able to:
1. Explain the basics of psychological health and list characteristics of psychologically healthy people.
2. Compare and contrast theories of personality development. 3. List common defense mechanisms and provide an
example of each. 4. Identify levels of Maslow’s hierarchy of needs and
characteristics of a self-actualized person. 5. Define psychological adjustment and growth. 6. Describe the relationships between psychological health, self-esteem, and autonomy. 7. Differentiate between healthy and unhealthy emotional responses. 8. Identify common psychological health disorders and describe the major symptoms of each. 9. List and describe common methods for treating psychological disorders. 10. Identify warning signs of suicide and describe methods of suicide prevention.
CHAPTER 2
39
Observing newborn infants in a hospital nurs-ery is a fascinating experience. Some of the babies sleep peacefully; others are awake, calmly gazing around at their surroundings while gently sucking their paci!ers. A few of the newborns are restless. Although tightly wrapped in swaddling, one infant tries to stretch her hand into the air as though she were reaching for something hanging above the bassinet. Another fussy baby frowns and closes his eyes tightly before spitting out his paci!er, kicking his feet, and howling in pain. Moments later, several other babies begin to grow fussy. Soon a cho- rus of crying babies shatters the calmness of the nurs- ery. "e infants’ caregivers scurry to each bassinet, trying to determine which babies are truly in need of their attention and the reasons why. Why do some newborns respond di#erently when all of them are in the same situation?
Each newborn is a unique person. All infants, however, have basic physical needs that must be met if they are to survive. These needs include nutritious food and a safe environment. Addition- ally, children have psychological needs for belong- ing, love, social acceptance, and respect that must be met if they are to mature into healthy adults. What if there was a crystal ball in the nursery that would enable you to predict each baby’s future? Which of these infants will be psychologically healthy, achieving personal fulfillment and being satisfied with themselves and their lives? Which ones will be emotionally distressed and lead trou- bled lives?
Psychology is the study of the thinking or mental (cognitive) processes that in'uence human behavior. Psychological (mental) health involves the ability to deal e#ectively with the psychological challenges of life. Psychological health is dynamic, becoming more positive or negative as a person responds to a constantly changing environment. Many individu- als, however, manage to maintain high degrees of positive psychological functioning throughout their lives. People with positive mental health are able to deal e#ectively with the psychological challenges of life. Such people accept themselves, have realistic
and optimistic outlooks on life, function indepen- dently, form satisfying interpersonal relationships, and cope e#ectively with change (Table 2.1). In addi- tion to these traits, psychologically healthy indi- viduals resolve their problems without resorting to substance abuse or violence, and they assert them- selves in social situations.
"e quality of one’s psychological health o$en a#ects the other components of health, such as social, spiritual, and physical health. "is chapter discusses factors that in'uence positive psychological health as well as those that contribute to the development of psychological disorders.
!e Basics of Psychological Health
Understanding psychological health involves learn- ing about physiology, the study of body functions, and psychology. Cognitive processes such as think- ing, decision making, and remembering rely on the functioning of the nervous system. "e ner- vous system is an elaborate biological communica- tions network that contains billions of nerve cells, or neurons, which are designed to receive, send, and interpret messages in your body by means of electrical and chemical signals. As you can see in Figure 2.1, this network consists of two interre- lated parts: the central nervous system (CNS), the
psychology The study of the mental processes that influence human behavior.
physiology The study of bodily functions.
central nervous system (CNS) Of the two primary divisions of the nervous system, the one that consists of the brain and spinal cord.
Psychologically Healthy People:
• Accept themselves and others • Display creative abilities • Respond to changing situations with spontaneity • Show appropriate emotional responses • Desire privacy • Are aware of reality • Function independently • Are concerned about the needs of others • Enjoy interpersonal relationships • Have goals in life
Adapted from Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York, NY: Harper & Row.
Table 2.1
Characteristics of Psychologically Healthy People
40 Chapter 2 Psychological Health
speech patterns as well as facial expressions and other forms of body language. Happiness, sadness, anger, and fear are among the basic emotions that we o$en call feelings. A psychologically healthy person is able to express his or her emotions appropriately. Much of the disability that is associated with psychological illness results from abnormal or extreme emotional responses to situations.
Parts of the brain, collectively referred to as the mind, process various types of information received from the rest of the body and the environment. As a result, the mind thinks about what takes place, !nds meaning in events, considers actions, makes deci- sions, directs responses, evaluates and remembers consequences, and plans for the future. "ese activi- ties involve neurotransmitters in the brain. Certain conditions can negatively a#ect the mind by altering neurotransmitter levels and disrupting normal brain chemistry and functioning. As a result, inappropriate moods, unrealistic thoughts, and maladaptive behav- iors occur. Maladaptive behaviors interfere with one’s ability to be productive, interact well socially, and adjust to the demands of everyday living. In many instances, treating these conditions involves taking medication that corrects abnormal neurotransmit- ter levels as well as learning how to change distorted ways of thinking.
Personality Development Personality is a set of distinct thoughts and behav- iors, including emotional responses, that character- izes the way a person responds to situations. Many factors, including biological, cultural, social, and psy- chological forces, interact to mold personality.
Biological In$uences Heredity is the transmis- sion of biological information, coded within genes, from parents to o#spring. "is information deter- mines, in part, an individual’s physical, emotional, and intellectual characteristics. Much of a person’s
brain and spinal cord; and the peripheral nervous system (PNS), nerves that relay information to and from the CNS.
Most nerves produce and release neurotransmit- ters, chemicals such as acetylcholine, dopamine, and serotonin that convey information between nerve cells. By altering the levels of various neurotransmit- ters, the nervous system transmits information and produces physical responses, thoughts, and emotions.
Emotions are a way of communicating our moods to others. Emotions are associated with typical behav- ioral and physical responses, including changes in
Central nervous system
Peripheral nervous system
peripheral nervous system (PNS) Of the two primary divisions of the nervous system, the one that consists of nerves, which relay information to and from the CNS.
neurotransmitters Chemicals produced and released by nerves that convey information between most nerve cells.
personality A set of distinct thoughts and behaviors that characterizes a person’s response to situations.
heredity The transmission of biological information, coded within genes, from parents to offspring.
Figure 2.1 The Nervous System. The nervous system consists of the brain, the spinal cord, and peripheral nerves.
The Basics of Psychological Health 41
Diversity in Health American Indians and Psychological Health Major health concerns affecting Ameri- can Indians (AIs) include problems asso- ciated with poor psychological health
such as alcoholism, suicide, and accidents. According to the results of a major survey conducted in 2013–2014, AI adults were more likely to have experienced serious psychological distress—feeling sad, restless, hopeless, nervous, or worthless—during the past 30 days than adults of other racial or ethnic groups. Rates of suicide deaths and attempts for AI teens in 2014 were signifi- cantly higher than for teens in other racial categories. AI teens were significantly more likely to think about committing suicide, and suicide was the second leading cause of death for AIs aged 10–34. A study of more than 3,000 Northern Plains and Southwest tribal members indicated that alcoholism and major depression were common among subjects. Factors that may contribute to AIs’ generally poor mental health status include pov- erty, low educational level, exposure to violence, and dis- crimination. AIs can obtain professional help for mental health problems through the Indian Health Service (IHS); however, AI adults are less likely to seek or receive psychological counseling or use prescription medica- tions for mental health treatment. Many AIs have more confidence in traditional healing practices than in thera- pies provided by conventional medical practitioners.
The traditional AI concept of health involves the medicine wheel, a circle divided into four equal parts representing the major aspects of health: context (nat- ural environment and social setting), mind, body, and spirit. When the four components of the medicine wheel are balanced with each other, people enjoy wellness or “harmony.” When people are not in harmony with nature, their community, or themselves, they suffer from physical and psychological illnesses. According to some traditional AI beliefs, an emotionally disturbed individ- ual is in a state of disharmony with the rest of nature or in a hopeless state of health. In other AI traditions, the symptoms of mental illnesses result from supernatural forces exerting control over the person.
Traditionally, AIs view alcohol abuse and other men- tal health problems as imbalances in the spiritual com- ponent of the medicine wheel. Because spiritual health is linked closely with psychological health, treatments are spiritual in nature and may involve prayer, sweat
lodges, or purification ceremonies led by natural healers. Efforts to restore spiritual balance may also include participation in activities that increase cultural identity and self-esteem, such as crafts, storytelling, and mak- ing drums and baskets. In addition to relying on tradi- tional healing methods, many AIs accept conventional forms of treatment, especially for serious psychological disturbances.
In the United States, conventional mental health prac- titioners have been taught to identify normal and abnor- mal behaviors and diagnose mental illness by using an established set of standards. Often, these healthcare providers do not consider the importance of culture when treating patients who are members of minority groups, particularly AIs. Medical practitioners need to recognize the importance of cultural traditions when treating an AI or any individual. Furthermore, mental healthcare providers can often gain the trust and respect of clients from various cultural backgrounds by learning about traditional healing methods. As a result, patients are more likely to accept the healthcare provider’s advice and suggestions for conventional treatment.
Data from U.S. Centers for Disease Control and Prevention, Office of Minority Health. (2017). Mental health and American Indians/ Alaskan Natives. Retrieved from http://minorityhealth.hhs.gov /templates/content.aspx?lvl=3&lvlID=9&ID=6475; Beals, J., et al. (2005). Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Archives of General Psychiatry, 62(1), 99–108; Walls, M. L., et al. (2006). Mental health and substance abuse services preferences among American Indian people of the Northern Midwest. Community Mental Health Journal, 42(6), 521–535.
42 Chapter 2 Psychological Health
A traditional Native American medicine wheel is divided into four equal parts to represent major aspects of health. © DC_Colombia/Getty Images.
using rationalization as a defense mechanism. Table"2.2 lists repression, projection, and some other common defense mechanisms and describes instances in which the unconscious mind employs them. Although these strategies may protect the mind and reduce anxiety in the short run, defense mechanisms usually do not pro- vide long-term solutions to problems.
Freud believed that unconscious desires or drives, particularly the libido, or sex drive, control human behavior by creating psychological tension. Relieving this tension produces pleasurable sensations. However, members of society establish moral values, rules for good and bad behavior that o$en prevent individuals from satisfying all of their desires. If a person who accepts the moral values of society acts or thinks in ways that con- 'ict with these rules, he or she usually feels anxious and guilty. Many people use moral values as guidelines to judge their behavior, themselves, and others.
Erikson’s Psychosocial Stages of Development Psychoanalyst Erik Erikson modi!ed Freud’s ideas by proposing that social in'uences play a greater role in shaping personalities than do sexual drives.1 Accord- ing to Erikson, individuals progress through eight psychosocial stages during their lifetimes (Table 2.3). Each stage has major social crises or con'icts that people must manage or resolve to achieve a sense of emotional well-being.
Infants require a considerable amount of care and nurturing from adults to survive and to develop nor- mally. Erikson thought that babies learn to trust other individuals if their parents or other caregivers meet their basic physical and emotional needs. Establishing trusting relationships with caring and loving adults enables infants to begin the process of developing high degrees of psychological well-being later in life.
Erikson viewed adolescence as a critical period in which youth develop a sense of identity. During this stage, adolescents become increasingly respon- sible for making their own decisions. "ey begin to function separately from their families and de!ne who they are as well as what their future roles will be. According to Erikson, the three major areas of concern that adolescents must clarify relate to their sexuality, future occupation, and social conduct.
temperament, the predictable way an individual responds to the environment, is inherited. Soon a$er birth, parents can usually describe their children’s temperamental styles, such as irritable, fearful, or pleasant. As children mature, social and cultural in'uences modify their temperaments.
Social and Cultural In$uences From the moment of birth, the social environment, such as interactions with parents and other family members, in'uences the psychological development of an individual. Most people learn how to respond to situations in socially and culturally acceptable ways when they are children. "e circumstances surrounding a situation in'uence the kind and extent of an emotional display. Consider, for example, emotions that are appropriate to express while attending the funeral of a child.
A person’s cultural and ethnic background can in'uence his or her responses to situations and per- ceptions of mental health disturbances. Although psychological problems a#ect people from every cul- ture, symptoms of these problems may di#er among cultures. "e Diversity in Health essay “American Indians and Psychological Health” discusses a tra- ditional American Indian concept of health, the medicine wheel, and healing methods.
Theories of Personality Development Freud’s Framework of Personality More than 100 years ago, physician Sigmund Freud pioneered modern approaches to the diagnosis and treatment of psychological disturbances. Freud observed that people have an element of the mind that lacks aware- ness of certain thoughts, feelings, and impulses. He proposed that this “unconscious” component of the mind in'uences much of an individual’s behavior. "e unconscious mind, for example, engages various defense mechanisms, such as repression and avoid- ance, to cope with anxiety and guilt.
Defense mechanisms are ways of thinking and behaving that reduce or eliminate anxiety and guilt feelings by altering the individual’s perception of real- ity. Nearly everyone uses defense mechanisms to pro- tect their minds against psychological con'icts and threats. A basic defense mechanism is repression, the unconscious forgetting of anxiety-producing feelings, thoughts, or impulses. For example, adults who were sexually or physically abused as children may repress the memories of the abuse. Students who blame teach- ers for their lack of academic success, instead of them- selves for skipping classes or not studying, may be
temperament The predictable way an individual responds to situations and others, such as being pleasant, outgoing, or shy.
defense mechanisms Ways of thinking and behaving that reduce or eliminate anxiety and guilt feelings by altering the individual’s perception of reality.
The Basics of Psychological Health 43
Defense Mechanism Behavior Example
Repression Blocking unpleasant thoughts or feelings A woman suppresses the memory of being sexually abused as a child.
Rationalization Making up false or self-serving excuses for unpleasant behavior or situations
A man makes excuses for not being hired for a job.
Denial Refusing to acknowledge unpleasant situations or feelings
A young man does not accept that he has been diagnosed with a terminal illness.
Projection Attributing unacceptable thoughts, feelings, or urges to someone else
A woman accuses her boyfriend of being unfaithful while repressing her desire to have an affair.
Displacement Redirecting a feeling or response toward a target that usually is less of a threat
An abused wife does not fight back but mistreats her child instead.
Avoidance Taking action to prevent situations that produce powerful feelings
A woman will not date because she is afraid of falling in love.
Regression Reducing anxiety by acting immature to feel more secure
A 6-year-old child begins to suck his thumb after the birth of his baby brother.
Defense Mechanisms
Table 2.2
Conflicts Approximate Age Ranges
Trust vs. mistrust Birth to 1 year
Autonomy vs. doubt and shame
1 to 3 years
Initiative vs. guilt 3 to 6 years
Industry vs. inferiority 6 to 12 years
Identity vs. identity confusion 12 to 18 years
Intimacy vs. isolation Young adulthood
Generativity vs. stagnation Middle age
Integrity vs. despair Old age
Table 2.3
Erikson’s Psychosocial Stages of Personality Development
As adolescents mature into young adulthood, they face the challenge of intimacy, forming close and lov- ing relationships with others. Adults who did not develop a sense of trust earlier in their lives or have not clari!ed their identities may be unable to establish intimate relationships and thus feel isolated. During middle age, individuals who have mastered previous developmental tasks o$en focus on meeting the needs of others through activities such as raising families and performing community service. Erikson coined the term generativity to refer to these psychosocial tasks. In the !nal stage of life, people seek integrity, a feeling that their lives have been ful!lling and complete.
Maslow’s Hierarchy of Needs According to psychologist Abraham Maslow, individuals behave in response to their values rather than to their uncon- scious drives.2 Maslow thought that healthy people value the freedom to achieve personal ful!llment by developing their talents and competencies. "is freedom becomes a psychological need that drives personality development. Maslow created a hierarchy of !ve human needs, from the most basic biological requirements that contribute to human survival to the one that is most essential for psychological ful!ll- ment, self-actualization (Figure 2.2). To achieve self- actualization, each level of needs, from the base to the top of the hierarchy, must be met in order.
Adolescents begin to establish their identities when they are able to clarify their feelings and positions about their roles in life. Identity confusion results when they are unable to develop sound self-concepts and function independently of their families.
44 Chapter 2 Psychological Health
the human needs hierarchy. Nevertheless, Maslow admitted that many people are satis!ed with their lives, even if they have not achieved self-actualization.
Adjustment and Growth Each day, individuals respond to the demands of other people, their physical environment, and them- selves. "roughout life, these demands are changing constantly. Being in college is especially demanding, but consider how your life will change a$er you grad- uate. What do you think your life will be like 10, 20, or 30 years a$er graduation? What kinds of adapta- tions do you expect to make over your lifetime?
Adapting to change, which is called adjustment, involves the responses people make to cope with the
demands of life. Psychological adjustment occurs when an individual learns that cer- tain responses meet these demands more e#ectively than others do. For example, one way a new student might psychologically adjust to college life is by scheduling time each week for various tasks, such as study- ing, attending classes, and going to work. Maintaining the new schedule may be chal- lenging, particularly if the student followed a less structured lifestyle in the past.
Psychological growth occurs when a person discovers that certain adjustment strategies, such as studying more or plan- ning for the future, enhance one’s sense of freedom and control over oneself and the environment. To adjust in bene!cial ways and to experience psychological growth, an individual needs to obtain reliable informa- tion, set realistic goals, plan e#ective ways to achieve those goals, take actions that are based on reasonable judgments and deci- sions, and evaluate the consequences of his or her choices.
If not managed e#ectively, interpersonal con'icts can hinder psychological adjust- ment and growth. Such con'icts o$en arise when people do not share opinions, values,
Self-actualized persons are psychologically healthy and mature. "ey feel free to pursue their creative and intellectual capabilities. "e possibility of self- actualization exists in all people, but unless the pre- requisite needs are met, individuals can never fully realize their potential. According to Maslow and oth- ers, only about 1 person in 100 will reach the top of
Establishing trusting relationships with loving adults enables infants to begin developing psychological well-being. © ClickPop/Shutterstock.
Self-Actualization A need for
achievement and mastery
Esteem Needs A need to have a high self-image
Love Needs A need to give love and receive love
Safety Needs The need for a secure environment in which one
can live, work, and play
Physiological Needs The most basic human needs for air, water, food, housing,
sleep, and sexual activity
Figure 2.2 Maslow’s Hierarchy of Human Needs. Maslow created a hierarchy of five human needs, from the basic biological survival requirements to psychological fulfillment (self-actualization). Before achieving self- actualization, a person must satisfy all the preceding needs.
psychological adjustment Changing one’s thoughts, attitudes, and behaviors to cope effectively with the demands of the environment.
psychological growth The process of learning from one’s experiences.
Adjustment and Growth 45
• Adjust more easily to change • Accept responsibility for actions when they make
mistakes
People with low self-esteem tend to:
• Have more di&culty making decisions • Resist changing their behavior • Resent any form of criticism, even if it is
constructive • Put down others to make themselves look or
feel%better • Experience more stress and anxiety • Have di&culty developing friendships or
romantic relationships • Be more vulnerable to drug and alcohol abuse
"e “Self-Esteem Inventory” in the Student Work- book at the end of this text can help you assess your self-esteem.
People begin developing self-esteem early in childhood. Parents and other caregivers play a crucial role in determining their children’s level of self-esteem. By interacting with parents and other family members, for example, young children learn that certain behaviors are good or bad. Children use this information to begin forming their self-image, the way they view themselves. Caregivers play an essential role in the development of children’s self-esteem. Children who% are listened to, who are spoken to with respect,% who are given appropriate attention and a#ection, who have accomplishment recognized, and who have failures acknowledged and accepted tend to become psychologically well- adjusted adults.3 Children with positive self-images have high self-esteem because they see themselves as being good, lovable, and possessing many worth- while and valuable characteristics such as honesty and sensitivity. Harsh criticism; physical, emotional, or sexual abuse; neglect or ridicule, or unreasonable expectations by caregivers, however, may lead to low self-esteem.
When children enter school, their social envi- ronment enlarges to include more children, teach- ers, and other members of the community. "ese individuals provide new learning experiences that can have positive or negative impacts on the person- ality, self-image, and self-esteem of children. If a child who has a negative self-image enters school and has experiences, such as being bullied, that reinforce this
needs, or beliefs. In these situations, many individuals respond by expressing anger or aggression. Aggressive reactions o$en injure other people physically or psy- chologically; therefore, these responses do not facili- tate social interactions.
Assertiveness is a way of reacting to social situa- tions by maintaining one’s rights without interfering with the rights of other people and without harming them. Consider how students respond to an instruc- tor who failed to consider certain possible answers to an essay question. An aggressive student might take class time to argue a point, verbally lashing out at the teacher. An assertive student might arrange to meet with the instructor a$er class, using the time to discuss his or her case in a more thoughtful and rational manner.
Another way healthy people constructively resolve interpersonal con'icts is by using compromise. An individual who disagrees with a friend over an issue, for example, may decide that preserving the friend- ship is more valuable in the long run than “winning” the argument. "is person is willing to compromise by modifying his or her attitudes. "e Managing Your Health feature provides additional suggestions for resolving con'icts constructively.
Psychological growth fosters the development of autonomy. People with a high degree of autonomy tend to function independently and display positive self-esteem, the extent to which a person feels wor- thy and useful.
Self-Esteem Self-esteem is a key component of personality that in'uences an individual’s thoughts, actions, and feel- ings. Positive self-esteem is a characteristic of psy- chologically healthy people. Individuals who have positive or high self-esteem tend to:
• Have a high degree of autonomy • Display self-con!dence and self-respect • Be satis!ed with themselves • Accept challenges and work well with others • Develop supportive and loving relationships
autonomy Sense of independence.
self-esteem The extent to which a person feels worthy and useful.
self-compassion Treating yourself with the same empathy you show others.
46 Chapter 2 Psychological Health
Managing Your Health
In addition to compromise, consider using the following tips to resolve conflicts constructively:
1. Focus on one issue; state your perception of the problem as clearly as possible.
2. Consider the feelings of others; avoid criticizing, name-calling, threats, or sarcasm.
3. Use “I feel” statements. “You” statements make others defensive. For example, say, “I feel angry when you . . .” instead of “You make me angry.”
4. Do not assume you know how other people feel, what they believe, or how they will react.
5. Discuss the current concern; avoid dredging up past arguments.
6. Think before you speak; choose your words carefully to avoid confusion.
7. Listen carefully to others; avoid interrupting them while they talk.
8. Accept responsibility for your actions. Apologize for making mistakes.
9. Offer reasonable solutions. 10. Give others time to consider, accept, or reject
your ideas. 11. Be patient; keep the door open for future
communication.
Resolving Interpersonal Conflicts Constructively
perception, emotional disturbances can develop that persist into adulthood. With the help of others, chil- dren can develop positive self-concepts that establish the foundation for a lifetime of wellness. Parents and other adults help children feel good about themselves by spending time with them, listening to their con- cerns, and treating them with respect.
During adulthood, experiences at school, work, and home and a variety of social factors, including relationships, in'uence self-esteem. Relationships and experiences that are rewarding, enriching, and satisfying support positive self-esteem. In addition to having self-respect, people with a high degree of self- esteem gain the respect and approval of colleagues and others.
Self-esteem is a deep-rooted aspect of an indi- vidual. Although self-esteem may rise or fall over the course of a day, its basic nature remains fairly stable over longer periods. Individuals with persistent low self-esteem can improve their negative thoughts and feelings about themselves. By analyzing their situa- tions, these people can determine factors that con- tribute to their poor self-concepts. For example, working in a dull job or remaining in an abusive rela- tionship can a#ect self-esteem negatively. In these instances, people may improve their situations and feelings of self-worth by !nding new jobs or ending the self-destructive relationships.
Self-esteem can be improved by identifying and learning to appreciate positive traits and abilities, while accepting our weaknesses (we all have them).
Practicing self-compassion, or treating yourself with%the empathy you show others, can also help facil- itate self-esteem improvement. Accepting construc- tive criticism can support personal growth; therefore, is it also important to recognize that not all criticism is destructive or insensitive.4 Making a few lifestyle changes, such as developing new interests, changing some bad habits, exercising regularly, or taking an assertiveness training class, can improve a person’s psychological outlook. To overcome low self-esteem, psychological counseling may be necessary to help individuals develop the ability to evaluate themselves realistically and form accurate self-perceptions.
Improving Your Psychological Health What can you do to improve your psychological health? You can enhance the quality of your men- tal health primarily by improving the other dimen- sions of your health. Exercising regularly may boost your mood.3,5 Getting enough sleep, eating a nutri- tious diet, and maintaining a healthy weight for your height may also enhance psychological health by improving physical health. In addition to taking good care of your physical needs, fostering positive social contacts, whether with family, friends, or col- leagues, is very important. Everyone needs to com- municate with other people on a regular basis. For example, one goal to improve your psychological health could be to make and maintain at least one new
Adjustment and Growth 47
children or become involved in your religious orga- nization. Finally, taking an active role in ensuring and protecting the quality of your environment will support all dimensions of your health.
Understanding Psychological (Mental) Illness
Having “the blues,” feeling “scared to death,” or being “worried sick”—perhaps you can recall situations in which you experienced these strong emotions or uncomfortable sensations. Occasionally, healthy peo- ple have disturbing thoughts, experience unpleasant feelings, or display inappropriate behaviors. In most instances, these are normal responses and adaptive reactions to unpleasant or threatening situations. For example, it is normal to be sad a$er learning about the death of a friend or to be afraid when a snake crosses your path. Given a reasonable amount of time, however, the strong emotional responses or unpleasant thoughts and feelings resolve, and you regain your sense of well-being.
"e observable physical and behavioral changes that signal emotional state are referred to as affect, or mood. Expressing emotions appropriately is a characteristic of a psychologically healthy individual;
Caregivers play a crucial role in determining children’s level of self-esteem. © Ilike/Shutterstock.
Adequate sleep can enhance psychological health by improving physical health. © auremar/Shutterstock.
affect Observable expressions of mood.
social contact each year. You can improve your intel- lectual health by reading challenging books, playing mind- stimulating games such as crossword puzzles or chess, or serving as a tutor. Some people !nd that keeping a journal or diary in which they record their most private feelings helps them cope with the chal- lenges of daily life. Attending to your spiritual needs can provide personal ful!llment also. For example, you can volunteer to serve as a mentor for troubled
4To experience psychological adjustment and growth, set realistic goals, plan effective ways to achieve those goals, take actions that are based on reasonable judgments and decisions, and evaluate the consequences of your choices.
4To facilitate your psychological adjustment, learn ways to manage interpersonal conflicts constructively, without being aggressive. When such conflicts arise, decide when it is best to compromise or assert your position.
4To improve your self-esteem, avoid making negative statements about yourself. Identify and be realistic about your strengths and weaknesses; focus on your accomplishments and positive characteristics.
4To improve your psychological health, take steps to improve the quality of the other dimensions of your health.
Healthy Living Practices
48 Chapter 2 Psychological Health
extreme or improper emotional responses can indi- cate a serious psychological disturbance. "e key fea- tures that distinguish a normal emotional response from an abnormal one are the intensity and duration of the feelings. Mentally ill individuals experience abnormal feelings, thoughts, and behaviors that per- sist, interfere with daily life, and hinder psychological adjustment and growth.
A psychosis is a severe type of mental illness characterized by disorganized thoughts and unreal perceptions that result in strange behavior, isola- tion, delusions, and hallucinations. Delusions are inaccurate and unreasonable beliefs that o$en result in decision-making errors. For example, a person su#ering from a delusion might think that he or she can 'y, so this individual jumps o# a tall building. Hallucinations are false sensory perceptions that have no apparent external cause, but they are real to the psychotic individual. Examples of hallucina- tions include hearing instructions from pictures, seeing ghostly images, or feeling insects crawling underneath the skin. Psychotic conditions (psycho- ses) can be acute or chronic, and they can result from brain damage, chemical imbalances in the brain, or substance abuse.
Situations and cultures provide the context in which behaviors are judged as normal or abnormal. If a person who is living in a country torn apart by civil war bombs a crowded marketplace, people may view this individual as a terrorist or a hero but not neces- sarily mentally ill. However, if this bombing occurs in an American shopping mall, and the bomber says that a dog gave the order to perform the deed, you might suspect that this person is psychotic.
The Impact of Psychological Illness Why is it important to learn about psychological illness? Most Americans have one or more family members who su#er from a psychological illness. Between 2006 and 2010, about 1 in 10 adult Ameri- cans reported experiencing “frequent mental distress” for 14 or more days during the previous 30% days.6 According to data from the National Comorbidity Survey Replication, depression and alcohol depen- dence are the most common psychological distur- bances that a#ect Americans (Table 2.4).7 In 2015, 18% of adults aged 18 or older had a mental illness, whereas 21.7% of those aged 18–25 and 14% of those aged 50 or older had some form of mental illness, respectively.8 Women and American Indians and
delusions Inaccurate and unreasonable beliefs that often result in decision-making errors.
hallucinations False sensory perceptions that have no apparent external cause.
Disorder Percentage of Americans Affected*
Any mental health disorder 46.4
Any anxiety disorder Panic disorder Specific phobia Social phobia Generalized anxiety disorder Obsessive-compulsive disorder
28.8 4.7
12.5 12.1 5.1 1.6
Impulse control disorders Attention-deficit hyperactivity disorder
24.8 8.1
Any substance abuse/ dependence Alcohol abuse Alcoholism Drug dependence other than alcoholism
14.6
13.2 5.4 3.0
Any mood disorder Major depressive episode Bipolar disorders
20.8 16.6
3.9
*The sum of these percentages is more than 100 because many individuals suffer from more than one disorder.
Data from Kessler, R. C., et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6): 593–602.
Table 2.4
Lifetime Prevalence of Mental Health Disorders
those who identi!ed as having two or more races had the highest rates of mental illness in 2015.
"e emotional and economic costs of mental ill- ness are high not only for a#ected individuals and their families but also for society. People may drop out of college or abuse alcohol and other drugs because of unresolved emotional problems or underlying psychological disorders. Mental illness frequently has a negative impact on the quality of life and the productivity of workers.
Understanding Psychological (Mental) Illness 49
Consumer Health Locating and Selecting Mental Health Therapists The following tips can help you find and select qualified mental health specialists:
• Discuss psychological health concerns with your personal physician or with medical staff at your student health center. These individuals can assess your health and refer you to qualified mental health specialists if necessary.
• Contact local mental health associations or agen- cies for information about psychological health. Members of these associations can give you infor- mation about local support groups and mental health services.
• Contact your state’s social welfare department or the social services department of a local hospital to identify qualified therapists.
• Interview therapists before making any agreements for services.
• Ask therapists about treatment philosophies, meth- ods, insurance coverage, and payment expectations before agreeing to use their services.
In the past, psychologically disturbed individuals were o$en misunderstood and mistreated. Having a mental illness was considered disgraceful by people who associated the condition with bizarre behav- iors, violent acts, and long stays in mental healthcare facilities. Today, being diagnosed with a psycho- logical disorder is no longer a hopeless situation, because scientists understand more about the vari- ous biological, environmental, and social factors that in'uence behaviors than they did in the past. Nev- ertheless, these disorders do not receive the kind of interest and concern from public health o&cials that conditions such as heart disease, cancer, and stroke generate. Why? Mental illnesses may not get much attention because of the stigma associated with them and the lack of major risk factors that can be modi- !ed to prevent them.
Although mental health disorders are common and can be quite disabling, mental illnesses are o$en not treated adequately worldwide.9 In 2015, fewer than 50% of Americans who have these con- ditions sought treatment.8 Approximately 50% of respondents to the 2002–2015 National Survey on Drug Use and Health indicated that the most sig- ni!cant barrier to treatment was cost. People’s beliefs that they can handle the problem them- selves or that treatment won’t work, not knowing where to go for mental health services, and nega- tive attitudes toward mental illness were identi- !ed as major reasons that individuals do not seek bene!cial therapy. To many medical and health professionals, however, seeking professional help for psychological problems is a sign of personal strength, not weakness.
What Causes Psychological Disorders? "ere are numerous psychological disorders, and in each case, it may be impossible to determine a single cause. Alterations in the normal chemical and physi- cal environment of the brain o$en produce mental illness. In many instances, these alterations are the result of genetic defects that adversely a#ect neu- rotransmitter levels. People whose brains have been physically damaged by injuries, tumors, or infections o$en display abnormal behavior. When introduced into the body, drugs such as cocaine can interfere with the brain’s ability to produce, use, or eliminate neurotransmitters. Furthermore, pollutants such as pesticides and toxic minerals, including lead, mer- cury, and arsenic, can damage the brain.
Scientists note that certain mental illnesses, such as schizophrenia and most major mood disorders, tend to occur within the same family. "ese observations support the role of inheritance in their development. Genetic factors alone, however, do not explain the development of every psychological disorder. Several members of a family could develop similar forms of mental illness because they are more likely to experi- ence the same physical, economic, and social envi- ronments than unrelated individuals.
Environmental conditions in'uence the expres- sion of many inborn traits, including psychological responses. Children, for example, o$en learn ways of reacting to situations by observing their parents. "ink about how you respond when angered or frus- trated. Are your responses like those of your mother or father?
50 Chapter 2 Psychological Health
Personal experiences can trigger the onset and in'uence the severity of some psychological distur- bances. Some experts think that a child’s brain can be altered by exposure to extremely stressful situa- tions, increasing the youngster’s risk of developing depression later in life. However, researchers have yet to understand completely the extent to which bio- logical, social, and environmental factors interact to in'uence psychological health.
Treating Psychological Disorders Many people with psychological disorders respond well to treatment. Treating these conditions involves the cooperation of the a#ected individuals and their families, and, in many instances, the assistance of mental health therapists who have specialized train- ing. Table" 2.5 lists the major types of mental health therapists and some information concerning their quali!cations.
Many people learn to cope with various psycho- logical problems, such as drug addictions or the loss
of loved ones, by joining support groups. "e sup- port group is an informal approach to treatment. Support group participants have regular meetings in which they can discuss personal adjustment prob- lems. Group members usually conduct these meet- ings rather than mental health therapists. In addition to attending regular meetings, some group members may need to obtain professional counseling.
Mental health therapists can o#er a variety of e#ective psychotherapies (treatments) that enable many individuals with psychological disorders to lead normal, productive lives. Psychotherapy uses many methods to provide counseling, including cog- nitive behavioral therapy, group therapy, and medica- tions. Cognitive behavioral therapy can help people who are anxious, angry, or depressed identify and change negative or inaccurate ways in which they think about themselves and their situations. As men- tioned earlier, medication can correct neurotrans- mitter imbalances in the brain.
More than one form of treatment may be neces- sary to alleviate or control the disorder. In severe cases, people su#ering from major psychological
Therapist Training and Degrees
Counseling and clinical psychologists
M.A. or Ph.D. in psychology, or Psy.D.; 5 or more years in psychotherapy methods, research, and assessment
Psychiatrists Medical (M.D. or O.D.) degree and at least 3 years of specialized training in psychiatry
Psychoanalysts Have undergone personal psychoanalysis and completed 7–10 years of part-time psychoanalytic training (most are psychiatrists)
Psychiatric social workers M.S.W.; most states require certification by the Academy of Certified Social Workers
Clinical mental health counselors
Master’s degree (or equivalent) and 2 years of counseling experience; certified by the National Academy of Certified Clinical Mental Health Counselors
Psychiatric nurse practitioners Registered nurses with additional education and experience working in psychiatric settings
Marital and family therapists Master’s degree. Licensed or certified in about half of the states; member of the American Association for Marriage and Family Therapy
Sexual therapists Minimum of a master’s degree, a license in a related field, specialized sex education and sex-therapist training, extensive supervised individual and group therapy experience; the American Association of Sex Educators, Counselors and Therapists provides certification
Abuse counselors Substance abuse training; often counselors are recovering substance abusers
Clergy Religious training; may have spiritual and family counseling training
Data from Cornacchia, H. J., & Barrett, S. (1993). Consumer health. St. Louis, MO: Mosby.
Major Types of Mental Health Therapists
Table 2.5
Understanding Psychological (Mental) Illness 51
your body physically prepares to deal with the danger. However, if the anxiety interferes with your ability to perform daily activities, the condition is abnormal. During their lifetimes, about 5% of the population su#ers from generalized anxiety disorder, a con- dition characterized by uncontrollable chronic wor- rying, anxiousness, and nervousness.10 People with this disorder have unrealistic and excessive concerns about their jobs, children, health, or minor situations such as making home repairs. "ey are tense, irri- table, and restless, and they o$en experience sleep- ing problems. Treatment usually includes antianxiety and antidepressant medications as well as cognitive behavioral therapy.
Phobias A phobia is an intense and irrational fear of a situation or object. Agoraphobia is the fear of open places or public areas. Social phobias are fears of performing in situations that involve people, such as giving speeches or taking tests. Speci#c phobias (formerly called simple phobias) are fears of cer- tain objects or situations, such as snakes or 'ying. According to the results of the National Comorbid- ity Survey Replication, phobias are among the most common psychological disturbances in the United States.7 About 12% of Americans report having social phobias, and about 12.5% of Americans report expe- riencing speci!c phobias. It is not uncommon for a person to be a#ected by more than one phobia. Although people who su#er from phobias know that their behavior is irrational, they still become anxious in the situations that arouse their fears (Figure 2.3).
conditions may require hospitalization for treatment and to prevent self-injury or harm to others. If you or someone you know needs mental health care, the Consumer Health box titled “Locating and Selecting Mental Health "erapists” provides some sugges- tions for !nding and choosing quali!ed help.
Common Psychological Disorders
Although all psychological disorders involve a pat- tern of behavioral or psychological symptoms, some are more common than others. Currently, common psychological disorders include anxiety disorder, clinical depression, bipolar disorder, attention- de!cit hyperactivity disorder, and posttraumatic stress syn- drome, among others.
Anxiety Disorders Do you feel uneasy when you ride in an elevator, enter a classroom to take a test, or give a speech? Nearly everyone experiences anxiety, the uncomfort- able feeling of apprehension or uneasiness that results while expecting a vague threat. "e physical changes associated with anxiety states include increased heart rate, rapid breathing, and elevated blood pressure. Anxious people may report feeling tense, distressed, or worried, and they may be emotionally upset, sweat- ing, and trembling.9 Anxiety disorders are common; according to the results of the National Comorbidity Survey Replication, nearly 30% of Americans su#er from these conditions at some time in their lives.7
Generalized Anxiety Disorder When you per- ceive a threat, it is normal to feel mildly anxious as
4Many psychological problems respond well to treatment. If you think you may have a mental health disorder, ask your personal physician or the medical staff at your campus health center for help.
Healthy Living Practices
Figure 2.3 Phobias. Phobias are intense and irrational fears of certain situations or objects that can interfere with functioning. Many people have a fear of flying. © dundanim/Shutterstock.
generalized anxiety disorder A condition characterized by uncontrollable chronic worrying and nervousness.
phobia An intense and irrational fear of an object or a situation.
52 Chapter 2 Psychological Health
Acute Stress Disorder Characterized by severe anxiety, disassociation, and other symptoms, acute stress disorder occurs within 1 month of exposure to a traumatic stressor.9 People su#ering from acute stress disorder display decreased emotional respon- siveness, including feelings of guilt about pursuing usual life tasks, and may !nd it di&cult to experience pleasure in previously enjoyable activities. In many cases, people experiencing acute stress disorder have di&culty concentrating or recalling speci!c details of the traumatic event, and they report feeling detached from their bodies. For acute stress disorder to be diagnosed, someone must experience distress or impairment in social, occupational, or other impor- tant areas of function that inhibits the individual’s ability to pursue necessary tasks. Further, symptoms must persist for a minimum of 2 days and a maxi- mum of 4 weeks and must not be associated with substance use or abuse.
Adjustment Disorders An adjustment disorder is a stress-related disorder that o$en consists of a group of symptoms, including feeling sad or having
Most cases of phobia are mild; a#ected individu- als o$en learn to live with this condition by avoiding situations that arouse the anxiety. Severe phobias can interfere with normal social functioning. For exam- ple, people with agoraphobia may refuse to leave their homes. Individuals who are severely a#ected by phobias can seek professional treatment that includes behavioral therapy and medications to control irra- tional feelings and reduce anxiety.
Panic Disorder An estimated 3 million Americans su#er from panic disorders that feature panic attacks, unpredictable episodes of extreme anxiety and loss of emotional control. During a panic attack, people usu- ally experience shortness of breath, shakiness, faint- ness, nausea, and a rapid, pounding heartbeat. A#ected individuals o$en feel terri!ed because they think they are becoming insane or having a heart attack. Severe phobias, certain drugs, or frightening experiences may trigger panic attacks, but they can occur spontaneously.
"erapists o$en combine cognitive behavioral therapy and medications to treat panic disorders. People who have frequent panic attacks should seek medical help because studies indicate that they are at risk of committing suicide.
Trauma- and Stressor-Related Disorders Psychological disorders in this category di#er from anxiety disorders because exposure to a traumatic or stressful event is explicitly listed as a criterion for diagnosis.10 For example, someone can develop posttraumatic stress disorder (PTSD) when he or she survives extraordinary life events such as a sex- ual assault, military combat, or a natural disaster ( Figure"2.4). "e diagnostic criteria for PTSD include (1) reexperiencing the traumatic event (e.g., recurrent dreams), (2)%heightened arousal (e.g., aggressiveness, sleep disturbances, hypervigilance), (3) avoidance (e.g., blocking reminders of the traumatic event), and (4)% negative thoughts, moods, or feelings (e.g., dis- torted sense of self-blame, estrangement from others).
Symptoms of PTSD may take months to develop fully and include having disturbing recollections or nightmares of the event and, in severe cases, feel- ing emotionally “numb.” A#ected people o$en avoid thinking about or discussing the traumatic experi- ences, and they may smoke heavily, overeat, or abuse drugs as a way of coping. Treatment of PTSD includes antianxiety medication and trauma-focused cogni- tive behavioral therapy that encourages survivors to talk about the traumatic events with others.11
Figure 2.4 Surviving a Disaster. Rescuers pull a boy from beneath a collapsed wall at Plaza Towers Elementary School after an EF-5 tornado destroyed it and thousands of homes in Moore, Oklahoma, on May 20, 2013. © Sue Ogrocki/AP Images.
panic disorder Psychological condition that features panic attacks, unpredictable episodes of extreme anxiety, and loss of emotional control.
Common Psychological Disorders 53
physical symptoms (e.g., twitching, skipping heart- beats, or nervousness), that occur a$er a stressful life event. Symptoms occur when someone has a di&cult time coping with events such as the death of a loved one, worries about money, sexuality issues, or major illness. Adjustment disorder is o$en diagnosed when a person’s reaction to a stressful event is stronger or greater than expected. In many cases, symptoms of adjustment disorder mirror acute stress disorder but do not meet clinical criteria for diagnosis.
Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder In the new Diag- nostic and Statistical Manual of Mental Disorders, DSM-5, obsessive-compulsive disorder (OCD) was placed in the new obsessive-compulsive and related disorders category. An obsession is a persistent, inappropriate, and repetitive thought or impulse that produces anxious feelings. Obsessions are o$en related to self-doubt or fears. A compulsion is the behavior that usually follows the obsessive thoughts or impulses. Compulsive behaviors reduce the obsessed individual’s anxiety. A young person, for example, might have recurring thoughts of injuring a family member. "is individual may wash his or her hands hundreds of times a day and take numer- ous long showers to reduce anxious feelings. Other typical compulsive behaviors include hoarding cats and dogs or useless items like plastic containers or making repetitive actions such as checking the oven frequently to see if it is turned o#. A#ected individu- als o$en think that their obsessions and compulsions are repulsive or troublesome, but e#orts to stop cre- ate more anxiety. Treatment includes medication and psychological counseling. In most cases, the longer the obsessive-compulsive behavior pattern has been in place, the more di&cult the disorder is to treat.
Other disorders, including hoarding disorder, trichotillomania, and excoriation disorder, are con- sidered related disorders because they also indicate obsessive tendencies. Hoarding disorder re'ects per- sistent di&culty discarding or parting with posses- sions because of a perceived need to save the items and distress associated with discarding them. Tricho- tillomania (hair-pulling disorder) is a compulsive urge to pull out, and in some cases eat, one’s own hair, and excoriation disorder (skin picking) is characterized by compulsively picking at one’s skin for no apparent rea- son. Treatment for compulsive disorders begins with proper diagnosis by a mental health professional.
Neurodevelopmental Disorders Neurodevelopmental disorders are de!cits in social communication and social interaction. "ose with a neurodevelopmental disorder may display repetitive or restrictive behaviors, may have di&culty coping with change, and may experience great distress when required to change focus or action. Attention-de#cit hyperactivity disorder (ADHD) and autism spectrum disorder are common neurodevelopmental disorders.
Attention-De!cit Hyperactivity Disorder ADHD is characterized by short attention span and/or hyperactivity-impulsivity that results in serious social impairment. An estimated 4.4% of American adults have ADHD; men are more likely to be diagnosed with ADHD than are women.12 "e causes of ADHD are unclear, but genetics plays a role in the develop- ment of the condition.
People with ADHD have di&culty focusing and maintaining their attention on tasks, such as ful!lling work-related responsibilities, studying, or complet- ing assignments. Unemployment, sleep disturbances, accident proneness, and cigarette smoking are associ- ated with adult ADHD.12
"ere is no generally accepted test for diagnosing adult ADHD, and the condition is o$en more di&- cult to recognize in adults than in children because the signs are less obvious.12 Adults with ADHD frequently su#er from anxiety, mood, and drug abuse disorders. Treatment may include stimulants such as methyl- phenidate (Ritalin) and psychological counseling. According to the results of one survey, only about 10% of adults with ADHD reported receiving treatment for the condition during the past 12 months.12 More consumer and physician awareness programs are needed to alert the public about adult ADHD and its treatments. If you would like more information about ADHD, visit the Centers for Disease Control and Pre- vention’s web site at www.cdc.gov/ncbddd/adhd/.
Autism spectrum disorder (ASD) encompasses autistic disorder, Asperger’s disorder, childhood%dis- integrative disorder, and pervasive developmental disorder—not otherwise classi!ed (or atypical autism). People with ASD tend to have di&culty communi- cating and may respond inappropriately in conver- sation, misread nonverbal interactions, and have di&culty building and maintaining relationships. Additionally, people with ASD are highly dependent on routine and sensitive to change.10 Between 2010 and 2012, approximately 1 in 68 children were diag- nosed with ASD.13 "ere is currently no known cause for ASD, although most scientists agree that genetics plays a large role. "e beliefs that ASD is linked to
54 Chapter 2 Psychological Health
poor parenting or routine vaccination, however, are not supported by evidence.14 Diagnosis of ASD can be di&cult and requires trained medical profession- als. For more information about ASD, visit the Cen- ters for Disease Control and Prevention’s web site at www.cdc.gov/ncbddd/autism/index.html.
Substance-Related and Addictive Disorders Substance Use Disorder Excessive use of 10 classes of drugs, including alcohol, ca#eine, cannabis, inhal- ants, opioids, sedatives, hypnotics, and stimulants, is classi!ed as substance-related disorder.10 Drugs taken in excess activate the brain’s reward system and cre- ate a feeling of pleasure, o$en referred to as a “high.” By doing so, drug abuse behavior is reinforced. For some people, activation of the reward system is so intense that normal activities are neglected. People with lower levels of self-control, which may re'ect impairments of the brain inhibitory mechanism, may be predisposed to substance use disorders. Genera- tional patterns, in which people are exposed to drug use in their family, social, or community environ- ments, are also major contributors to increased risk for addiction.
Problem Gambling Nearly every state permits some form of gambling, such as lotteries, track racing, or casinos. For most people who place bets, the activity is entertaining, occasional, and controllable. However, about 1% of adult Americans are problem gamblers who gamble compulsively, excessively, and at the expense of their families, jobs, and rela- tionships.15 Men are more likely to be compulsive gamblers than women are. Psychological disor- ders, including depression and anxiety disorders, and risky behaviors, such as binge drinking and illegal drug use, o$en accompany problem gam- bling behavior. Table 2.6 lists typical features of problem gamblers.
Gamblers Anonymous is a self-help group that can enable problem gamblers to control their troublesome behavior (www.gamblersanonymous.org). Many prob- lem gamblers, however, do not remain in treatment. Some counselors have certi!cation to treat compul- sive gambling, but health insurance providers may not cover their services. More research is needed to deter- mine e#ective ways to prevent and treat this condition.
Mood Disorders Until a few years ago, the two words that best described my life were fear and loneliness. As a child, I experi- enced physical, emotional, and verbal abuse from my
The problem gambler:
• Seems to think only about gambling or how to get money to gamble
• Loses friends, family members, and jobs because of his or her behavior
• Gambles more often over time • Has no control over the impulse to gamble • Becomes restless, angry, or agitated when he or
she tries to gamble less often (withdrawal) • Gambles to escape problems or cope with
depression, guilt, or anxiety • Gambles again, trying to recover losses • Lies to cover up the behavior • Has others financially bail him or her out • Resorts to illegal acts, such as forging checks and
stealing money, to obtain money for gambling • Abuses mind-altering drugs
Table 2.6
Typical Features of Problem Gambling
Do you know someone who is a problem gambler? © neal and molly jansen/Alamy Images.
Common Psychological Disorders 55
parents. There were some instances when the beatings were so severe, I just forgot about them. I married a man who also physically abused me. Having no sav- ings or college degree, I lacked the self-confidence to walk out of the marriage. I felt trapped. Deep depres- sion set in; I cried a lot of the time and felt guilty because I was unable to carry out the normal daily responsibilities of cooking and cleaning the house. I began to think suicidal thoughts.
Finally, I entered a hospital that had a stress unit. Between the group sessions and private therapy, I learned a lot about those who abuse others and how to handle stress. However, spending 3 weeks in the hospital did not cure my depression. I realized that the only thing that would do that would be to remove myself from its cause. I separated from my husband and started college.
It has been a struggle financially, but I am determined to make it. I am preparing to graduate this semester with a bachelor of arts degree, and I plan to continue on to get a master of arts degree. The best change is my new self-confidence gained from overcoming the obstacles and becoming independent.
"is middle-aged college student’s case illustrates not only the harsh origins of her depression but also how an emotionally resilient person can recover from depression, resolve problems, and regain self-esteem. How can you distinguish a normal period of sadness from one that signals a major depressive disorder?
It is normal for people to feel “down” a$er a loss or disappointment. A$er a signi!cant loss, such as the death of a close friend or relative, one normally feels grief, an intense sadness that may persist up to a year a$er the loss. Most grieving individuals soon recover their emotional balance and resume their usual activ- ities. Grieving people are probably severely depressed if they become so profoundly sad that they withdraw and isolate themselves for several months and harbor feelings of guilt, low self-worth, and suicide. Endur- ing other stressful experiences, such as a di&cult relationship or severe physical or emotional trauma, can trigger the !rst episode of depression in suscep- tible persons.
People su#ering from major depressive disorder generally experience the following:
• Persistent sad, “empty,” or hopeless feelings • Feelings of guilt, worthlessness, or helplessness • Loss of interest or pleasure in activities that used
to be enjoyed • Unexplainable fatigue • Di&culty concentrating, remembering, or
making decisions • Frequent insomnia, early-morning wakening, or
oversleeping • Changes in appetite resulting in weight loss or gain • Restlessness • Physical complaints that do not respond to
treatment, such as chronic headaches, intestinal tract disturbances, and pain
• "oughts about death, suicide, or attempting suicide
major depressive disorder A mood disorder characterized by persistent and profound sadness, hopelessness, helplessness, and feelings of worthlessness; lack of energy; loss of interest in usual activities; loss of the ability to concentrate; suicidal thoughts; and appetite and sleep disturbances.
“Cutting” can be a sign of depression. © Bubbles Photolibrary/Alamy Images.
56 Chapter 2 Psychological Health
by receiving therapies that include prescribed anti- depressant medications and psychotherapy, which teaches patients to focus on positive rather than neg- ative thoughts. However, physicians who are not psy- chiatrists o$en fail to diagnose the condition in their patients. As a result, many people with depression are not treated or are improperly treated.19,20 Younger people with depression, typically those 18–25 years of age, are less likely than older adults to receive men- tal health treatment.8,21
Alternative remedies for depression are becom- ing popular in the United States. "e herb St. John’s wort may be helpful as a treatment for mild to mod- erate depression.22 St. John’s wort has been reported to interact with certain prescription drugs and cause side e#ects, so individuals should not take this sub- stance without consulting a physician.
People who are depressed o$en feel better when engaging in regular physical activity. According to the Surgeon General’s report Physical Activity and Health,23 a moderate amount of physical activity each day may reduce symptoms of anxiety and depression and improve mood and a sense of well-being.
Managing Mild Depression If you experience mild depression, you can help yourself by:
• Setting priorities at work, home, or school • Avoiding excess responsibilities • Maintaining social contacts and con!ding in
someone you can trust • Participating in a few enjoyable activities,
especially if they are social and improve your mood
• Exercising regularly • Relaxing • Focusing on positive rather than negative
thoughts • Volunteering to help others in need
By taking these actions, your mood should gradu- ally improve. If you still feel depressed a$er a couple of weeks or your mood worsens, seek professional help. For more information about depression, visit the National Institute of Mental Health’s web site: http://www.nimh.nih.gov/health/topics/depression /index.shtml?utm_source=BrainLine.org&utm _medium =Twitter.
Bipolar Disorder Bipolar disorder, formerly called manic depression, is characterized by unusual shi$s in mood, energy and physical activity levels, and
"ese symptoms last for 2 weeks or more and inter- fere with relationships and responsibilities related to school, work, and home. Depressed people may be%anx- ious and irritable, and they o$en use alcohol%or illegal drugs to alter their emotional state. Self-mutilation (e.g., “cutting”) can also be a sign of depression. Depression can be devastating for individuals and their families. About 7% of men with a history of depression commit suicide, whereas only 1% of women with a history of depression will die by suicide.16
According to results of a survey conducted in 2006–2008, almost 10% of U.S. adults were depressed at the time of the study, and about one-third of those persons were su#ering from major depression.17 "e people who were most likely to have major depres- sion were:
• Between 45 and 64 years of age • Women • Blacks and Hispanics • People who had dropped out of high school • Divorced persons • People who were unable to work or !nd work • People without health insurance coverage
What Causes Depression? Depressive illnesses are disorders of the brain that have no single cause. "e condition probably results from a complex com- bination of genetic, biochemical, and environmen- tal factors as well as learned behavioral responses to situations. Some types of depression tend to run in families; however, depression also occurs in people who do not have family histories of the disorder.18 Researchers have detected abnormal neurotransmit- ter levels in depressed people’s brains.18 As a result, the parts of the brain that regulate mood, thoughts, sleep, appetite, and behavior function abnormally.
For reasons that are unclear but that may be related to hormonal 'uctuations, women are more likely to become depressed than are men. Men, how- ever, tend to experience depression di#erently from how women experience it. Men are more likely to be irritable, report lack of interest in formerly pleasur- able activities, be unusually fatigued, and have sleep disturbances; women are more likely to report feeling sad, worthless, and guilty.18
Like diabetes and high blood pressure, depres- sion is a chronic but treatable disease. Many people who are severely and chronically depressed can obtain dramatic relief from their disabling symptoms
Common Psychological Disorders 57
ability to carry out daily tasks. A person with bipo- lar disorder typically experiences distinct episodes of intense positive and negative emotional states. "e extremely happy and excited emotional state is called mania. Individuals with mania typically brag about themselves and their accomplishments, engage in excessive physical activity and rapid talking, and sleep very little. Another characteristic of mania is excessive participation in pleasurable and risky activities that can lead to unwelcome consequences, such as careless sexual encounters or costly shopping sprees. A$er the manic episode subsides, the person’s behavior and mood become more “normal.” In time, however, his or her emotional state swings to the neg- ative mood (severe depression) state, and this person feels extremely sad and hopeless.
During each phase of bipolar disorder, the mood of the a#ected person gradually reaches an extreme level, and the a#ected person may not be able to func- tion normally. When this occurs, the person with bipolar disorder may become suicidal and require hospitalization.
In addition to the extremes of mania and severe depression, bipolar disorder can cause a range of moods. People with bipolar disorder may develop hypomania, an emotional state that is characterized by increased energy and activity levels, which are not as excessive as in the manic state. A person with hypomania tends to feel very well and be highly pro- ductive. Although close associates of this individual may recognize that he or she is not behaving and functioning normally, the a#ected person may feel !ne. Unless people with hypomania receive proper treatment, they may develop severe mania or depres- sion. Table 2.7 lists typical symptoms of manic and depressive states, and Figure 2.5 shows the cyclic pattern of bipolar disorder.
Bipolar disorder tends to develop during the late teens or young adult years—before 25 years of age. People with bipolar disorder tend to have a family history of the illness, so medical researchers suspect the condition may be inherited.24
"e cyclic mood shi$s that characterize bipolar disorder may recur several times during an indi- vidual’s life. In many cases, however, the symptoms are not easy to recognize or distinguish from normal emotional responses. As a result, the illness may not
eating disorders Persistent abnormal eating patterns that can threaten a person’s health and well-being.
Mania Symptoms Depressive Symptoms
Experiences an unusually long period of acting “high” or being extremely happy or outgoing
Experiences an unusually long period of feeling worried or empty
Is extremely irritable; appears jumpy or “wired”
Loses interest in activities that he or she had enjoyed
Talks very fast, jumps from one idea to another, has “racing” thoughts
Feels tired or in “slow motion”
Is easily distracted Has difficulty concentrating, remembering, and making decisions
Takes on several new projects but does not complete them or performs poorly
Is restless and irritable
Is restless and sleeps very little
Experiences changes in usual eating, sleeping, and other habits
Has unrealistic beliefs about his or her abilities
Thinks about death or suicide, or attempting suicide
Behaves impulsively and engages in risky behaviors
Table 2.7
Typical Symptoms of Bipolar Disorder
be diagnosed or treated properly. "ere is no cure for bipolar disorder, but in many cases, the condition can be managed with medications.
Seasonal A#ective Disorder Besides bipolar dis- order, other mood disorders occur in cycles. Peo- ple with seasonal a!ective disorder (SAD) become depressed around mid- to late fall, and their depres- sion ends in late winter or early spring. Besides feel- ing depressed and tired, people with SAD also report craving sweets and gaining weight. Because these symptoms resolve when the daylight period length- ens or when people with the condition spend time in sunnier climates, medical experts think SAD may
58 Chapter 2 Psychological Health
Occasionally, most people engage in unusual eat- ing practices, such as skipping meals, fasting, or avoiding sweets in an e#ort to lose a few pounds. Disordered eating practices are mild and o$en tem- porary changes in an individual’s otherwise nor- mal food-related behaviors. In many instances, a person uses these behaviors to improve health or appearance. Disordered eating practices, however, can become eating disorders. Eating disorders are persistent abnormal eating patterns that can threaten a person’s health and well-being. Each year, millions of American lives are disrupted by the three major eating disorders—bulimia nervosa, anorexia nervosa, and binge eating disorder. "ese conditions o$en develop in adolescence or young adulthood, and they are more likely to a#ect females than males. An estimated 85–95% of people with anorexia nervosa and 65% of those su#ering from bulimia nervosa are female.
Hormonal, genetic, psychological, and sociocul- tural factors in'uence the development of eating dis- orders. Risk factors include family history, childhood abuse, depression and anxiety, low self-esteem, and family con'ict.26,27 Additionally, homosexual males may have a higher risk of eating disorders than het- erosexual males.26,27
Although it is true that excess body fat is not healthy, a society that emphasizes thinness as a sign of physical attractiveness makes many young people overly concerned about and dissatis!ed with their body size and shape, even when it is normal. As a result of societal in'uences, many American females admire the bodies of actresses, fashion models, and ballet dancers who look as though they are starving
be related to a lack of exposure to bright light. Light therapy is an e#ective form of treatment for this disorder.25
Feeding and Eating Disorders A female college athlete habitually skips breakfast. For lunch, she typically drinks an 8-ounce canned milkshake that is marketed as a weight loss supple- ment. By the time dinner is served in her dormitory, she describes herself as “starving.” A male college student whose height is 5( 9(( and weighs only 125 pounds also skips breakfast. Nearly every day, he eats cheeseburgers and french fries from a fast-food restaurant that is within walking distance of his cam- pus. He rarely eats fruits or green vegetables. A young man who describes himself as a vegetarian eats only brown rice, fruit, and tea. Are these behaviors examples of eating disorders?
Mild depression
Normal or balanced
mood
Severe depression
Hypomania
Severe mania
Figure 2.5 Bipolar Disorder. This scale illustrates the range of moods typically experienced by people with bipolar disorder.
Light therapy is an effective treatment for SAD. © Rocky89/iStockphoto.com.
Common Psychological Disorders 59
enough food to maintain a healthy body weight. People with anorexia nervosa have an irrational fear of becoming fat, usually maintain strict control over their food intake, and are preoccupied with calorie counting and food preparation. As mentioned ear- lier, females are more likely to su#er from anorexia nervosa than males are. During their lifetimes, an estimated 0.3–0.9% of American females su#er from this condition.27
People with anorexia nervosa have a distorted image of their bodies. "ey deny that they are severely underweight even though they weigh 15% or more below normal for their height. Typically, females with this condition do not have normal menstrual cycles and feminine body contours. Without an adequate supply of fat to insulate their bodies against heat loss, anorexics feel cold easily and o$en wear layers of clothing to provide extra warmth.
Some people su#ering from anorexia nervosa occasionally lose control over their food intake and eat excessive amounts of food (bingeing). To avoid gaining weight, these individuals induce vomiting, give themselves frequent enemas, or abuse laxatives (purging). People with anorexia nervosa o$en exer- cise excessively to “burn up” calories. Table 2.8 lists these and other typical signs of anorexia nervosa.
(Figure 2.6). Young males, on the other hand, may equate optimal health and attractiveness with the massive, well-de!ned muscles of action heroes that are typically portrayed in comic books and mov- ies. Such e#orts to achieve an ideal body shape can evolve into a disastrous and obsessive preoccupation with body weight and composition, food intake, and physical activity level. It is interesting to note that eat- ing disorders are uncommon in regions of the world where the food supply is limited and starvation is an everyday occurrence.
Although usually considered nutritional problems, eating disorders are o$en associated with psychologi- cal disturbances, including obsessive-compulsive and mood disorders as well as substance abuse. Goals of counseling include encouraging patients to cooperate in their recovery and change their unhealthy attitudes toward food and their bodies. Treating underlying psychological and family-related problems may help resolve the eating disorder or reduce the frequency of the abnormal eating behavior.
Anorexia Nervosa Occasionally, nearly every- one has anorexia, appetite loss that can occur under various circumstances, such as excitement or fever. Anorexia nervosa, however, is a severe psychologi- cal disturbance in which an individual refuses to eat
Figure 2.6 Anorexia Nervosa. Isabelle Caro, a young Italian model and actress, died in 2010 from anorexia nervosa. This photo was taken in 2008, when Caro weighed only about 66 pounds. © Lydie/Sipa/AP Images.
In addition to refusing to gain weight despite weighing 15% or more below a healthy weight, a person who has anorexia nervosa typically:
• Has an intense drive to achieve a thin body • Seems unaware that body size has changed
• Derives little satisfaction from his or her body shape • Fears losing control over appetite • Becomes full after eating small amounts of food • Is a “picky” eater; avoids foods that contain fat,
starch, or sugar • Exercises excessively • Lacks menstrual periods (females) • Is depressed • Has low self-esteem • Has perfectionist tendencies
Data from Garfinkel, P. (1992). Classification and diagnosis. In K. A. Halmi (Ed.), Psychobiology and treatment of anorexia nervosa and bulimia nervosa. Washington, DC: American Psychiatric Press.
Table 2.8
Typical Signs of Anorexia Nervosa
anorexia nervosa A severe psychological disturbance in which an individual refuses to eat enough food to maintain a healthy weight.
60 Chapter 2 Psychological Health
and elimination. Vomiting and abusing laxatives and diuretics can seriously disrupt the body’s normal 'uid and chemical balance, which can be life threatening.
Occasional episodes of bulimic behavior are com- mon among young women who are trying to con- trol their weight. It is estimated that about 1.5% of females su#er from bulimia nervosa during their lifetimes.27 Men may also have bulimia nervosa if they regularly consume too much food, along with excessive amounts of alcohol, and then vomit a$er- ward. Furthermore, some young men who partici- pate in sports that require maintaining a particular weight, such as wrestling and gymnastics, practice the behaviors associated with bulimia nervosa to remain competitive.
Many people who binge and follow up with purg- ing are disgusted with their disordered eating behav- ior, and they hide it from roommates, friends, and family members. Some people practice bingeing and purging twice a week; in severe cases, a#ected individuals engage in these behaviors several times a day. Severely bulimic people can become so pre- occupied with eating that they shopli$ food to sup- ply their binges and experience legal problems as a consequence. College students with bulimia nervosa frequently encounter academic problems a$er they neglect to attend their classes.
Typically, bulimic individuals are more socially outgoing than people with anorexia nervosa, yet they experience low self-esteem, anxiety, and depres- sion. Eating temporarily relieves the bulimic person’s anxiety. Although antidepressant medications and psychotherapy are useful treatments, people with bulimia nervosa o$en do not seek help for their behavior. An estimated 43.2% of people with bulimia seek treatment.27
Binge Eating Disorder About one-third of over- weight people engage in regular episodes of binge eating that are rarely followed up with purging or heavy exercise.28 "is behavior is called binge eating disorder. Some binge eaters report blackouts, peri- ods of time when they had overeating episodes that they cannot recall, but empty food containers provide them with evidence of the incidents. Like persons with bulimia nervosa, binge eaters have poor
Treatment for anorexia nervosa includes indi- vidual and family counseling; patients must reach about 85% of their normal body weight before anti- depressant therapy is useful. In severe cases, people with anorexia nervosa can die unless they are given special feedings and monitored closely in hospitals. Earlier estimates of the percentage of deaths that resulted from anorexia nervosa may have been too high. According to several recent studies in which the long-term outcomes of patients with anorexia nervosa were analyzed, about 5% of the patients died, in most instances from suicide, and less than 50% recovered completely.28,29 "e remaining individuals with anorexia nervosa were improved or remained chronically ill with the disorder.
Bulimia Nervosa Whereas people with anorexia nervosa are so thin they are easy to identify, those with bulimia nervosa may be more di&cult to rec- ognize because their weights are o$en normal. Bulimia nervosa is a craving for food that is dif- !cult to satisfy; bulimic people typically eat exces- sive amounts of food at one time because they are depressed or anxious rather than hungry (Table 2.9). Some bulimic persons are able to maintain normal body weights because a$er bingeing, they purge by fasting, practicing self-induced vomiting, taking lax- atives and diuretics, or exercising excessively. Vomit- ing prevents the body from absorbing and using the nutrients in food and beverages. Laxatives speed up the movement of the intestinal tract and can lead to watery diarrhea; diuretics increase urine production
• Evidence of consuming excessive amounts of food in short periods, such as empty food containers, without gaining weight
• Evidence of efforts to avoid digesting large amounts of food
• Spending time in the bathroom during meals or immediately after eating
• Odor of vomit in bathroom • Presence of empty laxative or diuretic packages • Sores or scars on knuckles that result from self-
induced vomiting • Dental decay from frequent contact with acidic
stomach contents • Preoccupation with obtaining food and exercising • Social withdrawal
Table 2.9
Typical Signs of Bulimia Nervosa
bulimia nervosa An eating disorder characterized by a craving for food that is difficult to satisfy.
binge eating disorder A pattern of eating excessive amounts of food in response to distress such as anxiety or depression.
Common Psychological Disorders 61
body builds. Muscle dysmorphia (“bigorexia”) is a psychological condition that a#ects weightli$ers, particularly bodybuilders.31 Despite their very mus- cular body builds, people su#ering from this condi- tion are not satis!ed with the size of their bodies, and as a result, they spend hours working out each day, particularly li$ing weights. Moreover, they are ashamed of their bodies and reluctant to expose themselves in public places such as beaches. Indi- viduals with muscle dysmorphia are obsessed with the need to gain muscle without adding body fat; they have a high risk of eating disorders and abuse of anabolic steroids, drugs that can increase muscle size. At this point, little is known about the preva- lence of muscle dysmorphia or e#ective ways to treat the condition.
We have discussed several major eating disor- ders in this section; however, people with disordered eating habits do not always display clear or consis- tent eating patterns that are easily diagnosable as an eating disorder. Emotional eating, overeating, and similar unhealthy eating patterns can also indicate an eating disorder. For more information about eating disorders and disordered eating, visit www.national eatingdisorders.org.
Schizophrenia An estimated 1% of Americans su#er from schizo- phrenia, a type of psychosis.32 Laypeople o$en believe schizophrenia means “split” or “multiple personalities”; actually, people with schizophrenia experience extremely disorganized thought processes, including hallucina- tions and delusions. People with paranoid delusions may think someone is trying to harm them. Individu- als with schizophrenia o$en display strange behav- ior and inappropriate emotions. Communicating
self-esteem, and they o$en feel disgusted, depressed, and guilty about their eating behavior and physical appearance. "ese feelings may trigger additional episodes of overeating. Night eating syndrome, which is more common among obese than normal-weight persons, may be a variation of binge eating disorder. People with night eating syndrome are not hungry during the day but have di&culty staying asleep at night; they awake o$en and frequently get out of bed to eat large amounts of food.
If you or someone you know su#ers from an eating disorder such as bulimia nervosa or binge eating, ask the sta# at your campus health center or your personal physician to recommend con- ventional mental health practitioners, such as psychiatrists, who specialize in treating these con- ditions. Additionally, check hospitals in your area because many have self-help groups for people with eating disorders.
Other Disordered Eating Conditions Athletes involved in sports that tend to emphasize leanness, such as gymnastics, wrestling, light-weight row- ing, horse racing, !gure skating, body building, and distance running, have an increased risk of devel- oping eating disorders. As many as 62% of female athletes and 33% of male athletes su#er from eat- ing disorders.30 A relatively small number of female athletes develop the female athlete triad, a condition characterized by low energy intake, menstrual cycle abnormalities, and bone mineral irregularities, such as osteopenia (low bone density). Osteopenia is gen- erally associated with postmenopausal women, not healthy young women.
Although most females with the female athlete triad do not show every sign of illness associated with anorexia nervosa or bulimia nervosa, their food-related practices, such as bingeing and self- induced vomiting, are similar. To prevent this con- dition, it is important to teach young athletes about healthy eating practices and body weights. Further- more, parents need to be aware of factors that con- tribute to the triad, such as having low self-esteem and few friends, identifying thin physiques with ideal body shapes, being preoccupied with weigh- ins, and having overly demanding coaches who crit- icize the young athlete for being “fat” and insist on weight loss.
In the United States, many men experience social pressure to attain larger, more muscular
schizophrenia A form of psychosis.
Could this be a case of muscle dysmorphia? © Anetta/Shutterstock.
62 Chapter 2 Psychological Health
with some a#ected individuals is di&cult because their speech o$en consists of words strung together into meaningless sentences. Table 2.10 lists common symptoms of schizophrenia.
"e brains of people with schizophrenia tend to have biochemical or structural defects that many medical experts think are inherited. A person who has a parent with schizophrenia has a 10% likelihood of developing the condition.32 If a person has an iden- tical twin with schizophrenia, he or she has a 45–65% chance of developing the illness.
Schizophrenia usually develops early in adult- hood. Some a#ected people have one schizophrenic episode and recover, but others experience recur- rent episodes and require long-term treatment. By taking special medications, many people with schizophrenia experience relief from their symp- toms and live as productive members of society. Individuals with severe forms of schizophrenia must live in mental healthcare facilities because their behavior is unmanageable or dangerous to themselves or others.
Suicide Suicide, the deliberate ending of one’s own life, is not a mental illness. However, such extreme violence against oneself is o$en the behavioral consequence of a severe psychological disorder. Most people who choose to end their lives feel overwhelmed by the demands of life; they are unable to solve their prob- lems or adapt to their situations.
Overall, suicide accounts for only a small per- centage of deaths in the United States. Over the past 15 years, the suicide rate in the United States has increased 24%.33 In 2015, suicide was the second leading cause of death for Americans between 15 and 34 years of age. Males are almost four times more likely to kill themselves than are females.34
Despite what many people believe, the Christ- mas holiday season is not the time that suicide rates peak; intentional deaths are generally low in winter, and high in late spring and early summer.35 Although women are more likely to attempt suicide, men are more likely to complete the act of killing themselves. Most people use a !rearm to end their lives; however, taking drug overdoses and crashing motor vehicles are also frequent suicide methods. "us, it is di&cult to determine the actual number of suicides that occur each year.
Preventing Suicide Psychological disturbance, particularly a mood dis- order that may have included substance abuse, is strongly associated with suicide.34 Other characteris- tics associated with a high risk of committing suicide are previous suicide attempts, family history of sui- cide, being abused as a child, loss (relational, work, or !nancial), illness, and feeling socially isolated.35 Some individuals with severe or terminal health problems seek the help of others, particularly family members or physicians, to commit suicide. People who know or treat individuals with these characteristics or conditions should be aware of their suicide risk and initiate intervention methods to prevent them from ending their lives.
Suicidal persons usually demonstrate suicide ideation, or thinking about, considering, or plan- ning for suicide. In many cases, suicidal people will communicate their intentions to friends or family members. "ese individuals might say “everyone would be better o# if I were dead” or “I am going to kill myself,” discuss the pros and cons of vari- ous suicide methods, talk about being a burden to
• Hallucinations, particularly hearing “voices” (auditory hallucinations)
• Delusions, including bizarre beliefs or paranoid beliefs
• Difficulty organizing thoughts; illogical thoughts • Garbled speech and use of meaningless words • Agitated body movements • Dull, monotonous voice • Little or no speaking • Neglect of personal hygiene • Inability to focus attention • Difficulty using recently learned information
Table 2.10
Common Symptoms of Schizophrenia
4If you or someone you know has an eating or other psychological disorder, seek help from the medical staff at the campus health center or from your personal physician.
Healthy Living Practices
Suicide 63
or visit their web site (www.suicidepreventionlifeline .org/) for help.
Suicide prevention begins long before suicidal thoughts occur. Protective factors, factors that reduce suicide risk, exist on multiple levels; there- fore, suicide prevention requires individual, com- munity, and legislative cooperation. Factors that protect against suicide include strong family and community connections, development of problem- solving and con'ict resolution skills, and cultural and religious beliefs that support self-preservation. Furthermore, easy access to e#ective clinical care for mental, physical, and substance abuse disorders and ongoing, supportive medical and mental health- care relationships reduce suicide risk.37,38 As dem- onstrated by this list, suicide prevention is not an individual behavior. Instead, prevention of suicide requires families to support psychological health and skill development, communities to develop and maintain healthy connections, and citizens and poli- ticians to advocate for and develop policy that makes treatment more available.
Table 2.11 lists these and other behavioral warning signs of suicidal persons.
others, increase drug or alcohol use, act anxious or agitated, or isolate themselves. A$er deciding to kill themselves, suicidal individuals o$en seem cheerful% and relaxed. Friends, family members, or acquaintances% o$en recall the positive emotional state of someone who committed suicide and may report that he or she showed no signs of distress before%dying.
Occasionally people express suicidal thoughts to family or friends. It is always important to take sui- cidal conversations or gestures seriously and react in a supportive manner. Most people are surprised by suicidal conversation and may try to reduce ten- sion by saying things like “it’s not that bad” or try to point out the positives in the person’s life. Although this reaction is natural, it can also deny the person’s feelings and cause him or her to stop speaking. Psy- chologists recommend speaking directly by asking the person why he or she wants to kill himself or herself.36 "en listen carefully with nonjudgmental empathy and concern, while !rmly and patiently obtaining professional help immediately. It is com- mon for suicidal people to resist help and say they were only joking; however, it is important for the friend or family member to be !rm and, if necessary, make an appointment with a professional. For more information about common presuicide behavior and suicide prevention, visit www.suicide.org.
Mental health centers with trained counselors who provide 24-hour crisis intervention services are available in most communities. On college campuses, student health centers o#er mental health services and can refer students to mental health profession- als when necessary. You may also !nd local suicide prevention resources using Internet search engines and web sites (e.g., yellowpages.com) by searching for “suicide” or “suicide prevention centers.” For more information, or if you or someone you know is thinking of committing suicide, call the National Sui- cide Prevention Lifeline at 1-800-273-TALK (8255),
4If you are or someone you know is suicidal, immediately contact a suicide prevention center to obtain specific instructions concerning ways to prevent yourself or another from committing this act.
Healthy Living Practices
• Discussing, joking, or writing about suicide or death
• Giving away prized possessions • Making final arrangements: planning a will or
making funeral plans • Displaying severe depressive symptoms • Reporting feelings of hopelessness and
helplessness • Performing risky behaviors: playing with guns,
driving while drunk, or performing daredevil stunts
• Injuring oneself by cutting, burning, or hitting • Behaving in a manner that is different from usual:
showing no interest in usual activities, becoming socially withdrawn
• Planning the suicide: buying a gun or hoarding a supply of barbiturates
• Expressing anxiety over an impending action: worrying about a divorce, dropping out of school, or losing a job
• Showing physical signs of a previous suicide attempt: cut or scarred wrists, neck bruises
Table 2.11
Behavioral Warning Signs of Suicide
64 Chapter 2 Psychological Health
who experiences a traumatic event, such as the loss of a parent through death or divorce. Children who are anxious about going to school o$en complain of morning headaches and stomach upsets before leav- ing for school, and they return home in a distressed state. Parents and teachers need to recognize the symptoms of childhood depression and anxiety. By receiving individual and family counseling, many distressed children and their families can learn posi- tive ways of handling crisis situations.
Attention-de!cit hyperactivity disorder (ADHD) is a common childhood behavioral disorder. In 2011, nearly 11% of American school-aged children, mostly boys, were reported to have ADHD.39 "is condition is characterized by an inability to focus and maintain attention on tasks, such as doing homework or fol- lowing simple instructions. Children with ADHD also display excessive levels of physical activity and restlessness. "ey cannot sit still; they rush through meals, dash away from their caregivers, and resist e#orts to relax or fall asleep. "eir attention spans are so short that they are o$en unable to follow instruc- tions or complete tasks. Children with this condition demonstrate impulsive behaviors such as interrupt- ing conversations, talking when it is inappropri- ate, and acting before thinking. Some children with ADHD are aggressive, argumentative, and de!ant. Not surprisingly, children with ADHD frequently have low self-esteem and con'icts with their family members, peers, and teachers.
In addition to prescribing medications, many physicians recommend behavioral and family coun- seling to treat the disorder. Recently, some people expressed concerns that ADHD is overdiagnosed and that too many children are being treated with stimulant medications, such as Ritalin, in the United States. In addition, questions were raised about the negative e#ects of stimulants on children’s growth and the potential for substance abuse among chil- dren treated with these medications. Although some studies indicate stimulants can mildly suppress the growth rates of children with ADHD, more long- term research is needed.
During the maturation process, an adolescent undergoes numerous hormonal, physical, social, and other changes necessary to become an inde- pendent adult. Many youth make this transition smoothly with a minimum of serious problems, but for some, the teenage years are !lled with emotional turmoil and family con'ict. Certain forms of mental illness, including major depression and eating dis- orders, are likely to develop during this period. As
PSYCHOLOGICAL HEALTH Children and adolescents establish the foundation for a lifetime of good mental health by develop- ing positive self-concepts. Parents can help their children feel good about themselves by spending time with them, listening to their concerns, and helping them learn to adjust to a changing world (Figure"2.7).
School-aged children who live in dysfunctional families are vulnerable to developing emotional dis- orders such as depression and school anxiety. How- ever, childhood depression can occur in any child
Across THE LIFE SPAN
Figure 2.7 Establishing Good Mental Health. Parents can help their children feel good about themselves by spending time with them. © Photodisc.
Suicide 65
Older adults who approach the end of their lives with a sense of satisfaction about their accomplishments are likely to feel emotionally fulfilled. © Noam Armonn/Shutterstock.
mentioned earlier, suicide is a major cause of death for adolescents.
By the time people reach late adulthood, they may have raised a family, retired from working outside the home, and maintained a network of friends and family. Older adults who approach the end of their lives with a sense of satisfaction with their accomplishments
are likely to feel emotionally ful!lled. Many elderly people, however, su#er from sleep disturbances and depression a$er the death of a spouse and friends, family separation or disintegration, !nancial instabil- ity, or a disabling physical illness. It is important for older adults and their families to recognize the symp- toms of depression and obtain professional help.
66 Chapter 2 Psychological Health
Health-Related InformationAnalyzing Critical Thinking
4. Is the source of information reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the benefits and risks of the product? Does the ad include a disclaimer?
5. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this ad is a reliable source of health-related information? Explain why you would or would not buy the CDs. Summarize your reasons for coming to this conclusion.
The following ad promotes a series of compact discs designed to improve mood and reduce anxiety. Read the advertisement and evaluate it using the model for ana- lyzing health-related information. The main points of the model are noted here.
1. Which statements in the ad are verifiable facts, and which are unverified statements or value claims?
2. What might be the motives and biases of the person making the claims?
3. What is the main point of the ad? Which information is relevant to the product? Which information is irrelevant?
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Analyzing 67
CHAPTER REVIEW Summary
A person’s psychological health a#ects and is a#ected by other wellness components such as physical and social health. Psychological health is dynamic, improving or declining as an individual responds to a constantly changing environment. Psychologically healthy people accept themselves, are assertive, have realistic and optimistic outlooks on life, function independently, form satisfying interpersonal rela- tionships, cope with change, and !nd e#ective solu- tions to their problems.
Understanding mental health involves the study of physiology and psychology. Biochemical changes in the brain elicit myriad human responses, including thoughts, emotions, and behaviors. Conditions that alter normal brain chemistry can disrupt the mind, producing negative moods or abnormal behaviors.
Personality is a set of distinct thoughts and behav- iors, including emotional responses that characterize the way an individual responds to situations. Biologi- cal, cultural, social, and psychological forces interact to mold a person’s personality.
Over the past 100 years, numerous psychologists, including Freud, Erikson, and Maslow, provided valuable insights into human behavior, laying the foundation for our present understanding of per- sonality development. Freud thought unconscious drives control human behavior. Erikson identi!ed eight stages of the life span in which di#erent social forces in'uence personality. Maslow believed that the freedom to achieve personal ful!llment is a psycho- logical need that motivates human behavior.
Psychological adjustment and growth occur when one adapts e#ectively to the demands of life by alter- ing one’s thoughts, attitudes, and responses. Self- esteem, a feeling of self-worth, is a key component of personality. Positive self-esteem is a characteristic of psychologically healthy people.
Intensity and duration are the key features that distinguish a normal emotional response from an abnormal one. Mentally ill individuals experience abnormal feelings, thoughts, and behaviors that
persist, interfere with daily life, and hinder psycho- logical adjustment and growth.
"ere are numerous psychological disorders; each may have multiple causes. Alterations in the normal chemical and physical environment of the brain o$en produce mental illness. "ese alterations may be the result of genetic defects, injuries, tumors, infections, or exposure to certain drugs or pollutants. Social interactions, including those with one’s family, also contribute to the quality of an individual’s psycho- logical health.
In many cases, medications and/or behavioral therapies are e#ective treatments for mental health problems. People can learn to cope with various%prob- lems by seeking the help of conventional mental health therapists or by joining self-help groups.
It is common for individuals to experience pho- bias, anxiety, panic attacks, or mood disorders at some time in their lives. In many cases, these disorders are mild and do not interfere with the a#ected person’s ability to function in society. In other instances, psy- chological illnesses such as schizophrenia, general- ized anxiety, or major depression impair functioning to the extent that a#ected individuals require profes- sional treatment.
Eating disorders are o$en symptoms of under- lying mental illnesses, particularly depression and obsessive-compulsive disorders. Self-imposed star- vation and denial of thinness characterize anorexia nervosa. Bulimic individuals and some people with anorexia nervosa engage in food bingeing and purg- ing practices. Binge eaters overeat but rarely follow up with purging.
Suicide is not a mental illness, but in many instances, suicide is the behavioral consequence of a major depressive illness that includes substance abuse. Individuals who are contemplating suicide o$en discuss their feelings and intentions with others. "us, people should take someone’s suicidal conver- sations or gestures seriously and assist the individual by obtaining immediate intervention.
68 Chapter 2 Psychological Health
CHAPTER REVIEW
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
Key
1. Investigate several factors that facilitate self- esteem development. Create three recommenda- tions for parents to foster children’s self-esteem development. Application
2. Determine your current position on Maslow’s human needs hierarchy. Explain, in detail, how you arrived at your conclusion, including discus- sion of psychological adjustment and growth and autonomy. Analysis
3. In the United States, cultural perceptions of mental illness o$en lead to social stigma. Explain how the media may contribute to these perceptions. Synthesis
4. Consider your current state of psychological health. Rate your psychological health as excel- lent, good, fair, or poor. Explain how you deter- mined this rating, and explain what steps you might take to improve your psychological health, if necessary. Evaluation
1. As described in this chapter, self-esteem devel- ops during childhood. When you were a child, how did your interactions with family members, peers, and teachers in'uence the development of your self-esteem?
2. Using Table 2.1, Characteristics of Psychologically Healthy People, identify the characteristics that describe you best. Why did you choose those traits?
3. What have you done to boost your psychologi- cal health by improving your physical, social, intellectual, spiritual, and environmental health? How did your actions help?
4. As mentioned in this chapter, people o$en have negative feelings toward psychologically disturbed persons. How would you feel if you, a close friend, or a family member were diagnosed with a psychological disorder? If you, a close friend, or a family member has a serious psycho- logical disorder, how does it a#ect you?
5. People older than 65 years of age have a high risk of depression. What could you do or have you done to enhance the psychological health of an elderly person you know, such as a grandparent?
Applying What You Have Learned
Reflecting on Your Health
problems as they mature into adults, but for some, the teenage years are !lled with turmoil. Certain forms of mental illness, including major depres- sion and eating disorders, are likely to develop dur- ing this period of life. Older adults who approach the end of their lives with a sense of satisfaction with%their accomplishments are likely to feel emo- tionally ful!lled.
Parents can help their children feel good about themselves by spending time with them, listening to their concerns, and helping them learn to adjust to a changing world. Some children develop psy- chological disturbances, particularly anxiety and depression. Attention-de!cit hyperactivity disorder is a common childhood behavioral disorder. Most adolescents experience relatively few emotional
Reflecting on Your Health 69
CHAPTER REVIEW References
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12. Kessler, R. C., et al. (2006). "e prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723.
13. U.S. Centers for Disease Control and Prevention. (2017). Autism spectrum disorder: Data and statistics. Retrieved from http://www .cdc.gov/ncbddd/autism/data.html
14. U.S. Centers for Disease Control and Prevention. (2017). Autism spectrum disorder: Facts about ASD. Retrieved from http://www .cdc.gov/ncbddd/autism/facts.html
15. Kessler, R. C., et al. (2008). "e prevalence and correlates of DSM- IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine, 38(9), 1351–1360.
16. U.S. Department of Health and Human Services. (n.d.). Does depression increase the risk of suicide? Retrieved from http:// answers.hhs.gov/questions/3200
17. Gonzalez, O., et al. (2012). Current depression among adults— United States, 2006–2008. Morbidity and Mortality Weekly Report, 59(38), 1229–1235.
18. National Institute of Mental Health. (2017). Depression basics. Retrieved from http://www.nimh.nih.gov/health/publications/depression /complete-index.shtml#pub5
70 Chapter 2 Psychological Health
CHAPTER REVIEW 36. Edlin, G., & Golanty, E. (2014). Health & wellness (11th ed.). Burl-
ington, MA: Jones & Bartlett Learning. 37. U.S. Centers for Disease Control and Prevention. (2017). Suicide
prevention, scienti#c information: Risk and protective factors, risk factors for suicide. Retrieved from http://www.cdc.gov /ViolencePrevention/suicide/
38. Suicide Prevention Resource Center. (2018). About suicide prevention. Retrieved from http://www.sprc.org/basics/about-suicide -prevention
39. U.S. Centers for Disease Control and Prevention. (2017). Attention- de#cit/hyperactivity disorder: Data and statistics. Retrieved from http://www.cdc.gov/ncbddd/adhd/data.html
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References 71
Across the Life Span Stress
Managing Your Health A Technique for Progressive Muscular Relaxation
Consumer Health Healthy Technology and Social Media Consumption
Diversity in Health Stress and Asian Americans
Chapter Overview The different meanings of stress
The ways your body responds to stress
How stressful life events can affect your health
Strategies for coping with stress
Skills that can help you manage stress
Student Workbook Self-Assessment: How Much Stress Have You Had Lately?
K6 Serious Psychological Distress Assessment
Changing Health Habits: Taking Steps to Reduce Your Stress
Do You Know? An easy way to manage your time more effectively?
If having a pet can reduce stress?
How to relax within just a few minutes?
If stress can be good for you? Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © YanLev/Shutterstock.
Stress and Its Management
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/Getty Im ages.
Learning Objectives “Going to college places considerable demands on your time and mind …”
After studying this chapter, you should be able to:
1. Define stress and stressors. 2. Differentiate between distress and eustress. 3. Differentiate between physical and psychological
responses to stressors. 4. Describe the three stages of the general adaptation
syndrome. 5. Describe how health is affected by stress and how
personality distinguishes responses to stress. 6. Explain how stress affects chronic health problems. 7. Describe various positive and negative ways of coping
with stress. 8. Highlight the difference between problem- and
emotion-focused strategies of coping with stress. 9. Identify three stress reduction techniques.
CHAPTER 3
73
I f you ask students to identify what makes college life stressful, you will receive a long list of situ-ations, including taking exams, preparing term papers and lab reports, applying for loans, and jug- gling hours to !t part-time jobs into their class sched- ules. College students probably cannot imagine any other period in their lives that will demand so much of their time, energy, and !nances.
How would you respond to the question, “What was the most stressful situation that you’ve expe- rienced in the past year?” "ree college students enrolled in a health course wrote the following answers to this question.
The most stressful situation I’ve encountered in the past 12 months must be the discovery that my wife was preg- nant and our financial security was at risk because the only source of income for us is her wages. I’m wondering if I will be able to continue pursuing my degree after the baby is born—this adds to my stress day by day.
I went away to a university last year and was the victim of a rape. The whole ordeal of talking to the police, confronting the man who did it, and telling my boyfriend was horrible, but the most stressful part was having to tell my parents.
The most stressful situation was the death of both of my grandparents within 6 months of each other. I watched them suffer as they passed away. It was very difficult. Also, my choice of a major was a mistake; I’ve had to change it.
Each of these students had to cope with a stressful situation. You may have had to cope with similar dis- tressing events. Although going to college places con- siderable demands on your time and mind, you can expect stressful situations to arise during every phase of your life, so learning how to identify and manage stressful situations is a life skill that will serve you well for the rest of your life.
What is stress? What e#ects can it have on your health and well-being? Can stress be good for you? What factors make a situation stressful? Is it possi- ble to reduce the negative e#ects that stress can have on your health? "is chapter examines the nature of stress, how it can a#ect you physically and mentally, and how you can manage your stress.
What Is Stress? Stress can refer to the situations that threaten or place demands on your mind and body. Stressful situa- tions can be physical, such as being confronted by an angry dog, or psychological, such as worrying over your future employment possibilities. Stress can also describe your responses to a threatening situation— in other words, how you feel stress. Imagine that you have three exams in one day; how do you feel?
Stress is commonly de!ned as a complex series of psychological and physical reactions that occur as one responds to a demanding or threatening situation. Given the uniqueness of each person’s views on what is demanding or threatening, how one appraises a situa- tion to determine whether it will have positive, nega- tive, or neutral consequences varies widely. In addition, a person determines his or her ability to manage the sit- uation according to his or her previous experiences and personality characteristics. For example, how would you respond if a friend were to ask you to go skydiv- ing with her? Would you be excited to join your friend? Would you be “stressed out” at the idea of skydiving and decline the invitation? If you have never gone skydiving, look forward to trying new and potentially dangerous activities, and have no major concern about the safety surrounding skydiving, you might accept your friend’s invitation. However, if jumping out of a plane with only a parachute to keep you from free fall- ing is not something you would look forward to doing, you probably would be very stressed out in anticipa- tion of the activity and would turn down your friend’s request. On the other hand, if you have gone skydiving before and found the activity thrilling and enjoyable, you would likely be excited to accompany your friend. "us, it is possible for di#erent individuals to form dif- ferent appraisals of the same event; as a result, stress responses are as unique and di#erent as people.
Stressors Stressors are situations that create stress. Physi- ologic (physical) stressors include engaging in exer- cise; experiencing illness, pain, or injury; and being exposed to dangerous pollutants or extreme temper- ature changes. Psychological stressors include man- aging extreme emotions, handling di&cult social situations, and dealing with troublesome thoughts and relationships. Certain psychologically demand- ing situations can add just enough stress to make life more challenging and interesting, but enduring too
stress A complex series of psychological and physical reactions that occur as one responds to a situation.
stressors Events that produce physical or psychological demands on an individual.
74 Chapter 3 Stress and Its Management
(39–52 years old), Boomers (53–71 years old), and older adults (72+ years old).1 "e following section describes the stress response and its e#ects on health.
Stress Responses "e environment constantly exposes people to stress- ful situations; to survive, they must deal physically with these stressors. Details about physical and psy- chological responses to stressors are discussed next.
Physical Responses "e body has a variety of ways to manage stress- ors, including the release of certain hormones. Hormones are chemical messengers that convey infor- mation from a gland to other cells in the body. "e glands of the endocrine system produce several dif- ferent hormones and secrete them directly into the bloodstream (Figure 3.1). Some endocrine hormones
much stress, physical or psychological, can have neg- ative e#ects on health and well-being. "is chapter focuses on the impacts of psychological stressors.
"e nature of psychological stressors has a major role in determining their impact on health. When people think of stress, they usually think of distress, that is, events that are di&cult to control and that have unwanted or negative outcomes. Distressing experi- ences include having problems with one’s education, job, family, and relationships. Other situations create posi- tive stress, or eustress. Becoming a new parent, com- peting in an athletic event, and accepting a desired job are examples of events that can have positive outcomes by making people feel happy, challenged, or successful.
Experiencing stressors with positive psychologi- cal consequences may reduce the unhealthy e#ects of negative stressors. Eustress, however, still has negative e#ects on the body and mind because any event that creates stress requires speci!c physical and psychological adjustments. "ese changes can dam- age the body, including the mind. In this chapter, the terms stress and distress are used interchangeably when referring to negative psychological stressors.
According to the results of the American Psycho- logical Association’s Stress in AmericaTM 2017 nation- wide survey, the most commonly identi!ed stressors for American adults were the future of our nation (63%), money (62%), work (61%), current political cli- mate (57%), and violence and crime (51%).1 Consistent with !ndings from previous years, millennials (18–38 years old) reported higher stress levels than Gen Xers
distress Events or conditions that produce unwanted or negative outcomes.
eustress (YOU-stress) Events or conditions that create positive effects, such as making one feel happy, challenged, or successful.
hormones Chemical messengers that convey information from a gland to other cells in the body.
endocrine system A group of glands that produce hormones.
Thymus
Adrenals
Pancreas
Pineal
Hypothalamus
Pituitary
Parathyroids
Thyroid
Testes (male)
Ovaries (female)
Figure 3.1 The Endocrine System. The glands of the endocrine system produce chemical messengers called hormones, which enter the bloodstream via small ducts.
Stress Responses 75
and intestinal organs. Under the in'uence of corti- sol, certain cells release fat and glucose (blood sugar) into the bloodstream, which transports these energy nutrients to active muscle or nerve cells.
"e nervous system also participates directly in the body’s response to stressors. When the body is exercising or under emotional stress, the CNS pro- duces and releases a group of chemical messengers that have pain-killing properties, including endor- phins. Temporary reduction in pain sensation may be a valuable adaptation during stressful situations, especially if an injured person has to react quickly when threatened. Table 3.1 lists major immediate or short-term physical adaptations to stress and their possible survival value.
Selye’s General Adaptation Syndrome "e clas- sic research of Hans Selye paved the way for our understanding of the relationship between the mind and body.2 Selye !rst used the term stress to describe the responses that allow a person to adapt physically or psychologically to any demand. As a result of his classic observations, Selye developed a three-stage description of the physical responses to stressors, the general adaptation syndrome (GAS). Selye identi- !ed the three GAS stages as alarm, resistance, and
regulate growth and development. Other hormones regulate body processes, including those necessary to function during stress.
In emergencies, a person’s nervous system instantly activates the adrenal glands that are on top of the kidneys to release cortisol, epinephrine (adrenaline), and norepinephrine (noradrenaline). "ese hor- mones are o$en referred to as the “stress hormones” because they can prepare the body to respond rapidly when danger threatens. As a result, the person’s body is able to confront or leave the dangerous situation quickly (fight-or-flight response).
Stress hormones increase heart rate, blood pres- sure, central nervous system (CNS) activity, and blood 'ow to the heart and skeletal muscles. "ese hormones also increase the metabolic rate, the rate at which cells use energy. At the same time, the stress hormones reduce blood 'ow to the skin, kidneys,
fight-or-flight response The physical responses to stressful situations that enable the body to confront or leave dangerous situations.
general adaptation syndrome (GAS) The three- stage manner in which the human body responds to stress: alarm, resistance, and exhaustion.
Physical Change Immediate or Short-Term Effect
Central nervous system activity increases Increases mental alertness and reduces reaction times
Pupils enlarge Improves vision
Energy nutrients released from storage Supplies fuels for muscular activity
Heart rate increases Pumps more blood and faster
Blood pressure increases Provides more pressure to circulate blood
Blood clots more easily Prevents bleeding
Skeletal muscles become tense and can work longer Allows for fighting or escaping threats
Sweating increases Removes extra heat created by muscular activity
Saliva flow decreases Avoids wasting valuable body water
Respiratory tract (the smaller airways) dilates Allows more air to move into and out of lungs, supplying more oxygen for energy and removing more carbon dioxide waste
Gastrointestinal tract movements decrease Shifts blood to skeletal muscles for more critical needs
Endorphin levels increase Reduces sensations of pain
Acute Physical Adaptations to Stress
Table 3.1
76 Chapter 3 Stress and Its Management
People with higher than normal levels of stress hormones, fat, and glucose in their blood are likely to develop chronic high blood pressure and other dis- eases of the heart and blood vessels. Enhanced blood clotting is a bene!cial adaptation to an immediate, life-threatening situation. Blood clots, however, pose a serious danger when they form too easily and block blood 'ow in arteries and veins. Stress hormones also increase appetite; elevated cortisol levels are associ- ated with increased body fat and weight gain.3 "e Diversity in Health feature in this chapter discusses the e#ects of severe stress on the psychological health of Asian immigrants, particularly Asian women, in the United States.
Psychological Responses Stressful situations a#ect the mind as well as the body, but the psychological impacts are not easy to test, observe, or measure. Several mental health con- ditions, including posttraumatic stress disorder and depression, have direct links to stressful life events.
Distressed individuals are more likely to report psychological symptoms such as frustration, anxiety, and anger. "ey may be irritable most of the time, eat too much (or too little) food, or abuse drugs. “Stressed-out” people o$en have di&culty focusing their attention, making decisions, and sleeping.
Burnout can be a consequence of experiencing too much psychological stress. People who are burned out feel as though they have exhausted their physi- cal and psychological abilities to cope with stressors.8 Typical signs and symptoms of burnout are loss of enthusiasm for job, school, or others; increased feel- ings of dissatisfaction, irritation, frustration, and pes- simism; loss of concern for others; and anxiety and depression. Burnout o$en results from unrealistic beliefs or expectations concerning one’s occupation (including caregivers) and workplace (or school) situation. "e stress management skills presented in this chapter, especially coping mechanisms based on social support, can help reduce the e#ects of burnout.
To some extent, stress can have positive e#ects on the mind. Low levels of psychological stress can enhance performance by increasing one’s e#ort and attention to the task. As the degree of stress increases, however, the individual may respond by worrying too much about performance, which creates even more psychological stress. "is response can reduce the ability of actors, athletes, and college students to concentrate on and perform tasks. For example, stage fright a#ects the best veteran actors, and many superb athletes “choke” under competitive pressure.
exhaustion; he described the physical status of the body in each stage.
When you think about or see a stressor, your brain sends an alarm through your nerves to your adrenal glands. Almost immediately, these glands release stress hormones to prepare your body to deal with the stressful event (alarm stage). In the alarm stage, your entire body undergoes the dramatic physical changes listed in Table 3.1. Consider, for example, how quickly you respond to an unexpected loud noise that sounds like a gunshot.
If you manage to survive the initial encounter but the stressor persists, your body enters the resis- tance phase of the response. During this stage, your body maintains its protective physical reactions to the stressor. As the threatening situation eases, your body recovers its normal physical state. Generally, by resting and avoiding additional exposure to stressors, your body can repair any damage that has occurred.
If the stressful situation persists, your body will not be able to maintain its resistance, and it will enter the exhaustion stage. In this stage, physical stress defenses are weakened, and you become more susceptible to infections. Prolonged exposure to stress may lead to death, if the body depletes its response mechanisms.
"e stress response evolved to enable humans to react immediately to physical threats. Indeed, when people are in life-threatening situations, these dra- matic physical changes may be essential for their sur- vival. "e same dramatic adaptations, however, take place when people deal with everyday hassles and concerns. Although these situations may be worri- some, they usually do not represent direct or serious threats to people’s physical well-being. Nevertheless, such stressors elicit the unnecessary release of stress hormones into the bloodstream.
Would you find skydiving distressing or thrilling? © Digital Vision/Thinkstock.
Stress Responses 77
Diversity in Health Stress and Asian Americans In the United States, the majority of recent Asian American immigrants are from China, the Philippines, India, Korea, and Vietnam. New immigrants
often face a variety of unfamiliar situations, as well as new and conflicting demands. Many of the immigrants must cope with being separated from friends and fam- ily members who remain in their homeland, learning an unfamiliar language, and adjusting to a different culture.
The cultural “shock” that often results after settling in the United States creates numerous psychological con- flicts for immigrants. Many members of this population experience homesickness, discrimination, unemploy- ment, racial stereotyping, language barriers, and social isolation. The stress of immigrating and adjusting to a new culture may lead to depression.4
Asian Americans who espouse traditional beliefs think that fate determines much of what occurs in their lives, and they often deny or hide feelings of sadness, dis- appointment, and anxiety. As a result, Asian Americans may avoid expressing negative feelings.
Recent immigrants from Asia tend to follow traditional gender-specific roles. Men are accustomed to having a dominant role over women, especially in making deci- sions, and they expect their wives to maintain households and take care of children. Although wives may work out- side the home, their incomes often are not crucial for sup- porting their families. In the United States, people who are descendants of immigrants who came to this country several decades ago tend to accept more equitable roles at work and home for men and women. Therefore, many women who recently immigrated to the United States from Asia perceive their status in society as very low, and they experience much psychological stress as a result.5
Instead of seeking treatment for anxiety or depres- sion, distressed Asian American women often visit con- ventional medical practitioners, such as their personal physicians, for treatment of various physical symptoms such as appetite loss, headaches, and fatigue.6 The effects of unrecognized and untreated stress can be
devastating. Suicide is the leading cause of death for Asian American women between 15 and 19 years of age, the second leading cause of death among the 20–24 and 35–44 age ranges, and the third leading cause of death for those aged 25–34 years.7
Regardless of one’s ethnic/racial background, the unwillingness to reveal conflicting feelings can produce stress. The serious effects of stress on the health and well-being of Asian American immigrants underscore the need for conventional medical practitioners to be culturally sensitive and recognize symptoms of emo- tional distress in members of this minority group.
Taking tests is stressful for many college stu- dents, but students with test anxiety experience heightened physical, emotional, and cognitive reactions to the testing situation. As a result, such students have difficulty recalling information and
concentrating on test questions. To avoid becom- ing overwhelmed by anxiety, students can learn to relax before and during exams by using the stress% management skills presented later in this chapter.
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78 Chapter 3 Stress and Its Management
Stressful Life Events In 1967, "omas Holmes and Richard Rahe intro- duced the Social Readjustment Rating Scale (SRRS), maintaining that people who experience numerous major life events within a short time span are likely to develop illnesses.9 Holmes and Rahe developed this scale by asking nearly 400 people to rate life events according to the average amount of social change the individuals thought would be needed to deal with the situation. Death of a spouse, for example, received the maximum score of 100 points (see Table 3.2).
!e Impact of Stress on"Health
It is generally accepted that exposure to stressful events indirectly impacts health outcomes. "e fol- lowing section explores the impact of stress on health including how stressful life events are related to ill- ness, the relationship between stress and the body’s immune functioning, the link between personality and stress response, and chronic health problems related to stress.
Social Readjustment Rating Scale
Table 3.2
Reproduced from Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11:213–218. Reprinted with permission from Elsevier Science.
Rank Life Event Value Rank Life Event Value
1 Death of spouse 100 23 Son or daughter leaving home 29
2 Divorce 73 24 Trouble with in-laws 29
3 Marital separation 65 25 Outstanding personal achievement 28
4 Jail term 63 26 Wife begins or stops work 26
5 Death of close family member 63 27 Begin or end school 26
6 Personal injury or illness 53 28 Change in living conditions 25
7 Marriage 50 29 Revision of personal habits 24
8 Fired at work 47 30 Trouble with boss 23
9 Marital reconciliation 45 31 Change in work hours or conditions 20
10 Retirement 45 32 Change in residence 20
11 Change in health of family member 44 33 Change in schools 20
12 Pregnancy 40 34 Change in recreation 19
13 Sexual difficulties 39 35 Change in religious activities 19
14 Gain a new family member 39 36 Change in social activities 18
15 Business readjustment 39 37 Mortgage or loan less than $10,000 17
16 Change in financial state 38 38 Change in sleeping habits 16
17 Death of close friend 37 39 Change in number of family get-togethers 15
18 Change to different line of work 36 40 Change in eating habits 15
19 Change in number of arguments with spouse
35 41 Vacation 13
20 Mortgage over $10,000 31 42 Christmas 12
21 Foreclosure of mortgage or loan 30 43 Minor violations of the law 11
22 Change in responsibilities at work 29
The Impact of Stress on Health 79
defends the body against disease-causing agents (Figure 3.2). "e white blood cells are the key soldiers of the immune system, serving as the body’s inter- nal scouts and commandos. "ese special cells !nd, identify, and destroy many agents that can endanger one’s health. In$ammation is a normal result of the immune system’s response to infection or injury and can assist in the recovery process.
In studies using the SRRS, Rahe found that subjects who accumulated higher scores because they had experienced more major life events in a year were more likely to become ill at some time in the follow- ing year.
Although a few items on the original SRRS are outdated, such as “mortgage over $10,000,” this scale continues to be a popular measurement of stress lev- els. Many stress experts, however, question the scale’s ability to predict the onset of illness. Also, the SRRS might not capture the top stressors faced by many college students. Using the SRRS as a model, Martin Marx and his colleagues developed the College Schedule of Recent Experience to assess the level of stress experienced by college freshmen.10 First-year college students o$en have di&culty coping with the unfamiliarity and demands of college life. Not surprisingly, these individuals have a high dropout rate. Concerned with the negative impact of change on !rst-year students, college administrators o$en establish academic, social, and counseling programs to ease the stress new students feel during their !rst year in school. What resources does your school pro- vide for students?
Medical experts generally agree with the idea that stressful life events are related to illness. However, observing an association between a stressful event and the onset of illness does not mean that stress causes health problems. An indirect link between stress and illness is widely accepted. For example, dis- tressed people may follow unhealthy lifestyles: "ey may not exercise regularly, eat nutritious foods, or get enough sleep. Such behaviors are likely to result in poorer health. "e following section explores the connections between psychological stress and physi- cal health.
The Mind–Body Relationship Psychoneuroimmunology, the study of the relation- ships among the nervous, endocrine, and immune systems, is the !eld of medical research that explores the connection between mind and body. "e immune system, which includes the red bone marrow, spleen, lymph nodes, white blood cells, and thymus gland,
psychoneuroimmunology (SIGH-ko- NEW-ro-im-mu-NOL-lo-gee) The study of the relationships between the nervous and immune systems.
immune system The specific defenses of the body that include combating infectious agents.
Figure 3.2 The Immune System. The immune system defends the body against disease-causing agents. The organs of the immune system include the thymus gland, spleen, and lymph nodes.
Thymus
Spleen
Lymph node
80 Chapter 3 Stress and Its Management
"e immune system functions in harmony with the nervous and endocrine body systems. By using nerves and neurotransmitters, the brain relays infor- mation about the person’s emotional state to the places where white blood cells are made and located in the body. "ese specialized cells produce their own chemical messengers that enable them to communi- cate information about the state of the body back to the brain and the endocrine system.
Scientists have discovered links between the ner- vous and immune systems that explain how some emotional responses a#ect physical health. Stress alters the normal functioning of the brain, which in turn a#ects immune system functioning. Stress depresses some aspects of the immune system, result- ing in delayed wound healing and increased suscep- tibility to infection. Stress may also stimulate other components of the body’s immune response, resulting in in'ammation. Immune system cells produce cyto- kines, a group of compounds that regulate the immune response and communicate with the nervous system. Stress increases the production of cytokines that pro- mote in'ammation. Under these circumstances, the in'ammatory processes are not necessary and cause harmful e#ects on the body. Chronic mild in'amma- tion is thought to be associated with the development of many serious diseases, including heart and other blood vessel diseases, obesity, diabetes, smoking, rheumatoid arthritis, in'ammatory bowel disorders, certain cancers, and Alzheimer’s disease.11–13
Autoimmune diseases occur when the immune system malfunctions and the system’s defense mech- anisms become aimed at the body’s own healthy cells. Rheumatoid arthritis, lupus, celiac disease, psoriasis, type 1 diabetes, and multiple sclerosis are autoim- mune diseases. Although these chronic health prob- lems have a genetic component, stress may contribute to their development.
Psychological stress can cause existing conditions to 'are or worsen (Table 3.3). For example, people with chronic health problems such as asthma, rheu- matoid arthritis, migraines, and genital herpes report that the signs and symptoms of their illness tend to recur or worsen during stressful periods.14 "erefore, stress management techniques may indirectly improve health by decreasing one’s response to stressful events.
Psychological, environmental, and biological%forces in'uence health in complex ways. Many people reap health bene!ts by modifying the way they respond to stressors. For example, a group of women with heart disease who participated in a group-based stress man- agement program lived longer than participants who
Eating disorders
Tension headaches
Migraines
Muscle spasms
Chest pains
Excessive menstrual cramps
Acne
Recurring herpes simplex
Chronic fatigue syndrome
Fibromyalgia syndrome
Itchy skin
Rapid or irregular heart rate
Intestinal ulcers
Nausea and vomiting
Frequent urination
Irritable bowel syndrome
Rheumatoid arthritis flare-ups
Asthma attacks
Premenstrual syndrome (PMS)
Table 3.3
Common Disorders Linked to Psychological State
Psoriasis. ©iStockphoto/Thinkstock.
The Impact of Stress on Health 81
which no physical cause can be found. In some instances, stressful or traumatic events, illnesses, or repetitive injuries seem to trigger FMS.17 People su#ering from FMS tend to be depressed and anxious; however, these negative psychological states may be the result of%the symptoms of the disorder rather than the cause.
Peptic Ulcers Approximately 15 million Ameri- cans have diagnosed peptic ulcers.18 Such ulcers are sores in the lining of the esophagus (the “food tube”), stomach, or duodenum, which is the !rst part of the small intestine that leads from the stomach. Ulcers form in the stomach (“peptic” or “gastric” ulcers) when its protective lining and overlying mucous lay- ers do not resist the normal amount of hydrochlo- ric acid that is secreted by the stomach. Ulcers of the esophagus develop when the acidic contents of the stomach chronically enter the structure and damage it. "is action, acid re$ux, o$en occurs when the ring muscle that serves as the “doorway” to the stomach from the esophagus relaxes. Cigarette smoking, alco- hol, chocolate, fats, and peppermints can relax this muscle. In addition, lying down immediately a$er eating or overeating promotes acid re'ux. People
did not receive the stress reduction training.15 Stress reduction techniques are presented in a later section of this chapter.
Personality and Stress Although exposure to any amount of stress can increase an individual’s susceptibility to illnesses, the same stressful situation can have a di#erent impact on di#erent individuals. Why do people o$en respond di#erently to a stressor? Each person’s unique com- bination of personality traits and background experi- ences contributes to his or her stress response.
People who see only the negative aspects of a stressor may view a di&cult situation as impossible to overcome and be more vulnerable to stress than those who make positive appraisals of the situation. As a result of this vulnerability, people may be more likely to become anxious, angry, or depressed, and to make poor decisions, thus adding to their stress. Distressed individuals may engage in behaviors that undermine their health, such as eating too much or too little, sleeping too much or too little, smoking cigarettes, or abusing drugs. Although such behaviors may be seen as a “quick !x,” they actually exacerbate the problem.
Stress and Chronic Health Problems As mentioned previously, some common chronic health problems are associated with stress. You or someone you know may have irritable bowel syn- drome, !bromyalgia, intestinal ulcers, or severe headaches, including migraines. Unwanted weight gain is also associated with stress. "e following sec- tions take a closer look at these conditions.
Irritable Bowel Syndrome (IBS) Anxiety and%stress worsen the signs and symptoms of irritable bowel syn- drome (IBS). People with IBS have recurrent bouts of intestinal cramps, constipation, diarrhea, and mucus in bowel movements. Medical testing and physical examination, however, fail to !nd a physical cause for the condition. Studies estimate that approxi- mately 12% of the U.S. adult population experiences IBS, that twice as many women as men are a#ected, and that it occurs most o$en among people younger than age 50.16
IBS o$en occurs with #bromyalgia syndrome (FMS), a% condition characterized by extreme fatigue, muscle and% joint pain, headaches, and sleep disturbances for
peptic ulcer A sore in the lining of the esophagus, stomach, or duodenum.
The most common type of headache is the “tension” headache. © Artem Furman/Shutterstock.
82 Chapter 3 Stress and Its Management
they do not consume them, and physical ailments such as sinus infections o$en cause headaches. "e most common type of headache is the tension-type (“tension”) headache. People su#ering from tension headaches report that the pain feels like a tight band has been placed around their forehead. "e mecha- nisms that result in tension headaches are unknown, but stress can trigger tension headaches.19 "e typical tension headache is not accompanied by visual prob- lems, sti# neck, nausea, vomiting, or fever.
Over-the-counter painkillers are usually e#ective for relieving tension-type headaches. For some people, sim- ply applying hot packs to the head or neck and relaxing by having a massage are helpful. It is important to note that “rebound headaches” can occur when remedies that contain ca#eine are used regularly to treat headaches.
Migraines are another type of recurring headache. About 10% of people worldwide su#er from migraine headaches, which are characterized by throbbing, intense pain that o$en a#ects one side of the head.19 Women are three times more likely than men to have migraine headaches.19 "e cause of migraine head- aches is unclear but thought to be related to genetic factors that a#ect potassium ion channels.20 Some- times a migraine attack is preceded by an aura, a nerve-related symptom that usually lasts for less than an hour. In most cases, the aura includes visual distur- bances such as 'ashing lights or zigzag lines, but “pins and needles” sensations, numbness, and speech prob- lems may occur as well (Figure" 3.3). In addition to being disabled by the headache, people with migraines o$en experience nausea and vomiting. Because their headaches are aggravated by light, sound, and routine physical activity, people with a migraine headache usually retreat to a darkened, quiet room to rest and
with intestinal ulcers usually experience burning or aching sensations in the middle of their abdomens from 30 minutes to 2 hours a$er eating. "ey may also feel bloated and nauseated a$er meals.
In many cases, the protective lining of the stomach may be chronically infected with the bacterium Heli- cobacter pylori (H. pylori). "is microscopic organ- ism is thought to weaken the stomach lining and make the person more susceptible to ulcers. However, not all individuals who are infected with H. pylori develop ulcers. Aspirin and ibuprofen (NSAIDs) are other common causes of peptic ulcers.18
Unavoidable risk factors associated with ulcers are age and family history. As you age, your risk for ulcers increases; most ulcers are diagnosed in persons older than 40 years of age. Infection with H. pylori is an addi- tional risk factor, although most people do not know if they are infected. "e avoidable risk factors are ciga- rette smoking, chronic alcohol use, and regular use of anti-in'ammatory drugs such as aspirin and ibuprofen.
Although stress does not cause peptic ulcers, it seems to worsen ulcer symptoms.18 Furthermore, peo- ple experiencing distress may smoke, drink too much alcohol, and not get enough sleep. Such unhealthy behaviors can negatively a#ect the immune system, reducing the body’s ability to control H. pylori infec- tion, thus making ulcers more likely.
Ulcers can be serious, especially if they bleed. Signs and symptoms of a bleeding intestinal ulcer include dark, tarry stools; a bloated sensation; and weakness. If you think you have a bleeding ulcer, seek medical attention immediately.
Headaches Nearly everyone has had a headache at one time or another. People who drink ca#ein- ated beverages regularly may get headaches when
Figure 3.3 Migraines. In 2011, Los Angeles TV news reporter Serene Branson was broadcasting “live” when she began to garble her words. Although she appeared to have had a stroke, doctors later determined she had a severe migraine headache. Difficulty speaking is a sign of severe migraines as well as strokes. © Al Seib/Los Angeles Times/Getty Images.
The Impact of Stress on Health 83
their eating practices consume less food; the other half eat more food than usual and are referred to as emotional eaters. When under stress, emotional eat- ers usually choose tasty foods. Such “comfort foods” tend to be high in sugar and/or fat, such as cookies, cake, and ice cream.25
As mentioned earlier in this chapter, stress increases the level of the stress hormone cortisol in the bloodstream. In response to increased blood cor- tisol levels, the pancreas releases the hormone insu- lin. "e combined e#ect of cortisol and insulin is an increased desire to consume pleasurable, energy-rich foods—fatty and/or sweet foods. "ese hormonal adaptations are bene!cial because the body needs a source of energy to fuel an immediate !ght-or-'ight response to threatening situations. In today’s world, however, threats to well-being are usually chronic and not life threatening, such as stressors generated by going to school, working, and dealing with fam- ily relationships and responsibilities. Furthermore, “stressed-out” Americans usually do not have to spend a lot of time hunting or searching for some- thing tasty to eat, as their ancestors did hundreds of years ago. Adults can simply stop at a convenience store to buy a large sugar-sweetened drink, dough- nuts, and candy bars as they drive to work, school, or home. When the extra energy is not needed to cope physically with a stressful situation, it is stored as fat in the body for future energy needs. "is adaptation o$en results in undesirable weight gain.
Heart Disease and Cancer Chronic stress increases the risk of cardiovascular disease.26 Some people’s minds overreact to stressors, and their bodies respond by releasing excessive amounts of stress hormones into the bloodstream. "is response may lead to in'am- matory processes that cause high blood pressure and other physical changes that damage the inside walls of
recover. Migraine headaches o$en persist for several hours and are quite debilitating.
"e !rst line of defense against migraines is identi- fying and avoiding their triggers. Some people develop migraines when they are anxious or under a lot of emotional stress. Others report having migraines when they do not get enough sleep or when they have disrupted sleep patterns. In these cases, maintain- ing a regular, su&cient sleep schedule is crucial to avoiding attacks. Other persons have migraines that are triggered by consuming certain foods, including chocolate, aged cheeses, and red wines, and foods containing aspartame and monosodium glutamate (MSG). Keeping a food diary can be important to determine which foods bring on headaches and then avoiding those triggers. In addition to managing or avoiding triggers, many people who have recurrent migraine headaches can take prescription medica- tions to prevent the attacks. Natural treatments are sometimes used, including magnesium, coenzyme Q10, butterbur, and vitamin B2.
21
If you su#er from frequent tension or migraine headaches, seek help from your physician. Headaches rarely signal life-threatening conditions. Table 3.4 describes circumstances under which you should seek immediate medical attention for a%headache.
Overweight and Obesity Do you lose your appe- tite or look for something sweet and creamy to eat when you are experiencing a lot of stress? About 80% of people alter their eating habits when they feel stressed out.25 About half of the people who change
Consult a physician if a headache:
• Is severe and accompanied by stiff neck, confusion, unconsciousness, or convulsions
• Occurs after a blow to the head • Is persistent in someone who has been free of
headaches previously • Is associated with ear or eye pain • Is accompanied by fever • Is recurrent, in children
Modified from National Institutes of Health, National Institute of Neurological Disorders and Stroke. Headache information page. (2018). Retrieved from https://www.ninds.nih.gov /Disorders/All-Disorders/Headache-Information-Page
Table 3.4
Serious Headache Signs and Symptoms
Are you an emotional eater? © Paul Maguire/Shutterstock.
84 Chapter 3 Stress and Its Management
Consumer Health Healthy Technology and Social Media Consumption Although technology has improved life for many Ameri- cans, unhealthy consumption of technology and social media can have negative effects on one’s stress levels. According to the Stress in AmericaTM 2017 survey, approxi- mately 43% of Americans reported they constantly check their e-mail, texts, and social media accounts—a group termed “constant checkers.”21 This constant connection to technology is associated with higher stress levels: Nearly 1 in 4 (23%) constant checkers identified their technology use as a somewhat or very significant source of stress (compared to 14% of non–constant checkers) and reported that the most stressful aspect of technol- ogy use is when it fails to work. On a 10-point scale, where 10 equals a great deal of stress, constant checkers reported higher levels than their non–constant-checker peers of overall stress (5.3 vs. 4.4) and stress in the prior month related to technology (3.0 vs. 2.5), respectively.
Constant checkers also identified more stress related to their social media use than their non–constant-checker counterparts.21 Specifically, constant checkers reported that political and cultural discussions on social media caused them stress (42% compared to 33% of non– constant checkers) and that they worry about the negative effects of social media use on their physical and mental health (42% compared to 27% of non– constant checkers). Negative impacts on relationships were also reported by constant checkers, including feelings of disconnection from family (44% compared to 25% of non–constant checkers) and being less likely to meet with loved ones in person because of social media (35% compared to 15% of non–constant checkers).
Social media worries followed a generational trend, with millennials reporting more worry about the impact of social media use on their physical and mental health (48%) compared to Gen Xers (37%), Boomers (22%), and older adults (15%).21 These findings align with cur- rent research that technology and social media use can have negative physical and mental health impacts, espe- cially for young adults.22,23 What can you do to reduce the potential stressful relationship with technology and
social media? Here are seven strategies suggested by the American Psychologi- cal Association24 to help you use tech- nology in a healthy manner:
1. Don’t use phones behind the wheel. When driving, turn off notifications and place your phone out of reach.
2. Defend your sleep. The stimulation of phone use, including the “blue light” emitted by tech devices, disturbs sleep patterns, so avoid late- night use of mobile devices.
3. Turn off notifications. Constant-checkers reported higher levels of stress and negative impacts related to their technology use than non–constant checkers. Turning off notifications has been linked to lower levels of inattention and hyperactivity and increased levels of productivity, social connectedness, and mental well-being.
4. Manage expectations. Let other people know that you won’t be checking text messages constantly, or make sure your boss is on board with you not checking e-mail on vacation. It is easier to disconnect from technology without managing frustrated family and coworkers.
5. Use social media wisely. Using social media to actively connect with others through comments and posts can improve well-being, whereas passively consuming social media by scrolling through and looking at others’ posts can decrease well-being. Remember that people’s lives are rarely as perfect as they make them seem on social media.
6. Be present. When you’re with family and friends, make an effort to unplug. To avoid temptation, silence your phone and put it out of sight.
7. Take time to recharge. Quiet time is important for relaxing, reflecting, and boosting creativity. Set aside time each day to disconnect. Although it may be difficult at first, over time it will become easier and will improve your well-being.
certain blood vessels. In addition, scientists have found that platelets, cell fragments that participate in the blood clotting process, become stickier when a person is dis- tressed.26 When a blood vessel is damaged and bleed- ing occurs, platelets clump together and form a plug that may stop blood loss. If a person is injured during a
!ght for survival, the ease with which the platelets form blood clots can be lifesaving. Many stressful experi- ences, however, do not include the risk of bleeding, yet the enhanced ability for blood clotting still occurs. In these instances, blood clots can be life threatening, par- ticularly when a clot forms and blocks the blood 'ow
The Impact of Stress on Health 85
Coping with Stress Stress is a consequence of living. In today’s world, many people cannot !ght or escape some of their stressors because the sources of stressors are di&cult to pinpoint and control. In other instances, distressed individuals can identify their stressors, but they lack the resources to improve their situations. By learn- ing ways to lessen the overall impact of everyday stressors on their health, many people can minimize the unhealthy impact of stress. Some healthy cop- ing strategies include lifestyle behaviors such as get- ting enough rest, exercising regularly, and becoming involved with spiritually upli$ing activities.
Coping strategies are behavioral responses and thought processes that individuals use to deal actively with sources of stress. Coping strategies can be problem-focused, emotion-focused, or social support methods of managing stressful situations. Although many coping strategies are useful, some can be harmful to health.
According to the results of the American Psycho- logical Association’s Stress in AmericaTM 2017 sur- vey, the top coping strategies reported by American women were exercising or walking (48%), spending time with friends or family (44%), reading (44%), praying (40%), and watching TV for 2 or more hours a day (39%).1 For American men, the coping strate- gies most o$en reported were exercising or walking (46%), watching TV for 2 or more hours a day (33%), going online (31%), reading (31%), and spending time with friends or family (30%).1
Problem-Focused Strategies Problem-focused strategies, such as planning, con- fronting, and problem-solving activities, are behav- iors that can directly reduce or eliminate the negative e#ects of stressors. For example, setting priorities, managing money and time, planning for retirement, and retraining for a career change are strategies that can make people feel more in control of stressful situ- ations. When individuals identify the sources of their stress and think that they have some control over their stressors, they feel less distress and experience fewer health problems.
Managing Your Time One of the most useful stress-reduction skills that you can learn is e#ec- tive time management. Begin by making a list of all work, school, family, and leisure activities that you perform in a day. "en, analyze the list so that you can rank the activities according to level of priority.
to the heart muscle or the brain. A heart attack results when blood 'ow to the heart is blocked; a stroke can occur when blood cannot circulate through the brain.
Are there speci!c personality types that increase a person’s risk of heart disease? For years, the popular belief has been that people who have a type A per- sonality (ambitious, restless, competitive, impatient, and hostile) are more likely to develop heart disease than people who do not have these characteristics. During the 1980s, medical researchers recognized that many people with type A personalities did not develop heart disease. More recently, scientists have associated a speci!c personality trait, hostility, with the development of heart and blood vessel diseases (cardiovascular disease). Hostile people harbor nega- tive feelings, such as anger, hostility, and mistrust. A hostile person’s immune system may respond to neg- ative feelings by producing chronic in'ammation, increasing the risk of heart disease.27
"e stress response can reduce the e#ectiveness of the immune system, possibly interfering with its ability to detect and destroy cells that become cancer- ous. Most scienti!c studies, however, do not show an association between stress and cancer onset.28 How- ever, the e#ects of stress on the immune, nervous, and endocrine systems may lead to biochemical changes in the body that aid the growth of cancerous tumors. More research is needed to determine whether stress has tumor-promoting e#ects.
coping strategies Behavioral responses and thought processes that people use to deal with stressors.
4To reduce the risk of peptic ulcers, avoid cigarette smoking and chronic alcohol use, lying down after eating, overeating, and chronic use of anti-inflammatory drugs.
4If you experience a burning or aching sensation in the middle of your abdomen after eating, or feel bloated and nauseated after meals, you may have a peptic ulcer. See your personal physician for diagnosis and treatment.
4To reduce the risk of tension headaches, learn relaxation techniques. Consult a physician if you have severe headaches.
Healthy Living Practices
86 Chapter 3 Stress and Its Management
Health-Related InformationAnalyzing Critical Thinking
4. What is the main point of the article? Which information is relevant to the main point? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable?
6. Does the author attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Sum- marize your reasons for coming to this conclusion.
The following article about sleep appeared in FDA Con- sumer. Read the article and explain why you think it is a reliable or an unreliable source of information. Use the model for analyzing health information to guide your thinking; the main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who wrote the article? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person who wrote the article?
Sleepless Society
Tamar Nordenberg , staff writer for FD
A Consumer
Million s of Americans und
ersleep by choice, b urn-
ing the candle at b oth ends because
of hectic
work and family sc hedules. American
s sleep 7 hours
each night on ave rage, down from 9
hours in 1910
when people gener ally went to sleep a
s darkness fell.
“People don’t resp ect sleep enough,”
says Daniel
O’Hearn, a sleep d isorders specialist
at Johns Hop-
kins University. “T hey feel they can d
o more—have
more time for wor k and family—by
allowing them-
selves less time fo r sleep. But they
do sleep; they
sleep at work, or dr iving to work.”
Like drunk driving , drowsy driving c
an kill. The
National Highway Traffic Safety Adm
inistration esti-
mates that more than 200,000 cras
hes each year
involve drivers fall ing asleep at the w
heel, and that
thousands of Ameri cans die in such acc
idents annually.
“Besides being an unpleasant
sensation,
when we’re tired, we’re less alert an
d less able to
respond,” says FD A drug reviewer B
ob Rappaport,
M.D. Lack of slee p can cause mem
ory and mood
problems, too, R appaport says, a
nd may affect
immune function, which could lead
to an increased
incidence of infec tion and other illn
esses. In stud-
ies performed on rats, prolonged sle
ep deprivation
resulted in death.
Beyond the observ -
able consequence s of
sleep deprivation, why
humans—or any ani-
mal, for that matte r—
need sleep rema ins
largely a mystery. “W hat
we do know is that s leep
is an important bio logi-
cal need, like food and
drink, and that the brain is very
active while
we’re sleeping,” s ays James Kiley, d
irector of the
National Center f or Sleep Disorder
s Research of
the National Inst itutes of Health.
So just how much sleep does a perso
n need? That
can change throug hout one’s life bas
ed on age and
other factors. For m ost people, though,
7.5 to 8.5 hours
of sleep each night fulfills the basic ph
ysical need, but
this is “very individ ual” and can range
from as few as
4 or 5 hours to as m any as 9 or 10. The
Mayo Clinic of
Rochester, Minneso ta, defines an adequ
ate amount of
sleep as whatever produces daytime
alertness and a
feeling of well-being . People should not
need an alarm
clock to wake them , if they are getting
enough sleep.
Data from Norden berg, T. (1998). Sle
epless society. FDA
Consumer, 32(4), 11 .
© lig
ht po
et /S
hu tte
rst oc
k.
Coping with Stress 87
High-priority activities are those that must be accom- plished if you are to meet your most important goals. Are some activities, such as watching television, chat- ting online, texting, or talking on the phone, relatively unimportant or “time wasters”? If so, these activities have low priority. To allocate and use time well, you may decide to eliminate some low-priority activities from your daily schedule.
A$er analyzing and ranking the high-priority activities, determine the amount of time that is needed to carry them out. Allow more time to com- plete the highest priority tasks than for those of lesser importance. Perform the high-priority tasks !rst. Putting o# an important task (procrastination) o$en results from fear—fear of failure or doing a less- than-perfect job. If the task appears overwhelming, break it into smaller jobs that can be checked o# as they are completed. Also consider when your “best time” of the day is; plan to do the most challenging tasks during that period. To be successful in col- lege, for example, you should allow time to attend all classes and prepare for each class, which includes set- ting some time aside daily for out-of-class tasks (e.g., reading, taking/reviewing notes, homework).
To manage time, using a calendar or personal elec- tronic device to record appointments and important due dates for papers and exams can be helpful. Many people also make daily lists of “things to do,” espe- cially on very busy days. Allow some time for unex- pected situations; it is not necessary to lock yourself into a rigid work schedule.
Of course, you also need time to relax, eat, exercise, socialize, and sleep. Arrange your schedule so that you can obtain 7–8 hours of sleep each night. Many college students are sleep deprived, and to stay alert, they o$en drink ca#einated beverages. Because excessive ca#eine can interfere with relaxation, you may need to reduce your consumption of these drinks.
If you work or have family responsibilities while you are in school, planning your time carefully is even more crucial. Individuals who balance the time that they spend performing task-centered responsi- bilities with that spent engaging in pleasurable activi- ties are o$en able to improve their performance and feel a sense of accomplishment.
Journal Writing In the past, I have seen a psychiatrist. There were times when I didn’t want to go, either because I didn’t have anything to say or I was in a good mood. But, I learned that no matter how I felt, it made me feel better just to talk about my life. Journaling acts somewhat like
a psychiatrist or even a friend. It allows you to “get it off your chest” . . . by writing down your feelings, you receive feedback from yourself.
Coping with daily stressors may be easier if you keep a written record of personal events, thoughts, and feel- ings. Entering your thoughts in a journal regularly can help you focus on your emotional responses to situa- tions. "ere are no rules to writing e#ective therapeutic journals. You do not have to write the passages in prose; some people express their feelings in poetry or as letters that are not to be mailed. Identify distressing problems or situations, and then write your thoughts concern- ing them, including ways to resolve these problems or manage the troublesome situations (see the Re'ecting on Your Health activity at the end of this chapter).
Emotion-Focused Strategies Instead of directly dealing with stressors, many individuals use emotion-focused strategies to alter their appraisal of stressful situations. "ese strate- gies involve reducing a person’s negative emotional response associated with a stressful event. Such alterations can improve mood and reduce anxiety by making the events seem less threatening. For exam- ple, many successful athletes cope with the stress of competition by appraising each competitive event as an opportunity to challenge themselves and achieve excellence in their sport. By viewing the competition as a challenge rather than a threat, athletes are less likely to experience the emotionally and physically destructive e#ects of stress on their performance.
Another emotion-focused coping strategy that encourages more positive thinking is humor. Humor
© Pa
tri k G
iar di
no /B
len d I
m ag
es /G
et ty
Im ag
es .
88 Chapter 3 Stress and Its Management
include seeking the advice, assistance, or consolation of close friends and relatives; participating in support groups; and obtaining spiritual help from members of the clergy or religious congregations.
When a major disaster occurs in a community, relief organizations such as the Red Cross provide valuable social and !nancial support services that reduce the impact of the catastrophe on people’s lives. "e knowledge that other people, even strangers, are willing to provide assistance is comforting and reas- suring for many distressed individuals. Humans are not the sole providers of social support; lonely people who love animals o$en !nd comfort in the compan- ionship of their pets (Figure 3.4).
can serve as a “stress bu#er,” lessening the nega- tive health e#ects of both daily hassles and major life events.29 For example, the homeowners who posted a “For Sale” sign in front of their hurricane-damaged house were using humor to relieve some of their distress. Forming constructive rather than% destruc- tive appraisals of stressful situations is another useful emotion-focused strategy.
However, emotion-focused strategies can have harmful impacts when used as a means to avoid or deny the existence of stressors. Defense mechanisms, such as denial and projection, serve as emotion- focused coping strategies to defend one’s mind against threats. Some people overeat or abuse alcohol to feel better during stressful periods. "ese unhealthy life- styles generally relieve stress for the short term, but the consequences of overeating and drinking o$en create even more stress in the long term.
Social Support Strategies Many individuals use social support strategies to cope with stressful situations. Social support strategies
Figure 3.4 Pets as Friends. People who love animals often find comfort in the companionship of their pets. © Photos.com.
4Accepting stress as a part of life can reduce the negative or harmful impact of stress on your health.
4Planning for the future, setting priorities, and managing time can help you feel more in control of your life.
4Recording your thoughts and feelings in a journal can help you manage stress.
4Viewing challenging situations as opportunities to experience psychological growth can help you manage your stress.
4Seeking the companionship and social support of others can reduce your stress.
Healthy Living Practices
Humor can be an emotion-focused coping strategy, like homeowners who placed a “For Sale” sign in front of their hurricane-damaged house as a humorous way to relieve some of their distress. © Lane V. Erickson/Shutterstock.
Coping with Stress 89
Relaxation Techniques Although no one can eliminate stress, you can use a variety of relaxation techniques to reduce its impact on your health. Furthermore, relaxation techniques help redirect your attention away from stressors and toward more pleasant thoughts and relieve physical tension.
As you relax, your intestinal functioning becomes normal, your breathing and heart rate slow, and your blood pressure declines. Practicing relaxation tech- niques when you feel stressed can help restore many body processes to normal, which reduces the poten- tially damaging e#ects that stress can have on your body. Relaxation activities o$en involve learning how to identify and relax your tense skeletal muscles while remaining mentally alert.
Most relaxation methods are relatively easy to learn, but to be e#ective, one needs a high degree of motiva- tion, self-control, and willingness to practice the skills for about 10–20 minutes daily. Learn each technique to determine which ones are e#ective for you. At !rst, learning to relax may be di&cult, but by practicing at least one of these techniques every day, you should be able to master the activity within a couple of weeks.
Deep Breathing While having panic attacks, people o$en hyperven- tilate (pant for air) and feel as though they are suf- focating. Hyperventilation alters the chemistry of the blood, which increases the heart rate and causes dizziness. By deliberately breathing more slowly and deeply, distressed people can feel more relaxed as their blood chemistry values return to normal. Con- centrating on breathing more deeply allows people to shi$ their attention away from stressors and toward the breathing activity.
Under normal conditions, you breathe an average of 12 to 18 times per minute, but to relax, you need to breathe only 8 to 10 times per minute. "e key is to take several deep breaths, using your abdominal muscles, and recognize how deep breathing feels di#erent from your usual breathing pattern. Results from studies show that deep breathing is a quick and simple method to reduce the impact of stress on your
health. You can use this breathing technique when- ever you begin to feel excited or stressed; so, before your next exam, speech, or job interview, relax by simply breathing deeply.
Because breathing is an automatic, natural activity, you can teach yourself deep breathing in only a few minutes. Many online resources exist to help people learn various deep breathing exercises. For example, TEDx Talks include Breathe to heal by Max Strom (www.youtube.com/watch?v=4Lb5L-VEm34), Breath – #ve minutes can change your life by Stacey Schuerman (www.youtube.com/watch?v=hFcQpNr_KA4), and How to breathe by Belisa Vranich (www.youtube.com /watch?v=1sgb2cUqFiY).
Of all the relaxation techniques we learned this semester, the deep breathing method was the most helpful. I can remember many situations when I’ve had to use it. While driving home from school, somebody pulled out in front of me and I had to make a ridiculous move to avoid hitting him head on. I didn’t turn my car around and try to find him, which I would have done 6 months ago; I simply took some deep breaths and was thankful that no one, including myself, was injured.
Progressive Muscular Relaxation Although some degree of skeletal muscular tension is necessary to maintain a comfortable body pos- ture, excess tension in forehead, scalp, jaw, and neck muscles may contribute to the development of ten- sion headaches. Distressed individuals o$en look tense because of their tightened facial muscles or clenched !sts. Even when they are resting, stressed people still report feeling excess muscle tension. Teeth grinding is a common sign of stress that o$en occurs during sleep and may lead to headaches and pain in the temporomandibular joint, the joint where the lower jaw attaches to the skull in front of the ear (Figure"3.5).
The progressive muscular relaxation technique teaches people how to recognize the di#erences between a tensed muscle and a relaxed one. Indi- viduals learn how to release muscle tension volun- tarily, becoming aware of the relaxed sensations. When a person’s skeletal muscles are completely relaxed, the individual is limp and feels calm. Peo- ple o$en use the technique to fall asleep. "e Man- aging Your Health feature titled “A Technique for Progressive Muscular Relaxation” highlights the steps of this particular stress reduction method.
temporomandibular (TEM-pe-row-man-DIB- you-ler) joint The place where the lower jaw bone (mandible) attaches to the temporal bone of the skull.
meditation An activity in which one relaxes by mentally focusing on a single word, object, or thought.
90 Chapter 3 Stress and Its Management
Temporomandibular joint
Figure 3.5 The Temporomandibular Joint. The temporo- mandibular joint is the point at which the lower jaw attaches to the skull in front of the ear. Pain in the temporomandibular joint may result from grinding teeth during sleep, a common sign of stress.
Managing Your Health
1. Choose a quiet location and sit in a comfortable position, hands down at your sides, and both feet flat on the floor.
2. Close your eyes and take a few deep breaths; con- centrate on becoming as relaxed as possible.
3. With your arms at your sides, make a fist with one of your hands. Hold your clenched fist for about 5 seconds, release your hand from this position, and concentrate on the feeling as the muscular ten- sion “drains” out of your hand.
This basic exercise is repeated as you tense muscles, hold the tensed position for 5 seconds, and then relax the major muscle groups in your body. It is important to focus on recognizing the difference between muscular tension and relaxation sensations. Continue breathing normally as the activity progresses. Begin with your head.
1. Tense your forehead and scalp muscles; feel the tight muscular sensations as you hold this position for 5 seconds; relax these muscles.
2. Tense your facial muscles; hold this position for 5 seconds; relax.
3. Tense the muscles of your neck and jaw; hold this position; relax.
4. Tense your back muscles—but not too tight; hold this position; relax.
5. Tense your right arm; hold; relax. 6. Tense your left arm; hold; relax. 7. Tense your chest muscles; hold; relax. 8. Tense your stomach muscles; hold; relax. 9. Tense your buttocks; hold; relax. 10. Tense your right leg—but not too tight; hold; relax. 11. Tense your left leg—but not too tight; hold; relax.
Now, imagine traveling back through your body searching for muscles that are not relaxed. As you find tense muscles, relax them. Maintain this position for several minutes, concentrating on your breathing. In this relaxed state, you may practice tranquil imagery and positive self-talk. To regain your normal physical activity, open your eyes, stand, and stretch your muscles.
A Technique for Progressive Muscular Relaxation
Meditation and the Relaxation Response For some people, praying or meditating reduces stress. Meditation is an activity in which a per- son relaxes by mentally focusing on a single word, object, or thought. Many online resources exist for those who want to learn meditation. For exam- ple, the University of New Hampshire provides a guided meditation exercise designed to help college students improve their academic performance: www .youtube.com/watch?v=7bZaTUCRJ2s.
Mindfulness meditation involves a variety of relax- ation methods that focus your attention completely and in a nonjudgmental way on what you are doing or experiencing at the moment. Instead of repeating one word or thinking about a single thing or object, you allow your thoughts to 'ow and experience as much as you can about what you are sensing and thinking. According to results of scienti!c studies, people who practice mindfulness meditation are better able to reg- ulate their emotional responses, and they report lower levels of emotional stress, anxiety, depression, and anger than people who do not use meditation to relax.29
Relaxation Techniques 91
You can engage in mindfulness-based stress reduc- tion while performing ordinary activities such as eating or walking, or by studying an interesting pho- tograph, painting, or object such as a seashell. By practicing this relaxation technique regularly, you can learn to regulate your attention and reduce your nega- tive reactions to stress.
Herbert Benson incorporated features of medita- tion into his relaxation response, claiming that this method is e#ective for reducing blood pressure and drug abuse.30 To practice Benson’s method, !nd a quiet place where you can sit comfortably for 10–20 minutes. Close your eyes, breathe normally, and con- centrate on repeating a simple word or maintaining a pleasant thought. Progressively relax groups of mus- cles, starting at your feet and moving up your body to your face. A$er relaxing your muscles, maintain this pose for at least 10 minutes. When you are ready to regain your usual degree of alertness, open your eyes, slowly stand up, and stretch. Online resources abound for those who wish to learn relaxation exercises. For example, the University of New Hampshire created the following guided video for college students to progressively relax muscle groups: www.youtube.com /watch?v=PYsuvRNZfxE.
Imagery Imagery is a mental activity that is o$en combined with progressive muscular relaxation exercises to enhance physical relaxation. "e technique is simple. A$er relax- ing their muscles, the person thinks of a peaceful, plea- surable scene, using imagination or past experiences as a guide. While relaxed, the person “sees” the scene in their mind and imagines other sensations as well. For example, someone who enjoys outdoor activities might recall 'oating down a small stream in a canoe. "is indi- vidual would imagine the peaceful feeling of 'oating gently on the water as well as the sound of birds singing and water 'owing. Imagery, or visualization, can be a creative and enjoyable way to relax because it disen- gages the mind from thinking about problems. Relax- ation audio and video guides o$en incorporate nature sounds with slow-tempo music to facilitate imagery. Are you interested in trying guided imagery exercises with nature sounds and slow-tempo music to reduce your stress? Find a video online that works for you. For example, the University of Minnesota’s guided imagery video includes both a guided nature video with sooth- ing nature sounds and relaxing music: www.youtube .com/watch?v=gU_ABFUAVAs.
Athletes, actors, and other performers o$en use imagery to reduce their stress and enhance their per- formance. Before an event, for example, a pole vaulter o$en visualizes the entire sequence of events that takes place when approaching and vaulting over the pole. Although imagery is not a substitute for actu- ally practicing the required skills, the technique is a useful training activity for many competitive athletes.
You do not have to be an athlete or an actor to use imagery to reduce your stress levels. Before facing a stressful situation, such as giving a speech or inter- viewing for a job, imagine the setting. Also imagine the other people’s responses and your own behavior. Men- tally rehearsing the situation can reduce your anxiety by making you feel better prepared. "en, immediately before the stressful event, breathe deeply to relax.
Self-Talk At times, people may have irrational or negative thoughts concerning their abilities to deal e#ec- tively with their stressors. Individuals can reduce their stress levels by identifying these self-defeating thoughts and replacing them with positive self-talk statements. Positive self-talk re'ects a person’s attri- butes and boosts self-con!dence. However, thinking about oneself in a positive manner may be di&cult for individuals who have low self-esteem. People with poor self-esteem o$en have self-degrading or self-critical thoughts, and they are unaccustomed to acknowledging their positive characteristics.
To practice positive self-talk, think of at least three a&rmative statements to say about yourself, including your feelings, accomplishments, skills, and characteristics. Self-talk can be personal com- pliments (“I look great today”), statements of encouragement (“I can handle this problem”), or statements that re'ect personal strengths (“I know I can ace that test”). Write these positive statements on a small card and place the card where you will see it daily. Repeat these statements to yourself every day and when you are feeling stressed out. You can begin your daily relaxation sessions with progres- sive muscular relaxation followed by imagery, and then complete the stress management activity by repeating your positive self-statements.
Physical Exercise Whether it is gardening or ballroom dancing, phys- ical activity can reduce stress by shi$ing one’s atten- tion away from stressors and toward the enjoyable
92 Chapter 3 Stress and Its Management
exercises can enhance the body’s muscular 'exibility and reduce stress.33
Interest in tai chi and yoga is increasing in the United States. "e number of Americans who reported using yoga as a stress-relieving activity increased approximately one-third between 2016 and 2017.1 If%you would like to learn tai chi or yoga, check with the physical education department or student rec- reation center on your campus or the local !tness club to determine if it o#ers classes. Additionally, online resources to learn these exercises abound; for example, www.doyogawithme.com provides free streaming yoga videos for all levels. Before begin- ning any new% physical activity program, especially the martial arts and yoga, it is advisable to receive approval from your personal physician.
aspects of the activity. Besides this psychological bene!t, physical activity can metabolize the extra energy released during the stress response, lessen- ing the impact of stress on the body. Engaging in physical activity with others can also enhance social and spiritual well-being. Nearly everyone can think of at least one physical activity that they can enjoy on a regular basis.
Regular exercise improves mood and self-image while reducing anxiety and stress.31 Exercising regularly enhances the functioning of the immune system and may reduce symptoms of depression and anxiety.32 Too much physical activity, however, can cause exhaustion or muscle damage, creating emotional stress. Athletes who engage in endur- ance activities and extensive physical training may have less e#ective immune systems while they are in active training.
During strenuous physical activity, such as run- ning, the nervous system releases endorphins that may be responsible for creating the “runner’s high,” the heightened sense of well-being that long-distance runners o$en experience. As mentioned earlier in this chapter, endorphins can relieve pain, but they also can reduce the activity of certain components of the immune system. However, most people can gain far more health bene!ts than harmful e#ects from regular, moderate exercise.
Tai Chi and Yoga Tai chi, a form of martial art that originated in China, emphasizes relaxation of the mind while the body is in motion. As people per- form the gentle, gliding movements of tai chi, they focus their attention on this physical activity and dis- regard all other thoughts. In addition to tai chi, the other martial arts can be e#ective in reducing stress, increasing the body’s 'exibility, and boosting self- con!dence. Tai chi, however, may be preferred by less physically active older adults because the exercises are less strenuous.
Yoga, a philosophy of living that originated in India thousands of years ago, includes speci!c physi- cal exercises, breathing techniques, meditation activ- ities, and dietary restrictions to promote a healthier body and manage stress (Figure 3.6). As individuals practice the yoga exercises, they slowly move their bodies into positions that stretch their skeletal mus- cles. A$er maintaining these positions, trained indi- viduals usually report feeling relaxed and refreshed. Although some of yoga’s teachings concerning nutri- tion and the health bene!ts of stretching organs are not based on modern medical concepts, these
Figure 3.6 Managing Stress with Yoga. Yoga includes specific physical exercises, breathing techniques, meditation activities, and dietary restrictions to promote a healthier body. After practicing yoga, trained individuals usually report feeling relaxed and refreshed. © Photodisc.
Relaxation Techniques 93
Parents can help their children learn healthy ways to cope with stressful situations by teaching them problem-solving skills and relaxation exercises.
"e adolescent years are stressful because individu- als undergo numerous physical and social changes during this time. A recent Stress in AmericaTM survey found that teens, like their adult counterparts, report having stress levels far higher than what they deem healthy and that stress is negatively impacting their lives.34 Distressed youth who do not have e#ective and healthy coping mechanisms are likely to su#er from depression, abuse drugs, have serious tra&c accidents, and experience problems with parents and school authorities. If an adolescent’s stress response persists or is severe, professional counseling is recommended.
For many people, the older adult years can be very stressful. Aging individuals o$en feel bored or use- less, especially if they have retired from the responsi- bilities of a job or raising a family. On the other hand, many older adults are distressed because they must work to supply an income, or they must raise their grandchildren. Older adults frequently experience distress when they must care for spouses with debili- tating mental or physical illnesses.
Coping with loneliness and the deaths of friends or close family members is especially di&cult for aging individuals as they face the reality of their own mortality. Su#ering from disabling illnesses creates additional distress for many older adults. "e inabil- ity to cope with stress can have serious results; rates of depression and suicide are high among the isolated elderly. To enhance the well-being of older adults, communities o$en have programs that encour- age social interaction among aged members of the population (Figure 3.7). Elderly residents of most long-term care facilities can participate in social and physical activities that combat the stress of isolation.
4If dwelling on negative self-thoughts creates stress for you, think about your strengths and develop a list of affirmative self-statements to repeat regularly.
4Consider setting aside some time to relax every day, perhaps by using the techniques discussed in this chapter.
4Try breathing slowly and deeply before or during a stressful situation as a simple but effective way to relax.
4Engaging in tai chi, yoga, and moderate exercise and physical activity on a regular basis can reduce your stress.
Healthy Living Practices
Figure 3.7 Social Interaction Among Older Adults. Many communities offer social and physical programs for older adults that can combat the stress of isolation.
STRESS Distressed adults may recall images of a carefree childhood, but children also experience stress. Com- mon stressors for children include separation from a parent through divorce or death, moving to a new neighborhood and changing schools, and illness of a close family member.
When children are distressed, they o$en exhibit regressive behaviors, like clinging to and acting% more dependent on their parents. In addition to acting imma- ture, distressed youngsters may become depressed and withdrawn; su#er sleep disturbances, headaches, and stomachaches; or experience problems at school.
Across THE LIFE SPAN
© Photodisc.
94 Chapter 3 Stress and Its Management
CHAPTER REVIEW
Application using information in a new situation.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
Key
1. Using the techniques described in this chapter, develop a personal stress-reduction program that you can incorporate into your daily schedule. Application
2. You have two !nal exams scheduled for the same day. Describe how you could use a negative cop- ing strategy to reduce your stress. Describe how
you could use a positive coping method to deal with the same situation. Application
3. Plan a program that uses social support as a cop- ing strategy to help distressed older adults who live in your community. Synthesis
4. Evaluate your present situation. Identify and list the sources of distress in your life. Evaluation
Stress can refer to a threatening or demanding situ- ation, a person’s responses to a situation, or the interactions that take place between a person and a situation. Various situations or conditions, referred to as stressors, create stress. Individuals, however, can appraise the same situation di#erently. Situa- tions with unwanted or negative outcomes produce distress, and those with positive outcomes produce eustress. Stress can make life more challenging and interesting, but too much can make life miserable.
In a combined response, the nervous, endocrine, and immune systems prepare the body to confront or leave dangerous situations. Hans Selye proposed the general adaptation syndrome to describe the three stages of the body’s adaptive physical responses to stressors. "e stress response produces physical changes that include altering the activity and e#ec- tiveness of the immune system. As a result, enduring too many stressful life events can increase one’s sus- ceptibility to disease.
People o$en use problem-focused, emotion- focused, or social support coping strategies to deal with stressful situations. Although these strategies can be e#ective methods of helping people take
control over their stressors, some coping methods can be harmful to health. For example, emotional eating and avoiding and denying stressors are cop- ing mechanisms that usually do not eliminate the sources of stress. Adopting healthy lifestyles can help one manage stress e#ectively.
Many stress management activities involve learning skills that enable one to relax. Relaxation can reverse many of the normal but damaging physical responses to stress. Relaxation techniques include deep breathing exercises, progressive mus- cular relaxation, meditation, and mental imagery. Journal writing, e#ective time management, posi- tive self-talk, and moderate physical activity can also reduce stress.
Common childhood stressors include separation from a parent through divorce or death, moving to a new neighborhood and changing schools, and the illness of a close family member. Older distressed youths are o$en depressed, abuse drugs, and experi- ence problems with parents and school authorities. Aging people o$en !nd that coping with loneliness, disability, and the deaths of friends or close family members is especially stressful.
Applying What You Have Learned
Summary
Applying What You Have Learned 95
CHAPTER REVIEW
1. Review the physical adaptations to stress listed in Table 3.1. "e last time you were faced with a stressful situation, did you experience these changes? How did you feel?
2. Recall that stress can have positive outcomes. Re'ect on a stressful experience that made you feel happy, challenged, or successful. Why did the experience make you feel this way?
3. Each person can appraise a situation di#erently; what is distressing to one can be thrilling to another. Choose a situation that distresses you.
Why do you think it a#ects you in this manner? Do you think other people would !nd this situa- tion distressing? Why or why not?
4. Chronic stress can have negative e#ects on health. What was the most stressful situation that you had to endure in the past year? How did this experience a#ect your health and well-being?
5. How do you usually react when faced with stress- ful situations? Are your responses positive or negative? How do you think you could reduce the impact of stress on your health?
Reflecting on Your Health
References 13. Wong, C. M. (2002). Post-traumatic stress disorder: Advances in
psychoneuroimmunology. Psychiatric Clinics of North America, 25(2), 369–383.
14. Levenson, J. L. (2003). Psychological factors a#ecting medical con- ditions. In R. E. Hales, et al. (Eds.), Textbook of psychiatry (3rd ed., pp. 635–661). Washington, DC: American Psychiatric Press.
15. Orth-Gomér, K., et al. (2009). Stress reduction prolongs life in women with coronary artery disease: "e Stockholm Women’s Intervention Trial for Coronary Heart Disease. Circulation, Cardio- vascular Quality and Outcomes, 2, 25–32.
16. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (2017, November). De#nitions and facts for irritable bowel syndrome. https://www.niddk.nih.gov /health-information/digestive-diseases/irritable-bowel-syndrome /de!nition-facts
17. National Institutes of Health, National Institute of Arthritis and Neuromuscular and Skin Diseases. (2014, July). Fibromyalgia. Retrieved% from http://www.niams.nih.gov/Health_Info/Fibromyalgia /default.asp
18. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (2014, November). H. pylori and pep- tic ulcers. Retrieved from http://digestive.niddk.nih.gov/ddiseases /pubs/hpylori/index.aspx
19. National Institutes of Health, National Institute of Neurologi- cal Disorders and Stroke. (2018, May). Headache: Hope through research. Retrieved from https://www.ninds.nih.gov/Disorders / P a t i e n t - C a r e g i v e r- E d u c a t i o n / Ho p e - T h r o u g h - R e s e a r c h /Headache-Hope-"rough-Research
20. National Institutes of Health, National Institute of Neurologi- cal Disorders and Stroke. (2018, May). Migraine information page. Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders /Migraine-Information-Page
21. American Psychological Association. (2017, February 23). Stress in AmericaTM: Coping with change. Retrieved from http://www.apa .org/news/press/releases/stress/2017/technology-social-media.PDF
1. American Psychological Association. (2017, November). Stress in AmericaTM : "e state of our nation. Retrieved from http://www.apa .org/news/press/releases/stress/2017/state-nation.pdf
2. Selye, H. (1976). "e stress of life (2nd ed.). New York, NY: McGraw-Hill.
3. Black, P. H. (2006). "e in'ammatory consequences of psychologic stress: Relationship to insulin resistance, obesity, atherosclerosis, and diabetes mellitus, type II. Medical Hypotheses, 67(4), 879–891.
4. Ayers, J. W., et al. (2009). Sorting out the competing e#ects of acculturation, immigrant stress, and social support on depression: A report on Korean women in California. Journal of Nervous and Mental Disease, 197(10), 742–747.
5. Ibrahim, F. A., & Ohnishi, H. (2001). Posttraumatic stress disor- der and the minority experience. In D. B. Pope-Davis & H. L. K. Coleman (Eds.), "e intersection of race, class, and gender in multicul- tural counseling (pp. 89–126). "ousand Oaks, CA: Sage Publications.
6. Ro, M. (2002). Moving forward: Addressing the health of Asian American and Paci!c Islander women. American Journal of Public Health, 92, 516–519.
7. Centers for Disease Control and Prevention. (2017). Leading causes of death in females, 2014 (current listing). Retrieved from https:// www.cdc.gov/women/lcod/2014/asian-paci!c/index.htm
8. Blonna, R. (2005). Coping with stress in a changing world (3rd ed.). Boston, MA: McGraw-Hill.
9. Holmes, T. H., & Rahe, R. H. (1967). "e social readjustment rating scale. Journal of Psychosomatic Research, 11, 213–218.
10. Marx, M. B., et al. (1975). "e in'uence of recent life experiences on the health of college students. Journal of Psychosomatic Research, 19, 87–98.
11. Holmes, C., et al. (2009). Systemic in'ammation and disease pro- gression in Alzheimer disease. Neurology, 73(10),768–774.
12. Kiecolt-Glaser, J. K., et al. (2003). Chronic stress and age-related increases in the proin'ammatory cytokine IL-6. Proceedings of the National Academy of Sciences, 100(15), 9090–9095.
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CHAPTER REVIEW 22. Kross, E., et al. (2013). Facebook use predicts declines in subjective
well-being in young adults. PLoS ONE, 8(8), e69841. 23. Chatterjee, A., & DeVol, R. C. (2012). Waistlines of the world: "e
e#ect of information and communications technology on obesity. Retrieved from http://assets1c.milkeninstitute.org/assets/Publication /ResearchReport/PDF/Waistlines-of-the-World.pdf
24. American Psychological Association. (2017). Connected and con- tent: Managing healthy technology use. Retrieved from http://www .apa.org/helpcenter/connected-content.aspx
25. Dallman, M. R. (2010). Stress-induced obesity and the emotional ner- vous system. Trends in Endocrinology & Metabolism, 21(3), 159–165.
26. Ho, R. C. M., et al. (2010). Research on psychoneuroimmunology: Does stress in'uence immunity and cause coronary artery disease? Annals of the Academy of Medicine of Singapore, 39(3), 191–196.
27. Brydon, L., et al. (2010). Hostility and physiological responses to laboratory stress in acute coronary syndrome patients. Journal of Psychosomatic Research, 68(2), 109–116.
28. Ross, K. (2008). Mapping pathways from stress to cancer progres- sion. Journal of the National Cancer Institute, 100(13), 914–915, 917.
29. Greeson, J. M. (2009). Mindfulness research update: 2008. Comple- mentary Health Practice Review, 14(1), 10–18.
30. Benson, H. (1975). "e relaxation response. New York, NY: William Morrow.
31. Kruk, J. (2009). Physical activity and health. Asian Paci#c Journal of Cancer Prevention, 10(5), 721–728.
32. Tsatsoulis, A., & Fountoulakis, S. (2006). "e protective role of exercise on stress, stress system dysregulation, and comorbidities. Annals of the New York Academy of Science, 1083, 196–213.
33. Kiecolt-Glaser, J. K., et al. (2010). Stress, in'ammation, and yoga practice. Psychosomatic Medicine, 72(2), 113.
34. American Psychological Association. (2014, February). American Psychological Association survey shows teen stress rivals that of adults. Retrieved from http://www.apa.org/news/press/releases/2014/02 /teen-stress.aspx
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow / EyeEm/Getty Images.
References 97
Across the Life Span Violence and Abuse
Managing Your Health Sexual Assault: Safety and Prevention
Consumer Health Natural Defense: Pepper Spray
Diversity in Health Spouse Abuse: An International Problem
Chapter Overview How violence affects your health
Factors that contribute to violence
Major types of violence and abuse
How to assess your risk of becoming a victim of violence
What you can do to prevent and avoid violence
Student Workbook Self-Assessment: Am I in an Abusive Intimate Relationship?
Changing Health Habits: Can You Reduce Your Risk of Violence?
Do You Know? Whether watching violent television shows can encourage
violent behavior?
How to tell if your partner is likely to become physically abusive?
What to do if you are sexually harassed?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Monalyn Gracia/age fotostock.
Violence and Abuse
© EyeEm
/Getty Im ages.
Learning Objectives “… one aggravated assault occurred about every 41 seconds …”
After studying this chapter, you should be able to:
1. Describe the effects of violence on society and personal health.
2. Classify various forms of violence. 3. Identify factors that contribute to violent behavior. 4. Identify actions that you can take to reduce your risk
of violence. 5. Explain why cases of violence are often unreported to law
enforcement. 6. Define sexual harassment and steps you can take to report such abuse. 7. Define terms such as pedophile, child molester, and elder abuse.
CHAPTER 4
99
Most of the campus security notices seemed to be for women, and I had a high school letter in wrestling, so I wasn’t worried. Late one night, I was walking across campus, hardly watching where I was going, when a guy with a gun jumped out of some bushes and demanded my money. I gave him my watch and wal- let, but he still hit me in the face with the gun barrel. I needed several stitches to close the wound.
A ccording to the Federal Bureau of Investiga-tion (FBI), in 2016 there were approximately 1.2 million incidences of violent crime reported to law enforcement in the United States.1 Of these reported crimes, 64.3% were aggravated assault, robbery accounted for 26.6%, rape accounted for 7.7%, and murder accounted for 1.4%.1
In 2015, an estimated 683,000 children were abused or neglected in the United States, and an estimated 1,670 children died as a result.2 Partner- against-partner violence is common in the United States. During their lifetimes, 1 in every 4 American women and 1 in every 14 American men su#er sexual and/or physical abuse at the hands of their intimate partners.3 For many Americans, violence is a way of life.
Every society tolerates certain controlled uses of force—for example, spanking a misbehaving child or playing contact sports. In this chapter, violence refers to interpersonal uses of force that are not socially sanctioned. Such violence occurs when at least one person intentionally applies or threatens physical force against one or more people. "ese incidents are usually one-sided—for example, a perpetrator attacking a victim—but they are sometimes mutual, such as in a barroom brawl, a schoolyard scu)e, or a !ght between a husband and wife.
No one is exempt from violence; it may be directed against infants, children, adolescents, and older adults. Certain groups of people, such as African Americans, homosexuals, and Jews, are o$en tar- gets of violence (hate crimes). Over the past 20 years, American citizens have become victims of violence as domestic and foreign terrorists waged deadly attacks in the United States.
Most physical violence in the United States could be regarded as nonsexual crimes against persons, primarily assault, robbery, and homicide. Assault is the intentional use of force to injure someone physi- cally. Abuse occurs when one takes advantage of a relationship to mistreat a person, o$en by using fre- quent threats of force. Examples of abuse include spouse abuse, child abuse, elder abuse, and sexual harassment.
At some time in your life, you may have been a victim of abuse or violence, or you may have been indirectly involved in violent incidents. As a child, you may have been verbally abused by a parent or punched or kicked by a playground bully. As a teenager, you may have been slapped, shoved, or forced to have sex by someone you dated. As an adult, you may have been threatened or assaulted by a person with a weapon, as was the male college student in the chapter opener. How likely are you to become a victim of abuse or violence in the days to come?
Many Americans feel that their lives are more dangerous than in the past, but national rates of violent crime have declined dramatically since the 1990s.4 For example, the homicide rate declined by 49% between 2002 and 2011, which is the lowest level in 50 years.5 However, the past few years have seen slight increases in the rate of homicide, rape, and aggravated assault among Americans, although the rates in 2016 were considerably lower than rates in the 1990s and early 2000s.4 Nevertheless, males, Blacks, American Indians, teens, and young adults experienced higher rates of violent crime than did others.6 "is chapter explores the causes of violence and describes its e#ects on health. It provides prac- tical steps you can take to reduce your risk of being a victim.
How Violence A#ects Health
Many patients who seek treatment in hospital emergency rooms are victims of violence. Although some victims just need medical attention for minor cuts or bruises, others have more serious inju- ries such as lost teeth, broken bones, and !rearm or knife wounds that may require hospitalization (Figure 4.1). Victims of rape or attempted rape may also need immediate treatment to reduce the risk of sexually transmitted infections (STIs) and uninten- tional pregnancies.
violence Interpersonal uses of force that are not socially sanctioned.
assault The intentional use of force to injure another person physically.
abuse Taking advantage of a relationship to mistreat a person.
100 Chapter 4 Violence and Abuse
the psychological e#ects of violence, one should seek help from quali!ed mental health professionals.
A possible social e#ect is the intergenerational transmission of violence, in which child victims of abuse mature and become abusive as parents, per- petuating family violence.8 "is particular e#ect, however, occurs only among some abused children; others have personality factors that bu#er them from the long-term e#ects of child abuse. Overall, the !nancial costs of violence on physical, psychological, and social health are staggering; the cost in human misery is immeasurable.
What Causes Violent Behavior?
Violence is complex; there is no single cause of vio- lent behavior. Indeed, several factors contribute to violence, including “frustration, exposure to violent media, violence in the home or neighborhood and a tendency to see other people’s actions as hostile even when they’re not. Certain situations also increase the risk of aggression, such as drinking, insults and other provocations and environmental factors like heat and overcrowding.”9,para.1 In many instances, violence is learned behavior: Children who are exposed to vio- lence in their homes are more likely to be abusive or violent as adults than children who do not witness violence.
Does exposure to violent screen media, particu- larly movies, video games, and television programs, contribute to violent behavior? "e average American 3rd to 12th grader spends more than 6 hours per day using various forms of screen media.10 In gen- eral, children who watch acts of violence in screen media are more likely to exhibit aggressive and vio- lent behavior than children who do not view violence in such media.10 How do television shows and other forms of screen media contribute to violence in the United States?
Screen media, such as violent computer games and movies, o#er opportunities for young people to learn violent behavior. Watching violent movies, for example, provides indirect ways to participate in the violence, experience emotional states associated with being violent, and observe the outcomes of vio- lence. Television programs and movies o$en glamor- ize violent and abusive people, and the perpetrators may avoid punishment. If violence is portrayed as an e#ective way of getting what one wants, an impres- sionable young observer may resort to violence when
In some cases, victims of violence su#er serious permanent physical disabilities such as blindness, brain damage, and loss of body movement (paraly- sis). Additionally, the stress of !ghting or living in an abusive situation alters the functioning of the immune system, which can lower one’s resistance against infectious illnesses. Death is, of course, the most serious consequence of violence. In 2015, homicide was the third leading cause of death for Americans 1–4 and 15–34 years of age and the fourth leading cause of death for those aged 5–14 years.7 In the same year, homicide was the leading cause of death for Black Americans aged 20–34 years and Black male Americans aged 15–34 years and the second leading cause of death for Black male Americans aged 1–4 years and 10–14 years and Black female Americans aged 1–4 years and 15–24 years.7
Experiencing violence also causes psychological damage—including anxiety and depression, which can heighten one’s risk of abusing drugs, develop- ing eating disorders, and having suicidal thoughts. Violence caused by persons outside the home can create serious problems for the victims’ family life. Family relationships may become strained, sus- pended, or even ended as a consequence. Violence that occurs within a family setting is very harmful. Cases of marital separation or divorce o$en involve violence against a spouse or child. To recover from
Figure 4.1 The Aftermath of Violence. Injuries resulting from violence often require medical treatment. © Westend61/Getty Images.
What Causes Violent Behavior? 101
Sexual Violence My first sexual experience was very unpleasant. It hap- pened on San Padre Island over Spring Break when I was a freshman. I was 18, and he was 25 years old. He took me to an area where no one could see him or hear me. I was naive and thought I could stop him, but I couldn’t. I had wanted to wait until I was mar- ried or at least in love with the person.
Sexual violence involves some type of sexual act committed through force, threat of force, or coer- cion. Rape is sexual intercourse by force or with a person who is not able to give legal consent, such as a 12-year-old child. Both men and women can be the perpetrators or targets of rape and sexual assault. Nevertheless, females are the targets of most attempted or completed rapes. "e most recent results from the National Intimate Partner and Sexual Vio- lence Survey reported approximately 1 in 5 American women (18.3%) and 1 in 71 American men (1.4%) have been victims of an attempted or completed rape at some time in their lives.11 "e prevalence of other sexual violence was higher for both American women (44.6%) and men (22.2%).11
Although sexual violence may happen in any rela- tionship, most victims of sexual assault know the perpetrator.12 In most cases, female victims of rape know the attacker—o$en a current or former hus- band, current or former ex-boyfriend, a date, class- mate, or live-in (cohabiting) partner. Although men are not as likely to be raped as women, male victims are usually raped by male strangers and acquain- tances.11 Marital rape generally refers to the use or threat of violence against one’s spouse to force sexual activity. Acquaintance rape is forced sexual activity
he or she is in similar situations. Another concern is that young people who o$en use violent forms of screen media for entertainment may become “desen- sitized” to real cases of violence and tolerate such behavior as a result.
Televisions are equipped with “V-chips” that enable adults to block certain programs from being viewed by children, but only 20% of parents use this control.8 "e screen media industry provides vari- ous rating systems to help parents select so$ware and programs with acceptable content for children. Many parents !nd the ratings confusing, and some children misuse the ratings to !nd violent pro- grams. "us, parents still must exercise good judg- ment concerning which media are appropriate and monitor their children’s use of screen media as a form of entertainment.
Major Types of Violence and Abuse
No one is immune to violence or abuse: People of all walks of life can be victims of violent or abusive behavior. Although perpetrators of violence are com- monly portrayed in media as strangers, many situa- tions of violence or abuse are from known persons. "e following sections describe common types of violence and abuse.
Violent video games offer opportunities for children to learn violent behavior. © Digital Media Pro/Shutterstock.
sexual violence A sexual act committed against someone without that person’s freely given consent.
rape Sexual intercourse by force or with a person who is incapable of legal consent.
When intoxicated, a person may act more sexually aggressive toward his or her date or partner or be less able to prevent forced sex. © Jupiterimages/Comstock/Thinkstock/.
102 Chapter 4 Violence and Abuse
Managing Your Health
The only person responsible for sexual assault is a perpetrator, but we all have a role to play in looking out for each other’s safety. Whether it’s providing a safe ride home for a friend or directly stepping in to confront a per- son with threatening behavior, anyone can intervene.
Bystander Intervention: There are many ways you can step in if you see some- one at risk. The key to helping keep your friends safe is learning how to intervene in a way that fits the situation and your comfort level. Stepping in can make all the dif- ference, but it should never put your own safety at risk. • Create a distraction. Do what you can to interrupt the
situation. A distraction can give the person at risk a chance to exit the situation. For example, you might cut off the conversation with a diversion like, “Let’s get pizza, I’m starving,” or “This party is lame, let’s try somewhere else.” Or you could offer fresh food or drinks to everyone, including the person who might be in trouble. You might start an activity that draws other people in, like a game or dance party.
• Ask directly. Speak directly with the person you are concerned about. Ask questions like, “Who did you come with?” or “Would you like me to stay with you?”
• Refer to an authority. Sometimes the safest way to intervene is to refer to a person with authority to change the situation, like a security guard, a resident advisor (RA), or law enforcement. Talk with a bar- tender, security guard, or RA about your concern; it is in their best interest to ensure the safety of their patrons. Don’t hesitate to call 911 if you are concerned for someone’s safety.
• Enlist others. It can be intimidating to step in alone. Enlist someone to support you; there can be power in numbers when expressing concern. Or ask someone to step in. For example, you might ask a friend who knows the person at risk to check on him or her. “Your friend looks like she’s had a lot to drink. Can you check on her?”
• Your actions matter. Stepping in helps change the way people think about their role in preventing sexual assault, regardless of whether you are able to change the outcome.
Alcohol Safety: Alcohol can inhibit a person’s physical and mental abili- ties. In the context of sexual assault, this means that alcohol may make it easier for a perpetrator to commit a crime and can even prevent someone from remem- bering that the assault occurred. You can take steps to
increase your safety in situations where drinking may be involved. These tips can help you feel safer and may reduce the risk of something happening; how- ever, like any safety tips, they are not foolproof. It’s important to remember that sexual assault is never the victim’s fault, regardless of whether he or she was sober or under the influence of drugs or alcohol when it occurred. • When you go to a social gathering, go with a group
of friends. Arrive together, check in with each other throughout the evening, and leave together. Knowing where you are and who is around you may help you to find a way out of a bad situation.
• Have a backup plan. Sometimes plans change quickly. You might realize it’s not safe for you to drive home, or your group might decide to go somewhere you don’t want to go. Have a backup ride planned with a trusted person, or have a reliable cab or rideshare company saved to your phone and keep cash on hand in case you decide to leave.
• Know what you’re drinking. Don’t recognize an ingredi- ent? Look it up on your phone. Consider avoiding large- batch drinks, like punches; they can have a deceptively high alcohol content, and you may not know exactly what’s in it.
• Trust your instincts. If you feel unsafe, uncomfortable, or worried for any reason, go with your gut. Get some- where you feel safe, and find someone you trust. If you see something suspicious, contact law enforcement.
• Don’t leave your drink unattended. This includes while talking, dancing, using the restroom, or making a phone call. Either take your drink with you, or throw it out. If you’ve left your drink out of sight, get a new one. Avoid using the same cup to refill your drink.
• Don’t accept drinks from people you don’t know or trust. This can be challenging in some settings, like a party or date. If you choose to accept a drink from someone you’ve just met, go with the person to the bar to order it, watch it being poured, and carry it yourself.
• Check in with yourself. Check in with yourself periodi- cally to register how you feel physically and mentally, even if you drink alcohol regularly.
• Be aware of sudden changes in the way your body feels. Do you feel more intoxicated than you should? Some drugs are tasteless, colorless, and odorless and can be added to your drink without your noticing. If you feel uncomfortable, tell a friend and have him or her take you to a safe place.
Sexual Assault: Safety and Prevention
Major Types of Violence and Abuse 103
• Ask yourself, “Would I do this if I was sober?” Alcohol can impact your overall judgment. Will you be com- fortable with this decision the next day? You wouldn’t drive or make medical decisions while intoxicated.
• If you suspect you or a friend has been drugged, con- tact law enforcement immediately. Be up-front with healthcare professionals so they can administer the correct tests.
If Someone Is Pressuring You: Perpetrators of sexual violence often use tactics, such as guilt or intimidation, to pressure a person into some- thing he or she does not want to do. It can be upsetting, frightening, or uncomfortable to be in this situation. Remember that it’s not your fault that the other person is acting this way—he or she is responsible for his or her own actions. The following tips may help you exit the situation safely. • Remember that being in this situation is not your fault.
You did not do anything wrong; it is the person who is making you uncomfortable who is to blame.
• Be true to yourself. Don’t feel obligated to do anything you don’t want to do. “I don’t want to” is always a
good enough reason. Do what feels right to you and what you are comfortable with.
• Have a code word with your friends or family members so that if you don’t feel comfortable, you can call them and communicate your discomfort without the person you are with knowing. Your friend or family members can then come get you or make up an excuse for you to leave.
• Lie. If you don’t want to hurt the person’s feelings, it is better to lie and make up a reason to leave than to stay and be uncomfortable, scared, or worse. Some excuses you could use are needing to take care of a friend or family member, not feeling well, or having somewhere else that you need to be.
• Try to think of an escape route. How would you try to get out of the room? Where are the doors? Windows? Are there people around who might be able to help you? Is there an emergency phone nearby?
Data from RAINN. (2018). Safety and prevention. Retrieved from https://www.rainn.org/safety-prevention
that occurs between unmarried adults who know each other. If the couple is involved in a dating rela- tionship, forced sexual activity is called date rape.
Sexual assaults on college campuses have a similar gender pattern: College women are more likely than college men to be assaulted and are more likely to be assaulted by a known person than by a stranger. According to one major research report, about 1 in 36 female college students are victims of a completed or attempted rape during an academic year; 90% of these college women knew the perpetrator.13 Most of the completed rapes occurred in campus residential housing; the remainder of these assaults took place in fraternity houses. "e Campus Sexual Assault Study, funded by the U.S. Department of Justice, found freshmen and sophomores to be at higher risk for sexual assault than upperclassmen, and the major- ity of sexual assaults occurred when the victims were incapacitated because of substances—namely, alco- hol.14 "e use of alcohol or other drugs may weaken a person’s inhibitions and alter his or her usual behav- ior. For example, while intoxicated, a person may act more sexually aggressive toward her/his date or part- ner or be less able to prevent forced sex. "e delib- erate use of Rohypnol and other so-called date rape
drugs to sexually assault unsuspecting persons (pri- marily women) is a growing problem in the United States. Rohypnol causes not only loss of conscious- ness but also loss of memory concerning events that occurred when the drug was taken. Although several date rape drug detection products have been devel- oped (like !ngernail polish and straws that change color in the presence of common date rape drugs), none has received FDA approval or is currently avail- able to U.S. consumers.
Reporting Sexual Assault Data from crime sur- veys consistently suggest that sexual crimes occur more o$en than reported. Rape victims frequently feel ashamed and embarrassed and are o$en reluc- tant to report their experiences to the authorities. Moreover, they may fear further victimization by the assailant or negative reactions from family, friends, and coworkers. Some victims, however, fail to report the assault because they do not want to become involved in the criminal justice system. Many victims of acquaintance rape are o$en unwilling to report the incidents because they feel partially to blame. For example, a female college student may feel that if she had consumed less alcohol or smoked less marijuana at a party, she would have been able to resist the forced
104 Chapter 4 Violence and Abuse
current or former spouse, boyfriend, or girlfriend.17 Child and elder abuse are o$en classi!ed as forms of family violence; the Across the Life Span feature of this chapter provides information concerning these forms of family violence.
Intimate Partner Violence Intimate partner vio- lence (IPV) involves actual or threatened physical or sexual violence, as well as emotional abuse, by a spouse, ex-spouse, lover, former lover, or date. Although the rates of IPV have mostly declined over the past few decades, the rate for women is more than 3 times larger than the rate for men, as of 2011 (4.7 and 1.5 per 1000 persons, respectively).18
In many instances, perpetrators of IPV emotion- ally abuse their partners for a period before they become overtly violent toward them.19 Violent acts may range from slapping, shoving, and punching to beating and murder. Typically, verbal and/or emo- tional abuse accompanies physical violence. Dating violence, the threat or use of force against one’s part- ner during courtship, is quite common. About 10% of U.S. high school students who reported going out with or dating someone in the previous 12 months reported that they had been hit, slapped, or physi- cally hurt (on purpose) by their boyfriend or girl- friend in 2015, with higher percentages reported by students who identify as gay, lesbian, or bisexual (17.5%) or are unsure about their sexual orienta- tion (24.5%).20 Further, 10% of U.S. high school students (9.1% of heterosexual students; 22.7% of gay, lesbian, or bisexual students; 23.8% of unsure students) reported that they had been forced to do sexual things in the past 12 months by a person they were dating.20
Compared to women, men are more likely to seri- ously injure or murder their female intimate partners (Figure 4.2).19 In 2014, Baltimore Ravens running back Ray Rice assaulted his then-!ancée, knocking her unconscious; the publicity ensuing a$er a video of the assault was posted online caused a national outcry and prompted the National Football League to revisit its policies regarding domestic violence cases. A U.S. Department of Justice special report revealed that the proportion of female victims of homicide killed by an intimate partner increased from 29.8% in 1993 to 39.3% in 2010, while the proportion of male victims of homicide killed by an intimate partner
sexual advances of others. "ese examples highlight the social stigma associated with sexual assaults, in which victim-blaming may occur, a trend that does not hold true in other crimes (e.g., victims of mug- gings are generally not blamed for being attacked).
Many organizations are actively combating the social stigma of sexual assault by providing education to the public and support to those a#ected by sexual assault. For example, RAINN (Rape, Abuse & Incest National Network)—the largest anti–sexual violence organization in the United States—provides a vari- ety of free con!dential services, including a National Sexual Assault Web-based hotline (www.rainn.org) and a 24/7 phone hotline (800-656-HOPE [4673]) for sexual assault victims and their friends and fam- ily members.15 In addition, the DoD Safe Helpline (877-995-5247), which is contracted out to RAINN as an independent, anonymous service, o#ers sexual assault support for member of the DoD (Department of Defense) community.16 Such services may alter the current social perceptions of sexual violence, which in turn may lower the perceived barriers of reporting sexual assault crimes.
Sexual assault victims may obtain immediate medical attention for their injuries and to preserve any physical evidence in case they choose to pros- ecute the perpetrator. "e preservation of physical evidence—such as semen and pubic hair—is vital to assist law enforcement with identifying the attacker; therefore, victims should not wash any part of their bodies or change clothes before receiving medical attention. Hospital emergency rooms o$en have sta# who are trained to respond to sexual assault victims with sensitivity, and local sexual assault crisis centers may have volunteers on standby to o#er assistance. In addition to receiving treatment for physical injuries, many rape victims need testing for sexually transmit- ted infections, medication to prevent pregnancy, and counseling to cope with the situation.
Family Violence Family (domestic) violence is a pattern of behav- ior characterized by physical assaults, including sexual violence; psychological/emotional abuse; and threats to cause harm that occur among family mem- bers, couples in intimate relationships, or unrelated individuals who live together. Such violence includes assaults and murders of spouses, children, and older family members. In 2016, domestic violence accounted for approximately 19% of all violent vic- timizations in the United States, and just over half of these incidences (52.3%) were committed by a
family (domestic) violence Violence or abuse between family members, people who are involved in intimate relationships, or unrelated individuals who live together.
Major Types of Violence and Abuse 105
Another major factor that contributes to inti- mate partner violence is drug use. O$en, one or both partners have consumed alcohol or used other mind-altering drugs when the violence between them erupts. Both perpetrators and victims tend to have low self-esteem and be highly dependent on their partners. Some men and women have di&culty asserting themselves without becoming angry and resorting to aggressive behavior to control and intimi- date their partners. "e activity “Am I in an Abusive Relationship?” in the Student Workbook can help you determine if your partner is abusive. Furthermore, Table 4.1 lists certain behaviors and attitudes that o$en characterize individuals who are physically abusive. Because dating violence is o$en a precursor to mari- tal violence, identifying abuse in a dating relationship can help you determine whether you wish to remain in the relationship. It is important to recognize that abuse usually does not lessen when the relationship moves from dating to marriage and can even worsen.
decreased during the same time period (from 3.7% in 1993 to 2.8% in 2010).18 Although both sexes commit violent acts against their dates or partners, women usually engage in violence against their male partners as acts of self-defense.
What factors contribute to violence between inti- mate partners? Such violence exists within every racial, ethnic, socioeconomic, and religious group. "e rates of intimate partner violence, however, are higher among those who have a lower socioeco- nomic status, are unemployed, or are employed in low-status occupations. Children who are exposed to violence between their parents have a greater risk of abusing their intimate partners later in life.21 As a result of witnessing violence between their par- ents, children may grow up thinking such abuse is a “normal” aspect of intimate relationships.
Figure 4.2 A Case of Domestic Violence. A woman is far more likely than a man to be seriously injured as the result of domestic violence. © Tatiana Belova/Shutterstock.
A person who is likely to become physically abusive:
• Insists that you do things that you do not want to do and prevents you from doing things that you would like to do
• Argues with you over any issue • Does not accept responsibility for his or her
mistakes and blames you or other persons for his or her problems
• Prevents you from associating with your family and friends and threatens to end the relationship if you do not stop interacting with others
• Displays excessive jealousy or is possessive • Attempts to control your behavior, for example,
tells you how to dress or wear your hair • Is verbally abusive, for example, criticizes you
or says degrading things to you either in private or in public
• Expects you to do everything perfectly and according to his or her wishes and expects you to know what they are, even without being told
• Pushes, slaps, or shoves you during disagreements • Reacts violently (“loses control” over his or her
behavior) toward you or others when things go wrong or not according to his or her wishes
• Exhibits cruelty to other persons or animals, usually without remorse
Data from Mariani, C. (1996). Domestic violence survival guide. Flushing, NY: Looseleaf Law Publications.
Table 4.1
Signs of Danger in a Relationship
106 Chapter 4 Violence and Abuse
Why do men and women stay in abusive rela- tionships? Women o$en remain in these situations because of their emotional attachment to and eco- nomic dependence on the abuser. "ey o$en feel trapped and isolated.22 Further, an abusive partner may be apologetic and loving a$er episodes of vio- lence, raising the victim’s hopes that the violence has ended. Spousal abuse is a worldwide concern: the Diversity in Health feature “Spouse Abuse: An Inter- national Problem” discusses the nature of this behav- ior in non-Western societies.
Sexual Harassment Sexual harassment involves unwelcome, uninvited sexually related comments or behaviors to intimidate people or coerce them into unwanted sexual activity, especially by a person in authority toward a subordi- nate. Such abusive behavior can include unwelcome requests for dates, sexually o#ensive jokes, lewd comments, or touching and fondling. It is di&cult to determine the scope of the problem because surveys o$en use di#erent de!nitions of sexual harassment. Furthermore, sexual harassment is not always easy to recognize. For example, if someone tells a sexually o#ensive joke, under what circumstances would you consider this sexual harassment?
Sexual harassment can happen anywhere. College instructors, for example, engage in sexual harassment if they provide special treatment, such as awarding a passing grade, to students who submit to their sexual advances. In addition to schools, sexual harassment frequently occurs in the workplace, where it creates stress and reduces employees’ job satisfaction, per- formance, and loyalty. It is especially devastating for individuals who feel that their grade, job, or career depends on enduring the harassment or submitting to the intimidating person.
How can one handle a person who engages in sexual harassment? Some people simply avoid or ignore harassing persons; others choose to con- front their tormentors by telling them, verbally or in writing, to stop the annoying and unprofessional comments or behaviors. If the harassment persists, victims can pursue more aggressive steps, includ- ing reporting the behavior to management or tak- ing legal action. Many educational institutions and businesses have policies concerning sexual harass- ment that follow guidelines established by the fed- eral government’s Equal Employment Opportunity Commission (EEOC). "ese policies usually identify steps that people can take to !le harassment-related complaints. Before initiating such action, a person
should document episodes of sexual intimidation, recording the date and nature of the unwanted com- ments or behaviors. In many instances, the abusive person has harassed other workers or students; therefore, a victim may be able to strengthen his or her case against this person by asking other victims to serve as witnesses.
Stalking Sensational stories about celebrities who are pur- sued relentlessly by overly aggressive, obsessive fans have led to interest and research into stalking behavior. Anyone, however, can be the victim of a stalking. Stalking is defined by the U.S. Department of Justice as “a pattern of repeated and unwanted attention, harassment, contact, or any other course of conduct directed at a specific person that would cause a reasonable person to feel fear.” The term stalker generally refers to a person who willfully and repeatedly harasses or threatens another person. Stalking behavior typically includes fol- lowing the targeted individual, hanging around this person’s home, making harassing or threat- ening phone calls, leaving threatening voicemail or electronic messages, or vandalizing his or her property. Other examples of harassment include sending unwanted text messages or gifts and mak- ing unwelcome visits to the targeted person’s work- place (see Table 4.2).
An estimated 6.6 million people are stalked annu- ally in the United States; 1 in 4 women and 1 in 13 men report being stalked at some point in their lives.25 "e stalker was a stranger to his or her victim in only about 10% of the cases; according to victims, most of the stalkers were a former intimate partner or a friend, roommate, or neighbor.25 Women are disproportionally a#ected by stalking: 66% of female victims are stalked by a current or former intimate partner (compared to 41% of male victims). Addi- tionally, more than three-quarters of intimate partner femicide victims were stalked by intimate partners, and more than half of femicide victims reported their stalkers’ behavior to law enforcement before being killed by their stalkers.25
"e majority of stalkers are males; the largest group of stalkers is composed of lonely men who are emotionally unstable and have been rejected by their partners.26 Despite his ex-partner’s e#orts
sexual harassment Unwelcome or uninvited verbal or physical behavior that is sexual in nature.
Major Types of Violence and Abuse 107
Diversity in Health Spouse Abuse: An International Problem Throughout the world, women of all cultural, religious, ethnic, and socio- economic groups are abused by their
intimate partners. Throughout the world, approximately 30% of all women have experienced violence or abuse on one or more occasions during their lifetimes.23 According to results of a study conducted by the World Health Organization, rates of IPV ranged from 15% in Japan to about 70% in Peru and Ethiopia.24 In many soci- eties, husbands are not punished for acting out violently against their wives, and female victims often accept blame for their mistreatment.
Why does spouse abuse persist? Certain non- Western cultures ascribe low status to women. Many
men living in these societies do not consider wife battering and other forms of mistreatment of their spouses as violence or abuse. In addition, certain prac- tices in such cultures increase the financial dependence of women on their spouses, which makes it difficult for women to leave their abusive husbands. For example, women living in some countries lose their inheritance or the opportunity to earn an income outside of the home when they marry. The economic power in these countries is unequally distributed in favor of men, and as a result, husbands feel entitled to control their wives and families. Male domination continues at commu- nity and state levels because women are often denied access to education and government positions. Thus, they lack the knowledge and political power necessary to change public policy. To eliminate violence against women, people from around the world must work to change the attitudes, behaviors, and laws that nega- tively affect the status of women.
• Repeatedly call you, including hang-ups • Follow you and show up wherever you are • Send unwanted gifts, letters, cards, or e-mail • Damage your home, car, or other property • Monitor your cell phone or computer use • Use technology, like hidden cameras, or global
positioning systems (GPS), to track where you go
• Drive by or hang out at your home, school, or work
• Threaten to hurt you, your family, friends, or pets • Find out about you by using public records or
online search services, hiring investigators, going through your garbage, or contacting friends, family, neighbors, or coworkers
• Post information or spread rumors about you online, in a public place, or by word of mouth
• Take other actions that control, track, or frighten you
Data from Stalking Resource Center, The National Center for Victims of Crime. (2008). Are you being stalked? Retrieved from http://victimsofcrime.org/docs/src/aybs_english _color.pdf?sfvrsn=4
Table 4.2
Typical Stalking Behaviors
to avoid him, the stalker o$en hopes he can convince% her to rekindle the relationship. When she ignores%or rebu#s his e#orts, he becomes angry with her and wants to harm her emotionally or physically.
Stalking can lead to violence, including homicide. Stalkers physically attack an estimated one-fourth to about one-third of their victims.27 Warning signs of a violent stalker include the use of verbal threats and prior involvement in an intimate relationship with the victim. Even if the victim is not physically threatened or harmed, he or she usually experiences extreme emotional distress and o$en seeks legal means to make the stalker stop the harassing behav- ior. Victims o$en continue to su#er severe emotional e#ects long a$er the stalking ends, and they may need treatment for depression and posttraumatic stress disorder (PTSD).
If you are being stalked, what can you do to dis- courage the stalker and end his or her terrifying behavior? If the stalker is a former intimate partner, experts advise that either you or a family member confront the stalker to tell him or her that the rela- tionship is over and you have no interest in renew- ing it. A$er that, avoid all communication with the person, but keep records of his or her harassing
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for safe social activities. Gang membership pro- vides an opportunity for some youths to belong to a group and !nd self-identity—that is, to “be some- one.” Involvement with gangs, however, dramatically increases one’s risk of being murdered, and homicide remains a leading cause of death for males, especially African American and Hispanic males, between 15 and 34 years of age.7
Gang violence is not limited to street youth gangs. According to one government estimate, the approxi- mately 1.4 million street, prison, and outlaw motor- cycle gang members in more than 33,000 gangs throughout the United States were responsible for nearly half of recorded violent crime and up to 90% of violent crime in select jurisdictions during 2011.29 Traditional gang-related criminal activities include armed robberies, drug and weapons tra&cking, car the$, identity the$, and murder. In recent years, gangs have been increasingly engaging in nontradi- tional gang-related crimes like human tra&cking and prostitution because of lower visibility and higher pro!tability and acquiring high-powered military- style weapons that pose a threat to law enforcement and citizens.29
behavior. If the stalker persistently telephones you, have an answering machine record calls on that line, and get a separate, unlisted phone number for other callers. If the stalker uses e-mail messages or text messages to annoy you (cyberstalking), contact your Internet service provider (ISP) or cell phone service provider for help. Additionally, seek support and help from family, friends, neighbors, and coworkers by telling them about the stalking incidents. Finally, make sure your home is secure, and if you feel threatened by the stalker, notify the%police.
Community Violence Community violence refers to violence that hap- pens in public settings such as street corners, bars, and public places, like the 2017 mass shooting in Las Vegas, Nevada (Figure 4.3). Among youths, commu- nity violence o$en occurs as gang violence. Typical members of a gang are males between 8 and 24 years of age who share similar racial or ethnic backgrounds. Such gangs are prevalent in certain neighborhoods of U.S. cities and are becoming more common in many suburbs. Recent results from the National Youth Gang Survey suggest that gang-related crime and the numbers of new street gang members have increased in recent years.28
Why are some youths attracted to gangs, placing themselves at high risk for serious injury and even death? Adolescents may join gangs for social reasons, especially if their communities o#er few opportunities
community violence Violence between strangers or acquaintances that occurs in public settings.
institutional violence Violence that occurs mainly in institutional settings such as college campuses or workplaces.
Figure 4.3 Community Violence. On October 1, 2017, a gunman killed 58 people attending an outdoor concert in Las Vegas. © Melissamn/Shutterstock.
Men who stalk women may send unwanted gifts, such as bouquets of flowers, to their victims. Courtesy of Wendy#Schi".
Major Types of Violence and Abuse 109
American university students and sparked e#orts to improve campus security and identify troubled col- lege students before they react violently. Before the Virginia Tech shootings, the results of nationwide surveys conducted between 1995 and 2002 indicated that college students were less likely to be victims of violent crime than nonstudents of the same age.30 According to these surveys, the majority of violent crimes against college students occurred o# cam- pus and during the evening or at night (6 P.M. to 6 A.M.). Only about one-third of the violent crimes committed against college students were reported to the police.
"e Student Right to Know and Campus Security Act requires administrators of colleges and univer- sities that receive federal funds to report informa- tion concerning the numbers of murders, assaults, rapes, and other speci!c crimes that take place on their campuses. "e administrators must also develop programs that are designed to educate stu- dents about personal safety and campus security. To reduce violence on their campuses, many college administrators have adopted security measures, such as restricting access to campus buildings, setting up emergency call boxes on campus, improving lighting near walkways and parking lots, limiting visitation hours in residence halls, and initiating escort services for students, sta#, and faculty. For information about the types and extent of crimes at your college or uni- versity, visit the Department of Education’s O&ce of Postsecondary Education web site www.ope.ed.gov /security/GetOneInstitutionData.aspx; an interactive tool on the site provides data concerning numbers of reported crimes on college campuses. You can also contact sta# at the campus police department.
Workplace Violence Workplace violence is any act of violence or abuse directed toward an individual who is performing his or her job. Although most people will never experi- ence the most dangerous types of workplaces, such as psychiatric hospitals and prisons, any workplace can be a setting for violence. In 2016, homicide was the cause of 24% (women) and 9% (men) of fatal occu- pational injuries for U.S. workers.31 "e stereotype of workplace violence as vengeful acts committed by disgruntled former workers is misleading. Work- related homicides are most likely to occur during armed robberies of retail businesses such as grocery stores, restaurants, bars, and gas stations. Work- place homicide victims were most commonly killed by a relative or domestic partner (women, 40%) or
Institutional Violence Most acts of institutional violence occur in schools, where students attack their peers or even their teach- ers and school administrators. Earlier generations of students may have shoved and punched to settle arguments; today’s students may use guns and knives.
In the past few years, several incidents in which stu- dents used guns to kill their classmates and teachers made headline news. Such terrible events, however, are rare. Less than 1% of murders involving youth take place on school property. According to Youth Risk Behavioral Surveillance System data, American youth were less likely to carry weapons to school and engage in !ghting in recent years than in the early 1990s.20
What can be done to reduce the risk of violence at school? Many urban schools now resort to using metal detectors and hiring uniformed police in an attempt to curb school violence. Other steps to man- age the problem include training elementary school teachers and administrators to identify potential troublemakers in their classrooms. Children who are prone to become violent o$en model the aggres- sive behaviors of their parents. Such high-risk chil- dren have di&culty controlling their anger; tend to poke, shove, or annoy other people; act impulsively; bully other children; and defy authorities, includ- ing parents and teachers. In many communities, schools now o#er con'ict resolution classes for children that emphasize socially acceptable ways of settling disputes.
Violence on College Campuses On April 16, 2007, a 23-year-old psychologically disturbed col- lege student shot 32 students and faculty to death on the Virginia Polytechnic Institute (Virginia Tech) campus before taking his own life. "e violent inci- dent raised serious questions about the safety of
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110 Chapter 4 Violence and Abuse
a robber (men, 33%) in 2016.31 Employees with the highest risk of being murdered while working are cab drivers, convenience store attendants, police o&cers, and security guards.
Certain workers have a high risk of becoming vio- lent, particularly when they are laid o#, !red, or not promoted. Persons most likely to resort to workplace violence are men between the ages of 25 and 40 who are loners, have marital and other family problems, appear angry and paranoid, abuse alcohol and/or other drugs, and blame others for their problems. Women are less likely to commit violent acts in work- places, but they are more likely to be victims.
One military base receiving much media atten- tion is Fort Hood, Texas, the site of two tragic shootings within a 5-year period. In each case, the shooters were soldiers who were involved in verbal altercations before the shootings that resulted in multiple fatalities.32,33 During the November 5, 2009, shooting, 13 people were killed and 32 wounded.32 In the April%2, 2014, shooting, 3 soldiers died and 16 others were wounded.33
Terrorism Terrorism is de!ned as intentional violent acts against civilians to produce extreme fear, severe property dam- age, and numerous deaths. Terrorists may attack spe- ci!c cultural or political symbols, such as places of worship or government buildings, or more random tar- gets, such as restaurants, subway stations, and airplanes (Figure 4.4). Regardless of whether terrorists are citi- zens of the country they attack or foreigners, a major purpose of terrorism is to frighten the general% pop- ulation and make them feel vulnerable and helpless.
"e use of conventional bombs by terrorists is not% new, but recently, terrorists have adopted more sinister methods of killing civilians and destroy- ing property. "e arsenal of terrorist weapons now includes poisonous chemicals, life-threatening infec- tious agents such as the bacterium that causes anthrax, and explosives strapped to suicidal individuals who intentionally blow themselves up in crowded places.
In addition to physical injuries, survivors of a ter- rorist attack o$en experience long-term psychological consequences such as PTSD and depression. Exten- sive media reporting of the disastrous event, however, indirectly a#ects the psychological health of those outside the zone of destruction. National surveys conducted a$er the September 11, 2001, attacks on the World Trade Center and the Pentagon indicated that many Americans who were not directly a#ected by the attacks su#ered from extreme psychological
stress symptoms as a result of the terrorism.34,35 A$er September 11, 2001, U.S. government o&cials took steps to reduce the risk of terrorism by, for example, erecting video surveillance cameras in public places and increasing airport security. Nevertheless, many Americans think additional terrorist attacks in the United States are likely. Living with such fear increases the risk of stress-related health problems.
Assessing Your Risk of Violence
What are the chances that you, or some of the people you care about deeply, are at risk for violence? "e risk is di&cult to determine because many violent inci- dents, especially rape and spouse battering, are never reported to the police. Nevertheless, some people are more likely to su#er serious or fatal injury than others. "e likelihood of a particular person experiencing such harm depends on speci!c risk factors, including
Figure 4.4 New York City, September 11, 2001. On this day, foreign terrorists used commercial jets to attack the World Trade Center and the Pentagon. © kentannenbaum/Fotolia.com.
Assessing Your Risk of Violence 111
rate for males was 3.8 times greater than the rate for females in 2015.39 While in their homes, women are as likely as men to use force, but in community set- tings, they are far less likely to do so. Men are more likely than women to be arrested for perpetrating crimes of violence, and they are more likely to be the victims of such crimes. Women, however, have a greater risk of being killed by their spouses than men do. African Americans were more likely than Whites to be victims of sexual assault, aggravated assault, and homicide.38,40 For example, recent government reports indicated that the rate of violent victimization for persons of two or more races, American Indians or Alaska Natives and African Americans was higher than for Asians, Native Hawaiians, and other Paci!c Islanders, Whites, and Hispanics.17
An objective of Healthy People 2020 is to reduce the homicide rate from 6.1 per 100,000 (the rate in 2007) to 5.5 per 100,000 Americans by 2020. "is is one national health indicator in which progress has been made; the homicide rate was 5.1–5.4 between 2010 and 2014 and slightly increased in 2015 to 5.7 murders per 100,000 Americans in 2010. However, data for the most recent year available (2015) reveal that disparities remain by race and ethnicity, sex, and age. Males are approximately 4 times more likely to die from homicide than females. African Americans and Hispanics are approximately 3.5 times more likely to be a victim of homicide than the total population. "ose who are 18–24 years of age are approximately 2.3 times more likely to be killed than the total popu- lation. Another Healthy People 2020 objective is to reduce !rearm-related deaths from 10.3%per 100,000 (the 2007 rate) to 9.3. Although the rate remained relatively stable between 1999 and 2014 (rates ranged from 10.0 to 10.5), the !rearm-related death rate increased to 11.1 in 2015. Similar trends exist by sex, age, and race and ethnicity, with African Americans, Hispanics, males, and those aged 18–24 years being nearly twice as likely to die from !rearms than the total population.41
Preventing and Avoiding Violence
To reduce violent crime, communities are turn- ing increasingly to environmental measures such as improved street lighting, neighborhood watch organizations, and surveillance by closed-circuit cameras. Many large companies have taken speci!c
his or her family situation, living conditions, person- ality, and activities.
Family disruption is a major risk factor for fam- ily and community violence. Parental con'ict that leads to separation, divorce, or desertion contributes to family disruption, as does the presence of a parent with a criminal or drug-use history. Neighborhood conditions, such as high rates of unemployment, can lead to high rates of family disruption. Other risk factors for family violence are social isolation, the presence of children with special needs, and a large number of children in the family. Factors that increase a youth’s risk for engaging in school violence include a history of violence, poor grades, drug use (including alcohol and tobacco), community pov- erty, and poor family functioning.36
As mentioned earlier in this chapter, the availabil- ity of alcohol, other drugs, and !rearms dramatically escalates the likelihood of serious injury or death in violent situations. A signi!cant percentage of people who commit violent crimes test positive for alcohol, marijuana, cocaine, or combinations of mind-altering drugs at the time of their arrest. In 2015, !rearms were used in about 71.5% of the nation’s murders, 41% of robberies, and 24% of aggravated assaults.37
Certain individuals are more likely than others to !nd themselves in places and situations in which vio- lence is likely to occur: Age, sex, and race and ethnic- ity are known risk factors. Americans younger than 25 years old are more likely to become involved in violence than persons over 25.17 Males consistently experience higher rates of both violent victimization and serious violent victimization than their female counterparts.17,38 For example, the average homicide
Increased airport security measures were an outcome of the September 11, 2001, terrorist attacks. © Christopher PB/Shutterstock.
112 Chapter 4 Violence and Abuse
campus security center to see if they will perform a free safety inspection of your residence. If you can keep a pet at your residence, consider getting a large dog as a companion and “bodyguard.” Following are other helpful safety measures:
• When leave your home, turn on lights and a radio to give the impression that someone is there.
• When you return to your home, do not enter if you see signs of a break-in or suspicious persons in the area. Go instead to a neighbor’s house or public place and call the police. If surprised, burglars o$en become assailants and attack the robbery victims.
• Lock the door immediately a$er entering your home or dorm room.
Community Security Measures If you live in a dangerous neighborhood, consider moving to a safer one if you can. "is is the most e#ective measure you can take to avoid violence. If you cannot leave the neighborhood, look for a place to live that is farther away from the most dangerous streets. If the new area looks safer, ask a few resi- dents, and even local police, if they would prefer to live elsewhere. "e police may have local crime sta- tistics, so you can compare crime rates of various neighborhoods.
Daily life is !lled with people and situations that cannot be avoided, but you can use certain tactics to reduce your chances of victimization. If your usual routine requires traveling through danger- ous neighborhoods, remove yourself from these high-risk areas by taking safer routes, when pos- sible, even if they are out of your way. Avoid isolated places, especially when you are alone. Jogging trails in parks, deserted buildings, infrequently used sec- tions of libraries, and nearly empty parking lots and garages are places where violent incidents are more likely to occur.
A considerable percentage of violent crimes, espe- cially sexual assaults, happen between 6 P.M. and midnight. "us, if you must go out at night, do not go alone. Stay in places where you can see other people. Being in the presence of others greatly reduces your risk of violence. If you are alone at night and on cam- pus, use the college’s escort service or the “buddy sys- tem” when walking to and from buildings. Following are other community safety measures:
steps to reduce workplace violence, such as hiring security sta#, controlling access to o&ces, requiring employees to wear identi!cation badges, and o#ering employee assistance programs that provide referrals for counseling services.
You can take numerous practical steps to reduce your personal risk of victimization. Many avoidance measures are simple, inexpensive, and e#ective. To be e#ective, however, these measures should become part of your routine. "e most e#ective action is staying away from high-risk situations and people. For example, a college student might decide not to attend a party where binge drinking and drug use are likely to occur. Simply put, people should avoid high-risk places and dangerous persons when realis- tically possible.
Another preventive measure is to learn to use interpersonal communication approaches to deesca- late potentially hostile situations. For example, avoid using potentially destructive responses such as angry verbal exchanges, including insults and name calling, that may escalate interpersonal con'icts. Arguments are the most frequently cited circumstances that result in murder. In 2015, for example, arguments were involved in about 52% of murders in which the circumstances were known.42 If you become involved in a heated dispute or threatening situation, keeping calm may prevent the situation from escalating into a violent one. For example, breathe deeply, count to 10, “bite your tongue,” or make some excuse and quickly leave the scene. Relaxation techniques can help you maintain your composure in such situations. If you have a “short fuse” and get angry easily, counseling can help you learn con'ict management strategies such as impulse control, anger management, and negotiation techniques.
Home Security Measures Improving your home’s security can discourage and possibly prevent criminals from breaking in to your home. In many break-ins, the intruder simply came through an unlocked door or window. Before you leave your residence, check to see if it is secure. "e most important safety measure is to always use good deadbolt locks on doors. If your entry door does not have windows, consider having a peephole installed in the door. When someone knocks at your door, do not open it until you are certain that you can safely welcome the visitor into your home. Also, keep windows securely locked, especially when you are not home. Contact your police department or the
Preventing and Avoiding Violence 113
• Do not walk, jog, or bike alone, especially at%night.
• Wear a whistle to signal an alarm or carry a can of pepper spray to use if threatened (see the Consumer Health feature).
• Look alert. • Park in a well-lit, busy area. Check inside and
underneath the car before entering. If you need to%use public transportation, choose well- populated stops.
• If violence erupts anywhere near you, run away if you can.
Reducing the Risk of Violence While in a Car Regardless of the time of day, as soon as you enter your car, lock the doors. Keep your car doors locked, and take the keys with you, even when you leave the car for a minute. Do not give rides to strangers or stop to help others. If you see someone in distress, call the police. If you spend a lot of time in your car, keep a charged cell phone with you to call for assis- tance in any emergency. If you are involved in a minor accident, stay in your car; call the police, and keep the doors locked and the windows rolled up until they%arrive.
If someone demands that you surrender your car, do not argue with or resist the person: Get out of the car and quickly move away from the area. Then contact the police. If you are driving and someone in a nearby vehicle drives aggressively and irresponsibly, avoid getting angry with the person. If a driver tailgates your car, flashes high beams at you, or makes angry gestures, do not stop to discuss the matter. Avoid making eye contact with this individual. In this situation, do not drive to your home because he or she is likely to follow you and confront you when you get out of your car. You can discourage this person from continuing to follow you by driving to a busy highway or other high-traffic area. If you still feel threatened, drive to a well-lit public place: Police and fire stations are the best choices.
Workplace Safety Measures In the workplace, learn your company’s security measures—for example, the locations of !re alarms— so you can activate one in case of any trouble. Keep your cell phone with you at all times. Perhaps most
important, strive to get along with coworkers and the public. Help create a positive working environment and relationships by displaying a friendly attitude, good manners, tact, and diplomacy. "e “Changing Health Habits” activity in the Student Workbook can help you identify and change habits that may increase your risk of becoming a victim of violence.
Self-Protection When faced with the threat of force, your actions can in'uence the outcome of the situation; however, it is important to remember that victims of violence are not responsible for their victimization. For exam- ple, you may obtain help from others by calling the police, pressing an alarm button, blowing a whistle, or screaming “Fire!” to attract attention. When cor- nered and facing a threatening person alone, you can try to defuse the situation verbally by reason- ing with your assailant. If you become overwhelmed by fear or conclude that you cannot escape, your response may be to o#er no resistance. However, the gut responses to danger are !ght-or-'ight reac- tions. Sometimes 'ight—simply running away—is the best means of escaping threatening situations. "e opposite response is to defend yourself by !ght- ing. Many Americans carry with them, or keep handy in their homes, a weapon for self-defense such as a gun, knife, or chemical defense spray. When dan- ger threatens, other people may rely on improvised weapons such as car keys, scissors, or a 'ashlight. Some people seek training in personal defense or in !rearm use to enhance their ability to defend them- selves (Figure"4.5).
Should victims always resist their attackers? No uniform answer can be given. Each potential vic- tim must assess each situation quickly to decide how to respond under the circumstances. In situations involving intimate partner abuse or stalking, civil protection orders that separate and prohibit contact between the abuser or stalker and the victim can be e#ective in preventing further abuse.
Safety Planning Because violence can escalate when someone tries to leave a relationship with an abusive partner, a safety plan is recommended. A safety plan is a personalized, practical plan that outlines ways to stay safe while planning to leave, while leaving, and a$er leaving an abusive rela- tionship (Table 4.3). Outlining a plan to follow helps you make safe decisions when you’re in cri- sis; your body might go through !ght-or-'ight, and increased adrenaline may make it harder to think clearly. "e National Domestic Violence Hotline
114 Chapter 4 Violence and Abuse
(800-799-7233) is available to help safely plan with anyone who is concerned about his or her own—or someone else’s—safety. "e National Domestic Vio- lence Hotline also o#ers online chat support on its web site (www.thehotline.org).
Reporting Violence If you are the victim of any attempted or completed crime of violence by strangers, acquaintances, relatives, or intimate partners, you must decide whether to report the incident to the police. Most large police departments include specially trained family violence and sexual assault units that pro- vide sympathetic and appropriate responses. A%911 call usually provides access to the appropriate emergency services.
In certain instances, you may feel reluctant to inform police about what happened to you. Con- sider reporting the incident to an agency, such as a rape crisis center or a women’s self-help service that can assist you in dealing with legal authorities and medical establishments. Nationwide, a 24-hour toll- free family violence hotline can be reached at 800- 799-SAFE (7233).
Seeking help is bene!cial to the victim’s recovery from violence. Managing the short- and long-term e#ects of the violent incident on the victim’s family and friends also is important. Useful services include marital counseling, couple therapy, !nancial and
Consumer Health Natural Defense: Pepper Spray One way to protect yourself against an aggressor is to use pepper spray. Pepper spray contains capsaicin, a compound that is found in hot chili peppers. When sprayed in an assailant’s eyes, pepper spray produces a painful burning sensation. Almost immediately, the person’s eyelids swell shut and tears begin to flow. The spray also causes the attacker to experience difficulty breathing and lose control over body movements. These effects last about 20–30 minutes, which gives you time to escape the situation and call police. Pepper spray is an effective and safe way to subdue an attacker, but it may take a few seconds to work on enraged or intoxi- cated individuals.
Pepper spray is available in small canisters that can be carried on a key chain or in a coat pocket or purse. Some states may impose age or other restrictions concerning the use of pepper spray. Therefore, before buying the product, check with local law enforcement
agencies to determine if it is legal to use pepper spray. Always follow the package directions when using it as a defense, and keep the canister out of the reach of children.
Figure 4.5 In Self-Defense. Fighting back is one way of responding to violent situations. © Hemera Technologies/AbleStock.com/Thinkstock.
Reporting Violence 115
How do I create a safety plan? Even if you don’t leave right away, creating a safety plan can help you know what to do if you choose to leave. A safety plan can help you be more independent and prepared when you leave.
• Identify a safe friend or friends and safe places to go. Create a code word to use with friends, family, or neighbors to let them know you are in danger without the abuser finding out. If possible, agree on a secret location where they can pick you up.
• Keep an alternate cell phone nearby. Try not to call for help on your home phone or on a shared cell phone. Your partner might be able to trace the numbers. If you don’t have a cell phone, you can get a prepaid cell phone. Some domestic violence shelters offer free cell phones.
• Memorize the phone numbers of friends, family, or shelters. If your partner takes your phone, you will still be able to contact loved ones or shelters for a safe place to stay.
• Make a list of things to take if you have to leave quickly. Important identity documents and money are likely the top priority. Get these items together, and keep them in a safe place where your partner will not find them. If you are in immediate danger, leave without them.
• If you can, hide an extra set of car keys so you can leave if your partner takes away your usual keys. • Ask your doctor how to get extra medicine or glasses, hearing aids, or other medically necessary items for you or your
children. • Contact your local family court (or domestic violence court if your state has one) for information about getting a
restraining order. If you need legal help can’t afford it, your local domestic violence agency may be able to help you find a lawyer who will work for free or on a sliding scale based on what you can pay.
• Protect your online security as you collect information and prepare. Use a computer at a public library to download information, or use a friend’s computer or cell phone. Your partner might be able to track your planning otherwise.
• Try to take with you any evidence of abuse or violence if you leave your partner. This might include threatening notes from your partner, copies of police and medical reports, or pictures of your injuries or damage to your property.
• Keep copies of all paper and electronic documents on an external thumb drive.
What do I need to include in my safety packing list? When you leave an abuser, the most important things are your life and safety, as well as your children’s. If you are able to plan ahead, it will help you to have important information with you, in addition to money, clothing, medicine, and other basic items.
Even if you are not sure you want to or are ready to leave, go ahead and make copies of as many of the following documents as you can, or secure them in a safe place outside the home:
• Birth certificates, Social Security cards, and passports or immigration papers for you and your children • Health insurance cards for you and your children • Financial records, including recent bank statements and stocks or mutual fund records • Housing documents, such as rental agreements, mortgage statements, or title or deed • Your most recent credit report (you can request one for free at www.freecreditreport.com) • The title or lease paperwork for your car • Statements for any retirement plans • The past two years’ tax returns • A written copy of phone numbers or important addresses in case you cannot get to your cell phone or address book • Many of these records are available online, so try to keep access to these accounts if you do not have paper copies.
You may also want to take photos of any valuable assets in the home (that is, anything you think may be worth some money). Also, if you have any family heirlooms such as jewelry, take them with you or put them in a safe place before you leave. You can get a safe deposit box at the bank to store copies of the paperwork listed, as well as small valuable items. If you have a joint checking account, consider opening your own checking account and storing money there. Any adult has the right to open his or her own bank account, even people who are married or dependent on another person.
Data from Office on Women’s Health, U.S. Department of Health and Human Services. (2017, November 14). Leaving an abusive relationship. Retrieved from https://www.womenshealth.gov/relationships-and-safety/domestic-violence/leaving-abusive-relationship
Table 4.3
Safety Planning
116 Chapter 4 Violence and Abuse
VIOLENCE AND ABUSE Child physical abuse includes beating, squeezing, burning, cutting, su#ocating, binding, and poisoning a child who is younger than 18 years of age. Although child physical abuse takes place in institutional set- tings, such as day care centers and schools, homes are by far the most common setting. Most physical violence against children is not committed by strang- ers or casual acquaintances but by parents and other adults known to the victims, such as neighbors, baby- sitters, and family friends. Abused children younger than 2 years of age are at greatest risk of fatalities, primarily from head injuries. Many children, how- ever, receive less severe injuries on a regular basis. Violence against children is present across all socio- economic groups, races, and ethnicities.
Data from various studies indicate that many adults were victims of sexual abuse during childhood. Child sexual abuse refers to sexual activity with a child
legal aid, and family therapy. Access to such services and information concerning local self-help groups can usually be arranged through your campus stu- dent health center or through social service agencies in your community.
Studies show that abused children behave more aggressively at every stage of the life span. As adults, they are more likely to be violent against dates, spouses, their children, and, later, their elderly parents.
Why do some parents abuse their children? Parents who are physically abusive to each other have a high risk of abusing their own children. Abusive parents generally lack e#ective parenting skills and frequently have faulty or unrealistic expectations about their children’s behavior. For example, a parent may shake a 3-month-old infant to make him or her stop crying or kick a 2-year-old child for not using the toilet. Abusive parents tend to be under tremendous psychological stress and o$en are isolated from people who could provide helpful advice and social support. Regard- less of the parents’ situation, suspected or observed cases of child neglect or abuse can be reported anony- mously by calling the Childhelp National Child Abuse hotline at 800-4-A-CHILD (800-422-4453). In some states, a person must report suspected cases of child abuse or neglect to%authorities.
child physical abuse Physical violence against a child who is under 18 years of age.
child sexual abuse Sexual activity involving a minor.
Reproduced from U.S. Department of Health and Human Services, Administration on Children, Youth, and Families. (2017). Child maltreatment 2015. Retrieved from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2015.
2015 Child Maltreatment
YEAR OF REPOR
TI NG
25thYEAR OF REPORTING26 th
U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children!s Bureau
4To reduce your risk of violence, avoid high-risk places and dangerous people. Take steps to make your environment safe.
4If a dispute turns into a heated argument, try to keep calm to prevent the threatening situation from escalating into a violent one.
4Conflict-management skills can help defuse tense, angry situations. Some college campuses offer courses in conflict management; consider taking a class to learn these techniques.
4There is no single way to react when someone threatens your safety; therefore, assess each situation to decide how to respond under the circumstances.
4If you are a victim of violence, consider reporting the attack to police. In addition, obtain prompt treatment of your physical injuries and emotional distress.
Healthy Living Practices
Across THE LIFE SPAN
Reporting Violence 117
that takes place as a result of force or threat or by tak- ing advantage of an age di#erence or a caretaking rela- tionship. A pedophile is an individual who is sexually attracted to children and fantasizes about having physi- cal contact with them. A child molester acts on his or her urges by having sexual activity with vulnerable children. Most molesters are heterosexual males who generally target girls between 8 and 10 years old. "e abuse usually involves fondling a child’s body, but it may include com- pleted or attempted vaginal, anal, or oral sex. According to a survey of more than 17,300 adult Americans, 16% of men and about 25% of women experienced sexual abuse as children.43 Such abuse o$en causes long-term serious psychological problems.44
Many people think that child molesters are strang- ers who are mentally ill, looking for children to kid- nap, rape, and murder. In fact, most cases involve adults whom the children know and trust, such as babysitters, family friends, relatives, teachers, camp counselors, coaches, and clergy. Only 3% of mur- dered children younger than 5 years of age were killed by strangers.45 However, children who have unsuper- vised access to personal computers provide a way for sophisticated child abusers to communicate with and befriend vulnerable children through online chat rooms, social networking sites, or electronic bulle- tin boards. Adult caregivers can teach their children safety tips to lessen their risk of being targeted elec- tronically by potential perpetrators.
Incest refers to sexual experiences between fam- ily members who are not married to each other. In many instances, incest involves an adult and his or her young children, stepchildren, or grandchildren. Vic- tims may be boys, although girls are at much greater risk. Incest is o$en nonviolent but forced, and it typi- cally escalates over time. Ignorance or fear may keep the child from disclosing the abuse to others. Because of its psychological and physical impact on the youth- ful victim, incest is a serious form of sexual abuse. "e risk factors for incest are similar to those of nonsexual abuse: childhood sexual victimization of the perpe- trator and high levels of stress within the family.
To reduce child sexual abuse risk, parents should teach their young children how to recognize and
report sexual abuse, regardless of their relationships with perpetrators. Because most cases involve per- petrators known to the child victim, telling children “Don’t talk to strangers” is insu&cient. Very young children need to learn which parts of their bodies are private and that they are in control of what happens to their bodies. Additionally, children need to learn that if anyone touches them in ways that make them feel uncomfortable, they should report the incidents to parents, teachers, or other responsible adults.
Elder abuse is the use of physical or sexual vio- lence against an older adult; some researchers include verbal threats and neglect in their de!nitions. Physical and psychological abuse of older persons takes place not only in institutional settings such as hospitals and nursing homes but especially in family settings. Such abuse occurs in all racial and ethnic groups and at all socioeconomic levels. An estimated 3% of older Americans experience abuse46 and are 2–7 times more% likely to experience negative emotional and physical health outcomes.47 As the average age of the American population increases, many experts expect that the prevalence of elder abuse will increase as well.
"e causes of elder abuse are complex. Older adults with chronic health conditions are most likely to be vic- timized by their spouses or adult children who must care for them. Caring for frail, aged relatives can be frustrating and stressful. Furthermore, the caregiver may depend on the older adult relative for his or her housing and income. In such situations, resentful care- givers may resort to abusive behavior. In severe cases, violence against older adults is associated with certain mental illnesses and drug (usually alcohol) abuse. If you observe an older adult being abused or neglected, report the situation to a local adult protective services agency.
pedophile (PE-doe-file) An individual who is sexually attracted to children.
incest Sexual relations between family members who are not spouses.
elder abuse Use of physical or sexual violence against an elderly person.
Some child abusers target and befriend vulnerable children who have unsupervised access to personal computers. © Margot Petrowski/Shutterstock.
118 Chapter 4 Violence and Abuse
Health-Related InformationAnalyzing Critical Thinking
The following article promotes an herbal tea formulated to reduce a person’s level of anger. Read the article and evaluate it using the model for analyzing health- related information. The main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who wrote the article? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person making the claims?
4. What is the main point of the article? Which information is relevant to the main point of the article? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the tea?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Sum- marize your reasons for coming to this conclusion.
A
Herb
Aunt Annie’s
Tranquility Tea
s you kno
w, I’ve been us ing herbs all m
y life to
treat ever
ything from ac ne to zinc defic
iency.
Most of m
y knowledge ab out herbs didn
’t come
from books or
the Internet; it was passed dow
n to me
in my Great Au
nt Annie’s diary . Annie had a f
abulous
herb garden in
the back of he r house. One a
fternoon in
1914 she made
the most amaz ing discovery, w
hich she
later recorded i
n her diary. She had dug up so
me com-
frey root and p
icked a bunch of pennyroyal a
nd lobelia
leaves from the garden. Since
coltsfoot was b looming, she th
ought it might be a nice chang
e
to add some of its leaves to he
r usual tea reci pe. She brewed
a pot of tea fro m the mixture
and drank abo ut 2 cups of it.
The tea was de licious. Very so
othing.
Less than an hour later, Gre
at Uncle Jeb ca me in from the
barn, tracking dirt all over Au
nt
Annie’s new ca rpet. Now I ne
ed to tell you t hat Annie had
a terrible temp er—she was on
ly
4' 8" tall, but s he used to pus
h big old Jeb ar ound a lot. Nee
dless to say, Un cle Jeb was exp
ect-
ing the worst fr om his wife. Bu
t this time, inst ead of flying of
f the handle an d kicking Jeb,
as
she was prone to do, Aunt An
nie laughed an d hugged him.
Happy as a kit ten rolling in c
at-
nip, Annie clea ned up the mes
s. Uncle Jeb su spected Annie
had added som ething differen
t to
her usual tea re cipe, so he had
her sit down a nd recall the he
rb mixture. Us ing her recipe,
Jeb
made a pot of t hat tea for Ann
ie to drink ever y day for the re
st of her life. W hen Uncle Jeb
began making whiskey in the
barn and stayi ng out late with
his friends, An nie never raised
a
fuss. She just s at in the bent o
ak rocking cha ir, sipping her
tea.
If you want to try Aunt An
nie’s Tranquilit y Tea on someo
ne you know w ho’s got a bad
temper, I’ll sen d the recipe to
you. I’m the ed itor of this mag
azine, so just s end $10 for sh
ip-
ping and hand ling to my add
ress, which is o n the inside of
the front cover . I’d love to hea
r
about your exp eriences with t
he tea; be sure and let me kno
w how it work ed for you.
Your friend,
Herb Z.Garde nia
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Analyzing 119
CHAPTER REVIEW
Applying What You Have Learned
Summary Violence refers to interpersonal uses of force that are not socially sanctioned. A violent social incident occurs when at least one person intentionally applies or threatens physical force on others. Violence is a major public health problem because it produces staggering physical, psychological, and social conse- quences. For many Americans, violence is a way of life; no one is exempt from violence.
Assault is the intentional use of force to injure someone physically; abuse occurs when one takes advantage of a relationship to mistreat a person. Examples of abuse include spouse abuse, child abuse, and sexual harassment.
Regardless of whether physical harm occurs, vio- lent victimization damages psychological health. Psychological e#ects of violence include anxiety, depression, and suicidal thinking, which can lead to drug abuse or other unhealthy “coping” strategies. Family relationships may become strained or end as a result of violence. Furthermore, intergenerational transmission of violence occurs when abused chil- dren mature and abuse their own children. To recover from the psychological e#ects of violence, one should seek help from mental healthcare professionals.
Violence is complex; there is no single cause of violence, and neither is violent behavior limited to a particular group of persons. Factors that contribute to violence include poverty, substance abuse, certain psychological disorders, and poor self-esteem. In many instances, violence is learned behavior. Watch- ing violent media, for example, may contribute to violent behavior.
Sexual violence involves areas of the body that are sensitive to sexual arousal. Such violence involves sexual activity gained through force, threat of force, or coercion. "e majority of sexual assaults are committed
not by strangers but by acquaintances, friends, family members, and spouses. Family (domestic) violence encompasses both friends and family members and usually takes place in homes. Community violence includes acts that occur between strangers or acquain- tances, usually in public places. Institutional violence occurs mainly within institutional environments such as schools, workplaces, or prisons. Terrorism involves violent acts against civilians to produce extreme fear, severe property damage, and numerous deaths.
To reduce the likelihood of becoming a victim of violence, individuals should limit their exposure to risky situations and take steps to make their resi- dences secure. When faced with a violent situation, a person can obtain help from others by attracting attention, defuse the situation by reasoning with an assailant, or simply run away. In some instances, the threatened individual may need to defend himself or herself physically.
Most physical violence against children is com- mitted by adults known to the victims, such as rela- tives, neighbors, or babysitters. Most violence against children occurs in their homes. Girls, especially those between the ages of 8 and 10 years, are more likely to be targets of sexual abuse than are boys. Par- ents and caregivers should teach their young children how to recognize and report sexual abuse. Children who experience violence o$en su#er emotional and social injuries that remain long a$er physical injuries have healed.
Elder abuse occurs in all racial and ethnic groups and at all socioeconomic levels. Family members are responsible for the vast majority of abuse directed toward older adults. As the average age of the Ameri- can population increases, many experts predict that the incidence of elder abuse will also increase.
1. If your friend reports being sexually harassed by a college professor, what advice could you give to him or her? Application
2. You have to attend classes or work at a job in the evenings. Determine at least two steps you can
take to reduce your risk of violence on campus or at work. Analysis
3. Plan a program to increase security in your dorm or on your campus. Consider forwarding it to an o&cial at the university who might be interested
120 Chapter 4 Violence and Abuse
CHAPTER REVIEW Key
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
in your plan, such as the dean of student a#airs. Synthesis
4. Evaluate your present security situation. Deter- mine situations in your life that provide some
risk of violence, and describe ways in which you can reduce these risks. Evaluation
Reflecting on Your Health 1. As mentioned in this chapter, visual media can
in'uence a person’s attitudes toward violence. Choose a violent movie or television show that you watched recently. What impact, if any, did it have on your feelings about violence?
2. Do you like to play violent computer games? If so, how does this activity a#ect your attitudes toward violence?
3. What could you do to avoid getting into an abu- sive relationship with an intimate partner? If you are already in an abusive relationship, what are
your feelings about your partner? What would make you change your current situation?
4. How safe do you feel at home or in the dorm? What worries you most about the safety of your environment? What steps could you take to make your residence more secure?
5. If you were out walking alone at night and real- ized someone was following you, describe what you would do to reduce your risk of being attacked. Do you think that it is safe for you to walk alone at night? Why or why not?
References 1. U.S. Department of Justice, Federal Bureau of Investigation. (2016).
Crime in the United States. Retrieved from https://ucr.*i.gov /crime-in-the-u.s/2016/crime-in-the-u.s.-2016
2. U.S. Department of Health and Human Services, Administration on Children, Youth, and Families. (2017, January). Child maltreat- ment 2015. Retrieved from https://www.acf.hhs.gov/cb/resource /child-maltreatment-2015
3. U.S. Centers for Disease Control and Prevention, National Insti- tutes of Justice, Department of Defense. (2017, April). "e national intimate partner and sexual violence survey. Retrieved from https://www.cdc.gov/violenceprevention/pdf/NISVS-StateReport Book.pdf
4. U.S. Department of Justice, Federal Bureau of Investigation, Criminal Justice Information Services Division. (n.d.). 2016 crime statistics in the United States. Retrieved https://ucr.*i .gov/crime-in-the-u.s/2016/crime-in-the-u.s.-2016/topic-pages /o#enses-known-browse-by/national-data
5. Cooper, A., & Smith, E. L. (2013 December 30). Homicide in the U.S. known to law enforcement, 2011. Retrieved from http://www .bjs.gov/index.cfm?ty=pbdetail&iid=4863
6. U.S. Department of Justice, Bureau of Justice Statistics. (2010, March 1). Key facts: Violent crime. Retrieved from http://bjs.gov /index.cfm?ty=k$p&tid=31
7. U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. (2017, November). National Vital Statistics Report, 66(5). Retrieved from https://www.cdc.gov/nchs/products /nvsr.htm
8. Tremblay, R. E., et al. (2005). Physical aggression during early child- hood: Trajectories and predictors. Canadian Child and Adolescent Psychiatry Review, 14(1), 3–9.
9. American Psychological Association. (2014). Violence. Retrieved from http://www.apa.org/topics/violence/
10. American Academy of Pediatrics. (2009). Policy statement—media violence. Pediatrics, 124(5), 1495–1503.
11. Black, M. C., et al. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention. Retrieved from https://w w w.cdc.gov/violencepre vent ion/p df/nisvs_rep or t 2010-a.pdf
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October 26). Victims and perpetrators. Retrieved from http://www . n ij. gov / topi c s / c r i me / r ap e - s e x u a l - v i ol e nc e / Page s / v i c t i ms -perpetrators.aspx#note1
13. Fisher, B. S., et al. (2000). "e sexual victimization of college women (Publication NCJ 182369). Washington, DC: National Institute of Justice, Bureau of Justice Statistics, U.S. Department of Justice.
14. Krebs, C. P., et al. (2007). "e campus sexual assault (CSA) study. (Publication NCJ 221153). Washington, DC: National Institute of Justice, U.S. Department of Justice. Retrieved from https://www .ncjrs.gov/pd&les1/nij/grants/221153.pdf
15. RAINN. (2014). National sexual assault online hotline. Retrieved from https://ohl.rainn.org/online/
16. DoD Safe Helpline. (2014). About Department of Defense (DoD) Safe Helpline. Retrieved from https://www.safehelpline.org/about -dod-safe-helpline
17. Morgan, R. E., & Kena, G. (2017, December). Criminal victimiza- tion, 2016 (Publication NCJ 251150). Washington, DC: National Institute of Justice, U.S. Department of Justice. Retrieved from https://www.bjs.gov/content/pub/pdf/cv16.pdf
18. Cantalano, S. (2013, November). Intimate partner violence: Attri- butes of victimization, 1993–2011 (Publication NCJ 243300). Retrieved from http://www.bjs.gov/content/pub/pdf/ipvav9311.pdf
19. Kann, L., et al. (2016, August 12). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12—United States and selected sites, 2015. Morbidity and Mortal- ity Weekly Report, Surveillance Summaries, 65(9).
20. Eaton, D. K., et al. (2010). Youth risk behavior surveillance—United States, 2009. Morbidity and Mortality Weekly Report, Surveillance Summaries, 59(SS5), 1–148.
21. McKinney, C. M., et al. (2009). Childhood family violence and per- petration and victimization of intimate partner violence: Findings from a national population-based study of couples. Annals of Epi- demiology, 19(1), 25–32.
22. Frank, J. B., & Rodowski, M. F. (1999). Review of psychological issues in victims of domestic violence seen in emergency settings. Emergency Medical Clinics of North America, 17(3), 657–677.
23. World Health Organization/London School of Hygiene and Tropi- cal Medicine. (2013). Global and regional estimates of violence against women: Prevalence and health e!ects of intimate partner vio- lence and non-partner sexual violence. Geneva, Switzerland: Author.
24. World Health Organization/London School of Hygiene and Tropical Medicine. (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: Author.
25. Stalking Resource Center, "e National Center for Victims of Crime. (2008). Are you being stalked? Retrieved from http:// victimsofcrime.org/docs/src/aybs_english_color.pdf ?sfvrsn=4
26. Lamberg, L. (2001). Stalking disrupts lives, leaves emotional scars. Journal of the American Medical Association, 286(5), 519, 522–523.
27. U.S. Centers for Disease Control and Prevention. (2008). Notice to readers: National Stalking Awareness Month—January 2008. Mor- bidity and Mortality Monthly Report, 57(3), 72.
28. Listenbee, R. L. (2014, December). Highlights of the 2012 National Youth Gang Survey. OJDJ Fact Sheet. Retrieved from https://www .ojjdp.gov/pubs/248025.pdf
29. "e Federal Bureau of Investigation. (2011). 2011 National Gang "reat Assessment: Emerging Trends (Document ID: 2009- M0335-001). Retrieved from http://www.*i.gov/stats-services /publications/2011-national-gang-threat-assessment/2011-national -gang-threat-assessment-emerging-trends
30. Baum, K., & Klaus, P. (2005). Violent victimization of college stu- dents, 1995–2002 (Publication NCJ 206836). Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, O&ce of Justice Programs. Retrieved from http://www.bjs.gov/index .cfm?ty=pbdetail&iid=593
31. U.S. Department of Labor, Bureau of Labor Statistics. (2017, December). Census of fatal occupational injuries charts, 1992-2016 (#nal data). Retrieved from https://www.bls.gov/iif/oshwc/cfoi /cfch0015.pdf
32. U.S. Department of Defense. (2009). Special report: Tragedy at Fort Hood. Retrieved from http://www.defense.gov/home /features/2009/1109_$_hood/
33. U.S. Department of Defense. (2014). Fort Hood Shooting: April 2, 2014. Retrieved from http://www.defense.gov/home /features/2014/0414_forthood/
34. Holman, E. A., et al. (2008). Terrorism, acute stress, and cardiovas- cular health: A three-year national study following the September 11th attacks. Archives of General Psychiatry, 65(1), 73–80.
35. Galea, S., et al. (2005). Posttraumatic stress disorder in the general population a$er mass terrorist incidents: Considerations about the nature of exposure. CNS Spectrums, 10(2), 107–115.
36. Centers for Disease Control and Prevention. (2013). Understanding school violence. Retrieved from http://www.cdc.gov/violenceprevention /pdf/school_violence_fact_sheet-a.pdf
37. U.S. Department of Justice, Federal Bureau of Investigation. (2013). 2015: Crime in the United States. Retrieved from https:// u c r. f bi. gov / c r i me - i n - t he - u. s / 2 0 1 5 / c r i me - i n - t he - u. s . - 2 0 1 5 /o#enses-known-to-law-enforcement/violent-crime
38. Langton, L., et al. (2013, October). Criminal victimization, 2012. Retrieved from http://www.bjs.gov/index.cfm?ty=pbdetail&iid =4781
39. Smith, E. L., & Cooper, A. (2013 December). Homicide in the U.S. known to law enforcement, 2011. Retrieved from https://www.bjs .gov/index.cfm?ty=pbdetail&iid=4863
40. U.S. Department of Justice, Bureau of Justice Statistics. (2018, May 31). Victim characteristics. Retrieved from https://www.bjs.gov /index.cfm?ty=tp&tid=92
41. U.S. Department of Health and Human Services, Public Health Service, Healthy People 2020. (2018, January). 2020 topics and objectives, injury and violence prevention. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic /injury-and-violence-prevention/objectives
42. U.S. Department of Justice, Federal Bureau of Investigation. (n.d.). Murder circumstances by relationship, 2011–2015. 2015: Crime in the United States. Retrieved from https://ucr.*i.gov/crime-in-the -u.s/2015/crime-in-the-u.s.-2015/tables/expanded_homicide _data_table_12_murder_circumstances_2011-2015.xls
43. Middlebrooks, J. S., & Audage, N. C. (2008). E!ects of childhood stress on health across the lifespan. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
122 Chapter 4 Violence and Abuse
CHAPTER REVIEW 44. Huyer, D. (2005). Childhood sexual abuse and family physicians.
Canadian Family Physician, 51, 1317–1319. 45. U.S. Department of Justice, Bureau of Justice Statistics. (2011,
March 30). Homicide trends in the United States: Infanticide. Retrieved March 30, 2011, from http://www.bjs.gov/content /-homicide/-children.cfm
46. Gibbs, L. M., & Mosqueda, L. (2007). "e importance of reporting mistreatment of the elderly. American Family Physician, 75(5), 628.
47. Acierno, R., et al. (2017). "e national elder mistreatment study: An 8-year longitudinal study of outcomes. Journal of Elder Abuse and Neglect, 29(4), 254–269.
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References 123
Across the Life Span Sexual Development
Managing Your Health Genetic Counseling and Prenatal Diagnosis Enlargement of the Prostate
Consumer Health Home Pregnancy Tests
Diversity in Health Menopause
Chapter Overview The functions and structures of the male and female
reproductive systems
What happens throughout the menstrual cycle
How a woman can prepare her body for pregnancy
How a fetus develops
The changes in a pregnant woman from conception through the postpartum period
The causes of and treatments for infertility
The benefits and drawbacks of contraceptive methods
Student Workbook Self-Assessment: Contraceptive Comfort and Confidence
Scale | Attitudes Toward Timing of Parenthood Scale
Changing Health Habits: Do You Want to Improve Your Reproductive Health?
Do You Know? How well your contraceptive method works compared to
others?
What causes birth defects?
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Reproductive Health
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Learning Objectives “The striking chapter-opening photograph depicts the essence of sexual reproduction: the fertilization of an egg (ovum) by a sperm …”
After studying this chapter, you should be able to:
1. Identify parts of the male and female reproductive sys- tems and describe the function and location of each part.
2. Identify actions that women can take to increase their chances of having healthy pregnancies and healthy babies.
3. Describe events that occur during each stage of the birth process.
4. Identify the various types of contraception, discuss how couples use each method correctly, and rate the effective- ness of each method.
5. List the pros and cons of using each method of contra- ception and note the effectiveness of each.
6. Identify three clinical abortion methods and describe when a particular method is used.
7. Describe how puberty affects the reproductive system and how aging affects reproductive health.
CHAPTER 5
125
The striking chapter-opening photograph depicts the essence of sexual reproduction: the fer-tilization of an egg (ovum) by a sperm, a pro- cess also called conception. "e photograph is color enhanced; the outside of the egg is shown as orange and the sperm as red. A layer of cells that extend from the egg covers its surface. During the maturation of the egg, these outer cells secrete a thick gel-like mate- rial that covers the egg beneath. Together, the gel and the outer cells form a protective covering, which sperm must penetrate by means of digestive enzymes in their heads. Although it is di&cult to see in this photograph, the head of only one sperm is making its way through these outer layers to ultimately fertilize this egg.
When the sperm enters the egg, it triggers the egg’s !nal maturation. Following this process, the heredi- tary material from the sperm and the mature egg unite, forming a new cell—the zygote. "is single cell has the potential to develop into a new person.
Fertility is the ability to conceive a child, whereas infertility is de!ned as the inability of a couple to conceive a child a$er 1 year of unprotected sex. Couples may have reduced fertility for a variety of reasons; it is not necessarily because of “a problem” with one partner or the other. Factors that slightly impair the fertility of both sexual partners may inter- act to render a couple infertile. "ese factors include a low sperm count, a high percentage of abnormally shaped sperm, scarring in the female genital tract, structural defects of the uterus, and hormonal imbal- ances. Treatments for infertility are speci!c to the causes and include surgical procedures, hormone therapy, medication, and lifestyle changes. In addi- tion to these therapies, physicians can harvest eggs and sperm to assist fertilization and implantation.
Whether physician-assisted or accomplished with no intervention, fertilization is preceded by a variety
of physiologic processes that make it all possible, and that is where we begin this chapter.
!e Male Reproductive System
"e male reproductive system is structured for the development and maturation of sperm and for deliv- ering sperm to the vagina. Figure 5.1 is a diagram of (a) a posterior view and (b) a lengthwise section of the male reproductive tract.
The Internal Organs of Sexual Reproduction Sperm Development Sperm are produced in the testes (singular, testis), which hang outside the body (in the angle formed between the legs) encased in a sac of skin called the scrotum. "e testes have two major functions: production of the sex hormone tes- tosterone and production of sperm cells. "e testes are packed with hundreds of feet of tubes (called seminiferous tubules) in which sperm are made. Each day, the testes of an adult male produce hundreds of millions of sperm. Various conditions are necessary for proper sperm production.
In a review of environmental and lifestyle e#ects on the development of sperm, Richard Sharpe noted that factors that result in a rise in scrotal tempera- ture have a negative e#ect on sperm development. "e testes must be cooler than body temperature to produce normal sperm; the position of the scrotum keeps the temperature of the testes below that of the rest of the body. However, behaviors that result in the scrotum not being able to dissipate heat can result in increased temperature of the testes. Such behaviors include taking long, hot baths and staying seated for long periods, especially when wearing tight pants. Obesity in men has also been shown to adversely a#ect sperm development.1
Semen Formation A$er sperm are manufactured in the seminiferous tubules, they are gently moved along by the 'uid in which they are suspended. "e sperm move through a network of ducts to the epididymis (plural, epididymides). "e epididymis is a coiled tube that lies on the back of each testis. "is is where the sperm mature, developing the ability to swim and to fertilize an egg.
Rhythmic contractions of the muscular walls of the epididymis slowly move the sperm to the vas deferens when maturation is complete. "e vas
sexual reproduction The fertilization of an egg (ovum; plural, ova) by a sperm.
testes (TES-tease) The male reproductive organs that produce sperm (the male sex cells) and testosterone (a male sex hormone).
scrotum (SKRO-tum) The sac of skin in which the testes are enclosed and hang outside the body.
epididymis (EP-ih-DID-ih-mis) A coiled tube that lies on the back of each testis and in which sperm mature.
vas deferens (VAS DEF-er-enz) A tube that links the epididymis and the urethra, the passageway through which sperm exit the body.
126 Chapter 5 Reproductive Health
deferens is a tube that links the epididymis and the urethra, the passageway through which sperm exit the body. Sperm are stored in the vas deferens until they are released from the body during ejaculation, their emission from the penis during orgasm, the peak of sexual excitement. Sperm can be stored for a few days in these ducts. If not ejaculated within that time, the sperm die and are ingested by the body’s white blood cells, and newly synthesized sperm take their place. For this reason, men who have had vasec- tomies should not be concerned that sperm are accu- mulating in their bodies.
"e sperm are suspended in relatively little 'uid while stored in the vas deferens. A variety of organs referred to as accessory sex glands add 'uid to the sperm as they exit the body during ejaculation. "is 'uid contains nutrients to fuel the sperm as they journey up the female reproductive tract, alkaline substances to neutralize the acidity of the vagina, and other chemicals to aid sperm movement. "e secre- tions of the accessory sex glands (called seminal $uid) and the sperm make up the semen, or ejaculate.
During ejaculation, sperm are swi$ly propelled through the vas deferens by the rhythmic contrac- tions of its muscular walls. Just before the merg- ing of the two vasa deferentia where they meet the urethra, the secretions of the paired seminal vesicles 'ow into the ejaculate. "e thick secre- tions of the seminal vesicles add much of the volume to the ejaculate (approximately 60%) and contain the sugar fructose, which provides nutri- tion for the sperm.
Pubis
Prostate gland
Urethra
Scrotum
Seminal vesicle
Epididymis
Testis
Anus
Penis
Urinary bladder
Ureter
Prostate gland
Rectum
Glans penis
Vas deferens
Bulbourethral gland
Urethra
SIDE VIEW
POSTERIOR VIEW
(a) (b)
Figure 5.1 The Male Reproductive System. (a) Posterior view of the internal organs, and (b) lengthwise section (side view) of the internal organs.
ejaculation The emission of semen from the penis during orgasm.
orgasm The peak of sexual excitement.
semen The ejaculate; the secretions of the accessory sex glands (called seminal fluid) and sperm.
seminal vesicles (SEM-ih-nal VES-ih-klz) Paired male sex organs located near the junction of the two vasa deferentia, which produce thick fructose- containing secretions that are added to the ejaculate.
The Male Reproductive System 127
As the ejaculate continues traveling through the male reproductive tract, the prostate gland adds its secretion. "is single walnut-sized gland lies just below the bladder. It surrounds the urethra and pro- duces a milky 'uid that protects sperm from the vagina’s acidic environment.
During sexual arousal, the bulbourethral glands produce a 'uid similar to mucus that precedes the ejaculate. "e bulbourethral glands (also called Cowper’s glands), paired glands about the size of peas, are located on either side of the urethra just below the prostate. "e secretions of these glands help neutralize the acidity of the male urethra and the vagina. "ese glands also contribute a small amount of lubrication for sexual intercourse. How- ever, this 'uid may contain sperm: For this reason (and others), the withdrawal method of birth control is not reliable.
The External Organs of Sexual Reproduction "e scrotum and the penis are the external organs of sexual reproduction (external genitals) in males (see Figure 5.1). "ree columns of spongy tissue in the inner structure of the penis (Figure 5.2) become !lled with blood during sexual arousal, which causes the penis to enlarge and become !rm so that it can be inserted into the vagina. During sexual intercourse, the penis can become stimulated enough to result in orgasm, during which ejaculation occurs.
!e Female Reproductive System
"e female reproductive system is structured for the development and maturation of ova, for receiving sperm, for providing an environment in which a fer- tilized ovum can develop and mature, and for giving
birth to the developed fetus. Figure 5.3 is a diagram of (a) a lengthwise section of the female reproductive tract and (b) a posterior view.
The Internal Organs of Sexual Reproduction Egg Development Ova are produced in the ovaries, which are two oval organs suspended by ligaments (a type of connective tissue) in the pelvic cavity. "e almond-sized ovaries contain follicles, which are masses of cells that contain immature ova in various stages of development (Figure 5.4). Each follicle con- tains one ovum.
"e scienti!c community has long believed that, unlike male sex cells, all female sex cells begin to develop before birth, that the process of egg devel- opment stops before birth, and the potential eggs remain dormant throughout childhood. However, recent stem cell research indicates that women may in fact be able to develop new eggs in their lifetime.
prostate gland A single, walnut-sized gland that lies just below the bladder, surrounding the urethra. The prostate produces a milky alkaline fluid that is added to the ejaculate.
penis A cylindrical external organ of sexual reproduction in males, which hangs in front of the scrotum.
ovaries Internal organs of female sexual reproduction within which eggs (ova) develop.
follicles Masses of cells in the ovaries that contain immature ova (eggs) in various stages of development. Each follicle contains one ovum.
Figure 5.2 The Erect and Flaccid Penis. (a) During an erection, blood fills the spongy erectile tissue of the penis. (b) When the blood drains from this tissue, as it does after orgasm, the penis becomes flaccid.
128 Chapter 5 Reproductive Health
Veins (dilated) Artery (constricted) Connective tissue
Spongy erectile tissue
Spongy erectile tissue Urethra
(b) Section of flaccid penis
Veins (constricted) Artery (dilated)
Connective tissue
Spongy erectile tissue engorged with blood
Spongy erectile tissue engorged with blood
Urethra
(a) Section of erect penis
Figure 5.3 The Female Reproductive System. (a) Side view (lengthwise section) of the internal organs, and (b) posterior view of the internal organs.
The Female Reproductive System 129
Suspensory ligament
Ovary
Urinary bladder
Urethra
Mons pubis
Pubic bone
Clitoris
Urethral opening
Labium majora
Labium minora
(a)
(b)
Vaginal opening Anus
Vagina
Rectum
Cervix
Uterus
Uterine tube
Suspensory ligament
Ovary
Ovarian ligament
Round ligament
Broad ligament
Body of uterus
Fimbriae
Wall of uterus
Vagina
Cervix
Uterine tube
Uterine cavity
Each month a$er the onset of sexual maturity, or puberty, but before menopause, a few ova con- tinue their development. Most of the time, one ovum matures and bursts from an ovary each month; this process is ovulation. "e ovulation of two ova can lead to the development of fraternal twins if both are fertilized. Identical twins result when the two cells formed from the fertilized ovum’s !rst division continue development as independent organisms. A woman’s reproductive life span lasts from puberty to age 50 years (on average); only about 400 ova mature during this period.
Egg Fertilization and Development During ovu- lation, an egg is released into the pelvic cavity. Lying close to the ovaries are the !mbriae, the fringed edges of the uterine tubes (see Figure 5.3), also called fal- lopian tubes or oviducts. "e uterine tubes are shaped somewhat like trumpets, with their wider ends near the ovaries and their narrower ends connected to the uterus. As the !mbriae move, they create a current of 'uid that gently sweeps the ovum into the tube. If sperm are present, the uterine tube is also the site of fertilization. "e fertilized ovum moves through the uterine tube as it journeys to the uterus.
"e uterus is a hollow, muscular, pear-shaped organ that protects and nourishes the developing organism. "e fertilized egg implants in the wall of the uterus and grows and develops during pregnancy, which is discussed shortly.
"e uterus opens into the vagina at the cervix, the narrow neck of the uterus. "e cervix produces mucus. At certain times of the month, the consistency of the cervical mucus changes, facilitating sperm movement into the uterus around the time of ovula- tion and hindering it at other times. "e vagina is a tube about 10 centimeters (approximately 4 inches) long. It receives the penis during intercourse, allows the passage of the menstrual 'ow, and is a birth canal.
The External Organs of Sexual Reproduction "e female external genitals (Figure 5.3a) collectively are called the vulva. "e vulva surrounds the vaginal opening. "e urethra, the tube that carries urine from the bladder to the outside, lies anterior to the vagina.
Although the urethra is shared by the urinary and reproductive systems in men, it has no reproductive or sexual function in women. Because it is close to the anal area, the urethra can become infected by diges- tive tract microorganisms during sexual intercourse if these bacteria become lodged in this tube. If micro- organisms are not washed from the urethra by urine, they may multiply and cause urethritis (also com- monly known as cystitis, a urinary tract infection, or a bladder infection). Healthcare providers recommend that women who o$en develop such infections uri- nate a$er sexual intercourse and drink plenty of 'uids to keep the urethra washed free of bacteria.
Located under a protective hood of tissue, the clitoris lies anterior to the urethra. "is tiny
puberty (PEW-ber-tea) A stage of sexual development during which the endocrine (hormone) and reproductive systems mature.
ovulation The maturation and release of an egg from an ovary, usually each month from puberty to menopause.
uterine tubes Passageways that extend from each ovary to the uterus.
uterus A hollow, muscular, pear-shaped organ that protects and nourishes the embryo/fetus during development.
cervix The narrow neck of the uterus.
vagina A tube about 10 centimeters (approximately 4 inches) long that receives the penis during heterosexual intercourse, allows the passage of the menstrual flow, and is a birth canal.
vulva The collective term for the external female genitals. The vulva surrounds the vaginal opening.
clitoris (KLIT-oh-ris) A female organ of sexual arousal. Located under a protective hood of tissue, the clitoris lies in front of the urethra.
Figure 5.4 The Developing Ovum. A highly magnified, colorized photograph of a developing ovarian follicle with developing egg (ovum).
130 Chapter 5 Reproductive Health
© Professor P.M. Motta, G. Macciarelli, S.A. Nottola/SPL/Science Source.
Developing egg
Ovarian follicle
structure has spongy tissue like that of the penis and becomes engorged with blood during sexual arousal. Like the penis, it has numerous nerve endings that send messages to the brain, which are interpreted as sensations of sexual pleasure when this organ is stimulated indirectly during sexual activity. Stimu- lating the clitoris directly may result in discomfort for some women.
Extending from over the clitoris to an area behind the vagina, two thin, hairless folds of skin called the labia minora (meaning “small lips”) cover and protect the vaginal opening and urethra. Within the area bounded by the labia minora, lying near the vaginal and urethral openings and the clitoris, are various glands that secrete lubri- cating substances during sexual activity. Next to these skin folds are the hairy, more rounded, and thicker labia majora (“large lips”). The labia majora extend forward to unite in a mound of fatty
tissue called the mons pubis. The mons pubis pro- vides a cushion over the pubic bone, a portion of the pelvic bones that is in front of the genitals.
"e breasts are also external organs of sex and reproduction in women. Breasts primarily consist of fat and glandular tissue (Figure 5.5). Exercise will not increase breast size; it can develop only the underly- ing pectoral muscles. Although their major purpose
labia minora (LAY-bee-ah my NOR-ah) Two thin, hairless folds of skin that extend from over the clitoris to an area behind the vagina. The labia minora cover and protect the vaginal opening and urethra.
labia majora (LAY-bee-ah mah-JOR-ah) Hairy, rounded, and thick folds of skin that lie adjacent to the labia minora and extend forward to unite at the mons pubis.
mons pubis A mound of fatty tissue that lies over the pubic bone, cushioning it.
Adipose tissue (fat)
Areola
Intercostal muscles
Ribs
Mammary duct
Lactiferous duct
Pectoralis minor muscle Pectoralis major muscle
Lung
Lobe
Figure 5.5 Mammary Gland Anatomy. The breasts, external organs of sex and reproduction in women, consist primarily of fat and glandular tissue.
The Female Reproductive System 131
is the production of milk to sustain an infant a$er birth, the breasts are also sensitive to sexual stimu- lation. "e nipples contain nerve endings that are sensitive to touch; smooth muscles in the nipples contract during sexual arousal, causing the nipples to become erect.
!e Menstrual Cycle Women, unlike men, experience a cyclic waxing and waning of their sex hormones each month. "ese hormonal changes orchestrate physiologic changes in the ovaries and uterus. "ese changes are collec- tively called the menstrual cycle, which literally means “monthly cycle.” "e average length of a cycle is 28%days, but menstrual cycles generally vary from 21 to 45 days in teens and 21 to 35 days in adults.2
"e menstrual cycle is usually described as begin- ning on the !rst day of the menses (menstrual period; Figure 5.6). "e menses are the sloughing of the inner lining of the uterus, which is the endometrium. "is lining develops gradually during the cycle, preparing for the implantation of a fertilized egg. If fertilization and implantation do not occur, the ovum dissolves,
and hormonal changes result in the lining being passed out of the body through the vagina (slough- ing of the endometrium). During each cycle, a new lining develops.
What happens to the uterine lining is controlled by the hormones estrogen and progesterone. Estrogen is a hormone secreted by ovarian follicles, the groups of cells within which ova mature (Figure 5.4); progesterone is secreted by the corpus luteum, the remnant of a follicle that has released its ovum (Figure 5.6).
Each cycle (roughly each month) during her child- bearing years, a woman’s body prepares for a preg- nancy. Usually only one ovarian follicle reaches the !nal stage of development in any particular cycle. About midcycle, hormonal changes trigger ovula- tion, the release of the egg from the ovary. "e cor- pus luteum (meaning “yellow body”) secretes high amounts of progesterone and lesser amounts of estro- gen, which cause the uterine lining to grow, thicken, and develop a rich blood supply in preparation for the implantation of a fertilized ovum. If fertilization does not occur, the corpus luteum degenerates and stops producing hormones. Without hormonal stimula- tion, the endometrium degenerates and is passed out of the body through the vagina during the menses.
If fertilization occurs, the corpus luteum does not degenerate. It produces estrogen and progeste- rone throughout pregnancy, maintaining the endo- metrium. As the pregnancy develops, so does the placenta, a structure consisting of maternal and fetal tissues that also secretes hormones that help main- tain the pregnancy. In addition, oxygen, nutrients, and wastes move between mother and fetus across the placenta, which is connected to the fetus by the umbilical cord.
Premenstrual Syndrome Approximately 70–90% of American women in their reproductive years report mild to moderate discom- fort during the week before menstruation as their hormonal levels drop. More than 20% report that premenstrual symptoms such as anxiety/ tension, mood swings, decreased interest in activities, appetite changes/food cravings, aches, and cramps interfere with their relationships and their daily activities.3 "is condition, originally termed premenstrual tension syndrome because most women experiencing it reported tension and anxiety among their symp- toms, is now simply referred to as premenstrual syndrome (PMS). A range of 5–8% of women report severe impairment of their daily activities because
menstrual (MEN-stroo-al) cycle The monthly changes in the levels of the female sex hormones that orchestrate physiologic changes in the ovaries and uterus.
menses (MEN-seez) The menstrual period; the sloughing of the endometrium.
endometrium (EN-doe-ME-tree-um) The inner lining of the uterus.
estrogen (ES-tro-jen) A hormone secreted by ovarian follicles, the groups of cells within which ova mature. With progesterone, estrogen stimulates the continued development and thickening of the uterine lining.
progesterone (pro-JES-te-rone) A hormone secreted by the corpus luteum. With estrogen, progesterone stimulates the continued development and thickening of the uterine lining.
corpus luteum (KOR-pus LOO-tea-um) The ruptured follicle left behind after ovulation.
placenta (plah-SEN-tah) A structure that develops after implantation of a fertilized ovum in the uterine wall and consists of maternal and fetal tissues that secrete hormones that help maintain the pregnancy.
premenstrual syndrome (PMS) Symptoms such as anxiety, mood swings, aches, and cramps that occur before the menses and that significantly interfere with daily life.
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Toxic Shock Syndrome A disease called toxic shock syndrome (TSS) is asso- ciated with the menses. "is disease became well known in the 1980s, when hundreds of women who used certain high-absorbency tampons during their menstrual periods were stricken. In TSS, staphylo- coccal (STAFF-ih-low-KAH-kul) bacteria grow in the blood-soaked tampon and in vaginal tissues, produc- ing toxins that can enter the woman’s bloodstream. TSS is associated with a wide variety of surgical con- ditions unrelated to the menses (such as skin, bone, and so$-tissue infections); fewer than 50% of TSS cases are associated with tampon use during menstru- ation.5 TSS can also occur from use of contraceptive diaphragms and sponges, but such occurrences are rare. Although TSS is an uncommon disease, women from 15 to 34 years old are at the highest risk.
"e most common symptoms of TSS are fever, muscle pain, headache, dizziness, diarrhea, vomiting, and a rash similar to a sunburn. One to two weeks a$er the onset of the disease, the skin of the palms,
of PMS symptoms.3 "is debilitating condition is called premenstrual dysphoric disorder (PMDD). Research results provide some evidence that both PMS and PMDD may be partly the result of interac- tions between sex hormone levels and certain brain neurotransmitters.4
Most women with mild to moderate PMS are helped by one or more of the following treatments: counseling, lifestyle modi!cation, such as including exercise in their daily regimen, or medications pre- scribed for speci!c symptoms. Fluoxetine (Prozac) has shown usefulness in the treatment of PMS, acting to reduce symptoms of depression and anxiety that are linked to problems with the proper regulation of serotonin, a brain neurotransmitter. Many women are helped by using low-dose COCs. Nutritional treat- ments include a diet low in salt, alcohol, ca#eine, and sugar. Taking calcium supplements may reduce the severity of symptoms of PMS. Women with more severe symptoms of PMS and with PMDD may bene- !t from medications prescribed for their speci!c situ- ation and symptoms.4
1 5 510 15 20 25 28 Days Menstrual phase Menstrual phaseProliferative phase Secretory phase
1 5 510 15 20 25 28
Primary follicle
Maturing follicle Ovulation
Corpus luteum
Degenerating corpus luteum
Anterior lobe of pituitary gland
Ovary
LHFSH
Estrogen FSH LH
Progesterone
Lining of uterus
Hypothalamus Figure 5.6 The Menstrual Cycle. The cycle begins on the first day of the menses. Hormones from the hypothalamus control the release of follicle- stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. Estrogen is secreted by the ovarian follicles, and progesterone is secreted by the corpus luteum. The rise and fall of hormone levels are related to ovulation and to the building up and sloughing of the endometrium.
The Menstrual Cycle 133
!ngers, toes, and soles of the feet begins to peel. Gen- erally, TSS patients are hospitalized and treated with 'uids and antibiotics.
To avoid contracting TSS from tampon use, women who use tampons should change them o$en and alternate their use with pads throughout the menses. Women should use only the level of absor- bency they require. If during tampon use a woman experiences fever, rash, dizziness, or diarrhea, she should remove the tampon and seek medical atten- tion immediately.
Pregnancy and Human Development
Pregnancy is the gestational process, that is, the pro- cess of development of a fetus from fertilization until birth. What can a woman do to prepare her body for pregnancy? What can she do during the prena- tal period, the time during which she is pregnant, to increase her chances of delivering a healthy baby?
Prepregnancy and Prenatal Care Various teratogens, environmental in'uences such as drugs, alcohol, viruses, cigarette smoking, and dietary de!ciencies, can damage the embryo or fetus. "e most highly sensitive periods of the developing structures of the embryo and fetus to teratogens occur primarily during the !rst 8 weeks a$er conception,
possibly before a woman knows that she’s pregnant. "erefore, if you are trying to become pregnant, to avoid birth defects, you should take care of your body as if you were pregnant. "e Analyzing Health- Related Information feature in this chapter discusses folic acid (folate), a B vitamin critical to proper neu- ral tube development of the embryo. Table 5.1 lists various teratogens and their detrimental e#ects on the embryo/fetus.
A woman preparing for pregnancy should have a medical checkup to determine if her level of anti- bodies against rubella (German measles) is su&cient. She should also be screened for sexually transmit- ted infections (STIs), especially HIV, and should avoid changing the cat’s litter box to protect herself from contracting toxoplasmosis (infection with a microscopic parasite found in cat feces). Addition- ally, a woman preparing for pregnancy should seek her healthcare provider’s advice regarding the use of medications.
It is important that a woman contemplating preg- nancy eat a well-balanced and nutritious diet to enter this critical period with su&cient nutrient stores and blood levels to meet the needs of the pre-embryo and embryo before the placenta is established. ("e body has both short-term and long-term nutrient stor- age capabilities.) A woman should also consult her healthcare practitioner regarding proper nutrition during pregnancy. A pregnant woman should not assume that she is “eating for two” in the sense that she should double her food intake. Her need for calo- ries, protein, and calcium is only somewhat greater than her prepregnancy need. Excessive weight gain during pregnancy may mean excess body fat retained long a$er pregnancy. Although certain nutrients are extremely important (such as folate, which helps pre- vent neural tube defects), a pregnant woman should take only the vitamin supplements that her health- care provider prescribes. Some nutrients, such as vitamin A, are teratogens in certain quantities.
It is critical that a woman avoid drinking alco- hol, smoking cigarettes, and taking any other drugs (unless they have been prescribed) when preparing for pregnancy and during pregnancy. Alcohol con- sumption can cause a fetal alcohol spectrum disor- der, which can result in a variety of birth defects, including intellectual disability, growth de!ciency, and hyperactivity. Smoking during pregnancy can result in a low-birth-weight baby who is weak, has a reduced brain size, and is vulnerable to illness. If a pregnant woman is addicted to a drug, her baby will be born addicted as well. In addition, she is more
pregnancy The gestational process; the process of development of a fetus from fertilization until birth.
teratogens Various environmental influences such as drugs, alcohol, viruses, and dietary deficiencies that can damage the embryo or fetus early in pregnancy.
amniocentesis A prenatal test performed generally between the 15th and 18th weeks of gestation, in which some of the amniotic fluid that surrounds the fetus is removed and studied to determine whether the fetus has a genetic abnormality.
chorionic villus sampling (CVS) A prenatal test performed generally between the 10th and 12th weeks of gestation, in which some of the fetal extraembryonic tissue is removed and analyzed to determine whether the fetus has a genetic abnormality.
human chorionic gonadotropin (hCG) In a pregnant woman, a hormone produced by embryonic tissues destined to become the placenta. Pregnancy tests rely on the detection of this hormone in the blood.
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likely to experience complications during pregnancy and have a baby with severe birth defects. Taking drugs—including alcohol—occasionally can also damage the embryo or fetus. No safe level of these teratogens has been determined.
Women older than 35 years of age have a higher risk of having babies with Down syndrome (a genetic
abnormality resulting in intellectual disability) than younger women. Older women may choose to have diagnostic tests such as amniocentesis and CVS dur- ing pregnancy to detect possible genetic disease or other abnormalities in the fetus. In addition, cou- ples o$en seek genetic counseling before becoming pregnant. If anyone in a couple’s family has a genetic
Pregnancy and Human Development 135
Teratogen Explanation
Maternal Infectious or Noninfectious Disease
Cytomegalovirus A herpes-type virus that can cross the placenta and infect the embryo and is found in about 1% of newborns. Most defects affect the nervous system. Risk of brain damage is 50% after infection early in pregnancy. One in 10 affected fetuses die.
Diabetes mellitus Risk of major malformations is about 18%. Heart malformations and neural tube defects are most frequent. Risk is greatest in uncontrolled or poorly controlled diabetes.
Phenylketonuria (PKU), untreated
Excess phenylalanine, not the defective gene, causes birth defects such as intellectual disability and malformations of the heart.
Rubella The German measles virus can cross the placenta and infect the embryo. Infection during the first 3 months of pregnancy is likely to result in abnormalities such as deafness, heart defects, and intellectual disability.
Drugs, Other Chemicals, and Radiation
Alcohol Main characteristics of the birth defects caused by maternal alcohol consumption are growth deficiency, hyperactivity, distractibility, small head, underdevelopment of the brain, and intellectual disability. No safe level of alcohol consumption during pregnancy is known.
Anticonvulsant medication Probability of birth defects varies with medications, dosage, and stage of pregnancy.
Chemotherapeutic agents Drugs used to treat cancer can also harm the embryo or fetus.
Cocaine Some possible birth defects from cocaine use during pregnancy are bleeding in the brain, death of part of the brain tissue, underdeveloped head and brain, prematurity, and seizures.
Diethylstilbestrol (DES) A drug formerly prescribed for women who were in danger of having a miscarriage. This drug affected some of their female offspring, causing unusual vaginal, cervical, and uterine changes beginning in adolescence, as well as an increased risk for developing a certain type of vaginal and cervical cancer.
Ionizing radiation Extremely high exposure to X-rays or exposure to radiation used in cancer therapy can affect the embryo or fetus and result in an underdeveloped head and brain.
Accutane The synthetic form of Vitamin A is used to treat certain types of acne. Birth defects that may result from use during pregnancy (when taken by mouth) include malformations of the ear, brain, and heart. Healthcare providers also suggest avoiding megadoses (more than 10,000 I.U.) of Vitamin A during pregnancy.
Thalidomide A drug taken for morning sickness in the 1960s. Taking this drug between 20 days and 36 days after conception resulted in major anatomic deformities of the limbs and heart.
Selected Teratogens Known to Cause Birth Defects
Table 5.1
Managing Your Health Genetic Counseling and Prenatal Diagnosis You and your partner have decided it’s time to have a baby. You are both wor- ried that a genetic disease may run in your families. (A genetic disease is caused by problems with the heredi- tary, or genetic, material.) Also, you’re
worried about the risk of birth defects because “mom” will be far past age 35 when she gives birth, and the likeli- hood of genetic diseases is higher than at younger ages. What can you both do to ensure the genetic health of your baby?
Your first step might be to discuss your concerns with an obstetrician/gynecologist. Your healthcare practi- tioner may send both of you to a genetic counselor to explore the incidence of genetic disease in your families and to determine the probability of you and your partner having a child with a genetic disorder.
There are many reasons to seek genetic counseling. Parents with a child who has a genetic disease often choose genetic counseling to determine the probabil- ity that future children will be affected. In populations at high risk for certain genetic diseases, such as sickle cell anemia in African Americans or Tay-Sachs disease in Ashkenazi Jews, families or prospective parents may visit genetics centers to undergo screening tests. Once screening has been done and the carriers and noncarri- ers of the disease have been identified, the genetic coun- selor can advise them of their probability of passing on problem genes to children.
After the fetus is conceived and before birth, vari- ous techniques are available to tell for sure if the fetus is affected with any of a wide variety of disorders. Tests performed on the fetus (or related tissues) to determine its health are called prenatal diagnoses. Methods that are frequently used are ultrasound amniocentesis and chorionic villus sampling (CVS). These methods can detect many, but not all, fetal abnormalities.
Ultrasound scanning, or sonography, is a common, painless, safe, and relatively inexpensive procedure for prenatal diagnosis that has been used since the 1960s. Ultrasound uses high-frequency sound waves to visu- alize the fetus, which can be seen as early as 7 weeks of development. The ultrasound probe is moved over the woman’s abdomen. Sound waves enter the uterus and bounce off fetal structures in ways that reflect their density and makeup. The reflected waves are projected on a monitor screen (Figure 5.A), and their patterns are interpreted by a healthcare provider. Using this tech- nique, a healthcare provider can detect many structural abnormalities, estimate the age of the fetus, confirm if
multiple fetuses are present, and confirm fetal position. In addition, ultrasound is often used to help guide nee- dle placement in amniocentesis, fetal blood sampling, and CVS.
Another common type of prenatal diagnosis is amnio- centesis, which was developed in the 1960s and was widely used by the 1970s. Amniocentesis involves the removal of some of the amniotic fluid that surrounds the fetus. This watery fluid protects the fetus from jar- ring movements and contains waste products and some cells from the fetus. Geneticists observe these cells to determine whether the fetus will be born with a genetic abnormality. In addition, medical technicians can per- form tests on the fluid to determine the presence of sub- stances that are indicators of various conditions, such as certain neural tube defects and Rh disease (a blood incompatibility problem between mother and fetus).
To extract some amniotic fluid and cells from around the fetus, the physician inserts a thin, long needle through the abdominal and uterine walls of the mother until the needle pierces the amniotic sac (Figure 5.B). (The physician guides the needle using ultrasound so that it will not injure the fetus and anesthetizes the
136 Chapter 5 Reproductive Health
Figure 5.A Ultrasound in Pregnancy. The ultrasound probe produces sound waves that bounce off fetal tissues. As the probe is moved across a pregnant woman’s abdomen, images that provide information about the position, size, and physical condition of the fetus are visualized on a screen. © Chris Ryan/OJO Images/Getty Images.
abdominal wall with a local anesthetic.) After the fluid is withdrawn, the cells must be grown, or cultured, which takes approximately 4 weeks. This technique is now per- formed as early as 11 weeks of gestation but is routinely performed between 15 and 18 weeks, so diagnosis is gen- erally completed by the 19th to 22nd week. This proce- dure is considered safe; the risk of miscarriage resulting from amniocentesis is 0.2% to 0.3% (1 in 300 to 500).
Fetal blood sampling was developed in the 1970s. Extracting blood from the fetus is risky; however, blood can be withdrawn safely from the umbilical vein. Using this technique, physicians can screen infants for various blood disorders, such as sickle cell anemia and hemo- philia, and check for fetal oxygen levels or infection. The risk of miscarriage with this technique is up to 2% (2 in 100). This technique is least risky when performed between 18 and 21 weeks of pregnancy but can be done as early as week 17.
Chorionic villus sampling (CVS) was also devel- oped around 1970 but came into wide use in the 1980s. The chorion is the outermost of the fetal membranes (Figure 5.C) that facilitate the exchange of nutrients, gases, and other materials such as waste products between the fetus and the mother. The umbilical cord extends from the fetus to the chorion. Fingerlike projec- tions called villi (singular, villus) extend from the chorion
into maternal tissues at the placenta, the part of the chorion that joins mother and fetus. In this way, the blood of the fetus, circulating through blood vessels in the chorion and its villi, comes into close contact (but does not mix) with maternal blood vessels. To perform CVS, a physician inserts a thin tube or a needle into the vagina and up into the uterus or can enter the uterus by puncturing the abdomen. The instrument vacuums up a tiny sample of villi. Although this technique has the advantages of early testing (weeks 10 to 12) and quick analysis of cells (no culturing is needed), the risk of miscarriage is approximately 1% (1 in 100). CVS was previously thought to cause birth defects of the limbs in some pregnancies, but it has been determined that such defects occur at the same rate as in pregnancies without CVS.
Today, using ultrasound to guide them, physicians are able to sample fetal skin and certain other tissues. In addition, some conditions can be treated before birth with a blood transfusion or one of the forms of fetal surgery currently available. The choices that remain are terminating the pregnancy or carrying the fetus to term. If the second choice is made, prenatal diagnosis is extremely helpful to ensure that the baby receives the best possible medical care for its condition immediately upon birth.
Figure 5.B Amniocentesis. In the amniocentesis procedure, a long, thin needle is used to pierce the mother’s abdominal wall and uterus and withdraw amniotic fluid. Free fetal cells are found in this fluid and can be analyzed for the fetus’s sex, age, and indications of chromosomal abnormalities.
Pregnancy and Human Development 137
Amniocentesis
Amniotic sac
Uterus
Placenta
Centrifuge
Cells from amniotic fluid
Analyzed for biochemical or chromosomal defects
Amniotic fluid withdrawn from cavity
Cell culture
Figure 5.C Chorionic Villus Sampling. One way to perform CVS is to insert a tube, or catheter, into the vagina, up through the cervix, and into the uterus. This tube is used to collect pieces of chorionic villi, which are part of the outer fetal tissue called the chorion (not part of the fetus). These cells are analyzed for chromosomal abnormalities.
disease, seeking genetic counseling may be prudent. ("e Managing Your Health essay “Genetic Counsel- ing and Prenatal Diagnosis” discusses prenatal tests and counseling.)
Many women want to know if exercising during pregnancy will hurt the fetus. Generally, if a woman was exercising before she became pregnant, she can continue exercising while she is pregnant. However, a healthcare provider may suggest modi!cations in a pregnant woman’s workout regimen. Also, some healthcare providers recommend that their previ- ously sedentary patients start a mild exercise pro- gram to help them become stronger and develop stamina for the birth process.
Determining If You Are or Your Partner Is Pregnant How do you know if you are (or your partner is) preg- nant? By noticing certain physical signs, you may become aware of this condition. A pregnant woman will not menstruate, so a missed menstrual period may be the !rst sign. However, a pregnant woman may
experience implantation bleeding about a week before the expected time of the menstrual period. "is small amount of blood 'ow from the uterus occurs when the fertilized ovum nestles into the uterine wall. "e breasts may feel sore, she may feel nauseated at certain times during the day or all day, and she may feel tired, moody, or both. "ese signs are bodily reactions to changes in hormone levels during pregnancy.
If a woman suspects that she is pregnant, she may choose to conduct a home pregnancy test or visit her gynecologist/obstetrician for such a test. "e Consumer Health feature “Home Pregnancy Tests” discusses how pregnancy tests work and provides guidelines for conducting such a test.
If a woman has missed more than one menstrual period and is certain that she is not pregnant, she should see her healthcare provider. Amenorrhea (ah-MEN-oh-REE-ah), or abnormal stoppage of the menses, is most o$en caused by stress, weight loss, or strenuous exercise regimens. However, it can have more serious causes, such as hormonal imbalances or tumorous growths.
138 Chapter 5 Reproductive Health
Bladder Abdominal wall
CervixThin tube
Chorionic villi Amniotic sacPlacenta
Fetus at 9-11 weeks
Pregnancy and Fetal Development Pregnancy usually lasts 38 weeks, or approximately 9% months. "e delivery date is calculated to be 40% weeks from a woman’s last menstrual period
because conception (fertilization) usually occurs in the middle of the cycle. Typically, pregnancy is described in terms of trimesters, or 3-month periods, dur- ing which certain developmental events take place. (Because months are more than 4 weeks, the month- to-week correlations given here are approximate.)
"e !rst trimester is a crucial time of development when all the organ systems of the body are forming and becoming functional. Cells in the embryo migrate to key developmental positions, shaping the fetus as it takes on a human form. In contrast, the second and third trimesters are periods of growth and re!nement of the organ systems. Figure 5.7 through Figure 5.11 depict the development of the pre-embryo (the !rst 2% weeks of development), the embryo (weeks 3–8), and the fetus (weeks 9–38). Figure 5.7 also describes ectopic pregnancy, implantation of the embryo out- side of the uterus.
While the fetus is developing, changing, and growing over 9 months, changes also take place in
Consumer Health Home Pregnancy Tests Most pregnancy tests rely on the detection of the hor- mone human chorionic gonadotropin (hCG). This hormone is produced by embryonic tissues destined to become the placenta, the organ that allows the exchange of nutrients, gases, and wastes between the fetus and a pregnant woman. Pregnancy tests to detect hCG can be conducted on either blood or urine. Urine tests are most frequently used to detect hCG because urine is easier to collect than blood. This is the type of test in home test kits.
The way pregnancy tests work is that hCG binds with specific antibodies in the test kit. If a woman is not preg- nant, hCG will not be present in her urine, binding will not occur, and the test will be negative. If a woman is pregnant, hCG will be present in her urine, binding will occur, and the test will be positive.
Home pregnancy tests are easy to use. These tests contain either a plastic stick with an absorbent part that is placed in the urine flow or immersed in a container of collected urine, or a plastic device with an opening con- taining absorbent material into which drops of urine are placed. While a woman waits, the urine moves through the absorbent material inside either type of device, and the hCG (if present) attaches to an antibody that has a color label such as blue or red. The hCG-antibody
complex then moves to another win- dow where it binds to a second antibody attached to the absorbent material in either a line, symbol, color, or the word pregnant. If hCG is not present in a woman’s urine, the line, symbol, color, or the word pregnant will not appear.
It is important to follow the directions of a home test carefully and wait the prescribed length of time to “read” the result. Testing the first urine of the day is best because hCG is most concentrated in the first urine. The manufacturers of home pregnancy tests claim that a woman can test her urine on the first day of her missed period or before and that she will obtain results that are 99% accurate. However, hCG levels are usually quite low this early in pregnancy. It may be advisable to obtain a blood test from a healthcare practitioner for a reliable early result or to wait at least a week after one’s missed period to use a home pregnancy test, using the first urine of the day. It is advisable to check the expira- tion date on the package and use only tests that have not expired. One may also decide to repeat the test after a few days regardless of the result of the initial test.
If you are unsure which test to choose, ask a pharma- cist for help. A woman who has a positive test should see her healthcare provider immediately for a confirma- tory test and appropriate prenatal care.
4Women preparing for pregnancy should have a medical checkup, eat a well-balanced and nutritious diet, and avoid drinking alcohol, smoking cigarettes, or using other drugs.
4Women and men concerned about the possibility of passing a genetic condition on to their offspring can seek genetic counseling when considering pregnancy.
Healthy Living Practices
Pregnancy and Human Development 139
the mother’s body. Figure 5.12 summarizes these changes. In addition, the pregnant woman may experience nausea, vomiting, frequent urination, leg cramps, vaginal discharge, fatigue, and constipation during the !rst trimester. Nausea, vomiting, and leg cramps (if present) usually subside by the second trimester. At that time, additional changes may take place. In her last two trimesters, a pregnant woman may experience swelling of the legs and feet, varicose veins, backache, heartburn, and shortness of breath, in addition to continuing vaginal discharge, frequent urination, fatigue, and constipation. Table 5.2 lists various problematic conditions that may occur dur- ing pregnancy. As women of childbearing age get older, their risks for pregnancy complications and adverse outcomes increase.6
The Birth Process No one is certain what events signal the beginning of labor, the process of childbirth. Labor, also called parturition, takes place in three stages: cervical dila- tion, fetal delivery, and placental delivery. "e birth process normally takes about 13 hours for a woman who is giving birth for the !rst time. In women who have previously given birth, the typical time shortens to about 8 hours.
Two main events occur during dilation: Rhythmic contractions of the uterine muscles cause the cervix (the opening of the uterus) to dilate (widen) and to e#ace (thin out). In the nonpregnant state, the cervix is hard and tubelike, with an extremely narrow open- ing. During the !rst stage of labor, the cervix becomes so$. "e opening widens and the tissue stretches so that by the end of the !rst stage of labor, the cervical opening is 3.5–4 inches wide, and the tubular cer- vix no longer exists as such—it 'attens and becomes
labor (parturition) (PAR-too-RISH-un) The process of childbirth.
Figure 5.7 Fertilization and Implantation. The first event in human development is fertilization, which takes place in the uterine (fallopian) tube. The fertilized ovum begins to divide as it moves along the tube to the uterus and is now referred to as a pre-embryo. At 4 days after fertilization, the developing ball of cells begins to fill with fluid, a stage of pre-embryonic development termed the blastocyst. Approximately 6 days after fertilization, the blastocyst implants in the back wall of the uterus. During implantation, the embryo attaches firmly to the inner lining of the uterus. This illustration shows the journey of the fertilized ovum from the fallopian tube to the uterus. Occasionally, implantation takes place outside of the uterus, a condition known as ectopic pregnancy. Pre-embryos may implant on an ovary, on the intestine, or in a fallopian tube. All ectopic pregnancies endanger the mother’s life.
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Endometrial wall
Corpus luteum
Blastocyst
Uterus
Ovary
Uterine (fallopian) tube
FERTILIZATION
Four-cell stage
OVULATION IMPLANTATIONOF BLASTOCYST
Figure 5.8 Human Embryo Between 4 and 5 Weeks of Development. As the pregnancy moves into the 3rd week, the pre-embryo is only 0.10 inches long. The flattened pre-embryo develops into a cylindrical embryo. Some of the organs, such as the heart, begin to develop. This 4.5-week-old embryo has established the beginnings of most of the major organ systems of the body. Its C-shaped body has a featureless head, a middle with the heart and liver bulging from the body, and a tail. During the 5th week, the embryo doubles in length, from 4 millimeters (0.18 inches) to 8 millimeters (0.38 inches). The brain grows rapidly. Wrists, fingers, and ears begin to form during the 6th week of development. Although development has been rapid, growth has not. By the end of the 6th week, the embryo is approximately a half-inch long.
Figure 5.9 Human Fetus at About 11 to 12 Weeks of Development. During the 7th week, eyelids begin to cover the eyes, and the face begins to look somewhat human. By the 8th week, the last week in the embryonic period, the embryo grows to about an inch. Most of the body systems are functional by this time. The fetal period begins at week 9, lasts throughout the rest of the pregnancy, and is characterized by growth and functional maturation of the organs. During weeks 9–13 (the 3rd month), facial features further develop, with eyelids completely covering the eyes and then fusing shut. (The eyes can be seen through the thin eyelids.) The genitals begin to develop, and the heart is now a four-chambered structure.
Figure 5.10 Human Fetus at About 5 Months (20 Weeks) of Development. The second trimester comprises the 4th, 5th, and 6th months of development, or weeks 14–26. The organs that developed during the first trimester mature and grow during this trimester. As the 4th month passes, the genitals become fully formed. The sensory organs nearly finish their development, and refinements of body structures occur. The mother becomes aware of fetal movements around the 5th month of pregnancy, the stage of development of the fetus in the photo. By the end of the 5th month, as fat deposits are laid down, the fetus begins to look more like a baby. Only 12 inches long and weighing 1 pound, it probably could not survive on its own. However, if born by the end of the 6th month, the fetus has a chance of surviving with special medical care.
Pregnancy and Human Development 141
© Kateryna Kon/Shutterstock. © Sebastian Kaulitzki/Shutterstock.
© Neil Bromhall/Science Photo Library/Science Source.
By the end of the !rst stage of labor, during a period called transition, contractions occur every 1–2 min- utes and last up to a minute each.
Some women experience preparatory contractions that are not a part of labor, which are called Braxton- Hicks contractions, or false labor. False labor con- tractions can be distinguished from the contractions of true labor in that they occur irregularly, the inter- vals between contractions do not shorten, and the contractions do not increase in strength. A woman experiencing these contractions should consult her physician to con!rm that she is not in labor.
During the second stage of labor, the baby is born. "e typical time for this stage is 30–60 minutes. Uterine contractions continue and move the baby
continuous with the lower portion of the uterus (Figure 5.13). During this time—or before labor in some cases—the amniotic sac ruptures (the water breaks), releasing the amniotic 'uid. "is 'uid cush- ions the fetus during development. "e baby must be born within 24 hours of the rupture, or serious infec- tion could occur.
In the beginning of her labor, a woman’s uterine contractions may last for 30 seconds and be 15–20 minutes apart. As labor progresses, the contractions become stronger, longer, and more closely spaced.
Figure 5.11 Human Fetus at Nearly Full Term—8–9 Months. During the third trimester, months 7–9 or weeks 27–38, the fetus primarily gains weight. Its lungs develop more fully, eyelids open, and the nervous system undergoes further development. However, the nervous system is not fully developed in utero, and its maturation continues after birth. At the end of the third trimester, the average fetus weighs about 7.5 pounds and is 20 inches long.
Figure 5.12 A Summary of the Physical Changes That Take Place During Pregnancy. (Left) The unpregnant female body; (right) changes that appear by 30 weeks of fetal development.
Braxton-Hicks contractions False labor; preparatory contractions that are not a part of labor.
© Petite Format/Nestle/Science Source.
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Anterior pituitary enlarges (increases secretory activity)
Patches of pigment appear on face (brown-pink)
Thyroid gland enlarges (increases metabolism)
Breathing becomes more frequent
Heart enlarges slightly
Pigmented streaks appear on breasts (brown-pink)
Breasts enlarge
Cortex of adrenal glands enlarges
Nipples darken, enlarge, become erectile
Areolas darken (brown) and enlarge
Skin darkens (brown) around areolas
Diaphragm rises
Pigmented (brown-pink) streaks appear on skin of abdomen
Uterus enlarges 50 to 60 times original size
Brown line appears in center of abdomen
Brown pigment appears around vulva and striations on thighs
into the birth canal (vagina). "e woman pushes and bears down, aiding this process. "e head usually appears !rst, but some babies are born in the breech position, feet or buttocks !rst. A breech birth is a more complicated delivery than a head-!rst delivery and may require surgical removal of the baby through the abdominal wall—a cesarean section. During a vaginal delivery, the physician may perform an episiotomy, making a cut in the tissue surrounding the vaginal opening to widen the opening. "is cut is usually made in the direction of the anus. Without
this procedure, the skin and surrounding tissues may sustain more damage and heal with more di&culty than surgically cut tissue.
breech birth A delivery in which the baby presents feet or buttocks first instead of the usual head-first position.
episiotomy (uh-pee-zee-OT-uh-me) A cut in the tissue surrounding the vaginal opening to widen it during a vaginal delivery so that the surrounding skin and tissues will be less likely to tear.
Pregnancy and Human Development 143
Name of Condition (Alternative or former names) Definition Cause Symptoms Treatment
Ectopic pregnancy Fertilized egg implants outside the uterus (majority occur in the uterine tube).
Problems with anatomy of uterine tubes, possibly resulting from pelvic inflammatory disease, uterine surgery, or use of an IUD.
Loss of menses, pelvic or abdominal pain, abnormal vaginal bleeding.
Surgery to remove embryo.
Nonsurgical treatments may be used in certain situations.
Pregnancy-induced hypertension [PIH] (Preeclampsia) (Toxemia of pregnancy)
A group of metabolic disturbances.
Unknown. High blood pressure, water retention, and an excess of protein in the urine, occurring in the third trimester.
Primarily a disease of first pregnancy. Occurs with higher frequency in adolescent women and those older than 35 years.
Bed rest. Medication to reduce blood pressure and prevent seizures.
Delivery usually cures the condition.
Eclampsia An extension of PIH to the point of seizure, coma, or both.
Unknown. Increase in blood pressure from that in PIH, abdominal pain, blurry vision, headache, shakiness.
May occur in third trimester or postpartum.
Convulsions and high blood pressure are treated with medication.
Delivery takes place as soon as patient is stabilized.
Diabetes mellitus associated with pregnancy (Gestational diabetes mellitus [GDM])
A metabolic disorder that leads to high glucose levels in the blood. In pregnancy, poor control of blood glucose levels can lead to fetal abnormalities.
Hormonal changes of pregnancy often result in a display of diabetes in women with risk factors for the disease.
Women with risk factors for diabetes (obesity and family history) should be screened before and during pregnancy.
Control of blood glucose level with diets and/or insulin injections.
Data from Rivlin, M. E., & Martin, R. W. (Eds.). (2000). Manual of clinical problems in obstetrics and gynecology (5th ed). Philadelphia: Lippincott Williams & Wilkins; and Zuspan, F. P., & Quilligan, E. J. (1998). Handbook of obstetrics, gynecology, and primary care. St. Louis, MO: Mosby
Pregnancy Problems and Symptoms
Table 5.2
A$er the baby is born, her or his nose and mouth are cleared of mucus by suctioning. "e umbilical cord is clamped in two places and cut between the clamps to prevent bleeding. Healthcare practitioners assess the baby’s ability to adjust to life outside the uterus at 1 minute and then 5 minutes a$er birth.
Within 15–30 minutes a$er delivery, the uterus continues to contract, separating the fetal placental tissues from maternal tissues. During this third stage of labor, the placenta is expelled from the uterus. Figure 5.13 visually summarizes the birth process, showing the three stages of labor.
Circumcision Although few data are available, the National Hos- pital Discharge Survey from the Centers for Disease Control and Prevention (CDC) shows that approxi- mately 56% of male newborns are circumcised in the United States.7 In some groups, such as followers
of the Jewish and Islamic faiths, circumcision rates approximate 100% because the procedure is prac- ticed for religious and cultural reasons. Circumcision is a surgical procedure to remove the foreskin of the penis, which is a fold of skin covering the end of the penis. "e photos in Figure 5.14 show both an uncir- cumcised and a circumcised penis.
Existing scienti!c evidence demonstrates poten- tial medical bene!ts of newborn male circumcision, such as lowered risk of urinary tract infections, espe- cially in infants younger than 1 year of age, lowered risk of penile cancer, and lowered risk of STIs, espe- cially herpes (HSV-2) and HIV infection. Evidence also suggests that circumcision may reduce the prevalence and transmission of human papilloma- virus, which is linked to the development of cervi- cal cancer.8 However, the policy statement of the American Academy of Pediatrics (AAP),9 which was rea&rmed in 200510 and again in 2012,11 notes that,
Figure 5.13 The Stages of Labor. (a) The position of the fetus at the beginning of labor. (b) Dilation, the cervix (the opening to the uterus) widens and thins. (c) Expulsion, the baby is born. (d) Placental delivery.
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Ruptured amniotic sac
Placenta
Uterus Umbilical cord
Urinary bladder
Symphysis pubis
Vagina Cervix
Rectum
Placenta Placenta
(a) Early first-stage labor (b) Later first-stage labor: the transition
(c) Early second-stage labor (d) Third-stage labor: delivery of placenta
in general, the di#erences in risk are small, and the data are not su&cient to recommend routine cir- cumcision of male newborns at this time. In addi- tion, circumcision has some risk, as does any surgical procedure, though complications are rare and usually minor. "erefore, the AAP suggests that parents, in conjunction with their pediatricians, decide what is in the best interest of the child, based on medical and nonmedical factors (e.g., parents’ cultural and reli- gious beliefs). If the decision is made for circumci- sion, the academy strongly recommends giving the infant pain relief medication.
The Postpartum Period "e postpartum period is the 6 weeks a$er childbirth during which a mother’s body returns to its pre- pregnant state. One of the areas of the body a#ected greatly, of course, is the reproductive system. "e uterus returns nearly to its original size. Within 2%weeks, the cervical opening closes to a slit, and tis- sue damage that occurred to it during the birth pro- cess heals. "e vagina, bruised and swollen from the newborn traveling through it, returns to normal a$er about 3 weeks. "e episiotomy and any torn tissues surrounding the vaginal opening heal within 1 week.
A variety of other organ systems and tissues in the mother’s body change during pregnancy and return to their prepregnant state during the post- partum period and beyond. For example, muscles in the pelvic region gradually regain their original tone,
but this process may take up to 6 months. During the !rst few days a$er delivery, a woman may have trouble urinating because of bruising of the bladder, the e#ects of anesthetics, and swelling of the ureters (tubes that lead from the kidneys to the bladder). "e ureters may remain swollen for up to 3 months, although problems with urination usually last only a few days. During the birth process and the expul- sion of the placenta, a woman loses blood. Her blood plasma and red blood cell volumes usually return to the normal nonpregnant state by the end of the post- partum period but may take a few additional weeks. Hormonal changes are comparatively rapid a$er delivery; some return to normal levels by the end of the !rst postpartum day, but others take 1–2 weeks to normalize.
Many women experience postpartum depression, especially in the week a$er delivery. Approximately 40–85% of women experience mild depression, o$en referred to as “the baby blues.” "is mild form of depression, o$en accompanied by mood swings, is thought to be a result of the physical and mental stresses of childbirth, as well as the variety of physi- cal (including hormonal) changes that take place during that time. Symptoms include periods of cry- ing, sleep disturbances, loss of appetite, and confu- sion. Whereas the baby blues do not require medical attention, more serious postpartum depression does. "is disorder can occur up to 1 year a$er giving birth and a#ects 10–15% of mothers.12 "e prevalence of
Figure 5.14 Circumcision. (a) Uncircumcised penis. (b) Circumcised penis.
Pregnancy and Human Development 145
$a) © John Henderson/Alamy Stock Photo.
(a) (b)
postpartum depression varies by age (ranging from about 23% of women aged 19 or younger to 10% women in their 30s), race/ethnicity (ranging from about 22% among non-Hispanic Black women, 17% among Hispanic women, and 12% among non- Hispanic White women), and geographic location (ranging from about 21% in Tennessee to just under 10% in Minnesota).13
At the beginning of the postpartum period, many women also start breastfeeding their infants.
from about 200 million to 800 million. A sperm count lower than 20 million sperm per milliliter (40%million to 160 million total) in the ejaculate may impair fertility.
In addition to a low sperm count, a high percent- age (usually more than 40%) of abnormally shaped sperm can a#ect male fertility. Abnormally shaped sperm, such as those with two heads or abnormally shaped heads or tails (Figure 5.15), may not be able to swim well. "ese defects may reduce their chances of reaching the egg.
Male infertility is o$en related to a variety of envi- ronmental factors or diseases. Cigarette smoking, chronic alcoholism, various medications, and pro- longed illnesses with accompanying fever all a#ect sperm production. Infection with the mumps virus can render a man sterile.
A man can also have a problem with sperm trans- port, which can cause infertility even if the sperm count is adequate for conception. Infections caused by certain STIs can block the vasa deferentia and injure these tubes. Erectile dysfunction is also a com- mon cause of infertility if a man is unable to ejaculate.
"ere are a variety of causes of infertility in women. In some instances, the vagina cannot be pen- etrated because of an intact hymen (a membrane that partially covers the vagina and that is usually rup- tured at the !rst intercourse, if it is present) or due to vaginismus (involuntary, painful contractions of
infertility Inability to conceive a child after 1 year of unprotected sex.
4If you are female and in your reproductive years, have missed a period, are nauseated at times, feel tired often, and are experiencing moodiness, check with a healthcare practitioner; you may be pregnant.
4Manufacturers claim that home pregnancy tests can be used before or on the day of a missed period or thereafter to determine pregnancy. However, early results may be unreliable. A healthcare practitioner can provide laboratory testing to confirm pregnancy.
Healthy Living Practices
Infertility Infertility is the inability of a couple to conceive a child a$er 1 year of unprotected sex and a#ects 12.1% of women aged 15–44 in the United States.14 Some infertility experts suggest that couples wait for 2 years before seeking help for infertility. Infertility is not necessarily the result of “a problem” with one partner or the other. Factors that slightly impair the fertil- ity of both sexual partners may interact to render a couple infertile.
Factors That Affect Fertility One reason for male infertility is faulty sperm produc- tion. In normal sperm production, the semen con- tains approximately 80 million to 120 million sperm per milliliter. Because the ejaculate volume ranges from 2 to 8 milliliters (slightly less than a teaspoon to nearly 2 teaspoons), the total sperm ejaculated ranges
Figure 5.15 Abnormal Sperm. Abnormal sperm exhibit various types of malformations. A normal sperm is shown at the top.
146 Chapter 5 Reproductive Health
Normal sperm
Double head sperm
Coiled tail sperm
Misshapen head sperm
Small head sperm
Kinked tail sperm
the vagina). Some abnormalities in the structure of the vagina, which may be present at birth or caused by scarring from STIs or trauma, allow only partial penetration. Unknowingly complicating the prob- lem, couples having trouble with penetration o$en use lubricants, which may have spermicidal proper- ties (i.e., kill sperm).
Once sperm travel up the vagina, they must pass through the cervix to reach the uterus and the fal- lopian tubes. Secretion of mucus by the cervix is important for sperm motility. Infection can dam- age the glands that secrete mucus or result in the presence of white blood cells. "e properties of this mucus also change if a woman has an estrogen de!ciency. Such changes in the quality and quan- tity of mucus can impair the sperm’s ability to reach an egg.
Structural defects of the uterus do not usually cause infertility; usually such problems result in repeated miscarriage. However, the uterine (fal- lopian) tubes can be another fertility trouble spot. Infection with Neisseria gonorrhoeae or Chlamydia trachomatis can result in severe tissue destruction, completely blocking the tubes and causing sterility. Infections of other origins, such as from appendici- tis or intrauterine device (IUD) complications, may result in less severe blockage. Pregnancy may occur, but the risk is increased for ectopic pregnancy. Endo- metriosis, the growth of abnormal tissue in the abdo- men, is another cause of sterility, ectopic pregnancy, or both.
"e ovaries can be the source of impaired fertility. Hormonal imbalances can interfere with ovulation, and a mumps infection, radiation, and chemotherapy can damage the ovaries. Function of the ovaries declines as a woman ages, reducing her ability to con- ceive. Occasionally, because of an unknown cause, a young woman can experience a decline in the func- tion of the ovaries known as primary ovarian insuf- !ciency, in which she prematurely “runs out” of cells destined to become eggs.15 Dietary de!ciencies, fre- quent strenuous exercise, smoking, and obesity have also been shown to negatively a#ect ovary function and the ability to conceive.16–18
Treating Infertility To treat infertility, a physician skilled in this practice begins with extensive histories of the couple’s health. "is may be followed by a series of relatively simple tests, such as a sperm count, to rule out common causes of infertility. Other, more extensive, physi- cal examinations may be necessary to determine the
cause. In some instances, the cause cannot be deter- mined. Treatments are speci!c to the known causes of the infertility and include surgical procedures, hormone therapy, medication, and lifestyle changes. In addition, nutritional treatment is currently being investigated. Research results reveal that either sperm quality or pregnancy rate rose in men a$er treatment with oral antioxidants, such as vitamins C and E, zinc, and folate.19
In addition to these therapies, physicians can har- vest ova and obtain semen to assist fertilization and implantation. For example, if a couple has problems with sperm reaching the cervix, cervical conditions that are hostile to sperm, or the health of the sperm themselves, a physician may suggest arti!cial insemi- nation, which has been practiced in the United States for more than 50 years. During this procedure, semen is placed in the cervical opening during the time of ovulation. With intrauterine insemination, concen- trated sperm are placed in the uterus.
Women who have no uterine tubes or blocked tubes that do not respond to surgery o$en choose in vitro fertilization (IVF) to conceive. In vitro means “in a test tube” or “in the laboratory.” In vitro fer- tilization involves fertilization of ova with sperm in laboratory glassware, with subsequent implantation of zygotes (fertilized eggs) in the woman’s uterus. "e birth of the !rst baby conceived through in vitro fer- tilization took place in 1978.
In 1992, a new IVF technique called intracyto- plasmic sperm injection, or ICSI, was developed to fertilize eggs directly. Early IVF techniques involved putting eggs and sperm together and allowing sperm to swim to and fertilize the eggs. In the late 1980s, a technique was developed in which a few sperm were injected into the space between the egg and its barrier, increasing the chance of fertiliza- tion. "e ICSI technique involves injecting a single sperm directly into the egg. It is used when men have a very low sperm count, nonmotile sperm, or sperm unable to penetrate the chemical barrier that protects the egg.
Any treatment of infertility in which the sperm and eggs are both handled outside the body is called assisted reproductive technology. Although assisted reproductive technology has been helpful, studies urge some caution. "e use of assisted reproduc- tive technology increases the risk of multiple births and infants born with low birth weights (under 5.5% pounds) for both multiple births and single births. "ese risks increase the chances of long-term neurological problems such as cerebral palsy.20
Infertility 147
Contraception Most of the time, people engage in sexual intercourse for nonreproductive reasons. "e timing may not be right for a pregnancy, or their family may be com- plete. "erefore, couples usually use some form of birth control (contraception), which are methods to avoid pregnancy. You can assess your attitude toward the timing of parenthood by using the self- assessment scale in the Student Workbook pages in this text.
Couples and individuals have many factors to con- sider when choosing a birth control method. "ey might consider its cost, e#ectiveness, reversibility, side e#ects, ease of use, convenience, and e#ective- ness against STIs. "ey must also consider their age and whether they need contraception on a regular basis, or if they have only infrequent contraceptive needs. Many people are also concerned about the ways in which a contraceptive interferes with or !ts in with their sex life. Some people also have religious considerations when making this choice.
Because a woman has a long reproductive life last- ing some 30–35 years (from her teenage years until age 50, on average), the form of contraception she chooses may vary to meet her needs throughout the stages of her life. A variety of contraceptive methods are available, and each has its own risks, bene!ts, and level of e#ectiveness. Most methods are based on the female reproductive cycle and rely on a woman taking action. However, many methods can rely on the action of both partners and be incorporated into their sex life.
"e e#ectiveness of a contraceptive method is an important factor to consider. "e theoretical e!ective- ness of a contraceptive refers to the number of women who will not become pregnant out of 100% couples using a method consistently and properly as their only means of birth control for 1 year. For example, if a method is 80% e#ective, 80 of 100%women using
this method will not become pregnant over a year; 20 women will become pregnant. Actual e!ectiveness refers to the number of women who will not become pregnant of 100 couples using a method under usual conditions (with human error). Many people forget to use the method or use it improperly, lowering its e#ectiveness. For example, if a method is 80% e#ec- tive with actual use, 80 of 100 women using this method will not become pregnant over a year; 20 women will become pregnant, which translates to a 20% failure rate.21 Table 5.3 lists the e#ectiveness of the various forms of birth control.
"e “Contraceptive Comfort and Con!dence Scale” in the Student Workbook pages can help you assess whether the method of contraception that you are using or considering is, or will be, e#ective for you.
Abstinence and Natural Methods With respect to contraception, abstinence means refraining from heterosexual vaginal intercourse. Without this act, a woman cannot get pregnant (unless sperm are introduced arti!cially into her reproductive tract by a physician or possibly if sperm are deposited at the opening to the vagina and are able to travel into the vagina and then into the uterus). Abstinence is 100% e#ective and is an excel- lent alternative for young adults who feel they are not ready to have sex. Also, people choose to abstain from sex during various periods of their lives for var- ied reasons.
Natural family planning, or fertility awareness (formerly called the rhythm method), is a group of birth control techniques in which a heterosexual couple abstains from sexual intercourse during the time of the month when a woman is most likely to conceive. Although the theoretical e#ectiveness of natural family planning/fertility awareness is high— 91–99% depending on the method—the actual e#ec- tiveness of these methods is about 75% because it is o$en di&cult to determine when ovulation has occurred and fertilization can take place. However, when couples consistently use two indicators of fer- tility, mucus inspection and temperature (the muco- thermal method), and strictly adhere to the guidelines of using these methods together, the methods have been shown to be more than 98% e#ective.22
Ovulation usually (but not always) takes place about 14 days before the woman’s next menstrual period. If she has sex with a man up to 72 hours before ovulation, she can become pregnant because
birth control (contraception) Methods to prevent pregnancy.
abstinence A method of birth control that involves refraining from vaginal intercourse.
natural family planning (fertility awareness) Formerly called the rhythm method; a group of birth control techniques in which a couple abstains from sexual intercourse during the time of the month when a woman is most likely to conceive.
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Table 5.3
Effectiveness of Various Birth Control Methods
Actual Effectiveness (%) Theoretical Effectiveness (%)
Modern Methods
Implants >99 >99
IUD, copper containing >99 >99
IUD, levonorgestrel >99 >99
Female sterilization (tubal ligation) >99 >99
Male sterilization (vasectomy) >99
(after 3 months and semen evaluation)
97–98
(with no semen evaluation)
Progestogen-only injectables >99 97
Monthly injectables or combined injectable contraceptives
>99 97
Combined oral contraceptives (COCs), or “the pill” >99 92
Contraceptive vaginal ring >99 91
Contraceptive patch >99 91
Progestogen-only pills, or “the minipill” 99 90–97
Standard days method 95 88
Diaphragm 96 88
Male condoms 98 85
Female condoms 90 79
Basal body temperature method 99 75
Spermicides 82 72
Combined contraceptive patch and combined contra- ceptive vaginal ring (CVR)*
* *
Traditional Methods
Calendar method or rhythm method 91 75
Withdrawal (coitus interruptus) 96 73
*The patch and the CVR are new, and research on their effectiveness is limited. Effectiveness studies report that they may be more effec- tive than the COCs.
Data from World Health Organization. (July 2017). Family Planning/Contraception. Retrieved from http://who.int/mediacentre/factsheets /fs351/en; Centers for Disease Control and Prevention. (2014). Contraception. Retrieved from http://www.cdc.gov/reproductivehealth /UnintendedPregnancy/Contraception.htm
sperm live approximately this long. "e egg survives for approximately 24 hours, so fertilization also can occur for 1 day a$er ovulation. In summary, fertiliza- tion can take place up to 3 days before and 1 day a$er ovulation.
"e time of ovulation varies with the length of a woman’s cycle and may vary within cycles of a con- sistent length. In fact, a woman can ovulate anytime during her cycle and can even become pregnant dur- ing her menstrual period. "e following are four ways
Contraception 149
to determine (but without 100% certainty) when ovulation takes place: the temperature method, the calendar method, mucus inspection, and the muco- thermal method. All but the calendar method are based on changes that take place in a woman’s body around the time of ovulation.
To use the temperature method, a woman takes her temperature with a special basal thermom- eter before she gets out of bed every day for a few months. Because the body temperature usually dips just before and rises just a$er ovulation (Figure 5.16), charting body temperature for a few months can help a woman determine when she ovulates and if ovula- tion is regular.
To use mucus inspection, a woman notes when her cervical mucus changes consistency. Four days before ovulation, cervical mucus (which 'ows to the vagina) becomes clearer and thinner. She should avoid intercourse from this time until the mucus
changes back to its cloudier, thicker appearance. "e mucothermal method combines this method with the temperature method described in the pre- vious paragraph.
To use the calendar method, the woman records the length of her menstrual cycles for a year, begin- ning on day 1 of menstrual bleeding. A$er determin- ing the length of her shortest and longest cycles, she uses a chart or formula provided by her healthcare practitioner to determine which days of the month she could become pregnant. "is method works best when a woman has cycles that are consistently the same length. If a woman’s cycle varies greatly, “safe” times within her cycle will be shorter than if her cycles are more regular.
Coitus interruptus, or withdrawal, is another natural form of birth control. To use this method, the man senses when he is close to ejaculation and then removes his penis from his partner’s vagina and genital area, interrupting intercourse. "ere are many problems with this method. A man must exer- cise a great deal of self-control, removing his penis from the vagina at a time when his desire may be to
thrust more deeply. Also, he must be able to sense when he has enough time to remove himself before ejaculation. Additionally, sperm from a recent ejaculation may be pres- ent in the urethra and may be carried to the tip of the penis with drops of preejaculatory 'uid and result in pregnancy. To reduce the possibility of sperm in the preejaculate, a man should urinate a$er ejaculation and carefully clean all semen from the penis. With perfect use, coitus interruptus is 96% e#ective. However, dur- ing actual use this form of contraception is only 78% e#ective. None of the natural methods of birth control protects against the transmission of STIs.
coitus interruptus (withdrawal) (KO-ih-tus in-ter-RUP-tus) A form of birth control in which the man removes his penis from his partner’s vagina and genital area, interrupting intercourse before ejaculation.
Figure 5.16 Basal Body Temperature Variations During the Menstrual Cycle. In this graph, basal body temperature is shown to vary during this “model” menstrual cycle. The time of ovulation is determined by noting the fall in temperature just before ovulation and the rise over 3 days just after. Remember, most menstrual cycles are not as regular as this model cycle. Safe days vary widely among women and may vary widely among an individual woman’s cycles. The days before ovulation are considered “unsafe” because a woman does not yet know whether ovulation has occurred.
150 Chapter 5 Reproductive Health
1 5 10 15
Days
20 25 30
99.0
98.8
98.6
98.4
98.2
98.0
97.8
97.6
97.4
97.2
97.0
0
Te m
p e ra
tu re
( °F
)
Safe Safe
Unsafe
Menstruation
Menstruation
Ovulation
Chemical Methods Spermicides are chemicals that kill sperm. "e most common active ingredient in spermicides marketed in the United States is nonoxynol-9. "e inactive ingredi- ents make up the carrier, or base, of the spermicides, which are sold as foams, creams, jellies, !lms, sup- positories, and tablets. (Spermicides are also added to many brands of condoms.) "e carrier distributes the spermicide in the vaginal canal. Shortly before vaginal sex, foams, creams, and jellies are placed high in the vagina near the cervix using an applicator, as shown in Figure 5.17 (a and b). Spermicidal !lms are placed near the cervix. Suppositories and tablets are placed in the vagina and given time to dissolve. Correct placement of the spermicide and timing of insertion are critical to the spermicide’s e#ectiveness, which is 82% if these prod- ucts are used correctly and consistently (i.e., theoretical e#ectiveness), and the actual e#ectiveness is 72%.
Advantages to using spermicides are that the side e#ects (such as allergy and vaginal irritation or infec- tion) are minimal, they are used only when birth con- trol is needed, and they are easy products to obtain over the counter. Disadvantages are a low rate of e#ectiveness and an increase in the frequency of genital irritation and lesions caused by nonoxynol-9. "e presence of geni- tal lesions and irritated membranes increases the risk of contracting a sexually transmitted infection such as HIV during intercourse with an infected partner.23
Some women use douching as a contraceptive method. Douching is the use of specially prepared solutions to cleanse the vagina. Douching is not e#ective for contraception. By the time a woman can douche a$er sexual intercourse, sperm have already reached the cervix and uterus and cannot be washed away. In addition, if a woman has used a contracep- tive product containing spermicide or has used sper- micide alone as a contraceptive, douching may wash away the chemical and render it inactive.
Barrier Methods Barrier methods of contraception block the path that sperm must take to reach the ovum. "ese forms of contraception include diaphragms, cervical caps, male condoms, and female condoms.
Diaphragms and Diaphragm-like Products "e diaphragm has been in use in the United States for over 60 years. Shown in Figure 5.17 (c and d), a dia- phragm is a dome-shaped rubber cup bordered by a 'exible spring that is designed to cover the cervix and surrounding area. "is prescription item must be !t- ted by a healthcare practitioner.
Before inserting a diaphragm, place spermicide on both its sides and around its rim. Compress the spring, collapsing the diaphragm so that it can be inserted into the vagina. When the diaphragm reaches the cervical area, its spring pops open, caus- ing the diaphragm to assume its dome shape and to be held !rmly in place over the cervix.
A$er insertion, a diaphragm is e#ective for 6%hours, so a woman could insert the diaphragm well before sexual intercourse. However, spermicide must be added before each additional act of intercourse. A$er the last intercourse, the diaphragm must be le$ in place for at least 6 hours but must not be worn for more than 24 hours because of risk of infection. Used prop- erly and consistently, the diaphragm is 94% e#ective.
"e Today Vaginal Contraceptive Sponge, an over-the-counter single-use, disposable sponge that contains spermicide and is used like a diaphragm, was taken o# the market in the United States in 1995. "e Food and Drug Administration (FDA) discovered that the water system used in the manu- facture of the product was contaminated with bac- teria that cause diarrhea, although the sponges were never shown to be contaminated with this pathogen. A New Jersey pharmaceutical company purchased the Today sponge from its original manufacturer in 1999. "e FDA approved U.S. sales of the Today sponge in April 2005.
"e cervical cap works much the same way as the diaphragm, but it is smaller and covers only the cervix. In 2003, the FDA approved the FemCap (Figure 5.17f ). "e FemCap can be inserted up to 24 hours before intercourse and should remain in place for 8 hours a$erward but for no longer than 48 hours total. Before inserting, put a small amount of spermicide in the dome of the FemCap, spread a thin layer on the brim, and put a small amount in the folded area between the brim and the dome. "e FemCap is inserted with% the long brim entering !rst and the dome side down. "e actual e#ectiveness of the FemCap is 86%.
spermicides Chemicals that kill sperm.
douching (DOOSH-ing) The use of specially prepared solutions to cleanse the vagina; not an effective birth control method.
barrier methods Types of birth control that block the path that sperm must take to reach the ovum; these forms of contraception include male condoms, female condoms, diaphragms, and cervical caps.
Contraception 151
(e)
Vagina
Cervix (not visible)
Uterus Cervical cap
(f)
Figure 5.17 Contraceptive Foam and Jelly, Diaphragm, and FemCap. (a) Contraceptive foam or jelly is placed high up in the vagina, covering the cervix, using a plunger-type applicator. (b) Contraceptive jelly and applicator. (c) The diaphragm is ringed with contraceptive spermicide before insertion. The diaphragm is pinched to narrow it and is then placed high in the vagina, covering the cervix. (d) Diaphragm. (e) A small amount of spermicide is spread on the rim and brim of the side of the FemCap that will face outward, away from the cervix. A larger amount of spermicide is spread in the groove on the side of the FemCap that will face inward, toward the cervix. The FemCap is pinched to narrow it and is then placed high in the vagina with the bowl facing upward and the long brim entering first. The FemCap is placed to cover the cervix completely. (f ) FemCap. (d) & (f ) Courtesy of the Cervical Barrier Advancement Society and Ibis Reproductive Health.
(a)
Vagina
Cervix Uterus
(b)
(c)
Vagina
Cervix Uterus
(d)
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Condoms A condom is a sheath, usually made of thin latex or polyurethane, that covers the erect penis (male condom) or lines the vagina and covers the labia (female condom) to provide a barrier against fertilization or sexually transmitted infections.
Male condoms, the only form of birth control pres- ently available for men other than vasectomy, are one of the most popular forms of birth control in the United States. Used for the prevention of pregnancy, condoms are 82% e#ective with actual use and 98% e#ective with consistent and proper use. At the time this text was written, a topical gel birth control for men had been approved for testing, and research tri- als are expected to be completed in 2020.
Figure 5.18 illustrates the correct procedure for putting on a male condom. Always read and follow the instructions provided by the manufacturer. Before opening a condom, verify that it has not expired and that there is an air bubble inside the wrapper by holding the condom between—and gently pressing
with—your thumb and index !nger. Do not used expired condoms or condoms that come from pack- aging that is torn or looks brittle or worn. Carefully open the wrapper, being sure not to tear or rip the condom. Visually inspect the condom to make sure it does not have any defects. Hold the tip of the condom away from the penis to determine which way it rolls. If you place the condom on the tip of the penis and it will not roll down, do not 'ip it over; discard the con- dom and select a new one. Put the condom on a$er the penis has become erect but before there is genital contact with a partner. Hold the top half-inch of the condom, squeezing the air out. "is space will form a reservoir for semen. If air is not removed from this
Figure 5.18 How to Put on a Male Condom. The text explains each step.
condom A sheath, usually made of thin latex or polyurethane, that covers an erect penis or lines the vagina and coves the labia to provide a barrier against fertilization or sexually transmitted infections.
Contraception 153
(a) (b)
(c) (d)
space, the semen cannot collect at the condom tip, and the condom is more likely to break during inter- course. Place the rolled-up condom over the head of the penis ( Figure% 5.18a). While still holding the tip, unroll the condom to cover the penis to its base ( Figure 5.18b and 18c). Gently smooth out any air that may have been trapped between the condom and the penis. A$er ejaculation, hold the condom !rmly at its base to prevent slippage while you withdraw the still-erect penis from your partner’s body. Remove the condom from the penis (Figure 5.18d), being careful not to spill semen on your partner and not to touch the exterior of the condom to your genital area, because the outside of the condom may have become contaminated from an infected partner. Check the used condom carefully to ensure it was not ruptured during intercourse; if any ruptures are found, other methods of contraception and STI prevention can be used. Discard the used condom.
Approved by the FDA in 1993, the Reality female condom, a polyurethane sheath with a ring at each end, lines the vagina. Female condoms, used con- sistently and properly as a form of birth control, are approximately 95% e#ective. "eir actual e#ective- ness, however, is 79%.
Figure 5.19 shows a female condom and the cor- rect procedure for inserting one. Holding the closed end of the condom, squeeze the ring inside the con- dom so that it 'attens and can be inserted into the vagina ( Figure 5.19a). Insert the 'attened ring and condom into the vagina (Figure 5.19b), gently push- ing it up to the cervix as shown in Figure 5.19c. You should be able to feel the ring positioned past the pubic bone. Straighten out the% part of the condom lining the vagina if it is twisted. "e outside ring should cover the labia, as shown in Figure 5.19d. A$er intercourse, !rst twist the condom to close it at the vaginal opening, which will prevent sperm and pathogens from touching your genital area. Remove the condom with gentle pulling and discard. Female and male condoms are intended for one-time use.
Hormonal Methods "ere are two basic types of hormonal contraception: combined estrogen and progestin contraceptives, and progestin-only contraceptives. With the exception of progesterone-only minipills, hormonal methods of birth control prevent pregnancy by suppressing ovulation.
Combined Estrogen and Progestin Contracep- tives Combined oral contraceptives (COCs; “the pill”) suppress ovulation through the combined actions of estrogen and progestin (a synthetic form of progesterone). With the exception of extended- cycle oral contraceptives, which are described later in this section, menstruation still occurs (typically monthly).
Figure 5.19 How to Insert a Female Condom. The text explains each step.
coitus interruptus (withdrawal) (KO-ih-tus in-ter-RUP-tus) A form of birth control in which the man removes his penis from his partner’s vagina and genital area, interrupting intercourse before ejaculation.
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Index fingerInner ring
Open end (a) (b) (c)
(d) Outside ring correctly covering lip area
"e Guttmacher Institute notes that the pill is the most common method of birth control reported by women who use birth control methods (25.3%), fol- lowed closely by tubal (female) sterilization (25.1%).24 "e pill has numerous advantages. It is highly e#ec- tive, decreases menstrual cramps, decreases the length of the menses and the amount of blood lost, has a protective e#ect against pelvic in'ammatory disease, reduces the risk for ovarian and endometrial cancer (cancer of the uterine lining), reduces the risk for benign (noncancerous) breast disease, and helps prevent osteoporosis (thinning of the bones). "e pill is a readily reversible form of contraception.
COCs have been available since 1960 and are some of the best-studied prescription medications. "e amount of estrogen and progestin in pills has decreased over the years, so today’s pills are much safer than pills of the past. Cardiovascular disease is the most serious complication of the pill. Women at high risk for developing this complication of COC use are those who are older than 50 years of age or who are older than 35 years of age and smoke ciga- rettes. Women who are sedentary, overweight, and have high blood pressure, diabetes mellitus, or an elevated serum cholesterol level are also at high risk. Table 5.4 lists symptoms that may warn of a potential
health complication when using the pill. "e mne- monic (memory aid) ACHES can help you remem- ber these symptoms.
A review of studies on the risk of cervical cancer in women taking COCs reveals that risk increases with increasing duration of use.25 "e studies included women on COCs and some on progestin-only prepa- rations, which are discussed shortly. Risk was shown to decline a$er use stopped. A$er 10 years, the risk was the same as that for women who never used oral contraceptives.
Extended-cycle oral contraceptives contain lower doses of hormones than conventional birth control pills and are taken for 84 days instead of the usual 21 before menstruation occurs. With this pill, a woman has only four menstrual periods per year, one each season, instead of the usual 13. In addi- tion to suppressing ovulation, this pill prevents buildup of the lining of the uterus. "erefore, the menses are light. Seasonale was approved by the FDA in 2003 and Seasonique in 2006. With Seaso- nale, a woman takes an inactive pill during the days of her period, and with Seasonique, she takes a low- dose estrogen pill. "e low-dose estrogen appears to reduce breakthrough bleeding during the time between menses.
Lybrel was approved by the FDA in 2007. Like Seasonale and Seasonique, it is a low-dose pill, but it is taken 365 days per year. Over time, menstruation stops, but a woman may experience some break- through bleeding and spotting, especially during the !rst few months of use. "us, a woman choos- ing to use this form of COC should weigh the con- venience of not menstruating with the uncertainty of breakthrough bleeding and spotting. "e health bene!ts, health risks, and theoretical e#ectiveness of Lybrel, Seasonale, and Seasonique are compara- ble to other COCs.
"e contraceptive patch (Ortho Evra) was approved by the FDA in 2001 and became available in late April 2002. "e patch delivers hormones through the skin for 1 week. A woman uses three patches over 3 weeks, and then “goes o# ” the patch, during which time men- struation occurs. A primary advantage of the patch over conventional birth control pills is convenience: A woman needs to remember to change the patch only once a week rather than remembering to take a pill% every day. Results of research show that women who used the patch were more satis!ed with this con- traceptive method than with contraceptive%pills.26
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Pill IUD
A Abdominal pain (severe)
P Period is late, abnormal spotting or bleeding
C Chest pain (severe), shortness of breath
A Abdominal pain or pain with intercourse
H Headache (severe), may include dizziness, weakness, numbness
I Infection (sexually transmitted) exposure, abnormal discharge
E Eye problems: vision loss, blurring, double vision, flashing lights
N Not feeling well, fever, chills
S Sudden, severe leg or arm pain; leg or arm numbness
S String is missing or is shorter or longer
Table 5.4
Warning Signs and Symptoms of a Potential Health Complication When Using “The Pill” or an IUD
In 2001, the FDA approved the contraceptive vaginal ring (NuvaRing), which became available in mid-2002. "is doughnut-shaped device !ts in the vagina much like a diaphragm but works by releasing progestin and estrogen. Instead of taking a pill every day, a woman keeps the ring in place for 3 weeks, and then removes it for 1 week, during which time she menstruates. Like the patch, the vaginal ring o#ers convenience: A woman needs to remember only to remove the ring a$er 3 weeks and insert a new one a$er a week without it.
Progestin-Only Contraceptives Nexplanon (for- merly Implanon), Depo-Provera, and minipills are all forms of progestin-only contraceptives. Progestin works to suppress ovulation in much the same way as COCs.
Nexplanon (formerly Implanon), approved by the FDA in 2006, is a matchstick-sized contraceptive implant. It is surgically inserted under the skin of the upper arm. While there, it releases progestin slowly and can inhibit ovulation for 3 years.
Depo-Provera, which has been used in the United States since 1992, is an injection of progestin that inhibits ovulation for 3 months. Minipills, introduced in 1970, are progestin-only pills that are taken con- tinually. "e minipill is o$en prescribed for women who are breastfeeding, have certain health conditions like blood clots, or have other health-related con- cerns about taking estrogen.
Although highly e#ective, progestin-only con- traceptives have a few serious disadvantages. "ese contraceptives change a woman’s menstrual cycle. In addition to amenorrhea (no periods), these changes can include opposite e#ects: an increased num- ber of days of menstruation with light bleeding, or an increased number of days with heavy bleeding. Women !nd some of these changes unacceptable. Another disadvantage is that long-term use of pro- gestin-only contraceptives may cause thinning of the bones because of low estrogen.
Intrauterine Devices An intrauterine device (IUD) is a small apparatus that a healthcare practitioner inserts into the uterus (Figure 5.20). A string hangs from the base of the IUD and extends into the vagina; the presence of the
intrauterine device (IUD) A small contraceptive device that either is covered with copper or contains a reservoir of progestin and is inserted into the uterus.
Figure 5.20 The Intrauterine Device. An IUD is a small apparatus that is inserted into the uterus. The active ingredient of an IUD is either copper or progestin. The far right photo shows two typical IUDs.
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Uterus
Applicator
Cervix
Vagina
IUD in place
an over-the-counter product for all women of child- bearing age, which removed the age restriction, thus making it available to all women of all ages.27 IUDs still require a prescription, and insertion by a trained medical practitioner.
Sterilization Sterilization is a permanent form of birth control. In the past, sterilization was available only as a sur- gical procedure, but in 2002, the FDA approved a nonsurgical, irreversible method of female steriliza- tion called Essure. Using a local anesthetic, a physi- cian inserts a tiny spring into each fallopian tube by passing it through the vagina and then the uterus. Over 3 months, the spring irritates the tube, caus- ing it to produce scar tissue that blocks the tube. A$er the 3-month period, a physician injects dye into the uterus and up into the tubes. An X-ray of the dye-injected area shows whether the tubes are fully blocked. In 2016, the FDA approved a new consumer warning labeling highlighting reported serious complications of Essure, including persis- tent pain, allergic reaction, and poking through to the fallopian tubes or uterus.28 Women considering this sterilization method are encouraged to discuss all bene!ts and risks with their healthcare provider.
"e surgical form of female sterilization is a tubal ligation, which involves cutting and tying o# the uterine tubes by means of clips, rings, or burning so that the sperm and egg cannot unite. Male steriliza- tion is a vasectomy, which involves cutting and tying o# the vasa deferentia to prevent sperm from becom- ing part of the ejaculate. Tubal ligation is a medically more complicated and more costly procedure than vasectomy, but both are highly e#ective. Failure is most o$en the result of surgical error or the spon- taneous rejoining of the tubes. Figure 5.21 illustrates tubal ligation and vasectomy.
string is an indication that the IUD is still in place. "e active ingredient of the IUD is either copper, which covers the IUD, or progestin, which is con- tained in a reservoir within the IUD.
IUDs are among the safest, most e#ective, and least expensive reversible contraceptives available. Although their modes of action aren’t precisely understood, IUDs seem to work primarily by inhib- iting the ability of sperm to reach and fertilize the egg. IUDs also appear to thin the uterine lining and sometimes may prevent ovulation. Table 5.4 lists signs and symptoms that may warn of a poten- tial health complication when using an IUD. "e mnemonic PAINS can help you remember these symptoms.
Emergency Contraception Emergency contraception (EC) helps prevent preg- nancy after sexual intercourse, rather than before or during sex. Therefore, some types of EC are called “the morning-after pill.” Despite the nick- name, EC does not have to be used right away; it can be used up to 3–5 days after sex, depending on the method. Women often choose EC if they did not use another form of contraception or if they think their method did not work (e.g., a condom was used, but it ruptured). EC can also be used in cases of rape.
EC methods are not 100% e#ective, but they reduce the likelihood that a woman will become pregnant by about 75% a$er unprotected sex or a$er sex with a method that has failed. Because of the lower level of e#ectiveness of EC compared to other birth control methods, it is not a wise choice for use as a woman’s primary method. Like most forms of birth control, EC does not protect against sexually transmitted infections.
"ree types of EC are currently available in the United States: a progestin-only pill (Plan B One- Step®), various brands of COCs, and insertion of the copper IUD. Both types of emergency contraceptive pills do one of three things, depending on when in the cycle they are taken and whether fertilization has already taken place: "ey temporarily stop the release of an egg from the ovary, they prevent ferti lization, or they prevent a fertilized egg from implanting in the uterine wall. EC will not abort an embryo already implanted. Insertion of the copper IUD works in the latter two ways as EC. "e Plan B One-Step emergency contraceptive was !rst approved for use without a prescription in 2009 but was limited to women age 17 and older; in 2013, the FDA approved its use as
emergency contraception (EC) Birth control methods that help prevent pregnancy after sexual intercourse, rather than before or during sex.
sterilization A permanent form of birth control that requires a surgical procedure.
tubal ligation Female sterilization that is performed by cutting and tying off the uterine tubes so that the sperm and egg cannot unite.
vasectomy Male sterilization that is performed by cutting and tying off the vasa deferentia to prevent sperm from becoming part of the ejaculate.
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"e surgical forms of sterilization can be reversed, but subsequent pregnancy rates vary depending on factors such as the type of procedure that was per- formed, the health of the tubes being rejoined, and the health and age of the patient. Microsurgical tech- niques provide excellent success rates.
Abortion Sometimes contraceptive methods fail, and an unplanned pregnancy occurs that a woman or a cou- ple chooses to terminate. Sometimes pregnancy seri- ously jeopardizes a woman’s health, and ending the pregnancy is the only means of saving her life. "ere are numerous other reasons why women and couples choose to terminate a pregnancy.
A controversial 1973 United States Supreme Court decision (Roe v. Wade) ruled that induced
abortion is a legal medical procedure. States may regulate abortions in the second trimester to pro- tect the health of the pregnant woman, but the deci- sion to end a pregnancy during the !rst trimester is the private concern of a woman and her healthcare practitioner.
An abortion is the removal of the embryo or fetus from the uterus before it is able to survive on its own. During a spontaneous abortion, the body expels the embryo, usually because of serious genetic defects, although there may be other causes. Spontaneous abortions (miscarriages) generally occur during the !rst trimester; 10–20% of pregnancies end in spon- taneous abortion.
An induced abortion is one that does not hap- pen on its own. It is caused by taking certain drugs (a medical abortion) or by having certain physical procedures performed (a surgical abortion). Dur- ing the !rst trimester, both types of abortions can be performed.
A medical abortion can be performed within 9% weeks of the !rst day of the last period and uses a combination of the drugs mifepristone and miso- prostol. Mifepristone causes changes in the pregnant woman’s body so that it cannot sustain the pregnancy,
Figure 5.21 Sterilization Methods. Female sterilization (a), or tubal ligation, involves cutting and tying off the fallopian tubes. Male sterilization (b), or vasectomy, involves cutting and tying off the vasa deferentia.
abortion Removal of the embryo or fetus from the uterus before it is able to survive on its own.
medical abortion A method of drug-induced abortion performed within 9 weeks of the first day of the last period.
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Vas deferens
Cut and tied
Testis
Uterine tube
Cut and tied
Ovary
Cut and cauterized
(a) (b)
and the embryo/fetus detaches from the uterine wall. Misoprostol causes the uterus to contract and expel its contents. According to the Centers for Disease Control and Prevention (CDC) surveillance data, 22.6% of abortions are early medical abortions per- formed by 8 weeks, gestational age.29
In a surgical abortion, a physician physically removes the embryo/fetus from the uterus. Vacuum (suction) aspiration is used from 3 to 12 weeks of ges- tation. It can be performed in the physician’s o&ce in approximately 10–20 minutes with the use of a local anesthetic. To perform a vacuum aspiration, the physician dilates (widens) the cervix slightly and inserts a slender, hollow plastic tube through the vagina and cervix into the uterus. "e tube is con- nected to a suction aspirator, which draws the tissue out of the uterus and into a container (Figure 5.22). According to CDC surveillance data, 67.4% of abortions were surgical procedures performed by 13 weeks’ gestation.29 "us, 90% of abortions are performed either medically (using drugs) or with vacuum aspiration early in pregnancy. Accord- ing to CDC data, most abortions—more than
two-thirds—are performed at 8 weeks or less of gestation.29
If the abortion is performed between 12 and 15% weeks of gestation, the uterus is o$en scraped with a tool called a curette a$er the vacuum aspira- tion is completed. "is procedure is commonly called a D&C, which means dilation and curettage.
Abortions that are performed during 15–21 weeks of development are performed somewhat like a D&C, but forceps are also used to remove larger pieces of tissue. "erefore, the cervix must be dilated to a greater extent to allow the entry of the forceps. "is procedure is called a dilation and evacuation, or D&E. General anesthesia is o$en used for this pro- cedure. According to the CDC, only about 8.5% of abortions are performed between 14 and 20 weeks of gestation.29
"ere are two basic methods of abortion for the 1% that are performed at 21 weeks of gestation or more: induction, and intact dilation and extrac- tion. Induction is a form of abortion in which labor is arti!cially induced (started). Saline abortions are one method of induction: A physician inserts a long needle through the abdominal wall and into the amniotic sac. A salt solution is injected into the sac, which causes the quick death of the fetus. "e uterus begins contractions within 12 to 24 hours, and the woman delivers a dead fetus. "is procedure is per- formed using a local anesthetic. Other types of solu- tions and prostaglandins (hormonelike substances that cause the uterus to contract) are also used for induction.
A special type of D&E procedure called an intact dilation and extraction (IDX or intact D&X) is the so-called partial-birth abortion procedure. President George W. Bush signed the Partial-Birth Abortion Ban Act in November 2003, which criminalizes the procedure. Physicians from many states challenged the constitutionality of the law. "ree federal judges from California, New York, and Nebraska ruled that the legislation had many constitutional defects and rejected the ban. "e question of the constitutionality of the law went to the Supreme Court, and on April 18, 2007, the high court ruled in a 5–4 decision that the federal Partial-Birth Abortion Ban Act of 2003 was constitutional.
Figure 5.22 Vacuum (Suction) Aspiration. During this procedure, a thin, hollow tube is inserted through the vagina and cervix to the uterus. A suction aspirator (vacuum pump) draws tissue out of the uterus and into a container.
surgical abortion Includes various methods of induced abortion in which the contents of the uterus are physically removed.
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To vacuum pump
Suction tube
Speculum (inserted into vaginal canal)
Amniotic sac
Embryo at less than 12 weeks
Uterus
SEXUAL DEVELOPMENT One’s sex is set at the time of fertilization and is deter- mined by the type of sex chromosomes (genes) the embryo receives from its parents. Females have two X chromosomes; males have an X and a Y. "us, the father’s genes determine the sex of o#spring.
During the 7th week of development, the embryo with a Y chromosome begins to develop testes. "e developing testes secrete male hormones collectively called androgens. "ese hormones direct the devel- opment of a male reproductive system. Embryos and fetuses without a Y chromosome begin to develop ovaries during the 9th week. "e absence of andro- gens results in the development of a female reproduc- tive system.
A$er birth, the secretion of the androgen testos- terone in male babies nearly ceases and does not resume until puberty, the time of sexual maturation. "e female reproductive system does not become active until that time as well.
Puberty is a stage of development during which the endocrine (hormone) and reproductive systems mature. Puberty begins at approximately 10 to 11%years
of age and concludes about 5 or 6 years later. Girls usually enter puberty about 2 years earlier than boys. Scientists do not know what triggers this developmen- tal process.
During childhood, the production of a hormone that stimulates the release of male and female sex hormones is suppressed. At the onset of puberty, the suppression ceases, and the brain begins releasing the hormone that regulates the production of testoste rone in males and estrogen in females. As puberty pro- ceeds, the brain secretes greater and greater amounts of this hormone; thus, more and more testosterone or estrogen is secreted. "ese hormones stimulate the physical changes of puberty. "ese changes include growth spurts resulting from the growth of the skel- eton (especially the long bones), the development of pubic and underarm hair, and the growth and matu- ration of the reproductive tract.
In males, building levels of testosterone result in an enlarging of the testes and penis, deepening of the voice as a result of an enlargement of the voice box, development of facial hair, broadening of the shoulders, and enlargement of the arm, chest, and leg muscles. Under the direction of testosterone, the seminiferous tubules begin manufacturing sperm. A signi!cant developmental event in pubertal boys is semen emission during sleep, called nocturnal emis- sions, or wet dreams. Initially, sperm are not present in the semen.
In females, estrogen results in the development of the breasts and the rounding of the hips. Females experience menarche, the !rst menstruation, at around 12 years of age. "e normal range for men- arche is 8–15 years of age. A delay of the menarche may occur in girls with chronic diseases, such as dia- betes mellitus; those with disorders that a#ect their nutritional status, such as anorexia nervosa; and those undergoing strenuous physical training, such as Olympic hopefuls.
When a woman reaches 45–55 years of age, most of her ovarian follicles (eggs) have matured, and the remaining follicles are aged. During some months, these aging follicles do not reach maturity, and ovu- lation does not take place. Without mature egg fol- licles, the normal cyclic secretion of estrogen and progesterone does not occur, and the menses become irregular. Eventually, all follicles stop maturing, estrogen and progesterone are no longer secreted, and the menses cease. "e cessation of the menses is called menopause. "is term means the !nal men- strual period, but it is widely used to refer to the few years of transition when a woman passes from her
4The most effective means to prevent an unwanted pregnancy are sexual abstinence, the use of an IUD, and sterilization, followed closely by hormonal methods.
4If you are using a hormonal method of birth control, consult your healthcare provider when you are taking antibiotics to determine if you should use a backup method of contraception while taking this medication.
4To reduce the risk of contracting or transmitting sexually transmitted infections, use a condom during sexual intercourse. The best way to protect yourself against STIs is to practice sexual abstinence.
Healthy Living Practices
Across THE LIFE SPAN
menarche (meh-NAR-key) The first menstruation.
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reproductive years to her nonreproductive years. "e Diversity in Health essay discusses menopausal symptoms and attitudes across cultures.
As the hormonal changes of menopause take place, women usually experience symptoms such as hot 'ashes and physiologic changes such as thinning of the vaginal walls and vaginal dryness. In addition, the loss of estrogen results in an increased risk of osteoporosis and heart disease.
In a 2013 report, and again in a 2016 report, the International Menopause Society (IMS) updated recommendations on menopausal hormone ther- apy (MHT), clarifying the sometimes confusing and con'icting information.30,31 In 2002, data from
the Women’s Health Initiative (WHI) trial showed that MHT did not protect postmenopausal women against heart attacks as previously thought.32 Since the initial 2002 report, more information has become available, and more importance has been placed on the fact that the study population for the WHI trial was women with a mean age of recruit- ment of 63%years.
"e IMS recommends that “consideration of MHT should be part of an overall strategy including lifestyle recommendations regarding diet, exercise, smoking cessation and safe levels of alcohol consumption for maintaining the health of peri- and postmenopausal women.” "e IMS notes that, if used, MHT and its
Diversity in Health Menopause Menopause is a time of transition for every woman who reaches her 50s, but transition is about the only thing women universally experience during this time. The symptoms of menopause and attitudes regarding this process vary extensively among women across cultures. Why do these differences exist?
One hypothesis is that if a society regards meno- pause as a positive time, the symptoms of menopause reported by its women will decrease in number and sever- ity. Certain evidence seems to support this hypothesis. For example, during their childbearing years, the Rajput women of Northern India are socially constrained and cannot move about freely in their villages. Those who no longer menstruate are freed of this constraint. Interest- ingly, these women report no symptoms of menopause. Similarly, Mayan women look upon menopause as a lift- ing of the burden of childbearing. They, too, report no symptoms of hot flashes or cold sweats such as are typi- cally reported by North American women. Yanomamo women (forest dwellers who live near the border between Brazil and Venezuela) eagerly await menopause, which is considered the time of “older age,” for this time of life brings increased status and decision-making power in their society.
In a multiethnic study of U.S. women, Green and Santoro found that most menopausal symptoms var- ied by ethnicity and culture as well. Night sweats and hot flashes were reported more often by African Ameri- can and Hispanic women, whereas vaginal dryness was reported most often by Hispanic women. And even though other menopausal symptoms varied among
Hispanic women, the symptoms corre- lated with their country of origin.
Nevertheless, the diversity of the symptoms and experiences of women of various cultures regarding menopause cannot be attributed solely to differences in culture. Ayers, Forshaw, and Hunter took a broader look at the correlation between menopausal symptoms and attitudes toward menopause, conducting a review of cross-cultural studies on the subject. The researchers determined that women with more negative attitudes toward menopause reported more symptoms of menopause when experi- encing this life transition, and those with less negative attitudes experienced fewer symptoms.
Menopausal symptoms and experiences must also be evaluated in the context of risk factors for death and disease. But just as it affects attitudes, culture affects lifestyle, and lifestyle affects health. Thus, culturally influ- enced lifestyles affect susceptibility to disease, the aging process, and the quality of life, and in turn may account for some of the differences in the perception of meno- pausal symptoms among women. Cultural differences in the experience of menopause exist but appear to be so intertwined with the various facets of a woman’s life that the effect of culture alone may be difficult to assess.
Data from Ayers, B., et al. (2010). The impact of attitudes towards the menopause on women’s symptom experience: A systematic review. Maturitas, 65(1):28–36; Green, R., & Santoro, N. (2009). Menopausal symptoms and ethnicity: The Study of Women’s Health Across the Nation. Women’s Health, 5(2):127–133; and Melby, M. K., et al. (2005). Culture and symptom reporting at menopause. Human Reproduction Update, 11:495–512.
Abortion 161
Managing Your Health Enlargement of the Prostate If you are male and older than 45 years, your prostate may be enlarging slowly; if you are not yet 45 years old, prostate enlargement may be in your future. This
process of enlargement is common for middle-aged and older men; it is part of the aging process and may never be a cause for concern. However, about 50% of men in their 60s and about 90% of men in their 70s and 80s complain of problems caused by an enlarged prostate gland, also known as prostatic hyperplasia, or benign prostatic hyper- trophy (BPH).
How can an enlarged prostate affect your health? Notice in Figure 5.1 that the prostate gland surrounds the urethra beneath the urinary bladder. As the prostate enlarges, it may squeeze the urethra, hampering the flow of urine through this tube. Therefore, the symptoms that may appear first as a result of BPH are difficulty in beginning to urinate, a decrease in the force of the urine stream, a dribbling of urine after urinating, a sensation of a full bladder after uri- nating, and a need to urinate 5 or 10 minutes after urinating.
As the prostate squeezes the urethra more and more, the muscles of the bladder wall respond by thickening as they forcefully push urine through the constricted ure- thra. This thickened bladder is irritated easily and con- tracts more readily. Therefore, the following symptoms develop: an urgency to urinate and/or leaking of urine; more frequent urination, especially at night; and painful urination. Eventually, urine flow can be blocked to the point that emergency treatment is necessary.
There are several treatments for BPH. Surgery is usu- ally undertaken when symptoms are severe. During the surgery, the portion of the prostate squeezing the urethra is removed. Laser therapy, radio frequency therapy, or microwave therapy can be used to destroy the enlarged prostate tissue as well. These procedures are less inva- sive than traditional surgical techniques and usually have fewer long-term side effects and complications.
Another treatment is balloon dilatation. During this procedure, an inflatable device is inserted into the urethra through the opening at the tip of the penis. The device is inflated at the area of constriction and is then removed. This procedure widens the urethra to alleviate symptoms. Various medications also ease the symptoms of BPH.
Enlargement of the prostate may also be caused by prostate cancer. This cancer is the second most common cause of cancer deaths in men (lung cancer being the first). However, it usually does not appear in men younger than 55 years, and it is generally a slow-growing form of cancer.
Its symptoms overlap with those of BPH and include diffi- cult, frequent, and painful urination and blood in the urine.
The symptoms of BPH and prostate cancer are more than just a nuisance. The restriction or blockage of urine flow can damage the kidneys, and prostate cancer can spread, resulting in death. To avoid the discomforts and possible serious consequences of these conditions, the prostate should be examined regularly.
Until about 2008, some physicians and health organi- zations recommended routine prostate screening for men with normal risk beginning at age 50, and men with higher risk at earlier ages. For more than 20 years, men were routinely screened for prostate cancer with the prostate- specific antigen (PSA) blood test and the digital rectal exam ( Figure"5.D). As more information on the risks and benefits of prostate cancer screening was learned, professional orga- nizations started to question routine population screening based solely on age. The most recent recommendations of the National Cancer Institute33 and the American Cancer Society34 are for men to discuss the risks and benefits of prostate cancer screening with their doctors before making a decision whether to be screened. Men who elect to be screened should be tested with the PSA blood test and the digital rectal exam may also be done.
Figure 5.D Digital Rectal Examination. During this examination, the physician inserts a gloved, lubricated finger into the rectum. Because the prostate lies next to the rectum, the physician can palpate (feel by pressing lightly) the size of the prostate.
162 Chapter 5 Reproductive Health
Rectum
Epididymis
Testicle
Penis
Urethral opening
Vas deferens
Prostate
Seminal vesicle
Bladder
dosage should be tailored to each patient by her phy- sician and that menopausal women should become knowledgeable of the risks and bene!ts of the therapy. "e IMS concludes that “MHT is the most e#ective treatment for moderate to severe menopausal symp- toms and is most bene!cial before the age of 60 years or within 10 years a$er menopause,” is e#ective “for the prevention of fracture in at-risk women before age 60 years or within 10 years a$er menopause,” and “reduces the risk of diabetes and, through improv- ing insulin action in women with insulin resistance, it has positive e#ects on other related risk factors for cardiovascular disease such as the lipid pro!le and metabolic syndrome.” Regarding potential serious adverse e#ects of MHT, the IMS concludes that the possible risk of breast cancer is less than 0.1% per year and that “the risk of venous thromboembolic
events and ischemic stroke increases with oral MHT but the absolute risk is rare below age 60 years.”30
Men also undergo changes in their reproductive systems during middle age. Men are fertile through- out their lives, although the number of healthy, active sperm they produce decreases as they grow older. Middle-aged men experience a decline in tes- tosterone, ejaculate with less force and less volume, and take longer to regain an erection a$er orgasm. In addition, the prostate gland usually enlarges. See the Managing Your Health essay “Enlargement of the Prostate.”
Although both men and women undergo changes in their reproductive systems beginning at middle age, these changes do not have to impair their abil- ity to have a healthy, enjoyable sex life extending into their elderly years.
Abortion 163
Health-Related InformationAnalyzing Critical Thinking
Explain why you think this web page about folic acid is a reliable or an unreliable source of information. Use the “Assessing Information on the Internet” portion of the model to analyze health-related information to guide your thinking; the main points of the model are noted here. If you wish to visit this site, the web address is www.cdc.gov/ncbddd/folicacid.
• What is the source of the information?
• Is the site sponsored by a nationally known health or medical organization or affiliated with a well-known medical research institution or major university? If not, is the site staffed by well- respected and credentialed experts in the field?
• Does the site include up-to-date references from a well-known, respected medical or scientific journal or links to reputable web sites, such as nationally recognized medical organizations?
• Is the information at the web site current?
Based on your analysis, do you think that this web page is a reliable source of health-related information? Summarize your reasons for com- ing to this conclusion.
If you are unsure of the credibility of the site after answering the preceding questions, con- tinue with the following six Analyzing Health- Related Information questions.
1. Which statements on the web site are verifiable facts, and which are unverified statements or value claims?
2. Does the person, organization, or institution that developed the web site have the appropriate background and credentials in the topic area? What can you do to check credentials?
3. What might be the motives and biases inherent to the web site?
4. What is the main point of the article, ad, or claim made on the site? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your additional analysis, do you think that this web page is a reliable source of health-related infor- mation? Summarize your reasons for coming to this conclusion.
Co ur
te sy
of CD
C.
164 Chapter 5 Reproductive Health
CHAPTER REVIEW
Sexual reproduction involves the fertilization of an egg by a sperm, forming the !rst cell of a new embryo. "e male reproductive system produces sperm (male sex cells) and delivers them to the vagina of the female. Sperm are produced in the testes and are moved along the male reproductive tract with the seminal 'uid secreted by accessory sex glands during ejaculation.
Eggs (ova; female sex cells) develop and mature in the female reproductive system, which also receives sperm and provides an environment in which a fer- tilized ovum can develop. Eggs mature in the ovaries, are fertilized in the uterine tubes, and develop in the uterus during pregnancy.
Women experience cyclic monthly hormonal changes that orchestrate physiologic changes that take place in the ovaries and uterus. "e changes are collectively called the menstrual cycle. During the menstrual cycle, an ovum matures and is released from the ovary while the lining of the uterus thick- ens in preparation for the implantation of a fertilized ovum. If pregnancy does not occur, the uterine lining sloughs o# during the menses.
If fertilization takes place, the embryo/fetus devel- ops in the uterus of the female. "is developmental process is termed pregnancy, or gestation. Various environmental in'uences (teratogens) such as drugs, alcohol, viruses, and dietary de!ciencies can damage the embryo or fetus early in pregnancy. A woman pre- paring for pregnancy should have a medical checkup; eat a well-balanced and nutritious diet; avoid drink- ing alcohol, smoking cigarettes, and taking drugs; and possibly seek genetic counseling.
Women who become pregnant may notice physi- cal signs of this condition such as a missed period, nausea, fatigue, and moodiness. A woman can con- duct a home pregnancy test or have a laboratory test performed to determine if she is pregnant.
Pregnancy lasts about 38 weeks and is typically described in terms of trimesters, or 3-month periods. During the !rst trimester, all the organ systems of the body form and become functional. "e second and third trimesters are periods of growth and re!ne- ment of the organ systems.
"e process of childbirth (labor) takes place in three stages: dilation, expulsion, and placental delivery.
During dilation, the uterine muscles contract, caus- ing the cervix to widen (dilate) and thin out (e#ace). During the second stage of labor, the baby is born. Within 15–30 minutes a$er delivery of the baby, the placenta is expelled from the uterus.
Couples o$en want to avoid pregnancy for various reasons, so they choose some form of birth control, or contraception. Contraceptive methods are varied and can be grouped into seven categories: abstinence and natural methods, chemical methods, barrier methods, hormonal methods, intrauterine devices, sterilization, and EC. Each method has di#erent advantages, disad- vantages, and levels of e#ectiveness. Abstinence, ster- ilization, IUDs, and hormonal methods are the most e#ective means of contraception. Using condoms and practicing abstinence are the best ways to prevent the transmission of sexually transmitted infections while at the same time preventing pregnancy.
Sometimes contraceptive methods fail, and an unplanned pregnancy occurs that a woman or a cou- ple chooses to terminate. Women and couples choose to terminate a pregnancy for other reasons, including health concerns of the mother. Terminating a preg- nancy involves the removal of the embryo or fetus from the uterus before it is able to survive on its own. "is process is called an induced abortion. In the United States today, there is great controversy over a woman’s right to choose induced abortion. More than 90% of abortions are performed either medically (using drugs) or with vacuum aspiration early in pregnancy; almost two-thirds are performed at 8 weeks or less of gestation.
One’s sex is set at the time of fertilization and is determined by the type of sex chromosomes (genes) that the embryo receives from its parents. "e male and female reproductive tracts develop during ges- tation. Further maturation does not continue until puberty, the time of sexual maturation, which begins at approximately 10–11 years of age and concludes about 5 or 6 years later. Men and women both undergo changes to their reproductive function dur- ing middle age. Women have a cessation of the menses (menopause) as a result of physiologic and hormonal changes and can no longer reproduce. Men can repro- duce throughout their lives but at middle age experi- ence a decline in testosterone and sexual functioning.
Summary
Summary 165
CHAPTER REVIEW
1. Contracting sexually transmitted infections can endanger your health and your ability to have children. What is the relationship between responsible sexual behavior and reproductive health in your life?
2. If you are a man, what did you learn in this chapter about female reproductive health that was new to you? If you are a woman, what did you learn in this chapter about male reproduc- tive health that was new to you? How will this new knowledge a#ect your behavior toward the opposite sex? How might it a#ect your attitudes?
3. Most contraceptive methods focus on the female reproductive system. Because of this focus,
should women have the primary responsibility for contraception? Why or why not?
4. In the United States, a woman’s right to choose to have an abortion (other than a “partial-birth” abortion) is protected by law. Do you think that the law should be changed to criminalize abor- tion in general? If so, why? Should abortion be legal only in certain circumstances? If so, when?
5. Table 5.1 lists selected teratogens. If a woman knowingly exposes her embryo or fetus to tera- togenic drugs such as alcohol, should she be prosecuted in the criminal justice system? Why or why not?
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
1. A woman is 42 years old, unmarried, and has sex regularly with a single sexual partner. She has been using an intrauterine device but has devel- oped an infection with the insertion of her most recent IUD. She must change to another method of birth control. If you were this woman, which method would you choose? Provide evidence that your choice is prudent. Application
2. In this chapter, much attention is given to the theoretical and actual e#ectiveness of vari- ous types of birth control. When you look at Table% 5.3, which column should carry more weight in your decision making—the theoretical
or the actual e#ectiveness? Give reasons for your answer. Analysis
3. You have been asked to lead a discussion in your health class about maximizing maternal and fetal health during pregnancy. You may discuss any information in this chapter relevant to this issue. (You may add topics not mentioned in this chapter as well.) List the topics you will discuss and brie'y describe the importance of each. Synthesis
4. Devise an assessment that will help people evalu- ate their attitudes toward abortion. Explain why you think that your assessment tool will accu- rately evaluate these attitudes. Evaluation
Reflecting on Your Health
Applying What You Have Learned
166 Chapter 5 Reproductive Health
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1. Sharpe, R. M. (2010). Environmental/lifestyle e#ects on spermato- genesis. Philosophical Transactions of the Royal Society B, 365, 1697–1712.
2. U.S. Department of Health and Human Services, O&ce on Wom- en’s Health. (2017, November 13). Menstrual cycle. Retrieved from https://www.womenshealth.gov/menstrual-cycle
3. Freeman, E. W., et al. (2011). Core symptoms that discriminate pre- menstrual syndrome. Journal of Women’s Health, 20(1), 29–35.
4. Shulman, L. P. (2010). Gynecological management of premenstrual symptoms. Current Pain and Headache Reports, 14(5), 367–375.
5. Medline Plus, U.S. National Library of Medicine, National Institutes of Health. (2017, December 21). Toxic shock syndrome. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000653 .htm
6. Luke, B., & Brown, M. B. (2007). Elevated risks of pregnancy com- plication and adverse outcomes with increasing maternal age. Human Reproduction, 22, 1264–1272.
7. Centers for Disease Control and Prevention. (2008). Estimated number of male newborn infants, and percent circumcised during birth hospitalization, by geographic region: United States, 1979– 2008. Retrieved from http://www.cdc.gov/nchs/nhds/nhds_tables .htm#male
8. Tobian, A. A. R., et al. (2009). Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. New England Journal of Medicine, 360, 1298–1309.
9. American Academy of Pediatrics. (1999). Circumcision policy statement. Pediatrics, 103(3), 686–693.
10. American Academy of Pediatrics. (2005). AAP publications retired and rea&rmed. Pediatrics, 116(3), 796.
11. American Academy of Pediatrics. (2012). Circumcision policy statement. Pediatrics, 130(3), 585–586.
12. Brett, K., & Bar!eld, W. (2008). Prevalence of self-reported post- partum depressive symptoms—17 states, 2004–2005. Morbidity and Mortality Weekly Report, 57, 361–366.
13. Reeves, W. C., et al. (2011). Mental illness surveillance among adults in the United States. Morbidity and Mortality Weekly Report, 60(03), 1–32.
14. Centers for Disease Control and Prevention. (2016). Infertility. Retrieved from http://www.cdc.gov/nchs/fastats/infertility.htm
15. De Vos, M., et al. (2010). Primary ovarian insu&ciency. Lancet, 376(9744), 911–921.
16. Olive, D. L. (2010). Exercise and fertility: An update. Current Opin- ions in Obstetrics and Gynecology, 22(4), 259–263.
17. Brewer, C. J., & Balen, A. H. (2010). "e adverse e#ects of obesity on conception and implantation. Reproduction, 140(3), 347–364.
18. Anderson, K., et al. (2010). Lifestyle factors in people seeking infer- tility treatment—A review. Australian and New Zealand Journal of Obstetrics and Gynaecology, 50(1), 8–20.
19. Ross, C., et al. (2010). A systematic review of the e#ect of oral antioxidants on male infertility. Reproductive Biomedicine Online, 20(6), 711–723.
20. Basatemur, E., & Sutcli#e, A. (2008). Follow-up of children born a$er ART. Placenta, 29, S135–S140.
21. Centers for Disease Control and Prevention. (2017, February 9). Contraception. https://www.cdc.gov/reproductivehealth/contraception /index.htm
22. Frank-Herrmann, P., et al. (2007). "e e#ectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behavior during the fertile time: A prospective longitudinal study. Human Reproduction, 22, 1310–1319.
23. Herold, B. C., et al. (2011). Female genital tract secretions and semen impact the development of microbicides for the prevention of HIV and other sexually transmitted infections. American Journal of Reproductive Immunology, 65, 325–333.
24. Guttmacher Institute. (September 2016). Contraceptive use in the United States. Retrieved from https://www.guttmacher.org /fact-sheet/contraceptive-use-united-states
25. International Collaboration of Epidemiological Studies of Cer- vical Cancer, Appleby, P., et al. (2007). Cervical cancer and hor- monal contraceptives: Collaborative reanalysis of individual data for 16,573 women with cervical cancer and 35,509 women with- out cervical cancer from 24 epidemiological studies. Lancet, 370, 1609–1621.
26. Wan, G. J., et al. (2007). Treatment satisfaction with a transder- mal contraceptive patch or oral contraceptives. Contraception, 75, 281–284.
27. U.S. Food and Drug Administration. (2013). FDA approves Plan B One-Step emergency contraceptive for use without a prescription for all women of child-bearing potential. Retrieved from https:// wayback.archive-it.org/7993/20170112033121/http://www.fda.gov /NewsEvents/Newsroom/PressAnnouncements/ucm358082.htm
28. U.S. Food and Drug Administration. (2017, February 11). What women should know about Essure permanent birth control. Retrieved from https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm529208 .htm
29. Jatlaoui, T. C., et al. (2017, November 24). Abortion surveillance— United States, 2014. Morbidity and Mortality Weekly Report, 66 (SS-24), 1–48.
30. Villiers, T. J., et al. on behalf of the Board of the International Meno- pause Society. (2013). Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric, 16, 316–337.
31. Baber, R. J., et al. (2016). 2016 IMS recommendations on women’s midlife health and menopause hormone therapy, Climacteric, 19(2), 109–150.
32. Women’s Health Initiative Memory Study Investigators. (2004). Conjugated equine estrogens and global cognitive function in post- menopausal women: Women’s health initiative memory study. Jour- nal of the American Medical Association, 291(24), 2959–2968.
33. National Cancer Institute. (2017, October 4). Prostate-speci#c antigen (PSA) test. Retrieved from https://www.cancer.gov/types /prostate/psa-fact-sheet#q2
34. American Cancer Society. (2016, April 1). American Cancer Society recommendations for prostate cancer early detection. Retrieved from https://www.cancer.org/cancer/prostate-cancer/early-detection /acs-recommendations.html
References
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 167
Across the Life Span Sexuality
Managing Your Health Minding Your Sexual Manners
Consumer Health Ginseng and Sexual Prowess
Diversity in Health The Perceived Virtue of Virginity Common Sexual Practices Between Partners
Chapter Overview How biological and psychological factors influence sexual
behavior
The phases of sexual response cycles
Symptoms of and treatments for sexual dysfunctions
How culture affects sexuality
Nature versus nurture and sexual orientation
The diversity of sexual behavior
Definitions and theories of love and commitment
Student Workbook Self-Assessment: Couples Satisfaction Index | The Love
Attitudes Scale
Changing Health Habits: Would a Behavior Change Improve Your Relationship?
Do You Know? What are common sexual practices?
How living together affects future marriage?
How to communicate effectively?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © dpaint/Shutterstock.
Romantic Relationships and"Sexuality
© EyeEm
/Getty Im ages.
Learning Objectives “… promoters and advertisers know that ‘sex sells.’”
After studying this chapter, you should be able to:
1. Define sexuality. 2. Describe factors that influence a person’s desire to form
intimate relationships. 3. List the characteristics of loving relationships. 4. Identify factors that contribute to compatibility. 5. Define homosexuality, heterosexuality, and bisexuality. 6. Explain how culture and society influence sexual behavior. 7. Differentiate between passionate and companionate love. 8. Describe factors that are associated with long-term loving relationships. 9. Discuss the biological origins and social ramifications of gender roles. 10. Identify the phases of the human sexual response and the physiologic changes that occur in males and females
during each phase. 11. Describe common sexual dysfunctions and their causes and treatments. 12. Describe the impact of aging on sexuality.
CHAPTER 6
169
S ex is everywhere in our society. You can !nd sexually explicit images and information in movies, songs, books, TV shows, advertise- ments, social media, and other online sources. If you browse through magazines or online, you are likely to see pictures of attractive young men and women in advertisements for clothes, perfumes, and cars. Whether their product is a movie, jewelry, or a pair of jeans, promoters and advertisers know that “sex sells.” What does sex mean to you?
"e term sex refers to the physiologic di#er- ences between men and women. In other words, sex is a term that identi!es whether one is bio- logically female or biologically male (e.g., men have testes; women have ovaries). "is biological sex is changeable only via a surgical operation. Sex can also refer to behavior (e.g., sexual inter- course, oral sex). Gender is a related, yet distinct and much more complex, term: It refers to the socially constructed distinctions between men and women, which include social and legal status. Gen- dered distinctions accepted by society are socially constructed norms—the accepted and expected behavior—that identify what is expected of one based on her or his biological sex. For example, in the United States, it is generally acceptable and sometimes expected that girls wear dresses: How- ever, it is not generally acceptable and is rarely expected that boys wear dresses. Gender also refers to one’s psychological identity (more on gender identity later in the chapter). Gender and gendered norms evolve as society evolves, whereas biologi- cal sex remains constant. "us, both sex and gender refer to di#erences between men and women: Sex refers to the biological/physiologic di#erences, and gender refers to the social/psychologic di#er- ences. Sexuality, however, is more than gender or reproductive organs. Sexuality is the aspect of personality that encompasses an individual’s sexual thoughts, feelings, attitudes, and actions. Each per- son has a unique collection of private and public sexual experiences that shapes his or her sexuality.
Numerous biological, psychological, social, and cultural forces interact to in'uence a person’s sexual development, sexual health, and interpersonal rela- tionships (Figure 6.1). Sexuality is woven into every aspect of human life; sex a#ects a person’s identity, self-esteem, emotions, personality, relationships, life- style, and overall health.
Being knowledgeable about sexuality is impor- tant for maintaining good health and optimal well-being. Misinformation can lead to serious consequences, such as unintentional pregnancies or sexually transmitted infections. Additionally, people who are well informed about sexuality can communicate e#ectively with their medical practi- tioners and sexual partners regarding reproductive or sexual concerns.
"roughout life, you make various sexually related decisions, such as deciding with whom to have an intimate sexual relationship. Such deci- sions can have serious e#ects on your health and well-being, as well as those of others. By consider- ing how your actions may a#ect yourself and your sexual partners, you can become a more sexually responsible person.
Religion
Associates
Media Teachers
Culture
PeersFamily
Legal System
Sex Partners
Medical Professionals
Individual Sexuality
sex The biological or physiologic differences that distinguish one as female or male.
gender Socially constructed differences (or psychological identity) that distinguish one as female or male.
sexuality The aspect of personality that encompasses a person’s sexual thoughts, feelings, attitudes, and actions.
Figure 6.1 Sexuality Model. Numerous biological, psychological, social, and cultural forces interact to influence sexual development, sexual health, and interpersonal relationships.
170 Chapter 6 Romantic Relationships and Sexuality
Human Sexual Behavior "e reproductive activity of most complex animals includes behaviors commonly referred to as court- ship and mating. Unlike other animals, humans exhibit a variety of complex sexual behaviors that do not necessarily result in reproduction. People o$en engage in sexual activity for pleasure and relaxation or to help maintain the emotional bonds of their inti- mate relationships. Some individuals, however, use their sexuality to dominate, exploit, or harm others. What factors in'uence human sexual behavior?
The Biology of Sexual Behavior "e motivation to pursue sexual activity—the sex drive, or libido—is an instinctual behavior moder- ated by the sex hormones. "e ovaries and the testes, glands that make up part of the hormonal (endo- crine) system, secrete these chemical messengers. "e endocrine system is so named because of the endocrine glands, such as the ovaries and the testes, which secrete the hormones. Glands are individual cells or groups of cells that secrete substances. "ey are called endocrine because they release substances within (endo-) the body, rather than secreting sub- stances that exit the body, such as sweat.
"e endocrine system plays an important role in sexual functioning. "e pituitary, located in the brain, and the ovaries and testes produce hormones that a#ect sexual functioning (Figure 6.2). "e hypothala- mus, located above the pituitary, produces hormones that trigger the secretion of pituitary hormones. Dur- ing puberty in males, pituitary hormones activate the maturation of the male reproductive structures and the release of increased levels of the male sex hormone, testosterone. Testosterone plays a role in the matura- tion of the male reproductive structures, stimulates the development of sperm, and triggers and maintains the development of the secondary sexual characteristics, such as the growth of a beard and the deepening of the voice. During puberty in females, pituitary hor- mones cause maturation of the ovaries, which then begin secreting the female sex hormones estrogen and progesterone. Estrogen stimulates maturation of the uterus and vagina, development of the female second- ary sexual characteristics such as the development of breasts, and a change in the distribution of body fat.
During middle age, the production of sex hor- mones declines. A$er 40 years of age, men produce less testosterone and fewer sperm, although accel- erated declines appear to be slowed by practicing healthy behaviors, such as maintaining a healthy body weight.1 Despite these reductions, elderly men can still father children. When women reach menopause,
Figure 6.2 Endocrine Glands. The pituitary, ovaries, and testes produce hormones that affect sexual functioning. The hypothalamus produces hormones that trigger the secretion of pituitary hormones.
Thymus
Adrenals
Pancreas
Pineal
Hypothalamus
Pituitary
Parathyroids
Thyroid
Testes (male)
Ovaries (female)
Human Sexual Behavior 171
usually between 45 and 55 years of age, their estro- gen and progesterone levels decrease dramatically. As a result, menopausal women are no longer fertile. However, most healthy elderly men and women con- tinue to have an interest in sex, and they engage in sexual activity. Research conducted for the AARP Survey of Midlife and Older Adults reveals that among those older than 70 years of age, 80% of men and 39% of women believed that a satisfying sexual relationship was important to the overall quality of life. In addition, 15% of men and 5% of women older than 70 years reported engaging in sexual intercourse at least once a week.2
The Psychology of Sexual Behavior Certain thoughts, sensations, and emotions modulate sexual behavior, as do the sex hormones. Included in this psychological mix are factors that can in'u- ence sexual behavior positively, such as satisfaction with one’s body, good physical and emotional health, absence of beliefs that can hinder sexual responsiveness or enjoyment, previous positive sexual experiences, and high self-esteem.
Many sexologists, scientists who study human sexuality, report that people who have high self-esteem are more likely to have positive attitudes concerning their sexuality than per- sons with poor self-concepts. How- ever, people frequently judge their bodies and sexual prowess against unrealistic standards of physical attractiveness and sexual ability that are presented in the media. As a result, some individuals develop
feelings of sexual inadequacy and low self-esteem because they feel sexually unattractive or inept. Peo- ple who have these feelings may be unable to enjoy their sexuality and may be unable to form ful!lling intimate relationships.
!e Sexual Response "e sexual response in both males and females is governed primarily by the nervous system rather than by hormones. Hormones are chemicals secreted in one part of the body that have an e#ect in another. Testosterone, the “male” hormone (women also secrete testosterone), helps maintain the sex drive, or libido.
"e two major physical changes that occur dur- ing sexual arousal are vasocongestion and myotonia. Vasocongestion occurs as blood 'ow away from the sexual organs is reduced. "e spongy tissue of the penis and clitoris expands with blood, and these structures become erect. Myotonia, an increase in muscle tension, occurs throughout the body.
%e Masters and Johnson Model Both sexes have broader responses than just these events. "is pattern of responses is termed the sexual response cycle. First de!ned by Masters and Johnson, the cycle is usually thought of as having four phases: excitement, plateau, orgasm, and resolution (Figure 6.3).
During the excitement phase of the sexual response cycle, both men and women have a heightened sex- ual awareness. Certain thoughts, sights, touches, and even sounds or odors lead to a rush of blood to the
sexologists Scientists who study human sexuality.
testosterone A male sex hormone (androgen) that plays a role in the development of functionally mature sperm and is responsible for the development and maintenance of male secondary sexual characteristics such as the deepening of the voice and the growth of facial hair.
vasocongestion A condition in which the spongy tissue of the penis and clitoris expands with blood during sexual arousal.
myotonia An increase in muscle tension throughout the body during sexual arousal.
Orgasm
Plateau
Excitement
1 2 3
R e so
lu tio
n
Female response
Resolution
R esolution
R esolution
Male response
Figure 6.3 The Masters and Johnson Model of the Female and Male Human Orgasmic Responses. The female response is much more variable than is the male response, as shown by the three female patterns and one male pattern illustrated here.
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clitoris and vaginal opening in women and to the penis in men.
In men, the penis expands as blood !lls spaces in its columns of spongy tissue. As a result, the penis becomes erect, and the expansion of the tissue com- presses the veins that take blood away from this organ. Consequently, as blood 'ow into the penis increases, blood 'ow out of the penis decreases. "is decrease in outward blood 'ow maintains the%erection.
In women, glands in the vulvar area secrete a lubricating 'uid. "e congestion of blood in the vulvar area and in the vagina swells the labia and pushes 'uid through the vaginal wall. "ese 'uids are lubricants for sexual intercourse. Blood also rushes to the breasts. In response, the breasts swell. "e nipples become erect as smooth muscles con- tract. Many women also exhibit a sex 'ush at this time, a reddening of the skin as blood 'ow through it increases.
As sexual excitement continues, the plateau phase begins. "e heart rate, blood pressure, respiration rate, and level of muscle tension all increase. During the plateau phase, the erection of the male intensi- !es as the penis is massaged rhythmically by inter- course (anal or vaginal), manual stimulation, or oral stimulation. Sensory impulses from tactile sensa- tions in both sexes reinforce their sexual sensations. In women, the lower third of the vagina constricts around the penis. "e upper two-thirds of the vagina widens as the uterus and cervix li$ up, creating a space for the semen. Continued stimulation of the clitoris and penis leads to the next phase of the sexual response—the orgasmic phase.
In men, ejaculation occurs during the orgasmic phase. "is involuntary response (over which men can exert some voluntary control) results when the nervous system sends messages to muscles in the walls of the vasa deferen- tia and urethra to contract. At the same time, the seminal vesicles and prostate receive messages to release their secre- tions. "e pelvic muscles also rhyth- mically contract. Orgasm in women is characterized by rhythmic contractions of the pelvic muscles and vaginal walls. Both sexes experience a peak of sexual pleasure at orgasm. Erection and ejacu- lation are the two primary components of the male sex act. "e clitoris of the female becomes erect during sexual
activity and she achieves orgasm, but women do not ejaculate like men.
During the resolution phase the body returns to its prearousal state. "e heart rate, blood pressure, and respiration slow; the muscles relax. In males, the erection subsides (the penis becomes 'accid) and sometimes fatigue sets in. Depending on the man and his age, he will not be able to develop another erection for a few minutes to a few hours. "is time is the refractory period. Unlike men, women have the capacity to reach the orgasmic phase again (have multiple orgasms) in sequence or rather quickly a$er dropping to the plateau phase.
"e Masters and Johnson model is considered a biological and linear model of sexual response. It is considered biological because it encompasses only physiologic aspects of the sexual response and not emotional or psychological aspects. It is considered linear because it has a beginning, middle, and end, starting at one place and ending at another. Although this model may re'ect the male sexual response well, it may not be as re'ective of the female sexual response.
Other Sexual Response Models Whipple and Brash-McGreer developed a circular model of female sexual response based on a previous linear four- stage model developed by Reed. "e circular model shows that a woman’s re'ection on a sexual encoun- ter a#ects her desire for the next sexual encounter. Satisfying sexual experiences reinforce her desire for another, whereas negative sexual experiences detract from her desire. "is circular model recognizes that the pleasure and emotional satisfaction derived from one sexual experience can lead to desire for the next sexual experience.3
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The Sexual Response 173
Consumer Health Ginseng and Sexual Prowess You’ve probably seen ads for ginseng in magazines, on television, or on the Web. The ads often make claims such as, “Ginseng will boost your energy and
sexual stamina,” or “Ginseng has been used for centu- ries in maintaining overall health and vitality,” or “Gin- seng will reduce stress and the effects of aging.” “Can it do that?” you might wonder.
Ginseng is an herb that grows wild or is cultivated in eastern Asia and North America. For thousands of years, the root of the plant has been used in Asia for medicinal purposes and as an aphrodisiac because it often looks like a human body (Figure 6.A). But what do we know about ginseng? Will it make you more sexu- ally “potent”? Can it harm you or, alternatively, enhance your health?
On the positive side, sperm motility and ability to fer- tilize an egg (capacitation) are enhanced after sperm are incubated with extracts of ginseng. Are sperm motility and capacitation enhanced in men who take ginseng? There is still no answer to that question. Does ginseng affect sexual arousal or performance? Ginseng has been shown to significantly enhance libido and copulatory behavior in male rats and mice. Additionally, ginseng has been shown to improve testicular ineffectiveness in aging male rats and to protect against heat-induced tes- ticular damage in rats, which led researchers to hypoth- esize that ginseng may have the ability to improve fertility for men. This herb appears to have a direct effect on penile tissue, which could be responsible for
its copulatory performance-enhancing actions, and has been used to treat erectile dysfunction.
On the negative side, medical researchers know that drug interactions occur with many herbals. Ginseng, in particular, may alter bleeding (or clotting) time, the time it takes for blood to stop flowing from a tiny wound. Ginseng also interacts with anticoagulant drugs, which “thin” the blood; that is, they decrease the ability of the blood to clot. Therefore, antico- agulants and ginseng should not be taken together. Ginseng also may interfere with the heart medication digoxin (digitalis), which affects the force and rate at which the heart beats.
In addition to its interaction with anticoagulants and digoxin, ginseng should not be used if a person is tak- ing estrogens or corticosteroid drugs such as cortisone because of possible additive effects. Ginseng may also affect blood glucose levels, so it should not be taken by persons with diabetes mellitus. For those on the antide- pressant drug phenelzine sulfate (Nardil), ginseng could provoke a manic episode (an extreme excited state). Its general side effects may include headache and involun- tary muscular contractions.
Should you take ginseng to boost your sexual prowess? This herb is commonly used in Asia to treat sexual dysfunction in humans. In addition, animal studies provide evidence that ginseng may be useful in such treatment, and it may enhance libido and cop- ulatory behavior in males. Results of one small-scale study show that Korean red ginseng improved sexual arousal in menopausal women. However, a review published in The Journal of Sexual Medicine in 2010 stated that “although there’s a positive trend towards recommending ginseng as an effective aphrodisiac,
however, more in depth studies involving [a] large number of subjects and its mechanism of action are needed before definite conclusions could be reached.” With all this evidence in mind, you might not want to rely on ginseng for better bedroom cal- isthenics just yet.
Data from De Andrade, E., et al. (2007). Study of the efficacy of Korean red ginseng in the treatment of erectile dysfunction. Asian Journal of Andrology, 9, 241–244.; Kim, M. K., et al. (2017). Pectinase-treated Panax ginseng protects heat stress-induced testicular damage in rats. Reproduction, 153(6), 737–747; Park, J. Song, H., Kim, S., Lee, M. S., Rhee, D., & Lee, Y. (2017). Effects of ginseng on two main sex steroid hormone receptors: Estrogen and androgen receptors. Journal of Ginseng Research, 41(2), 215–221; Zhang, H., et al. (2007). Ginsenoside Re promotes human sperm capacitation through nitric oxide-dependent pathway. Molecular Reproduction and Development, 74, 497–501.
Figure 6.A Ginseng Root. Use of the ginseng root as an aphrodisiac presumably began because it looks like a human body. © Blue Jean Images/Digital Vision/Thinkstock.
174 Chapter 6 Romantic Relationships and Sexuality
Basson also developed a cyclical model of the female sexual response, which is shown in Figure"6.4.4 "is model heavily incorporates emotional and psy- chosocial aspects. Sexual stimuli act on the sex drive as biological and psychological factors come into play, such as satisfaction with her sex partner, her self-image, and previous sexual experiences. A posi- tive psychological state can lead to sexual arousal and then sexual desire. "e resulting emotional and physical satisfaction she experiences from sexual activity leads to emotional intimacy with her partner and reinforces her being receptive to the next sexual encounter.
Sexual Dysfunctions A dysfunction is an impaired bodily process or a behav- ior that hinders the development or maintenance of healthy relationships. Sexual dysfunctions relate to the psychological and physical conditions that inter- fere with the sexual response.
Erectile Dysfunction (Impotence) A common problem with the sexual response that occurs in men, particularly middle-aged and older men, is impotence. More properly called erectile dysfunction (ED), impotence is the inability of a man to develop and/or sustain an erection !rm enough for penetration. "e inci- dence of ED rises as men age: 5% in men aged 20–39 years, 15% in men aged 40–59 years, 44% in men aged 60–69 years, and 70% in men 70 years or older.5 Some men with various degrees of erectile dysfunction are able, with proper stimulation, to reach orgasm and ejaculate.
Until recently, impotence was thought to be primarily a psychological problem, a con- clusion based on research stud- ies conducted by well-known sex therapists Masters and Johnson. However, medical researchers have discovered that
approximately 70–80% of cases of impotence are caused by physical problems. "e most common cause of physically based impotence is blood vessel disease. Lifestyle factors that a#ect ED are smoking, alcohol consumption, and physical activity. Smok- ing increases the risk of ED and is associated with its progression. Physical activity decreases the risk of ED, while moderate alcohol consumption (two drinks per day for men) decreases the risk of ED compared to no alcohol consumption or heavier consumption.6
To develop and maintain an erection, blood must !ll the spongy tissue of the penis and compress the veins that bring blood away from the penis. If a man has fatty deposits clogging his penile arteries, blood 'ow to the penis may be insu&cient to develop and maintain an erection. "e drugs Viagra (sildena!l), Levitra (vardena!l), and Cialis (tadala!l) work by
erectile dysfunction (ED) A sexual dysfunction in which a man is unable to develop and/or sustain an erection firm enough for penetration of the vagina. Also called impotence.
Emotional intimacy
Sexual arousal
Seeking out and being
receptive to
Sexual stimuli
Spontaneous sexual drive
Arousal and sexual desire
Emotional and physical satisfaction
Biologic
Psychological
Figure 6.4 Basson’s Blended Intimacy-Based and Sexual Drive–Based Circular Model of the Female Sexual Response. Women seek sexual intimacy for reasons beyond the physiologic sex drive, such as a desire to increase emotional closeness. This model shows that both the sex drive and the desire for emotional intimacy may motivate a woman to be responsive to sexual stimuli. In addition, biological and psychological factors combine to determine whether she becomes sexually aroused. For example, past sexual abuse may interfere with arousal even if she desires intimacy with her partner. Positive past experiences, however, will promote arousal. Her emotional and physical satisfaction from the sexual experience will then increase her desire for emotional intimacy, continuing the cycle of response. Reproduced from Basson, R. (2001). Female sexual response: The role of drugs in the management of sexual dysfunction. Obstetrics and Gynecology, 98(2), 350–353.
Sexual Dysfunctions 175
widening blood vessels in the penis, thus increasing blood 'ow.
Erectile dysfunction can also be caused by a vari- ety of other conditions, such as diabetes mellitus;5 damage to the spinal nerves or other nerves involved in erection; damage to the arteries that bring blood to the penis; certain medications used to control high blood pressure, anxiety, or depression; illness or injury that damages the penis; and hormonal imbal- ances. Research results show that use of a testoste- rone patch improves sexual function in men aged 50–70 years who exhibit symptoms of hormonal imbalance.7
Alcohol and illegal drugs such as marijuana, heroin, and cocaine have also been shown to a#ect penile function negatively. In addition, stress can be a cause of erectile di&culties. Epinephrine (adrenaline), a chemical released by the body dur- ing the stress reaction, impedes a man’s ability to have an erection.
Physicians advise that minor physical problems can cause erectile di&culties that can worry a man and lead to psychological problems with erection. A signi!cant !nding to help distinguish between a physical and psychological cause for impotence is whether the man has a normal pattern of erec- tions while asleep but not while engaged in sex with his partner. Men are encouraged to seek medical help for impotence immediately so that underly- ing, and possibly serious, physical problems can be diagnosed and treated promptly. If physical prob- lems are not the cause, the psychological health of the patient as well as the health of his relationships should be explored.
Premature (Rapid) Ejaculation Premature ejaculation (PE), also called rapid ejaculation, is the most common male sexual dysfunction, a#ecting from 3% to 30% of men of all ages, cultures, and ethnicities.8 "e wide range is due to a previous lack of de!nition, so studies o$en de!ned PE in di#ering ways. However, the term was !nally de!ned in 2008 by the International Society for Sexual Medicine’s Ad Hoc Committee for the De!nition of Premature Ejaculation, and updated in 2013 as%“(i) ejaculation that always or nearly always
occurs prior to or within about 1 minute of vaginal penetration from the !rst sexual experience (life- long PE) or a clinically signi!cant and bothersome reduction in latency time, o$en to about 3 minutes or less (acquired PE); (ii) the inability to delay ejac- ulation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as dis- tress, bother, frustration, and/or the avoidance of sexual intimacy”.7 Using this de!nition, the Inter- national Society for Sexual Medicine expects that the proportion of men a#ected by PE may be less than%3%.8
"e cause of PE is a controversial topic among medical researchers and psychologists who study sex-related disorders. One hypothesis suggests that PE is related to anxiety. Another hypothesis is that men who exhibit premature ejaculation may be phys- ically more sensitive to sexual stimulation. In recent years, however, the focus has shi$ed from psycholog- ical factors to biological factors that may underlie PE, such as genetically based di#erences in ejaculation or neurotransmitter problems. (Neurotransmitters are chemical messengers that allow nerve cells to communicate with one another.) Consequently, treatment focus is shi$ing from behavioral tech- niques to drugs.9 Nonetheless, specialists in sexual dysfunction advise that a variety of therapies may be useful in helping men with PE and suggest that a man or couple with this problem see a sex therapist as well as a physician.
Dapoxetine is a drug that is currently being con- sidered for approval by the FDA for the treatment of PE, although the drug was rejected initially by the FDA in 2005. Dapoxetine is a short-acting antide- pressant that allows the neurotransmitter serotonin to be used more e#ectively by the brain. (Serotonin is a brain chemical that a#ects emotions, behavior, and thought.) If approved, dapoxetine would be the !rst drug approved to treat PE. Although the drug appears to be e#ective and generally well tolerated by patients, it has serious side e#ects with long-term use, which include psychiatric problems, weight gain, skin reactions, lowered sex drive, nausea, and headache. "ese side e#ects have been one stum- bling block in the FDA approval process. Another similar drug called escitalopram (Lexapro), which has received FDA approval, is available for ED patients. Topical anesthetic creams are available, but they are messy, must be applied before sex and then thoroughly washed o#, and may numb the partner’s tissues if not removed completely.9
premature (rapid) ejaculation (PE) A common male sexual dysfunction in which a man consistently attains orgasm either before or shortly after intercourse begins and before he wishes it to occur.
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Female Sexual Arousal Disorder When a woman becomes sexually excited, the blood vessels in the pelvic area widen, tissues expand, and 'uid seeps through the walls of the blood ves- sels in the vaginal area, providing lubrication for sexual intercourse. Female sexual arousal disorder (FSAD) is a condition in which a woman is con- tinually unable, over an extended period of time, to attain or maintain adequate lubrication along with the swelling response during sexual activity. "e causes of FSAD include depression, stress, rela- tionship problems, past sexual or emotional abuse, and self-image problems. If the absence of this response is the result of a physiologic cause, such as the changes of menopause, injuries to the genital area, damage to nerves, a side e#ect of medications, or illness, the condition is considered a sexual dys- function resulting from a medical condition, and it is not considered FSAD.
Treatments for the absence of adequate lubrica- tion during sexual activity vary depending on the cause. Treatments for sexual dysfunction caused by a medical condition include hormone replacement therapy, prescription intravaginal hormone creams, and nonprescription lubricants. "e FDA-approved EROS clitoral therapy device, which is a small vac- uum pump designed to increase blood 'ow to the area, helps some women. In addition, research results show sildena!l citrate (Viagra) to be a moderately useful treatment.13 Treatments for FSAD include sex therapy and psychological%therapy.
Vaginismus Vaginismus is a sexual dysfunction of women in which the muscles of the lower third of the vaginal canal contract involuntarily (and o$en painfully) at the anticipation of sexual intercourse, the insertion of tampons, or a pelvic examination, causing dis- tress. "e muscular contractions are strong enough to prevent penetration. Women with vaginismus do not usually have other sexual dysfunctions and can achieve orgasm by stimulating the clitoris.
Vaginismus appears to have both physical and psy- chological causes. A variety of physical conditions
Hypoactive Sexual Desire Disorder Hypoactive sexual desire disorder (HSDD) refers to a persistent low interest in sex with personal distress resulting from this low desire.10 "is disorder a#ects both men and women, although HSDD occurs more o$en in women. Interest in sex declines with age in both men and women as hormone levels drop. "us, older women and men may not be as distressed as younger persons by a lowered sex drive and may consider it part of the normal aging process. Conse- quently, HSDD may have a lower frequency in older persons than in younger persons.
A study of a large national sample of U.S. women using the Women’s International Study of Health and Sexuality (WISHeS) questionnaire supports this hypothesis.11 Results of the study reveal that 24–36% of women between the ages of 20 and 70% years had low sexual desire. Nonetheless, not all of these women had HSDD because not all of them experi- enced personal distress as a result of their low desire. In premenopausal women aged 20–49 years, 24% had low sexual desire. In naturally postmenopausal women aged 50–70 years (those who had not had menopause induced surgically by removal of the ova- ries), 29% had low sexual desire. However, a much larger proportion of the younger women were dis- tressed by their low desire: 59% of the younger age group who experienced low sexual desire versus 33% of the older age group. "us, in calculating HSDD in these two groups of women, the researchers deter- mined that the younger women had a higher rate of HSDD (14%) than the older women (9%).
Hypoactive sexual desire disorder has a variety of psychological and physical causes, such as restric- tive views regarding sex, a history of sexual abuse, relationship problems, and certain chronic diseases such as rheumatoid arthritis, fatigue, stress, illness, and abnormal hormone levels. Stahl suggested that HSDD may be the result of a dysfunction of certain “reward pathway” neurotransmitters in the brain.10
Treatment of HSDD includes the identi!cation and elimination of the cause. Problems within the rela- tionship or con'icting personal feelings and beliefs regarding sexuality are best identi!ed and resolved via counseling and therapy. Other treatments include relaxation techniques, hormone treatments, and changes in medications that a patient may be taking. Drugs that act on the dysfunctional reward pathways in the brain may hold promise for the future treat- ment of HSDD as well.12
vaginismus A sexual dysfunction of women in which the lower portion of the vagina contracts involuntarily at the anticipation of penetration, preventing it.
Sexual Dysfunctions 177
Diversity in Health The Perceived Virtue of Virginity In many cultures and to many people, virginity is a virtue that is presented on the wedding night to one’s spouse. Since ancient times, people from various cul-
tures have used the condition of a bride’s hymen to deter- mine if this virtue is intact. Although the hymen has no known biological function, this thin membranous tissue usually covers part of the outer entrance to the vagina. Most hymens have at least one opening that is wide enough to permit the discharge of menstrual blood. In many instances, this opening is too narrow for a penis to penetrate without tearing the surrounding tissue, but the hymen can also be torn while engaging in nonsexual activi- ties, such as riding a bicycle, exercising, or using tampons.
According to the Old Testament of the Bible, a man who thought that his bride was not a virgin on their wed- ding night was entitled to have his townspeople stone her to death. In some ancient societies, a newly wed woman who could not prove her virginity might be banished from her hometown, tortured, or killed. Her lover, if known, often received the same treatment. Today, virginity is still an important criterion for selecting a mate in some places, especially in India, Indonesia, China, Taiwan, Iran, Turkey, and Arab nations. In most of these places, however, a new bride with sexual experience usually receives less harsh treatment than in the past. She may be rejected by her husband and returned to her family as “used goods.”
Facing embarrassment and ridicule from neighbors, the woman’s family may disown her.
According to Islamic tradition, a woman’s virginity is the basis for her honor and that of her family, her future groom, and his family. Muslims, followers of Islam, would arrange early marriages for their female children to ensure that these girls entered puberty as virgin brides. Fatima Mernissi, a sociologist in the African country of Morocco, thinks that Muslim men maintain their respect and pride by controlling the sexuality of their wives, daughters, and sisters. In many Muslim communities, young women are required to be heavily veiled in the presence of strange men and in public ( Figure 6.B). If they do not wear veils, young women may be punished severely.
Marriage and social customs in rural parts of Africa, Asia, and the Mediterranean often include some ritual that “proves” the bride has lost her virginity on her wedding night. In parts of Greece, the groom’s friends gather out- side the window of the newly married couple on the morn- ing after the wedding to receive the news that the bride is no longer a virgin. After the groom makes the expected announcement, the gathering of friends celebrates by fir- ing guns into the air. In many Middle Eastern villages, it is customary for the groom to display bloodstained sheets as evidence of wedding night virginity loss. In some societ- ies with such traditions, new brides keep a small amount of chicken blood handy to drip on sheets during the wed- ding night, or they make a small cut near the vaginal open- ing that will bleed during sexual intercourse. The social value of virginity is so powerful that cosmetic surgeons in Japan and Italy routinely reconstruct hymens so that their
Figure 6.B Culturally Appropriate Clothing. In some Islamic traditions, women wear the body-covering burka in public. A mesh screen covers the eyes. These women are at a bazaar in Afghanistan. © Lizette Potgieter/Shutterstock.
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unmarried female patients who have been sexually active or have torn hymens for reasons unrelated to sex can pre- sent themselves with the needed tissues intact.
Economic factors also play a major role in perpetuat- ing the value of premarital virginity. In many cultures, property is handed down from fathers to sons. There- fore, families strive to protect their financial interests and lines of inheritance by seeking virgin brides for male relatives. An unmarried woman who is not a vir- gin could be pregnant with a male child whose father is from another family. Without DNA testing to confirm a child’s paternity, rural people in underdeveloped regions rely on an intact hymen as a sign of virginity. Along with this view of women as property, cultural norms of sexual chastity, female virginity, pure bloodlines, and family honor may also serve to control women’s behavior.
In some societies, virginity tests, which usually involve inspection of the hymen, are used to document premarital virginity. For example, virginity testing existed in Turkey until 2002, when laws were changed that had previously allowed school administrators to require vir- ginity testing for female students. In 2010, the Indone- sian government was urged by Amnesty International to block attempts to institute virginity and pregnancy test- ing for high school girls, which it did.
Virginity testing has also been reported as retaliation for women political protesters. In 2011, women protest- ers in Egypt were forced to undergo virginity testing while under military detention; 1 year later, the military doctor was acquitted of any wrongdoing for performing the tests. Women protesters in Sudan also reported being sub- jected to virginity testing while under military detention.
In some areas of South Africa, virginity “tests” that are born of ancient tribal customs and that have no relation- ship to whether a young woman is really a virgin are still practiced alongside public genital inspection for an intact hymen (Figure 6.C). South Africans who support virginity testing explain that this tradition is important not only to retain long-held customs but also to promote sexual abstinence in a country with a high rate of HIV/AIDS.
Is disease prevention the “new” virtue of virginity? It may be, but promoting virginity by means of virginity testing is viewed by its opponents as nothing more than degrad- ing abuse. Virginity testing is placing ancient cultures and human rights on a collision course and makes virginity look less like a virtue and more like a condition to endure.
How do you view virginity? As something that is good, bad, or neither good nor bad? Do you agree or disagree with the statement, “Virginity testing is a viola- tion of human rights”? Why?
Data from Amnesty International. (2010, November 11). Indonesia urged to block discriminatory pregnancy tests for school girls. Retrieved from http://www.amnesty.org/en/news-and-updates/indonesia -urged-block-discriminatory-pregnancy-tests-schoolgirls-2010-11-11; Amnesty International. (2013, February 6). Egypt: Impunity fuels sexual violence. Retrieved from http://www.amnesty.org/en/for-media/press -releases/egypt-impunity-fuels-sexual-violence-2013-02-06; Brulliard, K. (2008, September 26). Zulus eagerly defy ban on virginity test: S. Africa’s progressive constitution collides with tribal customs. Washington Post. Retrieved from http://www.washingtonpost.com /wp-dyn/content/article/2008/09/25/AR2008092504625.html; Mernissi, F. (2003). Beyond the veil: Male–female dynamics in Muslim society. London, England: Saqi Books; Mthethwa, B. (2009, December 12). Virginity testing keeps boys pure. Retrieved from http:// www.timeslive.co.za/sundaytimes/article231102.ece
Figure 6.C This smiling girl has just completed her virginity testing in rural Natal, South Africa. © Per-Anders Pettersson/Getty Images.
Sexual Dysfunctions 179
can cause pain during intercourse (dyspareunia; dis- pah-ROO-nee-ah) and result in vaginismus. Causes of dyspareunia include a poorly healed episiotomy (an incision made to widen the vaginal opening dur- ing the birth process); infections, sores, or lesions of the vagina or vulva; estrogen de!ciency; sexu- ally transmitted infections; or inadequate lubrica- tion during intercourse. If a woman experiences pain during intercourse because of one or more of these conditions, involuntary vaginal contractions may occur as the body attempts to protect itself from penetration and subsequent pain. If the cause of the pain eventually subsides, the contractions may still occur as a conditioned response. Recent research suggests that vaginismus and dyspareunia should be considered as one “genito-pelvic penetration/ pain disorder” because the two conditions gener- ally occur together, and reliable diagnosis of vaginal spasm is di&cult.14
Psychogenic vaginismus usually begins without a physical cause. "e results of studies show that this type of vaginismus occurs as a protective response to perceived pain or violation of the body, with com- mon causes being child sexual abuse, early traumatic sexual experiences, early traumatic gynecological examinations, inadequate sex information, and cul- tural and religious taboos.
Treatments for vaginismus are usually tailored to the individual and are multidimensional. Educa- tion helps correct misconceptions a woman may have about the genitals in general and the vagina in particular. (For example, a woman may believe that the vagina is particularly narrow and delicate and therefore easily harmed by penetration.) Psychiatric or psychological therapy may be useful for a woman alone or for her and her partner. Physical treatment generally includes using vaginal inserts of graded sizes to slowly help a woman overcome her fear of penetration, but this step can be taken only when a woman feels ready.
Culture, Gender, and Sexuality
Society strongly in'uences the sexual attitudes and behaviors of a population by identifying acceptable sexual activities and placing restrictions on others. For example, some cultures value sexual abstinence before marriage; others value sexual experimentation during childhood. A value is a belief that an idea, object, or action has worth. "e Diversity in Health essay “"e Perceived Virtue of Virginity” provides a cross-cultural perspective concerning the value of sexual abstinence before marriage.
An individual usually formulates a personal value system before adulthood. A value system is a collec- tion of beliefs that helps a person identify and classify things as being good or bad, or neither good nor bad. "is value system guides the reasoning and behavior of the individual, especially in sexual decision making.
Many Americans derive their sexual values from Judeo-Christian religious teachings. However, people in the culturally diverse U.S. population adhere to a variety of sexual values, some of which con'ict with traditional Judeo-Christian teachings. No universally accepted set of sexual values applies to Americans.
Widely accepted values can help people determine behavioral norms, but these norms o$en change over time and across cultures. Before World War I, for example, it was socially unacceptable for “proper” American men or women to expose much of their bodies in public. Today, most Americans think that it is acceptable for people to wear clothing that exposes much of their bodies, especially in warm weather. However, in some cultures, persons are punished severely if they appear in public dressed in revealing out!ts; the only acceptable style of clothing is that which has been worn for centuries (Figure 6.B).
Gender Identity and Roles Gender is the socially constructed di#erences that distinguish one as female or male (or something else), as de!ned previously in this chapter. "e way we understand and refer to gender identity is evolv- ing with our society’s understanding and acceptance of nontraditional gender identities. Traditionally, gender identify referred to an individual’s perception of himself or herself as male or female. However, in recent years, our society’s understanding of gender has expanded beyond the binary categories of male and female.
value The belief that an idea, object, or action has worth.
gender identity An individual’s perception of himself or herself as male, female, or something else.
cisgender A term that refers to people whose gender identity is congruent with their biological sex.
transgender An umbrella term for various groups of people who do not conform to traditional gender identities.
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Most people have a gender identity that is con- gruent with their biological sex: "ese people are referred to as cisgender. Other people feel that their biological sex (male or female) does not align with their gender identity. For example, one might have the biological sex male, but the gender identity female. "ese people are referred to as transgender.
Transgender also refers to people who feel their gen- der cannot be categorized as either male or female. For example, some people feel their gender is neither male nor female; others feel that their gender is both male and female. Some people whose gender iden- tity falls outside the traditional male/female catego- ries call themselves genderqueer. Table 6.1 presents
Culture, Gender, and Sexuality 181
Common Gender Identity Terms
Table 6.1
Common Gender Identity Terms
There are a lot of ways that transgender people can describe their identities. Understanding the words and labels people use encourages respect and understanding.
Cisgender Those who identify and present as the gender they were assigned at birth. For example, a baby born with a vulva is categorized a girl. If she also sees herself as a girl throughout her life, she is considered cisgender. In its simplest terms, cisgender describes someone who is not transgender.
Cross-Dresser (sometimes shortened to CD)
A person, typically a straight-identified cisgender man, who sometimes wears clothing associated with the opposite sex in order to have fun, entertain, and gain emotional satisfaction; for sexual enjoyment; or to make a political statement about gender roles.
Drag King A female performer who exaggerates male behaviors and dress for the purposes of entertainment at bars, clubs, or events. Some drag kings might identify as transgender.
Drag Queen A male performer who exaggerates female behaviors and dress for the purposes of entertainment at bars, clubs, or events. Some drag queens might identify as transgender.
Gender Dysphoria A diagnosis, often used by psychologists and doctors, to describe the distress, unhappiness, and anxiety that transgender people may feel about the mismatch between their bodies and their gender identity. A person may be formally diagnosed with gender dysphoria to receive medical treatment to help them transition.
Gender Fluidity The flexibility of gender expressions and identities that may change over time or even from day to day. A gender-fluid person may feel male on some days, female on others, both male and female, or neither. A gender-fluid person might also identify as genderqueer.
Gender Nonconforming or Nonbinary
When a person’s gender expression doesn’t fit inside the traditional male or female categories (sometimes called the gender binary). These labels can include someone who identifies as both male and female, neither male nor female, or some other gender altogether. The term isn’t a synonym for transgender and should only be used if someone self-identifies as gender nonconforming or nonbinary.
Genderqueer A term for people who don’t identify as a man or a woman or whose identity lies outside the traditional gender binary of male and female. Some people use genderqueer, gender nonconforming, and nonbinary interchangeably, but others don’t. Genderqueer has a political history, so many use the term to identify their gender as nonnormative in some way. For example, someone could identify as both cisgender female and genderqueer.
Intersex A general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t fit the typical definitions of female or male. Sometimes a female or male gender is assigned to an intersex person at birth through surgery if external genitals are not obviously male or female. Intersex babies are always assigned a legal gender, but sometimes when they grow up, they don’t identify with the gender selected for them. Some intersex people are transgender, but intersex does not necessarily mean transgender.
(Continued)
common gender identity terms, but it is important to note that terminology is continually evolving, and it is best to use the language and terminology that each person prefers.
Various biological, social, and environmental forces mold a child’s gender identity. Before birth, genetic and hormonal factors in'uence the sexual development of the embryonic brain. A$er birth,
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Common Gender Identity Terms
Table 6.1 (Continued)
Transgender (sometimes shortened to Trans or Trans*)
A general term used to describe someone whose gender expression/gender identity are different from the sex assigned at birth. Some people put an asterisk on the end of trans* to expand the word to include all people with nonconforming gender identities and expressions.
Transgender Man (sometimes Trans Man, Female-to-Male, F to M, F2M, or FTM)
A person whose sex assignment at birth was female but whose gender identity is male. These identities can also refer to someone who was surgically assigned female at birth, in the case of intersex people, but whose gender identity is male. Many trans men identify simply as men.
Transgender Woman (sometimes Trans Woman, Male-to- Female, MTF, M2F)
A person whose sex assignment at birth was male but whose gender identity is female. These identities can also refer to someone who was surgically assigned male at birth, in the case of intersex people, but whose gender identity is female. Many trans women identify simply as women.
Outdated, Inaccurate, or Offensive Gender Identity Terms
Although some people may use the following terms to describe their own gender, most of the labels that follow range from out of date to offensive.
Gender Identity Disorder (or GID)
The preferred term is gender dysphoria.
Hermaphrodite The preferred term is intersex.
Pre-operative, Post- operative (also pre-op or post-op)
A set of terms to describe a transgender person who has had or has not had sex reassignment surgeries. Focusing on whether someone has had surgery can be considered invasive or a violation of someone’s privacy. Also, many transgender people don’t want (or don’t have access to) surgeries that would change their body. Finally, there are a variety of other ways transgender people transition besides sex reassignment surgery.
Sex Change Operation Preferred terms are sex reassignment surgery (SRS) or gender-affirming surgery.
Shemale An offensive term for a transgender woman, especially one who has had medical treatment for her breasts but still has a penis. This term may be used by sex workers or within the porn industry.
Tranny (sometimes referred to as The T-word)
While some transgender people use the word tranny to describe their gender, most find it highly offensive—a derogatory slur.
Transgendered Adding -ed to the end of transgender isn’t grammatically correct. You wouldn’t say that someone is gayed, womaned, or Latinoed. Similarly, you wouldn’t call someone transgendered.
Transsexual An older term for people whose gender identities don’t match the sex that was assigned at birth and who desire and/or seek to transition to bring their bodies into alignment with their gender identities. Some people find this term offensive, others do not.
Data from Centers for Disease Control and Prevention. (14 July 2014). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.cdc.gov/lgbthealth/; Doan, P.L. (2016). To count or not to count: Queering measurement in the transgender community. Women’s Studies Quarterly, 44(3/4), 89-110; Planned Parenthood. (2018). Transgender identity terms and labels. Retrieved from https://www.plannedparenthood.org/learn/sexual-orientation-gender/trans-and-gender-nonconforming-identities /transgender-identity-terms-and-labels
social factors have a major impact on gender iden- tity. As children interact with people, they observe and learn gender roles and stereotypes. A gender role refers to patterns of behavior, attitudes, and per- sonality attributes that are traditionally considered in a particular culture to be feminine or masculine. For example, women have traditionally borne more responsibility for child-rearing and household man- agement, and men have traditionally been viewed as the protectors and providers for their families. A gender stereotype is the widespread association of certain perceptions with one gender. Examples of gender stereotypes are associating household chores or childcare activities with women (e.g., cleaning the house and staying home to care for children is “women’s work”), or associating the responsibility for earning the family income with men (e.g., it is a man’s responsibility to provide for his family).
"roughout the world, obvious biological dif- ferences between the sexes form the basis for many traditional gender roles. Women being responsible for routine child-rearing and household manage- ment likely developed for a variety of reasons, such as a woman’s biological role in giving birth and nursing infants. It is also likely that because men, in general, are physically stronger than women, their customary roles have been protecting and provid- ing for their families, especially in hunter-gatherer or agrarian societies.
In addition to biological factors, culture and reli- gion heavily in'uence sexual attitudes and behaviors. In many cultures, men learn to be sexually aggressive, and women learn to be sexually passive. According to these sexual stereotypes, men are always eager for sex, and they are expected to demonstrate their inter- est and aggressiveness by initiating sexual encoun- ters. Women are expected to be less interested in sex than men are but to accept the sexual advances of men (such as their partners) willingly.
In the United States, parents, friends, teachers, and the media in'uence children’s perceptions of gender roles. Academic engagement, peers, and women’s studies courses appear to be relevant in shaping col- lege students’ perceptions of gender roles.15
Some Americans reject traditional gender stereo- types because these attitudes and practices can create and foster sexism. Sexism, discrimination and bias against one sex, is common in many societies. For many women in the United States and other coun- tries, sexist practices a#ect their status and health at work, school, and home. Sexual harassment and vio- lence against women are forms of sexism. Men can
experience sexism as well; males sometimes feel the object of sexist practices in the workplace when hir- ing guidelines favor females.
In recent years, societal norms in the United States have moved to a more liberal interpretation of appro- priate role behaviors for women. Women are now more comfortable initiating dates than in past gen- erations. Men and women may feel free to initiate or refuse sexual activity. Additionally, a growing num- ber of Americans feel free to choose nontraditional careers and adopt 'exible gender roles. For example, many mothers work outside the home; also, some fathers stay at home to care for their children and manage household tasks.
Transgender is an umbrella term that is com- monly used—but not universally accepted—to refer to people who do not conform to traditional gender roles for gender expression or whose gender identity di#ers from the societal norm.16 Gender expression is the external manifestation of one’s gender identity, which may or may not con'ict with society’s expecta- tions of behavior for traditional male and female gen- ders (for example, how one dresses). "e most recent population estimates suggest that approximately 700,000 people in the United States, or 0.3% of the U.S. adult population, are transgender.17,18
Historically, gender identities di#ering from soci- etal expectations were viewed as mental health disor- ders; however, in 2012, the American Psychological Association reclassi!ed gender identity disorder as gender dysphoria to signal that being transgender is not a mental health issue. Although being transgen- der is not a mental health disorder, emotional stress related to the mismatch between society’s expecta- tions and one’s gender identity can cause emotional distress, which is encompassed by the term gender dysphoria. In many cases, a person with gender dys- phoria feels trapped in the body of the opposite sex. Persons with gender dysphoria o$en seek psychother- apy and/or hormonal treatments in an e#ort to cope with their gender identity con'icts; some choose to have sex reassignment surgery to align their physical
gender role Patterns of behavior, attitudes, and personality attributes that are traditionally considered in a particular culture to be feminine or masculine.
gender stereotype The widespread association of certain perceptions with one gender.
sexism Discrimination and bias against one sex.
gender expression One’s external manifestation of one’s gender identity.
Culture, Gender, and Sexuality 183
body with their gender identity. Physicians who per- form sex reassignment surgeries usually remove cer- tain reproductive organs and reconstruct the patient’s genitals to make them resemble those of the opposite sex. A$er gender reassignment surgery, however, the newly fashioned reproductive organs do not func- tion like the organs of people who were born with them. Figure 6.5 is a before and a$er photo of Caitlyn Jenner, Olympic gold medalist, actor, and celebrity, who came out as transgender in 2015.
Unlike transgender people, crossdressers are com- fortable with their gender, but they occasionally dress and act like the opposite sex. Most crossdressers are cisgender heterosexual men. Drag performers, who can be cisgender or transgender, dress like the oppo- site sex as well, but they do it as a job or as play; it is not necessarily an identity for them. "us, while some transgender men and women engage in crossdress- ing and drag performing, these behaviors are distinct from gender identity (and sexual orientation).
Sexual Orientation One of the most emotionally charged aspects of human sexuality is sexual orientation, that is, the direction of a person’s romantic and sexual thoughts, feelings, and attractions. Sexual orientations include asexual, bisexual, gay (homosexual), lesbian, and straight (heterosexual).19 People who do not feel sex- ual attraction toward anyone o$en call themselves asexual. People who feel sexually attracted to both males and females o$en label themselves as bisexual. People who feel sexual attraction for people of the same gender o$en identify as being homosexual or gay. Women who identify as homosexual or gay might prefer identifying as lesbian. People who feel sexual attraction for people of the opposite gender o$en identify themselves as straight or heterosexual. However, some people prefer not to label their sexual
sexual orientation The direction of a person’s romantic and sexual thoughts, feelings, and attractions.
asexual A person who feels no sexual attraction to anyone.
bisexual A person who feels sexual attraction to both males and females.
gay (homosexual) A person who feels sexual attraction to people of the same gender.
lesbian A gay woman.
straight (heterosexual) A person who feels sexual attraction to people of the opposite gender.
Figure 6.5 Bruce Jenner to Caitlyn Jenner. Born William Bruce Jenner in Mount Kisco, New York, Jenner became an American hero after winning gold in the 1976 Olympics decathlon event. In a televised interview with Diane Sawyer, Jenner came out as a transgender woman in April 2015. Jenner debuted her new name, Caitlyn Marie Jenner, in June 2015. In September 2015, her name and gender were legally changed. (a) Bruce Jenner in 2008. (b) Caitlyn Jenner in 2018. (a) © s_bukley/Shutterstock; (b) © JStone/Shutterstock.
orientation, and others feel that none of these com- monly used labels are accurate descriptions of their sexual orientation. It is best to respect the labels that people choose for themselves. Sexologist Alfred Kinsey proposed that sexual orientation is a contin- uum, with exclusively heterosexual and homosexual designations at opposite ends, and degrees of bisexu- ality within this continuum (Figure 6.6).20 Sexual orientation percentages hold fairly consistent across sociodemographic groups.
For the !rst time in its 57-year history, the 2013 National Health Interview Study—conducted by the Centers for Disease Control and Prevention (CDC)— included questions regarding sexual orientation. According to the results, published in July 2014, of the 34,557 respondents 18 years and older, 96.6% identi- !ed as straight (heterosexual), 1.6% identi!ed as gay or lesbian, 0.7% identi!ed as bisexual, 0.2% identi!ed as “something else.” Although this study did not !nd any signi!cant di#erences in the percentages of men and women identifying as gay, lesbian, or straight, the percentage of women identifying as bisexual was more than twice that of their male counterparts (0.9% and 0.4%, respectively). Age di#erences were reported among those identifying as gay or lesbian:
(a) (b)
184 Chapter 6 Romantic Relationships and Sexuality
"e percentages of those aged 18–44 and 45–64 who identi!ed as gay or lesbian were more than 2.5 times higher than the percentage of those 65 and older. Age di#erences were also reported for those identifying as bisexual: "e percentage of those aged 18–44 who identi!ed as bisexual was 2.75 times higher than the percentage of those aged 45–64, and 5.5 times higher than for those aged 65 and older.21 Results from the most recent years of the National Health Interview Study were similar.22 Results from the National Survey of Family Growth (NSFG), also conducted by researchers at the CDC and most recently published in 2016, show that 6.2% of men and 17.4% of women aged 18–44 years engaged in sex with a same-sex partner at least once over their lifetime (Figure 6.7). Among this same population, more men (92.1%) reported feeling sexual attrac- tion only to the opposite sex more o$en than women (81.0%). Regarding sexual orientation identi!cation, 95.1% of men and 92.3% of women identi!ed as het- erosexual; 1.9% of men and 1.3% women identi!ed
as homosexual, gay, or lesbian; 5.5% of women and 2.0% of men identi!ed as bisexual; and 1.0% of men and 0.9% of women responded “don’t know” or did not report their sexual orientation.23
Nature or Nurture? Do people choose their sexual orientation? Formerly, there was widespread belief that homosexuality was learned behavior and that children became homo- sexual by having early social and sexual experiences with gay individuals. At present, researchers cannot !nd a common childhood characteristic that pre- dicts adult sexual orientation. Children may have same-sex experiences with other children, but most develop heterosexual orientations as they mature. Some gays and lesbians report that they knew they were di#erent at an early age, but they did not rec- ognize their homosexuality until they were in their teens or early 20s.
Today, researchers and mental health experts generally agree that people do not decide their
Figure 6.6 Kinsey’s Continuum of Sexual Orientation. Sexuality researcher Alfred Kinsey thought that sexual orientation is a continuum, with exclusively heterosexual and homosexual designations on the ends and degrees of bisexuality between them.
100% Heterosexual
A few homosexual fantasies or experiences
More heterosexual
than homosexual
Bisexual More homosexual
than heterosexual
A few heterosexual fantasies or experiences
100% Homosexual
100
80
60
40
20
0 Male
92.0
P er
ce n
ta g
e
87.4
42.3
6.2
94.2 86.2
35.9
17.4
Female
Vaginal intercourse with opposite sex Oral sex with opposite sex Anal sex with opposite sex Any same sex sexual contact
Figure 6.7 Sexual Behavior. Lifetime sexual behavior among males and females 18–44 years of age: United States. Reproduced from Copen, C.E., Chandra, A., Febo-Vazquez, I. (2016, January 7). Sexual behavior, sexual attraction, and sexual orientation among adults aged 18-44 in the United States: Data from the 2011-2013 National Survey of Family Growth. National Health Statistics Reports, 88. Retrieved from https://www.cdc.gov/nchs/data/nhsr/nhsr088.pdf
Culture, Gender, and Sexuality 185
sexual orientation and cannot alter their sexual pref- erences, whether they are at either end of the sexual orientation continuum or somewhere in between. Researchers have been studying the biological basis of homosexuality, and results of studies of the early 1990s show physical di#erences in small groups of cells in the hypothalamus of the brains of heterosex- ual and homosexual men.24 In 1993, molecular genet- icist Dean Hamer and his colleagues announced that a particular region of the X chromosome in homo- sexual males was involved in male sexual orientation in some, but not all, gay men.25 Males inherit this sex chromosome (condensed piece of hereditary mate- rial) from their mothers. "e particular region of the X chromosome was dubbed the “gay gene.” How- ever, the results of more recent research suggest that homosexuality is under the control of more than a single gene. Scientists are now studying how genes that control homosexuality are maintained in the population.26
Sexual Orientation and Society Since ancient times, homosexuality has existed in most societies. Homosexuals are members of every racial, ethnic, socioeconomic, religious, and occupa- tional group. Although many people choose to con- ceal their sexual orientation, others have decided to express their sexual preferences openly.
Homophobia is an intense fear of or hostility toward homosexuals. However, not every person who objects to homosexuality is afraid of gay people or is hostile toward them. "erefore, antihomosex- ual may be a more descriptive term than homopho- bic to describe people who harbor such fears and hostilities.
Many heterosexuals do not accept homosexu- ality because they think same-sex sexual behavior is unnatural or contradicts their religious beliefs. Other people are afraid of contact with gays because
they associate acquired immune de!ciency syn- drome (AIDS) with homosexuality. Results of a May 2017 Gallup poll on tolerance for gay rights revealed that 72% of respondents thought that gay and lesbian relations should be legal, up from 44% in 1996.27
U.S. President Bill Clinton signed the Defense of Marriage Act in 1996, which does not recog- nize marriages between same-sex individuals and allows states to ignore same-sex marriages that have been performed in other states. Gay couples, how- ever, o$en cohabit and form lifetime commitments, commonly called domestic partnerships. Because domestic partners o$en contribute to the economic survival of their households, share property, and raise children, they want the same legal rights and protections that opposite-sex married couples have, such as the right to claim insurance bene!ts when their partners die.
In 2003, Massachusetts became the !rst state to legalize same-sex marriages. In 2012, U.S. President Barack Obama became the !rst sitting president to announce support for same-sex marriage. Also in 2012, three states—Maine, Maryland, and Washington—became the !rst to legalize same-sex marriage through popular vote. In 2013, the Supreme Court struck down part of the Defense of Marriage Act, thus requiring the federal government to recog- nize same-sex marriages from the states in which they are legal. In 2014, federal courts struck down same- sex marriage bans in nine states: Utah, Oklahoma, Virginia, Texas, Michigan, Idaho, Wisconsin, Indiana, and Kentucky.28 In 2015, the U.S. Supreme Court ruled all state bans on same-sex mar- riage as unconstitutional, allowing same-sex marriages%nationwide. When asked in 2017 whether marriages between same-sex couples should or should not be recognized by the law as valid, with the same rights as traditional marriages, 64% of Gallup poll respondents said they should be valid, up from 27% in 1996, whereas 34% said they should not be valid, down from 68% in 1996.27
"ere are very few countries in the world where gay couples can legally marry. Mexico allows same- sex marriages in some jurisdictions. As of August 2017, the 26 countries allowing same-sex marriage were Argentina, Australia, Belgium, Brazil, Canada, Colombia, Denmark, England/Wales, Finland, France, Germany, Greenland, Iceland, Ireland, Luxembourg, "e Netherlands, New Zealand, Nor- way, Portugal, Scotland, South Africa, Spain, Sweden, United States, and Uruguay.29
homophobia An intense fear of or hostility toward homosexuals.
sexual intercourse Penetration of the vagina by a penis.
coitus (KO-ih-tus) The act of a penis penetrating a vagina, often referred to as vaginal intercourse.
cunnilingus Use of the mouth and tongue to stimulate a woman’s genitals.
fellatio Use of the mouth and tongue to stimulate a male’s genitals.
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v Diversity in Health Common Sexual Practices Between Partners Most heterosexuals are familiar with the notion of “hav- ing sex” or sexual intercourse as vaginal sex, the insertion of a penis into a vagina. Vaginal sex, or coitus, is the most common and popular form of intimate sexual activity between partners. According to findings from the National Survey of Sexual Health and Behavior (NSSHB) conducted by researchers from the Center for Sexual Health Promotion at Indiana University, about three-fourths of men and women aged 25–39 years and more than half aged 20–24 and 40–49 years engaged in vaginal intercourse in the month before taking the sur- vey.30 Results from the NSFG show that 92.0% of men and 94.2% of women aged 18–44 years had vaginal inter- course at least once over their lifetime (see Figure 6.7).
The report American Sexual Behavior: Trends, Sociode- mographic Differences, and Risk Behavior from the Univer- sity of Chicago’s National Opinion Research Center states that, on average, adult Americans say that they engage in vaginal intercourse about once a week. Married individu- als report having vaginal sex more frequently than never- married, divorced, or widowed persons. The results of various surveys indicate that the longer a couple has been married, the less frequently they engage in coitus.31
Men engaging in anal intercourse—whether with other men or with women—was reported much less frequently than vaginal intercourse. The highest incidence of past- month homosexual/heterosexual “insertive” anal inter- course (inserted penis into anus) was among men aged 25–29 years at 10.3%.30 The highest incidence of homo- sexual past-month “receptive” anal intercourse (received penis in anus) was among men aged 50–59 years at 2.9%.30
For women, the incidence of anal intercourse is low. The highest incidence of past-month anal intercourse reported on the NSSHB was among those aged 18–24 years, at about 7–8%.30 Lifetime anal sex for females aged 18–44 years was reported as 35.9% on the NSFG (see Figure 6.7).23
Many women and men find receptive anal intercourse unappealing because the practice can be painful, it increases the risk of contracting sexually transmitted infections, espe- cially HIV, and it increases the risk of developing urinary tract infections. The lining of the rectum tears easily—much more easily than the vagina—elevating the risk of bacteria and viruses entering the bloodstream. Lubricants that are often used with anal sex may irritate the tissues, increas- ing the risk further. Using latex condoms during anal sex reduces but does not eliminate this risk. For women, if anal intercourse is followed by vaginal intercourse, bacteria can be spread from the rectum into the vagina or the urethra, the tube that carries urine from the bladder. After anal sex,
one should wash the fingers and penis thoroughly before engaging in additional sexual activity, and a fresh condom should be used. Women should urinate after vagi- nal sex to help remove some of the bacteria that have entered the urethra, reducing the risk of a bladder infection.
People often engage in petting, more recently called mutual masturbation, as a pleasurable substitute for or a prelude to intercourse. During these activities, two or more people stimulate themselves or another sexu- ally, often with the hands, without vaginal or anal inter- course. Mutual masturbation activities include a variety of sex acts that range from kissing and fondling breasts to performing oral sex. Additionally, people may rub their genital areas together without penetration. For people who want to reduce their risk of pregnancy or sexually transmitted infections, mutual masturbation can be a safer alternative to vaginal or anal sex.
Although not as popular as vaginal intercourse, oral sex is a common sexual activity. Cunnilingus is the use of the mouth and tongue to stimulate a woman’s genitals; fellatio refers to oral stimulation of a male’s genitals. In the early part of the 20th century, heterosexuals, even those who were married, rarely practiced oral sex. By the 1970s, sex manuals and sexuality textbooks had begun to suggest that couples incorporate oral sex into their sexual routines. Women who are unable to have orgasms during coitus are often able to have them while receiving oral sex.
A study of more than 2,000 college students using an anonymous online survey found that 39.1% of virgins had given oral sex to someone in their lifetime and that 95.5% of nonvirgins had. Of the respondents, 53.5% considered oral sex to be an intimate act, compared to 91% who con- sidered sexual intercourse to be an intimate act.32
Results of the NSSHB show that the percentage of males who gave oral sex to a female within the month before the survey peaks at ages 25–29 years at 40%, and the percentage of males who gave oral sex to a male within the month is highest at ages 20–24 years at 5.2% and at 50–59 years at 6.4%. The percentage at other ages is much lower for male-on-male oral sex within the month. Results of the NSSHB also show that the percentage of females who gave oral sex to a male within the month before the survey peaks at ages 25–29 years at 49.9%, and the percentage of females who gave oral sex to a female within the month peaks at ages 16–17 years at 4.2%. The percentage at other ages is much lower for female-on- female oral sex within the month.32 On the NSFG, lifetime percentages for oral sex with the opposite sex were 87.4% for men aged 18–44 years and 86.2% for women of the same age group (see Figure 6.7).23
Culture, Gender, and Sexuality 187
be a way of life; the clergy of some religions practice sexual abstinence. Some celibate individuals engage in alternative sexual practices such as masturbation. Temporary sexual abstinence during the woman’s peak period of fertility is a feature of traditional fam- ily planning methods. Late in pregnancy, couples may decide to avoid vaginal intercourse, especially if the activity is too uncomfortable.
Former U.S. Surgeon General M. Jocelyn Elders. © Mike Wintroath/AP Images.
Romantic Relationships Giving and receiving love are so important to a per- son’s well-being that social scientists have speculated about love and studied its origins, characteristics, and stages. What is love? Why do people fall in love?
Defining Love Love is di&cult to de!ne because the term has di#er- ent meanings for di#erent people. One de!nition is that love is a collection of behaviors, thoughts, and
celibacy (sexual abstinence) Refrainment from sexual intercourse, usually by choice.
4Consider seeking professional counseling if you are confused by, or not yet comfortable with, your sexual orientation.
Healthy Living Practices
Solitary Sexual Behavior In 1994, statements on masturbation by the U.S. Surgeon General M. Joycelyn Elders resulted in her being forced to resign her post. Her comments were in response to a question at a United Nations confer- ence on AIDS and suggested that masturbation might be taught as a means to limit the spread of HIV/AIDS. Although masturbation was a taboo subject to speak about publicly at that time, Elders recognized in 2010 that “we have !nally included masturbation in our national conversation” as she discussed the reports from the NSSHB.33
Data from the NSSHB show that solo masturba- tion is a common sexual practice in the United States. From 28% to 69% of men report that they masturbated alone within the month before the survey, and from 12% to 52% of women did as well. Percentages varied by age group, with the lowest percentages reported by the oldest age group (70+ years old) and the highest percentages reported by those aged 25–29 years. "is was true for both men and women.30 "e NSSHB research team also reported data on solo masturba- tion within the past year by gender and age; although these data held a similar gender and age pattern, they were slightly higher than the past-month percent- ages. From 46% to 84% of men reported that they masturbated alone within the last year, and from 33% to 72% of women did as well. As with past-month data, the lowest percentages were reported by the oldest age group (70+ years old), and the highest per- centages reported by those aged 25–29 years for both men and women.34 A British survey reported similar !ndings: 73% of men and nearly 37% of women aged 16–44 years reported masturbating within the month before the survey.35
Celibacy Celibacy, or sexual abstinence, is refrainment from sexual intercourse, usually by choice. Celibacy can
4Wash after touching the anal area so as not to spread bacteria that live in the rectum to other parts of the body.
4To reduce the risk of transmitting the virus that causes AIDS, use latex condoms during vaginal or anal intercourse.
4Practicing sexual abstinence is the most reliable way to avoid pregnancy and sexually transmitted infections.
Healthy Living Practices
Celibacy is not known to be harmful; indeed, it is the most e#ective measure for preventing pregnan- cies and sexually transmitted infections.
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emotions that are associated with a psychological attraction toward other individuals. "ere are numer- ous kinds or degrees of love and a variety of feelings associated with love. Liking, fondness, a#ection, attraction, infatuation, and lust are feelings related to love. Also, the love of two friends can be quite dif- ferent from the feelings between parent and child or husband and wife. According to sexologists William H. Masters and Virginia E. Johnson, all forms of love involve the element of caring, the expression of con- cern for someone’s well-being.
Zick Rubin, one of the !rst psychologists to develop a questionnaire to measure the meanings of love, attempted to di#erentiate between loving and liking. He found that loving had characteristics of intimacy, attachment, caring, and commitment, whereas liking had characteristics of a#ection and respect.36 Intimacy is the disclosure of one’s most per- sonal thoughts and emotions to a trusted individual. Attachment is the desire to spend time with someone to give and receive emotional support. Commitment is the determination to maintain the relationship even when times are di&cult. Affection is a feeling of fondness toward another. Respect is the feeling that another has value and deserves attention.
Most humans seek loving relationships with other individuals to meet their emotional needs. Love that is ful!lling is reciprocal; that is, when one loves another, he or she is loved in return. Individuals who are in love feel free to achieve self-actualization because their relationship fosters mutual independence as well as emotional, social, and spiritual growth.
Psychologists’ Theories About Love Beginning with Sigmund Freud in 1922, psycholo- gists have tried to explain the phenomenon of love. Early “love theorists” such as Freud were clinical psychologists, professionals who diagnose, treat, and study mental or emotional problems and disabilities. Most of these early theories explained love as a rem- edy for psychological problems or de!ciencies.
In recent decades, social psychologists have for- mulated updated theories on love. "ese profession- als explore questions by examining the individual in a social context while taking into account personality, which is the distinctive pattern of behavior, thoughts, motives, and emotions that characterizes an individual.
In 1956, Eric Fromm presented his ideas about love in "e Art of Loving.37 A basic idea in Fromm’s book, as noted in its title, is that loving is an art and, as such, must be learned and practiced. Fromm also
distinguished between types of love, such as moth- erly love and erotic love.
In 1973, John Alan Lee theorized that six styles of loving exist.38 His ideas have since been upheld by results of studies of other researchers. Table 6.2 lists these styles, with their names (derived from the Greek), meanings, and characteristics. To see which of Lee’s styles you most closely align with, take “"e Love Attitudes Scale” provided in the Student Work- book section of this text.
caring The expression of concern for someone’s well-being.
intimacy Disclosure of one’s most personal thoughts and emotions to a trusted individual.
attachment The desire to spend time with someone to give and receive emotional support.
commitment The determination to maintain a relationship even when times are difficult.
affection Fondness.
respect The feeling that another has value and deserves attention.
Lee’s Six Styles of Loving
Table 6.2
Name Meaning Characteristics
Ludus Game- playing love
Enjoying “chasing” love interest but not “catching” him or her
Eros Romantic, passionate love
Believing in “true” love and “instant” chemistry
Storge Affectionate, friendly love
Believing that love grows out of friendship
Mania Possessive, dependent love
Believing that your lover’s attention is all that matters
Pragma Logical, practical love
Thinking that the best lover for you will fit a predetermined set of criteria
Agape Selfless love Wanting to bear your lover’s burdens so that he or she does not suffer
Romantic Relationships 189
In 1986, Robert Sternberg developed a triangular theory of love that incorporates three components— intimacy, commitment, and passion—as symbolized by the points of a triangle, shown in Figure 6.8.39 His intimacy component includes behaviors that foster a feeling of warmth, whereas the commitment compo- nent refers to the decision to love as well as to make a relationship last. Passion, in the love triangle, refers not only to sexual passion but also to the ful!llment of needs that elicit a passionate response. "e balance of these three components a#ects the shape of the tri- angle. Amount of love a#ects the area of the triangle.
People in a love relationship o$en have feelings of intimacy, commitment, and passion that di#er from
those of their partners. Although two people may be in love with each other, their love triangles will not match if one loves the other more than is reciprocated and if one di#ers from the other in the balances of the three kinds of love. According to Sternberg, couples with similar love triangles are more likely to be satis- !ed with their relationships because they share more love-related feelings and attitudes, as Figure 6.8b shows, than couples with mismatched triangles, as shown in Figure 6.8c. Sternberg developed a ques- tionnaire to measure love according to his love tri- angles theory.40,41
Finally, Sternberg asserted that although there are only three components of love, these three com- ponents combine in various ways to produce seven kinds of love.41 For example, an absence of all three components (intimacy, commitment, and passion) results in nonlove. "e presence of all three com- ponents results in consummate love. Figure 6.9 lists Sternberg’s kinds of love and their components.
Love Attachments "e early bonds, or attachments, that develop between parents and their o#spring may in'uence the ability of the children to form close, secure relationships when they are adults. Attachment is a biological drive in which a child seeks nearness to or contact with a speci!c person, such as a parent, when he or she is frightened, tired, hungry, or ill. A child will exhibit attachment behavior, such as eye contact, smiling, crying, and clinging, to obtain or maintain desired proximity to this person. How the person responds to the child largely determines the type of attachment the child will form: secure, ambivalent, or avoidant.
For example, when an infant is hungry, he or she will exhibit attachment behavior, such as crying, which usually evokes a nurturing response from the attachment !gure (e.g., mom or dad). A nurtur- ing response to this need usually includes touching, eye contact, smiling, and providing milk. When the infant receives this nurturing response consistently, trust is built. When the infant does not receive this response consistently, the child may develop mis- trust and may stop his or her attachment behavior. Over time, symptoms may emerge, such as lack of eye contact, destructive behavior, and poor peer relation- ships. Some children who have poor attachments to their parents may avoid becoming emotionally close to people in adulthood.
Intimacy
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Ideally matched couple
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Passion Commitment
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Intimacy
Passion Commitment
Self Partner
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Figure 6.8 Sternberg’s Love Triangle. Psychologist Robert Sternberg created a model that incorporates three components of love—intimacy, commitment, and passion—at the points of a triangle. Couples with identical love triangles (a) are more likely to be satisfied with their relationships because they share more sexual feelings and attitudes than couples with similar (b) or mismatched triangles (c).
190 Chapter 6 Romantic Relationships and Sexuality
Experts think that children who have emotion- ally distant and neglectful parents may mature into anxious lovers. Anxious lovers o$en have consider- able doubts about the quality of their sexual relation- ships, are unable to trust their partners, and may be unable to form long-term commitments. However, if parents meet the emotional needs of their chil- dren and frequently display a#ection toward them, the children are likely to mature into secure lovers. Secure lovers are more likely to form trusting and committed relationships with other adults than are anxious lovers.
Some people experience infatuation, a passion- ate but unrealistic attraction to someone. Infatuated individuals o$en exaggerate the positive character- istics of their partners while ignoring their faults. A relationship that is based on infatuation may not survive, especially when one or both lovers become aware of their partner’s weaknesses and !nd these faults unacceptable.
Eventually, the intense sexual attraction that characterizes the initial stage of a romantic rela- tionship subsides. "e couple, if sexually active, usually engages in sex less frequently than in the earlier phase of their relationship. "ey enjoy being
together, but they can endure separations. Other aspects of their relationship, such as companionship, o$en deepen. Although couples in this stage of love have con'icts, committed partners usually try to resolve their problems.
Not every couple experiences the stages of love in this order. Sometimes passionate love a#airs evolve from companionate relationships, such as when friends become lovers. Whatever the course of a romantic relationship, however, it will have phases of growth and change.
"e following Managing Your Health feature, “Minding Your Sexual Manners,” provides sug- gestions for socially responsible sexually related behaviors.
Non-love Liking Infatuation Empty Love
Romantic Love Fatuous Love Companionate Love Consummate Love
C om
m itm
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PassionPassion
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Figure 6.9 Sternberg’s Seven Kinds of Love. Modi!ed from Sternberg, R. J. (1998). Cupid’s arrow: The course of love through time. Cambridge, England: Cambridge University Press.
4To help you make responsible decisions concerning your sexuality, consider how your sexual behavior affects yourself and others.
Healthy Living Practices
Love Attachments 191
Establishing Romantic Commitments Have you ever been in love? Why did you fall in love with that person? Studies have shown that physical attraction is the most important factor that determines whether two individuals become romantically interested in one another. People often use other criteria as well, such as social sta- tus, occupation, and wealth, to select their sexual partners. Not surprisingly, Americans spend mil- lions of dollars annually to enhance their “sex appeal” by purchasing makeup, jewelry, clothing, and expensive cars.
Initially, two people who are physically attracted to each other usually make and hold eye contact.
Love Changes over Time Early in a relationship, when physical attraction is greatest and partners know very little about one another, their passion is high. Preoccupied with their sexual desire for each other, passionate lovers think about their partners and want to be with them constantly.
Couples may describe this behavior as “falling in love at !rst sight.” A$er two people !nd each other physically appealing, they need to determine if they
are compatible—that is, if they are capable of exist- ing together in harmony.
Which characteristics are important for establish- ing long-term satisfying and compatible relation- ships? Individuals in such relationships are usually close in age, and they usually share similar racial, ethnic, religious, and educational backgrounds (Figure 6.10). Members of couples who have extremely di#erent backgrounds or many dissimilar characteristics can certainly form satisfying and last- ing relationships, but these situations are less com- mon than those described previously.
Sexual satisfaction is another characteristic related to the establishment of long-term satisfying and compatible relationships. Several studies show an association between sexual satisfaction and over- all relationship satisfaction.42 One study focused on the association between sexual satisfaction and relationship quality in premarital heterosexual couples.43 Research results showed that over time, sexual satisfaction was positively associated with relationship satisfaction, love, and commitment for both men and women. When change occurred in sexual satisfaction over time, change also occurred in relationship satisfaction, love, and commitment. Overall, sexual satisfaction had stronger links with relationship quality for men than for women.
Managing Your Health
The following guidelines can help you make socially responsible decisions regarding your sexual behavior.
1. Ensure that each potential sexual partner is willing and able to give consent for each and every sexual act. Never force sex on another person, regardless of the situation.
2. Understand that at any time in any relationship, when a person says no, it means no, not yes or maybe, even if a person has said yes in the past.
3. Avoid situations that can impair your ability to make responsible sexual decisions, especially situations that involve alcohol and other drug use.
4. Be prepared to prevent pregnancies (if appli- cable) or sexually transmitted infections. Avoid risky sexual behaviors. Protect yourself and your
partner by taking appropriate precautions, such as using a new latex condom with each act of sexual intercourse.
5. Communicate your concerns about the risks of pregnancy (if applicable) and sexually transmitted infections to your partner.
6. Share the responsibility of preventing pregnancies (if applicable) and sexually transmitted infections with your partner.
7. Respect the sexual privacy of your partner and your relationship.
8. Consider the feelings of others. Public displays of intimate behavior can offend or embarrass people.
9. Do not sexually harass others. 10. Treat your partner with care and respect.
Reproduced from Hatcher, R. A., et al. (2002). Sexual etiquette 101 and more (4th ed.). Atlanta, GA: Bridging the Gap Communications.
Minding Your Sexual Manners
192 Chapter 6 Romantic Relationships and Sexuality
"e “Couples Satisfaction Index” in the Student Workbook helps identify relationship satisfaction or dissatisfaction.
Types of Romantic Commitments Cohabitation In the second half of the 20th century, a growing number of unmarried people decided to live with their heterosexual partners. Between 1960 and 2011, the number of adult heterosexual couples living together rose more than 17-fold.44 "e prac- tice of unmarried couples living together is called cohabitation. Recent research indicates a contin- ued rise in cohabiting couples in the United States and that approximately half are between the ages of 18 and 35; however, cohabitation among adults older than 50 has increased drastically in recent years, coinciding with divorce rates among this age group.45
Why do people live together rather than get married? One reason is that marriage is not a legal option for everyone. For example, couples in plu- ral (polygamous) relationships are unable to legally marry. In% some states, domestic partnerships and civil unions are options for those who cannot legally marry. Other reasons include convenience, economics, and recent changes in societal norms. Cohabitation is emerging as a “new normal” for many young adults and is replacing marriage as the
!rst living-together experience. Researchers esti- mate that approximately 25% of unmarried women in the United States between the ages of 25 and 39 are currently living with a heterosexual partner. An additional 25% are estimated to have cohabited at one time.44
Research presents con'icting results regarding cohabitation outcomes. Some research reports that people who cohabit before marriage (with the excep- tion of those who are engaged and have set a wed- ding date) are not more likely to enjoy longer and happier marriages than individuals who do not live together before marrying. Studies conducted in the United States, Sweden, and Canada document higher divorce rates among couples who cohabited before marriage than among those who did not. Research results suggest that this increased risk of divorce may be due to the result of self-selection; that is, per- sons who are less able to sustain long-term relation- ships may choose to cohabit before marriage rather than marry without !rst living with their partners.44 Additionally, research data show that persons with multiple cohabiting experiences are more likely to have failed future relationships than persons who do not cohabit.46
Figure 6.10 Many Personal Characteristics Contribute to Compatibility. Although this man and woman do not share the same racial background, they are similar in age and may have other similarities that foster their compatibility as a couple. © Bassittart/Shutterstock.
compatible Capable of existing together in harmony.
cohabitation Unmarried persons living together.
Love Attachments 193
Other—more recent—research presents di#er- ing perspectives. One study found more similarities between cohabitation and marriage than di#erences.47 "is study found no statistical di#erence between cohabiting and married partners’ depression or rela- tionship with family and friends. However, di#er- ences were reported: Married partners fared better in health, whereas cohabiters were happier and had higher self-esteem.
Although much research links marriage and cohabitation, Guzzo noted that many cohabiters enter into cohabitation without plans of marriage, in part because cohabitation is gaining societal acceptance, and today’s young adults may receive less pressure to marry than earlier cohorts. "ere- fore, cohabitation may simply be viewed as a con- venient arrangement rather than part of a marriage precursor.48
Marriage In most countries, marriage is a legally binding commitment between an adult man and an adult woman. Same-sex marriages and plu- ral marriages (between more than two people) are legal only in select places. Since 2015, same-sex marriages are legal in all parts of the United States. Most Americans desire marriage as a lifelong and loving partnership, and they expect sexual faithful- ness, emotional support, mutual trust, and lasting commitment.
Americans are marrying later in life today than in past decades. In 1960, the median age at !rst marriage was 20.3 years for women and 22.8 years for men.42 ("e median is the point below which 50% of the scores fall.) In 2016, the median age of marriage was 27.4 years for women and 29.5 years for men.49 Americans have also become less likely to marry; from 1960 to 2016, the percentage of adults aged 18 or older who were married decreased from 72% to 50%.49
What factors help make a marriage successful? Partners in successful marriages o$en demon- strate positive problem-solving and communication skills. When con'icts arise, couples with these skills can openly discuss their feelings, and they are will- ing to negotiate and compromise to !nd solutions. In addition, partners in successful marriages share basic values, have mutual concerns, and exhibit high degrees of physical intimacy. Married couples report the following as “very important” to a suc- cessful marriage: having shared interests (64%), having a satisfying sexual relationship (61%), sharing household chores (56%), having shared
religious beliefs (47%), having children (43%), hav- ing adequate income (42%), and agreeing on poli- tics (16%).50
Extrarelational Sex Some people have sexual relationships with individuals who are not their spouses or primary sex partners. Having sex with someone other than one’s spouse is commonly referred to as extramarital sex or adultery. Recent results from the General Social Survey on American Sexual Behavior show that although the majority of Americans reported they are faithful to their spouse, 21.2% of men and 13.4% of women had sexual rela- tions with a person other than their spouse while married.51 Additionally, this study reported a decline in the belief that having sex with someone other than one’s spouse is “always wrong,” from 79.4% in 2000 to 75.8% in 2016; however, the vast majority of respon- dents indicated they believed extramarital a#airs to be wrong.
Separation and Divorce Despite having high hopes for happiness and success during their wed- ding celebrations, many couples see their marriages end in separation or divorce. Nearly half of recent first marriages may end in divorce; the divorce rate for younger persons has risen in recent years. Accurate data concerning the number of married persons who separate permanently are unavail- able. Teenage marriages are especially vulnerable to dissolution. Women who marry when they are younger than 20 years of age are much more likely to be in a failed marriage than women who marry when they are at least 20. In addition, divorce rates are higher for high school dropouts than for col- lege graduates, and for marriages in which there is conflict over money matters, an extramarital affair has taken place, or an alcohol/drug problem exists.44
Early in the 20th century, divorce was uncom- mon: In 1940, the U.S. divorce rate was 2 divorces per 1,000 persons. "e divorce rate rose during World War II and peaked at more than 4 divorces per 1,000 at the war’s end. "e rate fell during the 1950s to nearly prewar rates and rose again in the%1960s and 1970s. From 1979 through 1981, the U.S. divorce rate was at its highest level of the 20th century, slightly more than 5 divorces per 1,000. "e decline in the divorce rate has been relatively steady since that time, and in 2014 (the most recent data available) was at 3.2 for every 1,000 persons (Figure 6.11).
194 Chapter 6 Romantic Relationships and Sexuality
Communication in Relationships
E#ective communication is a cornerstone of inter- personal and sexual relationships. To communicate e#ectively, people must express themselves as accu- rately and as clearly as possible but also must listen with attentiveness, openness, and patience. To express yourself accurately and clearly, !rst say exactly what you mean. If you avoid being straightforward so that you will not hurt someone’s feelings, for example, the person with whom you’re communicating may not understand your message. Second, your state- ments must be speci!c, not vague. For example, tell- ing your partner that you would like him to be more spontaneous will probably make him question what you really mean. Do you always want him to act in a spontaneous manner? Has he never been spontane- ous? Or do you really mean that you had wanted him to accept yesterday’s last-minute party invitation, and you wished that he could have just dropped what he was doing, changed his clothes, and dashed out the door with you? "ird, avoid sending mixed messages. For example, don’t tell your partner that everything is !ne when she can tell from your behavior and expres- sion that you are really feeling “down.”
Another mechanism to foster e#ective communi- cation is to express your feelings using “I” statements when discussing issues with a partner. "en, go on to say what you need to try to maintain (or change) the feeling. Statements that begin with “You” can hinder open communication between partners, particularly if the speaker is criticizing the listener’s behavior or blaming this person for something. For example, instead of saying “You always spend too much time with your friends,” you could say, “I feel lonely and miss you terribly when you are out with your friends.” (Express the feeling.) “Could I join you on those occa- sions so that we could spend more time together?” (State the remedy.) Try not to fall into the trap of “false” I statements: “I feel like you spend too much time with your friends” is really a “you” statement.
Besides being able to express oneself clearly, an e#ective communicator has good listening skills. Fail- ure to hear information accurately or completely can create misunderstandings that result in con'icts. In discussions, good listeners restate or paraphrase what they have heard their partners say. "is practice allows speakers, if necessary, to correct or clarify what they have said. For example, if your partner says, “When we get together with your friends or your family, you always ignore me,” you could respond by saying, “I didn’t realize that you feel neglected in those situa- tions. What can I do to make you feel more included?”
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Figure 6.11 U.S. Divorce Rates: 1940 to 2014. Since 1981, the divorce rate has declined in the United States. Data from U.S. Bureau of the Census, National Center for Health Statistics.
Communication in Relationships 195
In addition to words, people use nonverbal forms of communication, such as body positioning (body lan- guage) and facial gestures, to express their thoughts (Figure 6.12). Touching is a form of nonverbal com- munication that can convey important information about intimate sexual feelings. Many people report that being held, kissed, massaged, or fondled by their partners is as sexually gratifying as sexual intercourse. Sensual touching does not have to involve the geni- tals; gently massaging your partner’s back, for exam- ple, can convey your feelings of love to this individual.
SEXUALITY Most preschoolers masturbate. Parents who think masturbation is a healthy and normal aspect of sexu- ality usually let their children know that the behavior is inappropriate in public but do not attempt to stop this behavior in private. Preschool children typically play games in which they act out adult gender roles. By this age, children have learned that there are dif- ferences between the sexes. Children are curious about sexuality; they may “play doctor” by examin- ing each other’s genitals. Young children o$en ask questions such as, “Where did I come from?” If par- ents are uncertain how to answer this or other ques- tions about sexual matters, they can usually !nd a collection of age-appropriate sexuality books at their libraries that they can read with their children a$er reading them themselves.
It is not unusual for elementary school–aged chil- dren to engage in mutual sex play, activities that may include rehearsing adult sexual behaviors. Sex experts consider such sex play normal behavior when it is playful, occurs infrequently, and does not involve coercion.
"e ability to reproduce begins during puberty. Many teens avoid sexual activity because they fear becoming pregnant, contracting sexually transmit- ted infections, and losing self-esteem or parental trust. "e media, however, expose American youth to sexually explicit images that may con'ict with paren- tal values and encourage sexual experimentation.
Figure 6.12 Nonverbal Communication. Nonverbal forms of communication, such as body postures and facial gestures, can convey thoughts. What do this couple’s nonverbal signals communicate? © Pixland/Thinkstock.
4To increase your child’s chances of being able to form secure and trusting relationships as an adult, consider ways to be more attentive to his or her emotional needs; display your affection frequently.
4To increase your likelihood of having a happy and long-term romantic relationship, communicate as effectively as possible with your partner.
4To encourage discussions between you and your partner about issues that concern the relationship, use “I” statements to express your feelings and avoid using “You” statements. “You” statements can anger or belittle your partner.
4Listen carefully to your partner during your discussions. Repeat what your partner says to avoid misunderstandings. If your partner gives unclear responses to your questions, ask for additional information.
Healthy Living Practices
Across THE LIFE SPAN
196 Chapter 6 Romantic Relationships and Sexuality
Additionally, peers or older persons can exert considerable pressure on teens to engage in sex. To help youth maintain their abstinence, parents and educators can teach teens how to use sexual assertiveness skills.
Despite e#orts to promote teenage abstinence, approximately 40% of American high school stu- dents have sex by grade 12. Results of the Youth Risk Behavior Surveillance, 2015, conducted by the CDC, revealed that by age 13 years, more males (5.6%) reported having engaged in sexual intercourse than females (2.2%). In comparing behavior trends in youth from 1991 through 2015, the CDC has found that the percentage of high school students who have ever had sexual intercourse has decreased from about 54% in 1991 to about 41% in 2015. Also, more students are using condoms; in 1991, about 46% of sexu- ally active students used a condom during their last sexual intercourse, whereas in 2015, 56.9% reported having done so.52
Teenage birth rates have declined in the 21st century. "e teenage birth rate in 2015 (22.3 per 1,000), the most recent year data were available, was the lowest it has ever been since the CDC began keeping track of birth rates for teenagers in 1960 (Figure 6.13). Evidence suggests that the decline in teenage birth rates could be a result of teens abstaining from sexual activity and those who are sexually active using e#ective birth control methods. Although teen birth rates are at a record low, they remain substantially higher than most other Western, industrialized nations, and disparities by race and ethnicity continue to exist.53-54
Compared to women in their 20s, pregnant teen- agers have a greater risk of experiencing serious complications during pregnancy and delivery, and of giving birth to premature, underweight babies. Premature infants are born before the 37th week of pregnancy. "e risk of giving birth to a premature, low-birth-weight infant is especially high for preg- nant adolescents between 10 and 14 years of age. Underweight premature newborns have a greater risk of serious health and developmental problems than do normal-weight newborns who are born at term, that is, between the 37th and 41st weeks of pregnancy.
Most unmarried teenaged girls who give birth to live infants keep their babies rather than give them up for adoption. Adolescent mothers are more likely to be unmarried, to be poor, and to have less educa- tion than mothers who give birth when they are older.
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Figure 6.13 Birth Rates for Teenagers by Age: United States, 1960–2015. Reproduced from Hamilton, B. E., & Ventura, S. J. (2012). Birth Rates for U.S. teenagers reach historic lows for all age and ethnic groups. NCHS Data Brief, no. 89. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db89.pdf and updated with data from Martin, J. A., et al. (2017, January 5). Births: Final data for 2015. National Vital Statistics Reports, 66(1), Centers for Disease Control and Prevention. (2017, May 9). Teenage pregnancy in the United States. Retrieved from https://www.cdc.gov/nchs/data/nvsr /nvsr66/nvsr66_01.pdf
Many teenaged mothers have di&culty improving their educational and socioeconomic levels when they become adults.
Teenaged fathers do not usually marry the teen- aged mothers of their children, even though the rela- tionship between the teens may have been ongoing for 6 months or longer. If the father is 20 years old or older, he is more likely than his teenaged coun- terpart to marry the mother. As the child becomes older, the teenaged father typically becomes less and less involved with the child. When asked why they did not live with or marry their children’s mother, teenaged fathers cite !nancial concerns as one major issue.55
With respect to older adults, sex has enduring importance. Sexuality does not end because a person is older. According to !ndings from the NSSHB, 20% of Americans who are 70–79 years of age engage in sexual intercourse a few times per year, 20% a few times per month, and 5% two or three times per week. "ose aged 80 years and older enjoy sexual intercourse as well; almost 19% in this age group had
Communication in Relationships 197
Health-Related InformationAnalyzing Critical Thinking
Search the word impotence using Google or another search engine. Choose a web site that sells an impotence product. Explain why you think the web site you chose is a reliable or an unreliable source of information. Use the “Assessing Information on the Internet” portion of the model for ana- lyzing health-related information to guide your thinking; the main points of the model are noted here.
• What is the source of the information?
• Is the site sponsored by a nationally known health or medical organization or affiliated with a well-known medical research institution or major university? If not, is the site staffed by well- respected and credentialed experts in the field?
• Does the site include up-to-date references from a well-known, respected medical or scientific journal or links to reputable web sites, such as nationally recognized medical organizations?
• Is the information at the web site current?
Based on your analysis, do you think that this web page is a reliable source of health-related information? Summarize your reasons for drawing your conclusion.
If you are unsure of the credibility of the site after answering the preceding questions, continue with
the following six Analyzing Health-Related Informa- tion questions:
1. Which statements on the web site are verifiable facts, and which are unverified statements or value claims?
2. Does the person, organization, or institution that developed the web site have the appropriate back- ground and credentials in the topic area? What can you do to check credentials?
3. What might be the motives and biases inherent to the web site?
4. What is the main point of the article, ad, or claim made on the site? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your additional analysis, do you think that this web page is a reliable source of health-related information? Summarize your reasons for drawing your conclusion.
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198 Chapter 6 Romantic Relationships and Sexuality
sexual intercourse a few times per month. Twenty- one percent of those in their 70s received oral sex, and 25% gave oral sex within the past year. Fi$een percent of those aged 80 years and older received oral sex, and 22% gave oral sex within the past year.56 Sexual inactivity in the later years of life is more o$en the result of medical disabilities or lack of a sexual partner than lack of desire.
Older adults experience a gradual decline in sex- ual functioning. "erefore, elderly individuals should recognize that their sexual responses are likely to be di#erent from when they were young adults. For example, it usually takes longer for the older adult to become adequately sexually stimulated before sex, and orgasms are less intense. Chronic diseases such as diabetes and heart disease can further limit an aged person’s sexual responses or interest in sex. Certain antihypertensive and antidepressant medi- cations can produce side e#ects that impair sexual
functioning; a#ected individuals should discuss their sexual problems with their physicians. Frequently, changing medications can be helpful. In some cases, medical treatments are available that can improve sexual functioning. Elderly individuals who have sexual impairments that do not respond to treatment can rely on noncoital forms of sexual expression such as kissing, caressing, cuddling, and oral sex to obtain pleasure and ful!llment. For some, a#ection- ate behavior is more crucial to happiness than sex.
Besides physical factors, signi!cant social changes, such as the loss of a spouse or moving into a nursing home, can have negative impacts on the sexuality of aged individuals. Widows and widowers may have dif- !culty meeting sexual partners. Elderly nursing home residents may not feel free to express their sexuality because they lack privacy. As the number of elderly Americans rises, addressing sexual needs in this age group will become an increasingly important issue.
Communication in Relationships 199
CHAPTER REVIEW
Human sexuality is a complex set of thoughts, feel- ings, attitudes, and behaviors that are related to repro- duction as well as to being male or female. Numerous biological, psychological, social, and cultural forces interact to in'uence sexuality. Sexuality in'uences all aspects of an individual’s life, including identity, self- esteem, emotions, personality, relationships, lifestyle, and health. Being knowledgeable about sexuality is important for maintaining good health and optimal well-being.
"e sexual response of individuals engaging in sexual activity is usually described in phases. Dur- ing the excitement phase, both men and women have a heightened sexual awareness. During the plateau phase, the heart rate, blood pressure, respiration rate, and level of muscle tension all increase, and the erection of the male intensi!es. During the orgasmic phase, men ejaculate, and women’s vaginal walls con- tract rhythmically. During the resolution phase, the body returns to its prearousal state. Other models of the sexual response include emotional or psychologi- cal aspects as well as these physiologic aspects.
Some people have sexual dysfunctions that inter- fere with their sexual response. Common sexual dys- functions include erectile dysfunction, the inability of a man to develop and/or sustain an erection !rm enough for penetration; premature ejaculation, con- sistently attaining orgasm either before or shortly a$er intercourse begins and before he wishes it to occur; hypoactive sexual desire, a low interest in sex that causes distress, which occurs in both sexes but is more prevalent in women; and vaginismus, a sexual dysfunction of women in which the muscles of the lower third of the vaginal canal contract involuntarily at the anticipation of vaginal penetration.
Instincts, sensations, and hormones drive repro- ductive behavior, but social, cultural, and religious factors heavily in'uence a person’s sexual attitudes, values, and behaviors. Sexually responsible people consider how their sexual behavior a#ects themselves and others.
Sex is a classi!cation of a person based on many criteria, among them anatomic and chromosomal characteristics. Gender identity is an individual’s perception of himself or herself as male, female, or
something else. Various biological, social, and envi- ronmental forces mold a child’s gender identity. A%gender role refers to patterns of behavior, attitudes, and personality attributes that, in a particular culture, are traditionally considered feminine or masculine. In the United States today, gender roles and identities are undergoing dramatic changes and are becoming more 'exible than in the past.
Sexual orientation, the direction of one’s roman- tic thoughts, feelings, and attractions, can be toward the same sex, the opposite sex, or both sexes. Today, researchers and mental health experts generally agree that people do not decide their sexual orientation and cannot alter their sexual preferences, whether they are at either end of the sexual orientation continuum or somewhere in between.
Sexual partners may engage in a variety of intimate activities, including mutual masturbation and vagi- nal, oral, and anal sex. However, sex does not%require a partner for it to be a pleasurable experience—most people solo masturbate at some point during their lives. Some people choose to refrain from sexual activity for a variety of reasons, such as health con- cerns or religious beliefs. Abstaining from sexual activity is not known to be harmful, and it is an e#ec- tive measure for preventing pregnancies and sexually transmitted infections.
People need to establish and maintain satisfying attachments to others for optimal health and well- being. People who have high self-esteem, are satis!ed with their bodies, are in good health, and have posi- tive feelings about their sexuality are likely to form ful!lling intimate relationships. Although love is dif- !cult to de!ne, people in loving relationships share feelings of caring, respect, attachment, commitment, and intimacy.
Various psychologists have developed theories about love. However, experts generally agree that love changes over time. Early in a relationship, when physical attraction is greatest and partners know very little about one another, their passion is high. Even- tually, the intense sexual attraction that characterizes a romantic relationship in its initial stages subsides. Other aspects of the relationship, such as compan- ionship, o$en deepen. Compatibility, the ability to
Summary
200 Chapter 6 Romantic Relationships and Sexuality
CHAPTER REVIEW
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
1. Develop a plan to improve the way you convey your feelings in relationships. Application
2. Analyze your present intimate relationship or a past one. Explain why you think it will be (or was) a short-term or long-term relationship. Analysis
3. Propose a checklist of characteristics that you could use to select a suitable partner. Explain why these characteristics are important. Synthesis
4. Develop a position concerning the promotion of masturbation as a safe sex alternative. How would you defend your position? Evaluation
Applying What You Have Learned
exist in harmony, is crucial in the development of a healthy emotional attraction between partners. Usu- ally important for establishing a compatible rela- tionship is the sharing of similar interests, attitudes, and%values.
More couples of all ages are choosing to cohabit before marriage. "ose who are married are marry- ing later in life than in recent decades. E#ective com- munication is an essential ingredient for maintaining satisfying and successful marriages and intimate relationships.
Children are curious about sex; they frequently play sex games with other children and ask their par- ents questions about sex. Children’s sex play is nor- mal behavior when it is playful, occurs infrequently, and does not involve coercion.
"e teenage birth rate has declined dramatically since the 1960s. Compared with women in their 20s,
pregnant teenagers have a greater risk of serious com- plications during pregnancy and delivery, and of giv- ing birth to premature and underweight newborns. Additionally, adolescent mothers are more likely to be unmarried, to be poor, and to have less education than mothers who give birth when they are older. Many teenaged mothers have di&culty improving their educational and socioeconomic levels when they become adults.
Sexuality does not end at a particular age. Most healthy elderly men and women continue to be inter- ested and participate in sexual activity. However, sex- ual functioning declines with aging; sexual responses in older persons are di#erent from when they were young adults. As the number of elderly Americans rises, addressing sexuality needs in this age group will become an increasingly important issue.
1. What is the source of your sexual values (e.g., your parents, your religious upbringing)? Do you feel comfortable with those values? Why or why not? Do you feel as though your peers share some or all of your values, or do you feel intimidated or pressured to change your values?
2. Do you think that “traditional” gender roles are appropriate in American society today? If you
think that some are appropriate and some are not, pick one example from each category and explain your feelings about their appropriateness or inappropriateness.
3. Do you agree with former Surgeon General Joc- elyn Elders’s opinion that sex education in U.S. schools could include instruction about mastur- bation, particularly for the purpose of reducing
Reflecting on Your Health
Key
Reflecting on Your Health 201
CHAPTER REVIEW the spread of sexually transmitted infections, especially HIV/AIDS? Why or why not?
4. "ink about a current or former intimate rela- tionship you had. Do you think that your love relationship !ts one of Lee’s six styles of loving or one of Sternberg’s kinds of love? How does it !t or not !t?
5. "ink about the nature of your verbal interac- tions with someone important to you—a parent or spouse, for example. How could you commu- nicate more e#ectively with that person using suggestions in this chapter?
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References 203
Across the Life Span Drug Use and Abuse
Managing Your Health Falling Asleep Without Prescriptions
Consumer Health Over-the-Counter Medicines: Safety and the FDA
Diversity in Health Khat
Chapter Overview Differences between drug use, misuse, and abuse
The effects of psychoactive drugs on the mind and body
Why people use psychoactive drugs
Patterns of drug use in the United States
How physiologic and psychological drug dependence develop
The risk factors for drug dependence
The long-term effects of drug abuse
How the FDA regulates over-the-counter drugs
Goals and strategies for drug treatment and prevention
Student Workbook Self-Assessment: Are You Dependent on Drugs?
Changing Health Habits: Are You Using Drugs Inappropriately?
Do You Know? How drugs can affect the brain?
If smoking marijuana is safer than smoking cigarettes?
Which dietary supplements contain drugs that may be dangerous?
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Drug Use and Abuse
© EyeEm
/Getty Im ages.
Learning Objectives “Drugs … can have serious negative effects on the health and well-being of individuals when used improperly.”
After studying this chapter, you should be able to:
1. Define drug-related terms. 2. Describe the psychological and physical effects of
psychoactive drugs. 3. Differentiate between drug use, misuse, and abuse. 4. Explain why drugs are classified into five drug schedules
and describe each schedule. 5. Define drug addiction or dependence, and differentiate
between psychological and physical dependence. 6. Discuss risk factors for drug use, abuse, and
dependency. 7. Describe current trends related to licit and illicit drug
use in the United States. 8. Describe ways in which over-the-counter drugs
may be abused. 9. Describe common elements of drug treatment and prevention and drug programs. 10. Identify protective factors for drug abuse among young people.
CHAPTER 7
205
D rugs. For many people, this word produces thoughts of shadowy characters secretively injecting illegal and dangerous compounds into their veins. "is word may also evoke images of boarded-up crack houses, young people cooking heroin to liquefy it for injection, and women being assaulted while under the in'uence of date-rape drugs. To others, the word drugs brings positive thoughts, such as physicians prescribing medicines to relieve the signs and symptoms of illness. Other images might include you sitting comfortably in the dentist’s chair while drugs block the pain of the drill, or a person with cancer being treated with power- ful chemical therapies to eliminate deadly abnormal cells. What are drugs? Why do drugs elicit both nega- tive and positive images?
Drugs are nonfood chemicals that alter the way a person thinks, feels, functions, or behaves. For thousands of years, people have taken naturally occurring drugs that produce medicinal bene!ts or psychoactive (mood-altering or mind-altering) e#ects. Nearly everyone uses drugs, for a variety of reasons. Most people have taken aspirin or other pain relievers to treat headaches, sipped cups of co#ee or ca#einated so$ drinks to stay awake, or consumed alcoholic beverages to celebrate special occasions or to complement meals. Each of these familiar prod- ucts contains drugs that have bene!cial uses, but they can have serious negative e#ects on the health and well-being of individuals when used improp- erly. Additionally, inappropriate drug use is associ- ated with numerous social problems that plague our society, such as crime, unemployment, and family violence and dissolution.
"is chapter examines the e#ects of certain drugs on the functioning of the brain, the gen- eral nature of drug use and abuse, and the various problems associated with the use of these chemi- cals. Summary Table% 7.7 at the end of this chap- ter lists the major types of drugs that a#ect brain functioning and provides examples of each. Many Americans use alcoholic beverages and tobacco. Some people take steroid hormones to improve their appearance.
Drug Use, Misuse, and"Abuse
"e typical American household has a supply of pain relievers, cold remedies, cough syrups, and other medications. Medications are drugs that have bene!cial uses, such as treating diseases or correct- ing physiologic abnormalities. Medicinal drugs are frequently misused. Drug misuse is the temporary and improper use of a legal drug. Table 7.1 lists some typical misuses of drugs.
A prescription is necessary to legitimately purchase the most powerful and potentially hazard- ous medications. Most of the active compounds in prescription drugs have been tested scienti!cally for safety and e#ectiveness.
Nonetheless, mixing prescription drugs with other prescription or nonprescription drugs can be fatal. On January 22, 2008, actor Heath Ledger died from an accidental overdose of prescription drugs (Figure 7.1). "e Academy Award nominee took a
drugs Nonfood chemicals that alter the way a person thinks, feels, functions, or behaves.
psychoactive Having mind-altering or mood-altering effects.
drug misuse The temporary and improper use of a legal drug.
Behavior Example
Discontinuing the use of a prescribed medication prematurely even though you have been instructed to take it for a longer period
Taking an antibiotic only until symptoms disappear
Mixing drugs Taking barbiturates and drinking alcohol at a party (combining these depressant drugs can be fatal)
Taking more than the recommended dosage
Consuming 10 multiple vitamin and mineral supplements instead of one daily
Saving and using medications past their expiration date
Taking a pain reliever that was prescribed 5 years ago
Sharing medicines Giving your prescribed allergy medicine to a friend
Table 7.1
Typical Drug Misuse Behaviors
206 Chapter 7 Drug Use and Abuse
combination of painkillers, antianxiety drugs, and sleeping pills, and their combined e#ects led to his death. Together, these drugs can cause the brain and brainstem to stop sending messages to the heart and respiratory system. As happened with Ledger, the heartbeat and breathing stop. Over the past decade, several popular singers, including Michael Jackson and Prince, died from misuse of prescription drugs; additionally, actor Phillip Seymour Ho#man died from a mixture of illegal and prescription drugs.
People can buy thousands of medicines without prescriptions, commonly called over-the-counter, or OTC, drugs. Many OTC remedies contain chemicals that have not been evaluated scienti!cally. Although people o$en think that OTC drugs are completely safe, any substance that has druglike e#ects can be danger- ous if used improperly. Aspirin and antihistamines, for example, are toxic (poisonous) when ingested in high doses. A later section of this chapter examines prob- lems associated with the use of certain OTC drugs.
Foods are not considered drugs, but many foods contain substances, such as ca#eine, that a#ect the body. Furthermore, when some vitamins and minerals are consumed in large doses, they have druglike activity in the body. For example, physi- cians occasionally prescribe large doses of niacin (a B vitamin) to lower the blood cholesterol levels of certain patients. Many people, however, take massive doses of vitamins and minerals without consulting physicians because they think these nutrients are always safe to ingest; however, many vitamins and minerals are toxic when taken in such high doses.
In some instances, drug use becomes drug abuse, the intentional improper or nonmedical use of any drug. Drug abuse occurs whenever the use of a sub- stance negatively a#ects the health and well-being of the user, his or her family, or society. People are more likely to abuse psychoactive drugs than other drugs because of their e#ects on the mind.
"e government controls the use of most psy- choactive drugs because of their potential for abuse. Title% II of the Comprehensive Drug Abuse Preven- tion and Control Act of 1970, usually referred to as the Controlled Substances Act, is the legal foundation of narcotics enforcement in the United States. It clas- si!es psychoactive substances into !ve drug sched- ules according to their potential for abuse, medical usefulness, and safety (Table 7.2). Schedule I drugs have the most stringent control status. "ey are com- monly abused, have little medicinal value (although the medicinal value of marijuana is hotly debated), and lack accepted safety for use. In the United States, it is illegal to use, possess, or sell Schedule I drugs. Schedule V drugs have the least stringent control status. "ey are infrequently abused, have important medicinal uses, and are considered safe when taken as directed. Schedule II, III, IV, and V drugs are avail- able by prescription.
O&cials with the Drug Enforcement Administra- tion (DEA) evaluate medical and scienti!c informa- tion from the U.S. Department of Health and Human Services (HHS) before classifying a drug as a con- trolled substance. Although classi!ed together, drugs in each schedule do not necessarily have the same potential for producing harmful e#ects. Heroin and marijuana are Schedule I drugs, for example, but the e#ects of abusing heroin are more serious than those
Figure 7.1 Mixing Prescription Drugs. Academy Award nominee Heath Ledger died accidentally at the age of 28 from the abuse of prescription medications. The drugs Ledger took that resulted in his death included painkillers, tranquilizers, and antihistamines. Six prescription medications were found in Ledger’s body. © Carrie-nelson/Shutterstock.
drug abuse The intentional improper or nonmedical use of any drug.
Drug Use, Misuse, and Abuse 207
Schedule Examples of Drugs Description
I Heroin, LSD, mescaline, peyote, psilocybin, marijuana, GHB, China white
No current accepted medical use; high potential for abuse
II Ritalin, PCP, Dilaudid, cocaine, methadone, Demerol, morphine, OxyContin, codeine, opium
Current accepted medical use; medium potential for abuse
III Paregoric, anabolic steroids, Tylenol with codeine, Vicodin, Marinol
Current accepted medical use; medium potential for abuse
IV Rohypnol* (“roofies” or the “date-rape drug”), MDMA, Valium, Librium, Serax, Halcion, Darvon, Placidyl, phenobarbital, Xanax, khat
Current accepted medical use; low potential for abuse
V Robitussin A-C, Lomotil, Motofen, Parepectolin Current accepted medical use; lowest potential for abuse
*Penalties for the possession, trafficking, or distribution of Rohypnol are the same as for Schedule I drugs.
Data from U.S. Department of Justice, Drug Enforcement Administration.
Drug Schedules
Table 7.2
of abusing marijuana. In addition, drugs classi!ed in a more stringently controlled schedule do not necessarily have a greater potential for producing harmful e#ects than do drugs in a less stringently controlled schedule or drugs that are not scheduled. For instance, alcohol and nicotine are not scheduled drugs, yet the widespread abuse of these addictive substances is responsible for disabling and killing more people each year than the combined use of all controlled%drugs.
People abuse illegal drugs such as cocaine, legally available psychoactive substances such as alcohol, some prescription drugs, and OTC remedies. Many individuals abuse a combination of legal and illegal drugs. Regardless of its legal status, no drug is com- pletely safe. "e risk that a drug will cause serious side e#ects largely depends on the type of drug, the amount taken over time, and the health of the person using the drug.
Psychoactive Drugs: E#ects on the Mind and"Body
Psychoactive drugs a#ect the nervous system—the “quick” communication network of the body—by changing the way the brain perceives and processes information received from the environment. "e nervous system includes the brain and spinal cord (central nervous system, or CNS) and the sensory and motor nerves that transmit messages to and from the CNS.
How Psychoactive Drugs Affect the Brain Psychoactive drugs interact with nerve cells in the brain, altering the activity of chemical transmitters that carry messages from one nerve to another. As a result, these drugs in'uence perceptions, thought processes, feelings, and behaviors. Many commonly abused drugs a#ect speci!c regions of the brain, referred to as reward centers because they have a positive in'uence on mood and alertness. As a result, when used initially, these drugs o$en produce euphoria, an intense feel- ing of well-being commonly called a high. Although altering the normal internal chemical environment of
4Because no drug is completely safe, consider the effects a drug can have on your health and well-being before using it.
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208 Chapter 7 Drug Use and Abuse
the brain a#ects a person’s mood and behavior, exter- nal conditions can modify these responses.
What Happens to Drugs in the Body? A$er being taken, psychoactive drugs enter the bloodstream and eventually reach the brain, where they produce their characteristic e#ects. As drugs circulate, the body may eliminate small amounts of these substances in urine, feces, or exhaled breath. In most cases, the remaining drugs undergo detoxification, the process of converting harm- ful substances into less dangerous compounds that can be excreted. Detoxi!cation usually occurs in the liver. "e body stores some drugs, primarily in fat, for days and possibly weeks a$er exposure, partic- ularly when detoxi!cation occurs slowly. Until the body completely eliminates a drug, small amounts of the substance may be detectable in blood or urine.
A state of intoxication occurs when the amount of a substance reaches poisonous levels in the body. "is level varies among individuals, but genetic factors, body size, physical health, and prior drug exposure in'uence a person’s ability to metabolize, or pro- cess, a drug. "e signs and symptoms of intoxication include slurred speech, poor muscular coordination, and mental confusion.
An overdose occurs when an excessive amount of a drug circulates in the bloodstream and overwhelms the ability of the body to detoxify or eliminate the substance rapidly. Overdoses of OTC, prescription, and illegal drugs can damage or destroy tissues. In some instances, drug overdoses can be fatal. Table%7.7 (at the end of this chapter) describes some signs and symptoms of overdoses of various psychoactive drugs.
Polyabuse, abusing more than one drug at a time, is a common practice. For example, individuals o$en drink alcoholic beverages while they use heroin, bar- biturates, cocaine, or other drugs. When people take di#erent drugs that have similar actions, the e#ects of each drug may be greatly multiplied. "is phenom- enon, called synergism, can be deadly. Alcohol and barbiturates, for example, are depressant drugs that slow the functioning of the central nervous system. If a person drinks a few alcoholic beverages while tak- ing barbiturates, the combined e#ects of these sub- stances can depress respiration severely, producing coma or death. Polyabuse can cause drug interac- tions in addition to synergism that can have serious and even fatal outcomes. Many people are not aware that drinking alcohol while taking acetaminophen, a
compound contained in popular OTC pain relievers, can cause liver failure and death.
Illicit Drug Use in the United States
Illegal drugs, such as heroin, lysergic acid diethyl- amide (LSD), and marijuana, are those that have no currently accepted medical use in the United States, although some states allow medical and/or recre- ational marijuana use (Figure 7.2). Except for research purposes, it is illegal to buy, sell, possess, and use these drugs. "ey are listed as Schedule I drugs (see Table 7.2). Only registered, quali!ed researchers can obtain illegal drugs in the United States.
Legal drugs are those for which sale, posses- sion, and use as intended are not forbidden by law; however, use may be restricted. Restricted drugs, such as narcotics, depressants, and stimulants, are called controlled substances and are available with a prescription.
4Do not combine drugs, including alcohol and OTC medicines, without consulting a physician or registered pharmacist. Mixing drugs can kill you!
Healthy Living Practices
euphoria (you-FOR-ee-a) An intense feeling of well-being commonly called a “high.”
detoxification The process of converting harmful substances into less dangerous compounds.
intoxication The state of being poisoned by a drug or other toxic substance.
polyabuse Abusing more than one drug at a time.
synergism (SIH-ner-jism) The multiplied effects produced by taking combinations of certain drugs.
Illicit drugs are de!ned by the Substance Abuse and Mental Health Services Administration as illegal drugs and controlled substances held without a legal prescription.
Periodic (e.g., annual) surveys and interviews are used to estimate the prevalence of illicit drug use in the United States. Tens of thousands of Americans
Illicit Drug Use in the United States 209
12% years of age or older complete the National Sur- vey on Drug Use and Health (NSDUH) annually. NSDUH data from 2016 indicated an estimated 28.5%million Americans, or 10.6%, of Americans aged 12% years and older, were current illicit drug users, meaning that respondents used an illicit drug in the month before the interview (see Figure 7.9). "e 2016 !gure represents an increase in illicit drug users from 2012 (8%).1 "ese data indicate that more Americans used illicit substances in 2016 than in the late 1970s, when approximately 25 million Americans used illicit%drugs.
NSDUH 2016 data also suggest that more men than women used illicit drugs in the past month: 12.8% and 8.5%, respectively. Furthermore, certain segments of the American population use illicit drugs more than other groups do; for example, 20.8% of unemployed adults were current users of illicit drugs in 2016, whereas only 11.1% of full-time employed adults used illegal substances. Among people aged 18 years and older in 2016, those who completed some college had the highest rate of current illicit drug use (13.2%), and college graduates had the lowest rate of current use (8.4%).1
Rates of illicit drug use are especially high among teenagers and young adults. Figure 7.3 shows that
drug use peaks in adolescence and young adulthood, with 22% of those 18–25 years of age reporting past-month illicit drug use in both 2015 and 2016. Current illicit drug use was reported by nearly 8% of young people aged 12–17 years in 2016, with a slight decrease through the early to%mid-30s.
Data from the 2016 survey indicate that 25% of full-time college students aged 18–22 years took at least one illicit drug during 2016, down from 30.6% in 1992. In 2016, 20% of college students used mari- juana at least once during the past month, down from 27.7% in 1992. Additionally, the use of LSD (“acid”) rose in the mid- 1990s from 1989 and has since begun to fall. Furthermore, less than 1% of college students reported taking LSD during the previous 12 months in 2016. In 1994, this !gure was about 5%; in 1989, it was 3.4%.2
Why Do People Use Psychoactive Drugs? Drug users o$en provide numerous rea- sons that they began taking psychoactive
substances. Most people begin taking mood-altering drugs for nonmedical purposes. Some individu- als use alcohol or other drugs simply as a pleasur- able experience. Others use drugs to cope with their psychological problems, reduce stress, or escape from unpleasant aspects of their lives. Curiosity o$en motivates many teenagers and young adults to experiment with drugs. Movies and advertisements may stimulate this curiosity by showing, for exam- ple, sophisticated and attractive people smoking cigarettes or cigars or drinking alcoholic beverages while engaging in enjoyable activities ( Figure" 7.4). Additionally, teenagers may use drugs to experience new behaviors, relieve peer pressure, or enhance social interactions.
Patterns of Psychoactive Drug Use Drug experimentation and illicit use o$en occur during the teen years and peak between the ages of 18 and 25 years (see Figure 7.3). Most drug abus- ers in this age group begin by smoking cigarettes, and then they consume alcoholic beverages such as beer or wine. Some youth inhale chemicals, such as those in aerosols and plastic cements, to obtain their
Figure 7.2 Medical Marijuana. As of July 2018, 30 states and the District of Columbia allowed use of marijuana for medical purposes. In these states, registered outlets, such as the one in Denver, Colorado, shown in this photo, sold marijuana to people with a license. A variety of medical marijuana strains are shown on the dispensary shelves. © Alex Wong/Getty Images.
210 Chapter 7 Drug Use and Abuse
Figure 7.3 Past-Month Illicit Drug Use Among Persons Aged 12 Years and Older. Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health#Services Administration. Retrieved from https:// www.samhsa.gov/data/sites/default/!les/NSDUH -DetTabs-2016/NSDUH-DetTabs-2016.pdf
Figure 7.4 Grammy-winning British singer Amy Winehouse at Balans café bar in Soho, London. The media frequently portray sophisticated and attractive people smoking or binge drinking while engaging in enjoyable activities. As a result, some young people copy these unhealthy behaviors. Winehouse evidenced many other unhealthy behaviors. She died on July 23, 2011, at the age of 27 from accidental alcohol poisoning, drinking heavily after weeks of abstinence. © EDB Image Archive/Alamy Stock Photo.
mind-altering e#ects. Alcohol, nicotine, marijuana, and inhalants are o$en referred to as “gateway” drugs because adolescents use these substances before moving on to other psychoactive drugs.3
Many adolescents stop experimenting with new drugs a$er using alcohol or nicotine; however, those who continue to experiment with drugs o$en try marijuana next. "e rate of marijuana use among 8th and 10th graders in the United States remained relatively consistent between 2012 and 2015. In 2016, approximately 9% of 8th graders and 24% of 10th graders surveyed in the Monitoring the Future (MTF) survey reported trying marijuana. On the other hand, a%slight increase in marijuana use—from 33% in 2011 to 36% in 2016—was seen among 12th graders.3
Any combination of stimulants, depressants, or hallucinogens may follow marijuana use. A$er trying these drugs, some young people move on to use opiates; however, not every youthful drug user follows this stepping-stone pattern of drug experimentation. For example, many teenagers who experiment with alcohol or marijuana do not try other psychoactive%drugs.
"e recreational use of illegal drugs generally declines with increasing age beyond age 20 years as traditional adult roles, including marriage, parent- hood, and careers, are adopted. As they age, many individuals recognize that abusing illicit drugs can be self-destructive. Nevertheless, elderly persons who feel socially isolated and depressed, and those with
Age in Years
0
5
aThe difference between this estimate and the 2016 estimate is statistically significant at the .05 level. Rounding may make the estimates appear identical.
10
15
20
25
30
12 –1
3
14 –1
5
16 –1
7
18 –1
9
20 –2
1
22 –2
3
24 –2
5
26 –2
9
30 –3
4
35 –3
9
40 –4
4
45 –4
9
50 –5
4
55 –5
9
60 –6
4
65 o
r o ld er
P er
ce n
t U
si n
g in
P as
t M
o n
th
2 .6
2 .0
7 .2
6 .6
5
1 6 .2
5
2 1 .3
5 2 4 .2 2 5 .6
2 3 .0
5 2 2 .4
5
2 0 .9
5 2 1 .7
5
1 7 .7 1 8 .8
1 3 .5
a 1 5 .2
1 0 .6
8 .5
8 .4 8 .6 9 .2
8 .3
7 .8 8 .0
9 .3
6 .2
5 .4
1 .9
a 2 .9
1 1 .6
2 3 .1
5
1 4 .5
2015 2016
Illicit Drug Use in the United States 211
a history of substance abuse, are at greater risk of abusing prescription drugs than are adolescents and young adults.4
Drug Dependence Most people who use psychoactive drugs such as alcohol or marijuana take them for pleasure, to relax, or to feel comfortable in social settings, which is termed recreational drug use. To assess your use of drugs, complete the questionnaire in the exer- cise entitled “Are You Dependent on Drugs?” in the Student Workbook in this text.
Drug dependence or addiction occurs when users develop a habitual pattern of taking drugs that produces a compulsive need, which is both physical and psychological. "e terms dependency and addic- tion are o$en used interchangeably to describe any compulsive behavior that interferes with one’s health, work, and relationships.
Dependent individuals are unable to avoid using drugs; most have a history of unsuccessful attempts to stop. Over time, these people escalate their intake of drugs even as they recognize that their actions are harmful to themselves and others. People who are dependent on drugs are so preoccupied with the need to obtain and use these substances that other aspects of their lives, such as handling the responsibilities of family and work, become less important.
Physiologic and Psychological Dependence When people take certain psychoactive drugs repeatedly over an extended period, their bod- ies make various physiologic adjustments to func- tion as normally as possible. For example, dramatic chemical changes occur in the brains of chronic drug users that in'uence their thought processes and behaviors. As a result, these individuals display the characteristic signs and symptoms of physical
dependence or physical addiction: drug tolerance and withdrawal.
A$er chronic exposure to certain drugs, the body develops tolerance, the ability to endure larger amounts of these substances while the adverse e#ects decrease. When this occurs, users discover that their usual dose of drugs no longer produces the desired degree of physical or psychological e#ects. To get the desired e#ects, people must take larger quantities, which results in increased toler- ance. "is upward spiral is more di&cult to break at each successive level, increasing the risk of overdose.
Withdrawal is a temporary physical and psycho- logical state that occurs when certain drugs are dis- continued. "e signs and symptoms of withdrawal include trembling, anxiety, and pain. In cases of barbiturate addiction, withdrawal symptoms are so severe they can cause death. Table 7.7 at the end of this chapter indicates psychoactive drugs’ potentials for producing tolerance, withdrawal, and addiction.
Psychological dependence is a person’s need to use certain psychoactive drugs regularly to obtain their pleasurable e#ects and to relieve boredom, anxiety, or stress. Psychologically dependent people experi- ence powerful cravings for these substances, which motivates drug-seeking behavior. However, it may be di&cult to distinguish psychological dependence from physical dependence. As mentioned earlier, psychoactive drugs produce physiologic changes in the brain that in'uence behavior. "us, these changes may a#ect a person’s emotional responses, including feelings about the need to take psychoac- tive substances.
Not everyone who habitually uses or abuses psy- choactive substances becomes dependent on their use. For example, individuals who drive a$er becom- ing drunk at bars or parties are abusing alcohol, but they are not necessarily alcoholics. It is di&cult to determine when the habitual use of a psychoac- tive substance becomes a dependency. Scientists are interested in determining why some people seem to be more susceptible to drug dependency and addic- tion than others are.
Risk Factors for Drug Dependency Like many other health problems, there is no single risk factor for drug dependency. Substance addiction results from complex interactions among biological,
drug dependence (addiction) Occurs when users develop a habitual pattern of taking drugs that produces a compulsive need, which is both physical and psychological.
tolerance An adaptation to drugs in which the usual dose no longer produces the anticipated degree of physical or psychological effects.
withdrawal A temporary physical and psychological state that occurs when certain drugs are discontinued.
212 Chapter 7 Drug Use and Abuse
personal, social, and environmental factors. Results of research conducted by the National Institute on Drug% Abuse (NIDA) and reported in its most recent edition of Preventing Drug Use Among Chil- dren and Adolescents: A Research-Based Guide sug- gest that certain conditions in the home are probably the most crucial risk factors for children becoming drug abusers.5 Such factors include home environ- ments in which parents abuse drugs or su#er from mental illness; ine#ective parenting, particularly with children who have di&cult temperaments or conduct disorders; and a lack of mutual child– parent% attachments and parental nurturing. Risk factors for drug abuse that relate to a child’s behav- ior outside the home include inappropriately shy or aggressive behavior in the classroom; poor school performance; poor social skills; friendships with peers who use drugs; and a belief that parents, the school, peers, and the community approve of drug use. Conversely, protective factors, those associ- ated with reduced potential for drug abuse, include strong family and school ties; parental monitoring of behavior with clear rules of conduct; involve- ment of parents in% the lives of children; academic success in% school; and the belief that parents, the school, peers, and the community do not approve of drug%use.
Amphetamines and Methamphetamines Synthetic stimulants are amphetamines, metham- phetamines, and nonamphetamines (see Table 7.7). Amphetamines such as Dexedrine (dextroamphet- amine) increase energy and alertness, lessen the need to sleep, produce euphoria, and suppress appetite. In the early 1980s, 21–22% of college students reported using amphetamines within the past year. "eir use dropped signi!cantly each year from 1983 to 1992, when only 3.6% of college students reported using this drug. From 1993 to 2001, amphetamine use rose again, ranging from 4.2% in 1993 to 7.2% in 2001. By 2012, 11.1% of full-time college students reported using amphetamines, but only 1.8% reported using methamphetamines. Methamphetamine use in U.S. college students has steadily declined from its height of 3.3% in 1999 to 0.3% in 2016.1
Methamphetamines (“speed”) are powerful forms of amphetamines that have few medically approved uses. Methamphetamine is taken orally (usually as a pill), or the powder is snorted. It can also be injected or smoked. In small doses, methamphetamines pro- duce euphoria, appetite loss, excessive perspiration, and pounding heartbeats. "e e#ects of taking larger doses can be frightening: chest pains, irregular heart- beat, fever, hallucinations, and convulsions. People who drive while on methamphetamines exhibit erratic driving patterns and are o$en involved in high-speed collisions.
Methamphetamine use is associated with weaken- ing of the heart muscle in young people (those aged 45 years or younger).6 Overdoses of methamphet- amines can be deadly by resulting in cardiovascular collapse or strokes. When taken by pregnant women, the drug can stunt fetal growth and negatively a#ect the development of the fetal brain.7,8
Brain damage is a hallmark of chronic metham- phetamine abuse. Figure 7.5 shows this damage in a user: "e red areas are those with the greatest tissue loss. "e limbic region, which is involved in drug craving, reward, mood, and emotion, lost 11% of its tissue in this user’s brain. "e hippocampus, which is involved in memory making, lost 8% of its tissue. "e persons examined in the study were in their 30s and had used methamphetamine for 10% years, pri- marily by smoking it approximately every other day, using 4 grams per week.9 Withdrawal from metham- phetamines o$en results in anxiety, fatigue, sleep- lessness, paranoia, delusions, and severe depression.
4To avoid the destructive effects of a drug dependency or addiction, do not use psychoactive substances unless you are under a physician’s care.
Healthy Living Practices
Stimulants "roughout the world, people have used various stimulant drugs for thousands of years to relieve fatigue, suppress appetite, and improve mood. (See the Diversity in Health essay “Khat.”) Stimulants enhance chemical activity in parts of the brain that in'uence emotions, sleep, attention, and learning. Within minutes a$er taking stimulants, users are more alert, excitable, and restless. "ese drugs also increase blood pressure levels and heart rates.
Stimulants 213
Diversity in Health Khat Which psychoactive drug is associated with weddings and weekends? If your answer is alcohol, you may be wrong with respect to certain cultures. In the East African countries of Somalia and Ethiopia, and on the nearby Arabian
peninsula in Yemen, people chew khat, the leaf buds and leaves of the native bush Catha edulis, to celebrate wed- dings and other special events (Figure"7.A). For centuries, people from these cultures have chewed or smoked khat or drunk tea brewed from its leaves as a socially accept- able and enjoyable pastime. Many homes in Somalia have a special room in which family members and their friends (primarily men) gather to munch khat and chat. Like alcohol and other psychoactive substances that are more familiar to Americans, khat contains chemicals that are known to produce both pleasurable and harmful side effects.
Khat contains cathinone, more potent and found in fresh leaves, and cathine, less potent and found in older leaves. These compounds are chemically simi- lar to amphetamines and produce psychological and physiologic responses that resemble those produced by amphetamines and other stimulants. After using khat, people report feeling euphoric and alert; they have little desire to eat, sleep, or engage in sex. Khat users experi- ence elevated blood pressure and heart rate. After the stimulating and mood-elevating effects of the drug sub- side, khat users feel anxious and irritable.
Khat impairs thought processes such as mental con- centration and judgment; therefore, driving while under
its influence can be hazardous. Men who use khat regu- larly may develop permanent impotence; women who use khat during pregnancy are at risk of giving birth to underweight newborns. Overdosing on khat can pro- duce aggressive, paranoid, and psychotic behavior. Khat has also been found to be a significant risk factor for acute coronary syndrome, a range of life-threatening heart-related disorders.
In the early 1990s, thousands of Somalis and Ethio- pians fled the civil unrest raging in their homelands and sought refuge in Western countries, including England and the United States. After settling in the West, many of these immigrants maintained their habit of using khat. To satisfy their demand, the immigrants purchase khat leaves that have been flown into North America or the United Kingdom from East Africa.
Concerned about the drug’s effects on the central nervous system, officials at the U.S. Drug Enforcement Administration added cathine to its list of controlled substances in 1988 as a Schedule IV drug. In 1993, the Food and Drug Administration issued an import alert that recommended detention of khat by customs offi- cials to prevent its entry into the United States. Cur- rently, khat use does not pose a major drug enforcement problem.
Data from Valente, M. J., et al. (2014). Khat and synthetic cathinones: a review. Archives of Toxicology, 88(1), 15–45; Al-Hebshi, N. N., & Skaug, N. (2005). Khat (Catha edulis)—an updated review. Addiction Biology, 10, 299–307; El-Wajeh, Y. A. & Thornhill, M. H. (2009). Qat and its health effects. British Dental Journal, 206, 17–21; and Mwenda, J. M., Arimi, M. M., Kyama, M. C., & Langat, D. K. (2003). Effects of khat (Catha edulis) consumption on reproductive functions: A review. East African Medical Journal, 80, 318–323.
Figure 7.A Women selling khat in Ethiopia. © Vlad Karavaev/Shutterstock.
214 Chapter 7 Drug Use and Abuse
In the 1980s, drug suppliers from Korea, Taiwan, and the Philippines introduced an illegal crystal- line form of methamphetamine called crystal meth (also referred to as meth, crank, ice, and glass). An extremely potent and addictive drug, crystal meth can produce violent behavior and damage the liver, kidneys, and lungs, as well as physical appearance (Figure 7.6).
Both methamphetamine and crystal meth are synthetic drugs; that is, they are not made directly from plant material, as opium and cocaine are, but are made in laboratories from other chemicals, called precursor chemicals. Drug suppliers manu- facture the drug using temporary homemade labs that they move from place to place to evade law enforcement.
"e ingredients for making meth are lithium from batteries, acetone from paint thinner, lye, and ephedrine/pseudoephedrine, which are found in cold remedies and sinus medications. However, the Domestic Chemical Diversion Control Act of 1993 made it illegal to sell ephedrine over the counter (although it could still be sold in pills containing other active ingredients), and the Comprehensive Methamphetamine Control Act of 1996 placed addi- tional controls on products containing ephedrine
and pseudoephedrine. More recently, the Combat Methamphetamine Epidemic Act enacted in 2006 placed restrictions on the amount of medications containing ephedrine and pseudoephedrine that could be sold in one day and over a 30-day period to an individual. To circumvent the law, methamphet- amine “manufacturers” o$en use the drug ephedra (ma huang) as a substitute or have many individu- als purchase the drugs up to the daily and monthly limit, a practice called smur#ng.
Party Drugs Amphetamines and methamphet- amines are two drugs in a group called party drugs (club drugs). Party drugs also include alcohol, GHB, GBL, and Rohypnol (depressants); LSD (acid) and ketamine (special K) (both are hallucinogens); and MDMA (ecstasy, a drug with mixed e#ects). Adoles- cents, teenagers, and young adults use these drugs at all-night parties and in other social situations to reduce anxiety, induce euphoria, or build energy to keep on dancing or partying. However, these drugs are not harmless “fun” drugs because they can have long-lasting negative e#ects on the brain. (We discuss these drugs in this chapter.)
Ritalin, Adderall, and Other Medically Useful Stimulants Amphetamines and chemically related stimulants have a few medical uses, such as treat- ment of the sleep disorder narcolepsy, short-term weight loss, and attention control. One medici- nally useful stimulant is Ritalin (methylphenidate), prescribed for people with attention disorders. Ritalin is abused, however, by persons who do not
Figure 7.5 Brain Decay Caused by Methamphetamine Use. This magnetic resonance imaging (MRI) image of one hemisphere of the brain shows areas of brain- volume loss in a methamphetamine user. Courtesy of Paul Thompson, Kiralee Hayashi, Arthur Toga, Edythe London/UCLA.
Areas of Greatest Loss Emotion, reward (limbic system) Memory (Hippocampus)
0% Loss
3% Loss
5% Loss
Average difference in brain tissue volume of methamphetamine users, as compared with nonusers
Figure 7.6 Before and After Using Crystal Meth. The mug shot on the left is of a woman who committed a felony before using crystal meth. The mug shot on the right is of the same woman after 2.5 years of using this drug. © Images from the Faces of Meth V 1, 2005 CD ©, Multnomah County Sheri" ’s O%ce.
Stimulants 215
need the drug for its prescribed use but use it for its stimulant e#ect.
"e annual prevalence of nonprescription Ritalin use for high school seniors from 1976 to 1993 was very low and ranged from 0.1% to 0.7%. In 1994, Rit- alin use by high school seniors rose to 1% from 0.4% in 1993 and reached a peak of 3.9% in 2004. Since then, prevalence of use has fallen and was 1.3% in 2009.10 In 2001, MTF researchers changed the way they asked the question about nonprescription Rit- alin use, and the results yielded higher prevalence rates, from 5.1% in 2001, decreasing to 2.1% in 2009, and remaining steady at approximately 1% from 2010 to 2016.3 "e results from asking both questions sug- gest an ongoing, gradual decline in Ritalin use in recent years.
"e stimulant Adderall (amphetamine and dex- troamphetamine) more recently has been used for the treatment of attention-de!cit hyperactiv- ity disorder (ADHD), and the MTF researchers began asking questions of seniors regarding its use in 2007. In that year, 2.8% of high school seniors reported using the drug, and that !gure rose to 3.3% by 2009.10 Using a revised question, as with Ritalin, the prevalence of Adderall use by seniors in 2012 was 7.6%, but the rate fell to 4% in 2016.3 MTF researchers suggest that the decrease in Ritalin use may be occurring because it is being replaced by Adderall%use.
Among college students, the annual prevalence of Ritalin use is about the same as with high school seniors. MTF began asking the question of college students in 2002, using the revised format. Nonpre- scription prevalence of use for college students was 5.7% in 2002 but fell through 2016 to a rate of 1.1%.3 "e annual prevalence of use for young adults aged 19–28 years not enrolled in college was lower than for college students from 2002 to 2008 but was the same in 2012, at 1.7%. In 2016, however, use of Adderall was high for both college students and young adults not enrolled in college, at 5%.1
Although Adderall, as well as other psychothera- peutics, is used by some college students for weight loss, it is most commonly used as an academic per- formance enhancer. Some students rely on Adderall for mental endurance to get through the challenges of school and believe it will help them achieve bet- ter grades. Despite student perceptions of Adderall’s
ability to help them perform better academically, there is no evidence that it improves student grades or learning outcomes. Unfortunately, many col- lege students who use Adderall as a performance enhancer are unaware of negative health outcomes linked to nonprescription use of Adderall, includ- ing addiction, psychosis, and severe cardiovascular reaction.
Cocaine Cocaine is a white powdery substance extracted from the leaves of the coca bush, which is not the same plant as the cacao tree, from which cocoa and chocolate are derived. Crack is a rock crystal form of cocaine that can be heated and its vapors smoked (inhaled); its name comes from the cracking sound that is heard during the heating process. "e powdered form of cocaine can be snorted (inhaled through the nose) or dissolved in water and injected. Most people snort, rather than inject, cocaine.
"is potent stimulant has some medical uses, particularly as an anesthetic, a substance that% inter- feres with normal sensations. However, cocaine was the most widely used illegal stimulant in the United States during the late 1970s and early 1980s, a time during which the public was misinformed about the drug and its dangers. Additionally, many healthcare practitioners did not understand the dangers of cocaine use or its addictive nature; as a consequence, cocaine was viewed as glamorous and was used by many celebrities as well as mil- lions of other Americans. "e popularity of cocaine declined dramatically between 1985 and 1992, most likely from public understanding that accompanied increased knowledge about this drug and its danger- ous e#ects. "e level of cocaine use has not changed signi!cantly since 1992, but it has dropped some- what in recent%years. Experts estimate that approxi- mately 1.8 million Americans were current cocaine users in 2016, down from 2.4% million in 2006 (see Figure 7.9).1
Cocaine is highly addictive. In laboratory studies of the drug’s e#ects, animals prefer to self-administer cocaine rather than engage in reproductive behav- ior or obtain food. Many people who are dependent on cocaine demonstrate similar responses. Cocaine abusers o$en dissociate themselves from their fami- lies, friends, and associates.
Chronic cocaine abuse produces serious health problems (see Table 7.7). People who snort cocaine regularly o$en su#er from chronic irritation of their
anesthetic Substance that interferes with normal sensations.
216 Chapter 7 Drug Use and Abuse
nasal passages. "is irritation causes nosebleeds, and it can destroy the septum, the cartilaginous tis- sue that divides the area between the two nostrils (Figure" 7.7). Snorting cocaine and smoking crack damage lung tissue and increase susceptibility to respiratory tract infections.
Long-term use of cocaine may interfere with normal sexual functioning. Men who use cocaine regularly o$en experience a reduced sexual drive and inability to achieve erections. Women who are chronic users may experience infertility, menstrual problems, and di&culty achieving orgasms.
Cocaine use can have deadly consequences. People with hepatitis or AIDS can spread these diseases by sharing their used hypodermic needles with unin- fected drug users. Additionally, cocaine use increases the risk of dying suddenly from life-threatening dis- orders of the circulatory system such as irregular and rapid heartbeat, high blood pressure, stroke, and heart attacks. Death is especially likely when people take cocaine with other psychoactive substances such as alcohol and heroin. During the past few decades, several well-known individuals have died as a result of using cocaine, such as comedian/actor John Belushi, comic Chris Farley, and bassist John Entwistle of the rock band "e Who.
While under the in'uence of cocaine, some%indi- viduals experience severe psychotic reactions, including paranoia, which may result in violent behavior. It is not uncommon for cocaine abusers to report having delusions, such as the sensation that bugs are crawling beneath their skin. "e psy- chological symptoms of cocaine intoxication also lead some users to attempt suicide, and a number of them succeed.
Caffeine Worldwide, ca#eine is the most widely used psy- choactive substance. Ca#eine and its related chemi- cal compounds occur naturally in several varieties of plants that we use to make foods and beverages, including co#ee, tea, and cocoa. People may ingest ca#eine when they consume ca#einated so$ drinks or take certain OTC medications. Table 7.3 lists the amounts of ca#eine contained in certain beverages, foods, and OTC products.
Ca#eine has been generally recognized as a stim- ulant that causes limited dependence. "e aver- age American consumes about 200 mg of ca#eine daily—the equivalent of about two cups of co#ee or !ve cola beverages. Typical patterns of moderate caf- feine consumption do not appear to be harmful to healthy persons.
"e Center for Science in the Public Interest notes that—on the positive side—people who consume ca#eine regularly have a lower risk of developing Parkinson’s disease and gallstones. In addition, caf- feine intake improves alertness and reaction time, li$s the mood, helps the body burn fat, blunts pain, and helps relieve headache pain. On the negative side, however, ca#eine can disturb sleep and pro- voke migraine headaches in those prone to them. Consuming 200 mg or more per day may increase the risk of miscarriage.11
A$er abstaining from ca#eine for about half a day, a person who is accustomed to taking the drug typi- cally experiences withdrawal symptoms that include headache, tiredness, irritability, and depression. Individuals who consume more than 600 mg per day o$en experience psychological as well as physical problems known as ca!einism. "e manifestations of ca#einism include nervousness, trembling, irritation of the stomach lining, insomnia, increased urine production, diarrhea, sweating, and rapid heart rate. People who do not regularly consume ca#eine or who are sensitive to it may develop ca#einism a$er taking as little as 250 mg of the drug daily.
Figure 7.7 Perforated Nasal Septum. The nostril is being held open with a nasal speculum, showing the nasal passage and mucosa. The septum divides the inner passageways. The perforation (hole) in the septum, a common result of snorting cocaine, may cause symptoms such as bleeding, crusting, whistling, and difficulty breathing. © Medical-on-Line/Alamy Images.
Stimulants 217
Beverage, Food, or Product Typical Amount/ Range (mg)
Coffee
Cappuccino (2 oz) 100
Espresso (2 oz) 100
Brewed, drip method (5 oz) 60–180
Brewed, percolator (5 oz) 40–170
Instant (5 oz) 30–120
Decaffeinated, brewed (5 oz) 2–5
Decaffeinated, instant (5 oz) 1–5
Tea
Brewed, U.S. brands (5 oz) 0–90
Brewed, imported brands (5 oz)
25–110
Instant (5 oz) 25–50
Iced (5 oz) 28–32
Cocoa-Containing Products
Cocoa (5 oz) 2–20
Chocolate milk (5 oz) 1–4
Beverage, Food, or Product Typical Amount/ Range (mg)
Milk chocolate (1 oz) 1–15
Dark chocolate, semisweet (1 oz)
5–35
Chocolate-flavored syrup (1 oz) 4
Soft Drinks (12 oz)
Dr. Pepper 40
Cola-type beverages
Regular 30–46
Diet 2–58
Caffeine-free 0
Mountain Dew, Mello Yello 52
Jolt 75–100
Over-the-Counter Medications
Vivarin (1 pill) 200
NoDoz (1 pill) 100
Anacin, Empirin, or Midol (2 pills)
64
Caffeine Content of Popular Beverages, Foods, and Products
Table 7.3
Data from Caffeine: Grounds for concern? (1994). University of California at Berkeley Wellness Letter. 10(6), 5; Goldberg, R. (2005). Drugs across the spectrum. Belmont, CA: Brooks/Cole; and Sizer, F. & Whitnet, E. (2005). Nutrition: concepts and controversies. Belmont, CA: Wadsworth Publishing, Co.
Depressants Depressants produce sedative (calming) and hypnotic (trancelike) e#ects as well as drowsiness. "ese drugs slow the activity of the cerebral cortex, the part of the brain that is responsible for thought processes. Depressant drugs include alcohol, barbiturates such as phenobarbital (Luminal), and minor tranquilizers such as diazepam (Valium).
Dangerous side e#ects can result when people misuse depressants. All of these drugs slow the heart and respiratory rates, which increases the risk of dying from respiratory failure a$er taking an over- dose. Combining depressants—for example, drinking alcohol while taking Valium—produces synergistic
4If you have ill effects such as anxiety or sleep disturbances from consuming too much caffeine, gradually wean yourself from the drug to avoid its withdrawal symptoms, especially headaches.
Healthy Living Practices
sedative Producing calming effects.
hypnotic Producing trancelike effects.
218 Chapter 7 Drug Use and Abuse
(combined) e#ects. Such synergism of depressants can be life threatening.
Tolerance and dependency occur with regular use of depressants. Withdrawal from these drugs can cause delirium (mental confusion and disorientation) and seizures (abnormal brain activity that results in uncontrollable muscular movements). Some addicted people die while undergoing withdrawal from depressants.
Sedatives and Tranquilizers Physicians frequently prescribe sedatives and minor tranquilizers, especially for people su#ering from insomnia or mild anxiety. In many instances, people can treat their mild anxiety or insomnia without powerful depressants. Anxious individuals can try to reduce their feelings of stress by practicing relax- ation techniques. "e Managing Your Health feature “Falling Asleep Without Prescriptions” provides sug- gestions that may induce sleep without the use of depressants or other drugs. Prescription medications used to treat anxiety and sleep disorders are o$en abused. In 2016, 6 million people abused tranquiliz- ers, and 1.5 million abused sedatives.1
Rohypnol Rohypnol (row-HIP-nole), commonly called roo#es (along with a variety of other street names), is one of a few “date-rape drugs.” (See the section titled “GHB and GBL” that follows.) While under the in'uence of Rohypnol, women are unable to resist rapists,
and they cannot recall, for various lengths of time, what happened to them while under the in'uence. Because of concern about Rohypnol and other simi- larly abused sedative–hypnotics, Congress passed the Drug-Induced Rape Prevention and Punishment Act of 1996 to increase federal penalties for use of any controlled substance to aid in sexual assault. A$er 1996, Rohypnol use declined. It was used by less than 1% of high school seniors in 2016 and less than 0.1% of college students, which appears on MTF tables as 0%.3
Although not approved for use in the United States, this drug is widely available in Mexico, Colom- bia, and Europe, where it is used for the treatment of insomnia. Like other depressants, its e#ects include sedation, muscle relaxation, and anxiety reduction. It also causes dizziness, loss of motor control, lack of coordination, slurred speech, confusion, and gastro- intestinal disturbances, all of which can last 12 hours or more.
GHB and GBL Gamma hydroxybutyrate, better known as GHB, was formerly sold in health food stores as a dietary supplement to induce sleep and build muscle. Its OTC sale was banned by the Food and Drug Administration (FDA) in 1990. "e longer periods of sleep it induced were supposed to allow release of human growth hormone, which has been linked with increased muscle mass. However, GHB users reported unpleasant side e#ects, such as nausea and
Managing Your Health If you experience occasional sleepless nights, the follow- ing self-treatment tips for insomnia may be helpful:
1. Try to adhere to a regular sleeping and waking schedule, even on weekends, to foster natural sleep–wake timing.
2. Don’t eat big meals or drink large amounts of fluids in the evening. Have a light snack before bedtime if you like, but avoid alcohol, caffeine, and over-the-counter (OTC) pain relievers that contain caffeine.
3. Reserve time for vigorous regular exercise earlier in the day, at least 2 hours before bedtime.
4. Practice a prebedtime relaxing routine, such as taking a warm bath or shower.
5. Keep your bedroom dark, cool, and as quiet as possible.
6. Practice progressive muscular relaxation while in bed.
7. Don’t stay in bed if you can’t fall asleep; get out of bed and read a dull book. Avoid watching TV or using any screen; the flickering light stimulates the brain. Return to bed when you begin to feel sleepy.
8. Take an OTC sleep aid only as a last resort. Rec- ognize that most of these medications contain antihistamines that lose their effectiveness if used regularly.
Falling Asleep Without Prescriptions
Depressants 219
shaking. More dangerously, this drug has induced seizures and coma in some users and can also cause irregular heartbeat, slowed breathing, hypothermia, and vomiting.12 With legislation passed in February 2000, GHB became a Schedule I drug.
In January 1999, the FDA warned consumers about a drug related to GHB: gamma butyrolactone, or GBL. A$er ingestion, the body converts GBL to GHB. Some products labeled as dietary supplements contain GBL and claim to build muscles, improve physical performance, enhance sex, reduce stress, and induce sleep. However, GBL-related prod- ucts have been associated with reports of at least 55% adverse health e#ects, including seizures, vom- iting, slowed breathing, slowed heartbeat rate, and coma. One death had been reported from GBL at the time of the FDA warning. "e FDA considers GBL an unapproved drug. A$er the FDA warning, all but one manufacturer of GBL-related products agreed to recall these drugs and to stop their manufacture and distribution.
are derived from opium. Synthetic opiates include Darvon (propoxyphene) and Demerol (meperidine). "ese compounds have important medical uses as sedatives, analgesics, and narcotics. Analgesics alleviate pain; narcotics alter the perception of pain and induce euphoria and sleep. (Many people incorrectly use the term narcotic to describe any illegal drug.)
In addition to relieving pain, opiates slow the activity of the intestinal tract, so they are useful in treating severe diarrhea. In addition, physicians fre- quently prescribe codeine-containing syrups to sub- due severe coughing. Despite their medicinal value, opiates are extremely dangerous when taken in an uncontrolled manner. "ese drugs are highly addic- tive; people who use opiates daily develop depen- dence and tolerance within a few weeks.
Using opiates, especially heroin, can cause a variety of serious health problems as well as death. Excessive doses of opiates depress the CNS, slowing respiration and reducing mental functioning. Such overdoses require immediate medical attention.
analgesics (an-al-GEEZ-iks) Drugs that alleviate pain.
narcotics Drugs that induce euphoria and sleep as well as alter the perception of pain.
4Do not accept drinks from casual acquaintances or strangers; they may contain dangerous drugs.
4Do not drive or operate machinery while under the influence of depressant drugs because these substances can impair your thought processes and muscular coordination.
4Do not drink alcohol while taking other depressants. The synergistic effect of combining these compounds can be deadly.
Healthy Living Practices
Figure 7.8 Longitudinal Section Through a Seedpod of the Opium Poppy. The dried sap extracted from opium poppy seedpods is used to make the narcotic opium. Some white sap can be seen on the cut edge of this seedpod. © Nigel Cattlin/Holt Studios International/Science Source.
Opiates Opiates include opium, the dried sap extracted from seedpods of opium poppies shown in Figure 7.8, and drugs such as codeine, morphine, heroin, and Per- codan (aspirin and oxycodone hydrochloride) that
220 Chapter 7 Drug Use and Abuse
Sharing needles that are used to inject heroin intra- venously can cause life-threatening bacterial infec- tions and viral diseases, such as AIDS and hepatitis.
Opium and Heroin A$er it enters this country, opium is chemically converted to heroin by drug dealers. "ey also add various materials, such as quinine or cornstarch, to dilute the drug’s concentration. Substances that dilute the concentration of a drug are called adul- terants. Because heroin abusers lack information concerning the potency of their drug purchases a$er chemical conversion by drug dealers, they risk taking overdoses or having allergic reactions to the adulterants.
Heroin is one of the most widely abused illegal drugs worldwide;3 however, survey data indicate that it is not very popular with young people in the United States. Only 0.3% of American high school students and 0.1% of college students used heroin in 2016.1 In the United States overall, only 0.4% of those aged 12 years and older used heroin in 2016 (see Figure 7.9).
OxyContin and Vicodin In 2001, news reports of abuse of the time-released opiate pain reliever OxyContin became common. OxyContin (oxycodone) is a medication prescribed primarily for patients with terminal cancer and other illnesses that cause moderate to severe chronic pain. By 2002, hundreds of people had died from
OxyContin abuse, and researchers began collecting data on the use of OxyContin by high school students, college students, and adults. In 2016, the percentages of 8th, 10th, and 12th graders, college students, and Americans 12 years of age or older using OxyContin during the year before being surveyed (the annual prevalence) were 2.1%, 2.2%, and 4.3%, respectively. "e annual prevalence of use of OxyContin increased for all groups through 2009; however, rates steadily declined in all age groups through 2016. OxyContin is a time-release medication with the synthetic opiate oxycodone as its active ingredient.
Persons who abuse this prescription medication chew, crush, or dissolve the pills and then inject, inhale, or take them orally, which delivers the medi- cation all at once rather than slowly over time. "e result is a rapid and intense euphoria that does not occur when the drug is taken as prescribed, but such ingestion carries the dangers of opiates mentioned previously. Abusers also take OxyContin with other pills, marijuana, or alcohol, which can result in seri- ous injury or death.
Vicodin (hydrocodone bitartrate and acetamino- phen) is also a drug prescribed to reduce pain. Abuse of this drug is more prevalent than abuse of Oxy- Contin. In 2016, the annual prevalence of abuse of Vicodin among 8th, 10th, and 12th graders; college students; and Americans aged 12 and older was 1.8%, 2.2%, and 4.3%, respectively. "e annual prevalence of use of Vicodin rose for all groups between 2002 and 2009; however, the prevalence rate for all age groups
Figure 7.9 Past-Month Illicit Drug Use Among Persons Aged 12 Years and Older: 2016. Marijuana was the most widely used illicit drug in the United States in 2016. Here, the category “psychotherapeutics” includes four prescription- type drug groups: pain relievers, tranquilizers, stimulants, and sedatives. Reproduced from Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. Retrieved from https://www.samhsa.gov/data/sites/default/!les/NSDUH-DetTabs -2016/NSDUH-DetTabs-2016.pdf
0
10.6
8.9
2.3
0.7
0.5
0.2
0.2
Illicit Drugs1
Marijuana
Psychotherapeutics
Cocaine
Hallucinogens
Inhalants
Heroin
5 10
Numbers in Millions
1Illicit Drugs include Marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.
15 20 25
Opiates 221
has steadily declined since 2009. In 2016, the annual prevalence of use was highest for 12th graders.3
Marijuana Marijuana is the most widely used illicit drug in the United States. An estimated 18 million Americans aged 12 years and older were current users of mari- juana in 2016 (Figure 7.9).
"e marijuana plant (Cannabis sativa) contains the psychoactive compound delta-9-tetrahydro- cannabinol, or THC. Hashish is a dried resin made from marijuana 'owers, which contain a higher con- centration of THC than the leaves of the plant. Also extracted from marijuana 'owers, hashish oil con- tains a greater percentage of THC than hashish. A few drops of hashish oil added to a cigarette produce psychoactive e#ects that are the same as smoking a marijuana cigarette, or joint.
When people smoke marijuana or hashish, THC enters the brain rapidly. THC alters muscular coor- dination and normal thought processes such as men- tal concentration, problem-solving, time perception, and short-term memory. "ese e#ects not only are likely to decrease educational achievement, but also can have serious consequences for drivers. Results of studies on the e#ects of marijuana on driving abilities reveal that marijuana impairs driving per- formance in a dose-related manner, just like alcohol does. In addition, recent use of marijuana appears to increase the risk of a driver’s being involved in a car crash. Smoking marijuana and drinking alcohol together has signi!cant additive e#ects on driving ability and sharply increases a driver’s risk of a car crash, even at low doses.13
Marijuana and hashish smoke contain numerous irritants that can damage the bronchial tubes and lungs. Respiratory symptoms reported consistently by those who smoke these drugs on a regular basis include chronic bronchitis; shortness of breath; fre- quent coughing, wheezing, and phlegm production; and pneumonia. Long-term marijuana smokers have an increased risk for developing chronic obstruc- tive pulmonary disease (COPD), which is a group of lung diseases that make it hard to breathe. COPD can range from mild to life threatening. Physical and behavioral dependence on marijuana occurs in about 7–10% of users and is more likely in those who begin using this drug at an early age.13
Although many users think that marijuana enhances their sexual responsiveness, results of some
studies have found that the drug interferes with reproductive functioning. Men who use marijuana may experience a temporary reduction of their nor- mal testosterone levels. Testosterone is a sex hormone that maintains sex drive and sperm production. "is e#ect decreases the sperm count and increases the proportion of abnormal sperm, qualities that are asso- ciated with reduced fertility and an increased prob- ability of fetal abnormalities. Babies born of women who smoked marijuana during their pregnancy face an increased risk of low birth weight and mild devel- opmental abnormalities.13
Most Americans who smoke marijuana use the drug occasionally, particularly while they are in social settings. Although low-THC cannabis (the form gen- erally available in the United States) rarely produces physical dependence when taken infrequently and in low doses, it can cause psychological dependence. Psychologically addicted persons mentally crave the euphoric e#ects of THC; experience a heightened sensitivity to and distortion of sight, smell, taste, and sound; have mood changes; and have a slowed reac- tion time.13
Among marijuana’s medical uses is that it helps control seizures, reduces the 'uid pressure in the eyes of people with glaucoma, eases the symptoms of wasting syndrome in AIDS patients, lessens muscle spasms in patients with muscle disorders such as multiple sclerosis, and reduces the pain of migraine headaches and peripheral neuropathy (a% condition of the hands or feet that produces signi!cant nerve pain). Patients usually smoke medical marijuana, eat it in baked goods, or drink it in tea. Marinol, a drug that contains synthetic THC, is an alternative to medical marijuana, but many patients become sick or signi!cantly disoriented shortly a$er taking it.
As of July 2018, marijuana has been approved for medical use in the District of Columbia and 30 states: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, and West Virginia. Laws in these states also remove state-level criminal penal- ties for cultivation, possession, and use of medical marijuana. Furthermore, several states have legal- ized nonmedicinal use of marijuana.
In June 2005, the U.S. Supreme Court ruled that federal authorities may prosecute patients whose
222 Chapter 7 Drug Use and Abuse
physicians prescribe marijuana for their medical use and that state laws do not protect users from the fed- eral ban on the drug. Although against federal law, the sale, purchase, and use of medical marijuana by licensed individuals in accordance with state law was not prosecuted during the Obama administra- tion (see Figure 7.2) until October 2011, when fed- eral prosecutors in California targeted growers and dispensaries they believed were involved in drug tra&cking. Many medical societies support legal protection for those using marijuana medically and support research into its usefulness as a medici- nal treatment. In 2018, the Trump administration rescinded state protection from federal prosecution for marijuana sale and use.
LSD LSD (lysergic acid diethylamide) is a colorless, odor- less, 'avorless compound that is manufactured in pill, solution, and powder form. It is an extremely potent drug; taking very small amounts produces vivid hal- lucinations that can last up to 12 hours. While taking LSD, some people have severe psychotic reactions, such as paranoid delusions. Additionally, for weeks or months a$er taking LSD, some users may have “'ashbacks” in which they experience mild halluci- nations. Flashbacks usually subside over time, and few long-term psychological problems seem to result from hallucinogen use. LSD can stimulate uterine contractions, so pregnant women should avoid it.
During the early 1980s, LSD use by college stu- dents declined dramatically, from 6.3% in 1982 to 2.2% in 1985. By 1992, however, LSD use among college students had climbed to 5.7% and peaked in 1995 at 6.9%. Use then steadily declined to 0.7% in 2005, with the exception of a spike in 1999 of 5.4%. A$er 2005, LSD use among college students began to climb again; in 2016, 0.7% of college students had used LSD in the past year.3
Mescaline A small, round, spineless cactus that grows in Mexico and Texas produces the hallucinogen mescaline, or peyote (Figure 7.10). A$er eating peyote, people have hallucinations that last 1–2 hours. "ese “trips” are
4Smoking marijuana can impair your thought processes and ability to drive, damage your lungs, reduce your fertility, and lessen your motivation to work. To avoid these serious effects, abstain from using this drug unless prescribed for medical reasons.
Healthy Living Practices
Figure 7.10 Peyote Cactus (Lophophora williamsii). This small, round, spineless cactus grows in Mexico and Texas and produces the hallucinogen mescaline, or peyote. © Bob Cheung/Shutterstock.
Hallucinogens When taken internally, hallucinogens produce hal- lucinations, abnormal and unreal sensations, such as seeing distorted and vividly colored images. Many people report feeling pleasantly detached from their bodies or united with their environment while using hallucinogens. Hallucinogens, however, can produce frightening psychological responses such as anxiety, depression, and the feeling of losing control over your mind. "e physical side e#ects of hallucino- gens include elevated blood pressure, dilated pupils, and increased body temperature. Although chronic users of these drugs may develop psychological dependence and tolerance, physical addiction and withdrawal do not occur.
In the United States, the most potent and com- monly abused hallucinogens are LSD, mescaline, psi- locybin (SIGH-low-SIGH-bin), PCP, and ketamine. "ese drugs have no approved medical uses, and their recreational use is illegal. Native Americans, however, are permitted to use peyote, a cactus that contains mescaline, in certain religious rites.
Hallucinogens 223
milder and easier to control than LSD trips. Because pure mescaline is di&cult to produce for illicit sale, most mescaline sold on the streets contains LSD as the psychoactive agent.
Psilocybin Many mushrooms, including several wild-growing varieties that are found throughout the United States, contain psilocybin. A$er eating these fungi, some- times called magic mushrooms, people experience elevated blood pressure, body temperature, and pulse rate. Psilocybin produces euphoria and hallucina- tions, but these psychoactive e#ects are not as intense or long lasting as those produced by LSD. Unpleasant responses to psilocybin ingestion include wide mood swings and uncontrollable movements of arms and legs. Although fatal overdoses from psilocybin have not been reported, users may die if they eat other wild mushrooms that are poisonous.
4Do not eat wild mushrooms. Some are poisonous and can cause death.
Healthy Living Practices
PCP PCP (commonly called angel dust or rocket fuel) is di&cult to classify because the drug produces hallu- cinogenic, depressant, stimulant, or anesthetic e#ects depending on the dose in which it is taken. Within a few minutes a$er taking PCP, users begin to experience its psychoactive e#ects, which can last up to 6%hours.
Unlike other hallucinogenic drugs, high doses of% PCP can cause severe toxic reactions. Taking 1–5%milligrams of PCP produces confusion and loss of muscular coordination; users also feel warm, sweaty, relaxed, and euphoric. As the level of intake increases to about 10 milligrams, users become confused, para- noid, and agitated; they act drunk, have hallucinations, and report numbness in their arms and legs. Taking 10–25% milligrams produces the signs and symptoms of PCP toxicity, including trancelike or psychotic behav- ior. Doses that exceed 25–50 milligrams can produce fever, convulsions, coma, elevated blood pressure, and death. People who survive the acute toxic e#ects of PCP
o$en feel depressed and anxious. In addition, they may show signs of brain damage, such as confusion and dis- orientation, that can take weeks to disappear.
Ketamine In the 1960s, drug researchers developed ketamine, a PCP analog that has fewer troublesome side e#ects than PCP. An analog is chemically similar to another drug and may or may not produce similar responses. Today, legally manufactured PCP analogs such as Ketalar (ketamine hydrochloride) have limited human and veterinary medical use as anesthetics.
Teens and young adults most commonly abuse ketamine by snorting the drug for its dreamlike or hallucinatory e#ects. In addition, the drug can be swallowed, smoked, drunk, or injected intramus- cularly. Ketamine injection is highly risky because multiple injections typically occur during a single “session” in large groups, and the drug is drawn from shared bottles of liquid ketamine. "ese behaviors put ketamine injectors at risk of infectious diseases such as hepatitis C and HIV. At high doses, ketamine can cause delirium, amnesia, impaired motor func- tion, high blood pressure, and potentially fatal respi- ratory problems. "ese e#ects are magni!ed when the drug is taken with sedatives or depressants, such as alcohol, which is a common practice.
Inhalants Inhalants are gases (fumes) that are breathed in and produce euphoria, dizziness, confusion, and drowsi- ness. Most inhalants are taken to induce mood changes, but nitrites are used as a sexual enhancer because they dilate (widen) blood vessels. Table 7.4 lists the types of inhalants.
Inhalants are taken into the body in a variety of ways. Fumes can be sni#ed from a container, or aero- sols can be sprayed directly into the nose or mouth. Alternatively, fumes or sprays can be sni#ed directly or inhaled from a bag, a practice called bagging. Another approach is “hu&ng,” in which a rag is soaked with the inhalant and pressed to the mouth and nose. Nitrous oxide can be inhaled from balloons !lled with the gas or from poppers, small bottles of the gas (see Table 7.4).
Inhalants irritate the mucous membranes lining the eyes, mouth, nose, throat, and lungs. Inhalant abus- ers o$en develop watery, reddened eyes and a per- sistent cough. Some users experience double vision, nausea, vomiting, fainting, and a ringing sensation in their ears. Many teenagers are unaware of the serious
analog A drugs that is chemically similar but has different effects on the body.
224 Chapter 7 Drug Use and Abuse
Types of Toxic Inhalants What Are They? Examples
Volatile Solvents Liquids that form gases at room temperature
Paint thinner, paint remover, dry-cleaning fluid, gasoline, glues, felt-tip marker fluids
Aerosols Sprays that contain propellants and solvents
Spray paint, spray deodorant, hairspray, fabric protector sprays
Gases Medical anesthetics and other gases used in everyday products
Examples of toxic gases: ether, chloroform, nitrous oxide (laughing gas)
Examples of products containing toxic gases: whipped cream dispensers, butane lighters, propane tanks, refrigerants
Nitrites
© Martyn Vickery/Alamy Images.
Chemicals that dilate blood vessels and relax muscles
Known as “poppers” or “snappers”; sold in small bottles labeled as video head cleaner, room odorizer, leather cleaner, or liquid aroma
Data from the National Institute on Drug Abuse.
Types of Toxic Inhalants and Common Examples
Table 7.4
health e#ects of inhalant use: brain damage, irregular heartbeat, anemia, liver damage, kidney failure, coma, or death.
Inhalant use begins at young ages—sometimes in the !$h grade—and its use drops as students grow older. Inhalants are the second most widely used class of illicit drugs for eighth graders (a$er marijuana). In 2016, the annual prevalence for inhalant use for 8th, 10th, and 12th graders was 2.6%. "e lowest rate of use was by college students, at 0.5%.1,3 Inhalant use has gradually decreased in all age groups since 2008.
Designer Drugs: Drugs with Mixed E#ects
People who have some knowledge of chemistry can alter the chemical structure of a controlled substance to make a new compound that is not classi!ed as a controlled drug. "e new compound, called a designer drug, usually produces psychoactive responses simi- lar to the drug from which it was produced. Designer drugs are relatively easy and inexpensive to produce.
Designer Drugs: Drugs with Mixed Effects 225
"us, people who make these drug analogs can reap considerable pro!ts from selling them.
A$er o&cials with the DEA determine that a designer drug has the potential to be abused, they can classify the compound as a controlled substance. However, underground chemists o$en avoid pros- ecution by continuing to modify the substance, pro- ducing new generations of the drug that the DEA does not control. Table 7.5 lists some of the best- known designer drugs and their psychoactive e#ects and potential health risks.
Designer drugs are o$en more toxic than the com- pounds from which they are derived. China white, for example, is 1,000 times more potent than its par- ent drug, fentanyl, a powerful synthetic opioid o$en used for general anesthesia or in the treatment of chronic pain. In 2008, the Centers for Disease Con- trol and Prevention (CDC) reported that illicitly manufactured fentanyl and its analogs were respon- sible for more than 1,000 deaths in the United States from April 2005 to March 2007 alone.14 "is was the
most recent report from the CDC on fentanyl deaths as of January 2018.
Ecstasy "e illegal designer drug ecstasy, or MDMA (3,4-methylenedioxymethamphetamine), became a controlled substance in 1985. Chemically similar to mescaline and methamphetamine, ecstasy produces both hallucinogenic and stimulant e#ects. Ecstasy users report that the drug improves their self-esteem and increases their desire to have intimate contacts with other people. However, users may experience panic and anxiety, hallucinations, tremors, rapid heart rate, loss of coordination, and psychotic behav- ior. Some users report more serious%side e#ects, such as irregular heartbeat, hypertension, fever, memory loss, and seizures. Since the 1980s, several people have died a$er taking this drug.
"e use of ecstasy by high school students, college students, and young adults rose sharply between 1999 and 2001. Use has declined since then in all three groups. In 2016, annual prevalence rate for ecstasy use for 8th, 10th, and 12th graders was approximately 1.8%. For college students and for young adults not in college, the prevalence rates were 0.9% and 0.8%, respectively.1,3 "ese data indicate a decrease in ecstasy use among high school and college students since 2009.
K2 K2 is a drug that is made in the laboratory and works in the brain much like the THC of marijuana. It is sprayed on herbal and spice plant products and
Designer Drug Original Drug Psychoactive Effects Possible Health Risks
MPPP, MPTP Meperidine (Demerol)
Heroin-like euphoria (depressant)
Parkinsonian syndrome: drooling, uncontrollable skeletal muscle movements, muscle rigidity (permanent)
China white Fentanyl (Sublimaze) Euphoria, respiratory depression
Death from respiratory failure
Ecstasy, XTC, Adam, M & M, MDMA
Mescaline- methamphetamine
Euphoria, CNS stimulant, hallucinations
Panic, anxiety, paranoia, increased and irregular heart rate, fever, hypertension, brain damage, seizures, death
Love drug (MDA) Mescaline- methamphetamine
Euphoria, talkativeness, increased need to make friends
Fever, rapid heart rate, hypertension, seizures, death
Popular Designer Drugs
Table 7.5
4Use household products that release toxic fumes, such as paints, glues, and lighter fluids, in well-ventilated areas to avoid inhaling these chemicals.
Healthy Living Practices
226 Chapter 7 Drug Use and Abuse
Figure 7.11 “Bath Salts” Can Be Deadly. They are not for the bathtub but contain synthetic stimulants that can kill. Courtesy of DEA.
smoked. First synthesized and used recreationally in the mid-1990s, K2 became popular again in 2006. Although nicknamed “fake weed,” this drug is not marijuana and is much more potent and dangerous than marijuana. Some of K2’s side e#ects are severe, potentially life-threatening hallucinations, danger- ously elevated blood pressure and heart rate, pale skin, vomiting, and seizures.
Bath Salts Despite its name, this stimulant designer drug has nothing to do with the bath salts you put in your soak- ing tub. "e name is only a disguise for a cocaine-like, life-threatening drug that raises the blood pressure and heart rate, increases the risk of heart attack and stroke, and can cause hallucinations, delusions, and para- noia—possibly long term. Marketed under names like Zoom 2, Vanilla Sky, and Ocean Wave (Figure 7.11), reports of this drug began in 2010, and by 2011 legisla- tion was under way to make “bath salts” a controlled substance. Data on bath salt use were !rst collected in the 2012 version of the MTF survey. In 2016, bath salt use rates for 8th, 10th, and 12th graders was 0.8%.2
Over-the-Counter Drugs "e FDA regulates the production and marketing of prescription and nonprescription medications in the United States. To be sold in this country, an OTC medicine must be e#ective and safe when people fol- low the product information that comes with it (in packages or on labels). Although the FDA does not
evaluate the safety or e#ectiveness of every OTC product that is marketed, the agency requires that active ingredients in products be evaluated for safety and usefulness. Active ingredients have an e#ect on the body; inert ingredients do not a#ect the body. Products that contain unsafe or ine#ective ingredi- ents or that have dishonest labeling cannot be sold. Herbal products that are sold as food supplements in health food stores are not regulated by the FDA. Some of these products contain substances that pro- duce druglike e#ects and are toxic (see the Consumer Health box in this chapter).
Individuals, physicians, and sta# of healthcare facilities can report cases of harm that result from using medicinal and nutritional products. If you have any problem with a medication, medical device, or dietary supplement, report the problem to the FDA’s MedWatch hotline by calling 1-800-332-1088 or go to www.fda.gov/MedWatch/report.htm.
Misuse and abuse of OTC medicines are com- mon. As mentioned in the beginning of this chap- ter, the improper use of these medications can be harmful. Furthermore, some OTC products con- tain substances that can produce serious psycho- active effects, especially when they are taken in large doses.
An example of the potential dangers of abusing OTC medications is the tragic death of a 17-year-old track star in June 2007 from an overdose of methyl salicylate. "is chemical compound is an active ingredient in a popular sports muscle pain cream and other OTC medications. "e young woman used the sports cream liberally on her legs between runs while also using two other OTC medications containing methyl salicylate. "is drug is an anticlotting agent, and at high doses it can cause internal bleeding, changes in heart rhythm, and liver damage. "e death of the young woman emphasizes the need to use even seemingly harmless OTC medications according to directions and in moderation, and to remember that taking more than one medication simultaneously— even OTC preparations—may be risky.
Look-Alike Drugs The active ingredient in “stay-awake” pills is the stimulant caffeine. Some manufacturers produce caffeine-containing capsules or pills that look like prescription amphetamines or related prescribed stimulants. The production and sale of these look-alike drugs are difficult to regulate because they contain caffeine, an allowed substance. Fre- quently, people who sell street drugs misrepresent
Over-the-Counter Drugs 227
Consumer Health Over-the-Counter Medicines: Safety and the FDA To protect consumers, the Food and Drug Administration (FDA) regulates the test- ing, production, marketing, and labeling
of medical devices and medications; the safety of foods and truthfulness of information on their labels; and the safety of cosmetics. A medical device or OTC medicine that is sold in the United States must be effective for its intended use and safe when its instructions are followed.
The FDA also requires that the active ingredients in OTC products be evaluated for safety and usefulness. Active ingredients have an impact on the body; inert ingredients do not affect the body. The FDA allows man- ufacturers of OTC products to use ingredients that are generally recognized as safe (GRAS), generally recog- nized as effective (GRAE), and generally recognized as
honestly labeled (GRAHL). The FDA employs investiga- tors who review information that appears on the labels of OTC products. Products that contain unsafe or inef- fective ingredients or that have labels displaying dishon- est information cannot be sold.
In 1998, the FDA proposed an easy-to-read and easy-to-understand labeling format for OTC drugs. Figure 7.B shows the information that must appear on the labels of an OTC medicinal product. Note that the label clearly displays warnings concerning the safe use of the product. Always follow instructions on the pack- age or label concerning the use of any OTC medication.
Individuals, physicians, and staff of healthcare facili- ties can report cases of harm that result from using medicinal and nutritional products. If you have any problem with a medication, medical device, or dietary supplement, report the problem to the FDA’s MedWatch hotline by calling 1-800-332-1088, or go to www.fda.gov /MedWatch/report.htm.
Data from Food and Drug Administration.
Figure 7.B Certain information must appear on the labels of an OTC medicinal product. (a) Front of label, and (b) back of label.
Manufactured by J&B Pharmaceuticals48 Tablets
SOOTHE
SO O
TH E
COLD TABLETS
Drug Facts Active ingredient (in each tablet) Chlorpheniramine maleate 2 mg Uses: temporarily relieves these symptoms due to hay fever or other upper respiratory allergies: • sneezing • runny nose • itchy, watery eyes • itchy throat Warnings: Ask a doctor before use if you have: • glaucoma • a breathing problem such as emphysema or chronic bronchitis • trouble urinating due to an enlarged prostate gland Ask a doctor or pharmacist before use if you are taking tranquilizers or sedatives When using this product: • you may get drowsy • avoid alcoholic drinks • alcohol, sedatives, and tranquilizers may increase drowsiness • be careful when driving a motor vehicle or operating machinery • excitability may occur, especially in children
If pregnant or breast-feeding, ask a health professional before use. Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center right away. Directions
adults and children 12 years and over
children 6 years to under 12 years
children under 6 years Other Information: • store at 20-25°C (68-77°F) • protect from excessive moisture Inactive Ingredients: D&C yellow no. 10, lactose, magnesium stearate, microcrystalline cellulose, pregelatinized starch
Purpose Antihistamine
take 2 tablets every 4 to 6 hours; not more than 12 tablets in 24 hours take 1 tablet every 4 to 6 hours; not more than 6 tablets in 24 hours ask a doctor
Product Name List of Active IngredientsProduct Label Front Back of Label
Quantity Indications for UseWarningsDirectionsName and Address of Manufacturer
Ea ch
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look-alike stimulants as amphetamines to unsus- pecting users.
Weight-Loss Aids Nearly anyone who has tried to lose weight knows that it is frustrating and that hunger seems to be con- stant. Many overweight people have taken various
pills, powders, beverages, and foods for years to pro- mote weight loss and prevent hunger.
Ephedrine/Ephedra Ephedrine and pseudoephedrine are found in vari- ous OTC preparations such as weight-loss aids and cold remedies, and they act as a stimulant, appetite
228 Chapter 7 Drug Use and Abuse
suppressant, concentration aid, and decongestant. Because ephedrine and pseudoephedrine act as mild stimulants, some individuals misuse medicines that contain these compounds to pep themselves up. However, ephedrine-containing drugs can produce high blood pressure, sleeplessness, irregular and rapid heart rate, and restlessness; taking high doses of either substance may evoke psychotic symptoms.
Ephedra, known in Chinese as ma huang, is a plant extract that is the source of ephedrine and pseu- doephedrine. Many laws control the sale of ephed- rine-, pseudoephedrine-, and ephedra- containing products. For example, in 2004, FDA o&cials banned the sale of ephedra-containing dietary supplements because of their dangerous side e#ects. "e ban targeted supplements that had been advertised for weight loss, muscle building, and athletic perfor- mance. In 2003, ephedra was implicated in the death of 23-year-old Steve Bechler, a prospective pitcher for the Baltimore Orioles.
In addition to ephedra, numerous other herbs or plant extracts—such as lobelia, comfrey, yohimbine, Ginkgo biloba, or sassafras—contain substances that can produce harmful side e#ects when ingested as supplements or teas (Figure 7.12).
Drug Treatment and"Prevention
"e goal of drug treatment is to stop the drug abuse and reduce the likelihood that abusers will return to their previous drug use behaviors. Currently, three major forms of long-term drug abuse treatment exist: methadone maintenance, outpatient drug-free programs, and residential therapeutic communities.
Treating Drug Dependency Methadone maintenance is used to treat addiction to opiates; methadone reduces the cravings for these drugs. "is controversial treatment is o$en used a$er other attempts at treatment have failed. Methadone is taken orally, diluted in juice. When taken this way, the drug prevents opiate withdrawal symptoms and reduces cravings, but it does not produce euphoria or cloud the mind. In addition, it blocks the e#ects of heroin and other opiates, which reduces the desire of addicts to continue taking these drugs. "us, metha- done treatment helps people stop taking opiates while at the same time allowing them to go to work, go to school, and take care of themselves and their families. Some drug rehabilitation programs prescribe metha- done during opiate detoxi!cation and then taper o# methadone use. However, other programs allow people to stay on methadone as long as they feel it is necessary.
Most abusers prefer outpatient drug-free programs that provide medical care and a wide variety of counsel- ing and psychotherapy approaches while they continue to live with their families and work in their communi- ties. "ese programs do not include use of methadone.
Self-help groups are a popular and useful adjunct to professional outpatient drug treatment. Individu- als recovering from drug dependency attend regular meetings to receive encouragement and social sup- port from other former substance abusers. Alcoholics Anonymous (AA) is one of the oldest, most e#ective self-help programs. Many other community-based self-help programs that treat drug abuse, such as Narcotics Anonymous, are modeled a$er AA.
In severe cases, drug abusers may undergo detoxi- !cation and then live for several months in controlled environments called residential therapeutic communities or group homes. Living in these communities reduces the likelihood that patients will be exposed to drugs while they resocialize, or readjust to general society.
While in group homes, patients also receive medi- cal care, social services, and psychological counseling.
Figure 7.12 Hazardous Herbs. Numerous plants can be toxic. For example, when taken internally, comfrey (shown here) can cause hepatic veno-occlusive disease (VOD), in which some of the small veins of the liver are blocked. VOD can lead to liver failure and death. © Krzysztof Slusarczyk/Shutterstock.
Drug Treatment and Prevention 229
A$er they leave residential therapeutic communities, individuals usually attend community- or hospital- based counseling sessions to prevent relapse, the return to drug abuse. For people who lack health insurance, the high cost of medical care is a major barrier to obtaining treatment in a therapeutic community.
Most drug treatment programs that last fewer than 3 months have limited long-term e#ective- ness.15 According to the Partnership for a Drug-Free America, results of studies show that length of time in drug treatment is the best single predictor of posi- tive posttreatment outcomes. Many drug-dependent people need more than 3 months of outpatient care or living in controlled environments to change their substance-related behaviors and attitudes. Addition- ally, recovering addicts o$en need to acquire job skills while they are in therapy to improve their chances of becoming drug-free, productive members of society.
An antidrug vaccine works by stimulating the immune system to develop antibodies against a par- ticular drug, such as an anticocaine vaccine or an antimorphine vaccine. "ese antibodies attach to the drug in the bloodstream, making the molecules of the drug too large to pass through the membranous blood–brain barrier. If the drug does not reach the brain, the vaccinated person will not feel the e#ects of the drug because the pleasure centers of the brain will not be stimulated. With no “reward” for taking the drug, the addicted person soon loses the craving sensations that are a part of drug addiction.
One problem is that drug vaccines do not always elicit a robust antibody response in an individual. If the antibody response is weak, only some of the drug would be bound by the vaccine, and some would remain free and able to pass to the brain. In this situation, if the drug addict took a high-enough dose of the drug, he or she could likely attain their usual “high.” Researchers are working to resolve problems such as this and also note that counseling and behavior therapy in conjunction with vaccines would likely produce the best results.16
Preventing Drug Misuse and Abuse "e U.S. government devotes much of its drug pre- vention e#orts to reducing the supply of illicit drugs. "ese e#orts include destroying crops such as mari- juana and coca plants; stopping the 'ow of illegal substances through U.S. borders; and prosecuting individuals who manufacture, sell, and purchase drugs illegally. Such measures, however, are not e#ectively reducing the demand for illicit drugs in this country. Many people think that social and eco- nomic programs to reduce poverty and unemploy- ment would decrease the demand for illicit drugs. Educational programs that promote drug-free life- styles, especially among children and young adults, may help reduce the prevalence of drug abuse.
"e National Institute on Drug Abuse conducted research for 25 years to determine which drug preven- tion programs have the highest degree of long-term e#ectiveness. "ey found that successful prevention programs: • Enhance protective factors and reverse or reduce
known risk factors • Use interactive methods such as peer discussion
groups • Target all forms of drug use • Teach skills to resist drugs when o#ered
4Ask your physician about the need to use over- the-counter medications. If it is necessary for you to take these drugs, follow the labels’ instructions concerning their safe use. Your pharmacist is also a source of reliable information concerning the safe use of OTC drugs.
4Obtain reliable information concerning the safety and effectiveness of herbal products before you take them.
Healthy Living Practices
A considerable number of patients !nish treatment but relapse within a few weeks or months of abstinence. Former addicts are more likely to relapse if they have severe mental illness or polyabuse, and if they return to communities where illicit drugs are available and widely used. Recovering drug addicts are more likely to abstain from using drugs if they are married or in stable relationships, supported by their families, and employed. In 2016, 3.9 million Americans received treatment for their drug use, including alcohol use.1
Antidrug Vaccines Many drug treatment programs use medications to help individuals break their addictions. "ese medi- cations help by suppressing drug withdrawal symp- toms, reducing drug cravings, and helping reestablish proper brain function. One new type of drug that is being developed to help in drug treatment is the anti- drug vaccine.
230 Chapter 7 Drug Use and Abuse
4If you or someone you know is abusing drugs, obtain help from local substance abuse programs or from your healthcare practitioner.
Healthy Living Practices
• Strengthen personal commitments against drug use • Increase social skills and assertiveness • Reinforce attitudes against drug use
Additionally, drug education programs that involve parents, media, and the community are more successful than programs that limit educational activities to classrooms.17
DRUG USE AND ABUSE Pregnant drug users are at risk for miscarriage, ectopic (“tubal”) pregnancy, and stillbirth (giving birth to a dead infant). Babies born to women who used cocaine, opiates, amphetamines, or marijuana regu- larly during pregnancy are more likely to be premature (born too soon) and smaller than infants who were not exposed to these drugs before birth. Compared
Across THE LIFE SPAN
to other infants, premature, underweight, and prena- tally drug-exposed newborns are more likely to have serious health problems early in life. Drug-exposed newborns also tend to have smaller than normal head circumferences, a sign that brain growth has been negatively a#ected. Pregnant women should consult their physicians before taking any drug.
Adolescents who have certain risk factors are more likely to use alcohol and other drugs than adolescents without these characteristics. Table 7.6 lists risk factors and protective factors in drug use prevention.
Protective Factors
Strong and positive family bonds
Parental monitoring of children’s activities and peers
Clear rules of conduct that are consistently enforced within the family
Involvement of parents in the lives of their children
Success in school performance
Strong bonds with institutions, such as school and religious organizations
Adoption of conventional norms about drug use
Risk Factors
Chaotic home environments, particularly in which parents abuse substances or suffer from mental illnesses
Ineffective parenting, especially with children with difficult temperaments or conduct disorders
Lack of parent–child attachments and nurturing
Inappropriately shy or aggressive behavior in the classroom
Failure in school performance
Poor social coping skills
Affiliations with peers displaying deviant behaviors
Perceptions of approval of drug-using behaviors in family, work, school, peer, and community environments
Reproduced from National Institute on Drug Abuse. (2002, February). Risk and protective factors in drug abuse prevention. NIDA Notes, 16(6). Retrieved March 21, 2011 from http://archives.drugabuse.gov/NIDA_Notes/NNVol16N6/index.html.
Risk and Protective Factors for Drug Abuse Among Youth
Table 7.6
Drug Treatment and Prevention 231
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232 Chapter 7 Drug Use and Abuse
Despite living in situations that promote substance use and abuse, many young people abstain from tak- ing psychoactive drugs. Teenagers who stay in high school, attend classes regularly, make good grades, and get along well with their parents generally avoid using drugs. "ese children have personality traits that are collectively referred to as resilience. Resil- ient children accept responsibility, adapt to change, manage stress, solve problems, and are achievement and success oriented. Resilient young people have the ability to remain psychologically, socially, and spiri- tually healthy even if their families are dysfunctional or not supportive.
The abuse of illicit drugs is not a widespread problem among older adults in the United States. However, many older adults take a variety of pre- scribed medications to treat problems such as insomnia, depression, hypertension, and heart disease. These aged individuals have a higher risk of becoming intoxicated from taking medications because their bodies do not detoxify and elimi- nate the substances as effectively as the bodies of
younger people. More research is needed to deter- mine medication levels that are safe and effective for elderly individuals.
"e risk of serious drug interactions and drug synergism is high among aged people who take more than one prescribed drug. In many instances, elderly persons appear to have su#ered a stroke, developed Alzheimer’s disease, or become severely depressed when actually their confusion and weakness are the side e#ects of taking numerous prescribed medicines in bad combinations, in incorrect amounts, or on the wrong schedule.
4Do not use drugs of any kind during pregnancy without the approval of your physician.
Healthy Living Practices
Drug Treatment and Prevention 233
Critical Thinking
The following ad promotes a book that describes how to eliminate addictive urges. Read the advertisement and evaluate it using the model for analyzing health-related information. The main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who makes health-related claims? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person making the claims?
4. What is the main point of the ad? Which information is relevant to the issue, main point,
product, or service? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this ad and the book are reliable sources of health-related information? Explain why you would or would not buy the book. Summarize your reasons for coming to this conclusion.
Health-Related InformationAnalyzing
Escape from the Personal Prison of Addiction Dr. W. S. Davis-Crocker
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Escape Personal Prison of Addiction
from the
Dr. W.S. Davis-Crocker
234 Chapter 7 Drug Use and Abuse
CHAPTER REVIEW Summary
Drugs are nonfood chemicals that alter the way a per- son thinks, feels, functions, or behaves. Many drugs have bene!cial uses as medicines, but these sub- stances can have serious negative e#ects on the health and well-being of people who use them improperly. People o$en abuse psychoactive, or mood-altering, drugs. Drug abuse contributes to numerous social problems that plague our society, such as crime, unemployment, and family violence and dissolution.
By interacting with nerve cells in the brain, psy- choactive drugs in'uence perceptions, thought processes, feelings, and behaviors. Additionally, envi- ronmental factors can a#ect how people act and feel while under the in'uence of psychoactive drugs.
In most instances, the liver converts drugs into less dangerous compounds that can be eliminated in urine, feces, or exhaled breath. When the body is unable to detoxify and eliminate excessive amounts of a drug rapidly, the characteristic signs and symp- toms of intoxication occur. Drug overdoses and poly- abuse may produce serious, even deadly, e#ects.
In 2016, an estimated 28.5 million Americans older than 12 years of age were current illicit drug users. Rates of illicit drug use are especially high among teenagers and young adults. Initially, these individuals typically use alcohol, nicotine, or inhal- ants; they then may move on to marijuana. Some per- sons experiment with or use other illicit drugs a$er marijuana. In general, illicit drug use declines a$er age 20 years.
Dependency and addiction describe any habit- ual behavior that interferes with a person’s health, work, and relationships. Drug dependence or addiction occurs when users develop a pattern of taking drugs that usually produces a compulsive need to use these substances, a tolerance for them, and withdrawal when they are discontinued. The type of substance taken, the social environment of the person, his or her personality, and genetics influence an individual’s chances of developing a drug dependency.
Depressants such as alcohol and barbiturates slow the activity of the cerebral cortex, producing seda- tive and hypnotic e#ects as well as drowsiness. "us, people should not drive or operate machinery while
under the in'uence of depressants. Misusing depres- sants can be deadly.
Stimulants enhance chemical activity in parts of the brain that in'uence emotions, sleep, attention, and learning. Ca#eine is the most commonly con- sumed legal stimulant in this country. Stimulants such as Ritalin and cocaine have few medical uses. Cocaine is addictive and frequently abused. Metham- phetamine use in U.S. college students has declined since 1999.
Opiates have important medical uses as sedatives, analgesics, and narcotics. When misused, opiates are highly addictive and extremely dangerous.
Marijuana, which contains THC as its major psy- choactive compound, is the most widely used illicit drug in the United States. Although marijuana does not produce physiologic dependence, some people become compulsive users. Marijuana smoke contains numerous irritants that can damage the bronchial tubes and lungs.
Hallucinogens alter the brain’s ability to perceive sensory information, producing abnormal and unreal sensations. In the United States, the most potent and commonly abused hallucinogens are mescaline, psi- locybin, LSD, ketamine, and PCP. High doses of PCP and ketamine can be deadly.
Many common household products release toxic fumes that can produce psychoactive e#ects when inhaled. Teenagers may use inhalants before they move on to other psychoactive drugs. Inhalants can depress respiration, resulting in coma or death.
Designer drugs are made by altering the chemi- cal structures of controlled substances. In some cases, these drug analogs are more toxic than the com- pounds from which they were derived.
"e FDA regulates the production and marketing of all medications in the United States. Some health food and OTC products contain substances that are harmful or that produce psychoactive e#ects, espe- cially when they are misused or abused.
"e primary goal of drug treatment is to help abusers become drug-free. Drug treatment usu- ally involves participation in outpatient treatment programs and self-help groups. Drug prevention programs that target school-age children typically
Summary 235
CHAPTER REVIEW provide information about drugs and teach drug resistance and refusal skills.
Drug use during pregnancy increases the risk of miscarriage, ectopic pregnancy, and stillbirth. Women who use cocaine, opiates, amphetamines, and marijuana regularly during pregnancy are more likely to give birth to premature and smaller infants than pregnant women who do not use these drugs. "e extent to which prenatal drug exposure in'u- ences the long-term mental and physical develop- ment of children is unclear.
Adolescents who are more likely to use drugs are those who have parents and friends who abuse drugs, are failing in school, have poor social coping skills, and have a lack of parent–child attachment.
Although drug abuse is rare among older adults, these individuals may experience harmful e#ects from taking prescribed medicines because they do not detoxify and eliminate drugs as e#ectively as younger individuals do or because they misuse or become confused by multiple prescriptions.
1. Why do some people abuse certain drugs, such as cocaine, and not others, such as aspirin? Application
2. "ink of a time you have misused a drug (i.e., used a drug for a reason other than its intended use). Describe your misuse of the drug and re'ect on why you engaged in this behavior. Analysis
3. Plan an educational program for !$h-grade stu- dents that discourages illicit drug use. Include at
least three main ideas you want to convey and at least three activities you will use to deliver the information. Synthesis
4. One of your friends thinks that marijuana is safe and that its use should be decriminalized. Evaluate this person’s position by considering potential health e#ects on the population, both positive and negative, if marijuana were legalized. Evaluation
Applying What You Have Learned
1. Do you use drugs responsibly? Explain why you do or do not.
2. Under what circumstances would you intervene to stop a friend from abusing drugs?
3. What are you currently doing or what would you do to encourage your children not to use illegal drugs?
4. What kinds of over-the-counter drugs do you use? Do you think that your use of these drugs is helpful or harmful to your health?
5. If you abuse drugs, do you think that your health or the health of others is adversely a#ected by your behavior? Why or why not? A$er reading this chapter and learning about the health e#ects of illegal drugs, are you motivated to stop your drug abuse? Why or why not?
Reflecting on Your Health
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
236 Chapter 7 Drug Use and Abuse
CHAPTER REVIEW
1. Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/!les /NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
2. Hanson, G., et al. (2012). Drugs and society (11th ed.). Burlington, MA: Jones & Bartlett Learning.
3. Johnston, L. D., et al. (2017). Monitoring the Future national survey results on drug use, 1975–2016: Overview, key #ndings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan.
4. Culberson, J. W., & Ziska, M. (2008). Prescription drug misuse/ abuse in the elderly. Geriatrics, 63, 22–31.
5. National Institute on Drug Abuse. (2003). Preventing drug use among children and adolescents: A research-based guide (2nd ed.). Washington, DC: U.S. Government Printing O&ce. Retrieved from http://www.nida.nih.gov/pdf/prevention/RedBook.pdf
6. Yeo, K.-K., et al. (2007). "e association of methamphetamine use and cardiomyopathy in young patients. American Journal of Medi- cine, 120, 165–171.
7. Nguyen, D., et al. (2010). Intrauterine growth of infants exposed to prenatal methamphetamine: Results from the infant develop- ment, environment, and lifestyle study. Journal of Pediatrics, 157(2), 337–339.
8. Roussotte, F., et al. (2010). Structural, metabolic, and functional brain abnormalities as a result of prenatal exposure to drugs of abuse: Evidence from neuroimaging. Neuropsychology Review, 20(4), 376–397.
9. "ompson, P. M., et al. (2004). Structural abnormalities in the brains of human subjects who use methamphetamine. Journal of Neuroscience, 24, 6028–6036.
10. Johnston, L. D., et al. (2010). Monitoring the future: National sur- vey results on drug use, 1975–2009: Vol. 1. Secondary school students (NIH Publication No. 10-7584). Bethesda, MD: National Institute on Drug Abuse. Retrieved from http://www.monitoringthefuture .org/pubs/monographs/vol1_2009.pdf
11. Schardt, D. (2008, March). Ca#eine: "e good, the bad, and the maybe. Nutrition Action Health Letter. Center for Science in the Public Interest. Retrieved from https://www.highbeam.com /doc/1G1-181072127.html
12. Drasbek, K. R., et al. (2006). Gamma-hydroxy-butyrate—A drug of abuse. Acta Neurologica Scandinavica, 114, 145–156.
13. Hall, W., & Degenhardt, L. (2009). Adverse health e#ects of non- medical cannabis use. Lancet, 374(9698), 1383–1391.
14. Centers for Disease Control and Prevention. (2008, July 25). Non- pharmaceutical fentanyl-related deaths—Multiple states, April 2005 to March 2007. Morbidity and Mortality Weekly Report, 57, 793–796.
15. National Institute on Drug Abuse. (2009). Principles of drug addic- tion treatment: A research-based guide (NIH Publication No. 09-4180). Washington, DC: National Institutes of Health, National Institute on Drug Abuse. Retrieved from http://www.nida.nih.gov /PDF/PODAT/PODAT.pdf
16. Kinsey, B. M., et al. (2009). Anti-drug vaccines to treat substance abuse. Immunology and Cell Biology, 87(4), 309–314.
17. National Institute on Drug Abuse. (2014). Lessons from prevention research. NIDA InfoFacts. Retrieved from https://www.drugabuse .gov/publications/drugfacts/lessons-prevention-research
References
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 237
Across the Life Span The Effects of Alcohol and Tobacco Use
Managing Your Health Drinking and Date-Rape Drugs: Safety Tips | Guidelines for Safer Drinking | How to Say No to Secondhand Smoke | Tips for Quitters
Consumer Health Electronic Cigarettes or E-Cigarettes
Diversity in Health Tobacco Drinking?
Chapter Overview Factors related to and consequences of alcohol
abuse and dependence
Alcohol’s effects on college students
How to manage alcohol consumption
How alcoholism is diagnosed and treated
Who uses tobacco products and why
The short- and long-term health effects of tobacco use
The benefits and process of quitting
Student Workbook Self-Assessment: Why Do You Smoke?
Changing Health Habits: Do You Want to Change a Smoking or Drinking Habit?
Do You Know? Whether electronic cigarettes are safer than regular
cigarettes?
The major reasons why college students drink?
How smoking can affect your sex life?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © ShutterWorx/iStockphoto.com.
Alcohol and Tobacco
© EyeEm
/Getty Im ages.
Learning Objectives For 34 years—from 1984 to 2018—the health warnings on cigarette packs in the United States have been small and text only.
After studying this chapter, you should be able to:
1. Describe the effects of alcohol on health. 2. Identify factors that influence alcohol consumption. 3. Distinguish between alcohol use, abuse, and
dependence. 4. Identify signs of alcohol abuse and dependence. 5. Describe programs for prevention and treatment of
alcohol abuse and dependence. 6. Identify short- and long-term effects of tobacco use
on health. 7. Discuss the impact of environmental tobacco smoke on
nonsmokers. 8. Describe programs for quitting cigarettes or tobacco use. 9. Identify benefits of quitting cigarette or tobacco use. 10. Describe the impact of alcohol and tobacco use during pregnancy.
CHAPTER 8
239
The graphic and sobering warnings shown on the following page are among those that appear on cigarette packs and advertisements in Canada, Brazil, and Malaysia. For 34 years—from 1984 to 2018—the health warnings on cigarette packs in the United States have been small and text only. A major change occurred with the passage of the Tobacco Control Act, which was signed into law on June 22, 2009. With this law, the U.S. Food and Drug Administration (FDA) became empowered to regulate the manufacture, marketing, and distribu- tion of tobacco products. "e law also stipulated that the FDA develop color graphics—photos or drawings—to accompany nine new health warnings written to educate the American public about the dangers of smoking, similar to those in other coun- tries. "e goal of the educational warnings was to reduce the rate of smoking in the United States to 12% by 2020. "e new warnings were mandated to cover at least half of the front and back of each cigarette pack and at least one-!$h of the area of an advertisement.
However, !ve tobacco companies !led a lawsuit against the federal government in August 2011. "e companies contended that these huge graphics and accompanying statements were advocating for people not to buy cigarettes, rather than simply warning them of the risks of smoking. In 2012, two separate courts ruled that the newly proposed graphic warning labels went beyond simple factual warnings and were a form of advocacy imposed by the government—and therefore violated the First Amendment. In 2014, the FDA undertook new research to address issues identi!ed by the court and postponed implementation of the graphic warning labels; however, as of 2018, no changes to warn- ing%labels have been implemented.
Other countries, however, continue to require graphic images and strong health warnings on their cigarette packages, including Australia, Brazil, Canada, Malaysia, Singapore, and "ailand. Do these warning labels work to deter people from smoking?
To !nd out, researchers from the Centers for Disease Control and Prevention (CDC) asked smokers and nonsmokers aged 18–24 years to explain their reactions to large graphic and text cigarette warnings on packs of Canadian cigarettes compared to the much smaller text-only U.S. warn- ings.1 "e results from this investigation and other studies cited by the CDC revealed that the large graphic images, along with speci!c information,
such as those on the Canadian cigarette packs, were more likely to be noticed, read, and believed than the smaller, text-only, less speci!c messages on U.S. cigarette packs. Percentages, facts, and correspond- ing graphic images had more e#ect on the thinking of young adults than did vague text-only messages such as “Quitting smoking now greatly reduces seri- ous risks to your health.” "e CDC concluded that “stronger warnings on U.S. cigarette packages that include graphic images and factual messages may help consumers make more informed decisions about using tobacco products.”
Smoking cigarettes and drinking alcohol are behav- iors that usually begin in the preteen and teen years. Although many factors in'uence young people’s deci- sion to use tobacco or alcohol, tobacco and alcohol industry ads and products o$en target young people and can persuade young people to engage in alcohol or tobacco use.2 Although tobacco companies are not allowed to advertise, market, and promote their prod- ucts to those younger than 18%years as part of the 1998 Master Settlement Agreement (MSA) between the states and the tobacco industry, they still do. Results of a study conducted by researchers at the Cancer Prevention and Control Program at the University of California San Diego Cancer Center indicated that “recent RJ Reynolds advertising may be e#ectively targeting adolescent girls.”2 "e researchers were referring to the Camel No. 9 advertising campaign, which associated the thin cigarettes with romance, glamour, and Chanel perfumes. One of the Camel No. 9 advertisements is shown in Figure 8.1.
Hanewinkel et al. studied cigarette ads versus non- cigarette ads and the e#ect of each on smoking initia- tion among adolescents and teens.3 "e data revealed an association between cigarette ads and smoking initiation in youth aged 10–17 years but revealed no association between exposure to ads in general and smoking initiation in this age group. "e research- ers explained that cigarette ads are powerful mecha- nisms that draw young persons to smoking because they contain images to which this age group aspires— images of “masculinity (for boys), thinness (for girls), independence, extroversion, and sex appeal.” "e researchers noted: Cigarette marketers have created brands with multiple aspirational images, each designed to fit the needs common among adolescents. Adolescents are in the process of identity formation, when they face emotional instability and social self-consciousness. Aspirational imagery used in cigarette advertising is especially
240 Chapter 8 Alcohol and Tobacco
smoking behavior. If you do not smoke cigarettes or drink alcoholic beverages, you probably know fam- ily members, coworkers, or friends who may bene!t from these self-assessments. Taking these tests could be their !rst steps to healthier lifestyles.
Alcohol Use, Abuse, and"Dependence
Alcohol use is quite common in the United States. According to the 2016 National Survey on Drug Use and Health, 51% of Americans older than 12 years are current alcohol users, which means that they had at least one drink in the month before they took the survey.4 "is group includes binge alcohol users and heavy alcohol users. For the purposes of the survey, binge alcohol users had !ve or more drinks on the same occasion at least once in the month before the survey. Heavy alcohol users had !ve or more drinks on the same occasion on at least !ve days in the month before the survey. (All heavy alcohol users are also binge alcohol users.) Table 8.1 lists the number of drinks consumed by light to heavier drinkers as measured in standard drinks.
Alcohol use becomes harmful use when a person drinks alcoholic beverages while knowingly dam- aging his or her health. For example, a person who drinks heavily on a regular basis (see Table 8.1), gets injured o$en while drinking, or becomes depressed from drinking is engaging in harmful use.
Alcohol abuse includes the symptoms of harmful use but adds a social dimension. When drinking, the alcohol abuser has problems interacting with people in his or her family, in social settings, or at work. Typically, the abuser uses alcohol in physically dan- gerous situations, such as when driving a car. How- ever, he or she does not develop tolerance to the drug, exhibit withdrawal symptoms when not drinking, or compulsively use alcohol. Both harmful use and alco- hol abuse are patterns of behavior, not just one-time occurrences. Both are usually considered to be pres- ent if the behavior has occurred for at least 1 month or has occurred repeatedly over a longer period of time.
appealing, because it associates the behavior, smoking, with characteristics adolescents are trying to assimilate.3
Many medical researchers and healthcare pro- fessionals think that advertising alcohol and other drug-related products such as cigarettes encourages the use of drugs in general. "e practice of promot- ing alcohol and tobacco use is particularly dangerous because they are two primary “gateway” drugs; that is, most people who abuse drugs have followed a pro- gression in drug use from alcohol and/or tobacco to marijuana and “hard” drugs.
Both tobacco and alcohol can have negative e#ects on health, with some consequences being severe. "e National Cancer Institute’s quiz “Why Do You Smoke?” will help you understand the roots of your
Figure 8.1 Camel No. 9 Cigarette Advertisement. The magazine ads attracted adolescent and teen girls with flowery images and vintage fashion. The cigarette packs were a high-style glossy black with hot pink and teal blue borders. Promotional giveaways were hot pink as well and included cell phone jewelry and tiny purses. © Walter Bibikow/Mauritius images GmbH/Alamy Stock Photo.
harmful use Drinking alcoholic beverages while knowingly damaging one’s physical and/or psychological health.
alcohol abuse Includes the symptoms of harmful use, but when drinking the abuser exhibits long- term social interaction problems and uses alcohol in physically dangerous situations.
Alcohol Use, Abuse, and Dependence 241
50 years or so, scientists have gathered evidence show- ing that alcoholism has a variety of origins, many of them biological. In addition, research results show the importance of the interactions among heredity, brain e#ects, and psychological, social, and devel- opmental factors in the development of alcoholism. Researchers are increasingly studying the roles of the interaction between genes and the environment in alcohol use and dependence.6 A cause of alcoholism is unknown.
Heredity For centuries, people have observed that alcoholism runs in families. Researchers have explored environmental and hereditary (genetic) fac- tors of alcoholics to determine which are signi!cant in the development of alcoholism.
By studying the family history of alcoholics, scien- tists determined that people who have a !rst-degree relative (parent, brother, or sister) with alcoholism have a higher risk of developing alcoholism than do people in the general population. Scientists estimate this risk to be from 4 to 7 times higher. Sons of alco- holic fathers are at greatest risk. Additionally, data from adoption, twin, and animal studies indicate that there is a genetic component to alcoholism.
Scientists also study the reactions of people at risk for developing alcoholism (those who have a
Alcohol abuse becomes alcohol dependence, or alcoholism, when certain other symptoms occur that are part of the alcohol dependence syndrome. Table 8.2 lists the symptoms of this syndrome. A diagnosis of dependence is usually made if a person exhibits three or more of these symptoms over a year’s time. Excessive alcohol use is the third leading cause of preventable death in the United States, accounting for approximately 80,000 deaths per year.5
Factors Related to Alcohol Abuse and Dependence About 100 years ago, alcoholics were thought simply to have a “weak character” or to su#er from “moral weakness.” Since that time, especially within the past
alcohol dependence (alcoholism) A syndrome characterized by at least three of the following symptoms: a compulsion to drink, difficulty in controlling the amount of alcohol consumed, withdrawal symptoms when alcohol is not consumed, evidence of tolerance, progressive neglect of other interests because of drinking, and continuing to use alcohol despite its physical and psychological effects on the user.
Having three or more of the following symptoms over a year usually indicates alcohol dependence syndrome:
• A strong desire or compulsion to drink • Difficulty in controlling the amount of alcohol
consumed and when it is consumed • Withdrawal symptoms when alcohol is not
consumed, or consuming alcohol to avoid withdrawal symptoms
• Evidence of tolerance, that is, increased amounts of alcohol are needed to achieve the effects originally produced by lower amounts
• Progressive neglect of other interests because of drinking, while spending an increased amount of time obtaining and drinking alcohol, and recovering from its effects
• Continued use of alcohol despite clear evidence of its physical and/or psychological effects on the user
Table 8.2
Alcohol Dependence Syndrome
242 Chapter 8 Alcohol and Tobacco
Drinking Level Amount
Abstainer Fewer than 12 drinks in lifetime or no drinks in a year
Light Three or fewer drinks/week
Moderate More than 3 drinks/week but no more than 7 drinks/week for women and no more the 14 drinks/week for men
Heavy or high risk
Women: More than 3 drinks on any day or more than 7 drinks/week. Men: More than 4 drinks on any day or more than 14 drinks/week
*One standard drink is 0.5 oz absolute alcohol, 12 oz beer, 5 oz wine, or 1.5 oz 80-proof liquor. (Amounts for beer and wine vary depending on their alcohol content.)
Data from U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2018). Dietary guidelines for Americans, 2015-2020 (8th ed.). Washington, DC: U.S. Government Printing Office; and National Institute on Alcohol Abuse and Alcoholism.
Table 8.1
Drinking Levels as Shown in Standard Drinks*
person, the greater the amount of alcohol that must be consumed for a speci!c BAC. BACs also rise more quickly in women than in men. One of the reasons for this occurrence is that women have proportion- ately more fat and less water in their bodies than do men. Alcohol is more soluble in water than in fat; therefore, if a woman drinks the same amount as a man, her generally smaller size and lower water con- tent result in a higher concentration of alcohol in watery body tissues such as the blood. In addition, the stomach enzyme that breaks down alcohol before it reaches the bloodstream is less active in women than it is in men.
Why do certain changes take place in the body when a person consumes alcoholic beverages? "e answer has to do with how alcohol a#ects interac- tions among nerve cells in the brain. Psychoactive drugs (including alcohol) act at communication points among nerve cells. Psychoactive drugs inter- fere with the normal activity of the chemicals that carry nerve impulses from one nerve cell to another. "e manner of this interference varies among drugs.
Alcohol acts on parts of the brain that are respon- sible for drives and emotions, as well as the part of the brain that coordinates skeletal muscle movements. It also a#ects the “thinking” part and reward centers in the brain.
Many people drink alcohol to “get drunk,” but other factors o$en contribute to excessive alcohol
!rst-degree alcoholic relative) compared to those not at risk for alcoholism. In general, those at risk do not react to the consumption of alcohol with the same intensity as those not at risk. Some scientists think that persons at risk for alcoholism may not per- ceive that they are becoming intoxicated until they have had far more to drink than those not at risk for alcoholism.
Two other genetically linked factors are thought to in'uence the development of alcoholism: behavior and temperament. Behavior is the way people act—what they do. Temperament means disposition—the char- acteristic way in which people emotionally respond to the things and people around them. Behavior and temperament are thought to be inherited traits that are modi!ed by interactions with the environment. Certain characteristics of behavior and temperament appear to be associated with enhanced risk for alco- holism: hyperactivity, impulsivity, aggression, short attention span, quickly changing emotions, slowed ability to calm oneself following stress, thrill-seeking behavior, and inability to delay grati!cation.
Brain E#ects When a person drinks an alcoholic beverage, various behavioral changes occur that are commonly called intoxication, impairment of the functioning of the central nervous system (the brain and spinal cord). Table 8.3 lists the changes that char- acteristically take place as a person consumes more and more alcohol. In this table, alcohol consumption and blood alcohol concentrations (BACs) are listed as ranges because the number of drinks as related to body weight determines the concentration of alco- hol in the blood. "at is, in general, the larger the
intoxication Impairment of the functioning of the central nervous system as a result of ingesting toxic substances such as alcohol.
Number of Standard Drinks
Blood Alcohol Concentration (BAC)* Effects
1–2 0.02–0.06% Euphoria; reduction in anxiety
3–5 0.08–0.15% Impairment of judgment, motor coordination, and emotional control; involuntary rapid eye movements; double vision; speech disorders; may be accompanied by aggressive behavior as alcohol level rises
7–8 0.20–0.25% Sedation; impairment of ability to learn and remember information
12–18 0.40–0.50% Loss of adequate respiration; dangerously low blood pressure; dangerously low internal body temperature; coma or death may result
*BAC is expressed in percentages: A BAC of 0.05% means an alcohol concentration of 5 milliliters (mL) for every 10,000 mL of blood.
Effects of Various Levels of Alcohol Consumption on Inexperienced Drinkers
Table 8.3
Alcohol Use, Abuse, and Dependence 243
whereas light drinkers tend to view the positive e#ects as sedating.
Individuals o$en consume alcohol to ease their social interactions or because it’s the thing to do in a particular social setting. With adolescents and young adults, peers may pressure one another to drink alco- hol. "e section titled “Alcohol and College Students,” which follows, explores the role of peer pressure in the drinking patterns of college students. Cultural factors are additional important social reasons for drinking alcohol. In many cultures, people consume alcohol with meals or as a part of other traditional social activities.
Abusive and alcohol-dependent drinking patterns o$en begin in adolescence. A wide variety of factors a#ect children as they mature and in'uence the devel- opment of patterns of drinking alcoholic beverages. "e biggest early risk factor for alcohol abuse and depen- dence is having a parent who is an alcoholic or who abuses alcohol. Children of alcoholics are 4–10%times more likely to become alcoholics than are children of nonalcoholics. A child reared in an alcoholic family has a greater risk of developing alcoholism than a child who is not reared in such an environment.7,8
Another way in which parents in'uence their chil- dren is by their parenting practices. Teenagers who report receiving high levels of nurturing and support from their parents also report fewer alcohol-related problems than teenagers who report little parental nurturing and support. Teenagers who report feel- ing close to their parents drink alcoholic beverages less frequently than teenagers who report that they do not feel close to their parents. Children are more likely to use alcohol if their parents are not involved in their activities, if there is a lack of, or inconsistent, discipline, and if the parents have low educational aspirations for the children. Positive family relation- ships, involvement, and attachment appear to dis- courage youths’ initiation into alcohol use.
Psychological, social, and developmental factors all interact with genetic factors to result in a certain kind of behavior. "ese interactions explain why not all alcoholics have a family history of alcoholism, and why not all persons with a family history of alcohol- ism become alcoholics. "ese dynamic interactions occur throughout life, with varying contributions from genes and environment at di#erent times.
Alcohol and College Students Alcohol abuse is a serious problem that o$en appears to begin or accelerate during the college years. In fact, the most abused drug among college
consumption. Anxious people, for example, may use alcohol to relieve their anxieties. Researchers think that persons with a family history of alcoholism are more likely to be motivated to drink alcohol to get “high,” whereas persons with no family history of alcoholism are more likely to be motivated by anxiety.
At high doses, alcohol also has e#ects that are aversive; that is, they are su&ciently unpleasant (such as nausea and vomiting) that people o$en lose their desire to drink. Severe aversive e#ects, such as unconsciousness, result in a person’s inability to con- tinue drinking. "erefore, aversive e#ects help curb excessive alcohol consumption.
Chronic drug users develop tolerance to the drug; that is, increased amounts of alcohol are required to achieve e#ects previously produced by lower amounts. Tolerance develops because the chronic use of the drug stimulates liver enzymes to break down the drug with increasing swi$ness. Also, brain cells become less responsive to the drug over time. Toler- ance develops for both the pleasant and unpleasant e#ects of alcohol consumption, so chronic drinkers do not experience the aversive e#ects as quickly as do occasional drinkers. "erefore, their alcohol con- sumption is not curbed as quickly.
Psychological, Social, and Developmental Factors People drink for reasons other than to expe- rience the “brain e#ects” of feeling good or reduc- ing anxiety. Similarly, people curb their drinking or abstain from drinking for reasons other than aversive brain e#ects that may stimulate nausea and vomiting. Many of these reasons are psychological, having to do with thoughts, feelings, attitudes, and expectations about alcohol. Some of the reasons are social, relating to interactions with friends, relatives, and coworkers. Still other reasons are developmental, relating to the psychological, social, and biological changes in indi- viduals over time and as they mature.
People o$en consume alcoholic beverages because they expect positive psychological e#ects from their drinking, such as enhancing social interactions, feel- ing pleasurable e#ects, or producing sedation. People develop their expectations concerning alcohol from experience, observation, and what they are told. In fact, a person’s beliefs about alcohol can be predictive of their future drinking habits: Heavy drinkers tend to view the positive e#ects of alcohol as arousing,
tolerance A physiologic response in chronic users of drugs in which increased amounts of the drug are required to achieve effects previously produced by lower amounts.
244 Chapter 8 Alcohol and Tobacco
Additional student characteristics correlate with alcohol abuse as well. Although any student may abuse alcohol, abusers are more likely to be younger students with low self-esteem, high levels of anxiety, a mildly assertive personality, and at least one alco- holic parent. "e freshman and sophomore years are the most likely times for students to exhibit alcohol abuse. Additionally, students who are fraternity/ sorority members and who are athletes are more likely than nonfraternity/sorority members or non- athletes to abuse alcohol.9,10
Drinking alcohol during the college years poses many risks for students, including driving a$er drinking, getting behind in schoolwork, and getting into trouble with campus or local police. In fact, many students who abstain from alcohol do so because they want to avoid such risks. Alcohol can also be a vehicle for date-rape drugs. "e Managing Your Health box “Drinking and Date-Rape Drugs: Safety Tips” pro- vides guidelines to help avoid ingesting these dan- gerous substances in alcoholic beverages. Table 8.5 lists the primary reasons some students abstain from drinking alcohol.
Binge Drinking and Drinking Games College men who belong to fraternities, especially those who live in fraternity houses, make up a large proportion of students who drink heavily. Drinking in frater- nities, as in other campus social groups, including many sororities, is perceived as promoting a feeling
students is alcohol. Most studies of alcohol use by college students examine psychological and social issues; those issues are discussed here. However, there are also economic, political, and ecological factors of college alcohol use, such as the alcohol environment on college campuses and their sur- rounding communities.
Studies show that college students drink alcohol for a variety of reasons. Table 8.4 lists the primary reasons that students give to explain why they drink. However, there are di#erences between moderate and heavy drinkers with regard to their reasons for drinking.
Moderate drinkers who do not abuse alcohol do not cite many reasons for their drinking. "ey drink to feel more comfortable in social situations or to relieve stress. "ey do not drink with any goal in mind, such as getting drunk.
Heavy drinkers who abuse alcohol, however, o$en state many reasons for their drinking, including the reasons listed in Table 8.4, but their drinking tends to be escapist and goal oriented. "ey o$en drink to get drunk. Results of studies show that college students who drink heavily believe that drinking is part of the college experience and that it is something they are entitled to do as undergraduates. College men are more likely to think this way than women. In addi- tion, college students who are heavy drinkers tend to have been drinkers in high school and have friends who drink.9
Reason Category
It makes them feel good Enhancement
They want to get drunk Enhancement
It makes them feel more comfortable in social situations Social
It helps them relax Coping
It puts them in a better mood Coping
It helps relieve tension and stress Coping
It helps them feel more accepted by their peers Conformity
Data from Doumas, D. M. (2017). Alcohol use and motives among sanctioned and nonsanctioned students. Journal of College Counseling, 20(2), 113–125; Patrick, M. E., et al. (2011). Drinking motives, protective behavioral strategies, and experienced consequences: Identifying students at risk. Addictive Behaviors, 36, 270–273. LaBrie, J. W., et al. (2007). Reasons for drinking in the college student context: The differential role and risk of the social motivator. Journal of Studies on Alcohol and Drugs, 68, 393–398.
College Students: Major Reasons for Drinking
Table 8.4
Alcohol Use, Abuse, and Dependence 245
games. Compare this table with Table 8.4 and you will see some similarities. Although some motives for playing drinking games seem speci!c to the games (e.g., competition), current research has not conclu- sively established that the motives for playing drink- ing games are separate from the general motives for%drinking.
In drinking games, participants follow rules that specify when and how much they must drink and that mandate certain verbal, physical, or memory skills. When players make mistakes or are cued by game rules, they are required to drink. "e more game players drink, the more they make mistakes, and the amount of alcohol they consume increases. "e danger of unconsciousness, coma, and death increases as alcohol consumption increases.
What can you do to help an intoxicated person avoid serious medical consequences or death? A per- son who has slurred speech, a staggering walk, double vision, and is not alert (but is able to be aroused by voice) should be stopped from drinking and taken away from the source of the alcohol. A person with signs of more severe intoxication, such as not mak- ing sense, urinating on himself or herself, breathing irregularly, vomiting repeatedly, and not being able to be aroused with a strong stimulus like a slap, should be taken to an emergency room immediately.
Alcohol-Related Injury Deaths in College Students One sobering statistic is that more than 5,000 alcohol-related deaths occur each year among those aged 18–24 years (including college and non- college individuals), which is more than the number of U.S. soldiers killed in the Iraq war. Ralph Hingson and colleagues of the National Institute on Alcohol Abuse and Alcoholism made this comparison. "e researchers also determined that among college students aged 18–24 years, approximately 1,600 are killed each year as a result of alcohol-related injuries. About three-fourths of these deaths are from alcohol- related car crashes, and one-fourth are from other alcohol-related causes, such as drownings, falls, gunshots, and alcohol/drug poisonings.13
How the Body Processes Alcohol When an alcoholic beverage is consumed, the alcohol in the drink is absorbed into the bloodstream from the stomach and intestinal tract. "e blood transports alcohol to the “detoxi!cation center” of the body— the liver. "e liver breaks down harmful substances such as drugs, changing them into compounds that are safer or easier to excrete.
of unity and cohesiveness among their members. A Harvard School of Public Health survey found that about 75% of college students who lived in% fraternities and sororities binge drank, versus about%55% of stu- dents who lived in o#-campus housing alone or with a roommate; 45% who lived% in residence halls; 30% who lived o# campus with parents; and 27% who lived o# campus with a%spouse.11
Table 8.6 shows binge drinking prevalence, fre- quency, and intensity by sex and age group. "ose aged 18–24 years, including those attending and those not attending college, had the highest overall prevalence of binge drinking at 30.0%. "at is, 1 out of every 4 people in this age group who responded to the binge drinking telephone survey reported at least one binge drinking episode during the preceding month. "e table shows that the prevalence of binge drinking decreases as age increases. Although those aged 18–24 years did not have the highest number of binge drinking episodes during the preceding month (frequency), they did have the highest average num- ber of drinks consumed by binge drinkers on any occasion during the preceding month (intensity).
Binge drinking is o$en accompanied by drinking games. "ere is a high prevalence of drinking games on college campuses, with approximately two-thirds of college students engaging in these activities.12 Table 8.7 lists speci!c motives for playing drinking
246 Chapter 8 Alcohol and Tobacco
College students report that they abstain from drinking alcohol because of:
• Disapproval/lack of interest (against religious/ moral convictions)
• Risks of negative effects (hangovers/alcoholism/ medication interactions)
• Social responsibility (might interfere with job/ family/school/relationships)
• Loss of control (negatively affects mood/effects unpleasant)
• Lack of availability (expense/hard to obtain) • Health concerns (in training/fattening/bad
for health)
Adapted from Johnson, T. J., & Chen, E. A. (2004). College students’ reasons for not drinking and not playing drinking games. Substance Use & Misuse, 39, 1139–1162.
Table 8.5
College Students: Major Reasons for Not Drinking
Managing Your Health Drinking and Date-Rape Drugs: Safety Tips • When you can, drink from tamper-proof bottles or
cans and open them yourself. • If at a bar or club, accept drinks only from the bartender
or server. Try to watch your drink being prepared. • Always keep your drink with you, even in the restroom. • If you leave your drink or lose sight of it for any reason,
discard it and get a fresh drink. • Don’t trust someone to watch your drink. Even a friend
can get distracted. • Don’t share or exchange drinks. • Don’t take a drink from a punch bowl or container that
is passed around. • Don’t drink anything that has an unusual taste or
appearance, although a date-rape drug dissolved in
alcohol may not change the taste of your drink.
• If your drink changes color, suddenly becomes “fizzy,” or appears to have something floating in it, discard it. Someone likely tried to drug you.
• Don’t mix drugs with alcohol. • Limit your drinking to one to two
drinks to remain aware and able to follow safety procedures.
• If you feel ill or lightheaded while drinking away from home, tell a friend, call a cab, and return home. If you feel extremely ill, go to an emergency room.
Adapted from Munz, M. (2000, Feb. 3). Arrest is first in Missouri involving date-rape drug. St. Louis Post-Dispatch, 122(34), A1, A-11. Data compiled from rape treatment centers.
Sex/Age Group Prevalence
No. % Frequency†
No. % Intensity§
No. No. of Drinks
Sex
Men 179,224 24.6 34,859 4.6 32,564 8.7
Women 278,331 12.5 24,694 3.2 23,365 5.7
Age group (yrs)
18–24 20,016 30 6,210 4.4 5,792 8.9
25–34 44,441 29.7 12,167 3.8 11,493 8.2
35–44 58,980 21.1 11,781 3.9 11,158 7.4
45–64 187,811 14.1 23,710 4.2 22,293 6.6
! 65 146,307 4.3 5,685 4.9 5,193 5.6
Total 457,555 22.2 59,553 4.2 55,929 7.3
*Respondents were from all 50 states and the District of Columbia. †Average number of binge drinking episodes during the preceding 30 days. §Average largest number of drinks consumed by binge drinkers on any occasion during the preceding 30 days. Reproduced from Centers for Disease Control and Prevention. Kanny, D., et al. (2013, November 22). Binge drinking—United States, 2011. Morbidity and Mortality Weekly Report, 62(03), 77-80.
Binge Drinking Prevalence, Frequency, and Intensity, by Sex and Age Group—United States*
Table 8.6
Alcohol Use, Abuse, and Dependence 247
Consequences of Alcohol Abuse and Dependence Diseases and Conditions "e harmful use and abuse of alcohol result in multiple e#ects on the body that are serious threats to health. Alcohol consump- tion does not a#ect all individuals in the same way; various e#ects result from di#erences among abus- ers’ genetic makeup, general health, and drinking patterns. Despite these di#erences, however, exces- sive alcohol consumption exerts its most serious e#ects on the liver, cardiovascular system, immune system, reproductive system, and brain. It also a#ects how vitamins are used by the body and can result in vitamin de!ciencies. In pregnant women, it has devastating e#ects on the fetus.
Diseases of the Liver Because the liver is the major detoxi!cation site for alcohol, it is particu- larly prone to harm by chronic alcohol consumption. Years of drinking can result in three types of liver disease: fatty liver, alcoholic hepatitis, and cirrhosis of the liver. "e symptoms of each may overlap, and a person can have more than one of these conditions simultaneously. Women tend to develop these condi- tions at lower levels of alcohol intake than men do (see “Factors Related to Alcohol Abuse and Depen- dence” in this chapter).
Nearly 90% of heavy drinkers develop a fatty liver because alcohol stimulates the buildup of fat in liver cells. "is process begins immediately on drinking: Fat accumulation has been found in the livers of young men a$er only one night of heavy drinking. Most liver cells are not specialized for fat storage, and their ability to perform their normal functions declines when they store fat. "ese liver cells eventually die; the scar tissue that remains produces%cirrhosis.
Approximately 15–30% of alcoholics develop liver cirrhosis (Figure 8.2). "is disease develops as alco- hol begins to kill liver cells. Liver cells have the ability to regenerate, much like skin heals from a small cut. However, if cell damage is extensive, the liver can- not produce new cells quickly enough to replace destroyed ones. Connective tissue cells !ll the spaces le$ by the dead cells, similar to the way scar tissue may !ll the gap of tissue caused by a severe cut. How- ever, connective tissue is not functional liver tissue, and the liver’s ability to perform its many important functions declines. Eventually the person must have a liver transplant or he or she will die.
Approximately 40% of chronic abusers develop alcoholic hepatitis. Hepatitis is an in'ammation of
"e liver can break down only a certain amount of alcohol per hour, no matter how much has been consumed. "at rate depends, in part, on the con- centration of enzymes that break down alcohol in the liver, and this concentration varies among indi- viduals. Nevertheless, alcohol is absorbed into the bloodstream more quickly than it can be broken down by the liver, and the excess alcohol stays in the blood. "erefore, the intake of alcohol needs to be controlled to prevent its accumulation in the% blood, resulting in an increase in the blood alcohol level.
"e stomach also breaks down some alcohol. Eat- ing food while drinking alcoholic beverages results in the alcohol being held in the stomach for a longer time with the food. "erefore, more of it gets bro- ken down in the stomach, and less alcohol enters the bloodstream. A person who drinks while eat- ing will have a slower rise in the blood alcohol level than will a person who drinks on an empty stomach. Conversely, aspirin and cimetidine (an ulcer drug) inhibit the breakdown of alcohol in the stomach. A person who takes either of these drugs along with alcohol%will have a quicker rise in the blood alcohol level than will a person who does not take these drugs when drinking alcohol.
248 Chapter 8 Alcohol and Tobacco
Competition and thrills
Conformity (to fit in)
Novelty (to try something different)
Fun and celebration
Social lubrication
Sexual manipulation (in order to have sex with someone or get a date)
Boredom
Coping (to forget about problems)
Data from Mulligan, E. J., George, A. M., & Brown, P. M. (2016). Social anxiety and drinking game participation among university students: The moderating role of drinking to cope. American Journal of Drug & Alcohol Abuse, 42(6), 726–734; Johnson, T. J., & Sheets, V. L. (2004). Measuring college students’ motives for playing drinking games. Psychology of Addictive Behaviors, 18(2), 91–99.
Table 8.7
College Students: Major Reasons for Playing Drinking Games
Health-Related InformationAnalyzing Critical Thinking
The following news release appeared on the website of the National Institute on Alcohol Abuse and Alcoholism. Read the news release and explain why you think it is a reliable or an unreliable source of information. Use the model for analyzing health information to guide your thinking; the main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person (in this case, press office) who makes health-related claims? Does this press office have the appropriate background and education in the topic area? What can you do to check the credentials of this press office?
3. What might be the motives and biases of the press office making the claims?
4. What is the main point of the article? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Summarize your reasons for coming to this conclusion.
NIH Study— Research-Based Strategies Help Reduce Underage Drinking by NIAAA Press O"ce
Strategies recommended by the Surgeon General to reduce under-age drinking have shown promise when put into practice, according to sci- entists at the National Institute on Alco- hol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. "ese approaches include nighttime restrictions on young drivers and strict license sus- pension policies, interventions focused on partnerships between college campuses and the community, and routine screen- ing by physicians to identify and counsel underage drinkers.
NIAAA researchers Ralph Hingson, Sc.D., and Aaron White, Ph.D., evaluated studies conducted since the 2007 “Call to Action to Prevent and Reduce Under- age Drinking.” A report of their !ndings appears in the January issue of the Journal of Studies on Alcohol and Drugs.
“"e downward trend in under- age drinking and alcohol-related traf- !c deaths indicates that certain policies and programs put in place at the federal, state, and local levels have had an impact,” said NIAAA Acting Director Kenneth R. Warren, Ph.D.
Since 2007, alcohol use and heavy drink- ing have shown appreciable declines in national surveys of middle and high school students. One study found that 12th-grade alcohol use declined from 66.4% to 62% in 2013, with a similar downward trend seen in eighth- and tenth-graders.
"e researchers’ analysis of recent studies on driving policies found that cer- tain driving laws a#ecting underage driv- ers deter drunk driving and reduce fatal crashes. Graduated driver licensing laws for underage drivers, which include nighttime restrictions, and use/lose laws that lead to license suspension for an alcohol violation, have been e#ective, the review said. Indi- viduals under the age of 21 are half as likely to drive a$er drinking in states with the strongest use/lose and graduated licensing laws, based on a national study.
"e Surgeon General’s Call to Action also recommended addressing college drinking by increasingly involving the surrounding community in intervention e#orts. Studies since 2007 have shown the e#ectiveness of this approach, with suc- cessful programs implemented on cam- puses in North Carolina, West Virginia, Rhode Island, California, and Washington
state. "ese programs focused on address- ing alcohol availability, alcohol pricing and marketing, and enforcement of existing laws. Many campuses saw reductions in drunk driving and other alcohol-related harms.
Since the Call to Action, progress has also been made in establishing the e#ec- tiveness of screening and brief motivational interventions. In these types of short coun- seling sessions, individuals get feedback about their drinking patterns, and coun- selors work with clients to set goals and provide ideas for helping to make a change.
While studies show that brief motiva- tional interventions can reduce alcohol consumption, only a small proportion of individuals under 21 are screened for alco- hol use and advised of the risks. Among the 62 percent of 18- to 20-year-olds who saw a doctor in the past year, only 25 % percent were asked about driving and only 12% percent were advised of health risks.
“An evaluation of the recommendations in the Call to Action reveals that certain strategies show promising results,” said !rst author Dr. Hingson, director of NIAAA’s Division of Epidemiology and Prevention Research. “While progress has been made in addressing underage drinking, the con- sequences still remain unacceptably high. We must continue research to develop new interventions and implement existing strat- egies that have been shown to be e#ective.”
Drs. Hingson and White say expanded studies of the e#ects of alcohol on the
Alcohol Use, Abuse, and Dependence 249
the liver, which can be caused by hepatitis viruses or by toxic chemicals such as alcohol. A severe case of hepatitis can result in death.
"e majority of individuals who develop cirrhosis of the liver have been drinking heavily for 10–20%years. Women, however, are more at risk than men for liver disease. Because women detoxify alcohol less e&ciently than men do, the concentration of alcohol in their blood rises more quickly than in men when both consume the same number of drinks. "erefore, serious forms of alcoholic liver disease occur more frequently in women than in men. Additionally, women are more likely than men to develop these conditions at lower levels of alco- hol consumption and a$er shorter periods of alcohol dependence. Hereditary factors and body weight, as well as sex, appear to play a role in susceptibility to liver disease. Obese alcoholics have a higher risk of having alcoholic liver disease than nonobese alcoholics, and heavy alcohol consumption increases the severity of liver disease associated with obesity.14
Cardiovascular Disease and Cancer "ere is considerable evidence that limiting alcohol con- sumption to 1 oz or less of ethanol per day (two drinks or less) decreases the risk of death from coro- nary artery disease and stroke. Heavier drinking is associated with cardiovascular diseases such as car- diomyopathy (heart muscle disease), hypertension (high blood pressure), arrhythmias (disturbances in heart rhythm), and stroke.15
Alcohol abuse is a risk factor for certain cancers. "e heavy consumption of alcohol can cause cancers of the esophagus and liver. It is also associated with the development of stomach cancer and increases the
developing brain, legal penalties for providing alcohol to minors, and parent-family alcohol interventions are among the research opportunities that could lead to further reductions in underage drinking.
Recent studies show that interventions aimed at strengthen- ing family relationships in the middle-school years can have a lasting e#ect on students’ drinking behavior, but more studies are needed to build on this !nding, say the authors.
Underage drinking is linked to 5,000 injury deaths per year, poor academic performance, potential damage to the developing brain, and risky sexual behavior.
Reproduced from National Institute on Alcohol Abuse and Alcoholism. Retrieved February 25, 2014 from http://www.niaaa.nih.gov/news -events/news-releases/nih-study-research-based-strategies-help -reduce-underage-drinking ©
Vi kt
or iia
H na
tiu k/
Sh ut
te rst
oc k.
Figure 8.2 A Healthy and Unhealthy Liver (with Cirrhosis). (a) Healthy liver tissue is smooth and dark red/brown. (b) The liver with cirrhosis develops scar tissue and nodules (bumps) as it works to repair damage. Courtesy of Leonard V. Crowley, MD, Century College.
(a)
(b)
250 Chapter 8 Alcohol and Tobacco
of alcohol rather than food. In either case, if given thiamin, the alcoholic can be cured of the abnormal eye movements, posture, and gait if he or she stops drinking. However, the person% is le$ with antero- grade amnesia—the inability to remember new information for more than a few seconds.
Another e#ect of alcohol on the brain is intoxication, the impairment of the central nervous system (see Table 8.3). Withdrawal is also a brain e#ect of alcohol, but only in alcohol-dependent individuals who stop drinking or reduce their alcohol intake. Withdrawal symptoms usually occur about 24–36% hours a$er an alcoholic stops drinking. Typically, the alcoholic experiences mild agitation, shaking, anxiety, loss of appetite, restlessness, and insomnia; 5–15% of alco- holics experience grand mal seizures (convulsions) during withdrawal. Additionally, a small percentage of alcoholics have severe withdrawal symptoms that include hyperactivity, hallucinations, disorientation, and confusion. "is severe withdrawal syndrome is called delirium tremens, or%DTs.
Some researchers suggest that a hangover is a mild form of withdrawal that can occur in anyone who consumes alcoholic beverages heavily during a ses- sion of drinking. "e signs of a hangover can include headache, mental slowness, dry mouth, fatigue, diar- rhea, anxiety, stomach pains, and tremors. If the “mild withdrawal” explanation is true, it explains why consuming additional alcohol temporarily relieves hangover e#ects.
In addition to alcohol causing hangovers, other substances in alcoholic beverages may cause hang- overs too. Alcoholic beverages contain certain acidic compounds that have toxic e#ects on the body. "ese compounds di#er among types of alcoholic beverages and a#ect whether someone will experience a hang- over. Another compound called formaldehyde (a pre- servative of dead animals) is produced by the body when it cannot keep up with the breakdown of alcohol being consumed. "e buildup of formaldehyde con- tributes to a hangover. Alcohol causes the body to lose water. "is dehydration occurs in brain cells as well as other body cells. Pain accompanies their rehydration.
Whatever the causes of a hangover, home remedies such as taking vitamins, getting in a cold shower, or drinking co#ee will not cure the “morning a$er” pain of drinking too much. Time alone will cure a hangover.
E#ects on Behavior and Safety Serious and Fatal Injuries Statistics show that
alcohol use and abuse are related to serious and even fatal injuries. Alcohol frequently contributes to water-related accidents, motor vehicle accidents,
likelihood of larynx and mouth cancer. People who smoke cigarettes and drink alcohol, even in moderate amounts, multiply their risk of cancer of the esopha- gus because together these drugs have a multiplier e#ect. "at is, when people take both drugs routinely, their risk of cancer is much higher than if the risk of each was added.16
Even when not abused, alcohol can raise the risk of cancer. Consuming three-quarters to one drink per day raises a woman’s risk of developing breast cancer by 9%. "e risk increases as consumption increases. Consum- ing two to three drinks per day raises breast cancer risk by 43%. Data also suggest that women who drink alco- hol while taking estrogen in postmenopausal estrogen replacement therapy may increase their breast cancer risk more than if they used either one alone.17,18
Immune System Suppression "e immune system, which protects the body from invasion by pathogens, also su#ers as a result of chronic alcohol abuse. "is behavior impairs the functioning of the immune sys- tem, predisposing the drinker to infectious diseases such as colds, pneumonia, and tuberculosis. Chronic alcohol abuse even suppresses the activity of certain immune system cells that defend the body against the spread of cancer.
Detrimental E#ects on the Reproductive System Alcohol a#ects the reproductive systems of both men and women. It a#ects the functioning of the testes, decreasing the amount of the sex hormone, testosterone, that these organs produce. Alcoholic men o$en experi- ence shrinking of the testicles, impotence, and loss of libido, or sex drive. In women, alcohol a#ects the func- tioning of the ovaries. "e menstrual periods of alco- holic women are o$en irregular or cease altogether. As a result, alcoholic women o$en have di&culty becom- ing pregnant. Alcoholic women also have a higher rate of early menopause than nonalcoholic women. During pregnancy, alcohol consumption can have devastating e#ects on the fetus. "is topic is discussed in the Across the Life Span section of this chapter.
Detrimental E#ects on the Brain Alcohol con- sumption has multiple e#ects on the brain. Chronic alcoholics may experience brain disorders. One of the most serious is the Wernicke-Korsako# syndrome. "is syndrome includes mental confusion, abnor- mal eye movements, and an inability to coordinate skeletal muscles, which results in abnormal posture and a staggering walk. Scientists have discovered that this syndrome may be the result of the alcoholic’s inability to use the B vitamin thiamin properly. Some alcoholics are de!cient in this vitamin (and many other nutrients) because their diets consist primarily
Alcohol Use, Abuse, and Dependence 251
hours, especially on weekends, is more likely to be involved in a fatal alcohol-related motor vehicle acci- dent than when driving during the day and during the week. Using the subway system in safe areas, walking in safe areas away from the street, and staying at home during these peak alcohol-related tra&c fatality times are strategies to consider to help lower your risk of being involved in an alcohol-related car crash.
Alcohol-impaired driving fatalities declined over the 10-year period from 2005 (13,582 fatalities) to 2014 (9,967 fatalities). "e drivers with the highest percentage of intoxication in fatal crashes (0.08% BAC or higher) were young adults aged 21–24 years (32% of this group), followed closely by those aged 25–34 years (30%) and 35–44 years (24%).19
For safety, women who drink and drive must remem- ber that their BACs rise more quickly than the BACs of males who consume the same number of drinks. Both sexes must also remember that the risk of fatal crashes rises rapidly with increasing BAC. As Figure 8.5 shows, compared to persons with no alcohol in their blood, drivers with BACs between 0.050% and 0.079% have a 5-fold increased risk of having a fatal car crash, whereas males aged 16–20 years have a 10-fold increased risk% at this same BAC level. Male and female drivers aged%21–34 years with BAC levels between 0.80% and 0.99% (legally drunk) have a 13-fold increased risk, and those aged 35 years and older have a 6-fold risk. How- ever, while%driving at this BAC level, young men aged 16–20 years have a 24-fold risk of being killed in a car crash, and that increases to an 83-fold risk at a BAC level of 0.100–0.149%. At the same BAC level, others have about an 11- to 13-fold increased risk of killing themselves in a car crash. Not shown in Figure 8.5 is the fact that young men aged 16–20 years have a more than a 2,000-fold increase risk of being killed while driving with a BAC level of 0.150% and over. Others have an 84- to 88-fold increased risk.
Airplane Accidents Alcohol also impairs the ability of pilots to 'y aircra$. Alcohol has not been directly implicated in U.S. commercial airline crashes; however, it appears to play a more prominent role in general aviation crashes. Alcohol has been shown to impair 'ight performance in pilots when they drink, and up to 8 hours a$er drinking.21 Can!eld and colleagues from the Federal Aviation Administration Aerospace Medi- cal Institute found that 92 pilots (7%) out of the 1,353 pilots killed in the aviation accidents they studied had alcohol in their blood at the time of the crash.22
Water-Related Accidents Alcohol is also a sig- ni!cant factor in water-related accidents. Researchers estimate that alcohol consumption is associated with
general aviation crashes, domestic and nondomestic violence, including sexual assault and rape, suicides, and homicides.
Data show that 31% of all fatal motor vehicle crashes in 2014 were alcohol related.19 Other types of injury fatalities are also more likely for current drinkers as compared to abstainers and prior drinkers, including unintentional falls, !res, drownings, and poisonings. Current drinkers are also more likely to commit sui- cide or to be intentionally killed by another person.
Automobile Accidents Drinking and driving is potentially deadly because alcohol impairs the perceptual, intellectual, and motor skills needed to operate motor vehicles safely. Tra&c accidents are%the leading cause of death among people aged 5–24%years, the second leading cause of death% a$er% other unintentional injuries in children aged 1–4 years, and the !$h leading cause of death a$er cancer, heart disease, other unintentional injuries, and suicide in adults aged 25–44 years.20 In all states, the District of Columbia, and Puerto Rico, the legal BAC limit for operating an automobile is 0.08%. It is a criminal o#ense to operate a motor vehicle at or above that limit. All states have a lower unlawful BAC threshold for youth younger than 21 years of age and, in some cases, younger than 18 years of age. Figure 8.3 shows approximate BAC by body weight and the time from the !rst drink. Note the number of drinks a person can have over a period of time before he or she is con- sidered legally drunk. Also realize that some impair- ment occurs a$er a person consumes only one drink.
Alcohol-related fatal automobile accidents occur more frequently at certain times of the day and during certain days of the week than others. For example, in 2011, the rate of alcohol-related driving fatalities was 4.5 times higher at night than during the day. Furthermore, 41% of 2011 alcohol-related fatalities occurred on weekend nights in compari- son to 7% on weekend days. "e National Highway Transportation Safety Administration (NHTSA) noted that a BAC of 0.08% g/dL or higher indicates alcohol-impaired driving.19
Figure 8.4 shows that the percentage of tra&c fatalities resulting from alcohol-related crashes peaks between 6 P.M. and 5:59 A.M. A comparatively low percentage of tra&c fatalities are alcohol related between 6 A.M. and 3 P.M., but the percentage rises throughout the late a$ernoon and evening until the midnight-to-3 A.M. peak. A signi!cant percentage occurs from 3 A.M. to 6 A.M. as well. "e statistics in the previous paragraph, together with these, show that a person driving at night and in the early morning
252 Chapter 8 Alcohol and Tobacco
o$en target younger children to educate them about alcohol before they reach their teenage years. Preven- tion e#orts include school-based programs for chil- dren in grades 5–10, but most target !$h and sixth graders. Because this time is developmentally critical as students move from elementary school to middle school or junior high, those who have experimented with alcohol may begin to misuse it at this time.
"ere are a variety of school-based programs. A!ective education seeks to in'uence students’ beliefs about alcohol by helping them develop problem- solving and refusal skills as well as decision- making
between 30% and 70% of adult drownings.23,24 "e highest percentages are associated with males older than 25 years. Most alcohol-related drownings are asso- ciated with motor vehicle accidents, but alcohol is also present in the blood of more than half the drowning victims who were swimming, boating, or ra$ing when they died. Alcohol also contributes to diving accidents that leave victims with serious spinal cord injuries.
Prevention Because many people begin drinking alcoholic bev- erages during adolescence, prevention programs
Figure 8.3 Blood Alcohol Concentration (BAC) by Weight and Gender. These graphs show the approximate BACs of men and women in various weight ranges. All states have set 0.08% as the legal BAC limit while driving for those 21 years of age and older. All states have lower thresholds for those younger than 21 years of age. However, you may be convicted of driving under the influence (DUI) of alcohol if evidence exists that your driving is impaired. Commercial drivers may be convicted of a DUI at a BAC of 0.04%. Reproduced from “Alcohol Impairment Chart” from “Blood Alcohol Concentration by Weight and Gender.” University of Wisconsin Center for Health Sciences, 1988, and U.S. Dept. of Transportation, National Highway Tra%c Safety Administration, 1992. Formulation and compilation by the Pennsylvania Liquor Control Board, Bureau of Alcohol Education. Used by permission.
0 1 2 3 4 5 6 7 8 9
10
100 .00 .05 .09 .14 .18 .23 .27 .32 .36 .41 .45
120 .00 .04 .08 .11 .15 .19 .23 .27 .30 .34 .38
140 00 .03 .07 .10 .13 .16 .19 .23 .26 .29 .32
Your body can get rid of one drink per hour. Each 1.5 oz. of 80 proof liquor, 12 oz. of beer or 5 oz. of table wine = 1 drink.
160 00 .03 .06 .09 .11 .14 .17 .20 .23 .26 .28
180 00 .03 .05 .08 .10 .13 .15 .18 .20 .23 .25
200 .00 .02 .05 .07 .09 .11 .14 .16 .18 .20 .23
220 00 .02 .04 .06 .08 .10 .12 .14 .17 .19 .21
240 .00 ONLY SAFEDRIVING LIMIT
Impairment Begins
Driving Skills Affected
Possible Criminal Penalties
.02
.04
.06
.08
.09
.11
.13
.15
.17
.19
ALCOHOL IMPAIRMENT CHART
N E
V E
R D
R IN
K A
N D
D R
IV E
APPROXIMATE BLOOD ALCOHOL PERCENTAGE Body Weight in PoundsDrinks
Legally Intoxicated
Criminal Penalties
Your body can get rid of one drink per hour. Each 1.5 oz. of 80 proof liquor, 12 oz. of beer or 5 oz. of table wine = 1 drink.
ONLY SAFE DRIVING LIMIT
Impairment Begins
Driving Skills Affected
Possible Criminal Penalties
ALCOHOL IMPAIRMENT CHART
N E
V E
R D
R IN
K A
N D
D R
IV E
APPROXIMATE BLOOD ALCOHOL PERCENTAGE Body Weight in PoundsDrinks
Legally Intoxicated
Criminal Penalties
0 1 2 3 4 5 6 7 8 9
10
140 .00 .03 .05 .08 .11 .13 .16 .19 .21 .24 .27
160 .00 .02 .05 .07 .09 .12 .14 .16 .19 .21 .23
180 00 .02 .04 .06 .08 .11 .13 .15 .18 .20 .21
200 00 .02 .04 .06 .08 .09 .11 .13 .17 .19 .19
220 00 .02 .03 .05 .07 .09 .10 .12 .15 .17 .17
240 .00 .02 .03 .05 .06 .08 .09 .11 .13 .16 .16
260 00 .01 .02 .04 .06 .08 .09 .11 .13 .15 .16
280 .00 .01 .02 .04 .05 .07 .09 .10 .12 .14 .15
THIS CHART IS INTENDED FOR INDIVIDUALS 21 YEARS OF AGE OR OLDER.
IT IS A GUIDE, NOT A GUARANTEE. Alcohol can affect each person in a different way. The way your body reacts to alcohol depends on your gender, how much you weigh, how quickly you drink, and whether or not you have eaten. You also need to remember that drinks may contain different amounts of alcohol.
This chart uses 1.5 oz of 80 proof liquor, 12 oz of beer, or 5 oz of table wine as one drink.
Females reach a higher BAC level faster than males. A woman should use the female version on the chart that is highlighted in pink on the other side.
Pennsylvania has set .08% BAC as the legal limit for a Driving Under the Influence (DUI) conviction. You may be convicted of DUI at .05 % and abov e if there is supporting evidence of driving impairment. Commercial drivers can be convicted of DUI nationwide with a BAC level of .04%. A BAC reading is not necessary for an individual to be convicted of DUI. You may be convicted of DUI if there is circumstantial evidence that you imbibed a sufficient amount of alcohol such that you are incapable of safe driving.
The Zero Tolerance Law (Section 3802(e) of the PA Vehicle Code, Title 75) lowered the Blood Alcohol Content (BAC) for minors (persons under 21) to .02%.
REMEMBER: • A person must be 21 years of age or older to legally purchase, attempt to purchase, possess, consume, or transport any alcohol, liquor, malt or brewed beverages.
• Impairment begins with the first drink - the only safe driving limit is .00%.
• For safety’s sake, never drive after drinking! [Source: Refer to www.lcb.state.pa.us]
REFERENCES: http://www.wikihow.com/Calculate-Blood-Alcohol-Content-(Widmark-Formula)
http://www.alcohol.vt.edu/Students/alcoholEffects/estimatingBAC/index.htm http://www.ehow.com/how_7315381_calculate-estimated-blood-alcohol-content.html
http://www.ctduiattorney.com/dui_information/calculating_bac.html
LCB-79 09/13Reorder Item #0079
Alcohol Use, Abuse, and Dependence 253
in adolescent alcohol education. Current normative programs include teaching students how to resist peer in'uence and o$en incorporate activities and events outside the classroom.
Prevention e#orts that focus on the entire popula- tion of drinkers are called environmental approaches. Such approaches are important because the major- ity of Americans aged 12 years or older consume alcohol, and many drinkers experience moderate to severe alcohol-induced impairment at least occasion- ally. "ese drinkers are all at risk for alcohol-related injuries and health problems.
Beginning in 1989, one prevention strategy for the general population was the requirement by the U.S. government to place warnings on alcoholic beverage containers; however, survey data show that only about one-fourth of adults realize that the labels exist. Researchers have not found evidence that warning labels reduce alcohol consumption. Another
abilities. In addition, these programs promote an understanding of how alcohol use can interfere with personal values and goals. Results of research show that such programs have limited e#ectiveness. Life skills programs emphasize the development of com- munication, con'ict resolution, and assertiveness skills to help students cope with peer pressure to drink alcohol, smoke cigarettes, or take other drugs. Results of research show that life skills programs reduce alcohol use primarily among females. Resistance training—the “Just say no” approach— shows mixed results. Normative education aims to correct erroneous beliefs about the prevalence and acceptability of alcohol use among peers. (Results of survey research show that young people believe that alcohol use among their peers is more common than it really is.) Adding normative components to alcohol education programs for adolescents appears useful. In fact, normative education is a recent trend
Figure 8.4 Percentage of Traffic Fatalities Resulting from Alcohol-Related Crashes, by Time of Day. National Center for Statistics and Analysis. (2015, December). Alcohol-impaired driving: 2014 data. (Tra%c Safety Facts. DOT HS 812 231). Washington, DC: National Highway Safety Administration. Retrieved from https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812231
Time of Day
6 A.M. to 5:59 P.M. 6 P.M. to 5:59 A.M. 0
10
20
30
40
50
P er
ce n
t A lc
o h
o l-
R el
at ed
Multiple vehicle Single vehicle
6%
18%
23%
45% Crash Type
Figure 8.5 Fatality Risk at Various Levels of Blood Alcohol Concentration by Age and Sex. This graph shows that as the BAC rises, the likelihood of being killed while driving a car increases. The risk rises dramatically for males aged 16–20 years, well beyond that for females or for older males. Reproduced from Voas, R. B., et al. (2012). Alcohol-related risk of driver fatalities: An update using 2007 data. Journal of Studies on Alcohol and Drugs, 73(3), 341–350; permission conveyed through Copyright Clearance Center, Inc.
BAC
R el
at iv
e R
is k
0
10
20
30
40
50
60
70
80
90
.00 .01 .02 .03 .04 .05 .06 .07 .08 .09 .10
16–20, Female, 1996–7 16–20, Male, 1996–7 21–34, 1996–7 35+, 1996–7 16–20, 2006–7 21–34, 2006–7 35+, 2006–7
254 Chapter 8 Alcohol and Tobacco
“Guidelines for Safer Drinking” and are e#ective rules for controlling alcohol consumption.
Diagnosis and Treatment of Alcoholism and Alcohol Abuse According to the 2016 National Survey on Drug Use and Health, approximately 2 million Americans aged 12%and older received treatment for alcohol abuse during the year before the survey.4 Various types of treatments are available for those who need help. Screening tech- niques help identify those persons who need treatment.
"e cut-down, annoyed, guilty, and eye-opener (CAGE) screening test is considered one of the most e#ective screening devices for alcohol abuse or alco- holism. A variety of other screening instruments are available also.
Healthcare professionals who determine that their patients are alcohol dependent refer them to sub- stance abuse specialists for evaluation and possible treatment. Patients who show nondependent prob- lem drinking are o$en encouraged to participate in brief intervention programs.
In the past, physicians and substance abuse practi- tioners thought that an alcoholic could not be helped until he or she “hit bottom” and then asked for help. A person who did not ask for help was considered to be denying his or her alcoholism and lacking motiva- tion to change. Current thinking regards motivation as a process of behavioral change rather than a trait that people have or do not have.
prevention strategy was the establishment of 21 as the minimum age for purchase and consumption of alco- hol. Evidence shows that this strategy signi!cantly reduced youth drinking and related problems such as alcohol-related tra&c accidents in those younger than age 21 years.25
In 2007, in response to the !nding that alcohol was the number one abused substance by America’s youth, the acting Surgeon General of the United States, Kenneth P. Moritsugu, issued "e Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking.26 "is report noted that parents of adoles- cents do not recognize how widespread alcohol use is in this population and how the brains of adolescents are particularly susceptible to the negative e#ects of alcohol use. Noting that alcohol use by America’s youth is in'uenced by many factors, the report develops six goals, including fostering changes in society that facilitate healthy adolescent development, engaging not only adolescents but also the social sys- tems that interact with adolescents in a coordinated e#ort to prevent and reduce underage drinking, and conducting additional research on adolescent alcohol use and its relationship to development.
How to Manage Alcohol Consumption Studies show that light drinkers have certain behav- ior patterns that help them curb their drinking. "ese attributes are listed in the Managing Your Health box
v Managing Your Health
1. If you choose to drink, plan ways to drink that promote safety behind the wheel and safety for health. Considering some of the following points should help.
2. Eat before you drink and while you are drinking. 3. Drink alcoholic beverages slowly. Consider water-
ing down your drinks or alternating alcoholic drinks with nonalcoholic drinks.
4. For safety behind the wheel, set a limit on the amount of alcohol you can drink per hour. Use the chart in Figure 8.3 to determine how many drinks you can have per hour and still maintain a BAC of 0.05% or below. If you are a 120-pound woman, for example, you can have only one drink per hour to
stay below a BAC of 0.05%. Count drinks to stay within your limit.
5. For health safety, men should con- sume no more than 2 drinks per day/14 drinks per week, and women should consume no more than 1 drink per day/7 drinks per week.
6. Refuse drinks you do not want and that do not fit within your plan.
7. Cultivate alternatives to drinking to help you relax, such as meditating.
8. Learn to socialize without drinking. For example, use fun venues or fun foods as a social lubricant instead of alcohol.
Guidelines for Safer Drinking
Alcohol Use, Abuse, and Dependence 255
Before treatment, the role of clinical intervention is to help the patient understand the serious dangers inherent in his or her abusive or dependent drink- ing behavior. Once the alcoholic realizes the need to change his or her behavior, he or she tries to decide what course of action to take. "e clinician helps the patient select a course of action or treatment pro- gram that best suits his or her needs.
Both inpatient and outpatient programs exist. Inpatient treatment, in which the alcoholic resides at a treatment facility, is sometimes used for the early phases of treatment, particularly acute detoxi- !cation. During this time, the patient abstains from alcohol and experiences withdrawal symptoms (see “Detrimental E#ects on the Brain” in this chapter). Approximately 10–13% of patients need medication during this time to help them reduce potentially life- threatening e#ects of withdrawal. During the detoxi- !cation period, patients participate in group therapy and alcohol education sessions for several hours daily. Recovering alcoholics usually live with patients to help them through the process. Such programs usually last 28 days. Near the end of this process, the alcoholic’s family is usually asked to participate in treatment.
Because of rising medical costs, acute detoxi!ca- tion, as well as further treatment, may take place in outpatient programs. Such programs, developed over the past 25 years, have been extremely successful.
Approximately 90% of patients are now treated in outpatient facilities. In these programs, the patient spends a speci!c amount of time at the treatment facility but lives at home.
A$er a person has sought treatment for alcohol abuse or dependence, the next stage in behavior change is maintenance. For long-term maintenance treatment, recovering alcoholics take part in group meetings and attend individual counseling sessions once or twice a week at outpatient facilities, participate in self-help group meetings, and sometimes participate in family therapy. "e maintenance period usually lasts 1 year.
Sometimes relapse occurs. During a relapse, a recovering alcoholic returns to his or her drinking habits. Relapse can be triggered by a variety of factors such as stress, depression, alcohol craving, negative life events, and interpersonal tensions. To recover once again, the patient goes through the stages of behavior change. Treatment to prevent an initial or repeated relapse o$en involves self-help groups.
Alcoholics Anonymous (AA) is the best known and most widely available of the self-help groups. Governed by its members, the organiza- tion’s philosophy is that alcoholism is a physical, emotional, and spiritual disease for which there is no cure. Recovery is a lifelong process that involves attention to AA’s Twelve Steps, which are listed in Table" 8.8. AA also has related support groups for
256 Chapter 8 Alcohol and Tobacco
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
Reproduced from “The Twelve Steps” with permission of Alcoholics Anonymous World Services, Inc. (“AAWS”) Permission to reprint the Twelve Steps does not mean that AAWS has reviewed or approved the contents of this publication, or that AAWS necessarily agrees with the views expressed herein. A.A. is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities which are patterned after A.A., but which address other problems, or in any other non-A.A. context, does not imply otherwise.
Table 8.8
The Twelve Steps of Alcoholics Anonymous
40
30
20
10
0
P er
ce n
t U
si n
g in
P as
t M
o n
th
0.4 2.2
7.4
18.7
26.3 27.5 27.4
25.4
20.8 21.3 23.1 22.2
17.5
12 –1
3
14 –1
5
16 –1
7
18 –2
0
21 –2
5
26 –2
9
30 –3
4
35 –3
9
40 –4
4
45 –4
9
50 –5
4
55 –5
9
60 –6
4 65
+
10.1
Age in Years
Figure 8.6 Past-Month Cigarette Use Among Persons Aged 12 Years or Older, by Age. This graph shows that persons aged 36–64 years have the highest prevalence of current smoking. In general, smoking prevalence is greatest during young- and middle-adult years and gradually declines among older adults. Reproduced from Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. Retrieved from https://www.samhsa .gov/data/sites/default/!les/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
family members and friends of alcoholics, such as Alateen and Al-Anon.
Although not as well known, other self-help groups exist. "e Secular Organization for Sobriety (SOS) is a group similar to AA, except its program does not include spiritual aspects. "e Rational Recovery (RR) program is also a secular organization and emphasizes the importance of alcoholics becom- ing aware of their irrational beliefs, self- perceptions, and expectancies to be successful in changing their behavior. "ese groups suggest abstinence as a pre- ferred drinking goal but emphasize personal choice. One self-help approach for women is Women for Sobriety. "is group emphasizes women’s issues such as assertiveness, self-con!dence, and autonomy as part of the change process.
Tobacco Cigarettes are the most prevalent tobacco product in the United States, with approximately 65 million, or 20%, of Americans aged 12 years or older reporting cigarette use in the past month.4
Smoking rates increase with age to the early 20s, and then generally decline with age. Recent data indicate that approximately 3.5% of youths aged 12–17%years are current cigarette smokers, 23.5% of young adults aged 18–25 years are current smokers, and between 25% and 27% of those aged 26–34 years are current smokers. "e smoking rate of Americans 40 years of age and older is approximately 20%.4 Figure 8.6 shows the proportion of current smok- ers in each age group, with the younger and older groups broken down in more detail.
"e prevalence of smoking is high in college stu- dents. In 1991, 35.6% of college students smoked at least once during the past year. "is percentage rose throughout the 1990s, to a peak of 44.5% in 1999. "e current use prevalence rate has fallen by 87%, 84%, and 71% in grades 8, 10, and 12, respectively, since reaching peak levels in the mid-1990s.27
"e prevalence of smoking in high school students is lower than in college students; however, 'avored smoking products have remained popular among high school students, so much so that University of Michigan Monitoring the Future researchers, who
Tobacco 257
Worldwide, a variety of other tobacco prod- ucts exist besides those mentioned here. Addition- ally, methods of tobacco use vary among cultures. "e Diversity in Health essay “Tobacco Drinking?” describes a few tobacco-related practices of various South American cultures.
Who Uses Tobacco and Why? As mentioned earlier, most people who smoke ciga- rettes began this habit when they were adolescents, primarily in high school. Figure 8.7 shows the ages at%which adults say they started smoking. Only 11% of adult smokers started this habit a$er age 18. Smokeless tobacco use also usually begins in early adolescence or in childhood.
Data show that during the early 1990s through 1996–1997, there was an increase in the percentage%of high school students who smoked cigarettes daily, a$er a decrease had been seen in the prevalence of smoking by high school seniors from 1976 through 1992. However, those percentages have declined steadily through 2011 (Figure 8.8). Nevertheless, in the national Youth Risk Behavior Survey in 2015, 11% of high school students responded that they were current cigarette smokers.28
Psychosocial Reasons for Using Tobacco Products Adolescents initially try tobacco products for a variety of reasons. Adolescents who have family members or friends who smoke cigarettes or use
track drug, alcohol, and tobacco use among the nation’s youth, added a question about kreteks and bidis in 2001. "e use of kreteks (clove cigarettes) and bidis (small, strong 'avored cigarettes), once popular among adolescents, has declined since the enactment of the Family Smoking Prevention and Tobacco Control Act in 2009, which prevents the sale of 'avored cigarettes in the United States.27 Smoking cigars and pipes is not as popular in the American population as smoking cigarettes is; however, males are more likely to smoke cigars and pipes than are%females.4
Smokeless tobacco, which includes snu! and chew- ing tobacco, also is not very popular in the American population. Snu#, the most popular form of smoke- less tobacco, is powdered or !nely cut tobacco. It may be used loose or wrapped in a paper pouch. Although snu# can be inhaled, most users in the United States today place snu# between the cheek and gum. "is practice is called dipping.
Chewing tobacco is loose-leaf tobacco or a plug of compressed tobacco, which is sometimes called a quid. It is placed in the cheek. It can be chewed, as its name suggests, or, more o$en, it is sucked. During the time that snu# or chewing tobacco remains in the mouth, it forms a liquid that smokeless tobacco users usually spit out. For this reason, smokeless tobacco is o$en called spit- ting tobacco. Males are more likely to chew tobacco than females,% and less than 10% of the population engages in this behavior.4
27% By age 18: 89%
Cumulative percentage
By age 14: 37%
By age 12: 16%
After age 18: 11%
By age 16: 62%
11% 16%
21%
25%
Figure 8.7 Age at Which Adults Say They Started Smoking. Most smokers started this habit when they were in their teens or preteens. Data from Substance Abuse and Mental Health Services Administration. O%ce on Smoking and Health, Centers for Disease Control and Prevention.
258 Chapter 8 Alcohol and Tobacco
because they are addicted to nicotine. Nicotine is a psychoactive drug that acts at communication points among nerve cells in the brain, as do other psychoac- tive drugs. It becomes addicting during the !rst few years of use.
"e many reasons that people say they continue to smoke (other than craving or being addicted to ciga- rettes) include the following:
• It is arousing and gives them energy. • It helps concentration. • It li$s the mood. • It reduces anger, tension, depression, and stress. • It is a habit. • It is a pleasurable activity.
However, some of the pleasure of smoking (as well as using smokeless tobacco) is really the relief of the symptoms of nicotine withdrawal. During the day,
smokeless tobacco are more likely to begin these hab- its than teenagers who do not observe these%behav- iors in people close to them. Many adolescents try smoking, chewing, or dipping simply to experiment. Others use tobacco as a way to feel older and more independent, as a response to advertising, or as a response to social pressure.
Certain characteristics are associated with increased tobacco use among adolescents, includ- ing susceptibility to peer pressure, a sensation- seeking%nature, a rebellious personality, depression or anxiety, low academic achievement, and a low level of knowledge about the immediate health risks of smoking. Additionally, adolescents who think that their parents do not care about them or adolescents who are alone much of the time are more likely to try smoking. Girls are signi!cantly less likely to begin smoking if they are involved in an organized sport; however, participation in sports is not associated with decreased smoking among boys.
Nicotine Addiction Why do teenagers and adults continue smoking and using smokeless tobacco? Most people continue
nicotine An addictive psychoactive drug found in tobacco.
60 8th Grade
10th Grade
12th Grade50
40
20
30
10
0 ’76 ’78 ’80 ’82 ’84 ’88’86 ’90 ’92 ’94 ’96 ’98 ’00 ’02 ’04 ’06 ’08 ’10 ’12 ’14 ’16
P er
ce n
t
Year
Cigarettes (30-Day)
Figure 8.8 Cigarettes: Trends in Daily Use by Eighth, Tenth, and Twelfth Graders. Reproduced from Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenber, J. E. (2017). Monitoring the Future national survey results on drug use, 1975-2016: Overview, key !ndings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michgan.
Tobacco 259
with the development of lung cancer and other diseases. Since that famous report, scientists have learned a great deal about the health consequences of smoking and smokeless tobacco use, and the Surgeon General’s O&ce has issued 30 more tobacco-related reports. In these reports, cigarette smoking is recognized as the leading source of preventable illness and death in the United States. Every year, approximately 500,000 people die in the United States as a result of using tobacco prod- ucts.29 Figure 8.9 shows the cancers and chronic diseases to which smoking has a causal link.
Immediate Effects of Nicotine and Carbon Monoxide After entering the body, nicotine pro- duces a variety of effects. It increases the heart rate and the amount of blood that the heart pumps in a single beat. However, nicotine also constricts, or narrows, the blood vessels. As a result, the blood pressure rises. Nicotine also increases the meta- bolic rate—the speed at which all the chemical reactions of the body take place. These effects increase the body’s demand for oxygen. However,
as a person smokes, he or she builds up tolerance to nicotine. Nicotine withdrawal symptoms become more pronounced between each successive cigarette. To relieve these symptoms (Table 8.9), most cigarette addicts smoke more as the day goes on. Overnight, the level of nicotine in the blood drops and toler- ance decreases; thus, the smoker is resensitized to the e#ects of nicotine. "e !rst cigarette of the day is usually quite satisfying to the smoker as the cycle of tolerance and then resensitization begins once again.
The Health Effects of Tobacco Use In 1964, U.S. Surgeon General Luther Terry issued a landmark report that linked cigarette smoking
4Responsible drinking includes limiting consumption to reduce negative impacts on your health, while not endangering the safety of others or interfering with business or personal relationships.
4If drinking alcohol is damaging your physical and/or psychological health, you should seek medical help.
4If you use alcohol in physically dangerous situations, have developed a tolerance to alcohol, exhibit withdrawal symptoms when you are not drinking, and compulsively use alcohol, you are probably alcohol dependent and should seek medical help.
4Be sure to eat while drinking alcoholic beverages so that less alcohol will enter the bloodstream.
4If you consume alcohol and are male, drink only 1 oz of ethanol per day (two drinks) or less to decrease the risk of coronary artery disease and stroke. The safest alcohol consumption level for women is 0.5 oz of ethanol per day (one drink). Heavier alcohol consumption is associated with a variety of conditions and diseases.
4Do not drive after consuming alcoholic beverages. Alcohol impairs many of the skills needed to operate motor vehicles safely. As your blood alcohol concentration increases, your risk of having a car crash increases significantly.
Healthy Living Practices
260 Chapter 8 Alcohol and Tobacco
Anxiety/tension Heart palpitations
Cough/dry mouth/nasal drip
Impatience
Craving cigarettes Insomnia
Depression Irritability
Difficulty concentrating Loss of energy/fatigue
Disorientation Restlessness
Dizziness Stomach or bowel problems/nausea
Excessive hunger Sweating
Frustration Tightness in chest
Headaches Tremors
Data from Shiffman, S., West, R., & Gilbert, D. (2004). Recommendation for the assessment of tobacco craving and withdrawal in smoking cessation trials. Nicotine and Tobacco Research, 6, 599–614; Gritz, E. R., Carr, C. R., & Marcus, A. C. (1991). The tobacco withdrawal syndrome in unaided quitters. British Journal of Addiction, 86(1), 57–69.
Table 8.9
Typical Symptoms of Nicotine Withdrawal
caused by a viral infection. However, smokers are more susceptible than nonsmokers to acute bronchi- tis because of their impaired and irritated bronchi. "e signs and symptoms of this disease are soreness or tightness in the chest, slight fever, cough, chills, and a vague feeling of weakness or discomfort. Bron- chitis with accompanying high fever, breathlessness, and yellow, gray, green, or bloody sputum is seri- ous, and the person should seek medical attention immediately.
Chronic bronchitis is usually caused by cigarette smoking, but cigar and pipe smoking may also be causes. Chronic bronchitis is a persistent in'am- mation and thickening of the lining of the bronchi caused by the constant irritation of smoke. As the lining of these airways thickens, breathing becomes more di&cult, and coughing increases. "e cells lining the bronchi produce additional mucus, caus- ing congestion in the lungs and further hampering breathing. "e signs and symptoms of chronic bron- chitis are shortness of breath and a chronic cough that produces considerable amounts of mucus. Chronic bronchitis is a serious disease that can result in death.
the carbon monoxide in cigarette smoke binds to hemoglobin in the red blood cells, reducing its ability to carry oxygen.
Nicotine and carbon monoxide are not the only components of cigarette smoke that a#ect the body. "ere are more than 4,000 chemical compounds in the gases and particles that make up cigarette smoke. Some are poisonous, such as hydrogen cyanide; some are irritating to the lungs and mucous membranes, such as particulate matter; and some cause cancer, such as the tars—sticky substances similar to road tar. "e rest of this section describes speci!c health e#ects of smoking tobacco and using smokeless tobacco products.
Respiratory Illnesses "e windpipe and its major subdivisions are lined with microscopic hairlike structures called cilia, which are embedded in a layer of sticky mucus. "is mucus traps inhaled particles and microbes. As the cilia beat, the mucus moves upward, sweeping this debris up and out of the air passageways.
Inhaled cigarette smoke paralyzes the cilia. With continued smoking, the cilia are damaged. Cigarette smoke also irritates the airways and tar builds up on the cilia, causing excess mucus to be produced. "e chronic cough of smokers, usually called smoker’s cough, is a result of the body’s attempt to remove this excess stationary mucus.
Acute bronchitis is an in'ammation of the mucous membranes of the bronchi, which is usually
Oropharynx
Larynx
Esophagus
Stomach
Pancreas
Bladder
Kidney and ureter
Trachea, bronchus, and lung
Acute myeloid leukemia
Cervix (in women)
Cancers Chronic diseases
Stroke
Aortic aneurysm
Pneumonia
Hip fractures
Periodontitis
Blindness, cataracts
Coronary heart disease
Atherosclerotic peripheral vascular disease
Chronic obstructive pulmonary disease, asthma, and other respiratory effects
Reproductive effects in women (including reduced fertility)
Figure 8.9 Smoking Cigarettes Can Cause These Cancers and Chronic Diseases. Reproduced from U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from http://www.surgeongeneral.gov/library /tobaccosmoke/report/full_report.pdf
acute bronchitis A temporary inflammation of the mucous membranes of the bronchi.
chronic bronchitis A persistent inflammation and thickening of the lining of the bronchi.
Tobacco 261
resulting in larger air sacs with less surface area over which gas exchange can take place. Under these conditions, the lungs can no longer accom- modate normal amounts of air. Also, without the normal elasticity of the lungs, a person can no lon- ger inhale and exhale normally. Breathing becomes a continual e#ort.
In addition to bronchitis, smoking is also a risk factor for pneumonia, an in'ammation of the lungs that is caused by a variety of bacteria and viruses.
Smoking is also the main cause of emphysema (Figure 8.10), a condition in which the air sacs of the lungs lose their normal elasticity. Some air sacs become overstretched and eventually rupture,
Consumer Health Electronic Cigarettes or E-Cigarettes E-cigarettes are electronic devices used to inhale an aerosol, a behavior referred to as “vaping.” Other names used to
refer to vaping products include “e-cigs,” “vapes,” “vape pens,” “mods,” “cigalikes,” and “e-hookahs,” among others. These products come in many shapes and forms and are designed to mimic the look and feel of smoking without the use of tobacco; however, aerosols used in e-cigarettes usually contain nicotine, the active addic- tive ingredient in many tobacco products. Additionally, e-cigarette aerosols are often flavored and can contain many other additives.
Results from the 2012 National Youth Tobacco Sur- vey indicated that 20.3% of high school students have tried e-cigarettes, and 7.2% who have tried e-cigarettes reported never smoking conventional cigarettes. Addi- tionally, results from the 2016 Monitoring the Future study indicated approximately 27% of 8th-, 10th-, and 12th-grade students had tried e-cigarettes. These data suggest that vaping is becoming more popular among adolescents. Because e-cigarettes are relatively new, it is important to note that the short- and long-term impact of e-cigarette use on health is unclear; however, the use of e-cigarettes has become a major public health con- cern as the rate of e-cigarette use among adolescents has surpassed that of adults.
Although many e-cigarette users may believe they are less dangerous than tobacco products, the U.S. Centers for Disease Control and Prevention has stated that the use of any product containing nicotine is unsafe in any form for youth and is a risk factor for nicotine addic- tion. Additionally, use of e-cigarettes is dangerous for pregnant women and fetuses because of their nicotine content. Furthermore, e-cigarette aerosols are harm- ful. E-cigarette aerosols contain ultrafine particles that can be inhaled deep into the lungs as well as volatile organic compounds, and some chemicals used in some
flavorings have been linked to serious lung disease and cancer. Furthermore, in additional to nicotine, e-cigarette aerosols have been found to contain heavy metals such as lead, tin, and nickel, all of which can be toxic in the human body.
A primary concern related to the use of e-cigarettes among youth is nicotine addiction. Nicotine exposure during adolescence is associated with a significant increase in the likelihood of addiction and has been shown to harm developing brains. Additionally, some research- ers have cited concerns that availability of e- cigarettes could increase nicotine addiction among current non- smokers, which could lead to use of tobacco products later. As of 2016, based on these numerous concerns, the FDA began regulating the sale of e-cigarettes to youth. Currently, it is illegal for retailers to sell e-cigarettes to anyone under the age of 18, and e-cigarettes cannot be sold in vending machines; however, as noted, the rate of e-cigarette use among youth remained high in 2016.
Is vaping less harmful than smoking tobacco ciga- rettes, and are e-cigarettes a safer alternative? The answer is maybe, in some cases. Although e-cigarette aerosols contain fewer toxic chemicals than regular cigarettes, they are not harmless. Some contain heavy metals and other lung disease- and cancer-causing agents, and they increase the risk of nicotine addiction. Although the CDC suggests that e-cigarettes may help nonpregnant adult smokers quit if used as a complete substitute for all tobacco products, e-cigarette use is not recommended for pregnant women or youth.
Data from U.S. Centers for Disease Control and Prevention. (2017). Smoking & Tobacco Use: Electronic Cigarettes. https://www.cdc.gov /tobacco/basic_information/e-cigarettes/index.htm; Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenber, J. E. (2017). Monitoring the Future national survey results on drug use, 1975–2016: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan; U.S. Depart- ment of Health and Human Services. (2016). E-Cigarette use among youth and young adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Preven- tion and Health Promotion, Office on Smoking and Health. Retrieved from https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes /pdfs/2016_sgr_entire_report_508.pdf
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v Diversity in Health Tobacco Drinking? To North Americans, the phrase “using tobacco” usually means smoking cigarettes, cigars, or pipes. Occasion- ally, we might envision a person using chewing tobacco or placing a pinch of snuff between the gums and cheek. But various cultures use tobacco in other ways— including some ways that may be new to you.
Drinking liquid tobacco is one of the oldest methods of tobacco use. The members of certain tribal populations in South America, particularly those living in Guiana, the upper Amazon, and the mountainous regions of Ecuador and Peru, drink tobacco juice. The drinking of tobacco has also been reported in other South American regions, including northwestern coastal Venezuela, northwestern Colombia, and a few scattered places in Bolivia and Brazil.
The various groups of people who drink tobacco juice prepare it in different ways. The leaves may be first pounded, chewed, or shredded. Sometimes they are left untreated. Then, the tobacco leaves are placed in water; sometimes other ingredients are added, such as salt, pep- per, or plant materials such as tree bark. The mixture is boiled and then strained to obtain the liquid. Usually it is then set aside to allow much of the water to evaporate. The remaining material has the consistency of a paste, syrup, or jelly. The syrups and jellies are usually liquid enough to drink by mouth or pour in the nose. People from some areas squirt the juice from one person’s mouth to another.
Various tribes of the northernmost extension of the Andes in Colombia and Venezuela and in parts of the northwest Amazon make a thick extract of tobacco called ambil that they rub across their teeth, gums, or tongue. This thick black gelatin is made by boiling tobacco leaves for hours or days and then thickening the extract with starch. Recipes vary; some tribes add pepper, avocado seeds, sugar, or tapioca. Ambil is sometimes ingested with other tobacco products or hallucinogenic drugs.
Using chewing tobacco is practiced by about 2–3% of the population in the United States. It is more widely prac- ticed in South America and the West Indies. A person who uses tobacco in this way usually sucks or sometimes chews tobacco quids, which are simply pieces of tobacco made for this purpose. However, the South American and West Indian practices of preparing quids may seem unusual to North Americans. South American and West Indian recipes may include soil, ashes, salt, or honey with the finely crushed tobacco leaves. (North American quids are also flavored in various ways.) South American Indians generally swallow the juices from the tobacco rather than spit them out.
Another practice among South American Indians that may seem unusual to North Americans is the use of tobacco as an enema or suppository. Generally, these native people use tobacco in this manner to treat constipation
or worm infestations. Various tribes of Indians who reside in the mountains of Peru also use tobacco in this way during certain rituals.
People in different cultures often adopt different health-related behaviors. What seems unusual to persons in one culture may not seem unusual to individuals from another. In fact, tobacco drinking may be entering the American culture in trendy restaurants. An increasing number are including tobacco items on the menu or in the bar because the law does not allow their customers to light up their favorite cigarettes or cigars. Therefore, restaura- teurs have developed alternatives to smoking. In some eat- eries, tobacco leaves are used as overnight wraps for fish before the fish are smoked. Tobacco juice is being used as an ingredient in sauces and desserts. And an alcoholic beverage has been developed called a nicotini ( Figure"8.A), which includes “tea” brewed from tobacco leaves.
Tobacco drinking? It may be happening at the table next to yours, and its health effects are still to be determined.
Data from Daily Mail. (2008). Pour yourself a cigarette: The new “liquid smoking” drink that promises an instant high for smokers trying to beat the ban. Retrieved from http://www.dailymail.co.uk /health/article-1080594/Pour-cigarette-The-new-Liquid-Smoking -drink-promises-instant-high-smokers-trying-beat-ban.html; Kuntzman, G. (2003, May 19). Tobacco in your tiramisu? Newsweek. Available at http://gershkuntzman.homestead.com/files/tobacco _in_Your_Tiramisu.htm; U.S. Department of Health and Human Services. (1992). Smoking and health in the Americas: A 1992 report of the Surgeon General, in collaboration with the Pan American Health Organization (DHHS Publication No. CDC 92-8419). Atlanta, GA: U.S. Department of Health and Human Services, pp. 19–31.
Figure 8.A The Nicotini. Nicknamed the liquid cigarette, the nicotini is made by soaking tobacco leaves overnight in vodka or other spirits. Nicotine is a powerful, toxic drug, and the amount served in nicotinis is not regulated. Drinking a nicotini may result in unpleasant and harmful side effects. © PhotoEdit/Alamy Images.
Tobacco 263
(especially before symptoms develop), its destructive e#ects can be halted by stopping smoking.
People with chronic bronchitis and emphysema are said to have chronic obstructive pulmonary disease (COPD). Cigarette smoking is the major cause of COPD; it would probably be a minor health problem if people did not smoke. Smoking is thought to be responsible for approximately 108,000 deaths from COPD per year, or 85–90% of all COPD deaths.30
Cardiovascular Disease "irty-one percent of people who die from smoking-related causes die from cardiovascular disease (CVD), or dysfunction of the heart and blood vessels.31 "ere are a variety of car- diovascular diseases, including coronary artery disease (CAD), hypertension (chronic high blood pressure), and stroke (blood vessel disease of the brain). Athero- sclerosis, the buildup of fatty deposits in the arteries, is
"e lung damage of emphysema can never be repaired. As the disease progresses, the heart becomes increasingly overworked. Because the blood it is pump- ing is oxygen poor, the body sends signals to the heart to pump more blood more quickly. Eventually the person with extensive lung damage dies, usually from heart failure. However, if emphysema is detected early
emphysema (EM-fih-SEE-mah) A chronic condition in which the air sacs of the lungs lose their normal elasticity, impairing respiration.
chronic obstructive pulmonary disease (COPD) A syndrome that includes chronic bronchitis, asthma, and emphysema and that is characterized by extreme difficulty in breathing.
cardiovascular disease (CVD) Disorders of the heart and blood vessels.
Figure 8.10 A Healthy Lung and a Lung from a Person with Emphysema. (a) The healthy lung is smooth, a deep pink, and relatively uniform in color. (b) Because of emphysema, some of the alveoli have ruptured, creating tiny craters within the lung (difficult to see in this picture). Note the blackened tissue as a result of years of smoking. © SIU/Visuals Unlimited, Inc.
(a) (b)
264 Chapter 8 Alcohol and Tobacco
in the United States.32 Tobacco use causes or is related to cancers of the lungs, larynx, oral cavity, esophagus, kidneys, bladder, pancreas, stomach, and cervix (see Figure 8.9). Lung cancer is the most prevalent form of cancer caused by tobacco use.
Periodontal Disease Smoking tobacco and using smokeless tobacco can have serious e#ects on the oral cavity. "ese e#ects can range from embarrass- ing problems such as bad breath and stained teeth to life-threatening conditions such as oral cancer (Figure 8.11).
People who use tobacco products regularly o$en develop periodontal disease, commonly known as gum disease. Periodontal disease is actually more than just disease of the gums. It is a disease of all the supporting tissues around the teeth, which include the gums, the bone in which the teeth are embedded, and the ligaments that hold the teeth to the bone.
an important cardiovascular disease process that is an underlying cause in CAD and stroke.
According to the National Stroke Association, cigarette smokers are more than twice as likely as nonsmokers to have a stroke because of the e#ects of smoking on the cardiovascular system. As many as one-third of CVD deaths in the United States each year are attributable to cigarette smoking.31 Using smokeless tobacco is a signi!cant CVD risk factor also, but cigar and pipe smoking are less signi!cant.
Women who take oral contraceptives (birth con- trol pills) and who smoke cigarettes increase their risk of heart attack several times. Oral contracep- tives increase the risk of developing blood clots, which can block already narrowed arteries in persons with atherosclerosis, a disease that smokers have an increased risk of developing. For these reasons, smok- ing while taking oral contraceptives also increases the risk of peripheral vascular disease and stroke.
Smokers o$en think that smoking low-yield (“light”) cigarettes poses fewer health risks than smoking regular-strength cigarettes. Light cigarettes, which began to be marketed in the 1960s in response to health concerns, are lower in tar and nicotine. However, research data show that smokers gener- ally pu# on these cigarettes longer and inhale more deeply than when smoking regular cigarettes. Also, they o$en smoke more light cigarettes than they would regular cigarettes, so they may take in as much tar, nicotine, and other noxious and cancer-causing compounds than if they smoked regular cigarettes. Scientists have found no evidence that smoking low- tar and low-nicotine cigarettes reduces the risk of coronary heart disease.31
When a smoker quits, his or her risk of heart disease begins dropping immediately. "e time it takes for a former smoker’s risk of death from heart attack to reach that of a nonsmoker’s varies from 3 to 9% years. "e recovery time depends on the number of years a person smoked and how many cigarettes he or she smoked per day. However, if a smoker has already developed heart disease before quitting, the risk of heart attack will not return to that of a non- smoker, although it will be lower than if he or she had continued smoking.
Cancer Cancer is a group of diseases in which certain cells exhibit abnormal growth. Cancers can arise in various locations in the body and then spread to others.
Cancer is the second biggest killer of Americans, and tobacco use is responsible for about 30% of cancer deaths and 87% of lung cancer deaths annually
Figure 8.11 Gruen Von Behrens, After Using Smokeless Tobacco. Gruen began using smokeless (spit) tobacco at age 13, and by age 17 he had oral cancer and a 25% chance of survival. Formerly a star baseball player, Gruen can no longer play sports, and after 40 operations, he is still missing his lower teeth and jawbone. His body rejected a bone transplant that would have created a new jaw. Gruen is now a spokesperson for Oral Health America’s National Spit Tobacco Education Program (NSTEP), warning audiences of the dangers of using smokeless tobacco. © Ellis Neel, Alamogordo Daily News/AP Images.
periodontal (PER-ee-oh-DON-tal) disease A disorder of the tissues that support the teeth.
Tobacco 265
is serious because it places women at risk for bone frac- tures, back pain, and other accompanying problems. Hip fractures are particularly serious; the death rate for people who sustain hip fractures is 20–24% higher in the year following the fracture than for people of the same age who did not sustain this injury.33
Environmental Tobacco Smoke In the past three decades, nonsmokers have become increasingly aware that smoke in their indoor envi- ronments could pose a health risk. "is smoke, termed environmental tobacco smoke (ETS), or secondhand smoke, is made up of the sidestream smoke emitted from a lit cigarette, cigar, or pipe and the smoke exhaled by smokers.
In 1986, the National Research Council (NRC) and the United States Surgeon General’s O&ce compiled research data to assess the health e#ects of exposure to ETS.34,35,36 Both landmark reports concluded that ETS can cause lung cancer in adult nonsmokers. In 2006, the Surgeon General’s O&ce released another report on secondhand smoke, "e Health Consequences of Involuntary Exposure to Tobacco Smoke.37 At the press release of the report, Surgeon General Richard H. Carmona stated, “"e debate is over. "e science is clear: secondhand smoke is not a mere annoyance, but a serious health hazard that causes premature death and disease in children and nonsmoking adults.”
Conclusions from these reports prompted the des- ignation of government and other public buildings, many workplaces, and restaurants in many states as smoke-free environments to reduce the e#ects of ETS on the public. By 1993, nearly 82% of indoor workers were restricted from smoking in their workplaces.38 By 2006, almost all workplaces, government build- ings, and public places in the United States were smoke free.37 However, if a “smoke-free” area is adja- cent to a smoking area, it will contain unacceptable levels of airborne pollutants unless the two areas have separate ventilation systems.
Figure 8.13 shows the health consequences of repeated exposure to secondhand smoke for both children and adults. Avoiding secondhand smoke will help you stay healthier. "e Managing Your Health box includes tips on how to say no to second- hand smoke.
Quitting Most smokers want to quit. In a 2017 Gallup poll, 77% of smokers told Gallup interviewers that they would like to give up cigarettes. Eighty-nine percent
People can develop periodontal disease for a vari- ety of reasons, such as poor dental hygiene, overzeal- ous brushing that damages the gums, and clenching and grinding of the teeth. Using tobacco products is especially destructive to the gums and o$en is a cause of severe periodontal disease. Nicotine narrows the blood vessels in the gums, reducing the amount of oxygen that reaches these tissues. As a result, the gum tissue becomes less resistant to infection. Addi- tionally, good oral hygiene and proper periodontal treatment are o$en ine#ective when a person with periodontal disease continues to use tobacco.
Young people who use smokeless tobacco prod- ucts o$en develop periodontal disease. Gum reces- sion most o$en occurs where smokeless tobacco is held in the mouth. Leukoplakia, a disease character- ized by precancerous white patches that develop on the mucous membranes of the mouth (Figure 8.12), is common in adolescents who use these products. Approximately 5% of these lesions become cancerous within 5 years. However, if a smokeless tobacco user discontinues use, the leukoplakia regresses and may disappear.
Osteoporosis Smoking cigarettes can lead to lower bone density, or osteoporosis, which occurs most fre- quently in postmenopausal white women. "is disease
Figure 8.12 Advanced Leukoplakia. This precancerous condition often develops on the mucous membranes of the mouths of those who use smokeless tobacco products. Courtesy of J. S. Greenspan, B.D.S., University of California, San Francisco; Sol Silverman, Jr., D.D.S/CDC.
environmental tobacco smoke (ETS) The smoke emitted from a lit cigarette, cigar, or pipe and the smoke exhaled by smokers.
266 Chapter 8 Alcohol and Tobacco
dependence); or varenicline (Chantix) during the early cessation period may help reduce these symp- toms and make quitting easier. Varenicline eases with- drawal symptoms by providing some nicotine e#ects to the brain while simultaneously blocking the e#ects of nicotine from cigarettes. Of these therapies, vareni- cline appears to be the most e#ective.40
Electronic cigarettes, or e-cigarettes, which have sometimes been marketed as an alternative cigarette and as a quitting aid, have been cited by the FDA for “unsubstantiated claims and poor manufacturing practices.”41 For example, the FDA found nicotine in e-cigarettes labeled as having no nicotine and similarly labeled e-cigarettes as delivering di#ering amounts of nicotine.42 Some studies have shown limited suc- cess in using e-cigarettes as a quitting aid; however, !ndings are inconsistent,43 and current CDC rec- ommendations suggest using them only a$er other, more proven methods have failed. Most e-cigarettes are manufactured to look like cigarettes and contain a stainless steel shell encasing a heating element, a chemical-containing cartridge, and an atomizer that vaporizes the chemicals when heated (Figure 8.14).44 You can !nd more information about e-cigarettes in the Consumer Health feature in this chapter.
Availability of e-cigarettes could also create poten- tial health risks for nonsmokers. Some researchers have warned that cheap pricing, availability of many 'avors, and celebrity promotional activities, which are clearly targeted at adolescents, will increase use and lead to higher rates of nicotine addiction among young people.43
of smokers said that they think secondhand smoke is very or somewhat harmful to health, and 95% of smokers reported that they think smoking is very or somewhat harmful to health.39
Bene!ts of Quitting At any age, there are many reasons to stop smoking cigarettes. Some of those reasons are to lower your risk of various diseases and conditions, including certain cancers, heart attack, stroke, and chronic lung disease; in pregnant women, to reduce the risk of having a low-birth-weight baby; to stop exposing your family and other people around you to secondhand smoke; to rid yourself of a stale cigarette odor on your body and breath; and to rid yourself of an expensive addiction to nicotine.
On quitting, an addicted smoker experiences some or all of the nicotine withdrawal symptoms listed in Table 8.9. "ese unpleasant psychological and physi- ologic conditions peak 1–2 days following quitting but subside during the following weeks. "e two withdrawal symptoms that last the longest are the urge to smoke and an increased appetite. However, using a nicotine replacement therapy product, such as the nicotine patch, nicotine gum, or nicotine inhaler; buproprion (an antidepressant used to treat nicotine
Middle ear disease
Respiratory symptoms,
impaired lung function
Lower respiratory
illness
Sudden infant death
syndrome
Children Adults
Lung cancer
Nasal irritation
Coronary heart disease
Reproductive effect in women: low birth weight
Figure 8.13 The Health Consequences of Repeated Exposure to Secondhand Smoke. Reproduced from U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease: The"Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S.#Department of Health and Human Services. Retrieved from http://www.surgeongeneral.gov/library /tobaccosmoke/report/full_report.pdf
Figure 8.14 The Anatomy of an E-cigarette. An electronic cigarette has a stainless steel casing that is often manufactured to look like a filter-tipped cigarette but may look like a pen or a thumb drive for those who wish to conceal their use of the product. Internally, the e-cigarette contains a heating element, a chemical- containing cartridge, and a vaporizing unit. © iStockphoto/Thinkstock.
Tobacco 267
esophagus, and bladder cancers has been cut in half, and the excess risk of cervical cancer has been elim- inated. In 10 years a$er quitting, the excess risk of dying from lung cancer is cut in half, and the risk of cancer of the larynx and pancreas decreases.45 Figure"8.15 is a visual summary of the health bene!ts of quitting smoking.
%e Process of Quitting Cigarette smoking is an addiction, and an addicted smoker who is quitting goes through the same process of behavioral change as does anyone addicted to any drug. For a smoker to contemplate quitting, he or she must understand and accept that cigarette smoking is dangerous or must have other reasons for quitting that are impor- tant to him or her. "en, the smoker begins to see the potential bene!ts and negative e#ects associated with quitting. For example, the smoker may realize that nicotine is a drug and that he or she is addicted to this drug. Quitting will stop the addiction. How- ever, along with this positive behavior (stopping the addiction) comes negative consequences: withdrawal symptoms. To be prepared to quit, the smoker should analyze both the negative and positive aspects of change and prepare to deal with the negative aspects. O$en, discussion with a medical practitioner is helpful. Also, if a smoker analyzes the reasons he or she smokes (see “Why Do You Smoke?” in the Stu- dent Workbook pages of this text), the smoker will be better equipped to handle the consequences of quitting (see the Managing Your Health box “Tips for Quitters”).
Once the smoker realizes the need to quit, he or she should decide what course of action to take. Should it be quitting “cold turkey” or cutting down at !rst? (If a person is addicted to nicotine, stopping “cold turkey” may be best. "e assessment activity “Why Do You Smoke?” can help identify addiction.) Will the smoker join a smoking cessation program or stop without group support? Again, the advice of a medical practitioner may be helpful at this stage. A smoker can also call the American Lung Associa- tion, the American Heart Association, the American Cancer Society, or the National Cancer Institute for free literature on quitting and information on smok- ing cessation programs. Many programs are available, and the smoker needs to select the program that suits his or her needs best. Medication may also be helpful at this stage, such as a nicotine replacement product, buproprion, or varenicline to lessen the withdrawal symptoms from nicotine. Also, the smoker may enlist the support of family and friends through the quitting process.
A promising quitting aid is the nicotine addic- tion vaccine, which was in late-stage clinical trials in early 2011. "e vaccine, called NicVAX, works by stimulating the body to produce antibodies against nicotine so that the drug cannot get to the brain, stimulate pleasure centers, and reinforce the crav- ing for nicotine. In an early trial of 1,000 smokers who wanted to quit, NicVAX did spur production of antibodies against nicotine as expected; however, no signi!cant improvement in smoking cessation rate was found over the placebo group. Research- ers are currently studying whether vaccines such as NicVAX, along with evidence-based smoking cessa- tion programs, can increase the rate of quitting.
During the quitting process, as withdrawal symp- toms subside, former smokers report that favor- able psychological changes occur over time, such as enhanced self-esteem and an increased sense of self-control. Because smoking cigarettes has negative e#ects on the respiratory system, a person who quits notices that it is easier to breathe. Smoking cessation reduces the rate at which symptoms such as cough, mucus production, and wheezing occur a$er an ini- tial period of clearing mucus from the lungs subsides. It also reduces the incidence of respiratory infections such as bronchitis and pneumonia. (Pneumonia can be deadly for people who have chronic diseases.) Also, a$er sustained abstinence from smoking ciga- rettes, persons with COPD have less chance of dying from this disease than they did before they quit.
Quitting also has positive e#ects on the cardiovas- cular system. Data show that the smoker who quits cuts his or her elevated risk of coronary heart disease in half only 1 year a$er quitting. "e degree of risk that remains then declines gradually. At 15 years, a former smoker reaches the risk level of a nonsmoker for coronary heart disease and death.45 "e more cigarettes a person smoked and the earlier a person started to smoke, the longer the recovery time. Because the risk of cardiovascular disease increases as the number of cigarettes smoked increases, smok- ing fewer cigarettes can be a way to lower CVD risk if an individual has little success quitting. However, smoking low-yield (low tar and nicotine) cigarettes does not appear to reduce risk. Among persons diag- nosed with cardiovascular disease, smoking cessation markedly reduces the risk of additional heart attacks and cardiovascular death. "e bene!ts of quitting exist for people of all ages. Older individuals should not think that it is “too late” to quit.
Quitting reduces cancer risk. In 5 years a$er quitting, the excess risk of developing mouth, throat,
268 Chapter 8 Alcohol and Tobacco
goes through the stages of behavior change once again.
One barrier to quitting is the smoker’s fear of gain- ing weight. In fact, about 25% of smokers cite this possibility as the reason for not quitting. Likewise, about 25% of people who quit relapse because they begin to gain weight and are afraid of gaining more. "is fear is not unfounded—80% of persons who quit smoking gain weight. Data show, however, that the average weight gain is only 6–9 pounds, and the risk of signi!cant weight gain is extremely low. Individu- als who smoked heavily gain the most weight a$er quitting.
A$er the !rst 6 months, which is considered the quitting period, the former smoker enters the period of maintenance, which also lasts 6 months. Some quitters who join smoking cessation programs con- tinue to attend group meetings for support. Others get continued support from friends, family members, or other former smokers.
As with other addictions, sometimes relapse occurs. During a relapse, a former smoker returns to smoking habits. Relapse can be triggered by a variety of factors, such as stress, depression, a crav- ing for cigarettes, negative life events, and inter- personal tensions. To quit, the relapsed smoker
Managing Your Health
If you live with a smoker: • Ask him or her not to smoke in your home. Discuss
how his or her habit puts you and others living there at risk.
• If he or she is unwilling to go outside, suggest ways to limit the exposure to smoke for you and others. Maybe a room could be set aside for smoking—one that is seldom used by other members of the house- hold. Some smokers protect others at home by smok- ing near an open window or when no one is around.
• Keep rooms well ventilated. Open windows. • Support smokers who decide to quit.
When visitors come: • Ask all smokers who visit not to smoke in your
house or apartment, but to please smoke outside. • Do not keep ashtrays around.
In others’ homes or in vehicles: • Tell friends and relatives politely that you would
appreciate their not smoking while you are there. • Let people know when their smoke is causing
immediate problems. If it is making your allergies worse, making you cough or wheeze, or making your eyes sting, say so. Some smokers put their cigarettes away when they see the discomfort it causes.
If you have children: • Insist that babysitters, grandparents, and other
caregivers not smoke around your children. • Help children avoid secondhand smoke if smokers
do use tobacco around them. Have them leave the room or play outside while an adult is smoking. Air rooms out after smoking occurs.
• Keep smokers away from places in which children sleep.
When smoking is allowed at the workplace: • Talk to your employer about the com-
pany’s smoking policy. Give your employer copies of the Environmen- tal Protection Agency (EPA) report on the harmful effects of environmental tobacco smoke. Call 1-800- 438-4318 to obtain this report.
• Ask to work near other nonsmokers and as far away from smokers as possible.
• Ask smokers if they would not smoke around you. • Use a fan and open windows (if possible) to keep air
moving. • Hang a Thank You for Not Smoking sign in your
work area. • Volunteer to help develop a fair company policy that
protects nonsmokers. • Contact the local Lung Association, the American
Cancer Society, or the National Cancer Institute (1-800-4-CANCER) for inforation concerning smok- ing cessation programs that can be conducted at your workplace.
When you are in public places: • Always take the nonsmoking options that are avail-
able in rental cars, hotels, and restaurants. • If a restaurant puts you at a table near smokers (even
if you are in a nonsmoking section), ask to move. • Keep children out of smoking areas.
Adapted from National Cancer Institute. (n.d.). I mind very much if you smoke. Retrieved from http://dccps.nci.nih.gov/tcrb/i_mind_if _you_smoke/mindsmo.html
How to Say No to Secondhand Smoke
Tobacco 269
young people develop skills to identify and resist social in'uences to smoke, such as advertising and peer pressure. Additionally, they educate adolescents about the short-term negative e#ects of tobacco use. Understanding short-term consequences positively a#ects adolescent behavior more than knowledge of long-term e#ects. Data show that several types of pre- vention programs delay or reduce youth tobacco use for periods of 1–5 years and more. E#ective preven- tion programs engage the school, parents, and media.
Other programs have been developed that focus on smokeless tobacco use. "e goal of these programs is to counter the perception that smokeless tobacco is a safe alternative to smoking cigarettes.
Reducing the availability of cigarettes to adoles- cents is another prevention measure. Unfortunately, adolescents can get cigarettes quite easily even though the sale of tobacco products to minors is illegal in all states and the District of Columbia. One of the goals of Healthy People 2020 is to enforce laws that prohibit sales to minors to reduce the percentage of minors who successfully purchase cigarettes to 5%.
People gain weight when they stop smoking for two reasons: "ey eat more (o$en to put something other than a cigarette into their mouths), and their metabolism slows slightly. To combat this e#ect, as part of your smoking cessation plan, be sure to include an exercise program to maintain your met- abolic rate. Also, keep fat-free, low-calorie snacks handy, such as slices of vegetables with low-fat dip, fruits, pretzels, and sugar-free gelatin.
Prevention Prevention programs developed in the 1980s re'ect an understanding that smoking begins in early ado- lescence and that young people go through stages in the development of smoking behavior (see the section titled “Psychosocial Reasons for Using Tobacco Products” earlier in this chapter). Today’s programs also recognize that a child’s social environment is the most important determinant of whether he or she will smoke. "erefore, prevention programs now target seventh and eighth graders, reaching children before most start smoking. "eir focus is on helping
Stroke risk is reduced to that of a person who never smoked after 5 to 15 years of not smoking.
Risk of cancers of the mouth, throat, and esophagus are halved 5 years after quitting.
Cancer of the larynx risk reduced after quitting.
Coronary heart disease risk is cut by half 1 year after quitting and is nearly the same as someone who never smoked after 15 years after quitting.
Chronic obstructive pulmonary disease risk of death reduced after you quit.
Lung cancer risk drops by as much as half 10 years after quitting.
Peripheral artery disease goes down after quitting.
Ulcer risk drops after quitting.
Bladder cancer risk halved a few years after quitting.
Cervical cancer risk is reduced a few years after quitting.
Low-birth-weight baby risk drops to normal if you quit before pregnancy or during your first trimester.
Figure 8.15 The Health Benefits of Quitting Smoking. The risks of developing many diseases and conditions drop dramatically, in varied lengths of time, after a person quits smoking. Modi!ed from Centers for Disease Control and Prevention. (2004). The"bene!ts of quitting. Retrieved from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/posters/bene!ts/index.htm
270 Chapter 8 Alcohol and Tobacco
Managing Your Health
If you smoke and have not responded to the questions in the assessment activity in the Student Workbook pages of this text titled “Why Do You Smoke?” do so now. Then, read the suggestions for quitting that specifically address each reason you smoke. If you tailor your plan to quit smoking to match the reasons that you smoke, the cessation process will be easier.
Reason: “Smoking gives me energy.” • Get enough rest to feel refreshed and alert. • Exercise regularly to raise your overall energy level. • Take a brisk walk instead of smoking if you start
feeling sluggish. • Eat regular, nutritious meals for energy. • Drink lots of cold water to refresh you. • Avoid getting bored, which can make you feel tired.
Reason: “I like to touch and handle cigarettes.” • Pick up a pen or pencil when you want to reach for
a cigarette. • Play with a coin or handle nearby objects. • Put a plastic cigarette in your hand or mouth. • Hold a real cigarette if the touch is all you miss. • Eat regular meals to avoid confusing the desire
to eat with the desire to put a cigarette in your mouth. • Take up a hobby, such as knitting or carpentry, that
keeps your hands busy. • Eat low-fat, low-sugar snacks such as carrot sticks
or bread sticks. • Suck on sugar-free hard candy.
Reason: “Smoking gives me pleasure.” • Enjoy the pleasures of being tobacco free, such as
how good foods taste; how much easier it is to walk, run, and climb stairs; and how good it feels to be in control of the urge to smoke.
• Spend the money you save on cigarettes on another kind of pleasure, such as a shopping spree or a night out.
• Remind yourself of the health benefits of quitting. Giving up cigarettes can help you enjoy life’s other pleasures for many years to come.
Reason: “Smoking helps me relax when I’m tense or upset.”
• Use relaxation techniques to calm down when you are angry or upset. Deep breathing exercises, mus- cle relaxation, and imagining yourself in a peaceful setting can make you feel less stressed.
• Exercise regularly to relieve tension and improve your mood.
• Take action to alleviate situations that cause stress.
• Avoid stressful situations. • Get enough rest and take time to
relax each day. • Enjoy relaxation. Take a long, hot bath. Have a massage.
Lie in a garden hammock. Listen to sooth ing music.
Reason: “I crave cigarettes and am addicted to nicotine.” • Ask your medical practitioner about using a nicotine
patch or nicotine gum to help you avoid withdrawal symptoms.
• Go “cold turkey.” Tapering off probably won’t work for you because the moment you put out one cigarette, you begin to crave the next.
• Keep away from cigarettes completely. Get rid of ashtrays. Destroy any cigarettes you have. Try to avoid people who smoke and smoke-filled places like bars.
• Tell family and friends you’ve quit smoking. • Remember that physical withdrawal symptoms last
about 2 weeks. Hang on!
Reason: “Smoking is a habit.” • Cut down gradually. Smoke fewer cigarettes each
day, or only smoke them halfway down. Inhale less often and less deeply. After several months it should be easier to stop completely.
• Change your smoking routines. Keep your cigarettes in a different place. Smoke with your opposite hand. Do not do anything else while smoking. Limit smok- ing to certain places, such as outside or in one room at home.
• When you want a cigarette, wait 1 minute. Do some- thing else instead of smoking.
• Be aware of every cigarette you smoke. Ask yourself, “Do I really want this cigarette?” You may be sur- prised at how many you can easily pass up.
• Set a date for giving up smoking altogether and stick to it.
Adapted from National Cancer Institute. (1993). Learning why you smoke can teach you how to quit. Washington, DC: U.S. Department of Health and Human Services.
Tips for Quitters
Tobacco 271
4If you are a smoker, make a plan for quitting and follow through on your plan. Expect quitting to be difficult at times. Consider using an organized program, medication, or both to help you quit. To combat weight gain when quitting, exercise and keep lots of fat-free, low-calorie snacks handy.
4If you have or plan to have children, consider discussing the health effects of smoking with them when they are very young to discourage them from starting the habit.
4Do not allow your children to be near someone who is smoking. Children are particularly susceptible to the damaging effects of tobacco smoke.
4If you have bronchitis with accompanying high fever, breathlessness, and yellow, gray, green, or bloody sputum, seek medical attention immediately.
4If you have a smoker’s cough that produces considerable amounts of mucus and shortness of breath, seek medical attention immediately because you may have chronic bronchitis, a serious disease.
4See your healthcare provider regularly for an evaluation of your respiratory system.
4If you are a nonsmoker, avoid areas where cigarette smoke is present. Breathing in this smoke increases your risk of developing heart disease, lung cancer, and various respiratory diseases and conditions.
4If you use tobacco products, you can reduce your risk of developing various cancers, cardiovascular disease, and periodontal disease by quitting.
4If you are female and smoke cigarettes, you have a higher risk of developing osteoporosis than nonsmoking women. To reduce this risk, stop smoking.
Healthy Living Practices
THE EFFECTS OF ALCOHOL AND TOBACCO USE Fetuses and infants are signi!cantly a#ected by the alcohol and tobacco use of their mothers. Babies of women who consume alcohol while pregnant may be born with certain incurable birth defects caused by alcohol exposure during prenatal development. "ese disorders range in their severity and e#ects; the phrase fetal alcohol spectrum disorders (FASDs) refers to the entire group of disorders. "e various e#ects seen in FASDs include growth de!ciencies, brain dysfunctions, distinctive facial features, and structural birth defects. One of the most severe of these disorders is fetal alcohol syndrome (FAS).
"e predominant feature of FAS is brain e#ects and may include intellectual disability. "is syndrome is also characterized by slowed growth both before and a$er birth; other central nervous system defects, such as behavioral problems, and skull or brain malforma- tions; and characteristic facial features that include small eye openings, a broad, thin upper lip, and a 'at- tened nose bridge and midface (Figure 8.16).
Across THE LIFE SPAN
fetal alcohol spectrum disorders (FASDs) A variety of incurable conditions and birth defects caused by alcohol exposure during prenatal development.
fetal alcohol syndrome (FAS) The most severe FASD. Children born with FAS may suffer intellectual disability and have characteristic facial anomalies, growth deficiency, and central nervous system abnormalities.
Figure 8.16 Garrison Lee, a Victim of Fetal Alcohol Syndrome, Who Has Lived on the Streets of Gallup, New Mexico, for 11 Years. Garrison exhibits features characteristic of FAS: small eye openings, a broad, thin upper lip, and a flattened nose bridge and midface. © Richard Pipes/Albuquerque Journal/AP Images.
272 Chapter 8 Alcohol and Tobacco
have not changed. Alcohol also reacts adversely with many medications. Elderly persons taking medications for various conditions may appear to be reacting adversely to their medications rather than experiencing an alcohol problem. If alcohol worsens their health, their healthcare providers may prescribe additional or di#erent medications. A vicious circle of drug interactions and health complications may continue until the healthcare practitioner recognizes that the patient has an alcohol problem.
Older adults face special harm from smoking because most people older than 65 years of age who smoke have been doing so for 30, 40, or 50 years. As a result, a disproportionate number of elderly persons develop life-threatening diseases such as cancer and emphysema because these diseases usually take decades to develop.
Among those older than 65 years, the death rate of current smokers is twice that of people who never smoked. Smoking is associated with a variety of other ailments that are o$en seen in older adults, such as cataracts (a loss of transparency of the lens of the eye), delayed healing of broken bones, periodontal problems, ulcers, high blood pressure, brain hemorrhages, and skin wrinkles. Additionally, heavy smoking in middle age more than doubles the risk of Alzheimer’s disease and other dementias later in life.47
From prenatal development to the elderly years, no one who uses alcohol or tobacco products, or breathes in smoke from others’ use, can escape their health e#ects. Except in pregnant women, one drink per day for women and two drinks per day for men may confer health advantages, however.
Researchers have not determined an exact rela- tionship between the amount and timing of drinking during pregnancy and the e#ects on the fetus. "us, there is no identi#ed safe level of alcohol consumption during pregnancy. Women who are pregnant, who are trying to get pregnant, or who are of childbear- ing age, sexually active, and not using contraception consistently and well should refrain from drinking to avoid exposing their fetus to alcohol in the womb. In 2016, the prevalence of current alcohol consumption in pregnant women aged 15–44 years was 8.3%, and the prevalence of binge drinking was 4.3%. Heavy alcohol use was rare (0.9%).4
Maternal smoking during pregnancy can harm not only the fetus, but the pregnant woman as well. Abruptio placentae occurs when the placenta sepa- rates from the uterus, resulting in hemorrhage (life- threatening bleeding). ("e placenta is an organ shared with the mother through which the fetus obtains nutrients and oxygen, and excretes wastes.) Maternal smoking is associated not only with abruptio placentae but also with placenta previa, in which the placenta implants abnormally and covers the opening of the cervical canal. As this opening dilates at the beginning of the birth process, bleeding and severe hemorrhage can occur.
Smoking during pregnancy also reduces the 'ow of blood in the placenta, limits the nutrients that reach the fetus, and causes an average reduction in birth weight.46 Additionally, the fetuses or infants of women who smoke during pregnancy are 25–30% more likely to die between 28 weeks of gestation and 4 weeks a$er birth than those of women who do not smoke. Babies born of mothers who smoke also have a higher than average incidence of death from sudden infant death syndrome (SIDS) and from respiratory diseases. "e sudden, unexpected death of an apparently healthy infant, SIDS occurs while the baby is sleeping. It is the most common cause of death of children between the ages of 2 weeks and 1% year. In 2016, the percentage of women who smoked during pregnancy was 10%.4 Another age group of persons strongly a#ected by alcohol and tobacco use is the elderly. Because older adults are more physically vulnerable to the e#ects of alcohol, they may develop alcohol problems even though their formerly unproblematic patterns of drinking
4Do not consume alcoholic beverages when pregnant because alcohol exposure can result in incurable lifelong disabilities in the fetus.
4Smoking during pregnancy is associated with serious, and possibly deadly, health effects in both the mother and the fetus.
Healthy Living Practices
Tobacco 273
CHAPTER REVIEW
Drinking alcohol and smoking cigarettes are behaviors that o$en begin in adolescence. Alcohol use is quite prevalent in the United States; approxi- mately 51% of Americans use alcohol. Some people use alcohol responsibly, not allowing their drinking to threaten their health or interfere with their rela- tionships. In contrast, the harmful user drinks alco- holic beverages while knowingly damaging his or her health. "e alcohol-dependent person, or alco- holic, additionally develops tolerance to the drug, exhibits withdrawal symptoms when not drinking, compulsively uses alcohol, and may exhibit other behaviors that are a part of the alcohol dependence syndrome.
"e cause of alcoholism is unknown. However, alcoholism has a genetic (hereditary) component. People abuse alcoholic beverages and become alco- hol dependent for psychological, social, and develop- mental reasons as well.
When a person drinks alcoholic beverages, various behavioral changes that are commonly called intoxi- cation result from impairment of the central nervous system. "e harmful use and abuse of alcohol results in multiple e#ects on the body that are signi!cant threats to health. Excessive alcohol consumption exerts its most dangerous e#ects on the liver, cardio- vascular system, immune system, reproductive sys- tem, and brain. Alcohol use and abuse are also related to serious and even fatal injuries.
Approximately 2 million Americans were treated for alcohol abuse and dependence in 2016. Alco- hol abuse and dependence are o$en detected by the use of screening tests. Healthcare professionals who determine that their patients are alcohol dependent refer them to substance abuse specialists for evalua- tion and possibly treatment. Patients who show non- dependent problem drinking are o$en encouraged to participate in brief intervention programs. Self- help groups support the alcoholic on a long-term basis to help prevent relapse into abusive or depen- dent behaviors.
Cigarettes are the most prevalent type of tobacco product used in the United States today. Approxi- mately 20% of Americans smoked cigarettes regularly in 2016. Most people who smoke cigarettes and use
smokeless tobacco began this habit when they were adolescents. Adolescents initially try tobacco prod- ucts for a variety of reasons: to do what parents or peers do, to experiment, to feel older and more inde- pendent, or to join certain social groups. Adolescents most likely to use tobacco have particular character- istics such as low self-esteem, high susceptibility to peer pressure, and a sensation-seeking nature.
Most teenagers and adults continue to smoke and use smokeless tobacco because they are addicted to the psychoactive drug nicotine. Nicotine, like all psychoactive drugs, acts on certain communication points among nerve cells in the brain.
Cigarette smoking is the leading source of prevent- able illness and death in the United States because many of the 4,000 chemical compounds in cigarette smoke a#ect the body adversely. Every year, approxi- mately 500,000 people die in the United States as a result of using tobacco products.
Inhaled cigarette smoke a#ects the airways by damaging the cilia that sweep debris from this region, by causing the airways to secrete excess mucus, and by irritating and in'aming the airways. As a result, smokers su#er chronic cough and are at high risk for a variety of respiratory infections, such as acute and chronic bronchitis and pneumonia. Smoking is also the main cause of emphysema, a condition in which the air sacs of the lungs have lost their usual elasticity so that a person cannot inhale and exhale normally.
"irty-one percent of people who die from smok- ing-related causes die from cardiovascular disease. Scientists have found no evidence that smoking low- tar and low-nicotine cigarettes reduces the risk of coronary heart disease.
Cancer is the second biggest killer of Ameri- cans, and tobacco use is responsible for about 30% of cancer deaths annually in the United States. Lung cancer is the most prevalent form of cancer caused by tobacco use. Smokeless tobacco use does not cause lung cancer, but it does cause cancers of the larynx, oral cavity, and esophagus. "ese cancers are also caused by smoking cigarettes, cigars, and pipes.
People who use tobacco products regularly o$en develop periodontal disease, which is a disease of the supporting structures of the teeth. Eventually, if
Summary
274 Chapter 8 Alcohol and Tobacco
CHAPTER REVIEW periodontal disease is not treated and controlled, the teeth become loose and fall out.
Smoking cigarettes causes a loss of bone density in women. "is condition is serious because it places women at risk for bone fractures, back pain, and other accompanying problems.
Environmental tobacco smoke, the sidestream smoke emitted from a lit cigarette, cigar, or pipe and the smoke exhaled by smokers, can cause lung cancer in adult nonsmokers. Chronic ETS exposure is also a risk factor for cardiovascular disease and heart attack. Children of parents who smoke have an increased frequency of respiratory symptoms such as coughing and wheezing, and lower-respiratory-tract infections such as bronchitis and pneumonia.
Seventy-!ve percent of smokers say they would like to quit smoking. Quitting has major and imme- diate health bene!ts for people of all ages.
Cigarette smoking is an addiction, and an addicted smoker who is trying to quit goes through the same process of behavioral change as does anyone addicted to any drug. Quitting is easier if the smoker analyzes why he or she smokes and develops or chooses a method of quitting that addresses these reasons.
Successful smoking prevention programs re'ect an understanding that smoking begins in early
adolescence and that a child’s social environment is the most important determinant of whether he or she will smoke. Prevention programs help young people develop the skills to identify and resist social in'u- ences to smoke.
Fetuses and infants are signi!cantly a#ected by the alcohol and tobacco use of their mothers. "e syndrome of fetal e#ects from alcohol consumption during pregnancy is called fetal alcohol spectrum disorders. One of the most severe of these disorders is fetal alcohol syndrome. Children born with FAS may su#er intellectual disability and have character- istic facial anomalies, growth de!ciency, and central nervous system abnormalities. Maternal smoking during pregnancy can harm the pregnant woman and her fetus, placing both at risk for developing several serious conditions.
Another age group of persons strongly a#ected by alcohol and tobacco use is the elderly. Older adults are more physically vulnerable to the e#ects of alco- hol and are more likely to be taking a variety of medi- cations that may interact negatively with alcohol.
Smoking is associated with a variety of ailments in older adults. Among those older than 65 years, the death rate of current smokers is twice that of people who have never smoked.
1. Using the information in this chapter, write a paragraph that would describe what you might say to a friend to discourage him or her from abusing alcohol. Application
2. Analyze your reasons for smoking or those of a smoking friend or relative by using the assess- ment “Why Do You Smoke?” located in the Stu- dent Workbook section. "en, list the elements of a smoking cessation program that would be most helpful for you or for that individual. Synthesis
3. For the past two decades or so, researchers have viewed alcoholism from a “biomedical” point of view. Many researchers thought that it was only a matter of time before a gene for alcoholism would be found. Recently, many researchers have agreed that biology plays a role in addiction but suggest
that biology is only one factor in the develop- ment of alcoholism. Based on what we know to date, discuss factors associated with alcoholism. "en, determine which factors are addressed by programs such as Alcoholics Anonymous, with its 12 steps to recovery. Based on your !ndings, do you think the 12-step program is an e#ective method for alcoholism treatment? Evaluation
4. List all the places where you are regularly exposed to environmental tobacco smoke. Decide whether you should change any of your activities to reduce your exposure to ETS. Explain what you may lose by no longer attending these events or going to these places. Discuss whether these places or activities are worth being exposed to ETS. Evaluation
Applying What You Have Learned
Applying What You Have Learned 275
CHAPTER REVIEW Application using information in a new situation.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
1. Describe your attitudes toward alcoholics before reading this chapter. Have your attitudes changed a$er reading this chapter? Why or why not?
2. If you drink alcohol, what motivates your use of this drug? Are you comfortable with your pat- terns of drinking and reasons for doing so? Why or why not? If you are uncomfortable with your drinking patterns, what can you do to change them?
3. If you were out with friends who were drink- ing, would you attempt to stop someone from driving who was clearly un!t to get behind the wheel? If not, why not? If so, what strategy might
be successful? Why do you think this strategy would work?
4. If you are a smoker, what do you do to avoid having others breathe your secondhand smoke? If nothing, what might you do in the future? If you are a nonsmoker, what do you do to avoid breathing others’ secondhand smoke? If nothing, what might you do in the future?
5. Do you use e-cigarettes or other vaping products? If so, why did you start smoking these products? A$er reading the Consumer Health feature in this chapter, do you think you will continue this practice? Why or why not?
Reflecting on Your Health
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2. Pierce, J. P., et al. (2010). Camel No. 9 cigarette-marketing cam- paign targeted young teenage girls. Pediatrics, 125(4), 619–626.
3. Hanewinkel, R., et al. (2011). Cigarette advertising and teen smoking initiation. Pediatrics, 127(2), e271–e278.
4. Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/!les /NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf
5. Centers for Disease Control and Prevention. (2010, October% 5). Vital signs: Binge drinking among high school students and adults—United States, 2009. Morbidity and Mortality Weekly Report, 59, 1–6.
6. van der Zwaluw, C. S., & Engels, R. C. M. E. (2009). Gene–environment interactions and alcohol use and dependence: Current status and future challenges. Addiction, 104, 907–914.
7. Enoch, M. A. (2006). Genetic and environmental in'uences on the development of alcoholism: Resilience vs. risk. Annals of the New York Academy of Sciences, 1094, 193–201.
8. Tawa, E. A., et al. (2016). Overview of the genetics of alcohol use disorder. Alcohol & Alcoholism, 51(5), 507–514.
9. Wechsler, H., & Nelson, T. F. (2008). What we have learned from the Harvard School of Public Health College Alcohol Study: Focusing attention on college student alcohol consumption and the environ- mental conditions that promote it. Journal of Studies on Alcohol and Drugs, 69, 481–490.
10. Turrisi, R., et al. (2006). Heavy drinking in college students: Who is at risk and what is being done about it? Journal of General Psychol- ogy, 133, 401–420.
11. Wechsler, H., et al. (2002). Trends in college binge drinking during a period of increased prevention e#orts: Findings from 4 Harvard School of Public Health college alcohol study surveys: 1993–2001. Journal of American College Health, 50, 203–217.
12. Zamboanga, B. L., et al. (2015). Frequency of drinking games par- ticipation and alcohol-related problems in a multiethnic sample of college students: Do gender and ethnicity matter? Addictive Behaviors, 41, 112–116.
13. Hingson, R. W., et al. (2009, July). Magnitude of and trends in alco- hol-related mortality and morbidity among U.S. college students ages 18–24, 1998–2005. Journal of Studies on Alcohol and Drugs, Suppl. 16, 12–20.
14. Addolorato, G., et al. (2006). Alcoholic liver disease: Pathogen- esis and current management. Alcohol Research: Current Review, 38(2), 7–21.
15. Klatsy, A. L. (2010). Alcohol and cardiovascular health. Physiology and Behavior, 100(1), 76–81.
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18. Li, Y., et al. (2009). Wine, liquor, beer and risk of breast cancer in a large population. European Journal of Cancer, 45(5), 843–850.
19. National Center for Statistics and Analysis. (2015, December). Alcohol-impaired driving: 2014 data (Tra&c Safety Facts. DOT HS 812 231). Washington, DC: National Highway Safety Administra- tion. Retrieved from https://crashstats.nhtsa.dot.gov/Api/Public /ViewPublication/812231
20. Kochanek, K. D. (2016). Deaths: Final data for 2014. National Vital Statistics Reports, 65(4), 1–122. Retrieved from https://www.cdc .gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf
21. Mumenthaler, M. S., et al. (2003). Psychoactive drugs and pilot per- formance: A comparison of nicotine, donepezil, and alcohol e#ects. Neuropsychopharmacology, 28, 1366–1373.
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References 277
Across the Life Span Nutrition
Managing Your Health Trimming Unhealthy Fats from Your Diet
Consumer Health Dietary Supplements
Diversity in Health Asian American Food
Chapter Overview The basic principles of nutrition
How your body digests and uses the food you eat
The functions and sources of nutrients
How to plan a nutritious diet
How malnutrition affects health
Student Workbook Self-Assessment: Assessing the Nutritional Quality of Your
Diet | Diabetes Risk Test | Using MyPlate
Changing Health Habits: Are You Ready to Improve Your Diet?
Do You Know? Which foods might help prevent cancer?
How to judge the nutritional adequacy of your diet?
If any vitamins are poisonous?
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Nutrition
© EyeEm
/Getty Im ages.
Learning Objectives “Why do you eat certain foods and not others?”
After studying this chapter, you should be able to:
1. List the six classes of nutrients, including micronutrients and macronutrients.
2. Identify major roles and food sources for each class of nutrients.
3. Identify sources of unsaturated fat, saturated fat, and cholesterol.
4. Describe how a person can reduce fat intake. 5. Differentiate between complete and incomplete proteins. 6. Describe characteristics and benefits of well-balanced and plant-based diets. 7. Use resources and interactive tools at www.choosemyplate.gov. 8. Use Nutrition Facts panel and other food labeling to make informed food choices. 9. Describe health problems associated with nutritional deficiencies or excesses. 10. Discuss varying nutritional needs of young, middle-aged, and older populations.
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Hamburger, cola, french fries, pizza, potato chips, tofu, yogurt, olive oil, nonfat milk, mango, and wheat germ—which of these foods do you eat regularly? Have you eaten chut- ney, tri'e, black beans, calamari, sushi, or hummus? How o$en do you buy so$ drinks and snacks from vending machines? During the past week, how many times did you eat at fast-food restaurants? Why do you eat certain foods and not others? Before deciding what to eat, do you consider the nutritional value of food? When asked if they care about what they eat, three students who were enrolled in a college health class responded as follows:
Do I care about what I eat? Well, it depends on how hungry I am. If I am hungry enough, I’ll eat anything, except some processed meats. I don’t care about the amount of fat, calories, or nutritional value in foods. All I care about is how much the food costs and how much it takes to fill me up. I’m young and healthy and have hardly any body fat—I’ve been eating greasy, cheap, fast foods for years.
I care about what I eat, but my diet doesn’t show it. When I wake up, I don’t have time to eat. After class I eat burritos or pizza rolls before going to work. After work, I usually stop at a fast-food place. . . I eat lots of french fries. I do want to eat better, but it’s hard when you’re always on the go.
I’m not concerned about what I eat. People call me the “fast-food queen” because that’s all I eat. I know fast food is not always healthy, but I’m going to school full-time and working. It’s hard finding time to buy food and cook it.
If you are like these students, taste, cost, and conve- nience are the most important factors that in'uence your food choices. You may not be aware, however, that many other factors, including food advertising and moods, can also in'uence your diet. Although
people usually associate diet with losing weight, the term actually refers to one’s usual pattern of food choices. A healthful diet provides substances that are necessary for life, but most people do not eat simply to satisfy their nutritional needs.
Your diet re'ects not only your food likes and dis- likes but also your lifestyle, !nancial status, and edu- cational, cultural, religious, and ethnic backgrounds. Additionally, certain foods have social signi!cance. When you watch a major sports event at a friend’s apartment with a group of people, do you help share the cost of pizzas that are delivered?
Some foods have personal emotional meanings. People o$en use such foods, especially sweets, to li$ their mood when they are feeling sad or distressed. Do you head for the kitchen not because you are hungry, but because you are bored or lonely? At other times, do you reward yourself for achieving a desired goal by eating a favorite food? Eating food to feel better, substitute for social activity, or reward yourself can result in a nutritionally inadequate diet and unwanted weight gain.
For many young adults, selecting a nutritionally inadequate diet has a major e#ect on their current and future health. Poor diet can reduce the e#ec- tiveness of the immune system, the body’s defense against many acute illnesses, including the com- mon cold and other infectious diseases. Poor food choices can result in anemia, a group of conditions characterized by an insu&cient number of properly formed red blood cells. People who have anemia lack the energy to carry out their normal activi- ties and exercise without tiring easily. For women, unhealthy diets can increase the risk of having a baby born too early or with birth defects. Poor diet is also a major risk factor for serious chronic diseases that are the major killers of Americans: cardiovascular disease (CVD), which includes heart disease and stroke; diabetes; obesity; Alzheimer’s disease; kidney disease; and possibly certain cancers (Figure 9.1). Sensible lifelong eating and physical activity habits play important roles in maintaining good health and preventing these chronic diseases. By making speci!c dietary changes, people can improve their chances of enjoying good health now and later in life.
"is chapter highlights the nutrients, their major food sources and roles in the body, and the bene!ts of choosing a nutritious diet. "e information in this chapter will help you evaluate the nutritional adequacy of your diet and plan nutritious menus.
diet One’s usual pattern of food choices.
nutrients Substances in food that are necessary for growth, repair, and maintenance of tissues.
phytochemicals A group of non-nutrients that are produced by plants and may have beneficial effects on the body.
antioxidants Compounds that protect cells from free radical damage.
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Figure 9.1 Diet and Causes of Death. In the United States, diet contributes to several of the leading causes of death, especially heart disease, certain cancers, stroke, diabetes, Alzheimer’s disease, and kidney disease.
Basic Nutrition Principles A healthy diet is o$en de!ned as eating a variety of healthy foods that contain essential nutrients to maintain healthy body function. Our dietary patterns in'uence the types and amounts of nutri- ents we consume and signi!cantly impact our short- and long-term health.
What Are Nutrients? Nutrition is the study of the way the body processes and uses nutrients, substances in food that are needed for growth, repair, and maintenance of cells. In addi- tion to these functions, some nutrients regulate cel- lular activity or supply energy. Table 9.1 lists the six classes of nutrients, describes some of their roles in the body, and identi!es their major food sources. In general, carbohydrates and fats supply energy; vita- mins and minerals participate in chemical reactions that regulate body processes; and proteins provide the material for tissue (cellular) growth, repair, and main- tenance. Water transports materials in the body and also participates in numerous chemical reactions.
"e human body can synthesize (produce) certain nutrients. For example, exposing skin to sunlight enables the body to make vitamin D. Other nutrients are essential; that is, the diet must supply nutrients that the body does not make or does not make in the amounts needed for good health. Nutritional
de!ciency diseases can develop when diets contain inadequate amounts of essential nutrients. "ese diseases are uncommon in the United States because we have a wide variety of foods available to eat. Addi- tionally, many commonly eaten foods and certain beverages are enriched or forti#ed with vitamins and minerals. Enriched bread, for example, has iron and certain B vitamins added to it. Milk is usually forti- !ed with vitamins A and D, and you can purchase orange juice that has been forti!ed with calcium.
What Are Non-nutrients? Some foods contain substances that you can live without. Many of these non-nutrients are naturally found in plants and have bene!cial e#ects on the body. Other non-nutrient substances, such as pesti- cide residues or lead, enter food unintentionally and can be hazardous to health.
Plants produce phytochemicals, a large group of non-nutrients that may provide health bene!ts. Many phytochemicals, including beta-carotene, lutein, and anthocyanin, are antioxidants. Antioxidants prevent or reduce the formation of free radicals, unstable and highly reactive atoms or compounds that can cause cellular damage. Such damage may contribute to heart disease, certain cancers, and the aging process. "ere is no scienti!c evidence at this time, however, that people bene!t from taking pills that contain phytochemicals.
Chronic lower respiratory diseases 5.7%
Accidents (unintentional injuries) 5.4%
Cerebrovascular diseases 5.2%
Alzheimer’s disease 4.1%
Diabetes mellitus 2.9%
Influenza and pneumonia 2.1%
Nephritis, nephrotic syndrome and nephrosis 1.8%
Intentional self-harm (suicide) 1.6%
Septicemia 1.5% Chronic liver disease and cirrhosis 1.5%
Essential hypertension and hypertensive renal disease 1.2%
Parkinson’s disease 1.0%
Pneumonitis due to solids and liquids 0.7%
Diseases of heart 23.4%
Malignant neoplasms 22.0%
All other causes 19.9%
Basic Nutrition Principles 281
Nutrient Class Major Roles in the Body Rich Food Sources
Carbohydrates Energy Grain products, beans, vegetables, fruits, honey, sugar-sweetened soft drinks, and candy
Lipids Triglycerides: energy
Cholesterol: most steroid hormones, bile production, skin maintenance, vitamin D synthesis, and nerve function
Vegetable oils, nuts, margarines, fatty meats, cheeses, cream, butter, and fried foods
Proteins Growth, repair, and maintenance of all cells; production of enzymes, antibodies, and certain hormones
Dried beans, peas, nuts, soy products, meats, shellfish, fish, poultry, eggs, and dairy products (except cream and butter)
Vitamins Metabolism, reproduction, development, and growth
Widespread in foods: nuts, beans, peas, fruits and vegetables, whole grains, meats, enriched breads and cereals, fortified milk
Minerals Metabolism, development, and growth Widespread in food: nuts and whole grains; meats, fish, and poultry; dairy products; vegetables and fruits; enriched breads and cereals
Water Essential for life: many chemical reactions require water; helps maintain normal body temperature; dissolves and transports nutrients
Water, nonalcoholic and caffeine-free beverages, fruits, vegetables, and milk (nearly every food contributes water to the diet)
Table 9.1
The Six Classes of Nutrients
Vitamin D–fortified milk.
"erefore, nutrition experts recommend that peo- ple eat a variety of fruits, vegetables, and whole grains daily to obtain a natural array of these substances. Dark green, yellow, orange, red, and purple fruits and vegetables tend to have the most antioxidant phytochemicals, so let color be your key to selecting the richest food sources of antioxidants (Figure 9.2). Table 9.2 lists some phytochemicals as well as their food sources and possible e#ects on the body.
Natural, Health, Organic, and Functional Foods Food manufacturers can label their products as nat- ural if they are minimally processed and contain no arti!cial additives such as synthetic colors or 'avors. So-called natural foods are not necessarily more nutritious than foods that do not carry this descrip- tion. Many consumers think natural foods such as honey, herbal teas, and cider vinegar are health foods because they have medicinal bene!ts. Although these foods provide nutrients, there is little or no scienti!c evidence to support claims that they pre- vent or treat various health conditions. Regardless of
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Phytochemicals Major Plant Sources Possible Disease-Fighting Properties
Allium Garlic, onions, leeks Enhances immune function; may reduce risk of certain cancers
Indoles, isothiocyanates (includes sulforaphane)
Broccoli, cabbage, watercress, kale, cauliflower, bok choy, collard and mustard greens, brussels sprouts
May inhibit cancer tumor growth
Ellagic acid Nuts (especially walnuts), grapes, apples, berries
Has antioxidant activity; may inhibit tumor growth
Flavonoids (includes anthocyanin)
Soy products, apples, artichokes, red grapes and wines, tea, onions, berries, red cabbage
Have antioxidant activity; may reduce risk of heart disease and certain cancers
Polyphenols Black and green tea, red wine Inhibit tumor growth; may reduce risk of heart disease
Monoterpenes Citrus peel oils, citrus fruits, cherries Anticancer agents
Carotenoids (includes beta- carotene, lutein, and lycopene)
Dark orange, yellow, and green fruits and vegetables, tomatoes
May reduce risk of cancer, but more research is needed
Phytic acid Whole wheat (bran and germ) May reduce risk of certain cancers and heart disease
Data from Graziose, M. M. (2016). Why eat fruits and vegetables? Journal of Nutrition Education & Behavior, 48(1), 84; Heiner, B., et al. (2012). Critical review: Vegetables and fruit in the prevention of chronic diseases; Mojzisová, G., et al. (2001). Dietary flavonoids and risk of coronary heart disease. (1994). Nutrition Reviews, 52(2), 59–68; Marwick, C. (1995). Learning how phytochemicals help fight disease. Journal of the American Medical Association, 274, 1328–1330; A garden of phytochemicals. (1995). University of California of Berkeley Wellness Letter, 12(1), 6–7.
Table 9.2
Phytochemicals
Figure 9.2 Color Palette for Good Health. Add colorful fruits and vegetables to your meals and snacks to boost your intake of antioxidant phytochemicals. © ÊDenis Pepin/Shutterstock.
whether it is natural or manufactured, a “healthy” food contributes to your nutrient needs and is safe to eat. Herbs, for example, may contain bene!cial phy- tochemicals, but some are natural sources of toxic substances and should be avoided.
Food producers can label their fruits, vegetables, and meat and poultry products as organic if they
meet certain standards. Fruits and vegetables, for example, must be grown without the use of synthetic pesticides and fertilizers. Advertisers sometimes refer to their products as organic to imply that these items are superior. Although organically grown foods may contain less pesticide residue, they are not more nutritious than similar foods that have been grown
Basic Nutrition Principles 283
States Food and Drug Administration (FDA) only regulates claims manufacturers make about func- tional foods’ nutrient content and e#ects on disease, health, or body function. "e Academy of Nutrition and Dietetics’ position statement on functional foods indicates that many nutrition professionals consider the term functional food a marketing term and that all food is functional because it provides energy and nutrients necessary for sustained life.1
What Happens to the Food You Eat? Humans eat a wide variety of plants, animals, and ani- mal products to obtain nutrients and other bene!cial substances. In their natural state, many nutrients are in complex forms that the body cannot use. During the process of digestion, the gastrointestinal tract (digestive system) breaks down complex food sub- stances into nutrients (Figure 9.3). Various enzymes, compounds that speed up chemical changes, partici- pate in the process of digestion.
Absorption is the passage of nutrients through the walls of the intestinal tract and eventually into the blood. A$er nutrients enter the bloodstream, many are transported to the liver, where they are processed or stored.
By the time any remaining food material enters the colon (the major segment of the large intes- tine), most of its nutrients have been absorbed. "is residue, which makes up some of the feces or stool, remains in the rectum until the individual has a bowel movement to eliminate the waste. "e entire process of digesting the food, absorbing its nutri- ents, and eliminating fecal residue generally takes about 1–3 days.
"e kidneys play an important role in maintaining the body’s normal nutrient levels by !ltering excess
using conventional farming methods. Chemists clas- sify compounds as organic if they contain carbon. Carbohydrates, fats, proteins, and vitamins contain carbon; therefore, they are organic compounds. Because most foods naturally consist of these nutri- ents, all foods are organic.
Functional foods, sometimes called nutraceuticals, are de!ned by the Academy of Nutrition and Dietet- ics as “whole foods along with forti!ed, enriched, or enhanced foods that have a potentially bene!cial e#ect on health when consumed as part of a varied diet on a regular basis at e#ective levels.” Based on this de!- nition, functional foods include conventional foods such as whole grains, fruits and vegetables, modi!ed foods such as yogurt, cereal, and orange juice, and foods for special dietary needs such as infant formula or hypoallergenic foods. A person must eat a certain amount of these foods regularly to obtain the desired e#ects. For example, a phytochemical that can lower blood cholesterol levels has been added to certain margarines and salad dressings. Another example is food containing probiotics, live bacteria, which are o$en considered functional foods because they may bene!t digestive health. Many di#erent kinds of bac- teria naturally reside in the large intestine. If certain bacteria overpopulate this region, diarrhea and seri- ous infections can result. Eating foods that contain certain kinds of microbes (probiotics) regularly may help maintain or regain the normal balance of bacte- ria in the large intestine. Some brands of yogurt con- tain probiotics. Prebiotics are substances in certain foods that support probiotics.
In the future, a variety of other specially formu- lated or forti!ed foods with advertised health bene- !ts will be available in supermarkets, including those that claim to reduce appetite or risk of heart disease. In many cases, much larger portions of formulated or forti!ed foods are necessary to ingest the amount of a phytochemical found in whole foods; therefore, nutrition experts recommend using whole foods, rather than forti!ed foods or dietary supplements, as primary sources of nutrition.
It is also important to note that there is no current legal de!nition for functional foods. "e United
probiotics Microorganisms that may provide healthful benefits when consumed.
digestion The process of breaking down large food molecules into smaller molecules that the intestinal tract can absorb.
absorption The passage of nutrients through the walls of the intestinal tract.
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Energy from Foods Metabolism refers to all of the chemical reactions that take place in the body. "ese reactions are necessary to power muscular movements, synthesize and repair tissues, release and use energy, and produce enzymes and hormones. To carry out metabolic activities, cells need the energy stored in fat, certain carbohydrates, and, to a small extent, protein. Oxygen, which enters the body from the lungs, is needed to release the stored energy. "is energy powers cell activities and helps maintain body temperature.
"e amount of energy in foods is expressed as a number of kilocalories, commonly referred to as “calories.” A calorie is a unit of energy. Foods containing carbohydrates, fats, proteins, and the non-nutrient alcohol provide calories. Proteins and most carbohydrates supply 4 calories per gram, alcohol provides 7 calories per gram, and fat provides 9 calories per gram. "e body cannot extract energy from water, vitamins, and minerals; therefore, these nutrients do not provide calories. "e following sec- tions provide some basic information about the six major classes of nutrients.
Parotid gland
Tongue Pharynx
Trachea
Liver
Duodenum
Jejunum
Ascending colon
Descending colon
Transverse colon
Stomach
Esophagus
Oral cavity
Sublingual salivary gland
Submandibular salivary gland
Appendix
Anus
Rectum
Sigmoid colon
Ileum
metabolism Chemical reactions that take place in the body.
calorie A unit of energy.Figure 9.3 The Digestive System. The stomach and small intestine break down large compounds in foods into smaller molecules that can be absorbed through the intestinal walls.
water-soluble nutrients from the blood so that they can be eliminated in the urine. A water-soluble nutrient dissolves in water. Many nutrients, such as proteins, B vitamins, and vitamin C, are water soluble. Fat- soluble nutrients such as cholesterol and vitamin A do not dissolve in water, and the kidneys cannot eliminate them as easily. Fat-soluble nutrients gener- ally circulate until the liver or fat cells remove them for storage.
Nutrient toxicities occur when the body cannot use or store excess nutrients, especially minerals and fat-soluble vitamins. For example, signs of vitamin A toxicity include nausea, vomiting, headaches, bone pain, hair loss, liver damage, birth defects, and even death (see Table 9.7 later in this chapter). People rarely eat enough food to obtain excessive amounts of nutrients. Nutrient toxicities, however, are more likely to occur from taking too many pills (dietary supplements) that contain the substances. Cour
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Basic Nutrition Principles 285
bananas, citrus fruits, carrots, kidney beans, psyl- lium seeds, and oats are rich sources of soluble #ber. Brown rice, wheat bran, and whole grain wheat products are rich sources of insoluble #ber. Plants usually contain mixtures of these forms of !ber. Table 9.3 lists !ber-rich foods; note that none are from animal sources.
In the United States, carbohydrates constitute about 44–47% of the typical person’s caloric intake. According to the 2015–2020 Dietary Guidelines for Americans, we should consume mostly complex carbohydrates in the form of whole grains, fruits,
Energy-Supplying Nutrients
Nutrients that provide energy in the form of calories are referred to as macronutrients. Each macronutri- ent, including carbohydrates, lipids, and proteins, serves speci!c functions in our body. Our primary sources of energy are carbohydrates and fats, while protein helps us maintain body functions and structures.
Carbohydrates Carbohydrates include sugars and starches. "e simplest carbohydrates are sugars called monosac- charides and disaccharides. Glucose, fructose (fruit sugar), sucrose (table sugar), and lactose (milk sugar) are the major simple sugars in our diets. Fruits, veg- etables, milk, and honey are naturally rich sources of simple sugars.
Starches are complex carbohydrates that contain hundreds of glucose molecules. Grains, beans, and certain vegetables such as potatoes are rich sources of starch. Plant foods supply most of the carbohydrates in the diet. Except for honey and milk, most animal foods do not contain carbohydrates.
During digestion, the large starch molecules are broken down to release glucose molecules, and sucrose molecules are broken down to release glucose and fructose molecules. "e small intestine absorbs these monosaccharides, and the liver converts much of the fructose to glucose. Eventually, the glucose molecules enter the bloodstream and can be used by cells.
Glucose, commonly referred to as “blood sugar,” is the most important monosaccharide in the human body. All cells, especially nerves, metabolize glucose for energy. A healthy body carefully maintains a normal blood glucose level.
Plants make lignin and certain carbohydrates that the human small intestine cannot digest. "is mate- rial is called dietary fiber, or simply !ber. Soluble forms of !ber swell or dissolve in water; insoluble forms remain relatively unchanged in water. Apples,
carbohydrates A class of nutrients that includes sugars and starches.
glucose The most important monosaccharide in the human body.
dietary fiber Indigestible substances produced by plants.
Whole Grain Products
Whole wheat flour, high-fiber wheat bran cereals, psyllium,* oat bran,* oatmeal,* brown rice, whole grain crackers, buckwheat groats, barley,* wheat germ
Dried Beans and Peas
Lentils, pinto beans, lima beans, kidney beans,* navy beans, split peas
Fruits Bananas,* berries, oranges,* figs, grapefruits,* fruits with edible peels (e.g., apples,* peaches, pears)
Vegetables Vegetables with edible peels (e.g., potatoes), brussels sprouts, broccoli, okra, cabbage, peas, turnips, spinach, sweet potatoes, carrots*
*Rich source of soluble fiber.
Table 9.3
Fiber-Rich Foods
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to sweeten sugar-free gums, candies, and diet so$ drinks. When consumed in normal amounts by healthy people, these sweeteners are safe and contrib- ute few or no calories to diets.2,3
Carbohydrates and Health Recent data from the National Center for Health Statistics indicated that the average American consumed 11–14% of his or her total calories from sucrose and other caloric sweeteners.4 Women consumed a larger portion of their total calories from added sugars, and Americans 20–39 years of age consumed the most sugar. HFCS and sucrose are the primary caloric sweeteners in so$ drinks, candies, desserts, and many processed foods. "ese simple carbohydrates are blamed for numerous health problems, including diabetes, hyperactivity, mental illness, and criminal behavior. Does scienti!c evidence support these claims?
Despite popular beliefs, there is no scienti!c evi- dence that sucrose or other sugars cause or contribute to hyperactivity, mental illness, or criminal behavior. Sucrose cannot be absorbed by the intestinal tract. During digestion, the sugar is broken down into glu- cose and fructose, which are sources of energy for the body. However, recent research indicates that eat- ing less sugar is better for long-term health. Recent research indicates that added sugar intake increases the risk of obesity, type 2 diabetes, and death from cardiovascular disease.5,6,7
Tooth decay is also directly related to carbohy- drate consumption. Carbohydrates can stick to teeth, providing food for bacteria in the mouth. As the bac- teria metabolize carbohydrates, they produce acids that destroy the enamel of teeth, and decay results. Good oral hygiene practices, including brushing and 'ossing a$er meals and snacks, can reduce the risk of dental decay.
Some people avoid eating table sugar, which is made from sugar beets or sugar cane, but will use honey as a sweetener because they think it is more “natural” and nutritious than sugar. Although honey contains very small amounts of phytochemicals, it has essentially the same nutritional value as other sugars.
Honey should not be added to baby foods because it may contain spores of Clostridium botulinum, a bacte- rium that produces a dangerous toxin. "is toxin a#ects nerves, causing loss of muscle functioning, which can be life threatening when it impairs breathing. Infants who eat contaminated honey are at risk of developing infantile botulism because their stomachs do not pro- duce enough acid to kill the bacterial spores. Children older than 1 year of age and adults produce su&cient amounts of stomach acid, so they can eat honey safely.
and vegetagles.1 Furthermore, simple carbohydrates (sugars) should make up less than 10% of your total daily calories. Foods that contain high amounts of% the simple carbohydrate sucrose and another form of sugar called high-fructose corn syrup (HFCS) are o$en poor sources of vitamins and minerals. "us,% eating a lot of sugary foods can displace more nutritious foods from a person’s diet. It can be di&cult to identify sugars in foods by the ingre- dients listed on the label. Table 9.4 lists names for various sugars.
Most nutrition experts recommend that Americans reduce their intake of sucrose and HFCS by consum- ing fewer regular so$ drinks, candies, and bakery items. Sugar substitutes such as rebaudiana (a%form of stevia), aspartame (NutraSweet), sucralose, and sac- charin are available in packets for consumers to use. Food manufacturers may also use sugar substitutes
Sucrose
Table sugar, raw sugar, turbinado sugar
Granulated cane juice or evaporated cane juice
Confectioner’s or powdered sugar
Brown sugar
Invert sugar
Maple syrup
Molasses or blackstrap molasses
Honey
Date sugar
Corn syrup, cultured corn syrup, or high-fructose corn syrup
Fruit sugar
Levulose
Fruit juice concentrate
Concentrated fruit juice sweetener
Glucose or dextrose
Polydextrose
Maltose
Maltodextrin
Table 9.4
Other Names for Sugars
Energy-Supplying Nutrients 287
disease.9 "e two most prevalent forms of diabetes are type 1 diabetes and type 2 diabetes. Most people with diabetes have type 2. Table 9.5 lists the common signs and symptoms of each type.
Type 1 diabetes is caused by an inappropri- ate immune system response to an infection ( autoimmune disease) that damages the cells of the pancreas that make insulin. People with this condition require daily injections of insulin because the pancreas does not produce the hormone. Some people with type 1 diabetes wear a small device that pumps insulin into their bodies. Although type 1 diabetes is o$en called juvenile diabetes, the label is misleading because type%1 can strike at any age. "e majority of cases, however, are diagnosed in%childhood.
People with type 2 diabetes are usually older than 40 years and have excess body fat (obesity) and a family history of diabetes. Since 1997, the prevalence of type 2 diabetes has increased dramatically in the United States, particularly among black and Hispanic Americans.10 Moreover, this form of the disease is becoming more common among children and ado- lescents, as rates of obesity increase among younger members of the population.
diabetes mellitus A group of chronic diseases characterized by the inability to metabolize carbohydrates properly.
Contrary to popular myth, eating sugar does not make children hyperactive. © Thomas Northcut/Digital Vision/Thinkstock.
Diabetes Mellitus Diabetes mellitus, o$en simply called diabetes, is a group of chronic diseases charac- terized by an inability to metabolize carbohydrates properly. "is abnormality also a#ects metabolism of proteins and fats. A person with diabetes produces no insulin or insu&cient amounts of insulin, or has cells that do not respond normally to insulin. Insulin, a hor- mone that is produced in the pancreas (see Figure 9.3), helps glucose enter cells. Without the normal action of insulin, the cells cannot carry out their metabolic activities properly, and glucose builds up in the blood. High blood glucose levels can lead to serious chronic health disorders, including hypertension, loss of vision, and nerve damage. In the United States, poorly controlled diabetes is a major cause of kidney failure, blindness, and lower limb amputations. Furthermore, having diabetes greatly increases one’s risk of heart dis- ease and stroke. Each year, thousands of people die as a result of diabetes. Diabetes is the seventh leading cause of death in the United States.8
Over 30 million Americans have diabetes; 7% million of these people were unaware that they had the
Type 1 Diabetes
(Generally develops in childhood and young adulthood)
• Lack of energy • Listlessness • Frequent urination • Excessive thirst • “Fruity” odor in breath • Increased appetite with weight loss • Vision problems
Type 2 Diabetes
Usually few symptoms, but when they exist:
• Excessive thirst • Frequent urination • Vision problems • In women, recurrent vaginal infections • Skin sores that do not heal
Table 9.5
Common Signs and Symptoms of Diabetes Mellitus
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Poor diets o$en contain high amounts of added sugars, such as sucrose or HFCS. Although added sugars make foods and beverages more appealing to some people, they supply few vitamins and minerals. As a result, sugary foods displace more nutritious foods from meals and snacks. Americans’ high intake of products sweetened with HFCS may contribute to the rising prevalence of obesity and type 2 diabetes in the United States.6 So$ drinks sweetened with HFCS such as colas, fruit drinks, and energy drinks are the primary source of sugar in the typical American’s diet.11 In the United States, so$ drink consumption has increased dramatically since 1970. During this same period, the percentage of Americans who are obese and have diabetes increased as well. It is dif- !cult to prove that sugar-sweetened so$ drinks cause excess weight gain and diabetes; more research is needed to support these !ndings. Nevertheless, you may want to analyze your sugar-sweetened so$ drink consumption. Instead of satisfying your thirst with sugary so$ drinks, consider drinking plain water.
Type 2 diabetes can o$en be controlled by dietary modi!cations and regular exercise. Many a#ected persons, however, need to take medications, some of which increase the production of insulin by the pan- creas. Some people with type 2 diabetes need daily insulin injections. By carefully controlling their blood sugar levels through diet, exercise, and, if necessary, medication, people with diabetes can o$en lessen the long-term damaging e#ects of the disease.
You may be able to reduce your risk of type 2 dia- betes by losing excess weight and increasing physical activity.12,13 It is also important to have routine health checkups that include diabetes testing because many people with type 2 diabetes are not aware that they have the disorder. You may want to take the diabetes quiz in this text’s Student Workbook to assess your risk of developing this disease.
Metabolic Syndrome About one-fourth of Amer- ican adults have metabolic syndrome, a condition that increases the risk of CVD and type 2 diabetes.14 Peo- ple with metabolic syndrome have excess abdominal fat and at least two of the following health problems: hypertension (chronically elevated blood pressure), high blood glucose, high blood triglycerides (fat), and low HDL (“good”) cholesterol levels. People who have large waistline measurements generally have excess visceral fat, deposits of adipose cells that are located deep within the abdomen. Adipose cells
Obesity contributes to type 2 diabetes, especially when one has a family history of the disorder. In many instances, people with type 2 diabetes can improve their blood glucose levels by losing their excess body fat. Regular physical activity can also reduce high blood glucose levels, and adopting a physically active lifestyle helps people achieve and maintain healthy body weights.
Poor diet also contributes to the development of type 2 diabetes. When too much glucose enters the bloodstream a$er a high-carbohydrate snack or meal, the pancreas may respond by releasing an excess of insulin. High blood insulin levels may increase the risk of heart disease, obesity, and type 2 diabetes. Sci- entists have measured the intestinal absorption rates of many commonly eaten carbohydrate-rich foods and assigned glycemic index (GI) values to them. Foods with high GIs (over 70), such as white, short- grained rice, increase blood glucose levels more than foods with low GIs (under 55), such as kidney beans. People may reduce their risk of type 2 diabetes by eating diets that contain more low-GI than high-GI foods. Among nutrition experts, however, the contri- bution of a high-GI diet to the development of type 2 diabetes is controversial.
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adipose cells Cells that store fat.
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people may reduce their risk of developing metabolic syndrome, a condition that o$en precedes type% 2 diabetes. Table 9.3 lists some foods that contain !ber and indicates which are rich sources of soluble and insoluble !ber. Soluble !ber slows the absorption of glucose from the digestive tract, which is bene!- cial for people who already have diabetes. Further- more, eating a high-!ber diet, particularly one with plenty of soluble !ber, can reduce the risk of heart disease. Soluble !ber lowers blood cholesterol levels by reducing cholesterol absorption in the small intes- tine. Elevated blood cholesterol levels are associated with increased risk of CVD.
Many Americans are concerned with their bowel habits; they spend millions of dollars a year on laxa- tives that promise “regularity.” Eating !ber-rich foods can prevent constipation, a condition characterized by having fewer than three bowel movements per week.16 Insoluble #ber contributes to the formation of so$er, larger stools that stimulate the muscles of the colon, producing the urge to have bowel movements more frequently.
Constipation results when stools are too small and hard to stimulate the colon regularly. A constipated individual o$en has to strain while having bowel movements, increasing the pressure on veins in the rectum. "is pressure can result in hemorrhoids, which are painfully swollen veins in the rectal and anal areas. Straining during bowel movements causes diverticulosis, a chronic condition in which the lin- ing of the colon forms small pouches called divertic- ula (Figure 9.4). Fecal material that becomes lodged in some of these little pouches can cause serious bleeding and in'ammation (diverticulitis). Diver- ticulitis can be life threatening if an in'amed pouch ruptures and spills fecal material into the abdominal cavity. Diverticulosis commonly occurs in Ameri- cans older than 50 years, but the condition o$en pro- duces no serious symptoms.
In addition to eating more !ber-rich foods, you may prevent constipation by consuming adequate amounts of water. Regular exercise may also improve bowel functioning.16 If constipation persists, or if you have intestinal pain, blood in your stools, or rectal bleeding, check with a physician to rule out serious health problems.
Can eating a high-!ber diet reduce your chances of developing certain cancers of the intestinal tract? Over the past few years, several population stud- ies have provided con'icting !ndings concerning !ber intake and the risk of colon and rectal cancer. Some medical researchers have found no association
store fat, but the tissue also secretes substances that have important immune functions. Storing too much fat disrupts the normal functioning of visceral fat cells. As a result, these cells secrete C-reactive protein and other factors that are thought to contribute to systemic in'ammation—in'ammation that occurs throughout the body. Systemic in'ammation may be partially responsible for heart disease, hyperten- sion, and type 2 diabetes. Losing excess body fat can reduce levels of in'ammatory substances and lower the risk of these chronic conditions.
Poor dietary habits, such as eating a diet that lacks fruits, vegetables, and other !ber-rich foods, contrib- ute to metabolic syndrome. By exercising regularly, maintaining a healthy body weight, and eating plenty of !ber-rich foods, people may be able to avoid this common condition.
Lactose Intolerance Lactose (milk sugar) is com- posed of two monosaccharides. During digestion, lactose is broken down, releasing its component sim- ple sugars. Many older children and adults, however, cannot digest lactose. Such lactose-intolerant people may experience intestinal bloating, cramps, and diar- rhea if they consume milk or other products that contain the sugar. Lactose intolerance a#ects millions of Americans. Members of certain minority groups, especially people with Asian or African ancestry, are more likely to be a#ected than Caucasians.15
Because milk is an excellent source of the mineral nutrient calcium, it is important that lactose- intolerant people consume alternative calcium-rich foods, such as cheese, yogurt, broccoli, turnip and mustard greens, and some types of tofu. People with this condition can add a special enzyme to milk and other foods that contain lactose before consuming them. "e enzyme breaks down lactose, reducing the risk of unpleasant side e#ects. Also, supermar- kets o$en sell fresh milk that has been treated with the enzyme. A#ected individuals, however, can o$en consume small amounts of lactose-containing foods without experiencing discomfort.
Fiber and Health Fiber provides some important health bene!ts. By eating more high-!ber cereals,
constipation A condition characterized by having fewer than three bowel movements per week.
hemorrhoids Painfully swollen veins in the rectal and anal areas.
diverticulosis An intestinal disorder that occurs when the colon lining forms small pouches that protrude through the outer wall of the colon.
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between high-!ber diets and risk of these cancers, but others have determined that eating such diets lowers the risk. More research is needed to clarify the role of dietary !ber in gastrointestinal health.
"e typical American consumes less than%20%grams of !ber a day. Medical experts think individuals should consume at least 25 grams of !ber by eat- ing more fruits, vegetables, beans, and whole grain cereal products each day. During processing, grains o$en lose their vitamin, mineral, and !ber-rich parts.
Diverticula
Colon Sigmoid
colon
Figure 9.4 Diverticula. Diverticula are small pockets of the large intestine’s inner lining that protrude through the outer wall of the large intestine. Diverticula can become infected and rupture.
Dairy foods are often sources of lactose. © iStockphoto/Thinkstock.
White 'our, for example, is a re!ned grain product made from wheat kernels. Compared to whole wheat 'our, white 'our contains very little !ber. Replac- ing re!ned 'our products, such as white bread, with whole grain foods is an easy way to increase the !ber content of your diet. Some “100% wheat” breads con- tain little !ber; use the nutrient label to compare the !ber content of breads.
Lipids Dietary lipids include cholesterol and triglycerides. About 95% of the lipid content in foods consists of triglycerides, commonly called fats and oils. Because each cell contains triglycerides, it is not surprising that a small amount of fat is necessary for health. Compared to carbohydrates, fat is a more concen- trated source of calories. "e body stores energy in its fat deposits, which insulate the body from cold tem- peratures, give the body shape, and protect internal organs from jarring movements.
lipids A class of nutrients that includes triglycerides and cholesterol.
triglycerides The most prevalent form of lipids in foods; often called fat.
Energy-Supplying Nutrients 291
Animal foods also contain cholesterol, a com- pound that is structurally di#erent from a triglycer- ide. Despite its reputation for being a troublemaker, cholesterol has several very important functions in the body. Cell membranes contain cholesterol, and the body uses this lipid to produce steroid hormones, vitamin D, and bile, a substance needed for proper fat digestion. Even if you could avoid eating foods that contain cholesterol, your liver and small intestine would make this essential compound.
Only animals produce cholesterol; therefore, the compound is found in animal and not plant foods. Meats, whole-milk products, and egg yolks supply most of the cholesterol in the typical American diet. Table 9.6 lists cholesterol-rich foods and the amount of cholesterol in each serving.
Lipids and Health If you used to drink whole or reduced-fat (2%) milk, how did you react when you !rst tasted nonfat milk? Did you think the milk was watery or “thin”? "e fat contained in or added to foods makes them taste rich and 'avorful. Fat in
Each triglyceride has three fatty acids. Scien- tists classify fatty acids into three types—saturated, monounsaturated, and polyunsaturated—according to their chemical structures. Although the triglycer- ides found in foods contain mixtures of these three types of fatty acids, one type usually predominates. Figure 9.5 indicates the lipid amounts and the per- centages of saturated, monounsaturated, and poly- unsaturated fatty acids in a tablespoon of various fats and oils.
Animal foods generally contain more saturated fat than do plant foods. Olive, peanut, and canola oils are rich sources of monounsaturated fat; corn, sa)ower, cottonseed, and walnut oils are high in polyunsaturated fat. Oils from palm kernels or coco- nuts, commonly called tropical oils, are unusual in that they are from plants but contain large amounts of saturated fat.
0 20 40 60
Percentage
80 100 120
Safflower oil
Sunflower oil
Source or Type of Fat/Oil
Corn oil
Soybean oil
Soybean/Cottonseed oil
Olive oil
Canola oil
Peanut oil
Chicken fat
Lard (Pork fat)
Beef fat
Coconut oil
Hydrogenated vegetable shortening
Margarine (hard)
Butter
14 9 12 74
14 11 19 66
14 13 24 59
14 14 23 59
14 18 29 48
14 13 73 8
14 7 59 29
14 17 46 31
13 30 45 21
13 39 45 12
13 50 42 4
14 90 5 1
13 25 45 26
11 20 45 33
11 65 30 4
Total lipid/Tablespoon (g)
% Saturated % Monounsaturated % Polyunsaturated
cholesterol A type of lipid found only in animals.
Figure 9.5 Fatty Acid Content of Common Fats and Oils.
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risk of arrhythmias (irregular heartbeats), decrease blood fat levels, slow growth of plaque in arteries, and lower blood pressure.7 Other studies indicated that foods rich in omega-3 fatty acids slow aging and may reduce Alzheimer’s disease risk. Omega-6 fatty acids are also essential fatty acids. Along with omega-3 fatty acids, omega-6 fatty acids are nec- essary for brain functions; however, some studies indicate diets high in omega-6 fatty acids, such as the typical American diet, tend to increase in'am- mation and may play a role in increased pain asso- ciated% with arthritis.18 Although there is currently no recommended dietary intake for omega-3 and omega-6 fatty acids, nutrition experts recommend consuming more omega-3 fatty acids than omega-6 fatty acids by eating several servings of !sh, plants, and nuts each week.
Rich food sources of omega-3 fatty acids include fatty !sh and shell!sh from cold water, such as wild salmon, herring, tuna, mackerel, and shrimp. Plant foods such as canola and soybean oils, walnuts, and 'ax and pumpkin seeds also contain omega-3 fat. "e body, however, can convert only a small amount of the plant form of omega-3 fat into the types that are more e#ectively used by human cells. "erefore, it is best to rely on !sh and shell!sh for omega-3 fats.
Fish is not a staple of the typical American (Western) diet; therefore, some people take !sh oil supplements to obtain the omega-3 fats. Consuming too many !sh oil supplements, however, may interfere with blood clotting, making excessive bleeding likely. Instead of relying on !sh oil supplements, try to include cold- water !sh and shell!sh in your meals a couple of times each week.
Unlike the typical American diet, which contains large amounts of red meat and few fruits and veg- etables, traditional food choices of Mediterranean populations supply smaller amounts of meat, fried foods, and sweets and larger amounts of plant foods, !sh, and olive oil. "e risk of heart disease is lower for individuals who consume the traditional Medi- terranean diet.19 Unlike the traditional American diet, fruits, vegetables, legumes, nuts, !sh, and other sea- food are primary sources of nutrients in the Medi- terranean. Poultry and dairy are consumed less, and meat and sweets are rarely eaten. "e Diversity in Health essay discusses the traditional Asian diet, which also contains less animal protein and saturated fat than Western diets do.
Trans Fats Not all foods made with vegetable oil have healthful properties. Hydrogenation is a food
food also increases the absorption of vitamins% A, D, E, and K and many phytochemicals. Nutrition experts recommend that adults limit overall fat consumption and, when eating fats, eat mostly unsaturated fats.1
Diets that supply too much saturated fat are asso- ciated with an increased risk of heart disease. High intakes of saturated fat can increase blood cholesterol levels. Although eating foods that contain cholesterol may also raise blood levels of this lipid, saturated fat tends to increase blood cholesterol levels to a much greater extent.
Diets that contain an adequate amount of unsat- urated fatty acids, particularly omega-3 fatty acids, may reduce in'ammation in the body and reduce risk for some chronic diseases.17 "e American Heart Association reports that diets rich in foods contain- ing omega-3 fatty acids have been shown to decrease
Food Serving Size Cholesterol (mg)
Beef liver 4 oz 545
Egg
Yolk
White
1 large 212
212
0
Shrimp 3 oz 167
Turkey, ground cooked 4 oz 116
Beefsteak 4 oz 94
Ice cream (rich = 16% fat)
1 cup 90
Sherbet (2% fat) 1 cup 10
Yogurt, plain low-fat 1 cup 14
Whole milk 1 cup 33
Reduced-fat (2%) milk 1 cup 18
Nonfat milk 1 cup 4
Butter 1 tablespoon 31
Swiss cheese 1 oz 26
Cream cheese 1 oz 10
Bacon 3 slices 16
Table 9.6
Cholesterol in Foods
Energy-Supplying Nutrients 293
Most food labels provide nutrition information concerning the amounts of total fat, saturated fat, trans fat, and cholesterol in food products. A later section of this chapter describes how to use this information to control the amount and type of fat in your diet.
Proteins Your body needs proteins to build, maintain, and repair cells; to form structural components such as hair and nails; and to make enzymes, antibodies, and numerous hormones. Although carbohydrates and fats are its primary fuels, the body derives a small amount of energy from protein. Proteins consist of amino acids. During digestion, proteins in plant or animal foods are broken down, releasing amino acids for absorption. Human cells use about 20 di#erent amino acids to synthesize the thousands of proteins in the body. "e cells can make 11 of these amino acids; the other 9 amino acids are essential and must be supplied by the diet. If the diet lacks the essential amino acids, the body is unable to grow properly or carry out vital functions.
Most foods, even plant foods, contain some pro- tein. Animal foods generally contain adequate amounts of each essential amino acid; these foods are complete or high-quality protein sources. Most plants are sources of incomplete or low-quality pro- tein because they either contain insu&cient amounts or lack one or more of the essential amino acids. "e best plant sources of essential amino acids are soy- beans, quinoa, whole grains, seeds, nuts, peas, and lentils (Figure 9.6). Fruits do not contain appreciable amounts of essential amino acids.
processing technique that partially hardens the oil so that it can be made into shortening and sticks of margarine. "is process alters the natural chemi- cal structure of some unsaturated fatty acids in veg- etable oils, forming trans fatty acids. In the body, trans fatty acids behave like saturated fats, raising unhealthy forms of cholesterol in blood.17 To reduce your intake of trans fatty acids, use so$ or liquid margarines, eat less commercial cake frosting, and avoid baked goods and fried foods, which are o$en made with hydrogenated fats. In response to con- sumer concerns, many restaurant chains and food manufacturers have eliminated trans fats from their products. Other factors besides dietary lipids con- tribute to heart disease.
Fat Substitutes Engineered compounds such as Olestra, Oatrim, and Simplesse are used to replace some or all of the fat in certain processed foods. Olestra, for example, supplies no calories because it cannot be digested and absorbed. A 1-ounce serving of regular tortilla chips supplies 130 calories and con- tains 6 grams of fat; the same amount of chips fried in Olestra contains 76 calories and no fat. For consum- ers demanding a variety of fat-free snack foods that taste good, Olestra seems to be a good fat substitute. However, eating foods made with Olestra may pro- duce some unpleasant side e#ects. Additionally, the substance interferes with the absorption of certain vitamins. Food scientists are currently developing fat replacers that taste good, do not cause side e#ects, and are chemically stable when heated.
Setting Limits "e typical American diet contains too much fat, especially the unhealthy kinds of fat (saturated and trans fats) from dairy products, meats, baked goods, and processed snack foods. College students and other busy people o$en consume more fat than is necessary by eating greasy snacks and fast foods regularly. Popular fast foods, such as cheese- burgers, pizza, fried chicken and !sh, french fries, and milk shakes, contain large amounts of saturated fat. Many fast-food restaurants, however, o#er less fatty items such as roast chicken, low-fat yogurt, bean bur- ritos, and meatless salads. "e Managing Your Health feature “Trimming Unhealthy Fats from Your Diet” provides some practical ways to reduce your intake of saturated and trans fats.
proteins A class of nutrients that build, maintain, and repair cells.
amino acids The chemical units that compose proteins.
Figure 9.6 Soybean Products. Tofu and other processed soybean products are excellent plant sources of protein. © C Squared Studios/Getty Images.
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Tuna is an excellent source of omega-3 fat. © Hemera/Thinkstock.
Diversity in Health Asian American Food Asian populations consume large quantities of rice, wheat noodles, and vegetables combined with eggs or a small amount of meat (usually seafood, poultry, fish, or pork). The traditional Asian diet is high in starch and fiber and usually low in fat, especially saturated fat. Stir- frying vegetables and meats in a lightly oiled wok and steaming foods are popular Asian cooking methods that add fewer calories than deep-fat frying and preserve more vitamins and minerals than boiling. To season their foods, most Asian cooks use low-fat items such as garlic, ginger, and sauces made from mustard and soybeans.
Not all features of the traditional Asian diet are healthful. Asian meals contain little or no dairy prod- ucts; therefore, the amount of calcium in these diets is usually low. Among the residents of northern Japan, the consumption of soy sauce as well as fermented and pickled foods adds excessive amounts of sodium to diets and may contribute to the relatively high incidence of certain cancers and hypertension. After immigrating to the United States, many Asians adopt Western food preferences and preparation practices. For example, American-style Chinese meals often include larger por- tions of meat and breaded, deep-fried foods.
Some people experience an adverse reaction when they eat Asian or other foods to which the flavor enhancer monosodium glutamate (MSG) has been added. After eating food that contains MSG, persons who are sensitive to the compound may report a “tight” © t
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sensation in the face and chest, head- ache, and pain and reddening of skin, especially on the face. Results of clinical studies, however, fail to show consis- tently that MSG causes adverse reac- tions in most people.20
When you eat at Chinese, Japanese, Thai, and other Asian American res- taurants, select menu items carefully. Choose plenty of steamed vegetables and rice or noodles to accompany the entrée. Avoid dishes containing foods that have been dipped in batter and fried, avoid or limit your intake of fried wontons and egg rolls, and do not add soy sauce to your food. If you react adversely to MSG, many cooks, on request, will prepare your food without it.
Proteins and Health Animal products, especially meat, !sh, poultry, eggs, milk, and milk products, contribute almost two-thirds of the protein in the typical American’s diet.21 Although consuming more than the recommended amount of protein does not harm most healthy individuals, generous portions of animal foods contribute excessive amounts of saturated fat to the diet. Diets that contain high amounts of saturated fat are associated with increased risk of heart disease, the number one killer of Americans. Diets very high in protein are asso- ciated with increased risk for stroke, diabetes, and several types of cancer.22
Many athletes and bodybuilders think it is neces- sary to consume large quantities of animal foods and protein supplements to increase their muscle mass. "is practice does not build bigger muscles; instead,
Energy-Supplying Nutrients 295
Managing Your Health
Americans can reduce the amount of unhealthy fats in their diets by chang- ing the ways they select and prepare their food. The following tips can help you trim unwanted fat from your diet.
• Avoid breaded and fried vegetables, chicken, fish, and meats.
• Eat less red meat and more poultry and fish. • Avoid sausage, bacon, and fatty luncheon meats. • Eat boiled or baked instead of fried potatoes. • Trim all visible fat from meats before cooking them. • Chill cooked chili, stews, soups, sauces, and gravies.
Then, skim off the fat before reheating and serving these foods.
• Substitute fat-free (“skim”) milk for whole or reduced-fat (2%) milk.
• Substitute reconstituted, nonfat dry milk in recipes that use milk or cream.
• Eat low-fat or fat-free frozen yogurt and ice milk. • Replace hard cheeses with part-skim or low-fat cheeses. • Substitute fat-reduced cream cheese for regular
cream cheese.
• Substitute plain low-fat or fat-free yogurt for sour cream in recipes.
• Skim frostings from cakes; commercial frostings are often made with hydrogenated shortening, which is 100% fat and contains trans fats.
• When eating two-crust pies, eat the filling and only one crust; discard the remaining crust.
• Replace shortening in recipes with oil or margarine.
Trimming Unhealthy Fats from Your Diet
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the body must metabolize the extra amino acids for energy or convert them into body fat. Additionally, the kidneys need more water to eliminate the excess amino acid by-products. "e most e#ective way to enhance muscle mass is to combine a nutritionally adequate diet with a program of muscle-strengthening exercises.
Animal foods are among the most expensive items on the typical American’s grocery list. You can reduce your food costs and decrease your saturated fat intake by substituting certain plant foods for meat and other animal protein sources. "e following section discusses vegetarianism, a way to reduce your animal protein intake without sacri!cing the nutritional adequacy of your diet.
Vegetarianism A growing number of Americans are consuming plant-based, or vegetarian, diets that contain little or no animal foods. Many people associ- ate meat with protein, but processed soybean foods such as tofu, soy milk, and soy nut butter; quinoa; various beans, peas, and lentils; nuts; seeds; and foods made from cereal grains (for example, wheat and oats) are among the best sources of protein from plants.
"ere are several types of vegetarian diets. "e vegan, or total vegetarian, diet consists of plant foods only. Other vegetarian diets include some animal foods. For example, the lacto-vegetarian diet contains dairy products, and the lacto-ovo-vegetarian diet includes eggs as well as dairy products. Some people who eat !sh or poultry still call themselves vegetar- ians because they do not eat red meats. "ere are so many di#erent plant-based diets that it is di&cult to estimate the number of Americans practicing some form of vegetarianism.
Are vegetarian diets nutritious? Plant-based diets may promote good health because they contain more !ber, antioxidants, and phytochemicals and less saturated fat and cholesterol than the traditional meat-rich Western diet. Generally, the nutritional adequacy of a vegetarian diet varies according to the degree of its dietary restrictions. Animal foods are rich sources of essential amino acids as well as certain minerals and vitamins. Plant foods, on the other hand, generally lack one or more essential amino acids.
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In the past, nutrition experts advised vegans to consume mixtures of plant foods that supplied all the essential amino acids in one meal because it was believed the body did not save essential amino acids and was unable to make proteins unless all of them were available at one time. Now it is known that the body can conserve essential amino acids a$er a meal or snack and use them for protein production later in the day. Although it is not necessary to combine plant foods to obtain the proper mix of amino acids, com- binations such as peanut butter on toast or red beans and rice make vegetarian meals nutritious, inexpen- sive, and easy to prepare. Most vegetarians can obtain adequate amounts of essential amino acids and other nutrients by eating a variety of plant foods, consum- ing dairy products, and taking a multiple vitamin/ mineral supplement.
"us, with careful planning, most plant-based diets can be nutritionally adequate.23 If you are interested in learning speci!c details about vege- tarian cookery and menu planning, you can obtain this information from registered dietitians (RDs) or University Outreach Extension nutritionists in your area.
Food Allergies A 3-year-old child develops hives—small, itchy, swollen, reddened areas on her skin—soon a$er she eats eggs. Her older brother must avoid peanuts and foods that may contain pea- nuts because he can experience shock, a drop in blood pressure and loss of consciousness that can be deadly if not treated immediately. "ese reactions are the result of food allergies, the immune system’s inap- propriate response to harmless proteins (allergens) in certain foods. In the United States, 5% of children and about 4% of adults are allergic to one or more foods.24 Proteins in cows’ milk, eggs, peanuts, tree nuts (such as cashews and walnuts), wheat, soybeans, !sh, and shell!sh are most likely to cause allergic reactions in susceptible people. Food manufacturers must iden- tify ingredients that are common food allergens on labels (Figure 9.7).
Hives are the most common sign of food allergy; other signs include eczema, a scaly skin rash; asthma symptoms, such as wheezing and di&culty breath- ing; and vomiting and diarrhea. Shock (anaphylaxis) occurs when the entire body reacts to the allergen. As mentioned earlier, shock can be fatal.
If you think you or someone you know has a food allergy, consult an allergist/immunologist, a physi- cian who specializes in the diagnosis and treatment of allergies. Special skin and blood tests are used to identify food allergies (Figure 9.8). Alternative
Figure 9.7 Labeling Food Allergens. The Food Allergen Labeling and Consumer Protection Act requires food manufacturers to identify on their products’ labels common food allergens that may be in packaged foods. Courtesy of Wendy Schi".
Figure 9.8 Skin Testing for Food Allergies. Skin testing that is performed by a physician is an effective method of diagnosing food allergies. © Andy Lidstone/Shutterstock.
Energy-Supplying Nutrients 297
vomiting; pale, foul-smelling stools; and weight loss. Children with the disease are irritable and fail to grow properly.
Celiac disease is an autoimmune disorder. People with this chronic condition are also likely to have other autoimmune diseases, such as type 1 diabe- tes, rheumatoid arthritis, and Sjögren’s syndrome.27 Celiac disease has a genetic basis, so people who have family members with the condition are more likely to develop the disease.
"e only cure for celiac disease is the complete avoidance of gluten-containing foods and prod- ucts, such as lipstick, that may contain gluten. Many supermarkets have sections devoted to gluten-free foods, and in major urban areas, some restaurants have chefs that prepare meals in gluten-free kitchens for their customers with celiac disease. For people with celiac disease, a gluten-free diet is critical for maintaining good health. Gluten-free foods are not necessarily “low-calorie” or useful for people who do not have the condition but want to lose weight. For more information about celiac disease, visit the web- site of the American Celiac Disease Alliance at www .americanceliac.org.
medical procedures to diagnose allergies, such as food-speci!c IgG tests, leukocyte cytotoxic tests, sublingual and intradermal provocation tests, elec- trodermal (VEGA) testing, and applied kinesiology, are inappropriate and unproven.25
In the case of a true food allergy, the best treat- ment is to avoid the o#ending food. Additionally, the allergic person should be prepared to treat shock by taking antihistamines or administering inject- able epinephrine, a naturally produced substance that raises blood pressure. Parents of children with food allergies must read labels carefully to check ingredients for allergens. "ey should inform their children’s adult caregivers, teachers, and the parents of their children’s friends about the allergy and the importance of not o#ering foods that may contain allergens to their children. Although most children outgrow milk, egg, and wheat allergies, they are likely to remain allergic to peanuts, tree nuts, !sh, and shell!sh throughout their lives.
Celiac Disease People with celiac disease are hypersensitive to gluten, a protein in wheat, rye, and barley. When a person with the disease con- sumes gluten, his or her immune system responds by causing an inflammation of the lining of the small intestine. The inflammation damages the lining, and the body cannot absorb nutrients from food as a result.
Celiac disease a#ects about 1 in 141 people in the United States.26 Signs and symptoms of celiac disease include malnutrition; fatigue; arthritis; skin rash; abdominal bloating and pain; chronic diarrhea;
celiac disease A condition characterized by hypersensitivity to gluten.
Quinoa (keen’-wah) is a vegetable that is often prepared like cooked cereal. © Noam Armonn/Shutterstock.
4To reduce your risk of obesity, heart disease, type 2 diabetes, and certain digestive tract disorders, exercise regularly and consume at least 25 grams of fiber each day by eating more fruits, vegetables, beans, and whole grain cereal products.
4To lower your risk of diabetes and heart disease, limit your daily calories from fat, limit your intake of saturated fat, avoid trans fat, and limit cholesterol consumption.
4You can limit your dietary cholesterol and saturated and trans fat by consuming low- fat yogurt and nonfat milk and by eating less cheese, fatty meat, fried food, and fat-laden bakery goods and snack foods.
4Many fast foods are high in saturated fat. If you eat at fast-food restaurants regularly, reduce your intake of meat and fried foods by selecting salads or grilled chicken or fish items.
4If you eat large amounts of red meat and other animal foods, consider eating less and consuming more fatty, coldwater fish; beans; nuts; and whole grain cereals instead.
Healthy Living Practices
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free radicals. "ese antioxidants include vitamins E and C and a variety of phytochemicals such as beta- carotene, a yellow-orange pigment in plants that the body converts to vitamin A. Table 9.2 lists some phy- tochemicals that have antioxidant activity and their major food sources; Table 9.8 lists foods commonly consumed in the United States that have high anti- oxidant activity per serving.
Since the 1980s, scientists have been investigat- ing the possible risks and bene!ts of eating diets rich in antioxidants or taking antioxidant supplements. No strong scienti!c data support the popular belief that% vitamin C prevents the common cold, but taking% the vitamin may shorten the duration of the infection.28 Vitamin C may also reduce the risk of developing heart disease, but its usefulness in pre- venting diabetes, cancer, and Alzheimer’s disease is not supported by scienti!c evidence.28
Should you take large doses of vitamins, especially antioxidant vitamins, to prevent disease? Nutrition experts are divided over the issue of antioxidant vitamin supplementation. "e cells in your body make anti- oxidants. Some scientists think modern humans are exposed to much higher levels of environmental haz- ards, such as air pollution and pesticide residues, than were their ancestors. "ese conditions may increase the body’s need for antioxidants beyond the amounts that are made or that can be obtained from food, mak- ing supplementation necessary. Other scientists think plant foods are the best source of antioxidants. Unlike nutrient supplements, plant foods contain mixtures of vitamins and phytochemicals that collectively may provide healthful bene!ts. Taking large doses of antioxidant vitamins may have harmful side e#ects, including promoting the growth of cancer cells.
Approximately 33% of adult Americans have reported taking multiple vitamin supplements that contain three or more vitamins.29 Unless medically necessary, taking dietary supplements is o$en an eco- nomically wasteful and risky practice; however, 54% of Americans report using at least one dietary supple- ment. "e rate is higher among adults aged 60 years or older, with 70% reporting use of at least one dietary sup- plement and 29% reporting use of one or more dietary supplements.30,31 By eating a variety of whole grain products, fruits, and vegetables daily, you are less likely to encounter toxicity problems because these foods naturally supply vitamins in smaller quantities.
Non-Energy-Supplying Nutrients
Nutrients that help us maintain body functions but do not provide us with energy are referred to as micronutrients. "e body requires small amounts of micronutrients, but they are essential for many body functions, including energy production and cardio- vascular activity, among others.
Vitamins Vitamins are organic compounds that have numer- ous functions in the body. Vitamins help regulate growth; release energy from carbohydrates, fats, and proteins; and maintain tissues. Although many vitamins participate in the chemical reactions that release energy, they do not provide calories.
Scientists classify vitamins according to their ability to dissolve in water or fat. Vitamin C and the eight B vitamins are water soluble; vitamins A, D, E, and K are fat soluble. "e body does not store most water-soluble vitamins to any appreciable extent, whereas fat-soluble vitamins are stored in the liver and body fat and can accumulate to toxic levels. Table 9.7 lists most of the vitamins as well as their major roles in the body and rich food sources.
Compared to the energy-supplying nutrients and water, the body requires very small amounts of vitamins. Diets that include a wide variety of foods can meet the vitamin needs of healthy individuals. Some persons, however, take nutrient supplements that provide several times the recommended levels of vitamins to treat or prevent illness. Taking more of a nutrient than the body needs is not necessarily better. Cells use limited amounts of each vitamin daily. In many instances, excessive amounts of these nutrients accumulate in the body and cause harmful side e#ects. Vitamins A, B6, and niacin are very toxic when taken in large doses. Table 9.7 provides information concerning the signs and symptoms of vitamin toxicity disorders.
Antioxidants "e chemical structures of certain compounds, particularly polyunsaturated fatty acids, make them vulnerable to damage by free radicals. Free radical formation produces chemical changes in cells that may contribute to the development of cardiovascular disease (diseases of the heart and blood vessels), certain cancers, degenerative changes in the eye, and other chronic health conditions.
Many foods contain antioxidants that can pro- tect cells by preventing or reducing the formation of
vitamins A class of organic nutrients that help regulate growth; release energy from carbohydrates, fats, and proteins; and maintain tissues.
Non-Energy-Supplying Nutrients 299
Vitamin Major Functions Rich Food Sources Deficiency Signs/ Symptoms
Toxicity Signs/ Symptoms
A and provitamin A (beta-carotene)
Vision in dim light, growth, reproduction, maintains immune system and skin, antioxidant
Liver, milk, dark green and leafy vegetables; carrot, sweet potato, mango, oatmeal, broccoli, apricot, peach, and romaine lettuce
Poor vision in dim light, dry skin, blindness, poor growth, respiratory infections
Intestinal upset, liver damage, hair loss, headache, birth defects, death (beta-carotene has low toxicity)
D Bone and tooth development and growth; immune system functioning
Few good food sources other than eggs and fortified milk and orange juice
Weak, deformed bones (rickets)
Growth failure, loss of appetite, weight loss, death
E Antioxidant: protects cell membranes
Vegetable oils, whole grains, wheat germ, sunflower seeds, almonds
Anemia (rarely occurs) Intestinal upset, bleeding problems
C Scar formation and maintenance, immune system functioning, antioxidant
Citrus fruits, berries, potatoes, broccoli, peppers, cabbage, tomatoes, fortified fruit drinks
Frequent infections, bleeding gums, bruises, poor wound healing, depression (scurvy)
Diarrhea, nosebleeds, headache, weakness, kidney stones, excess iron absorption and storage
Thiamin Energy metabolism
Pork, liver, nuts, dried beans and peas, whole grain and enriched breads and cereals
Heart failure, mental confusion, depression, paralysis (beriberi)
No toxicity has been reported
Riboflavin Energy metabolism
Milk and yogurt, eggs and poultry, meat, liver, whole grain and enriched breads and cereals
Enlarged, purple tongue; fatigue; oily skin; cracks in the corners of the mouth
No toxicity has been reported
Niacin Energy metabolism
Protein-rich foods, peanut butter, whole grain and enriched breads and cereals
Skin rash, diarrhea, weakness, dementia, death (pellagra)
Painful skin flushing, intestinal upset, liver damage
Vitamin B 6
Protein and fat metabolism
Liver, oatmeal, bananas, meat, fish, poultry, whole grains, fortified cereals
Anemia, skin rash, irritability, elevated homocysteine levels
Weakness, depression, permanent nerve damage
Folate (folic acid) DNA production Leafy vegetables, oranges, nuts, liver, enriched breads and cereals
Anemia, depression, spina bifida in developing embryo, elevated homocysteine levels
Hides signs of B 12
deficiency; may cause allergic response
B 12
DNA production Animal products Pernicious anemia, fatigue, paralysis, elevated homocysteine levels
No toxicity has been reported
Table 9.7
Major Vitamins
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Minerals Minerals are a group of elements such as calcium, iron, and sodium. Several minerals are nutrients that have a wide variety of roles in the body. For example, the mineral nutrient magnesium regulates chemi- cal reactions; other mineral nutrients are structural components of certain organic molecules, like the iron in red blood cells and calcium in bones. "e body needs very small amounts of minerals, com- pared to the energy-supplying nutrients and water. Excesses of any mineral can create imbalances with other minerals or can be toxic.
minerals A class of inorganic nutrients that includes several elements, such as iron, calcium, and zinc.
calcium The most abundant mineral in the body and plays a role in vascular, muscular, and neurological functions.
osteoporosis An age-related condition in which bones lose density, becoming weak and breaking easily.
Table 9.9 lists some essential minerals, describes their major roles, and identi!es common foods that contain high amounts of these substances. "e fol- lowing section provides information about calcium and iron, two minerals that have considerable health importance for Americans.
Calcium is the most plentiful mineral in the body. You may be aware that calcium is necessary for the development of strong bones and teeth, but this min- eral has other important roles as well, such as regu- lating blood pressure and participating in muscular movements. "e body carefully maintains the level of calcium in the blood within a speci!c range. When the level is too high, the bones can remove and store the excess. If the amount of calcium in the blood begins to drop below normal levels, the bones release some of the mineral from storage, returning the level to normal.
As it adjusts to the demands of bearing the body’s weight, bone tissue undergoes a continual process of being built, torn down, and rebuilt. A$er about 40% years of age, the bones of most people begin to break down at a faster rate than they rebuild. As bones gradually lose mineral density, they become weak and brittle. Fragile bones break easily and sometimes shatter because they cannot support the © S
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Blackberries Cranberries Blueberries Cranberry juice Pineapple juice
Walnuts Coffee Cloves, ground Cherries, sour Guava nectar (beverage)
Strawberries Raspberries Grape juice Wine, red
Artichokes (cooked) Pecans Chocolate, baking, unsweetened
Power bar, chocolate
Data from Giver, A. K. (2013). Why fruits are rich in antioxidants? An opinion review. Canadian Journal of Physiology & Pharmacology, 91(3), 191–197; Halvorsen, B. L., et al. (2006). Content of redox-active compounds (i.e., antioxidants) in foods consumed in the United States. American Journal of Clinical Nutrition, 84(1):95–135.
Table 9.8
Antioxidant-Rich Foods
Non-Energy-Supplying Nutrients 301
Mineral Roles Rich Food Sources Deficiency Signs/ Symptoms
Toxicity Signs/ Symptoms
Calcium Builds and maintains bones and teeth, regulates muscles and nerve function, regulates blood pressure and blood clotting
Milk products; fortified orange juice, tofu, and soy milk; fish with edible small bones such as sardines and salmon; broccoli; hard water
Poor bone growth, weak bones, muscle spasms, convulsions
Kidney stones, calcium deposits in organs, mineral imbalances
Potassium Maintains fluid balance, necessary for nerve function
Whole grains, fruits and vegetables, yogurt, milk
Muscular weakness, confusion, death
Heart failure
Sodium Maintains fluid balance, necessary for nerve function
Salt, soy sauce, luncheon meats, processed cheeses, pickled foods, canned and dried soups
Muscle cramping, headache, confusion, coma
Hypertension
Magnesium Regulation of enzyme activity; necessary for nerve function
Green leafy vegetables, nuts, whole grains, peanut butter
Loss of appetite, muscular weakness, convulsions, confusion, death
Rare
Zinc Component of many enzymes and the hormone insulin, maintains immune function, necessary for sexual maturation and reproduction
Meats, fish, poultry, whole grains, vegetables
Poor growth, failure to mature sexually, improper healing of wounds
Mineral imbalances, gastrointestinal upset, anemia, heart disease
Selenium Component of a group of antioxidant enzymes, immune system function
Seafood, liver, and vegetables and grains grown in selenium-rich soil
May increase risk of heart disease and certain cancers
Hair and nail loss
Iron Oxygen transport involved in the release of energy
Clams, oysters, liver, red meats, and enriched breads and cereals
Fatigue, weakness, iron-deficiency anemia
Iron poisoning, nausea, vomiting, diarrhea, death
Table 9.9
Some Essential Minerals
body. Although any bone can be a#ected, bones in the hip, spine, and wrist are most likely to break. "is condition, osteoporosis, threatens the health of millions of aging Americans, especially older adult women. In the United States, 40 million Americans either have osteoporosis or are at risk of the disorder; most of these persons are older women.32 Men usually have denser bones than women, which may explain why most aging men are not a#ected by osteoporosis to the same extent that aging women are.
Fractures are associated with an increased risk of permanent disability or death, particularly if the frac- ture immobilizes the person; immobility increases the likelihood that fatal blood clots or pneumo- nia will develop. A painful and disabling condition known as “dowager’s hump” can occur when bones in the upper spine are so weak that they experience small compression fractures over time while trying to support the weight of the skull. As these bones heal into wedge shapes, the upper spine assumes an abnormal curvature (Figure 9.9). As a result, people
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racial groups are more susceptible to osteoporosis than others. African Americans tend to have larger bone masses that a#ord some protection against osteopo- rosis. On the other hand, slender, small-boned people of European and Asian ancestry are more likely than people with large bones to develop osteoporosis.
Certain lifestyle choices can increase a person’s risk of osteoporosis. Young people with low- calcium diets are likely to have less-dense bones that are sus- ceptible to osteoporosis as they grow older. Cigarette smoking and alcohol consumption can accelerate bone loss. Furthermore, young women who exercise excessively may disrupt their body’s normal estrogen production and menstrual cycles. "is reduction in estrogen levels can lead to premature bone loss. Spe- cial X-rays are used to diagnose bone loss clinically.
To treat menopausal women who are at risk of osteoporosis, physicians o$en prescribe hormone replacement therapy, that is, synthetic hormones that contain estrogen or a combination of estrogen and progesterone. Nonhormonal treatments are avail- able also. Women who are approaching menopause should consult their physicians about their risks of developing osteoporosis and their treatment options.
Most medical experts recommend that young men and women adopt behaviors that maximize their bone mass. If you are concerned about your risk of developing osteoporosis, consume foods that supply calcium, such as those shown in Figure 9.10.
with osteoporosis o$en “shrink”—they lose some of their height.
As one ages, a calcium-rich diet and weight- bearing physical activity help build and maintain strong bones. A$er menopause, however, such prac- tices may not be enough to prevent osteoporosis or slow its progress. Within the !rst 5–10 years a$er menopause, even healthy women are susceptible to losing a large percentage of their bone mass. Why?
"e hormone estrogen stimulates bones to main- tain their mass and retain calcium. A sign of normal estrogen production is regular menstrual cycles. A woman has reached menopause when her estrogen levels drop dramatically and her menstrual cycles have ceased. As women approach this time of life, those who have a history of regular menstrual cycles are more likely to maintain their bone mass than those who had irregular or absent menstrual cycles.
Besides being a postmenopausal woman, other characteristics increase one’s risk of osteoporosis. "e condition may be inherited, and members of certain
Figure 9.9 Dowager’s Hump. In people with osteoporosis, the bones in the upper spine develop small compression fractures. These bones heal into wedge shapes, and the upper spine assumes a deformed, curved shape known as “Dowager’s hump.” © JPC-PROD/Shutterstock.
Figure 9.10 Calcium-Rich Foods. Some of the richest food sources of calcium are low-fat milk and yogurt, and greens. Although most cheeses are high in saturated fat, they are good sources of calcium. © Mitch Hrdlicka/Photodisc.
Non-Energy-Supplying Nutrients 303
Annually, thousands of young children uninten- tionally poison themselves, a few of them fatally, a$er ingesting toxic amounts of iron-containing supplements. Many of these cases involve unsuper- vised young children who take overdoses of 'avored vitamin/mineral supplements, thinking they are candy. To prevent such tragedies, store nutrient and other dietary supplements like other medications, making them inaccessible to children.
Hemochromatosis An estimated 5 in 1,000 white Americans have hemochromatosis, a genetic condition that increases the intestinal absorption of dietary iron.33 "e iron accumulates in their organs and reaches toxic levels by the time they are middle- aged. "ese people are o$en unaware that they have the potentially fatal condition until it causes serious conditions such as diabetes, liver damage, and heart disease. A simple blood test can detect this treatable disorder. People with hemochromatosis should not take supplements that contain iron and should limit their intake of iron-rich foods.
Water Water is essential for life on earth. You can survive weeks, months, and even years without one of the other nutrients, but you cannot survive for more than a few days without water. Water has many functions in the body: dissolving and transporting materials, eliminating wastes, lubricating joints, and participating in numerous chemical reactions.
About 60% of an adult’s body is water. To function properly, the body maintains its 'uid levels within speci!c limits, generally by increasing or decreasing urine production. Although it carefully conserves water, the body loses water when one perspires, urinates, exhales, and defecates. Drinking plain water and 'uids such as milk, juices, and so$ drinks replenishes the body’s water. Most foods, especially fruits and vegetables, also supply water.
Advertisements o$en promote beer as a thirst quencher; however, drinking alcoholic bever- ages does not replace body water. Alcohol acts as a diuretic, a compound that increases urinary losses of water. Ca#eine is also a diuretic, but its e#ect is not as strong as that of alcohol. "e amount of caf- feine contained in co#ee, energy drinks, energy and%weight-loss pills, and soda varies; however, some popular brands contain as much as 400 milligrams per serving. Too much regular ca#eine intake can result in ca!einism, which includes nervous irritabil- ity, occasional muscle twitching, heart palpitations, rapid heartbeat, and gastrointestinal irritability.34
If you do not consume dairy products or foods forti!ed with calcium, ask your physician about alternative ways to obtain this mineral, such as calcium-containing supplements or antacids. In addi- tion to calcium, vitamin D and the mineral mag- nesium are important for bone health. Adopting healthful lifestyles, such as refraining from smoking, reducing alcohol consumption, and engaging in phys- ical activities that place stress on your bones,%such as walking, weight li$ing, or jogging, can help maintain your skeleton’s structural%integrity.
Osteoporosis can occur at any age. If you think your risk of developing this condition is high, ask your doctor to perform a bone density test. By treat- ing osteoporosis in its early stages, substantial bone loss can be prevented.
Iron Most of the body’s iron is found in the hemoglobin molecules within the red blood cells. Hemoglobin combines with oxygen in the lungs and transports it to cells throughout the body. Oxygen is necessary to release the energy stored in%glucose.
Anemia results when the body produces abnor- mal red blood cells. In cases of iron-de!ciency anemia, the bone marrow forms red blood cells that are smaller and contain less hemoglobin than nor- mal cells. Without su&cient hemoglobin, the red blood cells carry less oxygen than usual as they cir- culate. Anemic individuals o$en report feeling tired because their cells are unable to obtain adequate amounts of energy.
Iron de!ciency is one of the most prevalent nutri- tional disorders in the United States. Many indi- viduals, especially premenopausal women, are at risk of becoming iron de!cient because they do not consume enough iron-rich food to replace the iron lost each month in menstrual blood. Individuals undergoing rapid growth, such as infants, children, teenagers, and pregnant women, have high needs for iron and are at risk of iron de!ciency. If untreated, severe iron de!ciency can cause iron-de!ciency ane- mia. "is type of anemia o$en occurs in people who lose a lot of blood.
To ensure adequate iron intake, you can eat the iron-rich foods listed in Table 9.9. Normally, the small intestine does not absorb much of the iron in foods, especially the iron in plants. You can enhance the absorption of plant sources of iron by eating them% with meat or vitamin C–rich foods. In addition% to eating more foods that contain iron, people with iron-de!ciency anemia may need to take iron supplements.
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!e Basics of a Healthful Diet
When you eat a milk chocolate candy bar or some french-fried potatoes, you probably know that these foods contain carbohydrate and fat, but you may be surprised to learn that they also supply some protein, water, and even vitamins and minerals. Most foods are mixtures of nutrients that contain relatively large quantities of water, carbohydrate, fat, or protein, with much smaller quantities of vitamins and minerals. Candy bars and french fries are commonly called “junk” foods because they contain considerable calo- ries from fat and sugar. Dietitians, however, generally refer to such foods as “empty-calorie” foods rather than junk foods.
A nutritious diet has two key features: nutrient adequacy and nutrient balance. "e foods in a nutri- tionally adequate and balanced diet contain all essen- tial nutrients in the proper proportions. By selecting a wide variety of foods, you can usually obtain all essential nutrients. Many people upset the nutri- tional balance of their diets by consuming more food than they need, by making poor food choices, or by taking massive doses of nutrient supplements. Eat- ing too much food can make one overweight; eating too much salty food may raise one’s blood pressure; and ingesting too many supplements can cause nutri- ent toxicity disorders. Consuming mostly foods with high-quality nutrients, such as lean proteins, fruits, and vegetables, and limiting foods associated with increased health risk, such as re!ned grains, saturated fats, and trans fats, is the best approach to planning nutritionally adequate and well-balanced diets.
How much of each nutrient do you need for opti- mal health? How can you be certain that your diet is nutritionally adequate? "e following information provides answers to these questions.
Nutrient Requirements and Recommendations A nutrient requirement can be de!ned as the minimum amount that prevents an average person from developing the nutrient’s de!ciency disease. A required level of a nutrient, however, is not nec- essarily an optimal amount. By obtaining only the
Nutrition experts recommend consuming no more than 300 milligrams of ca#eine each day, or about two cups of regular co#ee.
According to a report issued by an expert panel of the National Institute of Medicine, the daily rec- ommended amounts of water from food and bev- erages are about 16 cups for men and 11 cups for women.35 In general, Americans’ water intake is adequate. Dehydration occurs when the normal level of body water declines and the a#ected indi- vidual does not consume replenishing 'uids. "e symptoms of dehydration include weakness, con- fusion, and irritability. During prolonged fevers or bouts of diarrhea or vomiting, the body can lose substantial amounts of water, causing dehydration. "ese conditions cause the loss of minerals such as sodium and potassium as well. If untreated, severe dehydration is usually fatal.
Healthy people can become dehydrated while working or exercising in hot conditions. Is it helpful to consume sports drinks under these situations? In addition to water and glucose, sports drinks contain small amounts of the minerals sodium and potas- sium; therefore, these beverages may be bene!cial for individuals engaging in prolonged strenuous physical activities during which considerable sweat- ing occurs. Most people, however, can maintain their 'uid and mineral balance by eating a variety of foods and by drinking water before and during the activity.
nutrient requirement The minimum amount of a nutrient that prevents that nutrient’s deficiency disease.
4To obtain all the vitamins and minerals you need, eat a wide variety of foods each day; include whole grains, dairy products, fruits, and vegetables.
4Store dietary supplements like other medications, making them inaccessible to children.
4If you are hot or exercising heavily, to prevent dehydration, drink plenty of water and other beverages that do not contain caffeine or alcohol.
4To increase the likelihood that you will maintain your bone mass as you age, consume adequate amounts of calcium-rich foods, drink less alcohol, do not smoke, and engage in weight- bearing exercise regularly.
Healthy Living Practices
The Basics of a Healthful Diet 305
the nutrient by using food composition tables, such as those on this text’s accompanying website, and eat more of these foods. You can learn more about RDAs and DRIs by viewing reports and tables from the National Institutes of Health at https://ods .od.nih.gov/health_information/dietary_reference _intakes.aspx.
The Dietary Guidelines Every 5 years, the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services issue the Dietary Guidelines for Americans, a publication that provides general recom- mendations for a healthful diet. "e Guidelines focus attention on the association between diet and chronic diseases, such as type 2 diabetes and cardiovascular disease. "ese guidelines provide basic advice con- cerning lifestyle behaviors that relate to nutritional health, such as choosing nutrient-dense foods, being more physically active, and following food safety prac- tices. You can view all elements of the guidelines by vis- iting the Dietary Guidelines for Americans 2015-2020 website (https://health.gov/dietaryguidelines/2015 /guidelines/). "e major guidelines and key recom- mendations of the 2015–2020 Dietary Guidelines are described here.
required levels of most vitamins, for example, the body does not have amounts to store in various tis- sues. "e body relies on its nutrient reserves if nutri- tious food becomes unavailable. "us, nutrition experts recommend that people consume more than just the required amounts of many nutrients.
To determine whether a diet supplies adequate amounts of certain nutrients that can prevent de!- ciency diseases, nutritionists now use a complex set of standards called the Dietary Reference Intakes (DRIs). "e DRIs are composed of four dif- ferent recommendations for nutrient and energy intake levels, including the Recommended Dietary Allowances (RDAs), which at one time were the only standards for planning nutritious diets and analyzing the nutritional adequacy of diets. To establish the RDA for a nutrient, scientists take the required level and add a certain amount to provide a margin of safety. For example, the current RDA for vitamin C is 90 milligrams/day for men and 75% milligrams/ day for women (nonsmokers). "e average person, however, requires only about 8–10 milligrams of vitamin C each day to prevent scurvy, the vitamin’s de!ciency disease. "erefore, most people will not develop scurvy even if their intake does not meet 100% of the RDA.
"e DRIs include a set of values called the Toler- able Upper Intake Level, or simply UL. "e UL is the maximum average daily intake amount for a nutri- ent that is unlikely to be harmful. "erefore, regularly consuming amounts of a nutrient that exceed its UL is likely to cause toxicity signs and symptoms. "e adult UL for vitamin C, for example, is 2,000 % milligrams per day. Tables 9.7 and 9.9% indicate toxicity signs and symptoms for certain vitamins and minerals, respectively.
You can evaluate the nutritional adequacy of your diet by using the RDAs or other DRI val- ues. A brief version of the DRI tables is shown in Appendix C. Complete the activity “Assessing the Nutritional Quality of Your Diet” in the Student Workbook section of this text. If your usual intake of a nutrient is between 75% and 100% of the rec- ommended amount, you probably are not at risk of developing that nutrient’s de!ciency disease. If you need to increase your intake of one or more nutri- ents, you can identify foods that are rich sources of
Dietary Reference Intakes (DRIs) A set of standards for evaluating the nutritional quality of diets.
Courtesy of U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/
DIETARY GUIDELINES FOR AMERICANS 2015-2020
EIGHTH EDITION
DietaryGuidelines.gov
306 Chapter 9 Nutrition
"e Guidelines 1. Follow a healthy eating pattern across the life span. 2. Focus on variety, nutrient density, and amount. 3. Limit calories from added sugar and saturated
fats and reduce sodium intake. 4. Shi$ to healthier food and beverage choices. 5. Support healthy eating patterns for all.
Key Recommendations 1. Consume a healthy eating pattern that accounts
for all foods and beverages within an appropriate calorie level.
2. A healthy eating pattern includes: • A variety of vegetables from all the
subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other
• Fruits, especially whole fruits • Grains, at least half of which are whole grains • Fat-free or low-fat dairy, including milk,
yogurt, cheese, and/or forti!ed soy beverages
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products
• Oils 3. A healthy eating pattern limits:
• Saturated fats and trans fats, added sugars, and sodium
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• Added sugars to less than 10% of calories per%day
• Saturated fats to less than 10% of calories per%day
• Sodium to less than 2,300 milligrams (mg) per day
• Alcohol to up to one drink per day for women and up to two drinks per day for men, if consumed; alcohol should be consumed in moderation if at all, and only by adults of legal drinking age
4. In tandem with dietary recommendations, Amer- icans of all ages—children, adolescents, adults, and older adults—should meet the Physical Activ- ity Guidelines for Americans to help promote health and reduce the risk of chronic disease.
MyPlate In spring 2011, the USDA introduced MyPlate, a practical guide for planning healthful diets that incorporates recommendations from the 2015–2020 Dietary Guidelines. MyPlate has !ve primary food
MyPlate The current nutrition guide published by the U.S. Food and Drug Administration Center for Nutrition Policy and Promotion. It replaced the Food Pyramid in 2011.
The Basics of aHealthful Diet 307
use MyPlate to evaluate the nutritional adequacy of your daily food choices.
Using Nutritional Labeling "e FDA requires nearly every packaged food to have nutritional labeling. Consumers can use food label- ing to determine and compare the nutritional value of most packaged foods. Figure 9.12 illustrates the cur- rent Nutrition Facts label and provides tips for using this information. In 2014, the FDA proposed changes to the Nutrition Facts label found on food packaging. Signi!cant changes include larger print to highlight calories per serving and the number of servings per container. Furthermore, serving sizes will be more realistic, re'ecting how much people typically eat at one time and including elements such as added sug- ars.36 As of February 2018, food manufacturers have until January 2020 to implement the new elements of the Nutrition Facts label.
Many consumers want to know how many grams of fat and calories are in a serving of packaged food. "is information appears at the top of the Nutrition Facts label (see Figure 9.12). People can also moni- tor the amounts of cholesterol, sodium, and !ber in packaged foods. "e Nutrition Facts label indicates these amounts by weight and as percentages of estab- lished nutrient labeling standards called the Daily Values (DVs).
Health o&cials at the FDA used various sources of nutritional information to determine the DVs for many nutrients and for !ber. As you can see in Figure%9.12, the lower part of the Nutrition Facts label shows two sets of DVs. One set of DVs is for people who consume 2,000 calories each day; the other set is for those who consume 2,500 calories daily. "e DVs for total fat, saturated fat, cholesterol, and sodium are maximum amounts. Most Americans should keep their daily intake of these nutrients below these amounts.
Speci!c information concerning the nutritional content per serving of the food product appears on the upper half of the label. In addition to showing amounts of fat, saturated fat, cholesterol, sodium, total carbohydrate, !ber, sugar, and protein by weight, the Nutrition Facts label displays most of this information as percentages of the DVs for a 2,000-calorie diet. Percentages of the DVs for key vitamins and minerals are shown below the second bold line.
According to the information near the top of the Nutrition Facts label shown in Figure 9.12, a serving
groups: grains, vegetables, fruits, dairy, and protein foods (Figure 9.11).
To obtain more information about MyPlate, access the USDA’s interactive website (www.choosemyplate .gov/index.html). Here, you can learn more about the foods in each food group.
Oils and Empty Calories "e MyPlate website includes information about oils and empty calories. Some fatty foods, such as olives, nuts, and seafood, naturally contain healthful oils. Depending on a per- son’s total daily caloric intake, MyPlate indicates an amount of oils to consume each day. Empty calories are sugars and fats added to foods. Fats and sugars can make foods very tasty, but in many instances, such foods are not as nutritious as foods without these ingredients. Alcohol is also an empty-calorie food. MyPlate sets a limit for the number of empty calories to consume each day. "e dietary plan has no recommendation for alcohol intake.
Diets that contain too many empty-calorie foods may contribute to excess body fat, heart disease, diabetes, and alcoholism. Additionally, these items can displace more nutrient-dense foods from your diet. Consuming a reasonable amount of empty-calorie foods may be acceptable if your diet is nutritionally adequate and you are physically active and need the extra calories to fuel physical activity. The Student Workbook section of this text includes an activity that enables you to
ChooseMyPlate.gov
Dairy
Protein Vegetables
Grains Fruits
Figure 9.11 Choose MyPlate. The USDA’s Choose MyPlate interactive tool at www.choosemyplate.gov can be used to plan nutritious menus and evaluate the nutritional quality of a person’s diet. Courtesy of the USDA.
308 Chapter 9 Nutrition
Figure 9.12 Nutrition Facts. Most packaged foods have nutrient facts on their labels. People can use this information to evaluate the nutritional quality of their food. The FDA has proposed changes to the Nutrition Facts label format.
Calories 2,000 2,500 Total fat Less than 65g 80g Sat fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg Total Carbohydrate 300g 375g Dietary Fiber 25g 30g
1. Serving Size This section shows how many servings are in the package. Remember: all nutrition information on the label is based on one serving.
2. Amount of Calories The calories listed are for one serving. “Calories from fat” are also for one serving.
4. Limit These Nutrients Too much total fat (especially saturated fat and trans fat), cholesterol, and sodium may increase your risk of certain chronic diseases.
5. Choose “Healthy” Carbohydrates Fiber and sugars are types of carbohydrates. Healthy sources like fruits, vegetables, beans, and whole grains can reduce the risk of heart disease and improve digestive functioning. Limit foods with added sugars (sucrose, glucose, fructose, corn or maple syrup), which add calories but not other nutrients such as vitamins and minerals.
6. The Daily Value Is a Key to a Balanced Diet The % DV is a general guide to help you link nutrients in a serving of food to their contribution to your total daily diet. It can help you determine if a food is high or low in a nutrient—5% or less is low, 20% or more is high. The % DV is based on a 2,000-calorie diet.
3. Consume Adequate Amounts of These Nutrients Get the most nutrition for your calories—compare the calories to the nutrients to make a healthier food choice.
Nutrition Facts Serving Size 1 cup (228g) Servings Per Container 2
Amount Per Serving Calories 250 Calories from Fat 110 % Daily Value* Total Fat 12g 18% Saturated Fat 3g 15% Trans Fat 3g Cholesterol 30mg 10% Sodium 470mg 20% Potassium 700mg 20% Total Carbohydrate 31g 10% Dietary Fiber 0g 0% Sugars 5g Protein
Vitamin A 4% Vitamin C 2% Calcium 20% Iron 4%
*Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or lower depending on you calorie needs.
The Basics of aHealthful Diet 309
make more educated decisions concerning their food choices when purchasing meals and snacks. At the time of this writing, the speci!c details of the guide- lines had not been established.
In response to consumer demand and govern- ment regulation, some restaurants, including fast- food establishments, have developed “healthy option” menus. It is important to note, however, that not all items on “healthy options” menus are actually healthy choices. For example, some salads served at fast-food restaurants contain added sugar and exces- sive amounts of salt. In some cases, items on healthy options menus contain more fat or calories than other options. To determine food content before ordering, it is best to review nutrition facts labels, which are now provided on menus or nutrition facts sheets in most restaurants.
Do You Need Vitamin or Mineral Supplements? Do you buy dietary supplements such as the ones listed in Table 9.10? If your answer is yes, why do you take them? Millions of Americans purchase dietary supplements, especially multivitamin/ multimineral products that contain mixtures of vitamins and minerals. Approximately 54% of adult Americans take at least one multivitamin/multimineral supple- ment.31 In 2014, sales of dietary supplements, which include vitamin and mineral pills, herbal products, and certain hormones, were estimated to be almost $37%billion in the United States.37
Many people take vitamin and mineral supple- ments to reduce the risk of heart disease, osteoporo- sis, and other serious chronic diseases. By carefully selecting a variety of foods and eating recommended amounts from the major food groups, healthy adults should be able to obtain enough nutrients with- out supplementation. Some people, however, need to supplement their diets with certain nutrients. Pregnant and breastfeeding women need more iron, calcium, and folic acid than what is available in foods. Some vegetarians need more calcium, iron, zinc, and vitamins B12 and D. Elderly persons may bene!t from extra vitamins D and B12.
Nutrient supplements do not contain all the sub- stances found in food that bene!t health; therefore, they are not substitutes for nutrient-dense foods. If your diet is nutritious and you still want to take a multiple vitamin and mineral supplement as an “insurance policy,” choose a reasonably priced prod- uct that contains no more than 100% of the DV for each of the vitamins and minerals listed on the label.
of the product supplies 250 calories, 110 of which are from fat. To determine the percentage of calo- ries from fat, divide the calories from fat (110) by the number of calories in the serving (250), and multiply the !gure by 100. Forty-four percent of the calories in this food are from fat. Because most health experts recommend that healthy Americans eat no more than 35% of their total calories from fat, you might decide to purchase other food products that contain lower percentages of calories from fat.
Another approach to controlling your fat intake is to eat foods with a variety of fat contents, but your intake should not exceed 65 grams of fat per day, the DV for a 2,000-calorie diet. For example, you might eat a 1-ounce serving of corn chips that contains 6% grams of fat and supplies 40% of its calories from fat. "e other foods eaten on this day should provide no more than 59 grams of fat (65–6 = 59).
Not everyone thinks that the Nutrition Facts label is easy to use or helpful. Because the percentage of total calories from fat is not listed, people cannot eas- ily compare the fat content of packaged food prod- ucts. Additionally, many adult Americans need to consume lower amounts of calories and fat than the DVs. Furthermore, most people eat a variety of foods, some of which are fresh or prepared in restaurants. As a result, these people may underestimate the amounts of calories and nutrients in their diet if they rely only on the information provided by food labels.
You can learn more about the calories and nutri- ents in your foods and beverages by using the “What’s in the Food You Eat” search tool at www.ars.usda .gov/Services/docs.htm?docid=17032. Furthermore, dietary guideline recommendations are provided on the Dietary Guidelines website by age, sex, and calorie%requirement in appendix 7 (https://health.gov /dietaryguidelines/2015/guidelines/appendix-7/).
What About Foods Sold in Restaurants? "e U.S. federal government passed legislation that required restaurants and food vendors with more than 20 locations to inform consumers about caloric and nutrient contents of products sold at these outlets. "e goal of the legislation was to provide accurate and easy-to-understand information about the nutritional value of prepared foods. By consid- ering this information, consumers would be able to
malnutrition Overnutrition or undernutrition that results when diets supply improper amounts of nutrients.
310 Chapter 9 Nutrition
Supplement Major Claims Health Risks/Benefits
Apple cider vinegar Cures arthritis, promotes weight loss, reduces blood cholesterol levels
No scientific evidence to support claims.
Beta-carotene Reduces risk of cancer and heart disease; antioxidant
Acts as antioxidant, but supplements may stimulate cancer cell growth.
Choline Improves memory No scientific evidence to support claim.
Chondroitin sulfate Treats arthritis (often combined with glucosamine)
No scientific evidence to support claim.
Coenzyme Q-10 Reverses signs of aging and disease; antioxidant
Helps cells generate energy and may have medicinal benefits, but more research is needed.
Dehydro epiandrosterone Slows aging process, increases muscular strength, and cures numerous ailments
Does not slow rate of aging or cure ailments; long-term effects of taking this naturally occurring hormone are unknown.
Fish oil Prevents heart disease and stroke, cures rheumatoid arthritis, reduces risk of disease
Reduces inflammation by suppressing the body’s immune response and lowers elevated triglyceride levels. May interfere with blood clotting, increasing the risk of hemorrhagic stroke. Cod liver oil contains vitamins A and D, which are toxic when taken in large doses.
Garlic Lowers blood cholesterol levels Does not lower cholesterol consistently; can cause allergic reaction and unpleasant body odor and interfere with prescription blood thinners.
Glucosamine sulfate Treats arthritis May slow the destruction of cartilage in the knee joint.
Lysine Prevents herpes simplex viral outbreaks from recurring
No scientific evidence to support claim.
Melatonin Treats insomnia and jet lag Scientific evidence suggests this hormone can treat certain sleep disorders, but information about its long-term safety is lacking.
S-adenosyl- L-methionine
Relieves pain and depression More research is needed to support claims and determine health risks; may increase risk of heart disease.
Yogurt (containing live bacterial cultures)
Slows aging process, prevents and cures vaginal yeast infections
No scientific evidence to support these claims, but may improve intestinal health.
Table 9.10
Nutritional Dietary Supplements
"e supplement should meet United States Phar- macopeia (USP) standards for strength, purity, and ability to dissolve. Vague advertising statements or labeling declarations, such as “meets laboratory stan- dards for quality,” do not guarantee product quality. Vitamin and mineral pills are dietary supplements. "e Consumer Health feature “Dietary Supplements” provides information about claims made for dietary supplements.
Malnutrition: Undernutrition and Overnutrition Malnutrition results when a person’s usual food intake supplies inadequate or excessive amounts of nutrients. Undernutrition occurs when a diet does not contain enough nutrients; overnutrition results from consuming excessive amounts of nutrients. Undernutrition can be especially devastating for
The Basics of aHealthful Diet 311
Consumer Health Dietary Supplements Provisions of the 1994 Supplement and Health Education Act allow manufactur- ers to classify vitamin and mineral pills, protein or amino acid preparations,
and certain hormones as “dietary supplements.” The FDA does not regulate dietary supplements as exten- sively as it regulates medicinal drugs. For example, a pharmaceutical company that is developing a new drug to treat diabetes must submit the medication to thorough testing and provide scientific evidence of its safety and effectiveness as a treatment before the drug can be introduced into the marketplace. Thus, the process of approving a new medication generally takes several years. When the medication finally becomes available, purchasing it is likely to require a physician’s prescription.
Dietary supplement manufacturers do not need to provide the FDA with scientific evidence that a supple- ment is safe for humans or provides measurable health benefits before they can market the product. As a result, many supplements contain ingredients that have not been scientifically tested for safety or effectiveness. Even if an ingredient in a dietary supplement is known to cause serious side effects, the product can still be sold through Internet outlets or in health food stores, pharmacies, and supermarkets without a prescription. If the FDA collects enough convincing evidence that a dietary supplement is dangerous, then the agency can ask manufacturers to remove the product from the marketplace voluntarily or require them to stop dis- tributing it. Table 9.10 lists popular nutritional dietary
supplements and their claimed health benefits and notes their potential risks.
The FDA requires manufacturers to provide certain information on dietary supplement labels. The label must show the product’s name, state that it is a supple- ment, provide a list of ingredients, and indicate the net weight of the product’s contents. The label also needs to display the name and address of the product’s packer, distributor, or manufacturer. Supplements must have a Supplement Facts label that lists the product’s ingredi- ents and includes other information, such as the sug- gested daily dose.
The FDA allows manufacturers to make certain claims about a dietary supplement’s nutrient content, health benefits, and structure/function usefulness. If manufacturers indicate that a dietary supplement treats a specific nutritional deficiency, supports health in some manner, or reduces the risk of a health condition, such claims must be followed by the disclaimer “This state- ment has not been evaluated by the Food and Drug Administration. This product is not intended to diag- nose, treat, cure, or prevent any disease.” To learn which kinds of health-related claims have been approved by the FDA, visit https://ods.od.nih.gov/HealthInformation /DS_WhatYouNeedToKnow.aspx.
According to the FDA, many consumers of dietary supplements want to know if health claims for these products on labels or in advertisements and printed material are truthful. Such claims do not require FDA approval before they can be used, but manufacturers are supposed to provide evidence to support the claims if the agency asks them to do so. The FDA, however, lacks sufficient funding and personnel to investigate all ques- tionable or misleading claims.
children. Undernourished youngsters o$en develop nutritional de!ciency diseases; as a result, they may not grow properly or perform physical and mental tasks optimally. In parts of the world where many babies are not vaccinated against common childhood diseases, undernourished children o$en die from infections such as measles.
Undernutrition also occurs in the United States. In the United States, approximately 12% of households are uncertain about having enough food or unable to obtain enough food for all members because of lack of resources.38 Even some people with adequate incomes are marginally nourished because they choose diets that supply barely enough vitamins and minerals.
Such individuals may experience more frequent infec- tions and take longer to recover from illnesses than those who are well nourished. Alcoholics, people with anorexia nervosa, and individuals with chronic diges- tive system diseases are also at risk for undernutrition.
People living in countries with high standards of living are more likely to su#er from the ill e#ects of overnutrition rather than undernutrition. Individuals who eat too much sugar and fat may develop obesity, which increases their risk of diabetes, hypertension, and heart disease.
Many elderly persons are unable to shop for grocer- ies or prepare foods because of arthritis and strokes. Older individuals who are psychologically depressed,
312 Chapter 9 Nutrition
that prepare her body for the nutritional demands of pregnancy. During pregnancy, malnourished women have a higher risk than well-nourished mothers-to- be of miscarrying, having premature or underweight infants, and delivering babies with birth defects.
Consuming diets that supply adequate folate (a B vitamin) is critical, especially during the !rst 4%weeks of pregnancy when the neural tube, the embry- onic region that forms the brain and spinal cord, develops. Occasionally, the neural tube fails to develop properly, resulting in spina bi#da and related defects. Spina bi!da occurs when a section of the spine does not fuse to form the channel that encases and protects the spinal cord. In severe cases, the spinal cord protrudes from the infant’s back, seriously impairing the child’s ability to control the lower part of his or her body.
socially isolated, or !nancially impoverished o$en lack the interest or the resources to prepare nutritious meals. "ese people are at risk of becoming malnour- ished. Many communities o#er federally subsidized nutrition programs such as Meals-on-Wheels and congregate meals for those who are at least 60 years old. "e Meals-on-Wheels program relies on com- munity volunteers to deliver a hot meal, milk, and fresh fruit to homebound people as o$en as !ve days a week. More mobile aged individuals can participate in congregate meal programs in which they visit com- munity centers where hot meals are served 5 days a week (Figure" 9.13). Besides providing a nourishing meal, these sites enable elderly participants to inter- act socially. Frequent contact with other people can reduce an elderly person’s risk of depression, a health problem that o$en a#ects isolated aged people.
Figure 9.13 Nutrition for Older Adults. Many older adult Americans participate in congregate meal programs within their community. © michaeljung/iStockphoto.com.
NUTRITION From conception until birth, the developing embryo/ fetus depends on its mother to supply the nutrients it needs for development and growth. Women o$en become more health conscious during pregnancy, and as a result, they may select more nutritious diets. A woman’s nutritional status before conception, how- ever, has a signi!cant impact on the health of her baby. By consuming a nutritious diet before becoming preg- nant, a woman can build optimal nutrient reserves
Across THE LIFE SPAN
4To plan well-balanced, nutritious daily menus, you can follow the recommendations of the latest Dietary Guidelines and MyPlate.
4Use the Nutrition Facts on food labels to compare the nutritional content of packaged foods and plan nutritious meals and snacks.
4If you want to take a multiple vitamin and mineral supplement, choose a product that meets United States Pharmacopeia (USP) standards and supplies no more than 100% of each nutrient’s DV.
Healthy Living Practices
Many pregnant women are not even aware of their pregnancy when the neural tube is forming. To maxi- mize the amount of folate in their tissues, women should eat plenty of folate-rich foods, especially enriched breads and cereals, lentils, fruits, and green leafy vegetables (see Table 9.7), before pregnancy. Dur- ing pregnancy, women should eat nutritious diets, obtain medical care, and take their prescribed doses of prenatal vitamin and mineral supplements. Before taking other supplemental nutrients, pregnant women should always check with their physicians. Consum- ing excessive amounts of nutrient supplements during pregnancy increases the risk of certain birth defects.
Current infant feeding recommendations include the following: provide breastmilk and a supplement that contains vitamin D and iron for at least the !rst 12 months of life. Iron-forti!ed infant formulas are acceptable alternatives, but every healthy pregnant woman should consider the bene!ts of breastfeeding
The Basics of aHealthful Diet 313
infants. However, most children eat enough calories to maintain their normal growth pattern. During this period, children o$en establish their food prefer- ences and eating habits; well-informed, responsible adults can serve as role models, teaching youngsters how to choose nutrient-dense foods.
Eating a nutritious breakfast is an important habit to develop early in life. "e child who routinely skips breakfast and eats too many sugary snacks can develop borderline or overt nutritional de!ciencies. "is child o$en lacks energy, has di&culty concen- trating on school work, and experiences behavioral problems. In severe cases, a malnourished child fails to grow properly.
Adolescents experience rapid growth during puberty, and their appetites increase accordingly. Teenagers o$en become overly concerned with their body size and shape. As a result, boys may experi- ment with dietary supplements to increase muscle mass. To lose weight, girls may skip meals or choose diets that limit nutritious foods, such as calcium-rich dairy products. Growing adolescents require plenty of calcium to maximize bone mass. An obsession with body size can foster poor eating practices and eating disorders that last into adulthood.
Older adults who have consumed a nutritious diet and have exercised regularly since their youth are more likely to enjoy good health than those who ate poor diets and were inactive. However, physical, psychological, social, and economic factors o$en in'uence the quality and quantity of the elderly person’s food intake. As one ages, production of acid and other stomach secretions decreases, reducing the ability of the small intestine to absorb calcium, iron, and vitamins D and%B12. "erefore, older adults should ask their physicians about the need to take certain nutrient supplements.
her baby. Breastmilk is the most suitable food for infants. Caregivers should not feed fresh whole or reduced-fat cows’ milk to babies before their !rst birthday. Furthermore, babies should not be fed solid foods before they are 4 months of age.
Breastmilk o#ers many health bene!ts to infants and their mothers. Babies who consume breastmilk have reduced risks for sudden infant death syndrome, childhood leukemia, ear infections, asthma, child- hood obesity, and diabetes.38 "e proteins in human milk will not cause allergies like those in formulas do. Women who breastfeed can also obtain impor- tant health bene!ts—they have lower risks of type 2 diabetes, breast cancer, and ovarian cancer than do women who do not breastfeed.
Breastfeeding is economical and convenient; mothers can breastfeed anywhere they feel comfort- able doing so.39 Individuals who are interested in breastfeeding can obtain educational materials and advice from members of the La Leche League, an organization with groups in many U.S. communities.
Many women do not breastfeed because they want to return to a job, they lack the support of family and friends, or they are uncomfortable with this prac- tice. "ese women should follow their pediatrician’s advice concerning the use of commercially prepared infant formulas.
Parents o$en describe their preschool-aged chil- dren as picky eaters because they do not seem to be as hungry or interested in eating as when they were
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4To increase your chances of having a healthy baby, improve the quality of your diet before you become pregnant.
4Excesses of certain nutrients can produce birth defects, so ask your physician for advice before you take nutrient supplements during pregnancy.
4If you are a woman who plans to have children, consider the benefits of breastfeeding, especially during their first 12 months of life.
Healthy Living Practices
314 Chapter 9 Nutrition
Health-Related InformationAnalyzing Critical Thinking
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Kiev, Russia—Russian researchers working under the direction of famed doctor Igor X. Ivanamiraculsky of Minsk have discovered that Russian garlic oil is a safe and effective treatment for chronic fatigue. In hundreds of double-blind studies performed at the Minsk Institute of Food Research, college students, athletes, and even elderly persons who took the garlic oil capsules reported having 25% more energy than those persons taking placebos. These results are nothing short of amazing!
Now, you can bene!t from Dr. Ivanamiraculsky’s discovery. For the !rst time, the doctor’s energy-boosting garlic oil pills are available in the United States. No prescription is needed for this 100% completely natural energizer. Just ask for odor-free GARGOIL at your local pharmacy or health-food store. Satisfaction guaranteed! If you are not completely satis!ed after taking GARGOIL, return the unused portion to the place of purchase for a refund. Remember to be careful and follow the label’s instructions; some people report feeling too energized after taking GARGOIL! Accept no garlic oil substitutes—ask for GARGOIL.
RUSSIAN SCIENTISTS
DISCOVER NEW TREATMENT FOR
FATIGUE!
The following advertisement promotes a dietary supple- ment, garlic oil tablets, to relieve fatigue. Read the ad and evaluate it using the model for analyzing health- related information. The main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who makes the health-related claims? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person making the claims?
4. What is the main point of the ad? Which information is relevant to the product? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this ad is a reliable source of health-related information? Summa- rize your reasons for coming to this conclusion.
Analyzing Health-Related Information 315
CHAPTER REVIEW Summary
Nutrients are substances in foods that supply energy; regulate body processes; and provide material for growth, maintenance, and repair of tissues. "e six classes of nutrients are carbohydrates, lipids, pro- teins, vitamins, minerals, and water. Many foods also contain non-nutrients, substances that are not essen- tial but may have healthful bene!ts. Phytochemicals may prevent various chronic diseases, including cer- tain cancers.
During digestion, food is broken down into nutri- ents that can be absorbed. Cells metabolize carbohy- drates, fats, and proteins for energy. "e amount of energy stored in food is measured in calories. Cells cannot release energy from water, vitamins, and minerals.
Carbohydrates, the sugars and starches, are a major source of energy for the body. "e only disor- der that is clearly associated with excessive carbohy- drate consumption is tooth decay. Plant foods supply dietary !ber and phytochemicals. Diets rich in !ber may reduce the risks of diverticulosis, hemorrhoids, constipation, and heart disease.
Many medical experts think Americans eat too much fat, especially saturated fat and trans fat. Eating excessive amounts of these lipids is associated with an increased risk of obesity, heart disease, and certain cancers.
Protein is essential for tissue growth, repair, and maintenance and for producing enzymes, antibod- ies, and certain hormones. "e average American consumes more than twice the amount of protein needed, particularly from animal foods. One way to reduce the amount of animal foods in the diet is to eat more protein from plants. Vegetarian diets are associated with lower risks of chronic conditions such as heart disease.
Vitamins and minerals regulate body processes; some minerals are structural components of tissues. Overdoses of many vitamins and most minerals can cause nutritional imbalances and be toxic; therefore, unless medically indicated, people should avoid tak- ing high doses of nutrient supplements.
A lifetime of inadequate calcium intake, coupled with low estrogen levels a$er menopause, increases a woman’s risk of osteoporosis. Iron de!ciency is a common nutritional problem, especially among women of childbearing age. Dehydration is a seri- ous condition that results when water intake is inad- equate or water losses are excessive.
"e key features of a nutritious diet are nutrient adequacy and nutrient balance. By selecting a variety of foods and by avoiding the indiscriminate use of nutrient supplements, one’s diet can be nutritionally adequate and balanced.
A requirement for a nutrient is the smallest amount that prevents a de!ciency disease. Dietary Reference Intakes (DRIs) are standards for planning nutritious diets and determining the nutritional ade- quacy of diets. MyPlate and the Dietary Guidelines are practical daily menu-planning guides. Nutrient labeling can help consumers select nutritious foods. Malnutrition occurs when diets supply too little or too many nutrients.
"e quality of a woman’s diet before and during pregnancy has an impact on the health of her devel- oping child. During the !rst year of life, human milk is the best food for infants; solid foods should not be fed to babies until they are 4 months old. Without proper supervision, children and teenagers may skip meals or select inadequate diets. Physical, psycholog- ical, economic, and social factors contribute to the risk of malnutrition among older adults.
1. Locate the nutrition label on three foods you o$en eat. View each label and explain how you would use nutrient labeling information
to determine the amount of complex carbohy- drates, sugar, protein, total fat, saturated fat, and trans fat. Application
Applying What You Have Learned
316 Chapter 9 Nutrition
CHAPTER REVIEW 2. Keep a food record for one day by writing down
all foods and beverages you consume during a 24-hour period. Analyze this day’s food choices by using the “Tracker” at the MyPlate website (www.choosemyplate.gov). Analysis
3. Consider the results of your food record. Of which foods should you reduce consump- tion? Which foods can be added to your diet
to improve the nutritional value of your food intake? Evaluation
4. Plan a menu for a day (meals, snacks, and bev- erages) that meets MyPlate’s recommended amounts of foods for a person of your age, sex, weight, height, and physical activity level. You’ll need to visit www.choosemyplate.gov to do this activity. Synthesis
1. A$er reading this chapter, what changes can you make to improve your diet? How is your present diet di#erent from what you ate as a child or while in high school? Why do you think your present diet is better or worse than your past diet?
2. What factors in'uence your food choices? Fac- tors may include personal preference, family/ social norms, economics, or food availability. How willing are you to try new healthy foods? Have you tried any new healthy foods in the past year? Did you continue to eat the new foods? Why or why not?
3. Do you use nutrition labels? If you do, which information do you think is most important?
How does nutritional labeling help you be a bet- ter consumer? If you do not use nutrition labels, why not? What do you think you might gain or lose by using nutrition labels?
4. Do you take dietary supplements? If you do, which supplements do you take? Why do you take them? Do you know if the supplement ingredi- ents have been tested for safety or e#ectiveness?
5. Females: Would you or did you breastfeed your children? Explain why you would or did breast- feed your children. Males: Would you want the mother of your children to breastfeed them, or do you have children who were breastfed? Why or why not?
Reflecting on Your Health
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
Key
1. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2015). 2015–2020 Dietary guidelines for Americans (8th ed.). Washington, DC: U.S. Government Printing O&ce. Retrieved from https://health.gov/dietaryguidelines/2015 /resources/2015-2020_Dietary_Guidelines.pdf
2. American Diabetes Association. (2017). Fitting in sweets. Retrieved from http://www.diabetes.org/food-and-!tness/food/planning-meals /holiday-meal-planning/making-sugar-count-during-the-holidays .html
3. American Dietetic Association. (2012). Position of the Academy of Nutrition and Dietetics: Use of nutritive and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112(5), 739–785.
4. Ervin, R. B., & Ogden, C. L. (2013). Consumption of added sugars among U.S. adults, 2005–2010 (NCHS Data Brief No. 122). Hyatts- ville, MD: National Center for Health Statistics.
5. Yang, Q., et al. (2014). Added sugar intake and cardiovascular dis- ease mortality among U.S. adults. Journal of the American Medical Association Internal Medicine, 174(4), 516–524.
References
References 317
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8. Murphy, S. L, et al. (2017). Deaths: Final data for 2015. National Vital Statistics Reports, 66(6). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data /nvsr/nvsr66/nvsr66_06.pdf
9. American Diabetes Association. (2017). Fast facts: Data and statistics about diabetes. Retrieved from https://professional.diabetes .org/sites/professional.diabetes.org/!les/media/fast_facts_8-2017 _pro_3.pdf
10. Centers for Disease Control and Prevention. (2017). National Dia- betes Statistics Report, 2017: Estimates of diabetes and its burden in the United States. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/diabetes /pdfs/data/statistics/national-diabetes-statistics-report.pdf
11. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. (2011, January). Age-adjusted incidence of diagnosed diabetes per 1,000 population aged 18–79 years, by race/ethnicity, United States, 1997–2009. Data and trends, National Diabetes Surveillance System.% Retrieved from https://www.cdc.gov/diabetes/statistics /hypoglycemia/!g5byage.htm
12. Malik, V. S., & Hu, F. B. (2012). Sweeteners and risk of obesity and type 2 diabetes: "e role of sugar-sweetened beverages. Current Diabetes Care, 12(2), 195–203.
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15. National Institutes of Health, National Digestive Diseases Infor- mation Clearinghouse. (2009). Lactose intolerance. Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/
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17. Cli$on, P. (2009). Dietary fatty acids and in'ammation. Nutrition & Dietetics, 66(1), 7–11.
18. Wall, R., et al. (2010). Fatty acids from !sh: "e anti-in'ammatory potential of long-chain omega-3 fatty acids. Nutrition Reviews, 68(5), 280–289.
19. Buckland, G., et al. (2009). Adherence to the Mediterranean diet and risk of coronary heart disease in the Spanish EPIC Cohort Study. American Journal of Epidemiology, 170(12), 1518–1529.
20. Williams, A. N., & Woessner, K. M. (2009). Monosodium gluta- mate “allergy”: Menace or myth? Clinical and Experimental Allergy, 39(5), 640–646.
21. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. (2011). Nutrient content of the U.S. food supply: Devel- opments between 2000–2006. Retrieved from http://www.cnpp.usda .gov/sites/default/!les/nutrient_content_of_the_us_food_supply /Final_FoodSupplyReport_2006.pdf
22. American Heart Association. (2017). Protein and heart health. Retrieved from https://healthyforgood.heart.org/Eat-smart/Articles /Protein-and-Heart-Health
23. American Dietetic Association. (2009). Position of the American Dietetic Association: Vegetarian diets. Journal of the American Dietetic Association, 109(7), 1266–1282.
24. National Institutes of Health, National Institute of Allergy and Infectious Diseases. (2017). Food allergy. Retrieved from http:// www.niaid.nih.gov/topics/foodallergy/Pages/default.aspx
25. Gerez, I. F. A., et al. (2010). Diagnostic tests for food allergy. Singa- pore Medical Journal, 51(1), 4–9.
26. Rubio-Tapia, A., et al. (2012). "e prevalence of celiac disease in the United States. American Journal of Gastroenterology, 107, 1538–1544.
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29. Bailey, R. L., et al. (2011). Dietary supplement use in the United States: 2003–2006. Journal of Nutrition, 141(2), 261–266.
30. Kanter, E. D., et al. (2016). Trends in dietary supplement use among U.S. adults from 1999–2012. Journal of the American Medical Association, 316(14), 1464–1474.
31. Gahche, J. J., et al. (2017). Dietary supplement use was very high among older adults in the United States in 2011–2014. Journal of Nutrition, 147(10), 1968–1976.
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CHAPTER REVIEW 34. Mayo Clinic. (2017). Ca!eine: How much is too much? Retrieved from
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35. Food and Nutrition Board, National Institute of Medicine. (2004). Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington, DC: National Academy Press.
36. U.S. Food and Drug Administration. (2017). Proposed changes to the nutrition facts label. Retrieved from http://www.fda.gov/Food /GuidanceRegulation/GuidanceDocumentsRegulatoryInformation /LabelingNutrition/ucm385663.htm#Summary
37. National Institutes of Health, O&ce of Dietary Supplements. (2015). Multivitamin/mineral supplements. Retrieved from http:// ods.od.nih.gov/factsheets/MVMS-HealthProfessional/
38. Jensen-Coleman, A., et al. (2017). Household food security in the United States in 2016 (Economic Research Report No. ERR- 237). Retrieved from https://www.ers.usda.gov/publications/pub -details/?pubid=84972
39. U.S. Department of Health and Human Services, O&ce of Women’s Health. (2018). Breastfeeding fact sheet. Retrieved from https:// www.womenshealth.gov/publications/our-publications/fact-sheet /breastfeeding.html
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 319
Across the Life Span Weight Management
Managing Your Health General Features of Reliable Weight Reduction Plans
Consumer Health Dietary Supplements: Weight-Loss Aids
Diversity in Health The Plight of the Pima
Chapter Overview The definitions of weight categories
How your body uses the energy from foods
How to determine your percentage of body fat
The causes of obesity
How to manage your weight
Student Workbook Self-Assessment: How Much Energy Do You Use Daily?
Changing Health Habits: Altering Caloric Intake and Physical Activity
Do You Know? How to shed fat and gain muscle?
What causes “middle-age spread”?
How to lose weight and keep it off?
<20%
20% – <25%
25% – <30%
30% – <35%
!35%
Insufficient data*AK
HI
PR
WA
ID
MT
WY
CO
ND MN
IA
MO
AR
LA
MS AL GA
FL
NJ
DE
MD
SC
NCTN
KY
INIL
WI MI
OH
PA
WV VA
NY
ME VT
NH MA
CT RI
SD
NE
KS
OK
TX
NMAZ
UTNV
OR
CA DC
GU
VI
50
P er
ce n
t
40 Overweight, men
Overweight, women
Obesity, women
Obesity, men
Extreme obesity, women
30
20
10
0
19 60
–1 96
2
19 71
–1 97
2
Notes: Age-adjusted by the direct method to the year 2000 U.S. Census Bureau estimates using age groups 20–39, 40–59, and 60–74. Overweight is body mass index (BMI) of 25 kg/m2 or greater but less than 30 kg/m2; obesity is BMI greater than or equal to 30; and extreme obesity is BMI greater than or equal to 40. Pregnant females were excluded from the analysis. Sources: NCHS, National Health Examination Survey and National Health and Nutrition Examination Surveys.
19 76
–1 98
0
19 88
–1 99
4
20 01
–2 00
2
20 05
–2 00
6
20 09
–2 01
0
20 13
–2 01
4
Extreme obesity, men
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: Courtesy of CDC.
After studying this chapter, you should be able to:
1. Identify major health problems that are associated with excess body fat.
2. Explain how the body mass index (BMI) is used to define degrees of overweight and obesity.
3. List the three major ways the body expends energy. 4. Explain the concept of energy balance and how it relates
to body weight. 5. Compare various methods of determining body
composition. 6. Explain how biological, environmental, and psychological factors influence the development of excess body weight. 7. Compare and contrast various weight-loss methods. 8. Describe the typical features of fad diets. 9. List characteristics of safe and reasonable weight reduction programs. 10. Describe steps a person can take to gain lean body weight safely. 11. Explain the importance of weight gain during pregnancy. 12. Describe how obesity affects the health of children and the elderly.
Body Weight and Its Management
© EyeEm
/Getty Im ages.
Learning Objectives “Approximately 70% of American adults are overweight or obese.”
CHAPTER 10
321
I n 2016, about 65% of American adults were over-weight or obese.1 A person who is overweight has more fat, muscle, bone, and/or body water than a person whose weight is classi!ed as normal (e.g., healthy). Being overweight is not necessarily unhealthy, but people who are overweight and have too much body fat are at risk of becoming obese. In this chapter, we use the term overweight to refer to overfat. Obesity is a condition characterized by excessive and unhealthy amounts of body fat. As indicated in the overweight and obesity timeline, the prevalence of obesity and extreme obesity in the United States has increased steadily for both men and women since the 1980s. "e 2016 prevalence map illustrates that every state had a prevalence of obesity of at least 20%, with 25 states having a prevalence of at least 30%. What is the prevalence of obesity in your state?
Overweight and obesity are the most common nutritional disorders in the United States.2 "ese con- ditions o$en result from a combination of two behav- ioral risk factors—poor diet and physical inactivity. In the United States, an increasing number of people are dying of causes related to these risk factors.3
"ere is a widespread misperception that persons who are overweight or obese lack the willpower to control their eating and weight. It is true that a person gains body fat by eating more food energy (calories) than needed and that losing the excess weight involves a considerable amount of motivation and commit- ment. However, overweight and obesity result from a complex combination of biological, psychological, environmental, cultural, and socioeconomic in'u- ences. "us, shedding excess fat to achieve a healthy body weight is not an easy task. According to most medical experts, obesity is a chronic metabolic dis- ease that is extremely di&cult to treat.
"is chapter examines factors that contribute to the development of excess body fat, identi!es health problems associated with this condition, and dis- cusses various weight-loss methods. Some individu- als are underweight and want to increase their muscle mass; therefore, this chapter also provides informa- tion concerning healthy ways to gain weight.
Overweight and Obesity A healthy body is not fat free; a small amount of fat is essential for the normal functioning of all cells. Addi- tionally, the body has specialized cells called adipose cells that store the extra energy from food as triglyc- eride (fat). If a person eats more food energy than is needed, his or her fat cells continue storing fat and increasing in size. Under certain conditions, addi- tional fat cells can develop, further enlarging the fat mass, and this person soon notices that his belts are too small or her slacks are too tight as a result.
Body Mass Index How much extra fat must a person have to be con- sidered overweight? At what point does a person who is overweight become obese? Most health experts use the body mass index (BMI) instead of height/weight tables to determine whether an indi- vidual weighs too much. BMI is calculated by divid- ing weight (kilograms) by height (meters squared): kg/m2. BMI correlates body weight with the risk of developing chronic health conditions.
To estimate your BMI, multiply your weight in pounds by 705. "en, divide that number by your height in inches squared. For example, if you weigh 150 pounds and your height is 5’7”, multiplying your weight times 705 equals 105,750, and squaring your height equals 4,489. Dividing 105,750 by 4,489 pro- duces approximately 23.56. "us, your BMI is 23.56. You can also determine your BMI by using the inter- active BMI calculator at the National Heart Lung and Blood Institute’s website (www.nhlbi.nih.gov /guidelines/obesity/BMI/bmicalc.htm) or the adult and child BMI calculators available on the Centers for Disease Control and Prevention’s website (www.cdc .gov/healthyweight/assessing/bmi/index.html).
Table 10.1 indicates weight classi!cations accord- ing to BMIs. Adults with BMIs below 18.5 are classi- !ed as underweight. Healthy BMIs are between 18.5 and 24.9. Adults with BMIs between 25.0 and 29.9 are overweight; those with BMIs of between 30.0 and
overweight A condition in which the body has more fat, muscle, bone, and/or body water than a person whose weight is healthy. Overweight is classified as having a BMI of 25.0–29.9.
obesity A condition in which the body has an excessive and unhealthy amount of fat. Obesity is classified as having a BMI of 30.0 or higher.
adipose cells Specialized cells that store extra food energy as fat.
body mass index (BMI) A standard that correlates body weight with the risk of developing chronic health conditions associated with obesity. BMIs are calculated with a person’s height and weight.
322 Chapter 10 Body Weight and Its Management
39.9 are obese. People who have BMIs of 40 or more are o$en referred to as morbidly or extremely obese.
By using your BMI as a guide, you can determine whether your weight is in the overweight or obese range for your height (Table 10.2).
You can also use the graph shown in Figure 10.1 to determine if your weight is within the healthy BMI range. Find your height, without shoes, on the le$- hand side of the graph and place your le$ index !nger on that point. "en, !nd your weight, without cloth- ing, on the bottom line of the graph, and place your right index !nger on that point. Move your le$ !nger to the right and your right !nger up until they meet. Note which range that point is in. Is your weight in the healthy BMI range?
Cell membrane
Cytoplasm
Nucleus
Fat droplet
Fat cells divide when they reach a certain size
With fat loss, the size of the cells, but not the number, decreases
The number of fat cells increases in normal growth
In obese people, fat cells are larger than in lean people
Adipose (fat) cells. Photo: © Photo Researchers/Science History Images/Alamy Stock Photo.
BMI Weight Classification
Below 18.5 Underweight
18.5–24.9 Healthy
25.0–29.9 Overweight
30–39.0 Obese
40.0 and higher Morbidly or extremely obese
Table 10.1
Weight Classifications
Height (in.)
Overweight (BMI 25.0–29.9) Lower Limit (lb)
Obese (BMI 30 or more) Lower Limit (lb)
58 119 143
59 124 148
60 128 153
61 132 159
62 136 164
63 141 169
64 145 174
65 150 180
66 155 186
67 159 191
68 164 197
69 169 203
70 174 207
71 179 215
72 184 221
73 189 227
Reproduced from National Institutes of Health, National Heart, Lung, and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: National Heart, Lung, and Blood Institute.
Table 10.2
Classifying Body Weight Based on BMI
Overweight and Obesity 323
of the adult American population.6 However, Americans did not meet this objective by 2010. A%later section of this chapter discusses factors that contribute to the rising prevalence of overweight in the United% States. Healthy People 2020 includes two objectives related to obesity: (1) reducing the proportion of adults who are considered obese and (2) reducing the proportion of children and adolescents who are obese.7 Do you believe these objectives will be met?
"e United States is not the only country experi- encing a rapid increase in the prevalence of obesity. "e World Health Organization (WHO) recognizes obesity as a global health problem. "e worldwide prevalence of obesity (globesity) is rising rapidly, especially in nations with developed market econo- mies such as those in western Europe. Globally, an estimated 500 million people, or more than 1 in 10% adults, were obese in 2008; by 2016, more than 650%million adults were obese, out of nearly 2 billion who were overweight.8
De!ning overweight and obese as certain BMIs can produce inaccurate conclusions, especially for very muscular people. For example, athletic individ- uals may have a BMI of 26 and be overweight accord- ing to Figure 10.1. Because muscle is denser than fat, an athletic, muscular person can be heavier but healthier than a physically inactive (sedentary) indi- vidual who is the same height and weighs less.
The Prevalence of Obesity "e prevalence of obesity has reached epidemic pro- portions in the United States. Since 1980, obesity rates have doubled for American adults and nearly tripled among children and adolescents who are 2–19 years of age. Although recent years have seen childhood overweight percentages level o#, obesity is still on the rise among American children and ado- lescents.4 More American infants and preschool chil- dren are also overweight than in the past.5
An objective of Healthy People 2010 was to reduce the prevalence of excess body fat to 40%
50 75 100 125 150 175 200 225 250
23 34 45 57 68 80 91 103 113
275
125
6'6" 6'5" 6'4" 6'3" 6'2" 6'1" 6'0"
5'11" 5'10" 5'9" 5'8" 5'7" 5'6" 5'5" 5'4" 5'3" 5'2" 5'1" 5'0"
4'11" 4'10"
Pounds
Kilograms
Weight †
*Without shoes. † Without clothes.
H ei
g h
t*
Underweight Healthy weight Overweight Obese
Figure 10.1 BMI Graph. Find your BMI by following the instructions provided in the text. Modi!ed from National Heart Lung and Blood Institute. (n.d.). Body mass index table 1. Retrieved September 17, 2011 from http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
324 Chapter 10 Body Weight and Its Management
who are obese can reduce their risks of obesity-related health problems such as heart disease and stroke.14 Additionally, this weight loss can save thousands of dollars that would have been spent on treating medi- cal conditions related to excess body fat.
Besides a#ecting physical health, excess body fat can have a negative impact on psychological health. People who are obese, particularly women who seek weight-loss treatment, o$en su#er from depression and low self-esteem.12 Some people may develop these psychological conditions a$er being discrimi- nated against or having humiliating and embarrass- ing experiences. Some people perceive individuals who are obese as physically unattractive, lacking willpower, and/or lazy. Not surprisingly, many people who are overweight or obese are dissatis!ed and pre- occupied with their body image.15
What are the factors that contribute to the develop- ment of excess body fat? Why are so many Americans overweight? Is it possible to control one’s weight?
How Does Excess Body Fat Affect Health? Excess body fat, particularly obesity, contributes to many serious and disabling health problems. Obesity increases one’s risk of developing gout, a condition that a#ects joints; carpal tunnel syndrome, a painful nerve disorder involving the wrist and hand; and sleep apnea, a condition in which one stops breathing peri- odically while sleeping. "ose with obesity are also more likely to su#er from metabolic syndrome, gall- bladder disease, hypertension, diabetes, and heart dis- ease. Obesity signi!cantly increases the risk of cancers of the large intestine (colon), breast (postmenopausal women), uterus, kidney, and esophagus.9 Compared with people who have healthy body weights, people who are obese are more likely to die prematurely.10 In the United States, excess body fat contributes to more than 90,000 cancer deaths each year.11
Surgery is riskier for people who are obese because physicians have more di&culty estimating the amount of anesthesia needed. Obese men and women are more likely to experience fertility problems than people whose weights are in the healthy range. Preg- nant overweight or obese women have greater risks of developing diabetes (gestational diabetes), a form of severe hypertension during pregnancy, and giv- ing birth to babies with birth defects and/or babies who do not survive.12 Furthermore, having too much body fat can interfere with one’s ability to perform daily activities that require walking, carrying, kneel- ing, and stooping.
Many physical health problems result from being overweight or obese. Excess body weight can stress joints, especially weight-bearing joints in the knees and hips, so they wear out sooner. People who are obese o$en have breathing problems because the excess fat interferes with lung expansion when they inhale.
When fat cells become too large, they lose their ability to respond to the hormone insulin, which leads to the development of diabetes. Fat tissue also contains cells called macrophages. Although these cells play a role in immune system processes that protect an individual from disease, they may multiply excessively and malfunction in people who have too much body fat. Macrophages found in fat tissue pro- duce chemicals that cause in'ammation, resulting in damage to the heart and blood vessels, which sets the stage for heart disease.13
A person who is obese does not have to become slim to reap some bene!ts of losing weight. By losing 10% of body weight and maintaining that loss, people
metabolism All chemical reactions that take place in the body.
This person has sleep apnea and sleeps with a device that regulates her breathing. © Brian Chase/Shutterstock.
!e Caloric Cost of Living Bodies need energy (calories) to survive and thrive. "e amount of energy needed depends on various factors, such as metabolism rates and physical activ- ity levels.
Energy for Basal (Vital) Metabolism Metabolism refers to all chemical changes that take place in cells. Human cells use energy (calories) from
The Caloric Cost of Living 325
feel warm, be nervous and shaky, have chronic diar- rhea, and lose weight despite eating large amounts of food. People with overactive thyroid glands can take medication or have surgery to reduce the amount of hormone produced by the organ. A person who su#ers from lack of thyroid hormone has a lower than normal metabolic rate. "is individual may feel cold, have little energy, be constipated, and gain weight easily. People su#ering from underactive thyroid glands can increase their metabolic rates by taking thyroid hormone pills. "e vast majority of people who have excess body fat, however, have normal thyroid hormone levels and normal metabolic rates.
"e proportion of muscle and fat tissue also in'u- ences the metabolic rate. Muscle cells use more energy than fat cells; therefore, people with greater amounts of muscle mass have higher metabolic rates than those with more fat tissue. Testosterone is a hormone that stimulates muscle mass development. Because men normally produce more testosterone than women, men usually have more muscle and less fat than women. On average, men have higher meta- bolic rates than women.
Age also in'uences the metabolic rate. Infants and children have higher metabolic rates than adults because they are growing rapidly. A$er 20 years of age, metabolic rates decline about 1–2% each decade. As a result of this gradual slowdown, people need less energy as they age. "us, if people continue to eat the same amount of food as their age increases, they gain weight (assuming consistent activity levels). Although the declining metabolic rate is a contributing factor, many health experts think physical inactivity is more responsible for “middle-age spread” than overeating is. As one grows older, exercising regularly can help retain muscle, which slows the metabolic rate decline.
Energy for Physical Activity In addition to the caloric cost of vital metabolic activities, the body expends energy to contract skel- etal muscles. "e amount of energy needed for physi- cal activity depends on the type of activity, the time spent performing the activity (its duration), and the intensity at which it is performed. Although it is not related directly to physical activity, a person’s body size in'uences the amount of physical e#ort needed to move. For example, a person who weighs 120 pounds and another who weighs 175 pounds might spend the same amount of time playing a game of tennis. If both of them play tennis with the same intensity, the muscles of the heavier person require more energy to move than those of the lighter person.
food to perform vital activities such as building and repairing tissues, circulating and !ltering blood, and producing and transporting substances. Nevertheless, cells release much of the calories from food as heat, which is necessary for maintaining one’s body temper- ature. Every day, the body expends the largest portion of calories (50–70%) to carry out these vital activities. "e metabolic rate is the amount of energy required to fuel cellular activities within a speci!ed time.
Metabolic rates vary; genetic factors probably play a major role in setting these rates. Hormones, especially thyroid hormone produced in the thyroid gland, regu- late metabolism (Figure 10.2). In some people, the thy- roid gland does not function properly, and as a result, the organ produces too much (hyperthyroidism) or too little thyroid hormone (hypothyroidism). An indi- vidual who produces too much thyroid hormone has a higher than normal metabolic rate. "is person may
metabolic rate The amount of energy the body requires to fuel cellular activities during a specified time.
Figure 10.2 The Thyroid Gland. The thyroid gland produces hormones that control the metabolic rate.
Thyroid gland Larynx
Right lobe Trachea Isthmus Left lobe
326 Chapter 10 Body Weight and Its Management
day, the typical American expends more energy for physical activities associated with daily living than for sports types of exercise. Spontaneous muscular movement includes !dgeting and maintaining bal- ance and body posture. Movements for daily living and spontaneous muscular movements are some- times referred to as nonexercise activity thermogen- esis (NEAT). As a result of NEAT, people can reduce the risk of gaining body fat by being restless and busy because they will metabolize far more energy each day than people who spend much of their day engaging in sedentary activities such as lying down or sitting still. Nevertheless, more research is needed to determine the role of NEAT in weight maintenance.
Table 10.3 lists some common physical activities and the number of calories people expend per minute of performing each activity. Note that the number of calories used for an activity varies according to body weight. For most people, the total number of calories expended daily for physical activity is less than the number expended for basal metabolism. To%assess your daily energy expenditure, visit www.choosemyplate .gov/body-weight-planner www.choosemyplate.gov /supertracker-tools/supertracker.html.
According to the Physical Activity Guidelines for Americans, adults need 150 minutes of moderate- intensity aerobic activities each week.16 However, approximately 1 in 5 adults report meeting this guideline.17
People can increase the amount of energy expended during physical activity by increasing its duration or intensity. Furthermore, the metabolic rate o$en remains elevated for several hours a$er one discon- tinues vigorous physical activity. "is elevation may result from an increase in the metabolic activity of muscle cells that occurs a$er physical exertion. "ere- fore, individuals who engage in regular vigorous activ- ity may be able to raise their resting metabolic rates.
Some health experts classify physical activities as sports types of exercise, movement for daily living, or spontaneous muscular movements. Sports types of exercise are physical activities that are planned and carried out for the purpose of improving health and well-being. Swimming, brisk walking, and li$- ing weights are sports types of exercises. Movement for daily living includes various unstructured physi- cal activities such as housework, gardening, walk- ing, and leisure-time physical activities that are not associated with sports, eating, or sleeping.18 Each
Physical Activity
Calories per Pound of Body Weight per Minute
Range for Women Range for Men
Sedentary
Sitting quietly, playing a musical instrument
Up to 0.017 Up to 0.017
Light
Playing pool, bowling, golf, volleyball, walking (3 mph)
0.017–0.033 0.017– 0.035
Moderate
Badminton, canoeing, gymnastics, hockey, cycling, swimming, dancing, tennis, skiing
0.033–0.050 0.035–0.052
Vigorous/Heavy
Basketball, climbing, cross-country running, rowing
0.05+ 0.052+
To estimate the number of calories you expend while performing a particular physical activity, multiply the calories per pound per minute by your weight. Use the figures in the left-hand column if you are a woman, and in the right-hand column if you are a man. Then, multiply that number by the number of minutes spent performing the activity. For example, you are a woman who weighs 120 pounds, and you spent 40 minutes cycling: 0.033 ! 120 = 3.96 calories per minute; 3.96 ! 40 minutes = about 158 calories spent. (The rates of caloric expenditure per minute are given as ranges. For example, if you cycled intensely, use a rate at the high end of the range.)
Adapted from Durnin, J. V. G. A., & Passmore, R. (1967). Energy, work, and leisure. London, England: Heinemann.
Approximate Energy Costs of Various Physical Activities
Table 10.3
The Caloric Cost of Living 327
The Basics of Energy Balance In general, people maintain, gain, or lose body weight according to the basic principles of energy balance, as illustrated in Figure 10.3. When the caloric intake from food equals the number of calories expended for energy needs, no change in body weight occurs. When caloric intake is less than caloric expendi- tures, the body loses weight as cells burn stored fat. If caloric intake is more than caloric expenditures, the body conserves much of the excess calories as fat, and weight gain occurs. Each pound of body fat represents about 3,500 calories of potential energy; therefore, consuming as little as 100 extra calories per day for a year can result in a 10-pound weight gain.
Body Composition When you step on a scale, you can determine your body weight as a number of pounds or kilograms. "at weight, however, does not specify how much water, muscle, or fat is in your body. Fat-free body
Energy for the Thermic Effect of Food Together, metabolic and physical activity energy needs constitute more than 90% of a person’s energy expenditure. A$er eating a meal, the body requires a small amount of energy to digest, absorb, and pro- cess the nutrients from food. "is use of energy, the thermic effect of food (TEF), accounts for a very small portion, less than 10%, of one’s total energy expenditures.
How many calories does your body need daily? To estimate your daily caloric expenditures, you can add the number of calories needed for basal metab- olism, physical activity, and TEF. "e assessment activity in the Student Workbook section in this text can help you estimate the number of calories you expend in a day.
thermic effect of food (TEF) The small amount of energy that the body uses to digest, absorb, and process the nutrients from foods.
Figure 10.3 Energy Balance. (a) When energy expenditure equals energy intake, the body maintains its weight; (b) when energy expenditure is greater than energy intake, the body loses weight; (c) when energy expenditure is less than energy intake, the body gains weight.
Carbohydrates Fats
Proteins Alcohol
(a) Energy is in balance.
Metabolism Physical Activity
TEF Metabolism
Physical Activity TEF
Metabolism Physical Activity
TEF
Carbohydrates Fats
Proteins Alcohol
Carbohydrates Fats
Proteins Alcohol
(c) Energy intake exceeds energy expenditure.
Weight Gain
(b) Energy intake is less than energy expenditure.
Weight Loss
No Weight Gain or
Loss
328 Chapter 10 Body Weight and Its Management
strands hold the fat in an irregular pattern, the fat tis- sue can extend into layers of skin, giving the skin a lumpy appearance. Women are more likely than men to have irregular connective tissue under their skin. "e best way to improve the appearance of thighs and buttocks is to exercise and lose excess weight.
Fat Cells Obesity can begin at any age. However, the number and size of fat cells increase dramatically when this condition occurs during childhood and other periods of rapid growth.20 People who become overweight in adulthood usually have normal num- bers of fat cells, but their fat cells are larger than nor- mal. "e number of fat cells, however, can increase when extreme obesity occurs during the adult years.
Once fat cells form, there is little evidence that they can disappear with short-term weight reduction e#orts. Under these conditions, most fat cells shrink as they release stored fat to meet the energy needs of other tissues. A$er shrinking, fat cells may send chemical signals to the nervous system that stimulate the urge to eat, making it di&cult for people to main- tain their reduced body weights.
Estimating Body Fat A variety of methods are used to determine one’s percentage of body fat, including hydrostatic weighing, bioelectrical impedance, dual-energy X-ray absorpti- ometry, air-displacement plethysmography, and skin- fold thicknesses. "e following sections discuss these techniques.
Hydrostatic Weighing Hydrostatic weighing (under water weighing) is one of the most reliable methods to estimate an individual’s percentage of body fat (Figure 10.4). Body fat is less dense than lean tissues or water; therefore, extra fat makes the body more buoyant. Because the equipment needed to perform hydrostatic weighing is not widely available, the method is not a practical or convenient way to determine a person’s percentage of body fat.
Bioelectrical Impedance Bioelectrical impedance uses electrical currents to estimate the percentage of body fat. Water and certain mineral elements conduct electrical currents, whereas fat is a poor conductor of electricity. "e equipment shown in Figure 10.5 safely measures the body’s electrical conductivity to deter- mine the percentage of body fat. When subjects have normal amounts of body water (i.e., are adequately hydrated), bioelectrical impedance provides reliable estimates of their percentage of body fat.
Dual-Energy X-Ray Absorptiometry Dual-energy X-ray absorptiometry (DEXA or DXA) is o$en used
weight consists of water, proteins, and minerals found in the bones, muscles, and organs (lean tis- sues). About 60% of a healthy adult’s weight is water, 6–22% is protein, and 3% is minerals. Most of the remaining weight is fat.
How Much Body Fat Is Healthy? Many health experts use the percentage of body fat to determine if a person is overfat. "e average healthy young woman has proportionately more body fat than the average healthy young man because the fat is needed for hormonal and reproductive purposes. Although people tend to gain fat as they age, the increase does not necessarily cause health problems. Table 10.4 indicates percentages of body fat that are healthy, overweight, and obese.
About one-half of an average healthy person’s body fat is located in a layer under the skin (subcuta- neous fat). Small amounts of fat are stored in muscles, which rely on the fat for energy. Besides subcutane- ous and muscle fat, regions of the abdomen, thighs, hips, and buttocks store considerable amounts of fat.
Every year, Americans spend money on ine#ec- tive treatments to eliminate “cellulite.” Many people think cellulite is an abnormal type of fat that appears as lumpy, dimpled skin on the buttocks and thighs. Cellulite fat, however, does not exist. "ere is no di#erence between the fat cells in so-called cellulite and those in subcutaneous fat.19 Strands of connec- tive tissue hold subcutaneous fat in place. If these
Classification
Body Fat (%)
Men Women
Healthy 13–20 23–30
Overweight 21–24 31–36
Obese !25 !37
Data from Food and Nutrition Board. (2005). Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients) (Table 5.5, p. 126). Washington, DC: National Academies Press.
Table 10.4
Classifying Adult Weight by Percentage of Body Fat
Body Composition 329
in clinical studies to measure body fat as well as bone density, which is useful for diagnosing osteo- porosis (Figure 10.6). Although the technique is very accurate for measuring body composition, the equipment is very expensive and requires trained X-ray technicians to use it.
Air-Displacement Plethysmography "e air- displacement plethysmography technique uses a spe- cial chamber (BOD POD) to measure a person’s body volume (Figure 10.7). "e BOD POD determines the volume of air that a body displaces while sitting in the device. A$er information about the air displacement has been obtained, the person’s fat mass can be calcu- lated. Air-displacement plethysmography is a quick and reliable way to measure fat mass and involves no exposure to radiation as DEXA does.21
Skinfold %icknesses Many years ago, adver- tisements for a breakfast cereal asked people to “pinch an inch” as a method of determining their amount of body fat. If people could pinch a fold of abdominal skin that was more than an inch wide, according to the advertisement, they were too fat. "is crude technique of measuring skinfold thick- nesses relied on the principle that one-half of a person’s fat is located beneath the skin, if the person has a healthy BMI.
Using skinfold thicknesses to assess body compo- sition is not as accurate as the underwater weighing
Figure 10.4 Hydrostatic (Underwater) Weighing. Hydrostatic weighing is one of the most reliable methods to estimate an individual’s percentage of body fat.
Figure 10.5 Bioelectrical Impedance. This woman is having her percentage of body fat determined by the bioelectrical impedance method. © David Young-Wol"/PhotoEdit, Inc.
Figure 10.6 Dual-Energy X-Ray Absorptiometry. DEXA is often used in clinical studies to measure body fat as well as bone density. © Photodisc.
330 Chapter 10 Body Weight and Its Management
thicknesses to determine the degree of body fat in individuals who are overweight or obese. Unlike per- sons with healthy weights, individuals who are obese have less than half of their body fat under their skin, because they store considerable amounts of fat in their abdomens.
Waist Circumference Waist circumference mea- surements determine the distribution—rather than percentage—of body fat. "e distribution of body fat may be more important than body fat percentage for determining risk factors for the health conditions that are associated with excess body fat. Men and women who have large body fat deposits centrally located deep within their abdomens tend to have higher blood cholesterol levels and a greater risk of developing diabetes, hypertension, and heart disease than individuals with the same amount of fat located below the waist.22 Why? Certain obese abdominal fat cells (visceral fat) may be more likely to release in'ammatory compounds into the blood than sub- cutaneous fat cells found in the hips and thighs. Excessive amounts of these substances in the blood increase the risk of cardiovascular disease and type 2 diabetes.23 More research is needed, however, to determine the link between abdominal fat and these chronic diseases.
and bioelectrical impedance techniques, but it is more practical and less costly. Instead of using !ngers to pinch a section of skin and its underlying layer of fat, a trained person uses special calipers to mea- sure skinfold thickness more precisely (Figure 10.8). Skinfold measurements should be taken at three or% more select body sites; averaging these measure- ments accounts for individual di#erences in body fat%distribution.
"e reliability of using skinfolds to estimate the percentage of body fat depends on the accuracy of the calipers, the number of skinfolds measured, and the skill of the person performing the measurements. Although measuring skinfolds is a popular technique, some health experts challenge the value of skinfold
Figure 10.7 Air-Displacement Plethysmography. The technique uses a special chamber to measure a person’s body volume. Courtesy of COSMED USA, Inc.
Figure 10.8 Skinfold Thickness Measurements. A trained person uses special calipers to measure skinfold thickness at three or more body sites. This person is having her triceps skinfold measured.
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the body loses weight when energy intake does not meet its needs. However, biological, environmental, social, and emotional factors contribute to weight gain by in'uencing food intake. "e following sec- tion examines these factors.
Biological Influences Genes control the development of many physical char- acteristics, including height, fat distribution, and body frame size. Genes may also code for weight gain by determining the production of hormones that regulate one’s metabolic rate and interest in eating tasty foods. As a result, cases of obesity are more likely to occur in certain families. When one or both parents are obese, they are more likely to have o#spring who gain exces- sive amounts of body fat than are two parents of nor- mal weights. Could a person bene!t from inheriting genes that code for gaining weight easily?
As both men and women grow older, they usually add body fat in their abdominal regions, which o$en increases their waist circumference to unhealthy levels. Figure 10.9 shows a man with central obesity (“apple- shaped”) and a woman whose excess body fat is located primarily below the waistline (“pear-shaped”).
"e only equipment you need to determine your waist circumference is a 'exible but nonstretchable tape measure. Figure 10.10 illustrates where to place the tape measure. To measure your waistline, place the tape around your body just below the ribcage and at the top of the hipbone. What is your waist circumfer- ence? Men who have waistlines greater than 40%inches and women with waist circumferences greater than 35 inches have increased risk of developing the health problems associated with excess body fat.24
What Causes Obesity? In most cases, there is no single cause for obesity. According to the principles of energy balance, the body gains fat when it has an excess of food energy;
Navel Waist measurement (top of hipbone)
Figure 10.9 Typical Fat Distribution in Persons Who Are Obese. Men and women who have large body fat deposits centrally located deep within their abdomens tend to have a higher risk of chronic health problems than do individuals with the same amount of fat located below the waist. (a) Men who are obese typically have central fat deposits (“apple-shaped bodies”). (b) Women who are obese often have excess body fat below the waist (“pear-shaped bodies”).
Figure 10.10 Measuring Waist Circumference. To determine one’s waist circumference, measure the waist directly above the hipbone.
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Diversity in Health The Plight of the Pima After the July rains, the Sonora Desert of southwestern Arizona becomes transformed for a brief time into a natu- ral fast-food restaurant. For hundreds of years, the Pima Indians residing in this harsh environment harvested the seasonal bounty of mesquite pods, acorns, wolfberries, prickly pears, tepary beans, and cholla blos- soms to supplement their regular diet of hunted animals and cultivated maize (corn) and lima beans. The Pima were slim, but they flourished while enduring this cycle of feast and famine.
By the 1930s, the Arizona Pima had dis- continued eating most of their ancient fare and adopted Western foods that provided generous amounts of lard (pork fat), refined starches, and sweets. Within a couple of decades, an alarming number of U.S. Pima had become obese and developed type 2 diabetes. According to one study, about 64% of U.S. Pima males and 75% of U.S. Pima females were obese. Among the U.S. Pima, about one-third of the men and almost half of the women had type 2 diabetes. Rates of obesity and diabetes are much higher in the U.S. Pima population than in the Mexican Pima Indians. U.S. Pima have the highest known incidence of type 2 diabetes in the world. Why are the U.S. Pima so severely affected by obesity and type 2 diabetes?
Medical experts suspect certain biological and environ- mental factors influence the development of obesity and diabetes in this population. Experts think the Pima have thrifty metabolisms that allow them to survive their harsh desert environment, with its natural cycles of feast and famine. Although their current dietary habits have made the need for such metabolisms obsolete, the Pima are still genetically programmed to conserve a major share of their food intake as fat. Recent studies have found a moderate association between genes and early-onset type 2 diabetes in Pimas, but further studies are needed to explore potential genetic associations. Additionally, most Arizona Pima lead more sedentary lives than their ancestors did or relatives living in Mexico do. The typical
Mexican Pima Indian has fewer labor- saving devices and performs more physi- cal work than the typical Arizona Pima.
The abandonment of ancient dietary practices may contribute to the current health problems of the Arizona Pima. Besides being lower in fat, traditional
Pima foods provide more complex carbohydrates than typical modern menus do. Furthermore, the ancestral diet supplied substances that may have protected the Pima from diabetes. Many desert plants contain significant amounts of amylose, a digestible carbohydrate, as well as gums and mucilages, two forms of soluble fiber. Eating foods rich in these substances slows diges- tion and delays the absorption of glucose from the small intestine. This delay prevents sharp increases in blood levels of insulin, the hormone that signals cells to remove glu- cose (blood sugar) from the blood. Under normal circumstances, the body can prevent sharp increases or decreases of blood glu-
cose. However, individuals who suffer from type 2 diabetes are unable to avoid dramatic fluctuations in blood glucose or insulin levels, which can damage the body.
Today, medical experts are studying the U.S. Pima to determine what steps can be taken to reduce their preva- lence of obesity and diabetes. Some scientists think tribal members should return to their former dietary practices; many of these ancestral foods are still available. By eating desert plant foods rich in amylose and soluble fibers, the Pima may reduce their risk of developing type 2 diabetes. If the U.S. Pima are to survive as a population, they may need to recover their traditional “roots.”
C a l i f o r n i a
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Data from Boyce, V. L., & Swinburn, B. A. (1993). The traditional Pima Indian diet: Composition and adaptation for use in a dietary intervention study. Diabetes Care, 16(51), 369–371; Cowen, R. (1990). Seeds of protection: Ancestral menus may hold a message for diabetes-prone descendants. Science News, 137, 350–351; Esparza- Romero, J., et al. (2015). Environmentally driven increases in type 2 diabetes and obesity in Pima Indians and non-Pimas in Mexico over a 15-year period: The Maycoba Project. Diabetes Care, 38, 2075–2082; Nair, S., et al. (2010). Association analysis of variants in the DIO2 gene with early-onset type 2 diabetes mellitus in Pima Indians. Thyroid, 22(1), 80–87; Valencia, M. E., et al. (1999). The Pima Indians of Sonora, Mexico. Nutrition Reviews, 57(5), S55–S58.
Courtesy of Library of Congress, Prints & Photographs Division, Curtis (Edward S.) Collection [Reproduction Number LC-USZ62-112212].
What Causes Obesity? 333
Appetite Regulation Nearly everyone knows what it feels like to be hungry. Hunger is the physi- ologic drive to seek and eat food. Appetite is the psy- chological desire to eat speci!c foods, which is not the same as being hungry. Satiety is the feeling that enough food has been eaten to relieve hunger and turn o# appetite.
"e digestive system, brain, and fat cells play important roles in controlling hunger and satiety. While a person is eating, the intestinal tract releases several chemicals that signal the brain to eat less food. "e sensation of stomach fullness results in termination of eating. Leptin, a hormone produced by fat cells, and insulin, the pancreatic hormone that lowers blood sugar levels, a#ect the hypothalamus, a region of the brain that regulates eating behavior (Figure 10.11). Leptin and insulin play important roles in regulating eating behavior, but in people who are obese, these hormones seem to lose their e#ectiveness.25
Composition of the Diet An excess of calories from carbohydrate, protein, fat, and alcohol can result in weight gain. Foods that are rich sources of simple carbohydrates (sugars) contribute to overconsumption of calories. Sugar-sweetened so$ drinks (“liquid candy”) are convenient to pur- chase from vending machines and convenience stores. However, high-fat diets are associated with overeating and gaining body fat.26 An ounce of fat supplies more than twice the number of calories as an ounce of carbohydrate or protein. Furthermore, the body stores more fat when the excess of calories is supplied by dietary fat rather than carbohydrate or protein.27
No speci!c calorie-restricted diet enhances long- term weight loss and maintenance. However, people who are overweight o$en lose weight when following a low-fat, high-complex carbohydrate diet because the food plan includes generous servings of fruits,
"ousands of years ago, “fat” genes were vital to human survival. Our early ancestors probably endured long periods of fasting, interrupted by shorter periods of feasting. When food was plentiful, our ancestors thrived on the bounty. Some members of the popu- lation may have inherited metabolisms that “burned o# ” the excess food energy as body heat. Others had “thri$y” metabolisms that enabled them to store much of the excess energy as body fat. When food was scarce, individuals with thri$y metabolisms were more likely to survive than those with metabolisms that did not store as much excess energy as fat. Today, most Americans have access to a steady supply of tasty, fattening food. "erefore, persons who have thri$y metabolisms !nd it di&cult to control their weight in such environments. "e Diversity in Health essay “"e Plight of the Pima” discusses the harmful e#ects that genetic and environmental factors have had on the Pima Indian population of southern Arizona.
%e Set Point %eory Although body weight usually 'uctuates slightly from day to day, most people report that their weight remains fairly stable for months, even years. "is observation led some medical experts to propose that the level of body fat is genetically preset. Once the level of body fat reaches this set point, the metabolic rate and other internal mechanisms maintain the degree of fatness, like a thermostat can be set to maintain the tempera- ture of a room. Persons who are lean may have lower set points than persons who are obese. For example, when people who are lean deliberately overeat to gain weight, they usually lose the extra weight a$er resuming their normal eating habits.
Although having a high set point may result in an unhealthy percentage of body fat, that amount of fat may be normal for that person. As a result, the per- son’s fat cells may resist e#orts to lose storage fat. Fur- thermore, when a person who is obese loses weight, he or she is likely to regain some or all of it within a few years. Why? Some scientists think “slimmed down” fat cells send messages to the brain that are interpreted as hunger. As a result, the person over- eats, and his or her fat cells expand again.
set point A theoretical level of body fat that resists weight-loss efforts.
hunger The physiologic drive to seek and eat food.
appetite The psychological desire to eat foods that are appealing.
satiety The feeling that enough food has been eaten to relieve hunger and turn off appetite.
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popular foods have increased.28 When the Hershey chocolate bar was introduced in 1906, it weighed a little over half an ounce; today, a regular-sized Her- shey bar weighs 1.6 ounces. Compared with original bakery bagels, an average bakery bagel now weighs three times as much and provides three times the amount of energy. Fast-food hamburgers and stan- dard servings of french fries and so$ drinks are o$en considerably larger than those served when these popular restaurants !rst opened in the 1950s and 1960s. Many fast-food and family-style restau- rants promote their “super-size” portions as being bargains. Such food production practices encourage overeating and excess caloric intake.
Advertisers know the value of making foods look appealing. To stimulate sales, for example, fast-food restaurants show hamburgers topped with crisp let- tuce and bacon extending beyond the bun. Actors in food ads appear to be happy and satis!ed with their food choices.
Today, it is easier to obtain meals and snacks when you are not at home than in the past. Many fast-food restaurants, convenience stores, and supermarkets are open 24 hours, many with drive-through or curb- side pickup options so you do not have to get out of a car. Supermarkets o$en have a deli section that o#ers cooked or fried chicken, baked macaroni and cheese, a variety of potato salads, and other ready-to- eat foods. You do not even have to leave home to buy food; pizza, Chinese, and other food can be delivered to your front door.
vegetables, beans, and whole grain cereals. "ese nutrient-dense, high-!ber foods are quite !lling, and dieters may fail to eat enough to meet their total per- missible number of calories.
Carbohydrate-rich foods o$en taste better when they are fried or when fats such as butter, sour cream, or gravy are added to them. Most desserts and snack foods contain re!ned carbohydrates and fat; mix- tures of sugar and fat are almost irresistible. "us, the typical American diet promotes overeating because it provides an interesting, tasty, and enjoyable variety of fatty, sweet foods.
People who are obese o$en claim that they gain weight by eating small amounts of food. Underreport- ing caloric intake, however, is common, especially by persons who are obese.26 Many people are unaware of, or they underestimate, the number of calories that are in their snacks and meals. Calorie and fat- counting guides are helpful if you are trying to control your weight. Keeping a record of everything you eat and drink each day can also be useful for identifying problem foods and poor eating habits. By eating more fruits and vegetables and fewer sugary and fatty foods, you can control your caloric intake.
Environmental, Social, and Psychological Influences A variety of environmental, social, and psychologi- cal factors promote overeating in the United States. Since the early 1900s, typical portion sizes of many
Figure 10.11 Hypothalamus. Research indicates that regions of the hypothalamus in the brain control hunger and satiety.
Cerebral cortex
Hypothalamus
Spinal cord
What Causes Obesity? 335
In developed nations, eating disorders such as bulimia nervosa and binge eating a#ect consider- able numbers of people, especially girls and women. "ese conditions are associated with serious psycho- logical disturbances.
Because families share environments as well as genes, and both the environment and genes a#ect obesity, obesity is classi!ed as a genomic disease. Not only do families share common eating and exercise practices, but they also o$en adopt similar perspec- tives regarding body weight and health. For example, some cultures view excess body fat favorably, as a sign of !nancial security, and may not perceive being overweight as a health risk. Such a perspective could contribute to the incidence of%obesity.
Weight Management According to a recent survey, the majority of Ameri- can adults who were overweight or obese were try- ing to lose weight.29 Improving one’s appearance and health were among the reasons subjects gave for deciding to reduce their excess weight. "e majority of the people who wanted to lose weight used calorie reduction as their primary method.
Dissatisfaction with body size is common, par- ticularly among Western cultures and young women. In a recent survey of American high school students, about 60% of females and 30% of males reported that they were attempting to lose weight at the time of the survey.30
Even though they may have gained the weight gradually, individuals who are overweight or obese who want to lose weight o$en seek methods that promise quick and dramatic results. When people are desperate to lose weight, they are more likely to believe advertisement promises for rapid weight loss without dietary or physical activity changes. Each year, Americans spend billions of dollars on vari- ous weight-loss products and services. "ese e#orts include joining weight-loss programs or spas and buying special foods, books, pills, and gadgets. Do these products and services enable people to lose weight? How can you judge the value of a weight- loss method? "e following sections answer these questions.
Weight Reduction Diets As mentioned earlier, the body loses weight when its caloric intake is less than its energy needs. In this situation, the body relies primarily on stored fat for
Many people respond to certain social situations by overeating. For example, you may be “stu#ed” a$er eating a "anksgiving dinner, but when you see pumpkin pie topped with whipped cream, you can !nd “room” in your stomach for dessert. Events that mark important milestones of life usually include big meals and special foods. Imagine a birthday party or wedding celebration that does not include a frosted layer cake!
Work and home environments o$en do not provide opportunities for Americans to be physi- cally active. Modern technology enables machines, instead of our muscles, to do much of our work. As a result, we tend to spend more time sitting than walk- ing around during the day. At home, many people spend their leisure time engaged in sedentary activi- ties such as watching television or using a computer or hand-held device. People who are physically inac- tive are likely to gain weight unless they restrict their food intake.
Psychological state can in'uence eating behavior. Some people eat long a$er satisfying their hunger because they are excited, anxious, or bored. Many people seek comfort from eating, especially foods that are fatty and sugary, when they are distressed or depressed. "e following personal re'ection written by a young woman who is overweight illustrates how emotions can a#ect eating behavior:
I gained 20 pounds between the ages of 16 and 18. At the time I was in an abusive relationship with my boyfriend. I felt like dirt and the only thing that made me feel good was food. I was totally devastated when he was killed in a car accident when I was 18. I ate even more. I went to a nutritionist for a diet. I tried to stay on it but failed. Looking back, every time I gained weight it was due to stress. When I am stressed, I need to get out of the house, take my mind off things.
Deli sections of supermarkets usually offer a variety of appealing prepared foods. © karamysh/Shutterstock.
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People who are overweight can lose weight while following fad diets because the diet plans that accom- pany the gimmicks usually provide fewer calories than the level of energy supplied by typical American diets. Regardless of the type of diet they used to lose excess fat, the majority of persons who were formerly overweight !nd it di&cult to maintain their reduced body weights.
Very-Low-Calorie Diets Very-low-calorie diets may provide fewer than 800 calories per day and be nutritionally inadequate because they limit food choices. Diets that provide 400 or fewer calories daily are o$en called fasts. Fasts are essentially starvation regimens. Some fasts permit only fruit juices and nutrient supplements. Fasting accelerates the loss of fat and lean body tissue, creating unhealthy meta- bolic by-products. Healthy individuals should not fast for more than a day without medical supervision.
Initially, people who are obese typically lose substantial amounts of weight while following a low- calorie diet or fast. When caloric intake is very low, the body burns fat as well as lean tissue for energy. Because fat and lean tissue store water, using these tissues for energy creates a surplus of water in the body. "e kidneys eliminate the excess water, causing a dramatic loss of weight that o$en encourages dieters during the early phase of their weight reduction e#orts. Within a few weeks, however, the body regains its normal water balance, and the rate of weight loss slows.
Very-low-calorie diets or fasts trigger energy- conserving mechanisms in the body that are designed to help people survive starvation. "e metabolic rate decreases with caloric restriction, especially when individuals consume fewer than 800 calories a day. "us, dieters must cut their caloric intakes even fur- ther to continue losing weight, which o$en makes adhering to their diets even more di&cult.
Despite their e#orts, most individuals experience a decline in their rate of weight loss a$er several weeks of following a calorie-reduced diet. Some of this slow- down occurs because the body expends fewer calo- ries to maintain the new weight. As the body adjusts to the reduced caloric intake, it metabolizes less fat and lean tissue for energy, slowing the rate of weight loss. Additionally, dieters who follow restrictive diet plans for more than a few weeks o$en become bored with the regimens and gradually return to their old eating habits.
energy. To lose weight, individuals should eat fewer calories than they need or expend more calories than they eat via physical activity. Most reliable weight reduction regimens incorporate both of these fea- tures by combining a low-calorie diet with a plan that increases physical activity.
Fad Diets Some of the more popular weight loss diets of the last few decades have included a variety of recommendations such as fasting, counting calories, not counting calories, avoiding certain food combi- nations, eating plenty of protein and little carbohy- drate, or eating only a few foods. Such diets are o$en referred to as fad diets because they remain popular for a period of time and then quickly lose their wide- spread appeal. "e low-carbohydrate “Atkins diet,” for example, gained many followers when it was !rst introduced in 1973, but dieters soon lost interest in its restrictive food choices. When the Atkins diet was reintroduced about 25 years later, its renewed pop- ularity resulted in the marketing of a wide array of “low-carb” foods.
Fad diets usually have a few common features— gimmicks and caloric restriction. A gimmick is a promotional feature that makes a fad weight-loss diet appear to be new, unique, and more e#ective than other diet plans. Some fad diets, including the Atkins diet, use carbohydrate restriction as a gimmick. Other fad diets use gimmicks such as prescribed food combinations based on your blood type, dietary supplements that “melt fat while you sleep,” and “secret” food ingredients that allow you% to eat all your favorite foods or retain fat in desirable places (the breasts of women, for exam- ple) while shedding it from the hips, abdomen, and thighs. Although such claims are untrue and not based on scienti!c evidence, they attract people who are seeking quick and easy ways to lose their excess body fat.
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SlimFast Diet (3.2). Full results for overweight weight- loss diets can be located on U.S. News’ website: https:// health.usnews.com/best-diet/best-weight-loss-diets.
Although the U.S. News diet rankings provide comparison data between the diets, it is important to note that these data are not from clinical trials. As such, they should be interpreted as subjective—if expert— opinions and not as objective fact. Persons wishing to lose weight should always consult with their physician before embarking on a new eating plan to ensure it meets their personal nutritional needs.
Physical Activity Many American adults are less active physically than when they were younger, partly because they have occupations that require little physical e#ort. Men who had trim, athletic builds during adolescence o$en develop bulging waistlines by the time they are 40 years old. As they reach middle age, women o$en blame “gravity” or pregnancy for the expand- ing dimensions of their waists, hips, and thighs. Can adopting more physically active lifestyles reverse these changes?
I gained 20 pounds before my wedding. My husband bought me a stepper for a wedding present (that’s what I wanted), and I use it with an exercise video. Now, I exercise more than ever, but I haven’t lost much weight.
"is student has discovered that exercising to lose body fat o$en does not produce the desired change in body weight. Physical activity alone is not as e#ective as low-calorie diets for treating obesity because most individuals who are over- weight cannot perform enough exercise to create a signi!cant de!cit of calories. However, this does not mean that they should abandon physical activ- ity as a means of losing excess body fat. Exercise retains lean tissue and builds muscle mass, which may stabilize or even increase one’s body weight. "us, what appears to be a lack of progress while restricting food intake and exercising may be the result of a healthy increase in muscle mass. ("is is one reason why measuring one’s body fat percent- age or waist circumference is more insightful than measuring weight alone.)
In addition to tracking weekly changes in body weight, physically active people who are overweight can keep weekly records of waist circumferences. People who become more physically active while diet- ing o$en report that their clothing !ts better, or they can wear smaller sizes even though they have not lost
Most people who have lost weight regain some or all of it—and o$en, even more weight—a$er a period of caloric restriction. Frustrated dieters o$en blame themselves for lack of self-control. Episodes of losing and regaining weight are referred to as “yo- yo dieting” or weight cycling. Results of studies do not provide consistent evidence that weight cycling is associated with increased disease or death.31 Although more research is needed, obesity appears to pose more health risks than does weight cycling. Rather than endure periodic fad dieting, people who have excess body fat should consider other, more suc- cessful methods of losing weight—namely, changing eating and exercise patterns for life.
In 2018, U.S. News & World Report published new rankings of 40 popular U.S. diets.32 A panel of nationally recognized experts in nutrition, obesity, food psychology, diabetes, and heart disease was assembled to evaluate the selected diets. Some of these diets can be classi!ed as fad diets; others are roadmaps of healthy nutritional plans that could be sustained over a lifetime. "e specialists ranked each diet on a scale of 1 to 5 on seven measures: short- term weight loss, long-term weight loss, ease of fol- lowing, nutrition, safety, performance as a diabetes diet, and performance as a heart diet. U.S. News used scores on all seven measures (not all measures were weighed equally) to compute an overall score for each diet and subsequently ranked the diets from highest (best) to lowest. "e following diets were identi!ed as the best diets overall: DASH Diet (with an over- all score of 4.1 out of 5.0), Mediterranean Diet (score of 4.1), "e Flexitarian Diet (4.0), Weight Watch- ers (3.9), MIND Diet (3.8), Volumetrics Diet (3.8), Mayo Clinic Diet (3.7), Ornish Diet (3.6), and "e Fertility Diet (3.5). Full results, including rankings, overall scores, and scores on the aforementioned seven measures, are published on U.S. News’ website: https://health.usnews.com/wellness/food/articles/ how-us-news-ranks-best-diets.
In addition to ranking these diets by best overall scores, six other rankings were derived from the data from !ve measures evaluated by the expert panel, including best weight-loss diets. "e best diets for over- all weight loss were computed using the short-term weight-loss and long-term weight-loss measures pre- viously identi!ed. "e following diets were identi!ed as the best weight-loss diets: Weight Watchers (with an overall weight-loss score of 3.7 out of 5.0), Volumet- rics Diet (3.5), Jenny Craig (3.4), Vegan Diet (3.4), "e Flexitarian Diet (3.3), DASH Diet (3.2), "e Engine 2 Diet (3.2), Ornish Diet (3.2), Raw Food Diet (3.2), and
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ultrasound (ultrasound-assisted lipoplasty). "is technique has cosmetic value when used to remove small areas of fat that create unsightly bulges, such as “saddlebag thighs” or double chins (Figure 10.13). Liposuction can be hazardous; infections, blood clots, dis!gurement, and even death can result. For most individuals who are overweight, liposuction is not a suitable weight loss method.
Medications People who are trying to follow low-calorie diets o$en lose control over their appetites and—as a result—overeat. For decades, medical researchers have been testing various compounds to determine whether they can help people adhere to their diet plans more easily or lose weight faster.
Orlistat (Xenical), approved in 1999, was the only prescription drug for weight loss approved by the Food and Drug Administration (FDA) for more than a decade. Orlistat does not suppress appetite but inter- feres with fat digestion. As a result, some of the fat in foods is not digested and is eliminated in feces. Fat- soluble vitamins are generally found in fats and oils, so a person taking orlistat will not absorb as many of these nutrients from foods and therefore should take
much weight. Besides improving physical appearance, exercise reduces elevated blood pressures and lipid levels. Furthermore, individuals who exercise for at least 250%minutes per week may be more likely to main- tain their weight loss than those who are less active.33
Most individuals who are overweight can safely increase their physical activity by walking, bicy- cling, or swimming for at least 30 minutes, prefer- ably on a daily basis. Regardless of the activity, it should be enjoyable and practical to perform on a year-round basis. Before beginning a vigorous phys- ical activity program, inactive people over 40 years of age should obtain the approval of their personal physicians.
Surgical Procedures Individuals who are morbidly obese generally expe- rience little success following low-calorie diet plans and exercising to lose weight. In such cases, bariatric surgeries, particularly gastric bypass procedures, may be used. Figure 10.12 illustrates the appearance of the stomach and small intestine a$er one type of gastric bypass surgery. A surgeon drastically reduces the capacity of the stomach by creating a small pouch in the upper part of the stomach for food to enter. A$er having this procedure, the patient loses weight rapidly because he or she can no longer eat large portions of food without vomiting or experiencing uncomfort- able feelings of fullness. On average, people who have had gastric bypasses can lose about 60% of their pre- surgery weight, improving their overall health.34
Liposuction, a surgical procedure that involves vacuuming subcutaneous fat out of the body, is the most common type of cosmetic surgery in the United States. Before removing the fat, the area is injected with an anesthetic-containing 'uid or treated with
Exercise may result in a healthy increase in muscle mass. © Konstantin Sutyagin/Shutterstock .
Upper stomach pouch
Stomach
Small intestine
Surgical staples
Figure 10.12 Gastric Bypass Surgery. Gastric bypass is a procedure used to treat severe obesity. After surgery, the obese person experiences discomfort after overeating and is less likely to overeat.
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however, do not recommend these products because reports of their safety and e#ectiveness are not based on well-designed clinical studies. Manufacturers of weight-loss products o$en recommend that diet- ers also follow a calorie-reduced diet and an exer- cise regimen. "erefore, any signi!cant weight loss can be attributable to the calorie-restricted diet and increased physical activity—not the product. People who have lost weight with the help of “diet drugs” usually regain it when they discontinue using the products and following the diet and exercise plan. "e Consumer Health feature “Dietary Supplements: Weight-Loss Aids” provides information about some popular over-the-counter weight-loss products. "e Analyzing Health-Related Information feature in this chapter includes an advertisement for a dietary supplement that is marketed for weight loss.
Strategies for Successful Weight Loss Individuals who are overweight can lose body fat and maintain their new weight by following sensible and safe weight-loss plans, which have four major characteristics:
1. "ey are medically and nutritionally sound. 2. "ey include practical ways to engage in regular
physical activity. 3. "ey are adaptable to one’s psychological and
social needs. 4. "ey can be followed for a lifetime.
Nutritionally sound weight reduction diets emphasize nutrient-dense foods, and they are nutri- tionally well balanced and adequate. Without being overly restrictive, such diets supply fewer calories than one needs. No special foods are necessary; the recommendations of the U.S. Dietary Guidelines and MyPlate (www.choosemyplate.gov) form the basis of nutritious calorie-reduced daily menus.
Reasonable and reliable diet plans recommend ways to increase physical activity such as by adding 30–90 minutes of walking, swimming, or bicycling to one’s routine on most days of the week. Addition- ally, weight-loss plans should meet the psychologi- cal and social needs of those attempting weight loss. A reliable plan, for example, helps a person set an achievable weight-loss goal, recognize faulty eating habits, build self-esteem and body shape satisfac- tion, and obtain family or group support. You can use the criteria listed in the Managing Your Health tips titled “General Features of Reliable Weight
a vitamin supplement. An over-the-counter version of orlistat (Alli) became available in 2007.35
In 2012, the FDA approved a second prescription drug for long-term use, Belviq. Belviq activates the serotonin 2C receptor in the brain, which may help one successfully eat less and feel full a$er consuming smaller food portions. Belviq was approved for use, in conjunction with a reduced-calorie diet and exercise plan, in adults who are obese (i.e., have a BMI of 30 or greater) or who have a BMI of 27 or greater and have at least one weight-related health condition (e.g., type 2 diabetes, high cholesterol, hypertension).36
As of 2018, three additional long-term weight-loss drugs have been approved by the FDA: Qsymia, Con- trave, and Saxenda. As with all prescription medica- tions, consumers are cautioned to consider the risks and bene!ts of taking weight-loss prescription drugs and to seek the counsel of their personal physician.
Alternative Therapies People who are overweight may turn to alternative therapies to lose weight, especially if they have had no success with conventional medical weight-loss prac- tices that include calorie restriction and increased physical activity. Acupressure, a therapy that is based on ancient Chinese medicine, is a popular alternative therapy for weight, but there is a lack of scienti!c evi- dence to support its long-term e#ectiveness.37
Dietary supplements, such as those containing chitosan, green tea, chromium picolinate, and hoo- dia, are promoted for weight loss. Medical experts,
Figure 10.13 Liposuction. Liposuction is a medical procedure in which a special instrument is inserted into body fat through an incision made in the skin, and the fat is vacuumed from the body. © Girish Menon/Shutterstock.
340 Chapter 10 Body Weight and Its Management
Behavior Actions to Modify Behavior
Identify faulty eating behaviors and eliminate or ignore improper eating cues.
• Keep daily food records to identify problem foods. • Use a shopping list and do not buy problem foods. • Eat fruit or a meal before shopping for food. • Discard problem foods. • While at home, restrict eating to the kitchen or dining room. • Do not eat while watching TV, reading, or talking on the phone. • Avoid places with vending machines. • Avoid fast-food restaurants that do not sell low-fat foods.
Reduce caloric intake. • Serve meals on smaller plates. • Prepare smaller amounts of food to reduce the likelihood of “seconds.” • Avoid buffet-style or all-you-can-eat restaurants. • Eat a low-fat, high-fiber snack such as a piece of fruit or vegetable before a meal. • Keep fruit and vegetables on hand to snack on when hungry. • Ask for salad dressing “on the side” at restaurants. • Prepare low-calorie lunches and snacks to take to work or school. • Substitute fresh fruit or yogurt for rich desserts. • Read nutrition labels to identify high-calorie foods. • Learn to leave some food on your plate.
Stay focused on weight- loss goal.
• Set reasonable incremental goals, such as losing 5 pounds in 5 weeks. • Place a picture of yourself on the refrigerator, pantry door, or bedroom mirror. • Measure your waistline once a week. • Place exercise equipment and walking shoes where you can see them. • Buy new pants that are one size smaller and hang them where you can see them. • Ask your friends and family to support your efforts. Give them examples of how they
can help.
Practice appropriate behaviors.
• Find ways to move around while at work, school, or home. For example, take the stairs instead of the elevator.
• If you relapse, tell yourself that this is normal. Do not label yourself a failure. Ask yourself what you can learn from the experience so it is less likely to affect your eating again. Minor occasional indulgences will not affect your weight. Continue to focus on your weight-loss goal.
• Set aside at least 30 minutes each day to engage in an enjoyable physical activity. Gradually increase the duration of the activity to 45–60 minutes daily.
Use nonfood rewards for behaviors.
• Praise yourself frequently for exercising or taking smaller servings of high-calorie appropriate foods.
• Buy a desired item such as a new CD or DVD, or an item of clothing. • Take a walk or ride a bike through a park.
Examples of Behavior Modification for Weight Management
Table 10.5
Reduction Plans” to judge the e#ectiveness of most weight reduction methods.
E#ective weight-loss plans usually empha- size behavior modi!cation. Behavior modi!ca- tion involves learning to identify behaviors that
contribute to one’s inability to lose weight, such as eating too much fatty food and not engaging in enough physical activity. "e person learns to modify inappropriate behaviors so that weight loss and its maintenance are possible. Table 10.5 lists key
Weight Management 341
Consumer Health Dietary Supplements: Weight-Loss Aids Anyone who has tried to lose weight knows it can be a frustrating effort. Hunger seems to be a constant com-
panion. For years, people attempting to lose weight have taken various pills and dietary supplements sold over the counter to promote weight loss and prevent hunger. Table"10.A includes several of the more popular supplements that people take to lose weight and pro- vides information concerning the scientific support for health-related claims associated with the product.
Consumers need to be wary of weight-loss products that are marketed on websites. Such products often include misleading or untruthful claims such as the following:
“Eat all you want without gaining weight.” “Lose weight by blocking starch.” “Clinically tested fat inhibitor instantly prevents
weight gain.”
“Prevents carbs from being converted into fat.” “Burns fat without increasing your metabolic rate.” Claims about a supplement’s effect on the structure
or function of the body must be supported by scientific evidence and not be misleading or dishonest.
Taking certain weight-loss products may be danger- ous. For example, the Food and Drug Administration determined that “Slim Xtreme Herbal Slimming Cap- sules,” which were available at various websites, con- tained an undeclared drug ingredient (sibutramine). The agency warned consumers to stop using the capsules and discard them because the product posed a threat to health. Sibutramine is known to increase blood pressure in some people and could be harmful for patients with heart disease and stroke.
Individuals should not use any dietary supplement for weight loss without the advice and monitoring of their physician. If you experience any side effects while taking such products, report the problem to the FDA’s MedWatch hotline by calling 1-800-332-1088 or visiting the agency’s online reporting site at www.accessdata .fda.gov/scripts/medwatch/medwatch-online.htm.
Dietary Supplement Claims Scientific Findings
Garcinia Reduces body fat The evidence to support the claim is weak.
Bitter orange Enhances weight loss Bitter orange can increase heart rate and blood pressure; therefore, its use is risky.
Blue-green algae (spirulina)
Promotes weight loss, boosts immune system functioning, and treats asthma, depression, and several other common disorders
No evidence to support claims. Algae may be contaminated with toxins that are in their environment.
Chitosan (chitin) Enhances weight loss, reduces blood lipid levels Limited evidence to support weight-loss claim.
Chromium picolinate Increases metabolic rate, facilitates weight loss
May result in slight reduction in body weight, but the loss is not impressive.
Glucomannan Enhances weight loss Some evidence to support claim, but more research is needed.
Yerba mate Enhances weight loss Results of one study suggest that a combination of yerba mate, guarana, and damiana may assist weight loss, but more research is needed.
Conjugated linoleic acid Enhances weight loss Clinical trials found no difference in body weight or BMI.
Hoodia Suppresses appetite No human studies support claims of hoodia’s effectiveness or safety.
Data from Swartzberg, J. E., et al. (2001). The complete home wellness handbook. New York, NY: Health Letter Associates; Pittler, M. H., & Ernst, E. (2004). Dietary supplements for body-weight reduction: A systematic review. American Journal of Clinical Nutrition, 79(4), 529–536; Hollarnder, J. M., & Mechanick, J. I. (2008). Complementary and alternative medicine and the management of the metabolic syndrome. Journal of the American Dietetic Association, 108(3), 495–509; Egras, A. M., Hamilton, W. R., Lenz, T. L., & Monaghan, M. S. (2011). An evidence-based review of fat modifying supplemental weight loss products. Journal of Obesity, 2011(article ID 297315).
Dietary Supplements: Weight Loss
Table 10.A
342 Chapter 10 Body Weight and Its Management
Health-Related InformationAnalyzing Critical Thinking
This advertisement promotes a weight-loss product. Read the ad and evaluate it using the model for analyzing health- related information. The main points of the model are:
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who makes the health-related claims? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person making the claims?
4. What is the main point of the ad? Which information is relevant to the product? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this ad is a reliable source of health-related information? Summarize your reasons for coming to this conclusion.
a weight-loss product that lives up to your expectations!
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behaviors, such as not watching television while eating, that can help people achieve their weight- loss goals. By identifying and modifying behaviors that resulted in weight gain, a person can develop a weight-loss and maintenance plan that works best for his or her speci!c needs.
To avoid regaining weight, successful dieters must make lifestyle changes they can follow through- out their lifetimes, such as exercising regularly and controlling caloric intake. Small incremental changes that are implemented gradually are easier to adopt than extreme exercise regimens and overly restrictive diets. Most fad diets do not focus on behavior modi- !cation. However, even reliable weight-loss pro- grams that promote behavior modi!cation do not o#er guarantees for long-term success. "e process of changing behaviors takes education, practice, time, and perseverance.
"e majority of people who have lost weight through nonsurgical methods experience relapse,
regaining some or all of the weight within 4 years.34 Relapses occur when one fails to modify eating behaviors and physical activity patterns perma- nently and has unrealistic weight-loss expectations. Individuals who lose weight while following fad diets are prone to relapse when they return to their usual food habits.
Presently, there is no safe or e#ective treatment that “cures” being overweight. "erefore, one should strive to prevent excessive weight gain by making permanent lifestyle changes that include appropri- ately reducing the size of food portions, especially fatty foods, and increasing physical activity.
Weight Gain Although it may seem that nearly everyone is on a diet to lose weight, some people are underweight and trying to gain weight. Many health experts
Weight Gain 343
Managing Your Health General Features of Reliable Weight Reduction Plans Use the following features to judge the quality of weight-loss programs.
The diet plan is medically sound if it • Provides recommendations that are safe and sup-
ported by scientific evidence • Suggests receiving a physician’s approval before
initiating the plan • Encourages gradual weight loss
The diet is nutritionally sound if it • Meets nutritional needs • Includes foods from each food group • Encourages eating smaller portions of nutritious
foods • Encourages self-control over problem foods such
as sweets • Considers individual food preferences • Includes reasonable amounts of fiber and complex
carbohydrates • Reduces caloric intake to no lower than 1,000 calo-
ries per day • Recommends losing 0.5 pound to 2 pounds per week • Avoids requiring special or costly supplements and
foods • Avoids claims about the superiority of the plan • Avoids guarantees concerning weight loss
The diet plan considers physical fitness needs if it • Recommends an exercise plan that is tailored to
the individual’s needs, time constraints, interests, and capabilities
• Includes practical suggestions for altering seden- tary behaviors
• Encourages daily aerobic activities that last at least half an hour
• Avoids promoting costly exercise equipment, join- ing exercise clubs, or buying special gadgets to shed pounds
• Recommends physical activities that are safe and enjoyable
• Considers special health concerns of the individual
The diet plan meets psychological and social needs if it • Provides practical suggestions for modifying food-
related attitudes and behaviors • Educates about the need to set realistic weight-loss
goals • Includes techniques to monitor progress (such as
weekly recording of waist circumference) • Builds self-esteem • Includes tips to control eating in social situations • Includes foods that family and friends eat • Provides strategies for coping with setbacks, diffi-
cult situations, and unsupportive people • Offers opportunities for group support
Adapted from Dwyer, J. T. (1992). Treatment of obesity: Conventional programs and fad diets. In P. Björntorp & B. N. Brodoff (Eds.), Obesity (pp. 662–676). Philadelphia, PA: Lippincott.
think underweight individuals should avoid gain- ing body fat unless their condition is the result of chronic illness. Nevertheless, individuals who are thin are o$en just as dissatis!ed with their body sizes as those who are overweight.
To gain lean tissue, persons who are underweight need to consume at least 700 to 1,000 more calories per day than they usually eat and perform muscle- building exercises. To obtain the extra calories, peo- ple who are underweight can eat more than three meals a day and snack on nutrient-dense foods such as dried fruit, whole wheat mu&ns, granola bars, yogurt and fruit smoothies, peanut butter, and nuts. You can !nd other nutritious foods that are high in food energy by consulting food composition tables.
Because fatty foods are a source of consider- able calories, physically active individuals can eat as much as 35% of their caloric intake from these items. Because of the association with cardiovas- cular disease, people trying to gain weight should avoid eating excessive amounts of saturated fats. Avocados, olives, and nuts are high in unsaturated fat, which is healthier than saturated fat. For people trying to gain weight, the e#ort must be maintained over the long term, just as it is for people trying to lose weight.
Childhood and adolescent obesity o$en becomes a problem that a#ects the entire family. Children who are obese may develop eating dis- orders and low self-esteem when parents, other
344 Chapter 10 Body Weight and Its Management
WEIGHT MANAGEMENT "e amount of weight a woman gains during preg- nancy a#ects the health of her baby. Women who begin pregnancy at a healthy weight should gain about 25–35 pounds during the following 9 months.38 "is weight gain includes not only the fetus’s weight but also the weight of the pregnant woman’s addi- tional body 'uids, fat stores, and breast and uterine tissues. Women who are underweight when they become pregnant can expect to gain more weight; those who are overweight may gain less. Table 10.6 indicates suggested ranges of weight gain for preg- nant women based on their prepregnancy BMIs.
In 2006, 21% of pregnant women gained more than 40 pounds during their pregnancies.39 Some pregnant women restrict their food intake to limit their weight gain because they do not want to struggle with los- ing the extra pounds a$er the baby arrives. However, caloric restriction during pregnancy may be hazard- ous to the developing fetus. "e time to lose weight is before or a'er pregnancy, not during this period. Nevertheless, within 2 years of giving birth, many women remain several pounds heavier than those who have not been pregnant.
adults, or peers treat them negatively. An e#ective program that helps children lose weight should not interfere% with their normal physical develop- ment and should not encourage the development of eating disorders. Successful treatment involves teaching children and their parents how to make appropriate dietary modi!cations, increase physi- cal activity, and resolve con'icts that may involve eating habits.
By 65 years of age, most people have experi- enced a decline in their lean mass and an increase in their% fat mass. "is change occurs to a lesser extent in individuals who maintain a high degree of physical activity as they age. Even modest increases% in physical activity, such as walking, swimming, or light exercise, can bene!t most elderly people.
Obese older adults who have chronic health prob- lems that are associated with excess body fat can fol- low the same recommendations for losing weight that younger individuals do: Select nutrient-dense foods, reduce intakes of fatty and sugary foods, and become more physically active.
4If you want to lose weight, modify your lifestyle. For example, eat fewer fatty and sugary foods by replacing them with more nutrient-dense foods.
4To decrease or control your body weight, engage in vigorous physical activity such as jogging, brisk walking, cycling, or swimming for at least 30 minutes, preferably every day.
4To judge whether a weight-loss plan or program is sensible and safe, determine whether it is medically and nutritionally sound, includes a plan to increase regular physical activity, is adaptable to your psychological and social needs, and can be followed for a lifetime.
4If you want to gain weight, add at least 700 to 1,000 calories to your usual daily intake and exercise to build muscle mass. To boost the caloric content of meals and snacks, eat more nutrient-dense foods such as dried fruit, whole wheat muffins, granola bars, peanut butter, and nuts.
Healthy Living Practices
Across THE LIFE SPAN
Weight Classification (before pregnancy) BMI
Range of Weight Gain (pounds)
Underweight <18.5 28–40
Healthy 18.5–24.9 25–35
Overweight 25.0–29.9 15–25
Obese 30.0 and up 11–20
Data from March of Dimes. (2016). Weight gain during pregnancy. Retrieved from http://www.marchofdimes.com /pregnancy/yourbody_weightgain.html
Table 10.6
Suggested Weight Gain During Pregnancy
Weight Gain 345
adequate amounts of energy for physical develop- ment and activity, but they o$en eat more calories than recommended by dietitians. Besides dietary factors, preoccupation with sedentary activities such as playing computer games and watching television contributes to the increase of childhood obesity.41
No one can predict whether a child who is obese will become an adult who is obese. However, children and adolescents who are obese are more likely to remain obese into adulthood.40 "us, preventing childhood obesity has become a national health priority. What are the consequences of childhood obesity?
According to the Centers for Disease Control and Prevention,42 childhood obesity is linked with the fol- lowing disorders:
• High blood pressure and high cholesterol (risk factors for heart disease and stroke)
• Type 2 diabetes • Breathing problems, such as sleep apnea and
asthma • Joint problems • Fatty liver disease, gallstones, and heartburn • Psychological problems, such as depression and
anxiety • Poor self-esteem • Social problems, such as stigma and bullying
Infancy is a period characterized by rapid gains in both weight and height. According to the rule of thumb, healthy babies double their birth weight by the time they are 6 months of age and triple their birth weight by their !rst birthday. A baby who was 7 pounds at birth, for example, should weigh about 14 pounds at 6 months of age and 21 pounds at 12%months of age.
Many babies who are overweight at their !rst birthday slim down by the time they enter school. However, rapid weight gain during the !rst 2 years of life is associated with increased blood pressure, BMI, and waist circumference in adulthood.40 Women who smoke cigarettes or gain too much weight during their pregnancies are more likely to have infants and young children who are overweight and obese.39 On the other hand, babies who are breastfed, particularly for the recommended length of time, are less likely to develop obesity in adulthood.
As mentioned in the beginning of this chap- ter, the percentage of school-aged children who are overweight is increasing in the United States ( Figure" 10.14). Children and adolescents need
Figure 10.14 Childhood Obesity. The percentage of overweight children is increasing in the United States. © Goga/Shutterstock.
4Weight gain is necessary during pregnancy, so if you are pregnant, follow recommendations concerning weight gain and do not try to lose weight at this time.
4Encourage your children to be physically active.
4To avoid becoming too fat as you age, select nutrient-dense, low-fat foods and maintain moderate to high degrees of physical activity.
Healthy Living Practices
346 Chapter 10 Body Weight and Its Management
CHAPTER REVIEW
1. Develop a day’s menu, including meals and snacks, for a nutritionally adequate weight-loss plan. Your plan should include foods from all major food groups. Application
2. You see an advertisement for a special drink that is supposed to eliminate excess body fat while you sleep. According to the ad, this product helps you lose weight “fast” by increasing your metabolic rate; there is no need to eat less food or exercise more o$en. Explain why you think this ad is a source of reliable or unreliable health- related information. Synthesis
3. A man has been maintaining his weight by con- suming 2,500 calories a day. If he does not alter his physical activity level, how many calories should he consume daily to lose 4 pounds in a month? Application
4. Compare your present weight to your weight of 2%years ago. If you have gained or lost weight over the past couple of years, explain how you reached your present weight by evaluating your lifestyle. What factors might account for the weight change? If you have not gained or lost weight during this period, explain why this situation has occurred. Evaluation
Recent health surveys indicate that more Americans are overweight or obese than in previous decades. Approximately 65% of the adult U.S. population is overweight. Excess body fat is associated with low self-esteem and increased risks of chronic health conditions such as osteoarthritis, sleep apnea, gall- bladder disease, gout, hypertension, diabetes, certain cancers, and heart disease.
"e body uses the energy in foods to power vital metabolic activity, to move skeletal muscles, and to process nutrients a$er meals. According to the prin- ciples of energy balance, the body requires a certain number of calories to maintain its weight. When one consumes more calories than needed, weight gain occurs; when one ingests fewer calories than needed, weight loss occurs. Because each pound of body fat represents about 3,500 calories, consuming 500 fewer calories a day than needed should result in a weight loss of about 1 pound per week.
Methods of determining the percentage of body fat include measuring subcutaneous fat (skinfold thicknesses), hydrostatic weighing, and bioelectrical impedance. To determine whether they are overfat, many people rely on waist circumference measure- ments and BMI scores. Risks of chronic health prob- lems and death increase as the waist circumference and BMI score increase.
Obesity is not simply the result of a lack of will- power. "e development of obesity is a complex
process involving interactions among biological, psy- chological, social, and environmental factors. "ese factors include genetics, responses to social situa- tions, food availability and composition, and levels of physical activity.
Obesity is a chronic disease. Most people who have lost weight will regain much or all of it within a few years. To lose weight and maintain the loss, individuals need to decrease their caloric intake by eating less food and increase their caloric expen- ditures by increasing their levels of physical activ- ity. A reliable weight loss regimen should include a well-balanced, nutritionally adequate but calorie- reduced diet and an exercise regimen that can be followed for life.
To increase her chances of having healthy babies, a woman with a healthy weight needs to gain about 25–35 pounds during pregnancy. While pregnant, women should not consume low-calorie diets because caloric restriction may harm the fetus. Children and adolescents need adequate amounts of energy for physical development and activity. In the United States, the percentage of children and teenagers who are obese is growing. Experts think that this increase is primarily the result of seden- tary lifestyles and poor eating habits. Children who are obese are at risk of being obese when they are adults. Many older adults bene!t from having some extra body fat.
Summary
Applying What You Have Learned
Applying What You Have Learned 347
CHAPTER REVIEW
1. Centers for Disease Control and Prevention. (n.d.). BFRSS Web Enabled Analysis Tool. Behavioral Risk Factor Surveillance Sys- tem. Retrieved from https://nccd.cdc.gov/weat/index.html#/cross Tabulation/view
2. Yanovski, S. Z., & Yanovski, J. A. (2002). Obesity. New England Jour- nal of Medicine, 346(8), 591–601.
3. Mokdad, A. H., et al. (2005). Correction: Actual causes of death in the United States, 2000. Journal of the American Medical Associa- tion, 293(3), 293–294.
4. Centers for Disease Control and Prevention. (2017, April). Child- hood obesity facts. Retrieved from https://www.cdc.gov/obesity /data/childhood.html
5. Ogden, C. L., et al. (2008). High body mass index for age among U.S. children and adolescents, 2003–2006. Journal of the American Medical Association, 299(20), 2401–2405.
6. U.S. Department of Health and Human Services, National Center for Health Statistics, Public Health Service. (2000). Healthy People 2010. Washington, DC: Government Printing O&ce.
7. U.S. Department of Health and Human Services, National Center for Health Statistics, Public Health Service. (2010). Healthy People 2020. Washington, DC: Government Printing O&ce.
8. World Health Organization. (2018, February). Obesity and over- weight. Geneva, Switzerland: Author. Retrieved from http://www .who.int/mediacentre/factsheets/fs311/en/
9. Olver, I. N., & Grogan, P. B. (2008). Cancer adds further urgency to prioritising obesity control. Medical Journal of Australia, 189(4), 191–192.
10. Flegal, K. M., et al. (2005). Excess deaths associated with under- weight, overweight, and obesity. Journal of the American Medical Association, 293(15), 1861–1867.
11. Calle, E. E., et al. (2003). Overweight, obesity, and mortality from cancer in a prospective studied cohort of U.S. adults. New England Journal of Medicine, 348(17), 1625–1638.
12. Kulie, T., et al. (2011). Obesity and women’s health: An evidence- based review. Journal of the American Board of Family Medicine, 24(1), 75–85.
Application using information in a new situation.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
Reflecting on Your Health 1. “Fat people could lose weight if they would
just push themselves away from the dinner table.” A$er reading this chapter, what have you learned about obesity and weight control that might cause you to react di#erently to this state- ment than you might have before reading this chapter?
2. As mentioned in this chapter, some people have negative feelings toward individuals who are obese. What were your feelings about people who are obese before you read this chapter? A$er reading this chapter, have your feelings changed? If so, describe how your feelings changed.
3. How would you respond if a close friend or rel- ative told you that you needed to lose weight?
If someone you know is trying to lose weight, what would you do to help with his or her weight-loss e#orts?
4. "e U.S. National Transportation Safety Board (NTSB) proposed reducing the weight limit of each airline passenger and his or her luggage because of concern that the excess load could result in plane crashes. Explain your reaction to this proposal.
5. How does the media in'uence your satisfaction with your body size and shape? Do you think the media should encourage people to be more satis- !ed with their body sizes and shapes? If you think the media should take such steps, how could this a#ect people’s health?
References
348 Chapter 10 Body Weight and Its Management
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19. Smalls, L. K., et al. (2005). Quantitative model of cellulite: "ree- dimensional skin surface topography, biophysical characterization, and relationship to human perception. Journal of Cosmetic Science, 56(2), 105–120.
20. Robertson, S. M., et al. (1999). Factors related to adiposity among children aged 3 to 7 years. Journal of the American Dietetic Associa- tion, 99(8), 938–943.
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26. Goris, A. H., & Westerterp, K. R. (2008). Physical activity, fat intake and body fat. Physiology & Behavior, 94(2), 164–168.
27. Little, T. L., et al. (2007). Modulation of high-fat diets of gastro- intestinal function and hormones associated with the regulation of energy intake: Implications for the pathophysiology of obesity. American Journal of Clinical Nutrition, 86(3), 531–541.
28. Young, L. R., & Nestle, M. (2003). Expanding portion sizes in the U.S. marketplace: Implications for nutrition counseling. Journal of the American Dietetic Association, 103(2), 231–234.
29. Bish, C. L., et al. (2007). Health-related quality of life and weight loss practices among overweight and obese U.S. adults, 2003 Behav- ioral Risk Factor Surveillance System. Medscape General Medicine, 9(2), 35.
30. Eaton, D. K., et al. (2010). Youth risk behavior surveillance—United States, 2009. Morbidity and Mortality Weekly Report, 59(SS-5), 1–141.
31. U.S. News best diets: How we rated 40 eating plans. (2018). U.S. News & World Report. Retrieved from https://health.usnews.com /wellness/food/articles/how-us-news-ranks-best-diets
32. Field, A. E., et al. (2009). Weight cycling and mortality among mid- dle-aged and older women. Archives of Internal Medicine, 169(9), 881–886.
33. Donnelly, J. E., et al. (2009). American College of Sports Medicine position stand: Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Medicine & Science in Sports & Exercise, 41(2), 459–471.
34. Sha!pour, P., et al. (2009). What do I do with my morbidly obese patient? A detailed case study of bariatric surgery in Kaiser Perma- nente Southern California. Permanente Journal, 13(4), 56–63.
35. U.S. Food and Drug Administration. (2013, June 17). Orlistat (mar- keted as Alli and Xenical) information. Retrieved from http://www .fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationfor patientsandproviders/ucm180076.htm
36. U.S. Food and Drug Administration. (2012, June 27). FDA news release: FDA approves Belviq to treat some overweight or obese adults. Retrieved from https://wayback.archive-it .org/7993/20170112023940/http://www.fda.gov/NewsEvents / Ne w s ro om / Pre ss A n n ou n c e m e nt s / u c m 3 0 9 9 9 3 . ht m http : / / w w w.fd a.gov/ne ws e vents/ne wsro om/press announcements /ucm309993.htm
37. Turk, M. W., et al. (2009). Randomized clinical trials of weight-loss maintenance: A review. Journal of Cardiovascular Nursing, 24(1), 58–80.
38. March of Dimes. (2016, November). Weight gain during preg- nancy. Retrieved from http://www.marchofdimes.com/Pregnancy /yourbody_weightgain.html
39. Wojcicki, J. M., & Heyman, M. B. (2010). Let’s move—Childhood obesity prevention from pregnancy and infancy onward. New England Journal of Medicine, 362(16), 1457–1459.
40. Tzoulaki, I., et al. (2010). Relation of immediate postnatal growth with obesity and related metabolic risk factors in adulthood. Ameri- can Journal of Epidemiology, 171(9), 989–998.
41. Speiser, P. W., et al., on behalf of the Obesity Consensus Working Group. (2005). Consensus statement: Childhood obesity. Journal of Clinical Endocrinology and Metabolism, 90(3), 1871–1887.
42. Centers for Disease Control and Prevention. (2016, December). Childhood obesity causes and consequences. Retrieved from https:// www.cdc.gov/obesity/childhood/causes.html
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Across the Life Span Physical Fitness
Managing Your Health Assessing the Intensity of Your Workout: Target Heart Rates
Consumer Health Choosing a Fitness Center
Diversity in Health New Interest in an Ancient Approach to Fitness
Chapter Overview The principles of physical fitness
The health-related components of fitness
Exercising for optimal health
Preventing and managing exercise injuries
Developing your own exercise program
Student Workbook Self-Assessment: Cardiorespiratory Fitness: The Rockport
Fitness Walking Test | Push-Up Test for Muscular
Endurance | Sit-and-Reach Test for Flexibility Assessment | Check Your Physical Activity and Heart Disease IQ
Changing Health Habits: Do You Want to Be More Physically Active?
Do You Know? How to calculate your target heart rate?
How to bulk up safely?
If muscles can turn into fat?
Physical Fitness
© EyeEm
/Getty Im ages.
Learning Objectives “Most people can derive important health benefits by exercising regularly.”
After studying this chapter, you should be able to:
1. Define physical activity and exercise. 2. Identify benefits of engaging in regular physical activity. 3. List health-related components of fitness. 4. Define aerobic exercise and list examples of aerobic
activity. 5. Calculate your target heart rate. 6. Differentiate between isometric and isotonic exercises. 7. Identify effects of anabolic steroids. 8. Develop a workout using the FITT principle. 9. Explain how to use RICE for exercise-related injuries. 10. Describe exercise considerations for various stages of life.
CHAPTER 11
351
I f you look around your home, you will see many devices and products that make your life easier: electric can openers, microwave ovens, dishwash- ers, garage-door openers, remote controls, smart- phones, and electronic tablets (e.g., iPad). Outside of your home, there are more labor-saving machines. You can ride a lawn mower instead of push one, drive a car rather than walk to places, use elevators and escalators rather than climb stairs, and take moving walkways rather than walk through some of the larger airports. You can even make your leisure time less physically demanding by using a motorized cart to get around a golf course or a motorboat to get around a lake. Besides using labor-saving products, you can have other people perform your physical work. For example, you can pay a team of people to mow your grass, wash your car, or clean your house.
A hundred years ago, Americans o$en performed hard physical work at home and on the job. By the begin- ning of this century, a variety of machines, products, and services had become available that made our daily lives less physically demanding. Today, we generally have more leisure time than our great- grandp arents did, but many of us spend it performing activities that do not contribute to our physical health. Most people can derive important health bene!ts by exer- cising regularly and becoming more physically active. Healthy adults under age 65 years should perform moderate-intensity physical activity for 150% minutes per week.1 Healthy adults can obtain similar health bene!ts by engaging in vigorous-intensity physical activity for 75 minutes a week. Moderate to vigorous activities should be performed in episodes that last at least 10 minutes, preferably spread throughout the week. Moderate-intensity physical activities include brisk walking, bicycling, housework, or other actions that cause small but noticeable increases in breath- ing or heart rates. Vigorous-intensity physical activi- ties, such as running, performing aerobic exercise, or doing heavy yard work, cause relatively large increases in breathing or heart rates.
Each year, lack of regular physical activity (a sed- entary lifestyle) contributes to thousands of Ameri- can deaths, primarily from heart disease, stroke, and
diabetes. Approximately 80% of adult Americans report engaging in physical activity; however, fewer than 25% of adults meet physical activity guidelines.2,3 "is chapter discusses the basic principles of !tness, including the health bene!ts of exercise and a physi- cally active lifestyle, and how to design a basic !tness program that you can follow for the rest of your life.
Principles of Physical Fitness
Physical !tness is a key component of a healthy life- style. A physically !t person has the physical strength, endurance, 'exibility, balance, and energy to per- form various daily living activities, including typical occupational responsibilities and recreational inter- ests that require physical movement. Physical !tness is attained by engagement in appropriate physical activity across a lifetime.
The Body in Motion Physical movement involves the interrelated func- tioning of the muscular and skeletal systems. "e functioning of the muscular system is so closely asso- ciated with the skeletal system that the two are o$en referred to as the musculoskeletal system.
"e skeletal muscles provide shape, support, and movement for your body. Most skeletal muscles are attached to bones of the skeleton. Figure 11.1 identi!es the major skeletal muscle groups of the human body. A typical skeletal muscle consists of hundreds of muscle cells called muscle #bers. Movement occurs when the muscle !bers contract, shortening the length of the muscle. Skeletal muscles can contract voluntarily, which means the muscles contract when a nervous impulse from the brain signals them. "us, a healthy person can choose when and how intensely to move a muscle.
Tendons, tough bands of !brous tissue, connect skeletal muscles to bones or other muscles and play an important role in muscular movement. Joints are places where two or more bones come together. Most joints are movable; therefore, such joints permit the move- ment between bones. Ligaments are tough bands of connective tissue that hold bones together at the joints.
The Circulatory and Respiratory Systems Optimal functioning of the circulatory and respira- tory systems (sometimes referred to as the cardio- respiratory system) is necessary to achieve a high
tendons Tough bands of tissue that connect many skeletal muscles to bones.
joints The places where two or more bones come together.
ligaments Tough bands of connective tissue that hold bones together at joints.
352 Chapter 11 Physical Fitness
Cells need oxygen to release the energy stored in glucose and fats. As the heart pumps blood through microscopic blood vessels in the lungs, carbon dioxide leaves the blood and is exhaled. While in the lungs, hemoglobin in the red blood cells picks up oxygen from the inhaled air. "e oxygen-rich blood returns to the heart, which pumps it to the rest of the body. As the blood moves through tiny capillaries in tissues, oxygen and nutrients move out of the bloodstream and into muscle !bers and other cells. Waste products move out of cells and into the blood. "e blood then circulates through veins back to the heart. "is cycle repeats itself with every heartbeat and breath.
degree of physical !tness. "e circulatory system includes the heart, blood, and blood vessels. "e lungs are the major structures of the respiratory system. As Figure 11.2 illustrates, the functioning of the heart and the functioning of the lungs are interrelated.
"e heart is a muscular pump that usually beats about 70–80 times each minute on average; however, some people may have slower or faster heart rates. Its job is to circulate blood throughout the body’s vast network of blood vessels: the arteries, veins, and cap- illaries. Blood transports oxygen and nutrients to cells and carries waste products such as carbon dioxide away from them.
Figure 11.1 Major Skeletal Muscles of the Human Body. (a) Front view. (b) Back view.
Latissimus dorsi
Adductor magnus
Triceps brachii
Extensor carpi radialis longus
Levator scapulae Splenius
Trapezius
Gluteus maximus
Semitendinosus
Semimembranosus
Gastrocnemius
Soleus
Biceps femoris
Sternocleidomastoid
Pectoralis minor
Serratus anterior
Tensor fasciae latae
Adductor longus Rectus femoris Vastus medialis Vastus lateralis
Tibialis anterior Peroneus longus
Sartorius Gracilis
Deltoid
Pectoralis major
Biceps brachii
External abdominal oblique
Brachioradialis
Rectus abdominis
Deltoid
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
Extensor carpi ulnaris
Brachialis
Thenars (group of 4)
Extensor carpi radialis longus Flexor pollicis longus
Palmaris longus Flexor carpi radialis Flexor digitorum superficialis
Flexor carpi ulnaris
Hypothenars (group of 3)
(a) (b)
Neck extensors
Rotator cuff Shoulder girdle muscle (Infraspinatus)
Foot and ankle extensors
Foot and ankle flexors
Part of quadriceps muscle group
Hamstring muscle group
Principles of Physical Fitness 353
Regular physical activity helps maintain bone mass, muscle strength, and joint function. Furthermore, older adults can improve their balance and reduce their risk of falls by performing certain exercises regularly. Men and women who are physically !t have a lower risk of dying prematurely from all causes, includ- ing cardiovascular disease, than do people who are not physically !t. Regular physical activity improves health by reducing excess abdominal fat and elevated blood pressure, glucose, and triglyceride levels.
In addition to improving physical health, regular exercise and physical activity can enhance psycho- logical health and sense of well-being. According to Physical Activity and Health: A Report of the Sur- geon General, physical activity “reduces symptoms of anxiety and depression and fosters improvements in mood and feelings of well-being.”5 "is does not mean that physical inactivity causes mental health problems or that exercising will cure these condi- tions; however, some studies indicate that a lack of physical activity may be associated with development of mental disorders.6 Additionally, regular physical activity can improve the quality of sleep, which ben- e!ts psychological health.7,8,9
Many people experience short-term psychological bene!ts during or immediately a$er exercising. Stren- uous physical activity produces chemical changes in the body that can improve psychological health. For example, the central nervous system releases beta-endorphins during exercise. Beta-endorphins
Defining Physical Activity and Exercise Physical activity is movement that occurs when skel- etal muscles contract; everyone engages in some phys- ical activity as part of his or her daily living routines. "ese activities include shopping, housekeeping, and walking pets. Exercise is physical activity that is usu- ally planned and performed to improve or maintain one’s physical condition. For example, doing biceps curls is an exercise that develops upper arm strength.
How does physical activity a#ect health? Before reading the following section, check your knowledge by taking the physical activity and heart disease quiz in the Student Workbook section of this text.
Physical Activity and Health
Being physically active can substantially reduce your risks of serious chronic diseases, including heart (cor- onary artery) disease, certain forms of cancer, type 2 diabetes, obesity, and hypertension (Table 11.1).4
Carbon dioxide leaves
the blood.
The blood carries the carbon dioxide back to the lungs.
The circulatory system carries the oxygenated blood to cells.
Blood picks up oxygen in the lungs.
Oxygen moves out of the blood and into cells. Waste products move out of cells and into blood.
O2
Air
CO2
O2CO2
Figure 11.2 Cardiorespiratory System. The functioning of the heart and the functioning of the lungs are interrelated. The heart pumps blood to the lungs, where it picks up oxygen. The oxygenated blood returns to the heart, which pumps it throughout the body.
physical activity Movement that occurs when skeletal muscles contract.
exercise Physical activity that is usually planned and performed to improve or maintain one’s physical condition.
354 Chapter 11 Physical Fitness
has a basal metabolic rate of 1,800 calories per day, and her average daily energy expenditure is 2,200 calories per day. We calculate Sarah’s PAL by dividing her daily energy expenditure (2,200 calories per day) by her basal metabolic rate of 1,800 calories per day for a PAL of 1.2, which indicates a sedentary lifestyle.
METS are multiples of the energy used while sitting or lying still per minute, which is de!ned as one MET. Physical activity that requires 3–6 METS is consid- ered moderate activity, whereas movement requiring more than 6 METS is considered vigorous. Table"11.2 lists some physical activities classi!ed as moderate and vigorous by calories per minute.
!e Health-Related Components of Physical Fitness
Cardiorespiratory !tness, muscular strength, mus- cular endurance, 'exibility, and body composition are the health-related components of physical !tness. "ese physical characteristics provide support for the body, sustain its e#ective and e&cient movement, and in'uence overall health and well-being.
are pain-killing substances that may provide natural relaxing and mood-elevating e#ects. Also, exercise can divert a person’s attention away from distressing thoughts and negative emotions, which relieves anxi- ety. Long-term psychological bene!ts of exercise may include boosting self-esteem.10 People who exercise with others can experience psychological bene!ts from the social interaction.
Physical activity can be measured in terms of caloric use per minute, physical activity level (PAL), or metabolic equivalents (METS). A calorie is de!ned as the amount of heat required to raise the temperature of 1 gram of water 1 degree Celsius. Energy is generated within muscle cells, which cre- ates movement; therefore, the number of calories burned during physical activity is a good indicator of exercise intensity.
PAL can also be used to determine energy expendi- ture during physical activity. It represents the amount of energy used each day over energy needs for our basal (resting) metabolism. Basal metabolism is our daily energy requirement to fuel life functions, such as brain function, food digestion, and breathing. A% person with a PAL of less than 1.4 is considered sed- entary. A PAL between 1.4 and 1.7 indicates moderate physical activity, and a PAL greater than 1.7 indicates a vigorous level of activity. For example, assume Sarah
Health Benefits of Physical Activity (Adults)
Table 11.1
Physical activity can lower the risk of:
• Early death • Heart disease • Stroke • High blood pressure • Type 2 diabetes
• Metabolic syndrome • Colon cancer • Breast cancer • Hip fracture
A physically active lifestyle:
• Prevents weight gain • Aids weight loss, particularly when
combined with reduced calorie intake • Improves cardiorespiratory and
muscular fitness
• Prevents falls • Reduces depression • Improves cognitive function
(for older adults) • Improves bone density
Reproduced from U.S. Department of Health and Human Services. (2008). Chapter 2: Physical activity has many health benefits. In: Physical activity guidelines for Americans. Retrieved May 25, 2011 from http://www.health.gov/paguidelines/guidelines/chapter2.aspx
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The Health-Related Components of Physical Fitness 355
needed to sustain their intense level of activity, and they become fatigued.
Individuals with high degrees of cardiorespira- tory fitness (or endurance) can perform muscular work more intensely and longer without becoming fatigued than persons with low levels of cardio- respiratory !tness can. Young, healthy 20-year-old individuals can raise their heart rates to about 190–200 beats per minute while engaging in intense aerobic activities. As people grow older, their maxi- mum heart rates decline. In addition to physical condition and age, other personal characteristics, including heredity, sex, and body composition, in'uence the maximum degree to which a person’s lungs and heart can function.
During vigorous physical activity, the heart of a physically !t person pumps more blood with each beat. When the activity ceases, the !t person’s heart and breathing rates rapidly return to normal. Even while resting, a !t individual’s heart is e&- cient; each minute, it can pump the same amount of blood with fewer heartbeats than the heart of an un!t person can.
Developing cardiorespiratory !tness requires aerobic (oxygen-requiring) activities that use our oxidative energy system. "e oxidative (aerobic) energy system, which requires oxygen to make energy, is used for physical activity that lasts lon- ger than 2 minutes. Aerobic activity increases heart and breathing rates and involves prolonged move- ment of large muscle groups, such as quadriceps and hamstrings. Examples of aerobic activities include running, jogging, racewalking, swimming, cycling, stair-stepping, aerobic dancing, and cross-country skiing. When you engage in vigorous physical activi- ties, your heart and breathing rates increase con- siderably above resting values, and you may sweat excessively.
While performing aerobic activities, people can use their heart rates to determine whether the intensity of the activities is high enough to provide cardiorespiratory bene!ts. To be very e#ective, a physical activity should be vigorous enough to raise your heart rate to reach the target heart rate zone. A$er raising your heart rate to the target heart rate zone, you should continue performing the aerobic activity, maintaining the level of intensity for at least 20 minutes. "e Managing Your Health box “Assessing the Intensity of Your Workout: Target Heart Rates” (in the next section) describes how to measure your heart rate and calculate your target heart rate zone.
Cardiorespiratory Fitness During intense physical activity, skeletal muscles need large quantities of oxygen to release enough energy to sustain movement. To supply more oxygen for working muscles, the heart and breathing rates increase as the intensity of physical activity increases. However, the lungs and heart have a maximum capacity to distribute an adequate supply of oxygen throughout the body within a certain time. Once the lungs and heart reach this maximum capacity, the skeletal muscles cannot obtain the additional oxygen
cardiorespiratory fitness The ability to perform muscular movements intensely and for long periods without tiring.
aerobic Refers to oxygen-requiring activities.
Moderate Activity (3.5–7 kcal/min)
Intense/Vigorous Activity (more than 7 kcal/min)
Walking at a brisk pace (3–4.5 mph)
Racewalking (5 mph or faster)
Hiking Jogging or running
Cycling on level terrain (5–9 mph)
Cycling (more than 10 mph or uphill)
Yoga Karate, tae kwan do, jujitsu
Table tennis Tennis–singles
Coaching a children’s sports team
Most competitive sports (e.g., football, soccer)
Weight training Circuit weight training
Skateboarding Long-distance running
Dancing (most kinds) Running up stairs
Gardening and yard work
Shoveling heavy snow
Scrubbing a floor Pushing a lawn mower
Modified from U. S. Centers for Disease Control and Prevention. (2010). General physical activities defined by level of intensity. Retrieved from http://www.cdc.gov/nccdphp /dnpa/physical/pdf/PA_Intensity_table_2_1.pdf
Table 11.2
Physical Activities by Level of Intensity
356 Chapter 11 Physical Fitness
Managing Your Health
To maximize the cardiorespiratory benefits of aerobic activity, you should work out at the level of intensity that raises your heart rate to within your target heart rate zone. To estimate your target heart rate zone, you need to take your pulse. Figure 11.A illustrates where you can feel your pulse using the carotid artery in your neck or radial artery in your wrist. Although locating the carotid artery pulse can be easier than the radial pulse, applying pressure to the carotid artery can reduce the heart rate, which interferes with obtaining a reliable measurement. For some people with cardiovascular disease, applying pressure to the carotid artery can be dangerous. Many medical experts advise using gentle pressure on your carotid artery to measure your pulse. Practice finding your radial pulse so that you can take it quickly while exercising.
To obtain the most accurate heart rate, measure your pulse while you are still engaging in the physical activity
or within 10 seconds after discontinuing the muscular movement. This timing is necessary because your pulse declines rapidly when you stop exercising. Count your pulse for 10 seconds, and then multiply that num- ber by 6 to obtain your heart rate per minute.
To estimate your target heart rate zone, obtain your age-predicted maximum heart rate by subtracting your age from 220. For example, if you are 20 years old and healthy, your age-predicted maximum heart rate is 200 beats per minute. Recently, a team of heart experts proposed a different formula for healthy women.11 According to their formula, a woman should multiply her age in years by 0.88 and then subtract that figure from 206. For example, a 20-year-old woman would multiply her age (20) by 0.88, which equals 17.6. By subtracting 17.6 from 206, she would determine her maximum heart rate to be about 188 beats per minute. Exercising at your
Assessing the Intensity of Your Workout: Target Heart Rates
Figure 11.A Taking Your Pulse. (a) Carotid site. (b) Radial site.
(a) (b)
The Health-Related Components of Physical Fitness 357
age-predicted maximum heart rate is undesirable and uncomfortable; this extreme level of intensity is unnec- essary for achieving cardiorespiratory fitness. Healthy people should exercise with enough intensity to raise their heart rates to within 65–90% of their age-predicted maximum heart rates. This interval is the target heart rate zone (Figure 11.B). People in excellent physical condition may calculate their target heart rates at the 85–90% intensity level. Most experts do not recommend that individuals raise their heart rates more than 90% of their age-predicted maximum levels.
If you are sedentary and just starting an exercise pro- gram, strive for a maximum heart rate at the low end of your target zone. As your physical condition improves, you will need to recalculate your target heart rate so that it is in “the zone.”
While exercising, if you can raise your heart rate to a value in your target zone and maintain this rate for 30–60 minutes, you are giving your heart and lungs a beneficial aerobic workout. During aerobic activity, you should measure your pulse about every 10 minutes with- out stopping the activity. If your heart rate is higher than the maximum value of your target heart rate zone, it is possible that you underestimated your zone, or you may be overexerting yourself at your present level of fitness. You may need to reduce your muscular workload. On the other hand, if your heart rate during aerobic exercise is less than the target range, you may not be working hard enough to achieve cardiorespiratory benefits.
Figure 11.B Target Heart Rate Zones. The shaded areas include pulse rates within the 65% to 90% intensity ranges.
75 80 85 90 95
100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180
20 25 30 35 40 45 50 55 60 65 70
94
97.5 99.5
104 105
110.5 111
117 117
123.5
122.0
130 130
138
145
153
162
170
135
144
153
162
171 180
Age (years)
65% to 90% Target Heart Rate Zone
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You do not have to jog 6 miles daily to reap the health bene!ts of a physically active lifestyle; most people can improve their health by performing a minimum of 30 minutes of moderately intense physi- cal activity 5 days a week.1 People can bene!t even from intermittent episodes of aerobic activity that last 10 minutes and accumulate to at least 30 minutes in one day.1 People who are sedentary or overweight can integrate more physical activity into their daily routines—for example, by climbing stairs instead of taking elevators and walking to nearby places instead of driving. By consistently engaging in moderate to vigorous activity, however, people can achieve even greater health bene!ts. Table 11.2 lists some physical activities classi!ed as moderate or vigorous.
If you have heart disease or other serious chronic conditions, are un!t, or are 40 years of age or older
(male) or 50 years of age or older (female), consult your physician before beginning an exercise pro- gram, especially if the program includes vigorous aerobic activities.
Assessing Cardiorespiratory Fitness You can judge your level of cardiorespiratory !tness by answering the following questions. While engaging in strenuous exercise, can you carry on a conver- sation with others, or are you panting for air and unable to talk? How long does it take you to catch your breath or for your heart to stop racing a$er you stop the activity? If you are unable to talk while exer- cising and it takes you a long time to recover your normal breathing and heart rates when you !nish the physical activity, you probably have a relatively low degree of cardiorespiratory !tness. "e !rst assess- ment activity for this chapter involves a simple test
358 Chapter 11 Physical Fitness
the limb, the weakened muscles ached for a brief time, but within days they became stronger. Even- tually, using these muscles enabled them to regain their full strength and original size. "e degree of detraining or atrophy, however, is associated with !tness level. "e rate of detraining and atrophy in people who are !t, especially highly trained ath- letes, is generally much slower than the rate for those who are less !t.12 "e rate of detraining also increases with age.
that you can perform to determine your level of car- diorespiratory !tness (see the Student Workbook section of this text).
A$er a few months of regular aerobic exercise, it is common for your resting heart rate to decrease. Observing such a decline in resting heart rate not long a$er beginning a regular aerobic exercise pro- gram is usually an indication that cardiorespiratory !tness has improved.
To track your aerobic !tness progress, record your resting heart rates before and a$er initiating an exercise regimen. Determine your resting heart rate by measuring your pulse when you !rst wake up, before getting out of bed, on 3 consecutive days. Calculate your average resting heart rate over this 3-day period, and record it and the date. A$er a few months of engaging in a vigorous exercise pro- gram, repeat the procedure to determine your rest- ing heart rate and compare the before and a$er measurements.
Muscular Strength Muscular strength is an important aspect of muscular !tness. Muscular strength is the ability of muscles to apply maximum force against an object that is resist- ing this force. Many individuals perform speci!c resistance training exercises to increase muscular strength because they want to li$ heavy objects with ease or improve their appearance (Figure 11.3). Other people are interested in developing larger, stronger muscles because they want to compete in sporting events that require strength. How do the strength and size of a muscle increase?
Resistance training is an e#ective method for developing muscular strength. To develop muscular strength, muscles must be progressively overloaded by moving heavy objects repeatedly. For example, using a weight-li$ing machine regularly can increase the size and strength of the biceps muscle in the upper arm. "is response is called the training e!ect. Under these conditions, the individual !bers of the biceps muscle can enlarge, or hypertrophy, making the entire muscle stronger and larger. Engaging in resis- tance training regularly helps maintain their size and strength.
"e saying “Use it or lose it” generally applies to skeletal muscles. Muscular atrophy, a condition of a muscle that has lost size and strength, results from a few weeks of detraining. If you have ever had a broken arm or leg, you may recall that a$er the cast was removed, the muscles of the recovered limb were atrophied and weak. When you !rst used
muscular strength The ability to apply maximum force against an object that is resisting this force.
hypertrophy A condition in which muscles become larger and stronger.
atrophy A condition in which muscles lose size and strength.
detraining A condition characterized by atrophied and weak muscles, which occurs when skeletal muscles are not used regularly.
Figure 11.3 Muscular Strength. Many individuals perform specific exercises to improve their appearance or to develop larger, more well-defined muscle groups. © LiquidLibrary.
The Health-Related Components of Physical Fitness 359
e#ectively. Furthermore, muscles can apply excessive pressure on certain arteries during isometric con- tractions, raising blood pressure. "erefore, many physicians do not recommend isometric exercises for people older than 35 years or those su#ering from cardiovascular disease.
Muscular Endurance Muscular endurance is another important aspect of muscular !tness. Muscular endurance is the ability of a muscle to contract repeatedly without becoming fatigued easily. For example, many people perform lunges to strengthen their leg muscles. A sedentary person will likely experience muscular fatigue a$er only a few repetitions; however, if she continues to perform lunges 2–3 times a week for several weeks or months, she will gradually develop muscular endurance in her legs and be able to perform more lunges in each exercise session. As she develops
Exercising for Muscular Strength A safe and e#ective way to increase muscle strength and size is to perform repetitive exercises that overload a par- ticular muscle group, such as li$ing weights. A rep- etition is the completion of a particular exercise, for example, li$ing a handheld weight and returning to the resting position. A set involves performing the same resistance exercise movement usually 8–12 times. Healthy people can begin to train their major muscle groups by performing a single set of exercises for each group of muscles.13 Over time, the individual should develop enough muscular strength to per- form multiple sets (generally three) during his or her resistance workout.14
Current American College of Sports Medicine (ACSM) resistance training guidelines for developing muscular strength indicate that adults should train major muscle groups 2 or 3 days each week using% a variety of exercises. Each exercise session should include 2–4 sets of each exercise and a minimum of 8–12 repetitions in each set. Additionally, adults should allow 48%hours between resistance training sessions.
Two forms of exercise that increase muscular strength are isotonic and isometric exercises. When performing isotonic exercises, a person exerts mus- cular force against a movable but constant source of resistance. During isotonic exercise, the muscle con- tracts and shortens. Isotonic exercises include li$- ing barbells, performing push-ups, or using weight machines (Figure 11.4). Instead of describing the exercises as isotonic, some !tness experts prefer to use the term dynamic constant external resistance because it re'ects the nature of these movements more accurately. An exercise is dynamic if the skel- eton moves during the activity.
In an isometric exercise, an individual exerts muscular force against a !xed, immovable object of resistance. For example, applying a constant amount of force while pushing against an immovable door frame is an isometric exercise. During isometric con- traction, the muscle does not shorten. Although iso- metric exercises can increase muscular strength, they do not increase muscular endurance or 'exibility
isotonic A type of exercise in which the individual exerts muscular force against a movable but constant source of resistance.
isometric A type of exercise in which the individual exerts muscular force against a fixed, immovable object.
muscular endurance A muscle’s ability to contract repeatedly without becoming fatigued.
Figure 11.4 Isotonic Contraction. While performing isotonic exercise, the muscle contracts, shortening in length. © Kristy-Anne Glubish/Design Pics Inc./Alamy Images.
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Dynamic stretching is performed by moving through a challenging but comfortable range of motion repeatedly in a controlled, smooth, and deliberate motion. Swinging your leg forward and backward to stretch your hamstrings and quadriceps several times, deliberately swinging your leg higher or further back each repetition, is an example of dynamic stretching. Dynamic stretching should not be confused with ballistic stretching, which involves uncontrolled jerking or bouncing. Dynamic stretch- ing has been shown to be bene!cial for sport per- formance and is commonly used by competitive athletes. Although the ACSM states that all forms of stretching can be e#ective, there are no speci!c rec- ommendations for dynamic stretching.
Proprioceptive Neuromuscular Facilitation (PNF) Although sources of !tness information o$en recommend static stretching for 15–30 seconds, a review of scienti!c literature indicates that a variety of stretching techniques, durations, and positions are e#ective means of increasing hamstring muscle 'exibility.15
Most !tness experts do not recommend ballistic stretching activities that involve bouncing. Addition- ally, you should not use unnatural stretching motions that injure muscles and tendons or extend joints beyond their normal ranges of motion. If pain occurs while stretching, discontinue the activity immedi- ately. "e Analyzing Health-Related Information activity in this chapter describes safe alternatives to outdated stretching exercises.
Low Back Pain "e majority of Americans encounter low back pain during their lives.16 As its name implies, low back pain occurs in the lumbar region of the spine (the lower back, above the hips), and it can be disabling (Figure 11.6). People with this condition are unable to perform activities essential to daily living comfortably, if at all. Furthermore, low back pain is responsible for a signi!cant percentage of worker absenteeism and workers’ medical com- pensation claims.
Weak abdominal, back, and leg muscles, as well as worn lumbar spinal discs, o$en contribute to the development of low back pain. "e spinal discs are 'exible pads that separate the bones of the spine and act as shock absorbers, protecting the bones from striking each other. As people age, their spi- nal discs become worn and sometimes bulge out of
muscular endurance, the e#ort required to perform lunges will also decrease. Current ACSM resistance training guidelines for developing muscular endur- ance are the same as for muscular strength: 2 or 3 days each week, 2–4 sets of each exercise per ses- sion, and a minimum of 15–20 repetitions in each set. You can assess your muscular endurance by tak- ing the push-up test in the Student Workbook sec- tion of this text.
Furthermore, the ability to sustain muscular con- tractions over a relatively long period requires a con- stant source of energy. Glucose is skeletal muscles’ preferred fuel for high-intensity endurance exercise. Muscles metabolize glucose derived from the blood- stream or from glycogen that is stored in muscle tis- sue. Muscle !bers can use fatty acids and amino acids for energy.
Flexibility A third aspect of muscular !tness is 'exibility. Move- ment is limited if joints are damaged or muscles can- not extend themselves fully. Flexibility refers to the ability to extend muscles, enabling a person to posi- tion a movable joint anywhere in its normal range of motion. Flexibility allows people to perform a variety of skeletal movements with ease, including bend- ing, gliding, rotating, and twisting. Many daily tasks require the ability to extend muscles and move joints easily: reaching for an item stored on a high shelf, stretching to pull up a back zipper, or bending to pick up a tennis ball. Having fully extendable muscles and 'exible joints enables you to care for yourself and to participate in enjoyable activities. You can assess your 'exibility by taking the sit-and-reach test in the Student Workbook.
Flexibility can be developed and maintained by engaging in activities such as yoga, Pilates, or stretch- ing exercises like those displayed in Figure 11.5. Static stretching involves slowly and fully extend- ing the muscle and nearby joints throughout their natural ranges of motion. When performing a static stretch, gently extend the muscle until you feel ten- sion; if you feel discomfort, relax the stretch slightly. While stretching, breathe normally; do not hold your breath. "e ACSM recommends engaging in 'exibil- ity exercises 2–3 times a week for each muscle group. Each stretch should be held for 10–30 seconds to the point of tightness in the muscle. Flexibility exercises should be repeated 2–4 times each session. Stretch- ing is most e#ective when muscles are warm; there- fore, stretching should be performed following a light aerobic warm-up.
flexibility The ability to move a muscle to any position in its normal range of motion.
The Health-Related Components of Physical Fitness 361
(a)
(c)
(d)
(e)
(f)
Figure 11.5 Stretching to Improve Flexibility. Flexible muscles enable one to make a variety of skeletal movements occur with ease. People can develop flexibility by performing stretching exercises such as the (a) low back stretch, (b) calf stretch, (c) modified hurdle, (d) lunge, (e) supine hamstring stretch, and (f ) groin stretch.
(b)
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the li$ing and sitting practices recommended in Figure 11.8.
Over-the-counter pain medicines and heat treat- ments can o$en relieve low back pain. A$er the dis- comfort subsides, people should perform exercises that strengthen the lower back, hip, and abdominal muscles. If the pain is intense or persists, however, the person should obtain a complete medical evalu- ation to determine the source of the pain. In some cases, surgery may be necessary.
Body Composition A healthy body contains large quantities of water and smaller amounts of fat and lean tissues (bones, muscles, and organs). Body composition, the per- centages of body weight contributed by lean tissue and fat mass, is a major factor in health. Although a small amount of body fat (about 4% in men and 10% in women) is essential, too much fat con- tributes to a variety of chronic diseases, including cardiovascular disease, hypertension, and diabe- tes. Regular exercise builds and maintains muscle mass% and helps keep the amount of body fat at healthy levels.
"e cells that constitute lean tissues, particularly muscle cells, are more metabolically active than fat cells are. "erefore, muscle cells burn more calories than fat cells do. By exercising and increasing muscle mass, you can increase your metabolic rate.18
Aging muscle cells eventually wear out and die. Unfortunately, the body does not replace these cells. As a result, people usually lose muscle mass and gain fat as they age. Some people believe unused or dying muscle cells can “turn into” fat cells; however, muscle cells are not able to transform themselves into fat cells. Muscle and fat cells have speci!c structures and functions; nevertheless, you can preserve more of your muscle mass as you get older by engaging in a regular exercise program.
Although regular physical activity can help a person maintain muscle mass while maintaining or losing body fat, “spot” reducing is not e#ective. For example, performing 100 crunches daily does not reduce the amount of fat stored in the abdominal area. During physical activity, fat deposits through- out the body release fatty acids into the blood- stream to supply energy for the vigorously moving muscles. Exercising a speci!c muscle group, how- ever, can improve physical !tness and appearance by increasing the strength of the exercised muscles and improving their ability to hold in the underly- ing fat mass.
their normal position. Pounding, twisting, and li$- ing place physical stress on the lumbar spine and are likely responsible for displacing or damaging some discs. Such movements include jogging on a sidewalk, swinging a golf club, carrying a heavy backpack, and picking up a heavy box or a child. In addition, people who have poor posture, sit for hours in awkward positions, wear high-heeled shoes, or have too much body fat are susceptible to low back pain, especially if they have weak abdomi- nal muscles.
Although medical experts agree that exercising to strengthen the abdominal, hip, upper leg, and back muscles can prevent or treat many cases of low back pain, they do not agree on which exercises to recommend. Some physicians recommend aerobic exercises; others promote various stretching activi- ties. Figure 11.7 shows various exercises designed to strengthen the weak muscles that contribute to low back pain and improve the 'exibility of the spi- nal joints.
You can reduce your risk of developing low back pain by practicing prevention behaviors, for exam- ple, exercising regularly, wearing shoes with low or no heels, and avoiding sitting for long periods.17 You can o$en prevent low back pain by following
Lumbar region Vertebra
(a) Normal disc
(b) Bulging disc
Spinal cord
Figure 11.6 Spinal Discs. (a) Normal disc position. (b) Bulging disc pressing on spinal cord.
The Health-Related Components of Physical Fitness 363
Figure 11.7 Exercises to Prevent Lower Back Pain.
(c)(a) (b)
Figure 11.8 Practices to Protect Your Lower Back. (a) To bend safely, bend your knees, not your back. (b) When lifting a child or heavy object, hold it close to your body, at chest level, and do not make twisting motions. (c) To protect your lower back while sitting, rest your lower back against the chair’s back and avoid bending forward. Use an adjustable seat and prop up your feet so that you sit with your hips slightly lower than your knees.
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Health-Related InformationAnalyzing Critical Thinking
The accompanying article describes safe alternatives to outdated exercises. Read the article and evaluate it using the model for analyzing health-related information. The main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who wrote the article? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person who wrote the article?
4. What is the main point of the article? Which information is relevant to the main point? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think this article is a reliable source of health-related information? Explain why you would or would not use the information. Sum- marize your reasons for coming to this conclusion.
Safe Alternatives for Outdated Exercises by Bryant Stamford, PhD
Stretching and strengthening exercises are, of course, good for you. As a part of a complete !tness program, they help you stay 'exible and avoid injury. Not all exercises, though, are good for all people. Healthy
young people can do almost any exercise with little risk. And older people who have exercised all their lives can exercise safely under most circumstances. But middle-aged and older%peo- ple who have been inactive need to know that some of the old standbys—such as sit-ups and toe touches—can result in injury.
So how do you get the important bene!ts of stretch- ing and strengthening but avoid the injuries? You need to choose exercises carefully, especially if you are getting up in years and haven’t exercised regularly. To help you, potentially troublesome exercises are cited below, with recommended alternatives.
If you aren’t very 'exible or have had back problems, it’s best to consult a doctor before starting an exercise program. You may be more susceptible to injury because of a number of factors, includ- ing past injuries, !tness, body type, 'exibility, technique, and age.
Regardless of the exercises you select, apply the following principles for maximum safety:
• Use strict technique. Stop using an exercise when physical limitation prevents you from performing it well. Also stop when you are tired.
• Use a slow, deliberate approach. Never bounce: "e momentum can make a safe exercise dangerous.
• Hold stretches at least 6 seconds initially, building gradually to 30 seconds, then to 2 minutes. Holding a stretched position is more e#ective than doing many repetitions.
• Reject the “no pain, no gain” philosophy. Pain means something is wrong, so stop immediately.
Many popular exercises stress the lower back. High on the list is the standing toe touch, which stretches the hamstring muscles at the back of your thighs. "is is a bad exercise even if done slowly, but it’s even worse if you bounce. A safer option is the one-legged stretch (Figure 1).
Figure 1 One-legged stretch.
Sit-ups are popular, supposedly for stomach toning. But full sit-ups stress the lower back, and they work the hip muscles more than the abdominal muscles. "e “crunch” is better (Figure 2).
Figure 2 The crunch.
The Health-Related Components of Physical Fitness 365
"e donkey kick can also be dangerous, especially to your neck and lower back. It involves being on all fours and li$ing one leg as high as possible in a kicking fashion. An alternative to the donkey kick is the rear-thigh li$ (Figure 3).
People do the yoga plow to stretch upper and lower back mus- cles by lying on their back and bringing their feet up and over until they touch the 'oor beyond their head. Unfortunately, this forces the discs in the neck to bulge, risking injury. For the same reason, avoid the “bicycle,” in which you lie on your back, raise your hips, and “pedal” your feet. An excellent alternative is the fold-up stretch (Figure 5).
Figure 3 Rear-thigh lift.
Exercises that involve twisting can be especially danger- ous. Windmills, in which you bend over and try to touch one hand to the opposite foot, are very stressful on the lower back. But in some sports—like golf—twisting plays a major part. Therefore, when recovering from a low-back injury, perform mild, pain-free twisting movements under profes- sional supervision.
Some exercises can harm the neck. Head rolls, in which you roll your head in a complete circle, are very stressful to the upper spine. Do neck stretches instead (Figure 4).
Figure 4 Neck stretch.
Figure 5 Fold-up stretch.
Full squats or deep knee bends can damage your knees, espe- cially when you bounce out of the squat. Partial squats done slowly and under control are safer.
Jumping jacks involve considerable forces on your legs, par- ticularly the knees. If you land on your toes, the Achilles tendons at the back of your heels bear a major load and could rupture if your legs aren’t in the best of shape. Gently running in place provides a lower-impact way to warm up.
Less Risky Business No matter what your age or physical condition, choosing safer exercise options will lower your risk of injury. And remember that whatever the exercise, good technique is essential.
Remember: "is information is not intended as a substitute for medical treatment. Before starting an exercise program, con- sult a physician.
Adapted from Stamford, B. (1995). Safer alternatives to outdated exer- cises. The Physician and Sportsmedicine, 23(6), 87–88.
This article was written when Dr. Stamford was director of the Health Pro- motion and Wellness Center and Professor of Allied Health in the School of Medicine at the University of Louisville, Kentucky.
To maintain a healthy weight, the U.S. Centers for Disease Control and Prevention recommends engaging in moderate- to vigorous-intensity aerobic activities for at least 150 minutes each week, which is approximately 30 minutes a day, 5 days a week. To reduce body fat, 60–90 minutes of moderate-intensity physical activity
daily may be necessary. Additionally, engaging in mus- cle-strengthening activities focused on major muscle groups, including legs, hips, back, chest, and shoulders, should also be performed at least 2 days a week. An appropriate level of physical activity, along with a sen- sible diet, is the most e#ective way to control weight.
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By% eating more servings of fruits and vegetables, athletes can obtain safe quantities of vitamins and minerals without taking supplements. "ere is no scienti!c evidence that protein-rich diets build big- ger muscles, so eating large servings of meat or tak- ing protein supplements is unnecessary. High protein intakes may cause dehydration and accelerate the loss of calcium from bones. Furthermore, protein-rich foods o$en contain a lot of fat, especially saturated fat. Protein supplements are o$en consumed to help build muscle and for quicker recovery; however, recent research indicated protein supplementation yielded no signi!cant increase in muscle size and reduction in soreness when protein supplementation was used before, during, or a$er a workout.19
Carbohydrate is the preferred fuel of the body, and a diet that supplies plenty of complex carbohydrates from starchy foods is recommended. Starchy foods usually contain more vitamins and minerals than sugary foods do. Some athletes practice “carbohy- drate loading” to maximize the amount of carbohy- drate stored in their muscles. A few days before an event, for example, the athlete gradually increases the amount of carbohydrate eaten to about 70% of calories and gradually decreases the amount of time working out. "en, 2–4 hours before the competitive event, the athlete eats a light meal composed of starchy foods such as bagels, pasta, or breads and cereals. Not all athletes !nd that carbohydrate loading helps their performance. "us, one should test the e#ects of the diet when not preparing for competition.
Ergogenic Aids Ergogenic (work-producing) aids include a variety of products such as dietary supplements, stimulant drugs, and mechanical devices that supposedly enhance physical development or performance. Some of these aids are bene!cial and harmless, but others are dangerous and illegal. Chromium picolinate, for example, is a popular dietary supplement that some people use to build lean body mass. Although results of some studies indicate chromium picolinate may provide some health bene!ts, more research is needed. Furthermore, information about the long-term safety of chromium picolinate supplementation is lacking.
Another popular ergogenic aid is creatine, a com- pound that is naturally in muscle tissue. According
Athletic Performance Although genetic factors contribute to cardiorespi- ratory !tness, muscular strength and endurance, and other common attributes of athletes, training is essential for athletes to develop their inborn physi- cal capabilities and compete successfully in sports. Additionally, performance-focused behaviors, such as dietary and sleep habits, contribute to athletic performance.
The Sports-Related Components of Fitness "e sports-related components of !tness include speed, power, coordination, agility, balance, and reac- tion time. Speed is the rate of movement; power is the ability to concentrate a considerable amount of force, usually from a particular group of muscles, when performing work. Coordination is the ability to per- form a series of complicated muscular movements in a continuous manner. Agility enables a person to make quick, precise movements, such as changing direction, with ease. Balance enables one to maintain a poised upright body position. Reaction time is the time it takes a person to adjust his or her body posi- tion to a changing environment. Although athletes o$en focus on improving the sports-related compo- nents of !tness that are associated with their speci!c sports, they also need to develop the health-related components of !tness.
Diet and Performance Most athletes are on the lookout for something—a diet, supplement, or drug—that may give them the competitive edge. "e best advice for all athletes is to drink adequate amounts of water and choose a well-balanced diet composed of a variety of foods.
4Engaging in intense aerobic activity regularly can improve your cardiorespiratory fitness and burn excess body fat.
4Engaging in regular resistance exercises, such as lifting weights, can increase the size and strength of your muscles.
4Stretching muscles can improve their flexibility.
Healthy Living Practices
ergogenic (work producing) aids Products or devices that enhance physical development or performance.
Athletic Performance 367
"e young man died a few hours later. "e autopsy of the cyclist’s body revealed he had used amphet- amines, a class of stimulant drugs. By the late 1960s, the International Olympic Committee (IOC) and some other sports federations had established lists of banned substances and required their athletes to be tested for these chemicals. In January 2008, a judge sentenced track star Marion Jones to several months in jail a$er she admitted lying to federal investi- gators about her use of performance-enhancing drugs and her involvement in a check-fraud scheme (Figure 11.9). As a result of her admission, the IOC disquali!ed Jones from the !ve track events in which she won medals at the 2000 Summer Olympic Games. Shortly before being disquali!ed, Jones returned her Olympic medals to the committee. Most recently, Lance Armstrong, seven-time winner of the Tour de
to research, creatine can be e#ective in increasing strength, especially for short bouts of high-intensity physical activities such as sprinting and jumping.20 Although creatine supplementation appears to be safe, more research is needed to determine the safety of tak- ing creatine supplements over the long term. Table 11.3 lists some dietary supplements, claims about their ergo- genic e#ects, and information concerning whether sci- enti!c studies support these claims. In many instances, more research is needed to support or refute claims.
For more than four decades, the outstanding physical accomplishments of many athletes have been tainted by reports of athletes relying on “dop- ing,” the use of foreign substances to enhance perfor- mance. For example, Danish cyclist Knud Enemark Jensen crashed his bike and fractured his skull while competing in the 1960 Summer Olympics.
Aid Claim Current Scientific Findings
Caffeine Improves strength; enhances fat metabolism
Increases alertness but at high doses causes nervousness; raises free fatty acid levels during exercise; might provide modest improvement of performance.
Creatine Enhances release of energy during exercise
May enhance performance during short bouts of intense exercise; more research is needed.
Carnitine Enhances fat metabolism No significant improvement in performance, but more research is needed.
Wheat-germ oil Increases oxygen uptake by cells, improving stamina
Results of well-designed studies do not support ergogenic claims.
Lecithin and choline Increase production of a neurotransmitter, resulting in more muscular strength
Results of well-designed studies do not support ergogenic claims.
Omega-3 fatty acids Makes blood flow better, stimulates muscle growth
Results of well-designed studies do not support ergogenic claims; large doses may increase the risk of stroke.
Amino acids, brewer’s yeast, enzymes, and DNA supplements
General performance- enhancing effects
Results of well-designed studies do not support ergogenic claims; large doses of amino acid can inhibit amino acid absorption and increase water requirement.
Co-Q-10 (coenzyme Q or ubiquinone)
Improves heart function Results of well-designed studies do not show consistent improvement in performance; more research is needed. Long-term safety is unknown.
Bee pollen Shortens recovery time Results of well-designed studies do not support ergogenic claims; may cause allergic responses in some individuals.
CLA (conjugated linoleic acid)
Increases lean body mass Results of well-designed studies do not support ergogenic claims. Long-term safety is unknown.
Table 11.3
Dietary Supplements as Ergogenic Aids
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stronger, more well-de!ned muscles. Men, however, are capable of developing larger muscles and having greater overall strength because their testosterone levels are higher than those of women. Testosterone is an anabolic (tissue-building) hormone.
Anabolic steroids are a group of synthetic and natural substances that are chemically related to testosterone and may have muscle-building proper- ties. Although certain anabolic steroids are classi!ed as controlled substances, they can be prescribed by physicians for legitimate medical uses. "ese drugs, however, are o$en illegally obtained and abused by athletes and others who want to enhance their physi- cal performance, muscle development, or both. In the United States, it is di&cult to estimate the preva- lence of anabolic steroid abuse because people are o$en unwilling to admit to taking the substances.
Medical experts are especially concerned about anabolic steroid use among adolescents because of the long-term serious health consequences. Gener- ally, fewer than 2% of American high school seniors reported using steroids at some point in their lives.22
Why is there so much concern over the abuse of anabolic steroids? Athletes who abuse these drugs to improve their physical strength can have an unfair competitive advantage over athletes who choose not to use them. Anabolic steroids can have serious irreversible e#ects on the body (Figure 11.10). Male anabolic steroid abusers o$en experience shrunken testicles and infertility. Women who abuse these drugs may become bald, grow facial hair, and experi- ence menstrual irregularities. Anabolic steroid abuse increases the risks of developing heart and kidney diseases, certain cancers, and liver tumors. In some cases, damage to the liver or kidneys is so severe that death occurs. Additionally, anabolic steroids can a#ect personality. People who abuse anabolic steroids may act more aggressive, hostile, and irritable than usual. Regular resistance exercise is the only safe way to increase the size and strength of a muscle.
France, admitted to using ergogenic aids. Armstrong was banned from competition for life by the World Anti-Doping Agency and stripped of all seven Tour de France titles. Nike, among other sponsors, cut all ties with Livestrong, Lance Armstrong’s foundation.
Athletes in other sports also use banned substances to improve their physical abilities. According to the 2007 Mitchell Report, doping is widespread among profes- sional baseball players.21 "e report includes the names of several Major League Baseball players who allegedly purchased illegal substances, particularly anabolic ster- oids, to enhance their performance. In the report, for- mer U.S. Senator George Mitchell recommends that the players and the management of Major League Baseball teams work together to rid the sport of doping.
Anabolic Steroids Both men and women may li$ weights during their workout sessions to build
Figure 11.9 Fallen Star. In January 2013, Lance Armstrong admitted to doping and received a lifetime ban from the World Anti-Doping Agency. Because of his admission, he was stripped of all seven of his Tour de France titles. © Marc Pagani Photography/Shutterstock.
4Do not use anabolic steroids to build your muscles; they can be very harmful.
Healthy Living Practices
anabolic steroids A group of drugs that can have muscle-building effects on the body.
Athletic Performance 369
exercises develop muscular strength, these activities may not increase cardiorespiratory !tness signi!- cantly. Many people combine aerobic and muscle- strengthening activities in their daily workouts to improve their overall physical condition; others per- form isotonic and aerobic workouts on alternate days. For example, one day’s workout session would be devoted to weight li$ing; the following day’s session would involve racewalking. "e ACSM recommends
Exercising for Health Regular exercise is important for long-term health and% is associated with better cardiovascular health, among other health bene!ts. Aerobic activities increase cardiorespiratory !tness and muscu- lar endurance. Performing high-impact aerobic activities, including basketball and jogging, can build stronger bones. Although isometric and isotonic
Male
• Premature balding • Severe acne, greasy skin • Sleep disturbances • Aggressive, hostile, and irritable behavior
• Increased blood pressure • Reduced HDL levels, increasing the risk of heart disease • Liver tumors and liver failure
• Reduced testosterone secretion and sperm production • Testicle shrinkage
Female
• Scalp hair loss • Severe acne, greasy skin • Sleep disturbances • Aggressive, hostile, and irritable behavior • Increased body hair, including facial hair
• Increased blood pressure • Breast shrinkage • Reduced HDL levels, increasing the risk of heart disease • Liver tumors and liver failure
• Ovaries malfunction • Menstrual irregularities
Anabolic steroids may cause:
Figure 11.10 Possible Effects of Anabolic Steroids on the Body. To increase their muscle mass, some men and women abuse anabolic steroids or other chemicals that are promoted for their muscle-building properties. These drugs can have serious irreversible effects on the body.
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physical activity assessment apps; however, some have not been tested for e&cacy. Before you begin a typical day’s activities, place the pedometer on your belt or waistband. "en, check the pedometer before going to bed and record the number of steps you took that day. If you have a sedentary lifestyle, you prob- ably will have taken fewer than 3,000 steps. Gradu- ally increase the number of steps you take by making a conscious e#ort to be more active. A brisk walk- ing routine, for example, can increase the number of steps you take daily and increase your cardiorespi- ratory !tness level. Your goal should be to record at least 8,000 steps each day.
Other, more interactive, tools such as FitBit can also help you track the number of steps you take daily, while serving several other functions. FitBit also tracks dis- tance traveled, calories burned, and activity minutes.
waiting 48–72 hours between strength training ses- sions using the same muscle groups.
"e FITT principle can be used to develop exercise programs to enhance health-related components of !tness. FITT is an acronym for frequency, intensity, time, and type components of exercise that in'uence the degree of health bene!ts a person derives from it. Using the FITT principle allows you to manipu- late your program for continued improvement. For example, it is common to reach a plateau in weight loss or muscular strength improvement when the same program is repeated for an extended period of time. Increasing exercising intensity or time can help break plateaus for continued improvement.
Exercise frequency is the number of times an indi- vidual exercises, usually reported as the number of days or exercise sessions in a week. People who exer- cise at least 3 times a week generally experience more rapid improvements to their overall !tness than do people who exercise less o$en. "e intensity of an exercise re'ects the amount of physical exertion a per- son uses while performing the activity. Fitness experts use several methods to estimate the intensity of exer- cise, including the rate of oxygen consumption dur- ing exercise, heart rate, and personal perceptions of physical exertion. For the average person, playing nine holes of golf while using a power golf cart or bowling for 30% minutes are light activities; playing tennis or walking briskly for a half hour are moderate activi- ties; and running for 6 miles or playing racquetball for 30%minutes are intense activities (see Table 11.2).
Time refers to the total time the person is physi- cally active during each exercise session. For exam- ple, people who jog for 40 minutes 3 days a week experience more cardiorespiratory bene!ts than do those who jog for 10 minutes 3 days a week.23,24 People who are currently sedentary can develop car- diorespiratory !tness if they engage in an aerobic exercise program that gradually increases the dura- tion of the activity, usually over several weeks. "e type of exercise, sometimes called mode, refers to the kind of exercise you choose. For example, to improve 'exibility, one person may choose to engage in static stretching, and another may choose to practice yoga. It is important to match the type of exercise chosen with desired abilities and goals.
Many tools are available to help you assess your level of activity. A relatively easy way to assess and increase your physical activity level is to measure the number of steps you take in a day. You can purchase a pedometer; inexpensive ones sell for under $30 (Figure 11.11). Some smartphone platforms also have
Figure 11.11 Examples of Pedometers. A pedometer is a relatively easy way to assess your physical activity level. (a) © Andrew Haddon/Shutterstock; (b) © Coprid/Shutterstock.
Exercising for Health 371
usually not recommended because extending “cold” muscles may injure them. Stretching, however, does not protect against sports injuries.27,28
A$er stretching, many persons perform active, task-speci!c activities to warm up speci!c muscles. For example, a jogger would jog slowly for a few min- utes, gradually increasing the pace until reaching his or her usual training speed. Before playing a sport, it can be helpful to perform sport-speci!c movements at a slower pace before the game. A recent study indicated that a soccer-speci!c warm-up reduced injury rate and injury severity among collegiate male soccer players.29
Warming up before exercising is essential for people with heart disease. Abnormal functioning of the heart may occur when sedentary, middle-aged people begin to exercise suddenly without warming up. Warm-up activities increase the blood 'ow to the heart gradually, reducing the risk of heart attack dur- ing physical exertion.
A$er exercising vigorously, people should cool down by gradually reducing the intensity of their activ- ity and by stretching. Many types of strenuous exercise increase the blood supply to the leg muscles; suddenly stopping these intense muscular movements can cause blood to accumulate in the leg veins, which can reduce the blood 'ow to the brain, causing dizziness, faintness, or loss of consciousness. Cooling down by engaging in 5–10 minutes of light exercise gradually decreases the blood 'ow to the leg muscles. Figure 11.12 illustrates a 50-minute workout session that consists of 10 min- utes of warm-up activities, 30 minutes of jogging, and 10%minutes of cool-down exercises.
Research indicates that receiving immediate feedback during exercise, as well as feedback on long-term goals, can reinforce regular exercise. Devices such as FitBit are, however, more costly than a pedometer.
"e frequency, intensity, time, and type of aerobic physical activities in'uence !tness. For example, you can exercise intensely for 20 minutes or moderately for 30 minutes and achieve similar cardiorespiratory bene!ts. Using the FITT principle allows you to indi- vidualize a workout program that works best for your particular needs and abilities.
The Exercise Session People should warm up before and cool down (“warm down”) a$er intense exercise. Warming up reduces the physical stress that vigorous exercise can place on the body. "e person’s skeletal muscles become warm and extend easily, joints become more 'exible, and heart and breathing rates increase gradually. Some studies indicate that warming up can reduce the extent of mus- cle soreness a$er exercise25 and may reduce the likeli- hood of injuries.26 More research is needed to support these !ndings. Cooling down facilitates the circulation of blood, especially in the leg muscles, enabling the body to recover from intense physical activity.
To warm up the entire body before engaging in a vigorous physical activity, you can walk at an easy pace and then gradually increase your speed until you have walked for 5–10 minutes. At this point, your muscles should be warm enough to perform stretch- ing exercises such as those shown in Figure 11.5. Stretching muscles before the warm-up session is
0
Slow pace or
light activity
Stretching exercises
Warm-up Cool-downAerobic activity Pulse within target heart rate zone
Stretching exercises
Slackened pace
5 10 15 20 25 30 35 40 45 50
Figure 11.12 A Suggested Workout Session. A reasonable 50-minute workout session may consist of 10 minutes of warm-up activities, 30 minutes of jogging, and 10 minutes of cool-down exercises.
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Strains and Sprains Almost everyone who is physically active has experi- enced muscle soreness or musculoskeletal injuries such as strains and sprains. Although there are no clear clini- cal de!nitions for strain or sprain, a strain generally refers to the damage that a muscle or tendon sustains when overextended rapidly. A sprain usually refers to a damaged ligament. Although these two types of injuries o$en occur together, a sprain tends to be more serious than a strain is. "e sprained ligament may be partially or completely torn, and the nearby mus- cle, joint, or bones may be damaged; therefore, severe sprains generally require immediate medical attention.
RICE, the acronym for rest, ice, compression, and elevation, is o$en e#ective for treating strains and sprains:
Rest can reduce the pain, but light exercise or activ- ity that uses the injured muscles is usually recom- mended, as long as the discomfort is tolerable.
Ice treatments should be limited to 20-minute ses- sions and can be repeated every 2 hours (while the injured person is awake) for 2–3 days. Do not place ice directly on the skin; instead, place a thin towel or wrap between the ice and your skin.
Compression, an external source of pressure, can prevent swelling. Apply a pressure bandage on the injury to produce compression. Make sure the ban- dage is not tight enough to interfere with circulation.
Elevation also reduces swelling. When an injured limb is elevated, gravity helps the veins of the limb return blood to the heart, reducing the amount of blood and other fluids that accumulate in the damaged tissue.
With RICE and over-the-counter pain medicines, muscle soreness usually disappears within a day or two. If an injured area does not improve with RICE and the pain persists or worsens, consult a physician.
Dislocation Healthy joints control the ability of muscles to move bones. Joints are susceptible to dislocation, that is, becoming displaced by force. Dislocation can result when joints and their supportive tissues are torn or
Exercise Danger Signs Exercise improves the functioning of the heart and reduces the risk of heart disease. Sudden and intense physical exertion, however, can strain the heart, espe- cially the heart of an un!t individual or someone with cardiovascular disease.
To reduce the risk of overtaxing your cardiovas- cular system during vigorous exercise, warm up !rst, and then exercise at a reduced intensity level for about 10–15 minutes. Keep records of your activity level and any discomfort that you experience. Dis- continue the activity and consult a physician if any of the following signs or symptoms of heart disease occur during or a$er exercising:
• Heart abnormalities, such as irregular rhythms or a feeling that your heart is pounding in your throat or 'uttering in your chest
• Pain or pressure in your chest, throat, or arms • Shortness of breath, dizziness, sudden loss of
coordination, cold sweating, or fainting
Preventing and Managing Common Exercise Injuries
Everyone should be concerned about personal safety while exercising. People should check their exercise equipment for defects and wear the proper clothing, shoes, and protective gear for the activ- ity. Bicyclists and joggers, for example, should obey tra&c signals and avoid busy roads that have narrow or rocky shoulders. Engaging in physical activity outdoors at night, or in very hot or very cold conditions, is especially dangerous; wearing clothing with re'ective strips can also help you be more visible.
Although engaging in regular physical activity is essential for optimal health, some activities are likely to result in musculoskeletal injuries. Suddenly rais- ing the intensity level or duration of a physical activ- ity may damage muscles or supportive tissues or aggravate existing injuries, so gradual changes are recommended. Using some general exercise precau- tions can help minimize the risk of musculoskeletal injury. Sudden, awkward movements are likely to injure muscles, tendons, and joints; therefore, avoid- ing physical activities that involve exaggerated twist- ing can reduce the risk of injury.
strain Generally refers to an injured muscle or tendon.
sprain Generally refers to an injured ligament.
Preventing and Managing Common Exercise Injuries 373
"ey need to move to a cooler area and drink plenty of cool water. If heat exhaustion is not recognized and treated, heatstroke can develop. "e signs and symptoms of heatstroke include hot, dry, reddened skin; rapid pulse; fever; and loss of consciousness. Heatstroke is a life-threatening emergency; victims should be removed from the heat and receive imme- diate medical attention.
When the weather is hot and humid, avoid exert- ing yourself outdoors during the hottest time of the day. If you must be outdoors when it is hot, follow a few precautions to reduce the likelihood of heat- related injury. Several hours before exercising or performing intense physical activity, especially in warm conditions, slowly drink water or other accept- able 'uids and eat salty foods or snacks to achieve adequate hydration.30 Alcoholic beverages are not acceptable 'uids for hydration because alcohol is a diuretic. A diuretic increases urine production; there- fore, people lose some body water when they drink alcohol-containing beverages. Although ca#eine is also a diuretic, drinking ca#einated beverages does not stimulate excess urine production by the body.30 Consuming large amounts of ca#eine can increase the risk of heat-related injury.
During and a$er engaging in activities that make you perspire heavily, consume enough 'uids to replace the amount of weight lost by sweating. Drink- ing too much 'uid before, during, or a$er physical activities should be avoided because the practice may cause overhydration, a potentially deadly condition. A%rule of thumb is to drink about 1.5 L (approximately 6.25 cups) of water or other acceptable beverage for every kilogram (2.2 lb) of body weight lost during the activity.30 When the weather !rst becomes hot, indi- viduals should begin working or exercising outdoors at a reduced intensity and then gradually increase the intensity over a 2-week period to become accli- matized, that is, physically adjusted to the extreme temperature change. Wearing light-colored, loose clothing in sunny, hot, and humid weather helps people stay comfortable because light colors re'ect sunlight, and loose clothing allows perspiration to evaporate more easily. When environmental temper- ature and humidity are very high, most individuals should consider reducing the intensity and duration of their outdoor workouts to reduce the risk of heat- related illness.
People who perspire excessively can lose consid- erable amounts of sodium chloride in their sweat. Most of these individuals can drink more water and fruit juices and consume foods to replace the
worn a$er engaging in certain strenuous physical activities. When a joint becomes damaged, the injury reduces its normal range of motion, and movement o$en becomes painful. Although involvement in cer- tain sports, such as American football, increases the risk that the participants will damage their joints, any physically active person can experience joint inju- ries. A later section of this chapter describes steps for designing personal !tness programs that can reduce the risk of such injuries.
Temperature-Related Injuries When exercising in hot weather, the body gains heat from the environment and from its active muscles. To cool itself, the body perspires heavily, transfer- ring heat to the environment. Dehydration (lack of body water) can occur if a person does not replace the 'uid lost by perspiration. Signs of dehydration include weight loss immediately a$er exercising and reduced urine production.30 "e muscles of a per- son su#ering from dehydration are less able to work e&ciently. It is essential that people replace the water lost in sweat by consuming adequate amounts of 'uids, especially plain water. Soups, fruits, veg- etables, and nonalcoholic drinks contribute water to the diet also.
Hyperthermia Hyperthermia, higher than nor- mal body temperature, can result from dehydration. If a person becomes hot and dehydrated, heat cramps, heat exhaustion, or heatstroke may occur. "e signs and symptoms of heat cramps include muscular tightening and pain in the limbs or abdomen. "e a#ected individual usually recovers a$er stopping the activity, resting in a shady area, stretching the cramped muscles, and drinking several ounces of water. A$er recovering, this person should not exer- cise for the remainder of the day.
Heat exhaustion and heatstroke are more seri- ous conditions than heat cramps. People su#ering from heat exhaustion have pale and clammy skin; sweat profusely; and feel nauseated, tired, and weak.
hyperthermia A condition that occurs when body temperature rises above the normal range.
heat cramps In a dehydrated and hot person, the signs and symptoms of heat cramps include muscular tightening and pain in the limbs or abdomen.
heat exhaustion The extreme fatigue that results from exercise or work in hot temperatures.
heatstroke A life-threatening condition that can occur when people exercise or work in hot temperatures.
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frostbitten. Frostbite requires immediate and proper medical treatment. Avoid rubbing frostbitten skin because it can further damage cold tissues. To pre- vent frostbite, people need to wear gloves or mittens, thick socks, hats that can be pulled down over the ears, and scarves when outdoors in cold weather.
Hypothermia occurs when the body’s core tem- perature drops below 95°F.33 (A rectal thermom- eter is used to measure core body temperature.) As body temperature declines, the person shivers, feels tired, displays poor judgment, acts disori- ented, and eventually loses consciousness. Death can occur when the core temperature falls below 82°F, and breathing and circulation are too weak to support life.
As in cases of frostbite, hypothermia requires prompt medical treatment. It is important to shelter people su#ering from hypothermia from the cold and remove their wet clothing. Covering them in dry blankets keeps them warm until they can be taken to a hospital. To protect against hypothermia, wear a hat and layers of warm, dry clothing when you are in cold environments.
lost nutrients. While engaging in strenuous exercise that lasts an hour or more, people can also consume sports drinks for 'uid replacement.31 In addition to water, these drinks contain sodium chloride and energy-supplying carbohydrate (e.g., sports drinks and gels). Salt (sodium chloride) tablets are typically not needed.32
Frostbite and Hypothermia Participating in out- door activities during the winter months increases the risk of cold injury. Exposed to cold temperatures, the body reduces its blood 'ow to the skin, conserv- ing body heat. "e chilled person shivers and feels tingling, numbness, or burning in exposed skin or body parts. Frostbite occurs when ice crystals form in the deeper tissues of the skin, damaging them. Blood 'ow to the a#ected area slows, causing clots to form. Unable to obtain oxygen and nutrients, the tissue dies. "e damage may be so extensive that the frostbitten areas must be amputated. A person’s !ngers, toes, nose, ears, and face are most suscep- tible to frostbite, but any exposed skin can become
Elevation and ice treatments can reduce swelling of a sprain or strain.
Frostbite. Courtesy of Neil Malcom Winkelmann.
hypothermia A condition that occurs when the body’s core temperature drops below 95°F.
4If you have musculoskeletal injuries as a result of exercise, use RICE as treatment. If pain and swelling persist, contact your personal physician.
4If you develop heat cramps or heat exhaustion while working or exercising, stop the activity immediately, get out of the heat, and drink plenty of water.
4If you plan to exercise or work in hot conditions, wear loose, light clothing and take an ample supply of water, fruit juices, or sports drinks with you.
4When you exercise or work in cold conditions, protect yourself against hypothermia and frostbite by wearing layers of warm, dry clothing, a hat or ski mask, gloves or mittens, and thick socks.
4Avoid drinking beverages that contain alcohol to replace body water that is lost by sweating.
Healthy Living Practices
Preventing and Managing Common Exercise Injuries 375
the !rst 2–3 weeks, do not try to exercise at a high intensity level or for more than 15 minutes. Keeping an exercise log or diary detailing exercises performed can help you track your progress. Making note of exercise frequency, intensity, time, and type (FITT), as well as how you felt during your workout, can help you make adjustments as needed. Stop when you experience signs of exercise intolerance, such as pain or breathlessness, and note this in your log. A com- mon problem encountered by enthusiastic but out- of-shape people is trying to do too much too soon.
When you do not experience fatigue or discomfort as a result of the activity, you are ready to move on to the improvement stage of the program. By gradually increasing the intensity and duration of your physical activity, you can progressively overload your muscles and achieve your !tness goals. For example, add 5%minutes to the time of your aerobic workout session each week, until you are exercising for 45–90 minutes most days of the week. If you are walking at 2 mph, gradually increase the pace until you are able to walk between 3 and 4 mph without e#ort. To acquire the !tness bene!ts of aerobic exercise, a person must engage in the activity for at least 30 minutes most days of the week. Engaging in aerobic exercise more o$en, for longer periods, or at higher intensity can help develop higher degrees of !tness; however, more is not always better for long-term health.
You can enhance muscular size and strength with a weight li$ing program that gradually overcomes the resistance of progressively heavier weights. As your muscles adapt to the workload, you should be able to develop strength by adding resistance while perform- ing fewer repetitions. A$er each bout of heavy train- ing, muscles engaged in resistance exercises need at least 48 hours to recover, to repair themselves, and to grow. "us, experts o$en recommend alternating the days of the week in which you perform cardiorespira- tory and strength training activities. Table 11.4 shows a sample aerobic and weight resistance program that includes stretching exercises. By the end of 6 months, you should be ready to move on to the maintenance stage of the program.
A major feature of the maintenance stage of your !t- ness program is sustaining your !tness level and inter- est. Adding new activities prevents boredom with the workout program and develops di#erent muscle groups or skills. Cross-training, incorporating a variety of aerobic activities into a !tness program, is an excellent way to maintain enthusiasm and interest. Working out in di#erent environments can also add interest. Walk- ing in parks or hiking on trails, for example, can be
Developing a Personal Fitness Program
A basic personal physical !tness program should include activities that enhance cardiorespiratory !t- ness, muscular strength and endurance, and 'exibil- ity. To develop an e#ective program, determine your needs, interests, and limitations. Answering the fol- lowing questions can help you accomplish this step:
• How can I schedule my day’s activities so that I have time to exercise?
• Which physical activities am I most likely to enjoy and practice regularly for the rest of my life?
• Do I want to develop or enhance speci!c sports- related skills?
• Would I rather work out alone or with others? • Where will I exercise? • Do I have physical limitations that require special
equipment or rule out certain activities?
"e “Changing Health Habits” activity for this chapter can help you determine whether you are ready to improve your level of physical !tness (see the Student Workbook section of this text).
A$er completing the !rst step, make a list of your general !tness goals. One of them should be to enhance the health-related components of !tness, for example, improving your cardiorespiratory !tness or 'exibil- ity. Other goals may be changing your appearance or building agility. Although your list may include several goals, choose one or two to work on at a time.
At this point, you need to choose enjoyable physi- cal activities that will help you meet your !tness goals. As mentioned earlier, aerobic exercise is nec- essary for achieving cardiorespiratory !tness. Resis- tance training is important for increasing lean body mass and maintaining muscular strength and endur- ance. Warm-up and cool-down stretching exercises can improve range of motion. Faculty who conduct personal !tness classes in the physical education department at your college can answer your ques- tions concerning the need for special equipment or how to perform activities safely.
If you are overweight or have been sedentary, give your body time to adapt to the !tness program. For
cross-training Incorporating a variety of aerobic activities into a fitness program.
376 Chapter 11 Physical Fitness
Week 1 Warm-Up (min) Workout Cool-Down (min)
Monday 5–10 Brisk walking 15 min. 5–10
Tuesday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Wednesday 5–10 Brisk walking 15 min. 5–10
Thursday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Friday 5–10 Brisk walking 15 min. 5–10
Saturday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Sunday 5–10 Brisk walking 15 min. 5–10
Week 2 Warm-Up (min) Workout Cool-Down (min)
Monday 5–10 Brisk walking 20 min. 5–10
Tuesday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Wednesday 5–10 Brisk walking 20 min. 5–10
Thursday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Friday 5–10 Brisk walking 20 min. 5–10
Saturday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Sunday 5–10 Brisk walking 20 min. 5–10
Week 3 Warm-Up (min) Workout Cool-Down (min)
Monday 5–10 Brisk walking 25 min. 5–10
Tuesday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Wednesday 5–10 Brisk walking 25 min. 5–10
Thursday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Friday 5–10 Brisk walking 25 min. 5–10
Saturday 5–10 Resistance training, beginning load Reps: 5, Sets: 4 5–10
Sunday 5–10 Brisk walking 25 min. 5–10
Week 4 Warm-Up (min) Workout Cool-Down (min)
Monday 5–10 Brisk walking 30 min. 5–10
Tuesday 5–10 Resistance training, beginning load Reps: 10, Sets: 4 5–10
Wednesday 5–10 Brisk walking 30 min. 5–10
Thursday 5–10 Resistance training, beginning load Reps: 10, Sets: 4 5–10
Friday 5–10 Brisk walking 30 min. 5–10
Saturday 5–10 Resistance training, beginning load Reps: 10, Sets: 4 5–10
Sunday 5–10 Brisk walking 30 min. 5–10
Table 11.4
A Sample 4-Week Combined Workout Program
Developing a Personal Fitness Program 377
cross-country skiing machines can be purchased for home !tness centers. Before buying any large piece of !tness equipment, you should visit a gym or !tness club to test the machine and discuss its value with quali!ed !tness experts. For additional information, check popular consumer magazines that occasionally rate exercise equipment.
Building or maintaining physical !tness does not require a long-term commitment with a gym or !t- ness club, but many people enjoy the social aspects of exercising at these facilities. "e quality and cost of gyms and !tness clubs vary, so you may want to consider the points listed in the Consumer Health fea- ture “Choosing a Fitness Center” before joining one.
Unless you have a job that requires physical exer- tion or you work at a company that provides a work- site !tness center for its employees, you need to !nd ways to be more physically active at work. If your o&ce building has stairways, climb the stairs rather than ride the elevators. Instead of eating lunches in restaurants, bring your lunches from home to eat at your desk, and use the remaining time to go outside and walk. You might consider buying two pairs of athletic shoes—one for your o&ce and one for home. You may like walking with others better than walk- ing alone; ask someone to walk with you. Colleagues, spouses, or friends can provide the valuable social support you may need to maintain your motivation to exercise at work or home. In addition to increasing your physical activity at work, you can move around more at home. Child care, housework, and gardening chores o$en require contracting large muscle groups, which expends energy and strengthens the muscles. How many times a week do you go up and down steps, walk a pet, or go shopping? What lifestyle changes can you make to increase your physical activity?
Like many people, you may want to be more active, but you cannot seem to !nd the time to exercise. It is important to remember that you do not have to spend hours each day engaging in strenuous exer- cises to improve your health. Even 10–20 minutes of vigorous aerobic activity can boost your !tness level. Determine how you spend your leisure time. Each day, how much time do you spend engaging in sed- entary activities such as watching TV, communicat- ing with others in a chat room, or playing computer games? Can you set aside at least 30 minutes each day to engage in some moderately intense physical activities? Figure 11.13 illustrates physical activity recommendations for healthy lifestyles. To track your physical activity, visit www.choosemyplate.gov /supertracker-tools.html.
more interesting than walking around indoor tracks. By working out with friends or family members, you can enhance your physical as well as social health.
Once people achieve high degrees of physical !t- ness, continued regular exercise is needed to main- tain the healthful bene!ts gained during training. Sometimes physically !t individuals discontinue intensive regular exercise regimens for a variety of reasons, such as experiencing injuries or losing moti- vation. Detraining can occur within a couple of weeks a$er exercise sessions are discontinued. "e rate of detraining is in'uenced by current !tness level. A very !t person will detrain at a slower rate than a less !t person. Even if they have to reduce the fre- quency of their exercise sessions, people can usually maintain their high level of physical !tness as long as they do not stop working out.
Active for a Lifetime People are more likely to engage in physical activity regularly if they enjoy it, recognize the health bene!ts, and make it a priority. Some people dislike vigorous exercise because they do not feel competent perform- ing the activity; others may associate the activity with sweating, strain, and pain. Adults who enjoy being active are more likely to make exercise and physical movement integral parts of their daily routines.
Many people !nd it easier to be physically active while in college than when they are out of school and working full time. Most college and university campuses have physical education departments that o#er a variety of sports and !tness courses; some of these departments have well-equipped !tness cen- ters. Additionally, the sta# of the physical education department may conduct intramural athletic pro- grams that are open to students, and at certain times, they may open the college’s gyms and athletic !elds to all students. While in school, students should take advantage of the !tness opportunities available on their college or university campus.
A$er leaving college, individuals can continue to build or maintain their !tness level by exercising at home or by joining !tness centers or clubs. Although large resistance exercise machines are highly e#ective for building muscular strength, their expense and size make them unlikely to be found in most homes. However, you can buy barbells and smaller hand- held weights at most department or sporting goods stores for use at home. To improve cardiorespira- tory !tness, rowing machines, stationary bikes, and
378 Chapter 11 Physical Fitness
Many aerobic and resistance activities do not require extensive time, complex skills, or special and costly equipment. For example, people can exercise by dancing to music or videos or by performing tai chi in the privacy of their homes. "e main objective is to select physical activities that you enjoy and can perform regularly for the rest of your life.
As mentioned earlier, if you are un!t, or a male older than 40 years or a female older than 50 years, consult a physician before beginning a physical !tness pro- gram, especially one that includes vigorous-intensity activities. "is precautionary measure can determine whether you have serious health problems. If you have a chronic condition, consult your physician for an exercise prescription. Most adults can begin a regular walking program to get into shape; a$er a few weeks, they can add more intense forms of physical activity to boost their cardiorespiratory !tness.
Resistance Training Weight lifting,
calisthenics, Pilates
High-Intensity Exercise and Competitive Sports
Combine days of intensive training or competition with periods of light
training and rest. Basketball, soccer, hockey, mountain climbing
Recreational Activities Golfing, bowling, surfing,
softball
Aerobic Exercise Running, bicycling, cross country skiing, dancing
Activities of Daily Living Work in your garden or rake leaves.
Take the stairs, walk the dog, park farther away at work or the store and walk.
Flexibility Stretching, yoga, tai chi
2– 3 days per week
3– 5 days per week
3– 5 days per week
Figure 11.13 The Activity Pyramid. This physical activity pyramid includes recommendations for healthy lifestyles.
4Perform isometric or isotonic exercises to increase your muscular strength, and also engage in aerobic exercises to enhance your cardiorespiratory fitness.
4You can enhance your muscular strength, muscular endurance, and flexibility by increasing the frequency, duration, and intensity of your exercise sessions.
4If you have heart disease or other serious chronic conditions, are unfit, or are a male older than 40 years or a female older than 50 years, obtain your physician’s approval before beginning an exercise program, especially if the program includes vigorous aerobic activities.
Healthy Living Practices
Active for a Lifetime 379
Consumer Health Choosing a Fitness Center Every year, millions of Americans join health clubs, gyms, and exercise and fit- ness centers. Thousands of these peo- ple complain about their membership
to states’ attorneys general, Better Business Bureaus, and other consumer protection groups. The following tips can help you avoid becoming another dissatisfied health and fitness center consumer:
• Determine whether you can afford to join the center. • Inspect the center for cleanliness, type and
quality of equipment, and especially staff qualifica- tions. Ask if staff are certified as aerobics instruc- tors, weight trainers, or athletic trainers. Are they trained in cardiopulmonary resuscitation (CPR) and first aid?
• Ask current members about their satisfaction with the center’s facilities.
• Ask your local Better Business Bureau about the number and nature of complaints against the organization.
• Ask for a trial period to use the facilities before joining.
• Never sign a contract under pressure at the center. Many centers use confusing and misleading adver- tising, including prizes or special short-term offers, to spark your interest. Once you are in the facility, aggressive sales staff engage in high-pressure sales tactics to convince you to sign a contract.
• Before signing, take a few days to read the contract carefully. Make certain that you understand the details concerning payment options, membership restric- tions, cancellation terms, and the membership period. If a staff member makes additional promises, have the individual record it in writing, on the contract.
It is a good idea for pregnant women to dis- cuss their exercise plans with their physicians. Nearly all pregnant women can safely walk, swim, or ride a stationary bicycle (Figure 11.14). Healthy
pregnant women should engage in at least 30 minutes of moderate-intensity exercise daily on most or all days of the week.35,36 "ose who are obese or severely underweight, are sedentary, or have histories of health problems should consult their physicians before following an exercise program.
As people age, they experience numerous changes that indicate a decline in their physical con- ditions. For example, the maximum age- predicted heart rates of older adults are lower during exer- cise, and their hearts pump less blood with each beat. Compared to when they were young adults, most aged persons have more body fat. Although exercise training of older adults does not prevent these physical changes, it can limit the extent of the%decline.
Most Americans become less active as they age. Less than 25% of all U.S. adults meet physical activity guidelines.37 It is important for people to continue exercising as they age (Figure 11.15). Phys- ically !t older adults usually have healthier hearts and body compositions than un!t people of the same age. Even by performing light physical activi- ties regularly, older adults can reduce their risk of heart disease, colon cancer, diabetes, obesity, and hypertension.38
Figure 11.14 Exercising During Pregnancy. Nearly all pregnant women can safely stretch, walk, swim, or ride a stationary bicycle. © Photodisc.
380 Chapter 11 Physical Fitness
about 30% of American high school students attend physical education (PE) classes 5 days a week.34 More research is needed to determine the long-term e#ects of childhood and adolescent activity habits on their future health.
Regular exercise is just as important during pregnancy as in the other times of a woman’s life. Healthy, physically !t women can continue engaging in a program of mild to moderate physical activity throughout their pregnancies.35 However, perform- ing strenuous exercise (e.g., jogging) !ve or more times per week may increase the risk of having a low-birth-weight baby.36 "e ability to engage com- fortably and safely in many physical activities o$en becomes limited in the latter stage of pregnancy. During this time, a woman’s weight usually increases dramatically, especially in the center and front part of her body. As a result, she o$en feels awkward while engaging in many physical activities, and her risk of injury increases.
A pregnant woman should avoid activities if they pose a risk to her health and that of her developing fetus. Physical activities that might result in falls or injuries to the abdominal area and exhaustive exercises such as contact sports, heavy weight li$ing, or training and participating in competitive events are generally not recommended for pregnant women. Addition- ally, exercising while lying down may interfere with blood 'ow to the uterus and is not recommended. It is important for pregnant women to be well hydrated before, during, and a$er exercise and to avoid over- heating. Physicians do not recommend that pregnant women exercise in hot, humid conditions or use hot tubs and saunas because these activities can raise the woman’s body temperature, endangering the fetus.
PHYSICAL FITNESS "e health habits that a person adopts in childhood, including physical and sports activities, are likely to be practiced and enjoyed for a lifetime. Children who are physically active have better measures of all health-related !tness components than those who are sedentary. Because sedentary lifestyles are associated with heart disease in adults, many pedia- tricians are concerned that children may begin to develop this disease, especially if they do not engage in physical activities regularly. To improve the overall health and well-being of children, parents and schools need to !nd ways to encourage youngsters who are physically un!t to increase their !tness levels.
Another major concern of health and !tness experts is the proportion of American children and adolescents who spend a considerable amount of time engaged in sedentary activities, such as play- ing computer games or viewing television. Currently,
Figure 11.15 Exercise Is for Everyone. It is important for people to continue exercising as they age. © Don Tremain/Photodisc/Getty Images.
Across THE LIFE SPAN
4To become physically fit or to maintain a high degree of fitness, design a personal fitness program that includes activities that you enjoy and can perform regularly while you are in college and throughout your lifetime.
4If you have a sedentary lifestyle, find ways to become more physically active at work and home, such as walking some of the way to work, using the stairs instead of elevators, doing housework, and walking during your leisure time.
Healthy Living Practices
Active for a Lifetime 381
Diversity in Health New Interest in an Ancient Approach to Fitness
In motion all parts of the body must be light, nimble, and strung together.
From T’ai chi ch’uan by Chang San-feng (1279–1386)
To people outside of China, it may seem difficult to believe that the graceful dancelike movements of t’ai chi ch’uan (tie-jee-chwahn), commonly called “tai chi,” are a form of exercise. Unlike Western physical activities that often require rapid, forceful, and extensive motions, tai chi involves gentle gliding muscular movements that do not overextend body parts. According to its promoters, tai chi promotes good health, physical fitness, and longevity.
The exact origins of traditional tai chi are unknown. For more than 2,000 years, the Chinese have practiced qigong (ch’i-kung), a series of simple exercises that focus on breathing, maintaining certain body postures, and relaxing. These features are also emphasized in tai chi. In fact, the word chi means “breath energy.” Thus, the ancient practice of qigong may have set the stage for the development of tai chi.
In addition to qigong, the Chinese martial arts prob- ably contributed to the development of t’ai chi ch’uan. Ch’uan means “the joy of fighting with bare fists.” Origi- nally t’ai chi ch’uan may have been used for self-defense or boxing. However, a major principle of t’ai chi ch’uan is to overcome brute force and harshness with softness, gentleness, and smoothness.
Chang San-feng, the 13th-century Taoist priest whose writing appears here, is usually credited with creating tai chi. Taoism is an ancient Chinese religion and phi- losophy that emphasizes living in harmony with nature. To Taoists, the harmonious functioning of the body is important if one is to achieve good health and live a long life. Today, tai chi is growing in popularity with Western exercise enthusiasts who are interested in achieving its potential health benefits (Figure 11.C). Promoters of tai chi claim that the physical exercises improve digestion and circulation, and increase alertness. People who prac- tice tai chi often report that the exercises reduce stress.
While performing the specific sequential exercises, the upper part of the body remains loose; the knees are
slightly bent but firmly supporting the weight of the body. Movements flow from one to another. Opposing arms and legs move in harmony; for example, as one arm grace- fully arches upward, the other moves down in the same fashion. According to those who teach tai chi, if one body part does not follow another, the body is not in harmony. The series of vertical and horizontal movements contin- ues until the sequence of exercises has been completed.
An important aspect of tai chi is mental concentra- tion. As individuals engage in these exercises, they focus their attention on the sensations associated with the sequential movements; such attention requires silence.
As with other physical activities, practicing tai chi every day improves flexibility, muscular strength, and balance. Because tai chi does not require rapid, forceful muscular movements, it is a beneficial form of physical activity for elderly people or anyone who cannot engage in aerobic exercises.
A specially trained instructor is necessary to teach the proper posture, sequences of coordinated movements, and breathing technique of tai chi. Therefore, if you are interested in learning the exercises, check with the physical education department at your college or university to see if it offers tai chi instruction. Fitness centers in your com- munity, such as the YMCA, might also offer tai chi classes.
Poem reproduced from The Essence of T’ai Chi Chi’uan: The Literary Tradition, translated and edited by Benjamin Pang Jeng Lo, Martin Inn, Robert Amacker, and Susan Foe, published by North Atlantic Books, © 1979 by Benjamin Pang Jeng Lo, Martin Inn, Robert Amacker, and Susan Foe. Reprinted with permission of publisher.
Figure 11.C Tai Chi. Practicing tai chi improves flexibility, muscular strength, and balance. © Kanjanee Chaisin/Shutterstock.
382 Chapter 11 Physical Fitness
gain healthful bene!ts such as improved muscular strength and endurance, 'exibility, and psychological well-being. To achieve these bene!ts, participation in strenuous formal exercise programs is not necessary; most elderly people can improve their overall health by engaging in light to moderate physical activities regularly, such as walking, gardening, or mall-walking every day.
Additionally, physical activity helps maintain or improve the 'exibility of joints as well as the strength and endurance of muscles. Regular exercise improves the mood of elderly people and increases their ability to live independently.38 Older adults can enjoy the social aspects of exercising by joining mall-walking, dancing, or !tness classes that are designed for older adults.
People lose their ability to maintain their balance as they age, which increases their risk of falling. A minor fall that would not injure a healthy 23-year-old person can have dire consequences for a frail 85-year-old one. An elderly person who falls is more likely to su#er a disabling bone fracture or die from the injury than a younger person is. Aged people who survive falls o$en experience some degree of immobility and pain that limits their ability to care for themselves and interact socially. By participating in exercise classes that improve balance and muscular strength, older adults can reduce their risk of falls.39 "e Diversity in Health essay in this chapter describes the bene!ts of tai chi, a form of mar- tial arts that helps some elderly people become healthier.
It is never too late to become physically !t. By increasing physical activity, even very old people can
4If you have children, consider limiting the amount of time they spend watching television or playing computer games. Encourage your children to be physically active.
4If you are pregnant, consult your physician to determine which physical activities are safe to perform during this time.
4As you age, exercise regularly and be physically active.
Healthy Living Practices
Active for a Lifetime 383
CHAPTER REVIEW Summary
Regardless of age and physical condition, nearly everyone can achieve numerous health bene!ts by engaging in physical activity and exercise. Perform- ing regular, vigorous exercise and physical activity can build, maintain, and preserve skeletal muscles; improve the circulation and functioning of the heart; and regulate the amount of body fat. Weight- bearing exercises such as walking, dancing, and jogging strengthen bones, which can prevent or delay the development of osteoporosis. Healthy adults younger than 65 years should perform mod- erate-intensity physical activity for 30 minutes a day, 5 days a week.
Besides improving physical health, exercise can have short-term and long-term psychological bene- !ts. Physical activity can reduce symptoms of anxiety and depression and improve mood and well-being.
"e health-related components of physical !t- ness are cardiorespiratory !tness, muscular strength, muscular endurance, 'exibility, and body composi- tion. Many !tness experts consider cardiorespiratory !tness the most important health-related element of physical !tness.
Regular aerobic exercise enhances cardiorespiratory !tness, increasing the stroke volume of the heart and reducing the resting heart rate. Examples of popular aerobic activities include running, jogging, racewalk- ing, lap swimming, cycling, stair-stepping, aerobic dancing, cross-country skiing, and rope skipping.
To develop muscular strength, muscles need to be overloaded by repeatedly moving objects that become progressively heavier. When muscles are overloaded, they hypertrophy; when muscles are not used, they atrophy or detrain. Detraining can occur within a couple of weeks a$er people discontinue
their exercise training regimen. "us, people must maintain their exercise programs to avoid detraining.
Immediate !rst aid for most musculoskeletal inju- ries includes RICE, the combination of rest, ice, compression, and elevation. Hypothermia and hyper- thermia are serious temperature-related injuries that can occur when the body is unable to maintain its temperature in the normal range. Exercising in hot weather can produce heat cramps, heat exhaustion, or heatstroke. If untreated, heat cramps or heat exhaustion can lead to heatstroke, which can be fatal. Maintain- ing adequate hydration and avoiding overexertion in hot and humid conditions can reduce the risk of heat- related illnesses. To avoid frostbite or hypothermia, people should dress warmly while outdoors in cold and windy conditions, keeping their skin well covered.
When planning an e#ective overall !tness regimen, people need to consider the type, frequency, duration, and intensity of their exercise activities. Individuals should design personal !tness programs that provide health bene!ts, satisfy their needs and interests, and can be followed for a lifetime. Before beginning !t- ness regimens that include aerobic activities, people with heart disease or other serious chronic conditions and people who are out of shape or older than 40 years should obtain the approval of their physicians.
Regular physical activity is just as important for youngsters as for adults. Performing certain activities may be risky during pregnancy; therefore, pregnant women should discuss their physical activity with their physicians. In most cases, it is never too late for people to begin !tness programs. By engaging in light to moderate physical activities regularly, such as walking or gardening every day, older adults can improve their overall health.
1. Calculate your target heart rate zone. Application 2. For 3 days, record the amount of time you spend
engaging in various physical activities, such as walking to class, playing racquetball, or riding a bike. Use Table 11.2 to classify your physical
activities as being light, moderate, or intense. Analysis
3. Plan an exercise program. Synthesis 4. Evaluate your current level of cardiorespiratory
!tness. Evaluation
Applying What You Have Learned
384 Chapter 11 Physical Fitness
CHAPTER REVIEW Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
Key
1. Are you satis!ed with your level of physical !t- ness? Why or why not? If you are dissatis!ed, what ideas did you get from reading this chapter that will help you improve your !tness? If you are satis!ed, how will you maintain your !tness?
2. What bene!ts would you derive from adopting a more physically active lifestyle? What factors interfere with, and what factors reinforce, your e#orts to become more physically !t?
3. Before reading this chapter, how did you feel about ergogenic aids, such as dietary supple- ments or anabolic steroids, to enhance athletic performance? Based on what you have read in
this chapter, has your attitude changed? Why or why not?
4. If you have children or are thinking about hav- ing children, how would you encourage them to maintain a balance between the time they spend engaging in sedentary activities, such as watch- ing TV, and in activities that develop physical !tness?
5. Which labor-saving devices would you be will- ing to stop using so that you could use your mus- cles to do the work? Why did you choose these devices or machines? Describe practical steps you can take to increase your physical activity level.
Reflecting on Your Health
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10. Anners, L., et al. (2013). Prescribed exercise: A prospective study of health-related quality of life and physical !tness among participants in an o&cially sponsored municipal physical training program. Journal of Physical Activity & Health, 10(7), 1016–1023.
11. Gulati, M., et al. (2010). Heart rate response to exercise stress test- ing in asymptomatic women: "e St. James Women Take Heart Project. Circulation, 122(2), 130–137.
12. Bosquet, L., et al. (2013). E#ect of training cessation of muscular performance: A meta-analysis. Scandinavian Journal of Medicine & Science in Sports, 23(3), 140–149.
13. Feigenbaum, M. S., & Pollock, M. L. (1999). Prescription of resis- tance training for health and disease. Medicine & Science in Sports & Exercise, 31(1), 38–45.
14. Garber, C. E., et al. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor !tness in apparently healthy adults: Guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43(7), 1334–1359.
15. Behm, D., & Chaouachi, A. (2011). A review of acute e#ects of static and dynamic stretching on performance. European Journal of Applied Physiology, 111, 2633–2651.
1. U.S. Department of Health and Human Services. (2018). Physi- cal activity guidelines. Retrieved from http://www.health.gov /PAGuidelines/factsheetprof.aspx
2. Centers for Disease Control and Prevention. (2015). Behavioral Risk Factor Surveillance System: Aerobic physical activity. Retrieved from https://www.cdc.gov/brfss/data_tools.htm
3. Centers for Disease Control and Prevention. (2014). Facts about physical activity. Retrieved from https://www.cdc.gov /physicalactivity/data/facts.htm
4. U.S. Department of Health and Human Services. (2008). Chapter 2: Physical activity has many health bene!ts. In Physical activity guidelines for Americans. Retrieved from http://www.health.gov /paguidelines/guidelines/chapter2.aspx
5. U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.
6. Ströhle, A. (2009). Physical activity, exercise, depression and anxi- ety disorders. Journal of Neural Transmission, 116(6), 777–784.
7. Youngstedt, S. D. (2005). E#ects of exercise on sleep. Clinics in Sports Medicine, 24(2), 355–365.
8. Lang, C., et al. (2013). Increased self-reported and objectively assessed physical activity predict sleep quality among adolescents. Physiology & Behavior, 120, 46–53.
References 385
CHAPTER REVIEW 23. Yu, S., et al. (2003). What level of physical activity protects against
premature cardiovascular death? "e Caerphilly study. Heart, 89(5), 502–506.
24. Sundquist, K., et al. (2005). "e long-term e#ect of physical activity on incidence of coronary heart disease: A 12-year follow-up study. Preventive Medicine, 41(1), 219–225.
25. Law, R. Y., & Herbert, R. D. (2007). Warm-up reduces delayed onset muscle soreness but cool-down does not: A randomised controlled trial. Australian Journal of Physiotherapy, 53(2), 91–95.
26. Fradkin, A. J., et al. (2006). Does warming up prevent injury in sport? "e evidence from randomised controlled trials. Journal of Science and Medicine in Sport, 9(3), 214–220.
27. Lepanen, M., et al. (2014). Interventions to prevent sport related injuries: A systematic review and meta-analysis of randomized con- trolled trials. Sports Medicine, 44(4), 473–486.
28. Hart, L. (2005). E#ect of stretching on sport injury risk: A review. Clinical Journal of Sport Medicine, 15(2), 113.
29. Grooms, D., et al. (2013). Soccer-speci!c warm-up and lower extremity injury rates in collegiate male soccer players. Journal of Athletic Training, 48(6), 782–788.
30. American College of Sports Medicine, Sawka, M. N., et al. (2007). American College of Sports Medicine position stand: Exercise and 'uid replacement. Medicine & Science in Sports & Exercise, 39(2), 377–390.
16. Hoy, D., et al. (2010). "e epidemiology of low back pain. Best Prac- tices in Research Clinical Rheumatology, 24(6), 769–781.
17. McGill, S. (2007). Low back disorders: Evidence-based pre- vention& and rehabilitation (2nd ed.). Champaign, IL: Human Kinetics.
18. Potteiger, J. A., et al. (2008). Changes in resting metabolic rate and substrate oxidation a$er 16 months of exercise training in over- weight adults. International Journal of Sport Nutrition and Exercise Metabolism, 18, 79–95.
19. Pasiakos, S., et al. (2014). E#ects of protein supplements on muscle damage, soreness and recovery of muscle function and physical performance: A systematic review. Sports Medicine, 44(5), 655–670.
20. Schoch, R. D., et al. (2006). "e regulation and expression of the creatine transporter: A brief review of creatine supplementation in humans and animals. Journal of International Society of Sports Nutrition, 3, 60–66.
21. Mitchell, G. J. (2007). Report to the commissioner of baseball of an independent investigation into the illegal use of steroids and other performance enhancing substances by players of Major League Baseball. Retrieved from http://!les.mlb.com/mitchrpt.pdf
22. National Institute on Drug Abuse. (2017). NIDA: Anabolic Ster oids. Retrieved from https://teens.drugabuse.gov/drug-facts/anabolic -steroids
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CHAPTER REVIEW 36. Campbell, M. K., & Mottola, M. F. (2001). Recreational exercise and
occupational activity during pregnancy and birth weight: A% case- control study. American Journal of Obstetrics and Gynecology, 184(3), 403–408.
37. Centers for Disease Control and Prevention. (2018). Facts about physical activity. Retrieved from https://www.cdc.gov /healthyschools/physicalactivity/facts.htm
38. U.S. Department of Health and Human Services. (2008). Chapter% 5: Active older adults. In Physical activity guidelines for Americans. Retrieved from http://www.health.gov/paguidelines /guidelines/chapter2.aspx
39. Liu, H., & Frank, A. (2010). Tai chi as a balance improvement exercise for older adults: A systematic review. Journal of Geriatric Physical "erapy, 33(3), 103–109.
31. Kene!ck, R., & Cheuvront, S. N. (2012). Hydration for recre- ational sport and physical activity. Nutrition Reviews, 70(Suppl. 2), s137–142.
32. Williams, M. H. (2007). Nutrition for health, #tness, and sport (8th ed.). New York, NY: WCB McGraw-Hill.
33. National Library of Medicine, National Institutes of Health. (2011, May 18). Hypothermia. Retrieved from http://www.nlm.nih.gov /medlineplus/hypothermia.html
34. Centers for Disease Control and Prevention. (2014). Youth risk behavior surveillance: United States, 2013. Morbidity and Mortality Weekly Report, 63(SS-4), 1–168.
35. American College of Obstetricians and Gynecologists. (2002; rea&rmed 2017). ACOG committee opinion: Exercise during pregnancy and the postpartum period. International Journal of Gynaecology and Obstetrics, 77(1), 79–81.
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 387
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Image Source/age fotostock.
Across the Life Span Cardiovascular Health
Managing Your Health Heart Attack and Stroke (Brain Attack) Symptoms: What to Do in an Emergency
Consumer Health Vitamin Pills for a Healthier Heart?
Diversity in Health The Italian Gene: A Hope for Reversing Atherosclerosis?
Chapter Overview How the cardiovascular system works
Symptoms of and treatments for cardiovascular disease
Risk factors for cardiovascular disease
How to maintain your cardiovascular health
Student Workbook Self-Assessment: What Is Your Risk of Developing Heart
Disease or Having a Heart Attack?
Changing Health Habits: Reducing Your Risk of Cardiovascular Disease
Do You Know? What to do to keep your heart and blood vessels healthy?
What to do if you or someone you know is having a heart attack?
If you are likely to have a heart attack or stroke?
Cardiovascular Health
© EyeEm
/Getty Im ages.
Learning Objectives “… reducing the likelihood of developing cardiovascular disease later in life involves controlling risk factors early in life.”
After studying this chapter, you should be able to:
1. Describe functions of the cardiovascular system. 2. Define atherosclerosis and explain how this process
results in cardiovascular disease. 3. Identify major risk factors for cardiovascular disease. 4. Identify recommendations for cholesterol and blood
pressure levels. 5. Differentiate between HDL and LDL and identify healthy
levels of each. 6. Explain the significance of HDL or LDL levels on
cardiovascular disease risk. 7. Describe the signs and symptoms of angina, heart
attack, and stroke. 8. Describe actions that can reduce cardiovascular
disease risk. 9. Discuss modern methods of treating cardiovascular
disease.
CHAPTER 12
389
"e “Changing Health Habits” feature “Reducing Your Risk of Cardiovascular Disease” in the Student Workbook pages of this text can help you understand the impact of your current lifestyle behaviors on your risk for developing CVD and may motivate you to implement heart-healthy lifestyle changes. But !rst, this chapter explores the cardiovascular system and how it works. It then describes the causes of CVDs and hypertension—noninfectious diseases in which hereditary, environmental, and lifestyle factors inter- act to create an individual’s risk level for developing any one of them. It also describes the interrelatedness of these diseases and how the development of one a#ects the development of another. Last, it explores the factors critical to maintaining cardiovascular health in order to help you preserve the !tness of your heart and blood vessels throughout your lifetime.
!e Cardiovascular System and How It Works
You may have heard the cardiovascular system also referred to as the circulatory system. "ese terms are o$en used interchangeably. "e term cardiovas- cular refers to the heart (cardio-) and blood vessels ( vascular). "e term circulatory refers to the circula- tion of the blood. In practical use, both terms describe a body system that pumps blood enclosed in blood vessels to all parts of the body.
Blood is a somewhat viscous 'uid made up of cells suspended in a liquid. Blood performs many functions:
• It contains red blood cells and 'uid (plasma) that transport the respiratory gases (oxygen and carbon dioxide), nutrients, hormones, enzymes, and waste products.
• It helps regulate body temperature by distributing the heat generated by chemical reactions in the body.
• It contains blood clotting factors (including pieces of cells called platelets) that protect the blood supply from excessive losses and help in tissue repair.
• It contains white blood cells (including the lymphocytes of the immune system) that help protect the body from infection.
"e blood is pumped by the heart, a muscular, !st- sized organ that lies in the chest cavity about midway between the shoulders and the waist, and slightly to the le$ of the midline (Figure 12.1). "e heart consists of four chambers: two upper chambers called atria
Do you think that you are immune from car-diovascular disease—dysfunction of the heart and blood vessels—because you are young? If so, think again! Even though cardiovascu- lar disease (CVD) does not normally occur in young adults, unhealthy lifestyle patterns practiced and ingrained during this stage of life predispose a per- son to CVD. Metabolic processes leading to CVD can begin in childhood and accelerate at adolescence.1
In one large multicenter study, medical research- ers examined the relationship of the risk factors for CVD (such as smoking, obesity, poor diet, and lack of exercise) to the development of fatty deposits in the arteries, which is one process that occurs in the devel- opment of this condition.2 "ey studied nearly 3,000 persons aged 15–34 years who died from accidents, homicides, and suicides. "e results of the study revealed that young persons with risk factors for CVD began developing fatty streaks within their arteries in their teenage years. By age 25, young persons with risk factors also had developed raised lesions in the major blood vessels of the heart. "e results of this and other studies show that reducing the likelihood of developing CVD later in life involves controlling risk factors early in life.3 Behaviors in adolescence and young adulthood do matter; they can in'uence your health for years to come and can a#ect your life span.
Research results also show that college students are aware of cardiovascular risk factors, but many do not put this knowledge into practice. In other words, their understandings of heart-healthy behaviors and their lifestyles do not match.4,5
One reason for this disconnection may be rooted in emotions and psychology; how people feel about what they know has an e#ect on their actions. For example, if you know smoking causes many types of cancers but you love to smoke, it may a#ect how you respond to that knowledge. For some, the pleasure derived from smoking may outweigh their concerns about cancer risk. "e disconnection between knowl- edge and actions may also be explained by misconcep- tions about heart disease.4 For example, some college students may think that heart disease is a signi!cant health concern only for men, when it is the leading cause of death in both genders. College-aged women holding this misconception may think that practicing heart-healthy behaviors is not important for them. Some college students may also think that people who are White are most a#ected by heart disease; however, Americans who are Black or Paci!c Islanders have higher death rates from heart disease in the United States. "us, some Blacks and Paci!c Islanders may perceive a lower level of risk for heart disease. 390 Chapter 12 Cardiovascular Health
External jugular v. Internal jugular v.
Brachiocephalic a. Subclavian v.
Cephalic v.
Brachial v.
Superior vena cava
Inferior vena cava
Renal v.
Inf. mesenteric a. Common iliac v.
Internal iliac v. External iliac v.
Great saphenous v.
Small saphenous v.
Femoral v.
Popliteal v.
Anterior tibial v.
Palmar venous network
Plantar venous network
Vertebral a.
Common carotid a. Subclavian a.
Axillary a. Aortic arch Pulmonary a.
Brachial a.
Celiac a. Sup. mesenteric a.
Abdominal aorta
Renal a.
Ulnar a. Common iliac a. External iliac a.
Palmar a. anastomoses
Plantar a. anastomoses
Internal iliac a.
Femoral a.
Popliteal a.
Anterior tibial a.
Posterior tibial a.
Dorsalis pedis a.
Figure 12.1 The Major Arteries of the Body. The heart is located to the left of the midline in the chest cavity. The arteries take blood away from the heart and are shown in red. Veins return blood to the heart and are shown in blue.
The Cardiovascular System and How It Works 391
vein thrombosis (blood clots in the deep veins), and chronic venous insu&ciency (swollen legs). Figure"12.2 shows varicose veins.
"e incidence of both moderate and severe venous disease increases with age. Although women are twice as likely as men to have moderate venous disease, men are more likely to have severe disease. In the United States, non-Hispanic White people are much more likely to have severe venous disease compared to Hispanic, African American, and Asian people. Other risk factors for venous disease include family health history, obesity, having borne more than one child, and consistently standing for pro- longed periods.6
Coronary arteries arise from the base of the aorta and bring freshly oxygenated blood to the heart muscle itself. (Although blood flows in and out of the heart’s chambers, the heart muscle is not nourished by the blood while it is in the chambers.)% There are two main coronary arter- ies: the left and the right coronary arteries (see Figure% 12.8 later in this chapter). Both of these arteries branch into multiple vessels that supply the entire heart with blood.
and two lower chambers called ventricles. "e upper chambers receive blood and then push it into the lower chambers, which pump blood to the lungs and the rest of the body.
Blood 'ows within a vast network of blood ves- sels. Arteries carry blood away from the heart. "ey have muscular, elastic walls that bulge slightly when the le$ ventricle contracts and pushes blood through them, and they recoil at the end of the beat. Arteries branch into smaller vessels called arterioles. When these vessels become so small that they allow the pas- sage of only one blood cell at a time, they are called capillaries.
"e capillaries permeate tissues. "ese tiny blood vessels have walls that are only one cell thick. "e thinness of capillary walls allows substances such as nutrients and oxygen to move out of the blood, and other substances such as waste products and carbon dioxide to move into the blood. Capillaries join to form larger vessels called venules, which in turn join to form still larger vessels, the veins.
Veins return blood to the heart. By the time the blood reaches the veins, it has lost most of the force (pressure) of its push from the heart. "erefore, veins have thinner walls than do arteries; they contain less muscle and elastic tissue. In addition, veins have one- way valves along their length, which help prevent the back'ow of blood. Blood returning to the heart from the head, neck, and shoulders is helped along by the force of gravity. Blood returning to the heart from the arms, legs, and torso combats the force of gravity but is pushed along as the skeletal muscles squeeze the veins in these areas.
If the walls of the veins in the arms, legs, and torso are weak, or if the valves are stretched or damaged, blood may not be returned to the heart e&ciently. Blood may collect in the veins and may 'ow back- ward. "is situation puts additional pressure on the walls of the veins and contributes to a condi- tion called venous disease. Venous disease includes varicose veins (distended or stretched veins), deep
arteries Blood vessels that carry blood away from the heart.
capillaries (KAP-ih-LAIR-eez) Microscopic blood vessels that permeate tissues, connecting small arteries to small veins.
veins Blood vessels that return blood to the heart.
coronary arteries Blood vessels that arise from the base of the aorta and bring freshly oxygenated blood to the heart muscle.
Figure 12.2 Close-up of Varicose Veins on a Man’s Leg. © Audie/Shutterstock.
392 Chapter 12 Cardiovascular Health
Atherosclerosis In many CAD cases, the blood supply to portions of the heart is reduced because the coronary arter- ies are blocked by fatty deposits. "ese fatty depos- its, or plaques, develop as part of a disease of the arteries called atherosclerosis. (Arterial plaque is not the same as dental plaque.) An atheroma is a deteriorated, thickened area on the inner lining of a large or medium-sized artery. Sclerosis refers to loss
Cardiovascular Diseases A person with blocked coronary arteries is said to have coronary artery disease (CAD), one type of CVD. (Coronary artery disease is also commonly called coronary heart disease [CHD].) CAD may result in a heart attack in which a portion of the heart muscle dies, or in angina pectoris (chest pain).
CAD is only one type of cardiovascular disease (CVD), or dysfunction of the heart and blood vessels. Other major CVDs are hypertension (chronic high blood pressure), stroke (blood vessel disease of the brain), and rheumatic heart disease (a complication of strep throat). Atherosclerosis (blood vessel disease) is an important CVD process that is an underlying cause of CAD and stroke. Other CVDs are described throughout this chapter. More than 82 million Americans (more than 1 in 3) are estimated to have one or more forms of CVD.7 As Figure 12.3 shows, CVD kills more people in the United States than does any other disease.
Of the CVDs, CAD is the number one killer, accounting for about half of all CVD deaths each year. Stroke is the next biggest CVD killer.7 CAD and stroke result from the development of yet another CVD: atherosclerosis.
Figure 12.3 Leading Causes of Death, United States, 2015. This graph shows that CVD is the number one cause of death for both men and women (all races, all ages). Murphy, S. L, Xu, J, Kochanek, K, Curtin, S. C., & Arias, E. (2017). Deaths: Final data for 2015. National Vital Statistics Reports, 66(6). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr66
/nvsr66_06.pdf
Cancer 22.8
Cancer 21.1
Heart disease 24.4
Heart disease 22.3
Other 24.5
Other 26.2
Unintentional injuries 6.8
Notes: CLRD is Chronic lower respiratory diseases. Values show percentage of total deaths.
Unintentional injuries 4.0
CLRD 5.3
Stroke 6.1
Stroke 4.2 CLRD 6.2
Diabetes 3.1 Diabetes 2.7
Suicide 2.5
Alzheimer’s disease 2.5
Alzheimer’s disease 5.7
Chronic Liver disease 1.9
Kidney disease 1.8 Septicemia 1.6Influenza and
pneumonia 2.0
Influenza and pneumonia 2.3
Men Women
coronary artery disease (CAD) A condition in which the coronary vessels are blocked partially or completely by fatty deposits, blood clots, or both. Also commonly called coronary heart disease (CHD).
angina pectoris (an-JEYE-nah PECK-tor- iss) Chest pain caused by insufficient oxygen in a portion of the heart.
cardiovascular disease (CVD) (KAR-dee-oh- VAS-ku-lar) Disorders of the heart and blood vessels.
plaques (plaks) Fatty deposits in artery walls.
atherosclerosis (ATH-er-oh-skle-ROW- sis) Disease of large and medium-sized arteries in which the inner lining has areas that are deteriorated, thickened, and inelastic.
Cardiovascular Diseases 393
cerebral arteries. Most of these vessels are labeled on Figure 12.1. As you can see, these arteries supply blood to the heart, torso, legs, and head. "e cerebral arteries, not shown in the diagram, branch from the carotid arteries and other vessels to supply large por- tions of the brain with blood. Atherosclerosis is most serious when it develops in the vessels that supply the heart, which can lead to heart attacks, and in the ves- sels that supply the brain, which can result in strokes.
Heart attacks can also be caused by coronary microvascular dysfunction. Heart disease in women is o$en the result of this dysfunction, alone or in addition to plaques that block blood 'ow in the large coronary arteries. In coronary microvascular dysfunction, the small blood vessels of the heart do not dilate (widen) properly to supply su&cient blood to the heart muscle. Because of di#erences in the sizes of vessels that may be blocked or that do not function properly in their hearts, men and women o$en experience di#erent symptoms when su#ering heart attacks (see the section titled “Heart Attack” later in this chapter).8
Any blockage of vessels other than those to the heart is o$en referred to as peripheral vascular disease. "is disease a#ects the organs and tissues that blocked vessels serve. One result of peripheral vascular disease, for example, can be erectile dys- function (impotence) in men.
Coronary Artery Disease In CAD, coronary vessels may become partially or completely blocked by one or more of the fol- lowing: fatty deposits, which narrow blood vessels (see the previous section titled “Atherosclerosis”); a blood clot that develops at the site of fatty depos- its; or a 'oating blood clot that lodges in a vessel. A stationary blood clot, called a thrombus, can block a vessel already narrowed by fatty deposits. Blood clots frequently form in vessels in which blood 'ow is slowed by fatty deposits. "e development of a thrombus that blocks a coronary artery is called coronary thrombosis.
A thrombus may dislodge from the place in which it forms and become a 'oating blood clot, or embolus. An embolus can block a coronary artery downstream from where it was formed, producing a coronary embolism. In the early stages of CAD, cor- onary arteries may also become narrowed by muscle spasms of these vessels, frequently triggered by expo- sure to cold, physical exertion, or anxiety. Usually such muscle spasms are short lived and do not dam- age the heart muscle.
of elasticity, or hardening of these arteries. Athero- sclerosis is one form of arteriosclerosis (hardening of the arteries).
Atherosclerosis may begin with an injury to the lining of a blood vessel. Factors such as high blood pressure, for example, can damage this lining, or the immune system may play a role. Lipids, especially cholesterol, accumulate at injury sites and cling to the interior of blood vessel walls. "ese plaques thicken blood vessel walls, which narrows the interi- ors of arteries (Figure 12.4) and interferes with arte- rial cells’ ability to obtain nutrients. Eventually, the wall beneath a plaque degenerates. Scar tissue forms and calcium is o$en deposited there, “hardening” the artery. Blood clots sometimes develop there too and may be the ultimate cause of a heart attack or stroke.
Although the incidence of atherosclerosis increases with age, not all elderly people have extensive plaques. Conversely, some young people do (see this chapter’s opening section).
Atherosclerosis occurs most o$en in the aorta and in the coronary, femoral, iliac, internal carotid, and
Endothelium (lining of artery)
Artery wall
Atherosclerotic plaque
Figure 12.4 A Plaque in an Artery. A plaque is formed by a buildup of fatty material on an artery wall. This illustration shows the interior of an affected artery that has been narrowed by plaque.
peripheral vascular disease Any blockage of vessels other than those to the heart.
thrombus (THROM-bus) A stationary blood clot.
coronary thrombosis (throm-BOW-sis) The development of a stationary blood clot that blocks blood flow in an artery that brings blood to the heart muscle.
embolus (EM-bow-lus) A floating blood clot.
coronary embolism (EM-bow-lizm) A floating blood clot that lodges in an artery that brings blood to the heart muscle, blocking blood flow.
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a contrast medium. "e contrast medium used in angiography is composed primarily of iodine because it absorbs X-rays, making visible the inte- riors of blood vessels. To perform coronary angi- ography, physicians !rst thread a thin plastic tube called a catheter through an artery in the arm or the groin until it reaches the coronary arteries. A$er injecting the contrast medium into the catheter, they take high-speed X-ray movies of blood 'ow- ing through the arteries. Figure 12.5 shows frames of such a movie and indicates where physicians are able to detect irregularities and narrowing of the coronary arteries.
Other tests, such as magnetic resonance imaging (MRI), are also performed at many medical centers to create images of the heart and its vessels for vari- ous diagnostic purposes. MRI uses magnetic !elds and radio waves to visualize structures.
Unclogging Arteries If a patient has athero- sclerosis in many coronary vessels, a physician may recommend coronary artery bypass gra$ surgery. If only one of a patient’s coronary arteries is nar- rowed signi!cantly, a physician may recommend widening the interior of the artery with a type of angioplasty, the reconstruction of damaged blood vessels. In balloon angioplasty, the physician threads a catheter through an artery in the arm or the groin until it reaches the coronary arteries, as is done when performing an angiogram. However, instead of injecting dye into the catheter, the phy- sician threads a second, balloon-tipped catheter through the !rst. When the second catheter reaches the area of blockage, the balloon is in'ated, break- ing up the plaque while compressing it against the arterial wall (Figure" 12.6). "is balloon technique also stretches the artery somewhat. In almost all balloon angioplasties, a stent is also used.
A stent is a springlike mesh device (Figure 12.7) that is mounted on an angioplasty balloon and implanted within an artery to cover the compressed plaque, support the artery, and smooth the artery wall. "e !rst stents were made of bare metal. A$er
Angina Pectoris Spasms, partial blockage, or complete blockage of one or more of the coronary vessels can cause insu&cient blood to reach part of the heart, which is called ischemia. When this hap- pens, the heart does not receive su&cient oxygen and a person experiences angina pectoris, or chest pain. Angina is felt beneath the breastbone and extends to the le$ shoulder and down the le$ arm. (Pain in the arm may help you distinguish between angina and heartburn or other gastric distress.) Angina pain may also be felt in the jaw and neck and, infrequently, in the back. "e pain is described as aching, squeez- ing, burning, heaviness, or pressure. Some people experience silent (painless) angina, which consists of strange feelings at angina sites without pain. Silent angina can be diagnosed by exercise testing or by wearing a portable device that monitors the electrical activity of the heart during a 24-hour period.
Angina attacks may come and go, brought on by physical exertion or by mental or emotional stress, but they are signs of serious CAD. Angina should not be ignored; a person experiencing angina attacks should seek medical attention immediately. Rest and drugs that dilate, or widen, the blood vessels (such as nitroglycerin) relieve attacks of angina. Other drugs used to treat angina include those to reduce blood pressure or those that slow the heart rate. Both types of drugs reduce the workload of the heart and its need for oxygen.
Diagnosis To diagnose whether chest pain is heart related and to !nd out how well the heart han- dles work, a physician may begin testing the heart with a stress test. During this test, the patient walks on a treadmill while hooked up to equipment that monitors the heart. "e physician notes the patient’s heart rate and electrical activity, along with breathing and blood pressure, as the conditions of the stress test change. "e physician may also suggest an echocar- diogram, in which the chambers of the beating heart are visualized using ultrasound (sound waves) at the same time that the heart’s electrical activity is mea- sured. In this way, a physician can examine the struc- ture of the heart and its pumping function.
If the physician suspects that one or more blood vessels of the heart are blocked, he or she may sug- gest a coronary angiography to visualize the coronary blood vessels. "is test can determine the degree and location of vessel blockage to help assess whether fur- ther treatment is necessary to reduce symptoms and avoid a heart attack.
An angiogram is an X-ray image of blood ves- sels a$er they have been injected with a 'uid called
ischemia (is-KI-me-ah) Insufficient blood in part of the heart.
angioplasty (AN-jee-oh-PLAS-tee) The reconstruction of damaged blood vessels.
stent A springlike mesh device that is implanted within an artery to cover compressed plaque, support the artery, and smooth the artery wall.
Cardiovascular Diseases 395
Figure 12.5 Angiogram. The arrows on the left angiogram point out some of the irregularities and areas of narrowing of this coronary artery. This same vessel is shown in the image on the right, taken minutes after balloon angioplasty. © Simon Fraser/Science Photo Library/Science Source.
People who have chronic angina, blockage in the vessels that supply the le$ side of the heart (the side that pumps blood to the body), or blockage in multiple coronary arteries are o$en candidates for bypass surgery. To perform this operation, surgeons !rst open the chest cavity. Using a blood vessel taken from another part of the patient’s body (usually the leg), they gra$ one end of the new vessel to the aorta, the major artery that carries blood away from the heart and to the body. Heart surgeons gra$ the other end of the new vessel to the damaged coronary artery, past the area of blockage (Figure 12.8). "e gra$ed vessel thus bypasses the blocked portion of the diseased vessel.
A therapy aimed at increasing blood 'ow to the heart muscle is transmyocardial laser revascular- ization (TMLR), which has been used for more than two decades. In TMLR, surgeons use a laser to bore narrow channels from the heart chamber into the heart muscle. Although TMLR does not help a heart patient live longer, it reduces the frequency of recurrent heart pain and increases the quality of life. In addition, TMLR is being used in con- junction with CABG. Together, these procedures appear to provide results superior to CABG alone or to TMLR alone.11
Heart Attack Victims of CAD are o$en unaware that the arteries supplying their heart with blood have become blocked. "ey may have no signs or symptoms of CAD or may not notice any. For this
a time, tissue frequently grew around the stent, increasing the risk of the artery reclogging. Newer types of stents are coated with drugs that inhibit reclogging, but improvements are still needed.9 Biodegradable stents are in development that sup- port the artery as it heals from angioplasty, and then the stent dissolves.10
Atherectomy refers to methods that remove plaque from the interior of an artery. "e procedure is performed like balloon angioplasty, but the second catheter contains a rotating cutting device (burr tip) or a laser instead of a balloon tip.
One technique that is used frequently to treat CAD is bypass surgery. In the United States in 2010, an estimated 395,000 of these procedures were performed.7
"e phrase bypass surgery usually means coronary artery bypass graft (CABG) surgery. "e coronary arteries are blood vessels that supply oxygen-rich blood to the heart muscle. When these vessels become blocked, blood 'ow is slowed, and the heart muscle does not get enough oxygen.
atherectomy (ATH-er-EK-toe-me) The removal of plaque from the interior of an artery.
coronary artery bypass graft (CABG) surgery A surgical procedure in which healthy blood vessels are used to redirect blood flow around blocked vessels of the heart.
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Figure 12.6 Balloon Angioplasty. In balloon angioplasty, a thin tube containing a balloon is threaded through an artery until it reaches the area of plaque that is narrowing the vessel. The balloon is inflated, compressing the plaque against the artery wall and stretching the artery.
Figure 12.7 An Arterial Stent. This springlike mesh device is implanted in an artery after a balloon angioplasty procedure to cover the compressed plaque, smooth the artery wall, and support the vessel.
Figure 12.8 Vessel Position in a Coronary Artery Bypass Graft. In a CABG, blood vessels taken from another part of the body are grafted to the aorta, the large artery emerging from the heart. The other ends of these vessels are grafted to the coronary arteries (those that serve the heart) beyond the area of blockage.
Aorta
Grafted arteries
Blocked portion of left coronary artery
Blocked portion of right
coronary artery
heart attack Myocardial infarction (MI); an area of heart muscle that dies because it does not receive enough oxygen as a result of insufficient blood supply.
arrhythmias (uh-RITH-me-uhs) Abnormal heartbeats.
heart failure Ineffective pumping of the heart, which results in the overfilling of the veins that bring blood to the heart.
reason, one-third to one-half of persons with CAD are stricken suddenly and unexpectedly with a heart attack, which healthcare practitioners call a myocar- dial infarction (MI). Myocardial simply means heart (cardium) muscle (myo-). An infarction is an area of heart muscle that dies because it does not receive enough oxygen as a result of insu&cient blood. As heart muscle dies, it may trigger abnormal electrical activity that causes the ventricles to beat irregularly. Abnormal heartbeats are called arrhythmias. Heart failure, cardiac arrest, and death may occur during ventricular arrhythmia.
Heart failure is sometimes called congestive heart failure because the veins bringing blood to the heart
Cardiovascular Diseases 397
become congested, or over!lled, with blood when the heart cannot pump e#ectively. Heart failure (ine#ective pumping) may be the result of all forms of cardiac disease, including CAD, structural heart defects, and rheumatic heart disease, and may also be a chronic condition, resulting in shortness of breath, retention of 'uid, congestion of the lungs, and fatigue. A person experiencing severe cardiac failure may be a candidate for a heart transplant or the implantation of a le$ ventricular assist device (which has replaced the arti!cial heart) while wait- ing for a donor heart. "e pump is implanted in the abdomen and is connected to the main pumping chamber of the heart, the le$ ventricle. "e power source for the pump is located outside the patient’s body on a rolling cart or is a portable battery that hangs by a strap from the shoulder (Figure 12.9).
sudden cardiac arrest Cessation of the heartbeat.
Figure 12.9 The Left Ventricular Assist Device (LVAD). This LVAD is implanted in the patient’s body. A tube from the LVAD exits his body at the abdomen and connects to a power source attached to his belt. © JFs Pic S. Thielemann/Shutterstock.
Sudden cardiac arrest (sudden cardiac death) may also occur as a result of a heart attack. During cardiac arrest, the heart suddenly stops beating. Getting immediate medical care is crucial in such a situation because the heart must be de#brillated (given electric shock) within a few minutes of its stopping to cause it to begin beating again and avoid heart, lung, kidney, and brain damage and to avoid death. Sudden cardiac death is the result of an unresuscitated cardiac arrest, usually the result of ventricular !brillation, the rapid, erratic con- traction of the lower chambers of the heart. On March% 10, 2014, Dallas Stars player Rich Peverley collapsed on the bench a$er exiting the ice. Medi- cal sta# at the American Airlines Center responded quickly by providing oxygen and using a de!brilla- tor located near the benches to shock his heart back into rhythm. Peverley survived and continues to recover a$er surgery to correct an irregular heart- beat. Unfortunately, a de!brillator is not always as readily available as one was when Peverley collapsed.
Approximately 80% of heart attacks occur at home, where most Americans do not have an automated external de!brillator, or AED. On the other hand, public AEDs are increasingly available in public build- ings, transportation centers, large o&ces, commercial locations, and many other places where large groups of people gather. "e American Red Cross believes that all Americans should be within 4 minutes of an AED and someone trained to use it. A recent study, however, revealed that access remains limited and is further restricted during the evening, nighttime, and weekends, when the majority of cardiac arrests occur.12
Although AEDs are automated, the American Heart Association (AHA) states that AED operators must be able to recognize signs of cardiac arrest, know when to activate the emergency medical system (EMS), and be able to perform cardiopul- monary resuscitation (CPR). Also, because various models of AEDs exist, the user must understand how to successfully operate the speci!c device he or she will use. "erefore, anyone who may use an AED, either as a medical professional or bystander, should be trained in AED use.
CPR is also used during a cardiac event such as sudden cardiac arrest. Approximately 92% of sudden cardiac arrest victims die before reaching the hospital; however, administering CPR immediately can double or triple a victim’s chance of survival. "e AHA lists Two Steps for Staying Alive with Hands-Only CPR: (1)%call 9-1-1 and, when asked, be speci!c about your location, and (2) push hard and fast in the center of
398 Chapter 12 Cardiovascular Health
help reduce damage to the heart while transporting him or her to the hospital.
Most heart attacks are the result of coronary artery thrombosis. Blood clots o$en form suddenly when the plaque in an artery breaks apart and blood plate- lets clump at that site (Figure 12.11). "erefore, in the emergency room, heart attack patients are quickly given clot-dissolving drugs intravenously.
Most patients who survive a heart attack do not experience complications a$er the attack if they receive appropriate medical treatment. Some may not even have detectable heart abnormalities if their heart attack involved only a small portion of the heart muscle; unfortunately, some patients do experience
the chest to the beat of the classic Bee Gees’ disco song “Stayin’ Alive.” If you are unfamiliar with the song, you can hear it by going to www.youtube.com and using the search term “Bee Gees Stayin’ Alive.”
For more information about CPR and AEDs, including how to use an AED, AED cost, and AED and CPR training, visit www.heart.org. Between 250,000 and 350,000 persons in the United States die each year from sudden cardiac arrest. In the United States, the average age for a man to have his !rst heart attack (but not necessarily die from it) is 66 years, and for women, it is 70 years. Most of the time, the under- lying cause of a heart attack and cardiac arrest is CAD, although medical researchers now realize that heart attacks in women o$en may be caused by coronary microvascular dysfunction (see the section titled “Ath- erosclerosis”). Other causes of heart attacks include conditions such as an in'ammation of the heart caused by infection, rheumatic fever, or medications; heart muscle disorders with unknown causes; con- genital heart defects; and drug abuse ( Figure 12.10). (Rheumatic fever is a disorder that sometimes occurs as a result of strep throat. It a#ects the heart.) One of these conditions is o$en the reason a young, physi- cally !t person such as an athlete dies suddenly on the basketball court, track, or skating rink.
Learn the warning signs of a heart attack and what to do if you or someone you are with experi- ences one (see the Managing Your Health feature). You can distinguish a heart attack from angina by the severity of the pain: Heart attack pain is much more severe and lasts longer than that of angina. "e pain of a heart attack is usually described as pressure (heaviness), burning, aching, and tight- ness, which is felt in the same locations as angina pain. "e person su#ering a heart attack may also experience shortness of breath, profuse sweating, weakness, anxiety, or nausea. Women may have these symptoms, or they may have more subtle symptoms: discomfort spread over a wide chest area, exhaustion, depression, and shortness of breath. In addition, women are more likely than men to have nausea, vomiting, back or jaw pain, and shortness of breath with chest pain.
If you experience some or all of these signs and symptoms or are with someone who does, obtain emergency medical care immediately. Many heart attack victims die because they do not seek medi- cal attention quickly, denying that they are having a heart attack; however, if you call for help quickly, an emergency response team trained to provide prompt medical care can keep a heart attack victim alive and
Figure 12.10 A Heart Attack Prematurely Ended the Life of Professional Surfer Andy Irons. Irons died of a heart attack in 2010 at age 32. Following his death, Irons’s family acknowledged his use of prescription drugs to treat anxiety and insomnia, as well as his recreational drug use. © jarvis gray/Shutterstock.
Cardiovascular Diseases 399
A$er diagnosing a heart attack, the physician evaluates the health of the patient’s heart. Using mea- surements of enzymes released from the heart and techniques to visualize the heart and blood vessels, such as an angiogram or MRI, the physician assesses cell damage and ventricular function (the ability of the heart to pump blood to the body) to select a patient’s therapy. Such therapy may include surgical procedures, medications, and lifestyle changes.
Stroke A stroke (brain attack) occurs when arteries that supply the brain with blood become blocked, pre- venting blood 'ow. "e primary cause of stroke is the same as that for heart attacks or angina pec- toris: atherosclerosis—the buildup of plaque or a blood clot that blocks arteries bringing blood to the organ. Blood clots are a common cause of a stroke. If the stroke is caused by a stationary clot, the con- dition is called a cerebral thrombosis. If the blood clot was formed elsewhere and becomes lodged in a cerebral artery, blocking 'ow, it is called a cerebral embolism.
A stroke may also occur if an artery supplying the brain bursts. "is situation is called a cerebral hemorrhage and may occur when atherosclerosis and high blood pressure are present. Cerebral hem- orrhage may also occur from a head injury or from a burst aneurysm (a swollen, weakened blood vessel).
During a stroke, the brain cells normally supplied by the blocked or burst vessel do not receive oxygen. Brain cells, like heart cells, die when they do not receive the oxygen they need. A cerebral hemorrhage a#ects the brain in an additional way: Pressure builds in the brain as a result of blood that has leaked out of the burst vessel. When this blood clots, it can damage brain tissue, causing physical disability.
"e signs and symptoms of a stroke vary (see Managing Your Health), depending on the location of the damage. In most cases, one side of the body becomes weak, numb, or paralyzed.
People with atrial fibrillation are in the group with the highest risk for a stroke. Atrial fibrillation is a type of arrhythmia. During atrial fibrillation, the upper chambers of the heart contract with no set pattern, which upsets the normal rhythm of the heartbeat. This arrhythmia can result in the formation of floating blood clots (emboli) that can travel to the brain, block a blood vessel, and result in a stroke.
More than 1 million Americans have atrial !bril- lation. Its incidence increases with age because its
life-threatening complications. If a substantial por- tion of the heart was involved, the heart attack victim may develop cardiogenic shock, in which the le$ ven- tricle of the heart does not pump su&cient blood to sustain the body. Although physicians can treat this condition with angioplasty or surgery, cardiogenic shock is fatal more than 50% of the time.13
stroke A brain injury that occurs when arteries that supply the brain become blocked and prevent blood flow or become damaged and leak blood onto or into the brain.
cerebral thrombosis A stroke caused by a stationary blood clot.
cerebral embolism A stroke caused by a floating blood clot that becomes lodged in a cerebral artery, blocking blood flow.
cerebral hemorrhage (HEM-ah-rij) A stroke caused by a burst artery that supplies the brain.
aneurysm (AN-you-rizm) A swollen, weakened blood vessel.
atrial fibrillation (fih-brih-LAY-shun) A type of arrhythmia in which the upper chambers of the heart contract with no set pattern.
Figure 12.11 An Occluded (Blocked) Vessel. This coronary artery is totally blocked with plaque and a blood clot (dark area). © Kevin Somerville/Medical images.
400 Chapter 12 Cardiovascular Health
Managing Your Health
IF YOU NOTICE ONE OR MORE OF THESE SIGNS IN ANOTHER PERSON (OR IF YOU HAVE THEM YOUR- SELF), DO NOT WAIT. CALL 9-1-1 OR YOUR EMER- GENCY MEDICAL SERVICES AND GET TO A HOSPITAL RIGHT AWAY!
Common or “classic” signs of heart attack:
• Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest that lasts more than a few minutes or goes away and comes back
• Pain that spreads to the shoulders, neck, or arms • Chest discomfort with light-headedness, fainting,
sweating, nausea, or shortness of breath
Less common warning signs of heart attack:
• Atypical chest, stomach, or abdominal pain • Nausea or dizziness (without chest pain) • Shortness of breath and difficulty breathing (with-
out chest pain) • Unexplained anxiety, weakness, or fatigue • Palpitations, cold sweat, or paleness
Not all of these signs occur in every heart attack. Sometimes they go away and return. If some occur, get help fast.
Some or all of these signs accompany a stroke:
• Weakness, numbness, or paralysis on one side of the body
• Loss or dimming of vision, particularly in one eye
• Loss of speech, or difficulty speak- ing or understanding speech
• Sudden, severe headache • Sudden dizziness, unsteadiness, or
episodes of falling
Be prepared: • Keep a list of emergency rescue service numbers
next to the telephone and in your pocket, wallet, or purse.
• Find out which area hospitals have 24-hour emer- gency cardiovascular care.
• Know (in advance) which hospital or medical facil- ity is nearest your home or office.
Take action: • If you have heart attack or stroke symptoms
that last more than a few minutes, don’t delay! Immediately call 9-1-1 or the emergency medical services (EMS) number so that an ambulance (ideally with Advanced Life Support) can quickly be sent for you.
• If ambulance service isn’t available in your area, immediately have someone drive you to the nearest hospital emergency room (or another facility offer- ing 24-hour life support).
• If you’re with someone who may be having heart attack or stroke symptoms, immediately call 9-1-1 or EMS. Expect the person to protest—denial is common. Don’t take “no” for an answer. Insist on taking prompt action.
• Give cardiopulmonary resuscitation (CPR—mouth- to-mouth breathing and chest compressions) if it’s needed and you’re properly trained.
Heart Attack and Stroke (Brain Attack) Symptoms: What to Do in an Emergency
primary underlying causes, hypertension and CAD, also increase with age.
Another group at high risk for strokes consists of people with stenosis (narrowing) of one or both of the carotid arteries. "e right and le$ carotid arteries branch o# major vessels leaving the heart and bring blood up the neck to the brain (see Figure% 12.1). Physicians diagnose carotid artery stenosis by using ultrasound (a technique that uses sound waves to visualize so$ tissues of the body) or angiography.
Physicians o$en recommend carotid endarter- ectomy to reduce signi!cantly the risk of stroke in patients with carotid artery stenosis. In this proce- dure, surgeons remove the inner lining of the par- tially blocked carotid artery along with the plaque. Also, physicians may prescribe long-term aspirin therapy or anticoagulant drugs for treatment of either carotid artery stenosis or atrial !brillation.
In the hospital, physicians usually perform com- puted tomography (CT) scans (detailed X-rays of cross-sectional slices of body structures) or MRI
Cardiovascular Diseases 401
scans of the brain of the stroke victim to con!rm the diagnosis and determine the location and extent of injury (Figure 12.12). "e standard ther- apy for stroke is a clot-dissolving drug called tissue plasminogen activator (tPA). If given within 3 hours of a stroke’s onset, it raises the chances that no per- manent brain damage will occur. Researchers are exploring ways to lengthen the window of time during which this drug can be administered.14 Post- stroke rehabilitation focuses on helping patients redevelop skills that may have been lost as a result of damage to part of the brain. "ese skills may involve movement, language, thinking, and mem- ory. Mental health professionals work with stroke patients who may have had personality changes or who may have developed emotional disturbances, such as depression.
Just as heart attacks may be preceded by smaller angina attacks, major strokes may be preceded by minor strokes called transient ischemic attacks (TIAs). Ischemic attacks are similar to strokes, usu- ally cause no permanent damage, and have signs that last only a short time. A TIA is a serious warn- ing that a stroke may occur within weeks or months.
Persons experiencing a TIA should see their phy- sicians immediately. O$en, blood-thinning drugs such as aspirin are prescribed to lessen the possibil- ity of a stroke.
%e Incidence of Strokes Is Rising Among&Young Americans Over the past 3 decades, stroke research- ers found that the rate of stroke has increased by approximately 25% in people aged 20–64 years and that those patients make up nearly 33% of all stroke cases worldwide.15 At an American Stroke Associa- tion conference in early 2011, researchers reported that the incidence of strokes rose 51% among men and 17% among women aged 15–34 years between 1994–1995 and 2006–2007. "e incidence of strokes also rose 47% in males aged 35–44 years and 36% in females in the same age group. Researchers hypothesize that the obesity epidemic is a major factor in the increase in the stroke incidence in these age groups.
While the occurrence of strokes was rising in young adults, it was declining in older adults. "e incidence of strokes dropped 25% among men and 28% in women aged 65 years and older between 1994–1995 and 2006–2007. Researchers suggest that this decline is caused in part by better treat- ment of risk factors in older adults and better pre- vention e#orts.16
Risk Factors for Cardiovascular Disease
Medical researchers have identi!ed several risk factors for CVD, traits that have been shown to be associated with the incidence of CVD. In general, people with more than one of these traits, which are listed in Table 12.1, have a greater probability of developing atherosclerosis and su#ering a heart attack or stroke than do people with one or none of these risk factors. Many of these risk factors are modi!able; in other words, people can o$en reduce their risk of CVD by changing one or more health- related behaviors.
"e major risk factors for the development of CVD are male gender (comparable rates of a !rst major cardiovascular event occur 10 years later in women than in men), increasing age (the incidence of CAD rises in both men and women with each decade from age 40 to age 79 years), family health history of CVD, cigarette smoking, obesity, hyperten- sion (chronic high blood pressure), abnormal blood
transient ischemic (is-KI-mik) attacks (TIAs) Minor strokes that usually cause no permanent damage and have signs that last for only a short time.
Figure 12.12 CT Scan of a Stroke Victim. The darkened area on the left side of the brain scan reveals dead tissue due to a lack of oxygen during a stroke. © Mehau Kulyk/Science Photo Library/Science Source.
402 Chapter 12 Cardiovascular Health
Abnormal Blood Lipid Levels Another major risk factor in the development of ath- erosclerosis, CAD, and stroke is abnormal blood lipid levels, including elevated blood cholesterol levels (also called serum cholesterol). "e AHA states that the desirable range of total blood cholesterol is less than 200 milligrams per deciliter (200 mg/dL). A cholesterol level of 200–239 mg/dl is considered borderline high, and a total cholesterol level of 240 mg/dL and higher is considered high. In 2012, a little more than 12% of U.S. adults had high total cholesterol, which represents a signi!cant decrease from 1999 (Table 12.2).17
What is cholesterol? "is substance is a steroid, a type of lipid. "e most abundant steroid in the human body, cholesterol is used to make the sex hormones and composes part of the membranes of the body’s cells. Some cholesterol is essential for health but a high blood cholesterol level is associated with development of CVD. We take in cholesterol when consuming most animal foods, such as egg yolks, fatty meats, and but- ter, but our bodies can also produce cholesterol.
Cholesterol circulates in the blood as part of particles called lipoproteins, which consist primar- ily of triglycerides, protein, and cholesterol, and are also critical to cardiovascular health. "e major lipoproteins are high-density lipoproteins (HDL) and low-density lipoproteins (LDL). HDL carries
lipid levels, and lack of physical activity. All these risk factors are important in the development of CAD; however, hypertension is the most important risk factor for stroke.
Family Health History A family health history of atherosclerosis, stroke, or CAD indicates a genetic predisposition to these conditions or re'ects similar diets, stresses, and life- styles among family members. A person with a fam- ily health history of premature CAD is twice as likely to su#er a heart attack as a person with no family health history. A family health history of premature atherosclerosis, heart attack, or sudden death among males before 55 years of age or females before the age of 65, especially in a !rst-degree relative (e.g., father, mother, or sibling), is more meaningful than having relatives who developed atherosclerosis in the elderly years. "e genetic e#ect decreases at older ages. Unfortunately, you cannot change your family health history, but you can monitor other factors to reduce your risk in other ways.
• Cigarette smoking • Diabetes mellitus • Blood cholesterol above 200 mg/dL • A ratio of total cholesterol to high-density lipoprotein
(HDL) cholesterol above 5:1 (optimum ratio is 3.5:1)
• High levels of low-density lipoprotein (LDL) cholesterol
• Physical inactivity • Family history of cardiovascular disease • Obesity • Uncontrolled, persistent high blood pressure • Heavy alcohol use • Gender (women are at a lower risk of heart attack until
menopause) • Age (risk increases with age) • Anxiety disorders (increased risk of fatal heart attack
in men) • Elevated C-reactive protein*
*Elevated C-reactive protein is an indicator of inflammation and is not specific to coronary artery disease.
Table 12.1
Risk Factors for Cardiovascular Disease
4Any person who experiences chest pain, especially pain beneath the breastbone that extends to the neck, shoulders, and/or arms, should seek medical attention immediately.
4Any person experiencing weakness, numbness, or paralysis on one side of the body; loss or dimming of vision; loss of speech, or difficulty speaking or understanding speech; a sudden, severe headache; or sudden dizziness or unsteadiness should seek medical attention immediately.
Healthy Living Practices
high-density lipoproteins (HDL) (LIP-oh- PRO-teenz or LIE-poe-PRO-teenz) “Good” cholesterol that carries cholesterol from the cells and to the liver for removal from the body.
low-density lipoproteins (LDL) “Bad” cholesterol that carries cholesterol to the cells, including the cells that line the blood vessel walls.
Risk Factors for Cardiovascular Disease 403
recycles LDL cholesterol by transporting it to the liver; thus, higher levels of HDL cholesterol help control the level of LDL cholesterol. Furthermore, HDL choles- terol helps “clean” arterial walls to prevent damage to inner arterial walls, which is the !rst step in develop- ment of atherosclerosis. By performing these functions, HDL cholesterol helps reduce the risk of CVD. High HDL levels are also the key to why premenopausal women, in general, do not experience heart attacks at as young an age as men; the female sex hormone estro- gen raises women’s HDL levels by about 20%. As noted in Table% 12.2, desirable levels of HDL cholesterol are above 40 mg/dl. Women are encouraged, however, to maintain an HDL cholesterol level above 50 mg/dl.18
cholesterol from the cells and to the liver for removal from the body. LDL carries cholesterol to the cells, including the cells that line the blood vessel walls. You may have heard these molecules referred to as “good” cholesterol and “bad” cholesterol, respectively.
It is !rmly established that the level of bad choles- terol, or LDL, is of major importance in the develop- ment of atherosclerosis and CAD. As the level of LDL rises, the risk of CAD and atherosclerosis rises because LDL is related to the formation and growth of plaques.
"e level of good cholesterol, or HDL, is very impor- tant too. As the level of HDL rises, the risk of CAD and atherosclerosis falls (Table 12.2 lists the classi!cation levels for HDL and LDL.) HDL cholesterol reduces and
Total Cholesterol Levels
Less than 200 mg/dl Desirable level that puts you at lower risk for heart disease. A cholesterol level of 200 mg/dl or greater increases your risk.
200–239 mg/dl Borderline high.
240 mg/dl and above High blood cholesterol. A person with this level has more than twice the risk of heart disease compared to someone whose cholesterol is below 200 mg/dl.
HDL Cholesterol Levels
Less than 40 mg/dl A major risk factor for heart disease.
40–59 mg/dl The higher your HDL, the better.
60 mg/dl and above An HDL of 60 mg/dl and above is considered protective against heart disease.
LDL Cholesterol Levels
Less than 100 mg/dl Optimal.
100–129 mg/dl Near optimal/above optimal.
130–159 mg/dl Borderline high.
160–189 mg/dl High.
190 mg/dl and above Very high.
Triglyceride Levels
Less than 150 mg/dl Normal.
150–199 mg/dl Borderline high.
200–499 mg/dl High.
500 mg/dl or above Very high.
Data from Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Circulation. 2002;106:3237).
© 2002 American Heart Association, Inc. Lippincott Williams & Wilkins.
Classification of Total, HDL, and LDL Cholesterol Levels and Triglyceride Levels (mg/dl)
Table 12.2
404 Chapter 12 Cardiovascular Health
High Blood Pressure Blood pressure becomes elevated during periods of excitement or exertion; however, in healthy indi- viduals, it returns to normal levels when the activity stops. Hypertension, persistently high arterial blood pressure, is a major risk factor for heart attack and the most important risk factor for stroke. Data show that nearly one-third of Americans aged 20 years and older are hypertensive; furthermore, nearly 54% of Americans with hypertension had uncontrolled hypertension in between 2012 and 2015.25
"e cause of most cases of high blood pressure is unknown. It has been shown, however, that hyper- tension may have a genetic link; it runs in families. "ere are also racial genetic links in hypertension. African Americans and Latinos are more likely to have hypertension than Whites and, as a result, suf- fer strokes at an earlier age and with greater sever- ity. Nongenetic, modi!able factors that contribute to hypertension include obesity, lack of physical activ- ity, cigarette smoking, stress, and long-term intake of excessive amounts of salt. Other identi!able causes of hypertension include increasing age, enzyme de!- ciencies, sleep apnea, drugs, chronic kidney disease, and thyroid or parathyroid disease.26 Social and psy- chological factors, although not fully understood, may also increase blood pressure. When the sym- pathetic nervous system is activated by stress, fear, anxiety, or other emotions, blood vessels constrict, which increases blood pressure. "is may explain why people with low incomes or educational achieve- ment, who generally su#er from more distress, are at increased risk for developing hypertension.27,28
You may know your blood pressure reading, such as 120/75 mm Hg (millimeters of mercury). "e !rst (higher) number is the systolic pressure, which is the pressure exerted by the blood on the artery walls when the le$ ventricle contracts and is able to move blood through the constricted artery (Figure" 12.13). "e second (lower) number is the diastolic pressure,
A primary component of HDL is apolipoprotein A-I (apoA-I), which has been shown to reverse ath- erosclerosis and is therefore a potentially power- ful treatment for vascular diseases. "e Diversity in Health essay describes how a mutant form of this cholesterol-lowering protein found in a certain Italian family (apoA-I [Milano]) protects them against vas- cular disease. ApoA-I (Milano) has a more e#ective cholesterol-removing function than apoA-I and may therefore prove to be a more e#ective treatment.19
Triglycerides, which are plasma lipids di#erent from cholesterol, are also important in cardiovas- cular health. When the body does not immediately use all the energy-supplying nutrients consumed, it converts them to triglycerides and transports them to fat cells for storage. Excess triglycerides in the plasma are linked to CAD in some people. Additionally, researchers have linked high levels of triglycerides to an increased risk of stroke. A normal, fasting triglyc- eride level is less than 150 mg/dl (see Table 12.2).
Cigarette Smoking Smoking cigarettes signi!cantly increases the risk of heart attack and stroke. Cigarette smokers are 2–4% times more likely than nonsmokers to develop CAD and over 10 times more likely to develop periph- eral vascular disease.17 In addition, smoking interacts with other risk factors, multiplying its negative health e#ects. Even more alarming is that cigarette smoking is directly responsible for the majority of heart disease in women under the age of 50 years.20,21 "ese !gures show that premenopausal women, who are generally protected from heart attacks by estrogen, raise their risk of heart disease signi!cantly when they smoke.
Research results show that cigarette smokers tend to have reduced HDL levels, increased LDL levels, and increased levels of blood clotting factors. In addition, evidence suggests that compounds in cigarette smoke enter the bloodstream and may damage blood vessel linings directly, leading to the formation of plaques.22 Chewing tobacco is a signi!cant CVD risk factor also, but cigar and pipe smoking appear to be less impor- tant because cigar and pipe smokers are less likely than cigarette smokers to inhale the smoke.23
Passive smoking, breathing in other people’s smoke, has also been identi!ed as an important risk factor for CVD. "e AHA estimates that approximately 40,000 people die each year from heart and blood vessel dis- ease caused by passive smoking.23 Results of research show a harmful e#ect of passive smoking on the cir- culation of blood within the heart tissue itself.24
hypertension Persistently high arterial blood pressure.
systolic (sis-TOL-ik) pressure The higher number in the blood pressure reading, which is the pressure exerted by the blood on the artery walls when the left ventricle contracts.
diastolic (DIE-as-TOL-ik) pressure The lower number in the blood pressure reading, which is the pressure exerted by the blood on the artery walls when the left ventricle relaxes.
Risk Factors for Cardiovascular Disease 405
Physical Inactivity Within the past two decades, physical inactivity has been shown to be a major risk factor for developing CVD, although research results have linked physical activity and health for more than 60 years. People who are physically inactive are about twice as likely as active people to develop CAD. "is risk extends to people who sit for a large portion of the day rather than stand and move about, independent of exercising. Results of research studies show that sitting for extended periods raises the risk of dying from CVD, and the longer one sits, the higher the mortality risk.29,30
"e 1996 Surgeon General’s report on physical activity and health recommends that persons of all ages obtain “a minimum of 30 minutes of physical activity of moderate intensity (e.g., brisk walking) on most, if not all, days of the week.”31 In 2011, the Centers for Disease Control and Prevention (CDC) suggested at least 150 minutes per week of physical activity of mod- erate intensity to lower the risk of heart disease and stroke.32 However, as a group, Americans are relatively sedentary; more than 75% of American adults do not get enough physical activity to provide health bene!ts, and 25% are not active at all during leisure time.33
In addition to its direct cardiovascular bene!ts, rou- tine exercise helps alleviate stress, reduce body weight, and control diabetes—other CVD risk factors.
which is the pressure exerted by the blood on the artery walls when the le$ ventricle relaxes. "e units, mm Hg, refer to the force needed to push a column of mercury to a particular height, such as 120 mm or 75 mm. "e normal blood pressure level for people older than 18 years is less than 120/80 mm Hg. Prehypertension is indicated by a systolic blood pressure between 120 and 139 mm Hg, or a diastolic pressure between 80 and 89 mm Hg. Stage 1 hypertension is indicated by a systolic reading between 140 and 159, or a diastolic reading of 90 to 99. Stage 2 hypertension is indicated by a systolic reading of 160 or more or a diastolic reading of 100 or more.
Persistently high arterial blood pressure con- tributes to the development of atherosclerosis in two ways. First, high blood pressure may injure the lining of artery walls, triggering plaque formation. In addition, the increased pressure enhances the amount of lipid added to plaques, especially if serum LDL cholesterol levels are elevated. "ese factors combined increase risk for development of athero- sclerosis and, over time, narrowing of the arteries. "is narrowing limits or blocks blood 'ow to the heart and deprives heart muscle of needed oxygen. When the heart’s oxygen supply is depleted, a heart attack can occur.
Inflatable rubber cuff
Brachial artery
Sphygmomanometer (blood pressure meter)
No sounds (artery is closed)
Systole
Diastole
300
0 20 40 60 80 100 120 140 160 180 200 220 240 260 280
No sounds (artery is open, ventricle is relaxed, and blood is flowing freely)
Turbulent blood sounds heard (artery is partically constricted. Ventricular contration is able to push blood through constricted artery)
Air valve
Squeezable bulb inflates cuff with air
Sounds are heard with stethoscope
Column of mercury indicating pressure in millimeters of mercury (mm Hg)
Figure 12.13 Blood Pressure. The inflatable cuff, which is wrapped around the upper arm, squeezes the brachial artery tightly so that blood cannot pass. The systolic reading is taken when turbulent blood sounds can first be heard in this artery, indicating the strength of the pressure against the artery wall when the ventricle contracts and can push the blood through the constricted artery. If the blood pressure is high, it will force the blood vessel open sooner (at a higher reading) than if the blood pressure is low. The diastolic reading is taken when the turbulent blood sounds stop, indicating the strength of the pressure against the artery wall when the ventricle relaxes, the artery is no longer constricted, and the blood is flowing freely. © Brand X Pictures/Thinkstock.
406 Chapter 12 Cardiovascular Health
v Diversity in Health The Italian Gene: A Hope for Reversing Atherosclerosis? The University of Milan’s Dr. Cesare Sirtori could hardly believe it: Thirty-eight members of one Italian family had no atherosclerosis. If that was not surprising enough, many of them smoked cigarettes and ate high amounts of fat in their diets. What was protecting them from developing plaques in their blood vessels? The answer to that question is a mutation in the gene that directs the production of a cholesterol-lowering protein.
We all have this cholesterol-lowering protein in our bodies: apolipoprotein A-I (apoA-I). ApoA-I is a primary component of high-density lipoprotein (HDL), so-called good cholesterol. HDL helps bring excess cholesterol to the liver for transport out of the body. (Researchers do not fully understand the exact mechanism of this action.) In women, estrogen increases the body’s pro- duction of apoA-I and is thought to be one reason that premenopausal women have a greater protection than men of the same age from the development of athero- sclerosis and heart attacks.
Apolipoprotein A-I (Milano) (apoA-IM) is a mutant apoA-I protein produced by the mutated Italian gene. The change in the molecular structure of apoA-IM from the nonmutant form makes this HDL molecule more stable and alters its properties so that it works even better than
its normal counterpart. Those who carry the apoA-IM gene—the members of the Italian family that Sirtori studied—are protected against vascular disease.
Researchers have been able to make apoA-IM in the laboratory. They have used this synthetic molecule in animal models to study its potential as a treatment to reverse atherosclerosis and CVD. Results showed a rapid regres- sion of atherosclerosis in the treated animals. Similar studies have been performed with humans and have shown similar results. In recent studies, scientists have begun testing the effectiveness of intravenous injection of various forms of apoA-IM and have seen a significant reduction in arterial plaque in rabbits and mice. Scientists are currently conducting larger clinical trials. If successful, scientists and generations of one Italian family will have made a medical breakthrough in slowing the death rate from the United States’ number one killer.
Data from Tian, F., et al. (2014). Comparative antiatherogenic effects of intravenous AAV8- and AAV2-mediated ApoA-IMilano gene transfer in hypercholesterolemic mice. Journal of Cardiovascular Pharmacology and Therapeutics, 20(1), 66–75; Chowdhury, M. A. U., et al. (2012). High-density lipoprotein as a therapeutic target: Treatment strate- gies. Cardiovascular Journal, 5(1), 73–80; Speidl, W. S., et al. (2010). Recombinant apolipoprotein A-I Milano rapidly reverses aortic valve stenosis and decreases leaflet inflammation in an experimental rabbit model. European Heart Journal, 31(16), 2049–2057; Spillmann, F., et al. (2010). High-density lipoprotein-raising strategies: Update 2010. Current Pharmaceutical Design, 16(13), 1517–1530.
Obesity Most medical researchers agree that obesity increases the risk of CVD. "e risk of developing CAD is nearly double for people who have a BMI over 30. Being moderately overweight also increases CVD risk. Studies show a strong positive association between weight and heart disease in both men and women. In addition to heart disease, obesity also increases risk for type 2 diabetes, some cancers, and osteoar- thritis. Are you within the desirable weight range for your age and height? Do you have a body mass index (BMI) of less than 25?
Diabetes Mellitus Diabetes mellitus is a group of diseases in which glu- cose is not metabolized properly. A#ected individu- als are at a higher risk of developing CVD because
of their elevated blood glucose levels, which damage heart muscle, small coronary vessels, and major arteries. "erefore, atherosclerosis occurs more fre- quently and at an earlier age in diabetic patients, particularly women. Unfortunately, people with dia- betes mellitus are about 5 times as likely to develop CVD as are persons without this disease.
Anxiety and Stress As mentioned previously, stress can result in spasms of the coronary arteries, which can contrib- ute to angina attacks. In addition, research studies link anxiety disorders (such as phobias and panic disorders) to an increased risk of fatal CAD and particularly to sudden, fatal heart attacks in men.34 Persons with anxiety disorders are from 2 to 6 times as likely to die from a heart attack as persons with- out anxiety disorders.
Risk Factors for Cardiovascular Disease 407
Consumer Health Vitamin Pills for a Healthier Heart? Vitamins A, C, E, B
6 , B
12 , folate, and the
non-nutrient beta-carotene . . . what do they have to do with cardiovascular health? Should you be rushing to the
store for vitamin supplements to keep your blood ves- sels healthy?
Vitamins play many roles in cardiovascular health. For example, our bodies use vitamins B
6 , B
12 , and folate in
the metabolism of amino acids, including the essential amino acid methionine. In the process of metabolizing methionine, cells produce homocysteine (ho-mo- SIS-teen), another amino acid. High blood levels of this amino acid can damage artery walls and encourage the formation of blood clots and plaques. However, if the cells have enough folate, B
6 , and B
12 , then methionine is metabo-
lized normally and the blood level of homocysteine does not rise.
Methionine intake also affects homocysteine levels. In general, the more methionine people eat, the higher their blood levels of homocysteine. Diets rich in animal protein contain high amounts of methionine and may elevate blood homocysteine levels. Conversely, diets rich in plant protein may lower homocysteine levels because plant foods are relatively low in methionine yet rich in folate and vitamin B
6 .
Other factors also influence homocysteine blood lev- els. Smoking cigarettes, drinking coffee, and a sedentary lifestyle are all associated with decreased B
6 activity, and
therefore higher homocysteine levels. The use of oral contraceptives and hormone replacement therapy low- ers homocysteine blood levels in women. Homocyste- ine levels also depend on age, gender, kidney function, genetics, and general health.
So, do you need to take vitamin pills to lower your blood homocysteine levels? The answer is not simple, and only your physician can advise you based on your health. If you show evidence of B
6 or B
12 deficiency
(more likely in elderly than in younger populations) or evidence of folate deficiency (more likely in younger than in elderly populations), your physician may suggest test- ing. Also, if you are experiencing kidney failure, are on a special metabolic diet, have cancer, or have a strong family health history of heart attack, stroke, or abnormal blood clotting, your physician may recommend that your homocysteine levels be checked. The determination of
homocysteine levels is complex, and interpretation of the finding is not simple.
So, what about vitamins A, C, E, and beta-carotene? (Beta-carotene is a yellow pigment in plants that the body converts to vitamin A.) Vitamins E and C and beta- carotene are antioxidants, substances that can protect cells by preventing or reducing the formation of free radicals. Studies have consistently shown that the more antioxi- dants a population consumes in its food, the lower the rate of CVD. But what about vitamin supplements? In general, vitamin supplements, including vitamins B, C, D, and E, and supplements of beta-carotene, calcium, and folic acid have not been found to lower the risk of CVDs. In addition, the AHA does not recommend taking antioxidant vitamin supplements or other supplements such as selenium to prevent CAD. The AHA also notes that consuming soy protein products instead of dairy or other proteins does not show a direct cardiovascular health benefit.
So . . . should you take vitamin pills to reduce your risk of CVD? Only your physician can advise you properly because the answer depends on the status of various facets of your health, family health history, and lifestyle. The best advice at this time is to get your vitamins in the food you eat—be sure to have at least 2 " cups of fruits and vegetables every day, including dark, leafy greens and members of the cabbage family. Consult your physi- cian to determine whether you might also need to take vitamin pills because of possible vitamin deficiencies for a healthier heart and blood vessels.
Data from American Heart Association Nutrition Committee. (2006). AHA scientific statement: Diet and lifestyle recommenda- tions revision 2006. Circulation, 114, 82–96; Debreceni, B., et al. (2014). The role of homocysteine-lowering B-vitamins in the primary prevention of cardiovascular disease. Cardiovascular Therapeutics, 32(3), 130–138; Clarke, R., et al. (2010). Effects of lowering homo- cysteine levels with B vitamins on cardiovascular disease, cancer, and cause-specific mortality: Meta-analysis of 8 randomized trials involving 37,485 individuals. Archives of Internal Medicine, 170(18), 1622–1631; Clarke, R., et al. (2011). Homocysteine and vascular disease: Review of published results of the homocysteine-lowering trials. Journal of Inherited Metabolic Disease, 34(1), 83–91; Fortmann, S. P., et al. (2013). Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: An updated systematic review for the U.S. preventive services task force. Annals of Internal Medicine, 159(12), 824–834; Lichtenstein, A. H., et al. (2009). Nutrient supplements and cardiovascular disease: A heart- breaking story. Journal of Lipid Research, 50(Suppl.), S429–S433; Wang, L., et al. (2010). Systematic review: Vitamin D and calcium supplementation in prevention of cardiovascular events. Annals of Internal Medicine, 152(5), 315–323.
408 Chapter 12 Cardiovascular Health
Maintaining Cardiovascular Health
Table 12.3 presents a summary of recommenda- tions to help you maintain cardiovascular health and lower your risk of CVD. As you can see, there are many factors to consider. You cannot control heredity, gender, and age. However, you can stop smoking, exercise regularly, lose weight, eat less fat, learn to relax, and reduce your salt intake. Results of research reveal that adopting a healthy lifestyle (at least 2 + cups of fruits and vegetables daily,37 exer- cising regularly, maintaining a BMI of 18.5 to 29.9, and not smoking) is extremely important to cardio- vascular health and a long life. When middle-aged
Elevated C-Reactive Protein Results of research show that elevated blood levels of C-reactive protein (CRP) can be a positive risk factor for CAD.35 CRP is produced by the liver during acute in'ammation. In'ammation may be present at the site of plaques in CAD, but it may also be present in other diseases such as rheumatoid arthritis. "ere- fore, it is not a test speci!c to CAD and cannot iden- tify where, exactly, the in'ammation is occurring. In addition, a low CRP value does not mean that in'am- mation is absent. In some cases, a doctor may choose to perform a high-sensitivity C-reactive protein (hs-CRP) test to determine a person’s risk for heart disease. Although CRP is considered a risk factor for heart disease, whether CRP is a sign of heart disease or a cause remains unclear. Regardless, several clini- cal trials are currently ongoing to determine e#ec- tiveness of medications to lower CRP levels in people with elevated CRP levels.36
4If any of your male first-degree relatives had a heart attack before age 55, or female first- degree relatives before age 65, you may be genetically predisposed to heart disease. See your physician for an evaluation and advice.
4If you are a healthy adult, you should have your serum cholesterol level and HDL level measured once every 5 years.
Healthy Living Practices
• Get regular medical checkups. • Do not smoke cigarettes. • Manage diabetes mellitus properly. • Exercise regularly. • Maintain an intake of dietary cholesterol of less than
300 milligrams per day, or less than 200 milligrams per day if you have high LDL levels.
• Maintain an intake of dietary fat of between 20% and 35% of daily calories.
• Maintain an intake of saturated fats of 5–6% or less and trans fat of less than 1% of daily calories.
• Eat foods rich in soluble fiber, such as fruits, beans, and oats.
• Eat a diet rich in fruits, vegetables, and low-fat dairy products.
• Maintain an appropriate weight for your height. • Limit alcohol consumption to 1 drink per day for
women and 2 drinks per day for men. • Maintain salt intake at approximately two-thirds
teaspoon or 2,300 milligrams of sodium per day. • Reduce your stress level.
Data from U.S. Department of Agriculture and U.S. Depart- ment of Health and Human Services. (2015). 2015-2020 Dietary guidelines for Americans. (8th ed). Washington DC: U.S. Government Printing Office. Retrieved from https:// health.gov/dietaryguidelines/2015/resources/2015-2020 _Dietary_Guidelines.pdf
Table 12.3
How to Reduce Your Risk of Cardiovascular Disease
adults (45–64 years) who were not following this healthy lifestyle changed their behavior to adopt these healthy habits, they reduced their risk of dying during the next 4 years by 40% and their risk of CVD by 35% compared to those who did not change. Only 8% of middle-aged adults practice these healthy lifestyle behaviors.38,39 Adopting a healthy lifestyle while you are young not only promotes immedi- ate health but also increases the chances that you will continue these behaviors throughout your life, thereby increasing your chances of living a longer, heart-healthy life.
In addition to adopting healthy lifestyle behav- iors, you can enhance your cardiovascular health by managing stress properly. Emotional stress contributes to hypertension and the incidence of angina attacks.
Maintaining Cardiovascular Health 409
these studies documented a substantial inverse rela- tionship between physical activity and risk for these two related diseases: As the level of physical activity rose, the risk of CAD and atherosclerosis declined and vice versa. "ese !ndings have been upheld by more recent studies.33 Research results also show that exercise is associated with a decreased risk of stroke.42
Exercise has been shown to lower blood pressure and boost HDL levels. "e AHA recommends that healthy people perform any moderate- to vigorous- intensity aerobic activity, such as brisk walking, hiking, stair-climbing, jogging, bicycling, and swim- ming, for at least 30 minutes per day, 5 days per week.43 (Aerobic activities are those that raise the heart rate for a sustained period of time.) "e AHA notes that regular physical activity for longer peri- ods or at greater intensity will likely provide greater health bene!ts. Even moderate-intensity activities, such as slow walking, gardening, housework, and recreational activities, can have some long-term health bene!ts when performed daily and can help lower the risk of CVD.
Lowering Blood Pressure Nearly 1 of every 3 American adults has hyperten- sion. In 90–95% of cases, hypertension can be con- trolled. Doing so reduces the risk of both stroke and heart attack. "e AHA recommends having your blood pressure checked every 2 years and more o$en if it is high.
To lower blood pressure, the AHA suggests decreasing sodium intake to a maximum of 1,500 milligrams per day.44 Nutritionists suggest checking the amount of sodium that you consume in prepack- aged, processed foods and not salting your food. "e sodium in salt causes the body to retain 'uids and may contribute to hypertension in some people.
Other dietary factors, in addition to sodium, also a#ect blood pressure. "e DASH diet (Dietary Approaches to Stop Hypertension) has been shown to lower blood pressure in diverse subgroups of the U.S. population. "is diet is low in total and saturated fat compared to a more typical U.S. diet and is rich in fruits, vegetables, and low-fat dairy foods. Research- ers also studied decreased sodium intake with both the DASH diet and the typical U.S. diet. Data show highly signi!cant decreases in blood pressure with either diet. Researchers conclude that the DASH diet plus reduced sodium intake is e#ective in controlling blood pressure.45
The blood pressure of overweight individu- als often drops when they lose weight. If you are
If you have diabetes mellitus, work with your pri- mary diabetes physician, such as an endocrinologist, to develop a diabetes management plan that is spe- ci!c for you; diabetics who conscientiously manage their disease and their blood sugar level lower their risk of CVD.
Getting regular medical checkups (the frequency of which should be determined by your physician) can help you assess your CVD risk factors. Your phy- sician may recommend other steps to lower CVD risks. "e following sections describe actions that physicians o$en recommend for reducing CVD risk and maintaining cardiovascular health.
Smoking Cessation If you smoke, stop now. If you do not smoke, avoid breathing in secondhand (other people’s) smoke. Approximately 150,000 cardiovascular deaths could be avoided each year if people did not smoke ciga- rettes.22 Studies suggest that when someone quits smoking, his or her elevated risk of CAD is cut in half only 1 year a$er quitting. Within 15 years, the elevated risk of a former smoker declines to the level of a nonsmoker.40 According to the National Stroke Association, the risk of stroke may revert to that of nonsmokers within 5 years a$er quitting. "e more cigarettes a person smokes and the earlier a person started to smoke, the longer the recovery time. In addition, the risk of CVD increases as the number of cigarettes smoked increases. "erefore, smoke fewer cigarettes if you cannot quit. Smoking “low-yield” (low tar and nicotine) cigarettes does not appear to reduce CVD risk.
Maintaining a Healthy Weight Maintaining a healthy weight, a BMI measure- ment of 20 to 24.9, reduces your risk of heart dis- ease. If your BMI is 25 or more, losing weight will reduce your risk of CVD. In general, a regular exercise program coupled with a low-calorie diet will reduce body fat. Weight reduction lowers total blood cholesterol levels, raises HDL levels, and low- ers LDL levels. It also helps maintain proper blood glucose levels.
Regular Exercise In the late 1980s, a review of 43 studies about the rela- tionship between physical activity and the risk of CAD and atherosclerosis was conducted.41 Two-thirds of
410 Chapter 12 Cardiovascular Health
tuna, cod, and sole, appear to lower the risk of CAD and stroke. "e AHA suggests that individu- als should adjust their total fat intake to meet their caloric needs. People who are overweight or obese should limit their overall fat intake to less than 30% of their daily intake of calories and replace saturated and trans fats in their diet with poly- and monoun- saturated fats.45
Studies show that, on average, people can achieve a 10% reduction in cholesterol levels by following these dietary guidelines. Each 1% reduction in the blood cholesterol level reduces the risk of CAD by 2–3%, so a 10% reduction reduces your risk of CAD by 20–30%. If you are at high risk for CVD, your phy- sician will likely place you on a diet that has choles- terol and other fat intake recommendations di#erent from those mentioned here, which are for the general population.
Eating whole grains and foods rich in soluble !ber (such as fruits, beans, oats, and barley) can help reduce your LDL and total cholesterol levels (Figure 12.14).46 Soluble !ber, which dissolves in water, makes its way into your bloodstream during digestion, where it interferes with the absorption of cholesterol. By doing so, soluble !ber helps decrease CVD risk. "e AHA notes that insoluble dietary !ber, found in many foods such as green leafy veg- etables, fruit skins, seeds, and nuts, also appears to decrease cardiovascular risk and slows progression
overweight and have high blood pressure, weight reduction is the most important action you can take to lower your blood pressure and risk of CVD. Regular aerobic exercise lowers blood pressure and will also help control weight. Reducing the intake of dietary saturated fat and cholesterol will pro- mote overall cardiovascular health and will also help reduce caloric intake, which is important for weight control.
"e heavy consumption of alcoholic beverages has also been shown to lead to high blood pres- sure, increasing the risk of heart attack, stroke, and death from CAD. Limiting consumption to 1 ounce of alcohol (ethanol) per day (two drinks or fewer) for men and 0.5 ounce (one drink) for women may help lower blood pressure and may reduce your risk of CVD. One ounce of ethanol is equivalent to 2 ounces of 100-proof whiskey, 8–10 ounces of wine (the alcohol content in wines varies), or two 12-ounce cans of beer.
If none of these lifestyle changes lowers the blood pressure su&ciently, hypertension can be treated with a wide array of antihypertensive drugs. "ese% drugs are not suitable or appropriate for all hypertensive individuals but may be essential ther- apy for many.
Reducing Blood Cholesterol Decades of scienti!c research show that a high level of cholesterol in the blood is a major risk factor for CVD. Eating saturated fats (found in foods such as red meat, cream, and whole milk), trans fats (found in many baked goods and french fries), and dietary cholesterol (found in foods such as meats, egg yolks, and dairy products) tends to raise blood cholesterol. "erefore, the AHA recommends that healthy Americans older than age 2 years should limit their saturated fat intake (primarily animal fats and tropical oils) to less than 5–6% and their trans fat intake to less than 1% of daily calories.45 "e AHA also recommends that Americans restrict dietary cholesterol intake to 300 milligrams per day (one large egg, for example, has slightly more than 200 milligrams, and a quarter-pound cheeseburger has slightly more than 100 milligrams).
Polyunsaturated fats (found in nuts, seeds, and certain plant oils, such as canola, sa)ower, and sesame oil) and monounsaturated fats (found in avocados and olive, canola, and peanut oil) tend to lower blood cholesterol levels. Omega-3 fatty acids, which are found in certain !sh such as salmon,
Figure 12.14 Foods High in Soluble Fiber. Soluble fiber helps lower LDL cholesterol. The foods shown here include whole wheat bread, oatmeal, broccoli, navel oranges, beans, avocado, and pitted prunes. Courtesy of Wendy Schi".
Maintaining Cardiovascular Health 411
of CVD in high-risk individuals. "e AHA suggests a total dietary !ber intake of 25 grams from foods, not supplements, to ensure enough nutrients in the diet.42 Currently, most Americans take in only half that amount.
If eating a heart-healthy diet and exercising regularly do not signi!cantly reduce elevated blood cholesterol levels, cholesterol-lowering medica- tions called statins are available by prescription. Research results have shown that statins are safe, reduce CAD deaths, reduce total cholesterol and LDL cholesterol, and appear to reduce the risk of stroke.47
Aspirin Therapy A treatment to reduce the risk of CVD that has gained attention in recent years is long-term use of aspirin in a dosage no greater than a baby aspirin (80 mg). "e bene!t of aspirin therapy increases with increas- ing cardiovascular risk; it reduces the risk for heart attack in men and strokes in women.48 Aspirin can have damaging e#ects on the gastrointestinal system and reduces the blood’s ability to clot; therefore, long- term aspirin therapy should be undertaken only on the advice of a physician.
Hormone Replacement Therapy Hormone replacement therapy (HRT) is the use of estrogen plus progestin in postmenopausal women or the use of estrogen alone in postmenopausal women with prior hysterectomy (surgical removal of the uterus). Analysis of data from the Women’s Health Initiative (WHI) 15-year research program, which addresses the most common causes of death, disability, and poor quality of life in postmenopausal women, suggests that cardiovascular risk is neither increased nor decreased in women who begin hor- mone therapy less than 10 years a$er menopause.49–51 Cardiovascular risk increases in women beginning hormone therapy a$er that time. Women who are between 50 and 59 years of age when they begin post- menopausal hormone therapy appear to have a lower risk of death from any cause than women who do not take postmenopausal hormones or who begin taking hormones later in life. Researchers caution, however, that HRT is not without risk and do not recommend postmenopausal hormone therapy for the prevention of heart attacks. Women nearing menopause should talk with their physicians to determine whether HRT is appropriate for them.
4One of the most important things you can do to lower your risk of coronary artery disease and stroke is to reduce your modifiable risk factors, which include quitting smoking, maintaining a healthy body weight, and maintaining an active lifestyle that includes regular aerobic exercise.
4To lower your blood pressure, engage in regular aerobic exercise, lose weight if you are overweight, limit your alcohol consumption to 1 ounce of ethanol per day for men and 0.5 ounce per day for women, and limit your daily sodium intake to 2,300 milligrams.
4To reduce your total cholesterol level, raise your HDL level, and lower your LDL level, eat no more than 20–35% of your daily intake of calories from fat, no more than 5–6% from saturated fat, and less than 1% from trans fat. Also, eat foods rich in soluble fiber, such as fruits, beans, and oats.
Healthy Living Practices
CARDIOVASCULAR HEALTH "e AHA estimates that approximately 1% of babies are born each year with a variety of heart and blood vessel structural and functional abnormalities.52 Many congenital defects (those present at birth) can now be diagnosed before birth with the use of echocardiography, or ultrasound of the heart. Sound waves are directed through the heart of the fetus; as they pass through di#erent types of tissues (such as heart muscle and blood), they are re'ected, or echoed, producing an image of the movements of the heart structures. "is technique can also be used with infants, children, and adults. Such early diagnos- tic techniques have helped surgeons correct infants’ cardiovascular defects within the !rst few weeks of life. "is approach helps avoid complications from cardiovascular defects in older children and adults. Presently, about 1 million Americans have congenital heart defects.
"e Bogalusa Heart Study, a long-term study of the development of CAD, showed that CVD caused by atherosclerosis is a process that begins in child- hood.53 Habits of diet and lifestyle develop at an
Across THE LIFE SPAN
412 Chapter 12 Cardiovascular Health
intake and about 49% of daily total fat intake—too high a proportion. Many school lunch programs have reduced their percentages of total fat, saturated fat, and sodium. In addition, several innovative “heart- healthy” school lunch programs, such as Healthy Edge, Lunch Power, and Heart Smart, have been developed in schools across the nation.
"e results of studies show that older adults should be treated with lipid-lowering therapy when needed because it will help prevent the progression of CVD and other diseases common in this age group.56 Treating hypertension in older adults is also recom- mended because it reduces the risk of cardiovascular events. However, treating hypertension in the very elderly (those older than 80 years) may have more risks than bene!ts.57,58
early age and o$en continue into adulthood, a#ect- ing this disease process. Data from the Bogalusa Heart Study show that the average diet of children and adolescents consisted of 14% of their total daily calories from protein, 50% from carbohydrate, and 36% from fat.54 "e more recent School Nutrition Dietary Assessment Study found that most children and adolescents had nutritionally adequate diets, but 80% had diets too high in saturated fat, and 92% had diets too high in sodium.55 Such diets do not meet the recommendations of the AHA and can lead to the development of atherosclerosis and obesity, both risk factors for CAD and stroke.
In the Bogalusa study, school breakfasts and lunches had a major impact on the diets of children, providing approximately half of the day’s total caloric
Maintaining Cardiovascular Health 413
Health-Related InformationAnalyzing Critical Thinking
This article focuses on claims that manufacturers make on food labels. Explain why you think this article is a reliable or an unreliable source of information. Use the model for analyzing health information to guide your thinking; the main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the source making these health-related claims? Does the source have the appropriate background and education in the topic area? What can you do to check the credentials of this source?
3. What might be the motives and biases of the source making the claims?
4. What is the main point of the article? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Sum- marize your reasons for coming to this conclusion.
Trans Fat Now Listed with Saturated Fat and Cholesterol on the Nutrition Facts Label Trans Fat Coming to a Label Near You! "e Food and Drug Administration (FDA) now requires food manufacturers to list trans fat (i.e., trans fatty acids) on Nutrition Facts and some Sup- plement Facts panels. Scienti!c evidence shows that consumption of saturated fat, trans fat, and dietary cholesterol raises low-density lipoprotein (LDL, or “bad”) cholesterol levels that increase the risk of coro- nary heart disease (CHD). According to the National Heart, Lung, and Blood Institute of the National Institutes of Health, over 12.5 million Americans suf- fer from CHD, and more than 500,000 die each year. "is makes CHD one of the leading causes of death in the United States today.
Since 1993, the FDA has required that saturated fat and dietary cholesterol be listed on the food label. By adding trans fat on the Nutrition Facts panel (required as of January 1, 2006), consumers now know for the !rst time how much of all three— saturated fat, trans fat, and cholesterol—are in the foods they choose. Identifying saturated fat, trans fat, and cholesterol on the food label gives consum- ers information to make heart-healthy food choices that help them reduce their risk of CHD. "is revised label, which includes information on trans fat as well as saturated fat and cholesterol, will be of
Reproduced from Food and Drug Administration. (2011, June 24). Available at http://www.accessdata.fda.gov/videos/cfsan/hwm/hwmres.cfm
Appearing on product labels
as of January 2006
Nutrition Facts Serving Size 1 cup (228g) Servings Per Container 2
Calories 250
Total Fat 12g
Protein 5g
Colesterol 30mg Sodium 470mg Total Carbohydrate 31g
Saturated Fat 3g Trans Fat 1.5g
10%
10% 0%
Vitamin A 4% Vitamin C 2% Calcium 20% Iron * Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higer or lower depending on your calorie needs:
Calories: 2,000 2,500
Total Fat Sat Fat Cholesterol Sodium Total Carbohydrate Dietary Fiber
Less than Less than Less than Less than
65g 20g 300mg 2,400mg 300g 25g
80g 25g 300mg 2,400mg 375g 30g
4%
20%
Dietary Fiber 0g Sugar 5g
Calories from Fat 110 Amount Per Serving
414 Chapter 12 Cardiovascular Health
particular interest to people concerned about high blood cholesterol and heart disease.
However, all Americans should be aware of the risk posed by consuming too much saturated fat, trans fat, and cholesterol. But what is trans fat, and% how can you limit the amount of this fat in your diet?
What Is Trans Fat? Where Will I Find Trans Fat? Vegetable shortenings, some margarines, crackers, cookies, snack foods, and other foods made with or fried in partially hydrogenated oils.
Unlike other fats, the majority of trans fat is formed when liquid oils are made into solid fats%like shortening and hard margarine. However, a small amount of trans fat is found naturally, primar- ily in some animal-based foods. Essentially, trans fat is made when hydrogen is added to vegetable oil—a process called hydrogenation. Hydrogenation increases the shelf life and 'avor stability of foods containing these fats.
Trans fat, like saturated fat and dietary cholesterol, raises the LDL (or “bad”) cholesterol that increases your risk for CHD. On average, Americans consume four to !ve times as much saturated fat as trans fat in their diet.
Although saturated fat is the main dietary culprit that raises LDL, trans fat and dietary cholesterol also contribute signi!cantly. Trans fat can o$en be found in processed foods made with partially hydrogenated vegetable oils such as vegetable shortenings, some margarines (especially margarines that are harder), crackers, candies, cookies, snack foods, fried foods, and baked goods.
Are All Fats the Same? Simply put: no. Fat is a major source of energy for the body and aids in the absorption of vita- mins A, D, E, and K, and carotenoids. Both ani- mal- and plant-derived food products contain fat, and when eaten in moderation, fat is impor- tant for proper growth, development, and main- tenance of good health. As a food ingredient, fat provides taste, consistency, and stability and helps us feel full. In addition, parents should be aware that fats are an especially important source of calories and nutrients for infants and toddlers
(up to 2 years of age), who have the highest energy needs per unit of body weight of any age group.
Saturated and trans fats raise LDL (or “bad”) cho- lesterol levels in the blood, thereby increasing the risk of heart disease. Dietary cholesterol also contributes to heart disease. Unsaturated fats, such as mono- unsaturated and polyunsaturated, do not raise LDL cholesterol and are bene!cial when consumed in moderation. "erefore, it is advisable to choose foods low in saturated fat, trans fat, and cholesterol as part of a healthful diet. What Can I Do About Saturated Fat, Trans Fat, and Cholesterol? When comparing foods, look at the Nutrition Facts panel (NFP), and choose the food with the lower amounts of saturated fat, trans fat, and cho- lesterol. Health experts recommend that you keep your intake of these nutrients as low as possible while consuming a nutritionally adequate diet. However, these experts recognize that eliminating these three components entirely from your diet is not practical because they are unavoidable in ordinary diets.
Where Can I Find Trans Fat on the Food Label? Take a look at the NFP accompanying this article. Consumers can !nd trans fat listed on the NFP directly under the line for saturated fat. If trans fat is not declared on the label and you are curious about the trans fat content of a product, contact the manu- facturer listed on the label.
How Do Your Choices Stack Up? With the addition of trans fat to the NFP, you can review your food choices and see how they stack up. "e following labels illustrate total fat, saturated fat, trans fat, and cholesterol content per serving for selected food products.
Don’t assume similar products are the same. Be sure to check the NFP when comparing products because even similar foods can vary in calories, ingredients, nutrients, and the size and number of servings in the package. When buying the same brand product, also check the NFP frequently because ingredients can change at any time, and any change could a#ect the NFP information.
Maintaining Cardiovascular Health 415
Look at the highlighted items on the sample labels. Combine the grams (g) of saturated fat and trans fat and look for the lowest combined amount. Also, look for the lowest percent (%) Daily Value for cholesterol. Check all three nutrients to make the best choice for a healthful diet.
Note: "e following label examples do not represent a single product or an entire product cat- egory. In general, the nutrient values were combined for several products, and the average values were used for these label examples.
How Can I Use the Label to Make Heart-Healthy Food Choices? "e NFP can help you choose foods lower in satu- rated fat, trans fat, and cholesterol. To lower your intake of saturated fat, trans fat, and cholesterol, compare similar foods and choose the food with the lower combined saturated and trans fats and the lower amount of cholesterol.
Data from Food and Drug Administration. (2014, June 13). Retrieved from http://www.fda.gov/food/ingredientspackaginglabeling /labelingnutrition/ucm20026097.htm
Serving Size 1 Tbsp (14g) Servings Per Container 32
Calories 100 Calories from Fat 100
% Daily Value* Total Fat 11g 17% Saturated Fat 7g 35% Trans Fat 0g Cholesterol 30mg 10%
Amount Per Serving
Serving Size 1 Tbsp (14g) Servings Per Container 32
Calories 100 Calories from Fat 100
% Daily Value* Total Fat 11g 17% Saturated Fat 2g 10% Trans Fat 3g Cholesterol 0mg 0%
Amount Per Serving
Serving Size 1 Tbsp (14g) Servings Per Container 32
Calories 60 Calories from Fat 60
% Daily Value* Total Fat 7g 11% Saturated Fat 1g 5% Trans Fat 0.5g Cholesterol 0mg 0%
Amount Per Serving
Saturated Fat : 7 g + Trans Fat : 0 g Combined Amt. : 7 g Cholesterol : 10 % DV
Saturated Fat : 2 g + Trans Fat : 3 g Combined Amt. : 5 g Cholesterol : 0 % DV
Saturated Fat : 1 g + Trans Fat : 0.5 g Combined Amt. : 1.5 g Cholesterol : 0 % DV
Nutrition Facts Nutrition Facts Nutrition Facts
Compare Spreads!* Keep an eye on saturated fat, trans fat, and cholesterol!
*Nutrient values rounded based on the FDA’s nutrition labeling regulations. Calorie and cholesterol content estimated. **Butter values from FDA Table of Trans Values, 1/30/95. †Values derived from 2002 USDA National Nutrient Database for Standard Reference, Release 15.
Butter** Margarine, stick† Margarine, tub†
416 Chapter 12 Cardiovascular Health
*Nutrient values rounded based on FDA’s nutrition labeling regulations. ±Values for total fat, saturated fat, and trans fat were based on the means of analytical data for several food samples from Subramaniam, S.,
et al., (2004). Trans, saturated, and unsaturated fat in foods in the United States prior to mandatory trans-fat labeling. Lipids, 39, 11–18. Other information and values were derived from food labels in the marketplace.
Serving Size 1 bar (33g) Servings Per Container 10
Calories 140 Calories from Fat 45 Amount Per Serving
Serving Size 2 cookies (28g) Servings Per Container 19
Calories 130 Calories from Fat 45 Amount Per Serving
Serving Size 2 cakes (66g) Servings Per Container 6
Calories 280 Calories from Fat 140 Amount Per Serving
Saturated Fat : 1 g + Trans Fat : 1.5 g Combined Amt. : 2.5 g Cholesterol : 0 % DV
Saturated Fat : 1 g + Trans Fat : 0 g Combined Amt. : 1 g Cholesterol : 0 % DV
Saturated Fat : 3.5 g + Trans Fat : 4.5 g Combined Amt. : 8 g Cholesterol : 3 % DV
% Daily Value* Total Fat 5g 8% Saturated Fat 1g 5% Trans Fat 0g Cholesterol 0mg 0%
% Daily Value* Total Fat 5g 8% Saturated Fat 1g 5% Trans Fat 1.5g Cholesterol 0mg 0%
% Daily Value* Total Fat 16g 25% Saturated Fat 3.5g 18% Trans Fat 4.5g Cholesterol 10mg 3%
Nutrition Facts Nutrition Facts Nutrition Facts
Compare Desserts!* Keep an eye on saturated fat, trans fat, and cholesterol!
Granola Bar± Sandwich Cookies± Cake, Iced and Filled±
Compare Snacks!* Keep an eye on saturated fat, trans fat, and cholesterol!
*Nutrient values rounded based on the FDA’s nutrition labeling regulations. ±Values for total fat, saturated fat, and trans fat were based on the means of analytical data for several food samples from Subramaniam, S.,
et al., (2004). Trans, saturated, and unsaturated fat in foods in the United States prior to mandatory trans-fat labeling. Lipids, 39, 11–18. Other information and values were derived from food labels in the marketplace.
Serving Size 3 oz (84g / about 12 pieces) Servings Per Container 11
Calories 160 Calories from Fat 50
% Daily Value* Total Fat 6g 9% Saturated Fat 1g 5% Trans Fat 1.5g Cholesterol 0mg 0%
Amount Per Serving
Serving Size 1 oz (28g / about 20 chips) Servings Per Container 12
Calories 150 Calories from Fat 90
% Daily Value* Total Fat 10g 15% Saturated Fat 2g 10% Trans Fat 0g Cholesterol 0mg 0%
Amount Per Serving
Serving Size 14 pieces (31g) Servings Per Container 10
Calories 160 Calories from Fat 70
% Daily Value* Total Fat 8g 12% Saturated Fat 2g 10% Trans Fat 2g Cholesterol < 5mg 1%
Amount Per Serving
Saturated Fat : 2 g + Trans Fat : 0 g Combined Amt. : 2 g Cholesterol : 0 % DV
Saturated Fat : 1 g + Trans Fat : 1.5 g Combined Amt. : 2.5 g Cholesterol : 0 % DV
Saturated Fat : 2 g + Trans Fat : 2 g Combined Amt. : 4 g Cholesterol : 1 % DV
Nutrition Facts Nutrition Facts Nutrition Facts
Frozen Potatoes± (e.g., French Fries)
Potato Chips± Mini-Sandwich Crackers±
Maintaining Cardiovascular Health 417
CHAPTER REVIEW
"e leading cause of death in the United States is a noninfectious disease: coronary artery disease (CAD). In CAD, the arteries that supply blood to the heart become blocked, restricting blood 'ow. CAD is only one disease of the cardiovascular system; hyper- tension, stroke, and rheumatic heart disease are three other prominent cardiovascular diseases (CVDs). Atherosclerosis is an important CVD process that is an underlying cause of CAD and stroke.
"e cardiovascular system includes the heart and blood vessels. "e heart, a muscular, !st-sized organ, pumps blood to the body. "e blood performs many functions, such as bringing nutrients and oxygen to the tissues and removing wastes, including the waste gas carbon dioxide. Blood vessels called arteries bring blood away from the heart; veins return blood to the heart. Microscopic vessels called capillaries join the two and allow the exchange of nutrients, gases, and wastes at the tissues.
Fatty deposits develop in arteries as part of a dis- ease called atherosclerosis. Atherosclerosis occurs most frequently in the arteries that supply blood to the heart, brain, and legs. In CAD, the coronary arteries, which supply the heart muscle with blood, become blocked by fatty deposits, a blood clot, or both. When the heart is deprived of the blood (and therefore the oxygen) that it needs, chest pain (angina pectoris) or a heart attack results. A physician usually performs diagnostic tests to assess the degree and location of blockage. Medication can help widen blood vessels and reduce symptoms.
During a heart attack, part of the heart muscle dies. As the muscle dies, it may trigger electrical activity
that causes the ventricles to stop beating properly, possibly resulting in heart failure, cardiac arrest, and death. A heart attack victim needs immediate medi- cal care.
A stroke occurs when arteries that supply blood to the brain become blocked by fatty deposits or by a blood clot. A stroke may cause a loss or dimming of vision, di&culty in speaking or understanding speech, headache, dizziness, unsteadiness, and even death.
"e major risk factors for developing CVD are family health history, abnormal blood lipid levels, cigarette smoking, high blood pressure, physical inactivity, obesity, diabetes mellitus, and stress. Behaviors that may lower the risk of CVD are stopping smoking, maintaining a healthy weight, exercising regularly, maintaining healthy blood pres- sure levels, maintaining favorable blood lipid levels, managing diabetes mellitus to stabilize the blood glu- cose level, and coping e#ectively with stress.
Infants may be born with a wide variety of heart and blood vessel structural and functional abnor- malities. Many of these congenital defects can now be diagnosed before birth and treated during the !rst few weeks of life.
CVD caused by atherosclerosis may begin in childhood. American children are still consuming diets that promote CVD. Healthy school meal pro- grams can help change this fact, and education can promote healthy lifestyles.
Data suggest that physicians should treat abnormal lipid levels and high blood pressure in older adults.
Summary
1. If a family member experienced a transient is chemic attack, how would you recognize it? What would you do? What long-term action might this family member take to avoid the onset of a stroke? Analysis
2. Analyze your lifestyle to determine which modi- !able risk factors are raising your probability of developing cardiovascular disease. List these risk factors and explain how each increases your risk for developing cardiovascular disease. Analysis
Applying What You Have Learned
418 Chapter 12 Cardiovascular Health
CHAPTER REVIEW course of action. Which changes do you realisti- cally expect to make, and which do you expect not to make? What can you do to o#set uncon- trollable risk factors (e.g., family health history)? Give rationales for your answers. If you follow this plan, do you think that you will substantially reduce your risk of developing CVD? Why or why not? Evaluation
3. Using the list you developed by answering Ques- tion 2, describe how you could modify your behavior to lower your risk of developing cardio- vascular disease. Synthesis
4. List all your risk factors for developing cardio- vascular disease, both those you can change and those you cannot. Using the information from your answer to Question 3, evaluate your
1. If you are a parent or plan to be a parent some day, what are you doing (or will you do) to encourage your child’s heart-healthy lifestyle?
2. If you are a cigarette smoker, identify your rea- sons or motivations for smoking. A$er learning about the e#ects of smoking on cardiovascular health, do you want to quit? If so, what steps might you take to reduce the amount you smoke or to stop smoking? Be sure to include things you can do as an individual, as well as sources of help to assist you in the process. If you are a non- smoker, list the situations in which you regularly breathe secondhand smoke. Re'ect on what you believe to be your increased risk of cardiovascu- lar disease because of your exposure. What can you do to lessen your exposure?
3. Do you feel con!dent that you would be able to recognize when another person is having a stroke, TIA, or heart attack and help him or her? Visit
helpful websites, such as the American Heart Association (www.heart.org), and review warn- ing signs of stroke and/or TIA. "en, re'ect on what you would do to handle such an emergency.
4. Rate your lifestyle on a scale of 1 to 10, with 1 being an extremely heart-unhealthy lifestyle and 10 being an extremely heart-healthy lifestyle. Discuss why you rated your lifestyle as you did. Based on what you read in this chapter, what changes can you make to move closer to a 10 if you’re not already there?
5. Do you think medical researchers are able to assess accurately the factors that are detrimental or helpful to cardiovascular health? Why do you feel this way? How do you think your attitudes concerning medical research a#ect your behav- ior? Have your attitudes about medical research and cardiovascular health changed since reading this chapter? Why or why not?
Reflecting on Your Health
1. Tailor, A. M., et al. (2010). An update on the prevalence of the meta- bolic syndrome in children and adolescents. International Journal of Pediatric Obesity, 5(3), 202–213.
2. Zieske, A. W., et al. (2002). Natural history and risk factors of atherosclerosis in children and youth: "e PDAY study. Pediatric Pathology and Molecular Medicine, 21, 213–237.
3. Roberts, C. K., et al. (2007). E#ect of a short-term diet and exercise intervention in youth on atherosclerotic risk factors. Atherosclerosis, 191, 98–106.
4. Collins, K. M., et al. (2004). Heart disease awareness among college students. Journal of Community Health, 29(5), 405–420.
References
Key
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
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52. Women’s Health Initiative Participant Web site. (2007, April). Post- menopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. Retrieved from https://www.whi .org/participants/!ndings/Pages/ht_cvd.aspx
53. American Heart Association. (2014, May 6). About congenital cardiovascular defects. Retrieved from http://www.heart.org / H E A RTORG / C ond it i ons / C onge n it a l He ar t D e fe c t s / Ab out -C ongenitalHeartDefects/About-C ongenital-Heart-Defects _UCM_001217_Article.jsp
54. Tulane University School of Medicine, Center for Cardiovascular Health. (n.d.). "e Bogalusa Heart Study. Retrieved from http:// tulane.edu/som/cardiohealth/index.cfm
55. Nicklas, T. A., et al. (2001). Trends in nutrient intake of 10-year-old children over two decades (1973–1994): "e Bogalusa Heart Study. American Journal of Epidemiology, 153, 969–977.
56. Clark, M. A., & Fox, M. K. (2009). Nutritional quality of the diets of U.S. public school children and the role of the school meal pro- grams. Journal of the American Dietetic Association, 109(2 Suppl.), S44–S56.
57. Petersen, L. K., et al. (2010). Lipid-lowering treatment to the end? A review of observational studies and RCTs on cholesterol and mortality in 80+-year olds. Age & Ageing, 39(6), 674–680.
58. Pinto, E. (2007). Blood pressure and aging. Postgraduate Medical Journal, 83, 109–114.
34. Katerndahl, D. A. (2008). "e association between panic disorder and coronary artery disease among primary care patients present- ing with chest pain: An updated literature review. Primary Care Companion to the Journal of Clinical Psychiatry, 10, 276–285.
35. Zakynthinos, E., & Pappa, N. (2009). In'ammatory biomarkers in coronary artery disease. Journal of Cardiology, 53(3), 317–333.
36. Buckley, D., et al. (2009). C-reactive protein as a risk factor for coro- nary heart disease: A systematic review and meta-analyses for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 151(7), 483–495.
37. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2015) 2015-2020 dietary guidelines for Americans (8th ed.). Washington DC: U.S. Government Printing O&ce. Retrieved from https://health.gov/dietaryguidelines/2015 /resources/2015-2020_Dietary_Guidelines.pdf
38. King, D. E., et al. (2007). Turning back the clock: Adopting a healthy lifestyle in middle age. American Journal of Medicine, 120, 598–603.
39. King, D. E., et al. (2009). Adherence to healthy lifestyle habits in U.S. adults, 1988–2006. American Journal of Medicine, 122(6), 528–534.
40. American Heart Association. (2014, May 30). Smoke-free living: Bene#ts and milestones. Retrieved from http://www.heart.org /HEARTORG/GettingHealthy/QuitSmoking/YourNon-SmokingLife /Smoke-free-Living-Bene!ts-Milestones_UCM_322711_Article.jsp
41. Powell, K., et al. (1987). Physical activity and the incidence of coro- nary heart disease. Annual Review of Public Health, 8, 253–287.
42. Galimanis, A., et al. (2009). Lifestyle and stroke risk: A review. Current Opinion in Neurology, 22, 60–68.
43. American Heart Association. (2014, May 16). American Heart Associ- ation guidelines. Retrieved from http://www.heart.org/HEARTORG /GettingHealthy/PhysicalActivity/GettingActive/American-Heart -Association-Guidelines_UCM_307976_Article.jsp
44. American Heart Association. (2016). American Heart Association praises USDA’s strong stance on new dietary guidelines. Retrieved from https://newsroom.heart.org/news/american-heart-association -praises-usdas-strong-stance-on-new-dietary-guidelines
45. Appel, L. J., et al. (2006). Dietary approaches to prevent and treat hypertension: A scienti!c statement from the American Heart Association. Hypertension, 47, 291–308.
46. American Heart Association. (2017). Know your fats. Retrieved from http://www.heart.org/HEARTORG/Conditions/Cholesterol /PreventionTreatmentofHighCholesterol/Know-Your-Fats_UCM _305628_Article.jsp
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References 421
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Across the Life Span Cancer
Managing Your Health Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People | Breast Self- Examination | Testicular Self- Examination | Reducing Your Risk for Cancer | Cancer’s Seven Warning Signs
Consumer Health Alternative Cancer Therapies
Diversity in Health Stomach Cancer: Variation in Mortality Among Countries
Chapter Overview What is cancer?
How cancers develop and spread
How physicians detect cancer
How cancer is treated
Which cancers are the most prevalent in the United States
How you can reduce your risk for cancer
Student Workbook Self-Assessment: What Are Your Cancer Risks?
Changing Health Habits: Modifying Behavior to Reduce Cancer Risk
Do You Know? What the most prevalent cancer is for your age group?
What you can do to lower your risk of cancer?
Which cancers are on the rise?
Cancer
© EyeEm
/Getty Im ages.
Learning Objectives “Many cancers can be cured, especially those detected early.”
After studying this chapter, you should be able to:
1. List three traits of cancer cells that make them different from normal cells.
2. Name four factors that can cause mutations in human cells. 3. Describe at least two important differences between a
benign and a malignant tumor. 4. List risk factors for major cancers, including cancers of
the skin, breast, prostate, lung, cervix, uterus, ovary, and oral cavity.
5. Identify which types of cancer are responsible for most deaths in the United States. 6. Describe lifestyle factors that contribute to the development of cancers. 7. Identify tests or examinations used to identify major forms of cancer. 8. List the seven warning signs of cancer. 9. List three cancer risk factors over which a person has no control. 10. Describe steps that can be taken to reduce cancer risk.
CHAPTER 13
423
stages, as Armstrong’s was, may respond to therapies available today.
Cancer researchers are making discoveries daily that help win the war against cancer. A tremendous body of research is available that provides guidelines to help people avoid cancer, and people can take many actions to lessen their risk of developing certain can- cers. "is chapter discusses such preventive measures.
What Is Cancer? People o$en talk about cancer as if it were a single disease. However, cancer is many diseases. Lung can- cer, for example, is a very di#erent disease from leu- kemia (cancer of the blood) or skin cancer. Although di#erent, all cancers have common characteristics: "eir cells exhibit abnormal growth, division, and di#erentiation. Di#erentiation is the process by which cells develop into certain types, such as liver cells or muscle cells. In addition, cancer cells have the potential to metastasize, or spread from where they develop to another part of the body.
Cells are the building blocks of all organisms; they are the smallest unit of living material. In any mul- ticelled organism such as a human, cells divide and di#erentiate as an individual grows and develops and when its tissues need repair. "e timing and events of cell division, growth, and di#erentiation are highly controlled by regulatory proteins. Cells make regula- tory proteins in response to the instructions of the hereditary material, or genes. Normal cells are pro- grammed to grow and divide, and to stop growing and dividing at appropriate times.
Unlike normal cells, cancer cells do not stop growing and dividing at appropriate times. Additionally, cancer cells do not di#erentiate normally and tend to spread. "ese cells may form masses called malignant tumors that invade body tissues and interfere with the normal functioning of tissues and organs. Tumors o$en cause pain as they invade nerves or press on nerves. Why do cancer cells behave di#erently than noncancer cells? "e answer lies in the genetic material in the cell.
How Cancers Develop and"Spread
Cancer develops only in cells that have mutations, that is, damaged genes. Mutations can be inherited or can occur from exposure to low-dose radiation, drugs, or toxic chemicals. Infection with certain viruses can also
By winning the Tour, you stick in the minds and hearts of the cycling public. You can win every classic and the world championship, but the Tour is everything. It’s a global event.”1 "ese words were uttered to newspaper reporters by Lance Armstrong, the second American to win the Tour de France and the only person to win the Tour seven times. Armstrong o&cially retired from competitive cycling in February 2011, but on that clear sunny day in July 1999, he won more than this most rigorous and prestigious 3-week cycling race. He showed the world that he had truly won his battle with testicular cancer—a battle that had nearly cost him not only his career but also his life. His cancer, diagnosed in 1996, had spread to his lungs and brain, but aggressive che- motherapy helped his body win the war against this dreaded disease.
For years, questions about Armstrong’s use of per- formance-enhancing drugs cast a shadow of doubt over his wins. In January 2013, Armstrong !nally admitted to using performance enhancers during competition. Despite this revelation, Armstrong’s story highlights the ability of humans to be healthy and productive a$er recovering from cancer.
Armstrong won the Tour de France each year from 1999 through 2005. "en, at age 37, a$er a 4-year hia- tus from biking competition, Armstrong entered the 2009 Tour to promote his cancer-support foundation Livestrong. He !nished third on the Tour. At the time of Armstrong’s retirement in 2011, International Cycling Union President Pat McQuaid referred to Armstrong as “the global icon for cycling.”2
Although it is still the nation’s second biggest killer (cardiovascular disease is the !rst), cancer is not an automatic death sentence. Armstrong and other can- cer survivors, such as former Major League Baseball pitcher Dave Dravecky, pro football Hall of Famer Len Dawson, and American !gure skater and gold medal Olympian Peggy Fleming are living testimony to that fact. Many cancers can be cured, especially those detected early. Even cancers in advanced
metastasize (meh-TAS-tah-size) The ability of cancer cells to spread from where they develop to another part of the body.
malignant (mah-LIG-nant) tumors Masses of cancer cells that invade body tissues and interfere with the normal functioning of tissues and organs.
mutations (myou-TAY-shunz) Changes in genes or chromosomes; damaged genes.
“
424 Chapter 13 Cancer
cause changes in genes. Excluding inheritance, then, cancer is determined largely by environmental factors, including components of lifestyle. Lifestyle factors play a major role in cancer prevention.
Genes and Cancer Development Oncogenes are “on” switches that speed cell growth. Successive mutations to the hereditary mate- rial of particular body cells produce oncogenes. Tumor-suppressor genes are “o# ” switches that slow cell growth. If tumor-suppressor genes mutate or are lost from the hereditary makeup of a cell, they will no longer restrict cell growth.
"e activation of oncogenes and deactivation of tumor-suppressor genes (and, therefore, the devel- opment of cancer) is a multistage process. In other words, successive genetic changes must take place for a normal cell to change into a cancer cell. "ese changes take place over time as various environmen- tal factors a#ect cells and cause mutations. "erefore, the chances of developing cancer generally increase with age and with exposure to cancer-causing sub- stances, or carcinogens. Of course, many factors determine an individual’s risk for developing can- cers. "ese factors, discussed throughout this chap- ter, modify this generalization.
Cells that begin to grow abnormally, although not yet cancer cells, may form growths called benign tumors. Surrounded by a !brous capsule, benign tumors remain in one location; they do not invade surrounding tissues. Usually these growths are not life threatening unless their presence interferes with a vital function. For example, a benign brain tumor may be life threatening if it compresses blood ves- sels serving a vital center in the brain. In most cases, benign tumors can be removed completely by surgery.
Some benign tumor cells exhibit traits that are characteristic of the development of cancer cells. "ese cells are said to exhibit dysplasia. Notice that the dysplastic cells in Figure 13.1a vary in size, shape, and the appearance of their nuclei. "ey are not dif- ferentiating properly into a speci!c type of cell. "e normal cells, however, are somewhat regular in these same characteristics (Figure 13.1b). Dysplastic cells have the potential to develop into cancer cells.
Metastasis One of the characteristics of cancer cells is their abil- ity to spread, or metastasize, from where they initially developed to other places in the body. Cells with the
oncogenes (ONG-ko-geenz) Tumor genes that manufacture altered proteins that speed cell growth and decrease the level of cell differentiation.
tumor-suppressor genes Pieces of hereditary material that slow cell growth; antioncogenes.
carcinogens (kar-SIN-oh-jenz) Cancer-causing substances.
benign (be-NINE) tumors Encapsulated masses of abnormal cells that remain in one location and do not invade surrounding tissues.
(b)
Figure 13.1 A Comparison of Dysplastic and Normal Cells. (a) Dysplastic cells. These cells (stained differently from those in [b]) are irregular in size and in the appearance of their nuclei. (b) Normal cells. These cells are all approximately the same size and have nuclei that look similar. (a) © David Litman/Shutterstock; (b) © Plenoy m/Shutterstock.
(a)
How Cancers Develop and Spread 425
vessels at a distant location, enter the tissues there, and divide to form new masses of malignant cells. Figure 13.2 shows this process of cancer cell division and metastasis. Once metastasis occurs, the cancer becomes much more di&cult to control.
Cancers are named according to the type of tissue from which they develop. Carcinomas (which con- stitute most adult cancers) arise from epithelial tissue, which lines and covers internal and external body surfaces. Lung, oral, stomach, skin, breast, colon, and ovarian cancers are carcinomas. Sarcomas are cancers that arise from connective or muscle tissue. Leukemias are cancers of the blood and related cells.
Lymphomas are cancers of the lymphatic system, the network of vessels and nodes that transport and !lter tissue 'uid. Cancers of the nervous system have a variety of names.
Figure 13.3 shows death rates (the number of per- sons dying per year per 100,000 people) of various cancers in the United States. Overall cancer death
ability to metastasize are malignant. As a cancer devel- ops, metastasis does not take place immediately. As cancer cells grow and divide, they o$en form a malig- nant tumor. At this stage, the cancer is in situ (in place) because it has not invaded other tissues. However, these localized cancer cells begin to secrete chemicals that destroy the substances that hold the surrounding tissues together. When this occurs, cancer cells enter blood and lymph vessels and travel to other parts of the body. Cancerous cells can move out of the blood
carcinomas (KAR-si-NO-mahz) Cancers that arise from epithelial tissues.
sarcomas (sar-KO-mahz) Cancers that arise from connective or muscle tissue.
leukemias (lew-KEY-me-ahz) Cancers of the blood and related cells.
lymphomas (lim-FOE-mahz) Cancers of the lymphatic system.
Capillary
Connective tissue
Tumor in bronchial epithelium.
Cells break through base of epithelium to invade capillary.
Cells multiply to form metastasis of the liver.
Cells travel through bloodstream and may eventually adhere to the capillary wall in the liver or other organ.* The cells then move out of the capillary.
*Less than 1 in 1,000 survive to form metastases.
(a)
(c) (d)
(b)
Figure 13.2 How Cancer Cells Multiply and Spread. Cancer cells secrete chemicals that destroy the substances holding tissues together. As these tissues break down, cancer cells move from their original site, enter the blood and lymph, and travel to other parts of the body.
426 Chapter 13 Cancer
Figure 13.3 Cancer Death Rates,* 1930–2015. (a) Male. (b) Female. Reproduced from American Cancer Society (2018). Cancer Facts and Figures 2018. Atlanta: American Cancer Society, Inc.
1935 19401930 1950 1960 1970 1980 19901945 1955 1965 1975 1985 1995
R at
e p
er 1
0 0,
0 0
0 M
al e
P o
p u
la ti
o n
*Age adjusted to the 2000 U.S. standard population. †Mortality rates for pancreatic and liver cancers are increasing. Note: Due to changes in ICD coding, numerator information has changed over time. Rates for cancers of the liver, lung and bronchus, colon and rectum, and uterus are affected by these coding changes.
2000 2005 2010 2015
20
40
60
80
100
0
Lung & bronchus
Colon & rectum
Prostate
Stomach
Pancreas†
Liver†
(a)
R at
e p
er 1
0 0,
0 0
0 F
em al
e P
o p
u la
ti o
n
*Age adjusted to the 2000 U.S. standard population. †The mortality rate for liver cancer is increasing. ‡Uterus refers to uterine cervix and uterine corpus combined. Note: Due to change in ICD coding, numerator information has changed over time. Rates for cancer of the liver, lung and bronchus, colon and rectum, and uterus are affected by these coding changes.
1935 19401930 1950 1960 1970 1980 19901945 1955 1965 1975 1985 1995 2000 2005 2010 2015
20
40
60
80
100
0
Lung & bronchus
Colon & rectum
Stomach
Pancreas
Liver†
Breast Uterus‡
(b)
How Cancers Develop and Spread 427
process is possible, for example, for detecting can- cer of the cervix and of the esophagus. Even mucus coughed up from the lungs can be analyzed for the presence of cancer. Some cancers, such as colon can- cer and stomach cancer, can be detected by !ber- optic examination. To see these internal areas of the body, the physician inserts a 'exible tube called a #berscope% into the area to be examined. "e !ber- scope contains bundles of specially coated glass or plastic !bers that transmit an image from the lighted end of the scope to an eyepiece.
X-rays are used in some screening techniques. "e computed tomography (CT) colonography, or virtual colonoscopy, can be used to screen for colon cancer. "is technique uses special X-ray equipment to create two- and three-dimensional images of the interior of the colon. Other cancers that grow embedded in tissues, such as breast cancer and lung cancer, can be detected by X-rays as well. Chest X-rays are o$en used for lung cancer screening, and mammograms, used for breast cancer screening, employ a type of low-dose X-ray.
Positron emission tomography (PET) scans and magnetic resonance imaging (MRI) can also be used to detect deeply embedded cancers, such as brain cancer. PET scans use small amounts of radioactive positrons (positively charged particles) to visualize body structures. MRI uses magnetic !elds and radio waves for visualization. MRI is sometimes used in breast cancer screening (Figure 13.4).
rates have decreased since the early 1990s.3 Continued declines for overall cancer death rates and for many of the top cancers (see Figure 13.3) re'ect progress in the prevention, early detection, and treatment of cancer.
Cancer Detection and Staging
Cancer screening is an examination to detect malignancies in a person who has no symptoms. "e American Cancer Society (ACS) recommends the screening procedures listed in the Managing Your Health section that follows.
Cancer screening or detection methods vary depending on the location of the possible cancer. Super!cial cancers, such as cancers of the skin and oral cavity, can be detected by visual examination, or a biopsy can be performed. A biopsy is the removal of a small piece of tissue from a suspect area. It can be cut from the body with a scalpel or removed with a needle.
Some cancers in internal areas can be detected by collecting cells for microscopic examination. "is
cancer screening An examination to detect malignancies in a person who has no symptoms.
biopsy (BI-op-see) A small piece of tissue that is taken from a growth so that the cells can be studied and a diagnosis confirmed.
(a) (b)
Figure 13.4 (a) PET and (b) MRI Scans of the Brain. In (a), the round blue area on the side of the brain is a benign tumor. In (b), the round blue area toward the back of the brain is a cancerous tumor. The round structures at the front of the brain are the eyes. (a) Courtesy of Dr. Giovanni Dichiro, Neuroimaging Section, National Institute of Neurologic Disorders and Stroke/National Cancer Institute; (b) © National Cancer Institute/Photodisc/Getty Images.
428 Chapter 13 Cancer
All Stages Local Regional Distant All Stages Local Regional Distant
Breast (female) 90 99 85 27 Ovary 47 93 73 29
Colon & rectum 65 90 71 14 Pancreas 8 32 12 3
Esophagus 19 43 23 5 Prostate 99 >99 >99 30
Kidney† 74 93 67 12 Stomach 31 67 31 5
Larynx 61 77 45 34 Testis 95 99 96 73
Liver‡ 18 31 11 3 Thyroid 98 >99 98 56
Lung and bronchus
18 56 29 5 Urinary bladder
77 70 35 5
Melanoma of the skin
92 99 63 20 Uterine cervix
67 92 57 17
Oral cavity and pharynx
65 84 64 39 Uterine corpus
81 95 69 16
*Rates are adjusted for normal life expectancy and are based on cases diagnosed in the SEER 18 areas from 2007–2013, all followed through 2014. †lncludes renal pelvis. ‡Includes intrahepatic bile duct. §Rate for in situ cases is 96%. Local: an invasive malignant cancer confined entirely to the organ of origin. Regional: a malignant cancer that (1) has extended beyond the limits of the organ of origin directly into surrounding organs or tissues; (2) involves regional lymph nodes; or (3) has both regional extension and involvement of regional lymph nodes. Distant: a malignant cancer that has spread to parts of the body remote from the primary tumor either by direct extension or by discontinuous metastasis to distant organs, tissues, or via the lymphatic system to distant lymph nodes.
American Cancer Society (2018). Cancer Facts and Figure 2018. Atlanta: American Cancer Society Inc.
Five-Year Relative Survival Rates* (%) by Stage at Diagnosis, 2007–2013
Table 13.1
Ultrasound, an imaging technique that uses sound waves, is used occasionally to detect cancerous growths.
Cancer staging describes the extent of the growth and metastasis of the cancer so that physicians can determine appropriate therapy and provide a prognosis (outlook) for the patient. To stage a cancer, physicians usually use the TNM system !rst: T describes the origi- nal tumor, N describes whether the cancer has reached nearby lymph nodes, and M describes whether the cancer has metastasized (spread) to distant body parts. Once the T, N, and M are determined, they are com- bined for an overall stage. "ese overall stages are I, II, III, and IV, with stage I cancer being the least advanced and stage IV cancer being the most advanced. Some- times stages are subdivided (such as stage IIB), and sometimes other staging systems are used.
"e 5-year survival rate is the percentage of persons who are alive 5 years a$er their cancer is diagnosed,
whether they are disease free, under treatment, or in remission (having a partial or complete disappear- ance of the signs and symptoms of the cancer). Over the past 3 decades, the overall 5-year survival rate for all cancers diagnosed has increased by approximately 20%.3 Table 13.1 shows the 5-year survival rate for cancers discussed in this chapter.
Cancer Treatment "e principal forms of cancer treatment are surgery, radiation, and chemotherapy. Newer modes of treat- ment are biomodulation (immunotherapy), photo- dynamic therapy, antiangiogenesis therapy, and bone
cancer staging A description of the extent of the growth and metastasis of a cancer to determine appropriate therapy and prognosis.
Cancer Treatment 429
Managing Your Health Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People
Cancer Site Population Test or Procedure Frequency
Breast Women ages 20+
Breast self-examination (BSE) It is acceptable for women to choose not to do BSE or to do BSE regularly (monthly) or irregularly. Beginning in their early 20s, women should be told about the benefits and limitations of BSE. Whether or not a woman ever performs BSE, the importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who do chose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination.
Clinical breast examination (CBE)
For women in their 20s and 30, it is recommended that CBE be part of a periodic health examination, preferable at least every 3 years. Asymptomatic women ages 40 and over should continue to receive a CBE as part of a periodic health examination, preferably annually.
Mammography Women 40 to 44 years of age have the option to begin annual mammography; those 45 to 54 should under annual mammography; and those 55 years and older may transition to biennial mammography.*
Cervix Women, ages 21-65
Pap test and HPV DNA test Cervical cancer screening should begin at age 21. For women ages 21-29, screening should be done every 3 years with conventional or liquid-based Pap tests. For women ages 30-65, screening should be done every 5 years with both the HPV test and the Pap test (preferred), or every 3 years with the Pap test alone (acceptable). Women ages 65+ who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the past 10 years, with the most recent test occurring within 5 years, and women who have had a total hysterectomy should stop cervical cancer screening. Women should not be screened annually by any method at any age.
Colorectal Men and women ages 45+
Fecal occult blood test (FOBT) with at least 50% test sensitivity for cancer, or fecal immunochemical test (FIT) with at least 50% test sensitivity for cancer, or
Annual, starting at age 45. Testing at home with adherence to manufacturer’s recommendation for collection techniques and number of samples is recommended. FOBT with the single stool sample collected on the clinician’s fingertip during a digital rectal examination is not recommended. Guaiac-based toilet bowl FOBT tests also are not recommended. In comparison with guaiac-based tests for the detection of occult blood, immunochemical tests are more patient-friendly, and are likely to be equal or better in sensitivity and specificity. There is no justification for repeating FOBT is response to an initial positive finding.
430 Chapter 13 Cancer
Cancer Site Population Test or Procedure Frequency
Stool DNA test, or Every 3 years, starting at age 45
Flexible sigmoidoscopy (FSIG), or
Every 5 years, starting at age 45. FSIG can be performed alone, or consideration can be given to combining FSIG performed every 5 years with a highly sensitive gFOBT or FIT performed annually.
Double contrast barium enema (DCBE), or
Every 5 years, starting at age 45
Colonoscopy Every 10 years, starting at 45
CT Colonoscopy Every 5 years, starting at age 45
Endometrial Women, at menopause
At the time of menopause, women at average risk should be informed about risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians.
Lung Current or former smokers ages 55-74 in good health with at least a 30 pack-year history
Low-dose helical CT (LDCT) Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with apparently healthy patients ages 55-74 who have at least a 30 pack-year smoking history, and who currently smoke or have quit within the past 15 years. A process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with LDCT should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation.
Prostate Men, ages 50+
Digital rectal examination (DRE) and prostate-specific antigen test (PSA)
Men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their healthcare provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with prostate screening. Prostate cancer screening should not occur without an informed decision-making process. If you are African American or have a father or brother who had prostate cancer before age 65, you should discuss prostate screenings with your doctor at age 45.
Cancer- related checkup
Men and women, ages 20+
On the occasion of a periodic health examination, the cancer-related checkup should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure, diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures.
Reproduced from American Cancer Society. Cancer Facts and Figures 2018. Atlanta: American Cancer Society, Inc. *Beginning at age 40, annual clinical breast examination should be performed prior to mammography. Reproduced from American Cancer Society. Cancer Facts and Figures 2018. Atlanta: American Cancer Society, Inc.
Cancer Treatment 431
Consumer Health Alternative Cancer Therapies Modern medicine has its limitations; not every condition can be prevented, managed, or cured. It is not surprising, therefore, that some individuals who
are diagnosed with incurable conditions seek help from anyone who offers a cure. Cancer patients who seek
alternative therapies also hope to find a “softer” treat- ment with fewer side effects. Many want to use a holistic approach or take charge of their health when conven- tional medicine offers no more options. When faced with a potentially life-threatening illness such as cancer, most people feel the need to do everything possible to survive.
Most users of alternative cancer therapies expect their treatments to boost their immune system or slow the progression of or cure their cancer. However, the effectiveness of most alternative therapies in cancer treatment has not been established in scientific stud- ies. Additionally, cancer patients erroneously perceive alternative therapies as safe because they are “natural,” but therapies such as herbal and vitamin supplements may interact in dangerous ways with drugs or therapies being used in conventional cancer treatment. Many have serious side effects of their own. And if cancer patients delay conventional treatment in favor of unconventional treatment, they may diminish their chances of survival, spend money needlessly, and lower their quality of life.
Herbal therapies, plant extracts, and therapeutic vita- mins are the most common alternative therapies in can- cer treatment today, and up to 50% of cancer patients use some form of alternative treatment. The greatest danger with the use of substances not controlled by the Food and Drug Administration (FDA) in cancer treatment is the risk of contamination, misidentification, or substitution with a harmful substance because of lack of quality control.
If you or someone you know is thinking about using alternative therapies for cancer treatment, remember that it is important to evaluate all evidence about these meth- ods carefully and make decisions with a cancer physician (oncologist). At the least, informing the physician about other therapies being used can help avoid adverse drug interactions. Also, in evaluating therapies, remember that any remedy used by a large number of people will, by chance, be used by a long-term survivor. In many cases, the patient used conventional treatments as well as alter- native ones. However, the alternative method often gets the credit even though there is no evidence to show that it played a role in the patient’s long-term survival.
Data from Wilkinson, J. M., et al. (2014). Use of complementary and alternative medical therapies (CAM) by patients attending a regional comprehensive cancer care centre. Journal of Complementary & Integrative Medicine, 11(2), 139–147; Wilson, M. K., et al. (2014). Review of high-dose intravenous vitamin C as an anticancer agent. Asia Pacific Journal of Clinical Oncology, 10(1), 22–37; Ulbricht, C., et al. (2009). Essiac: Systematic review by the Natural Standard Research Collaboration. Journal of the Society for Integrative Oncology, 7, 73–80; Yang, A. K., et al. (2010). Herbal interactions with anticancer drugs: Mechanistic and clinical considerations. Current Medicinal Chemistry, 17(16), 1635–1678; Yang, C. S., & Wang, X. (2010). Green tea and cancer prevention. Nutrition and Cancer, 62(7), 931–937.
Figure 13.A Plant Extracts Are a Common Type of Alternative Cancer Therapy. (a) Astragalus membranaceus. An extract of this plant is used to produce Huang ch’i. (b) Camellia sinensis. Green tea is made from the dried leaves and leaf buds of this shrub. (a) Courtesy of John Martin (http://www.geocities.com/herbalogic2001/index.html); (b) © Tracing Tea/Shutterstock.
(a)
(b)
432 Chapter 13 Cancer
beam of radiation rotates around the patient while continually targeting the tumor so that various areas of healthy tissue receive minimal doses of radiation but the tumor receives high doses. Another method is to implant tiny radioactive “beads” in the cancerous tissue for a speci!c time and then remove them. With either approach, cancer patients usually undergo numerous treatments over a 5- to 8-week period.
Figure 13.5 shows a highly e#ective treatment against cancer called proton therapy. In this treatment, a patient’s cancer is bombarded with a stream of posi- tively charged subatomic particles called protons.
At high doses, proton irradiation kills cells, as does any type of high-dose radiation. Proton radia- tion, however, can be focused more precisely on the cancer than can other forms of radiation. "erefore, a higher dose of radiation can be used with less radia- tion a#ecting surrounding cells. Nonetheless, proton therapy is still not in widespread use because it is about three times as costly as traditional radiation therapies, and few treatment facilities in the United States o#er proton irradiation.
Chemotherapy Chemotherapy is the use of anticancer drugs to inhibit cancer cell reproduction or to destroy can- cer cells. Chemotherapy is used most o$en when cancer has spread to various regions of the body. As with radiation therapy, chemotherapy may be used in
marrow and peripheral blood stem cell transplants. In the past, physicians referred to a cancer as “cured” if the patient survived for 5 years with no sign of the cancer returning. "is is no longer the case, however, because some cancers grow a$er extended periods, and others recur a$er they seem to have been elimi- nated. Today, the term cure means that all traces of a localized tumor have been removed from the body and the former cancer patient has the same life expectancy as a person who never had cancer.
Surgery During surgery, physicians remove a localized cancer by cutting it away from noncancerous tissue. Micro- scopic extensions of cancerous tissue may not be easy to detect during surgical procedures, so a physician usually removes tissue beyond the obvious cancer to increase the probability that all the cancerous tissue is removed. Although surgery is o$en a life-saving treatment, one drawback is that removal of healthy tissue with unhealthy tissue may impair the body’s functioning or cause dis!gurement. "e other draw- back is that surgery is futile if the cancer has spread to multiple sites in the body.
Radiation Radiation is also used to treat localized cancers, either alone or in conjunction with surgery. Radiation is energy or particles emitted from the nucleus of an atom. "e energy of any high-dose radiation interferes with the molecular structures of cells, killing them. Healthy cells recover more quickly and easily from radiation treatment than do cancer cells, so the healthy tissue surrounding a cancer usually survives while the cancer dies. For this reason, a physician may recom- mend radiation over surgery in particular instances. Preserving healthy tissue surrounding a cancer is extremely important, especially with cancers such as laryngeal cancer (cancer of the voice box), in which it may mean the di#erence between a patient’s retaining or losing the ability to speak. Physicians also choose radiation over surgery for treatment of cancers that respond well to radiation therapy, such as cervical can- cer, prostate cancer, and Hodgkin disease. Physicians o$en use radiation treatment with elderly patients because their chance of recovering from it may be higher than that of recovering from surgery.
High-dose X-ray and gamma-ray irradiation are widely used today. Patients may undergo one of two methods of radiation treatment. One method is to focus a beam of radiation on the cancerous tissue from an outside source. "e machine delivering the
Figure 13.5 Proton Therapy. This patient at the James M. Slater, M.D. Proton Treatment and Research Center at Loma Linda University Medical Center is ready to receive proton therapy to treat cancer of the brain. The mask immobilizes the head to ensure that the beam will hit its target. Courtesy of the James M. Slater, M.D. Proton Treatment and Research Center, Loma Linda University Medical Center.
Cancer Treatment 433
therapies. Because these therapies target speci!c molecules in speci!c cancers, they are o$en more e#ective than general types of treatments and harm only the cancer, not surrounding tissues. One major limitation of targeted therapies, however, is that the cancer cells may develop mutations (changes) that no longer allow the therapy to work. "erefore, targeted therapies are o$en used alongside other targeted therapies and conventional treatments, such as sur- gery and radiation.
"e two primary types of targeted therapies are small-molecule drugs and immunotherapy.
Small-Molecule Drugs Small-molecule drugs are tiny enough to pass through pores in the cell membrane and do their work from within the cancer cell. An array of small-molecule drugs for targeted cancer therapy have been developed and approved by the FDA for use. Some are not yet approved but are in clinical trials.
Small-molecule drugs each do a speci!c job, such as blocking certain enzymes and growth factor recep- tors that cancer cells use as they grow and multiply, modifying the function of proteins that regulate can- cer cell functions and stopping cancerous tumors from developing new blood vessels.
Immunotherapy Some targeted therapies help the immune system destroy cancer cells. "e umbrella term for these methods is biomodulation (biological response modi!cation), or immunotherapy.
Key to the working of the immune system is its ability to recognize an intruder as foreign. "e immune system does this by recognizing foreign antigens (certain foreign proteins) on intruders as nonself. However, tumor cells appear to contain antigens that evoke only a weak response from the immune system. As a result, the immune sys- tem has di&culty detecting and identifying malig- nant tumors, so it does a poor job destroying these abnormal cells.
Immunotherapies involve a variety of techniques that help boost the immune system response. For example, injecting tumor antigens into the patient’s bloodstream can increase the numbers of tumor- !ghting immune system cells in the body. "is procedure is similar to the way in which a vaccine works to boost the body’s immune response against an infectious disease. For this reason, such cancer- !ghting products are called cancer vaccines. However, cancer vaccines are given to patients who already have cancer to help rid them of their disease, not to cancer-free persons to prevent cancer. Some medi- cal facilities involved in cancer vaccine research are
conjunction with surgery. In certain cases, physicians combine all three approaches to cancer treatment.
Radiation and chemotherapy treatments also kill and damage healthy cells and may cause serious side e#ects such as severe nausea and hair loss. In addi- tion, these treatments do not always destroy cancers completely because their doses are not high enough to do so. Doses su&ciently high to kill all cancer cells o$en cause too much damage to normal tissue. Also, certain tumors are drug resistant or develop drug resistance during therapy.
Laser and Photodynamic Therapy Lasers are high-intensity lights that can be focused with great precision. A few types of lasers are used in cancer treatment, and they shrink and destroy tumors. Lasers can be used not only to remove super- !cial cancers, such as some skin cancers, but also with an endoscope to deliver the laser light to inte- rior body locations, such as the uterus, esophagus, and colon.
In photodynamic therapy, a chemical called a photosensitizer, which is administered to the patient, reacts with a laser or other types of special light, kill- ing tumor cells. "e treatment is speci!c to tumors because they take up the photosensitizer better than normal tissues do, and physicians target the light at the tumors. "erefore, this type of treatment does not signi!cantly damage normal tissues. Death of the tumor cells results from the interaction of the light and the chemical.4 In addition, as the tumor cells become in'amed before dying, they trigger an immune response that acts not only on the treated cells but also on the same type of tumor cells that may be elsewhere in the body.5
Targeted Therapies "e National Cancer Institute de!nes targeted therapies as “drugs or other substances that block the growth and spread of cancer by interfering with speci!c molecules involved in tumor growth and progression.”6 Targeted therapies are also called molecularly targeted drugs and molecularly targeted
targeted therapies Drugs or other substances that block the growth and spread of cancer by interfering with specific molecules involved in tumor growth and progression.
immunotherapy Manipulation of the body’s immune system to rid the body of cancer.
434 Chapter 13 Cancer
treatments can be lifesaving, prevention and early detection are still the best ways to live a healthy, long, cancer-free%life.
Prevalent Cancers in the United States
Over decades of research, scientists have learned what causes certain cancers. In some cases, scien- tists are unsure of the cause but know which factors are related to cancer development. "ese factors, when present, increase the chances that a person will develop a particular cancer and thus are called risk factors. Although heredity in'uences cancer risk, it explains only a fraction of all cancers and varia- tions in cancer risk. Behavioral factors such as ciga- rette smoking, dietary patterns, physical activity, and weight control, however, substantially a#ect the risk of developing cancer.8
"is chapter organizes the discussion of cancers according to factors that appear to be signi!cant in the development of particular cancers, most of which are prevalent in the United States. Advanced age is a signi!cant risk factor for most cancers except certain childhood cancers, testicular cancer, cervical cancer, and, in part, breast cancer.
Before reading this section, take the self-assess- ment “What Are Your Cancer Risks?” found in the Student Workbook section of this text.
Cancers Caused by or Related to Tobacco In 2004, U.S. Surgeon General Richard Carmona issued a report on smoking and health that listed tobacco smoking as a cause of various cancers.9 Table" 13.2 lists these cancers. In 2010, U.S. Surgeon General Regina Benjamin expanded on the informa- tion in the 2004 report by issuing a new report on how tobacco smoke causes disease.10 "irty percent of all cancer deaths, including 87% of lung cancer deaths, can be attributed to tobacco use.11
"is section explores the !rst seven cancers in Table 13.2 because they are all caused primarily by this preventable risk. Stomach cancer and cancer of the cervix are discussed in other sections of this chapter because their primary causes relate to factors other than tobacco use. Pancreatic cancer has a vari- ety of risk factors.
Lung Cancer Looking at Table 13.3, you can see that lung cancer is the leading cause of cancer deaths
using a patient’s own tumor cells to develop personal- ized cancer vaccines that hold promise for boosting immune system function higher than can vaccines developed from tumor antigens from other sources.7
Examples of other immunotherapies are drugs that decrease the suppressor mechanisms of the immune system, thus increasing the host’s immune response. Another approach is to augment the patient’s immune system through bone marrow transplants (tissue that produces immune system cells; see the next subsec- tion) or transfusions of particular immune system cells. Other immunotherapies are chemicals that act on tumor cells by making them more recognizable by the body or more susceptible to dying as a result of immune system processes.
Bone Marrow and Peripheral Blood Stem Cell Transplants Stem cells are undi#erentiated cells whose daughter cells can develop into a variety of cell types. Bone marrow cells are stem cells that continually give rise to a variety of types of blood cells. Peripheral blood (blood in the bloodstream) can be used as a source of blood stem cells too, but donors must be treated with growth factors (hormonelike substances) a few days before the donation, which causes their stem cells to grow and enter their bloodstream. "eir har- vested blood is processed by a machine that separates out the stem cells; the rest of the blood is returned to the%donor.
Bone marrow and peripheral blood stem cell transplants are used in two primary ways in cancer treatment: (1) to resupply the bone marrow when it has been destroyed by chemotherapy or radiation, or (2) to supply healthy stem cells to a person who has cancer of the blood-forming tissue, such as leukemia. In the !rst situation, a patient’s own stem cells are harvested before chemotherapy or radiation, and the stem cells are given back to the patient a$er the treat- ment. In the second instance, the stem cells come not from the patient but from a healthy donor whose tis- sue type best matches the patient. "e healthy stem cells are transplanted into the patient, and these cells produce healthy blood cells.
Patients receive stem cell transplants (whether the stem cells are their own or those of a donor) in a process much like a blood transfusion. "e stem cells take up residence in the bone marrow, grow, and send out new blood cells.
"is section discusses many types of cancer treatments. Although these useful and amazing
Prevalent Cancers in the United States 435
in both men and women in the United States. Death rates resulting from lung cancer have risen dramati- cally in men since the 1930s through the 1980s and in women since the 1960s through the early 1990s (see Figure 13.3). Estimates put tobacco use as the main cause of 90% of male lung cancers and 79% of female lung cancers; about 90% of lung cancer deaths overall can be attributed to smoking cigarettes.12
"e increases in lung cancer death rates shown in Figure 13.3 are due to increases in the percentage of the population who smoked tobacco in the decades before the 1960s. Lung cancer, like most cancers, takes years to develop, so a rise in lung cancer death rates occurs decades a$er a rise in the percentage of the population who smoke.
Incidence rates of lung cancer (the number of people diagnosed per 100,000 population) have begun to stabilize in women and drop in men (see Figure% 13.3). "is stabilization and drop re'ect the beginning of a predicted decline in incidence rates resulting from the steady decline in cigarette smok- ing in the U.S. population since 1964. In that year, U.S. Surgeon General Luther Terry issued a report that linked cigarette smoking to the development of lung cancer and other diseases.13
Signs and Symptoms In the early stages of dis- ease, the signs and symptoms of lung cancer may be hard to detect. Cigarette smokers o$en have chronic cough, chronic bronchitis, or excess sputum (saliva and mucus) production. Tumors growing in the bron- chioles (small airways in the lungs) also cause a cough and sputum production; they may also cause blood to appear in the sputum because they disrupt airway tissues. A lung cancer victim may also wheeze when breathing if the airways become substantially narrowed by tumor growth. In addition, the air sacs in that part of the lung may collapse and cease to function; infec- tion may develop. "e patient may experience pain in the chest, shoulder, and arm if the cancer spreads to the chest wall and a#ects certain nerves there.
Physicians use chest X-rays and other imaging techniques, including MRI and CT scans; analyses of the types of cells in the sputum; and !ber-optic examination of the bronchial passageways to assist in their diagnoses.
Risk Factors and Prevention Malignant growths develop in the lungs and airways in many persons as they inhale cancer-causing substances such as tobacco smoke over long periods of time. "e risk of lung cancer rises proportionately with the num- ber of cigarettes (or cigars or pipes) a person smokes per day, the number of years a person smokes, and how deeply he or she inhales. Persons who smoke low-tar cigarettes have a lower risk of lung cancer than those who smoke high-tar cigarettes.9 (Smoking “low-yield” cigarettes does not lower cardiovascular disease risk.) Likewise, those who smoke !lter-tipped cigarettes have a lower risk of lung cancer than those who smoke un!ltered cigarettes. However, results of research show that people who smoke !lter-tipped or low-yield cigarettes are at increased risk for develop- ing deep lung tumors because, when smoking, they inhale more deeply and forcefully than people who smoke non-!lter-tipped or “regular-yield” cigarettes.9
If you smoke, giving up cigarette smoking will slowly lower your risk of developing lung cancer, sev- eral other cancers, and cardiovascular disease as well. Your risk of developing lung cancer will never return to that of a lifetime nonsmoker, but a$er 10 years it will be about half that of a person who continued to smoke.9 However, your risk of developing cardiovas- cular disease will lower considerably in only 1 year and return to that of a nonsmoker in 3–15 years, depending on how much and how long you smoked.
Other lifestyle factors that appear to raise the risk of lung cancer are regular, high consumption of alcoholic beverages and obesity. Combined estrogen
Bladder
Esophagus
Kidney
Larynx (voice box)
Acute myeloid leukemia
Lung
Mouth and throat
Pancreas
Stomach
Cervix
Data from U.S. Department of Health and Human Services. (2004). The health consequences of smoking: A report of the Surgeon General. Washington, DC: U.S. Government Printing Office.
Table 13.2
Cancers Caused by Cigarette Smoking
passive smoking The inhalation, by nonsmokers, of tobacco smoke in the air.
436 Chapter 13 Cancer
higher risk of developing lung cancer if they smoke than do smokers with no relatives who have lung cancer. Scientists speculate that relatives of lung cancer patients may inherit a defect in their cells’ ability to resist genetic damage by the carcinogens in cigarette smoke.
In the early 1970s, medical researchers began investigating the e#ects of passive smoking on the development of lung cancer. Passive smoking is
and progestin postmenopausal hormone therapy does not increase the incidence of lung cancer, but it does appear to increase the risk of death from lung cancer.14 "e relationships between various dietary factors and lung cancer are controversial;11,15 more research is needed to determine clear associations.
Scientists have been unable to show that lung cancer is inherited. Nonetheless, correlational stud- ies show that relatives of lung cancer patients have a
Estimated New Cases* Male Female
Estimated Deaths Male Female
Prostate
164,690 (19%)
Breast
266,120 (30%)
Lung and bronchus
83,550 (26%)
Lung and bronchus
70,500 (25%)
Lung and bronchus
121,680 (14%)
Lung and bronchus
112,350 (13%)
Prostate
29,430 (9%)
Breast
40,920 (14%)
Colon and rectum
75,610 (9%)
Colon and rectum
64,640 (7%)
Colon and rectum
27,390 (8%)
Colon and rectum
23,240 (8%)
Urinary bladder
62,380 (7%)
Uterine corpus
63,230 (7%)
Pancreas
23,020 (7%)
Pancreas
21,310 (7%)
Melanoma of the skin
55,150 (6%)
Thyroid
40,900 (5%)
Liver and intrahepatic bile duct
20,540 (6%)
Ovary
14,070 (5%)
Kidney and renal pelvis
42,680 (5%)
Non-Hodgkin lymphoma
32,950 (4%)
Leukemia
14,270 (4%)
Leukemia
10,100 (4%)
Non-Hodgkin lymphoma
41,730 (5%)
Melanoma of the skin
36,120 (4%)
Esophagus
12,850 (4%)
Uterine corpus
11,350 (4%)
Oral cavity and pharynx
37,160 (4%)
Kidney and renal pelvis
22,660 (3%)
Urinary bladder
12,520 (4%)
Non-Hodgkin lymphoma
8,400 (3%)
Leukemia
35,030 (4%)
Pancreas
26,240 (3%)
Non-Hodgkin lymphoma
11,510 (4%)
Liver and intrahepatic bile duct
9,660 (3%)
Liver and intrahepatic bile duct
30,610 (4%)
Leukemia
25,270 (3%)
Kidney and renal pelvis
10.010 (3%)
Brain and other nervous system
7,340 (3%)
All sites
856,370 (100%)
All sites
878,980 (100%)
All sites
323,630 (100%)
All site
286,010 (100%)
*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.
Reproduced from American Cancer Society (2018). Cancer Facts and Figures 2018. Atlanta: American Cancer Society, Inc.
Leading New Cancer Cases and Deaths—2018 Estimates
Table 13.3
Prevalent Cancers in the United States 437
who do not smoke,” “More than 50 carcinogens have been identi!ed in sidestream and second- hand smoke,” and “"e evidence is su&cient to infer a causal relationship between secondhand smoke exposure and lung cancer among lifetime nonsmokers.”16
Substances other than those in tobacco smoke have also been linked to lung cancer. For example, certain metals, listed in Table 13.4, are carcinogenic. Only people in certain occupations encounter most of these substances.
the inhalation by nonsmokers of environmental tobacco smoke (ETS; secondhand smoke) present in the air from others who smoke. Environmental tobacco smoke has been associated with a 20–30% increase in lung cancer risk for persons who live with a smoker. "e following are a few of the many conclusions regarding the e#ects of secondhand smoke in the 2006 Surgeon General’s report "e Health Consequences of Involuntary Exposure to Tobacco Smoke: “Secondhand smoke causes pre- mature death and disease in children and in adults
Metal Cancers Present in Human Carcinogen? Workers Exposed
Arsenic Skin, lung, bladder, kidney, liver
Wood preservatives, glass, pesticides
Yes Smelting of ores containing arsenic, pesticide application, and wood preservation
Beryllium Lung Nuclear weapons, rocket fuel, ceramics, glass, plastic fiber- optic products
Yes Beryllium ore miners and alloy makers, phosphor manufacturers, ceramic workers, missile technicians, nuclear reactor workers, electric and electronic equipment workers, and jewelers
Cadmium Lung Metal coatings, plastic products, batteries, fungicides
Yes Smelting of zinc and lead ores; producing, processing, and handling cadmium powders; welding or remelting of cadmium-coated steel; and working with solders that contain cadmium
Chromium Lung Automotive parts, floor covering, paper, cement, asphalt roofing, anticorrosive metal plating
Yes Stainless steel production and welding, chromate production, chrome plating, ferrochrome alloys, chrome pigment, and tanning industries
Lead Kidney, brain Cotton dyes, metal coating; driers in paints, varnishes, and pigment inks; certain plastics; specialty glass
Probable carcinogen
Construction work that involves welding, cutting, brazing, or blasting on lead paint surfaces; most smelter workers, including lead smelters where lead is recovered from batteries; radiator repair shops
Nickel Nasal cavity, lung
Steel, dental fillings, copper and brass, permanent magnets, storage batteries, glazes
Nickel metal: Probable carcinogen
Nickel compounds: Yes
Battery makers, ceramic makers, electroplaters, enamellers, glass workers, jewelers, metal workers, nickel mine workers, refiners and smelters, paint-related workers and welders
Reproduced from National Cancer Institute. (2003). Cancer and the environment. Retrieved from http://www.cancer.gov/newscenter /Cancer-and-the-Environment
Carcinogenic Metals Found in the Workplace
Table 13.4
438 Chapter 13 Cancer
radiation or chemotherapy with surgery, targeted therapies, and/or laser therapy.
Cancers of the Larynx, Oral Cavity, and Esophagus Although these cancers are not as preva- lent as others, they have preventable causes: tobacco use, which includes the use of cigarettes, cigars, pipes, and smokeless (chewing) tobacco of all types, and excessive alcohol consumption. Heavy consump- tion of alcohol is o$en a causal factor in cancers of the esophagus and liver, but if a heavy drinker is also a smoker, the e#ects of both substances multiply the risk of developing cancer of the larynx, oral cavity, and esophagus.
Results of recent research show that an increas- ing percentage of oral cancers are associated with the human papillomavirus (HPV), which enters the mouth during oral sex with an infected person. "e primary population developing HPV-related oral cancers is White men between the ages of 40 and 55%years.17
Cancers of the larynx, or voice box, are usually detected early if they involve the vocal cords because the voice quickly becomes hoarse. However, cancers of the larynx that do not involve the vocal cords are
Two substances signi!cantly associated with the development of lung cancer and o$en encountered in the environment are asbestos and radon. Asbestos is a !berlike mineral found in rocks that resists damage by !re or other natural processes. Because of these properties, asbestos has been used in the manufacture of a variety of products and is used in the construc- tion, shipbuilding, and railroad industries. People in these industries as well as those who mine asbestos are at risk of developing lung cancer if they inhale asbestos particles. Additionally, the e#ects of inhal- ing asbestos particles multiply the e#ects of smoking tobacco and therefore greatly increase risk.
Exposure to radon gas also appears to multiply the carcinogenic e#ect of tobacco smoke. Radon gas is colorless and odorless and is produced as the radioactive element uranium decays, emitting sub- atomic particles and energy. When inhaled, radon can cause mutations in cells because it is radioactive also. Radon is present in the rocks and soils in many areas in the United States (Figure 13.6). People who live in these regions may be exposed to radon gas if it leaks through cracks in basement walls and collects in their homes. Home radon detectors can ascertain the presence of this gas. If radon is present, special- ists in radon abatement can advise a homeowner on procedures to prevent this gas from leaking into and accumulating in the house (Figure 13.7).
Treatment Physicians treat lung cancer primarily with surgery, radiation, and chemotherapy. Surgeons o$en remove the lobe of the cancerous lung. "ey may combine therapies if the cancer has spread, using
asbestos (as-BES-tose) A fiberlike mineral found in rocks that, when inhaled, can cause lung cancer or other lung conditions.
radon gas A colorless, odorless radioactive gas present in the rocks and soils in many areas in the United States that, when inhaled, can cause mutations in cells.
FL
NM
DE MD
DC
TX
0 100 Miles
0 100 Kilometers
0 250 Miles
0 250 Kilometers
0 300 Miles
0 300 Kilometers
More than 4 picocuries per liter 2–4 picocuries per liter Less than 2 picocuries per liter
OK
KS
NE
SD
NDMT
WY
CO UT
ID
AZ
NV
WA
CA
OR
KY
ME
NY
PA MI
VT
NH MA
RI CT
VA WV
OH INIL
NC TN
SC
ALMS
AR
LA
MO
IA
MN
WI
NJ
GA
HIAK
Figure 13.6 Areas of the United States Where Radon Gas Is Most Prevalent.
Prevalent Cancers in the United States 439
white patches that do not go away, or thickened areas of tissue. Oral cancer metastasizes relatively quickly; over half of cases are diagnosed in advanced stages. To detect oral cancer early, persons older than age%50 years should have complete oral exami- nations as part of their annual physical checkups. Dentists should routinely screen all their patients for oral cancer.
Cancers of the Kidney and Bladder "e kidneys and bladder are organs of the urinary system, yet tobacco smoking is a causal factor in cancers of these organs. "ese organs come in contact with inhaled carcinogens in tobacco smoke (or other inhaled car- cinogens) a$er they enter the bloodstream at the lungs. "e kidneys !lter the carcinogens into the urine, which exposes the kidneys and bladder to these substances before urination.
Most signs and symptoms of kidney and bladder cancer are the same as those of several other condi- tions, so experiencing any of them is not a sure sign of cancer. One such sign of both cancers is blood in the urine. Frequent, urgent, or di&cult urination is also a sign of bladder cancer. Additional signs and symp- toms of kidney cancer include a fever of unknown origin, weight loss, and anemia (a decrease in the hemoglobin in the blood).
Most people who get bladder or kidney cancer are men older than 50 years of age who are heavy smok- ers. Cigarette smokers have 2–10 times the risk of developing bladder or kidney cancer as nonsmokers. As with lung cancer, the risk increases with the num- ber of cigarettes smoked per day and the number of years a person has been a smoker. People lessen their risk when they decrease the number of cigarettes they
more di&cult to discover early. "eir symptoms may include a sore throat, di&culty swallowing, or a vis- ible lump in the neck.
"e esophagus is the tube that carries food and drink from the mouth to the stomach. Di&culty swallowing is also a symptom of esophageal cancer. In addition, people who have recurrent heartburn or a burning sensation while swallowing should be checked for possible esophageal carcinoma.
In oral cancer, malignant or benign growths are o$en visible (Figure 13.8). Malignancies may appear as sores that bleed easily and do not heal, red or
Figure 13.7 Radon Gas Abatement. Although many types of radon gas abatement exist for homes, one of the most common and reliable is active sub- slab suction. This technique is used in homes with basements or built on slabs. One or more pipes are inserted through the floor slab into the crushed rock or soil below. The pipe travels up the wall to the attic, where the gas is vented. (a) The part of the pipe in the attic houses a radon exhaust fan. The fan draws the radon up the pipe while simultaneously creating a vacuum beneath the slab. The radon gas is vented to the outside. (b) Somewhere along its length, the pipe has a vacuum monitor so that the homeowner can see that the system is operating. (a) Courtesy of Robert Fingland; (b) Courtesy of Wendy Schi".
Figure 13.8 Tongue Cancer. This close-up of a cancer patient’s mouth shows a malignant tumor on the edge of the tongue. This type of cancer spreads rapidly. The survival rate is low. Tongue cancer may be related to smoking cigarettes or to the use of smokeless tobacco. © John Radcli"e Hospital/Science Source.
(a) (b)
440 Chapter 13 Cancer
v Diversity in Health Stomach Cancer: Variation in Mortality Among Countries More Americans died of stomach cancer in 1930 than of any other type of cancer. In the United States, the death rate resulting from this cancer has fallen dramati- cally since then (see Figure 13.3). However, the Inter- national Agency for Research on Cancer at the World Health Organization reports that stomach cancer is still the number two cancer killer worldwide (lung cancer is number one). Why has the death rate from this cancer fallen in the United States? Why is this cancer so preva- lent in other parts of the world?
As scientists studied worldwide patterns of mortal- ity from stomach cancer, they noticed high mortality rates in Central and South American countries such as Brazil, Chile, Colombia, Costa Rica, and Venezuela. They also noticed large differences in death rates from stom- ach cancer in some of these countries. In Colombia, for example, death rates from this disease differ dramatically in populations living in the mountains compared to pop- ulations living along the coast. A similar situation exists in central and eastern European countries. There are high mortality rates from stomach cancer in these countries; however, the death rates between countries and within countries in this part of the world vary. In addition, coun- tries in Eastern Asia, which includes China, Taiwan, Japan, North Korea, South Korea, and Mongolia, have extremely high mortality rates from stomach cancer. Why are some countries’ rates of death resulting from stomach cancer dramatically higher than others? (You can research inci- dence and mortality rates for various cancers in countries around the world at http://gco.iarc.fr/.)
Scientists have determined that differences in world- wide stomach cancer death rates are related to diet and environment rather than to race or country of origin. Likewise, the reduction in stomach cancer deaths in the
United States is the result primarily of these factors.
Regarding diet, methods of food pro- cessing and preservation affect the inci- dence of stomach cancer. In the early 1900s in the United States, methods of food processing and preservation changed dramatically. By midcentury, refrigeration and freezing replaced salting, pickling, and smoking as the primary methods of food preserva- tion. Scientists have since discovered that the regular consumption of highly salted foods (including pickled foods) increases the risk of developing stomach cancer. Foods that are smoke cured, charbroiled, or grilled con- tain high quantities of polycyclic aromatic hydrocarbons (PAHs), which are carcinogenic and mutagenic. These compounds are also found in cigarette smoke and air pol- lution because they are the products of the incomplete combustion of fossil fuels such as charcoal and gasoline. Although many Americans enjoy eating grilled foods, their consumption of smoked, salted, and pickled foods has decreased since the early 1900s, reducing Americans’ risk of developing and dying from stomach cancer. However, peoples of various cultures still use salting and smoking to preserve meats and pickling to preserve vegetables, thereby increasing their risk of stomach cancer.
Another dietary factor with an environmental link plays a role in the development of this disease. Ingest- ing nitrosamines, which are found in nitrite-cured foods (such as bacon, cold cuts, and some hot dogs) and in water supplies in some parts of the world (such as Colombia and South America), appears to increase the risk of stomach cancer. Nitrosamines are also found in cigarette smoke. Chemical reactions that occur in the stomach produce nitrosamines from other compounds. For example, substances in certain fish consumed in Japan and in fava beans consumed in Colombia are con- verted in the stomach to nitrosamines.
smoke or stop smoking. Obesity is another known risk factor for kidney cancer.18
Cancer of the Pancreas A long, slender gland, the pancreas lies near the stomach. As an accessory organ of the digestive system, the pancreas secretes digestive enzymes that enter the small intestine by means of a duct. As an endocrine gland, the pancreas secretes the hormones insulin and glucagon, which help regulate blood levels of glucose.
Pancreatic cancer is a particularly deadly form of cancer, striking men and women fairly equally.
"e fourth most common cause of cancer death in men and women (see Table 13.3), pancreatic can- cer is o$en called a silent cancer because the early symptoms, which include nausea, vomiting, weak- ness, and discomfort in the abdomen, are vague and nonspeci!c. "e more speci!c signs and symptoms of pancreatic cancer—jaundice (yellowing of the eye- balls and skin), pain, and weight loss—do not usu- ally occur until the disease is advanced and then may be confused with many other diseases, such as gallbladder or liver disease.
(Continues)
Prevalent Cancers in the United States 441
bloodstream. Risk also appears to increase with obes- ity, physical inactivity, chronic in'ammation of the pancreas, diabetes, and cirrhosis of the liver. In addi- tion, rates of pancreatic cancer appear to be higher in those who use smokeless tobacco.
Only about 6% of people who have pancreatic cancer survive beyond 5 years.3 Late detection and metastasis reduce survival. For the rare patients who
"e risk of pancreatic cancer increases a$er age 50; most cases occur in persons aged 65–79 years. "e incidence of pancreatic cancer for smokers is more than twice that for nonsmokers. Other persons at risk for developing pancreatic cancer are chemists and those in occupations that involve close expo- sure to gasoline and dry cleaning agents. Inhaled carcinogens appear to reach the pancreas via the
v
Eating fruits and vegetables appears to inhibit the reactions in the stomach that form nitrosamines. In addition, they appear to protect the stomach from the effects of carcinogens. Populations who consume large quantities of fruit and vegetables generally have a low risk of stomach cancer.
In addition to dietary factors, infection with the bacte- rium Helicobacter pylori has been found to be associated
with the development of stomach cancer. H. pylori, which also increases the risk of digestive system ulcers, is highly prevalent in Asian countries. Persons with H. pylori can be treated with antibiotics to eradicate the stomach infection. Although killing this microorganism is an effective treatment for ulcers, it results in only a slowing of the precancerous process and does not pre- vent all stomach cancers.
400 4000200 100300 100 200 300
Male Female
Australia/New Zealand
South America
Western Europe
Southern Europe
Northern Europe
Northern America
Central and Eastern Europe
More developed regions
World
Southern Africa
Western Asia
Polynesia
Caribbean
Micronesia
South-Eastern Asia
Melanesia
Less developed regions
Eastern Asia
Central America
Eastern Africa
Northern Africa
Middle Africa
South-Centeral Asia
Western Africa
Incidence Mortality
Figure 13.B Estimated Rates of Stomach Cancer Around the World, 2012. Reproduced with permission from Ferlay J, Soerjomataram I, Ervik M, Dikshit#R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012#v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available#from: http://globocan.iarc.fr, accessed on August 15, 2018.
442 Chapter 13 Cancer
Cancer of the Stomach "e incidence of and mortality from stomach cancer has declined dramati- cally over the past 75 years in the United States. In the early part of the twentieth century, stomach cancer, not lung cancer, was the number one cancer killer of Americans. (See the Diversity in Health essay titled “Stomach Cancer: Variation in Mortality Among Countries” for an explanation of this decline.)
Stomach cancer is another of the silent cancers because no signs and symptoms appear early in its course. As the disease progresses, a person may expe- rience mild stomach discomfort with gas pains or vague sensations of fullness. Suspecting minor diges- tive problems, a person with these symptoms may take antacid tablets, and the symptoms disappear. As the cancer continues to grow, the malignancy causes more severe pain that is less responsive to antacids. "e stomach cancer victim may then experience a decreased appetite, a feeling of fullness a$er just beginning to eat, pain on eating, nausea and vomit- ing, weight loss, excessive burping, and weakness.
"e risk of stomach cancer increases with age and doubles each decade over the age of 55. However, the primary risk factors for cancer of the stomach are dietary factors. Diets high in salt-cured, nitrate- cured, or smoked food increase the risk of stom- ach cancer. Cigarette smoking and consuming large quantities of alcoholic beverages are also risk fac- tors. "e Diversity in Health essay discusses the risk factors for stomach cancer in greater detail.
Stomach cancer is easily diagnosed with barium studies. During this procedure, the patient swallows
discover their cancer in its early stages, surgery is a primary treatment that may lead to a cure and long- term relief of symptoms. In patients diagnosed in later stages of the disease, surgery, radiation, chemo- therapy, and certain targeted cancer therapies may extend survival.
Acute Myeloid Leukemia Acute myeloid leuke- mia (AML) a#ects blood-producing cells in the bone marrow. In AML, white blood cells that combat bac- terial infection (neutrophils) are primarily a#ected, but occasionally red blood cells or platelets are a#ected as well. "ese cells do not di#erentiate prop- erly from stem cells in the bone marrow (see the sec- tion titled “Bone Marrow and Peripheral Blood Stem Cell Transplants” in this chapter), resulting in lower than normal numbers of these cells in the blood- stream. AML is a serious disease and is likely fatal if not treated. Chemotherapy and stem cell transplanta- tion are standard treatments.
"e primary known causes of AML are exposure to benzene and ionizing radiation. Cigarette smoke contains benzene and substances that emit ioniz- ing radiation, along with other substances thought to cause AML. Data from human and experimental animal studies show a causal relationship between smoking and acute myeloid leukemia. "e risk for AML increases with the number of cigarettes smoked and with the duration of smoking.9
Cancers Related to Diet Research results suggest that about one-third of the cancer deaths that occur annually in the United States result from nutrition and physical activity factors, including obesity.8 For Americans who do not use tobacco (to which another one-third of cancer deaths are attributed annually), dietary choices and physical activity are the most important modi!able determi- nants of cancer risk. Along with adopting a physically active lifestyle and maintaining a healthful weight, the American Cancer Society recommends eating a variety of healthful foods, with an emphasis on plant sources. Table 13.5 lists the ACS’s dietary recommendations.
As you can see from Table 13.5, diet has both a positive and a negative e#ect on the development of cancer. Some dietary components raise the risk of certain cancers and others lower the risk of cer- tain cancers. One cancer strongly related to diet is stomach cancer. "e other cancer related to diet— colorectal cancer—can be a#ected signi!cantly by one’s heredity. Other cancers, such as breast cancer, have risk factors related to diet but are related to other risk factors as well.
• Eat five or more servings of fruits and vegetables per day.
• Eat whole grain foods rather than processed (refined) grain foods.
• Limit consumption of red meats and processed meats.
• Choose foods that help maintain a healthy weight. • Limit alcoholic beverages to one per day if you are
female and two if you are male.
Adapted from American Cancer Society. (2018). Cancer facts and figures, 2018. Atlanta, GA: Author.
Table 13.5
Dietary Recommendations for Reducing Cancer Risk
Prevalent Cancers in the United States 443
consumption. People with type 2 diabetes are at higher risk as well. A diet high in red or processed meat (hot dogs and some luncheon meats) and meat cooked at very high temperatures as in grilling, and an inadequate intake of fruits and vegetables might raise colorectal cancer risk.3
Beginning at age 40, both men and women are at increased risk for developing colorectal cancer; this risk doubles with each decade a$er age 50 and peaks at about age 70. More than 90% of people diagnosed with colorectal cancer are older than age 50.19 People who have hereditary conditions in which they tend to grow numerous (sometimes hundreds) polyps in their gastrointestinal tracts have very high incidences of colorectal malignancies. In addition, people who have a !rst-degree relative (parent or sibling) with colon cancer are 3–5 times more likely to develop colorectal cancer than are people with no such family history of this disease.
Aspirin has been found to have a protective e#ect against colorectal cancer when taken daily at a dose of at least 75 mg, about one baby aspirin, for 5 years or more.20 In addition, exercising moderately and consistently reduces the risk of colon cancer. Con- suming a diet that contains adequate amounts of fruits, vegetables, and whole grains; replaces red and processed meats with chicken and !sh; and replaces most saturated fats with unsaturated fats can reduce the risk of colorectal cancer. Postmenopausal hor- mone replacement and calcium reduce colorectal cancer risk as well.11,21
Early detection of colorectal cancer usually results in a high chance of survival. Although colorectal cancer may have no easily recognizable early symp- toms, tests are available to screen for this cancer. Common tests are the fecal occult blood test, digital rectal examination, sigmoidoscopy, and colonoscopy. Less common tests are the double-contrast barium enema, the CT colonography (virtual colonoscopy), and the stool DNA test (sDNA).
"e fecal occult blood test (FOBT) detects hid- den blood in the stool. "e patient performs the simple test at home by smearing stool onto a piece of paper that has been sensitized to detect occult blood. O$en, the test papers can be mailed to a laboratory or to the physician for interpretation. "is test will not detect all colorectal cancers, however, because not all colorectal cancers bleed. Also, positive tests may indicate conditions other than colorectal cancer.
A stool DNA test for colorectal cancer screen- ing was developed recently and is endorsed by the American Cancer Society. Using extremely sensitive
a milky 'uid called barium sulfate. As this material reaches the stomach, a series of X-rays are taken that show the movement of this 'uid through the stomach, while visualizing obstructions and other growths. Physicians o$en obtain stomach cells by the use of a !ber-optic tube, which can be !tted with instruments for such procedures. If a tumor is found, a biopsy is taken of the growth so that the cells can be studied and the diagnosis con!rmed.
In the United States, stomach cancer is no longer a major killer; therefore, routine screening is not per- formed as it is in high-risk populations such as Japan. "us, most stomach cancers are not diagnosed early in the United States. If found early, however, stom- ach cancer can be treated with surgery to remove the tumor. Chemotherapy and radiation are also used to treat stomach cancer and may be used in conjunction with surgery.
Cancer of the Colon and Rectum "e colon, or large intestine, is an organ of the digestive system that reabsorbs water and certain chemicals from waste materials (feces). Bacteria in the colon decompose materials that the human body cannot digest. "e rectum is the lower part of the large intestine; it terminates at the anus.
Cancer of the colon and rectum, jointly referred to as colorectal cancer, is the third most deadly cancer in the United States (see Table 13.3). "e signs and symptoms of colorectal cancer depend on the loca- tion of the tumor. A person may have no symptoms or few symptoms at !rst. Some persons !rst experi- ence vague or crampy abdominal pain that may be mistaken for an ulcer. Other indications may be a change in bowel habits, such as constipation alternat- ing with diarrhea. Blood may be visible in the stool (feces), or on screening, a person may have a positive occult (hidden) blood test. As the cancer worsens, a person with colorectal cancer may have a complete obstruction of the colon that requires emergency surgery.
"e primary risk factors for developing colorec- tal cancer are advanced age, heredity, personal or family history of colorectal polyps (small growths) or in'ammatory bowel disease, physical inactiv- ity, obesity, smoking cigarettes, and heavy alcohol
colon The large intestine.
rectum The lower part of the large intestine.
fecal occult (FEE-kle ok-KULT) blood test (FOBT) Home test that detects hidden blood in the stool.
444 Chapter 13 Cancer
widespread use. More cancers in earlier stages were detected than previously, which showed up as an increase in the incidence rate. "e incidence rate held steady from 1987 to 1994 but rose 1.6% from 1994 to 1999. "e American Cancer Society suggests that this increase was due to rising rates of obesity and an increased use of postmenopausal combined estrogen plus progestin hormone replacement therapy (HRT). Combined HRT has since been shown to increase the risk of breast cancer, with the cancer risk rising with increasing length of use of HRT. From 1999 to 2006, incidence rates fell 2%; this may have been the result of a decrease in mammography screening and a decrease in the use of HRT following the publica- tion of the Women’s Health Initiative study revealing the link between combined HRT and breast cancer in 2002.23,24 "e rate of breast cancer declined through 2015; however, an estimated 252,000 new cases of invasive breast cancer were diagnosed in 2017.25 Breast cancer is rare in men; it accounts for 1% of U.S. cases. Even so, men should report any changes in their breast tissue to their doctor.
Signs and Symptoms "e signs and symptoms of breast cancer involve changes in the breast tissue, including lumps in the breast; dimpling, thickening, discoloration, irritation, or scaling of the breast skin; tenderness of the nipple or nipple discharge; and swelling or distortion of the breast. Pain is not usually a sign of breast cancer; most breast cancers are pain- less in their early development. Breast pain is usually caused by cyclic hormonal changes and related breast swelling.
Risk Factors and Prevention Approximately 5–10% of breast cancers are the result of the inheri- tance of mutations in the breast cancer susceptibil- ity genes BRCA1 and BRCA2.25 In addition, women with !rst-degree relatives (mothers, sisters, daugh- ters) who have breast cancer are at increased risk for developing the disease. Men are at very low risk for developing breast cancer. Genetic testing is available for people whose family history suggests that they carry breast cancer susceptibility genes.
laboratory methods, the sDNA test detects cells shed into the stool from precancerous or cancerous polyps, which have recognizable changes in their DNA. Research results show sDNA tests to be more e#ective than FOBT in detecting colorectal cancer.22
To perform the digital rectal exam, a physician uses a gloved !nger to feel the rectum for abnor- mal growths. Sigmoidoscopy is a procedure in which the physician views the lower portion of the colon (the sigmoid [S-shaped] colon) with a 'exible !ber-optic tube. During a similar procedure called a colonoscopy, the !ber-optic tube is threaded through the entire length of the colon. "e sigmoido- scope or colonoscope can also be used to remove or biopsy polyps or other growths.
"e double-contrast barium enema is an X-ray examination of the colon when it is !lled with a bar- ium solution. Additional X-rays are taken a$er the patient expels the solution. "e barium provides a contrast medium that helps visualize polyps or other growths. Another method to visualize the entire length of the colon is the virtual colonoscopy. "is test is a type of CT or MRI scan that produces both two- and three-dimensional images of the colon. Although expensive and not as sensitive as the colon- oscopy, the virtual colonoscopy could become an option for patients who want a test that is less inva- sive than a colonoscopy.
See the Managing Your Health box titled “Screening Guidelines for the Early Detection of Cancer in Aver- age-Risk Asymptomatic People” earlier in this chapter for information on early detection of colorectal can- cer. When colorectal cancer is detected early, surgery is the primary treatment. Physicians o$en use chemo- therapy and radiation therapy a$er surgery to kill any metastasized cancer that was not detected or removed by surgery. If surgery is not possible, a physician may treat the cancer with chemotherapy or radiation ther- apy alone. Targeted therapies may also be used.
Cancers Related to Hormone Function Breast Cancer From the mid-1950s until 1985 in the United States, breast cancer was the number one can- cer killer of women. Lung cancer then usurped the top position because the death rate from lung cancer in women continued to rise while the death rate from breast cancer began to decline.
"e incidence of breast cancer in women has remained stable for decades, but its incidence increased nearly 4% per year between 1980 and 1987, when mammography screening came into
digital rectal exam A test in which a physician uses a gloved finger to feel the rectum or the prostate for abnormal growths.
sigmoidoscopy (SIG-moid-OS-ko-pee) A procedure in which a physician views the lower portion of the colon via a flexible fiber-optic tube.
colonoscopy (KO-lon-OS-ko-pee) A procedure in which a physician views the entire length of the colon using a flexible fiber-optic tube.
Prevalent Cancers in the United States 445
Managing Your Health Breast Self-Examination Breast self-examination should be done once a month so you become familiar with the usual appearance and feel of your breasts. Familiarity makes it easier to notice any changes in the breast from month to month.
Early discovery of a change from what is “normal” is the main idea behind BSE. The outlook is much better if you detect cancer in an early stage.
If you menstruate, the best time to do BSE is 2 or 3 days after your period ends, when your breasts are least likely to be tender or swollen. If you no longer men- struate, pick a day such as the first day of the month to remind yourself it is time to do BSE.
Here is one way to do BSE:
1. Stand before a mirror. Inspect both breasts for anything unusual, such as any dis- charge from the nipples or puckering, dimpling, or scal- ing of the skin.
The next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten
2. Watching closely in the mirror, clasp your hands behind your head and press your hands forward.
3. Next, press your hands firmly on your hips and bow slightly toward your mirror as you pull your shoulders and elbows forward.
Some women do the next part of the exam in the shower because fingers glide over soapy skin, making it easy to concentrate on the texture underneath.
4. Raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the area between the breast and the under- arm, including the underarm itself. Feel for any unusual lump or mass under the skin.
5. Gently squeeze the nipple and look for discharge. (If you have any discharge during the month—regardless of whether it is during BSE—see your doctor.) Repeat steps 4 and 5 on your right breast.
6. Steps 4 and 5 should be repeated lying down. Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine. Use the same circular motion described earlier. Repeat the exam on your right breast.
446 Chapter 13 Cancer
as well. "e longer HRT is taken, the greater the increase in risk.
Overweight and obesity are other risk factors for breast cancer because fat tissue produces estrogen. "erefore, overweight and obese women have higher circulating levels of estrogen than do nonoverweight and nonobese women. Postmenopausal obesity is thought to increase the risk of breast cancer three- fold;12 overweight and obese women can lower their risk of breast cancer by exercising and losing weight. Regular exercise not only helps a person maintain a healthy weight but also appears to have an e#ect on hormones and energy balance in a way that lowers breast cancer risk.
Smoking cigarettes and drinking alcohol are also associated with breast cancer risk. Drinking more than one alcoholic drink per day raises the risk of breast cancer, so to lower risk, minimize alcohol intake. With smoking, women at greatest risk are those who have smoked for decades and who started smoking at a young age.26
"e American Cancer Society notes that there is no scienti!c evidence linking breast cancer risk with wearing underwire bras, having breast implants, or using antiperspirants, as has been stated on many Internet sites. In addition, there is no evidence linking spontaneous or induced abortion with breast%cancer.23
Early Detection "ree methods are generally used to detect breast cancer as early as possible: the
Another major risk factor for the development of breast cancer in women is age. Breast cancer is rare in women younger than 20 years, but the incidence begins to climb throughout the 20s, rises dramati- cally during the 30s through the mid-70s, and then drops signi!cantly (Figure 13.9). Researchers at the American Cancer Society estimated that 90% of new breast cancer cases and 93% of breast cancer deaths occurred in women aged 45 years and older. Incidence and death rates from breast cancer are generally high- est among White and African American women.25
In addition to age and heredity, a third major group of breast cancer risk factors consists of those that increase a woman’s cumulative exposure to ovar- ian hormones, particularly estrogen. Evidence sug- gests that having a high number of menstrual cycles is a breast cancer risk factor. For example, early me narche (younger than age 12) and late menopause (older than age 55) are risk factors for breast cancer. Also, women who did not have a full-term pregnancy (therefore did not have their cycles interrupted) are at a higher risk than those who have. Women who did not have a full-term pregnancy until a$er age 30 are also at higher risk.25
Breast cancer risk is slightly elevated in women currently taking oral contraceptives and remains slightly elevated until about 10 years a$er use is discontinued. Recent use of HRT that combines estrogen and progestin increases breast cancer risk
Figure 13.9 Breast Cancer: Incidence and Mortality Rates by Age and Race, United States, 2010–2014. Reproduced from American Cancer Society. Breast Cancer Facts and Figures 2017-2018. Atlanta: American Cancer Society, Inc.
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Prevalent Cancers in the United States 447
breast self-examination, the breast clinical examina- tion, and mammography. Breast self-examination (BSE) is considered optional by the American Can- cer Society because research results do not show that monthly BSE saves lives. Research results also reveal that when women !nd changes or lumps in their breasts, it is usually not during structured breast self-examinations but during the normal course of dressing, bathing, or other similar activities.25 How- ever, women should become aware of how their breasts normally feel and report any breast change to a healthcare professional immediately. "e Manag- ing Your Health box titled “Breast Self-Examination” shows how to perform the BSE should you choose to do so. "e breast clinical examination is performed by a healthcare professional. "e ACS recommends that a clinical examination be performed every 3%years for women 20–39 years of age and every year therea$er.
Mammography is the process of taking X-rays of breast tissue to detect benign and malignant growths. As you can see in Figure 13.10, each breast is placed over a plate containing X-ray !lm, and the tissue is compressed. "e ACS recommends that women aged 40 years and older have a mammogram every year. Women at high risk for breast cancer, such as those with a strong family history of the disease, should consult their physicians regarding the need for mam- mograms on a di#erent schedule (e.g., at an earlier age, or more o$en).
If screening reveals a suspicious mass in the breast tissue, a physician usually performs a biopsy. To per- form this procedure, a physician inserts a !ne needle into the mass and withdraws cells. An individual trained to detect cancer studies the cells to determine if the growth is malignant. Fine-needle biopsy is rela- tively painless and is about 90% accurate.
Treatment Stage 0, I, or II breast cancer is usu- ally treated with lumpectomy, surgical removal of the tumor, followed by breast irradiation. (Stage 0 in breast cancer is o$en a precancerous condition.) "e surgeon also removes a layer of normal tissue surrounding the tumor so that it is less likely that cancer tissue is le$ in the breast. He or she also
removes some lymph nodes under the nearby arm- pit to determine if the cancer has spread. About 6% weeks of radiation therapy typically follows lumpectomy. Clinical trials are under way to deter- mine whether irradiating only the part of the breast with the excised tumor might be a better postsur- gical approach than irradiating the entire breast, which is the current approach.
Accelerated partial-breast irradiation (APBI) might reduce the amount of radiation absorbed by normal breast tissue and increase the percentage of lumpectomy patients who choose radiation therapy. APBI would be a shorter course of treatment—only 1–2 weeks—but the doses of radiation would be higher than in whole-breast irradiation.27
Women with advanced breast cancer may need more aggressive surgery than a lumpectomy. Total mastectomy is removal of the entire breast and
lumpectomy (lum-PECK-toe-me) Surgical removal of a breast tumor, including a layer of surrounding tissue.
total mastectomy (mas-TEK-toe-me) Surgical removal of a breast and involved lymph nodes for the treatment of breast cancer.
Figure 13.10 Mammography. Each breast is placed on a platform, and the tissue is compressed while the X-ray is taken. © Photodisc.
448 Chapter 13 Cancer
Most endometrial cancer is diagnosed at an early stage because of postmenopausal bleeding. "e Pap test for cervical cancer does not detect cancer in the body of the uterus. ("is test is discussed shortly.) However, if the physician suspects that a patient has endome- trial cancer, he or she usually performs an endometrial biopsy, in which a sample of tissue is removed from the endometrium and examined microscopically.
Although the cause of endometrial cancer is unknown, it is associated with prolonged exposure to estrogen. "erefore, the risk factors for endome- trial cancer are similar to those for breast cancer: early menarche, late menopause, not bearing chil- dren, and delaying pregnancy. Additionally, women who are more than 50 pounds overweight, especially postmenopausal women, have a tenfold greater risk for developing endometrial cancer than women who are not overweight. As with breast cancer, exercising reduces risk.3 Using oral contraceptives that combine estrogen and progesterone reduces risk as well, but estrogen replacement therapy without progesterone (unopposed ERT) is a risk factor.14 Infertility and dia- betes are possible risk factors for endometrial cancer as well.3
Many women diagnosed with endometrial cancer undergo total hysterectomy: removal of the uterus, fal- lopian tubes, and ovaries. Radiation, hormones, and/ or chemotherapy are sometimes used a$er surgery. "e outlook for survival a$er treatment for endome- trial cancer is good: "e 1-year and 5-year survival rates are approximately 92% and 82%, respectively.3
Cancers Related to Viral Infection: Cervical Cancer Certain viruses are implicated in the development of a variety of cancers; Table 13.6 lists these viruses and the cancers to which they are related. However, viruses alone do not appear to cause cancer. Scien- tists think that interactions between these viruses and other agents, or cocarcinogens, result in the development of cancer. For example, the high inci- dence of liver cancer in certain regions of Africa and Asia appears to be caused by interactions between the hepatitis B virus and a'atoxins. A'atoxins are a
involved lymph nodes. A radical mastectomy is removal of the entire breast and underlying muscle as well as the underarm lymph nodes and fat. In a modi#ed radical mastectomy, underlying muscle is not removed.
Immunotherapy, hormonal therapy, and che- motherapy are also used in breast cancer treatment in addition to surgery and radiation. Trastuzumab (Herceptin) is a drug used in targeted immuno- therapy. Women with late-stage recurring cancer are o$en treated with this monoclonal antibody. Anti- bodies are receptor proteins that recognize foreign substances (antigens) in the body and bind to them. Monoclonal antibodies are made in the laboratory from a single type of antibody. In this case, trastuz- umab is an antibody that targets a particular breast tumor protein. A$er binding to this protein, the anti- body works in various ways to shrink breast cancer tumors and stop tumor cells from multiplying. Women treated with both trastuzumab and chemo- therapy have been found to be less likely to experi- ence a recurrence of their cancer than women treated with chemotherapy alone.25
"e primary drug used in hormonal therapy is tamoxifen, an antiestrogen. Antiestrogens coun- teract the e#ects of estrogen on breast cancers that depend on estrogen for their growth. Tamoxifen has few serious side e#ects compared to other antican- cer drugs, reduces the annual recurrence rate by approximately 40%, and reduces the death rate by approximately 35%.25
Chemotherapy is also used to treat breast cancer, sometimes in conjunction with tamoxifen. Com- pounds have been discovered that have demonstrated good antitumor activity in breast cancer treatment. Taxol was the !rst to be discovered. (Taxol is found in the bark of the Paci!c yew tree Taxus brevifolia.) Today a variety of drugs are used in breast cancer chemotherapy, with combinations of drugs providing more e#ective results than single drugs.25
Endometrial Cancer "e endometrium is the lin- ing of the uterus, the organ in which a fetus develops until birth. Endometrial cancer most o$en occurs in postmenopausal women; only 5% of endometrial cancers occur in women younger than 40 years.28 "e primary symptom of this cancer is abnormal uterine bleeding. Premenopausal women usually experience symptoms of irregular, heavy, or prolonged uter- ine bleeding during menstrual periods or bleeding between periods. Postmenopausal women experi- ence uterine bleeding although they no longer have menstrual periods.
radical mastectomy Surgical removal of a breast, underlying muscle, and underarm fat and lymph nodes as a treatment for breast cancer.
endometrial cancer Begins in the uterus when cells that form that from the lining (endometrium) of the uterus begin to grow out of control.
Prevalent Cancers in the United States 449
35 and 54 years, with a median age at diagnosis of 48. Approximately 14% of cervical cancer cases are diagnosed in women between the ages of 20 and 34% years.29 If untreated, cervical cancer can invade surrounding tissues and metastasize. Having regu- lar screening tests can reduce the risk of developing invasive cancer of the cervix.
A causal association exists between infection with human papillomavirus (HPV) and cervical cancer. HPV is transmitted by infected men to their female partners during sexual intercourse and vice versa. "erefore, the greater the number of male sexual partners a woman has over time, the greater are her chances of becoming infected with HPV. If a woman is monogamous but her male sex partner is not, her risk rises because he is more likely to become infected than if he were monogamous. Also, women who had their !rst sexual intercourse before age 17 are at increased risk because they are more likely to have a greater number of sexual partners over time than those women who became sexually active at an older age. In addition, long-term use of oral contra- ceptives is associated with an increased risk of cervi- cal cancer.3
At low risk for cervical cancer are women who are celibate or who are monogamous with a monog- amous partner over many years. Sexually active women with multiple partners or with nonmonoga- mous partners can lower their risk by using male or female condoms to protect themselves against infection with HPV.
In 2006, the U.S. Food and Drug Administration approved the !rst vaccine developed to prevent cervi- cal cancer (Gardasil) and in 2009 approved a second (Cervarix). Gardasil is highly e#ective in preventing infection by four types of HPV. Two types (HPV-16 and HPV-18) cause approximately 70% of cervi- cal cancers,8 and the other two types (HPV-6 and HPV-11) cause about 90% of all genital warts. "e FDA in 2009 expanded the approval of Gardasil for use in boys and young men to prevent genital warts. Cervarix acts against HPV-16 and HPV-18 only. "e American Cancer Society recommends routine HPV vaccination for females aged 11 and 12 years and for females aged 13–18 years “to catch up on missed vac- cine or complete the vaccination series.”8
HPV vaccines do not prevent infection with all types of HPV, so vaccinated women should still have regular Pap tests. In addition, neither vaccine pro- tects nor treats women already infected with HPV, so it is important for girls and young women to be vac- cinated before they become sexually active.
group of carcinogens produced by a mold that grows on improperly stored peanuts and grains. Many people in these regions eat these moldy foods.
"e virally related cancer most prevalent in the United States is cervical cancer. Since 1960, the inci- dence of cervical cancer has declined dramatically, primarily because of the widespread routine use of the Papanicolaou test (Pap test) to screen women for cervical cancer. To perform the Pap test, a physi- cian or other specially trained healthcare professional takes a sample of cells from the cervical canal. "ese cells are examined under a microscope. A% newer method of collecting and analyzing samples is the liquid-based thin-layer slide preparation, which appears to be more sensitive than standard Pap tests. In addition, computer-automated readers improve the analysis of Pap tests.
Most women who are diagnosed with cervical can- cer have no symptoms; their cancers are discovered at an early stage during their annual gynecological examination and Pap test. If undiagnosed, the cancer may cause symptoms of abnormal vaginal bleeding (the most common symptom), pelvic pressure or pain, and/or a foul-smelling vaginal discharge.
Cervical cancer most o$en develops in young and middle-aged women, generally between the ages of
Virus Cancer Type
Hepatitis B virus (HBV) Primary liver cancer
Human T-cell lymphotropic/leukemia virus (HTLV)
Adult T-cell lymphoma/ leukemia
Cytomegalovirus (CMV) Kaposi’s sarcoma
Human papillomavirus (HPV)
Cervical cancer, penile cancer, oropharyngeal cancer
Epstein-Barr virus (EBV) Burkitt’s lymphoma, nasopharyngeal cancer
Table 13.6
Viruses and Cancers to Which They Are Related
Papanicolaou (PAP-eh-nik-eh-LOUW) test (Pap test) A screening procedure for cervical cancer in which cells from the cervical canal are removed and then smeared on a glass slide for microscopic examination.
450 Chapter 13 Cancer
"ere are three types of ultraviolet radiation: UVA, UVB, and UVC. All three types are harmful and have the potential to cause skin cancer. Claims by tanning parlors that using only UVB rays will protect you from the e#ects of UV radiation are false. "is type of ultraviolet radiation is associated with sun- burn and skin cancer formation, as is UVA radiation. UVA radiation is also strongly associated with pre- mature aging e#ects. Arti!cial UV sources, such as sun lamps and tanning beds, may also generate UVC rays. UVC radiation is a highly potent cancer-causing radiation. Although a danger from arti!cial sources, these rays are !ltered out by the Earth’s atmosphere and pose little danger from environmental sources.
"ere are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and malig- nant melanoma. Approximately 60% of skin cancers are basal cell carcinomas, and approximately 30% are squamous cell carcinomas. Although malignant melanoma makes up less than 10% of skin cancers, this fast-growing, metastasizing cancer results in the most deaths. Malignant melanoma spreads quickly via the blood and lymph. Death is usually the result of either respiratory failure or brain or spinal cord complications. Table 13.7 lists steps for preventing skin cancer.
Basal cell carcinoma, the most common can- cer of the skin, o$en a#ects persons older than 40
"e American Cancer Society recommends that all women have annual conventional Pap tests or biannual liquid-based Pap tests 3 years a$er their !rst vaginal intercourse but no later than age 21. "e ACS suggests that a$er three consecutive normal Pap tests, women older than 30 years may have this test performed every 2–3 years or at the discretion of their physicians.
If the Pap test shows that cervical cancer may be present, a physician usually performs a colposcopy. Using a specially designed microscope, the physi- cian examines the cervix. If the physician observes abnormal cervical tissue during this procedure, he or she usually performs a biopsy to con!rm the diagnosis.
Physicians treat dysplasia or cervical cancers in situ with surgery, electrocoagulation, cryotherapy, and carbon dioxide (CO2) laser surgery. Laser energy destroys the tissue. Cryotherapy is the use of extreme cold to destroy cells. Usually solid car- bon dioxide or liquid nitrogen is applied brie'y to the abnormal tissue with a sterile cotton-tipped applicator. A blister forms and the tissue dies. Elec- trocoagulation kills the tissue through intense heat by electric current.
With invasive cervical cancers, surgeons may perform a simple hysterectomy (removal of just the uterus) or a total hysterectomy (removal of the uterus and ovaries). With certain cervical cancers, radiation is the treatment of choice. Detected early, cervical cancer is highly survivable.
Cancers Related to Ultraviolet Radiation: Skin Cancers Lying on the beach or on a tanning bed to develop a tanned “healthy” look is anything but healthy! When skin tans, it is a sign of skin damage. Certain skin cells produce a pigment called melanin to protect the skin from the damaging rays of the sun. Melanin is a built-in sun protector for dark-skinned people and is produced in response to sun damage in light-skinned people. In addition to causing the skin to wrinkle and age prematurely, the ultraviolet (UV) radiation in sunlight can result in the development of skin cancer. In fact, UV light exposure is the most important fac- tor (other than heredity and age) that in'uences the development of skin cancer. In addition to tanning (UV rays) causing skin damage in general, sunburns during childhood and intense intermittent sun expo- sure increase the risk of melanoma and other skin cancers later in life.8
• Do not use tanning beds. • Avoid exposure to the sun (particularly sunbathing),
especially between 10 A.M. and 4 P.M. when UV radiation is highest.
• When in the sun, wear sunglasses that block at least 99% of UVA and UVB radiation. Larger glasses and wraparounds provide the best protection.
• When in the sun, wear wide-brimmed hats and clothing that covers the arms, legs, and torso as much as possible.
• Use sunscreens with a sun protection factor (SPF) of 15 or higher regularly on sun-exposed skin.
Table 13.7
Steps to Reduce the Risk of Melanoma and Other Skin Cancers
basal (BAY-sl) cell carcinoma The most common cancer of the skin, which frequently develops on portions of the skin exposed to the sun.
Prevalent Cancers in the United States 451
melanoma develops more o$en in persons who are exposed to the sun in short, intense sessions, such as persons who work indoors and then vacation
years. A slow-growing cancer that rarely metasta- sizes, basal cell carcinoma frequently develops on portions of the skin exposed to the sun: the face, head, neck, and arms. Lesions may look like moles or chronic pimples with pearl-like borders. "ey o$en become crusty and scaly and may ulcerate and bleed (Figure 13.11a). Basal cell carcinoma tumors are usually removed by surgery and cryotherapy, freezing with liquid nitrogen. "e cure rate for basal cell carcinoma is high.
Squamous cell carcinoma is the second most common skin cancer in light-skinned persons; it develops in the same sun-exposed areas as basal cell carcinoma. However, people with darker skin can develop this type of cancer, not from sunlight exposure but from exposure to noxious chemicals and high levels of X-rays, as well as from trauma (burns and chronic ulcers). "e skin lesions of squamous cell carcinoma look 'at, red, and scaly, and may be slightly elevated (Figure 13.11b). "ese tumors are removed by the same methods as basal cell carcinoma.
Both basal and squamous cell carcinomas develop from prolonged, repeated exposures to the sun. At risk are persons who are outdoors much of the time, such as construction workers, farmers, and people who regularly sunbathe and use tanning beds.
Malignant melanoma is a deadly skin cancer that a#ects men at a 50% higher rate than women and usu- ally occurs in people who are White. "e incidence of melanoma has been rising over the last 30 years, most notably in young women aged 15–39 years who are White. Additionally, an increase has been seen in both sexes aged 65 years and older.3
"e risk for developing malignant melanoma and other skin cancers is higher the closer a person lives to the equator because of the increasing intensity of UV rays. Fair-skinned people are at greater risk than those who have darker skin. At highest risk are per- sons with light blue eyes, very light hair, and skin that burns easily and freckles rather than tans. Malignant
squamous (SKWAY-muss) cell carcinoma A common form of skin cancer that develops from exposure to noxious chemicals and high levels of X-rays, as well as from trauma.
malignant melanoma (MEL-ah-NO-mah) A deadly form of skin cancer that develops most often in persons who have been exposed to the sun in short, intense sessions, have had severe sunburn and extensive sun exposure in childhood, or have first-degree relatives who had the disease.
(a)
(b)
(c)
Figure 13.11 Skin Cancers. (a) This basal cell carcinoma is a raised lesion with central depressions that bleed and crust over. (b) Squamous cell carcinoma looks like a red rounded mass or a flat sore, as shown in the photo. (c) Lesions of malignant melanoma are usually characterized by irregular borders with red, white, blue, or blue-black spots. Some portions may be raised. Courtesy of National Cancer Institute.
452 Chapter 13 Cancer
Health-Related InformationAnalyzing Critical Thinking
This article focuses on the use of tanning beds and the link to malignant melanoma. Explain why you think this article is a reliable or an unreliable source of informa- tion. Use the model for analyzing health information to guide your thinking; the main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the source making these health-related claims? Does the source have the appropriate background and education in the topic area? What can you do to check the credentials of this source?
3. What might be the motives and biases of the source making the claims?
4. What is the main point of the article? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Sum- marize your reasons for coming to this conclusion.
Study Links Tanning Bed Use to Increased Risk of Melanoma
People who use tanning beds are more likely to develop mela-noma, the deadliest form of skin cancer, than never-users, according to a new study from the University of Minnesota. "e more regularly a person frequents tanning salons, the greater the risk, the study shows.
In July 2009, a$er a comprehensive review of the available research, the International Agency for Research on Cancer (IARC) elevated tanning devices to its highest cancer risk category— “carcinogenic to humans” (Group 1). Despite this risk, approximately 30 mil- lion Americans still visit indoor tanning salons each year. "at may be at least in part because the tanning industry has pointed to limitations in previous stud- ies and continues to tout the purported health bene!ts of tanning, including vita- min D production.
"e new study, funded by the National Cancer Institute and the American Cancer Society, was designed to help answer more de!nitively whether tanning bed use is linked to skin cancer.
“Most reports were not able to adjust for sun exposure, con!rm a dose-response,
or examine speci!c tanning devices,” said study author DeAnn Lazovich, PhD, professor of epidemiology, University of Minnesota School of Publishing and coleader of the Masonic Cancer Center’s Prevention and Etiology Research Pro- gram. “Our population-based, case- control study was conducted to address these limitations.”
What %is Study Found "e researchers, led by Lazovich, collected detailed information on the tanning hab- its of more than 1,100 Minnesotans aged 25–59 who had been diagnosed with mela- noma between July 2004 and December 2007, as well as a matched group of more than 1,100 people without melanoma.
"e researchers gathered data on tanning bed use, including years of use, age at which use began, and the speci!c devices used, as well as other factors such as age, sunscreen use, and family history of melanoma.
According to their !ndings, people who had ever used an indoor tanning device were about 75% more likely to have devel- oped melanoma. Frequent users—de!ned as using a tanning device for at least 50% hours, at least 100 sessions, or at least 10 years—were 2.5–3 times more likely to develop melanoma than those who had never used them. "e risk went up with increasing tanning bed use, the study showed, and was elevated regardless of the type of device.
“We found that it didn’t matter the type of tanning device used; there was no safe tanning device,” Lazovich said. “We also found—and this is new data—that the risk of getting melanoma is associated more with how much a person tans and not the age at which a person starts using tanning devices. Risk rises with frequency of use, regardless of age, gender, or device.”
Lazovich and her team’s !ndings are published in Cancer Epidemiology, Bio- markers and Prevention, a journal of the American Association for Cancer Research.
Melanoma on the Rise "e number of new cases of melanoma in the United States has been increasing for at least 30 years. "e American Cancer Society estimates that about 90,000 new melanomas will be diagnosed in the United States during 2018. Melanoma is 10 times more common in Whites than in African Americans. It is slightly more common in men than in women.
More than 2 million skin cancers are diagnosed each year in the United States. "at’s more than cancers of the prostate, breast, lung, colon, uterus, ovaries, and pancreas combined.
Most skin cancers are caused by too much exposure to ultraviolet (UV) rays. Much of this exposure comes from the sun, but it also comes from manmade sources, such as tanning beds.
Because of the popularity of tanning among young people, both the World
Prevalent Cancers in the United States 453
this objective is to increase to at least 80.1% the pro- portion of persons age 18 years or older who fol- low protective measures that may reduce the risk of skin cancer, such as limiting sun exposure and using sunscreens and protective clothing when exposed to sunlight. Baseline data from Healthy People 2020 show that about 70% of U.S. adults followed sun- protective measures in 2015. Another objective is to increase the proportion of high school students who follow sun-protective measures from 9.3% (baseline in 2009) to 11.2%.31
Reducing the proportion of adults and high school students who use tanning beds and lights is another Healthy People 2020 cancer-reduction objective. For high school students, the baseline was 15.6% who used tanning beds and lights in 2009; the target is a decrease to 14%. For adults, the baseline was 15.2% in 2008; the target is a decrease to 13.7%.31
Cancers with Unknown Causes Prostate Cancer "e prostate is a walnut-sized accessory sex organ in men. It lies beneath the blad- der, surrounding the urethra, and secretes part of the seminal 'uid.
Prostate cancer is the most prevalent cancer in men, and the second most prevalent cause of can- cer deaths in men (see Table 13.3). (Lung cancer is the% most prevalent cause of cancer death in men.) "e signs and symptoms of prostate cancer mimic those of benign prostatic hypertrophy (BPH) and other noncancerous conditions of the prostate. "erefore, experiencing symptoms that include uneven 'ow of urine while urinating, incomplete
in a sunny climate. Severe sunburn and extensive sun exposure in childhood also increase the risk for developing malignant melanoma in adulthood. First-degree relatives of people with melanoma have a two- to eightfold increase in their risk of develop- ing this cancer. Individuals who have two or more relatives with a history of melanoma may be at sub- stantially higher risk.
Malignant melanoma can develop on any skin surface as well as in the eye and on mucous mem- branes. In men, the trunk is the most common site; in women, the legs are a common site. If you are in a high-risk group for skin cancer, especially mela- noma, examine your skin regularly. Early detection is key to curing this disease. Typically, melanoma tumors are asymmetrical and have irregular bor- ders, multiple colors (such as blue, black, red, or gray), and a diameter greater than a pencil eraser ( Figure"13.11c). An easy way to remember these signs is ABCD: asymmetry, border, color, and diameter. Medical researchers recently determined, however, that very rapidly growing melanomas do not neces- sarily show the ABCD signs. "ese melanomas, most o$en found in men and women older than 65%years, may be red and raised with regular borders. "ey o$en itch and bleed.30
Healthy People 2020 is a program to improve the health of all Americans by guiding individu- als to make healthy choices and monitoring prog- ress made. A Healthy People 2020 objective is to reduce the death rate from malignant melanoma from 2.7%deaths per 100,000 population (baseline in 2007) to 2.4 deaths per 100,000. One way to achieve
Health Organization and the International Commission on Non-ionizing Radiation Protection recommend that the use of indoor tanning should be restricted in any- one under the age of 18. On May 29, 2014, the U.S. Food and Drug Administration announced that tanning beds must now carry a visible warning explicitly stating that the device should not be used by peo- ple under age 18. "e mandate was spurred by building evidence that tanning in child- hood and early adulthood signi!cantly
increases a person’s risk of melanoma later in life.
"e American Cancer Society recom- mends that people avoid tanning beds altogether. For information on how you can lower your risk of skin cancer, see Skin Cancer Prevention and Early Detection.
Data from Snowden, R. V. American Cancer Society. Retrieved April 25, 2011, from http:// www.cancer.org/Cancer/news/News/study -links-tanning-bed-use-to-increased-risk-of -melanoma© Stockbyte/Thinkstock.
454 Chapter 13 Cancer
New surgical techniques with fewer side e#ects have been developed, leading to a resurgence of prostate surgery as a treatment. Advanced prostate cancer is sometimes treated with drug/hormone therapy or by removal of the testicles to reduce male sex hor- mone levels, which may in'uence the progression of this cancer. Chemotherapy, radiation, or a com- bination of therapies may be used if the cancer has metastasized.3
Prostate cancer is, in many cases, a slow-growing cancer. Many prostate cancer patients die with pros- tate cancer rather than of it. Because the side e#ects of prostate cancer treatment can be quite serious, physicians carefully consider “watchful waiting” as the treatment of choice for this cancer.3
Testicular Cancer "e testicles, or testes, are the organs in which sperm develop and are located in the scrotal sac beneath the penis. Cancer of the testicles is a rare and highly curable cancer. Only 1% of can- cers in men occur in the testicles.
"e signs and symptoms of testicular cancer are a painless, swollen testis and a sensation of heaviness or aching in the testis. Men who perform testicular self-examination might feel a small lump in one testis.
Youth is a risk factor for testicular cancer. "is cancer strikes primarily men between the ages of 20% and 54 years. Another risk factor for testicular cancer is the failure of one or both of the testicles to descend into the scrotum by age 1 year. White males have the highest risk, Latino males have less risk, and African American men have the least risk. Men with a family history of testicular cancer are at increased risk, as are men who are infected with HIV or have AIDS. Men who have had testicular cancer in one testicle may develop it in the other.33
To detect testicular cancer early, the American Cancer Society recommends that men perform a testicular self-examination (TSE) once a month a$er a warm bath or shower (see the Managing Your Health box titled “Testicular Self-Examination”). "e heat relaxes the scrotal skin, making tumors easier to detect. If detected and treated early, testicular cancer is one of the most curable cancers. Surgery is most o$en used, frequently in conjunction with radiation or chemotherapy.
emptying of the bladder, reduced urine 'ow, and urinating more frequently at night does not neces- sarily mean a man has prostate cancer. However, serious signs and symptoms that are more likely to be related to prostate cancer are pain in the 'oor of the pelvis, sudden development of impotence, and presence of blood in the urine.
In the United States, African Americans have the highest prostate cancer incidence rate, followed by Whites, Hispanics, Native Americans, and Asian/Paci!c Islanders, in that order. Advanced age% and heredity are strong risk factors for pros- tate cancer. Along with family history of prostate cancer, having certain genetic mutations, such as BRCA2, increases risk. "is disease is rare in men younger than 45 years, but its incidence rises as men age. "e median age of death from prostate cancer is 80 years.3
"e American Cancer Society suggests that main- taining a healthy body weight and being physically active may reduce the risk of developing aggres- sive prostate cancer. Statins—cholesterol-lowering drugs—may reduce the risk of advanced prostate cancer. Long-term low-dose aspirin therapy may reduce prostate cancer risk as well, but taking aspirin for prostate cancer prevention is not recommended by the ACS.3 Substituting !sh for red meat in the diet may lower prostate cancer risk.12
For early detection of prostate cancer, the American Cancer Society recommends that all men 50 years and older have an annual prostate-speci!c antigen (PSA) test, with or without a digital rectal exam. During the digital rectal exam, a physician inserts a gloved !nger into the rectum to feel the prostate gland. "e PSA is a blood test that detects a protein secreted by the prostate. If the protein concentration in the blood is elevated, it indicates that the prostate may be abnormal but not neces- sarily cancerous and should be checked further. "e topic of prostate screening and the use of the PSA test is controversial. "e United States Preven- tive Services Task Force recommends that healthy men not be screened for prostate cancer using the PSA because the test has been shown to not save lives. "e American Cancer Society suggests that men make this decision with their physician a$er being fully informed of the risks and bene!ts of test%results.32
Physicians may treat localized prostate cancer by surgically removing the prostate and some surround- ing tissue. However, this treatment can result in impotence, incontinence, and other complications.
testicular (tes-TIK-you-lar) self-examination (TSE) A self-screening test that males can perform to detect cancer of the testicles.
Prevalent Cancers in the United States 455
Managing Your Health Testicular Self- Examination How the Test Is Performed Perform this test during or after a shower. This way, the scrotal skin is warm and relaxed. It’s best to do the test while standing.
1. Gently feel your scrotal sac to locate a testicle. 2. Hold the testicle with one hand while firmly but
gently rolling the fingers of the other hand over the testicle to examine the entire surface.
3. Repeat the procedure with the other testicle.
Why the Test Is Performed A testicular self-exam is done to check for testicular cancer. Normal testicles contain blood vessels and other struc- tures that can make the exam confusing. Performing a self-exam monthly allows you to become familiar with your normal anatomy. Then, if you notice any changes from the previous exam, you’ll know to contact your doctor.
You should perform a testicular self-exam every month if you have or have had any of the following risk factors:
1. Family history of testicular cancer
2. Previous testicular tumor
3. Undescended testicle
4. Are a teenager or young adult (to about 35 years old)
Normal Results Each testicle should feel firm but not rock hard. One testicle may or may not be lower or slightly larger than the other.
Always ask your doctor if you have any doubts or questions.
What Abnormal Results Mean If you find a small hard lump (like a pea), have an enlarged testicle, or notice any other concerning differences from your last self-exam, see your doctor as soon as you can.
Consult your doctor if: • You can’t find one or both testicles—the testicles
may not have descended properly in the scrotum. • There is a soft collection of thin tubes above the
testicle—it may be a collection of dilated veins (varicocele).
• There is pain or swelling in the scrotum—it may be an infection or a fluid-filled sac (hydrocele), causing blockage of blood flow to the area.
Sudden, severe (acute) pain in the scrotum or testicle is an emergency. If you experience such pain, seek immedi- ate medical attention.
Considerations A lump on the testicle is often the first sign of testicular cancer. Therefore, if you find a lump, see a doctor immedi- ately. Keep in mind that some cases of testicular cancer do not show symptoms until they reach an advanced stage.
Ovarian Cancer "e ovaries are female organs in which eggs mature and are ovulated each month. Ovaries also produce the female sex hormones estrogen and progesterone. Cancer of the ovaries is di&cult to detect, especially in its early stages, when most women have no symptoms. However, as the cancer progresses and the ovarian tumor enlarges, many women develop symptoms such as frequent urination or bloating and pressure in the abdomen. "us, advanced ovarian can- cer is confused frequently with other urinary and gastrointestinal% tract% disorders. Postmenopausal
women may experience vaginal bleeding, and premenopausal women may have irregular or heavy menses.
Advancing age is a risk factor for ovarian cancer. Most deaths from this disease occur in women 55% years and older. Other than advanced age, the risk factors for ovarian cancer are similar to those of breast and endometrial cancer: early menarche, late menopause, and not bearing children. "e links between these risk factors and ovarian cancer, how- ever, are not as well de!ned as they are in breast and endometrial cancer. Additional risk factors
456 Chapter 13 Cancer
4To lower your risk of developing lung cancer, do not smoke cigarettes, avoid inhaling airborne asbestos fibers, and avoid exposure to radon gas.
4If you are exposed to lung carcinogens at your place of work, explore ways to avoid future exposure.
4To prevent the development of larynx, mouth, and esophagus cancers, avoid smoking and chewing tobacco and excessive drinking of alcoholic beverages.
4Have a complete oral examination annually for early cancer detection.
4To lower your risk of developing cancer of the bladder and kidney, avoid smoking cigarettes.
4To lower your risk of pancreatic cancer, avoid smoking cigarettes and inhaling chemical fumes.
4To lower your risk of developing stomach cancer, avoid eating salt-cured, nitrate-cured, or smoked foods. Also avoid smoking cigarettes and drinking excessive amounts of alcoholic beverages.
4To reduce your risk of developing colorectal cancer, follow the American Cancer Society’s
Healthy Living Practices
screening guidelines and remove precancerous polyps.
4If you are female, you can reduce your risk of breast cancer by exercising and avoiding alcoholic beverages.
4To detect breast cancer in its early stages, follow the ACS guidelines for breast clinical examination and mammography. Be aware of any changes in your breasts.
4If you are female, you can reduce your risk of developing endometrial cancer by losing weight if you are overweight and by controlling diabetes mellitus if you have this disease.
4Discuss the impact of estrogen replacement therapy on the development of endometrial cancer with your healthcare provider if you are considering or are taking this medication.
4If you are female and older than 40 years, have annual pelvic examinations for early detection of endometrial cancer.
4If you are a sexually active woman with multiple partners or with nonmonogamous partners, you can lower your risk of cervical cancer by using male or female condoms to protect yourself against HPV. Young women can be vaccinated against certain types of HPV.
4All women can lower their risk of cervical cancer by avoiding cigarette smoking.
4If you have been sexually active and are age 21 years or older, the American Cancer Society recommends that you have annual Pap tests to screen for cervical cancer. See the ACS guidelines for detailed recommendations.
4To protect against skin cancer, stay out of the sun, wear sunscreen when outdoors, and do not use tanning beds or lights.
4Detect melanoma early by checking your skin for growths that exhibit these warning signs: asymmetry, irregular border, multiple colors, and large diameter. Be aware that fast-growing melanomas may be red, raised, and itchy with symmetrical borders.
4If you are male and older than 50, talk to your healthcare provider about annual digital rectal exams and PSA tests for the early detection of prostate cancer.
4If you are male, perform a testicular self- examination once every month to detect this cancer early.
include having had breast cancer, having a fam- ily member who had breast or ovarian cancer, and having mutations in the BRCA1 or BRCA2 breast cancer genes.34
Research results show that the use of oral contra- ceptives that contain both estrogen and progesterone lowers a woman’s risk of developing ovarian cancer. Estrogen replacement therapy without progesterone increases a woman’s risk of this cancer.34
No accurate routine screening test for women at average risk for ovarian cancer is available. How- ever, screening techniques are available for women who have symptoms of, or are at high risk for, ovar- ian cancer. Screening techniques include a thor- ough pelvic examination, transvaginal ultrasound, a blood test for tumor marker CA125, and a CT or MRI scan of the pelvic area. Ovarian cancer is treated with surgery, chemotherapy, and, rarely, radiation.34
Prevalent Cancers in the United States 457
detailed early warning signs for the various cancers described in this chapter. If you have concerns about your risk of developing cancer, discuss them with your healthcare provider. Early detection and treat- ment are critical to winning the war against cancer.
Reducing Your Risk for Cancer
You cannot change some of your cancer risk factors: heredity, age, ethnicity, lifelong exposure to naturally produced estrogen (in women), and the nondescent of testes (in male children). However, you can avoid many risk factors, thereby reducing your risk of developing one or more cancers. "e Managing Your Health box titled “Reducing Your Risk for Cancer” lists modi!able cancer risks and actions you can take to lower your risk.
A summary of the American Cancer Society’s recommendations for the early detection of can- cer is listed in the Managing Your Health box titled “Screening Guidelines for the Early Detection of Can- cer in Average-Risk Asymptomatic People” earlier in this chapter. Finally, the next Managing Your Health box lists cancer’s seven warning signs. In addition to being aware of these signs, you can learn the more
Managing Your Health Reducing Your Risk for Cancer DO’S • Eat a diet low in red meats, espe-
cially high-fat and processed meats. • Eat a variety of fruits and vegeta-
bles daily. • Follow the American Cancer Society’s recommen-
dations for screening tests to detect cancer in its early stages.
• Men should perform monthly testicular self- examinations.
• Know the warning signs of cancer and see your healthcare provider immediately if you detect any of them.
• Sexually active women with multiple partners or with nonmonogamous partners should use male or female condoms during sexual intercourse to protect themselves against infection with human papillomavirus.
• Maintain a healthy weight. • Women should consult their healthcare providers
regarding the use of oral contraceptives and estro- gen replacement therapy with respect to cancer prevention and risk.
• Exercise most days of the week. • When in the sun, wear wide-brimmed hats and
sunglasses that block UV radiation. • Wear sunscreen on sun-exposed skin.
DON’TS • Avoid cigarette use. If you already smoke and can’t
quit, try to smoke less. • Avoid breathing environmental tobacco smoke. • Don’t chew tobacco products. • Don’t drink excessive amounts of alcoholic
beverages. • Women should avoid drinking alcoholic beverages
to reduce the risk of breast cancer. • Avoid unnecessary exposure to ionizing radiation,
such as X-rays and ultraviolet light. • Don’t lie in the sun or in tanning beds. • Avoid direct sun exposure between 10 A.M. and
4 P.M. • Avoid exposure to toxic chemicals, such as certain
occupational carcinogens. • Avoid inhaling chemical fumes, such as gasoline
fumes. • Avoid breathing asbestos dust and radon gas. • Avoid eating salt-cured, nitrate-cured, or smoked
foods.
CANCER Most cancers arise in people older than 50 years, and the risk continues to rise as people grow older. "e only cancers described in this chapter that are prevalent in young adults are malignant melanoma, testicular cancer, cervical cancer, and breast can- cer. Only 1% of cancers occur in children. However, cancer is the most frequent cause of death from dis- ease in American children older than 1 year of age.
Across THE LIFE SPAN
458 Chapter 13 Cancer
"e most prevalent cancers of children up to 5 years old are listed in Table 13.8.
Adult cancers rarely occur in children. "ese cancers are largely related to the e#ects of cancer- causing agents acting on cells over a lifetime, whereas children’s cancers seem more o$en related to genetic factors.
Although pediatric cancers usually grow more rapidly than adult cancers do, they are, in gen- eral, more responsive to anticancer drugs than are adult cancers. For this reason, chemotherapy is the treatment of choice for most childhood can- cers, while surgery and radiation are the primary treatments for adult cancers. E#ective cancer che- motherapy has produced a remarkable decline in childhood deaths resulting from cancer over the past 30 years.
Managing Your Health
You can remember the following signs easily by knowing that they are a CAUTION: These signs do not necessar- ily mean you have cancer but that you should see your healthcare provider to evaluate the sign.
Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in the breast or elsewhere
Indigestion or difficulty in swallowing
Obvious change in a wart or mole
Nagging cough or hoarseness
Cancer’s Seven Warning Signs
Leukemia (cancer of the blood)
Central nervous system cancers
Lymphomas (cancer of the lymph nodes)
Nervous system tumors (often in adrenal glands)
Wilms’ tumor (cancer of the kidney)
Bone cancer
Retinoblastoma (cancer of the eye)
Liver cancer
Table 13.8
The Most Prevalent Cancers of Children up to Age 5 Years
Reducing Your Risk for Cancer 459
CHAPTER REVIEW Summary
Cancer is a variety of diseases that have common characteristics: "eir cells exhibit abnormal growth, division, and di#erentiation and have the potential to spread from where they develop. "ese cells form masses called malignant tumors that interfere with normal body processes.
Cancer develops in cells that have damaged or mutated genes. Mutations can be inherited or can occur from exposure to low-dose radiation, drugs, toxic chemicals, or certain viruses. Successive genetic changes must take place for a normal cell to change into a cancer cell. "erefore, the probability of devel- oping cancer generally increases with age and with exposure to cancer-causing substances.
"is chapter organizes the discussion of cancers according to factors that appear to be most signi!- cant in their development. Advanced age is a risk factor for most cancers; heredity is a signi!cant risk factor in some cancers.
Tobacco use causes cancers of the lung, larynx, oral cavity, esophagus, kidney, bladder, pancreas, stomach, blood, and cervix. To lower the risk of developing any of these cancers, avoid smoking and chewing tobacco products. Additionally, avoid drink- ing excessive amounts of alcoholic beverages to lower the risk of developing larynx, oral, and esophageal cancer. Have a complete oral examination annually for early cancer detection in this area.
Diet accounts for a signi!cant number of cancers and has both a positive and a negative e#ect on the development of cancer. A primary risk factor in the development of stomach cancer is eating salt-cured, nitrate-cured, or smoked foods. To lower the risk of developing this cancer, avoid eating these foods. To reduce the risk of developing colorectal cancer, avoid having more than one alcoholic drink per day and eat a diet adequate in vegetables and fruits. Refer to the ACS recommendations for screening recommenda- tions for colon cancer in persons over the age of 50.
"e cancers related to hormone function are breast cancer and endometrial cancer. "ese cancers are associated signi!cantly with prolonged exposure to estrogen. Risk factors associated with these can- cers are early menarche, late menopause, not bearing children, and delaying pregnancy. Exercising helps
reduce breast cancer risk in women. Avoiding alco- holic beverages also reduces the risk. For early can- cer detection, women aged 20–39 years should have a breast clinical examination every 3 years, and every year at age 40 and a$er. Women should become aware of the normal condition of their breasts and seek medical attention if they notice any changes. Women aged 45–54 years of age should have mammography every year. For early detection of endometrial cancer, women at menopause should report any unexpected bleeding or spotting to their physician.
Certain viruses are implicated in the development of a variety of cancers. "e virally related cancer most prevalent in the United States is cervical cancer. "e virus implicated in this disease, human papilloma- virus (HPV), is transmitted by infected men to their female partners during sexual intercourse, and vice versa. Sexually active women with multiple partners or with nonmonogamous partners can lower their risk of cervical cancer by using male or female condoms to protect themselves against HPV. Women can also lower their risk by avoiding cigarette smoking. Young women can be vaccinated against certain types of HPV.
"e ultraviolet radiation in sunlight is the most important factor that in'uences the development of cancer of the skin. "ere are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. Of these cancers, malig- nant melanoma results in the most deaths because it is a fast-growing metastatic cancer. Light-skinned, fair-haired Whites are a high-risk group for develop- ing skin cancer. To protect against skin cancer, stay out of the sun and wear sunscreen when outdoors. Detect melanoma early by checking your skin for growths exhibiting these warning signs: asymmetry, irregular border, multiple colors, and large diameter. Seek medi- cal attention for any suspicious lesions that do not heal.
Cancers with unknown causes include prostate cancer, testicular cancer, and ovarian cancer. "e risk factors for prostate cancer are age and heredity. For early detection of this cancer, men older than 50 should have annual prostate-speci!c antigen blood tests with or without a digital prostate exam. Men between the ages of 20 and 54 years are at the highest risk for testicular cancer. For early detection of this
460 Chapter 13 Cancer
CHAPTER REVIEW disease, all males 15 years and older should perform monthly testicular self-examinations. Ovarian cancer is primarily a disease of postmenopausal women.
Childhood cancers, although rare, are the most frequent cause of death from disease in American
children older than 1 year. Children develop can- cers as a result of hereditary or developmental factors. Occasionally, environmental agents are the cause.% Treatment for childhood cancers is highly%e#ective.
1. Imagine that you or a female friend had an annual Pap test. "e report from the lab stated that cells exhibiting dysplasia were seen in the smear. What does this statement mean? How would these cells look di#erent from normal cells? What would be your or your friend’s next course of action? Application
2. List three cancer risk factors over which a person has no control. Suppose that at least one of them was a risk factor for you. List this hypothetical (or real) factor and the cancer(s) related to this risk. What might you do regarding cancer pre- vention if you are aware of this (these) factor(s)? Application
3. Your good friend is a heavy drinker, eats lots of spicy food, and experiences heartburn regu- larly. He takes antacids, but recently they have not helped. He also tells you that he seems to have some di&culty swallowing, but he’s not quite sure. He thinks it’s “all in his head.” What would you advise your friend to do? Might can- cer be causing his problems? If so, which type?
Which symptoms led you to this conclusion? Application
4. List two dietary factors related to the develop- ment of cancer and two dietary factors related to lowering the risk of cancer. Name the cancers to which these dietary factors relate. Now list, as best you can remember, the foods you ate for the past 2 days. What is your intake of the types of foods related to cancer development and preven- tion? Based on this analysis, should you make changes in your diet to lower your risk of certain cancers? Evaluation
5. With respect to the cancers discussed in this chapter, which cancer(s) are you at least risk for developing? Why? Which cancers are you at highest risk for developing? Why? Synthesis
6. Referring to your answer to Question 5, what can you do to lower your risk of developing the can- cers for which you are at high risk? State ratio- nales for each suggestion. Why will these lifestyle changes lower your risk? Evaluation
Applying What You Have Learned
Key
Application using information in a new situation.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
1. Have your attitudes about cancer changed since reading this chapter? If so, explain how your atti- tude has changed and discuss why.
2. Were you aware of all the ACS recommenda- tions for the early detection of cancer before reading this chapter? If you were not, which
recommendations were new to you? Will you follow these recommendations? Why or why not? If you were aware of all the ACS recommendations, do you follow those recom- mendations for your sex and age group? Why or why not?
Reflecting on Your Health
Reflecting on Your Health 461
CHAPTER REVIEW 3. Do you know anyone who has or has had
cancer, or have you read stories written by cancer patients about their disease? Did you learn something about cancer from them that a#ected your life? Did you make any changes to your lifestyle based on these individuals’ experiences?
4. Complete the assessment “What Are Your Can- cer Risks?” in the Student Workbook pages of this text. Do your cancer risks match your self- perception of your risks? Did the self-assessment identify cancer risks of which you were unaware? A$er reading this chapter, develop a list of things you could do to reduce your cancer risks.
1. Abt, S. (1999, July 26). Armstrong wins tour and journey. "e New&York Times, D00001.
2. BBC News. (2011, February 16). Lance Armstrong con#rms retire- ment from cycling. Retrieved from http://news.bbc.co.uk/sport2/hi /other_sports/cycling/9399280.stm
3. American Cancer Society. (2018). Cancer facts and #gures, 2018. Atlanta, GA: Author. Retrieved from https://www.cancer.org/content /dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer -facts-and-!gures/2018/cancer-facts-and-!gures-2018.pdf
4. Davila, M. L. (2011). Photodynamic therapy. Gastrointestinal Endoscopy Clinics of North America, 21(1), 67–79.
5. Mroz, P., et al. (2011). Stimulation of anti-tumor immunity by photodynamic therapy. Expert Review in Clinical Immunology, 7(1), 75–91.
6. National Cancer Institute. (2018). Targeted cancer therapies. Retrieved from http://www.cancer.gov/cancertopics/factsheet /"erapy/targeted
7. Noguchi, M., et al. (2013). Personalized peptide vaccination: A%new approach for advanced cancer as therapeutic cancer vaccine. Cancer Immunology, Immunotherapy, 62(5), 919–929.
8. American Cancer Society. (2018). Cancer prevention and early detec- tion facts and #gures, 2018. Atlanta, GA: Author. Retrieved from http://www.cancer.org/acs/groups/content/@research/documents /document/acspc-042924.pdf
9. U.S. Department of Health and Human Services. (2004). "e health consequences of smoking: A report of the Surgeon General. Washington, DC: U.S. Government Printing O&ce. Retrieved from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm
10. U.S. Department of Health and Human Services. (2010). How tobacco smoke causes disease: "e biology and behavioral basis for smoking-attributable disease. Washington, DC: U.S. Government Printing O&ce. Retrieved from http://www.ncbi.nlm.nih.gov /books/NBK53017/
11. U.S. Department of Health and Human Services. (2014). "e health consequences of smoking—50 years of progress: A report of the Surgeon General, 2014. Washington, DC: U.S. Government Printing O&ce. Retrieved from http://www.surgeongeneral.gov/library/reports/ 50-years-of-progress/full-report.pdf
12. Khan, N., et al. (2010). Lifestyle as risk factor for cancer: Evidence from human studies. Cancer Letters, 293(2), 133–143.
13. U.S. Public Health Service. (1964). Smoking and health: Report of& the advisory committee to the Surgeon General of the Public Health Service (PHS Publication No. 1103). Atlanta, GA: U.S. Department% of Health, Education, and Welfare, Public Health Service, CDC.%Retrieved from http://pro!les.nlm.nih.gov/ps/access /NNBBMQ.pdf
14. Taylor, H. S., & Manson, J. E. (2011). Update in hormone therapy use in menopause. Journal of Clinical Endocrinology and Metabo- lism, 96(2), 255–264.
15. Bradbury, K. E., et al. (2014). Fruit, vegetable, and !ber intake in relation to cancer risk: Findings from the European Prospective Investigation into Cancer and Nutrition (EPIC). American Journal of Clinical Nutrition, 100(Suppl.), 394S–398S.
16. U.S. Department of Health and Human Services. (2006). "e health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: Author. Retrieved from http:// www.surgeongeneral.gov/librar y/reports/secondhand-smoke -consumer.pdf
17. Cole, L., et al. (2012). Examining the incidence of human papillo- mavirus-associated health and neck cancers by race and ethnicity in the U.S., 1995–2005. PLoS ONE, 7(3), 1011.
18. Lowrance, W. T., et al. (2010). Obesity is associated with a higher risk of clear-cell renal cell carcinoma than with other histologies. BJU International, 105(1), 16–20.
19. American Cancer Society. (2018). Colorectal cancer early detec- tion. Retrieved from https://www.cancer.org/cancer/colon-rectal -cancer/detection-diagnosis-staging/acs-recommendations.html
20. Rothwell, P. M., et al. (2010). Long-term e#ect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of !ve randomized trials. Lancet, 376(9754), 1741–1750.
21. Chan, A. T., & Giovannucci, E. L. (2010). Primary prevention of colorectal cancer. Gastroenterology, 138(6), 2029–2043.
22. Mayo Clinic Sta#. (2017). Stool DNA test. Retrieved from http:// www.mayoclinic.com/health/dna-stool-test/MY00623
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References
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regimens of hormone therapy and risk of breast cancer. Journal of the American Medical Association, 289(24), 3254–3263.
25. American Cancer Society. (2018). Breast cancer facts and #gures, 2017–2018. Atlanta, GA: Author. Retrieved from https://www .cancer.org/content/dam/cancer-org/research/cancer-facts-and -statistics/breast-cancer-facts-and-!gures/breast-cancer-facts-and -!gures-2017-2018.pdf
26. Luo, J., et al. (2011). Association of active and passive smoking with risk of breast cancer among postmenopausal women: A prospective cohort study. British Medical Journal, 342, d1016.
27. Shaitelman, S. F., et al. (2014). Shortened radiation therapy sched- ules for early-stage breast cancer: A review of hypofractionated whole-breast irradiation and accelerated partial breast irradiation. Breast Journal, 20(2), 131–146.
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33. American Cancer Society. (2015). Risk factors for testicular can- cer. Retrieved from http://www.cancer.org/cancer/testicularcancer /detailedguide/testicular-cancer-risk-factors
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Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 463
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Interfoto/Personalities/Alamy Stock Photo.
Across the Life Span Infectious and Noninfectious Diseases
Managing Your Health Eliminating or Reducing Your Risk of HIV Infection and Other STIs
Consumer Health CAM Products and Colds
Diversity in Health Sickle Cell Disease: Why Does This Deleterious Gene Persist?
Chapter Overview Causes of noninfectious diseases
Symptoms of and treatments for noninfectious diseases
Trends in infectious diseases since 1900
How the chain of infection works
How nonspecific and specific immunity work
How to protect yourself against infectious disease
Symptoms of sexually transmitted infections
Treatments and prevention methods for sexually transmitted infections
Student Workbook Self-Assessment: STI Attitude Scale
Changing Health Habits: Reducing Your Risk of Contracting an STI
Do You Know? How to protect yourself from sexually transmitted
infections?
If over-the-counter cold remedies really work?
Which types of diseases you can catch and which you cannot?
Infection, Immunity, and Noninfectious Disease
© EyeEm
/Getty Im ages.
Learning Objectives “Exercise-induced asthma has not deterred this outstanding athlete from making her indelible mark in the world of sports . . .”
After studying this chapter, you should be able to:
1. Distinguish between infectious and noninfectious disease. 2. Distinguish between communicable and noncommunicable
transmission of infectious disease. 3. Explain the process of infection. 4. Describe the chain of infection. 5. Discuss the body’s specific and nonspecific defenses
against pathogens. 6. Explain the transmission of sexually transmitted
infections (STIs). 7. Explain risk factors for contracting human immunodefi-
ciency virus (HIV) and describe how HIV is transmitted. 8. Describe steps you can take to reduce your risk of
contracting STIs. 9. Describe long-term health effects of genital herpes,
human papillomavirus, HIV, syphilis, gonorrhea, and chlamydial infection.
CHAPTER 14
465
passageways than before exercise began, which draws moisture and heat from the airways. A$er a person is warmed up, the breathing rate falls, and the airways return to their normal temperature. Health scientists do not know how airway cooling and reheating trig- gers asthma attacks.
Asthma is one of a variety of noninfectious diseases. Diseases are processes that a#ect the proper functioning of the body and are usually accompanied by characteristic signs and symptoms. Infectious diseases, such as colds or the 'u, are caused by pathogens, which are agents of infection: bacteria, rickettsias, viruses, fungi, protozoans, and parasitic worms. (Infectious diseases are discussed later in this%chapter.)
Noninfectious Diseases Noninfectious diseases are caused by abnormalities in the hereditary material (genetic diseases), interac- tions between heredity and environmental factors (especially those related to lifestyle, such as asthma), or environmental factors alone, as in repetitive-use injuries or lead poisoning; for example, sickle cell dis- ease, cystic !brosis, Down syndrome, and carpal tun- nel syndrome are considered noninfectious diseases.
Genetic Diseases "ere are two types of genetic diseases: inherited dis- eases and diseases caused by errors in cell division when gametes (sex cells) are formed.
Inherited Diseases Inherited diseases are trans- mitted solely by gene transfer from parents to o#spring. "ey occur more frequently among close relatives than in the general population and show patterns in their transmission. An inherited disease may strike only males, for example.
Inherited diseases are caused by disorders of genes, the physical and functional units of heredity. Genes are segments of DNA, a complex chemical compound that codes for the production of proteins. Genes carry information about every aspect of an organism and may carry normal instructions for a particular char- acteristic in one person and defective instructions in another. A defective gene in the eggs or sperm of an individual can be passed on to a child unless the per- son dies before reaching reproductive age.
Defective genes arise through mutation. A mutation is a change in a gene or a chromosome. A chromosome is a strand of DNA with associated protein; humans have 23 pairs of chromosomes. One
Jackie Joyner-Kersee: Olympian gold, silver, and bronze medalist. "e photo shows Kersee lead-ing her competitors in the 100-meter hurdle portion of the women’s heptathlon. Some consider Joyner-Kersee the greatest woman athlete ever. At this writing, she is the heptathlon world record holder and the American record holder in the indoor long jump. She has won six Olympic medals, more than any woman in track and !eld history. Joyner- Kersee o&cially retired from track and !eld in 2001.
In late 2004, Joyner-Kersee was honored by USA Track & Field, the national governing body for track and !eld, long-distance running, and race walking in the United States. "ey cited Joyner-Kersee’s break- ing of her own women’s heptathlon world record at the 1988 Olympic Games as the ninth greatest moment in U.S. track and !eld history in the last 25 years. In mid-2007, Joyner-Kersee was named one of six “women of power” by the National Urban League. In 2010, she was one of the !rst inducted into the new St. Louis Sports Hall of Fame, which hon- ors achievements of St. Louis teams and athletes past and present. Clearly, exercise-induced asthma has not deterred this outstanding athlete from making her indelible mark in the world of sports, nor has it deterred other athletes.
Exercise-induced asthma is a condition in which the airways narrow a$er sustained exertion, making it more di&cult than usual for a person to breathe. What triggers this problem is the cooling and reheat- ing of the airways as a person exercises. As exercise begins, a person begins to breathe deeply and rap- idly. During this deep and rapid inhalation, more air is moistened and warmed in the respiratory
diseases Processes that affect the proper functioning of the body and are usually accompanied by characteristic signs and symptoms.
infectious (in-FEK-shus) diseases Diseases caused by bacteria, rickettsias, viruses, fungi, protozoans, or parasitic worms.
pathogens (PATH-oh-jenz) Disease-causing agents of infection; the first link in the chain of infection.
noninfectious (NON-in-FEK-shus) diseases Illnesses caused by genetic abnormalities, by interactions between hereditary and environmental factors, or solely by environmental factors.
inherited diseases Genetic diseases transmitted solely by gene transfer from parents to offspring.
mutation (mew-TAY-shun) In reference to human biology, a change in a gene or a chromosome.
466 Chapter 14 Infection, Immunity, and Noninfectious Disease
Diversity in Health Sickle Cell Disease: Why Does This Deleterious Gene Persist? Sickle cell disease is one of the most common genetic disorders among African Americans, having arisen in their African ancestors. It has also been observed in people whose ancestors came from the Mediterranean basin, the Indian subcontinent, the Caribbean, and parts of Central and South America (particularly Brazil). The sickle cell gene has persisted in these populations— even though the disease eventually kills its victims— because of a curious interaction between this disease and another disease prevalent in these regions. Today, an estimated 70,000 to 100,000 Americans of African and Hispanic origins have the disease. Medical researchers estimate that 1 out of 10 African Americans and 1 out of 100 Hispanic Americans carry the trait.
Sickle cell disease gets its name from the curved (sickle) shape of the red blood cells of individuals with this disease (Figure 14.A). Anemia, or a low number of red blood cells, results from the short life of these abnor- mal cells. An error in the gene that codes for hemoglo- bin, the oxygen-carrying molecule in red blood cells, is responsible for the signs and symptoms of sickle cell disease.
These sickle-shaped cells cause pain when they become trapped in the small blood vessels of the body. This condition results in oxygen depletion to the tissues surrounding the blocked vessels, which damages tissues and causes infections. Most sickle cell patients die in their 40s or 50s from conditions such as stroke, infec- tion, kidney failure, or congestive heart failure.
To have sickle cell disease, a person must inherit two defective hemoglobin genes—one from each parent. A person who inherits a single defective gene is a car- rier and is said to have sickle cell trait. People with sickle cell trait do not have sickle cell disease, but they do have something in common with sufferers of sickle cell disease—resistance to malaria.
Those with the sickle cell gene have a survival advan- tage in regions of the world in which malaria is prevalent. The map in Figure 14.B shows where malaria is wide- spread; notice from the listing of affected populations in the first paragraph that sickle cell disease is prevalent in these areas as well. Although many of these peoples have since migrated from these areas, this ancestral gene persists in their populations.
How does a defective hemoglobin gene protect against malaria? In sickle cell trait, red blood cells sickle under a variety of conditions, such as when the oxygen tension is low (at high altitudes, for example) and if these cells become acidic. Results of research show that infection of the red blood cells by malaria parasites causes the infected cells to become acidic as a result of the metabolism of the parasite. This change induces the red blood cells to sickle, which interrupts multiplication of the parasite. The spleen, an organ that destroys worn-out red blood cells, traps the sick- led cells. Under these conditions, the parasites die and malaria does not develop. For populations who live in regions where malaria is prevalent, the sickle cell gene persists because people who harbor the gene are more likely to live to reproductive age than those who do not have the gene and die from malaria. Therefore, this “deleterious” gene is beneficial to those with sickle cell trait living in malaria-infested areas and is passed from generation to generation. Unfortunately, some off- spring inherit sickle cell disease and not simply sickle cell trait.
Healthcare providers alleviate symptoms in those with worsening anemia and sickle cell complications by administering painkillers and blood transfusions. Those receiving transfusions to prevent stroke must continue transfusions indefinitely, or the risk of stroke returns.
Figure 14.A Normal and Sickled Red Blood Cells. The red blood cell on the left has a normal, rounded shape. The one on the right has the curved shape of sickle cell disease, which results in its becoming trapped in the small blood vessels of the body. © Decade3d-anatomy online/Shutterstock.
Noninfectious Diseases 467
toxic chemicals, which can lead to poisoning, is a third source of genetic damage. People o$en come into contact with toxic chemicals in the workplace and do not realize the danger because they feel no ill e#ects.
"ree hereditary diseases that are common in the United States are sickle cell disease, cystic !brosis, and muscular dystrophy. "e Diversity in Health essay “Sickle Cell Disease: Why Does "is Deleteri- ous Gene Persist?” discusses this hereditary disease, which is common among African Americans.
Cystic fibrosis (CF) is the most common lethal genetic disease in the White population. (It seldom
member of each pair is inherited from the mother and one pair from the father.
A mutation can be inherited from a parent and passed on to children, or it can arise suddenly in a person and be passed on to children. Mutations in eggs and sperm can occur for no apparent reason or from exposure to a variety of environmental sources. One source is ionizing radiation such as X-rays, which is the reason the dentist places a protective lead shield over your pelvic area when taking X-rays of your teeth. Another source of damage to genes is drugs such as lysergic acid diethylamide (lysergide, LSD) or marijuana (Cannabis sativa). Exposure to
Penicillin is given to children aged 1–5 years to ward off infection. The drug hydroxyurea reduces the frequency of pain, hospital admissions, and life-threatening com- plications by about 50%. Bone marrow stem cell trans- plantation is also used to treat sickle cell disease. Bone marrow stem cells are undifferentiated cells that give rise to all types of blood cells.
The Sickle Cell Treatment Act of 2003 helps expand services for patients with this blood disorder. The fed- eral government provides states with funding for patient counseling, educational initiatives, and community outreach programs and provides patients with federal matching funds for sickle cell disease-related services under Medicaid. In addition, this law has initiated the development of sickle cell treatment centers across the country and has established a National Coordinating
and Evaluation Center Sickle Cell Disease and Newborn Screening Program.
Couples can be screened to detect if they are car- riers of the trait to help them in their family planning decisions. Researchers are studying new medications and treatments for sickle cell anemia, and eventually, medical experts may discover a way to weed out this life-threatening gene in populations no longer living in malaria-prone areas.
Data from Centers for Disease Control and Prevention. (2014, March 31). Sickle cell disease. Retrieved from http://www.cdc .gov/ncbddd/sicklecell/index.html; St. Jude Children’s Research Hospital. (2018). Sickle cell disease. Retrieved from http://www .stjude.org/stjude/v/index.jsp?vgnextoid=0f3c061585f70110VgnVCM 1000001e0215acRCRD&vgnextchannel=bc4fbfe82e118010VgnVCM1 000000e2015acRCRD
No malaria risk Areas with limited risk Malaria risk
Figure 14.B Areas of the World in Which Malaria Is Prevalent. Malaria is a serious infectious disease in the tropical and subtropical regions of the world. Sickle cell disease is prevalent in these regions as well.
468 Chapter 14 Infection, Immunity, and Noninfectious Disease
have been lost, gained, or moved to new positions. If conception takes place with a gamete that has a severe defect, the usual result is a spontaneous abortion. However, some genetic defects result in a fertilized egg that is capable of developing into a full-term baby. "e child may be born with structural or functional prob- lems, or%both.
Down syndrome, which a#ects approximately 1 in 1,000 newborns,4 is a common genetic disorder caused by improper cell division in gametes. Cell division problems occur more o$en in eggs than in sperm because men produce new sperm through- out their lives, whereas women are born with all the potential eggs they will ever have. "erefore, a wom- an’s eggs age as she ages. Each month, a single egg reaches maturity. During this maturation process, a division of the potential egg takes place. "e division may result in an error in the number of chromosomes in the mature egg. "e majority of Down syndrome children have three number 21 chromosomes instead of the usual pair (Figure 14.1). For this reason, Down syndrome is also called trisomy 21. As the graph in Figure 14.2 shows, the risk of bearing a child with Down syndrome or another chromosomal abnor- mality rises dramatically a$er the maternal age of 30. "is association between the incidence of Down syn- drome and increasing age is not observed in fathers.5 Various screening methods have been developed to detect whether a fetus is a#ected with trisomy 21 or other chromosomal problems.
Noninfectious Disease and the Interaction of Genetic Factors with the Environment "e genetic diseases just discussed have simple and predictable inheritance patterns. "ey involve a change in a single gene or an error in sex cell division.
a#ects African Americans, Asians, or Jews.) Cystic !brosis a#ects the glands that secrete mucus and sweat. In CF patients, the sweat glands produce an abnormally salty secretion, and the mucous glands produce an exceptionally thick and sticky secre- tion that builds up and plugs the ducts of glands and other passageways. Although the pancreas (an organ that secretes digestive juices) is o$en seriously a#ected, lung disease accounts for most of the illness and nearly all deaths from CF. Multiple disorders of the lungs arise when mucus blocks the airways. Infections result, and breathing becomes impaired. According to the Cystic Fibrosis Foundation, the median predicted age of survival with CF is approxi- mately 40, which means that half of those with CF would be expected to live to that age.1
Duchenne/Becker muscular dystrophy (DBMD) is the most common type of muscular dystrophy (dys means “abnormal”; trophy means “growth”). DBMD is a disease in which the muscles gradually weaken and degenerate. "e two versions of the disease are similar, but Becker muscular dystrophy has a later onset than Duchenne and a slower progression of symptoms. Recent estimates by the Centers for Disease Control and Prevention (CDC) reveal that DBMD occurs in 1 in every 7,250 newborn males in the United States, usually striking before the age of 5%years, which is the average age at diagnosis.2
Children with DBMD are usually slow to walk and talk. "eir thigh and pelvic muscles gradually dete- riorate, resulting in unsteadiness in standing, walk- ing, climbing stairs, and getting up from a seated position. As the muscles of the shoulder, trunk, and back weaken, the child’s spine begins to curve, and the posture becomes swayback. "is abnormal body posture interferes with the functioning of internal organs, especially the lungs. Although heart problems sometimes cause sudden death in DBMD patients, these children and young adults usually die in their teens or 20s of respiratory infections or respiratory failure when the diaphragm (a sheetlike muscle that forms the 'oor of the chest cavity and that is essential to breathing) becomes a#ected. Survival of patients with DBMD is enhanced by the use of noninvasive mechanical ventilation at night, along with the use of assisted coughing techniques and medications that protect the heart.3
Diseases Caused by Errors in Sex Cell Division Gametes, or sex cells, are produced in the ovaries or testes. Sometimes eggs or sperm are made that have too many or too few chromosomes. Other times, gam- etes may be formed in which parts of chromosomes
cystic fibrosis (SIS-tik fie-BROH-sis) (CF) A common, lethal inherited disease that affects the glands that secrete mucus and sweat, resulting in multiple disorders of the lungs and pancreas.
Duchenne/Becker muscular dystrophy (do-SHAYN BECK-er MUSS-ku-lar DIS- tro-fee) (DBMD) An inherited disease in which the muscles gradually weaken and degenerate. It usually strikes boys before the age of 6 years.
Down syndrome A genetic disease usually caused by the presence of three (rather than two) number 21 chromosomes; the child is usually mentally retarded, with a short body and a broad, flat face.
Noninfectious Diseases 469
Other noninfectious diseases have no simple and predictable inheritance patterns like genetic diseases do, but their development involves interplay between genetic and environmental factors. For example, a person with a family health history of type 2 diabe- tes is more likely to develop this disease if he or she becomes overweight or obese than is a person with- out the genetic link. Moreover, even in those geneti- cally predisposed, type 2 diabetes can be prevented or managed with weight loss and regular physical activity.
Until recently, scientists were able to look at genet- ics only in a limited way when studying disease. "ey did not have the tools to identify genetic factors and the roles they play in diseases with complex genetic links, such as type 2 diabetes, heart disease, and can- cer. However, in 1989, an international e#ort began that would change this narrow view of genetics and health. Research scientists around the world set out to map the entire set of human genes—the human genome—determining its complete DNA sequence. With this endeavor, called the Human Genome Project, a new branch of molecular biology was born: genomics. "is science focuses on understanding the structure and function of the genome. By 2003,
Figure 14.1 Down Syndrome. (a) This girl has Down syndrome. She exhibits the stocky build, short hands, and flattened facial features characteristic of this genetic condition. (b) Down syndrome is called trisomy 21 because it is caused by the presence of an extra chromosome 21, as shown in the karyotype, the array of chromosomes in a cell. In addition, Down syndrome individuals experience delays in physical and intellectual development. Although some Down syndrome individuals function in the low average range of intellectual capability, the majority function in the mild to moderate range of mental retardation. (a) © PhotoCreate/Shutterstock; (b) Courtesy of Viola Freeman, Associate Professor, Faculty of Health Sciences, Dept. of Pathology and Molecular Medicine, McMaster University.
Figure 14.2 The Effect of Maternal Age on the Incidence of Down Syndrome. As maternal age increases, the age of a woman’s eggs also increases, and genetic abnormalities become more common. The graph shows that the incidence of Down syndrome rises significantly as maternal age increases beyond 30 years.
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470 Chapter 14 Infection, Immunity, and Noninfectious Disease
Noninfectious Conditions with Environmental or Unknown Causes Many conditions are caused by exposure to various substances in the environment. In general, environ- mental factors that are the sole cause of disease are toxic chemicals. Not only are toxic chemicals present in the home, workplace, and environment, but they are also used and abused in ways that seriously a#ect health.
A few noninfectious conditions are caused by the ways in which people use their bodies. Temporoman- dibular disorder is characterized by pain in the jaw and chewing muscles that o$en results from grind- ing or clenching the teeth. Carpal tunnel syndrome, a painful condition of the hands and !ngers, results
researchers had mapped the entire human genome, revealing the “genetic code” of humans.
Genomics holds promise for helping researchers understand how genetic factors interact with envi- ronmental factors, resulting in health or disease. Researchers can now look for genetic variations that increase the risk of certain diseases and may, in turn, be able to develop more e#ective approaches to prevention and treatment of those diseases. In the future, diagnosis and treatment could be based on an individual’s unique genetic makeup.
Asthma, ulcers, diabetes, migraine headaches, cardiovascular disease, and cancer are common non- infectious diseases that have both genetic and envi- ronmental causes. Ulcers are sores in the lining of the esophagus, stomach, or duodenum. Diabetes is a group of diseases in which a person does not metab- olize carbohydrates properly. Migraine headaches are thought to be an inherited disorder that can be triggered by a variety of environmental factors. "e nation’s number one killers are cardiovascular dis- ease and cancer.
Asthma, the most common chronic illness in childhood, is a disease of the airways. "e bronchioles of people with asthma narrow in response to certain stimuli much more easily than do the bronchioles of those who do not have asthma. (Bronchioles are air passageways, about the diameter of a pencil lead, that lead to the air sacs of the lungs; see Figure 14.3.) When these airways become narrowed, air'ow to and from the lungs is blocked. As a result, asthmatic people have trouble breathing and begin to wheeze, which people refer to as having an asthma attack.
Environmental factors such as air pollution, respi- ratory infections, tobacco smoke, and allergens such as dust mites o$en trigger asthma attacks. (Dust mites are microscopic organisms that live in carpets, mattresses, pillows, and curtains.) As mentioned in the opening paragraphs of this chapter, exercise may also stimulate asthma attacks. Breathing warm, moist air is best for the athlete with exercise-induced asthma. For example, swimming in a warm pool will usually cause fewer problems than snow skiing. Also, warming up before exercise reduces the like- lihood of an exercise-induced asthma attack. With other types of asthma, the key to management is dis- covering what stimulates attacks and avoiding these factors. For example, if a trigger is house dust mites, exposure can be reduced by not using carpeting or draperies and washing bedding o$en in hot water. Medication is another important tool for asthma management.
Figure 14.3 The Respiratory System. The bronchioles are the narrow air passageways that branch from the bronchi and lead to the air sacs of the lungs. The bronchioles are covered with muscle tissue that constricts during asthma attacks, narrowing these passageways and making it difficult to breathe.
ArteryNasal cavity
Mouth (oral cavity)
Pharynx
Larynx
Trachea
Right bronchus
Left bronchus
Terminal bronchiole
(a) Alveoli Capillaries
Alveolus
Bronchiole
Capillary network
Vein
(b)
asthma (AZ-mah) A common chronic childhood illness characterized by sensitive airways.
carpal tunnel syndrome Numbness, pain, or pins- and-needles sensations in either of the hands that extends down the fingers, resulting from improper alignment of the wrist while engaging in repetitive-use activities.
Noninfectious Diseases 471
Trends in Infectious Disease
In 1900, the three leading causes of death were infec- tious diseases: pneumonia, tuberculosis, and enteri- tis (in'ammation of the intestine, causing severe
from improper positioning of the wrist while engag- ing in repetitive activities that use the hands, wrists, and arms; 10% of the population experiences occa- sional symptoms of this syndrome.
Carpal tunnel syndrome is usually the result of repetitive use. Activities such as using power tools frequently, typing for a long time, and playing piano or guitar o$en result in such injuries because people hold the wrist in a bent position rather than holding it straight. "e injury causes in'ammation and a buildup of 'uid in a tunnel that runs through the bones of the wrist, or carpals. "e 'uid presses on the nerves and blood vessels in the tunnel. Other conditions, such as arthritis, diabetes, and pregnancy, may also contribute to pressure in the carpal tunnel. To help avoid injury when typing for a long time, place your computer key- board at elbow height and keep your wrists unbent as shown in Figure 14.4. Use wrist rests and arm rests only when you are resting, not when you are typing.
Soft incoming light
Thigh parallel to floor
Display at eye level or slightly below
18 to 28 inches
Keyboard at elbow height
Feet flat on floor or foot rest
Figure 14.4 The Proper Sitting Position for Typing at the Computer. The screen should be at eye level or slightly lower. The keyboard should be at elbow height, the forearms parallel to the floor, the back supported, the thighs parallel to the floor, and the feet flat on the floor or foot rest.
4The risk of chromosomal abnormalities in a woman’s eggs increases significantly after her 30th birthday. Therefore, if you and your partner are considering a pregnancy at or beyond this
Healthy Living Practices
age, consult your healthcare provider for advice regarding options to increase your chances of having a healthy infant.
4If you have asthma, learn your asthma triggers and avoid them. If you have exercise-induced asthma, consider restricting your activity on cold days or when the pollen count or air pollution levels are high.
4Abusing drugs or living and working under toxic conditions can damage the hereditary material of your cells, particularly the sex cells. Therefore, to protect your health and possibly that of your offspring, avoid exposure to toxic substances.
4Carpal tunnel syndrome often results from bending the wrists while engaging in a repetitive activity such as typing, using hand tools, or completing various household chores. To help prevent repetitive-use injury, always keep your wrists unbent while engaging in such activities.
472 Chapter 14 Infection, Immunity, and Noninfectious Disease
!e Chain of Infection Infection results from the interaction between a pathogen (also called an agent of infection), a host (the organism that supports the growth of the patho- gen), and the environment surrounding the host. "e chain of infection illustrates how an infection spreads from an infected person to an uninfected person. A pathogen leaves the host through the portal of exit. Disease transmission can be direct or indirect, with a pathogen entering a susceptible host through the portal of entry to establish a new infection. For example, let’s examine transmission of the in'uenza (the 'u) virus through the chain of infection. "e pathogen (in'uenza virus) leaves the reservoir (nose, throat, bronchial tubes, and lungs) through the portals of exit (mouth and nose) when the host sneezes. Transmission can occur directly, if the expelled droplets enter a susceptible host’s mouth or nose (portals of entry), or indirectly, if the expelled droplets dry and become airborne. If either direct or indirect transmission occurs, a new infection is established. Figure 14.5 depicts the chain of infection, including the relationship among factors important for the contraction and spread of infectious diseases.
Pathogens "e severity of an infectious disease depends on a variety of factors:
• "e type of pathogen (such as a bacterium or virus) • Its virulence (how easily it causes disease) • Its ability to multiply and spread within the body • Its ability to combat the defense mechanisms of
the body • "e body’s reaction to this invader
"is chapter !rst describes pathogens that cause infectious diseases. A later section focuses on the host’s defense mechanisms.
diarrhea). Since that time, the United States (and other industrialized countries) has made achievements in public health that have changed this picture dramati- cally. Early in the twentieth century, U.S. departments of public health were established, whose activities pro- vided for clean drinking water, uncontaminated food, and proper sewage disposal and treatment. "ese actions have reduced the transmission of pathogens tremendously. Antibiotics, which are medications that kill bacteria, and vaccines, which are prepara- tions that boost the immune system to help it ward o# infection from speci!c pathogens, combat infec- tion as well. Additionally, new treatments for certain viral illnesses such as in'uenza have been developed. As a result, a$er a century, the three leading causes of death in 2010 were no longer infectious diseases, but noninfectious diseases: heart disease, cancer, and stroke. "e only infectious diseases in the “top 15” were pneumonia and in'uenza, together ranked as the ninth leading cause of death.6
Although infectious diseases are less signi!cant contributors to death in the United States at this time, the worldwide picture is much di#erent. Infec- tious diseases are the leading cause of death in the world. At least 30 new diseases have emerged in the past 30 years, including human immunode!ciency virus (HIV) infection and a new strain of hepatitis— hepatitis C. Additionally, many bacterial diseases once easily cured with antibiotics are appearing as incurable diseases, resistant to the variety of antibi- otics available at this time. “Old” diseases that once seemed under control, such as diphtheria and tuber- culosis, are making a comeback as well.
Ebola, a viral hemorrhagic fever, causes severe internal hemorrhaging and can decrease kidney and liver function. For many, contracting Ebola results in death. "e largest outbreak of Ebola occurred in 2014 in the western African nations of Guinea, Sierra Leone, and Liberia and lasted through early 2016. Of the 28,637 people infected, 11,315 died from Ebola infection.
With international travel commonplace, transmis- sion of infection is a worldwide concern, not just a con- cern in our own country, state, or city. "e resistance of many strains of bacteria to antibiotics and the reemer- gence of serious diseases once thought conquered make complacency to infection a dangerous attitude. In this time of increasing illness and death from infec- tious disease in the global community, it is important to understand how infectious diseases are transmitted and how pathogens interact with the body. "is knowl- edge is key to avoiding infection and staying healthy.
host In reference to disease, an organism that supports the growth of a pathogen; the third, and last, link in the chain of infection.
chain of infection The relationship among the factors important in the development of infectious diseases: the pathogen, transmission, and the host.
transmission In reference to disease, the means by which a pathogen gets to a host; the second link in the chain of infection.
The Chain of Infection 473
Rickettsias are bacteria-like organisms that live within host cells. "ese organisms cause diseases such as typhus, which is transmitted by lice, and Rocky Mountain spotted fever, which is transmitted by ticks.
Viruses Viruses cause many diseases that you are familiar with: the common cold, in'uenza (the 'u), mumps, measles (Figure 14.6), chicken pox, hepati- tis, and acquired immune deficiency syndrome (AIDS). Viruses are very di#erent from bacteria and, in fact, are very di#erent from any organism: "ey do not have a cellular structure. Because the basis of life is the cell, viruses are not considered living organisms. "ey are simply hereditary material sur- rounded by a coat of protein.
Like bacteria, viruses cause disease by adhering to host cells, but unlike bacteria, viruses enter the cells of the body and use those cells to make more virus particles. "e new virus particles break open the infected cell, killing it, and are then ready to infect
bacteria Unicellular, microscopic organisms with a simple cell structure; some are pathogenic to humans and produce infections such as strep throat, bacterial pneumonia, food poisoning, and infected cuts.
viruses Hereditary material surrounded by a coat of protein; some viruses are pathogenic to humans and produce infections such as the common cold, influenza, mumps, measles, chicken pox, hepatitis, and AIDS.
acquired immune deficiency syndrome (AIDS) A set of certain diseases and conditions that result from infection by the human immunodeficiency virus (HIV).
Figure 14.6 Child with the Typical Rash of Measles. This highly contagious viral disease is characterized by a spreading rash. The rash consists of small, red spots; some of the spots may be raised. Courtesy of CDC.
Reservoir
Portal of Exit
Transmission
Establishment of Infection in
New Host
Pathogen
Portal of Entry
Chain of Infection
Figure 14.5 The Chain of Infection. Infection is the invasion of the body by disease-causing organisms, or pathogens. Infection results when the pathogen is transmitted to a host. The host is the organism that supports the growth of the pathogen.
Bacteria and Rickettsias Bacteria produce infec- tions such as strep throat, bacterial pneumonia, food poisoning, and infected cuts. "ese organisms are uni- cellular and microscopic, with a simple cell structure.
When bacteria enter the body, they adhere to the surfaces of host cells and grow and multiply there. Some bacteria penetrate deeply into the tissues (moving between body cells). Many pathogenic bac- teria produce one or more chemicals that aid their invasion. A few types of bacteria produce toxins, or poisons, that cause diseases, such as certain types of food poisoning.
474 Chapter 14 Infection, Immunity, and Noninfectious Disease
infections, with the exception of yeast infections, are caused by molds.
Medical researchers know less about how fungi cause disease in humans than they know about the other agents of infection. However, fungi appear to invade humans in much the same way as bac- teria do. Humans have a high degree of resistance to fungi, which may explain why humans become infected with fungi less o$en than with bacteria or viruses. Fungi are considered opportunistic organ- isms; that is, they invade the human body when the host has another disease or condition that dimin- ishes its ability to combat fungal infection. People with diabetes or AIDS, for example, are more likely to contract fungal infections than people with no underlying illness.
Other Types of Pathogens Two additional groups of organisms cause infections in humans: protozoans and worms. Protozoans cause diseases such as malaria (a tropical disease transmitted by mosquitoes) and trichomonas urogenital infections, or “trich” infec- tions. All protozoans that cause infectious diseases in humans are single-celled organisms, but they di#er from one another in the ways they cause disease.
"e other group of infectious organisms is the parasitic worms: certain types of roundworms, 'at- worms (tapeworms), and 'ukes. Tapeworms are contracted by eating infected pork or beef; these worms live in the intestines, producing digestive dis- turbances. Adult roundworms also inhabit the intes- tinal tract and cause digestive disorders; they enter the body in various ways depending on the species of worm. Flukes di#er in that they can inhabit the intestine, the liver, the lungs, or the veins depend- ing on the species; they are contracted from water infected with human feces and are not prevalent in the United States.
One other group of organisms important to men- tion is the arthropods. Certain species of this group live on or in the skin of humans, a condition usually referred to as infestation rather than infection. Arthro- pods are organisms such as lice, 'eas, mites, and ticks. Some STIs are caused by certain lice and mites (dis- cussed later in this chapter). Ticks only occasionally infest humans but may transmit other pathogens to humans, as can mosquitoes, lice, and 'ies.
additional body cells. "e death of body cells causes many of the signs and symptoms of viral disease.
Certain types of viruses invade cells but enter a latent state, during which time infective virus particles are not produced. Although no signs or symptoms of the viral infection are apparent, latency may cause changes in a cell that lead to cancer. In many instances, the latent viral hereditary material can become reactivated and replicate once again, causing disease.
Some infections are characterized by a cycling of latent and actively replicating periods, such as the sexually transmitted infection (STI) genital herpes. During the usual course of this disease (discussed later in this chapter), a person su#ers active episodes when he or she can transmit this disease to others. "e infection then subsides (latency), only to reap- pear at another time, o$en triggered by stress or other factors.
Fungi You have probably heard of, or may have experienced, yeast infections or athlete’s foot (Figure"14.7), which is a type of ringworm (a fungal infection of the skin, hair, or nails). "ese diseases are caused by fungi, more commonly known as molds and yeasts. Fungi cannot make their own food and, therefore, grow on a wide range of organisms that they use as food sources, such as rotting logs, spoil- ing fruit, and the human body. Most human fungal
Figure 14.7 Athlete’s Foot. Athlete’s foot, or tinea pedis, is a fungal infection that usually arises between the toes or on the soles of the feet. This condition often develops when a person wears enclosed footwear without socks or stockings, and the feet become moist for long periods. To help avoid athlete’s foot, dry the feet between the toes after bathing or showering and use powder to help keep the feet dry. © Science Photo Library/Science Source.
fungi (FUN-jeye) Cellular organisms that cannot make their own food; some are pathogenic to humans and produce infections such as athlete’s foot, ringworm, and yeast infections. Fungus is the singular term.
The Chain of Infection 475
Clostridium botulinum. "is organism most o$en grows in improperly home-canned, low-acid foods such as green beans and green peppers. Boiling home-canned foods for 10–15 minutes inactivates the toxin. (Infants can contract botulism from raw honey.)
A third type of noncommunicable infection is caused by pathogens that infect people via envi- ronmental or animal sources. Legionnaire’s disease, caused by the bacterium Legionella pneumophila, is an infectious disease contracted from an envi- ronmental source. Under favorable conditions, this pathogen can grow in and be dispersed by any appa- ratus that provides a water aerosol or mist, such as air conditioners, whirlpool spas, humidi!ers, decorative fountains, showerheads, and water faucets. When this water mist is inhaled, these microbes lodge in the lungs and multiply, producing a pneumonia-like dis- ease that includes high fever, cough, chest pain, and diarrhea. "is disease is quite serious; 5–30% of its victims die, but victims are o$en those who are older (65 years and older) and people who smoke, have a compromised immune system, and/or have chronic lung disease. To reduce the growth of this organism and protect against infection, periodically clean and thoroughly disinfect mist-creating items, such as those mentioned previously, and maintain an appro- priate concentration of chlorine in home spas.7
Lyme disease is an example of a noncommunicable infection contracted from an animal source. Named for the small community of Lyme, Connecticut, where the disease was !rst recognized in 1975, this bacterial disease is transmitted by ticks that infest animals such as white-footed mice and white-tailed deer. "e ticks ingest the bacterial pathogen that causes Lyme disease from infected animals. When a tick harboring this bacterium bites a human, it injects the bacterium into the bloodstream. Usually a pain- less but large rash (sometimes looking like a bull’s- eye) appears at the site of the bite from a few days to 1 month a$er being bitten (Figure 14.8). "is rash is generally accompanied by severe headaches, fatigue, chills, and fever. If the disease is not treated with anti- biotics at this early stage, it may develop into severe in'ammation of the heart muscle or nervous system weeks to months later. Within 2 years, if untreated, arthritic attacks develop (in'ammation of the joints) that can become chronic.
In the United States, Lyme disease is found pri- marily in the Northeast, the mid-Atlantic region (Virginia and North Carolina area), and the upper Midwest. It has also been reported in several areas
Transmission Some infectious diseases are passed from person to person and others are not. "ose that are spread from person to person, such as colds, 'u, strep throat, and STIs, are communicable diseases. Diseases that are not transmitted from person to person, includ- ing both infectious and noninfectious diseases, are noncommunicable.
Noncommunicable Infectious Diseases Non- communicable infectious diseases can be caused in various ways: by the growth of bacteria that normally inhabit the body, the ingestion of poisons produced by some bacteria, or infection with pathogens from environmental or animal sources.
Many species of bacteria normally reside on and in the human body. However, these bene!cial bac- teria can cause occasional problems. For example, Staphylococcus bacteria normally present on the skin can multiply and cause skin infections, especially in persons with chronic diseases such as diabetes.
Noncommunicable infections can also be caused by the ingestion of toxins, or poisons, produced by some bacteria. Staphylococcal food poisoning (for- merly called ptomaine poisoning), for example, is caused by taking in a toxin that certain staphylococ- cal bacteria produce when they grow on foods. Dairy products and poultry are the foods most commonly contaminated with staphylococcal bacteria from their animal sources or from infected food handlers. "e staphylococcal bacteria grow well in high-protein, high-carbohydrate foods. Most o$en, staphylococcal food poisoning occurs when people eat foods such as potato salad, chicken salad, custard, or cream pies that have not been refrigerated properly a$er preparation. Picnics are a common time of infection because such foods are le$ out under warm conditions for long periods of time, which allows the bacteria to grow and produce toxin. Because the bacteria grow on the food and not in the body, this type of noncommunicable infection is more properly called intoxication (poison- ing) rather than infection. Staphylococcal food poi- soning should not be confused with Salmonella food infection, in which the bacteria are taken in with food and multiply in the small intestine.
Botulism is another type of food poisoning, caused by a powerful toxin produced by the bacterium
communicable (ka-MYOO-ni-kah-bl) Transmissible from person to person.
noncommunicable Not transmissible from person to person.
476 Chapter 14 Infection, Immunity, and Noninfectious Disease
by direct or indirect contact, by means of a common vehicle, through the air, and by means of vectors such as mosquitoes.
Some infectious diseases, such as STIs, are passed from person to person by close physical (direct) con- tact. In the case of STIs, of course, the close contact is usually vaginal intercourse, anal intercourse, genital contact without intercourse, or oral sex. Other dis- eases such as colds and the 'u are o$en transmitted by direct contact also, such as shaking hands. "ere- fore, it is important to wash your hands well and frequently to help avoid transmitting or contracting such communicable diseases. "ese diseases can also be transmitted indirectly by means of an object, such as a shared drinking glass, or through close contact with droplets sneezed or coughed by a person. Strep throat and measles are spread in this way.
Frequently, a source contaminated with pathogens from humans may transmit an infectious disease to many people. Examples of common sources of infec- tion are a blood supply contaminated with HIV, food
in northwestern California. Deer ticks favor a moist, shaded environment, particularly areas of woods, brush, or tall grass. If you are walking, gardening, or engaging in other activities in these types of areas and in which deer and mice live (and, therefore, deer ticks; see Figure 14.9), wear long pants and a long- sleeved shirt. Tuck your pant legs into your socks or boots. Spray insect repellent containing at least 30% DEET on your clothing and exposed skin. (Do not spray it on your face.)
Spray it on your hands and then pat it on your face. (Use products with no more than 10% DEET on chil- dren.) Check yourself carefully for ticks, removing any you !nd with tweezers.
A Lyme disease vaccine was introduced in 1999, but the manufacturer withdrew the vaccine from the market in 2002, citing poor sales. Moreover, the pub- lic was concerned about possible serious side e#ects of the vaccine even though preliminary evidence showed the vaccine was safe. Currently, no vaccine is available to prevent Lyme disease in humans.8
Communicable Infectious Diseases Communi- cable diseases are transmitted from person to person
Figure 14.8 The “Classic” Rash That Develops at the Site of a Tick Bite in Lyme Disease. Not everyone who contracts Lyme disease will develop this type of rash. Courtesy of James Gathany/CDC.
Figure 14.9 Deer Ticks Transmit the Bacterium that Causes Lyme Disease from Infected Animals to Humans. (a) © iStockphoto/Thinkstock; (b) Courtesy of Jim Gathany/CDC.
The Chain of Infection 477
contaminated with the hepatitis virus by an infected food handler, and water contaminated by the feces of a person infected with typhoid fever. A variety of infectious diseases are transmitted via food or water.
Some communicable diseases can be transmit- ted from infected persons to noninfected persons through the air on microscopic water droplets or on dust particles. Certain disease-causing organ- isms of the respiratory tract, such as the bacterium that causes tuberculosis, can be transmitted in this way, propelled into the air when an infected person coughs or sneezes. When not in isolation, persons with communicable tuberculosis should wear surgi- cal or other types of masks to help prevent transmis- sion of their disease.
Other communicable diseases are spread indi- rectly by means of vectors. A vector is an organism (other than a human) that transmits a pathogen from one person to another. Usually a part of the life cycle of the pathogen takes place in or on the vec- tor. For example, the malaria organism is a proto- zoan that carries out part of its life cycle in humans and another part in the gut of Anopheles mosquitoes. When a mosquito bites an infected person, it ingests blood that contains the protozoan. A$er the organ- ism undergoes sexual reproduction in the mosquito, its progeny can infect new hosts when the mosquito bites them.
The Host Why do you remain healthy sometimes, yet get sick at other times? How did you avoid getting the cold that everyone else seems to have? Why didn’t your spouse come down with the 'u like the rest of the family? So far we’ve seen that some of the answers to these questions have to do with the pathogen and certain of its characteristics, such as its virulence. Transmis- sion may also mean the di#erence between infection and health. Persons exposed frequently to pathogens are likely to become infected more o$en than those exposed less frequently. "e other answers to these questions have to do with your body’s resistance to the invading microbe.
Stress can be one factor that reduces your resis- tance to infection. High-intensity or exhaustive exer- cise, such as running more than 60 miles per week or for 3 or more hours per session, also suppresses the immune system. Moderate exercise, however, such as running fewer than 20 miles per week or walking for 45 minutes per day for 5 days per week, stimulates the immune system. Exercising when you are sick lowers the body’s defenses.
Race and age a#ect an individual’s resistance or sus- ceptibility to certain diseases. Africans or people with African ancestry, for example, have a higher resistance
4Refrigerate starchy and protein-rich foods and cold foods made with dairy products or poultry immediately after preparation. At picnics, keep these foods chilled until it is time to eat.
4Boil all low-acid home-canned foods before eating or avoid eating home-canned foods.
4Periodically clean and thoroughly disinfect mist-creating items such as humidifiers and maintain an appropriate concentration of chlorine in home spas.
4Avoid close contact with people who have communicable diseases.
4Wash your hands well and frequently to help avoid contracting communicable diseases, such as colds and the flu.
4Do not share drinking glasses and eating utensils with others.
4Do not share hypodermic needles with others because they may be contaminated with pathogens such as the hepatitis B virus or the AIDS virus.
4Use a condom when engaging in sex unless you are in a long-term, mutually monogamous relationship with an uninfected partner. Infectious bodily secretions can be passed from one partner to another during sexual activity.
4Use insect repellents formulated to repel ticks and flying insects that may be carriers of disease-producing organisms.
4Do not drink the water when traveling in developing countries. Also avoid raw fruits, vegetables, and salads because they may have been washed with contaminated water.
4Avoid the following hazardous foods when traveling in developing countries: uncooked or poorly cooked beef, pork, fish, and seafood and unpasteurized milk and other local dairy products.
4Avoid or limit stress; high levels of stress reduce your resistance to infection.
4Avoid high-intensity or exhaustive exercise because it reduces your resistance to infection.
4Engage in moderate exercise to boost the immune system.
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respiratory tracts, are lined with tissue called mucous membranes. Most mucous membranes have a thin layer of cells that produce a sticky, viscous secretion called mucus. Mucus keeps the membrane moist and traps foreign particles and organisms.
Another defense mechanism that works with the mucous membranes is cilia. "ese short, hairlike structures project from the surfaces of the cells lining the upper respiratory tract. As they beat in wavelike
to tropical diseases such as malaria and yellow fever than do non-Africans. People of Asian ancestry are more resistant to the STI syphilis than are non-Asians. Children are more likely to contract certain “child- hood” infectious diseases such as measles and chicken pox, whereas older adults are more susceptible to pneumonia and in'uenza. And, as mentioned earlier, people with other diseases, such as AIDS, diabetes, and cancer, have weakened defense mechanisms.
Your body has two main types of defenses against infectious agents: mechanisms of nonspeci!c resis- tance, which are a variety of defenses that combat any foreign invader, and the immune system, which is a speci!c defense system that combats the particular invading pathogen. "e following sections describe these two major defense mechanisms.
Immunity Immunity is protection from disease, particularly infectious disease. You have two types of immunity: nonspeci!c and speci!c. Nonspecific immunity comprises a variety of defense mechanisms that combat any type of damage to the body, including the invasion of infectious agents. Specific immunity is carried out by the immune system. "e immune system recognizes and combats pathogens and other foreign cells (such as cancer cells or tissue trans- plants) with cells and proteins that are speci!c for particular invaders. "e immune system is discussed later in this chapter.
Nonspecific Immunity Pathogens can enter the body at sites called portals of entry (Figure 14.10). "e mucous membranes lin- ing the respiratory, digestive, urinary, and reproduc- tive systems are all portals of entry. Whether resulting from a cut, insect bite, burn, or injection, broken skin is a portal of entry. "e placenta may be a portal of entry for a fetus, which may become infected with pathogens (mostly viruses) from an infected mother. Unbroken skin is a portal of entry only for some fungi and the larvae of certain parasitic worms.
%e Skin and Mucous Membranes "e skin pro- vides a mechanical barrier to pathogens. "e hardened cells at the surface of the skin provide a waterproof barrier that most infective agents cannot penetrate. In addition, acidic skin oils and sweat help make the skin an inhospitable environment for most organisms.
Body openings, such as the eyes, and tubes that open to the outside, such as the digestive and
immunity (im-MYOU-nih-tea) Resistance to disease.
nonspecific immunity A variety of defense mechanisms that combat any type of damage to the body, including the invasion of infectious agents.
specific immunity Defense mechanism carried out by the immune system.
immune system A collection of cells and organs of the body that recognize and combat pathogens and other foreign substances with cells and proteins that are specific for particular invaders. The immune system has two branches: antibody-mediated immunity and cell- mediated immunity.
portals of entry Sites on or in the body where pathogens enter.
Nose
Mouth
Throat (digestive tract)
Urinary and genital tract
Respiratory tract
Unbroken skin
Broken skin
Figure 14.10 Portals of Entry of the Human Body. Portals of entry are areas of the body where pathogens can intrude: the skin and mucous membranes lining the respiratory, digestive, urinary, and reproductive systems; the placenta; broken skin; and unbroken skin (only for some fungi and the larvae of certain parasitic worms).
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Two types of leukocytes—the neutrophils and the macrophages—are important phagocytes in the human body. Other white blood cells called lympho- cytes help protect the body against infection and are part of the immune system.
%e Lymphatic System "e lymphatic system, another key player in nonspeci!c immunity, is com- posed of vessels and nodes through which tissue 'uid, or lymph, 'ows. Pictured in Figure 14.12, the lymphatic system also consists of lymphocytes and three lymphatic organs: the tonsils, the spleen, and the thymus (which is active only until puberty). "e lymphatic system removes microorganisms and other foreign substances from the tissue 'uid, the 'uid sur- rounding the cells that is derived from the blood.
Lymph nodes are located at many points along the lymphatic vessels. Lymphatic vessels enter and exit each lymph node, which is a mesh of tissue containing lymphocytes and macrophages. "e nodes cleanse tissue 'uid by trapping microorgan- isms and other foreign substances in their weblike structures; macrophages in the nodes phagocytize this material.
"e tonsils are large groups of lymph nodes located at the back of the oral cavity; they rid the nose and mouth area of bacteria and other debris. "e spleen, located in the upper le$ corner of the abdominal cav- ity (see Figure 14.12), not only performs the func- tion of a lymph node but also destroys worn-out red blood cells and stores red blood cells to provide an emergency supply in the case of severe loss. "e thy- mus, located just above the heart at the midline of the chest, is the place where the lymphocytes des- tined to be T cells mature during fetal life and early childhood (see the section titled “Speci!c Immunity” later in this chapter). "ese T cells then reside in the lymphatic tissue and produce new T cells when the thymus is no longer active.
In$ammation Can you remember the last time you got a splinter or a cut? If so, you can probably remember (quite well!) your body’s response. "e in'ammatory response is a series of events that take place when the body is harmed by occurrences such as bacterial or viral invasion (infection), cuts, chemi- cal damage, and burns. "is response can be local, as in the case of getting a splinter in your !nger, or systemic (a#ecting the whole body), as in the case of contracting a cold. In'ammation involves a variety of defense mechanisms that isolate and destroy the pathogens or other injurious agents and then remove the foreign materials and damaged cells so that the body can repair itself.
fashion, they move mucus that contains trapped for- eign material such as dust and bacteria up toward the back of the mouth where it can be swallowed, keep- ing it away from lower respiratory structures, espe- cially the lungs.
Other tissues have a chemical defense mechanism. "e lacrimal glands (located above the upper, outer corners of the eyes) produce tears that wash away for- eign material on the eyes and also contain a chemical called lysozyme that kills certain bacteria. Lysozyme is also found in saliva. Another structure that pro- vides a nonspeci!c chemical defense is the stom- ach. Stomach acid kills most of the microorganisms ingested with food.
White Blood Cells and Phagocytosis Another nonspeci!c line of defense is the action of certain white blood cells, or leukocytes, that ingest foreign cells and debris, such as the dirt or dead cells in a cut. "is process is phagocytosis (literally, phago, “eat- ing,” and cyto, “cell”) and is shown in Figure" 14.11.
leukocytes (LEWK-oh-sites) White blood cells; active in both specific and nonspecific defenses of the body.
phagocytosis (FAG-oh-sigh-TOE-sis) The process of white blood cells ingesting foreign cells and debris, such as the dirt or dead cells in a cut.
lymph (limf) Tissue fluid.
Figure 14.11 White Blood Cell Ingesting Bacteria. This is a highly magnified, colorized photo of a white blood cell called a macrophage (yellow/orange). Macrophages are the scavengers of the body and protect it by “eating” bacteria and other foreign material. The bacteria (green) being ingested in this image cause tuberculosis in humans. © Prof. S.H.E. Kaufman & Dr. J.R. Golecki/Science Source.
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infected area, which prevents the spread of the infec- tion. Figure 14.13 illustrates the in'ammatory process.
"e signs and symptoms of local in'ammation are redness, heat, swelling, pain, and a loss of func- tion. "e redness, heat, and swelling are results of increased blood 'ow to the a#ected area, including movement of 'uids into surrounding tissues. Pain results as nerves are stimulated by the swelling and the chemicals released during in'ammation. "e pain, tissue damage, and swelling may contribute to a temporary loss of function of the a#ected body part.
Systemic in'ammation occurs when you have a widespread infection such as a cold, the 'u, strep throat, or pneumonia. Systemic in'ammation has
"e presence of infectious agents or damage to the body triggers the in'ammatory response. As a result, many chemicals are released. Some of these chemi- cals, such as histamine, cause an increase of blood 'ow to the a#ected area, which brings phagocytes and other white blood cells to ingest microorganisms and debris—pieces of a splinter, for example. In addi- tion, other chemicals stimulate phagocytes to move to the a#ected area, where they leave the blood and enter the damaged tissues. Yet other chemicals allow the surrounding blood vessel walls to leak, permitting phagocytes, certain blood-clotting factors, and other chemicals that enhance the in'ammatory response to enter the tissues. "e blood-clotting factors wall o# the
Figure 14.12 The Lymphatic System. The lymphatic system is made up of blind-ended vessels, nodes, and a few organs. Tissue fluid, derived from the blood, flows through the lymphatic vessels and is cleansed of debris and microorganisms by white blood cells that reside in the nodes. The fluid eventually returns to the blood.
Tonsils
Adenoids
Lymph nodes
Spleen
Lymphatic vessels
Thymus
Area drained by right lymphatic duct
Peyer’s patches (in intestinal wall)
Appendix
Bone marrow of long bones, vertebrae, ribs, sternum, and pelvis
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"e in'ammatory process continues until the pathogens are killed or inactivated, or other injuri- ous agents are walled o# from the rest of the body and no longer pose a threat. Phagocytes ingest cel- lular debris and other organic material as the tissues recover from the infection.
Natural Killer Cells Natural killer cells are spe- cialized white blood cells that attack cancer cells and body cells invaded by viruses. Natural killer cells secrete a chemical that pokes holes in the mem- branes of these two types of cells, destroying them. "e response of natural killer cells to viral infections or developing cancer cells is quick, providing the body with protection until the immune system takes over (see the section titled “Speci!c Immunity” that follows).
Interferons Released from virally infected cells, interferons are proteins that protect uninfected cells from viral invasion. Interferons stimulate these cells% to produce a protein that breaks down the hereditary material of the virus. When the dam- aged viruses enter cells, they are unable to replicate, and the viral infection is eventually halted. Interfer- ons enhance the activity of the phagocytes as well as the action of other, more speci!c immune system responses. In this role, interferons enhance the body’s ability to !ght invasions from most disease-causing agents, not just viruses.
Specific Immunity Speci!c immunity is a function of the immune sys- tem. "e immune system is made up of cells residing in tissues scattered throughout the body. "ese cells can react to speci!c pathogens and foreign molecules.
"e immune system has two branches: antibody- mediated immunity and cell-mediated immunity, which are discussed shortly. Each branch works slightly dif- ferently to attack foreign invaders and stop an infec- tion. "e immune system also has a memory: cells that react quickly to subsequent attacks by an invader.
Antigens: %e Triggers of Speci!c Immunity Antigens are usually foreign, or “nonself,” proteins. Sometimes, entire infectious agents act as antigens. In other instances, parts of pathogens or the poi- sons they may secrete act as antigens. Noninfectious agents such as plant pollens, blood transfusions, or tissue transplants are antigenic, although the response to these antigens may di#er from person to person. Unfortunately, the body sometimes perceives its own cells as foreign, attacking them and causing localized and systemic reactions, as in the case of autoimmune diseases such as rheumatoid arthritis.
interferons (IN-ter-FEAR-onz) Proteins produced by the body during a viral infection that protect uninfected cells from viral invasion.
antigens (AN-tih-jenz) Proteins that are foreign or recognized as “nonself” by the body.
autoimmune diseases Diseases in which the body perceives its own cells as foreign, attacking them and causing localized and systemic (whole-body) reactions.
White blood cells phagocytizing bacteria
Dermis
Epidermis
Bacteria released
Splinter
White blood cells migrating through vessel wallBlood vessels
(a) (b)
Bacteria proliferating
Figure 14.13 The Inflammatory Process. (a) A splinter damages the skin, thrusting bacteria deep into the wound. Injured cells release chemicals such as histamine that cause the blood vessels to widen, bringing more blood to the area. (b) White blood cells squeeze through vessel walls and migrate to the bacteria, where they phagocytize them. Blood clots and connective tissue wall off the area.
the same signs as local in'ammation, but additional processes occur that result in more signi!cant signs. "e red bone marrow, located in the ends of certain bones, produces and releases large numbers of white blood cells. In addition, invading microorganisms and white blood cells release chemicals that a#ect the body’s temperature-regulating system in the brain, resulting in a fever.
A fever is a rise in the internal body temperature from the human average of about 98.6°F. A fever lower than 104°F helps the body !ght infection by enhancing phagocytosis and inhibiting the growth of certain microorganisms. However, a prolonged fever of 104°F, or a fever higher than 104°F, is dangerous because it can destroy proteins in the body. Other symptoms of systemic in'ammation are fatigue, aches, and weakness.
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Cytotoxic T cells destroy invading intracellular pathogens (primarily viruses) by secreting chemicals that break apart infected host cells. By destroying
In this disease, the reactions include in'ammation and deformity of the joints. "e following sections describe how the immune system reacts to antigens that enter the body.
Antibody-Mediated Immunity "e antibody- mediated portion of the immune system reacts to extracellular antigens, that is, antigens that reside outside of body cells, such as most bacteria and any toxins they produce. Antibodies are proteins that interact in a lock-and-key fashion with anti- gens. When they bind with an antigen, antibodies interfere with the normal functioning of the anti- gen. Antigen–antibody binding also stimulates the in'ammatory response and promotes phagocytosis of the antigen.
"e workhorses of antibody-mediated immunity (the cells that produce antibodies) are specialized white blood cells called B lymphocytes, or B cells. Each B cell has receptors on its membrane that bind to a speci!c antigen. When a foreign antigen enters the body, B cells bind to it. A$er stimulation by lym- phocytes called helper T cells, the B cells reproduce in large numbers and become plasma cells, which produce antibodies. Figure 14.14 illustrates the anti- body-mediated immune response.
Some of the stimulated B cells do not di#erenti- ate into plasma cells. "ese cells circulate as memory B cells, which respond more rapidly and forcefully whenever the antigen is encountered in the future. Memory cells confer immunity (resistance) to a disease. Many infections stimulate lifelong immu- nity (measles and chicken pox, for example); oth- ers, such as diphtheria, confer immunity for only a few years. Unfortunately, not all infectious agents stimulate the formation of memory cells, so no immunity is produced as a result of their infection. Examples of such infections are strep throat and gonorrhea (an STI).
Cell-Mediated Immunity "e cell-mediated%por- tion of the immune system reacts to intracellular antigens—that is, antigens that reside inside our body cells, such as viruses, fungi, a few types of bac- teria, and parasites. It also acts against foreign tissues, such as organ transplants, and controls the growth of tumor cells.
Lymphocytes called T cells function in cell- mediated immunity. T cells reside in lymphoid tissues and in the bloodstream with the B cells. "e body contains thousands of di#erent T cells. On binding to antigens, T cells reproduce and di#erentiate into four types: cytotoxic T cells, helper T cells, suppressor T cells, and memory T cells.
Figure 14.14 The Antibody-Mediated Immune Response. White blood cells called macrophages ingest invading microbes and display their antigenic parts. Helper T cells and B cells specific to the antigens attach to them, which activates both types of cells. The helper T cells produce a chemical that stimulates the growth of the B cells. These B cells, now called plasma cells, secrete proteins called antibodies. Antibodies attach to and promote the death of the invading microbes.
antibodies Proteins that interact in a lock-and-key fashion with antigens, interfering with the normal functioning of the antigen.
B cells Specialized white blood cells (lymphocytes) that function in antibody-mediated immunity and produce antibodies.
T cells Specialized white blood cells (lymphocytes) that function in cell-mediated immunity; there are four types of T cells.
Activated helper T cell
Helper T cell
Macrophage
Bacterial antigen
Invading bacteria
B cell
Plasma cell
Antibodies
B cell growth factor+
+
Immunity 483
Interactions Between Nonspecific and Specific Immunity "e mechanisms of nonspeci!c and speci!c defense work together to prevent infection or combat infec- tion when it occurs. For example, the intact skin, mucous membranes, and chemicals in body 'uids are e#ective barriers against viral invasion. How- ever, if viruses gain entry to the body, macrophages phagocytize them before they can enter body cells. Activated helper T cells secrete chemicals that stimu- late the B cells to become antibody-producing cells.
If some of the virus particles enter body cells despite these defenses, the infected cells produce interferons, which protect uninfected cells. Natural killer cells poke holes in the infected cells, killing them, thus destroying the virus’s host. A$er binding to infected cells, cyto- toxic T cells reproduce, developing large populations speci!c for this viral infection. As armies of cytotoxic T cells break apart infected cells, the freed viruses are phagocytized by macrophages and inactivated by anti- bodies. Usually this complex process stops the viral infection. "e memory B cells and T cells continue to circulate and recognize this same virus quickly if it reenters the body. Most likely, the virus will never again cause infection because it will have been stopped before it could gain a foothold in the cells.
Protection Against Infectious Diseases
A variety of factors determine whether a person develops an infectious disease. In general, to prevent infectious disease, you must break the chain of infec- tion. "is chapter o#ers many tips on breaking the chain of infection and preventing disease. However, one of the best ways to protect yourself against infec- tion is to increase your resistance.
Speci!c immunity is either inborn or acquired. Inborn immunity is inherited, such as immunity to infectious diseases that attack other organisms (your cat or dog, for example) but not humans. Acquired immunity is not inherited; it develops during a per- son’s lifetime. Acquired immunity develops in a vari- ety of ways: either actively or passively and by natural or arti!cial means.
Active acquired immunity is an immune system response developed as a result of contact with a patho- gen, which includes development of memory B cells or T cells. Contact with the pathogen can occur naturally,
host cells, the cytotoxic T cells take away what a virus or any other intracellular infective agent needs to reproduce or replicate. Cytotoxic T cells destroy non- self tissue transplants or tumorous growths in much the same way (Figure 14.15).
Helper T cells and suppressor T cells regulate the activities of both branches of the immune system.
Helper T cells secrete various chemicals that enhance the activity of cytotoxic T cells and suppres- sor T cells and attract phagocytes to the area. Some helper T cells secrete chemicals that enhance the development and reproduction of B cells.
When the infection has subsided, suppressor T% cells shut down the immune system. Although these cells inhibit the activity of various immune sys- tem cells, they increase in number more slowly than do other T cells. "erefore, suppressor T cells shut down the immune response only a$er it has success- fully done its job.
A group of stimulated T cells circulate as mem- ory T cells. Like memory B cells, memory T cells respond rapidly and forcefully during subsequent encounters with antigens, resulting in immunity to a disease.
acquired immunity Specific resistance to infection that is not inherited but develops during a person’s lifetime.
Virus-invaded host cell
Cytotoxic T cell
Self-antigen
Viral antigen Virus
Host cell
(a) (b) (c)
Nucleus
Virus-invaded host cell
Cytotoxic T cell
Self-antigen
Viral antigen Virus
Host cell
(a) (b) (c)
Nucleus
Figure 14.15 The Cell-Mediated Immune Response. Cytotoxic T cells are key to the cell-mediated immune response. Here, whole T cells, not just antibodies, attach to cells infected with viruses, to cancer cells, or to tissue transplants. The T cell then secretes chemicals that destroy the host cell before the virus can enter the nucleus and begin to replicate.
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Drugs !at Combat Infection
Once a person has an infection like the common cold, what can he or she do to combat it? Most o$en, getting rest and drinking su&cient 'uids help the body as it mounts its defense. Sometimes over-the- counter cold medications such as decongestants, antihistamines, and cough medicines can help relieve symptoms. Many products are also available that are considered part of complementary and alternative medicine (CAM). See the Consumer Health feature “CAM Products and Colds” for more information. For other infections, individuals can obtain speci!c recommendations from a physician. "ese medical practitioners o$en prescribe medicines to inhibit the growth of or inactivate the infectious agent.
Antibiotics are a group of chemicals that kill bac- teria or inhibit their growth. Antibiotics work by attacking parts of bacterial cells or bacterial processes that di#er from human cells. When taking an anti- biotic, it is important to !nish the medication your physician prescribed, even though your symptoms may be gone before that time. All the bacteria may not have been killed, and the infection could return.
Antibiotics do nothing to combat viral infections and may kill some of the body’s normal bacterial inhabitants. "ese bacteria control the growth of troublesome microorganisms; when they are gone, it is easier for unwanted disease-causing bacteria to multiply and cause a secondary bacterial infection. "erefore, taking antibiotics when they are unneces- sary can be harmful. Furthermore, the unnecessary use of antibiotics provides additional opportunities for antibiotic-resistant strains of bacteria to develop.
Various topical antibiotics (those applied to the skin, such as bacitracin) are available without pre- scription to treat or prevent minor skin infections. Over-the-counter topical antifungal drugs are also available to treat fungal infections of the skin, such as athlete’s foot and ringworm, and vaginal yeast infec- tions. Antifungal drugs that must be taken orally for more serious fungal infections require a prescription.
Progress in the production of e#ective antiviral drugs has been slow because viruses reside inside the body’s
during day-to-day life. It can also occur arti!cially, by a vaccine prepared from a killed or weakened pathogen or its antigenic parts. Depending on how the vaccine is prepared, it may have long- or short-term e#ects. "at is why people need booster vaccinations every few years against some infectious diseases.
Children develop active acquired immunity to many serious childhood diseases by being vacci- nated according to a schedule recommended by the American Academy of Pediatrics and the American Academy of Family Physicians. "e CDC, at www.cdc .gov/vaccines, lists the current childhood and adoles- cent immunization schedule. In addition, immuni- zation of adults and children before travel to foreign countries leads to active acquired immunity to diseases not generally found in the United States. If you are trav- eling outside the United States, consult your physician 4–6 weeks before your trip for the required and recom- mended immunizations. "e CDC provides health- related travel information at www.cdc.gov/travel.
Passive acquired immunity is conferred when a person is given antibodies. Passive immunity can be acquired naturally when antibodies from a mother cross the placenta and enter the bloodstream of a developing fetus. A$er birth, a breastfed infant passively acquires antibodies from its mother’s milk. "ese antibodies help a newborn resist disease for the !rst month of life until its own immune system becomes functional. Pas- sive immunity can also be acquired arti!cially, when a person receives an injection of antibodies a$er expo- sure to a serious infection (such as hepatitis A or rabies) or a lethal poison (such as certain snake venoms).
4Protect yourself against infection by having the appropriate vaccinations before traveling.
4Protect children from infection by having them immunized according to the most recent childhood immunization schedule.
4If you contract a localized infection such as an infected sore or wound, consult your physician for specific recommendations on treating it.
4If you contract a systemic infection such as a cold or the flu, rest and drink sufficient fluids to help your body mount its defense.
4If you are prescribed a medication to combat an infection, follow all instructions and take the prescribed amount.
Healthy Living Practices
vaccine A preparation of a killed or weakened pathogen or its antigenic parts to be administered to a person to induce immunity and thereby prevent infectious disease.
antibiotics (AN-tie-by-OT-iks) A group of chemicals that kill bacteria or inhibit their growth.
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Consumer Health CAM Products and Colds Adults have an average of two to four colds per year, and children have more— about six to eight. Each year, Americans experience many colds, making the mar-
ket for cold/cough/flu remedies huge and manufactur- ers anxious to tap into it. The last time you had a cold or the flu, you likely roamed the aisles of your local phar- macy trying to find a product to shorten the duration of your illness and lessen its symptoms.
Pharmacy shelves are stocked with the usual over-the- counter kinds of decongestants, cough suppressants, and antihistamines. However, you might have noticed other products packaged as cold or flu treatments and labeled “homeopathic medicine” or “dietary supplement.” These are two types of alternative cold products. Complemen- tary and alternative medicine (CAM) is a diverse group of healthcare systems, treatments, and products that differ from conventional (scientific or evidence-based) medicine. Can the alternative cold treatments available on pharmacy shelves help support your immune system, quiet your cough, shorten the duration of your cold or flu infection, relieve your sinus pain and pressure, or dry up your nasal congestion as they claim?
Homeopathic Products Within the CAM classification framework, homeopathic (ho-me-oh-PAH-thick) “medicine,” or homeopathy ( ho-me-AH-pah-thee), is a type of alternative medical system. Developed in Germany more than 200 years ago, homeopathy operates on the principle of “similar” or “like cures like.” Proponents believe that a disease or condition can be cured by using small amounts of a sub- stance that in much larger amounts causes those same symptoms in healthy people. For example, homeopaths use substances from onions to stop the watery eyes and runny nose of a cold—the same substances that cause tears when an onion is cut during food preparation.
To prepare homeopathic products, the “principle of dilutions” is used, which states that the lowest dosage possible has the greatest effect. Therefore, substances are diluted with water in a stepwise fashion, with a spe- cial and specific type of shaking occurring after each dilution. Scientific and mathematical analyses have determined that no molecules of the original substance are present in most preparations after the dilution pro- cess. However, homeopaths believe that the “essence” of the original substance remains because the water used in the dilutions has a “memory” of it and can
therefore stimulate the body to heal itself. These basic principles, beliefs, and methods of homeopathy oppose the basic principles, understandings, and methods of science and evidence-based medicine.
A variety of products labeled “homeopathic medicine” can be found on drugstore shelves claiming “to reduce the duration and severity of flulike symptoms,” “to shorten the duration of the common cold,” or “for sinus pain, nasal congestion, sinus pressure, and headache pain.” The “active ingredients” listed on the package are the substances used at the beginning of the dilution pro- cess and can range from a single item to a long list. These substances come from plants, animals, or minerals.
Are these products safe, and are they effective? The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) states that “there is little evidence to support homeopathy as an effective treatment for any specific condition.” Edzard Ernst, physician and director of the Complementary Medicine Peninsula Medical School at the Universities of Exeter in the United Kingdom, agrees with this NCCAM assessment and notes, “Today, about 200 clinical trials of homeopathy are available. Col- lectively these data fail to provide good evidence that the clinical effects of homeopathic remedies are differ- ent from those of placebos.” Placebos are sugar pills or sham therapies that often make patients feel better solely because of patients’ belief that they are being given a helpful treatment.
Although the NCCAM notes that the side effects and risks of homeopathic products have not been well researched, it adds that most homeopathic products contain little to no active ingredients. Therefore, the NCCAM concludes that these products are likely safe but ineffective.
Dietary Supplements and Supplement Drops Alongside homeopathic products in the cough/cold section of your local pharmacy, you will also find prod- ucts labeled as “dietary supplements” or “supplement drops” for “immune support” to help combat or prevent colds or flu, or to calm your cough. Within the CAM classification framework, these products are considered biologically based treatments. They generally contain a variety of vitamins and minerals along with various herbal extracts. Garlic, echinacea, vitamin C, and zinc are among the dietary supplements often included in over-the-counter cold and flu remedies. The following sections describe the results of scientific research that has been conducted on these substances to determine their effectiveness to prevent and treat colds.
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Garlic (Allium sativum) Garlic is touted to have many and varied health benefits, including clearing acne, reducing high blood cholesterol, preventing cancer, and repelling mosquitoes. It is also said to have antimicrobial, antiviral, and anti- inflammatory properties, which work to relieve colds. Gar- lic contains various substances, such as sulfur- containing compounds, that could result in positive health effects when ingested.
Laboratory studies show that garlic appears to have some antiviral and antimicrobial properties. Few studies have been conducted on the effects of garlic on human health, however. Weak evidence shows that garlic may prevent occurrences of colds, but much more evidence is needed.
Echinacea Extracts of the flowering plant Echinacea (eh-kih-NAY- sha) are used to make over-the-counter products claim- ing to reduce the severity and duration of colds and flu and prevent these upper respiratory infections when taken regularly. Results of studies with mice show that various compounds from echinacea appear to stimulate white blood cells, act against viruses, and help reduce inflammation, which lends credence to these claims. However, it is difficult to study the effects of echinacea products in humans because over-the-counter echi- nacea products differ greatly. Products are formulated from different species and parts of the plant, by using differing extraction processes, and by combining echina- cea with other substances.
There is some evidence that echinacea preparations made of the above-ground parts of Echinacea purpurea (Figure 14.C) might shorten the duration or decrease the severity of symptoms of a cold when taken as soon as symptoms appear. There is no evidence to support its prolonged use for cold prevention, and its long-term safety has not been established. Side effects are reported infrequently. Well-designed studies are needed to con- firm the effects of echinacea in humans and to charac- terize its active ingredients and mechanism of action.
Vitamin C Vitamin C is essential for good health, and most bal- anced diets provide a sufficient quantity. Eating a citrus fruit or drinking its juice along with having a serving of another vitamin-C-containing vegetable or fruit, such as broccoli, butternut squash, pineapple, or strawber- ries, is adequate to achieve the recommended dietary allowance. The tolerable upper limit to avoid side effects or toxicity is 2,000 milligrams per day. Although it is a water-soluble vitamin, which means that it dissolves in
bodily fluids and the excess is flushed out in the urine, vitamin C can cause a variety of side effects, includ- ing diarrhea, heartburn, cramps, headache, and kidney stones if too much is ingested.
Among the many jobs it performs in the body, vitamin C enhances various functions of the immune system. Therefore, it has been used for the treatment of a variety of ills, including treating and preventing colds. Although taking vitamin C does not appear to prevent colds, regular vitamin C ingestion (200 milligrams/day, for example) might reduce the duration, and possibly the severity, of cold symptoms.
Zinc Zinc is a mineral that is an essential part of the diet. It plays a variety of roles in metabolism and is involved in proper immune function. Zinc is stored in bone and skeletal muscle, but infection can cause a drop in nor- mal blood levels of the mineral.
Zinc is sold in various forms, including lozenges, tablets, capsules, and nasal sprays, for the treatment of colds. Scientists hypothesize that zinc may compete for cold virus receptors in the lining of the nose, and this is the reasoning behind zinc nasal sprays. Put simply, if the cold virus receptors in the nose are saturated with zinc, the viruses cannot gain entry into the body.
According to results of recent studies, zinc- containing nasal sprays appear to shorten the duration of cold symptoms and lessen symptoms. However, a loss of smell—possibly a permanent loss—has been reported
Figure 14.C Echinacea purpurea. © motorolka/Shutterstock.
Drugs That Combat Infection 487
reproductive system and surrounding tissue of another. Infectious organisms can also be transferred from the mouth to the genitals and vice versa during oral sex.
Contracting an STI is more likely when other STIs are present. For example, infection with the herpes simplex virus (HSV) or with syphilis has been shown to increase the risk of HIV transmission by as much as 10- to 100-fold for a single act of intercourse. Both HSV and syphilis cause sores on the genitals, which apparently facilitate the transfer of HIV.
Most pathogens that cause STIs cannot survive long (or at all) outside the human body. "erefore, most STIs cannot be contracted by genital contact with contaminated toilet seats or bed linens. Most STIs are passed directly from one person to another.
Some STIs are caused by yeasts, protozoans, mites (organisms closely related to spiders), and lice (organ- isms closely related to 'eas). Most STIs are caused by bacteria and viruses.
Before you read more of this chapter, complete the “STI Attitude Scale” self-assessment in the Stu- dent Workbook pages of this text. A high score on this assessment indicates a predisposition toward high-risk STI behavior. A low score indicates a
cells. "erefore, a drug must inactivate the virus with- out harming its host. A few antiviral drugs treat infec- tions caused by the herpesvirus (such as genital herpes, cold sores, and chicken pox), and others treat diseases associated with AIDS. Antiviral medications have been developed to control in'uenza ('u) infection.
Speci!c medications have also been developed to treat protozoal diseases such as malaria, amebic dys- entery, and trichomoniasis. Likewise, prescription medicines are available to treat infestations of worms such as tapeworms and pinworms.
Sexually Transmitted Infections
Sexually transmitted infections (STIs), which are also called sexually transmitted diseases (STDs), are spread from person to person by the intimate contact that occurs during sexual activity, primarily vaginal intercourse and anal intercourse. In general, the patho- gens that cause STIs are passed from the sores, secre- tions, or tissues of an infected individual’s reproductive system to the mucous membranes or broken skin of the
and appears to be a major roadblock to the study and use of zinc nasal sprays.
Along with competing for cold virus receptors in the lining of the nose, zinc also appears to inhibit the repli- cation of the cold virus, which makes it an excellent can- didate as a cold treatment when taken orally. A review of decades of scientific studies on the use of zinc as a treat- ment for colds concludes that zinc reduced the dura- tion and severity of cold symptoms when taken within 24 hours of the onset of symptoms. Supplementation of the diet with zinc over a 5-month period also reduced the incidence of colds. Zinc lozenges, however, can produce undesirable side effects, such as stomach disturbances and diarrhea. Scientists are unable to make recommen- dations concerning which formulation of zinc might be used, and how much might be taken and for how long, for the possible prevention and treatment of colds.
Complementary and alternative products for the pre- vention and treatment of colds can differ dramatically from one another. In addition, the scientific evidence supporting their usefulness is often weak or absent. When evidence supporting the usefulness of a therapy becomes strong, it usually becomes accepted by the
scientifically based (conventional) medical community and is no longer considered “alternative.” Being an informed consumer will help you make the best choices for your health. Always check with your physician before taking any new medications or other treatments, includ- ing CAM products; they can react with medications you are already taking or have adverse effects of which you are unaware.
Reproduced from National Center for Complementary and Alternative Medicine. (2017). Homeopathy: An introduction. National Institutes of Health. Retrieved from http://nccam.nih.gov/health/homeopathy/; Sultan, M. T., et al. (2014). Immunity: Plants as effective mediators. Critical Reviews in Food Science and Nutrition, 54, 1298–1308; Barrett, B., et al., & CRD. (2011). Echinacea for upper respiratory infection ( structured abstract). Cochrane Library Database of Abstracts of Reviews of Effects, no. 2; Dass, R. R., et al. (2014). Oral zinc for the common cold. Journal of the American Medical Association, 311(14), 1440–1441; Ernst, E. (2011). Pharmacists and homeopathic remedies. American Journal of Health-System Pharmacy, 68, 478; Hemila, H., et al. (2013). Vitamin C for preventing and treating the common cold. Cochran Database Systematic Reviews, Cochrane Library, no. 1; Heimer, K. A., et al. (2009). Examining the evidence for the use of vitamin C in the prophylaxis and treatment of the common cold. Journal of the Ameri- can Academy of Nurse Practitioners, 21, 295–300; Allan, G., et al. (2014). Prevention and treatment of the common cold: Making sense of the evidence. Canadian Medical Association Journal, 186(3), 190–199.
488 Chapter 14 Infection, Immunity, and Noninfectious Disease
death rates from AIDS began to decline; by 1997, AIDS had dropped to the !$h leading cause of death in this age group; and by 2016, it was the ninth leading cause of death. In the United States, about three-fourths of new HIV infections each year occur in men.9
Since AIDS was !rst recognized in the early 1980s, the number of known deaths in all age groups in the United States increased annually through 1995. "en, with the introduction of antiretroviral therapy, deaths declined from 1996 through 1998. Antiretro- viral therapy uses combinations of medications to slow the replication (copying) of the AIDS virus and reduce its levels in the bloodstream. Deaths have lev- eled o# since the decline (Figure 14.16).
"e annual number of new AIDS cases increased steadily from 1984 until its dramatic increase in 1993. Much of the 1993 increase was the result of a change in the de!nition of AIDS, which broadened the list of conditions reportable as AIDS and included mea- sures of immune system function. Beginning in 1994, the annual number of new AIDS cases declined steadily through 2001. "is decrease re'ects, in part, the waning e#ect of the 1993 de!nition change. A slight decline occurred beginning in 2006 and extended through 2014, although the rates have risen in Hispanic and African American populations.
Globally, HIV infection is a widespread epidemic disease. Approximately 36.7 million people were liv- ing with HIV in 2015. In that same year, approxi- mately 2.1 million people became newly infected, and about 1.1 million died from HIV/AIDS.10 "e majority of new HIV infections occur in sub- Saharan Africa, a poor, developing part of the continent. Although death rates from AIDS have not fallen as dramatically in developing regions of the world as they have in industrialized countries, they are falling somewhat because of antiretroviral therapy, which has !nally become more available and a#ordable.
Overall, United Nations Programme on HIV/ AIDS (UNAIDS) reports that the global AIDS epi- demic has stabilized, and the annual number of new HIV infections has been declining worldwide.
%e Progression of the Disease: HIV Infection and AIDS Although medical researchers realized in 1981 that AIDS was a new disease, its cause (infection
predisposition toward low-risk STI behavior. "is chapter can help you develop low-risk behaviors.
4To protect yourself and others against the transmission of sexually transmitted infections, use latex condoms during sexual intercourse.
Healthy Living Practices
Sexually Transmitted Infections Caused by"Viruses
STIs caused by viruses are extremely serious because they cannot be cured. Certain medications ease the discomfort of viral STI symptoms, but virus particles remain in the tissues and can cause recurrent symp- toms. Also, the virus can be passed continually from chronically infected individuals to others during sexual activity.
In addition to causing STIs, three sexually transmit- ted viruses have been implicated in the development of particular cancers: HIV, human papillomavirus (HPV), and hepatitis B virus (HBV). "erefore, con- tracting any one of these viruses not only results in an incurable infectious disease but also increases the risk of developing particular types of cancers. HPV is discussed later in this chapter. HBV causes a seri- ous in'ammation of the liver and can result in liver cancer. Although hepatitis is caused by a variety of hepatitis viruses (such as A, B, C, and D), hepatitis B virus is the one most commonly transmitted by sexual contact. Although hepatitis B is a serious and long-term disease, people can recover from it.
HIV is the most serious viral sexually transmit- ted pathogen. HIV infection not only raises the risk of developing the cancer Kaposi’s sarcoma but also attacks the immune system, disabling the body’s defenses. Eventually, the immune system of an HIV- infected individual becomes so weakened that he or she succumbs to an array of illnesses (the syndrome known as AIDS) that lead to death.
Human Immunodeficiency Virus As of January 1995, AIDS became the leading cause of death among Americans aged 25–44 years. By 1996,
sexually transmitted infections (STIs) Infection spread from person to person by intimate sexual contact, primarily anal or vaginal intercourse and oral sex.
hepatitis B virus (HBV) A serious infectious disease of the liver transmitted via blood or blood products.
Sexually Transmitted Infections Caused by Viruses 489
with HIV) was not discovered until 1983. AIDS is a syndrome, a set of signs and symptoms occurring together. Being infected with HIV does not mean that a person has AIDS; infection leads to AIDS. Current data suggest that all infected individuals will develop AIDS eventually because HIV infection results in a continuous, prolonged, and ongoing disease process that still cannot be cured.
Approximately 1–3 weeks a$er becoming infected with HIV, most people experience a brief 'ulike illness that lasts for 1–2 weeks. During this stage of infection, people usually do not know that they are infected with HIV and think that they have a particularly bad case of the 'u. When this initial illness subsides, the HIV-infected person seems to be healthy but is in the asymptomatic phase of HIV disease, which usu- ally lasts about 8–10 years (asymptomatic means that no disease symptoms are apparent). "is time varies widely among individuals; it can be as short as a few months or longer than 10 years. During this time, many HIV-infected individuals do not realize that they are infected and may pass the virus on to others.
Although people with asymptomatic HIV infec- tion may feel well, the virus is actively killing helper T cells in their bodies. Gradually, the number of helper T cells declines.
Although various laboratory tests can detect abnormalities in infected asymptomatic patients, these persons remain relatively symptom free until they enter the symptomatic phase of HIV disease.
"e symptomatic phase usually begins when mature helper T cells (also called CD4 cells) have declined to about 500 cells (or fewer) per cubic millimeter of blood (500 cells/mm3). "e normal level is 800 to 1,200 helper T cells/mm3. When the T cell count drops to 500/mm3, the body begins to have trouble warding o# infections that a normal, healthy body resists. "ese infections are called opportunistic infec- tions because they are caused by organisms that nor- mally cannot produce infections except in people with lowered resistance.
During this phase of disease, the HIV-infected individual experiences a tremendous array of signs and symptoms. Some of these are nonspeci!c; that is, they are not in response to any opportunistic infec- tion. "ese nonspeci!c signs and symptoms include fever, night sweats, headache, and fatigue. Chronic diarrhea usually occurs as opportunistic organisms infect the digestive system. Also, the HIV-infected individual o$en contracts minor oral infections such as thrush, caused by the yeast Candida albicans (KAN-de-dah AL-bih-kanz) (Figure 14.17). "ese symptoms and infections of the symptomatic phase are not usually life threatening, but the infected indi- vidual has trouble maintaining the normal pace of his or her lifestyle.
As the helper T cell count declines further to about 200/mm3, the rate of contracting serious opportunistic diseases increases. Common infec- tions at this stage include Pneumocystis carinii
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Figure 14.16 Reported Cases and Known Deaths from AIDS, United States, 1984–2016. The extreme rise in reported cases in 1993 is the result of a change in the definition of AIDS, which broadened the list of conditions reportable as AIDS and included measures of immune system function. Data from Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2016. HIV Surveillence Report 2017. Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv -surveillance-report-2016-vol-28.pdf
490 Chapter 14 Infection, Immunity, and Noninfectious Disease
labor and delivery, and during breastfeeding. "ese transmission routes are related in that, with the exception of breastfeeding, they all require the blood of the uninfected person to come into direct contact (or close contact, as in the case of placental transfer) with the blood, semen, or vaginal secretions of an infected person.
In 2014, approximately 70% of all HIV/AIDS cases diagnosed were men who had sex with men, and 23% of cases were both men and women exposed through heterosexual sex.13 Gay and bisexual men and adoles- cents accounted for approximately 90% of new HIV infections for all people aged 13–24 years. Sexual behaviors that carry risk of HIV infection are unpro- tected anal intercourse between men and unpro- tected anal or vaginal intercourse between a man and a woman. However, any sexual behavior that results
pneumonia (a%fungal infection of the lungs), Cryp- tococcus meningitis (a fungal infection of the cov- erings that surround the brain), toxoplasmosis (a protozoal infection of the brain, heart, and/ or lungs), Kaposi’s sarcoma (a type of cancer; Figure"14.18), and cytomegalovirus retinitis (a viral infection of the retina). A condition called wasting syndrome can also occur at this stage, which includes a marked loss of weight and a decrease in physical stamina, appetite, and mental activity. A person with HIV infection is usually diagnosed as hav- ing AIDS when the helper T cell count falls below 200/mm3 and one of these conditions (or another condition typical of this stage) is present.
On average, if treated with antiretroviral therapy, people live about 29 years from their initial HIV diagnosis11 and about 5 years with AIDS.12 Again, the amount of time varies tremendously from individ- ual to individual. But as the T cell count falls below 50/mm3, the risk of death increases dramatically.
How HIV Is Transmitted HIV is transmitted in three ways: sexual contact with an infected person; exposure to infected blood or blood products; and placental transfer during fetal development, during
Figure 14.17 Thrush, or Oral Candidiasis. This oral infection is caused by the yeast Candida albicans and is a common infection of the symptomatic stage of HIV infection. It can also occur in persons taking broad-spectrum drugs or medications that suppress the immune system. Infants can acquire the disease during birth from mothers with vaginal candidiasis. © BioPhoto Associates/Science Source.
Figure 14.18 Kaposi’s Sarcoma. Named after an Austrian dermatologist, this cancer is a serious, opportunistic disease of the HIV-infected person. It begins in the skin and metastasizes to the lymph nodes and body organs. Courtesy of National Cancer Institute.
Sexually Transmitted Infections Caused by Viruses 491
can take place through oral sex, but the level of risk is lower than with vaginal or anal intercourse.16 Trans- mission of the virus by mosquitoes or other insects does not occur.17
Protecting Yourself Against HIV Infection "e primary means of protecting yourself against becom- ing infected with HIV is to avoid behaviors that put your blood in contact with the blood, semen, or vaginal secretions of an infected person. Abstaining from sex with infected individuals eliminates that particular risk of HIV infection. Engaging in sex in a mutually monogamous relationship in which neither partner is infected also eliminates that risk. HIV test- ing before engaging in sex can assure both of you that there is no risk of contracting the disease. Of course, both partners must remain monogamous throughout the relationship.
Unfortunately, sexual partners do not always know if a potential sexual partner is infected; also, the part- ner may be unaware of his or her own infection. "ere- fore, to reduce your risk of HIV infection, reduce your number of sexual partners. Table 14.1 lists the char- acteristics of high-risk partners. Avoid casual sexual encounters (having sex with people you do not know well) so that you have time to evaluate whether poten- tial partners have any of these characteristics.
Always use a latex condom or a polyurethane vaginal pouch (female condom) during each act of sexual intercourse. Both types of condoms provide a
in the contact of infected blood, semen, or vaginal secretions with the blood of an uninfected individual is risky because it may result in HIV transmission. Because minor abrasions or tears in the skin and mucous membranes of the genitals o$en occur dur- ing sex without partners being aware of it, such con- tact may take place much more readily than might be thought. Another primary route of HIV transmission is the sharing of contaminated needles and syringes among injecting drug abusers.
Some children and adults with AIDS acquired the disease by receiving contaminated blood during blood transfusions. "ese incidents occurred before blood banks instituted HIV antibody testing. How- ever, sta# at U.S. blood banks use new, sterile needles and syringes with each person who donates blood, so donating blood never has been a risk and is not a risk now.
Most children with AIDS contracted it during the birth process from their infected mothers. "e fetus is thought to become infected during labor contrac- tions, a$er the rupture of the membranes, or while in the birth canal. Elective cesarean section is one way to prevent mother-to-child transfer of the virus during the birth process and does not always pre sent a higher risk than vaginal delivery for the mother.14 An HIV-infected pregnant woman can also take the drug zidovudine (AZT) to decrease the chance of HIV being transmitted to her fetus.
Transmission of HIV also occurs via breastmilk. "erefore, women with HIV who live in industrial- ized countries such as the United States, where infant formula is available and safe, should not breastfeed their children.
How HIV Is Not Transmitted "ere is no need to worry about contracting HIV disease if you work, go to school, and come into casual contact with a person who is infected with HIV. People in certain professions, such as health professionals and police o&cers, are at some risk of HIV infection because they may come into contact with HIV-infected blood. "e results of numerous studies show that HIV is not transmitted by sharing such things as tele- phones or drinking fountains. Likewise, living with an HIV-infected person and sharing personal items such as combs, towels, eating utensils, and dishes do not transmit the virus.
Although HIV has been detected in saliva, it does not appear to be transmitted by kissing, except in the remote chance of transfer during open-mouth, deep kissing with an infected person who has bleeding gums or other spots in the mouth.15 HIV transmission
Injecting drug users
People who have had sex with injecting drug users
Homosexual or bisexual men
Women who have had sex with bisexual men
People who received blood transfusions between 1978 and 1985
People with hemophilia
People who have another STI, particularly syphilis or herpes
Women from countries where heterosexual transmission is common (Latin America, the Caribbean, and Africa)
Table 14.1
People at High Risk for HIV Infection (United States)
492 Chapter 14 Infection, Immunity, and Noninfectious Disease
In summary, medical researchers have discovered the ways in which HIV is transmitted and the ways in which it is not. "is information was used to develop the lists shown in the Managing Your Health box “Eliminating or Reducing Your Risk of HIV Infection and Other STIs.” One list summarizes the behaviors that virtually eliminate your risk of HIV infection, and the other summarizes the behaviors that reduce your risk.
Treatment of HIV Infection "ere is no cure for HIV infection and AIDS. "us far, attempts to develop an e#ective vaccine to protect against HIV infection have been unsuccessful. Because of the variability of the virus, developing an e#ective HIV vaccine is extremely di&cult. It is unlikely that a vac- cine will be available before 2020.19
Researchers are continually working on ways to treat HIV infection by boosting the immune system, inactivating the virus, or protecting immune system cells from infection. All approved anti-HIV drugs interfere with viral replication. However, the virus becomes immune to the drugs quite quickly as it mutates. "erefore, combinations of drugs appear to work best to retard HIV.
AIDS researchers consider a lifelong drug regimen referred to as ART (antiretroviral therapy; also called HAART [highly active antiretroviral therapy]) as the best treatment for HIV/AIDS. ART combines three
barrier between you and the body 'uids of another. Never use a male condom and a female condom at the same time. "e two materials may tear as they rub against one another, and the condoms may not stay in place. Also, do not use contraceptives that contain the spermicide nonoxynol-9. Some contra- ceptives containing this chemical might increase the risk of transmission of HIV and other STIs.18 Using a cut-open condom or a dental dam (a rectangular sheet of latex used in dentistry) as a physical barrier between the mouth and the genitals or anus during oral sex can reduce the likelihood of HIV or other STI transmission.16
Another risk factor for HIV infection is drug abuse of both injecting and noninjecting drugs. Eliminate this risk by abstaining from using drugs. Injecting drug abusers are primarily at risk because HIV- contaminated needles transmit the virus to anyone who shares the contaminated needles. Noninjecting drug abusers are also at an increased risk of contract- ing HIV because drug abusers engage in risky sexual behaviors while under the in'uence of drugs.
If you use drugs, you can reduce your risk of HIV infection by never sharing needles or syringes. If you do share needles and syringes, cleaning this equip- ment with bleach and then rinsing it with water will reduce your risk of infection. It is also best to avoid having sex while under the in'uence of drugs.
Managing Your Health
How to Eliminate Your Risk of Becoming Infected with HIV or Other STIs Abstain from sex. If that is not an option:
• Avoid having sex with HIV-infected individuals or those infected with any STI.
• Engage in sex only in a monogamous relationship in which it is certain that neither partner is infected.
• Abstain from using drugs.
Note: People in certain professions, such as health- care workers and police officers, have additional risks of infection because of the nature of their work. Such risks are not eliminated by these practices. These people can become infected with hepatitis B virus or HIV if their blood mixes with the blood or bodily secretions of an infected person.
How to Reduce Your Risk of Becoming Infected with HIV or Other STIs
• Limit your number of sexual partners.
• Avoid having sex with high-risk partners. • Avoid having sex with people you do not know well. • Avoid having sex while under the influence of
drugs, including alcohol. • Use a new latex condom during each act of anal or
vaginal intercourse. • Never share needles or syringes. • Do not use contraceptives containing the spermi-
cide nonoxynol-9. • Use a cut-open condom or a dental dam during
oral sex.
Eliminating or Reducing Your Risk of HIV Infection and Other STIs
Sexually Transmitted Infections Caused by Viruses 493
then, as Figure 14.19 shows. Because HSV-2 is not a disease that must be reported to the CDC, epide- miologists (medical researchers who study such top- ics as the spread of disease) use data such as visits to doctors’ o&ces and the results of blood tests to estimate its prevalence. (Reportable STIs are gonor- rhea, syphilis, chlamydia, and chancroid, a disease that is rare in most parts of the United States and is not discussed in this chapter.) CDC data show that the prevalence of HSV-2 based on the number of the persons aged 14–49 years who tested positive for the virus has decreased in the past two decades or so, from 21% in the period 1988–1994 to 16.2% in 2009–2012. "e CDC noted, however, that “most persons with HSV-2 have not received a diagnosis” and that the increase in the number of doctor visits “may indicate increased recognition of infection.”22
Like all STIs, HSV-2 is contracted through vaginal and anal intercourse with an infected individual. In addition, HSV-1 (which causes cold sores/fever blisters in the mouth) can infect the genital and anal areas dur- ing oral sex, and HSV-2 can infect the mouth. Either virus gains a foothold in the body by !rst infecting the skin cells in the immediate area of contact and spread- ing to surrounding cells. During an incubation period (the time between exposure to the pathogen and the onset of symptoms) that lasts about a week, the virus begins to replicate and destroy skin cells. "e patient may experience irritation at these sites of infection before the eruption of skin lesions. "e !rst lesions appear as groups of tiny, raised, solid bumps that turn clear or yellowish and become !lled with 'uid. "ese blisters eventually break open, oozing virus-contain- ing 'uid, and then develop into painful sores. "e sores turn gray, crust over, and heal usually in 5–10 days. With this initial infection, the patient o$en expe- riences a headache, fever, weakness, and muscle pain.
HSV-2 usually infects the labia, vagina, and cer- vix in women and the penis in males, but it can also
or more HIV drugs that suppress HIV replication. Researchers have found that the concentration of HIV in the bloodstream of some patients declines to undetectable levels with ART treatment. When HIV is suppressed, the concentration of mature helper T cells (CD4 cells) rises. HIV-infected patients who respond in this way to ART treatment may have their CD4 cell concentrations return to normal levels with long-term ART treatment. Although ART is extend- ing the lives of AIDS patients, it has serious side e#ects with long-term use, including cardiovascular problems and bone demineralization.
ART may be used to prevent HIV; it appears to reduce susceptibility to infection in HIV-uninfected individuals. A vaginal gel incorporating the anti- retroviral drug tenofovir has also shown promising results in reducing the rate of HIV transmission. "e gel is still under study and not yet approved for use in the United States.20
Another promising area of research in the treat- ment of HIV/AIDS is gene therapy. In this approach, the HIV-infected cells of an AIDS patient are replaced with cells engineered to resist virus replication. Prog- ress has been slow, but the results of clinical trials suggest that this approach may be useful.21
Genital Herpes Genital herpes (herpes simplex virus-2; HSV-2) is another STI that many people fear contracting because it is painful and incurable. When asked, “Do you worry about contracting an STI?” one health student responded, “I am really worried about getting herpes. Once you have it, you can’t get rid of it. "at’s scary!”
"e herpes “scare” began in the United States in the 1970s, and the number of initial visits to doctors’ o&ces for concerns about HSV-2 has increased since
genital herpes An STI caused by the herpes simplex virus that results in sores in the genital and anal areas.
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Figure 14.19 Genital Herpes—Initial Visits to Physicians’ Offices, United States, 1966–2012. Reproduced from Centers for Disease Control and Prevention. (2014, January). Sexually transmitted disease surveillance 2012. Retrieved from http://www.cdc.gov/sTD/stats12/Surv2012.pdf
494 Chapter 14 Infection, Immunity, and Noninfectious Disease
may die or su#er damage to their nervous systems. In cases of active maternal infection, cesarean sec- tion (delivering the baby surgically, by cutting through the abdominal wall and the uterus) is o$en recommended.
Genital Warts Genital warts (Condylomata acuminata) are not painful, unlike the sores of herpes infection, but some of the viruses that cause this STI are associated with the development of cervical cancer. "is asso- ciation with cancer and the possible transmission of this disease to the respiratory tract of infants during birth are the gravest concerns of this disease.
Warts are noncancerous skin tumors, masses of cells that result from uncontrolled cell growth. All warts are called papillomas and are caused by the human papillomavirus (PAP-ih-LOW-mah-vigh-rus) (HPV). However, there are more than 60 types of papillomaviruses (named HPV-1, HPV-2, and so on); each a#ects only certain areas of the body.
About 40 types of HPV can infect the genital tract, but visible genital warts are usually caused by HPV-6 and HPV-11. "ese viruses cause warts par- ticularly in the cervical, vaginal, and vulvar areas in women and various parts of the penis in men. "ey can also infect the urethra and anal areas in both sexes (Figure"14.20). "e HPV types that infect
infect tissues in the genital/anal area that are not pro- tected by a condom. "erefore, the use of latex con- doms can only reduce the risk of herpes transmission; it does not eliminate the risk for neighboring tissues. "e tenofovir vaginal gel being tested to reduce HIV transmission has been shown to reduce transmission of HSV as well.20 Follow the practices outlined in the section “Protecting Yourself Against STIs” (later in this chapter).
Transmission of HSV occurs when the infected tissues of a person who is shedding virus come in contact with the mucous membranes or with small cracks in the skin in the genital, anal, or oral areas of another. A person sheds virus when the virus is pres- ent in the skin cells, usually just before the appear- ance of sores and when they !rst appear. O$en, a person shedding virus is unaware of this danger; he or she may have no symptoms of disease at the time. "e sexual partners of a person shedding virus may not see sores or other indications that their partner is infected.
When the sores heal, the herpes infection is not cured—the virus is establishing itself in the nervous system for life. "e virus particles enter the nerve end- ings in the area of infection and move up these nerves until they are close to the base of the spinal cord. "ere, the virus particles lie dormant. During the dormant phase, the infected person shows no signs or symp- toms of herpes and is not shedding the virus.
From time to time, the virus becomes reac- tivated. Researchers are unsure about the exact mechanisms of reactivation, but infected individu- als appear to have triggers that initiate a recurrence of infection. Common triggers are stress, lack of sleep, and menstruation. During a recurrence, the virus descends along the nerves close to the areas of original infection. No symptoms may be pres- ent, but the person sheds virus and can infect oth- ers during this time. O$en, skin lesions appear, but these sores are not usually as painful, nor do they last as long as during the initial infection. Most individuals experience !ve to eight recurrences per year. However, treatment with the drug acyclovir reduces the recurrence rate dramatically. Some persons have no recurrences for as long as 2 years. No vaccine is currently available to protect against HSV-2. A recent vaccine trial failed; however, two clinical trials are currently in progress with positive initial results.23,24
Herpesvirus can also infect newborns as they pass through the cervical opening and vagina of a mother with an active infection. Infected newborns
genital warts An STI caused by the human papillomavirus that results in noncancerous skin tumors of the genital area.
Figure 14.20 Condylomata acuminata (Genital Warts). These warts are growing around the anus of a man, nearly obscuring that opening. Courtesy Dr. Wiesner/CDC.
Sexually Transmitted Infections Caused by Viruses 495
Furthermore, infants may acquire such infections from an infected mother during the birth process.
Although genital warts may go away on their own, the virus particles may remain in the tissue and can reactivate and infect others. "ese warts may also persist, grow larger, and spread. "e removal of geni- tal warts involves applying medications to the skin that break down the wart tissue, freezing them with liquid nitrogen, cauterizing (burning) them, or treat- ing them with carbon dioxide lasers. Treatment for hard-to-remove warts involves the injection of the antiviral agent alpha-interferon directly into the tumorous growths. If you contract genital warts, you may want to discuss the bene!ts and drawbacks of various treatments with your physician. Many treat- ments are far more painful than the warts, interferon treatments can be costly, and medical researchers are unsure whether treatment to remove warts reduces the risk of transmission.
In June 2006, the U.S. Food and Drug Administra- tion (FDA) approved a new vaccine (Gardasil) that protects against four major types of HPV: HPV-16 and HPV-18, which cause about 70% of cervical can- cers, and HPV-6 and HPV-11, which cause about 90% of genital warts. "e vaccine is recommended for adolescent girls who have not yet had sex because they have not yet been exposed to HPV. Once infec- tion with a type of HPV occurs, the vaccine cannot protect against it. A girl’s or young woman’s physician is the best person to determine whether she should be vaccinated. In 2009, the FDA expanded the approval of Gardasil for use in boys and young men to prevent genital warts and approved a second HPV vaccine (Cervarix), which acts against HPV-16 and HPV-18 only.25 See the following Analyzing Health-Related Information feature for more information on another approved use of Gardasil.
the genital area but do not result in the growth of warts cause tissue changes that a physician usually can see by using special techniques. Some of these viruses, particularly HPV-16 and HPV-18, are asso- ciated with cancer of the cervix and less o$en with cancer of the vulva and penis. "e American Can- cer Society recommends that women have regular Papanicolaou tests (Pap smears) to detect atypical, precancerous, or cancerous cells within the cervix and that men consider having any abnormal tissue growth in the genital area microscopically examined for the presence of cancer. In addition, the HPV DNA test, which is used along with the Pap test, can determine whether a woman is infected with one of the 13 high-risk types of HPV.
Healthcare professionals are not required to report cases of genital warts to the CDC, so data are collected on initial visits to physicians’ o&ces to receive medical care for this STI, as shown in Figure 14.21. "e number of initial visits for warts fell between 1987 and 1997 but has been rising since then. In 2012, the number of initial visits to physi- cians’ o&ces for genital warts was slightly above that for herpes.
To avoid infection with this cancer-causing virus, follow the precautions in “Protecting Yourself Against STIs.” Remember, however, that HPV, like genital herpes, can infect genital and anal tissue that is not protected by a condom. Additionally, because skin-to-skin contact can transmit HPV, infection can occur even if anal or vaginal intercourse does not take place. Transmission is also possible during oral sex, so a person with genital HPV could infect the lips, tongue, or palate of an uninfected sexual partner.
Adults as well as infants can develop warts on the larynx, or voice box, if the virus is breathed in.
Figure 14.21 Genital Warts—Initial Visits to Physicians’ Offices, United States, 1966–2012. Reproduced from Centers for Disease Control and Prevention. (2014, January). Sexually transmitted disease surveillance 2012. Retrieved from http://www.cdc.gov/sTD/stats12/Surv2012.pdf
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Health-Related InformationAnalyzing Critical Thinking
The following article was written to inform the general public about additional approved uses of the cervical cancer vaccine Gardasil. Explain why you think this article is a reliable or an unreliable source of informa- tion. Use the model for analyzing health information to guide your thinking; the main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the source making these health-related claims? Does the source have the appropriate background and education in the topic area? What can you do to check the credentials of this source?
3. What might be the motives and biases of the source making the claims?
4. What is the main point of the article? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic or the benefits and risks of the product?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related informa- tion? Summarize your reasons for coming to this conclusion.
Gardasil Approved to Prevent Anal Cancer FDA Press O"ce
The U.S. Food and Drug Adminis-tration today approved the vaccine Gardasil for the prevention of anal cancer and associated precancerous lesions due to human papillomavirus (HPV) types 6, 11, 16, and 18 in people ages 9 through 26 years.
Gardasil is already approved for the same age population for the prevention of cervical, vulvar, and vaginal cancer and the associated precancerous lesions caused by HPV types 6, 11, 16, and 18 in females. It is also approved for the pre- vention of genital warts caused by types 6 and 11 in both males and females.
“Treatment for anal cancer is challenging; the use of Gardasil as a method of prevention is important as it may result in fewer diag- noses and the subsequent surgery, radiation or chemotherapy that individuals need to endure,” said Karen Midthun, M.D., director of the FDA’s Center for Biologics Evaluation and Research.
Although anal cancer is uncommon in the general population, the incidence is increasing. HPV is associated with approx- imately 90% of anal cancer. "e American Cancer Society estimates that about 5,300 people are diagnosed with anal cancer each year in the United States, with more women diagnosed than men.
Gardasil’s ability to prevent anal can- cer and the associated precancerous lesions [anal intraepithelial neoplasia (AIN) grades 1, 2, and 3] caused by anal HPV-16/18 infection was studied in a ran- domized, controlled trial of men who self- identi!ed as having sex with men (MSM). "is population was studied because it has the highest incidence of anal cancer. At the end of the study period, Gardasil was shown to be 78% e#ective in the pre- vention of HPV 16– and 18–related AIN. Because anal cancer is the same disease in both males and females, the e#ectiveness data was used to support the indication in females as well.
Gardasil will not prevent the develop- ment of anal precancerous lesions associ- ated with HPV infections already present at the time of vaccination. For all of the indications for use approved by the FDA, Gardasil’s full potential for bene!t is obtained by those who are vaccinated prior
to becoming infected with the HPV strains contained in the vaccine.
Individuals recommended for anal can- cer screening by their healthcare provider should not discontinue screening a$er receiving Gardasil.
As of May 31, 2010, more than 65 mil- lion doses of Gardasil had been distrib- uted worldwide, since its approval in 2006 according to the manufacturer, Merck and Co. Inc, of Whitehouse Station, N.J. "e most commonly reported adverse events include fainting, pain at the injec- tion site, headache, nausea, and fever. Fainting is common a$er injections and vaccinations, especially in adolescents. Falls a$er fainting may sometimes cause serious injuries, such as head injuries. "is can be prevented by keeping the vac- cinated person seated for up to 15 min- utes a$er vaccination. "is observation period is also recommended to watch for severe allergic reactions, which can occur a$er any immunization.
Food and Drug Administration. (2010, December 22). FDA news release. Retrieved from https://www.fda.gov/BiologicsBlood - Vaccines/SafetyAvailability/VaccineSafety /ucm179549.htm
Sexually Transmitted Infections Caused by Viruses 497
the reproductive system, possibly resulting in infer- tility. Some diseases such as syphilis can cause even more devastating health e#ects. "erefore, it is cru- cial to seek medical attention immediately if you sus- pect that you are infected and to refrain from sex to avoid transmitting the disease to others.
Syphilis For centuries, syphilis, a serious STI caused by the bacterium Treponema pallidum (TREP-oh-NEE-mah PAL-ih-dum), has been a dreaded disease. Histori- cally, the infection rate of syphilis reached a peak in the United States at the end of World War II. Physicians were soon able to demonstrate the e#ectiveness of the antibiotic penicillin against the syphilis bacterium. Although syphilis is not as prevalent as it once was, its incidence increased in the late 1980s, declined dramat- ically through 2000, and increased overall from 2001 to 2016, as Figure 14.22 shows. "e increases between 2001 and 2016 were primarily among men who have sex with men. Female infection rates dropped from 2001 to 2003 and then remained relatively steady through 2016. "e male-to-female rate ratio (see Fig- ure 14.22) was about 8 to 1 in 2016. Syphilis remains an important problem in the South and in some urban areas in other regions of the country.22
An individual can contract syphilis by having sex with a person who has sores caused by T. pallidum. "ese bacteria enter the body through a break in the
Sexually Transmitted Infections Caused by"Bacteria
In contrast to viral STIs, bacterial STIs can be cured with treatment. Nevertheless, bacterial infections can be quite serious. If not treated, or not treated promptly and properly, bacterial STIs can damage
Figure 14.22 Primary and Secondary Syphilis—Rates by Sex and Male-to-Female Rate Ratios, United States, 1990–2016. Reproduced from Centers for Disease Control and Prevention. (2017). Sexually transmitted disease surveillance 2016. Retrieved from https://www.cdc.gov/std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf
4To virtually eliminate your risk of contracting HIV infection, do not have sex with infected persons or share needles and syringes.
4To reduce your risk of contracting HIV, use a new latex condom with each act of sexual intercourse.
4Adolescent girls and young women, and boys and young men, should consult with their physician to determine whether they should receive an HPV vaccine.
Healthy Living Practices
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syphilis (SIF-ih-lis) An STI that can progress from skin sores to more generalized symptoms (e.g., weight loss and muscle pain) to life-threatening, tissue- destroying skin abnormalities.
498 Chapter 14 Infection, Immunity, and Noninfectious Disease
infected individual may enter tertiary syphilis. Dur- ing the tertiary stage of infection, tissue-destroying lesions called gummas develop. Gummas not only a#ect the skin but also can destroy any type of tis- sue in the body—even bones. "erefore, this stage of syphilis is o$en dis!guring. If the tissues of the heart, major blood vessels, or brain are destroyed, paralysis and death can result.
Since the introduction of antibiotics, few people with syphilis in the United States reach this stage of the disease. Most people are given antibiotics for various infectious diseases over a period of years; even if they are not treated speci!cally for syphilis, the administration of penicillin for any reason will kill T. pallidum. Nevertheless, approximately 40–50 people each year die in the United States as a result of untreated tertiary syphilis.
Unfortunately, the syphilis bacterium can cross the placenta during pregnancy, infecting the fetus. Infants infected with T. pallidum are born with a wide variety of serious conditions, such as bone deformi- ties, low birth weight, lung damage, brain damage, deafness, and blindness. In addition, the infant can be infected during birth or a$er birth by coming into contact with the mother’s lesions.
Gonorrhea "e incidence of gonorrhea declined dramatically between 1975 and 1996, remained relatively stable through 2006, and declined through 2009; how- ever, a slight increase was seen between 2009 and 2016 (Figure 14.24). In 2015, the age group with the highest prevalence of gonorrhea infection was young men and women aged 15–29 years.22 "is fact is worrisome to health o&cials because gon- orrhea can cause irreversible damage to the repro- ductive tract.
Gonorrhea is caused by tiny spherical bacte- ria called Neisseria gonorrhoeae (neye-SEE-ree-ah GON-ah-REE-ah) that enter the body via the mucous membranes. "e bacteria infect primarily the urethra in men and the cervix in women. "erefore, con- doms are an excellent measure to prevent gonorrhea because they protect these areas well.
"e incubation period of gonorrhea is from 2 to 8 days. In men, infection with gonorrhea bacte- ria usually causes urethritis, an in'ammation of the urethra, the tube through which urine exits the body.
skin of an uninfected person. Some syphilis bacteria remain in the skin at the site of entry, where a dime- sized sore called a chancre forms. Some of these bac- teria move to the lymph nodes.
"e incubation period for syphilis is about 3%weeks. "e !rst sign of the disease is a chancre, which is char- acteristic of the !rst stage of syphilis, primary syphilis. Most o$en this sore appears in the genital or anal areas, but it can occur on the lips, tongue, breast, or !n- gers. "e chancre !rst appears as a dull, red, 'at spot, but becomes raised and then ulcerates. Figure" 14.23 is a photograph of a chancre on the penis. Although it looks as though it would be extremely painful, a chancre does not hurt. If untreated, a chancre usu- ally heals in 3–6 weeks. During that time, however, T. pallidum is multiplying in the body; the disease is not gone.
A$er the chancre heals, the signs and symptoms of secondary syphilis appear. "ese symptoms are through- out the body because the bloodstream has distributed the bacteria to most of the tissues. Common symp- toms of secondary syphilis are sore throat, weakness, headache, weight loss, fever, and muscle pain. In some patients, wartlike growths develop in moist areas of the body such as the genital region and under the arms. Most persons develop a rash that covers the body— even the soles of the feet. Although the appearance of this rash varies from person to person, it is o$en scaly.
When the symptoms of secondary syphilis sub- side, the infected person is said to be in latent syph- ilis. He or she has no outward signs of disease but is still infected. "is stage may last a lifetime, or the
gonorrhea (GON-ah-REE-ah) An STI characterized by infection of the urethra in men and the cervix in women, usually resulting in a thick discharge from the penis or vagina.
Figure 14.23 A Syphilitic Chancre of the Penis. These painless sores can occur on the genital or anal areas, lips, tongue, breast, or fingers. They are characteristic of the first stage of syphilis. Courtesy of Dr. N. J. Fiumara/CDC.
Sexually Transmitted Infections Caused by Bacteria 499
"e bacteria can infect the prostate, epididymis, and seminal vesicles in males. Although infection of these male reproductive structures is rare, it does occur and can result in sterility. Women are more prone to widespread infection of the reproductive tract than are men. Infection of the uterine (fallo- pian) tubes or other female reproductive organs is called pelvic in$ammatory disease (PID).
Gonorrhea is the most common cause of PID, a serious, painful condition. Its symptoms are lower abdominal pain, pain during sexual intercourse, abnormal menstrual periods, bleeding between peri- ods, and sometimes fever. O$en, the uterine tubes become constricted from infection, resulting in ste- rility or in ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most o$en in a uterine tube. Ectopic preg- nancies are extremely serious situations. Abscesses (collections of pus) on the pelvic organs are also com- plications of PID and may require a hysterectomy, an operation to remove some or all of a woman’s repro- ductive organs.
Another complication of gonorrhea is that the eyes of newborns can become infected with N. gonorrhoeae during birth if the mother is infected. If untreated, blindness may occur. For this reason, the eyes of all newborns in the United States are treated with antibiotic ointment or silver nitrate immediately a$er birth.
Gonorrhea can be treated with a variety of anti- biotics. In recent years, many antibiotic-resistant strains of bacteria have emerged, sometimes making treatment di&cult. However, laboratory testing of the particular strain can determine the most e#ective antibiotic to administer. Although gonorrhea is cur- able, reinfections are possible.
Urethritis is also commonly known as a urinary tract infection (UTI). A UTI caused by the gonorrhea bac- terium results in a pus-containing discharge from the urethra (Figure 14.25). (Pus is a thick 'uid made up of tissue 'uid, white blood cells, dead microorgan- isms, and dead body cells.) "e infected male then experiences painful urination and an urgency to uri- nate. Most men seek attention quickly because of these symptoms, but if the infection is untreated, within several weeks to several months, their body’s natural defenses will suppress the infection. Until an infec- tion is suppressed, however, a man can spread it to his sexual partners.
Gonorrhea infection in females may cause ure- thritis, but it more commonly causes in'ammation of the cervix and uterus, resulting in a pus-containing vaginal discharge, uterine bleeding, and abnormally long and heavy menstrual periods.
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Figure 14.24 Gonorrhea—Rates, United States, 1941–2016. Reproduced from Centers for Disease Control and Prevention. (2017). Sexually transmitted disease surveillance 2016. Retrieved from https://www .cdc.gov/std/stats16/CDC_2016_STDS_Report -for508WebSep21_2017_1644.pdf
Figure 14.25 Pus-Containing Discharge from the Penis as a Result of Gonorrhea. © Dr P. Marazzi/Science Source.
500 Chapter 14 Infection, Immunity, and Noninfectious Disease
infections, so men tend to wait longer to seek treatment than with gonorrheal infections. Occasionally, C. tra- chomatis travels to other parts of the male reproductive tract and causes epididymitis, an in'ammation of the epididymides, tubules located on the back of the testes in which sperm mature. "is bacterium also infects the rectum in people who engage in anal sex.
Some women develop urethritis when they are infected with C. trachomatis. Most o$en, the main site of female infection is the cervix, and a vaginal discharge may occur.
One of the most serious consequences of infection with chlamydia is PID. No matter which organism causes it, PID has similar symptoms and can result in sterility or ectopic pregnancy, even though chla- mydia causes less painful infection than other organ- isms such as N. gonorrhoeae.
Babies born to mothers with chlamydial infections can develop not only serious eye infections but also lung infection. Chlamydial pneumonia in a newborn can cause long-term damage to the lungs, which a#ects lung function throughout childhood.
Chlamydia trachomatis infections are treated with various antibiotics. "e CDC suggests using latex condoms to reduce the risk of contracting chla- mydial infections and following suggestions such as those in the section entitled “Protecting Yourself Against STIs.”
Chlamydial Infections Chlamydia trachomatis (klah-MID-dee-ah trah-ko- MA-tiss) causes chlamydial infections, which are similar to gonorrhea. "e bacteria that cause both STIs infect mucous membranes in the genital area, primar- ily infecting the urethra in males and the urethra and cervix in females. "e symptoms of both infections are similar, and both organisms can travel throughout the reproductive tract to spread infection. Both can cause PID in women. One di#erence is that the incubation period for gonorrhea is from 2 to 8 days, and that of chlamydial infections is from 2 to 3 weeks.
Chlamydia is the most frequently reported STI in the United States, and its rate is increasing, as Figure"14.26 shows. One reason for its prevalence is that infection with the organism causes only mild symptoms or no symptoms in most people. "ere- fore, many infected people transmit the disease unknowingly to their sexual partners. "is disease is important to diagnose, however, because women with silent chlamydial infections are at a high risk for developing more serious illness such as PID, and they can transmit the infection to their children dur- ing birth. Men rarely develop serious disease from C. trachomatis infection, but men with undiagnosed infection continue to transmit the organism to women.
"e symptoms of chlamydial infection in men are painful urination and a whitish or clear discharge from the urethra. "e amount of discharge and the level of pain are usually much milder than with gonorrheal
Figure 14.26 Chlamydia—Rates by Sex, United States, 1992–2016. Reproduced from Centers for Disease Control and Prevention. (2017). Sexually transmitted disease surveillance 2016. Retrieved from https://www.cdc.gov/std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf
chlamydial (klah-MID-dee-ahl) infections An STI that results in gonorrhea-like symptoms.
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Sexually Transmitted Infections Caused by Bacteria 501
"e symptoms of this STI in men are that of a mild infection of the urethra: mildly painful urination and urgency to urinate. "e symptoms in women are more extensive and serious: an abnormal, bad-smelling vag- inal discharge, which may be thin and foamy, along with itching, burning, swelling, redness, and tender- ness of the vulva. "ese symptoms vary in their sever- ity among patients. Trichomonas infections are treated with a speci!c drug that kills the organism.
Yeast Infections Yeast infections (candidiasis) are common among women and are acquired in a variety of ways, includ- ing sexual intercourse. Candida albicans is the organ- ism most commonly responsible for yeast infections. ("ese infections are not caused by the yeasts used to make certain baked products or beer.) "ese organisms are thought to be always present in the genital-anal area (as are a variety of bacteria) because they are present in fecal material. "e bacteria that normally inhabit the vagina in high numbers keep yeast and other bacteria from growing because they produce acids and outcom- pete other organisms for nutrients and space. However, under certain conditions, yeast may grow in the vagina.
Yeast may begin to grow and produce a vaginal infection during antibiotic use or pregnancy. Women who have poorly controlled diabetes or other STIs are also prone to yeast infections. Yeast grows best under warm and moist conditions, so clothing that is tight and poorly ventilated in the crotch may also contrib- ute to the development of yeast infections. All these factors change the vaginal environment, allowing the yeast to grow.
"e most common symptom of yeast infections in women is itching in the genital area. Other symp- toms are soreness, burning, irritation, swelling, and a vaginal discharge that is white and looks some- what like cottage cheese. Although numerous over- the- counter preparations are available to treat yeast infections, women should report symptoms to their healthcare providers before self-treatment.
Women infected with Candida can pass the infec- tion to their male partners during sexual intercourse. Typically, the penis becomes infected; parts of this organ, the scrotum, and the groin may become irri- tated and swollen and may develop a rash, white patches, or both. Infected men may also experience the symptoms of a mild urethritis.
Pubic Lice Phthirus pubis (THIR-us PEW-bis) is a pubic louse, o$en called a crab louse because it has crablike claws
Other Sexually Transmitted Infections
Organisms other than bacteria and viruses also cause STIs. "e itch mite (a close relative of spiders) and the pubic louse (a close relative of 'eas) cause sexu- ally transmitted infestations, conditions in which these organisms live on the skin in the genital area. "e yeast Candida albicans causes an infection of the genital tract, primarily in women, that can be acquired sexually or in nonsexual ways. Trichomonas vaginalis, a protozoan (a single-celled organism much more complex than a bacterium), causes an infection of the lower genital tract of both men and women.
Trichomonas Vaginalis Infections As the name of this organism implies, T. vaginalis infections (trichomoniasis) are more of a problem for women than for men. Women are 20 times more likely to contract trichomoniasis than are men. "e reason for higher infection rates in women is that T. vaginalis lives on the surface tissues of the repro- ductive tract, such as the walls of the vagina, and uses glucose (a sugar) as a principal nutrient. "is nutri- ent is more abundant in the reproductive tract of women than men. However, Trichomonas does not grow well in acidic conditions, which is the normal environment of the vagina (and of the male urethra). If the acid environment of the vagina changes, such as when a woman has another genital infection, is taking antibiotics, or is pregnant, the organism will grow easily if she becomes infected.
According to the CDC, an estimated 3.7 million women and men in the United States are infected annually with Trichomonas. Men usually contract the disease by having sexual intercourse with an infected woman, but women can contract it not only from sexual intercourse with an infected man but also from genital contact with an infected woman.
T. vaginalis infections An STI caused by a protozoan, resulting in infection of the urethra in men and of the urethra and walls of the vagina in women.
yeast infections A condition in which the fungus Candida albicans grows in the vagina or on the penis; also known as candidiasis or moniliasis.
pubic louse A close relative of fleas that causes sexually transmitted infestation; also called crabs.
502 Chapter 14 Infection, Immunity, and Noninfectious Disease
(Figure 14.27). "erefore, infestation with pubic lice is o$en referred to as “having crabs.” Pubic lice are closely related to head lice but are not found in the scalp or on head hair. Crab lice can also attach to underarm hair and eyelashes and occasionally infest these body areas.
Pubic lice are transmitted primarily by sexual contact and are rarely spread via contaminated toi- let seats and bed linens, although these routes of infestation are possible. "ey move from the pubic hairs of an infected individual to a partner when the genital areas touch. "e lice then anchor themselves by grasping pubic hairs. For nourishment, pubic lice pierce the host’s skin with their mouthparts and suck the blood of their host. When a person contracts pubic lice, he or she may notice tiny droplets of blood on the underwear before the symptoms of itching, swelling, redness, and irritation begin.
Pubic lice also reproduce in the pubic area. Female lice lay their eggs and then glue them to pubic hairs, where they eventually hatch and mature. Unless the infestation is treated, the lice will continue to repro- duce and infest their host.
Both nonprescription and prescription medica- tions are available to treat infestations of pubic lice, but a healthcare provider should be consulted to con- !rm the diagnosis. Bed linens and clothing should be washed in hot water and dried to kill any eggs or lice. Sexual partners must also be treated at the same time, as with all STIs, so that reinfestation (or reinfection) does not occur.
Scabies Scabies (Sarcoptes scabiei) (sar-COP-tees SKAY- bee-ee) produce infestations of the pubic area similar to those of the pubic louse. "ese spider- like organisms (o$en called itch mites) burrow into the skin and lay eggs there. "erefore, one sign of infestation with scabies is thin, red lines or bumps in the skin, which result from burrowing and egg laying. In addition to the pubic region, these organ- isms infest other areas of the body (Figure 14.28).
Itch mites are transmitted by prolonged, close personal contact, including sexual intercourse. How- ever, if one member of a family becomes infested, the infestation can spread to other family members via infected bed linens, towels, or other household items. Outbreaks also occur in institutional settings such as hospitals and nursing homes. Scabies is treated with prescription medications that are applied to the skin and sometimes with accompanying oral medications.
Protecting Yourself Against STIs
"e !rst step in protecting yourself against STIs is to realize that STIs can strike anyone who is sexually active. Regardless of your age, gender, ethnicity, or socioeconomic status, if you are sexually active, you can contract an STI.
"e Managing Your Health box in this chapter lists behaviors that will help protect you from infec- tion with HIV and other STIs. Of course, you may choose to abstain from sexual activity and drug use, which virtually eliminates your risk of contracting an STI. If you choose not to abstain from sex, hav- ing sex with noninfected individuals also elimi- nates your risk. How do you know if your partner is infected?
"e best way to know if you are having sex with an uninfected partner is to be in a long-term, monoga- mous relationship in which you and your partner have been tested for STIs. A monogamous relation- ship is one in which a person has only one mate or partner at any one time. Unfortunately, monogamy is not foolproof. You must be absolutely certain that your partner is not having sex with anyone else. Consider the comment by a health student when
Figure 14.27 The Pubic Louse. This color-enhanced scanning electron microscope image shows two pubic lice, one adult and one juvenile, magnified about 40 times. They are hanging from pubic hair by their massive, crablike claws. © Oliver Meckes, Science Source/Science Source.
scabies (SKAY-beez) An infestation of the pubic area in which a spiderlike organism burrows into the skin and lays eggs there.
Protecting Yourself Against STIs 503
you know them well enough to assess their risk as sexual partners. Although you may question your partner about his or her previous sexual experiences, history of STIs, and drug use habits, be aware that people o$en conceal this information. Avoid having sex with individuals who consistently have sex with multiple partners. Also avoid having sex with indi- viduals who are in the high-risk categories listed in Table 14.1. If you choose to have sex with a person in one or more of these categories, avoid penetrat- ing activities: anal, vaginal, and oral sex. Also, do not use contraceptives that contain nonoxynol-9, which might increase the risk of transmission of STIs.
If you use drugs, you are putting yourself in jeop- ardy of contracting an STI. To avoid contracting STIs, never share needles and syringes if you are an injecting drug user, and never have sex while under the in'uence of drugs or alcohol. While under the in'uence, you are more likely to engage in sexually risky and dangerous behaviors.
"e most e#ective strategy to prevent HIV and other STIs is to refrain from anal and vaginal inter- course as well as oral sex with infected partners. "e
asked, “Do you know someone who has an STI? What was their reaction when they found out?”
A married friend of mine went to the doctor right away after she suspected she had a sexually transmitted infection. The doctor said she had herpes. She was so upset with her husband; she later divorced him.
Apparently, this “monogamous” relationship was one sided. It obviously did not eliminate this woman’s risk of contracting an STI. Also, don’t equate serial monogamy with elimination of risk. Having sex with only one person for a short period and then hav- ing sex only with a new partner, and so on, does not eliminate your risk of contracting an STI.
Because it is di&cult to eliminate your risk of con- tracting an STI (or to be certain that you have no risk), it is prudent to adhere to behaviors that reduce your chances of becoming infected.
Limiting your number of sexual partners statisti- cally reduces your chances of contracting any STI. With regard to the partners you have, you will lower your risk if you delay having sex with people until
Figure 14.28 The Distribution of Scabies Skin Lesions. The red dotted areas show where infestation usually occurs. The areas without dots are rarely affected.
504 Chapter 14 Infection, Immunity, and Noninfectious Disease
second most e#ective strategy is to use latex condoms during sexual activity. According to the CDC, con- dom use substantially reduces the risk for contracting gonorrhea, HSV infection, syphilis, HIV infection, hepatitis B, and chlamydial infection. By reducing the risk of gonorrheal and chlamydial infections in women, condoms also reduce their risk of contract- ing pelvic in'ammatory disease.
Although the use of synthetic condoms will reduce your risk of becoming infected, they do not provide a guarantee against transmission because they may tear or slip (although with proper use, this is unlikely), and they do not cover the entire geni- tal area. Condoms made of natural membranes such as sheep intestine are not e#ective barriers. HIV and other sexually transmitted viruses can penetrate this type of condom, so use latex ones. When using latex condoms, however, do not use oil-based lubricants such as petroleum jelly, mineral oil, vegetable oils, massage oils, and body lotions, which can weaken the latex. Apply only water-based lubricants such as K-Y Jelly.
Another practice to avoid is storing condoms in hot cars or wallets for extended periods of time; keep them in a cool, dry place and out of direct sun- light. Do not use them a$er the expiration date or if the packaging on the condom shows signs of dam- age or deterioration, such as brittleness, stickiness, or discoloration.
It is important to use condoms consistently (a new one for each act of intercourse) and properly for them to be e#ective in reducing your risk against STIs. As you use a condom, handle it carefully, being sure not to damage it with your !ngernails, teeth, or other sharp objects.
Female polyurethane condoms are also available. Laboratory tests show that viruses such as HIV cannot pass through the polyurethane; studies with actual use show the female condom to be e#ective in preventing transmission of STIs. In 2009, the FDA approved the “second-generation” female condom (FC2).26
"e female condom is a plastic sheath that covers the cervix much like a diaphragm, lines the vagina, and covers the labia. "e same precautions and care regarding the use of male condoms should be fol- lowed when using female condoms. Female con- doms can also be used as protection during anal intercourse.
Condoms can be slit open and used 'at to cover the genital areas during oral sex to help prevent STI transmission. Dental dams ('at pieces of latex) are useful for this purpose as well.
4If you are sexually active, you are at risk for contracting STIs. You can reduce your risk by abstaining from sex or by engaging in sex only within a mutually monogamous relationship in which you and your partner are free of disease.
4You can reduce your risk by limiting your number of sexual partners, never sharing needles and syringes during drug use, and not engaging in sex while under the influence of alcohol or drugs.
4Another way to reduce your STI risk is by using synthetic condoms for each act of anal or vaginal intercourse. In addition, you can use a flat piece of latex to cover the genital areas during oral sex. If you choose not to use condoms, you can reduce STI risk by having both yourself and your partner screened for STIs before engaging in sex.
Healthy Living Practices
INFECTIOUS AND NONINFECTIOUS DISEASES Noninfectious diseases and conditions that are pres- ent at birth are termed birth defects. According to the CDC, 1 in 33 babies in the United States are born with a birth defect, and more than 5,500 of these chil- dren die.27
Some birth defects are caused by environmental in'uences, such as fetal exposure to teratogens— drugs, alcohol, viruses, or other substances that directly damage the tissues of the embryo (during weeks 3–8 of pregnancy) or fetus (during week 9 of pregnancy through birth). Dietary de!ciencies dur- ing pregnancy can also cause birth defects.
Metabolic diseases are also types of birth defects. An infant born with a metabolic disease lacks an enzyme necessary for normal metabolism. Such problems are genetic and result in an infant’s cells being unable to make a necessary body compound. Sometimes abnormal substances are made that build up in the blood and urine; these substances can damage tissues in the body, such as the liver, brain, and kidney.
Across THE LIFE SPAN
Protecting Yourself Against STIs 505
adults is Alzheimer’s disease. "is disease has a strong genetic link.
Infectious diseases also have a variety of e#ects across the life span. As life begins, infection can do harm. Viral infections can be dangerous to a preg- nant woman because many viruses can cross the placenta, the organ through which the fetus absorbs nutrients and excretes wastes. Certain viruses, such as the German measles virus, can cause birth defects, including deafness, heart defects, and intellectual disability. Other viruses, such as HIV, can infect the fetus, resulting in an infected newborn. Most bacte- ria cannot cross the placenta, but if bacteria infect the birth canal at the time of delivery, the baby can become infected as it passes through, as in the case of gonorrhea (discussed earlier).
In the past, certain bacterial diseases (e.g., diphtheria and whooping cough) and viral diseases (e.g., measles, mumps, and German measles) were common childhood infectious diseases in the United States. However, vaccines for these diseases have been developed, and most children are immunized routinely in the United States according to a schedule. Occasionally, serious outbreaks of these diseases occur in people who are not immunized. "ese childhood diseases are still prevalent in developing countries.
Other than contracting common infections such as colds and the 'u, sexually active adolescents, teens, and young adults are at highest risk for contracting STIs because they frequently have unprotected inter- course. "e one nonsexually transmitted infectious disease prevalent in adolescents and young adults is infectious mononucleosis. “Mono” primarily strikes young adults ranging in age from 15 to 25 years (although some suggest this age range extends from 10 to 35).
Infectious mononucleosis has been nicknamed the “kissing disease” because it is spread via infec- tious saliva. However, it is also contracted by inhal- ing infectious droplets sneezed or coughed into the air by an infected person or by drinking from an infected person’s glass. "is disease is usually not serious, but the Epstein-Barr (EB) virus (a her- pesvirus), which causes mononucleosis, has been associated with the subsequent development of two forms of cancer: Burkitt lymphoma in certain African populations and nasopharyngeal (nose and throat) carcinoma in Asian populations. Further- more, infection with EB virus can cause a prolonged period of exhaustion, lasting up to 3 months. Rest is the primary treatment.
Most metabolic diseases are rare; two of the better known are Tay-Sachs disease and phenylketonuria. In Tay-Sachs disease, which occurs predominantly among Ashkenazi Jews (the descendants of Jews who settled in eastern and central Europe), certain fatlike molecules accumulate in the brain and other tissues, retarding development and causing death by the age of 3–4 years. In phenylketonuria (PKU), cells are unable to convert the amino acid phenylalanine to other needed compounds. Phenylalanine and related chemicals build up in the blood and damage tissues, causing intellectual disability. Because the ill e#ects of this disease can be avoided by restricting the amount of phenylalanine in the diet, most newborn infants are tested for this disorder.
Although many genetic diseases claim the lives of infants and children, genetic disorders persist in those children who survive to become adolescents or young adults. Down syndrome, cystic !brosis, and Duchenne muscular dystrophy are all noninfectious diseases, discussed earlier in this chapter, that a#ect children. "e hope for curing these and other genetic diseases is gene therapy, in which corrected copies of defec- tive genes are inserted into the hereditary material of infected individuals. A preventive measure is genetic counseling, in which prospective parents seek advice regarding the probability that they will have a child with particular genetic disorders. Couples can use this information to make family planning decisions.
Most genetic diseases strike early in life. How- ever, one disease, Huntington’s chorea (also called Huntington’s disease), does not become evident until approximately age 40. By this time, victims may have already passed on the genes for this disease to their children. In Huntington’s chorea, the individual makes involuntary, purposeless, rapid motions such as 'exing and extending the !ngers or raising and lowering the shoulders. (Chorea refers to involuntary muscle twitching.) "e mental faculties of the person also deteriorate. Fi$een years or so a$er the onset of the disease, the individual dies. Although there is no cure or e#ective treatment for this disease, certain medications can relieve or lessen some of the symp- toms. Genetic testing is available so that young adults who have a#ected parents can learn whether they carry the lethal gene. "e gene is dominant, which means that if you inherit one gene from either parent, you will develop this disease. "is information allows people at risk for this disease to make informed reproductive choices.
Other than heart disease, cancer, and stroke, one of the best known noninfectious diseases of older
506 Chapter 14 Infection, Immunity, and Noninfectious Disease
Older adults are more susceptible to infec- tions and have a more di&cult time recovering from them than do younger persons for a variety of reasons. "e cell-mediated component of the immune system functions less e#ectively as peo- ple age. Also, the respiratory tract changes during the aging process, resulting in decreased elasticity of the lungs and a diminished cough re'ex, mak- ing elderly people more susceptible to respiratory infections. Other organ systems may also experi- ence structural and degenerative changes that pre- dispose elderly persons to infection. Many elderly people have chronic diseases too, which lower their organs’ functional reserves and contribute to their decreased resistance to infection. However, older adults are in a low-risk category for contracting STIs because they usually have fewer sexual part- ners than younger people do.
"e most common symptoms of infectious mono- nucleosis are a sore throat; low-grade, long-term fever; swollen lymph nodes and spleen (which may result in pain in the upper le$ side of the abdomen); fatigue; and weakness. However, the symptoms can vary and may include a rash, headache, or nausea. Previously, mono was di&cult to diagnose in some cases, but healthcare practitioners can now test for mono in their o&ces.
Infections are a major cause of illness and death among older adults; respiratory infections are the sixth leading cause of death in persons 85 years and older, and the seventh leading cause of death for those aged 75–84 years. Bacterial pneumonia and in'uenza, for example, together have well over 100 times the fatality rate for persons 75–84 years than for those between the ages of 25 and 34 years, and nearly 600 times the fatality rate for persons 85 years and older.6
Protecting Yourself Against STIs 507
CHAPTER REVIEW
(and usually harmlessly) reside on a person’s body, by the ingestion of toxins produced by pathogens, or by pathogens from environmental or animal sources.
"e severity of a disease’s symptoms depends on a variety of factors: the type of organism; its viru- lence; the manner in which it enters, multiplies, and spreads in or on the body; the chemicals it produces, if any; its ability to combat the defense mechanisms of the body; and the body’s reaction to the invading microbe.
Two primary causes of infectious diseases are bac- teria and viruses. Bacteria, microscopic organisms that have a simple cell structure, cause disease by !rst adhering to the surfaces of cells. Some penetrate more deeply into tissues, and many bacteria produce chemicals that break down the connections between cells, aiding their invasion. Viruses are noncellular, nonliving, protein-coated pieces of hereditary mate- rial. "ey cause infection by adhering to cells also, but then enter cells and use them to make more viruses, killing the cells in the process.
"e human body has two main types of immu- nity, or defense against disease: nonspeci!c and spe- ci!c immunity. Nonspeci!c immunity combats any foreign invader. Mechanisms of nonspeci!c immu- nity include the skin and mucous membranes, white blood cells and their phagocytic properties, the lym- phatic system, the in'ammatory response, natural killer cells, and interferons.
Speci!c immunity combats each speci!c invading pathogen and is carried out by the immune system. "e immune system has two branches: antibody- mediated immunity and cell-mediated immunity. Antibody-mediated immunity reacts to antigens (for- eign proteins) that reside outside the body cells, such as most bacteria and the toxic products they produce.
Cell-mediated immunity reacts to antigens that reside inside body cells, such as viruses, fungi, a few types of bacteria, and parasites. It also acts against foreign (nonself ) tissues such as transplanted organs and controls the growth of tumor cells.
Immunity is either inborn or acquired. Inborn immunity is inherited, such as immunity to infectious diseases that attack other organisms but not humans. Acquired immunity develops during a person’s
Summary Noninfectious diseases are processes that a#ect the proper functioning of the body, are usually accom- panied by characteristic signs and symptoms, and are not caused by pathogens; rather, abnormalities in the hereditary material, factors in the environment, or an interaction of the two cause noninfectious diseases.
Genetic factors are the sole cause of some nonin- fectious diseases; such genetic diseases are inherited or are caused by errors during cell division when gametes are formed. Inherited diseases are caused by disorders of the hereditary material, or genes. Two inherited diseases that are prevalent in the United States are cystic !brosis and Duchenne/Becker mus- cular dystrophy. Down syndrome is a genetic disease caused by errors during gamete formation.
Some diseases are caused by an interaction of genetic and environmental factors. Genetic factors can predispose a person to a disease. Diseases having both genetic and environmental causes include asthma, ulcers, diabetes mellitus, and migraine headaches.
Some noninfectious conditions have environmen- tal or unknown causes. A few noninfectious condi- tions are caused by improperly performing certain activities. Carpal tunnel syndrome, for example, is a painful condition of the hands and !ngers that results from improper positioning of the wrist while engag- ing in repetitive activities that use the hands, wrists, and arms.
Birth defects are noninfectious conditions pres- ent at birth that a#ect either the body’s structures or how it functions. Anatomic defects can be caused by genetic or environmental factors or a combination of both. Metabolic defects are genetic and a#ect a per- son throughout life. Alzheimer’s disease is a promi- nent noninfectious disease of older adults.
Infectious diseases a#ect the proper function- ing of the body, are usually accompanied by char- acteristic signs and symptoms, and are caused by disease-producing (pathogenic) bacteria, viruses, fungi, protozoans, or worms. Some infectious dis- eases are communicable; that is, they are spread from person to person either directly or by means of an intermediary organism called a vector. Other infectious diseases are noncommunicable; they are caused by organisms such as bacteria that normally
508 Chapter 14 Infection, Immunity, and Noninfectious Disease
CHAPTER REVIEW
1. Based on the information in this chapter, describe two ways in which you can lower your or your unborn children’s risk of contracting noninfec- tious diseases. Analysis
2. "e human immunode!ciency virus (HIV) attacks helper T cells. How does this a#ect the body’s ability to resist disease? Application
3. "ink about the last infectious disease you con- tracted (e.g., common cold, in'uenza). Outline what you think might have been the chain of infection for this disease. What could you have done to break the chain of infection and avoid becoming infected? Analysis
4. Analyze your behaviors regarding your risk for contracting STIs (e.g., having multiple sex
partners, drug use). What can you do to lower your risk of contracting a sexually transmitted infection? Analysis
5. A man develops a sore on his genitals but is too busy to go to his healthcare provider. "e sore heals, so he decides that he “got better” on his own. State two reasons why his reasoning is faulty and dangerous. With which STI(s) might this man be infected? Support your answer with evidence. Synthesis
6. State a behavior or behaviors that you could adopt or change to help you become more resistant to infection in general. How would this behavioral change increase your resistance to infection? Evaluation
particular type of cancer, but it also attacks the immune system, disabling the body’s defenses. Even- tually, the immune system of an HIV-infected indi- vidual becomes so weakened that he or she succumbs to an array of illnesses that lead to death. "is stage in HIV infection is called acquired immunode!ciency syndrome (AIDS). "e best ways to protect yourself against contracting this deadly disease or any STI are to refrain from having sex with infected individuals, reduce your number of sexual partners, avoid sex with high-risk partners, and use a latex condom with each act of sexual intercourse.
STIs caused by bacteria are curable with antibiot- ics. "ree prevalent bacterial STIs are syphilis, gonor- rhea, and chlamydial infections.
One protozoan, Trichomonas vaginalis, causes an STI primarily in women. "e yeast Candida albicans may cause troublesome, itchy infections in women that can be transmitted sexually. "e crab louse, Phthirus pubis, and itch mite, Sarcoptes scabiei, both can cause sexually transmitted infestations of the genital area.
Adolescents and young adults are in the age cate- gory at highest risk for contracting STIs. Infants are at risk of infection from infected mothers. Middle-aged and older people are less likely to contract STIs because they are less likely to have multiple sex partners. How- ever, anyone who practices high-risk behaviors or who has sex with an infected person can contract an STI.
lifetime. Immunity is acquired either actively or pas- sively and by natural or arti!cial means.
Many drugs have been developed to combat infec- tion. Antibiotics kill or inhibit the growth of bacte- ria and are in wide use. Antiviral drugs are limited in availability and scope. Speci!c medications have been developed to treat protozoal diseases and infec- tions caused by worms.
Sexually transmitted infections (STIs) are infec- tious diseases spread from one person to another during sexual activity, primarily sexual intercourse. Most pathogens that cause STIs can survive for only a short time outside the body; therefore, transmission of these diseases from objects, such as toilet seats, is either impossible or rare, depending on the STI. STIs are caused primarily by viruses and bacteria, but some infections and infestations are caused by yeast, protozoans, mites, and lice. "e transmission of STIs is o$en facilitated in persons infected with other STIs.
STIs caused by viruses are incurable, although the body may clear itself of some human papillomavirus (HPV) infections. In addition to causing STIs, three sexually transmitted viruses have been implicated in the development of particular cancers: human immunode!ciency virus (HIV), HPV, and hepatitis B virus (HBV).
"e most serious viral STI is HIV infection; not only does the virus raise the risk of developing a
Applying What You Have Learned
Applying What You Have Learned 509
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1. Cystic Fibrosis Foundation. (2018). About cystic #brosis. Retrieved from http://www.c#.org/AboutCF/Faqs/
2. Centers for Disease Control and Prevention. (2017). Muscular dystro- phy. Retrieved from https://www.cdc.gov/ncbddd/musculardystrophy /data.html
3. Ishikawa, Y., et al. (2011). Duchenne muscular dystrophy: Survival by cardio-respiratory interventions. Neuromuscular Disorders, 21(1), 47–51.
4. University of California San Francisco Medical Center. (2018). Prenatal testing for down syndrome. Retrieved from http://www .ucs,ealth.org/education/down_syndrome/
5. Allen, E. G., et al. (2009). Maternal age and risk for trisomy 21 assessed by the origin of chromosome nondisjunction: A report from the Atlanta and National Down Syndrome Projects. Human Genetics, 125, 41–52.
6. Murphy, S. L., et al. (2013, May 8). Deaths: Final data for 2010. National Vital Statistics Reports, 61(4), 1–118. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf
7. Mayo Clinic Sta#. (2014). Legionnaires’ disease: Risk factors. Retrieved from http://www.mayoclinic.com/health/legionnaires-disease /DS00853/DSECTION=risk-factors
1. "ink back to a time when you dated a person you’d only recently met. What did you do to be sure that you would not catch an STI from this person? What did you do to reduce your risk of infection? A$er reading this chapter, would you behave any di#erently now to protect your- self ? Why or why not? If so, what would you do di#erently?
2. When you have a common communicable infectious disease like a cold or the 'u, do you do anything to protect others, such as members of your family, from catching your illness? If so, what? Would you do anything di#erently a$er reading this chapter? If so, what? Would you%use CAM to help “cure” your cold? Why or why not?
3. Have you ever traveled outside the United States? If so, to what countries did you travel? "ink back to your trip(s) and describe what you did before departing to protect yourself from infec- tion. What did you do to protect yourself while you were there? Has reading this chapter alerted you to additional steps you should take to pro- tect yourself from infection? If so, what? If you
have never traveled outside the country, pick a country you would like to visit and explain what steps you would take before you le$ to protect yourself from infection. What steps would you take while you were there?
4. Do any hereditary diseases run in your family? If you are not sure, ask your family members, including parents, grandparents, uncles, aunts, and cousins, if possible. What steps can you take to protect your future children from a hereditary disease? Include speci!cs about diseases that run in your family, if any.
5. Many strains of bacteria are becoming resistant to the antibiotics used to treat them. One rea- son for this is that people pressure their health- care providers for antibiotics when they do not have bacterial illnesses. Also, some people stop taking antibiotics before their physician says they should. Both of these situations provide an opportunity for resistant strains of bacteria to develop and replicate. Do you practice either of these behaviors? If so, why? What have you learned in this chapter that may cause you to change those behaviors?
References
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
Reflecting on Your Health
510 Chapter 14 Infection, Immunity, and Noninfectious Disease
CHAPTER REVIEW 8. Centers for Disease Control and Prevention. (2017). Lyme disease
vaccine. Retrieved from https://www.cdc.gov/lyme/prev/vaccine.html 9. Centers for Disease Control and Prevention. (2016). HIV surveillance—
Diagnoses of HIV infection in the United States and dependent areas, 2016. Retrieved from https://www.cdc.gov/hiv/pdf/library /reports/surveillance/cdc-hiv-surveillance-report-2016-vol-28.pdf
10. United Nations Programme on HIV/AIDS. (2016). UNAIDS report& on the global AIDS epidemic. Retrieved from http://www .unaids.org/sites/default/files/media_asset/global-AIDS-update -2016_en.pdf
11. Siddiqi, A., et al. (2016). Population-based estimates of life expec- tancy a$er HIV diagnosis, United States 2008–2011. Journal of Acquired Immune De#ciency Syndrome, 72(2), 230–236.
12. Schneider, M. F., et al. (2005). Patterns of the hazard of death a$er AIDS through the evolution of antiretroviral therapy: 1984–2004. AIDS, 19(17), 2009–2018.
13. Chama, C. M., & Morrupa, J. Y. (2008). "e safety of elective caesar- ean section for the prevention of mother-to-child transmission of HIV-1. Journal of Obstetrics and Gynaecology, 2, 194–197.
14. Centers for Disease Control and Prevention. (2018). Basic informa- tion about HIV and AIDS. Retrieved from http://www.cdc.gov/hiv /basics/index.html
15. Centers for Disease Control and Prevention. (2016). Oral sex and HIV risk. Retrieved from http://www.cdc.gov/hiv/risk/behavior /oralsex.html
16. Crans, W. J. (2014). Why mosquitoes cannot transmit AIDS. Rutgers Center for Vector Biology. Retrieved from http://www.warren countymosquito.org/files/cms_files/Why%20Mosquitoes%20 Cannot%20Transmit%20AIDS.pdf
17. Moscicki, A.-B. (2008). Vaginal microbicides: Where are we and where are we going? Journal of Infection and Chemotherapy, 14, 337–341.
18. Willyard, C. (2010). Tiny steps toward an HIV vaccine. Nature, 466(7304), S8.
19. Centers for Disease Control and Prevention. (2015). Sexually trans- mitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report, 64(3), 1–140. Retrieved from https://www.cdc.gov /std/tg2015/tg-2015-print.pdf
20. Zhou, J., & Rossi, J. J. (2011). Current progress in development of RNA-based therapeutics for HIV-1. Gene "erapy, 18, 1134–1138.
21. Centers for Disease Control and Prevention. (2017). Sexually transmitted disease surveillance 2016. Retrieved from https:// w w w.cdc.gov/std/stats16/CD C_2016_STDS_Rep or t-for508 WebSep21_2017_1644.pdf
22. Cohen, J. (2010). Immunology: Painful failure of promising genital herpes vaccine. Science, 330(6002), 304.
23. Reuters. (2013, November, 7). Genital herpes vaccine succeeds in mid- stage trial. Retrieved from http://www.foxnews.com/health/2013/11 /07/genital-herpes-vaccine-succeeds-in-mid-stage-trial/
24. American Cancer Society. (2013). xCancer prevention and early- detection facts and #gures, 2013. Atlanta, GA: Author. Retrieved from http://www.cancer.org/acs/groups/content/@epidemiology surveilance/documents/document/acspc-037535.pdf
25. Witte, S. S., et al. (2010). Can Medicaid reimbursement help give female condoms a second chance in the United States? American Journal of Public Health, 100(10), 1835–1840.
26. Centers for Disease Control and Prevention. (2018). National Center for Birth Defects and Developmental Disabilities: What we do. Retrieved from https://www.cdc.gov/ncbddd/aboutus/what-we-do.html
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 511
Across the Life Span Dying and Death
Managing Your Health After the Death of a Loved One
Consumer Health Choosing a Long-Term Care Facility
Diversity in Health Hunting for Supercentenarians
Chapter Overview The status of aging Americans
Why we age
The effects of aging on health and well-being
The spiritual and emotional aspects of dying
The options for terminal care
The definition of death
How to prepare for death
Student Workbook Self-Assessment: Preparing for Aging and Death
Changing Health Habits: Can Changing a Health Habit Extend Your Life?
Do You Know? Who was the oldest person to ever live?
What happens to your body as you age?
How to increase your chances of living a long and healthy life?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Larry Beckner/Great Falls Tribune/AP Images.
Aging, Dying, and"Death
© EyeEm
/Getty Im ages.
Learning Objectives “Take care of your mind and body.”After studying this chapter, you should be able to:
1. Define aging, senescence, life span, life expectancy, and ageism.
2. Discuss the effects of ageism. 3. Describe physical and psychological changes associated with the normal aging process. 4. Explain aging theories. 5. Explain what is meant by “successful aging” and a “good death.” 6. Discuss Kübler-Ross’s five stages of emotional responses of dying persons. 7. Differentiate between active and passive forms of euthanasia. 8. Explain the benefits of advance directives. 9. Differentiate between normal and abnormal grieving.
CHAPTER 15
513
On April 15, 2011, Walter Breuning died in Montana. You might be thinking, “So what?” When Walter died of natural causes, he was 114 years of age—the oldest man in the world. Walter’s recipe for living more than 100 years included the following recommendations:
• Accept change. “Every change is good.” • Take care of your mind and body. • Eat two meals a day. • Work as long as possible. • Help others. • Accept death. “You’re born to die.”1,2
Centenarians are people who are older than 100 years of age; people who are at least 110 are supercen- tenarians. Why are centenarians able to live such long lives? Lifestyle, environmental, and social factors are known to in'uence longevity, but genetic di#erences play a major role in determining whether a person lives to be at least 100 years of age.3
In December 2010, nearly 53,364 Americans were 100 years of age or older.4 Today in the United States, more people are living to be 100 years old than in past decades. According to the U.S. Census Bureau, more than 600,000 Americans will be centenarians by 2060.5
Gerontologists, scientists who study aging, note that individuals who have the genetic potential to live longer than average o$en eliminate this advantage by adopting unhealthy lifestyles, such as using tobacco and being physically inactive.6 "erefore, an impor- tant key to enjoying a long and healthy life is taking actions now to improve your health and well-being.
For humans, growing old is a natural and universal process. "e prospect of aging and dying, however, has troubled people for centuries. Instead of dread- ing this time of life, many older adult Americans are busy pursuing a variety of enjoyable and rewarding activities. Healthy people do not let the aging process interfere with their active lifestyles.
This chapter provides more detailed informa- tion concerning the aging process, including ways
to enjoy good health and a positive sense of well- being while growing old. Additionally, this chap- ter examines dying and death as well as ways of coping with loss and grief. The assessment activ- ity for this chapter in the Student Workbook can help you examine your current beliefs about aging and death.
Aging We can de!ne aging as the sum of all changes that occur in an organism during its life. "e life span is the maximum number of years that members of a species can live when conditions are optimal. "e life span of an adult may'y is a few days; the life span of a human is 122 years. In 1997, Jeanne Calment of Marseilles, France, died at the age of 122. Accord- ing to o&cial records, Ms. Calment lived longer than any other person (Figure 15.1). However, very few
gerontologists Scientists who study aging.
aging The sum of all changes that occur in an organism during its life.
life span The maximum number of years that members of a species can expect to live when conditions are optimal.
senescence (seh-NES-ens) The stage of life that begins at age 65 years and ends with death.
Figure 15.1 Jeanne Calment. © Launette/AP Images.
514 Chapter 15 Aging, Dying, and Death
people live longer than 105 years. Contrary to popu- lar belief, there are no regions of the world where populations usually live more than 100 years (see the Diversity in Health feature “Hunting for Supercente- narians” above).
Medical experts customarily divide the human life span into stages or periods. Most people reach physical maturity or adulthood by the time they are
25% years old, but adulthood usually refers to the period spanning 21–65 years of age. Older adult- hood, or senescence, is the stage of life that begins at 65 years of age and ends with death. In this chapter, the terms older adulthood, old, aging, older adult, and elderly are interchangeable with senescence. "e ages that de!ne these life stages are arbitrary; there are no obvious physical signs that indicate the precise ages
Diversity in Health Hunting for Supercentenarians Despite the high standard of living and excellent quality of medical care in the United States, few Americans live to be 100 years old. According to verifiable records, no one in the United States has lived longer than 120 years. Yet in certain isolated parts of the world, hundreds of people claim to be more than 120 years old (supercentenarians). Do people who live in these places actually live longer than Americans or the rest of the world’s population?
In the first half of the 20th century, reports emerged concerning the extreme longevity of people living in the Hunza area of northern Pakistan, in the village of Vilca- bamba in Ecuador, and in the Caucasus region in the east- ern European country of Georgia. Scientists visited these regions to question the very old people and determine factors that were associated with their extreme longevity. After interviewing the oldest people in these regions, some experts concluded that living in an isolated and unpolluted rural environment, eating a simple nutritious diet, avoid- ing the use of alcohol and tobacco, and maintaining an active daily schedule were the keys to superlongevity.
By the 1970s, however, the real story began to unfold concerning the existence of the so-called supercente- narians. As some investigators returned to locate and interview the same old people they had met previously, their elderly subjects gave ages that did not match. For example, if 5 years had lapsed since the first interview, instead of being 5 years older, the old person reported being 7 or 10 years older. It did not take researchers long to realize that these elderly people typically inflated their ages. How could so many people have been fooled into believing that supercentenarians existed?
It is difficult to verify the ages of very old individuals who live in rural, undeveloped places. During the 1800s, birth records that could document the ages of very elderly persons were not kept, or they were destroyed. In some cases, investigators initially believed the authen- ticity of an extremely old individual’s birth record but later rejected it after determining that the person shared
the name of a long-dead ancestor who was the rightful owner of the document. Even if individuals who claim to be extremely old have their birth records, the documents’ value is questionable because birth dates can be altered.
Why would elderly people add years to their actual ages? In many isolated and impoverished places, conditions are not ideal for enjoying a lengthy life. Aged members of these popu- lations know that the longer they live, the more fame, respect, and status they can expect to receive from younger members of the population. Government offi- cials often do little to refute citizens’ astounding super- longevity claims because the notoriety attracts a steady stream of curious international visitors whose money supports the local economy.
Scientists who study individuals who claim to be supercentenarians think that their subjects are old but not that old. They may be older than 80 years of age, but few are older than age 90. Thus, no convincing evidence exists that supports the amazing longevity claims of supercentenarians. Many people, however, persistently believe stories that there are concentrations of extremely old people living in certain regions of the world.
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when one passes from young adulthood into middle age or from middle age into senescence.
Life Expectancy Life expectancy is the average number of years that an individual who was born in a particular year can expect to live. In the United States, life expectancies vary according to age, sex, and socioeconomic status. Overall, American females outlive American males by about 5 years.7 As a result, the older adult popula- tion consists of about one-third more women than men. "e reasons for these di#erences are unclear, but hormonal, genetic, and socioeconomic factors are thought to in'uence life expectancy.
Life expectancies increased dramatically dur- ing the 20th century, especially for people who live in developed countries. In the United States, for example, individuals born in 1900 could expect to live 47%years; individuals born in 2014 can expect to live 78.9 years.7 An increase in life expectancy gener- ally occurs when fewer people die during the earlier stages of life rather than in the later ones.
In the !rst part of the 20th century, people lived past 65 years of age, but so many younger individu- als died from serious injuries, from infections, and in childbirth that these statistics lowered overall life expectancy. By the 1950s, advances in scienti!c and medical technology signi!cantly reduced the num- ber of deaths from these conditions. Today, a greater proportion of the American population lives beyond age 65 than in the past.
In 2015, 14.9% of the U.S. population was 65 years of age and older.4 Between the mid-1940s and the mid- 1960s, the birthrate was unusually high in the United States. As a result, experts estimate that about 23.3% of the U.S. population will be 65 years of age and older by the year 2030.5 Figure 15.2 shows estimates of the number of Americans who are or will be 65%years of age or older in 2020, 2040, and 2060.
Scientists are learning more about the causes of aging and are seeking ways to extend life expectancy. "eir e#orts have led to the development and testing of new therapies for today’s major killers: cancer and cardiovascular disease. Advances in genetic engi- neering o#er ways to prevent and treat inherited disorders that can lead to disability and premature death. Additionally, organ transplantation gives
thousands of dying individuals the opportunity to survive by replacing their failing organs with healthy ones. Living longer, however, does not necessarily mean living better.
Preserving the quality of life becomes increas- ingly important as people grow older. By the time Americans reach 65 years of age, chronic illnesses and disabilities o$en reduce their quality of life. A measurement called years of healthy life estimates the negative impact that quality of life can have on life expectancy. Two broad goals of Healthy People 2020 include attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death and promoting quality of life, healthy development, and health behaviors across all life stages. Presently, American males and females can still expect to live in good health for 65%and 68 years, respectively.8
The Characteristics of Aged Americans "e majority of Americans older than 65 years of age own their homes or live with family members, and they can handle their !nancial matters and manage various daily living activities such as bathing, dress- ing, and cooking. Most older adults su#er from at least one chronic health problem, particularly hyper- tension, heart disease, arthritis, cancer, and diabetes.9 Many older adults with mild physical disabilities live independently by making some adaptations to their homes. For example, installing elevated toilets, grab bars, and shower seats makes it easier for people with physical conditions such as arthritis to take care of their personal hygiene (Figure 15.3).
In 2013, slightly more than 6 million Americans were 85 years of age or older.4 "is population is increasing so rapidly that experts think about 21 mil- lion people will be in this age group by 2060. People who are 85%years old and older, the “oldest of the old,” are more likely to be severely disabled and unable to live independently than the “young old” who are 65–74 years of age. In 2016, 3.1% of Americans 65 years of age and older lived in institutional set- tings, such as extended care or long-term care facili- ties (“nursing homes”).10 However, more than 9% of people 85 years of age or older lived in these places.
A signi!cant number of older adults are inde- pendent and !nancially secure, o$en because they planned for their retirement needs when they were young. Today, fewer older Americans live in pov- erty than in the late 1960s, thanks largely to federal programs such as Social Security, Medicaid, and
life expectancy The average number of years that an individual who was born in a particular year can expect to live.
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Figure 15.2 Estimates of the U.S. Population 65 Years of Age and Older in 2020, 2040, and 2060. The number of older adults in the United States is expected to increase significantly in the next 40 years. Data from U.S. Census Bureau. (n.d.). U.S. population projections. Retrieved from https://www.census.gov/newsroom/facts-for-features/2017/cb17-"08.html
Aging 517
Medicare. Nevertheless, many older Americans must live on lower incomes than when they were younger. In 2016, 8.8% of older adults had incomes that were less than the federal government’s poverty level.10 Older adults who are members of minority groups, particularly African Americans and Latinos, are more likely to have lower retirement incomes and live in poverty than are elderly White people.
Although some of retirees’ expenses are lower because they are no longer working, their health- care costs are generally higher than those of younger individuals. Almost all older American adults have Medicare. Medicare is a federal health insurance program that provides bene!ts for people 65 years of age and older. "e program, however, does not pay for every medical expense. "us, elderly people must
o$en buy additional health insurance. Nevertheless, people with low incomes and less education o$en have di&culty paying for medical expenses not cov- ered by insurance. Without adequate insurance, seri- ous chronic health conditions can drain the !nancial resources of older adults and their families. Many older adults continue working beyond the usual retirement age to help pay for health insurance and other expenses.
Why Do We Age? People age at di#erent rates. A person’s chronologi- cal age, as measured in years, may not match his or her physiologic age, as measured in functional ability. For example, some 50-year-old people experience the physical changes of aging earlier than average; they look, act, and feel older than others who are the same age. Inheritance accounts for some of this variation because a person’s genes determine when certain physiologic events occur.
Genes are hereditary material located on chromo- somes within a cell’s nucleus. Genes provide chemi- cal instructions for the production of vital proteins that are needed for cellular activities. For example, most body cells can divide to form new cells. A cell’s genes control the number of times it can divide. A$er dividing its maximum number of times, the cell dies. Most tissues produce a surplus of cells, so they can a#ord the death of some cells. As people age, how- ever, the rate of new cell production in tissues nor- mally slows, and the number of living cells declines as existing cells die.
Telomeres are structures that form the tips of chro- mosomes. Telomeres play a major role in the aging process by serving as biological clocks that control the number of times cell division can occur. Each time a normal cell divides, its telomeres shorten. When telomeres reach a certain length, they cannot become shorter, and chemical processes that initi- ate cellular death occur. "eoretically, people who inherit instructions to produce chromosomes with longer telomeres have the genetic potential to live longer than those who inherit instructions to pro- duce shorter telomeres. More research, however, is needed to determine the role of telomere length in the human aging process.
External factors such as environment also in'uence the aging process. For example, exposure to certain environmental conditions can damage genes. Dam- aged genes make mistakes in copying and transferring information concerning protein production. Young cells can correct many of these errors, but aging cells
Medicare A federal health insurance program that provides benefits for people 65 years of age and older.
Figure 15.3 Independent Living. Adding certain features to homes, such as grab bars in and next to the shower stall and supportive arms around the toilet, can help older adults with physical disabilities live independently. Courtesy of Wendy Schi".
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are less e&cient at correcting such mistakes. When the parts of cells that manufacture proteins receive faulty instructions from the genes, they are unable to produce these compounds. Without an adequate sup- ply of proteins, the a#ected cells eventually die.
An organ fails if it does not contain enough func- tioning cells. "e systems of the body are interrelated, so when the organs of one system fail, the organs of the other systems soon lose their functional capaci- ties. For example, when a heart that has been weak- ened by disease cannot pump blood e&ciently, the lungs and kidneys are not able to function properly. As a result, other organs fail to perform their jobs, and death occurs.
Radiation, pollution, and some drugs and viruses may damage genes, thereby accelerating the rate of aging and shortening life expectancy. By limiting contact or exposure to these agents, you may be able to lengthen your life expectancy.
Furthermore, adopting a lifestyle that includes reg- ular exercise and a diet high in fruits and vegetables,
as well as avoiding smoking, can signi!cantly reduce your risk of common chronic diseases (e.g., heart dis- ease, cancer). "e “Changing Health Habits” feature in the Student Workbook can help you identify and change unhealthy practices.
The Effects of Aging on Physical Health People begin to experience a gradual and irreversible decline in the functioning of their bodies when they are about 30 years old. Even healthy people experi- ence this progressive decline as they grow older. Some common signs of aging, such as menopause, delayed sexual responsiveness, graying and thinning hair, loss of height, and presbyopia, the inability to see close objects clearly, re'ect normal changes asso- ciated with growing old. Table 15.1 describes some signi!cant physical changes that are associated with normal senescence. As you can see, growing old a#ects every system of the body.
System Normal Changes
Cardiovascular Heart function remains normal, but the heart muscle thickens; arterial walls thicken; pulse rate declines
Skeletal Bone loss occurs, which can be abnormal if excessive (osteoporosis)
Nervous Brain weight decreases, especially in the cerebral cortex; neurotransmitter levels decline, nervous message transmission and muscular responses slow; short-term memory becomes less efficient; visual and hearing ability decreases; the ability to taste bitter and salty foods declines; sleep disturbances, such as taking longer to fall asleep and frequent awakening during the night, often occur
Immune Immune response against pathogens or developing cancer cells declines
Endocrine Many hormone levels decline, including insulin (regulates carbohydrate metabolism), aldosterone (regulates sodium metabolism), thyroid, estrogen, and growth hormones
Digestive Tooth loss becomes more likely as gums recede; levels of stomach acid drop; intestinal absorption of calcium is less efficient; constipation can occur, often the result of medications or poor diet
Muscular Muscle mass declines, resulting in less strength; stamina reduction occurs
Reproductive Menopause occurs in women, resulting in thinning of vaginal lining, less vaginal lubrication, and shrinkage of reproductive organs; breast tissue shrinks; prostate gland enlarges in men; sexual responsiveness slows so that it takes longer for erections to occur; orgasms are shorter and less intense
Urinary Kidneys become less efficient at filtering wastes from the blood
Skin (integument)
Skin becomes drier and less elastic, resulting in wrinkles; scalp hair growth slows, and its loss increases; hair growth in the nose and ears increases; fingernails often become yellow, develop ridges, and split
Table 15.1
Biological Effects of Normal Aging
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Aging is an individual process. "ere is no time- table that speci!es at what age people can expect a particular physical change to occur. "e rate at which these alterations occur, however, accelerates a$er 65%years of age. As a result of these normal changes, the aging body is less able to adapt to stress, repair itself, and resist or !ght infection. Infections and accidents that were minor health problems when a person was young can become disabling or deadly experiences when a person is old.
Compared to young adults, elderly people are more likely to develop nutritional de!ciencies, espe- cially of vitamins D and B12, because aging bodies are less able to absorb or use certain nutrients. "e serious health problems that o$en a#ect older adults, such as heart disease and hypertension, are associ- ated with lifestyle and are preventable to some extent.
Although certain chronic conditions such as arthritis commonly a#ect elderly people, they are not normal aspects of aging. "ese ailments may not be life threatening, but they frequently reduce the qual- ity of life.
Age-Related Macular Degeneration In the United States, macular degeneration is a leading cause of vision loss for people age 60 and older.11 "e macula is a small region in the eye that enables you to see objects in your central line of vision clearly. As many people age, the light-sensitive cells in the macula gradually die, resulting in distorted, blurry, or lost central vision. People with macular degeneration have di&culty reading, driving, and viewing television or a computer monitor. To test your vision for macular degeneration, visit www.macular.org/amsler-chart.
In about 10% of cases, tiny blood vessels form under the macula and leak 'uid and bleed, causing severe vision loss (“wet” or advanced macular degeneration). Medication and laser surgery can stop the bleeding in early stages of wet macular degeneration, but these treatments cannot restore lost vision. "ere is no e#ec- tive treatment for the “dry” form of macular degenera- tion, and this condition can lead to the wet form.
Preventing macular degeneration is important. Aging people who smoke and have a family history of
macular degeneration have a high risk of developing the condition. Other risk factors include age, obesity, and female sex. Eating a diet that contains plenty of dark green leafy vegetables, such as spinach, collards, and mustard greens, may protect against macular degeneration. For people who have been diagnosed with the disease, zinc and antioxidant supplements may slow the deterioration of the macula. However, these dietary substances can be toxic and should not be taken without consulting a physician.
Cataracts Although the reasons for their occur- rence are unclear, cataracts are common in people older than 50 years of age. A cataract forms when the normally transparent lens of the eye becomes cloudy and opaque with aging. Clouded lenses scatter light as it enters the eyes, making it di&cult to see images clearly. Symptoms of cataracts include blurry and double vision, sensitivity to bright light, and seeing halos around objects. Without surgery to remove damaged lenses, cataracts can lead to blindness. In many cases, surgeons can replace natural lenses with arti!cial ones; in others, they remove the damaged lenses and prescribe eyeglasses or contact lenses.
Some medical experts think that exposure to ultraviolet light can cause cataracts. You may be able to reduce your risk of cataracts by wearing sunglasses to shield your eyes when you are outdoors.
Glaucoma Glaucoma is another ailment that fre- quently a#ects the vision of aged people. In this con- dition, an abnormal amount of 'uid accumulates in the eyeball. Over time, the high 'uid pressure causes vision loss by permanently damaging the optic nerve, the nerve that transmits visual information to the brain. Eye pain, headache, and loss of peripheral vision are symptoms of glaucoma. Risk factors for develop- ing glaucoma include family history, African ancestry, diabetes, and cardiovascular disease. In most cases, placing medicinal drops into the eyes can control the condition. In severe cases of glaucoma, surgery is nec- essary to reduce the 'uid pressure within the eyeball.
Glaucoma may not produce noticeable symptoms; therefore, early detection is the best way to control the e#ects of the disorder. A simple, painless screening test
macular degeneration A leading cause of vision loss for people age 60 years and older.
cataracts A chronic condition in which the lens of the eye becomes cloudy and opaque, impairing vision.
glaucoma (glaw-KO-mah) A chronic ailment that occurs when fluid pressure increases in the eye.
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is available that can identify the disease before serious damage to the optic nerve occurs. "us, you can pre- vent the irreversible e#ects of glaucoma by having a physician or optometrist perform periodic screenings.
Arthritis Arthritis is a broad group of chronic joint diseases characterized by in'ammation, pain, swelling, and loss of mobility (“sti#ness”) of a#ected joints. Rheumatoid arthritis, osteoarthritis, “lupus,” !bromyalgia, and gout are forms of arthritis. Rheu- matoid arthritis and lupus can a#ect multiple organs and cause a wide variety of symptoms (Figure 15.4).
According to the Centers for Disease Control and Prevention (CDC), an estimated 54 million adult Americans su#er from doctor-diagnosed arthritis.12 Regardless of age, arthritis is the leading cause of disability among Americans.12 In osteoarthritis, the cartilage that protects the ends of bones and keeps them from rubbing together at joints wears away and breaks down. As a result, tiny bits of cartilage or bone 'oat in the 'uid that !lls the joint and the joint becomes misshapen (Figure 15.5). People o$en confuse osteoarthritis with osteoporosis, a di#erent condition that a#ects older adults.
Older adults are more likely to develop osteoarthri- tis than young persons are.12 Joints simply wear out as a person ages. Other contributing factors include heredity, overuse, injury, and obesity. Overuse and injury of joints can occur when performing sports or jobs that place excessive stress on joints. Obese older adults have a high risk of developing osteoarthritis because carrying around extra weight stresses joints, especially the knees.
Figure 15.4 Effects of Arthritis on the Hands. Arthritis damages joint tissue, resulting in deformities and the loss of flexibility. © Martynova Anna/Shutterstock.
Figure 15.5 Effects of Osteoarthritis. (a) In a healthy joint, such as the knee joint, the ends of bones are encased in smooth cartilage. The bone ends are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues. (b) This illustration shows a knee joint severely affected by osteoarthritis. Note that the cartilage has worn away. Spurs grow out from the edge of the bone, and synovial fluid within the joint increases. As a result, the joint is sore and difficult to move.
Normal synovial joint
Bone
Epiphyseal plate
Synovial membrane
Joint cavity
Synovial fluid
Articular cartilage
Joint capsule
(a)
(b)
Pathologic changes in osteoarthritis
Cyst in bone
Osteophyte or bone spur
Narrow joint space
Erosion of cartilage and bone
Cartilage fragments
arthritis A group of diseases characterized by inflammation of the joints.
Although arthritis is a chronic disease, symptoms tend to come and go. Treatment for osteoarthritis includes medications to relieve in'ammation and pain and exercises to strengthen muscles and improve or maintain joint mobility. Losing weight reduces
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stress on weight-bearing joints in obese people. In some cases, surgery is necessary to replace damaged joints with arti!cial implants.
Urinary Incontinence Urinary incontinence, the inability to control the 'ow of urine from the bladder, is an embarrassing and costly problem for millions of Americans. As people age, the muscles that control bladder emptying weaken, making it easier for urine to leak out when people move, sneeze, cough, or li$ heavy things. Many older adults experience involun- tary contractions of their bladders that cause some urine to be eliminated unexpectedly. Medications, infections, strokes, tumors, history of childbirth in women, and enlargement of the prostate gland in men can contribute to urinary incontinence.
"e fear of leaking urine accidentally while in public o$en makes many incontinent people avoid social situations. If family members cannot manage an incontinent elderly relative at home, they o$en !nd it necessary to place him or her in an extended- care facility.
Many older adults restrict their 'uid intake to reduce their urine production. "is practice can lead to dehydration. "e majority of individuals who expe- rience urinary incontinence can bene!t from treat- ment, such as behavioral techniques that enable them to be more aware of the bladder’s state of fullness. By learning to empty the bladder more frequently, a per- son may be able to avoid the leakage. People can learn and practice a series of exercises that strengthen the pelvic muscles that control urination. "ese exer- cises, called Kegel exercises, involve imitating the same muscular movements that individuals make when they voluntarily stop urinating. Incontinent people can also wear absorbent pads and undergar- ments designed to prevent incidents of urine leakage. Medication and surgery may alleviate incontinence. Embarrassment or concerns about surgery, however, keep many incontinent people from discussing this common problem with personal physicians.
Alzheimer’s Disease You cannot !nd your keys; you forget an appointment; you sometimes call your child by your cat’s name. Do you ever have the feeling
that you are losing your mind? It may be reassuring to know that everyone has these and other similar annoying experiences from time to time, but many middle-aged Americans worry that instances of forgetfulness are early symptoms of Alzheimer’s disease (AD). According to the Alzheimer’s Asso- ciation, the most common early sign of the disease is di&culty recalling newly learned information.13
AD is an incurable, progressive, degenerative disease that a#ects the functioning of the brain. People with AD have abnormal amounts of a protein that forms clumps between cells in the brain. "ese clumps inter- fere with brain cells’ ability to communicate with each other. Furthermore, tangled bundles of useless protein !bers form within the brain cells, disrupting cell func- tion. As an increasing number of brain cells die, the signs and symptoms of AD become more apparent.
Experts with the Alzheimer’s Association estimate that more than 5 million Americans, mostly elderly persons, currently live with AD.14 As the baby boomer generation ages, 10 million more people will be added to this number. By the year 2050, three times as many Americans will su#er from this dreaded disease.
AD is the most common form of dementia, a brain disorder that seriously a#ects normal cognitive (thinking) abilities, such as recalling information and solving problems. Strokes and Parkinson’s disease also are major causes of dementia. Common features of AD include memory loss, mental confusion, and loss of control over behavior and body functions. Although AD is incurable, a few medications can be prescribed to slow the decline in cognitive func- tioning, control certain inappropriate behaviors of patients, and improve patients’ moods.
Age and family history are major risk factors for AD. Although the disease is common among older adults, it is not a normal feature of growing old. What are the signs of AD? Is it preventable?
In the early stages of Alzheimer’s, a#ected people may notice lapses in their memories and cognitive abilities. For example, they may have unusual dif- !culty remembering events that happened recently, learning new information, and using information to make reasonable conclusions. "ese symptoms typi- cally begin between 40 and 60 years of age. Over time, people with the disease become increasingly forgetful, confused, disoriented, restless, and moody. Commu- nicating becomes di&cult as their speech deteriorates; depression is common. "ese changes are distress- ing to patients with AD, their family members, and their% associates. One woman recalls her a#ected mother- in-law’s gradual loss of cognitive functioning:
urinary incontinence The inability to control the flow of urine from the bladder.
Alzheimer’s disease (AD) An incurable, progressive, degenerative disease that affects the functioning of the brain.
dementia A brain disorder that seriously affects normal cognitive abilities.
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The first time I had a feeling that my elderly mother- in-law might have a serious problem with her memory occurred in April when she got lost while driving to our house. We live close to her and she had made the short trip dozens of times. When I told my husband that this was unusual behavior for her and could be a sign of a memory problem, he disagreed and said it was “easy” to make a wrong turn on the way to our house. A few months later, I was driving Mother to a store when she insisted that I should be making a right turn instead of a left one at a familiar intersection in our town. When I told her she was wrong, she became angry and argued with me about the directions to the store. When I finally reached the store, she recognized the place but didn’t apologize for her behavior. At Christmas, Mother was very quiet and seemed to be in a fog. My husband and his sister finally recognized that she was “not herself,” and they took her to the doctor’s for an evaluation. After a series of medical tests to rule out minor strokes and other causes of brain damage, her condition was diagnosed as mild-to-moderate Alzheimer’s disease.
Mother now takes two medications that seem to help her memory a little. At this point, she is not supposed to drive, and she needs help with housework. She still cooks, but I’m concerned she’ll forget that she’s making something and she’ll start a fire in her kitchen. My hus- band and his sister are thinking about selling Mother’s house and placing her in a special group home for people with this terrible disease. I dread the day when my hus- band greets his mother and she doesn’t recognize him.
As AD progresses, its victims neglect their per- sonal hygiene; their facial expressions become “'at” (emotionless); and they exhibit inappropriate and unpredictable behaviors such as undressing in public and attacking caregivers. In the terminal stages, indi- viduals with this devastating illness require constant care. "ey are bedridden and unable to talk and eat. Nothing can be done to stop the relentless progres- sion of the disease. A$er diagnosis, the average per- son can expect to survive about 8 years. Some people with AD live only 4 years a$er diagnosis, whereas others are able to live for 20 years with the disease.14 Death o$en results from pneumonia and starvation as the degenerating brain is unable to control vital functions such as breathing, swallowing, and diges- tion. In 2015, about 110,561 Americans died of AD, making it the sixth leading cause of death.7
Physicians o$en diagnose AD when patients cannot answer questions like those listed in Table"15.2.
Until recently, the only way to con!rm the diagno- sis was by examining the patient’s brain a$er death.
Brain imaging techniques such as magnetic resonance imaging (MRI) scans can now detect shrinkage in areas of the cerebral cortex, the thinking part of the brain. Such brain shrinkage is a sign of AD.
"e factors that cause AD are unclear. At least two forms of the disorder are inherited. Although genetic testing is available to determine whether rela- tives of patients with AD have the genes associated with the condition, many people who test positive do not develop the disease. Other forms of AD may be
Ask the person:
1. His or her age
2. His or her date of birth
3. The time to the nearest hour
4. His or her address
5. The current year
6. Where he or she is
7. The names of two people who are pictured in family photos
8. The years of World War II
9. The name of the current president of the United States
10. To count backward from 100 to 1
11. His or her phone number
Adapted from Wattis, J. (1996). What an old age psychiatrist does. British Medical Journal, 313, 101–104.
Table 15.2
Simple Memory Test for Identifying Dementia
Using aluminum cookware does not increase the risk of Alzheimer’s disease. © Hemera Technologies/PhotoObjects.net/Thinkstock.
Aging 523
Health-Related InformationAnalyzing Critical Thinking
The following article is an abbreviated version of “Alzhei- mer’s: Few Clues on the Mysteries of Memory” that appeared in FDA Consumer magazine. Read the article and evaluate it using the model for analyzing health-related information. The main points of the model are noted here.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the person who wrote the article? Does this person have the appropriate background and education in the topic area? What can you do to check the person’s credentials?
3. What might be the motives and biases of the person who wrote the article?
4. What is the main point of the article? Which information is relevant to the issue? Which information is irrelevant?
5. Is the source reliable? What evidence supports your conclusion that the source is reliable or unreliable? Does the source of information present the pros and cons of the topic?
6. Does the source of information attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this article is a reliable source of health-related information? Explain why you think it is or is not. Summarize your reasons for coming to this conclusion.
Alzheimer’s Few Clues on the Mysteries of Memory by Audrey T. Hingley
It happened some years ago but the memory is still !rmly implanted in my mind. One sunny a$ernoon I heard the sound of a car pulling into our driveway, peered out of my living room window, and saw one of my father’s friends, Sam (not his real name), then in his early 80s. Sam got out of his car and walked just a few steps. I watched as he stood for a few moments,
gazing at our house with an expressionless face. "en he silently returned to his car, got in, and drove away, without ever knock- ing on our door or communicating with us in any way.
I thought the incident puzzling, but it wasn’t until months later that I learned the reason for it. Sam had Alzheimer’s, a progressive disease in which nerve cells in the brain degenerate and brain substance shrinks.
A widower living alone, Sam clearly was in a dangerous position. Once he was fol- lowed home by a police o&cer, who told his grown children he had found Sam stopped
by the side of the road, not able to remem- ber how to get home by himself.
Sam’s story is being played out in the lives of up to 5 million Americans who suf- fer from Alzheimer’s disease. "e disease plays no favorites, attacking rich and poor, famous and ordinary. Among its most famous su#erers: former President Ronald Reagan.
With an annual cost of approximately $260 billion, it is the third most expensive disease in America, following only heart disease and cancer. But perhaps even more staggering than the monetary costs are the emotional and psychological costs borne by both patients and their families.
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of the disorder. Nevertheless, scientists are investigat- ing whether environmental factors, such as exposure to other minerals, may contribute to AD.
Can Alzheimer’s disease be prevented? Lifestyle factors appear to play a role in reducing the risk of AD. Keeping physically active, being involved in a variety of intellectually stimulating activities, and maintaining an extensive social network are associ- ated with a lower risk of AD.15 Making certain dietary changes may also help. Results of one study indicated
the result of slow-acting brain viruses, brain injury, or exposure to pollutants. At one time, scientists thought that aluminum poisoning caused the disease because higher than normal amounts of this metal are found in the brains of patients who died of AD. Many people are concerned about the safety of using aluminum cookware and the natural presence of this element in drinking water. However, most experts think that the unusual concentration of aluminum in the brains of persons with AD is a result, not a cause,
“People are very frightened of the pos- sibilities because they know it represents a loss of one’s self,” says Steven T. DeKosky, M.D., director of the Alzheimer’s Disease Research Center at the University of Pitts- burgh and a practicing neurologist. “It’s a very frightening prospect to see a loved one who looks the same but doesn’t talk or act the same.”
“I Have Lost Myself ” Alzheimer’s disease, a progressive, degen- erative disease attacking the brain and resulting in impaired thinking, behav- ior and memory, was !rst described by Alois Alzheimer, M.D., in 1906. German researchers recently found an important set of notes from Alzheimer’s journal of the world’s !rst documented case of the disease. "e patient exhibited many of the symptoms seen in Alzheimer’s patients today. But perhaps most poignant of all is the patient’s own description of the disease: “I have lost myself.”
In Alzheimer’s, nerve cells in the part of the brain responsible for memory and other thought processes degenerate for still-unknown reasons. Some of the most severely a#ected cells normally use ace- tylcholine, a brain chemical, to commu- nicate. Tacrine (brand name Cognex, also called THA), the !rst drug approved by the Food and Drug Administration speci!- cally to treat Alzheimer’s disease, works by slowing the breakdown of acetylcholine. "is results in relieving some memory impairment.
Tacrine does not cure Alzheimer’s or slow the disease’s progression. It has only been studied in those with mild to moder- ate Alzheimer’s disease who were otherwise in generally good health. Because tacrine
can increase the blood levels of a liver enzyme that can indicate liver damage, regular monitoring is necessary. Other side e#ects include nausea, vomiting, diarrhea, abdominal pain, skin rash, and indigestion.
Aricept (generic name donepezil hydro- chloride, also called E2020), approved by the Food and Drug Administration (FDA) in 1996, is by far the most used drug for Alzheimer’s treatment. Like tacrine, Aricept inhibits the breakdown of acetylcholine but does not cause the kind of increase in liver enzymes that tacrine does. It can also cause diarrhea, vomiting, nausea, fatigue, insomnia, and anorexia, but in most cases, such side e#ects are mild and decline with continued use of the drug. Again, the drug helps only those patients with mild to mod- erate symptoms of Alzheimer’s and does not stop or slow the disease’s progression.
Forgetfulness or Alzheimer’s? Although most people understand at least some of the horrifying aspects of Alzhei- mer’s disease, DeKosky says a big challenge is educating people regarding the widely held assumption that people are supposed to have memory impairment as they age.
“"ere’s this huge prejudice where we think people should have severe men- tal impairment as they get older,” he says. Memory loss, disorientation, and confu- sion are not part of the normal aging pro- cess, he explains. "ey are symptoms of dementia, and the most common form of dementia is Alzheimer’s.
“You need to look at the functional consequences of what someone cannot remember,” DeKosky says. “If mom for- gets where she put her car in the parking lot at the mall, that’s not abnormal. But if she walks home from the mall because she
forgot she took her car, that’s not normal. Memory is the !rst and worst change, but you will also see social withdrawal and less willingness to interact with others.”
%e Need for Answers Although no cure for Alzheimer’s is avail- able now, planning and medical/social management can help ease the burden on both patient and family members. Physi- cal exercise, good nutrition, and social activities are important. A calm, struc- tured environment may also help the person to continue functioning. At some point, however, people with Alzheimer’s require 24-hour care. While federal and state governments cover some Alzheimer’s care costs, much of the remaining costs are borne by patients and their families.
“It’s a national imperative to !nd e#ec- tive means to diagnose, treat and prevent this disease,” says David Banks, R.Ph., a public health specialist in the FDA’s O&ce of Special Health Issues. “When you look at it demographically, the nearly 80 million baby boomers living in the United States . . . now have an average life expectancy of approximately 78 years. One in !ve Ameri- cans could be age 65 or older by 2030, and tens of millions of baby boomers will live into their 80s. "e Alzheimer’s Association projects that as many as 16 million Ameri- cans could have Alzheimer’s disease in 2050 with an annual cost of 1.1 trillion dollars. When viewed in the context of accelerat- ing Social Security and Medicare costs . . . , the future monetary costs of Alzheimer’s disease may be unsustainable. "e human costs could be even greater.”
Note: Audrey T. Hingley is a freelance writer in Mechanicsville, Virginia.
Aging 525
that people who eat high amounts of salad dress- ing, fruit, nuts, !sh, tomatoes, cruciferous vegetables (broccoli and cabbage, for example), dark green and leafy vegetables, and low amounts of high-fat milk products, red meat, and butter have a lower risk of AD than people who did not have this dietary pat- tern.16 More research is needed to determine whether a particular dietary pattern protects against AD.
Elevated blood cholesterol levels, particularly LDL cholesterol, are associated with increased risk of AD.17 Results of recent studies, however, do not support taking cholesterol-lowering medications, such as cer- tain statins, to reduce the risk of AD.17,18 Nevertheless, more research is needed to con!rm these !ndings.
In'ammation and the e#ects of excess oxidation in the body, especially in the brain, may increase the risk of AD.19 "us, herbal preparations and sub- stances in foods that have anti-in'ammatory and antioxidant activity may protect against AD. Cur- cumin, a chemical with anti-in'ammatory and anti- oxidant activity, may help prevent the disease.20,21 "e spice and food coloring agent turmeric contains curcumin. EGb 761, an extract made from leaves of the Ginkgo biloba tree, has antioxidant activity. Pro- moters of dietary supplements that contain ginkgo claim their products can treat memory loss, confu- sion, depression, and other conditions associated with Alzheimer’s disease.22
Although a review of several scienti!c studies indi- cated that EGb 761 can improve cognitive function- ing, the extract’s bene!cial e#ects were slight.23 Results of the Ginkgo Evaluation Memory Study indicate that ginkgo had no e#ect on memory loss or AD.24
Vitamins E and C have antioxidant e#ects. Accord- ing to results of certain studies, populations that consume vitamin E–rich diets have lower risk of Alzheimer’s disease.25 No such bene!t, however, was
observed in groups of people taking high amounts of vitamin E, multivitamin, or other vitamin sup- plements.24 Researchers continue to investigate the association between dietary sources of antioxidants, such as fruits, vegetables, and vegetable oils, and the risk of Alzheimer’s disease. At present, there is no conclusive scienti!c evidence that supports the e#ectiveness of any speci!c dietary supplement in preventing the disease.24
Patients with Alzheimer’s o$en live at home until they reach the terminal stage and require the care provided in a skilled nursing care facility. Liv- ing with an a#ected loved one can be emotionally stressful and physically demanding. While caring for a patient with this disease, family members must try to maintain their own health and well-being. To provide assistance, many communities have special “adult day care” centers where persons with AD can spend a few hours during the day before returning to their homes. Not every community o#ers this ser- vice, so if you need help caring for someone with AD, check with your local mental health association or Alzheimer’s Association for information about adult day care centers in your area.
The Effects of Aging on Psychological Health As they approach the end of middle age, most employed people face retirement, and many aging parents have grown children with families who have moved away. If older adults equate retirement from jobs and separation from their families with being old and useless, they may experience serious psycho- logical distress. Additionally, the dramatic reduction of !nancial resources that o$en accompanies retire- ment can mean a serious loss of economic stability.
On the other hand, many older adults approach retirement age with a positive outlook and look for- ward to this time of life. Some !nd pleasure from traveling, volunteering in their communities, spend- ing time with their grandchildren, and exploring new interests. Others choose to continue working, especially if they enjoy what they do and their work is intellectually stimulating and personally ful!lling. Older adults o$en have a wealth of knowledge and experience that they can share with younger mem- bers of society.
Older adults, especially those older than 85 years of age, can experience deteriorating health, di&cult social circumstances, and poor economic condi- tions. Deaths of spouses and friends, separations
Older adults often enjoy caring for their grandchildren. © LiquidLibrary.
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from family, and reductions in !nancial resources create emotional stress. As a result, elderly persons o$en su#er depression.
Regardless of one’s age, depression is associ- ated with an increased risk of suicide. In the United States, older adults are twice as likely to commit sui- cide when compared to people who are 10–24 years of age.26 Older adults who are divorced or widowed are more likely to commit suicide than married older adults.27 Poor health is another risk factor for suicide. Older adults su#ering from chronic conditions, par- ticularly mental illness, heart failure, obstructive lung disease, and pain, are more likely to commit suicide than older adults who do not have these conditions.28
Like younger people, older people who are depressed or isolated can bene!t from participation in social and physical activities. In addition, anti- depressant medications or psychotherapy can help people regain and maintain their emotional balance.
The Effects of Aging on Social Health Although a large segment of the U.S. population is older than 65 years, our society is highly youth oriented. Not surprisingly, middle-aged Americans o$en worry that aging will mean losing their jobs to younger people, being forced into early retire- ment, becoming widowed, and su#ering from debilitating illnesses. Growing old in America can have serious social impacts on older adults; they may be ignored, neglected, and abused by younger members of the population.
Some people in our society have negative attitudes toward older adults and stereotype older people as poor, sick, useless, and dependent. Some young adults believe that older adults demand too much from the rest% of society. Ageism is a bias against older adults. Ageism creates con'ict between the generations because the old do not trust the young and vice versa. Realizing that growing older does not always mean hav- ing poor health, living in an institution, depending on public support, or being useless can help combat ageism.
Older adults represent a valuable social asset that is not well used. Aging parents and grandparents o$en have experience and wisdom that they can share with younger family members. Additionally, many retirees have a variety of talents and special organizational skills that enable them to serve as consultants, managers, or advisors in business, gov- ernment, or education settings. Although many younger people think they can !nd any information
needed by “Googling it,” older people have a wealth of knowledge and social, relationship, and employ- ment experiences to share. Both young and old ben- e!t when each accepts, values, and trusts the other.
Successful Aging Many people would like to believe that it is possible to prevent aging or delay the process. Restricting caloric intakes without creating nutritional de!ciencies may slow the rate of aging.29 "e modern search for a “fountain of youth” has resulted in the promotion of pills, potions, diets, or treatments that are touted as having “antiaging” or “life-extending” capabilities. Contrary to the claims of advertisers, none of these substances or regimens prevents or slows aging.30
Instead of searching for magic formulas to extend your life, you can engage in lifestyle choices while you are young to increase your chances of aging successfully. Although there is no generally agreed- on de!nition for “successful aging,” people who age successfully have good physical functioning.29 Other characteristics of such healthy older adults include having positive attitudes toward themselves and the future and being connected socially with others.
To increase your chances of aging successfully, evaluate your health status and lifestyle, identify spe- ci!c unhealthy or risky behaviors, and then work at changing those behaviors. Although modifying all unhealthy behaviors is commendable, certain prac- tices are associated more closely with lengthening one’s life span than others are.
Physically active people live longer, have a better quality of life, and report being happier than people who are sedentary.31 Engaging in regular exercise throughout your life will help you control your body weight as well as improve your circulation, strengthen your heart, and maintain your muscle and bone mass. People older than 65 years of age who perform regular exercise improve their physical strength and 'exibility, features that can enhance their quality of life.31 Exercise may improve some cognitive abilities of aging adults, such as memory, and delay the onset of Alzheimer’s disease.32 More research, however, is needed to further support these !ndings.
"e CDC guidelines indicate that older adults should exercise, at a moderate intensity, for at least 150 minutes a week; for greater health bene!ts, 300% minutes of moderate-intensity exercise is rec- ommended each week. Aerobic exercises, including
ageism A bias against elderly people.
Aging 527
walking, jogging, water aerobics, cycling, hiking, and exercise machines (stationary bike, elliptical), help maintain cardiovascular health, weight management, and mental/emotional stress relief.
Strength training exercise is recommended for all adults, and it an important part of health main- tenance as we age. "e CDC recommends that older adults engage in strength training at least 2 days a week. Maintaining strength in major muscle groups, especially around important joints (i.e., hips, shoul- ders, knees), can help us avoid accidents and injuries that become more common as we age (e.g., falling). Weight-bearing exercises are also important for maintaining bone mass and avoiding osteoporosis. Li$ing weights, using resistance bands, doing yoga, and performing body weight exercise (e.g., pushups) are all appropriate exercises for older people.
Flexibility exercises (e.g., stretching) are also an important aspect of maintaining health as we age. As with strength training, engaging in 'exibility exercise regularly helps us maintain range of motion in our hips, shoulders, and backs. Scienti!c evidence sug- gests that maintaining strength and 'exibility helps us maintain healthy circulation and reduces our risk of injury as we age. "e American College of Sports Medicine recommends engaging in 'exibility exer- cises at least twice a week, although doing so more o$en can lead to better results. Flexibility can be gained or maintained through static stretching or engaging in exercises such as yoga or Pilates.
Maintaining social and psychological health is also important for healthy aging. Social isolation is associ- ated with physical and psychological health problems, injuries, and hospitalization. In contrast, older adults who maintain or develop social networks tend to be happier and have better health.33 Older adults who engage in social activities display better cognitive, psy- chological, and emotional health and are more likely to adhere to any necessary medical treatment plans. Institutionalization is also less common among older adults who have active social networks. Organized events, such as game nights or dances, and transpor- tation services are available in many areas and can help facilitate social connections among older people. Although we can maintain our social network as we age, it is also important for family members to actively maintain connections with older family members.
As previously stated, engaging in regular exercise and socialization are associated with positive health outcomes as we age. "ese activities have also been shown to reduce our risk of cognitive decline, which has become more common over past decades. Brain
training, or mind games, has also been suggested as a means for maintaining cognitive function. Early studies on rodents demonstrated positive e#ects on brain function; however, few human studies have shown signi!cant brain function improvement in participants.34 "e e#ectiveness of brain training remains unclear; however, continued learning, read- ing, and engaging in social activities appear to help us maintain brain function as we age.
Table 15.3 lists some basic recommendations for enhancing your health and quality of life as you age, such as managing stress, maintaining relationships, and developing a positive attitude. It is worth remem- bering the words of Eubie Blake, a jazz musician who died in 1983 at the age of 100: “If I had known that I was going to live this long, I would have taken better care of myself.”
Taking the following actions now, while you are still young, may help you enjoy a healthier, longer life:
• Maintain a healthy weight and eat a nutritious, low- fat diet that includes plenty of whole grains, fruits, and vegetables.
• Be physically active; exercise daily. • Do not smoke, drink too much alcohol, or abuse
other drugs. • Manage stress; take time to relax daily. • Have regular physical examinations. • Adopt safer sex practices. • Do not drive while under the influence of alcohol or
other drugs; always wear a seat belt in vehicles. • Protect your skin and eyes from sunlight. • Obtain enough sleep. • Be concerned about your safety at home, work,
or play. • Maintain social networks with your family and
friends. • Be flexible; expect changes. • Develop a positive attitude; have a sense of humor. • Find opportunities to learn new skills or
information. • Get involved with living while accepting your
mortality.
Data from Kerschner, H., & Pegues, J. A. (1998). Productive aging: A quality of life agenda. Journal of the American Dietetic Association, 98, 1445–1448; and Turner, L. W., et al. (1992). Life choices: Health concepts and strategies. Minneapolis, MN: West Publishing.
Table 15.3
Tips for Successful Aging
528 Chapter 15 Aging, Dying, and Death
Dying Many Americans, including health professionals, fear dying and death, especially the possibility that dying will be premature and painful. Fearing death makes it di&cult to be around someone who is dying. One reason many Americans may fear dying and death is that few have had contact with dying per- sons or dead bodies. Usually an ambulance rushes the critically injured or terminally ill person to a hospital, where he or she is connected to a variety of life-support machines and placed in an intensive care unit (Figure 15.6). Most hospitals permit fam- ily members to visit the seriously ill patient for only a few minutes each hour. In other instances, elderly or incurably ill patients die in long-term care facili- ties with few or no family members present. In the United States, dying o$en becomes a mechanized, isolated, and depersonalized process.
Dying was very di#erent a hundred years ago. In that era, nearly everyone died at home, surrounded by family and friends. Shortly a$er death, the body was cooled, and it o$en remained in the home for the funeral ceremony. It was even customary for people to have photographs taken of their deceased loved ones to remember them (Figure 15.7). "ese practices helped survivors accept dying and death as a part of life.
The Spiritual Aspects of Dying Some people who have been revived a$er being unre- sponsive describe “near-death” experiences and relate them as spiritually upli$ing events. "ey report that
4Planning for your future financial needs while you are still young can help you enjoy your retirement years.
4To age successfully, evaluate your present health and lifestyle, identify risky behaviors, and then consider changing those behaviors.
Healthy Living Practices
Figure 15.6 Intensive Care. Treatment of a critically injured or terminally ill person may include being connected to a variety of life-support machines in a hospital’s intensive care unit. © mauritius images/age fotostock.
Figure 15.7 Remembrance Photo, Circa 1895. A hundred years ago, nearly everyone died at home, surrounded by their families and friends. It was customary for people to have photographs taken of their deceased loved ones to remember them. Courtesy of Library of Congress, Prints and Photographs Division. [Reproduction number LC-DIG-ppmsca-11042]
Dying 529
they were aware of what was happening before they recovered consciousness. "ey o$en recall feeling temporarily disengaged from their bodies and having unusual but peaceful sensations. Accounts of near- death experiences o$en include some features of the person’s spiritual or religious beliefs. People who have been in these situations are o$en profoundly a#ected by their experiences, but scientists have no ways to verify their stories.
People who believe in an a$erlife may have less fear of dying and death. Many people believe that a soul exists, which leaves the body a$er death and goes to heaven or hell. Others believe in reincar- nation, coming back to life as another person or organism a$er death. Some individuals are not con- cerned with what happens to them a$er death. In many instances, cultural and religious backgrounds provide the foundation for a person’s feelings about life a$er death.
The Emotional Aspects of Dying Although coping with the death of a beloved person is one of life’s most di&cult experiences, knowing that your own death is near is especially di&cult. In the late 1960s, Elisabeth Kübler-Ross, a psychia- trist at the University of Chicago Billings Hospital, pioneered e#orts to understand the psychological processes of dying and death.35 A$er interviewing more than 200 terminally ill patients, she formu- lated a !ve-stage model to describe the emotional responses that people o$en experience as they face their deaths (Table 15.4).
"e !rst stage of this coping process is denial. Peo- ple in denial may act shocked a$er receiving news of their terminal condition. Frequently, they do not believe their physician’s prognosis. While in denial, dying individuals may ignore their troublesome symptoms or seek more optimistic outlooks from other physicians. Some dying patients completely lose faith in the value of conventional medical care; some maintain hope of “beating this thing” by using untested alternative treatments.
As the dying begin to accept their situation, they may enter the second stage, anger. In this stage, dying people are provoked easily; they may lash out at loved ones, medical sta#, and anything or anybody. "ey o$en demand to know, “Why me? Why not someone else?” It is important for people who care for or visit dying individuals to expect this reaction and not take such anger personally.
"e third emotional stage of dying is bargaining. Incurably ill individuals may make deals with medi- cal sta# or God, promising to exchange exception- ally good behavior for a few more years of life or a painless death. In the fourth stage, depression, dying people become increasingly aware that their con- dition will not improve. Terminally ill individuals mourn for themselves a$er realizing that they will not live long enough to enjoy experiences such as watching their children mature or playing with their grandchildren.
"e !nal emotional stage of dying is acceptance. Although terminally ill people continue to hope for cures, they accept the possibility that nothing can be done to save them. Friends, family members, and caregivers can help maintain the self-esteem and dig- nity of the dying by visiting and touching them, as well as by listening to their concerns.
Critics of Kübler-Ross’s research charge that she focused on people who were dying prematurely of chronic illnesses and had time to experience each stage. "erefore, her !ndings may have been di#er- ent if she had studied people who were dying of acute illnesses or very sick elderly persons. Some people,
Stage Typical Responses
Denial Feels emotionally numb, avoids thinking about his or her condition, ignores the reality of his or her condition
Anger Lashes out at healthcare providers and loved ones
Bargaining Makes deals with healthcare providers, loved ones, or God to live long enough to do special things or experience certain events
Depression Mourns his or her impending death, withdraws socially
Acceptance Realizes that his or her condition is terminal, gives away cherished items, makes funeral plans
Data from Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Table 15.4
Kübler-Ross’s Stages of Emotional Responses to Dying
530 Chapter 15 Aging, Dying, and Death
particularly the elderly, may not experience all !ve stages of dying. In addition, aged people who are ter- minally ill may accept their impending deaths more readily than people who face the prospect of dying while they are still young. "e Kübler-Ross model, however, is useful for understanding the complex emotions of dying people.
Dying people are usually under extreme emo- tional distress. "ey o$en feel helpless and hope- less, and they have di&culty relaxing. Treatments such as surgery, chemotherapy, or radiation add to their discomfort. Some terminally ill people !ght the prospect of dying; others accept what is happening to them and choose to make the most of the time they have remaining. In modern societies, death can be the !nal stage of personal ful!llment if dying people have opportunities to satisfy their social and emo- tional needs. "us, some terminally ill people choose to spend more time with their friends and families; others travel far from home.
As the end of life nears, some terminally ill peo- ple may become more detached from others and the environment. "ey may sleep more o$en and may lapse in and out of consciousness. When awake or conscious, dying persons may not want to talk as much as they did before reaching this stage. Accord- ing to Kübler-Ross, dying individuals are almost without feelings; most die without fear.
When you know that a beloved person is dying, you may experience a variety of intense emotions. You may be afraid of enduring the emotional pain of watching a close friend or relative die. You may be angry at the dying person, physicians, or God because you feel they are responsible for the impend- ing death, or they are unable or unwilling to prevent it. You may feel guilty about your feelings toward the dying individual. Recognizing that someone is ter- minally ill forces us to face the reality that we will someday die.
Family and friends of a dying person typically feel helpless and intensely sad. As a result, they may avoid the person because such feelings are di&cult to hide and uncomfortable to bear. "is reaction does little to boost the dying person’s dignity and sense of well- being. Being avoided makes the dying person feel isolated and rejected at a time when he or she usually has a high need for the compassionate support and comfort of others.
Physicians and family members have become increasingly aware that positive thinking, includ- ing hopefulness, can improve one’s well-being while dying. Meeting the emotional and spiritual needs of
terminally ill persons can help them live better while dying. Many physicians actively seek the participa- tion of their seriously ill patients and their families in decisions concerning treatment. Medical prac- titioners can enhance the dignity and self-worth of dying patients by discussing the serious nature of their conditions with them, listening carefully to their concerns, and allowing them to make decisions regarding their medical care.
Terminal Care: The Options "e majority of Americans die in hospitals or extended-care facilities such as nursing homes. "e goal of hospital-based health care is to provide tech- nologically sophisticated medical care that enables sick people to become well. Because hospital care is costly, elderly patients who are too ill or frail to return home o$en move into extended-care facilities (e.g., nursing homes). "ese extended-care facilities o#er less comprehensive medical care than hospitals, but they are designed and equipped to manage the long- term care of people recovering from surgery or illness. Not every condition is curable; many chronically ill patients die while residing in these care centers.
Choosing to place an aged parent or relative into a nursing home is o$en an emotionally di&cult deci- sion. Family members may have to select an avail- able facility quickly and without researching their options. "e Consumer Health feature “Choosing a Long-Term Care Facility” lists some important ques- tions to answer when selecting a residential facility that provides long-term and/or skilled nursing care.
When patients have only a few months to live, their personal physicians may refer them to hos- pice. Hospice is health care speci!cally designed to give emotional support and pain relief to terminally ill people in the !nal stage of life, where patients receive palliative care. Palliative care, specialized medical care for people with serious illness, o$en occurs in hospice; however, it is not limited to older adults. Any patient with a serious illness may receive palliative care, at any age. For those with a terminal illness, care may be provided in the patient’s home or in a hospice center. "e primary goal of hospice care is not to save dying patients with aggressive treatments but to relieve their discomfort. Hospice physicians o$en prescribe powerful medications to
hospice Health care specifically designed to give emotional support and pain relief to terminally ill people in the final stage of life.
Dying 531
keep terminally ill patients as free from pain as pos- sible. Freedom from extreme pain permits the dying person to manage his or her activities more e#ec- tively and die with dignity.
Hospice sta# receive specialized training to work closely with, and to provide emotional and spiri- tual support to, dying patients and their families. Sta# encourage patients and their relatives to par- ticipate in decision making regarding care. Most terminally ill people and their families can obtain
hospice services in their homes from a team of medical professionals. Family members are taught simple medical procedures, such as care of surgical wounds or maintenance of feeding tubes. Hospice nurses make home visits to check patients’ condi- tions and are available to answer questions con- cerning their care. Dying at home allows patients to remain in a comfortable and familiar environment where they can participate in holiday and other family-oriented events.
Consumer Health Choosing a Long-Term Care Facility The most important feature to consider when choosing a residential facility is the quality of medical care that it provides.
Before making this decision for a loved one, visit a few facilities, observe the condition of the buildings, rooms, and residents, and answer the following questions:
1. Is the facility licensed by the state?
2. Is the facility clean, well maintained, and free of objectionable odors?
3. Are staff members friendly, helpful, and respectful to visitors and residents?
4. Does the family member’s physician provide services at the facility?
5. Are the rooms clean, comfortably furnished, well lit, and cheerful?
6. Do the residents appear to be appropriately dressed, clean, and well groomed? Do they appear to be alert?
7. Are there enough staff members to take care of the number of residents?
8. Are there handrails along the hallways and grab bars in the bathrooms?
9. Does the facility have rehabilitation and exercise areas, a quiet place with reading material, and a chapel?
10. Does the facility have an activities director and scheduled social events that are appropriate for elderly people?
11. Are the dining room and kitchen clean?
12. Are menus nutritious? Do menus indicate that a variety of foods are offered? Can you sample
a meal? How are the special dietary needs of patients handled?
13. If you have an opportunity, ask some residents and staff (privately) what they like and dislike about the facility.
14. What are the monthly fees? Can you afford this facility? Does the facility accept Medicaid or other forms of insurance?
15. Contact your state’s division of aging to obtain information about the facility’s inspection reports.
16. Using the Eldercare Locator found at www .eldercare.gov (or 1-800-677-1116) can also help you locate an appropriate facility.
Before making a final decision, visit the facility at least one additional unscheduled time to make another set of observations.
Adapted from Goldsmith, S. B. (1990). Choosing a nursing home. New York, NY: Prentice Hall; Centers for Medicare and Medicaid Services. (2013). Your guide to choosing a nursing home or other long-term care facility. Baltimore, MD: U.S. Department of Health and Human Services.
Older adults enjoying a social activity at a long-term care facility. © Monkey Business Images/Dreamstime.com.
532 Chapter 15 Aging, Dying, and Death
Some dying patients receive hospice care in clinical settings that have rooms designed to look more like patients’ homes than hospitals. "e sta# encourage patients to decorate their rooms with favorite posses- sions to foster a homelike environment. Visiting family and friends provide additional social, emotional, and spiritual support and o$en participate in caring for their ill loved ones. Regardless of whether the terminally ill person dies at home or in a hospice center, hospice sta# provide grief counseling services for survivors.
Many nursing homes and hospitals o#er hospice services that are covered by health insurance plans. To !nd such resources in your community, contact local hospitals or check the Yellow Pages under Hos- pice. Social workers in these facilities can provide information about local support groups for the termi- nally ill and their families. "e National Hospice and Palliative Care Organization can also provide infor- mation about hospice programs in your area; this group’s toll-free phone number is 1-800-658-8898.
Death Some people have a di&cult time thinking about and discussing death. For example, they may avoid using the term died, preferring to use euphemisms such as passed away. Whether people believe in an a$erlife or not, most are reluctant to handle matters concerning their own dying and death, such as preparing a will or signing an organ donor card.
What Is Death? Death, the cessation of life, occurs when the heart or lungs stop functioning. When this happens, no oxy- gen is available for metabolism, and brain cells begin to die. Within 4–5 minutes, the dying person loses consciousness. As remaining body cells die, other signs of death become obvious.
When a person dies, the muscles that control vol- untary and involuntary movements no longer func- tion. As a result, the body eliminates the contents of the bladder and rectum, and re'exes are absent. Re$exes are neuromuscular responses that do not require thinking, such as eye blinking. Gradually, skeletal muscles become rigid, and body temperature cools until it matches that of the environment. Unless the body is chilled or treated with embalming chemi- cals, it decomposes rapidly. Decomposition occurs because the immune system no longer prevents bac- teria and other microorganisms from breaking down the organic material of the body.
"e physician who attended the dying patient is usually responsible for certifying that the patient has died. "en, the medical sta# inform family members. In most cases, they deliver the body to a funeral home or medical school, according to the deceased per- son’s wishes. If there are any questions or suspicions about the cause of death, the family, physicians, or coroner can request an autopsy. During an autopsy, a specially trained physician conducts various medi- cal examinations and tests that usually determine the cause of death.
In 1968, a team of experts at the Harvard Medical School de!ned death according to four irreversible physical criteria:
• "e absence of electrical activity in the brain • No spontaneous muscular movements, including
breathing • No re'exes • No responses to the environment
"ese criteria de!ne what is commonly referred to as brain death. "e majority of state laws recognize these criteria as the basis for de!ning death. A legal de!nition of death is important for criminal cases that involve murder. De!ning death is necessary for phy- sicians who need to establish that patients are dead before removing tissues or organs for transplantation.
Since the 1980s, advances in medical technology have made it necessary for medical experts to recon- sider the traditional de!nition of death. By using car- diopulmonary resuscitation (CPR), respirators (devices that assist breathing), and feeding machines, physi- cians can o$en save the lives of certain seriously ill persons and, in some instances, may sustain patients who have virtually no chance of recovering.
Cerebral Death "e cerebral cortex of the brain controls thoughts, interprets sensory information, and integrates voluntary muscular activities. An individual who experiences severe damage to his or her cerebral cortex is comatose, that is, unresponsive to the environment and in a coma. If the damage is irreversible, it is unlikely that the person will regain
death The cessation of life, which occurs soon after a person’s heart or lungs stop functioning.
autopsy The various medical examinations and tests that usually can determine the cause of death.
comatose The condition in which a person is unresponsive to the environment and in a coma.
Death 533
consciousness. In some comatose patients, the areas of the brain that control and regulate vital activi- ties, including digestion and breathing, continue to function. Although their conditions do not meet the standard criteria for brain death, such individuals have experienced cerebral death. With specialized care, a person with a nonfunctioning cerebral cor- tex can exist in an irreversible coma, a persistent vegetative state, for years.
"e level of care required to maintain patients in persistent vegetative states is stressful for their families, as well as expensive. Under what circum- stances can physicians remove life-sustaining care from a patient in an irreversible coma? "e U.S. Supreme Court decision in the Quinlan case pro- vides an answer.
In 1975, Karen Ann Quinlan, a 21-year-old New Jersey woman, was hospitalized in an unconscious state a$er allegedly consuming a combination of alcohol and tranquilizers. A$er realizing that she would not recover, Ms. Quinlan’s parents requested that the medical sta# and hospital administrators allow their daughter to die by disconnecting her res- pirator. However, the administrators and attending physicians denied the parents’ request, noting that the young woman was not dead according to estab- lished criteria.
A$er lower state courts supported the hospital’s position, the Quinlans took their daughter’s case to the New Jersey Supreme Court. In 1976, this court ruled that because Karen had previously told her mother and some friends that she would not want to live in a persistent vegetative state, her parents had the right to ask physicians to remove her res- pirator. A$er being removed gradually from the ventilation device, Karen was able to breathe with- out the machine’s assistance, but she continued to be fed through tubes. "e Quinlans moved their comatose daughter to a nursing home, where she died 10 years later.
Since the Quinlan case, several states have passed laws that establish steps for withholding or removing life-sustaining care in similar cases involving the terminally ill. A later section of this chapter describes how you can inform other peo- ple in advance about your wishes concerning such medical care.
Euthanasia and the Right to Die Euthanasia is the practice of allowing permanently comatose or incurably ill persons to die. In cases of active euthanasia, physicians hasten the deaths of dying people by giving them large doses of pain- relieving medications that can completely suppress breathing. Passive euthanasia involves cases in which terminally ill people die because physicians do not provide life-sustaining treatments, or they withdraw such care.
Since the Quinlan case, the courts have decided several right-to-die cases, particularly those involv- ing people who were seriously ill but not dying. Some chronically ill individuals decide that life is not worth living or that they are tired of living in pain. To has- ten death, these people may refuse life-prolonging medical treatment, demand that it be withdrawn, or remove it themselves. In recent years, the courts o$en have made or upheld decisions that give such seri- ously ill people the right to die. A$er physicians dis- continued their life support, many of these patients died naturally within a couple of weeks.
In some instances, the seriously ill person is too physically or mentally incapacitated to actively end his or her life. Concerned relatives, friends, or care- givers risk criminal prosecution by helping people commit suicide. Although most physicians strive to preserve life, some assist in the suicides of dying patients by prescribing overdoses of certain drugs. In the 1990s, retired physician Jack Kevorkian focused national attention on the controversial practice of physician-assisted suicide by helping more than 125 people end their lives. In 1999, a judge sentenced Kevorkian to prison for injecting a deadly dose of drugs into a man who was su#ering from an incur- able deadly disease. Kevorkian spent about 8 years in prison before being paroled. In 2011, Kevorkian died a$er a brief illness.
Oregon, Colorado, Washington, California, Vermont, and Washington, D.C. have Death with Dignity statues that allow physicians to prescribe drugs to terminally ill patients so they can end their lives. Oregon and Washington maintain records concerning the number of deaths attributed to physician-assisted suicide each year. Between 1998 and 2016, a total of 1,275 Oregonian patients chose to end their lives by taking a prescribed dose of deadly medications.36
"e most recent highly publicized right-to-die case occurred in 2014, when Brittany Maynard chose
persistent vegetative state The condition in which a person has a nonfunctioning cerebral cortex and is in an irreversible coma.
534 Chapter 15 Aging, Dying, and Death
to end her life in Oregon by taking lethal doses of barbiturates a$er a terminal brain cancer diagnosis. "e most highly publicized right-to-die debate, how- ever, began in 1990, when 26-year-old Terri Schiavo’s heart failed and the young woman’s body entered a persistent vegetative state a$er a signi!cant num- ber of her brain cells died from lack of nutrients and oxygen (Figure 15.8). For several years, Terri’s par- ents fought legal battles with her husband over their desire to keep her alive in a long-term care facility by providing nourishment through tube feedings. Terri’s husband contended that her life-supporting care
should be withdrawn because before her heart attack, she had indicated to him that she would not want to be kept alive in such a manner if she was incapaci- tated. By spring of 2005, the parents’ legal options were exhausted a$er courts ruled consistently in favor of Terri’s husband. When the comatose wom- an’s feeding tube was removed, the tragic case made headline news in the United States and around the world, rekindling debate over euthanasia. Terri died almost 2 weeks a$er her feeding tube was withdrawn.
Preparing for Death Young adults may see the need to plan for a comfort- able retirement, but planning for a good death may seem too morbid to consider (see Table 15.5). When a person dies while maintaining a high degree of dig- nity and experiences little physical and emotional pain during the dying process, it is considered a good
Figure 15.8 Terri Schiavo. These photographs show Terri before and after a heart attack deprived her brain of oxygen and resulted in a persistent vegetative state. (a) & (b) © Schindler Family Photo/AP Images.
Advance Directive Indicates a person’s wishes about treatment should he or she become incapacitated.
Living Will A legal document that specifies how you want your property and assets to be distributed after death. Guardians for minor children can also be designated; the document must be signed and witnessed by at least two people.
Executor A person appointed to manage your estate after death. Executors use existing resources to pay your debts and funeral costs.
Organ Donation Receiving donated organs can allow people who are seriously ill to live normal lives. You can choose to donate your organs by completing an organ donation card or by signing the back of your driver’s license.
Funeral Arrangements
Funerals can be costly and difficult for grieving survivors to attend. Having adequate life insurance allows the executor to pay for the funeral and protects survivors’ assets.
Table 15.5
Planning for Death
Death 535
death. A good death also causes minimal amounts of emotional trauma for the person’s survivors.
Not everyone has time to prepare for a good death; death can be premature and unexpected, such as in cases of homicides, fatal accidents, or sudden, unexpected disease. Healthy people, however, can make various legal, !nancial, emotional, and spiri- tual preparations for their deaths. Such planning can reduce their survivors’ confusion and anxiety.
Advance Directives "e Patient Self-Determination Act gives people the right to prepare advance direc- tives that indicate their wishes concerning treatment if they become incapacitated. "e act also allows physi- cians and administrators of certain medical facilities to withhold or remove life-support care from comatose patients who have no hope of regaining conscious- ness and who would not want to be kept alive in such conditions.
A living will or a durable power of attorney docu- ment can specify your wishes concerning your medi- cal care in the event that you become permanently incapacitated. Figure 15.9 shows a sample living will.
Not every state honors such documents. For exam- ple, your state may exclude the right to have arti!- cial feeding and hydration (water) tubes removed, regardless of your wishes.
Although some states do not sanction living wills, they allow other advance directives, such as a durable power of attorney. In this document, you identify a mentally competent individual to serve as a healthcare surrogate or proxy. A healthcare proxy will make deci- sions concerning your care if you become unable to do so. Additionally, you may indicate which life-prolong- ing medical actions are acceptable or necessary under certain circumstances. "e results of surveys indicate that most Americans would want limited care if they became incapacitated. Few Americans, however, have prepared living wills or other advance directives.
Before preparing an advance directive, it is a good idea to discuss your wishes with family and address their concerns. Your physician can prob- ably answer questions that you or your family may have about life-support care. Family members or the person who agrees to serve as your healthcare
Figure 15.9 A Living Will. While still able, a person can sign a living will to specify wishes concerning medical care in the event that he or she becomes permanently incapacitated. This advance directive is for the District of Columbia. © 2005 National Hospice and Palliative Care Organization. Revised 2013. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden.
536 Chapter 15 Aging, Dying, and Death
surrogate and your personal physician will need copies of these documents. It is a good idea to store your copy along with your other important docu- ments in a safety deposit box.
Estate Management In addition to an advance directive, it is important to have a will, a legal docu- ment that speci!es how you want your property to be distributed a$er your death. To prepare a formal will, it is a good idea to consult an attorney, preferably one who specializes in estate administration. For the will to be valid, you must be of “sound mind” (aware of your actions) when you write and sign your will, and the document must be signed and witnessed by at least two people.
Most Americans die without having a will. When this happens, probate courts follow state laws concerning the division and distribution of the deceased person’s estate. An estate includes the individual’s sources of money, such as check- ing and savings accounts, life insurance policies, and retirement plans. In addition, possessions that can be sold, such as jewelry, real estate, furniture, and collectibles, are part of one’s estate. A carefully constructed will can ensure that these assets go to whomever you want and not to whom the courts choose. Furthermore, a will can eliminate much unhappiness, stress, and confusion among your survivors. If family members feel that provisions stated in your will unfairly distribute the estate, they can contest it in court.
In addition to making a will, it is a good idea to appoint an executor to manage your estate a$er your death. "e executor uses income from the estate to pay your debts and funeral costs. If you have young children, it is important to identify and ask a per- son who will act as their legal guardian in case they become orphans. Most people choose a guardian who is a close relative or friend to whom they can entrust the care of their children.
In addition to having a will and an executor, you can protect your survivors’ assets by having enough health and life insurance to cover your !nal medical and funeral expenses. "e best time to buy life and health insurance is while you are young and healthy.
Organ Donation In dying, people can make a priceless contribution to the living by donating their tissues or organs. Soon a$er death, a donor’s kidneys, liver, skin, heart, and corneas can be removed and transplanted into people whose organs or tissues are failing. Many seriously ill patients who would have died without receiving donated organs are able to live nearly normal lives a$er having the procedures.
As of July 2018, approximately 115,000 people in the United States were on waiting lists to receive organ transplants.37 Patients are more likely to need kidneys and/or livers than other organs. Unfortu- nately, the demand for organs is greater than the sup- ply. In 2017, more than 6,000 Americans died while waiting for matching organs to become available for transplantation.38 Although people may express an interest in having their organs donated when they die, they o$en do not make their wishes known to others, nor do they document them formally. For example, potential donors may fail to inform family members of their decision or sign organ donor cards. In most states, family members can override the deceased person’s wishes concerning organ donation.
People can help those who need healthy tissues and organs by completing and signing uniform donor cards like the one shown in Figure 15.10. "is card should be kept in a person’s wallet. Additionally, people have their desire to be an organ donor desig- nated on their driver’s license. "e process for having “donor” identi!ed on your driver’s license may vary by state. Individuals who would like to become organ donors when they die should inform their relatives of their wishes. Although there are no guarantees that surgeons will be able to transplant a person’s tissues a$er death, it may be reassuring for some people to know that, even a$er death, they might be able to help others.
Some Final Thoughts on Death Funeral and memorial services can help friends and family members deal with the loss of a loved one. You can ease some of the emotional and !nancial burdens
Figure 15.10 A Uniform Donor Card. By completing and signing a donor card like this one, people can help others who need healthy tissues and organs. Courtesy of the US Department of Health and Human Services.
Death 537
Regardless of the circumstances surrounding a death, resolving the grief that follows the loss of a loved one (bereavement) involves regaining emo- tional balance and stability. Mourning, the culturally de!ned way in which survivors observe bereavement, can be a di&cult and lengthy process.
"e emotional and physical reactions to the death of a beloved person vary; some people have a more di&cult time coping with the loss than others do. People’s emotional reactions are usually more severe a$er unexpected deaths than a$er anticipated deaths. Typically, the initial responses of survivors are psy- chological shock, disbelief, and denial. "ey next enter the acute mourning stage, which is character- ized by crying, withdrawal, and other symptoms of depression. In many societies, people in mourning are expected to display their grief, for example, by crying and by wearing somber clothing. A$er mourn- ing, survivors are o$en able to accept the death of their loved one, recognize that they have grieved, and regain a sense of emotional balance.
"e most intense period of grieving normally lasts about 4–6 weeks a$er the death. It is not uncommon for people to continue mourning for a year or longer a$er the loss. Some people experience psychological and physical problems if they are unable to resolve their feelings of grief.
Much of the research that examines the impact of grieving on health involves people whose spouses have% recently died. Most widowed people experi- ence some signs and symptoms of depression, such as sadness, withdrawal, and sleep disorders. With the support of family and friends, however, people who are grieving can o$en regain their emotional bal- ance within a few months. Survivors may become saddened again over the loss of a spouse, especially on anniversaries, on holidays, and during family reunions. An estimated 10–20% of widowed people su#er severe depression that lasts a year or more a$er their spouses die. "e Managing Your Health feature “A$er the Death of a Loved One” contains some sug- gestions that can help people endure the !rst year a$er the death of a spouse or other beloved individual.
In addition to a#ecting emotional health, bereave- ment o$en in'uences the physical health of survi- vors. Most people who are grieving are emotionally distressed, and such stress o$en has a negative impact on their immune systems. Individuals who have weakened immune systems are at risk of develop- ing frequent infections and chronic health problems such as cardiovascular disease. Additionally, griev- ing people may not take good care of themselves; for
grief An emotional state that usually occurs after the loss of something or someone special.
mourning The culturally defined way in which survivors resolve the grief surrounding a death.
of your survivors by planning your funeral arrange- ments. A funeral can be very costly, and it is o$en a di&cult emotional task for families to make such arrangements when a loved one dies.
Many mortuaries o#er prearranged funerals that enable you to specify the kind of funeral you want and the most a#ordable services. For example, you could choose to have a simple memorial service, your body cremated (burned), and your ashes placed in a container and given to your survivors. You can con- tact mortuaries in your area for more information about making funeral and burial prearrangements.
In addition to making funeral and burial arrange- ments, you can prepare spiritually for your death. One spiritual arrangement you can make in preparation for death is to write your own obituary or death notice. Many obituaries include a brief biography. If you pre- pare these documents, you can give copies of them to your survivors and let them know where to send them. Newspapers, college alumni associations, and profes- sional organizations usually print death notices.
A$er a beloved person dies, survivors o$en expe- rience confusion and distress because they cannot locate the deceased person’s will and other important documents. To reduce the likelihood that this situa- tion will occur a$er your death, share copies of these personal papers with your spouse, adult children, the executor, and the individual who has the power of attorney. A safety deposit box is a safe place to store such documents. To help your survivors !nd these important papers, you can keep a small card in your wallet that lists their location.
Grief Grief is the emotional state that nearly all people experience when they lose something special or someone with whom they enjoyed a close relation- ship. Losing someone you love is one of the most sig- ni!cant emotional events that can occur during your life. Some of life’s losses are predictable, such as the death of beloved grandparents, parents, and spouses. Unexpected or premature losses, such as the death of a child or the sudden death of a spouse, can be emo- tionally devastating to the surviving parents, spouse, and other family members.
538 Chapter 15 Aging, Dying, and Death
v Managing Your Health After the Death of a Loved One
The “Managing Grief” sections of this box provide some suggestions that may help you cope with the death of a beloved individual. The “Managing Legal, Social, and Financial Concerns” sections provide some actions that you can take to manage various concerns that often arise after the death of a spouse or other beloved person.
Immediate Actions and Concerns Managing Grief • Resolve to survive the first few days of the sorrowful
event.
• Accept the support and company of friends, family, and professionals (e.g., counselors, clergy).
• Permit yourself to vent your feelings, for example, to cry or to feel anger.
Managing Legal, Social, and Financial Concerns
• Notify your attorney; obtain the deceased person’s will and make several photocopies of it.
• Order several copies of the death certificate; the funeral director may do this for you.
Within the First 4 Weeks Managing Grief • Acknowledge those who sent food or flowers or who
made memorial donations. Consider responding to those who visited or sent cards. This is an emotionally difficult task, but the process may be beneficial in itself.
• Anticipate feelings of grief: the tears, anger, guilt, and blame. Delayed or prolonged absence of grief may lead to negative physical and psychological consequences.
• If troubled by sleeplessness, nightmares, agitation, headaches, and even skin rashes, consult your physician for help to alleviate these conditions.
• Note changes in your appetite.
Managing Legal, Social, and Financial Concerns
• Notify relevant government agencies and other organizations of the death, such as the Social Security Administration, Veterans Administration, and insurance companies.
• Submit insurance claims and apply for refunds and benefits where applicable. Keep records of all response letters from agencies and organizations.
• Notify the deceased person’s banks, credit card accounts, custodians of mutual funds and annuities, and accountant of the death.
Within 6 Months Managing Grief • Join a grief support group. For information concerning
support groups in your area, contact social workers at a local hospital or hospice or your local United Way.
• Adapt to lifestyle changes. You may need to learn how to do unfamiliar chores such as maintaining the house, tracking investments, cooking meals, or paying bills.
• Continue previous activities such as participating in hobbies or clubs if they are satisfying.
• Participate in healthful physical activities such as walking, swimming, or golfing. Join a health spa or similar organization.
Managing Legal, Social, and Financial Concerns • Share meals with friends and accept the invitations of
others to dine out with them.
• Update your will: change beneficiaries, trustees, or executors if necessary.
• Consult your accountant; your tax situation may have changed.
Long Term Managing Grief Establish your own identity to function independently. Your degree of dependence and attachment to the deceased may determine the time needed for adjustment. • Establish new relationships; continue existing
relationships.
• Consider participating in activities or organizations that help others.
Managing Legal, Social, and Financial Concerns • Plan for the future. Do not rush into making major
changes or decisions.
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Grief 539
example, they may not eat nutritious foods or exer- cise, and some may abuse drugs, including alcohol.
4If you would like to be an organ donor when you die, complete a uniform donor card or sign the declaration on the back of your driver’s license. Inform your relatives of this decision.
4Preparing a will can help your survivors manage your estate.
4To convey your wishes concerning treatment in case you become severely disabled and cannot communicate, consider preparing an advance directive.
Healthy Living Practices
People who undergo an abnormal grieving process may have had a poor relationship with the deceased person. According to Kübler-Ross, grief includes some degree of anger that is directed toward the dead individual. Survivors may hide their anger; others may express it by lashing out at someone else or by grieving for an unusually long period. Table 15.6 lists the signs of abnormal grieving. People with these signs may need professional counseling.
Professional counseling to handle grief may be necessary if the grieving person:
• Doubts that his or her grieving is normal • Experiences frequent outbursts of anger • Finds little or no pleasure in life and has persistent
suicidal thoughts • Is preoccupied with thinking about the deceased
loved one, or has hostile or guilty feelings that persist for more than a couple of years
• Experiences significant weight loss, weight gain, or persistent insomnia
• Begins engaging in risky behaviors such as abusing drugs or practicing unsafe sex
• Loses interest in taking care of personal hygiene for more than 2 weeks
Adapted from Kouri, M. K. (1991). Keys to dealing with the loss of a loved one. Hauppauge, NY: Barrons Educational Series.
Table 15.6
Grieving Danger Signs
DYING AND DEATH In the United States, parents o$en !nd it di&cult to discuss death with their children until someone or something, such as a pet, is dying or has died. Young children have di&culty grasping the concepts of dying and death (Figure 15.11). For example, if a 4-year-old child attends a funeral and views a loved one’s body, the youngster may think this person is asleep.
Children as young as 2 years old miss a familiar person who has died, especially if the deceased was a parent. Preschool-aged children, however, do not express grief as older children or adults do. At this age, children typically grieve di#erently from how adults grieve; they may act unconcerned about the death and become intensely involved in play activi- ties or misbehave.
Across THE LIFE SPAN
Figure 15.11 Children’s Responses to End-of-Life Concepts. Young children have difficulty grasping the concepts of dying and death. When faced with the loss of a loved one, preschool children typically grieve differently from how adults grieve. © Cheryl Casey/Shutterstock.
540 Chapter 15 Aging, Dying, and Death
4Consider seeking professional counseling if your grief is severe or does not subside over time after the death of a loved one.
4If your child becomes preoccupied with death or depressed after someone or something has died, professional counseling can help him or her deal with the loss.
Healthy Living Practices
School-aged children are able to understand that dead things do not come back to life, and they respond to the loss much like adults: crying, with- drawing, or being angry. Older children o$en asso- ciate death with being old, particularly if they have experienced the death of a grandparent. "us, they may have a great deal of di&culty coping when a peer dies.
Experts suggest being honest and straightforward when discussing terminal illness and death with children, while also considering the child’s ability to understand the meaning of death. Frequently, children begin to understand and accept death when caring people share what is happening with them. It is impor- tant to allow grieving children to express their con- cerns and feelings about dying and death. Professional
counseling may be necessary if the child’s responses are excessive, if the young person becomes preoccu- pied with death, or if the child becomes depressed.
Grief 541
CHAPTER REVIEW Summary
Aging is the sum of all changes that occur in an organism over its life span. "e human life span is divided into stages. "e !nal stage, senescence, generally refers to the stage of life that begins at 65%years of age.
The overall life expectancy of Americans has increased since 1900. In the United States, a person born in 2014 can expect to live for about 78.9%years. Life expectancies, however, vary according to age, sex, and socioeconomic status. For example, American females outlive American males by about 5 years.
As of 2015, 14.9% of the U.S. population was 65 years of age and older. By the year 2030, nearly 23% of Americans will be in this age group. This segment of the American population is increasing at a rapid rate.
Aged people must o$en live on incomes that are lower than when they were younger. In the United States, older adult members of certain minor- ity groups are more likely to have lower retirement incomes and live in poverty than are White aged per- sons. With appropriate !nancial planning, Ameri- cans who have adequate incomes when they are young may be able to maintain adequate incomes during their retirement years.
A gradual and irreversible decline in the func- tioning of the human body begins to occur around 30%years of age. However, people age at di#erent rates. Genetic, environmental, and lifestyle factors in'u- ence the rate of aging.
Some of the physical changes associated with the aging process, such as gray hair, presbyopia, and menopause, are normal and inevitable. Other age- related physical changes such as heart disease, can- cer, and osteoporosis are not normal and are signs of disease processes. People who modify their lifestyles while they are young may be able to prevent or delay such conditions.
According to Kübler-Ross, the typical emotional responses to dying include denial, anger, bargaining, depression, and acceptance. However, death can be
the !nal stage of personal ful!llment if dying people have opportunities to satisfy their social and emo- tional needs. Family, friends, and medical care pro- viders can help terminally ill individuals live better while dying by taking steps to enhance their dignity and self-worth.
Death occurs when the heart or lungs cease func- tioning and cells in the brain do not receive oxygen. "e criteria for brain death include no brain waves, no spontaneous muscular movements, no re'exes, and no responses to the environment. A brain-dead person can exist in a persistent coma for years as long as the heart is functioning, nutritional needs are met, and the supply of oxygen to the heart is maintained by the use of a respirator. Euthanasia is the practice of allowing a permanently comatose or an incurably ill person to die.
"e Patient Self-Determination Act gives people the right to prepare advance directives, documents that indicate a person’s wishes concerning life- support measures if the individual becomes incapable of making such decisions.
Nearly everyone experiences grief with the loss of something special or someone with whom he or she enjoyed a close relationship. Although it is normal to grieve a$er such a loss, grief can have negative e#ects on health. To resolve grief, a person accepts the death of a loved one, recognizes that he or she has grieved for this person, and regains a sense of emotional balance. An individual who grieves for a prolonged period may require professional counseling.
Preschool children do not understand the con- cept of death, yet they still experience distress over the missing loved one. At this age, children may mourn by acting uninterested about the death or by misbehaving. Older children o$en grieve like adults, by crying, withdrawing, and being angry. Grieving youngsters need to express their concerns and feel- ings about death. Like adults, children may need pro- fessional counseling if their emotional responses to death are severe or prolonged.
542 Chapter 15 Aging, Dying, and Death
CHAPTER REVIEW
Reflecting on Your Health
Key
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.
1. How do you feel about aging? Are you under- going the age-related changes that Table 15.1 describes? Which age-related changes trouble you the most? Are you making any lifestyle changes that will increase your chances of living a long and healthy life? If you answered yes to the previous question, what changes are you mak- ing, and how do you think they will a#ect your longevity?
2. If you su#ered severe brain damage in an acci- dent, would you want to be maintained in a per- sistent vegetative state? Why or why not? If so, for how long would you want to be kept alive? Why?
3. Do you intend to donate your organs if you die in an accident? Why or why not? Have you signed an organ donor card on the back of your driver’s license, enabling survivors to donate your organs when you die? If you have not signed an organ donor card on the back of your license, explain why.
4. Have you ever known someone who knew he or she was dying? If so, describe any stages of Kübler-Ross’s emotional responses to dying that you observed in that person.
5. If someone you loved has died, how did the griev- ing process a#ect your psychological, social, and spiritual health? What did you do to overcome the grief ?
Applying What You Have Learned 1. Using the sample will provided in Figure 15.9,
develop a will that re'ects your wishes concern- ing the distribution of your assets a$er death. Application
2. Analyze how your present lifestyle may a#ect your life span. Analysis
3. Propose a program to reduce ageism by promot- ing understanding and cooperation between young and old members of your community. Synthesis
4. Choose a position concerning the issue of eutha- nasia. How would you defend your position? Evaluation
References 1. Volz, M. (2011). World’s oldest man dies in Montana at 114.
Associated Press. Retrieved from http://www.foxnews.com/us /2011/04/14/worlds-oldest-man-dies-age-114/
2. Colton, A. (2011, April). Survival skills: World’s oldest man. Men’s Journal, p. 126.
3. Flachsbart, F., et al. (2009). Association with FOXO3A variation with human longevity con!rmed in German centenarians. Proceed- ings of the National Academy of Sciences, 106(8), 2700–2705.
4. U.S. Census Bureau. (2018). Older Americans Month: May 2018. Retrieved from https://www.census.gov/newsroom/stories/2018 /older-americans.html
5. U.S. Census Bureau. (n.d.). U.S. population projections. Retrieved from https://www.census.gov/programs-surveys/popproj.html
6. Kahana, E., et al. (2002). Long-term impact of preventive proactivity on quality of life of the old-old. Psychosomatic Medicine, 64(3), 382–394.
References 543
CHAPTER REVIEW 7. Murphy, S. L., Xu, J., Kochanek, K., Curtin, S. C., & Arias, E. (2017).
Deaths: Final data for 2015. National Vital Statistics Reports, 66(6). Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_06.pdf
8. U.S. Department of Health and Human Services. (2018). Healthy People 2020: About Healthy People. Retrieved from http://www .healthypeople.gov/2020/about/default.aspx
9. Centers for Disease Control and Prevention. (2013, November 22). Life expectancy free of chronic condition-induced activity limitations— United States, 1999–2008. Vital and Health Statistics, 62(3). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml /su6203a15.htm
10. U.S. Department of Health and Human Services, Administration on Aging. (2016). A pro#le of older Americans: 2016. Retrieved from https://www.acl.gov/sites/default/!les/Aging%20and%20Disability %20in%20America/2016-Pro!le.pdf
11. U.S. National Library of Medicine, National Eye Institute. (2015). Facts about age-related macular degeneration. Retrieved from https://nei.nih.gov/health/maculardegen/armd_facts
12. Centers for Disease Control and Prevention, Chronic Disease Pre- vention and Health Promotion. (2017). Improving the quality of life for people with arthritis: At a glance 2016. Retrieved from http:// www.cdc.gov/chronicdisease/resources/publications/aag/arthritis .htm
13. Alzheimer’s Association. (2018). What is Alzheimer’s? Retrieved from http://www.alz.org/alzheimers_disease_what_is_alzheimers .asp#basics
14. Alzheimer’s Association. (2018). 2017 Alzheimer’s disease facts and !gures. Alzheimer’s and Dementia, 13, 325–373. Retrieved from
https://www.alz.org/documents_custom/2017-facts-and-!gures .pdf
15. National Institute on Aging. (2017). Looking for the causes of AD. Retrieved from http://www.nia.nih.gov/alzheimers/publication /part-3-ad-research-better-questions-new-answers/looking -causes-ad
16. Otaegui-Arrazola, A., et al. (2014). Diet, cognition, and Alzheimer’s disease: Food for thought. European Journal of Nutrition, 53(1), 1–23.
17. Wood, G. W., et al. (2014). Cholesterol as a causative factor in Alzheimer’s disease: A debatable hypothesis. Journal of Neurochemistry, 129(4), 559–572.
18. Ligthart, S. A., et al. (2010). Treatment of cardiovascular risk fac- tors to prevent cognitive decline and dementia: A systematic review. Vascular Health and Risk Management, 6, 775–785.
19. Lau, F. C., et al. (2007). Nutritional intervention in brain aging: Reducing the e#ects of in'ammation and oxidative stress. Subcel- lular Biochemistry, 42, 299–318.
20. Shah, R. (2013). "e role of nutrition and diet in Alzheimer dis- ease: A systematic review. Journal of the American Medical Directors Association, 14(6), 398–402.
21. Wang, Y., et al. (2013). Curcumin as a potential treatment for Alzheimer’s disease: A study of the e#ects of curcumin on hippocampal expression of glial !brillary acidic protein. American Journal of Chinese Medicine, 41(1), 59–70.
22. Evans, J. G., et al. (2004). Evidence-based pharmacotherapy of Alzheimer’s disease. International Journal of Neuropsychopharma- cology, 7(3), 351–369.
544 Chapter 15 Aging, Dying, and Death
CHAPTER REVIEW 23. O’Brien, J. T., & Burns, A. (2011). Clinical practice with
anti-dementia drugs: A revised (second) consensus statement from British Association for Psychopharmacology. Journal of Psycho- pharmacology, 25(8), 997–1019.
24. Dwyer, J., & Donoghue, M. D. (2010). Is risk of Alzheimer disease a reason to use dietary supplements? American Journal of Clinical Nutrition, 91(5), 1155–1156.
25. Usoro, O. B., & Mousa, S. A. (2010). Vitamin E forms in Alzheimer’s disease: A review of controversial and clinical experiences. Critical Reviews in Food Science & Nutrition, 50(5), 414–416.
26. American Foundation for Suicide Prevention. (2016). Suicide statistics. Retrieved from https://afsp.org/about-suicide/suicide -statistics/
27. Podgorski, C. A., et al. (2010). Suicide prevention for older adults in residential communities: Implications for policy and practice. PLoS Medicine, 7(5), e10000254.
28. LeFevre, M. L. (2014). Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 160(10), 719–726.
29. Jeste, D. V., et al. (2010). Successful cognitive and emotional aging. World Psychiatry, 9(2), 78–84.
30. Perls, T. T. (2010). Antiaging medicine: What should we tell our patients? Aging Health, 6(2), 149–154.
31. Warburton, D. E., et al. (2006). Health bene!ts of physical activity: "e evidence. Canadian Medical Association Journal, 174(6), 801–809.
32. Larson, E. B., et al. (2006). Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Annals of Internal Medicine, 144(2), 73–81.
33. Nicholson, N. R. (2012). A review of social isolation: An impor- tant but underassessed condition in older adults. Journal of Primary Prevention, 33, 137–152
34. Nouchi, R., et al. (2012). Brain training game improves executive functions and processing speed in the elderly: A randomized con- trolled trial. PLoS ONE, 7(1), e29676.
35. Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan. 36. Oregon Department of Human Services. (2017). Death with Dignity
Act annual reports. 2017 Summary. Retrieved from http://www . o r e g o n . g o v / o h a / P H / P R OV I D E R PA RT N E R R E S O U R C E S / EVA LUAT IO N R E SE A R C H / D E AT H W I T H D IG N I T YAC T /Documents/year20.pdf
37. United Network for Organ Sharing. (2018). Data: Waiting list can- didates. Retrieved from http://www.unos.org
38. U.S. Department of Health and Human Services, Health Resources and Services Administration, Organ Procurement and Transplant Network. (2018). Death removals by region by year. Retrieved from https://optn.transplant.hrsa.gov/data/view-data-reports/national -data/#
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References 545
Across the Life Span Environmental Health
Managing Your Health Tips to Prevent Poisonings | Avoiding ELF Radiation | Reducing Pesticide Levels in the Food You Eat
Consumer Health Carbon Monoxide Detectors: Are They Reliable?
Diversity in Health Hunger, the Environment, and the World’s Population
Chapter Overview Which types of poisoning are prevalent in the United
States?
How to avoid poisoning in the home
Which toxic chemicals are prevalent in the workplace?
What factors contribute to indoor air pollution?
How water supplies become contaminated
Why air pollution is a threat to health
How noise pollution affects hearing
Student Workbook Self-Assessments: Poison Lookout Checklist | Checklist for
the Prevention of Carbon Monoxide Poisoning
Changing Health Habits: Can You Reduce Environmental Threats to Your Health?
Do You Know? If you work or go to school in a “sick” building?
If you are in danger of pesticide poisoning?
If your house or apartment is painted with lead-based products?
Diversity: © LeoPatrizi/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Chapter opener: © Aurora Photos/Alamy Images.
Environmental Health
© EyeEm
/Getty Im ages.
Learning Objectives “[One way] in which U.S. children are poisoned by lead … is by eating lead-based paint chips …”
After studying this chapter, you should be able to:
1. Describe ways to reduce the risk of accidental poisoning in the home.
2. Identify common environmental health hazards and their sources.
3. Identify federal legislation intended to protect consumers from being harmed by toxic chemicals and products.
4. Describe the negative effects that air pollution, water pollution, and loud sounds have on health.
5. Distinguish between gray-air and brown-air cities. 6. Take practical steps to reduce exposure to environmental
health hazards. 7. Relate the effects of overpopulation on world health.
CHAPTER 16
547
A zarcon, greta, litargirio, and pay-loo-ah … if you have Hispanic or Asian ancestry, the names of one or more of these traditional eth- nic remedies may be familiar to you. Greta and azarcon are Mexican remedies for empacho, a colicky digestive disorder. Pay-loo-ah is a Southeast Asian tonic for rash or fever. All three are !ne powders and may be given as a tea, or a pinch may be added to a baby’s bottle. "ey also can be mixed with milk or sugar and administered by teaspoon. Litargirio is used as an antiperspirant/ deodorant and as a folk remedy for burns and fungal infections of the feet. Family members who rely on folk medicine give these remedies regularly to children.
Many folk remedies contain substances that are use- ful in medical practice. In fact, pharmaceutical com- panies o$en start looking for new drugs by chemically analyzing the herbs and other plants used in many tra- ditional folk remedies that have been part of a culture for generations. However, some remedies, like those mentioned here, can cause harm. Azarcon, greta, lit- argirio, and pay-loo-ah all contain high levels of lead. Even seemingly harmless over-the- counter herbal dietary supplements have been found to be associ- ated with high lead levels in women. Some Ayurvedic “medications” contain lead as well.1–4 Ayurveda (AH-yer-VAY-da) is a type of traditional or folk medi- cine practiced in India and other South Asian countries.
Lead is only one of the many substances in our environment that can cause serious illness. "e major ways in which U.S. children are poisoned by lead are by eating lead-based paint chips and by inhaling lead particles in contaminated dust or soil.5 In adults in the United States, about 95% of lead poisoning occurs from occupational exposure, such as the mining and smelting of lead ore, the manufacture of batteries, and construction work involving lead-based products.6 Nonetheless, folk remedies containing lead, and lead- based paints and other products in the home, pose a serious health risk for both children and adults.
"e study of the e#ects of environmental factors on humans and the e#ects of humans on their environ- ments is called environmental health. People o$en a#ect the environment in ways that later in'uence their health. For example, people emitted chloro'uo- rocarbons (CFCs) into the atmosphere when they used certain spray can propellants before they were banned in 1979. CFCs contribute to the depletion of the ozone layer in the upper atmosphere. "ese depleted areas are commonly referred to as ozone holes. "e upper atmospheric ozone layer protects people from some of the sun’s harmful ultraviolet (UV) radiation, which can cause skin cancer. Many automobile air condition- ers still contain chemicals harmful to the ozone layer. In another example, people in industrialized countries such as the United States produce millions of tons of municipal solid waste per year—all of those items that trash collectors pick up from homes and o&ces each week. "is waste is usually placed in land!lls. Along with running out of space for this trash, a prob- lem with land!lls is that chemicals may seep into the ground from these massive waste sites and pollute water supplies. We discuss water pollution from vari- ous sources later in this chapter.
Many toxic chemicals present in the home, work- place, or outdoor environments a#ect human health. "ey may be in the form of dusts, fumes, particles, or liquids and are found in a wide variety of substances, such as household products, plants, products manu- factured or used in the workplace, and prescription and illegal drugs. Toxic chemicals are also present in the air we breathe and the water we drink.
Toxic chemicals result in poisoning, or toxicity, which damages body tissues and a#ects bodily func- tioning in various ways. Toxins may a#ect chemi- cal reactions of the body. "ey may also hinder the normal functioning of body cells. Additionally, toxins may cause cells in the body to release chemicals that may have an adverse e#ect on certain body structures. "e consequences of these e#ects are a variety of con- ditions such as dermatitis (in'ammation of the skin), asthma, lung disease, and immune system disorders.
Environmental Health in and Around the Home
"e Toxic Exposure Surveillance System (TESS) is composed of participating poison centers that report on human poisoning incidents. Begun in 1983, TESS grew from 16 participating centers to a high of 73% centers in 1991; in 2018, TESS was made up of
environmental health The effects of environmental factors on humans and the effects of humans on their environments.
ozone holes Depleted areas of the ozone (O 3 ) layer
in the upper atmosphere.
municipal solid waste Nonhazardous refuse generally collected from homes and offices.
toxic chemicals Poisonous substances present in the home, workplace, or outdoor environments that affect human health.
toxicity (tok-SIH-si-tea) Poisonous quality.
548 Chapter 16 Environmental Health
55 centers. TESS data are compiled by the American Association of Poison Control Centers (AAPCC). Because the number of centers composing TESS has changed from year to year, the data from 1983 to the present cannot be used to determine a trend in human poisoning incidents. TESS reported that there were nearly 2.2 million human exposures in 2016, which represents a 3% decline from 2015.7
Poisoning Most human poisonings in 2015 occurred in the home. A little more than 1% occurred in work- places and schools. Poisoning in healthcare facilities accounted for less than 1% of exposures. Most poison- ings were unintentional, which included medication errors, bites and stings, food poisonings, and occupa- tional mishaps. Approximately 18% were intentional and included suicides and drug abuse. "e remaining cases were the result of causes such as malicious intent and adverse reactions to drugs or food.7
Only about 1% of all human poisoning inci- dents in 2016 were fatal. Most poisoning fatalities occurred in adults aged 20 years and older.7 Nonfa- tal poisonings are most o$en caused by the inges- tion of household products and over-the-counter or prescription drugs. In 2016, they occurred in chil- dren younger than the age of 6 years approximately 46% of the time.7 Table"16.1 lists the substances most frequently involved in the poisoning of children younger than 6 years. Table 16.2 lists substances that are usually not toxic.
Unless a child or adult is observed ingesting a toxic substance, it may be di&cult to determine whether he or she is poisoned. Poisoning does not always start the moment exposure occurs. Also, symptoms vary depending on the substance and how it entered the body, which can occur by ingestion, inhalation, or skin contact (Figure 16.1).
A list of substance categories most frequently involved in pediatric exposures can be found at Gummin, D.D. et al. (2017). 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clinical Toxicology, 55(10), 1027–1254. Retrieved from https://www.tandfonline .com/doi/abs/10.1080/15563650.2017.1388087
Reproduced from Gummin, D.D. et al. (2017). 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clinical Toxicology, 55(10), 1027–1254. Retrieved from https://aapcc .s3.amazonawsz.com/pdfs/annual_reports/12_21_2017 _2016_Annua.pdf
Substance Categories Most Frequently Involved in Pediatric ("5 years) Exposures (Top 25)a
Table 16.1
Antacids Hand dishwashing detergents
Antibiotics Hydrogen peroxide (3%)
Baby oil Lotions
Ballpoint pen ink Noncoloring shampoos
Bath oil Paint (latex)
Bubble bath Pencil graphite
Calamine lotion Perfume
Candles Petroleum jelly
Chalk Play-Doh
Clay (modeling) Poinsettia (Euphorbia pulcherrima)
Conditioners Shaving cream
Cosmetics Silica or charcoal dehumidifying packets
Crayons Soaps
Deodorants Toothpaste
Deodorizers Topical steroids (e.g., hydrocortisone cream)
Diaper rash products
Vitamins
Etch-A-Sketch Water colors
Fabric softener Water-based paints
Furniture polish White glue
Note: Some of these products, although considered nontoxic, may present a choking hazard.
Data from Muller, A. A. (2005). Common nontoxic pediatric ingestions. Journal of Emergency Nursing, 31(5), 494–496; and Mofenson, H. C., et al. (1984). Ingestions considered nontoxic. Clinics in Laboratory Medicine, 4(3), 587–602.
Frequently Ingested Products by Children ("5 years) That Are Usually Nontoxic
Table 16.2
Environmental Health in and Around the Home 549
Feces Urine
Secretion Exhaled Air
Excretion Fat
Tissue Organs
Blood Cells Distribution and
Metabolism
InhaleIngest
Storage
Absorption
Toxic Substance
Skin
Figure 16.1 The Path of Toxic Substances Through the Body. The body absorbs toxic substances via the digestive system if they are ingested or via the respiratory system if they are inhaled. Some toxic substances can be absorbed through the skin. Once in the body, toxic substances reach the blood and lymph, which brings them to all the cells. Body cells (principally the liver) metabolize toxins; the products of metabolism are stored or excreted.
Suspect poisoning in a person who becomes sud- denly ill with symptoms that a#ect many systems of the body, appears drowsy and indi#erent, or exhibits bizarre behavior. Also, consider poisoning as a pos- sibility in children or young adults with chest pain; they may have ingested poison or an overdose of drugs. If poisoning may have occurred, call the local poison control center immediately. If the suspected poisoning victim is experiencing severe symptoms such as unconsciousness, seizures, intense chest pain, or repeated vomiting, he or she should be rushed to the emergency room of the closest hospital. Fol- low the tips in the following Managing Your Health box titled “Tips to Prevent Poisonings” to lessen the chances of being accidentally poisoned.
Toxic Plants Toxic (poisonous) plants can be the source of poisoning emergencies, especially in chil- dren. A wide variety of plants have parts that are poi- sonous and parts that are not. For example, tomatoes are not poisonous, but the stems and leaves of tomato plants are. Some common plant parts that are poi- sonous include holly berries, morning glory seeds, narcissus and da#odil bulbs, rhubarb leaves, and sweet pea seeds. "e entire hemlock, jimson weed, die#enbachia, philodendron, and mountain laurel plants are poisonous. Some plants are so poisonous that drinking the water from a vase in which their cut 'owers were kept can result in poisoning.
Although many plants are not poisonous— including the poinsettia, which for years has been inaccurately reported to be toxic—house plants and cut 'owers should be kept out of reach of children younger than 5%years old, and all children should be instructed that eating house and yard plants can make them sick. Many plants, such as the poinsettia, may be highly irritating when ingested, even if they are not poisonous. If a child ingests a plant, call the local poison control center and describe the plant, where it was growing, and what part of the plant the child ate. If possible, take a leaf from the plant for identi!cation when seeking emergency medi- cal treatment. Only plant experts should rely on their knowledge of whether the plant is poisonous.
In addition to plants, approximately 1–2% of mush- room species are poisonous. (Mushrooms are not plants, but fungi.) One type of mushroom is so poi- sonous that eating one-third of its cap can be lethal.
Symptoms of mushroom poisoning may occur immediately a$er ingestion and may include increased salivation, tearing, increased urination, diarrhea, dif- !culty breathing, and an abnormal heartbeat. Other mushroom species have toxins that produce symp- toms 12–24 hours a$er ingestion; these include headache, jaundice (a yellowish cast to the skin), confusion, convulsions, and possible coma. Because poisonous mushrooms can be lethal or cause severe poisoning, do not eat any mushrooms that you !nd growing wild. Only a person trained in mushroom identi!cation should attempt to distinguish between mushrooms that are safe to eat and those that are not.
Ingestion of Household Cleaning Aids, Medica- tions, and Vitamins Children younger than the age of 5 years are most in danger of being poisoned from household cleaning aids and from over-the-counter and prescription drugs and vitamins. "e Federal Hazardous Substances Act, passed into law by the Consumer Product Safety Commission in 1966, has been helpful in lowering the incidence of poisoning
550 Chapter 16 Environmental Health
Never suggest to a child that any medication or vitamin pill is candy because the child will seek out the pills at another time. Never take medication or vitamins in front of a young child who may think that it is candy or food and try to do the same.
Children rarely become poisoned by vitamins and mineral supplements in the amounts they accidentally consume (see Table 16.2), but adults become poisoned by intentional overdose. Megadosing with vitamins (taking much greater amounts than that recommended per day) has become a popular practice but may cause health problems. Vitamin overdosing in adults most o$en occurs with vitamins A and D, two fat-soluble vitamins that are readily stored in the body. Daily overdoses of most fat-soluble vitamins build up, result- ing in chronic intoxication. Daily doses of 3–10 times the recommended amount of vitamin A over a few months to a few years produce toxic symptoms. Accu- tane, a form of vitamin A taken to treat skin condi- tions, can cause vitamin A toxicity when taken by mouth. Daily doses of 10 times the recommended amount of vitamin D over 6 months to a year produce toxic symptoms as well. Minerals that most commonly cause poisoning are iron, selenium, and zinc.
Lead Poisoning Lead poisoning is still a health problem in children in the United States even though many sources of lead poisoning have been eliminated in this country: leaded gasoline, leaded solder in food and so$ drink cans, and leaded paint. (Solder is a metal that is heated and then used, when so$, to join other metals. It hardens on cooling and makes the joint solid.)
Even though many sources of lead have been removed from the environment, leaded dangers still exist. Ceramicware that is poorly made can have very high levels of leaching lead (that is, lead that dissolves out of the dishes and passes into food). Car batter- ies contain lead and should be brought to collection centers for proper disposal or recycling. Some pipes that bring water to homes contain lead-based solder. Additionally, the soil surrounding roads and highways o$en contains lead from years-past auto emissions.
Houses and apartments built before 1978 were o$en painted with lead-based paint. Although layers of nonleaded paint may cover leaded paint, the top coats of paint can chip. "e exposed leaded paint creates leaded dust that may be inhaled, or the leaded paint
in children by controlling the concentration of toxic chemicals in household products. "e Poison Pre- vention Packaging Act of 1972 established standards for the packaging of potentially harmful household products and medications by requiring child-resistant caps and packaging on products that present a serious danger to children. "e intent of this packaging is to make it di&cult for children to open toxic substances so that adults will discover their attempts before they are successful. "e use of blister packs in which pills are individually encased is another approach to lessen a child’s ability to remove pills from packaging.
Although warning stickers such as Mr. Yuk ( Figure" 16.2) are available for placing on hazardous substances, the results of research suggest that their use does not lower the incidence of poisoning in children.8 Additionally, children and adults do not view the facial expression of disgust, which Mr. Yuk portrays, as pre- cautionary; a facial expression of fear might be more appropriate as a deterrent.9 Because child-resistant packaging can be opened by children (although with di&culty) and because warning stickers do not appear to discourage children from investigating package con- tents, all dangerous household substances, including medications and cleaning aids, should be locked in cab- inets. Special child-proof locks are available that enable an adult to open a cabinet easily but bar the child from doing so. Placing items on high shelves is not a good substitute and is not safe; children easily stack items and climb on them to reach these substances.
Figure 16.2 Poison Prevention Symbols. The skull and crossbones used to be the traditional warning symbol of poison, but the symbol was and is used to denote fun things like pirates and adventure. Therefore, Mr. Yuk (left) was developed as a warning label in the early 1970s. The image on the right is the updated skull and crossbones figure for poisons. Using these labels on toxic substances are unreliable deterrents, however. Lock all toxic substances in cabinets, away from children.
lead poisoning A toxic condition that affects the central nervous system, caused by the ingestion or inhalation of the metallic element lead.
Environmental Health in and Around the Home 551
lead poisoning are rare in the United States. None- theless, many children are severely a#ected by this toxin. Whereas adults absorb about 11% of lead that reaches the digestive tract, children absorb from 30% to 75%. When lead is inhaled, up to 50% is absorbed.11
Low levels of lead in the blood (10 micrograms per deciliter [-g/dL]) are associated with decreased intel- ligence, learning disabilities, impaired development of the nervous system, and delayed or stunted growth. Behavioral disorders also have been linked to lead poisoning. At slightly higher levels of lead poisoning, the body does not metabolize certain%vitamins prop- erly or manufacture red blood cells correctly.
A child with high blood levels of lead (70 -g/dL) will show some of the following symptoms: decreased appetite, vomiting, abdominal pain, constipation, drowsiness, and indi#erence. Children who have even higher blood levels will exhibit some of the signs and symptoms of degenerative brain disease: coma,
may chip, and children may eat it. Leaded paint on the exterior of homes and apartments o$en contaminates the surrounding soil in which children may play.
Decorating techniques that use old, salvaged building components, such as old doors, and old decorative items, such as distressed-looking old fur- niture, old dishes, and old toys, can be a lead health hazard.10 Many cases of lead poisoning occur when older homes are remodeled without attention to the containment of leaded dust and paint chips. When doing such work, use a high-e&ciency particulate air-!lter-equipped vacuum cleaner, properly !tted respirators, wet sanding equipment, and protective clothing (Figure 16.3). Seal o# work areas with heavy- duty polyethylene plastic sheeting, and keep all non- workers away from the area.
Lead poisoning is serious because it a#ects the central nervous system and can cause coma, convul- sions, and even death. Today, deaths resulting from
Managing Your Health
Keep Young Children Safe • Keep all drugs in medicine cabinets
or other childproof cabinets that young children cannot reach.
• Never call medicine “candy” when giving medicine to children.
• Be aware of any legal or illegal drugs that guests may bring into your home. Do not let guests leave drugs where children can find them, for example, in a pill- box, purse, backpack, or coat pocket.
• When you take medicines yourself, do not put your next dose on the counter or table where children can reach them.
• Never leave children alone with household products or drugs. If you have to do something else while using chemical products or taking medicine, such as answer the phone, take any young children with you.
• Do not leave household products out after using them. Return the products to a childproof cabinet as soon as you are done with them.
• Identify poisonous plants in your house and yard and place them out of reach of children or remove them.
Drugs and Medicines • Follow directions on the label when you give or take
medicines. Read all warning labels. Some medicines cannot be taken safely when you take other medicines or drink alcohol.
• Turn on a light when you give or take medicines at night so that you know you have the correct amount of the right medicine.
• Keep medicines in their original bottles or containers. • Never share or sell your prescription drugs. • Keep opioid pain medications, such as methadone,
hydrocodone, and oxycodone, in a safe place that can be reached only by people who take or give them.
Household Chemicals • Always read the label before using a product that may
be poisonous. • Keep chemical products in their original bottles or
containers. Do not use food containers to store chemical products.
• Never mix household products together. For example, mixing bleach and ammonia can result in toxic gases.
• Wear protective clothing (gloves, long sleeves, long pants, socks, shoes) if you spray pesticides or other chemicals.
• Turn on the fan and open windows when using chem- ical products such as household cleaners.
Adapted from Department of Health and Human Services, Centers for Disease Control and Prevention. (2015, November). Tips to prevent poi- sonings. Retrieved from http://www.cdc.gov/homeandrecreationalsafety /poisoning/preventiontips.htm
Tips to Prevent Poisonings
552 Chapter 16 Environmental Health
seizures, bizarre behavior, impaired muscular coor- dination, and vomiting. Either situation is a medi- cal emergency, and the child should be hospitalized. Tests should be performed to determine the child’s lead blood level, and medications will be administered to reduce that level. However, the most important therapy is removing sources of lead from the child’s environment. Call the National Lead Information Center at 1-800-424-LEAD for more information on how to avoid lead poisoning, or visit its website at www .epa.gov/lead/.
Carbon Monoxide Poisoning Carbon monoxide (CO) is a colorless, odorless, tasteless gas that can kill. In fact, unintentional CO poisoning from nonauto- motive sources causes about 170 deaths in the United States per year.12 Carbon monoxide is produced by the incomplete combustion of carbon-containing fuels such as oil, coal, wood, natural gas, charcoal,
and gasoline. Fires are a major source of carbon monoxide poisoning; persons caught in a !re o$en die from inhaling carbon monoxide and other toxic gases rather than from the !re. Fire!ghters also are at risk for carbon monoxide poisoning. Other primary sources of carbon monoxide poisoning are auto- mobile exhaust, malfunctioning furnaces, charcoal !res, gasoline-powered tools, wood stoves, !replaces, unvented kerosene and gas space heaters, gas cooking stoves and ovens, and tobacco smoking. See the self- assessment “Checklist for the Prevention of Carbon Monoxide Poisoning” in the Student Workbook pages of this text to determine whether your home, auto, cabin, or camper is as safe as it can be.
"e proper maintenance and use of tools and appliances that burn fuel cuts down on the amount of CO they produce; these levels are usually not hazardous. Improper maintenance and incor- rect use o$en result in dangerous levels of CO. To protect against these dangers, be certain that home heating stoves or furnaces are vented properly and are inspected regularly for carbon monoxide leakage. Use charcoal grills and gas-powered tools only in well-ventilated areas. (Don’t use your charcoal grill in your garage or in a tent while camping.) Do not leave a car running in an attached garage where fumes can leak into the house. Run the car engine outdoors only. Carbon monoxide can also leak into a car if the exhaust system is faulty.
Carbon monoxide sensors are available for home use. "ese products are designed to sound an alarm%when indoor air contains dangerously high%lev- els of this toxin. Research results show that the use of carbon monoxide detectors could reduce by half the number of unintentional deaths by CO poisoning in the home. (See the Consumer Health box “Carbon Monoxide Detectors: Are "ey%Reliable?”)
Carbon monoxide kills because it binds to the oxygen-carrying molecule hemoglobin in the blood- stream. When CO is bound to hemoglobin, oxygen cannot bind, and the person dies of su#ocation. Before carbon monoxide poisoning kills, however, it produces signs and symptoms that become more severe as blood levels of this gas increase. At !rst, a person may have a slight headache that worsens as blood levels rise. ("is level of poisoning can even occur if you jog near rush-hour tra&c.) Fatigue sets
Figure 16.3 Lead Paint Removal. These experts are removing lead paint from an old home in Providence, Rhode Island. They are using a specialized vacuum cleaner and are wearing protective clothing and respirators. © Chitose Suzuki/AP Images.
carbon monoxide poisoning A toxic condition that affects red blood cells’ ability to carry oxygen, caused by the inhalation of the gas carbon monoxide.
Environmental Health in and Around the Home 553
microscopic asbestos !bers can result in asbestosis as well as cancer of the lungs and stomach. When asbestosis occurs, scar tissue forms in the lungs as a response to irritation by asbestos !bers. "e patient experiences shortness of breath, which progresses to a fatal lack of oxygen or heart failure. Because of the danger that asbestos exposure poses to humans, the U.S. Environmental Protection Agency (EPA) banned the use of various asbestos-containing prod- ucts during the 1970s and 1980s. In 1989, the EPA announced a ban on all asbestos products by 1996.
Aside from the danger to those who mine asbes- tos, those in primary danger of asbestos exposure are people who live in houses built between 1920 and 1978. Various asbestos products were developed at di#erent times during those years and were used in home construction. Asbestos was also widely used in schools built between 1950 and 1973. Intact asbestos products do not pose a hazard. Danger exists when asbestos !bers are released from the products of which they were a part and become airborne. Asbes- tos !bers are released from products that are dete- riorating; banged, rubbed, or handled frequently; or disturbed during home remodeling. Asbestos !bers are also released when asbestos-containing 'ooring is sanded or seriously%damaged.
in, and the poison victim may become dizzy. As the poisoning continues, nausea, vomiting, a cherry-red skin color, and blurry vision result. Eventually the person collapses, may have convulsions, and dies.
Carbon monoxide poisoning is an emergency; immediately get the victim to fresh air and seek medical help. Healthcare practitioners treat CO poisoning victims with oxygen and test them for other medical problems that may have occurred at the time of the poisoning (such as a blow to the head in a fall). In some circumstances, the poisoning victim is placed in a hyperbaric (pressure) chamber and administered oxygen.
Inhalation of Asbestos Fibers Asbestos is a !berlike mineral that resists damage by !re and other natural processes. Because of these qualities, asbestos has been used in the manufacture of products exposed to !re, such as stoves, furnaces, and appliances; insulation in walls and ceilings; insulation surrounding pipes; patching compounds and textured paints (as a binding compound and texturizer); roo!ng and siding materials; and vinyl 'ooring (as a strengthener).
Asbestos-containing products came into use beginning in the 1920s, but by the early 1970s, scientists discovered that long-term inhalation of
Consumer Health Carbon Monoxide Detectors: Are They Reliable? Carbon monoxide (CO) detectors should be thought of only as a backup to proper use and maintenance of fuel-burning
appliances. The technology of these detectors is still developing, and a variety of types are available for home use. However, none is considered to be as reliable as home smoke detectors.
The U.S. Environmental Protection Agency reports that CO detectors have been laboratory tested with vary- ing results. Some performed well, others failed to alarm at high CO levels, and still others alarmed at low levels that do not pose an immediate health risk. Because CO is invisible and odorless, it is hard to tell if an alarm is false or a real emergency.
When purchasing a CO detector, research the features of various models and brands and use this knowledge,
not the price, as your basis for selection. Carefully fol- low the manufacturer’s instructions for its placement, use, and maintenance. CO detectors have an average life span of approximately 2 years, after which they should be replaced. If your CO detector goes off:
• Make certain it is the CO detector alarm and not the smoke detector alarm.
• Seek medical help for anyone experiencing CO poison- ing symptoms.
• Ventilate the home with fresh air and turn off all poten- tial sources of CO.
• Have a qualified technician inspect all fuel-burning appliances and chimneys to make sure they are oper- ating correctly and that there is nothing blocking fumes from being vented.
Adapted from U.S. Environmental Protection Agency, Indoor Environ- ments Division, Office of Air and Radiation. (2014, May). Protect your family and yourself from carbon monoxide poisoning (EPA-402-F-96-005). Retrieved from http://www.epa.gov/iaq/pubs/coftsht.html
554 Chapter 16 Environmental Health
government and industrial safety standards. CRT tele- visions and computer monitors are no longer manu- factured. Liquid-crystal displays (LCDs) and plasma screens do not emit ELF radiation.
Cell phones and microwave ovens emit a form of electromagnetic radiation called nonionizing radio- frequency (RF) energy. RF energy is not able to break bonds in DNA—the hereditary material—so it cannot cause cancer in that way. However, at high enough lev- els, RF energy can heat living tissue; this is the principle used in microwave cooking. A person using a micro- wave o$en stands away from the oven, and results of studies show that radiation exposure from microwaves during regular use is unlikely to be harmful.
"e heat generated by cell phones is small in com- parison with that generated by microwave ovens. A cell phone’s main source of RF energy is its antenna, which is part of the body of the phone. "e closer the phone (and therefore the antenna) is to the user’s head, the higher the user’s exposure to the phone’s RF energy. Cell phones (and lower energy cordless home phones) with antennas mounted away from the user are considered safe.
In recent years, many studies and reviews have been conducted regarding cell phone use and an%increased risk of cancer or other adverse health e#ects.
"e American Cancer Society has summarized research results with this statement: Most studies published so far have not found a link between cell phone use and the development of tumors. However, these studies have had some important limi- tations that make them unlikely to end the controversy about whether cell phone use a!ects cancer risk.15
"e World Health Organization’s International Agency for Research on Cancer (IARC) in a May 31, 2011, press release revealed that it had “classi!ed radiofrequency electromagnetic !elds as possibly carcinogenic [cancer-causing] to humans . . . based on an increased risk for glioma, a malignant type of brain cancer, associated with wireless phone use.” "e many sources of data that the IARC reviewed suggest a 40% increase in risk for glioma in heavy cell phone users, de!ned as an average of 30 minutes per day for 10 years. "e IARC concludes that further research was needed to clarify links between cancer risk and cell phone use.16
To protect against the inhalation of asbestos !bers, avoid disturbing this material. Do not vacuum par- ticles that may be asbestos laden; vacuuming them releases microscopic asbestos !bers that are inhaled. If possible, contact the contractor who built the house to determine whether asbestos was used. If this is not possible, contact a certi!ed professional trained in asbestos removal and repair to determine whether the house contains asbestos. Sometimes materials must be sent to a laboratory to assess their content. If so, use a laboratory accredited to perform asbestos analysis. If removal, repair, or sealing of the material is necessary, hire only trained, certi!ed per- sonnel who can do this job safely and properly.
Electromagnetic Radiation Are computer screens, television sets, electric blan- kets, microwave ovens, cell phones, or electric appli- ances health hazards? Are people putting their health at risk if they live near high-power electric lines or electrical distribution substations? A variety of stud- ies have been conducted regarding the e#ects on the body of extremely low frequency (ELF) radiation, which is emitted by some of these sources. ELF radia- tion has been associated with negative e#ects such as risk of cancer, DNA damage,%and changes in human brain electrical activity. So far, however, most scien- tists see no major negative e#ects and no reason to recommend extreme caution.13,14 However, taking reasonable preventive measures against undue expo- sure may be prudent.
ELF radiation is a type of electromagnetic radiation— electric and magnetic !elds of energy that travel at the speed of light through the atmosphere. Sunlight, for example, is electromagnetic energy. Other forms of electromagnetic radiation include X-rays, ultraviolet light, infrared light, and radio waves.
"e electric !elds of ELF radiation are not as poten- tially problematic as their magnetic !elds are. Although the strength of both the electric and magnetic !elds decreases dramatically and quickly as a person moves away from the source, magnetic !elds penetrate the walls of buildings that electric !elds cannot.
Cathode ray tube (CRT) televisions and computer monitors produce radiation that spans the electromag- netic spectrum from X-rays to radio waves. However, they were manufactured with protective shielding to prevent most of the radiation from escaping. "e small amount that does escape results in electric and mag- netic !elds in the atmosphere surrounding the user, but the level of radiation where the user sits is well below occupational and exposure limits recommended by
asbestosis (AS-bes-TOE-sis) A condition in which scar tissue forms in the lungs as a response to irritation by asbestos.
Environmental Health in and Around the Home 555
Health-Related InformationAnalyzing Critical Thinking
The following abstract is from an online environmental health journal, written to inform the general public about research and current thinking on cell phone use and cancer. Explain why you think this abstract is a
reliable or an unreliable source of information. Use the model for analyzing health information to guide your thinking; the main points of the model are noted at the end of this abstract.
1. Which statements are verifiable facts, and which are unverified statements or value claims?
2. What are the credentials of the researchers/journal abstract making these health-related claims? Do the researchers/journal abstract have the appropriate background and education in the topic area? What can you do to check the credentials of this source?
3. What might be the motives and biases of the researchers/journal abstract making the claims?
4. What is the main point of the abstract? Which information is relevant to the issue, main point, product, or service? Which information is irrelevant?
5. Are the researchers/journal abstract reliable? What evidence supports your conclusion that the source
is reliable or unreliable? Do the researchers/ journal abstract present the pros and cons of the topic or the benefits and risks of the product?
6. Do the researchers/journal abstract attack the credibility of conventional scientists or medical authorities?
Based on your analysis, do you think that this abstract is a reliable source of health-related information? Sum- marize your reasons for coming to this conclusion.
Reproduced from Swerdlow, A. J., Feychting, M., Green, A. C., Kheifets, L., Savitz, D. A., & International Commission for Non-Ionizing Radiation Protection Standing Committee on Epidemiology. (2011). Mobile phones, brain tumors, and the interphone study: Where are we now? Environmental Health Perspectives, 119,1534–1538. https://www.ncbi .nlm.nih.gov/pmc/articles/PMC3226506/
Mobile Phones, Brain Tumors, and the Interphone Study: Where Are We Now?
Anthony J. Swerdlow1, Maria Feychting2, Adele C. Green3,4, Leeka Kheifets5, and David A. Savitz6,7, International Commission for Non-Ionizing Radiation Protection Standing Committee on Epidemiology 1Section of Epidemiology, Institute of Cancer Research, Sutton, United Kingdom 2Karolinska Institutet, Institute of Environmental Medicine, Stockholm, Sweden 3Cancer and Population Studies Unit, Queensland Institute of Medical Research, Brisbane, Australia 4School of Translational Medicine, University of Manchester, Manchester, United Kingdom 5Department of Epidemiology, University of California at Los Angeles, Los Angeles, California, USA 6Department of Community Health 7Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, USA
Abstract Background In the past 15 years, mobile telephone use has evolved from an uncommon activity to one with >%4.6 billion subscriptions worldwide. However, there is public concern about the possi- bility that mobile phones might cause cancer, especially brain tumors.
Objectives We reviewed the evidence on whether mobile phone use raises the risk of the main types of brain tumor—glioma and menin- gioma—with a particular focus on the recent publication of the largest epidemiologic study yet: the 13-country Inter- phone Study.
Discussion Methodological de!cits limit the conclusions that can be drawn from the Interphone study, but its results, along with those from other epidemiologic, biological, and animal stud- ies and brain tumor incidence trends, suggest that within about 10–15 years a$er !rst use of mobile phones there is unlikely to be a material increase in the risk of brain tumors in adults. Data for childhood tumors and for periods beyond 15 years are currently lacking.
Conclusions Although there remains some uncertainty, the trend in the accumulating evidence is increasingly against the hypothesis that mobile phone use can cause brain tumors in adults.
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Managing Your Health
• Do not sleep or sit for a long time near electric devices, particularly those with motors.
• Sit a minimum of 18 inches (at arm’s length) from your CRT computer screen.
• Turn off your CRT computer monitor when it is not being used.
• Sit several feet away from the back or sides of a CRT computer monitor or television. Follow this rule even if the TV or monitor is in another room; magnetic fields travel through walls.
• Adults and especially children should sit several feet away from a CRT televi- sion screen.
• Turn on your waterbed heater or electric blanket before going to bed. Unplug it when you get into bed.
• Use a mobile phone in the car with an antenna located outside the vehi- cle, or use a cell phone with a headset.
Avoiding ELF Radiation
4Teach children not to ingest house or yard plants because they may be poisonous. In homes with young children, substitute safe plants for poisonous ones.
4Eat only mushrooms that you are certain are nonpoisonous.
4In homes with small children, store all dangerous household substances, including medications and cleaning aids, in locked cabinets.
4Never suggest to a child that medications or vitamin pills are candy.
Healthy Living Practices
Irradiation of Food Many types of organisms contaminate the food supply. Escherichia coli (a common intestinal bacterium) can be found in such foods as hamburger and unpasteur- ized apple juice. A particularly deadly strain of E.&coli (O157:H7) has caused illness and death. Salmonella bacteria are common contaminants of poultry. Certain insects and their larvae contaminate wheat and wheat 'our. A wide range of organisms cause not only food- borne illness but the spoilage of food.
One method of killing organisms in food is irradiation—that is, treating food with radiation. Radi- ation is the emission of energy by the unstable nuclei
To decrease your risk of these adverse health e#ects, put distance between yourself and your cell phone; RF exposure decreases rapidly with increasing distance from the source. "us, use a headset or earpieces and carry the phone away from your body, or use a cell phone connected to a remote antenna. Household cordless phones operate at lower power levels and do not appear to have these adverse health e#ects. "e Analyzing Health-Related Information activity in this chapter contains an article that discusses the results of research on the cancer–cell phone link.
Regarding exposure to ELF radiation of all types, medical researchers have adopted the position of “prudent avoidance” until research data indicate that another course of action should be taken. "e Managing Your Health box titled “Avoiding ELF Radiation” gives some tips.
4Do not take large doses of fat-soluble vitamins except under the direction of a physician.
4If you live in a house or apartment built before 1978, be certain that children do not ingest peeling paint. Consult a professional to test for lead, and, if lead is present, to minimize its release into the home.
4To avoid carbon monoxide poisoning, maintain and use fuel-burning tools and appliances properly, be certain that heating stoves and furnaces are correctly vented, and warm up the car outside rather than in the garage.
4Seek medical assistance immediately for anyone who exhibits symptoms of carbon monoxide poisoning.
4Do not disturb asbestos that is deteriorating.
4Seek professional help for asbestos cleanup.
4Avoid exposure to ELF radiation.
Environmental Health in and Around the Home 557
more frequently occurs on the job in people who man- ufacture or apply pesticides. Poisoning by exposure to certain solvents, metals, plastics, and adhesives gener- ally occurs only during their manufacture.
Pesticide Poisoning Pesticides are chemicals that kill plant and animal pests; they are used on farms and in homes and busi- nesses to control insects, rodents, and weeds. People rarely become poisoned from spraying pesticides in their homes or yards; however, they should be cau- tious, spray downwind, and protect their skin and eyes. Occasionally, people accidentally drink or eat pesticides (or other toxic chemicals) stored in unmarked food containers in storage areas. For this reason, pesticides always should be kept in clearly marked containers. A person who has ingested pes- ticides should receive immediate medical attention.
People also ingest pesticides in the food they eat. "ese pesticides are not simply what is sprayed on fruits and vegetables but are found in !sh, seafood, and meat. Animals o$en ingest foods sprayed with pesticides. Marine and freshwater organisms also eat food contaminated with pesticides when rain washes chemicals from the land into the water. Animals store certain pesticides they eat (and other toxic chemicals such as heavy metals) in their tissues, especially in fat.
Although many harmful pesticides, such as DDT, have been banned in the United States, these toxic chemicals, as well as pesticides being manufactured today, persist in the food chain. In addition, certain harmful pesticides such as DDT are still used in other countries on crops that are imported to the United States. However, pesticide levels in humans from eat- ing supermarket produce are not considered toxic. "e FDA, EPA, and Food Safety and Inspection Service of the U.S. Department of Agriculture together ensure that the levels of pesticides in food are not hazardous to the health of consumers. Data collected by the FDA over a 7-year period show that pesticide residues on infant foods and adult foods that infants and children eat are almost always well below the highest levels legally allowed by the EPA (and that includes testing foods such as bananas without washing and peeling them). See the Managing Your Health feature for tips on reducing the level of pesticides in your food.
Most o$en, pesticide poisoning occurs in workers who manufacture or apply pesticides (Figure 16.4). Such workers inhale or have their skin exposed to toxic chemicals over a period of time if their skin and respi- ratory passageways are not properly protected. "e signs and symptoms of poisoning in such cases may be
of certain atoms in the form of rays or waves. Food is irradiated in its packaging by exposing it either to gamma (g) rays (a form of electromagnetic radiation similar to X-rays) or to high-energy electron beams produced by electron accelerators. Radiation is harm- ful to living tissue, so it kills living organisms in the food as the energy passes through it, much like micro- waves pass through food in a microwave oven. And just as a dentist’s X-ray does not make your teeth radio- active, irradiation does not make food radioactive.
Food irradiation is a process that was patented in the United States in 1921 but was not approved for use on the !rst food products (wheat, wheat 'our, and white potatoes) by the Food and Drug Administration (FDA) until the early 1960s. Since then, whether to irradiate food in the United States has been a conten- tious issue. Approximately 50 years a$er its approval, irradiation remains in limited use, although the FDA has since approved the use of irradiation on fresh pro- duce, herbs, spices, pork, poultry, and red meat.
Numerous national and international organiza- tions (such as the American Medical Association and the World Health Organization) as well as many university-based research institutes endorse the irra- diation of food. Irradiation has been shown to be the only way to rid ground beef of E. coli O157:H7 before cooking. (Cooking ground beef thoroughly also kills this pathogen.) Irradiation also kills other bacteria, as well as insects and fungi that can make people sick or spoil food. Additionally, irradiating food inhibits the sprouting of vegetables and delays the ripening of fruits. Using this process makes the food supply safer, provides a better quality of food, and extends the “shelf life” of food.
Environmental Health in the Workplace
Exposures to some toxins can occur both at home and at work, depending on one’s occupation. Accidental carbon monoxide poisoning, for example, is certainly a hazard for automobile mechanics if car exhaust is not properly vented, but carbon monoxide poisoning more frequently occurs in the home. Pesticides are another group of toxic substances that persons may acciden- tally ingest at home if these chemicals are placed in unlabeled containers. However, pesticide poisoning
pesticides Chemicals that kill plant and animal pests and that can cause poisoning when ingested.
558 Chapter 16 Environmental Health
Figure 16.4 Protection Against Pesticides. This worker is using proper protection for his skin and respiratory passageways. Courtesy of Tim McCabe/USDA NRCS.
latter case, the coating is dissolved in the solvent, which then evaporates on drying.)
Exposure to most solvents slows nerve transmis- sion in the brain and spinal cord, resulting in slowed movements and thought processes. Continued solvent exposure can lead to unconsciousness. Some solvents are irritants that can cause 'uid to collect in the lungs or cause the skin to redden. Chronic exposure to sol- vents can also cause cracking or scaling of the skin.
Metals (such as aluminum, tin, copper, and iron) are elements that are usually shiny, are good conduc- tors of heat and electricity, and can be melted, fused, hammered into thin sheets, or drawn into wires. Metals are extracted from ores by various processes.
During these processes, ores are crushed, melted, and poured, which results in the production of metal dusts and vapors (Figure 16.5). Processing metal ores sometimes uses toxic and caustic chemicals such as sulfuric acid or cyanide and o$en produces other toxic gases such as carbon monoxide and sulfur diox- ide (discussed later in this chapter). Various indus- tries use metals in the manufacture of products such as bearings, solder, batteries, cutting tools, plumbing supplies, cookware, and roo!ng materials.
Exposure to heavy metals results in a variety of signs and symptoms depending on the metal and how it enters the body. Inhaling metal dusts or fumes, for example, can cause a variety of lung disorders such as lung scarring, 'uid in the lungs, and emphy- sema (a lung disease in which the air sacs break apart and breathing is di&cult). Inhaling fumes of heavy
vague and nonspeci!c at !rst: headache, intermittent dizziness, and general discomfort. As the poisoning worsens, the symptoms progress to include insomnia, nausea, increased sweating, involuntary eye move- ments, double or blurred vision, ringing in the ears, and involuntary body movements. If exposure continues, the poisoning victim may have convulsions. Treatment of chronic pesticide poisoning requires careful medical evaluation and is individualized for each patient.
"e relationship of high-level exposure to pesti- cides and cancer has been studied by many research- ers. Determining whether a causal link exists between pesticide exposure and cancer is di&cult in that occu- pational exposure may include a variety of pesticides and cancer can have many causes. Cancers that have been associated with heavy pesticide exposure include non-Hodgkin lymphoma (cancer of the lymphoid tissue), leukemia (cancer of the blood), and multiple myeloma (cancer of antibody-producing cells of the bone marrow), as well as cancers of the brain, breast, prostate, colon, rectum, lung, and skin. Continued research is needed to clarify these associations.17,18
Exposure to and Inhalation of Other Toxic Chemicals A solvent is a liquid in which another substance is dissolved. Solvents are varied and perform a broad range of tasks in business and industry, such as removing unwanted substances (e.g., dry-cleaning solvents remove stains from clothing) or adding coatings such as paints and sealers to surfaces. (In%the
Figure 16.5 Processing Steel. This factory worker in east China is working at the furnace of a steel plant. He is wearing an asbestos suit for protection as he takes a sample of the molten ore with a long tool. In the process, he is exposed to metal vapor. © Imagechina/AP Images.
Environmental Health in the Workplace 559
conducted during the past two decades to address this concern and determine the cause of “sick build- ing syndrome.”
Sick building syndrome refers to a variety of symptoms reported by occupants of large buildings. "ese symptoms are attributed to the physical envi- ronments of the buildings. Buildings are identi!ed as problems when a large proportion (sometimes as many as 30%) of their occupants complain about the same vague health-related problems, such as head- aches; unusual fatigue; eye, nose, and throat irrita- tion; and shortness of breath.
"e results of studies of sick buildings show the predominant problem to be inadequate ventilation. Another cause of health problems is chemical con- tamination from a variety of sources such as building materials, carpets, paints, adhesives, and furniture. In addition, if the building moisture level is too high, it can promote the growth of mold and cause symptoms in those allergic to mold.19 Other sources of contamination of indoor air include asbestos and combustion-generated pollutants (discussed earlier in this chapter), radon, and formaldehyde. Authors of a study in England, however, concluded that poor psychosocial conditions in a workplace may far outweigh poor physical conditions of a building in causing symptoms of sick building syndrome.20
Formaldehyde is a chemical used in the manu- facture of many building materials and furnishings, which then release formaldehyde into the air. Speci!c products that are most frequently responsible for high levels of formaldehyde in indoor air are pressed wood products such as !berboard, particleboard, and hardwood plywood paneling and urea-formaldehyde foam, which is usually used to insulate walls.
Formaldehyde irritates the eyes, nose, and sinuses; people who inhale formaldehyde may have di&- culty breathing, experience chest pain, and begin to wheeze. Some people experience headaches, fatigue, and nausea and have di&culty sleeping, whereas
metals can also irritate the eyes and mouth, damage the kidneys, and damage the brain and spinal cord, especially with exposure to lead, mercury, or man- ganese. Skin contact with fumes can cause burns, rashes, reddening, swelling, and itching. Exposure to many heavy metals also causes cancer.
Adhesives are used to join substances during assembly operations. To join parts, other processes may also be used, such as etching, roughening, or sol- vent cleaning. Each of these processes may introduce its own speci!c hazards.
In most cases, the U.S. Occupational Safety and Health Administration (OSHA) of the U.S. Depart- ment of Labor regulates procedures in industries to protect the health of workers. However, many small companies, such as auto repair shops, are not regu- lated by OSHA.
Managing Your Health
• Scrub all fruits and vegetables with water for at least 20 seconds.
• Remove and discard the outer leaves of leafy vegetables.
• Trim the fat from red meats. • Remove the skin and underlying fat from fish and poultry. • Discard pan drippings and broths from animal
products.
Reducing Pesticide Levels in the Food You Eat
4Always keep pesticides and other chemicals away from children and stored in sealed, marked containers.
4When working with pesticides, wear clothing that protects your skin, eyes, nose, and mouth.
4If you work with toxic chemicals, take measures to protect yourself from damage to skin and eyes, assess the danger from toxic fumes that may be created as a result of your work, and contact OSHA for more information.
Healthy Living Practices
Indoor Air Pollution As people became concerned about the excessive use of energy in the 1970s and started creating “tighter” buildings to conserve energy in heating and cooling, they also became concerned about the quality of indoor air. Numerous studies have been
560 Chapter 16 Environmental Health
Both sources of water can become contaminated with toxic chemicals. Surface water, however, can also become contaminated with pathogens, plant fertiliz- ers, sediments (soil), radioactivity, and heat.
In developed countries, waterborne pathogens are infrequently a cause of disease because sewage plants treat wastewater so that it will not contaminate water supplies. Additionally, public drinking water is chlorinated to kill pathogens. However, infection can occur when water puri!cation and supply systems break down. Waterborne infectious disease is a wide- spread problem in developing countries, which have no water puri!cation systems.
Plant fertilizers, sediments, and heat, which o$en contaminate surface waters, do not generally harm humans. "e radioactivity emitted by nuclear power plants that enters the water supply is thought to be so low as to be harmless to humans. However, chemi- cal contaminants such as toxic chemical compounds (including pesticides), heavy metals (such as mercury and lead), and acids (from acid precipitation; see the section titled “Air Pollution” later in this chapter) can cause noninfectious diseases and poisoning.
Chemical contaminants pollute both groundwater (aquifers) and surface water. Such pollutants enter surface water when industries spill waste chemi- cals into waterways, mining wastes 'ow into rivers, pesticides wash into rivers and lakes during a rain, and salt used to de-ice roads washes into rivers and streams during spring rains.
Heavy metals can also contaminate surface water. Metals enter the water when they are dumped into rivers and streams from industrial sources. However, the Clean Water Act of 1972 and the Federal Water Pollution Control Act of 1972 and their amendments have all been instrumental in prohibiting industry from discharging such toxic chemicals into surface water. Metals also get into drinking water on its way to homes by leaching from lead solder in water pipes. (Leaching is the removal of the dissolvable parts of
others exhibit gastrointestinal disturbances such as vomiting and diarrhea. Formaldehyde’s role in the development of asthma and cancer is controversial.
If formaldehyde contamination occurs in a home or public building (as noted by occupants’ symptoms), the source must be determined and removed, or other measures must be taken to reduce the level of this gas in the indoor air. "is process may be di&cult%and expen- sive. Removing urea- formaldehyde foam insulation from walls is costly and damages the% walls. (How- ever, urea-formaldehyde foam insulation installed 5–10% years ago is unlikely to still release formalde- hyde.) Paneling may need to be removed or furniture discarded. Alternatives are to install an air ventilation system designed to remove toxic substances such as formaldehyde from the air, bring large amounts of fresh air into the building, or seal the surfaces of the formaldehyde-containing%products.
Radon gas may also contaminate indoor air. Radon is present in the rocks and soils in many areas in the United States. People who live in these regions may be exposed to radon gas if it leaks through cracks in basement walls and collects in their homes
Homes that were built or remodeled between 2001 and 2008 may have been constructed with defective imported drywall (o$en called Chinese drywall) that emits various sulfur-containing com- pounds. Along with causing corrosion in the homes’ plumbing and electrical systems, the drywall emis- sions have been linked to negative health e#ects in some sensitive individuals.21
Environmental Health in"the Outdoors
Although engaging in outdoor activity is associated with numerous health bene!ts, our environment also contains many hazards that may be detrimental to our health. Contaminants in our water supply and air can contribute to poor drinking water quality and air qual- ity, which is associated with poor health outcomes. Additionally, hazardous waste, noise pollution, and other pollutants can greatly in'uence our short- and long-term individual and community health. In the following paragraphs, we will highlight some of the most common environmental health factors.
Water Pollution People get the water they drink from underground reservoirs called aquifers and from above-ground sources: lakes, rivers, and human-made reservoirs.
sick building syndrome A variety of vague health- related problems reported by many occupants of large buildings.
formaldehyde (form-AL-de-hide) A chemical used in the manufacture of certain building materials and furnishings; may cause health problems when released into indoor air.
radon gas A substance present in the rocks and soils in many areas in the United States; it may seep through cracks in basements and cause health problems.
Environmental Health in the Outdoors 561
are not useful for all water-treatment needs. Some persons choose to use only bottled water for cooking and drinking. However, bottled water is not necessar- ily better than tap water. To judge its purity, have your bottled water tested for the presence of toxic chemicals, or write to the International Bottled Water Association (IBWA), 1700 Diagonal Road, Suite 650, Alexandria, VA 22314, for information regarding a speci!c bottler. "eir information hotline is 1-800-WATER-11.
Air Pollution Air pollution is also a threat to health. "e primary substances in the air that harm humans are sul- fur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), and particulates. "ese substances are formed when fossil fuels are burned. Fossil fuels are carbon-containing substances formed over time and under pressure from once-living organisms (both plants and animals). Gasoline, coal, natural gas, and oil are all fossil fuels.
"e two main contributors to air pollution are automobiles and coal-!red power plants. "e use of small gasoline-powered machines such as leaf blow- ers, chainsaws, weed cutters, and snow blowers also contributes to air pollution.
Coal-!red power plants generate particulates and sulfur dioxide as their primary pollutants. People who live downwind of such power plants experi- ence the greatest impact from these pollutants. Sulfur dioxide combines with water in the atmosphere to produce sulfuric acid, the major component of acid precipitation. Acid precipitation (rain, snow, and fog) damages both living and nonliving things and acidi!es surface water. When it falls in cities, it can harm vegetation as well as damage stone statues and buildings, as shown in Figure 16.6. Acid water in res- ervoirs leaches metals from pipes carrying the water into the drinking water supplies. "e regions of the United States a#ected most heavily by acid precipi- tation are the Great Lakes area and New England. Southern Canada also experiences the e#ects of U.S. power plant emissions.
Sulfur oxides and particulates also combine with atmospheric moisture to form a grayish haze called smog (smoke plus fog). Smog can harm the lungs. Cities with sulfur oxide smog (called gray-air cities) are usually located in cold, moist climates and rely on coal and oil for electricity and home heating. "e smog in gray-air cities, such as New York City and Paris, France, is worst during cold, wet winters ( Figure 16.7a).
a substance as water moves through or over it.) "e Safe Drinking Water Act and its 1986 amendments authorize the EPA to monitor the safety of drink- ing water and requires the use of lead-free solder in plumbing pipes.
Groundwater becomes polluted from deteriorat- ing underground petroleum storage tanks at gasoline stations, chemicals from road salting, or agricul- tural chemicals that leach into the ground. However, hazardous waste (toxic chemical waste) is the pri- mary source of groundwater pollution as toxic chem- icals leach into aquifers.
In 1980, Congress passed a toxic waste cleanup bill and allocated funds to clean up hazardous sub- stances. Known as the Superfund, it provides money to !nd the parties guilty of dumping toxic waste at speci!c sites and forces them to pay cleanup costs. If the government cannot !nd the guilty parties, it pays to have the sites cleaned up. Since 1980, the Super- fund program has fostered the cleanup of hundreds of hazardous waste sites nationwide. Sites are con- tinually being deleted and added to the National Pri- orities List, which is the list of hazardous waste sites eligible for cleanup under Superfund.
To ensure the safety of drinking water, puri!ca- tion methods in the United States o$en involve chlo- rination to kill unwanted pathogens. In fact, 75% of the nation’s drinking water is treated with chlorine. In 1974, however, scientists realized that this chemi- cal interacts with other chemicals in drinking water to form new compounds such as chloroform. Since this discovery, scientists have been studying whether these compounds are associated with the incidence of cancer. At normal levels of consumption, compounds formed from chlorine in drinking water are not likely to produce cancer, miscarriages, or birth defects.
Becoming aware of the potential for water pol- lution is only the !rst step in protecting against the short-term and long-term health e#ects of drinking contaminated water. Tap water can be tested to be sure that it does not contain toxic or other unwanted chem- icals. If it does, it can be treated using various methods such as carbon !ltration. Carbon !lters remove many carbon-containing compounds and chlorine from the water, improving its taste, odor, and color. "e !lters
hazardous waste Toxic chemical refuse.
acid precipitation Rain, snow, or fog combined with sulfur dioxide from fossil fuel emissions.
smog A haze in the atmosphere formed by various pollutants.
562 Chapter 16 Environmental Health
Of the sulfur oxides and particulates in smog, particulates do the most damage to the lungs. Particulates are small particles that are dispersed in the air. Although nasal hairs and mucus in the nose and throat trap large particles, particulates reach the lungs and accumulate over time. Eventually, this material irritates the lungs and blocks their microscopic air sacs, making breathing more di&cult. Particulates in the air passageways and lungs can also be a factor in the development of respiratory diseases such as bronchitis, emphysema, and asthma. "ey also make existing respiratory illness worse.
Sulfur dioxide in the air irritates the mucous lining of the eyes and lungs. Like particulates, sulfur diox- ide worsens respiratory illness. Together, particulates and sulfur dioxide have a greater e#ect on respira- tory problems than if only one of these pollutants was present. At highest risk are older adults and people with chronic lung and/or heart disease.
Cities located in the warm, dry climates of the southwestern United States are plagued by smog too, but the smog of these brown-air cities is created pri- marily by the emissions of automobiles. Photochemi- cal smog comprises carbon monoxide (discussed earlier in this chapter), nitrogen dioxide, and ozone. Nitrogen dioxide is formed when nitrogen gas in the air chemically combines with oxygen during the combustion of fuel. "is compound irritates the eyes, lungs, and other mucous membranes. It also reacts with hydrocarbons (the hydrogen and carbon in fuel) in the presence of sunlight to produce a secondary
Figure 16.6 The Effects of Acid Rain. This stone statue is located on the side of a church in England. The pitting of the stone is due to the effects of acid rain. © Peter Clark/Shutterstock.
Figure 16.7 Two Forms of Smog Created in Two Ways. (a) New York City exhibits the gray haze of a gray-air city. Its smog is formed from the by-products of coal and oil combustion mixing with moisture in the air. (b) Los Angeles exhibits the brown haze of a brown-air city. Its smog is formed from the by-products of vehicle emissions that react with sunlight. (a) © Jupiterimages/Photos.com/Thinkstock; (b) © Chad Littlejohn/Shutterstock.
(a) (b)
Environmental Health in the Outdoors 563
is composed of sound waves. If sound waves were visible, they would look much like ripples on water— areas of compressed air molecules followed by areas in which the molecules are more spread out. "ese waves in the air are the result of the vibration of an object disturbing the air around it.
"e human ear detects these sound vibrations in the air as they hit the eardrum, causing it to vibrate. "e vibrating eardrum moves the tiny bones of the middle ear, which in turn cause the 'uid of the inner ear to move across delicate hairs. "e hairs of the inner ear are connected to nerves that send mes- sages to the brain. "ese messages are interpreted%as sound. "e fragile hairs, however, can be perma- nently injured by sound waves that are too loud.
How loud are everyday sounds? Table 16.3 lists some everyday sounds and their loudness. Sound intensity, or loudness, is expressed in decibels (dB). "e faintest sound a human can hear is considered zero (0) dB. As the intensity of sound increases on the decibel scale, each 10-dB increase means a 10-fold increase in the intensity of the sound. "erefore, a 50-dB sound is 10 times louder than a 40-dB sound.
Sounds that are considered quiet or so$ are 50%dB or less. "e National Institute on Deafness and Other Communication Disorders (NIDCD) states that sounds of less than 75 dB are unlikely to cause hearing loss. When sounds get as loud as 80 dB, they
pollutant—ozone. In the upper atmosphere, ozone protects us from the sun’s damaging ultraviolet rays. But when it is in the air we breathe, ozone is irritating to the lungs. "e smog in brown-air cities, such as Los Angeles and Phoenix, is worst during the sum- mer months (Figure 16.7b).
"e Air Quality Index (AQI) is a means by which the public is informed of air quality. Levels of !ve major air pollutants (CO, NO2, O3, SO2, and par- ticulates) are monitored and used to determine AQI values (Figure 16.8). "e descriptor for air quality (good, moderate, unhealthful, and so forth) is deter- mined by the highest concentration of each pollutant in the air. When the air is unhealthful or worse, the AQI cautionary statements should be heeded; many elderly persons and those with chronic lung or heart conditions can die during times of unhealthful and hazardous air quality. Since strict amendments to the Clean Air Act were passed in 1970 and even tougher standards were set with the passage of amendments in 1990, the quality of the air in the United States has improved greatly, but many cities and areas of the country still have high levels of pollution.
Noise Pollution Noise pollution can have a negative e#ect on health, but it is unlike any of the environmental dusts, fumes, vapors, gases, and liquids discussed previously. Noise
Air Quality Index (AQI) Values
Levels of Health Concern
Colors
When the AQI is in this range:
...air quality conditions are:
...as symbolized by this color:
0 to 50 Good Green
51 to 100
101 to 150 Unhealthy for Sensitive Groups Orange
151 to 200
201 to 300
301 to 500
YellowModerate
RedUnhealthy
PurpleVery Unhealthy
MaroonHazardous
Figure 16.8 The Air Quality Index (AQI). Reproduced from United States Environmental Protection Agency. (2016, August 21). Air Quality Index: A guide to air quality and your health. Retrieved from http://www.airnow.gov/index.cfm?action=aqibasics.aqi
Air Quality Index (AQI) A guide to air quality that uses levels of various pollutants to determine its values.
Sounds dB
Rustling leaves 10
Normal conversation 50
Suburban neighborhood noise 52
Vacuum cleaner 70
City noise; busy traffic 80
Inside a passenger jet (takeoff ) 78–83
Heavy trucks at 50 feet 76–88
Home shop tools 65–110
Subway noise 80–114
Nearby jet airplane 150
Shooting a gun 150–170
Loudness of Some Everyday Sounds
Table 16.3
564 Chapter 16 Environmental Health
linked% to impaired learning ability and perfor- mance in school.
Paying attention to the noise in your environ- ment will help save your hearing. For example, many health clubs blast loud music as an aerobics instructor yells commands. O$en, these sounds top 110 dB. Request that the volume be turned down. If you wear ear protection, use only materials and items manufactured to reduce sound; placing cot- ton or tissue in your ears does not do an adequate job of protecting your ears.
If you attend loud concerts, check your hearing when you leave. Set your car or home radio to a level at which you can barely hear the words. "en, as soon a$er the concert as possible, turn on the radio. Can you hear the words? If not, you have sustained short- term hearing loss from the loudness of the music. Frequently listening to such loud music could result in a permanent hearing problem.
begin to be annoying and can be harmful over time. At 85 dB, hearing is at risk of permanent damage. Pain sets in at 120 dB.
"e EPA estimates that 40% of the U.S. population is exposed to enough noise to cause permanent hear- ing loss. "e average person can damage his or her hearing if he or she:
• Uses a power lawn mower (90 dB) for 8 hours • Is at a loud party (90 dB) for 6–8 hours • Uses a chain saw (100 dB) for 2 hours • Uses a gasoline-powered leaf blower (110 dB) for
30 minutes • Is at a dance club or rock concert (115 dB) for
15%minutes
Although you may not be at one party for 8 hours, damage to hearing from loud sounds is cumula- tive. "at is, the e#ects add up. "ese e#ects can be devastating; the National Institutes of Health have determined that permanent hearing loss will result from years of exposure, 8 hours per day, to 85 dB and louder sounds. Permanent deafness may result from such continual exposure and can also result from a single exposure, such as being close to an explosion of 140 dB.
How do people know if they are losing their hearing? First, a person may lose the ability to hear high-frequency sounds. He or she may be unable to hear occasional words in conversation or have di&culty hearing on the telephone. Addi- tionally, people with partial hearing loss o$en experience ringing or roaring in their ears, called tinnitus. Tinnitus makes hearing even more di&cult. Hearing aids may be helpful to the person with par- tial hearing loss but cannot totally compensate for the problem.
Total or partial hearing loss is only one of the e#ects of listening to sounds that are too loud. Parts of the body other than the ear react to noise. Researchers have shown that exposure to 70-dB noise% results in an increase in the heart rate and a rise in blood pressure; muscles tighten, and breathing patterns change. Exposure to noise also increases the rate at which stress-related hormones are secreted into the bloodstream. Even moderate daytime noise levels have been shown to increase anxiety and hostile behavior in some persons. Environmental noise exposure has also been
4To avoid hearing loss and the other effects of noise pollution, avoid situations in which the sound is over 80 dB. Pay attention to noise levels, and complain if they are too high.
Healthy Living Practices
ENVIRONMENTAL HEALTH Environmental health hazards are a risk for all seg- ments of the population. However, young children are most at risk for unintentional poisoning by ingestion of toxic substances because they lack understanding that these materials are harmful and they put most things in their mouths; this is a normal exploratory behavior for small children. Carbon monoxide and lead are particularly injurious to fetuses and young children because their brains and nervous systems are still developing. Also extremely susceptible to carbon monoxide poisoning or air pollutants are older adults and persons with chronic lung or heart disease, whose lung function may be impaired.
Across THE LIFE SPAN
Environmental Health in the Outdoors 565
vwwv Diversity in Health Hunger, the Environment, and the World’s Population Nearly 1 in 6 people in the world suf-
fers from acute or chronic hunger. Hunger is more than appetite, the psychological desire for food, or feeling hungry after not eating for a few hours. Acute hunger, or starvation, is a condition in which a person has not eaten for a prolonged period and will eventually die from lack of food. Chronic hunger refers to a long-term con- dition in which food intake is inadequate. People who experience chronic hunger are undernourished and do not have the nutrients they need for proper growth, development, and body function.
Although many of the factors that lead to hunger are political, social, and economic, environmental condi- tions play a role in the many perceived causes of world hunger. Overpopulation, environmental limits to food production, and land use problems are factors that sci- entists debate with regard to their roles in hunger. In fact, many scientists assert that there is no global hun- ger problem. Instead, they assert, regional hunger prob- lems exist, each with diverse causes.
The world population reached 7.5 billion people in 2017. The 2017 Revision of World Population Prospects issued by the United Nations (UN) projects that the world population will reach 9.8 billion by 2050 and 11.1 billion by 2100. By the turn of the century, projects the UN, only high-fertility countries such as those in Africa will have populations on the increase. The populations of medium-fertility countries, such as India and the United States, will peak in about 2060 and then very slowly start to decline. Populations in low-fertility countries, such as most countries in Europe, will peak in 2030 and decline more quickly than the populations of medium-fertility countries.
Various experts predict that the world population will level off, reaching its carrying capacity between 12.4 billion and 14 billion people. The carrying capacity is the
maximum number of individuals who can be supported by the available resources. However, scientists disagree as to whether the global food output can support that many individuals. Many scientists calculate that even with the use of the best agricultural technologies, the carrying capacity of the Earth will be limited to 7.5 billion people.
Scientists disagree as to whether the increase in food production during the 1980s kept up with the need for food worldwide. They also disagree as to whether tech- nological advances in various areas of agriculture, such as changes in machinery, seed varieties, fertilizers, pesti- cides, and management practices, as well as the genetic engineering of plants to resist certain crop pests, will allow the world’s farmers to produce greater and greater crop yields. Many scientists assert that to increase suf- ficiently the amount of food produced around the world, farmers must increase the amount of land they cultivate. However, using marginal land (land not well suited for cultivation) may increase the danger of erosion, land- slides, and floods. Marginal land is also likely to produce lower crop yields than land already in cultivation. Addi- tionally, the limited availability of water in many regions may constrain agricultural expansion.
Many parts of the Earth cannot support the population that now exists on their lands. A country is overpopulated when its natural resources cannot sustain its people. An example of such overpopulation is Africa, the continent with the fastest population growth in the world. According to the UN’s Revision of World Population Prospects, in 2010, 41% of the African population was younger than age 15 years. Therefore, the size of this population will increase in the next decade and beyond because a large proportion of the population is and will be in its reproductive years. Much of the land in Africa has a low natural carrying capacity. Its climate is highly changeable and therefore unreliable for growing crops.
The problem of world or regional hunger is serious. Environmental issues such as overpopulation, methods of food production, and approaches to land use inter- act with political, cultural, social, and economic issues to create situations that can affect the health of many peoples throughout the world.
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CHAPTER REVIEW
In general, environmental factors that are the sole cause of disease are toxic chemicals. Such substances damage body tissues and a#ect bodily functioning; they are present in the home, workplace, and envi- ronment. Toxic chemicals are found in a wide variety of substances, such as household products, plants, products used in the workplace, and prescription and illegal drugs.
Toxic (poisonous) plants can be the source of poi- soning emergencies, especially in children. Although many plants are not poisonous, house plants and cut 'owers should be kept out of reach of children younger than 5 years old. In addition to plants, approximately 1–2% of mushroom species are poisonous.
Children younger than the age of 5 years are those most in danger of being poisoned from household cleaning aids and from over-the-counter and pre- scription drugs and vitamins. Special packaging that makes it di&cult for young children to open hazard- ous products has lowered the incidence of poison- ing in this age group. Nevertheless, such substances should be locked in cabinets in homes where young children reside or visit o$en.
Lead poisoning is still a health problem in chil- dren in the United States even though many sources of lead poisoning have been eliminated in this coun- try. Lead poisoning is serious because it a#ects the central nervous system and can cause coma, convul- sions, and death. Children can exhibit a wide range of symptoms of lead poisoning, depending on the level of lead in the blood. It is extremely important to remove sources of lead, such as lead-based paint, from a child’s environment.
Carbon monoxide poisoning can occur when lev- els of this gas build up in an enclosed environment. Major sources of carbon monoxide poisoning are !res, automobile exhaust, malfunctioning furnaces, charcoal !res, gasoline-powered tools, wood stoves, !replaces, unvented kerosene and gas space heaters, gas cooking stoves and ovens, and tobacco smoke. To avoid this hazard, properly maintain and use tools and appliances that burn fuel, avoid running the car in the garage, vent home heating stoves and furnaces properly, and use charcoal grills and gas-powered tools only in well-ventilated areas.
Extremely low frequency (ELF) radiation is emitted by computer screens, microwave ovens, cell phones, television sets, electric blankets, electric appliances, high-power electric lines, and electrical distribution substations. ELF radiation has been associated with negative e#ects such as risk of cancer, DNA dam- age, and changes in human brain electrical activity. Nonetheless, scientists have seen no major negative e#ects in most situations and with most products and see no reason to recommend extreme caution. Medi- cal researchers suggest, however, that people avoid being unnecessarily close to products and power lines that emit ELF radiation. Additional caution is needed with cell phones. It is recommended that cell phones be used with a headset or earpieces or that a cell phone be connected to a remote antenna.
Many types of environmental hazards exist in the workplace. Common workplace hazards include exposure to pesticides while manufacturing or apply- ing them and exposure to toxins in the industrial man- ufacture and use of certain solvents, metals, plastics, and adhesives. People who work with toxic chemi- cals should protect themselves from damage to their skin and eyes and should assess the danger from toxic fumes that may be created as a result of their work.
Indoor air may be contaminated with pollutants such as formaldehyde, asbestos, and combustion- generated products. Some buildings have poor venti- lation systems, which appear to be a primary cause of vague health-related symptoms in building occupants.
"e air we breathe and the water we drink are also contaminated with toxins to a greater or lesser degree in various parts of the United States. Contaminated drinking water can result in both short-term and long-term health e#ects. "e air is contaminated with emissions from coal-!red power plants and vehicles. When the air is unhealthful, older adults and those with respiratory illness are most at risk for further damage to their health.
Noise pollution can have a negative e#ect on health. Sounds of less than 75 dB are unlikely to cause hearing loss. To avoid hearing loss and other negative health e#ects of noise pollution, avoid sit- uations in which the sound is over 80 dB or wear specially designed ear protection in such situations.
Summary
Summary 567
CHAPTER REVIEW
1. Your 4-year-old cousin is coming to visit for the summer. What steps would you take to make your house or apartment safe for your cousin? Application
2. List and then analyze your interactions with your environment in the last 24 hours. Develop a list of potential environmental threats to your health from these interactions. Analysis
3. You have just moved to a part of the country that is new to you. Develop a plan to assess whether you are being exposed to hazardous chemicals and toxins and to evaluate which health hazards might be present, if any. Synthesis
4. Develop a !ctitious set of at least three outcomes based on Question 3. What will be your course of action to diminish or eliminate these threats to your health? Evaluation
5. Gather the chemicals that you use in your home, such as cleaning products. Many such products have warnings on their labels about physical haz- ards, storage, and disposal. Read the labels of the products you have gathered and list the types of warnings you see. State what you learned about safeguarding not only your health but also the health of the environment when using these chemicals. Synthesis
Applying What You Have Learned
1. Do you take steps to protect your hearing? If so, what do you do? Do you think about possible hearing loss when you are in noisy environ- ments? Describe three situations in which you regularly are exposed to harmful noise levels and discuss what you can do to avoid hearing loss in these situations.
2. Go through your house or apartment and iden- tify environmental health risks. What can you do to reduce these risks to health?
3. Do you ever put yourself or others at risk for car- bon monoxide poisoning? If so, describe your behaviors that increase risk and what you can do to reduce or eliminate the risk. If not, identify behaviors in others that you have observed that put people at risk for carbon monoxide poison- ing. How might you help others avoid such risks?
4. Find out about environmental risks in your area. For example, is your tap water chlorinated to levels that are worrisome? Do you live in a region of the country in which water comes to your home in lead pipes? What might you do in either of these situations to reduce or eliminate your health risks from water? Investigate air pol- lution in your area. How can you protect your respiratory health in the region in which you live? Describe any environmental health risks that a#ect your community and suggest what you might do to reduce health risks to yourself and your family.
5. Do you ever discard toxic waste improperly, such as putting old batteries (especially car batteries), solvents, or paints in the trash? If so, describe the proper disposal methods for these substances in your city or town.
Reflecting on Your Health
Application using information in a new situation.
Analysis breaking down information into component parts.
Synthesis putting together information from different sources.
Evaluation making informed decisions.Ke
y
568 Chapter 16 Environmental Health
CHAPTER REVIEW
1. Gupta, N., et al. (2011). Lead poisoning associated with Ayurvedic drug presenting as intestinal obstruction: A case report. Clinica Chimica Acta, 412(1–2), 213–214.
2. Fernandez, S., et al. (2015). Outbreak of lead poisoning associated with Ayurvedic medicine. Medicina Clinica, 144(4), 166–169.
3. Centers for Disease Control and Prevention. (2005). Lead poison- ing associated with use of litargirio—Rhode Island, 2003. Morbidity and Mortality Weekly Report, 54(9), 227–229.
4. Buettner, C., et al. (2009). Herbal supplement use and blood lead levels of United States adults. Journal of General Internal Medicine, 24(11), 1175–1182.
5. Gaitens, J. M., et al. (2009). Exposure of U.S. children to residential dust lead, 1999–2004: I. Housing and demographic factors. Envi- ronmental Health Perspectives, 117, 461–467.
6. Centers for Disease Control and Prevention. (2015). Adult blood lead epidemiology and surveillance—United States, 1994–2012. Morbidity and Mortality Weekly Report, 62(54), 52–75.
7. Gummin, D. D., et al. (2017). 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clinical Toxicology, 55(10), 1027–1254. Retrieved from https://aapcc.s3.amazonaws.com/pdfs/annual_reports/12_21 _2017_2016_Annua.pdf
8. Vernberg, K., et al. (1984). "e deterrent e#ect of poison- warning stickers. American Journal of Diseases of Children, 138, 1018–1020.
9. Pooley, A. J., & Fiddick, L. (2010). Social referencing “Mr. Yuk”: "e use of emotion in a poison prevention program. Journal of Pediatric Psychology, 35(4), 327–339.
10. Sharmer, L., et al. (2010, December). A potential new health risk from lead used in consumer products purchased in the United States. Journal of Environmental Health, 73(5), 8–12.
11. Farley, D. (1998). Dangers of lead still linger. FDA Consumer, 32(1), 16–21.
12. U.S. Consumer Product Safety Commission. (2014). Carbon mon- oxide: "e invisible killer. Retrieved from http://www.cpsc.gov //PageFiles/121843/464.pdf
13. Kheifets, L., et al. (2010). A pooled analysis of extremely low- frequency magnetic !elds and childhood brain tumors. American Journal of Epidemiology, 172(7), 752–761.
14. Kheifets, L., et al. (2010). Extremely low frequency electric !elds and cancer: Assessing the evidence. Bioelectromagnetics, 31(2), 89–101.
15. American Cancer Society. (2018). Learn about cancer: Cel- lular phones. Retrieved from http://www.cancer.org/Cancer /CancerCauses/OtherCarcinogens/AtHome/cellular-phones
16. International Agency for Research on Cancer. (2011, May 31). IARC classi#es radiofrequency electromagnetic #elds as possibly carcinogenic to humans [Press Release No. 208]. Geneva, Switzerland: World Health Organization. Retrieved from http:// www.iarc.fr/en/media-centre/pr/2011/pdfs/pr208_E.pdf
17. Weichenthal, S., et al. (2010). A review of pesticide exposure and cancer incidence in the Agricultural Health study cohort. Environ- mental Health Perspectives, 118(8), 1117–1125.
18. Clapp, R. W., et al. (2008). Environmental and occupational causes of cancer: New evidence 2005–2007. Reviews on Environmental Health, 23(1), 1–37.
19. Buckmaster, P. K. (2009). Sustaining acceptable indoor environ- mental quality. Occupational Health and Safety, 78(10), 48, 50.
20. Norbäck, D. (2009). An update on sick building syndrome. Current Opinion in Allergy and Immunology, 9, 55–59.
21. Centers for Disease Control and Prevention. (2011, March). Imported drywall and your home. Retrieved from http://www.cdc .gov/nceh/drywall/imported_drywall_and_your_home.html
References
Design Credits: Yoga: © PeopleImages/Getty Images; Consumer: © Betsie Van der Meer/Getty Images; Leaf Icon: © marko187/Getty Images; Bridge: © Dave and Les Jacobs/Getty Images; Workout: © Caiaimage/Sam Edwards/Getty Images; Diversity: © LeoPatrizi/ Getty Images; Lightbulb: © maglyvi/Getty Images; Garden Path: © Simon Marlow/EyeEm/Getty Images.
References 569
© EyeEm
/Getty Im ages.
!e Mission, Vision, and Goals of Healthy People 2020
Vision—A society in which all people live long, healthy lives.
Mission—Healthy People 2020 strives to:
• Identify nationwide health improvement priorities
• Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress
• Provide measurable objectives and goals that are applicable at the national, state, and local levels
• Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge
• Identify critical research, evaluation, and data collection needs
571
APPENDIX A
Foundation Health Measures Healthy People 2020 includes broad, cross-cutting measures without targets that will be used to assess progress toward achieving the four overarching goals.
Overarching Goals of Healthy People 2020
Foundation Measures Category Measures of Progress
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
General Health Status Life expectancy
Healthy life expectancy
Physical and mental unhealthy days
Self-assessed health status
Limitation of activity
Chronic disease prevalence
International comparisons (where available)
Achieve health equity, eliminate disparities, and improve the health of all groups
Disparities and Inequity Disparities/inequity to be assessed by:
Race/ethnicity
Gender
Socioeconomic status
Disability status
Lesbian, gay, bisexual, and transgender status
Geography
Create social and physical environments that promote good health for all
Social Determinants of Health
Determinants can include:
Social and economic factors
Natural and built environments
Policies and programs
Promote quality of life, healthy development, and healthy behaviors across all life stages
Health-Related Quality of Life and Well-Being
Well-being/satisfaction
Physical, mental, and social health-related quality of life
Participation in common activities
Reproduced from U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC.
572 Appendix A The Mission, Vision, and Goals of Healthy People 2020
Topic Areas "e Topic Areas of Healthy People 2020 identify and group objectives of related content, highlighting speci!c issues and populations. Each Topic Area is
assigned to one or more lead agencies within the fed- eral government that are responsible for developing, tracking, monitoring, and periodically reporting on objectives.
1. Access to Health Services 22. HIV
2. Adolescent Health 23. Immunization and Infectious Diseases
3. Arthritis, Osteoporosis, and Chronic Back Conditions 24. Injury and Violence Prevention
4. Blood Disorders and Blood Safety 25. Lesbian, Gay, Bisexual, and Transgender Health
5. Cancer 26. Maternal, Infant, and Child Health
6. Chronic Kidney Disease 27. Medical Product Safety
7. Dementias, Including Alzheimer’s Disease 28. Mental Health and Mental Disorders
8. Diabetes 29. Nutrition and Weight Status
9. Disability and Health 30. Occupational Safety and Health
10. Early and Middle Childhood 31. Older Adults
11. Educational and Community-Based Programs 32. Oral Health
12. Environmental Health 33. Physical Activity
13. Family Planning 34. Preparedness
14. Food Safety 35. Public Health Infrastructure
15. Genomics 36. Respiratory Diseases
16. Global Health 37. Sexually Transmitted Diseases
17. Healthcare-Associated Infections 38. Sleep Health
18. Health Communication and Health Information Technology 39. Social Determinants of Health
19. Health-Related Quality of Life and Well-Being 40. Substance Abuse
20. Hearing and Other Sensory or Communication Disorders 41. Tobacco Abuse
21. Heart Disease and Stroke 42. Vision
Reproduced from U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC.
Topic Areas 573
Injury Prevention During the next hour, at least 11 people will die in the United States from unintentional injuries. "e causes will be diverse, including automobile crashes, drown- ings, poisonings, and !res. Some of those who die during this hour will probably be children because unintentional, preventable injury is the number one killer of children (through young adulthood, from 1%through 21 years old) in the United States. In fact, unintentional injuries kill more children than all childhood diseases combined.
Until recently, the number of fatal unintentional injuries had been steadily declining, reaching a 68-year low of approximately 89,000 in 1994. How- ever, that number has been rising annually since then. In 2011, approximately 126,500 people died
from unintentional injuries. "is appendix alerts you to the most prevalent types of unintentional injuries and deaths in the United States today and discusses their causes, prevention, and emergency treatment.
Automobile Safety Motor vehicle crashes are the greatest cause of pre- ventable death resulting from injuries, but the num- ber of deaths has been dropping. In 2011, 33,783 people died on U.S. roads and highways, resulting in the lowest highway fatality rate ever recorded. Approximately 30% of the fatalities involved alcohol. In addition to deaths, motor vehicle accidents are the leading cause of unintentional injury in the United States. To keep yourself and others safe while riding in automobiles, heed the following recommenda- tions. For general vehicle safety:
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Injury Prevention and Emergency Care
575
APPENDIX B
• Never drink and drive or take other drugs that impair your ability to drive.
• Always wear your seat belt; this practice reduces by half your chance of injury or death in a motor vehicle crash.
• Slow down and prepare to stop as you approach yellow lights. Many people cause automobile crashes because they try to “beat” the light.
• Yield the right of way at intersections. • Don’t tailgate; allow at least one car length for
each 10 mph (e.g., stay four car lengths behind the car ahead if you are traveling at 40 mph).
• Know the tra&c laws of the state in which you are driving and obey these laws.
• Read and heed tra&c signs, especially railroad warning signals and gates. Always proceed cautiously across railroad tracks. Not all railroad crossings have gates or sound warnings to signal oncoming trains.
• Obey the speed limit.
Children and Automobile Safety To protect chil- dren while they are passengers in automobiles, follow these safety recommendations:
• Place infants and toddlers in properly secured rear-facing safety seats until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
• Always put rear-facing child safety seats in the back seat. Deploying passenger-side air bags in the front seat can injure or kill infants and toddlers in rear-facing seats.
• Children older than age 2, or those children who have outgrown the rear-facing seat before age 2, should be restrained in a forward-facing car seat with a harness in the back seat until they reach the highest weight and height allowed by the manufacturer.
• When children outgrow the forward-facing car seat, and until the vehicle seat belt !ts properly, they should be restrained in a belt-positioning booster seat in the back seat. "e vehicle seat belt typically !ts properly when the child reaches a height of 4 feet 9 inches and he or she is between 8 and 12 years old.
• When adolescents reach age 13, they can ride in%the front seat. Push the seat back as far as
possible to create distance between the child and the air bag.
• An infant’s or child’s car seat needs to be secured so tightly that it will not move more than 1%inch from side to side. Locate a certi!ed child passenger safety seat technician in your area to check the installation of your child’s safety seat.
• Never leave a child alone in the car.
Pedestrian Safety Pedestrians accounted for 12% of preventable deaths involving motor vehicles in the United States and approximately 3% of motor vehicle–related injuries in 2009. Not only are drunk drivers o$en a cause of these injuries and deaths, but intoxicated pedestrians also put themselves at increased risk. Other high-risk groups for sustaining unintentional pedestrian– automobile injuries and deaths are older adults and young children. Children are most frequently hit when they dart into tra&c from between parked cars. Children younger than 10 years old do not have fully developed cogni- tive, developmental, behavioral, physical, and sensory abilities to be safe pedestrians on their own. To help prevent pedestrian injuries, practice these safety steps:
• Help children develop injury-prevention skills by modeling proper safety behaviors such as those listed here.
• Be sure that children younger than 10 years of age are accompanied by an older person when they cross the street.
• Cross at marked crosswalks and at corners whenever possible. Do not assume that drivers will stop because you are in a crosswalk.
• Stop, look both ways, and listen before deciding that it is safe to cross. Continue to look and listen as you cross.
• Cross only on a green light or a “walk” signal. • Never cross between parked cars. • Never run into the street. • Walk on sidewalks whenever possible. If you must
walk in the street, walk to the le$ facing tra&c. • When walking at dusk or at night, wear light
colors and some type of re'ective device. Walk with someone, not alone.
• Do not allow children to play in driveways, in adjacent unfenced yards, in streets, or in parking lots.
576 Appendix B Injury Prevention and Emergency Care
Water Safety Between 2005 and 2009, an average of 3,533 people died from drowning, not including those involved in boat-related incidents. Drowning is the second leading cause of injury-related death for children aged 1–14 years, with the highest rates being for children aged 1–4 years. (Fatalities involving auto- mobiles are the leading cause of injury-related death for children.) Children younger than 1 year of age most o$en drown in bathtubs, buckets, or toilets. Children older than 1 year of age most o$en drown in pools, hot tubs, or spas owned by their parents, rel- atives, or friends, and they happen within 5 minutes of the child’s being missing from sight. Children usu- ally drown silently, so don’t think that splashing or screaming will alert you to the danger.
Safety for Small Children To protect small chil- dren from drowning in residential pools or other accessible bodies of water, follow these safety practices:
• Provide barriers to water, such as fences and walls. If the house is part of the barrier, install door alarms so that you know when the child has gone outside, and install a power safety cover over the pool, hot tub, or spa.
• Fence gates should be self-closing and self- latching. "e latch should be out of a child’s reach.
• Never prop open the fence gate. • Instruct babysitters about pool hazards for young
children. • If a young child is missing, check the pool !rst. • Do not assume that children will not drown
because they know how to swim. • Never leave a child unsupervised near a pool,
and while at the pool, watch small children continuously; do not become preoccupied with something else.
• Never leave children alone, even for a minute, when they are in or near any type of water.
Safety for Swimmers Even good swimmers have accidents in the water and drown. For safety in the water, follow these guidelines:
• Never swim alone. • Don’t push or jump on others. • Check water depth before you dive or jump into
the water.
• Never swim in unsupervised areas such as quarries, canals, or ponds.
• Don’t swim or use a hot tub or spa while drinking alcoholic beverages or taking other drugs that could impair your judgment or your ability to swim, or make you drowsy. (Alcohol is involved in 25–50% of adolescent and adult deaths associated with water recreation.)
Bicycle Safety In 2009 in the United States, 630 people died in tra&c-related bicycle crashes. Seventy-!ve percent of such deaths are caused by head injuries. Supporters of wearing bicycle helmets contend that 40–75% of head-injury deaths could be prevented if riders wore helmets. Opponents suggest that these statistics are unreliable and that most bicycle fatalities involve a crash with an automobile, a situation in which a helmet cannot protect the bicyclist. "ose who take a middle stance suggest that it is prudent to wear helmets because they protect the head in many types of falls and make bicyclists more visible to automo- bile drivers.
As of August 2014, 22 states, the District of Colum- bia, and approximately 201 local governments had enacted legislation regarding bicycle helmets. Most of these laws pertain to children and adolescents. In 1999, the U.S. Consumer Product Safety Commis- sion issued a new safety standard for bike helmets.
Bicycle helmets are designed to absorb much of the impact when the head hits another object, like a car or the road. O$en, a cyclist hits a car and then the road, so the helmet needs a strap to ensure that it stays on during multiple hits. Also, it should not be covered with any material that can catch on some- thing during a fall and twist the cyclist’s head. When purchasing a helmet, make sure that it is level on the head, covers the top of the forehead, touches all around, and is comfortably snug. Many sellers and manufacturers of helmets o#er instructions regard- ing proper !t.
Bicycle injuries are a leading cause of preventable death in children, exceeding the death rate from poi- sonings, falls, and !rearm injuries combined. Most bicycle-related deaths occur from head trauma and are not caused by colliding with cars. Rather, chil- dren fall from their bikes or lose control of their bikes and collide with objects such as curbs and trees. "erefore, all children bene!t from wearing helmets while bicycling. "ey should also wear helmets while being carried as passengers on adults’ bikes. Have
Injury Prevention 577
a pediatrician check a toddler’s helmet, however, because the neck muscles of toddlers are weak and may be unable to properly support a helmeted head.
Bicycle Safety Rules For bicycling safety, follow these simple rules:
• Make yourself or your children visible with light- colored clothing and re'ective tape.
• Be certain that your bicycle horn or bell is working properly.
• Drive on the right-hand side of the road in single !le, obeying all tra&c signs and signals. Small children should ride their bikes on the sidewalk.
• When cycling in the road, leave a distance of about 3 feet between you and parked cars. You will be more noticeable to drivers and will not be knocked o# your bike by the opening doors of parked cars.
• Walk your bike at busy street corners in pedestrian crosswalks.
• Never carry a passenger on your bicycle unless you have a tandem bike or are carrying a child in a properly mounted child seat.
• When exiting a driveway into a lane of tra&c, stop, look both ways, and listen to determine that it is safe to enter.
• Before turning, use hand signals and look in all directions.
• Don’t ride your bike on rainy nights. Your chances of being involved in a crash are 30 times greater than on a dry night because roads are slippery, wet bicycle brakes do not work well, and automobile drivers cannot see bicyclists well in the rain.
• If you are falling o# your bike, tuck and roll rather than extend an arm to break your fall.
• Children should not ride in the street until they are 10 years old, demonstrate good riding skills, and are able to observe the basic rules of the road.
Fire Prevention Although the number of residential !res has declined since 1980, there were 365,000 residen- tial !res in 2012 in which 2,380 people died, not including !re!ghters. Most home !res are started by cooking. Lit cigarettes, cigarette lighters, or matches cause the lowest number of residential !res but result in the most !re-related deaths. Fewer !res are ignited by faulty electrical wiring or
supplemental home heating devices such as wood stoves, kerosene heaters, gas-!red space heaters, and portable electric heaters than by cooking but more than by cigarette-related causes.
"e number of supplemental home heaters has decreased in recent years, as has the number of !res associated with them. However, supplemental heaters still cause about 13% of residential !res. Additionally, thousands of people are burned each year by coming into contact with the hot surfaces of these devices, and hundreds are poisoned by their carbon monox- ide emissions.
Home Heaters Some safety recommendations for the use of supplemental home heaters include the following:
• Be certain that any supplemental heater is properly installed and meets building codes.
• Inspect wood stoves according to the manufacturer’s directions (usually twice monthly) and have chimneys inspected and cleaned by a professional chimney sweep.
• Use a 'oor protector designed for use under the type of supplemental heater you have. It should extend 18 inches beyond the heater on all sides.
• Follow directions regarding how far the heater must be from combustible walls and other materials such as draperies.
• Never burn trash in a wood-burning stove because this practice could cause overheating.
• Never use gasoline to start a wood !re. • Use only the fuel(s) the manufacturer has
designated as safe in the heater. • If using a liquid fuel, be certain that its container
is well marked and is out of the reach of children. • Place kerosene heaters out of the path of tra&c
and where they cannot be knocked over. • Always !ll a kerosene heater outdoors and when
the heater is not operating. • Kerosene heaters are not usually vented;
therefore, keep a window ajar for ventilation. • Use unvented gas heaters only in large, open areas
that are well ventilated; do not operate vented styles unvented.
• Do not use supplemental heating devices while you are sleeping or not at home; many !res and deaths occur at these times from the unsupervised use of supplemental heaters.
578 Appendix B Injury Prevention and Emergency Care
• With electric heaters, follow the manufacturer’s recommendations regarding the type of power cord to use. Avoid using extension cords, but if you do, be certain that they are marked with a power rating at least as high as that of the heater itself. Keep the cord stretched out, and do not place anything on top of the cord.
General Fire Prevention Many residential !res could have been prevented with little trouble. To% decrease your risk of fire, take the following precautions:
• Keep matches and cigarette lighters away from children.
• Do not store food items that are attractive to children, such as candy, above the stove.
• Always check ashtrays to be certain that cigarettes are out. A$er a party or other gathering, check under and between the cushions of upholstered furniture to%make sure%no smoldering ashes are present.
• Never place ashtrays on the arms of furniture, especially upholstered furniture that is likely to ignite from lit cigarettes or their ashes.
• Avoid placing lit candles near draperies or other 'ammable materials. Be certain that they do not tip easily and are not positioned where they can be easily knocked over.
• Consider purchasing clothes made out of fabrics that are di&cult to ignite and tend to self- extinguish, such as 100% polyester, nylon, wool, and silk. Cotton, cotton/polyester blends, rayon, and acrylic ignite easily and burn rapidly.
• Store 'ammable liquids, such as gasoline and paint thinners, outside the house. "ey produce invisible explosive vapors.
• Install at least one smoke detector on each 'oor of your home and near the bedrooms. Replace the%batteries annually or when they make a chirping sound.
• Plan an escape route from each room in the house. Have each family member rehearse the plan o$en. Designate a safe place to meet if you have to escape a !re in your home. "is helps !re!ghters determine whether there are people in%a burning building.
Source of statistics for injury prevention: American Acad- emy of Pediatrics; Bicycle Safety Helmet Institute; Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; Department of Transpor- tation, National Highway Tra&c Safety Administration; and the U.S. Fire Administration.
Emergency Care When to Call for Help Know the emergency number in your area; in most areas, that number is 9-1-1. Calling for help in a med- ical emergency is important and may save a person’s life. When a serious situation occurs, call for emer- gency medical help !rst. Do not call your doctor, the hospital, a friend, relatives, or neighbors. Calling anyone else !rst only wastes time.
Call for emergency help in the following situations:
• Fainting • Chest or abdominal pain or pressure • Sudden dizziness, weakness, or change in vision • Di&culty breathing or shortness of breath • Severe or persistent vomiting • Sudden, severe pain anywhere in the body • Suicidal or homicidal feelings • Bleeding that does not stop a$er 10–15 minutes
of pressure • A gaping wound with edges that do not come
together • Problems with movement or sensation following
an injury • Cuts on the hand or face • Puncture wounds • "e possibility that foreign bodies such as glass or
metal may have entered a wound • Most animal bites and all human bites • Hallucinations and clouding of thoughts • A sti# neck in association with a fever or a
headache • A bulging or abnormally depressed fontanel (so$
spot) in infants • Stupor or dazed behavior accompanying a high
fever that is not alleviated by acetaminophen or aspirin
Emergency Care 579
• Unequal pupil size, loss of consciousness, blindness, staggering, or repeated vomiting a$er a head injury
• Spinal injuries • Severe burns • Poisoning • Drug overdose • When in doubt, CALL
Good Samaritan Laws States have enacted laws to protect physicians and other medical personnel from legal actions that may arise from emergency treatment they give while not on duty. Although Good Samaritan laws cover medi- cal personnel primarily, several states have expanded them to include laypersons who, in good faith, help others in emergency situations. Unless a person acts in a reckless or wantonly negligent manner when try- ing to voluntarily assist another, he or she is usually immune from conviction in a legal action. "ese laws vary from state to state; !nd out about your state’s Good Samaritan laws by contacting a legal profes- sional or checking with your local library.
Heart Attack For information on recognizing the signs of a possi- ble heart attack and on how to respond, see the chap- ter on cardiovascular health (Chapter 12).
Poisoning For information on preventing poisonings and how to treat a person who has been poisoned, see the chapter on environmental health (Chapter 16), espe- cially the section titled “Environmental Health in and Around the Home.”
Bleeding If a person is bleeding heavily from a wound, it is important to stop the bleeding as quickly as possible. First, take the following action, and then call for help or take the person to an emergency room.
• Protect yourself from disease by wearing medical exam gloves.
• Expose the wound by removing or cutting the clothing to see where the blood is coming from.
• Place a sterile gauze pad or a clean cloth (such as a washcloth or towel) over the entire wound
and apply direct pressure with your !ngers or the palm of your hand.
• If the bleeding is from an arm or leg, while still applying pressure, elevate the injured area above heart level to reduce blood 'ow.
• When the bleeding stops, wrap a roller gauze bandage tightly over the dressing to hold it in place and prevent further bleeding.
Breathing Emergencies Signs of inadequate breathing include a rate of breathing signi!cantly less than 12 times per minute (for adults), skin that is pale or bluish and cool, and nasal 'aring, especially in children. Ask someone to call for emergency care, and then if the person is not breathing:
• Tilt the head back and li$ the chin to open the airway.
• Pinch the victim’s nose shut, take a deep breath, and make a tight seal around the victim’s mouth with your mouth.
• Slowly blow air into the victim’s mouth until you see the chest rise.
• Remove your mouth to allow the air to come out, and turn your head away as you take another breath.
• Repeat one more breath. • Check the victim for signs of circulation
(breathing, coughing, or movement). If the victim is not breathing and has signs of circulation:
• Give one breath about every 4–5 seconds for an adult.
• Recheck for signs of circulation about every minute.
• Continue this process as long as the person has signs of circulation, until help arrives.
If the !rst breath does not go in, retilt the victim’s head and try a second breath. If the second breath does not go in, use the procedure to aid a choking victim.
Choking You can tell if a person is choking if he or she is unable to speak, breathe, or cough or breathes with a high- pitched wheezing. A choking victim may instinc- tively reach up and clutch his or her neck. To help,
580 Appendix B Injury Prevention and Emergency Care
!rst tell someone to call for emergency care. "en, do the following:
• Stand behind the choking person. • Wrap your arms around the victim’s waist. (Do
not allow your forearms to touch the ribs.) • Make a !st with one hand and place the thumb
side just above the victim’s navel. • Grasp your !st with your other hand. • Press your !st into the victim’s abdomen with
quick inward and upward thrusts. • Continue thrusts until the object is removed or
the victim becomes unresponsive.
Each thrust should be a separate and distinct e#ort to dislodge the object.
Burns If a person is burned by !re and his or her clothing is on !re, have the victim roll on the ground using the “stop, drop, and roll” method. You can also smother the 'ames with a blanket or douse the victim with water. Ask someone to call for emergency help. "en, do the following:
• Remove jewelry and hot or burned clothing immediately, but do not remove clothing stuck to the skin.
• Cool the burn. Use large amounts of cool water, not ice. Immerse the burn in cool water if possible.
• Apply a thin layer of antibiotic ointment and cover the burn with dry, sterile dressings or clean cloths.
• Wait for help or transport the person to the emergency room of the local hospital.
Heat-Related Emergencies Everyone is susceptible to heat illness if environmen- tal conditions overwhelm the body’s temperature- regulating mechanisms. Such illnesses are progressive conditions and could become life threatening. "ere- fore, it is important to recognize heat-related illness early and treat it immediately.
Heat cramps are painful muscular spasms that happen suddenly, usually in the legs and abdomen. If someone has heat cramps, have him or her do the following:
• Rest in a cool place. • Drink lightly salted cool water (. teaspoon salt
per quart of water) or a commercial sports drink diluted to half strength.
• Lightly stretch and gently massage the cramped muscle.
Heat exhaustion is another heat-related emer- gency. It is characterized by heavy perspiration with normal or slightly above normal body temperatures and is caused by water or salt depletion or both. To help a person with heat exhaustion, have him or her do the following:
• Rest in a cool place. • Drink lightly salted cool water (. teaspoon salt
per quart of water) or a commercial sports drink diluted to half strength.
• Remove excess clothing. • Lie down and raise the legs 8–12 inches, while
keeping them straight.
Sponge the victim with cool water and fan him or her. If no improvement occurs within 30 minutes, seek medical attention.
In its advanced stages, heat exhaustion is called heat- stroke and can cause death. It must be treated rapidly. Heatstroke is characterized by red, hot, dry skin and an altered mental state ranging from slight confusion and disorientation to coma. To treat heatstroke, send some- one for emergency care and do the following:
• Have the person rest in a cool place. • Remove clothing down to the victim’s underwear. • Keep the victim’s head and shoulders slightly
elevated. • Cool the person by placing ice bags wrapped in
wet towels on the wrists, ankles, groin, and neck, and in the armpits.
• Fan the person.
Emergency Care 581
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Food Intake Patterns Based on MyPlate Recommendations
The following table indicates suggested amounts of food to consume from the basic food groups in order to meet recommended nutri- ent intakes at 12 different calorie levels. Nutrient and energy contributions from each group are calculated
according to the nutrient-dense forms of foods in each group (e.g., lean meats and fat-free milk). This appen- dix also includes a sample 7-day menu guide for a 2,000 calorie/day food pattern.
583
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s gr
ou p
. 6 D
ai ry
G ro
u p
in cl
u d
es a
ll flu
id m
ilk p
ro d
u ct
s an
d fo
od s
m ad
e fr
om m
ilk t
h at
r et
ai n
t h
ei r
ca lc
iu m
c on
te n
t, s
u ch
a s
yo gu
rt a
n d
c h
ee se
. F oo
d s
m ad
e fr
om m
ilk t
h at
h av
e lit
tl e
to n
o ca
lc iu
m , s
u ch
a s
cr ea
m c
h ee
se , c
re am
, a n
d b
u tt
er , a
re n
ot p
ar t
of t
h e
gr ou
p . M
os t
d ai
ry g
ro u
p c
h oi
ce s
sh ou
ld b
e fa
t- fr
ee o
r lo
w -f
at . I
n g
en er
al , 1
c u
p o
f m ilk
o r
yo gu
rt , 1
" o
u n
ce s
of n
at u
ra l c
h ee
se , o
r 2
ou n
ce s
of
p ro
ce ss
ed c
h ee
se c
an b
e co
n si
d er
ed a
s 1
cu p
fr om
t h
e d
ai ry
g ro
u p
.
A lt
h ou
gh M
yP la
te d
oe s
n ot
in cl
u d
e an
“ oi
ls ”
gr ou
p , s
om e
fa t
is e
ss en
ti al
fo r
go od
h ea
lt h
. O ils
in cl
u d
e fa
ts fr
om m
an y
d iff
er en
t p
la n
ts a
n d
fr om
fi sh
t h
at a
re li
qu id
a t
ro om
t em
p er
at u
re , s
u ch
a s
ca n
ol a,
co
rn , o
liv e,
s oy
be an
, a n
d s
u n
flo w
er o
il. S
om e
fo od
s ar
e n
at u
ra lly
h ig
h in
o ils
, l ik
e n
u ts
, o liv
es , s
om e
fis h
, a n
d a
vo ca
d os
. F oo
d s
th at
a re
m ai
n ly
o il
in cl
u d
e m
ay on
n ai
se , c
er ta
in s
al ad
d re
ss in
gs , a
n d
s of
t m
ar ga
ri n
e.
C ou
rt es
y of
t h
e U
n it
ed S
ta te
s D
ep ar
tm en
t of
A gr
ic u
lt u
re , W
as h
in gt
on , D
C .
584 Appendix C Food Intake Patterns Based on MyPlate Recommendations
Estimated Daily Calorie Needs To determine which food intake pattern to use for an individual, the following chart gives an estimate of individual calorie needs. "e calorie range for each age/sex group is based on physical activity level, from sedentary to active.
Calorie Range
Children Sedentary* Æ Active†
2–3 years 1,000 Æ 1,400
Females
4–8 years 1,200 Æ 1,800
9–13 1,600 Æ 2,200
14–18 1,800 Æ 2,400
19–30 2,000 Æ 2,400
31–50 1,800 Æ 2,200
51+ 1,600 Æ 2,200
Males
4–8 years 1,400 Æ 2,000
9–13 1,800 Æ 2,600
14–18 2,200 Æ 3,200
19–30 2,400 Æ 3,000
31–50 2,200 Æ 3,000
51+ 2,000 Æ 2,800
*Sedentary refers to a lifestyle that includes only the light physical activity associated with typical day-to-day life. †Active refers to a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3–4 miles per hour, in addition to the light physical activity associated with typical day- to-day life.
Estimated Daily Calorie Needs 585
Sa m
pl e
M en
us fo
r a 2
,0 00
-C al
or ie
F oo
d Pa
tte rn
D A
Y 1
D A
Y 2
D A
Y 3
B R
E A
K FA
ST C
re am
y oa
tm ea
l ( co
ok ed
in m
ilk ):
! c
up u
nc oo
ke d
oa tm
ea l
1 cu
p fa
t- fr
ee m
ilk 2
ta bl
es po
on s
ra is
in s
2 te
as po
on s
br ow
n su
ga r
B ev
er ag
e: 1
c u
p o
ra n
ge ju
ic e
LU N
C H
Ta co
s al
ad :
2 ou
nc es
t or
ti lla
c hi
ps 2
ou nc
es c
oo ke
d gr
ou nd
t ur
ke y
2 te
as po
on s
co rn
/c an
ol a
oi l (
to c
oo k
tu rk
ey )
" c
up k
id ne
y be
an s*
! o
un ce
lo w
-fa t
ch ed
da r
ch ee
se !
c up
c ho
pp ed
le tt
uc e
! c
up a
vo ca
do 1
te as
po on
li m
e ju
ic e
(o n
av oc
ad o)
2 ta
bl es
po on
s sa
ls a
B ev
er ag
e: 1
c u
p w
at er
, c of
fe e,
o r
te a*
*
D IN
N E
R S
p in
ac h
la sa
gn a
ro ll-
u p
s: 1
cu p
la sa
gn a
no od
le s
(2 o
un ce
s dr
y) !
c up
c oo
ke d
sp in
ac h
! c
up r
ic ot
ta c
he es
e 1
ou nc
e pa
rt -s
ki m
m oz
za re
lla c
he es
e !
c up
t om
at o
sa uc
e*
1 ou
n ce
w h
ol e
w h
ea t
ro ll
1 te
as po
on t
ub m
ar ga
ri ne
B ev
er ag
e: 1
c u
p fa
t- fr
ee m
ilk
SN A
C K
S 2
ta bl
es p
oo n
s ra
is in
s 1
ou n
ce u
n sa
lt ed
a lm
on d
s
B R
E A
K FA
ST B
re ak
fa st
b u
rr it
o: 1
flo ur
t or
ti lla
( 8”
d ia
m et
er )
1 sc
ra m
bl ed
e gg
1 ⁄ # c
up b
la ck
b ea
ns *
2 ta
bl es
po on
s sa
ls a
" la
rg e
gr ap
ef ru
it B
ev er
ag e:
1 c
u p
w at
er , c
of fe
e, o
r te
a* *
LU N
C H
R oa
st b
ee f s
an d
w ic
h :
1 sm
al l w
ho le
g ra
in h
oa gi
e bu
n 2
ou nc
es le
an r
oa st
b ee
f 1
sl ic
e pa
rt -s
ki m
m oz
za re
lla c
he es
e 2
sl ic
es t
om at
o "
c up
m us
hr oo
m s
1 te
as po
on c
or n/
ca no
la o
il (t
o co
ok
m us
hr oo
m s)
1 te
as po
on m
us ta
rd B
ak ed
p ot
at o
w ed
ge s:
1 cu
p po
ta to
w ed
ge s
1 te
as po
on c
or n/
ca no
la o
il (t
o co
ok p
ot at
o) 1
ta bl
es po
on k
et ch
up B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
D IN
N E
R B
ak ed
s al
m on
o n
b ee
t gr
ee n
s: 4-
ou nc
e sa
lm on
fi le
t 1
te as
po on
o liv
e oi
l 2
te as
po on
s le
m on
ju ic
e 1 ⁄ #
c up
c oo
ke d
be et
g re
en s
(s au
té ed
in 2
t ea
sp oo
ns c
or n/
ca no
la o
il) Q
u in
oa w
it h
a lm
on d
s: !
c up
q ui
no a
! o
un ce
s liv
er ed
a lm
on ds
B ev
er ag
e: 1
c u
p fa
t- fr
ee m
ilk
SN A
C K
S 1
cu p
c an
ta lo
u p
e ba
lls
B R
E A
K FA
ST C
ol d
c er
ea l:
1 cu
p re
ad y-
to -e
at o
at c
er ea
l 1
m ed
iu m
b an
an a
! c
up fa
t- fr
ee m
ilk 1
sl ic
e w
h ol
e w
h ea
t to
as t
1 te
as po
on t
ub m
ar ga
ri ne
B ev
er ag
e: 1
c u
p p
ru n
e ju
ic e
LU N
C H
Tu n
a sa
la d
s an
d w
ic h
: 2
sl ic
es r
ye b
re ad
2 ou
nc es
t un
a 1
ta bl
es po
on m
ay on
na is
e 1
ta bl
es po
on c
ho pp
ed c
el er
y !
c up
s hr
ed de
d le
tt uc
e 1
m ed
iu m
p ea
ch B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
D IN
N E
R R
oa st
ed c
h ic
ke n
: 3
ou nc
es c
oo ke
d ch
ic ke
n br
ea st
1 la
rg e
sw ee
t p
ot at
o, r
oa st
ed "
c up
s uc
co ta
sh (
lim a
be an
s &
c or
n) 1
te as
po on
t ub
m ar
ga ri
ne 1
ou n
ce w
h ol
e w
h ea
t ro
ll 1
te as
po on
t ub
m ar
ga ri
ne B
ev er
ag e:
1 cu
p w
at er
, c of
fe e,
o r
te a*
*
SN A
C K
S "
c u
p d
ri ed
a p
ri co
ts 1
cu p
fl av
or ed
y og
u rt
( ch
oc ol
at e)
U se
th is
7- da
y m en
u as
a m
ot iv
at io
na l t
oo l t
o he
lp p
ut a
he al
th y
ea tin
g pa
tte rn
in to
p ra
ct ic
e an
d to
id en
tif y
cr ea
tiv e
ne w
id ea
s fo
r he
al th
y m
ea ls.
A ve
ra ge
d ov
er a
w ee
k, th
is m
en u
pr ov
id es
th
e re
co m
m en
de d
am ou
nt s
of k
ey n
ut ri
en ts
a nd
fo od
s fr
om
ea ch
fo od
g ro
up . "
e m
en us
fe at
ur e
a la
rg e
nu m
be r
of d
i# er
- en
t f oo
ds to
in sp
ire id
ea s
fo r
ad di
ng v
ar ie
ty to
fo od
c ho
ic es
. "
ey a
re n
ot in
te nd
ed to
b e
fo llo
w ed
d ay
-b y-
da y
as a
s pe
ci !c
pr
es cr
ip tio
n fo
r w ha
t t o
ea t.
Sp ic
es a
nd h
er bs
c an
b e
us ed
to ta
st e.
T ry
s pi
ce s
su ch
a s
ch ili
po
w de
r, ci
nn am
on ,
cu m
in ,
cu rr
y po
w de
r, gi
ng er
, nu
tm eg
, m
us ta
rd , g
ar lic
p ow
de r,
on io
n po
w de
r, or
p ep
pe r.
Tr y
fr es
h or
dr
ie d
he rb
s su
ch a
s ba
si l,
pa rs
le y,
ci la
nt ro
, c hi
ve s,
di ll,
m in
t, or
eg an
o, ro
se m
ar y,
th ym
e, o
r t ar
ra go
n. A
lso tr
y sa
lt- fr
ee sp
ic e
or h
er b
bl en
ds .
W hi
le t
hi s
7- da
y m
en u
pr ov
id es
t he
r ec
om m
en de
d am
ou nt
s of
fo od
s a nd
k ey
n ut
ri en
ts , i
t d oe
s s o
at a
m od
er at
e co
st . B
as ed
on
n at
io na
l a ve
ra ge
fo od
c os
ts , a
dj us
te d
fo r i
n' at
io n
to M
ar ch
20
11 p
ri ce
s, th
e co
st o
f th
is m
en u
is le
ss t
ha n
th e
av er
ag e
am ou
nt sp
en t o
n fo
od p
er p
er so
n in
a fo
ur -p
er so
n fa
m ily
.
586 Appendix C Food Intake Patterns Based on MyPlate Recommendations
Sa m
pl e
M en
us fo
r a 2
,0 00
-C al
or ie
F oo
d Pa
tte rn
(C on
t’d )
*F oo
ds th
at a
re r
ed uc
ed s
od iu
m , l
ow
so di
um ,
or n
o- sa
lt ad
de d
pr od
uc ts
. "
es e f
oo ds
ca n
al so
b e p
re pa
re d
fr om
sc
ra tc
h w
ith n
o ad
de d
sa lt.
A ll
ot he
r fo
od s
ar e
re gu
la r
co m
m er
ci al
p ro
d- uc
ts , w
hi ch
c on
ta in
v ar
ia bl
e le
ve ls
of
so di
um . "
e av
er ag
e so
di um
le ve
l o f
th e 7
-d ay
m en
u as
su m
es th
at n
o sa
lt is
ad de
d in
co ok
in g
or at
th e t
ab le
.
** U
nl es
s in
di ca
te d,
a ll
be ve
ra ge
s ar
e un
sw ee
te ne
d an
d w
ith ou
t ad
de d
cr ea
m o
r w hi
te ne
r.
Ita lic
iz ed
fo od
s a re
p ar
t o f t
he d
ish o
r fo
od th
at p
re ce
de s t
he m
.
D A
Y 4
D A
Y 5
D A
Y 6
D A
Y 7
B R
E A
K FA
ST 1
w h
ol e
w h
ea t
E n
gl is
h m
u ffi
n 1
ta bl
es po
on a
ll- fr
ui t
pr es
er ve
s 1
h ar
d -c
oo ke
d e
gg B
ev er
ag e:
1 cu
p w
at er
, c of
fe e,
o r
te a*
*
LU N
C H
W hi
te b
ea n
-v eg
et ab
le s
ou p:
1 "
c up
c hu
nk y
ve ge
ta bl
e so
up w
it h
pa st
a !
c up
w hi
te b
ea ns
*
6 s
al ti
n e
cr ac
ke rs
*
" c
u p
c el
er y
st ic
ks B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
D IN
N E
R R
ig at
on i w
it h
m ea
t sa
u ce
: 1
cu p
ri ga
to ni
p as
ta
(2 o
z dr
y) 2
ou nc
es c
oo ke
d gr
ou nd
b ee
f (9
5% le
an )
2 te
as po
on c
or n/
ca no
la o
il (t
o co
ok b
ee f)
! c
up t
om at
o sa
uc e*
3 ta
bl es
po on
s gr
at ed
pa
rm es
an c
he es
e S
p in
ac h
s al
ad :
1 cu
p ra
w s
pi na
ch le
av es
! c
up t
an ge
ri ne
s ec
ti on
s !
o un
ce c
ho pp
ed w
al nu
ts 4
te as
po on
o il
an d
vi ne
ga r
dr es
si ng
B ev
er ag
e: 1
cu p
w at
er , c
of fe
e, o
r te
a* **
SN A
C K
S 1
cu p
n on
fa t
fr u
it y
og u
rt
B R
E A
K FA
ST C
ol d
c er
ea l:
1 cu
p sh
re dd
ed w
he at
! c
up s
lic ed
b an
an a
! c
up fa
t- fr
ee m
ilk 1
sl ic
e w
ho le
w he
at t
oa st
2 te
as po
on s
al l-f
ru it
p re
se rv
es B
ev er
ag e:
1 cu
p fa
t- fr
ee c
h oc
ol at
e m
ilk
LU N
C H
Tu rk
ey s
an d
w ic
h :
1 w
ho le
w he
at p
it a
br ea
d
(2 o
un ce
s) 3
ou nc
es r
oa st
ed t
ur ke
y, s
lic ed
2 sl
ic es
t om
at o
" c
up s
hr ed
de d
le tt
uc e
1 te
as po
on m
us ta
rd 1
ta bl
es po
on m
ay on
na is
e "
c u
p g
ra p
es B
ev er
ag e:
1 c
u p
t om
at o
ju ic
e*
D IN
N E
R S
te ak
a n
d p
ot at
oe s:
4 ou
nc es
b ro
ile d
be ef
s te
ak $⁄ %
c up
m as
he d
po ta
to es
m ad
e w
it h
m ilk
a nd
2 t
ea sp
oo ns
t ub
m
ar ga
ri ne
" c
u p
c oo
ke d
g re
en b
ea n
s 1
te as
po on
t ub
m ar
ga ri
ne 1
te as
po on
h on
ey 1
ou n
ce w
h ol
e w
h ea
t ro
ll 1
te as
po on
t ub
m ar
ga ri
ne Fr
oz en
y og
u rt
a n
d b
er ri
es :
! c
up fr
oz en
y og
ur t
(c ho
co la
te )
" c
up s
lic ed
s tr
aw be
rr ie
s B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
SN A
C K
S 1
cu p
fr oz
en y
og u
rt (
ch oc
ol at
e)
B R
E A
K FA
ST Fr
en ch
t oa
st :
2 sl
ic es
w ho
le w
he at
b re
ad 3
ta bl
es po
on fa
t- fr
ee m
ilk a
nd $⁄
% eg
g (i
n Fr
en ch
t oa
st )
2 te
as po
on s
tu b
m ar
ga ri
ne 1
ta bl
es po
on p
an ca
ke s
yr up
" la
rg e
gr ap
ef ru
it B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
LU N
C H
3- be
an v
eg et
ar ia
n c
h ili
o n
b ak
ed p
ot at
o: "
c up
e ac
h co
ok ed
k id
ne y
be an
s, *
na vy
b ea
ns ,*
a nd
b la
ck b
ea ns
*
! c
up t
om at
o sa
uc e*
" c
up c
ho pp
ed o
ni on
2 ta
bl es
po on
s ch
op pe
d ja
la pe
ño p
ep pe
rs 1
te as
po on
c or
n/ ca
no la
o il
(t o
co ok
o ni
on
an d
pe pp
er s)
" c
up c
he es
e sa
uc e
1 la
rg e
ba ke
d po
ta to
" c
u p
c an
ta lo
u p
e B
ev er
ag e:
1 cu
p w
at er
, c of
fe e,
o r
te a*
*
D IN
N E
R H
aw ai
ia n
p iz
za :
2 sl
ic es
c he
es e
pi zz
a, t
hi n
cr us
t 1
ou nc
e le
an h
am "
c up
p in
ea pp
le "
c up
m us
hr oo
m s
1 te
as po
on s
af flo
w er
o il
(t o
co ok
m
us hr
oo m
s) G
re en
s al
ad :
1 cu
p m
ix ed
s al
ad g
re en
s 4
te as
po on
s oi
l a nd
v in
eg ar
d re
ss in
g B
ev er
ag e:
1 c
u p
fa t-
fr ee
m ilk
SN A
C K
S 3
ta bl
es p
oo n
s h
u m
m u
s 5
w h
ol e
w h
ea t
cr ac
ke rs
*
B R
E A
K FA
ST B
u ck
w h
ea t
p an
ca ke
s w
it h
b er
ri es
: 2
la rg
e (7
”) p
an ca
ke s
1 ta
bl es
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Estimated Daily Calorie Needs 587
Average Amounts for Weekly Menu
Food Group Daily Average over 1 Week
GRAINS 6.2 ounce equivalent
Whole grains 3.8
Refined grains 2.4
VEGETABLES 2.6 cups
Vegetable subgroups (amount per week)
Dark green 1.6 cups per week
Red/Orange 5.6
Starchy 5.1
Beans and Peas 1.6
Other Vegetables 4.1
FRUITS 2.1 cups
DAIRY 3.1 cups
PROTEIN FOODS 5.7 ounce equivalent
Seafood 8.8 ounces per week
OILS 29 grams
CALORIES FROM ADDED FATS AND SUGARS
245 calories
Nutrient Daily Average over 1 Week
Calories 1,975
Protein 96 grams
Protein 19% kcal
Carbohydrate 275 grams
Carbohydrate 56% kcal
Total fat 59 grams
Total fat 27% kcal
Saturated fat 13.2 grams
Saturated fat 6.0% kcal
Monounsaturated fat 25 grams
Polyunsaturated fat 16 grams
Linoleic acid 13 grams
Alpha-linoleic acid 1.8 grams
Cholesterol 201 milligrams
Total dietary fiber 30 grams
Potassium 4,701 milligrams
Sodium 1,810 milligrams
Calcium 1,436 milligrams
Magnesium 468 milligrams
Copper 2.0 milligrams
Iron 18 milligrams
Phosphorus 1,885 milligrams
Zinc 14 milligrams
Thiamin 1.6 milligrams
Riboflavin 2.5 milligrams
Niacin equivalents 24 milligrams
Vitamin B6 2.4 milligrams
Vitamin B12 12.3 micrograms
Vitamin C 146 milligrams
Vitamin E 11.8 milligrams (AT)
Vitamin D 9.1 micrograms
Vitamin A 1,090 micrograms (RAE)
Dietary folate equivalents 530 micrograms
Choline 386 milligrams
588 Appendix C Food Intake Patterns Based on MyPlate Recommendations
Alters & Schi! ESSENTIAL CONCEPTS FOR
Healthy Living
Je! Housman
Mary Odum
EIGHTH EDITION
STUDENT WORKBOOK TO ACCOMPANY
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 591
This self-test, which is a modi!ed version of one developed by the U.S. Public Health Ser-vice, assesses several health-related behaviors. Although these behaviors apply to most individuals, pregnant women and people with chronic health concerns should follow the advice of their physicians. Answer each of the following questions by circling the number of the response that applies best to you. Add the number of points under each health-related behavior category to obtain a score for that category. Use the scoring guide at the end of the test to deter- mine the level of risk you are incurring by your health-related behavior.
Tobacco, Alcohol, and Other Drugs If you have never used tobacco products, enter a score of 10 for this section, and skip questions 1 and 2.
Almost Always Sometimes
Almost Never
1. I avoid using tobacco products. 2 1 0
2. I smoke only low-tar cigarettes. 2 1 0
Smoking Score: ______
3. I avoid drinking alcoholic beverages, or I drink no more than one or two drinks a day.
2 1 0
4. I avoid using alcohol or other drugs (especially illegal drugs) as a way of handling stressful situations or problems in my life.
2 1 0
5. I avoid driving while under the influence of alcohol and other drugs.
2 1 0
6. I am careful not to drink alcohol when taking certain pain medications or when pregnant.
2 1 0
7. I read and follow the label directions when using prescribed and over-the-counter drugs.
2 1 0
Alcohol and Other Drugs Score: ______
SELF#ASSESSMENT 1
Healthstyle
1CHAPTER
592 Student Workbook Copyright © Jones & Bartlett Learning 2019
Eating Habits Almost Always Sometimes
Almost Never
8. I eat a variety of foods each day, including fruits and vegetables, whole grain products, lean meats, low-fat dairy products, seeds, nuts, and dry beans.
3 1 0
9. I limit the amount of animal fat in my food, which includes cream, butter, cheese, and fatty meats.
3 1 0
10. I limit the amount of salt that I eat by avoiding salty foods and not using salt at the table.
3 1 0
11. I avoid eating too much sugar by eating few sweet snacks and sugary soft drinks.
3 1 0
Eating Habits Score: ______
Exercise/Fitness Almost Always Sometimes
Almost Never
12. I maintain a body weight that is reasonable for my height. 3 1 0
13. I do vigorous exercise (for example, running, swimming, or brisk walking) for at least 30 minutes at least three times a week.
3 1 0
14. I do exercises to enhance my muscle tone and flexibility (for example, yoga or calisthenics) for 15–30 minutes at least three times a week.
2 1 0
15. I use part of my leisure time participating in individual, family, or team activities that increase my level of physical fitness (for example, gardening, bowling, or golf ).
2 1 0
Exercise/Fitness Score: ______
Stress Management Almost Always Sometimes
Almost Never
16. I take time every day to relax. 2 1 0
17. I find it easy to express my feelings without harming others. 2 1 0
18. I recognize and prepare for events or situations that are likely to be stressful.
2 1 0
19. I have close friends, relatives, or others whom I can talk to about personal matters and contact for help when needed.
2 1 0
20. I participate in hobbies that I enjoy or group activities such as religious or community organizations.
2 1 0
Stress Management Score: ______
Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 593
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Safety Almost Always Sometimes
Almost Never
21. I wear a seat belt while riding in a motor vehicle. 2 1 0
22. I obey traffic rules and speed limits while driving. 2 1 0
23. I have a working smoke detector in my home. 2 1 0
24. I am careful when using potentially harmful products or substances, such as household cleaners, poisons, and electrical devices.
2 1 0
25. I avoid smoking in bed. 2 1 0
Safety Score: ______
What Your Scores Mean Scores of 9 or 10 for each section: Excellent! Your responses show that you are aware of the impor- tance of this area to your health and that you are practicing good health-related habits. As long as you continue to do so, this area of health should not pose a risk.
Scores of 6–8 for each section: Your health practices in this area are good, but there is room for improvement. Look at the items that you answered with “Sometimes” or “Almost Never.” What lifestyle changes can you make to improve your score and reduce your risk?
Scores of 3–5 for each section: Your health-related behaviors are risky. What lifestyle changes can you make to improve your score in this area of health and reduce your risk?
Scores of 0–2 for each section: You may be taking serious and unnecessary risks with your health and possibly the health of others. What lifestyle changes can you make to improve your score and reduce your risk?
Adapted from Healthstyle: A Self-Test, U.S. Department of Health and Human Services Public Health Service, DHHS Publication Number (PHS) 81-50155.
594 Student Workbook Copyright © Jones & Bartlett Learning 2019
CHAPTER 1 SELF#ASSESSMENT 2
Personal Health History
B eing aware of your family’s health history, especially which relatives had or have serious chronic diseases or inherited conditions, can help you and your physician assess your risk of such diseases or conditions. As a result of having this information, you can make choices concerning your lifestyle now that may reduce the likelihood of developing these health problems in the future.
To compile your personal health history and design a health history diagram, start with your own health and that of your brothers and sisters. "en indicate health conditions that a#ect your mother and father and their brothers and sisters. A$er completing health information for that generation, collect information about your grandparents’ health. You may be aware of some family members’ health problems, such as heart disease, obesity, drug addiction, or mental health conditions. In other instances, however, you will need to speak with your relatives to determine whether they have or had diseases or conditions such as prostate or breast cancer, diabetes, hypertension, liver disease, and so on. If you are adopted or cannot !nd information about individual family members, you may have to leave blanks.
A sample family health history diagram is shown in this assessment. Note that it has spaces for a person to !ll in his or her personal health and the health of siblings, parents, aunts, uncles, and grandparents. Of course, your diagram will re'ect your family’s makeup. A$er developing your personal health history diagram, answer the following questions.
1. If a particular disease or condition occurs repeatedly in your family, it may be the result of inherited and/or lifestyle factors that are common within your family. Such repeated occur- rences may indicate that your risk of the disease or condition is greater than average. Which serious health problems occur more than once in your family health history?
2. Which diseases or conditions in your family history do you think are related to lifestyle prac- tices, such as food choices, lack of regular physical activity, or smoking?
Copyright © Jones & Bartlett Learning 2019 Self-Assessment 2 595
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3. Are you aware of actions you can take that may reduce your risk of developing the health prob- lems that o$en a#ect or have a#ected members of your family? If so, list those actions.
4. "e course of many diseases and conditions is in'uenced by lifestyle factors. Your physician can help you determine such factors. "erefore, consider discussing your family health history with your physician. Your physician can also provide advice concerning steps you can take to reduce your risk of developing the health problems that a#ect or have a#ected members of your family.
DiabetesOverweight Breast cancerHeart disease
Family Health History Example
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Depression Diabetes
Alcoholism Heart diseaseBreast cancer
Female Male Deceased female Deceased male
Paternal Uncle Father Mother
Brother SisterSELF
Maternal Aunt Hypertension
Maternal UncleMaternal Uncle
596 Student Workbook Copyright © Jones & Bartlett Learning 2019
CHAPTER 1 CHANGING HEALTH HABITS
Model Activity for Better Health
This critical thinking feature describes a useful model of a decision-making process. "e !rst part of the model involves deciding to change a health-related behavior; the second part describes implementing the behavioral change. To practice making responsible health- related decisions, complete the Changing Health Habits activities for each chapter. Chapter 1 (which follows) is already completed as an example of how to use this model.
Deciding to Change 1. Identify the problem, goal, or question. Example: I’m overweight. I know that being over-
weight increases my risk for diabetes, certain cancers, and heart disease. 2. List the reasons you should make this change and the reasons you should not. Assign each
reason a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to lose weight (pros): Reasons not to lose weight (cons):
Points Reasons Points Reasons
3 Losing weight will reduce my risk of diabetes, certain cancers, and heart disease.
2 I’ll have to spend money on new clothes.
5 Losing weight will improve the way my clothes fit.
2 I’ll have to spend money to join a health club or weight loss group.
4 Losing weight will help me feel better about myself.
4 I’ll have trouble keeping the weight off.
5 Losing weight will reduce my flab. 5 I can continue eating fatty and sugary foods
17 Total 13 Total
3. Draw a conclusion. Add the scores in each category. If the score of the positive reasons (pros) is greater than the score of the negative reasons (cons), you likely think that a change is in your best interest. Also, you are probably motivated to make the change and are likely to succeed. However, if your cons outweigh your pros, you likely think that changing is not in your best interest at this time. You may not be motivated to make the change now. Study your list of pros
Copyright © Jones & Bartlett Learning 2019 Changing Health Habits 597
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and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. Depending on the type of
decision, a behavior change could involve setting a beginning date and a goal date. For example, you could decide to lose 10 pounds by May 31, then begin changing your eating and physical activity patterns tomorrow.
2. Identify and list the factors that will help you reach your goal and those that will stand in the way of reaching your goal.
Factors that help My roommate has also decided to lose weight. I just got a check for my birthday to buy a new out!t when I lose 10 pounds. My student fees include the use of the health facility. Factors that hinder My mother insists that I eat a lot of food when I visit. My roommate keeps lots of high-calorie snacks in the house. I’m so busy that !nding a time to exercise is di&cult. 3. Prepare an action plan for making the change. An action plan speci!es how you will change
your behavior to meet your goal. a. Identify alternative methods for reaching your goal. Example Alternative 1: Consume a 1,200-calorie diet that consists of eating only one meal a day and
drinking a diet supplement for breakfast and lunch. Alternative 2: Consume a 1,200-calorie diet that permits three nutritious meals daily. Alternative 3: Consume a 1,200-calorie diet and increase exercise by 30 minutes a day. Alternative 4: Go to a weight loss clinic for help. b. Gather information about each method. Seek information that supports and criticizes
each method. (People tend to gather data that only support what they think they want to do.) Ask yourself questions to guide your information gathering.
Example: How long do people who reduce their caloric intake without exercising keep the weight o# ? By which method am I more likely to lose weight fastest? Is it better for my health to lose weight as quickly as possible, or does the length of time not matter? What changes will I have to make in my life if I decide to eat more nutritious foods and exercise? Are diet supplement drinks safe? Where can I !nd information about the caloric content of foods?
c. Choose the method that !ts your situation best. Example: A$er researching alternative methods, you decide to follow a 1,200-calorie-per-
day diet and increase the amount of exercise you engage in each day. d. Consider the factors that can help or hinder your e#ort to change (see step 2). What can
you do that will take advantage of the helps and minimize the hindrances? For example, keep plenty of low-calorie snacks on hand to avoid being tempted by your roommate’s sup- ply of high-calorie munchies. Also, discuss the situation with your roommate to enlist his or her support in your e#ort.
598 Student Workbook Copyright © Jones & Bartlett Learning 2019
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. Track your progress on a regular basis. Recording your weight once a week, for example, may be helpful. Are you losing weight?
6. Evaluate how e#ective you were in reaching your goal. Did your plan work? What can you learn from the experience?
Example: You lost 5 pounds instead of 10 pounds. What seemed to keep you from reaching your goal? What can you do di#erently that might help you succeed? Do you need more time to lose weight, or do you need to reevaluate your decision?
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 599
I f the following statement describes how you usually feel, put a check in the column “Like Me.” If the statement does not describe how you usually feel, put a check in the column “Unlike Me.” "ere are no right or wrong answers. Read each statement quickly and answer the questions o# the top of your head.
Statement Like Me Unlike Me
1. I spend a lot of time daydreaming. _____ _____
2. I’m pretty sure of myself. _____ _____
3. I often wish I were someone else. _____ _____
4. I’m easy to like. _____ _____
5. My family and I have a lot of fun together. _____ _____
6. I never worry about anything. _____ _____
7. I find it very hard to talk in front of a group. _____ _____
8. I wish I were younger. _____ _____
9. There are lots of things about myself I’d change if I could. _____ _____
10. I can make up my mind without too much trouble. _____ _____
11. I’m a lot of fun to be with. _____ _____
12. I get upset easily at home. _____ _____
13. I always do the right thing. _____ _____
14. I’m proud of my work. _____ _____
15. Someone always has to tell me what to do. _____ _____
16. It takes me a long time to get used to anything new. _____ _____
17. I’m often sorry for the things I do. _____ _____
18. I’m popular with people my own age. _____ _____
19. My family usually considers my feelings. _____ _____
20. I’m never unhappy. _____ _____
21. I’m doing the best work that I can. _____ _____
22. I give in very easily. _____ _____
23. I can usually take care of myself. _____ _____
24. I’m pretty happy. _____ _____
SELF#ASSESSMENT
!e Self-Esteem Inventory
2CHAPTER
600 Student Workbook Copyright © Jones & Bartlett Learning 2019
Statement Like Me Unlike Me
25. I would rather associate with people younger than me. _____ _____
26. My family expects too much of me. _____ _____
27. I like everyone I know. _____ _____
28. I liked to be called on when I am in a group. _____ _____
29. I understand myself. _____ _____
30. It’s pretty tough to be me. _____ _____
31. Things are all mixed up in my life. _____ _____
32. People usually follow my ideas. _____ _____
33. No one pays much attention to me at home. _____ _____
34. I never get scolded. _____ _____
35. I’m not doing as well at work as I’d like to. _____ _____
36. I can make up my mind and stick to it. _____ _____
37. I really don’t like being a man/woman. _____ _____
38. I have a low opinion of myself. _____ _____
39. I don’t like to be with other people. _____ _____
40. There are times when I’d like to leave home. _____ _____
41. I’m never shy. _____ _____
42. I often feel upset. _____ _____
43. I often feel ashamed of myself. _____ _____
44. I’m not as nice-looking as most people. _____ _____
45. If I have something to say, I usually say it. _____ _____
46. People pick on me very often. _____ _____
47. My family understands me. _____ _____
48. I always tell the truth. _____ _____
49. My employer or supervisor makes me feel I’m not good enough. _____ _____
50. I don’t care what happens to me. _____ _____
51. I’m a failure. _____ _____
52. I get upset easily when I’m scolded. _____ _____
53. Most people are better liked than me. _____ _____
54. I usually feel as if my family is pushing me. _____ _____
55. I always know what to say to people. _____ _____
56. I often get discouraged. _____ _____
57. Things usually don’t bother me. _____ _____
58. I can’t be depended on. _____ _____
Reproduced with permission from Ryden, M. B. (1978). An adult version of the Coopersmith Self-Esteem Inventory: Test-retest reliability and social desirability. Psychological Reports, 43, 1189–1190.
Copyright © Jones & Bartlett Learning 2019 Self-Assessment 601
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Scoring the Self-Esteem Inventory To determine your score, count the number of times your responses agree with the keyed responses below.
2. Like 22. Unlike 42. Unlike
3. Unlike 23. Like 43. Unlike
4. Like 24. Like 44. Unlike
5. Like 25. Unlike 45. Like
7. Unlike 26. Unlike 46. Unlike
8. Unlike 28. Like 47. Like
9. Unlike 29. Like 49. Unlike
10. Like 30. Unlike 50. Unlike
11. Like 31. Unlike 51. Unlike
12. Unlike 32. Like 52. Unlike
14. Like 33. Unlike 53. Unlike
15. Unlike 35. Unlike 54. Unlike
16. Unlike 36. Like 55. Like
17. Unlike 37. Unlike 56. Unlike
18. Like 38. Unlike 57. Like
19. Like 39. Unlike 58. Unlike
21. Like 40. Unlike
"e majority of the items measure self-esteem, but the eight items below that fall into the “Lie Scale” identify people who are trying to conceal their feelings about themselves. Count the number of times your responses to the questions listed agree with the responses shown below. If three or more responses agree, you may be trying to conceal feelings of low self-esteem.
1. Like 27. Like
6. Like 34. Like
13. Like 41. Like
20. Like 48. Like
How do you compare with other men and women taking this self-assessment? "e average man obtains a score of 40; an average woman obtains a score of 39. Scores below 33 for men and 32 for women may indicate low self-esteem.
602 Student Workbook Copyright © Jones & Bartlett Learning 2019
CHAPTER 2 CHANGING HEALTH HABITS
Are You Ready to Improve Your Psychological Health?
Do you need to change a behavior that relates to or a#ects your psychological health? For example, do you blame others for problems for which you should take responsibility? Do you eat too much fattening food or drink too much alcohol as a way of dealing with your problems? "e “Deciding to Change” section of the worksheet can help you determine whether you are ready to alter your behavior to improve your psychological health. Use the “Implementing the Change” section of the worksheet if you decide to make the necessary changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change thoughts or behaviors (pros): Reasons not to change thoughts or behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change that concerns your psychological health. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, how- ever, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan that you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 605
To estimate the amount of stress that you have endured recently, indicate the number of occa-sions (to a maximum of four) that you have experienced the following in the past year. Event
Number of Occasions Points Total
1. Death of a spouse ____ 87 ____
2. Marriage ____ 77 ____
3. Death of a close relative ____ 77 ____
4. Divorce ____ 76 ____
5. Marital separation ____ 74 ____
6. Pregnancy, or fathered a pregnancy ____ 64 ____
7. Death of a close friend ____ 68 ____
8. Personal injury or illness ____ 65 ____
9. Loss of your job ____ 62 ____
10. Breakup of a marital engagement or a steady relationship ____ 60 ____
11. Sexual difficulties ____ 58 ____
12. Marital reconciliation ____ 58 ____
13. Major change in self-concept ____ 57 ____
14. Major change in health or behavior of a family member ____ 56 ____
15. Engagement to be married ____ 54 ____
16. Major change in financial status ____ 53 ____
17. Major change in the use of drugs (other than alcohol) ____ 52 ____
18. Mortgage or loan of less than $10,000 ____ 52 ____
19. Entered college ____ 50 ____
20. A new family member ____ 50 ____
21. A conflict or change in values ____ 50 ____
22. Change to a different line of work ____ 50 ____
23. A major change in the number of arguments with spouse ____ 50 ____
24. Change to a new school ____ 50 ____
SELF#ASSESSMENT 1
How Much Stress Have You Had Lately?
3CHAPTER
606 Student Workbook Copyright © Jones & Bartlett Learning 2019
Event Number of Occasions Points Total
25. A major change in amount of independence and responsibility ____ 49 ____
26. A major change in responsibilities at work ____ 47 ____
27. A major change in the use of alcohol ____ 46 ____
28. Revised personal habits ____ 45 ____
29. Being in trouble with school administration ____ 44 ____
30. A major change in social activities ____ 43 ____
31. Holding a job while attending school ____ 43 ____
32. Change of residence or living conditions ____ 42 ____
33. A major change in working hours or conditions ____ 42 ____
34. Trouble with in-laws ____ 42 ____
35. Your spouse beginning or stopping work outside the home ____ 41 ____
36. Change in dating habits ____ 41 ____
37. A change involving your major field of study ____ 41 ____
38. An outstanding personal achievement ____ 40 ____
39. Trouble with your boss ____ 38 ____
40. A major change in amount of participation in school activities ____ 38 ____
41. A major change in type and/or amount of recreation ____ 37 ____
42. A major change in religious activities ____ 36 ____
43. A major change in sleeping habits ____ 34 ____
44. A trip or vacation ____ 33 ____
45. A major change in eating habits ____ 30 ____
46. A major change in number of family get-togethers ____ 26 ____
47. Found guilty of minor violations of the law ____ 22 ____
Multiply the number of occasions times the point value for each event. Add the scores.
TOTAL POINTS ________
Your degree of stress is low if your score is lower than 347. If your score is higher than 1,435, you are under a high degree of stress.
Reproduced from Marx, M. B., et al. (1975). The influence of recent life experiences on the health of college students. Reprinted from Journal of Psychosomatic Research, 19(1), 87–98, with permission from Elsevier.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 2 607
Answer the following questions by checking the statement that best applies. During the past 30 days, how often did you feel...
All the time
4
Most of the time
3
Some of the time
2
A little of the time
1
None of the time
0
so sad that nothing could cheer you up?
nervous?
restless or fidgety?
hopeless?
that everything was an effort?
worthless?
Total
Scoring: To score the K6, add the points for each of the questions together. Scores can range from 0 to 24. A threshold of 13 or more points indicates a high degree of distress and possibility of serious mental illness.
Weissman, J., Ph.D, Pratt, L. A., Ph.D, Miller, E. A., Ph.D, & Parker, J. D., Ph.D. (may 2015). Serious Psychological Distress Among Adults: United States, 2009–2013. National Center for Health Statistics, (203), 1-8. Retrieved August 22, 2018, from https://www .cdc.gov/nchs/data/databriefs/db203.pdf.
SELF#ASSESSMENT 2
K6 Serious Psychological Distress Assessment
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CHAPTER 3 CHANGING HEALTH HABITS
Taking Steps to Reduce Your Stress
Follow the steps of the decision-making and implementation model to identify and change a health-related habit that contributes to your level of stress. For example, do you work too many hours per week? Are you in a relationship that causes you continual stress? Are you try- ing to take care of your home and family with no help while going to school and working part time?
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that reduces stress. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change out- rank your reasons to change.
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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R ead the following statements and indicate whether you agree or disagree with them. Draw a circle around your answer. Your responses can help you assess whether you are in an abusive intimate relationship. 1. My partner often embarrasses me in front of others. Yes No
2. My partner often criticizes my appearance, belittles my accomplishments, or makes fun of my ideas.
Yes No
3. My partner frequently uses threats to make me do what he/she wants. Yes No
4. My partner has told me that I am worthless without him/her. Yes No
5. When my partner physically hurts me, he/she apologizes or says “It was an accident,” or “I didn’t mean to hurt you.”
Yes No
6. My partner frequently has trouble controlling his/her anger. Yes No
7. My partner often makes me feel guilty when I want to spend time away from him/her.
Yes No
8. My partner often mistreats me when he/she gets drunk or high on drugs. Yes No
9. My partner usually blames me for his/her problems. Yes No
10. My partner pressures me for sex when I don’t want it. Yes No
11. I often think about breaking up with my partner, but I don’t because I’m afraid of what he/she might do to me or himself/herself.
Yes No
12. My friends and family members have told me that my partner is abusing me. Yes No
13. When I’m with others, I usually make excuses for my partner’s abusive behavior. Yes No
14. I often sacrifice what I would like to do because I’m afraid of how my partner will respond if I don’t follow his/her plans.
Yes No
15. I often avoid saying or doing things that might anger my partner because I’m afraid that he/she will hurt me.
Yes No
If you agreed with any of these statements, you may be in an abusive relationship. If you’re not sure that your partner is abusive, seek counseling from a licensed professional therapist. If you are afraid of your partner, get help immediately. Contact your campus counseling center or a local domestic violence intervention center listed in your “Yellow Pages” phone book. "e phone number for the National Domestic Violence Hotline is 1-800-799-7233.
SELF#ASSESSMENT
Am I in an Abusive Intimate Relationship?
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CHAPTER 4 CHANGING HEALTH HABITS
Can You Reduce Your Risk of Violence?
Follow the steps of the decision-making and implementation model to identify and change a health-related habit that contributes to your risk of violence. For example, do you ignore basic security measures? Are you involved in an abusive relationship that you feel hopeless about improving or terminating? Does your work, family, and college schedule force you to be exposed to risky situations and places?
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that reduces your risk of violence. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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The following series of questions, which are adapted from the Contraceptive Comfort and Con!dence Scale, is designed to help you assess whether the method of contraception that you are using or may be considering for future use is or will be e#ective for you. With regard to the method of birth control you are currently using or are considering using,
answer YES or NO to the following questions:
1. Have you had problems using this method before? 2. Are you afraid of using this method? 3. Would you really rather not use this method? 4. Will you have trouble remembering to use this method? 5. Have you ever become pregnant using this method? (Or has your partner ever become pregnant
using this method?) 6. Will you have trouble using this method correctly? 7. Do you still have unanswered questions about this method? 8. Does this method make menstrual periods longer or more painful? 9. Does this method cost more than you can a#ord? 10. Could this method cause you or your partner to have serious complications? 11. Are you opposed to this method because of religious beliefs? 12. Is your partner opposed to this method? 13. Are you using this method without your partner’s knowledge? 14. Will using this method embarrass your partner? 15. Will using this method embarrass you? 16. Will you enjoy intercourse less because of this method? 17. Will your partner enjoy intercourse less because of this method? 18. If this method interrupts lovemaking, will you avoid using it? 19. Has a nurse or doctor ever told you (or your partner) not to use this method?
SELF#ASSESSMENT 1
Contraceptive Comfort and Confidence Scale
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20. Is there anything about your personality that could lead you to use this method incorrectly? 21. Does this method leave you at risk of being exposed to HIV or other sexually transmissible
infections?
Total number of YES answers: ____
Interpreting Your Score Most individuals will have a few yes answers. Yes answers predict potential problems. If you have more than a few yes responses, you may want to talk to your physician, counselor, partner, or a friend. Talking it over can help you decide whether to use this method or how to use it so it will be e#ective. In general, the more yes answers you have, the less likely you are to use this method con- sistently and correctly.
In choosing a method of contraception, keep in mind that if you want a highly e#ective meth- od of contraception and a method that is highly e#ective in preventing transmission of sexually transmitted infections (STIs), you may have to use two methods. Hence, any method of contracep- tion (except abstinence, of course) should be combined with condom use for maximum protection against STIs.
Adapted from Hatcher, R. A., et al. (1990). Contraceptive technology: 1990–1992 (15th ed., rev., p. 150). New York, NY: Irvington.
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CHAPTER 5 SELF#ASSESSMENT 2
Attitudes Toward Timing of"Parenthood Scale (ATOP)
Directions Circle the response that most closely represents your feelings. "e options are strongly agree (SA), agree (A), undecided (U), disagree (D), and strongly disagree (SD).
SD D U A SA
1. The best time to begin having children is usually within the first two years of marriage.
1 2 3 4 5
2. It is important for a young couple to enjoy their social life first and to have children later in the marriage.
1 2 3 4 5
3. A marriage relationship is strengthened if children are born in the early years of marriage.
1 2 3 4 5
4. Women are generally happier if they have children early in the marriage.
1 2 3 4 5
5. Men are usually tied closer to the marriage when there are children in the home.
1 2 3 4 5
6. Most young married women lack self-fulfillment until they have a child.
1 2 3 4 5
7. Young couples who do not have children are usually unable to do so.
1 2 3 4 5
8. Married couples who have mature love for each other will be eager to have a child as soon as possible.
1 2 3 4 5
9. Couples who do not have children cannot share in the major interests of their friends who are parents and are therefore left out of most social circles.
1 2 3 4 5
10. Children enjoy their parents more when the parents are nearer their own age; therefore, parents should have children while they are still young.
1 2 3 4 5
11. In general, research indicates that the majority of couples approaching parenthood for the first time have had little or no previous childcare experience beyond sporadic babysitting, a course in child psychology, or occasional care of younger siblings. Considering your background preparation for parenthood, would you judge that you are well prepared for the parenting experience?
1 2 3 4 5
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Items 1–10 are from the Attitudes Toward Timing of Parenthood Scale (Maxwell & Montgomery, 1969). Item 11 was an additional item constructed to determine perceived degree of preparation for parenthood.
Scoring: Response options that favor early parenthood receive the highest score (5 points), and those that favor delayed parenthood receive the lowest score (1 point). "e range of possible scores is from 10 to 50. Item number 2 is reverse scored, so if you chose option 4, change it to 2 (or vice versa); if you chose option 5, change it to 1 (or vice versa). "en sum the value of the options you selected for all items to compute your total score.
Reliability and validity: No reliability information was provided. "e scale’s developers, Maxwell%and Montgomery (1969), reported that in an item analysis, each of the original 10-scale items discriminated signi!cantly between upper and lower quartile groups. In their study of 96% married women, consistent attitudes and behavior were found; those who waited longer before having their !rst child scored lower on the ATOP.
Interpreting your score: Maxwell and Montgomery (1969) found that the following factors related to lower scores (favoring delay of parenting): higher age of respondent, higher education level and socioeconomic status, and having fewer children. Studies in the decade following publi- cation of this measure reveal that women in the late 1970s and early 1980s were more likely than Maxwell and Montgomery’s original sample to favor delayed parenthood (Knaub, Eversol, & Voss, 1981, 1983). In the 1983 study of 213 female students at a large midwestern university (Knaub et al., 1983), the mean total score (on items 1–10) on the ATOP was 21.
Researchers using this measure typically present the percentage of respondents who agree and disagree with each item. Following is a table that summarizes the responses of 213 female students at a large midwestern university (Knaub et al., 1983) and 76 male students from colleges in four states (Eversoll, Voss, & Knaub, 1983). Percentages for the response options “strongly agree” and “agree” are combined, as are the percentages for “disagree” and “strongly disagree.”
ATOP Items by Percent of Respondents Agreeing and Disagreeing (Refer to questions at the beginning of this assessment)
Women Men
Agree Disagree Undecided Agree Disagree Undecided
Question 1 7.5 86.8 5.7 6.6 84.1 9.2
Question 2 78.8 10.8 11.3 76.0 11.8 13.2
Question 3 6.6 76.9 16.5 10.5 68.5 21.0
Question 4 5.2 72.7 22.1 5.3 58.0 36.5
Question 5 34.9 44.8 20.8 21.1 56.6 22.4
Question 6 8.9 81.7 9.4 7.9 72.4 19.7
Question 7 2.8 93.9 2.8 2.6 88.2 9.2
Question 8 4.3 84.4 11.3 9.2 81.6 9.2
Question 9 14.6 77.8 7.5 12.8 78.9 5.3
Question 10 15.6 71.2 13.2 19.8 64.5 15.8
Question 11 34.7 53.1 12.2
Data from Eversoll, D. B., et al. (1983). Attitudes of college females toward parenthood timing. Journal of Home Economics, 75, 25–29.
Knaub, P. K., et al. (1981). Student attitudes toward parenthood: Implications for curricula in the 1980s. Journal of Home Economics, 73, 34–37.
Knaub, P. K., et al. (1983). Is parenthood a desirable adult role? An assessment of attitudes held by contemporary women. Sex Roles, 9, 355–362. Reprinted with kind permission from Springer Science and Business Media and Patricia K. Knaub.
Maxwell, J. W., & Montgomery, J. E. (1969). Societal pressure toward early parenthood. Family Coordinator, 18, 340–344.
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Do you need to change a behavior that relates to or a#ects your reproductive health? For example, if you are sexually active, are you using contraception irregularly, risking preg-nancy? Are you using a method that does not provide the level of protection you desire? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you determine whether you are ready to alter your behaviors to improve your reproductive health. Use the “Imple- menting the Change” section of the worksheet if you decide to make the necessary changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that improves your reproductive health. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHANGING HEALTH HABITS
Do You Want to Improve Your Reproductive Health?
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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INSTRUCTIONS: Circle the number corresponding to your response for each item. Extremely Unhappy
Fairly Unhappy
A Little Unhappy Happy
Very Happy
Extremely Happy Perfect
1. Please indicate the degree of happiness, all things considered, of your relationship
0 1 2 3 4 5 6
All the time
Most of the time
More often than not Occasionally Rarely Never
2. In general, how often do you think that things between you and your partner are going well?
5 4 3 2 1 0
Not at all true
A little true
Somewhat true
Mostly true
Almost completely true
Completely true
3. Our relationship is strong 0 1 2 3 4 5
4. My relationship with my partner makes me happy
0 1 2 3 4 5
5. I have a warm and comfortable relationship with my partner
0 1 2 3 4 5
6. I really feel like part of a team with my partner
0 1 2 3 4 5
SELF#ASSESSMENT 1
Couples Satisfaction Index
6CHAPTER
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Not at all A little Somewhat Mostly Almost Completely Completely
7. How rewarding is your relationship with your partner?
0 1 2 3 4 5
8. How well does your partner meet your needs?
0 1 2 3 4 5
9. To what extent has your relationship met your original expectations?
0 1 2 3 4 5
10. In general, how satisfied are you with your relationship?
0 1 2 3 4 5
11–16. For each of the following items, select the answer that best describes how you feel about your relationship. Base your responses on your !rst impressions and immediate feelings about the item.
INTERESTING 5 4 3 2 1 0 BORING
BAD 0 1 2 3 4 5 GOOD
FULL 5 4 3 2 1 0 EMPTY
STURDY 5 4 3 2 1 0 FRAGILE
DISCOURAGING 0 1 2 3 4 5 HOPEFUL
ENJOYABLE 5 4 3 2 1 0 MISERABLE
Scoring: To score the CSI-16, simply sum the responses across all the items. "e point values of each response of each item are shown above. Interpretation: CSI-16 scores can range from 0 to 81. Higher scores indicate higher levels of relationship satisfaction. CSI-16 scores falling below 51.5 suggest notable relationship dissatisfaction.
Reproduced from Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item response theory: Increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. Journal of Family Psychology, 21, 572–583.
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SELF#ASSESSMENT 2
!e Love Attitudes Scale
CHAPTER 6
L isted below are several statements that re'ect di#erent attitudes about love. For each state-ment, !ll in the response that indicates how much you agree or disagree with the statement. "e items refer to a speci!c love relationship. Whenever possible, answer the questions with your current partner in mind. If you are not currently in a love relationship, answer the questions with your most recent partner in mind. If you have never been in love, answer in terms of what you think your responses would most likely be.
For Each Statement 1 = strongly agree with the statement 2 = moderately agree with the statement 3 = neutral—neither agree nor disagree 4 = moderately disagree with the statement 5 = strongly disagree with the statement
1. My partner and I have the right physical “chemistry” between us. _____
2. I feel that my partner and I were meant for each other. _____
3. My partner and I really understand each other. _____
4. My partner fits my ideal standards of physical beauty/handsomeness. _____
5. I believe that what my partner doesn’t know about me won’t hurt him/her. _____
6. I have sometimes had to keep my partner from finding out about other lovers. _____
7. My partner would get upset if he/she knew of some of the things I’ve done with other people. _____
8. I enjoy playing the “game of love” with my partner and a number of other partners. _____
9. Our love is the best kind because it grew out of a long friendship. _____
10. Our friendship merged gradually into love over time. _____
11. Our love is really a deep friendship, not a mysterious, mystical emotion. _____
12. Our love relationship is most satisfying because it developed from a good friendship. _____
13. A main consideration in choosing my partner was how he/she would reflect on my family. _____
14. An important factor in choosing my partner was whether he/she would be a good parent. _____
15. One consideration in choosing my partner was how he/she would reflect on my career. _____
16. Before getting very involved with my partner, I tried to figure out how compatible his/her hereditary background would be with mine in case we ever had children.
_____
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17. When my partner doesn’t pay attention to me, I feel sick all over. _____
18. Since I’ve been in love with my partner I’ve had trouble concentrating on anything else. _____
19. I cannot relax if I suspect my partner is with someone else. _____
20. If my partner ignores me for a while, I sometimes do stupid things to try to get his/her attention back.
_____
21. I would rather suffer myself than let my partner suffer. _____
22. I cannot be happy unless I place my partner’s happiness before my own. _____
23. I am usually willing to sacrifice my own wishes to let my partner achieve his/hers. _____
24. I would endure all things for the sake of my partner. _____
Scoring Add your scores for the following groups of questions: 1–4, 5–8, 9–12, 13–16, 17–20, and 21–24. Each of these six groupings of questions corresponds to one of Lee’s six styles of loving. Your lowest group score means that you most closely align yourself with that style of loving. Table 6.2 in Essen- tial Concepts for Healthy Living, Eighth Edition, lists meanings and characteristics for each of Lee’s six styles of loving. 1–4 = Eros 5–8 = Ludus 9–12 = Storge 13–16 = Pragma 17–20 = Mania 21–24 = Agape
Modified from Hendrick, C., et al. (1998). The love attitudes scale: Short form. Journal of Social and Personal Relationships, 15, 147–159. Reprinted with permission of SAGE.
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CHANGING HEALTH HABITS
Would a Behavior Change Improve Your Relationship?
CHAPTER 6
Do you need to change a behavior that relates to or a#ects your relationships? For example, are your communication patterns ine#ective with those close to you, such as your lover, spouse, or parents? Are you having trouble communicating e#ectively with other persons, such as a friend or your boss? Do you want to change those patterns so that you will be more e#ective in maintaining successful relationships? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you determine whether you are ready to alter your behaviors to improve your communication skills. Use the “Implementing the Change” section of the worksheet if you decide to make the necessary changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total 3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the
point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that improves your communications skills. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
626 Student Workbook Copyright © Jones & Bartlett Learning 2019
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods to reach your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 627
Answer the following questions about your use and abuse of drugs. Yes No
1. Have you used drugs other than those required for medical reasons? _____ _____
2. Have you abused prescription drugs? _____ _____
3. Do you abuse more than one drug at a time? _____ _____
4. Can you get through the week without using drugs (other than those required for medical reasons)?*
_____ _____
5. Are you always able to stop using drugs when you want to?* _____ _____
6. Do you abuse drugs on a continuous basis? _____ _____
7. Do you try to limit your drug use to certain situations?* _____ _____
8. Have you had “blackouts” or “flashbacks” as a result of drug use? _____ _____
9. Do you ever feel bad about your drug abuse? _____ _____
10. Does your spouse (or parents) ever complain about your involvement with drugs? _____ _____
11. Do your friends or relatives know or suspect you abuse drugs? _____ _____
12. Has drug abuse ever created problems between you and your spouse? _____ _____
13. Has any family member ever sought help for problems related to your drug use? _____ _____
14. Have you ever lost friends because of your use of drugs? _____ _____
15. Have you ever neglected your family or missed work because of your use of drugs?
_____ _____
16. Have you ever been in trouble at work because of your use of drugs? _____ _____
17. Have you ever lost your job because of drug abuse? _____ _____
18. Have you ever gotten into fights while under the influence of drugs? _____ _____
19. Have you ever been arrested for unusual behavior while under the influence of drugs?
_____ _____
20. Have you ever been arrested while driving under the influence of drugs? _____ _____
21. Have you ever engaged in illegal activities in order to obtain drugs? _____ _____
22. Have you ever been arrested for possession of illegal drugs? _____ _____
SELF#ASSESSMENT
Are You Dependent on Drugs?
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Yes No
23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? _____ _____
24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?
_____ _____
25. Have you ever gone to anyone for help for a drug problem? _____ _____
26. Have you ever been in a hospital for medical problems related to your drug use? _____ _____
27. Have you ever been involved in a treatment program specifically related to drug use? _____ _____
28. Have you ever been treated as an outpatient for problems related to drug abuse? _____ _____
Scoring !is Assessment If you answered yes to 6 or more of these questions (including answering no to questions 4, 5, and%7), you may have a drug abuse problem.
*Items 4, 5, and 7 are scored in the no, or false, direction.
Reproduced with permission from Elsevier from Skinner, H. A. The Drug Screening Test. Addictive Behaviors, 7(4):363–371.1982.
Resources If you are dependent on drugs, the following government agencies or private organizations may be able to provide you with help:
National Drug and Alcohol Treatment Referral Routing Service
1-800-662-HELP Cocaine Anonymous World Services 21720 S. Wilmington Ave., Ste. 304 Long Beach, CA 90810 E-mail: [email protected] www.ca.org Nar-Anon Family Groups 22527 Crenshaw Blvd., #200B Torrance, CA 90505 (310) 534-8188 1-800-477-6291 http://nar-anon.org Narcotics Anonymous World Services P.O. Box 9999 Van Nuys, CA 91409 (818) 773-9999 E-mail: [email protected] www.na.org
National Council on Alcoholism and Drug Dependence
244 East 58th Street, 4th Floor New York, NY 10022 Hope Line: 800-NCA-CALL (24-hour a&liate
referral) (212) 269-7797 www.ncadd.org National Institute on Drug Abuse National Institutes of Health 6001 Executive Blvd., Rm. 5213 Bethesda, MD 20892-9561 (301) 443-1124 Contact: https://www.drugabuse.gov/about-nida
/contact-us www.nida.nih.gov/nidahome.html www.nida.nih.gov
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Copyright © Jones & Bartlett Learning 2019 Changing Health Habits 629
CHANGING HEALTH HABITS
Are You Using Drugs Inappropriately?
CHAPTER 7
A re you taking any drugs now, such as ca#eine or much stronger drugs, that may be habit forming, that may have negative health e#ects, and that were not prescribed by your health-care practitioner? If you are using drugs inappropriately, follow the steps of the decision- making and implementation model to identify and change a drug-related habit.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life regarding a drug-related habit. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
630 Student Workbook Copyright © Jones & Bartlett Learning 2019
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 631
Directions Answer the following questions by circling O (o!en), S (sometimes), or N (never).
Often Sometimes Never
Group 1
I smoke to keep from slowing down. O S N
I reach for a cigarette when I need a lift. O S N
When I’m tired, smoking perks me up. O S N
Group 2
I feel more comfortable with a cigarette in my hand. O S N
I enjoy getting a cigarette out of the pack and lighting up. O S N
I like to watch the smoke when I exhale. O S N
Group 3
Smoking cigarettes is pleasant and enjoyable. O S N
Smoking makes good times better. O S N
I want a cigarette most when I am comfortable and relaxed. O S N
Group 4
I light up a cigarette when something makes me angry. O S N
Smoking relaxes me in a stressful situation. O S N
When I’m depressed, I reach for a cigarette to make me feel better. O S N
Group 5
When I run out of cigarettes, it’s almost unbearable until I get more. O S N
I am very aware of not smoking when I don’t have a cigarette in my hand. O S N
When I haven’t smoked for a while, I get a gnawing hunger for a cigarette. O S N
Group 6
I smoke cigarettes automatically without even being aware of it. O S N
I light up a cigarette without realizing I have one burning in an ashtray. O S N
I find a cigarette in my mouth and don’t remember putting it there. O S N
SELF!ASSESSMENT
Why Do You Smoke?
8CHAPTER
632 Student Workbook Copyright © Jones & Bartlett Learning 2019
Interpretation: Look at each group separately. If you answer “o!en” or “sometimes” to the questions in a particular group, that signi"es one reason you smoke.
Reasons: Group 1: Smoking gives you more energy. Group 2: You like to touch and handle cigarettes. Group 3: Smoking is a pleasure. Group 4: Smoking helps you relax when you’re tense or upset. Group 5: You crave cigarettes; you are addicted to smoking. Group 6: Smoking is a habit.
Refer to the Managing Your Health essay “Tips for Quitters” in Chapter 8 for strategies to quit that address each of these reasons you smoke.
The National Cancer Institute. (1993). Learning why you smoke can teach you how to quit. Washington, DC: U.S. Department of Health and Human Services.
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Copyright © Jones & Bartlett Learning 2019 Changing Health Habits 633
CHAPTER 8 CHANGING HEALTH HABITS
Do You Want to Change a Smoking or Drinking Habit?
Follow the steps of the decision-making and implementation model to identify and change a health-related habit that concerns your drinking of alcoholic beverages or your use of tobacco. For example, are you a heavy smoker who would like to smoke less or stop smoking cigarettes completely? Do you have drinking habits that you would like to change, such as drinking a six-pack in front of the TV every night, drinking on an empty stomach, or drinking too much at parties and sporting events?
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life regarding a smoking or drinking habit. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons care- fully, however, before making your "nal decision. You may decide to change even if your rea- sons not to change outrank your reasons to change.
634 Student Workbook Copyright © Jones & Bartlett Learning 2019
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that "ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 635
M easure or estimate the amounts of everything you eat and drink for 3 days. For each day, record this information on a daily food record-keeping form (a sample form follows). To determine the nutritional value of your food items, you can use the “SuperTracker” tools at www.choosemyplate.gov/.
At the end of each day, add the amounts in each column and write the totals at the bottom of the form. Determine your average intake of calories and nutrients for that period. (Add the three daily totals for calories, then divide by 3. Do the same for each nutrient listed in the record-keeping form.) You can evaluate the nutritional quality of your diet by comparing your average intakes with the Dietary Reference Intakes (DRIs) for those nutrients, which are shown in Appendix C.
1. Write a one-page description of the nutritional quality of your diet; in your summary, provide answers to the following questions: a. Did your average intake of calories and nutrients meet at least 75% of the DRIs for your age
and gender? b. If your average intake of one or more nutrients did not meet 75% of the DRIs, which foods
could you add to your diet to boost the amounts of the nutrient(s) you are lacking? c. For each of the 3 days, what percentages of your calories were from protein, fat, and alcohol? d. If the percentage of calories from fat exceeded 35%, which foods contributed to your high
fat intake? 2. Do you need to make any changes to improve the nutritional quality of your diet? Would you
like to eat more fruits or vegetables? Should you replace whole or reduced-fat (2%) milk with nonfat milk? Do you need more calcium or iron in your diet? Do you think you eat too much sugar, salt, or fat?
3. Use your responses to number 2 to complete the Changing Health Habits activity for this chapter.
SELF#ASSESSMENT 1
Assessing the Nutritional Quality of Your Diet
9CHAPTER
636 Student Workbook Copyright © Jones & Bartlett Learning 2019
Daily Food Record Name _____________________________________
Date _________
Food Item Amount Eaten
Calories Prot. (g)
Fat* (g)
Vit. D (mg)
Vit. C (mg)
Vit. E (mg)
Folate (mg)
Calcium (mg)
Iron (mg)
Totals
*No DRI
Total calories from alcohol ____________
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 2 637
CHAPTER 9 SELF#ASSESSMENT 2
Diabetes Risk Test
ARE YOU AT RISK?
American Diabetes Association
ALERT DAY
Calculate Your Chances for Type 2 or Pre-Diabetes DIABETES RISK TEST
© 2009 American Diabetes Association. Available at www.diabetes.org/risktest. Reproduced with permission of The American Diabetes Association.
638 Student Workbook Copyright © Jones & Bartlett Learning 2019
Start here
LOW RISK: Right now your risk for having pre-diabetes or diabetes is low. But your risk goes up as you get older. Talk to your doctor about how to keep your risk low.
AT RISK FOR PRE-DIABETES: You are at higher risk for pre-diabetes which means your blood glucose is higher than normal but not high enough to be diagnosed as diabetes. Talk to your doctor about ways to reduce your risk for diabetes.
STOP DIABETES.
I-800-DIABETES diabetes.org/risktest
HIGH RISK: You are at higher risk for having type 2 diabetes. However, only your doctor can tell for sure if you do have type 2 diabetes. Talk to your doctor to see if additional testing is needed.
WEIGHTHEIGHT
4’10” 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5”
148 LBS 153 LBS 158 LBS 164 LBS 169 LBS 175 LBS 180 LBS 186 LBS 192 LBS 198 LBS 203 LBS 209 LBS 216 LBS 222 LBS 228 LBS 235 LBS 241 LBS 248 LBS 254 LBS 261 LBS
Q: Have you ever been told by a doctor or other health professional that you had hypertension (high blood pressure)?
Q: Are you Caucasian (white)?
Q: Does your mother, father, sister or brother
have diabetes?
Q: Are you under 57 years of age?
Q: At your height (see AT-RISK WEIGHT
CHART), is your weight equal to or more than
tha at-risk weight?
Q: At your height (see AT-RISK WEIGHT
CHART), is your weight equal to or more than
tha at-risk weight?
Q: Have you ever developed diabetes during pregnancy?
Question: Are you under
45 years of age?
Yes No
NoNo
No
No
Yes Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
AT-RISK WEIGHT CHART
© 2009 American Diabetes Association. Available at www.diabetes.org/risktest. Reproduced with permission of The American Diabetes Association.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 3 639
To complete this self-assessment, you will need to access MyPlate via the Internet. When you open your Web browser, type www.choosemyplate.gov/myplate/index.aspx in the address window. "is will take you to the U.S. Department of Agriculture’s MyPlate page. Insert your age in the appropriate box. In the other boxes, select your sex, weight, height, and the activity level that approximates your physical activity habits most days of the week. Fill in the same information below. Age _____ Sex _____ Weight _____ Height _____ Physical Activity Level ________________________________________________
Click on the Submit button. "e next page provides a personalized plan that includes informa- tion about the number of calories you need to support your activity level as well as amounts of foods from each food group that you should eat daily. By following this food pattern, you are likely to obtain the nutrients you need each day and maintain your body weight.
Part I Complete the following table with the information provided at your personal Daily Food Plan page. Note that vegetables are divided into subgroups, and amounts for weekly consumption are recom- mended for each subgroup. Daily amounts are suggested for the other food groups.
Food Group Amount of Food
Grains * ____ ounces (refined grains)
____ ounces (whole grains)
Vegetables (daily)
Dark green (weekly)
Red and orange (weekly)
Beans and peas (weekly)
Starchy (weekly)
Other (weekly)
____ cups
____ cups
____ cups
____ cups
____ cups
____ cups
Fruits ____ cups
Dairy ____ cups
CHAPTER 9 SELF#ASSESSMENT 3
Using MyPlate
640 Student Workbook Copyright © Jones & Bartlett Learning 2019
Food Group Amount of Food
Protein Foods ____ ounces
Oils (daily) ____ teaspoons
* At least half of your choices from the grains group should be whole grains.
Part II Use the MyPlate Daily Food Record form to record everything you eat and drink for a day. You’ll need to estimate the amounts of foods and beverages eaten and place that !gure in the middle col- umn. If you need to record information for more than one day, make copies of the form before you use it.
Name
MyPlate Daily Food Record
Food/Beverage Item Consumed Amount Consumed (Ounces/Cups)
MyPlate Plan Food Group
Copyright © Jones & Bartlett Learning 2019 Self-Assessment 3 641
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Part III Self-Evaluation 1. According to your records, did you eat the recommended amounts of foods from each food
group? ____ yes ____ no a. If you did not eat the recommended amounts, identify the food groups that had inadequate
intakes.
2. Explain why this day’s food intake was typical or unusual for you.
3. As a result of completing this activity, describe at least one step you can take to improve your daily food choices.
642 Student Workbook Copyright © Jones & Bartlett Learning 2019
CHAPTER 9 CHANGING HEALTH HABITS
Are You Ready to Improve Your Diet?
A$er completing the summary for the nutritional assessment activity in Self-Assessments 1 and 3 of this chapter, do you think you need to improve the nutritional quality of your diet? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you determine whether you are ready to improve your diet and what the health bene!ts might be if you do so. If you decide to change some food-related habits, use the “Implementing the Change” section of the worksheet to help you make your dietary changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that improves the nutritional quality of your diet. If your cons out- weigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
Copyright © Jones & Bartlett Learning 2019 Changing Health Habits 643
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 645
U se the following activity to estimate your daily caloric needs. A. Estimating energy needs for basal metabolism: 1. Convert your body weight to kilograms. Since each pound equals about 2.2 kilograms, divide
your weight in pounds by 2.2 to obtain your weight in kilograms.
____ weight in pounds ÷ 2.2 = ____ kilograms (kg)
2. To sustain its basal metabolic needs, the body needs about 1.0 calorie per kg of body weight per hour (men) or 0.9 calorie per kg of body weight per hour (women). To estimate the amount of calories you need for basal metabolism in an hour, multiply your body weight (kg) by 1.0 if you are male or 0.9 if you are female.
____ body weight (kg) / 1.0 or 0.9 = _____ calories per hour
3. To estimate the amount of calories you need for basal metabolism in a day, multiply the amount of calories you obtained in step 2 by 24 (hours in a day).
______ calories per hour / 24 hours = ______ calories per day (basal metabolism)
B. Estimating energy needs for physical activity: 4. To determine your energy needs for physical activity, you can keep records of every activity you
perform during the day, and the time spent engaging in each activity. An easier but less precise way to estimate your energy expenditures for physical activity is to use the following rule of thumb. To use this method, choose the category of physical activity in the table on the next page that best describes your usual physical activity level. For example, if you spend most of your day sitting while taking classes, studying, and watching TV, you probably have a very light level of activity. If you sit some of the time, but move around while working, you might rate your level of physical activity as light. If you are on your feet most of the time and engage in strenuous work such as li$ing heavy objects, you are probably expending energy at the heavy level of intensity.
My activity level is ____________________
SELF#ASSESSMENT
How Much Energy Do You Use Daily?
10CHAPTER
646 Student Workbook Copyright © Jones & Bartlett Learning 2019
5. Note the Activity Factor in the table below for your level of intensity and gender. For example, if you are male, and you consider your overall physical activity pattern to be in the moderate range, your Activity Factor is 1.7.
"e Activity Factor for my gender and level of physical activity intensity is _____
6. Multiply your basal metabolic energy needs (the number of calories per day estimated in step 3) by the Activity Factor (step 5).
___ calories for basal metabolism / __ Activity Factor = ____calories for physical activity
7. To estimate the number of calories you expend each day for the thermic e#ect of food (TEF), multiply the number of calories determined in step 6 by 0.10.
_____ calories / 0.10 = ___ calories for TEF
8. To estimate your total energy needs for a day, add the number of calories determined in steps 6 and 7.
________ calories for basal metabolism and physical activity + ________ calories for TEF
= ________ total calories
"is is an estimation of the total number of calories you use each day. If you take in more calo- ries than needed, they may be converted to body fat.
9. If you completed the assessment in Chapter 9, you were able to determine an average number of calories that you consumed during the three-day record-keeping period. Is your average caloric intake about the same, greater than, or less than the total number of calories that you need for a day?
____ about the same ____ greater than ____ less than
10. If you continue to consume this average amount of calories, explain what may happen to your body weight.
Activity Factor
Intensity Physical Activity Men Women
Very light Standing, sitting, driving, typing, sewing, cooking, playing cards or a musical instrument
1.3 1.3
Light Walking on a level surface at 2.5–3.0 mph, carpentry, child care, golf, sailing, table tennis
1.6 1.5
Moderate Walking 3.5–4.0 mph, gardening, carrying a load, cycling, skiing, tennis, dancing
1.7 1.6
Heavy Walking uphill carrying a load; digging by hand; playing basketball, football, or soccer; climbing
2.1 1.9
Exceptionally heavy
Athletic training or participation in professional or world-class events 2.4 2.2
Data from Recommended dietary allowances (10th ed.) Copyright © 1989 by the National Academy of Sciences. Courtesy of the National Academies Press, Washington DC.
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Copyright © Jones & Bartlett Learning 2019 Changing Health Habits 647
CHAPTER 10 CHANGING HEALTH HABITS
Altering Caloric Intake and Physical Activity
Do you need to lose or gain weight? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you determine whether you are ready to alter your caloric intake and physical activity level to gain or lose weight. If you decide to change some of your eating and physical activity habits, use the “Implementing the Change” section of the worksheet to help you make the necessary lifestyle changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make the lifestyle changes necessary to lose or gain weight. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
648 Student Workbook Copyright © Jones & Bartlett Learning 2019
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 649
This activity assesses cardiorespiratory (aerobic) !tness. To perform the test, you need a watch with a second hand to record your time, and you need to wear good walking shoes and loose clothes. You should have your physician’s consent before undertaking this exercise test. Instructions 1. Find a measured track or measure 1 mile using your car’s odometer on a level uninterrupted
road. 2. Warm up by walking slowly for 5 minutes. 3. Walk 1 mile as fast as you can, maintaining a steady pace. Note the time that you began walking. 4. When you complete the mile walk, record your time to the nearest second and keep walking at
a slower pace. Count your pulse for 15 seconds and multiply by 4, then record this number. "is gives you your heart rate per minute a$er your test walk.
Heart rate at the end of a mile walk: ______ beats per minute
Time to walk the mile: _____ minutes
5. Remember to stretch once you have cooled down. 6. To !nd your cardiorespiratory !tness level, refer to the appropriate Rockport Fitness Walking
Test™ charts according to your age and sex. "ese show established !tness norms from the American Heart Association.
Using your !tness level chart, !nd your time in minutes and your heart rate per minute. Follow these lines until they meet, and mark this point on your chart. "is tells you how !t you are compared to other individuals of your sex and age category. Level 5 represents the highest !tness level.
"ese charts are based on weights of 170 pounds for men and 125 pounds for women. If you weigh substantially less, your cardiovascular !tness will be slightly underestimated. Conversely, if you weigh substantially more, your cardiovascular !tness will be slightly overestimated.
SELF#ASSESSMENT 1
Cardiorespiratory Fitness: !e Rockport Fitness Walking Test™
11CHAPTER
650 Student Workbook Copyright © Jones & Bartlett Learning 2019
Men’s Fitness Level Chart
Age 20–29
Time (min.) to complete mile walk
120
140
160
180
200
220
8 1210 14 16 18 20 22
H e
a rt
R a
te (b
e a
ts p
e r
m in
.)
Age 30–39
Time (min.) to complete mile walk
120
140
160
180
200
220
8 1210 14 16 18 20 22
H e
a rt
R a
te (b
e a
ts p
e r
m in
.)
Age 40–49
Time (min.) to complete mile walk
100
120
140
160
180
200
9 1311 15 17 19 21
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Age 50–59
Time (min.) to complete mile walk
Level 5
Level 4
Level 3
Level 2
Level 1
100
120
140
160
180
200
1210 14 16 18 20 22
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Age 60+
Time (min.) to complete mile walk
100
120
140
160
180
200
1210 14 16 18 20 22
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Level 5
Level 4
Level 3
Level 2
Level 1
Level 5
Level 4
Level 3
Level 2
Level 1
Level 5
Level 4
Level 3
Level 2
Level 1
Level 5
Level 4
Level 3
Level 2
Level 1
Age 20–29
Age 30–39
Age 40–49
Age 50–59
Age 60+
Women’s Fitness Level Chart
Time (min.) to complete mile walk
120
140
160
180
200
220
10 1412 16 18 20
H e
a rt
R a
te (b
e a
ts p
e r
m in
.)
Time (min.) to complete mile walk
120
140
160
180
200
220
1210 14 16 18 20
H e
a rt
R a
te (b
e a
ts p
e r
m in
.)
Time (min.) to complete mile walk
100
120
140
160
180
200
10 1412 16 18 20
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Time (min.) to complete mile walk
100
120
140
160
180
200
1311 15 17 19 21
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Time (min.) to complete mile walk
80
100
120
140
160
180
12 14 16 18 20 22
H e a rt
R a
te (b
e a ts
p e r
m in
.)
Level 5
Level 4 Level
3 Level 2 Level 1
Level 5
Level 4
Level 3 Level
2 Level 1
Level 5
Level 4
Level 3 Level
2 Level 1
Level 5
Level 4 Level
3 Level 2 Level 1
Level 5
Level 4
Level 3 Level
2 Level 1
Reproduced with permission of the Rockport Company, Inc., Canton, MA. © 1989 The Rockport Company, Inc. All rights reserved.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 2 651
CHAPTER 11 SELF#ASSESSMENT 2
Push-Up Test for Muscular Endurance
The push-up test can help assess your muscular endurance. To take the test, follow these instructions. Procedure
Men • Assume the standard position for a push-up, with the body rigid and straight, toes tucked
under, and hands about shoulder-width apart and straight under the shoulders. • Lower the body until the elbows reach 90 degrees. Some prefer to place an object such as a
paper cup beneath to touch. • Return to the starting position with the arms fully extended. • "e most common error is not keeping the back straight and rigid throughout the entire
push-up. • Count the number of push-ups you can perform in one minute. • See the accompanying table for your !tness level.
Women Women tend to have less upper body strength and therefore should use the modi!ed push-up posi- tion to assess their upper body endurance. "e test is performed as follows:
• Directions are the same for women as for men, except that women should perform the test from the bent-knee position. Make sure that your hands are slightly ahead of your shoulders in the up position so that when you are in the down position, your hands are directly under the shoulders.
• Keep the back straight and rigid throughout the entire push-up. • Count the number of push-ups you can perform in one minute. • See the accompanying table to rate your muscular endurance.
Note: Women who wish to do full-body push-ups can rate their performance by using the table on the next page.
652 Student Workbook Copyright © Jones & Bartlett Learning 2019
Muscular Endurance Ratings 1-Minute Push-Up
Males
Age
% 20–29 30–39 40–49 50–59 Endurance Level
99 100 86 64 51
95 62 52 40 39 Superior
90 57 46 36 30
85 51 41 34 28
80 47 39 30 25 Excellent
75 44 36 29 24
70 41 34 26 21
65 39 31 25 20
60 37 30 24 19 Good
55 35 29 22 17
50 33 27 21 15
45 31 25 19 14
40 29 24 18 13 Fair
35 27 21 16 11
30 26 20 15 10
25 24 19 13 9.5
20 22 17 11 9 Poor
15 19 15 10 7
10 18 13 9 6
5 13 9 5 3 Very Poor
n 1,045 790 364 172
Total n = 2,371
Note: Norms are based on worksite wellness program participants.
Reproduced with permission from The Cooper Institute®, Dallas, Texas, from a book called Physical Fitness Assessments and Norms for Adults and Law Enforcement. Available online at www.CooperInstitute.org
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Muscular Endurance Ratings 1-Minute Modified Push-Up
Female
Age
% 20–29 30–39 40–49 50–59 Endurance Level
99 70 56 60 31
95 45 39 33 28 Superior
90 42 36 28 25
85 39 33 26 23
80 36 31 24 21 Excellent
75 34 29 21 20
70 32 28 20 19
65 31 26 19 18
60 30 24 18 17 Good
55 29 23 17 15
50 26 21 15 13
45 25 20 14 13
40 23 19 13 12 Fair
35 22 17 11 10
30 20 15 10 9
25 19 14 9 8
20 17 11 6 6 Poor
15 15 9 4 4
10 12 8 2 1
5 9 4 1 0 Very Poor
n 579 411 246 105
Total n = 1,341
Note: Norms are based on worksite wellness program participants.
Reproduced with permission from The Cooper Institute®, Dallas, TX, from a book called Physical Fitness Assessments and Norms for Adults and Law Enforcement. Available online at www.CooperInstitute.org
654 Student Workbook Copyright © Jones & Bartlett Learning 2019
Muscular Endurance Ratings 1-Minute Full-Body Push-Up*
Females
Age
% 20–29 30–39 40–49 Endurance Level
99 53 48 23
95 42 39.5 20 Superior
90 37 33 18
85 33 26 17
80 28 23 15 Excellent
75 27 19 15
70 24 18 14
65 23 16 13
60 21 15 13 Good
55 19 14 11
50 18 14 11
45 17 13 10
40 15 11 9 Fair
35 14 10 8
30 13 9 7
25 11 9 7
20 10 8 6 Poor
15 9 6.5 5
10 8 6 4
5 6 4 1
1 3 1 0 Very Poor
* Full-body push-ups are generally used by law enforcement and public safety organizations. These norms are based on > 1,000 female U.S. Army soldiers who were tested in the 1990s by the U.S. Army.
Reproduced with permission from The Cooper Institute®, Dallas, TX, from a book called Physical Fitness Assessments and Norms for Adults and Law Enforcement. Available online at www.CooperInstitute.org
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CHAPTER 11 SELF#ASSESSMENT 3
Sit-and-Reach Test for Flexibility Assessment
The sit-and-reach test can help assess your 'exibility. Read the following precautions, and if they do not apply, take the test. Precautions If any of the following apply, seek medical advice before performing the test.
• You are presently su#ering from acute back pain. • You are currently receiving treatment for back pain. • You have ever had a surgical operation on your back. • A healthcare professional told you to never exercise your back.
Procedure Warm up. Stop the test if pain occurs. Do not perform fast, jerky movements.
Step 1: Sit on the 'oor with your legs straight and knees together. Your toes should point upward toward the ceiling and rest against the side of a box.
Step 2: Place one hand over the other. "e tips of your two middle !ngers should be on top of each other.
656 Student Workbook Copyright © Jones & Bartlett Learning 2019
Step 3: Slowly stretch forward without bouncing or jerking. Stop when tightness or discomfort occurs in the back or legs. Measure how far your hands reached on the top of the box.
Step 4: Repeat this test two more times and record scores.
First attempt _________ points
Second attempt _________ points
Third attempt _________ points
How to score (average of 3 attempts)
Reached well past toes and side of box
Reached just to toes
Up to 4 inches from toes (did not reach side of box)
More than 4 inches from toes (did not reach side of box)
1 point; excellent
2 points; good
3 points; fair
4 points; poor
Reproduced from David Imrie. (1998). Back power. Toronto, Canada: Stoddart.
Total points = _______ divided by 3 = ________ points, which is rated as _________.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 4 657
T est your knowledge about the e#ects that physical activity can have on your heart. Mark each statement true or false. Answers are on the following page. 1. Regular physical activity can reduce your chances of getting heart disease. T F
2. Most people get enough physical activity from their normal daily routines. T F
3. You don’t have to train like a marathon runner to become more physically fit. T F
4. Exercise programs do not require a lot of time to be very effective. T F
5. People who need to lose some weight are the only ones who will benefit from regular physical activity.
T F
6. All exercises give you the same benefits. T F
7. The older you are, the less active you need to be. T F
8. It doesn’t take a lot of money or expensive equipment to become physically fit. T F
9. There are many risks and injuries that can occur with exercise. T F
10. You should consult a doctor before starting a physical activity program. T F
11. People who have had a heart attack should not start any physical activity program.
T F
12. To help stay physically active, include a variety of activities. T F
How well did you do?
CHAPTER 11 SELF#ASSESSMENT 4
Check Your Physical Activity and Heart Disease IQ
658 Student Workbook Copyright © Jones & Bartlett Learning 2019
Answers to the Check Your Physical Activity and Heart Disease IQ Quiz 1. True. Heart disease is almost twice as likely to develop in inactive people. Being physically
inactive is a risk factor for heart disease, along with cigarette smoking, having high blood pres- sure, having high blood cholesterol, and being overweight. "e more risk factors you have, the greater your chance for heart disease. Regular physical activity (even mild to moderate exercise) can reduce this risk.
2. False. Most Americans are very busy but not very active. Every American adult should make a habit of getting at least 30 minutes of low to moderate levels of physical activity daily. "is includes walking, gardening, and walking up stairs. If you are inactive now, begin by doing a few minutes of activity each day. If you only do some activity every once in a while, try to work something into your routine every day.
3. True. Low- to moderate-intensity activities, such as pleasure walking, stair climbing, yard work, housework, dancing, and home exercises can have both short- and long-term bene!ts. If you are inactive, the key is to get started. One great way is to take a walk for 10–15 minutes during your lunch break, or take your dog for a walk every day. At least 30 minutes of physical activity every day can help improve your heart health.
4. True. It takes only a few minutes a day to become more physically active. If you don’t have 30%minutes in your schedule for an exercise break, try to !nd two 15-minute periods or even three 10-minute periods. "ese exercise breaks will soon become a habit you can’t live without.
5. False. People who are physically active experience many positive bene!ts. Regular physical activity gives you more energy, reduces stress, and helps you to sleep better. It helps to lower high blood pressure and improves blood cholesterol levels. Physical activity helps to tone your muscles, burns o# calories to help you lose extra pounds or stay at your desirable weight, and helps control your appetite. It can also increase muscle strength, help your heart and lungs work more e&ciently, and let you enjoy your life more fully.
6. False. Low-intensity activities—if performed daily—can have some long-term health bene!ts and can lower your risk of heart disease. Regular brisk, sustained exercise for at least 30 minutes three to four times a week, such as brisk walking, jogging, or swimming, is necessary to improve the e&ciency of your heart and lungs and burn o# extra calories. "ese activities are called aerobic—meaning the body uses oxygen to produce the energy needed for the activity. Other activities, depending on the type, may give you other bene!ts such as increased 'exibility or muscle strength.
7. False. Although we tend to become less active with age, physical activity is still important. In fact, regular physical activity in older persons increases their capacity to do everyday activities. In general, middle-aged and older people bene!t from regular physical activity just as young people do. What is important, at any age, is tailoring the activity program to your own !tness level.
8. True. Many activities require little or no equipment. For example, brisk walking only requires a comfortable pair of walking shoes. Many communities o#er free or inexpensive recreation facil- ities and physical activity classes. Check your shopping malls, because many of them are open early and late for people who do not wish to walk alone, in the dark, or in bad weather.
9. False. Under normal conditions, exercise does not involve many risks and injuries. However, the most common risk in exercising is injury to the muscles and joints. Such injuries are usually caused by exercising too hard for too long, particularly if a person has been inactive. To avoid injuries, try to build up your level of activity gradually, listen to your body for warning pains, be aware of possible signs of heart problems (such as pain or pressure in the le$ or mid-chest area, le$ neck, shoulder, or arm during or just a$er exercising, or sudden light-headedness, cold sweat, pallor, or fainting), and be prepared for special weather conditions.
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10. True. You should ask your doctor before you start (or greatly increase) your physical activity if you have a medical condition such as high blood pressure, have pains or pressure in the chest and shoulder, feel dizzy or faint, get breathless a$er mild exertion, are middle-aged or older and have not been physically active, or plan a vigorous activity program. If none of these apply, start slow and get moving.
11. False. Regular physical activity can help reduce your risk of having another heart attack. People who include regular physical activity in their lives a$er a heart attack improve their chances of survival and can improve how they feel and look. If you have had a heart attack, consult your doctor to be sure you are following a safe and e#ective exercise program that will help prevent heart pain and further damage from overexertion.
12. True. Pick several di#erent activities that you like doing. You will be more likely to stay with it. Plan short-term and long-term goals. Keep a record of your progress, and check it regularly to see the progress you have made. Get your family and friends to join in. "ey can help keep you going.
Reproduced from U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute.
660 Student Workbook Copyright © Jones & Bartlett Learning 2019
A$er completing the cardiorespiratory !tness assessment in the workbook, do you think you need to increase your physical activity level to become more !t? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you identify the health bene!ts of adding physical activity to your schedule and decide whether you are ready to do so. If you choose to increase your present level of physical activity, use the “Implementing the Change” section of the worksheet to help you.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change that increases your level of physical activity. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 11 CHANGING HEALTH HABITS
Do You Want to Be More Physically Active?
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the exercise-related behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 663
In general, the higher your LDL level and the more risk factors you have (other than LDL), the greater your chances of developing heart disease or having a heart attack. Some people are at high risk for a heart attack because they already have heart disease. Other people are at high risk for developing heart disease because they have diabetes (which is a strong risk factor) or a combination of risk factors for heart disease. Follow these steps to !nd out your risk for developing heart disease. Step 1: Check the following table to see how many of the listed risk factors you have; these are the risk factors that a#ect your LDL goal.
Major Risk Factors That Affect Your LDL Goal • Cigarette smoking
• High blood pressure (140/90 mm Hg or higher or on blood pressure medication)
• Low HDL cholesterol (less than 40 milligrams per deciliter [mg/dL])*
• Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65)
• Age (men 45 years or older; women 55 years or older)
* If your HDL cholesterol is 60 mg/dL or higher, subtract 1 from your total count.
Even though obesity and physical inactivity are not counted in this list, they are conditions that need to be corrected. Step 2: How many major risk factors do you have? If you have two or more risk factors in the bul- leted list above, use the risk scoring tables at the end of this assessment (which include your cho- lesterol levels) to !nd your risk score. Risk score refers to the chance of having a heart attack in the next 10 years, given as a percentage. My risk score is ________%. Step 3: Use your medical history, number of risk factors, and risk score to !nd your risk of develop- ing heart disease or having a heart attack in the following table.
SELF#ASSESSMENT
What Is Your Risk of Developing Heart Disease or
Having a Heart Attack?
12CHAPTER
664 Student Workbook Copyright © Jones & Bartlett Learning 2019
If You Have You Are in Category
Heart disease, diabetes, or risk score more than 20%* I. High Risk
2 or more risk factors and risk score 10–20% II. Next Highest Risk
2 or more risk factors and risk score less than 10% III. Moderate Risk
0 or 1 risk factor IV. Low-to-Moderate Risk
* Means that more than 20 of 100 people in this category will have a heart attack within 10 years.
My risk category is ______________________.
Treating High Cholesterol "e main goal of cholesterol-lowering treatment is to lower your LDL level enough to reduce your risk of developing heart disease or having a heart attack. "e higher your risk, the lower your LDL goal will be. To !nd your LDL goal, see the bulleted list that follows for your risk category. "ere are two main ways to lower your cholesterol:
1. "erapeutic lifestyle changes (TLC): includes a cholesterol-lowering diet (called the TLC diet), physical activity, and weight management. TLC is for anyone whose LDL is above goal.
2. Drug treatment: If cholesterol-lowering drugs are needed, they are used together with TLC treatment to help lower your LDL.
If you are in . . .
• Category I, Highest Risk, your LDL goal is less than 100 mg/dL. You will need to begin the TLC diet to reduce your high risk even if your LDL is below 100 mg/dL. If your LDL is 100 or above, you will need to start drug treatment at the same time as the TLC diet. If your LDL is below 100 mg/dL, you may also need to start drug treatment together with the TLC diet if your doctor !nds your risk is very high—for example, if you had a recent heart attack or have both heart disease and diabetes.
• Category II, Next Highest Risk, your LDL goal is less than 130 mg/dL. If your LDL is 130%mg/dL or above, you will need to begin treatment with the TLC diet. If your LDL is 130 mg/dL or more a$er 3 months on the TLC diet, you may need drug treatment along with the TLC diet. If your LDL is less than 130 mg/dL, you will need to follow the heart-healthy diet for all Americans, which allows a little more saturated fat and cholesterol than the TLC diet.
• Category III, Moderate Risk, your LDL goal is less than 130 mg/dL. If your LDL is 130 mg/dL or above, you will need to begin the TLC diet. If your LDL is 160 mg/dL or more a$er you have tried the TLC diet for 3 months, you may need drug treatment along with the TLC diet. If your LDL is less than 130 mg/dL, you will need to follow the heart-healthy diet for all Americans.
• Category IV, Low to Moderate Risk, your LDL goal is less than 160 mg/dL. If your LDL is 160%mg/dL or above, you will need to begin the TLC diet. If your LDL is still 160 mg/dL or more a$er 3 months on the TLC diet, you may need drug treatment along with the TLC diet to%lower your LDL, especially if your LDL is 190 mg/dL or more. If your LDL is less than 160%mg/dL, you will need to follow the heart-healthy diet for all Americans.
To reduce your risk for heart disease or keep it low, it is very important to control any other risk factors you may have, such as high blood pressure and smoking.
Lowering Cholesterol with Therapeutic Lifestyle Changes TLC is a set of things you can do to help lower your LDL cholesterol. "e main parts of TLC are:
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• "e TLC diet. "is is a low-saturated-fat, low-cholesterol eating plan that calls for less than 7% of calories from saturated fat and less than 200 mg of dietary cholesterol per day. "e TLC diet recommends only enough calories to maintain a desirable weight and avoid weight gain. If your LDL is not lowered enough by reducing your saturated fat and cholesterol intakes, the amount of soluble !ber in your diet can be increased. Certain food products that contain plant stanols or plant sterols (for example, cholesterol-lowering margarines) can also be added to the TLC diet to boost its LDL-lowering power.
• Weight management. Losing weight if you are overweight can help lower LDL and is especially important for those with a cluster of risk factors that includes high triglyceride and/or low HDL levels and being overweight with a large waist measurement (more than 40 inches for men and more than 35 inches for women).
• Physical activity. Regular physical activity (30 minutes on most days, if not every day) is recommended for everyone. It can help raise HDL and lower LDL and is especially important for those with high triglyceride and/or low HDL levels who are overweight with a large waist measurement.
Foods low in saturated fat include fat-free or 1% dairy products, lean meats, fish, skinless poultry, whole grain foods, and fruits and vegetables. Look for soft margarines (liquid or tub varieties) that are low in saturated fat and contain little or no trans fat (another type of dietary fat that can raise your cholesterol level). Limit foods high in cholesterol, such as liver and other organ meats, egg yolks, and full-fat dairy products.
Good sources of soluble fiber include oats, certain fruits (such as oranges and pears) and veg- etables (such as brussels sprouts and carrots), and dried peas and beans.
Drug Treatment Even if you begin drug treatment to lower your cholesterol, you will need to continue your treatment with lifestyle changes. "is will keep the dose of medicine as low as possible, and lower your risk in other ways as well. "ere are several types of drugs available for cholesterol lowering, including statins, bile acid sequestrants, nicotinic acid, !bric acids, and cholesterol absorption inhibitors. Your doctor can help decide which type of drug is best for you. "e statin drugs are very e#ective in lowering LDL levels and are safe for most people. Bile acid sequestrants also lower LDL and can be used alone or in combination with statin drugs. Nicotinic acid lowers LDL and triglycerides and raises HDL. Fibric acids lower LDL somewhat but are used mainly to treat high triglyceride and low HDL levels. Cho- lesterol absorption inhibitors lower LDL and can be used alone or in combination with statin drugs.
Note: Before beginning any diet and exercise regimen, you should speak with your physician to be sure it is right for you. Your physician will also advise you whether you should begin drug treatment to lower your cholesterol level.
Once your LDL goal has been reached, your doctor may prescribe treatment for high triglycer- ides and/or a low HDL level, if present. "e treatment includes losing weight if needed, increasing physical activity, quitting smoking, and possibly taking a drug.
Resources For more information about lowering cholesterol and lowering your risk for heart disease, write to the NHLBI Health Information Center, P.O. Box 30105, Bethesda, MD, 20824-0105 or call 301-592-8573. Reproduced from National Heart, Lung, and Blood Institute. (2005). High blood cholesterol: What you need to know. Retrieved from http://www.nhlbi.nih.gov/health/public/heart/chol/hbc_what.htm
666 Student Workbook Copyright © Jones & Bartlett Learning 2019
Risk Scoring Tables: Estimate of 10-Year Risk for Coronary Heart Disease
Men (Framingham Point Scores)*
Age Points
20–34 –9
35–39 –4
40–44 0
45–49 3
50–54 6
55–59 8
60–64 10
65–69 11
70–74 12
75–79 13
Women (Framingham Point Scores)*
Age Points
20–34 –7
35–39 –3
40–44 0
45–49 3
50–54 6
55–59 8
60–64 10
65–69 12
70–74 14
75–79 16
Points
Total Cholesterol
Age 20–39
Age 40–49
Age 50–59
Age 60–69
Age 70–79
<160 0 0 0 0 0
160–199 4 3 2 1 0
200–239 7 5 3 1 0
240–279 9 6 4 2 1
!280 11 8 5 3 1
Points
Total Cholesterol
Age 20–39
Age 40–49
Age 50–59
Age 60–69
Age 70–79
<160 0 0 0 0 0
160–199 4 3 2 1 1
200–239 8 6 4 2 1
240–279 11 8 5 3 2
!280 13 10 7 4 2
Points
Age 20–39
Age 40–49
Age 50–59
Age 60–69
Age 70–79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1
Points
Age 20–39
Age 40–49
Age 50–59
Age 60–69
Age 70–79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1
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Systolic BP (mmHg) If Untreated If Treated
<120 0 0
120–129 0 1
130–139 1 2
140–159 1 2
!160 2 5
Systolic BP (mmHg) If Untreated If Treated
<120 0 0
120–129 1 3
130–139 2 4
140–159 3 5
!160 4 6
HDL (mg/dL) Points
!60 –1 50–59 0
40–49 1
<40 2
HDL (mg/dL) Points
!60 –1 50–59 0
40–49 1
<40 2
Point Total 10-Year Risk
(%)
<0 <1
0 1
1 1
2 1
3 1
4 1
5 2
6 2
7 3
8 4
9 5
10 6
11 8
12 10
13 12
14 16
15 20
16 25
!17 !30 10-year risk ______%
Point Total 10-Year Risk
(%)
<9 <1
9 1
10 1
11 1
12 1
13 2
14 2
15 3
16 4
17 5
18 6
19 8
20 11
21 14
22 17
23 22
24 27
!25 !30 10-year risk ______%
* Reproduced from The Framingham Heart Study, a long-term ongoing medical study conducted by the National Heart, Lung, and Blood Institute.
668 Student Workbook Copyright © Jones & Bartlett Learning 2019
In completing the “Applying What You Have Learned” questions for this chapter in the textbook, you analyzed your lifestyle to determine which modi!able risk factors are raising your prob-ability of developing cardiovascular disease. "en you described how you could modify your behavior to lower your risk of developing cardiovascular disease. Pick one of these behaviors and take the following steps to facilitate change.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that reduces your risk of cardiovascular disease. If your cons out- weigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 12 CHANGING HEALTH HABITS
Reducing Your Risk of Cardiovascular Disease
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods to reach your goal. b. Gather information about each method. c. Choose the method that !ts your situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 671
Breast or Ovarian Cancer 1. Are you female? Yes No
2. Do you have a family history of breast and/or ovarian cancer? Yes No
3. Are you over the age of 18? Yes No
4. Do you have at least one first-degree relative (mother, sister, daughter) with breast or ovarian cancer?
Yes No
If you answered yes to all these questions, you may be at increased risk of developing breast or ovarian cancer.
Prostate Cancer 1. Are you male? Yes No
2. Are you African American? Yes No
3. Do you have a family history of prostate cancer? Yes No
4. Do you have one first-degree relative (father, brother, or son) with prostate cancer? Yes No
5. Was your relative diagnosed at a young age? Yes No
If you answered yes to most of these questions, or if you are an African American male, you may be at increased risk of developing prostate cancer.
Skin Cancer (Melanoma) 1. Do you have one or more first-degree relatives (parent, brother, sister, child) with
a history of melanoma? Yes No
2. Do you experience severe blistering sunburns (especially at young ages)? Yes No
3. Do you sit in the sun with the purpose of getting tan, use tanning lamps, or visit tanning booths?
Yes No
4. Do you have red or blond hair and fair skin that freckles or sunburns easily? Yes No
If you answered yes to any of these questions, you may be at increased risk of developing skin cancer (melanoma).
SELF#ASSESSMENT
What Are Your Cancer Risks?
13CHAPTER
672 Student Workbook Copyright © Jones & Bartlett Learning 2019
Liver Cancer 1. Have you ever been diagnosed with the hepatitis B virus (HBV) or hepatitis C
virus (HCV)? Yes No
2. Do you drink large amounts of alcohol? Yes No
3. Have you been diagnosed with cirrhosis of the liver (a progressive disorder that leads to scarring of the liver)?
Yes No
If you answered yes to any of these questions, you may be at increased risk of developing liver cancer.
Gastrointestinal Cancer 1. Do you or one of your close relatives have a history of colorectal cancer, colon
polyps, or other cancers (uterine, stomach, bile duct, urinary tract, or ovarian)? Yes No
2. Were you previously treated for colon cancer or polyps? Yes No
3. Do you have inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease?
Yes No
4. Have you consumed foods that contain aflatoxins? Aflatoxins are a group of chemicals produced by a mold that can contaminate certain foods, such as peanuts, corn, grains, and seeds; they are carcinogens (cancer-causing agents) for liver cancer.
Yes No
If you answered yes to one or more of these questions, you may be at increased risk of developing gastrointestinal cancer.
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In completing the “Applying What You Have Learned” questions for this chapter in the textbook, you analyzed your lifestyle to determine which modi!able risk factors are raising your prob-ability of developing cancer. "en you described how you could modify your behavior to lower your risk of developing cancer. Pick one of these behavior changes and take the following steps to facilitate change.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change that reduces your risk of cancer. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 13 CHANGING HEALTH HABITS
Modifying Behavior to Reduce Cancer Risk
674 Student Workbook Copyright © Jones & Bartlett Learning 2019
Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Directions Please read each statement carefully: STIs are sexually transmitted infections, once called venereal diseases. Record your !rst reaction by circling the letter that best describes how much you agree or disagree with the idea.
Use this key: SA = Strongly agree; A = Agree; U = Undecided; D = Disagree; SD = Strongly disagree.
Remember: STIs means sexually transmitted infections, such as gonorrhea, syphilis, genital herpes, chlamydia, HPV, and AIDS.
1. How one uses his or her sexuality has nothing to do with STIs. SA A U D SD 2. It is easy to use the prevention methods that reduce one’s chances of getting an STI. SA A U D SD 3. Responsible sex is one of the best ways of reducing the risk of STIs. SA A U D SD 4. Getting early medical care is the main key to preventing harmful e#ects of STIs. SA A U D SD 5. Choosing the right sex partner is important in reducing the risk of getting an STI. SA A U D SD 6. A high rate of STIs should be a concern for all people. SA A U D SD 7. People with an STI have a duty to get their sex partners to seek medical care. SA A U D SD 8. "e best way to get a sex partner to STI treatment is to take him or her to the doctor with you. SA A U D SD
SELF#ASSESSMENT
STI Attitude Scale
14CHAPTER
676 Student Workbook Copyright © Jones & Bartlett Learning 2019
9. Changing one’s sex habits is necessary once the presence of an STI is known. SA A U D SD 10. I would dislike having to follow the medical steps for treating an STI. SA A U D SD 11. If I were sexually active, I would feel uneasy doing things before and a$er sex to prevent getting
an STI. SA A U D SD 12. If I were sexually active, it would be insulting if a sex partner suggested we use a condom to
avoid STIs. SA A U D SD 13. I dislike talking about STIs with my peers. SA A U D SD 14. I would be uncertain about going to the doctor unless I was sure I really had an STI. SA A U D SD 15. I would feel that I should take my sex partner with me to a clinic if I thought I had an STI. SA A U D SD 16. It would be embarrassing to discuss STIs with one’s partner if one were sexually active. SA A U D SD 17. If I were to have sex, the chance of getting an STI makes me uneasy about having sex with more
than one person. SA A U D SD 18. I like the idea of sexual abstinence (not having sex) as the best way of avoiding STIs. SA A U D SD 19. If I had an STI, I would cooperate with public health persons to !nd the sources of the STI. SA A U D SD 20. If I had an STI, I would avoid exposing others while I was being treated. SA A U D SD 21. I would have regular STI checkups if I were having sex with more than one partner. SA A U D SD 22. I intend to look for STI signs before deciding to have sex with anyone. SA A U D SD 23. I will limit my sexual activity to just one partner because of the chances I might get an STI. SA A U D SD 24. I will avoid sexual contact anytime I think there is even a slight chance of getting an STI. SA A U D SD 25. "e chance of getting an STI would not stop me from having sex. SA A U D SD 26. If I had a chance, I would support community e#orts toward controlling STIs. SA A U D SD 27. I would be willing to work with others to make people aware of STI problems in my town. SA A U D SD
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Scoring Calculate total points for each subscale and total scale, using the point values below. For items 1, 10–14, 16, 25: Strongly agree = 5 points; Agree = 4 points; Undecided = 3 points; Disagree = 2 points; and Strongly disagree = 1 point. For items 2–9, 15, 17–24, 26, 27: Strongly agree = 1 point; Agree = 2 points; Undecided = 3 points; Disagree = 4 points; and Strongly disagree = 5 points. Total scale: items 1–27 Belief subscale: items 1–9 Feeling subscale: items 10–18 Intention to act subscale: items 19–27
Interpretation High score predisposes one toward high-risk STI behavior. Low score predisposes one toward low- risk STI behavior.
Yarber, Torabi, and Veenker (1989) developed the STI Attitudes Scale by administering three experimental forms of 45 items each. Respondents were 2,980 students in six secondary school districts in the Midwest and East. Based on statistical analysis, the scale was reduced to the !nal 27 items. Reliability coe&cients for the entire scale and the three subscales ranged from 0.48 to 0.73. "e developers reported evidence of construct validity in that the scale was sensitive to positive attitude changes resulting from STI education.
Reproduced from Yarber, W. L. (1989). Development of a three-component STD attitude scale. Journal of Sex Education and Therapy, 15, 36–39. © 1989. Reprinted with permission of American Association of Sex Educators Couns. & Ther.
678 Student Workbook Copyright © Jones & Bartlett Learning 2019
In completing the “Applying What You Have Learned” questions for this chapter in the textbook, you analyzed your risk for contracting STIs. "en you determined what you could do to lower your risk of contracting a sexually transmitted infection. Pick one of these behavior changes and take the following steps to facilitate change.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change that reduces your risk of contracting an STI. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 14 CHANGING HEALTH HABITS
Reducing Your Risk of Contracting an STI
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods to reach your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Answer the following questions. Depending on your situation, some of the questions may not apply. 1. Are you doing anything to increase your chances of living a long and healthy
life? ___ Yes ___ No
If you answered yes, discuss the steps you are taking to live a long and healthy life.
2. How do you want to spend your retirement years? Are you doing anything to prepare for retirement?
___ Yes ___ No
If you answered yes, what actions are you taking to prepare for retirement?
3. How do you feel about elderly people? Do you think they are “over the hill” and should be “put out to pasture”?
___ Yes ___ No
Why do you feel this way about older adults?
4. Do you worry about growing old? ___ Yes ___ No
If you do, what worries you about aging?
5. Have you prepared a will and a living will or durable power of attorney? ___ Yes ___ No
If yes, have you informed your family about these documents? ___ Yes ___ No
Have you selected a guardian for your children? ___ Yes ___ No
Have you discussed guardianship with this individual? ___ Yes ___ No
6. Have you thought about your funeral? ___ Yes ___ No
If you have thought about your funeral, what kind of funeral would you want?
Do you want to be buried or cremated?
Have you discussed your wishes with your family? ___ Yes ___ No
Have you made funeral prearrangements? ___ Yes ___ No
7. Have you considered donating your body or your tissues or organs after your death?
___ Yes ___ No
If you want to donate your body, tissues, or organs, have you made any preparations and informed relatives? Do you carry a card in your wallet that identifies you as a donor?
___ Yes ___ No
8. If you were told that you have a terminal disease and have only 6 months to live, how would you spend these last months of your life?
9. Have you written your obituary? ___ Yes ___ No
What would you like people to remember most about you?
Examine your responses to these questions; there are no correct answers.
SELF#ASSESSMENT
Preparing for Aging and Death
15CHAPTER
682 Student Workbook Copyright © Jones & Bartlett Learning 2019
Do you have a habit, such as cigarette smoking, that increases your chances of dying pre-maturely? Which habit? "e “Deciding to Change” section of the Changing Health Habits worksheet can help you determine whether you are ready to change this habit. If you decide to change, use the “Implementing the Change” section of the worksheet to help you make the neces- sary lifestyle changes.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make the lifestyle changes necessary to change the unhealthy habit. If your cons outweigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 15 CHANGING HEALTH HABITS
Can Changing a Health Habit Extend Your Life?
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Implementing the Change 1. Set a target date to begin the new behavior or reach the goal. 2. Identify and list the factors that will help you reach your goal and those that will stand in the
way of reaching your goal. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods to reach your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
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Copyright © Jones & Bartlett Learning 2019 Self-Assessment 1 685
The home areas listed below are the most common sites of accidental poisonings. Follow this checklist to learn how to correct situations that may lead to poisonings. If you answer no to any questions, !x the situation quickly. Your goal is to have all your answers be yes. !e Kitchen
Yes No
1. Do all harmful products in the cabinets have child-resistant caps? Products like furniture polishes, drain cleaners, and some oven cleaners should have safety packaging to keep little children from accidentally opening the packages.
____ ____
2. Are all potentially harmful products in their original containers? There are two dangers if products aren’t stored in their original containers. Labels on the original containers often give first aid information if someone should swallow the product. And if a product is stored in a container like a drinking glass or a soda bottle, someone may think it is food and swallow it.
____ ____
3. Are harmful products stored away from food? If harmful products are placed next to food, someone may accidentally get food and poison mixed up and swallow poison.
____ ____
4. Have all potentially harmful products been put up high and out of reach of children? The best way to prevent poisoning is making sure that it’s impossible to find and get at the poisons. Locking all cabinets that hold dangerous products is the best poison prevention.
____ ____
!e Bathroom Yes No
1. Did you ever stop to think that medicines could poison if used improperly? Many children are poisoned each year by overdoses of aspirin. If aspirin can poison, just think of how many other poisons might be in your medicine cabinet.
____ ____
2. Do your aspirins and other potentially harmful products have child-resistant closures? Aspirins and most prescription drugs come with child-resistant caps. Check to see that yours have them and that they are properly secured. Check your prescriptions before leaving the pharmacy to make sure the medicines are in child-resistant packaging. These caps have been shown to save the lives of children.
____ ____
SELF#ASSESSMENT 1
Poison Lookout Checklist
16CHAPTER
686 Student Workbook Copyright © Jones & Bartlett Learning 2019
Yes No
3. Have you thrown out all out-of-date prescriptions? As medicines get older, the chemicals inside them can change, so what was once a good medicine may now be a dangerous poison. Flush all old drugs down the toilet. Rinse the container well, then discard it.
____ ____
4. Are all medicines in their original containers with the original labels? Prescription medicines may or may not list ingredients. The prescription number on the label will, however, allow rapid identification by the pharmacist of the ingredients if they are not listed. Without the original label and container, you can’t be sure of what you’re taking. After all, aspirin looks a lot like poisonous roach tablets.
____ ____
5. If your vitamins or vitamin/mineral supplements contain iron, are they in child- resistant packaging? Most people think of vitamins and minerals as foods and therefore nontoxic, but a few iron pills can kill a child.
–––– ––––
!e Garage or Storage Area Did you know that many things in your garage or storage area are serious poisons that can be swal- lowed? Death may occur when people swallow such everyday substances as charcoal lighter, paint thinner and remover, antifreeze, and turpentine.
Yes No
1. Do all these poisons have child-resistant caps? ____ ____
2. Are they stored in the original containers? ____ ____
3. Are the original labels on the containers? ____ ____
4. Have you made sure that no poisons are stored in drinking glasses or soda bottles?
____ ____
5. Are all these harmful products locked up and out of sight and reach? –––– ––––
When all your answers are yes, continue this level of poison protection by making sure that when- ever you buy potentially harmful products, they have child-resistant closures and are kept out of sight and reach. Post the number of the Poison Control Center near your telephone.
Courtesy of Consumer Product Safety Commission. CPSC Document 4383.
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Carbon monoxide is o$en referred to as CO, which is its chemical symbol. Unlike many gases, CO is odorless, colorless, tasteless, and nonirritating. Red blood cells absorb CO over 200%times more readily than oxygen. As levels of CO in the air rise, this gas replaces oxygen in the bloodstream. As a result, body tissues are damaged and may die of a lack of oxygen. Knowing the major causes of carbon monoxide poisoning and using measures to eliminate them will prevent many needless tragedies.
"e following questions relating to various areas in your environment will help you in dealing properly with the unseen, deadly hazard of carbon monoxide. "e questions have been divided into sections that may directly apply to your particular situation. You can compare your answers with the correct explanation provided at the end of the list of questions.
Questions Draw a circle around your answer.
The Home, Cabin, and Camper Most questions will apply equally to homeowners, campers, and those who rent. Renters, however, should refer any questions regarding maintenance to the management.
1. Have you had the fireplace draft and the drafts of other fuel-burning appliances checked by an expert within the past year?
Yes No
2. Have all gas appliances been checked annually for proper operation? Yes No
3. Are all combustion appliances properly vented? Yes No
4. Has your chimney vent been checked for defects within the past year? Yes No
5. Have you patched any vent pipe with tape, gum, or other substances? Yes No
6. Are all horizontal vent pipes to fuel appliances perfectly level? Yes No
7. Do you use your gas range or oven for heating? Yes No
8. Does the cooling unit of your gas refrigerator give off an odor? Yes No
9. Have you ever used a charcoal grill such as a barbeque grill for cooking within your home, cabin, or camper other than in a vented fireplace?
Yes No
10. Have you ever brought burning charcoal into your home, cabin, or camper for heating purposes?
Yes No
CHAPTER 16 SELF#ASSESSMENT 2
Checklist for the Prevention of Carbon Monoxide Poisoning
688 Student Workbook Copyright © Jones & Bartlett Learning 2019
11. Do you consider portable flameless chemical heaters (catalytic) safe for use in your cabin, camper, or home?
Yes No
12. Have you ever used a portable gas camp stove in your home, cabin, or camper for heating purposes?
Yes No
The Auto 13. Have you had a reliable mechanic check the exhaust system of your car within
the past year? Yes No
14. Do you ever run your auto engine in the garage while the garage door is shut? Yes No
15. Do you leave the door closed between your attached garage and your house when you run your car engine?
Yes No
16. Do you keep your windows slightly open while driving in heavy traffic, although you have an air conditioner?
Yes No
17. While driving your station wagon, do you lower the tailgate to get a greater flow of air in the car?
Yes No
Other 18. When you are selecting gas equipment, do you buy only those items that carry
the seal of a national testing agency, such as the American Gas Association or the Underwriters’ Laboratory?
Yes No
19. Have you ever converted, or are you about to convert, a fuel burner from one fuel to another without having it done by an expert?
Yes No
20. As an overnight guest at motels or hotels that have heating units located in the room, do you read operating instructions or ask how such appliances operate?
Yes No
Correct Answers
The Home, Cabin, and Camper 1. Yes. A yearly checkup of all fuel-burning venting systems in the home is desirable. 2. Yes. A yearly checkup of all combustion appliances is suggested. In many areas, on request, the
gas company will provide this service. 3. Yes. All gas appliances must have adequate ventilation so that CO will not accumulate. 4. Yes. Chimney vents o$en become blocked by debris, causing a buildup of CO. "ey should be
checked annually. 5. No. O$en a makeshi$ patch can lead to an accumulation of CO and, therefore, should be
avoided. 6. No. In-room vent pipes should be on a slight incline as they go toward the exterior. "is will
reduce leaking of toxic gases in case the joints or pipes are improperly !tted. 7. No. Using a gas range for heating can result in the accumulation of CO. 8. No. An unusual odor from a gas refrigerator o$en is the result of defects within the cooling unit.
Odorless CO also may be given o#. 9. No. "e use of barbecue grills indoors will quickly result in dangerous levels of CO. 10. No. Burning charcoal—whether black, red, gray, or white—gives o# CO.
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11. No. Although catalytic heaters produce heat without 'ame, combustion is occurring that can cause the production of CO.
12. No. Using a gas camp stove for heating the home, cabin, or camper can result in the accumula- tion of CO.
The Auto 13. Yes. Small leaks in the exhaust system of a car can lead to an accumulation of CO in the interior. 14. No. CO can rapidly build up while your auto engine is operated in a closed garage. Never run
your car in a garage unless the outside door is open to provide ventilation. 15. Yes. CO can easily escape from a garage through a connecting door that opens into the house,
although the garage door is open. Doors connecting a garage and house should be kept closed when the auto is running.
16. Yes. Even with an air conditioner, CO can be drawn into a car while it is being driven slowly in heavy tra&c. "erefore, windows should be slightly opened.
17. No. If the tailgate is open, be sure to open vents or windows to increase the 'ow of air in the car. If the tailgate window is open and the other windows or the vents are closed, CO from the exhaust will be drawn into the car.
Other 18. Yes. Buy only equipment carrying the seal of a national testing agency; otherwise, one may get
poorly designed equipment, which may soon result in the production of CO. 19. No. An expert is needed to make proper modi!cations and to evaluate the venting capabilities
of your appliance. 20. Yes. Even with adequately designed and properly installed heating equipment, the improper
operation of this equipment can result in its malfunctioning and lead to the production of CO. "erefore, be sure you understand the correct way to operate any fuel-burning appliance before using it.
Courtesy of Centers for Disease Control and Prevention. HEW Pub. No.(CDC) 77 8335.
690 Student Workbook Copyright © Jones & Bartlett Learning 2019
In completing the “Applying What You Have Learned” questions for this chapter, you analyzed your interactions with the environment to develop a list of environmental threats to your health. Determine ways in which you could change your behavior to remove or reduce these environmental threats. Pick one of these behaviors and use the following steps to facilitate change.
Deciding to Change 1. Identify the problem, goal, or question. 2. List the reasons you should make this change and the reasons you should not. Assign each rea-
son a point value from 1 to 5, with 5 being the highest (it has the most value to you) and 1 being the lowest (it has the least value to you).
Choices Reasons to change behaviors (pros): Reasons not to change behaviors (cons):
Points Reasons Points Reasons
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ ________________________ ____ ________________________
____ Total ____ Total
3. Draw a conclusion by adding the points in the pros section and then in the cons section. If the point total of the pros section is greater than the total of the cons section, you are probably ready to make a change in your life that reduces environmental risks to your health. If your cons out- weigh your pros, you may not be motivated to make the change now. Study your list of pros and cons carefully, however, before making your !nal decision. You may decide to change even if your reasons not to change outrank your reasons to change.
CHAPTER 16 CHANGING HEALTH HABITS
Can You Reduce Environmental !reats to Your Health?
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Implementing the Change 1. Set a target date to begin the new behavior. 2. Identify and list the factors that will help you change this behavior and those that will stand in
your way. Factors that help: Factors that hinder:
3. Prepare an action plan for making the change. a. Identify alternative methods for reaching your goal. b. Gather information about each method. c. Choose the method that !ts your particular situation best. d. Consider the factors that can help or hinder your e#ort to change (see step 2).
Factors that help: Factors that hinder:
4. Change the lifestyle behavior that you have decided to improve by implementing the action plan you developed in step 3.
5. Chart your daily progress toward your goal. 6. Evaluate how e#ective you were in reaching your goal.
abortion Removal of the embryo or fetus from the uterus before it is able to survive on its own.
absorption The passage of nutrients through the walls of the intestinal tract.
abstinence A method of birth control that involves refraining from vaginal intercourse.
abuse Taking advantage of a relationship to mistreat a person.
acid precipitation Rain, snow, or fog combined with sulfur dioxide from fossil fuel emissions.
acquired immune deficiency syndrome (AIDS) A set of certain diseases and conditions that result from infection by the human immunodeficiency virus (HIV).
acquired immunity Specific resistance to infection that is not inherited but develops during a person’s lifetime.
acute A condition or illness that tends to develop quickly and resolve within a few days or weeks.
acute bronchitis A temporary inflammation of the mucous membranes of the bronchi.
adipose cells Specialized cells that store extra food energy as fat.
aerobic Refers to oxygen-requiring activities. affect Observable expressions of mood. affection Fondness. ageism A bias against elderly people. aging The sum of all changes that occur in an organism
during its life.
Air Quality Index (AQI) A guide to air quality that uses levels of various pollutants to determine its values.
alcohol abuse Includes the symptoms of harmful use, but when drinking the abuser exhibits long-term social interaction problems and uses alcohol in physically dangerous situations.
alcohol dependence (alcoholism) A syndrome characterized by at least three of the following symptoms: a compulsion to drink, difficulty in controlling the amount of alcohol consumed, withdrawal symptoms when alcohol is not consumed, evidence of tolerance, progressive neglect of other interests because of drinking, and continuing to use alcohol despite its physical and psychological effects on the user.
Alzheimer’s disease (AD) An incurable, progressive, degenerative disease that affects the functioning of the brain.
amino acids The chemical units that compose proteins. amniocentesis A prenatal test performed generally
between the 15th and 18th weeks of gestation, in which some of the amniotic fluid that surrounds the fetus is removed and studied to determine whether the fetus has a genetic abnormality.
anabolic steroids A group of drugs that can have muscle-building effects on the body.
analgesics (an-al-GEEZ-iks) Drugs that alleviate pain. analog A drugs that is chemically similar but has different
effects on the body.
anecdotes Personal reports of individual experiences. anesthetic Substance that interferes with normal
sensations.
aneurysm (AN-you-rizm) A swollen, weakened blood vessel.
angina pectoris (an-JEYE-nah PECK- tor-iss) Chest pain caused by insufficient oxygen in a portion of the heart.
angioplasty (AN-jee-oh-PLAS-tee) The reconstruction of damaged blood vessels.
anorexia nervosa A severe psychological disturbance in which an individual refuses to eat enough food to maintain a healthy weight.
antibiotics (AN-tie-by-OT-iks) A group of chemicals that kill bacteria or inhibit their growth.
antibodies Proteins that interact in a lock-and-key fashion with antigens, interfering with the normal functioning of the antigen.
antigens (AN-tih-jenz) Proteins that are foreign or recognized as “nonself” by the body.
antioxidants Compounds that protect cells from free radical damage.
appetite The psychological desire to eat foods that are appealing.
arrhythmias (uh-RITH-me-uhs) Abnormal heartbeats.
arteries Blood vessels that carry blood away from the heart.
arthritis A group of diseases characterized by inflammation of the joints.
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Glossary
asbestos (as-BES-tose) A fiberlike mineral found in rocks that, when inhaled, can cause lung cancer or other lung conditions.
asbestosis (AS-bes-TOE-sis) A condition in which scar tissue forms in the lungs as a response to irritation by asbestos.
asexual A person who feels no sexual attraction to anyone.
assault The intentional use of force to injure another person physically.
asthma (AZ-mah) A common chronic childhood illness characterized by sensitive airways.
atherectomy (ATH-er-EK-toe-me) The removal of plaque from the interior of an artery.
atherosclerosis (ATH-er-oh-skle-ROW- sis) Disease of large and medium-sized arteries in which the inner lining has areas that are deteriorated, thickened, and inelastic.
atrial fibrillation (fih-brih-LAY-shun) A type of arrhythmia in which the upper chambers of the heart contract with no set pattern.
atrophy A condition in which muscles lose size and strength.
attachment The desire to spend time with someone to give and receive emotional support.
autoimmune diseases Diseases in which the body perceives its own cells as foreign, attacking them and causing localized and systemic (whole-body) reactions.
autonomy Sense of independence.
autopsy The various medical examinations and tests that usually can determine the cause of death.
B cells Specialized white blood cells (lymphocytes) that function in antibody-mediated immunity and produce antibodies.
bacteria Unicellular, microscopic organisms with a simple cell structure; some are pathogenic to humans and produce infections such as strep throat, bacterial pneumonia, food poisoning, and infected cuts.
barrier methods Types of birth control that block the path that sperm must take to reach the ovum; these forms of contraception include male condoms, female condoms, diaphragms, and cervical caps.
basal (BAY-sl) cell carcinoma The most common cancer of the skin, which frequently develops on portions of the skin exposed to the sun.
benign (be-NINE) tumors Encapsulated masses of abnormal cells that remain in one location and do not invade surrounding tissues.
binge eating disorder A pattern of eating excessive amounts of food in response to distress such as anxiety or depression.
biopsy (BI-op-see) A small piece of tissue that is taken from a growth so that the cells can be studied and a diagnosis confirmed.
birth control (contraception) Methods to prevent pregnancy.
bisexual A person who feels sexual attraction to both males and females.
body mass index (BMI) A standard that correlates body weight with the risk of developing chronic health conditions associated with obesity. BMIs are calculated with a person’s height and weight.
Braxton-Hicks contractions False labor; preparatory contractions that are not a part of labor.
breech birth A delivery in which the baby presents feet or buttocks first instead of the usual head-first position.
bulimia nervosa An eating disorder characterized by a craving for food that is difficult to satisfy.
calcium The most abundant mineral in the body that plays a role in vascular, muscular, and neurological functions.
calorie A unit of energy.
cancer screening An examination to detect malignancies in a person who has no symptoms.
cancer staging A description of the extent of the growth and metastasis of a cancer to determine appropriate therapy and prognosis.
capillaries (KAP-ih-LAIR-eez) Microscopic blood vessels that permeate tissues, connecting small arteries to small veins.
carbohydrates A class of nutrients that includes sugars and starches.
carbon monoxide poisoning A toxic condition that affects red blood cells’ ability to carry oxygen, caused by the inhalation of the gas carbon monoxide.
carcinogens (kar-SIN-oh-jenz) Cancer-causing substances.
carcinomas (KAR-si-NO-mahz) Cancers that arise from epithelial tissues.
cardiorespiratory fitness The ability to perform muscular movements intensely and for long periods without tiring.
cardiovascular disease (CVD) (KAR-dee-oh-VAS- ku-lar) Disorders of the heart and blood vessels.
caring The expression of concern for someone’s well-being.
carpal tunnel syndrome Numbness, pain, or pins- and-needles sensations in either of the hands that extends down the fingers, resulting from improper alignment of the wrist while engaging in repetitive-use activities.
cataracts A chronic condition in which the lens of the eye becomes cloudy and opaque, impairing vision.
Glossary 693
celiac disease A condition characterized by hypersensitivity to gluten.
celibacy (sexual abstinence) Refrainment from sexual intercourse, usually by choice.
central nervous system (CNS) Of the two primary divisions of the nervous system, the one that consists of the brain and spinal cord.
cerebral embolism A stroke caused by a floating blood clot that becomes lodged in a cerebral artery, blocking blood flow.
cerebral hemorrhage (HEM-ah-rij) A stroke caused by a burst artery that supplies the brain.
cerebral thrombosis A stroke caused by a stationary blood clot.
cervix The narrow neck of the uterus.
chain of infection The relationship among the factors important in the development of infectious diseases: the pathogen, transmission, and the host.
child physical abuse Physical violence against a child who is under 18 years of age.
child sexual abuse Sexual activity involving a minor.
chlamydial (klah-MID-dee-ahl) infections An STI that results in gonorrhea-like symptoms.
cholesterol A type of lipid found only in animals.
chorionic villus sampling (CVS) A prenatal test performed generally between the 10th and 12th weeks of gestation, in which some of the fetal extraembryonic tissue is removed and analyzed to determine whether the fetus has a genetic abnormality.
chronic A condition or disease that often takes months or years to develop, progresses in severity, and can affect a person over a long period.
chronic bronchitis A persistent inflammation and thickening of the lining of the bronchi.
chronic obstructive pulmonary disease (COPD) A syndrome that includes chronic bronchitis, asthma, and emphysema and that is characterized by extreme difficulty in breathing.
cisgender A term that refers to people whose gender identity is congruent with their biological sex.
clitoris (KLIT-oh-ris) A female organ of sexual arousal. Located under a protective hood of tissue, the clitoris lies in front of the urethra.
cohabitation Unmarried persons living together.
coitus (KO-ih-tus) The act of a penis penetrating a vagina, often referred to as vaginal intercourse.
coitus interruptus (withdrawal) (KO-ih-tus in-ter-RUP-tus) A form of birth control in which the man removes his penis from his partner’s vagina and genital area, interrupting intercourse before ejaculation.
colon The large intestine.
colonoscopy (KO-lon-OS-ko-pee) A procedure in which a physician views the entire length of the colon using a flexible fiber-optic tube.
comatose The condition in which a person is unresponsive to the environment and in a coma.
commitment The determination to maintain a relationship even when times are difficult.
communicable (ka-MYOO-ni-kah-bl) Transmissible from person to person.
community violence Violence between strangers or acquaintances that occurs in public settings.
compatible Capable of existing together in harmony.
condom A sheath, usually made of thin latex or polyurethane, that covers an erect penis or lines the vagina and covers the labia to provide a barrier against fertilization or sexually transmitted infections.
constipation A condition characterized by having fewer than three bowel movements per week.
conventional medicine The form of medicine that relies on modern scientific principles, modern technologies, and scientifically proven methods to prevent, diagnose, and treat health conditions.
coping strategies Behavioral responses and thought processes that people use to deal with stressors.
coronary arteries Blood vessels that arise from the base of the aorta and bring freshly oxygenated blood to the heart muscle.
coronary artery bypass graft (CABG) surgery A surgical procedure in which healthy blood vessels are used to redirect blood flow around blocked vessels of the heart.
coronary artery disease (CAD) A condition in which the coronary vessels are blocked partially or completely by fatty deposits, blood clots, or both. Also commonly called coronary heart disease (CHD).
coronary embolism (EM-bow-lizm) A floating blood clot that lodges in an artery that brings blood to the heart muscle, blocking blood flow.
coronary thrombosis (throm-BOW-sis) The development of a stationary blood clot that blocks blood flow in an artery that brings blood to the heart muscle.
corpus luteum (KOR-pus LOO-tea-um) The ruptured follicle left behind after ovulation.
cross-training Incorporating a variety of aerobic activities into a fitness program.
cunnilingus Use of the mouth and tongue to stimulate a woman’s genitals.
cystic fibrosis (SIS-tik fie-BROH-sis) (CF) A common, lethal inherited disease that affects the glands that secrete mucus and sweat, resulting in multiple disorders of the lungs and pancreas.
death The cessation of life, which occurs soon after a person’s heart or lungs stop functioning.
694 Glossary
defense mechanisms Ways of thinking and behaving that reduce or eliminate anxiety and guilt feelings by altering the individual’s perception of reality.
delusions Inaccurate and unreasonable beliefs that often result in decision-making errors.
dementia A brain disorder that seriously affects normal cognitive abilities.
detoxification The process of converting harmful substances into less dangerous compounds.
detraining A condition characterized by atrophied and weak muscles, which occurs when skeletal muscles are not used regularly.
diabetes mellitus A group of chronic diseases characterized by the inability to metabolize carbohydrates properly.
diastolic (DIE-as-TOL-ik) pressure The lower number in the blood pressure reading, which is the pressure exerted by the blood on the artery walls when the left ventricle relaxes.
diet One’s usual pattern of food choices. dietary fiber Indigestible substances produced by
plants.
Dietary Reference Intakes (DRIs) A set of standards for evaluating the nutritional quality of diets.
dietary supplement A product that is consumed to add nutrients, herbs, or other plant materials to a person’s diet.
digestion The process of breaking down large food molecules into smaller molecules that the intestinal tract can absorb.
digital rectal exam A test in which a physician uses a gloved finger to feel the rectum or the prostate for abnormal growths.
diseases Processes that affect the proper functioning of the body and are usually accompanied by characteristic signs and symptoms.
distress Events or conditions that produce unwanted or negative outcomes.
diverticulosis An intestinal disorder that occurs when the colon lining forms small pouches that protrude through the outer wall of the colon.
douching (DOOSH-ing) The use of specially prepared solutions to cleanse the vagina; not an effective birth control method.
Down syndrome A genetic disease usually caused by the presence of three (rather than two) number 21 chromosomes; the child is usually mentally retarded, with a short body and a broad, flat face.
drug abuse The intentional improper or nonmedical use of any drug.
drug dependence (addiction) Occurs when users develop a habitual pattern of taking drugs that produces a compulsive need, which is both physical and psychological.
drug misuse The temporary and improper use of a legal drug.
drugs Nonfood chemicals that alter the way a person thinks, feels, functions, or behaves.
Duchenne/Becker muscular dystrophy (do-SHAYN BECK-er MUSS-ku-lar DIS-tro- fee) (DBMD) An inherited disease in which the muscles gradually weaken and degenerate. It usually strikes boys before the age of 6 years.
eating disorders Persistent abnormal eating patterns that can threaten a person’s health and well-being.
ejaculation The emission of semen from the penis during orgasm.
elder abuse Use of physical or sexual violence against an elderly person.
embolus (EM-bow-lus) A floating blood clot. emergency contraception (EC) Birth control
methods that help prevent pregnancy after sexual intercourse, rather than before or during sex.
emphysema (EM-fih-SEE-mah) A chronic condition in which the air sacs of the lungs lose their normal elasticity, impairing respiration.
endocrine system A group of glands that produce hormones.
endometrial cancer Begins in the uterus when cells that form the lining (endometrium) of the uterus begin to grow out of control.
endometrium (EN-doe-ME-tree-um) The inner lining of the uterus.
environmental health The effects of environmental factors on humans and the effects of humans on their environments.
environmental tobacco smoke (ETS) The smoke emitted from a lit cigarette, cigar, or pipe and the smoke exhaled by smokers.
epididymis (EP-ih-DID-ih-mis) A coiled tube that lies on the back of each testis and in which sperm mature.
episiotomy (uh-pee-zee-OT-uh-me) A cut in the tissue surrounding the vaginal opening to widen it during a vaginal delivery so that the surrounding skin and tissues will be less likely to tear.
erectile dysfunction (ED) A sexual dysfunction in which a man is unable to develop and/or sustain an erection firm enough for penetration of the vagina. Also called impotence.
ergogenic (work producing) aids Products or devices that enhance physical development or performance.
estrogen (ES-tro-jen) A hormone secreted by ovarian follicles, the groups of cells within which ova mature. With progesterone, estrogen stimulates the continued development and thickening of the uterine lining.
euphoria (you-FOR-ee-a) An intense feeling of well- being commonly called a “high.”
Glossary 695
eustress (YOU-stress) Events or conditions that create positive effects, such as making one feel happy, challenged, or successful.
exercise Physical activity that is usually planned and performed to improve or maintain one’s physical condition.
fad diets Eating plans that are popular for a time, then quickly lose their widespread appeal.
family (domestic) violence Violence or abuse between family members, people who are involved in intimate relationships, or unrelated individuals who live together.
fecal occult (FEE-kle ok-KULT) blood test (FOBT) Home test that detects hidden blood in the stool.
fellatio Use of the mouth and tongue to stimulate a male’s genitals.
fetal alcohol spectrum disorders (FASDs) A variety of incurable conditions and birth defects caused by alcohol exposure during prenatal development.
fetal alcohol syndrome (FAS) The most severe FASD. Children born with FAS may suffer intellectual disability and have characteristic facial anomalies, growth deficiency, and central nervous system abnormalities.
fight-or-flight response The physical responses to stressful situations that enable the body to confront or leave dangerous situations.
flexibility The ability to move a muscle to any position in its normal range of motion.
follicles Masses of cells in the ovaries that contain immature ova (eggs) in various stages of development. Each follicle contains one ovum.
formaldehyde (form-AL-de-hide) A chemical used in the manufacture of certain building materials and furnishings; may cause health problems when released into indoor air.
fungi (FUN-jeye) Cellular organisms that cannot make their own food; some are pathogenic to humans and produce infections such as athlete’s foot, ringworm, and yeast infections. Fungus is the singular term.
gay (homosexual) A person who feels sexual attraction to people of the same gender.
gender expression One’s external manifestation of one’s gender identity.
gender identity An individual’s perception of himself or herself as male, female, or something else.
gender role Patterns of behavior, attitudes, and personality attributes that are traditionally considered in a particular culture to be feminine or masculine.
gender stereotype The widespread association of certain perceptions with one gender.
gender Socially constructed differences (or psychological identity) that distinguish one as female or male.
general adaptation syndrome (GAS) The three- stage manner in which the human body responds to stress: alarm, resistance, and exhaustion.
generalized anxiety disorder A condition characterized by uncontrollable chronic worrying and nervousness.
genes Segments of DNA that code for specific proteins. genital herpes An STI caused by the herpes simplex
virus that results in sores in the genital and anal areas.
genital warts An STI caused by the human papillomavirus that results in noncancerous skin tumors of the genital area.
genomics (JEE-nom-iks) The scientific study of an organism’s entire set of genes.
gerontologists Scientists who study aging. glaucoma (glaw-KO-mah) A chronic ailment that
occurs when fluid pressure increases in the eye.
glucose The most important monosaccharide in the human body.
gonorrhea (GON-ah-REE-ah) An STI characterized by infection of the urethra in men and the cervix in women, usually resulting in a thick discharge from the penis or vagina.
good health The ability to function adequately and independently in a constantly changing environment.
grief An emotional state that usually occurs after the loss of something or someone special.
hallucinations False sensory perceptions that have no apparent external cause.
harmful use Drinking alcoholic beverages while knowingly damaging one’s physical and/or psychological health.
hazardous waste Toxic chemical refuse. heart attack Myocardial infarction (MI); an area of
heart muscle that dies because it does not receive enough oxygen as a result of insufficient blood supply.
heart failure Ineffective pumping of the heart, which results in the overfilling of the veins that bring blood to the heart.
heat cramps In a dehydrated and hot person, the signs and symptoms of heat cramps include muscular tightening and pain in the limbs or abdomen.
heat exhaustion The extreme fatigue that results from exercise or work in hot temperatures.
heatstroke A life-threatening condition that can occur when people exercise or work in hot temperatures.
hemorrhoids Painfully swollen veins in the rectal and anal areas.
hepatitis B virus (HBV) A serious infectious disease of the liver transmitted via blood or blood products.
heredity The transmission of biological information, coded within genes, from parents to offspring.
696 Glossary
high-density lipoproteins (HDL) (LIP-oh-PRO- teenz or LIE-poe-PRO-teenz) “Good” cholesterol that carries cholesterol from the cells and to the liver for removal from the body.
holistic (hole-IS-tic) A characteristic involving all aspects of the person.
homophobia An intense fear of or hostility toward homosexuals.
hormones Chemical messengers that convey information from a gland to other cells in the body.
hospice Health care specifically designed to give emotional support and pain relief to terminally ill people in the final stage of life.
host In reference to disease, an organism that supports the growth of a pathogen; the third, and last, link in the chain of infection.
human chorionic gonadotropin (hCG) In a pregnant woman, a hormone produced by embryonic tissues destined to become the placenta. Pregnancy tests rely on the detection of this hormone in the blood.
hunger The physiologic drive to seek and eat food. hypertension Persistently high arterial blood pressure. hyperthermia A condition that occurs when body
temperature rises above the normal range.
hypertrophy A condition in which muscles become larger and stronger.
hypnotic Producing trancelike effects. hypothermia A condition that occurs when the body’s
core temperature drops below 95°F.
immune system A collection of cells and organs of the body that recognize and combat pathogens and other foreign substances with cells and proteins that are specific for particular invaders. The immune system has two branches: antibody-mediated immunity and cell-mediated immunity.
immunity (im-MYOU-nih-tea) Resistance to disease. immunotherapy Manipulation of the body’s immune
system to rid the body of cancer.
incest Sexual relations between family members who are not spouses.
infectious (in-FEK-shus) diseases Diseases caused by bacteria, rickettsias, viruses, fungi, protozoans, or parasitic worms.
infertility Inability to conceive a child after 1 year of unprotected sex.
inherited diseases Genetic diseases transmitted solely by gene transfer from parents to offspring.
institutional violence Violence that occurs mainly in institutional settings such as college campuses or workplaces.
integrative medicine A system of medical care that emphasizes personalized health care and disease prevention.
interferons (IN-ter-FEAR-onz) Proteins produced by the body during a viral infection that protect uninfected cells from viral invasion.
intimacy Disclosure of one’s most personal thoughts and emotions to a trusted individual.
intoxication Impairment of the functioning of the central nervous system as a result of ingesting toxic substances such as alcohol.
intrauterine device (IUD) A small contraceptive device that either is covered with copper or contains a reservoir of progestin and is inserted into the uterus.
ischemia (is-KI-me-ah) Insufficient blood in part of the heart.
isometric A type of exercise in which the individual exerts muscular force against a fixed, immovable object.
isotonic A type of exercise in which the individual exerts muscular force against a movable but constant source of resistance.
joints The places where two or more bones come together. labia majora (LAY-bee-ah mah-JOR-ah) Hairy,
rounded, and thick folds of skin that lie adjacent to the labia minora and extend forward to unite at the mons pubis.
labia minora (LAY-bee-ah my NOR-ah) Two thin, hairless folds of skin that extend from over the clitoris to an area behind the vagina. The labia minora cover and protect the vaginal opening and urethra.
labor (parturition) (PAR-too-RISH-un) The process of childbirth.
lead poisoning A toxic condition that affects the central nervous system, caused by the ingestion or inhalation of the metallic element lead.
lesbian A gay woman. leukemias (lew-KEY-me-ahz) Cancers of the blood
and related cells.
leukocytes (LEWK-oh-sites) White blood cells; active in both specific and nonspecific defenses of the body.
life expectancy The average number of years that an individual who was born in a particular year can expect to live.
life span The maximum number of years that members of a species can expect to live when conditions are optimal.
lifestyle A way of living, including behaviors that promote or impair good health and longevity.
ligaments Tough bands of connective tissue that hold bones together at joints.
lipids A class of nutrients that includes triglycerides and cholesterol.
low-density lipoproteins (LDL) “Bad” cholesterol that carries cholesterol to the cells, including the cells that line the blood vessel walls.
lumpectomy (lum-PECK-toe-me) Surgical removal of a breast tumor, including a layer of surrounding tissue.
Glossary 697
lymph (limf) Tissue fluid. lymphomas (lim-FOE-mahz) Cancers of the
lymphatic system.
macular degeneration A leading cause of vision loss for people age 60 years and older.
major depressive disorder A mood disorder characterized by persistent and profound sadness, hopelessness, helplessness, and feelings of worthlessness; lack of energy; loss of interest in usual activities; loss of the ability to concentrate; suicidal thoughts; and appetite and sleep disturbances.
malignant (mah-LIG-nant) tumors Masses of cancer cells that invade body tissues and interfere with the normal functioning of tissues and organs.
malignant melanoma (MEL-ah-NO-mah) A deadly form of skin cancer that develops most often in persons who have been exposed to the sun in short, intense sessions, have had severe sunburn and extensive sun exposure in childhood, or have first-degree relatives who had the disease.
malnutrition Overnutrition or undernutrition that results when diets supply improper amounts of nutrients.
medical abortion A method of drug-induced abortion performed within 9 weeks of the first day of the last period.
Medicare A federal health insurance program that provides benefits for people 65 years of age and older.
meditation An activity in which one relaxes by mentally focusing on a single word, object, or thought.
menarche (meh-NAR-key) The first menstruation. menses (MEN-seez) The menstrual period; the
sloughing of the endometrium.
menstrual (MEN-stroo-al) cycle The monthly changes in the levels of the female sex hormones that orchestrate physiologic changes in the ovaries and uterus.
metabolic rate The amount of energy the body requires to fuel cellular activities during a specified time.
metabolism All chemical reactions that take place in the body.
metastasize (meh-TAS-tah-size) The ability of cancer cells to spread from where they develop to another part of the body.
minerals A class of inorganic nutrients that includes several elements, such as iron, calcium, and zinc.
mons pubis A mound of fatty tissue that lies over the pubic bone, cushioning it.
motivation The forces or drive that leads people to take action.
mourning The culturally defined way in which survivors resolve the grief surrounding a death.
municipal solid waste Nonhazardous refuse generally collected from homes and offices.
muscular endurance A muscle’s ability to contract repeatedly without becoming fatigued.
muscular strength The ability to apply maximum force against an object that is resisting this force.
mutation (mew-TAY-shun) In reference to human biology, a change in a gene or a chromosome.
mutations (myou-TAY-shunz) Changes in genes or chromosomes; damaged genes.
myotonia An increase in muscle tension throughout the body during sexual arousal.
MyPlate The current nutrition guide published by the U.S. Food and Drug Administration Center for Nutrition Policy and Promotion. It replaced the Food Pyramid in 2011.
narcotics Drugs that induce euphoria and sleep as well as alter the perception of pain.
natural family planning (fertility awareness) Formerly called the rhythm method; a group of birth control techniques in which a couple abstains from sexual intercourse during the time of the month when a woman is most likely to conceive.
neurotransmitters Chemicals produced and released by nerves that convey information between most nerve cells.
nicotine An addictive psychoactive drug found in tobacco. noncommunicable Not transmissible from person
to person.
noninfectious (NON-in-FEK-shus) diseases Illnesses caused by genetic abnormalities, by interactions between hereditary and environmental factors, or solely by environmental factors.
nonspecific immunity A variety of defense mechanisms that combat any type of damage to the body, including the invasion of infectious agents.
nutrient requirement The minimum amount of a nutrient that prevents that nutrient’s deficiency disease.
nutrients Substances in food that are necessary for growth, repair, and maintenance of tissues.
obesity A condition in which the body has an excessive and unhealthy amount of fat. Obesity is classified as having a BMI of 30.0 or higher.
oncogenes (ONG-ko-geenz) Tumor genes that manufacture altered proteins that speed cell growth and decrease the level of cell differentiation.
optimal wellness A sense that one is functioning at his or her best level.
orgasm The peak of sexual excitement. osteoporosis An age-related condition in which bones
lose density, becoming weak and breaking easily.
ovaries Internal organs of female sexual reproduction within which eggs (ova) develop.
overweight A condition in which the body has more fat, muscle, bone, and/or body water than a person whose weight is healthy. Overweight is classified as having a BMI of 25.0–29.9.
698 Glossary
ovulation The maturation and release of an egg from an ovary, usually each month from puberty to menopause.
ozone holes Depleted areas of the ozone (O3) layer in the upper atmosphere.
panic disorder Psychological condition that features panic attacks, unpredictable episodes of extreme anxiety, and loss of emotional control.
Papanicolaou (PAP-eh-nik-eh-LOUW) test (Pap test) A screening procedure for cervical cancer in which cells from the cervical canal are removed and then smeared on a glass slide for microscopic examination.
passive smoking The inhalation, by nonsmokers, of tobacco smoke in the air.
pathogens (PATH-oh-jenz) Disease-causing agents of infection; the first link in the chain of infection.
pedophile (PE-doe-file) An individual who is sexually attracted to children.
penis A cylindrical external organ of sexual reproduction in males, which hangs in front of the scrotum.
peptic ulcer A sore in the lining of the esophagus, stomach, or duodenum.
periodontal (PER-ee-oh-DON-tal) disease A disorder of the tissues that support the teeth.
peripheral nervous system (PNS) Of the two primary divisions of the nervous system, the one that consists of nerves, which relay information to and from the CNS.
peripheral vascular disease Any blockage of vessels other than those to the heart.
persistent vegetative state The condition in which a person has a nonfunctioning cerebral cortex and is in an irreversible coma.
personality A set of distinct thoughts and behaviors that characterizes a person’s response to situations.
pesticides Chemicals that kill plant and animal pests and that can cause poisoning when ingested.
phagocytosis (FAG-oh-sigh-TOE-sis) The process of white blood cells ingesting foreign cells and debris, such as the dirt or dead cells in a cut.
phobia An intense and irrational fear of an object or a situation.
physical activity Movement that occurs when skeletal muscles contract.
physiology The study of bodily functions. phytochemicals A group of non-nutrients that are
produced by plants and may have beneficial effects on the body.
placebo A sham treatment that has no known physical effects; an inactive substance.
placenta (plah-SEN-tah) A structure that develops after implantation of a fertilized ovum in the uterine wall and consists of maternal and fetal tissues that secrete hormones that help maintain the pregnancy.
plaques (plaks) Fatty deposits in artery walls. polyabuse Abusing more than one drug at a time. portals of entry Sites on or in the body where
pathogens enter.
pregnancy The gestational process; the process of development of a fetus from fertilization until birth.
premature (rapid) ejaculation (PE) A common male sexual dysfunction in which a man consistently attains orgasm either before or shortly after intercourse begins and before he wishes it to occur.
premenstrual syndrome (PMS) Symptoms such as anxiety, mood swings, aches, and cramps that occur before the menses and that significantly interfere with daily life.
probiotics Microorganisms that may provide healthful benefits when consumed.
progesterone (pro-JES-te-rone) A hormone secreted by the corpus luteum. With estrogen, progesterone stimulates the continued development and thickening of the uterine lining.
prostate gland A single, walnut-sized gland that lies just below the bladder, surrounding the urethra. The prostate produces a milky alkaline fluid that is added to the ejaculate.
proteins A class of nutrients that build, maintain, and repair cells.
psychoactive Having mind-altering or mood-altering effects.
psychological adjustment Changing one’s thoughts, attitudes, and behaviors to cope effectively with the demands of the environment.
psychological growth The process of learning from one’s experiences.
psychology The study of the mental processes that influence human behavior.
psychoneuroimmunology (SIGH-ko-NEW-ro- im-mu-NOL-lo-gee) The study of the relationships between the nervous and immune systems.
puberty (PEW-ber-tea) A stage of sexual development during which the endocrine (hormone) and reproductive systems mature.
pubic louse A close relative of fleas that causes sexually transmitted infestation; also called crabs.
quackery The practice of medicine without having the proper training and credentials.
radical mastectomy Surgical removal of a breast, underlying muscle, and underarm fat and lymph nodes as a treatment for breast cancer.
radon gas A colorless, odorless radioactive gas present in the rocks and soils in many areas in the United States that, when inhaled, can cause mutations in cells.
rape Sexual intercourse by force or with a person who is incapable of legal consent.
rectum The lower part of the large intestine.
Glossary 699
respect The feeling that another has value and deserves attention.
risk factor A characteristic that increases an individual’s chances of developing a health problem.
sarcomas (sar-KO-mahz) Cancers that arise from connective or muscle tissue.
satiety The feeling that enough food has been eaten to relieve hunger and turn off appetite.
scabies (SKAY-beez) An infestation of the pubic area in which a spiderlike organism burrows into the skin and lays eggs there.
schizophrenia A form of psychosis. scrotum (SKRO-tum) The sac of skin in which the
testes are enclosed and hang outside the body.
sedative Producing calming effects. self-compassion Treating yourself with the same
empathy you show others.
self-efficacy (EF-fih-ka-see) Regarding health education, the belief that one is capable of changing his or her behavior.
self-esteem The extent to which a person feels worthy and useful.
semen The ejaculate; the secretions of the accessory sex glands (called seminal fluid) and sperm.
seminal vesicles (SEM-ih-nal VES-ih-klz) Paired male sex organs located near the junction of the two vasa deferentia, which produce thick fructose- containing secretions that are added to the ejaculate.
senescence (seh-NES-ens) The stage of life that begins at age 65 years and ends with death.
set point A theoretical level of body fat that resists weight- loss efforts.
sex The biological or physiologic differences that distinguish one as female or male.
sexism Discrimination and bias against one sex. sexologists Scientists who study human sexuality. sexual harassment Unwelcome or uninvited verbal or
physical behavior that is sexual in nature.
sexual intercourse Penetration of the vagina by a penis. sexual orientation The direction of a person’s romantic
and sexual thoughts, feelings, and attractions.
sexual reproduction The fertilization of an egg (ovum; plural, ova) by a sperm.
sexual violence A sexual act committed against someone without that person’s freely given consent.
sexuality The aspect of personality that encompasses a person’s sexual thoughts, feelings, attitudes, and actions.
sexually transmitted infections (STIs) Infection spread from person to person by intimate sexual contact, primarily anal or vaginal intercourse and oral sex.
sick building syndrome A variety of vague health-related problems reported by many occupants of large buildings.
sigmoidoscopy (SIG-moid-OS-ko-pee) A procedure in which a physician views the lower portion of the colon via a flexible fiber-optic tube.
signs Observable and measurable features of an illness. smog A haze in the atmosphere formed by various pollutants. specific immunity Defense mechanism carried out by
the immune system.
spermicides Chemicals that kill sperm. sprain Generally refers to an injured ligament. squamous (SKWAY-muss) cell carcinoma A
common form of skin cancer that develops from exposure to noxious chemicals and high levels of X-rays, as well as from trauma.
stent A springlike mesh device that is implanted within an artery to cover compressed plaque, support the artery, and smooth the artery wall.
sterilization A permanent form of birth control that requires a surgical procedure.
straight (heterosexual) A person who feels sexual attraction to people of the opposite gender.
strain Generally refers to an injured muscle or tendon. stress A complex series of psychological and physical
reactions that occur as one responds to a situation.
stressors Events that produce physical or psychological demands on an individual.
stroke A brain injury that occurs when arteries that supply the brain become blocked and prevent blood flow or become damaged and leak blood onto or into the brain.
sudden cardiac arrest Cessation of the heartbeat. surgical abortion Includes various methods of induced
abortion in which the contents of the uterus are physically removed.
symptoms Subjective complaints of illness. synergism (SIH-ner-jism) The multiplied effects
produced by taking combinations of certain drugs.
syphilis (SIF-ih-lis) An STI that can progress from skin sores to more generalized symptoms (e.g., weight loss and muscle pain) to life-threatening, tissue-destroying skin abnormalities.
systolic (sis-TOL-ik) pressure The higher number in the blood pressure reading, which is the pressure exerted by the blood on the artery walls when the left ventricle contracts.
T cells Specialized white blood cells (lymphocytes) that function in cell-mediated immunity; there are four types of T cells.
T. vaginalis infections An STI caused by a protozoan, resulting in infection of the urethra in men and of the urethra and walls of the vagina in women.
targeted therapies Drugs or other substances that block the growth and spread of cancer by interfering with specific molecules involved in tumor growth and progression.
700 Glossary
temperament The predictable way an individual responds to situations and others, such as being pleasant, outgoing, or shy.
temporomandibular (TEM-pe-row-man-DIB- you-ler) joint The place where the lower jaw bone (mandible) attaches to the temporal bone of the skull.
tendons Tough bands of tissue that connect many skeletal muscles to bones.
teratogens Various environmental influences such as drugs, alcohol, viruses, and dietary deficiencies that can damage the embryo or fetus early in pregnancy.
testes (TES-tease) The male reproductive organs that produce sperm (the male sex cells) and testosterone (a male sex hormone).
testicular (tes-TIK-you-lar) self-examination (TSE) A self-screening test that males can perform to detect cancer of the testicles.
testimonials Individual claims about the value of a product.
testosterone A male sex hormone (androgen) that plays a role in the development of functionally mature sperm and is responsible for the development and maintenance of male secondary sexual characteristics such as the deepening of the voice and the growth of facial hair.
thermic effect of food (TEF) The small amount of energy that the body uses to digest, absorb, and process the nutrients from foods.
thrombus (THROM-bus) A stationary blood clot. tolerance A physiologic response in chronic users
of drugs in which increased amounts of the drug are required to achieve effects previously produced by lower amounts.
total mastectomy (mas-TEK-toe-me) Surgical removal of a breast and involved lymph nodes for the treatment of breast cancer.
toxic chemicals Poisonous substances present in the home, workplace, or outdoor environments that affect human health.
toxicity (tok-SIH-si-tea) Poisonous quality. transgender An umbrella term for various groups
of people who do not conform to traditional gender identities.
transient ischemic (is-KI-mik) attacks (TIAs) Minor strokes that usually cause no permanent damage and have signs that last for only a short time.
transmission In reference to disease, the means by which a pathogen gets to a host; the second link in the chain of infection.
triglycerides The most prevalent form of lipids in foods; often called fat.
tubal ligation Female sterilization that is performed by cutting and tying off the uterine tubes so that the sperm and egg cannot unite.
tumor-suppressor genes Pieces of hereditary material that slow cell growth; antioncogenes.
urinary incontinence The inability to control the flow of urine from the bladder.
uterine tubes Passageways that extend from each ovary to the uterus.
uterus A hollow, muscular, pear-shaped organ that protects and nourishes the embryo/fetus during development.
vaccine A preparation of a killed or weakened pathogen or its antigenic parts to be administered to a person to induce immunity and thereby prevent infectious disease.
vagina A tube about 10 centimeters (approximately 4 inches) long that receives the penis during heterosexual intercourse, allows the passage of the menstrual flow, and is a birth canal.
vaginismus A sexual dysfunction of women in which the lower portion of the vagina contracts involuntarily at the anticipation of penetration, preventing it.
value The belief that an idea, object, or action has worth. vas deferens (VAS DEF-er-enz) A tube that links the
epididymis and the urethra, the passageway through which sperm exit the body.
vasectomy Male sterilization that is performed by cutting and tying off the vasa deferentia to prevent sperm from becoming part of the ejaculate.
vasocongestion A condition in which the spongy tissue of the penis and clitoris expands with blood during sexual arousal.
veins Blood vessels that return blood to the heart. violence Interpersonal uses of force that are not socially
sanctioned.
viruses Hereditary material surrounded by a coat of protein; some viruses are pathogenic to humans and produce infections such as the common cold, influenza, mumps, measles, chicken pox, hepatitis, and AIDS.
vitamins A class of organic nutrients that help regulate growth; release energy from carbohydrates, fats, and proteins; and maintain tissues.
vulva The collective term for the external female genitals. The vulva surrounds the vaginal opening.
withdrawal A temporary physical and psychological state that occurs when certain drugs are discontinued.
yeast infections A condition in which the fungus Candida albicans grows in the vagina or on the penis; also known as candidiasis or moniliasis.
Glossary 701
A AARP, 172 abnormal blood lipid levels,
403–405, 404t abortion, 158–163 absorption, 284 abstinence, 148–150, 188 abuse
alcohol, 241–246, 255, 256t child, 100, 101, 105, 117 de!ned, 100 drug, 207, 230, 231t elder, 100, 105, 118 sexual, 102, 104, 105 spousal, 105, 107 statistics, 113
accelerated partial-breast irradiation (APBI), 448–449
accidents, alcohol consumption and, 251–255, 253f–254f
Accutane, 135, 551 acid precipitation, 562 acid rain, e#ects of, 563f acid re'ux, 82 acquaintance rape, 102 acquired immune de!ciency
syndrome (AIDS) de!ned, 474 homosexuality and, 186 people at risk for, 492 progression of, 489–491 protection against, 492–493 statistics, 490f transmission of, 492 treatment of, 493–494
acquired immunity, 484–485 action stage, 17 active acquired immunity, 484 activity pyramid, 379 actual e#ectiveness, 148 acupuncture, 26, 26f acute bronchitis, 261 acute condition or illness, 6 acute myeloid leukemia
(AML), 443 acute stress disorder, 53 Adderall, 215–216 addiction
drug, 212 nicotine, 259–260, 260t
ADHD. See attention-de!cit hyperactivity disorder
adhesives, 560 adipose cells, 289, 322
adjustment disorders, 53–54 and growth, 45–48
adolescence age for, 32–33 alcoholism, 242 anabolic steroid use, 369 drug abuse, 207, 213, 229 health concerns, 32–33 immunizations, 485 infectious diseases, 506 metabolic rate and, 326 obesity, 345–346 pregnancy rates, 197 psychological health, 65 psychosocial stages of
personality development, 43–44, 44t
sexuality, 196–197 smoking, 240–241, 257–260,
268–269 stress, 94
adulterants, 221 adultery, 194 adulthood
age for, 32, 515 cancer, 454, 459 infectious diseases, 506 metabolic rate and, 326 physical !tness, 378, 380, 381f psychological health, 66 psychosocial stages of personality
development, 44, 44t self-esteem, 47 stress, 94 strokes, 402
advance directives, 536 aerobic exercises, 356, 527–528 a#ect, 48 a#ection, 189 a#ective education, 255 a'atoxins, 449 African Americans, 14
death, causes of, 14 health status of, 11 hypertension in, 405 lactose intolerance and, 290 osteoporosis, 301–302 prostate cancer in, 454–455 sickle cell anemia in, 467 testicular cancer in, 455–456
ageism, 527 age-related macular
degeneration, 520
aggression, 46 aging
biological changes caused by,%519t
characteristics of, 517–518 de!ned, 514 life expectancy, 4, 516 metabolic rate and, 326 physical health, e#ects on,
518–523, 526–527 psychological changes caused
by, 526 successful, 527–528, 528t
agoraphobia, 52 AHA. See American Heart
Association AI/ANs. See American Indians/
Alaska Natives AIDS. See acquired immune
de!ciency syndrome air-displacement plethysmography,
330 airplane accidents, alcohol
consumption and, 252–253 air pollution
indoor, 560–561 outdoor, 562–564
Air Quality Index (AQI), 564 Al-Anon, 257 alarm stage, 77 Alaskan natives. See American
Indians/Alaska Natives Alateen, 257 alcohol (alcoholism)
abuse, 241–246, 255, 256t accidents and, 251–255, 253f behavior a#ected by,
251–252, 253f binge drinking, 4, 245–246, 247t college students and, 4, 244–246,
245t–247t consumption, detrimental
e#ects of, 256 date rape and, 104, 247 de!nitions, 241 dependence (alcoholism),
241–245, 242t dependence syndrome,
242, 242t diagnosis and treatment of
alcoholism and abuse, 255–256, 256t
drinking games, 245–246, 248t
e#ects on brain and body, 243–244, 243t, 248, 251–252
fetal alcohol spectrum disorders (FASDs), 272
fetal alcohol syndrome (FAS), 272, 272f
guidelines for safer drinking, 255 heredity and, 242 how body processes, 246–248 how to control consumption,
255 pregnancy and consumption of,
134–135, 251, 273 prevention, 253–255 psychological, social, and
developmental factors, 244 related birth defects
(ARBD), 272 related injury deaths in college
students, 244, 246 statistics, 242, 251–252 violence and use of, 104
alcoholic hepatitis, 248, 250 Alcoholics Anonymous (AA), 229,
256, 256t alcoholism. See alcohol alcohols, 374 Alli, 340 alternative medical systems, 26 alternative therapies, 340 Alzheimer’s disease, 506, 522 ambil, 263 amenorrhea, 138 American Association of Poison
Control Centers (AAPCC), 549
American Cancer Society (ACS), 428, 444, 447, 453–455, 496, 555
American Celiac Disease Alliance, 298
American College of Sports Medicine, 528
American family, 11, 11f American ginseng, 28 American Heart Association
(AHA), 268, 398, 403, 405, 410–412
American Indians/Alaska Natives (AI/ANs)
culture and psychological health, 42
health status of, 15 prostate cancer in, 454–455
702 Index
Note: Page numbers followed by f or t indicate materials in !gures or tables, respectively.
Index
Index 703
American Lung Association, 268 amino acids, 294, 296–297, 368t amniocentesis, 134–137, 137f amphetamines, 213–216, 215f, 368 anabolic steroids, 62, 369, 370f analgesics, 220 anal intercourse, 187 analogs, 224 anal sex, 187 analysis model, 20 anecdotes, 20–21 anemia, 280, 304 anesthetics, 216, 224, 225t aneurysm, 400 angel dust, 224 angina pectoris, 393, 395 angiogram, 395, 396f, 400 angiography, 395, 401 angioplasty, 395, 396, 397f, 400 anorexia nervosa, 60–61, 60f, 61t antiangiogenesis therapy, 429 antianxiety medications, 53 antibiotics, 473, 485 antibodies, 482, 483 antibody-mediated immunity,
483, 483f anticonvulsant medications, 135 antidepressants, 52 antidrug vaccines, 230 antifungal drugs, 485 antigens, 482 antihomosexual, 186 antioxidants, 280, 281, 282f,
296, 301t antiretroviral therapy (ART), 493 anxiety. See also stress
cardiovascular diseases and, 407 disorders, 52–53, 52f
anxious lovers, 191 APIs. See Asian Americans and
Paci!c Islanders apolipoprotein, 405, 407 appetite regulation, 334, 335f Armstrong, Lance, 368–369,
369f, 424 arrhythmias, 397
atrial !brillation, 400–401 arteries, 390–392, 391f
hardening of, 394 narrowing of, 395, 396f, 401, 406 unclogging, 395
arterioles, 392 arthritis
de!ned, 520 osteo-, 520, 521f rheumatoid, 482, 521
arthropods, 475 Art of Loving, "e (Fromm), 189 asbestos
de!ned, 439 inhalation of, 554–555
asbestosis, 554, 555 ASD. See autism spectrum disorder Ashkenazi Jews, 506 Asian Americans and Paci!c
Islanders (APIs) health status of, 14–15
lactose intolerance and, 290 prostate cancer in, 454–455
Asian Americans, stress and suicide, 78
aspirin therapy, 412, 455 assault, de!ned, 100 assertiveness, 46 assisted reproductive
technology, 147 asthma
attack, 471 causes of, 471 de!ned, 471 exercise-induced, 466, 471 smoking and, 264
asymptomatic phase of HIV disease, 490
atherectomy, 396 atheroma, 393–394 atherosclerosis, 264, 393–394
Italian gene, 407 athletes
anabolic steroids, 369, 370f diet and performance, 367 doping, 368 ergogenic aids, 367–369, 368t female athlete triad, 62 foot, 475, 475f physical !tness, components
of, 367 Atkins diet, 337 atria, 390–391 atrial !brillation, 400–401 atrophy, 359 attachment, 190–191 attention-de!cit hyperactivity
disorder (ADHD), 54, 65, 216 aura, 83 autism spectrum disorder
(ASD), 54–55 autoimmune diseases, 81, 482 automobile accidents, alcohol
consumption and, 252–253, 253f
automobile safety, 575–576 autonomy, 44t, 46 autopsy, 533 AZT, 492
B back pain, low, 361, 363, 363f, 364f BACs. See blood alcohol
concentrations bacteria, 473, 474
caused by, 498–502 bagging, 224 ballistic stretching, 361 balloon angioplasty, 395, 396,
396f, 397f bariatric surgeries, 339 Barrett, Stephen, 22 barrier methods, 151, 153–154 basal cell carcinoma, 451, 452, 452f Basson, R., 175, 175f bath salts, 227, 227f B cells, 483, 484 bee pollen, 368t
behavior alcoholism and, 251–252, 253f drug misuse, 206 maladaptive, 41 modi!cation for weight
management, 341t behavioral change, stages of,
16–17, 16f behavioral disorders, 552 benign prostatic hypertrophy
(BPH), 162, 454 benign tumors, 425 Benjamin, Regina, 435 Benson, Herbert, 92 beta-endorphins, 354 bias, 22 bicycle safety, 577–578 bidis, 258 binge drinking, 4, 245, 246t binge eating disorder, 61–62, 336 bioelectrical impedance, 329, 330f biological in'uences
obesity and, 332, 334–335 personality development and,
41, 43 biologically based treatments, 26 biomodulation, 429, 434 biopsy, 428 bipolar disorder, 57–58, 58t, 59f birth control (contraception), 148
abstinence, 148–150 barrier methods, 151, 153–154 cervical cap, 151 coitus interruptus (withdrawal),
150 combined oral contraceptives,
154–156 condoms, female, 153, 154f,
492, 505 condoms, male, 153, 153f, 492,
505 de!ned, 148 douching, 151 e#ectiveness of various forms,
148, 148t emergency contraception (EC),
157 hormonal methods, 154–156 injection, 156 intrauterine devices (IUD),
156–157, 156f natural family planning
(fertility awareness or rhythm method), 148
oral, 264 patch, 155 spermicides, 151–152 sponge, 151 sterilization, 157–158 tubal ligation, 157 vaginal ring, 156 vasectomy, 157, 158f
birth defects, 134, 135, 325, 412, 505
birth process, 140–144 bisexual, 184, 185 Black Americans, 14
blackouts, 61 bladder infection, 130, 187 bleeding, implantation, 138 blood alcohol concentrations
(BACs), 243, 243t, 252–253, 253f
blood cholesterol, reducing, 411–412, 411f
blood clots, 392, 394 blood-clotting factors, 481 blood, function of, 390–392 blood pressure
hypertension (high), 393, 405–406, 406f
lowering, 410–411 meditation and reducing, 91–92 reading, 405–406, 406f
BMI. See body mass index body
composition, 328–332, 363 e#ects of alcohol, 243–244, 243t,
248, 251–252 e#ects of drugs, 209–210 mind–body relationship, 80–82 in motion, 352
body fat. See also obesity and overweight
adult weight, percentage of, 329, 329t, 331
body mass index (BMI), 322–324, 323f
composition, 328–332 estimating, 329–332 health a#ected by excess, 325
body mass index (BMI), 322–324, 323t, 324f, 407
Bogalusa Heart Study, 412–413 bone marrow stem cell
transplantation, 468 bone marrow transplants, 435 botulism, 476 BPH. See benign prostatic
hypertrophy brain, 41
attack (strokes), 393, 400–402, 402f
death, 533 e#ects of alcohol, 243–244, 243t,
248, 251–252 e#ects of drugs, 209–210
Brash-McGreer, 173 Braxton-Hicks contractions, 142 breasts, 131f
cancer, 428, 443, 445–447, 446f–447f
self-examination, 430, 446, 448 breast self-examination (BSE),
446, 448 breathing, stress and use of
deep, 90 breech birth, 143 Breuning, Walter, 514 brewer’s yeast, 368t bronchioles, 436, 471 bronchitis, smoking and acute and
chronic, 261–262 bulbourethral glands, 128
704 Index
bulimia nervosa, 61, 61t, 336 Burkitt lymphoma, 506 burnout, 77 Bush, George W., 159 bypass surgery, 396, 397f
C CAD. See coronary artery disease ca#eine, 207, 217, 218t, 227, 368t CAGE screening test, 255 calcium, 301–302, 302t calendar method, 149, 150 calf stretch, 362f Calment, Jeanne, 514 calming. See sedatives caloric cost of living
energy balance, 328 energy for basal (vital)
metabolism, 325–326 energy for physical activity,
326–327 energy for thermic e#ect of
food, 328 calories, 285
empty, 305, 308 CAM. See complementary and
alternative medicine Camel cigarettes, 240, 241f cancer, 454, 459
alcohol consumption and, 251 cell phones and, 555 de!ned, 424 development, 424–427, 427f diet and, 443–445, 443t gender di#erences and death
rates, 426, 427f genes and, 425, 425f hormones and, 447, 448f reducing risk for, 458 screening, 428, 428f, 430, 444 smoking and, 264–265, 431,
435–443, 436t–438t spreading of, 424–427,
426f–427f staging, 428, 428f stress and, 84–86 survival rates, 429, 429t ultraviolet radiation and,
451–454, 451t unknown causes, 454–457 vaccines, 434 viral infections and, 449–451, 451t warning signs, 459
cancer screening, 428 cancer staging, 428, 428f cancer vaccines, 434 Candida albicans, 490, 502 Cannabis sativa, 222 capillaries, 392 carbohydrates, 281, 282t, 284–294,
286t–288t loading, 367
carbon monoxide (CO) cigarette smoke and, 257, 258 detectors, 554 poisoning, 553–554, 558 sensors, 553
carcinogens, 425 metals found in workplace,
437, 437t carcinomas
basal cell, 451, 452, 452f squamous cell, 451, 452, 452f
cardiopulmonary resuscitation (CPR), 401, 533
cardiorespiratory !tness, 356–359 cardiorespiratory system, 352–353,
354f cardiovascular disease (CVD), 264,
268, 280, 287, 299, 389–419 alcohol consumption and, 251 atherosclerosis, 264, 393–394 coronary artery disease (CAD),
264, 393–402, 393f–394f, 396f–400f, 402f
de!ned, 393 diabetes and, 407 heart attacks, 393, 396–400,
398f–400f hypertension, 393, 402–403,
405–406, 406f obesity and, 407 physical !tness and, 357,
406, 407 preventing, 409–412, 409t, 411f rheumatic fever, 399 risk factors for, 390, 402–409,
404t, 406f smoking and, 264, 405, 410 stress and, 85–86, 407 strokes, 393, 400–402, 402f
cardiovascular system, 390 e#ects of aging on, 519t how it works, 390–392,
391f–392f caring, 189 Carmona, Richard, 266, 435 carnitine, 368t carotid endarterectomy, 401 carpal tunnel syndrome, 325,
471, 472 cataract, 520 catheter, 395 Caucasians. See whites CDC. See Centers for Disease
Control and Prevention celiac disease, 298 celibacy, 188 cell-mediated immunity,
483–484, 484f cellulite, 329 centenarians, 514 Centers for Disease Control and
Prevention (CDC), 9, 23, 54, 159, 182, 197, 226, 240, 258f, 263f, 270f, 406, 469
central nervous system (CNS), 40 ceramicware, 551 cerebral death, 533 cerebral hemorrhage, 400 cerebral thrombosis, 400 Cervarix, 450 cervical cancer, 270, 435, 449–451,
450t–451t, 495, 496
cervical cap, 151 cervix, 130, 140, 142, 144, 159, 430 chain of infection, 473–479, 474f Chang San-feng, 382 Chantix, 267 CHD. See coronary heart disease check-fraud scheme, 368t chemical defense mechanism, 480 chemicals, toxic, 550, 559–560 chemotherapeutic agents, 135t chemotherapy, 429, 433–434,
449, 455 chest pain, diagnosing, 395, 396f chewing tobacco, 253, 257, 258,
263 child abuse/violence, 100, 101,
105, 117 childbirth, 140, 165 Childhelp National Child Abuse
hotline, 117 child molester, 118 child physical abuse, 117 children (childhood), 94
abuse/violence, 100, 101, 105, 117
age for, 32 alcoholism and, 244 alcohol prevention programs
for, 251, 255 attention-de!cit hyperactivity
disorder (ADHD), 54, 65 cardiovascular health, 412–413 death and dying, discussing,
540–541 drug abuse, 213 food allergies, 297–298, 297f genetic disorders, 506 health concerns, 32 immunity to diseases, 485 immunizations, 485 infectious diseases, 492,
505–507 lead poisoning, 551–553 metabolic rate and, 326 obese and overweight, 322, 324,
326, 344–345, 346f physical !tness, 378 psychological health, 65–66 self-esteem, 46–47 sexual development, 160 sexuality, 196–197 smoking, 258 weight management, 345–346,
346f child sexual abuse, 117–118 China white, 226, 226t chlamydial infections, 147,
501–502, 501f chloro'uorocarbons (CFCs),
548 cholesterol, 292
cardiovascular disease and, 394, 403–405, 404t
lowering protein, 405, 407 chorionic villus sampling (CVS),
134, 137, 138f chromium picolinate, 367
chromosomal abnormalities, risk of, 472
chronic bronchitis, 261–262 chronic condition or disease, 6 chronic diarrhea, 490 chronic health problems, stress
and, 82–86 chronic hunger, 566 chronic obstructive pulmonary
disease (COPD), 222, 264, 270
Cialis, 175 cigarettes. See smoking cilia, 261, 479 circulatory system, 352–353, 354f circumcision, 144–145, 145f Clean Air Act (1970), 564 Clean Water Act of 1972, 561 clinical studies, 24 Clinton, Bill, 186 clitoris, 130–131 Clostridium botulinum, 476 clove cigarettes, 258 club drugs, 215 CMV. See cytomegalovirus CNS. See central nervous system coal-!red power plants, 562 cocaine, 135, 208–209, 216–217,
217f COCs. See combined oral
contraceptives coenzyme Q (Co-Q-10), 368t cognitive abilities, 522 cognitive behavioral therapy, 51, 52 cognitive processes, 40 cohabitation, 102, 193 coitus, 186, 187 coitus interruptus (withdrawal), 150 colds, 476, 486–488 College Schedule of Recent
Experience, 80 college students
alcohol and, 4, 244–246, 245t–247t
cardiovascular risk factors and, 390
drug abuse and, 210, 213, 216, 219
physical !tness/exercise and, 378
rape and, 104 smoking and, 258 stress and, 74, 77, 78, 80 violence and, 102, 104, 108–109,
109f colonoscopy, 428, 445 colorectal cancer, 443–445 colposcopy, 451 comatose, 533 Combat Methamphetamine
Epidemic Act (2006), 215 combined oral contraceptives
(COCs), 154–156 commitments
de!ned, 189, 190 establishing, 192 types of, 193–194
Index 705
communicable diseases, 476, 478 communicable infectious diseases,
477–478 communication in relationships,
195–197 community security measures,
113–114 community violence, 109 compatible, 192–193 complementary and alternative
medicine (CAM), 24, 26–27, 27t, 432, 485–488
components of health, 6–8, 8f Comprehensive Drug Abuse
Prevention and Control Act (1970), 207
Comprehensive Methamphetamine Control Act (1996), 215
compromise, 46, 47 compulsion, 54 computed tomography (CT),
401–402, 402f, 428 computer monitors, 555 conception. See fertilization condoms
female, 153, 154f, 492, 505 male, 153, 153f, 493, 505
Condylomata acuminata, 495f con'icts, resolving, 46 congestion, 261, 398, 486 congestive heart failure, 397–398 conjugated linoleic acid
(CLA), 368t constipation, 290 Consumer Product Safety
Commission in 1966, 550 consumer protection, 21 contemplation stage, 16 contraception. See birth control contraceptive patch, 155 contraceptive vaginal ring, 156 contrast medium, 395 controlled substances, 209 Controlled Substances Act
(1970), 207 conventional medicine, 24 COPD. See chronic obstructive
pulmonary disease coping strategies, 86, 88–89 coronary angiography, 395 coronary arteries, 392–395,
393f–394f coronary artery bypass gra$
(CABG) surgery, 396, 397f coronary artery disease (CAD),
393–402, 393f–394f, 396f–400f, 402f
coronary embolism, 394 coronary heart disease (CHD),
393, 414–415 coronary microvascular dysfunc-
tion, 394, 399 coronary thrombosis, 394 corpus luteum, 132, 133 cortisol, 76, 77, 84 coughs, 476, 486 counterconditioning, 17
Cowper’s glands, 128 crab lice, 503 crackle. See kreteks C-reactive protein (CRP), 290,
407, 409 creatine, 367–368, 368t criticism, constructive, 47 crossdressers, 184 cross-training, 376 crunch, 365, 365f cryotherapy, 451, 452 Cryptococcus meningitis, 491 crystal meth, 215, 215f CT. See computed tomography CT colonography, 444 cues, 17 cultural (ethnic) di#erences
health status and, 11 life expectancy, 516 personality development and, 43 sex and, 180–186 violence and, 108 virginity and, 180
cunnilingus, 186, 187 curcumin, 526 curettage, 159 CVD. See cardiovascular disease CVS. See chorionic villus sampling cyberstalking, 109 cystic !brosis (CF), 468–469, 506 Cystic Fibrosis Foundation, 469 cystitis, 130 cytokines, 81 cytomegalovirus (CMV),
135t, 491 cytotoxic T cells, 483
D dapoxetine, 176 DASH diet. See Dietary
Approaches to Stop Hypertension diet
date rape avoiding, 103 de!ned, 104 drinking and, 103, 245–246 drugs, 103, 206, 208t, 219
Dawson, Len, 424 D&C. See dilation and curettage D&E. See dilation and evacuation death, 513–543
cancer rates, 426–427, 427f de!ned, 533–534 euthanasia and right to die,
534–535 funeral and burial decisions, 538 major causes of, 8, 393, 393f major causes of, and by age
groups, 9 near-death experiences, 529 preparing for, 535–537
decision-making model, 16–18, 16f decorating techniques, 552 defective genes, 466 defense mechanisms, 43, 44t Defense of Marriage Bill
(1996), 186
dehydration, 374 DeKosky, Steven T., 525 delirium, 219 delirium tremens (DTs), 251 delusions, 49 dementia, 522, 523t Demerol, 220, 226t Department of Defense (DoD)
community, 105 Depo-Provera, 156 depressants, 218–220 depression, 56–59, 58t, 59f
postpartum, 145–146 DES. See diethylstilbestrol designer drugs, 225–227, 226t,
227f detoxi!cation, 209, 229, 256 detraining, 359 DEXA or DXA. See dual-energy
X-ray absorptiometry diabetes, 471
cardiovascular disease and, 407 gestational, 143, 325 obesity and, 325 pregnancy and, 143, 325 type 1 and 2, 4
diabetes mellitus, 288–289, 288t, 407
diaphragms, 151, 152f diastolic pressure, 405–406 diet(s)
cancer and, 443–445, 443t cardiovascular disease and,
410–411 composition and weight gain,
334–335, 343–345 de!ned, 281 Dietary Approaches to Stop
Hypertension (DASH) diet, 410
diseases caused by poor, 280 fad, 337 and performance, 367 very-low-calorie, 337–338 weight reduction, 336–338
Dietary Approaches to Stop Hypertension (DASH) diet, 410
dietary !ber, 286 Dietary Guidelines for Americans,
306–307 Dietary Reference Intakes (DRIs),
306 dietary supplements, 26, 285, 340,
342, 342t, 486 as ergogenic aids, 368, 368t FDA and, 27–29
diethylstilbestrol (DES), 135 digestion, 284–285 digestive system, e#ects of aging
on, 519t digital rectal exam, 162, 445, 455 dilation and curettage (D&C), 159 dilation and evacuation (D&E),
159 dimensions of health, 5–8 diphtheria, 473
dipping, 258 disclaimers, 21 disease(s)
alcohol abuse and dependence and, 244, 248–253, 250f, 253f
communicable, 476, 478 de!ned, 466 immunity, 479–484 infectious, 466, 473–479,
484–485 interaction of genes and
environment and, 469–471 medications that combat,
485, 488 noncommunicable, 476 noninfectious, 466–472 prevention, goals of, 18 stress and, 85–86
dislocations, 373–374 disordered eating, 59 distress, 75 diuretic, 374 diverticula, 290, 291f diverticulosis, 290, 291f divorce, 19, 195f DNA, 11–12, 368t DoD. See Department of Defense
community Domestic Chemical Diversion
Control Act (1993), 215 domestic partnerships, 186 domestic violence, 105–107,
106f, 106t a#ects on brain and body,
208–209 double-blind studies, 24 douching, 151 Down syndrome, 135, 469,
470f, 506 drag performers, 184 Dravecky, Dave, 424 drinking. See alcohol (alcoholism) DRIs. See Dietary Reference
Intakes Drug Enforcement Administration
(DEA), 207, 226 Drug-Induced Rape Prevention
and Punishment Act (1996), 219
drugs. See also medicine (medications)
abuse, 207, 230, 231t breast cancer and, 449 categories and e#ects of,
230–231, 231t controlled substances, 209 date rape, 104, 206, 208t, 219 de!ned, 206 dependence or addiction,
212–213, 230 depressants, 218–220 designer, 225–227, 226t, 227f domestic violence and, 106 e#ects on brain and body,
208–209 ergogenic aids, 367–370,
368t, 369f
706 Index
gateway, 211 hallucinogens, 223–224, 223f HIV/AIDS and use of, 217, 221,
222, 228, 493–494 HIV/AIDS treated by, 493–494 illegal vs. illicit, 208t, 209–212,
210f, 211f infections and use of, 485, 488 inhalants, 224–225, 225t marijuana, 209, 210f, 222–223 misuse, 206–208, 206t, 207f,
208t opiates, 220–221, 220f–221f,
229, 231 overdose, 209, 212 over-the-counter, 207, 485 party (club), 215 physiologic and psychological
dependence, 212 pregnancy and taking, 134, 135,
214, 222, 231 prevalence of illicit, 208t,
209–212, 210f, 211f psychoactive, 206, 208–209,
210f, 217 reasons and patterns of using,
210–212, 211f recreational, 212, 223 schedules, 207, 208t stimulants, 209, 211, 213–217,
214f, 218t summary of, 235 tolerance, 212, 219, 220, 223 treatment and prevention,
230–231 weight management and use of,
229, 339–340, 345–346, 410 withdrawal, 212, 213, 217–219,
223, 230 dual-energy X-ray absorptiometry
(DEXA or DXA), 329, 330f Duchenne/Becker muscular dys-
trophy (DBMD), 506 duodenum, 82 durable power of attorney, 536 dying
emotional aspects of, 530–531 Kübler-Ross’s stages of, 530 spiritual aspects of, 529–530 terminal care options, 531–533
dynamic constant external resistance, 360
dynamic stretching, 361 dyspareunia, 180 dysplasia, 425, 451
E eating disorders, 58, 336, 345
feeding and, 59–62, 60f, 60t, 61t ebola viral hemorrhagic fever, 473 EC. See emergency contraception echinacea, 28, 29t, 487 Echinacea purpurea, 487, 487f echocardiogram, 395 e-cigarettes, 267, 267f eclampsia, 143
ecstasy, 215, 226, 226t ectopic pregnancy, 140f, 143, 501 EEOC. See Equal Employment
Opportunity Commission e&cacy, 13 EGb 761, 526 egg development and fertilization,
128, 130 ejaculation, 173
de!ned, 127 premature/rapid, 176
elder abuse, 100, 105, 118 elderly
abuse, 100, 105, 118 age for, 32, 515 Alzheimer’s disease, 506,
522–526 cancer, 454, 458 cardiovascular health and, 413 characteristics of, 517–518 death, 533–538 drug abuse, 233 grief, 538–540 health concerns, 32 infectious diseases, 506 life expectancy, factors
a#ecting, 516 metabolic rate and, 326 obesity, 345–346 physical !tness, 383 psychological health, 66 psychosocial stages of personality
development, 43–44, 44t sex and, 172, 197, 199 sexuality, 197, 199 stress, 94, 94f
Elders, M. Joycelyn, 188 electrocoagulation, 451 electromagnetic radiation,
555–557 electronic cigarettes, 267, 267f embolus, 394 embryo, 139–140, 159 emergency contraception (EC), 157 emergency medical system (EMS),
398, 401 emotional eaters, 84 emotion-focused strategies, 88–89 emotions, 41
feelings, 41 intensity and duration of, 49
emphysema, 262, 264f EMS. See emergency medical
system endocrine system, 75f
de!ned, 75–76, 171 e#ects of aging on, 171–172, 519t sexual behavior and, 172
endometrial cancer, 449, 456 endometrium, 132 endorphins, 76, 93 endurance, muscular, 360–361 energy
balance, 328, 328f for metabolism, 285, 325–326 for physical activity, 326–327
for thermic e#ect of food (TEF), 328
energy therapies, 26 enteritis, 472 environmental approaches, 254 environmental health
air pollution, indoor, 560–561 air pollution, outdoor, 562–564 asbestos !bers, inhalation of,
554–555 de!ned, 7–8, 7f, 548 electromagnetic radiation,
555–557 hunger, 566 irradiation of food, 557–558 noise pollution, 564–565 pesticide poisoning, 558–559 poisoning, in homes, 549–554 toxic chemicals, inhalation of,
559–560 water pollution, 561–562
environmental in'uences diseases caused by interaction of
genes and, 469–471 noninfectious conditions and,
471–472 overeating and, 335–336
Environmental Protection Agency (EPA), 269, 554, 565
environmental tobacco smoke (ETS), 266, 438
enzymes, 284, 368t ephedra (ma huang), 28 ephedrine, 215, 228–229, 229f epididymis, 126 epinephrine, 76, 176 episiotomy, 143 Epstein-Barr virus (EBV), 506 Equal Employment Opportunity
Commission (EEOC), 107 erectile dysfunction (ED)
( impotence), 175–176 erection, 173 erect penis, 128f ergogenic aids, 367–370,
368t, 369f Erikson, Erik, 43 escitalopram, 176 esophagus, cancer of, 437–440 Essure, 157 estate management, 537 estrogen, 132, 153–154, 160,
171–172 replacement therapy (ERT), 449,
457, 458 ethnic di#erence. See cultural
(ethnic) di#erences euphoria, 208, 209, 215, 220,
226t, 229 eustress, 75 euthanasia, 534 excitement phase, 172 excoriation disorder, 54 exercise(s), 351–385. See also
physical !tness
alternatives for outdated, 365–366, 365f, 366f
cardiovascular disease and, 357, 406, 410
cool down, 372 danger signs, 373 de!ned as, 354 duration, 371 energy for, 326–327, 352 FITT principle for, 371 'exibility, 361, 362f, 363, 363f frequency, 371 for health, 370–373 injuries, preventing and
managing, 373–375 intensity, 357–358, 371 isometric, 360 isotonic, 360 Kegel, 522 long-term psychological bene!ts
of, 355 mode of, 371 pregnancy and, 380, 380f, 381 psychological health and, 7 repetitive, 360 session, 372, 372f set, 360 stress reduction and, 92–93 stretching, 361, 362f tai chi, 93, 382 type of, 371 warm up, 372 yoga, 93, 93f
exercise-induced asthma, 466, 471 exhaustion stage, 77 extended-cycle oral contraceptives,
154–155 extramarital sex, 194 extrarelational sex, 194 extremely low frequency (ELF)
radiation, 555
F fad diets, 337 fallopian tubes, 130 false labor, 142 family health history, cardiovascular
disease and, 403 family violence, 105–107 fast food, 335 fasting, 337 fatal injuries, alcohol consumption
and, 251–252 fat cells, 329 fat-soluble nutrients, 285 FDA. See Food and Drug
Administration fecal occult blood test (FOBT),
430, 444 Federal Hazardous Substances
Act, 550 Federal Trade Commission (FTC),
20, 21 Federal Water Pollution Control
Act of 1972, 561 fellatio, 186, 187
Index 707
female athlete triad, 62 female condoms, 153, 154f,
492, 505 female polyurethane condoms, 505 female sexual arousal disorder
(FSAD), 177 female sexual reproduction, 129f
external organs of, 130–132 internal organs of, 128–130
FemCap, 151, 152f fentanyl, 226, 226t fertility awareness, 148 fertilization, 126, 130, 132,
134, 139 and implantation, 140f
fetal blood sampling, 136 fetal development, 139–140 fetus, 136, 137, 159 fever, 482 !berscope, 428 !bromyalgia syndrome (FMS), 82 !ght-or-'ight response, 76 !re prevention, 578–579 FitBit, 371 !tness center, choosing, 378, 380 !tness, physical. See also physical
!tness 'accid penis, 128f Fleming, Peggy, 424 'exibility, 361, 362f, 363, 363f
exercises, 528 'uoxetine, 133 FMS. See !bromyalgia syndrome fog, 562 fold-up stretch, 366, 366f folic acid, 164 folk medicine, 548 follicles, 128, 130, 160 food
allergies, 297–298, 297f digestion and absorption of,
284, 285f energy from, 285 functional/nutraceuticals, 284 health, 282–283 irradiation of, 557–558 labels, 297, 297f natural, 282–283 organic, 282–283 pesticides in, 558 poisoning, 476 thermic e#ect of, 328
Food and Drug Administration (FDA), 20, 21, 23, 284, 339, 412, 558
barrier methods and, 151 cervical cancer drugs and, 450 dapoxetine and, 176 dietary supplements, 340,
342, 342t dietary supplements and,
27–29, 229 electronic cigarettes and,
267, 267f food irradiation and,
557–558
Gardasil and, 497 GHB and GBL and, 215,
219–220 khat and, 208t, 214, 214f oral contraceptives and, 155 over-the-counter drugs and,
227–229, 229f pesticides and, 558 smoking aids and, 267 smoking and, 240 sterilization, 157
formaldehyde, 251, 560–561 fraudulent products, 20 free radicals, 281 frequency, intensity, time, and type
(FITT) principle, 371 Freud, Sigmund, 43, 189 Fromm, Eric, 189 frostbite, 375 FTC. See Federal Trade
Commission functional foods, 282–284 funerals, 537, 538 fungi, 475
G gambling, problem, 55, 55t gamma butyrolactone (GBL),
215, 220 gamma hydroxybutyrate (GHB),
215, 220 gang violence, 109 Gardasil, 450, 497 garlic, 283t, 487 GAS. See general adaptation
syndrome gastric bypass surgery, 339, 339f gays, 185–186 GDM. See gestational diabetes
mellitus gender
blood alcohol concentration (BAC) by, 252–253, 253f
de!ned, 170, 180 determination, 160 dysphoria, 181 identity, 180 roles, 180–181
gender di#erences, 170 alcohol consumption and,
243t–244t, 245–246 cancer and, 426, 427f cardiovascular disease and,
390, 402 depression and, 56–59, 58t, 59f eating disorders, 59–62, 60f,
60t, 61t gambling and, 55, 55t illegal drug use and, 208t,
209–212, 210f, 211f life expectancy and, 11 liver disease and, 248, 250 metabolic rate and, 326 osteoporosis and, 302 rape and, 104 sexuality and, 180
smoking and, 240 stalking and, 107–109 suicide and, 63 venous disease and, 392 violence and, 104
gender dysphoria, 181t gender stereotype, 181 general adaptation syndrome
(GAS), 76–77 generalized anxiety disorder, 52 generally recognized as e#ective
(GRAE), 228 generally recognized as honestly
labeled (GRAHL), 228 generally recognized as safe
(GRAS), 228 generativity, 44, 44t genes, 11, 12
disorders of, 466 gene therapy, 494, 506 genetic counseling, 136–138 genetics
aging and, 516 counseling, 136–138, 506 diseases, 466–469, 506 health status and, 11–12 life expectancy and, 516 metabolic rate and, 326 obesity and, 332, 334–335
genetic testing, 506 genital herpes, 494–495, 494f genital warts, 495–496,
495f, 496f genomics, 11–12, 470 German measles, 134, 135, 506 gerontologists, 514 gestational diabetes mellitus
(GDM), 143 Ginkgo biloba, 229, 526 Ginkgo Evaluation Memory Study,
526 ginseng, 174, 174f glaucoma, 520 globesity, 324 glucose, 286 gonorrhea, 499–500, 500f good cholesterol, 407 good health, 6 gout, 325 gray-air cities, 562 green tea, 432 grief (grieving), 538–540 groin stretch, 362f group homes, 229 growth, psychological, 45, 46 gummas, 499
H hallucinations, 49, 213, 223–224 hallucinogens, 223–224, 223f Hamer, Dean, 186 hangovers, 246t, 251 harmful use, 241 Harvard Medical School, 533 hashish, 221f, 222 hate crimes, 100
hazardous waste, 561 hCG. See human chorionic
gonadotropin HDL. See high-density
lipoproteins headaches, 83–84
signs and symptoms, 84, 84t health, 3–34
analyzing health information, 20–24
components of, 6–8, 8f continuum, 6, 6f de!ned, 5 dimensions of, 5–8 good, 6 nation’s, 8–11 and physical activity, 354–355,
355t, 356t preventing, health problem, 18 promotion, 10–11, 18 status of Americans, 10 understanding health behavior,
13, 16–18 wellness and, 6
Health and Human Services (HHS), 207
health care for disease prevention, 19
healthcare practitioner-patient relationship, 31–32
health!nder, 23 healthcare providers alleviate
symptoms, 467 health concerns, 32–33 health continuum, 6f health food, 282–284 health information, analyzing,
20–24 addiction, 234 alternatives for outdated,
365–366, 365f, 366f cell phones and cancer, 556 college drinking, strategies to
reduce, 249 herbal tea to reduce anger, 119 Internet, 23–24 model for, 20–24 mood and anxiety, 67 sample analysis of an ad, 22 sleeplessness, 87 tanning beds, 451–452 tips for, 20–23 trans fats, 414–417 wary consumer of, 20–23 weight-loss products, 343
health insurance, 8 Health on the Net (HON)
Foundation, 23 health problem, preventing, 18 health promotion, 10–11, 18 health-related behavior
changing, 13, 16 making positive decisions about,
16–18 health-related information,
analyzing, 24
708 Index
health status impact of social conditions
on, 15 minority, 11
Healthy People, 270 Healthy People 2000, 10 Healthy People 2010, 10, 324 Healthy People 2020, 10–11, 10t,
112, 324, 454, 571–573 heart
attacks, 393, 396–400, 398f–400f chambers of, 390 failure, 397–398, 398f rates, target, 357–358, 357f, 358f
heart disease, 85–86 heat
cramps, 374 exhaustion, 374
heatstroke, 374 height tables, 322, 323t Helicobacter pylori (H. pylori),
83, 442 helper T cells, 483, 484 hemochromatosis, 304 hemoglobin, 261 hemorrhoids, 290 hepatitis, alcoholic, 248–249 hepatitis C, 473 herbal supplements, 28, 29t herbs, use of, 27–29, 486
cancer and, 432 for depression, 57 to reduce anger, 119 for stress, 84, 85
Herceptin, 449 heredity
alcoholism and, 242 breast cancer and, 449 cardiovascular disease and, 409 de!ned, 41 hypertension and, 409 mental illness and, 49 personality development and, 41
heroin, 217, 221, 221f herpes simplex virus (HSV), 488,
494–495 herpes simplex virus-1 (HSV-1),
494 herpes simplex virus-2 (HSV-2),
494 herpesvirus, 495 heterosexual, 184 hierarchy of human needs,
44–45, 45f high blood pressure. See
hypertension high-density lipoproteins (HDL),
403–405, 404t highly active antiretroviral therapy
(HAART), 493 high-sensitivity C-reactive protein
(hs-CRP), 409 Hingson, Ralph, 246, 249–250 Hispanics (Latinos)
depression in, 57 health status of, 11 hypertension in, 405
prostate cancer in, 454–455
testicular cancer in, 455–456
histamine, 481 HIV. See human immunode!-
ciency virus hoarding disorder, 54 Hochbaum, Godfrey, 6 holistic, 6 Holmes, "omas, 79–80 homeopathic products, 486 homeopathy, 26, 27, 486 home security measures, 113 homophobia, 186 homosexuality, 184 honey, 476 HON Foundation. See Health on
the Net Foundation hormone replacement therapy
(HRT), 412, 445, 447 hormones
cancer and, 447, 448f, 449 de!ned, 75 reproductive/sex, 131, 160,
170–171 stress, 75–76
hospice, 531–532 host, 473, 478–479 hostility, 86 HPV. See human papillomavirus H. pylori. See Helicobacter pylori HRT. See hormone replacement
therapy Huang ch’i, 432f hu&ng, 224 human chorionic gonadotropin
(hCG), 134, 139 Human Genome Project, 470 human immunode!ciency virus
(HIV), 473 people at risk for, 492 progression of, 489–491 protection against, 492–493 statistics, 490f transmission of, 492 treatment of, 493–494
human papillomavirus (HPV), 430, 439, 450, 450t, 495, 497
humor, use of, 88 hunger, 334, 566 Huntington’s chorea, 506–507 Huntington’s disease, 506 hydrogenation, 415 hydrostatic weighting, 329, 330f hypertension, 5, 250, 264, 393,
402–403, 405–406, 406f hyperthermia, 374 hypertrophy, 359 hyperventilation, 90 hypnotics, 219 hypoactive sexual desire disorder
(HSDD), 177 hypomania, 58 hypothalamus, 334, 335f hypothermia, 375
I IBS. See irritable bowel syndrome ICSI. See intracytoplasmic sperm
injection identity, 42, 43 IHS. See Indian Health Service illegal drugs, de!ned, 209 illicit drugs, 209–212, 211f imagery, 91–92 immune system, 80f
alcohol consumption and suppression of, 251
de!ned, 80–81, 479 e#ects of aging on, 519t role of, 479 stress and, 80–81
immunity acquired, 484–485 de!ned, 479 nonspeci!c, 479–482 speci!c, 479, 482–484
immunizations, 485 immunotherapy, 429, 434 Implanon, 156 implantation bleeding, 138 implants, contraceptive, 130 impotence, 175 IMS. See International Menopause
Society inborn immunity, 484 incest, 118 Indian Health Service (IHS), 42 induced abortion, 158 induction, 159 infants (infancy)
age for, 32 AIDS, 492 birth defects, 134, 135, 325,
412, 506 cardiovascular health, 412 chlamydial infections, 501 drug abuse and, 231 genetic disorders, 506 gonorrhea, 499 health concerns, 32 herpes virus and, 496 infectious diseases, 505–507 life expectancy of, 4 metabolic rate and, 326 obesity and, 324 psychological health, 40 psychosocial stages of personality
development, 43 weight management, 345–346,
346f infatuation, 189, 191 infection(s), 465–509
chain of, 473–479 medications used to combat,
485, 488 infectious diseases, 466, 473–479,
506 protection against, 484–485
infectious mononucleosis, 506, 507
infertility, 146–147 infestation, 475
in'ammation, 80, 480–482 systemic, 480–481
in'ammatory process, 482f in'uenza, 474 inhalants, 224–225, 225t inherited diseases, 466 injury prevention
automobile safety, 575–576 bicycle safety, 577–578 !re prevention, 578–579 pedestrian safety, 576 water safety, 577
inpatient treatment, 256 insomnia, 217, 219 institutional (school) violence, 110 insulin, 84, 334 intact dilation and extraction, 159 integrative medicine, 26 integrity, 44, 44t intellectual health, 7 intensive care, 529 interferons, 482 intergenerational violence, 101 International Agency for Research
on Cancer (IARC), 555 International Bottled Water
Association (IBWA), 562 International Menopause Society
(IMS), 161 International Olympic Committee
(IOC), 368 Internet, assessing information on
the, 23–24 intersex, 181, 182 intestinal ulcers, 82–83 intimacy, 44, 44t, 189, 190 intimate partner violence (IPV),
105–106 intoxication, 209, 217, 243, 246,
251, 252, 476 intracellular antigens, 483 intracytoplasmic sperm injection
(ICSI), 147 intrauterine devices (IUD), 147,
156–157, 156f in vitro fertilization (IVF), 147 IPV. See intimate partner violence iron, 302t, 304 irradiation of food, 557–558 irritable bowel syndrome (IBS), 82 ischemia, 395 isometric exercise, 360 isotonic exercise, 360 itch mites, 503 IUD. See intrauterine devices IVF. See in vitro fertilization
J Jensen, Knud Enemark, 368 Johnson model, 172–173, 172f Johnson, Virginia E., 189 joints, 352
dislocation of, 373–374 Jones, Marion, 368 journal writing, 88 Joyner-Kersee, Jackie, 466
Index 709
K K2, 226–227 Kaposi’s sarcoma,
491, 491f kava, 28, 29t Kegel exercises, 522 ketamine, 215, 224 Kevorkian, Jack, 534 khat, 214, 214f kidneys, cancer of, 440 kilocalories, 285 Kinsey, Alfred, 184 kreteks, 258 Kübler-Ross, Elisabeth, 530
L labia majora, 131 labia minora, 131 labor, 140, 142–144
stages of, 144f lactose, 290 lactose intolerance, 290 larynx, cancer of, 439–440 lasers, cancer treatment and use of,
429, 434 latent state, 475 latent syphilis, 499 latex condom, 492 Latino people, 14 Latinos. See Hispanics laws, health, 20 LDL. See low-density
lipoproteins lead paint removal, 553 lead poisoning, 548, 551–553 Ledger, Heath, 206, 207f Lee, John Alan, 189
six styles of loving, 189t le$ ventricular assist device
(LVAD), 398, 398f Legionella pneumophila, 476 Legionnaire’s disease, 476 leptin, 334 lesbians, 185 leukemia, 426, 435, 443 leukocytes, 480 leukoplakia, 266, 266f Levitra, 175 libido, 43, 171 lice, 474, 475
pubic, 502–503 life expectancy
de!ned, 4, 516 factors a#ecting, 516 gender di#erence, 11
life skills programs, 254 life span, 514 life stages, ages for, 32, 32t lifestyle
de!ned, 4, 5 sedentary, 352
ligaments, 352 light therapy, 59 lipids, 282t, 291–294, 292f, 293t lipoproteins, 403–405, 404t liposuction, 339, 340f literature search, doing, 22
liver alcohol consumption and
diseases of, 248, 250–251, 250f cirrhosis, 248, 250, 250f
living wills, 536 long-term care, 529, 531, 532 love
attachments, 190–191 commitments, types of, 193–194 de!ned, 188–189 Sternberg’s love triangle, 190,
190f, 191f styles of, 189 theories about, 189–190
low back pain, 361, 363, 363f, 364f low back stretch, 362f low-density lipoproteins (LDL),
403–405, 404t lower bone density. See
osteoporosis LSD. See lysergic acid diethylamide lumpectomy, 448 lung cancer, 424, 428, 435,
437t, 440f Lybrel, 155 Lyme disease, 476
vaccines for, 477 lymph, 480 lymphatic system, 480, 481f lymph nodes, 480 lymphocytes, 480, 483 lymphomas, 426 lysergic acid diethylamide (LSD),
208–210, 215, 223, 468 lysozyme, 480
M macrophages, 325, 480 macular degeneration, 520 magic mushrooms, 224 magnetic resonance imaging
(MRI), 395, 400, 401, 428, 428f
ma huang (ephedra), 28, 215, 229, 229f
maintenance stage, 17, 256 major depressive disorder, 56–57 maladaptive behaviors, 41 malaria, 467, 468f, 479 male condoms, 151, 153, 153f,
492, 505 male sexual reproduction, 127f
external organs of, 128 internal organs of, 126–128
malignant melanoma, 451, 452, 452f, 458
malignant tumors, 424 mammary gland anatomy, 131f mammography, 445, 448f mania, 58 manic depression, 57–58 manipulative therapies, 26 marijuana, 209, 210f, 222–223, 468 marital rape, 102 marriage, 193f, 194
same-sex, 186 Marx, Martin, 80
Maslow, Abraham, 44–45 mastectomy, 448 Masters and Johnson model,
172–173, 172f Master Settlement Agreement
(MSA), 240 Masters, William H., 189 masturbation, 187, 188 MDMA, 215, 226, 226t measles, German, 134, 135, 506 medical abortion, 158–159 medical professionals, choosing,
31–32 Medicare, 518 medicine (medications). See also
drugs complementary and alternative,
24, 26–27, 27t conventional, 24 herbs as, 27–29, 486 HIV/AIDS treated by, 493–494 infections and use of, 485 integrative, 26 misuse of, 206–208, 206t,
207f, 208t for psychological disorders,
51–52, 51t use of term, 206 weight management and use of,
339–340, 345–346 wheel, 42, 43
meditation, 91–92 MedWatch, 227, 228 melanin, 451 memory B cells, 483 memory T cells, 484 menarche, 160 meningitis, 491 menopausal hormone therapy
(MHT), 161, 163 menopause, 161, 412 menses, 132 menstrual cycle, 132–134, 133f
premenstrual syndrome (PMS), 132–133
toxic shock syndrome (TSS), 133–134
mental health. See psychological health
mental health therapists locating and selecting, 50 types of, 51t
mental illness. See psychological illness/disorders
meperidine, 220, 226t mescaline, 223–224, 226t metabolic diseases, 505 metabolic equivalents (METS),
355, 356t metabolic rate, 326 metabolism, 285, 325–326 metals, carcinogenic, 438, 438t metastasize, 424–426, 426f–427f methadone maintenance, 229 methamphetamines, 213–216, 215f MHT. See menopausal hormone
therapy
mifepristone, 158–159 migraines, 83–84, 83f, 471 mind. See brain mind–body interventions, 26 mind–body relationship, 80–82 mindfulness meditation, 91 minerals, 282t, 301–304, 301f, 302t mini-pills, 156 minority, health status of, 11 miscarriages, 158 misoprostol, 158 modi!ed hurdle, 362f modi!ed radical mastectomy, 449 Monitoring the Future (MTF), 211,
216, 219, 227 mononucleosis, 506 mons pubis, 131 mood disorders, 55–59, 58t, 59f moral values, 43 morbidly obese, 323, 339 Moritsugu, Kenneth P., 255 morning-a$er pill, 157 motivation, 13 mourning, 538 MRI. See magnetic resonance
imaging mucothermal method, 148, 150 mucous membranes, immunity
and, 479 mucus inspection, 148, 150 municipal solid waste, 548 muscle(s)
dysmorphia, 62 e#ects of aging on, 519t !bers, 352 progressive relaxation, 90
muscular atrophy, 359 muscular endurance, 360–361 muscular strength, 359–360,
359f, 360f musculoskeletal system, 352 mushroom poisoning, 550 mutations, 424, 466 mutual masturbation, 187 myocardial infarction (MI), 397 myotonia, 172 MyPlate, 307–308, 308f, 340,
583–588
N narcotics, 207, 220, 229 National Cancer Institute, 434 National Center for Comple-
mentary and Alternative Medicine, 30, 486
National Center for Health Statistics, 11
National Coordinating and Evaluation Center Sickle Cell Disease and Newborn Screening Program, 468
National Highway Transportation Safety Administration (NHTSA), 252
National Hospice and Palliative Care Organization, 533
710 Index
National Institute of Mental Health, 57
National Institute on Alcohol Abuse and Alcoholism (NIAAA), 242t, 246, 249–250
National Institute on Deafness and Other Communication Disorders (NIDCD), 564
National Institute on Drug Abuse (NIDA), 213, 225t, 230, 231t
National Institutes of Health, 30, 486, 565
National Lead Information Center, 553
National Library of Medicine, 22 National Priorities List (NPL), 562 National Research Council (NRC),
266 National Survey of Sexual Health
and Behavior (NSSHB), 187 National Survey on Drug Use and
Health (NSDUH), 50, 210, 211f, 221f
nation’s health health promotion, 10–11 minority health status, 11 tracking, 8–9
natural family planning ( fertility awareness or rhythm method), 148
natural food, 282–284 natural killer cells, 482, 484 naturopathy (natural
medicine), 27t NEAT. See nonexercise activity
thermogenesis neck stretch, 366, 366f needs, hierarchy of human,
44–45, 45f Neisseria gonorrhoeae, 147, 499 nervous system, 40–41, 41f
e#ects of aging on, 519t stress and, 80–81
neurodevelopmental disorders, 54–55
neurotransmitters, 40, 41 neutrophils, 480 newborns. See infants (infancy) nicotine
addiction, 259–260, 260t de!ned, 259 e#ects of, 260 quitting aids, 266, 267 replacement therapy, 267 withdrawal symptoms, 259,
260t, 267 nicotini, 263, 263f NicVAX, 268 NIDA. See National Institute on
Drug Abuse night eating syndrome, 62 nitrogen dioxide, 562, 563 noise pollution, 564–565 noncommunicable diseases, 476 nonexercise activity thermogenesis
(NEAT), 327 nonfatal poisonings, 549
noninfectious diseases, 466–472 non-nutrients, 281–282 nonsexually transmitted infectious
disease, 506 nonspeci!c immunity, 479–482 normative education, 254 nose, runny, 486 NSDUH. See National Survey on
Drug Use and Health nutraceuticals, 282–284 nutrients
carbohydrates, 281, 282t, 284–294, 286t–288t
classes of, 281, 282t de!ned, 281 fat-soluble, 285 lipids, 282t, 291–294, 292f, 293t minerals, 282t, 301–304,
301f, 302t proteins, 282t, 301–304,
301f, 302t requirements and recommenda-
tions, 305–306 vitamins, 282t, 299–300, 300t water, 282t, 304–305 water-soluble, 285
nutrition basic principles, 281–286, 282f,
282t, 283f, 283t facts labels, 308–310, 309f supplements, 310–311, 311t under- and over-, 311–313, 313f
Nutrition Facts, 308, 309f Nutrition Facts panel (NFP), 415
O obesity and overweight, 347
body composition, 328–332 body mass index (BMI),
322–324, 323f breast cancer and, 447 cardiovascular disease and, 406 causes of, 332, 334–336 de!ned, 322–324 health a#ected by, 325 prevalence of, 4, 324 sperm development and, 126 stress and, 84 surgical procedures, 339 underweight, 322 weight management, 336–346
obsession, 54 obsessive-compulsive disorder
(OCD), 54 Occupational Safety and Health
Administration (OSHA), 560 OCD. See obsessive-compulsive
disorder older adults. See elderly omega-3 fatty acids, 368t oncogenes, 425 one-legged stretch, 365, 365f opiates, 220–221, 220f–221f,
229, 231 opium, 220–221, 220f–221f opportunistic infections, 490 optimal wellness, 6
oral cancer, 439–440 oral candidiasis, 491f oral contraceptives, 154–156, 265 oral sex, 187, 199 organ donation, 537 organic food, 282–284 orgasm, 127, 172, 173 orgasmic phase, 173 Orlistat, 340 osteoarthritis, 521, 521f osteopenia, 62 osteoporosis
calcium, 301–302, 302t de!ned, 302 smoking and, 266
OTC drugs. See over-the-counter drugs
Ottawa charter for health promotion, 5
outpatient drug-free programs, 229 ovarian cancer, 456–457 ovaries, 128, 147 overdose, 209 overhydration, 374 overnutrition, 311–314, 313f over-the-counter (OTC) drugs,
207–209, 217, 227–229, 229f, 485
overweight. See obesity and overweight
oviducts, 130 ovulation, 130, 149 ovum, 130f oxidative (aerobic) energy
system, 356 oxycodone. See OxyContin OxyContin, 221 ozone, 548 ozone holes, 548
P paneling, 561 panic attacks, 53 panic disorders, 53 papillomas, 495 Pap test (Papanicolaou), 430,
449–450, 457, 496 paralysis, 101 partial-birth abortion, 159 Partial-Birth Abortion Ban Act
(2003), 159 particulates, 562 Partnership for Drug-Free
America, 230 parturition, 140 party drugs, 215 passive acquired immunity, 485 passive euthanasia, 534 passive (secondhand) smoking,
266–267, 267f, 269, 438 pathogens, 466, 475 Patient Self-Determination
Act, 536 PCP, 224 pedestrian safety, 576 pedometer, 371, 371f pedophile, 118
peer reviews, 22 pelvic in'ammatory disease (PID),
500, 501 penis, 128 Pentagon, 111 pepper spray, 115 peptic ulcers, 82–83 periodontal disease, smoking and,
265–266, 265f peripheral blood stem cell
transplants, 429, 435 peripheral nervous system
(PNS), 40, 41 peripheral vascular disease,
394, 405 persistent vegetative state, 534, 535 personality
de!ned, 41 development, 41, 43 stress and type of, 82–86 theories of, 43–45, 44t, 45f
pesticide poisoning, 558–559 pets, 89, 89f petting, 187 Peverley, Rich, 398 peyote, 223–224, 223f phagocytosis, 480 phenylketonuria (PKU), 135, 506 phobia, 52, 52f, 53 photodynamic therapy, 429, 434 photosensitizer, 434 physical abuse, child, 117 physical activity, 338–339
bene!ts of, 352, 355t cardiovascular disease and, 357,
406, 410 de!ned as, 354 energy costs of, 327, 327t energy for, 326–327 health and, 354–355, 355t, 356t intensity levels, 356t moderate-intensity, 352 vigorous-intensity, 352 weight reduction and,
336–339 Physical Activity and Health,
57, 354 physical activity level (PAL), 355 physical activity pyramid, 379 physical exercise, 92–94 physical !tness
athletic, 367–369 bene!ts of, 352, 355t body composition, 328–332, 363 cardiorespiratory !tness,
356–359 composition, 328–332 'exibility, 361, 362f, 363 health-related components of,
355–367 muscular endurance, 360–361 muscular strength, 359–360,
359f, 360f principles of, 352–354 programs, developing, 376–378,
377t weight management and, 344
Index 711
physical health de!ned, 6 e#ects of aging on, 518–523,
526–527 physical inactivity, cardiovascular
disease and, 406 physical responses to stress, 75–77 physicians
characteristics of good, 31, 31t choosing, 31–32
physiology, 40 phytochemicals, 281, 283t picnics, 476 PIH. See pregnancy-induced
hypertension pill (combined oral contracep-
tives), 154–156 PKU. See phenylketonuria placebo, 24 placebo e#ect, 26 placenta, 132 plants, toxic, 550 plaques, 394, 394f, 405 plateau phase, 173 platelets, 390 Plight of the Pima, "e, 333 PMDD. See premenstrual
dysphoric disorder PMS. See premenstrual syndrome Pneumocystis carinii pneumonia,
490–491 pneumonia, 262, 474, 491, 501 PNS. See peripheral nervous
system poisoning
carbon monoxide, 558 food, 476 household cleaning aids,
medications, and vitamins, 550–551
lead, 549 pesticide, 558–559 tips for reducing incidence
of, 552 toxic plants, 550
Poison Prevention Packaging Act, 551
poison prevention symbols, 551f pollution
air, indoor, 560–561 air, outdoor, 562–564 noise, 564–565 water, 561–562
polyabuse, 209 polycyclic aromatic hydrocarbons
(PAHs), 441 polyurethane vaginal pouch, 492 portals of entry, 479, 479f positron emission tomography
(PET), 428, 428f postpartum depression, 145–146 postpartum period, 145–146 posttraumatic stress disorder
(PTSD), 53, 111 prebiotics, 284 precontemplation stage, 16 precursor chemicals, 215
preeclampsia, 143 pre-embryo, 140f, 141f pregnancy, 134
alcohol consumption and, 134–135, 251, 273
birth process, 140–144 circumcision, 144–145 de!ned, 134 drugs/medications, taking,
134–135, 214, 222, 231 ectopic, 140f, 143, 500 fetal development, 139–140 genetic counseling, 136–138 gestational diabetes, 134,
143, 325 HIV/AIDS and during, 492 nutritional needs, 147 physical changes during, 142f physical !tness during, 380,
380f, 381 postpartum period, 145–146 prenatal care, 134–138 problems and symptoms, 143t smoking during, 134 teenage, 197–199, 197f tests, 138–139 weight management during,
345–346, 345t pregnancy-induced hypertension
(PIH), 143 prehypertension, 406 premature ejaculation, 176 premature newborns, 32, 32f prematurity, 32 premenstrual dysphoric disorder
(PMDD), 133 premenstrual syndrome (PMS),
132–133 premenstrual tension
syndrome, 132 prenatal care, 9, 134–138 prenatal diagnosis, 136–138 preparation stage, 16 prevention, goals of, 18–20 primary syphilis, 498f, 499 probiotics, 284 problem-focused strategies, 86, 88 processing metal ores, 559 procrastination, 88 progesterone, 132, 133f,
154, 160, 171 progestin, 154–156 progressive muscular relaxation, 90
technique for, 91 proprioceptive neuromuscular
facilitation (PNF), 361 prostate gland
cancer of, 162 de!ned, 128 enlargement of, 162, 162f
prostate speci!c antigen (PSA), 431, 455, 457
proteins, 282t, 301–304, 301f, 301t–302t
proton therapy, 433, 433f protozoans, 475, 478 Prozac, 133
psilocybin, 224 psychoactive drugs. See also drugs
de!ned, 206, 208–209, 210f, 217 reasons and patterns of using,
210–212, 211f psychogenic vaginismus, 180 psychological adjustment, 45, 46 psychological growth, 45–46 psychological health, 39–69
adjustment and growth, 45–48 basics, 40–45, 41f, 44t, 45f de!ned, 7 e#ects of aging on, 526–527 improving, 47–48
psychological illness/disorders anxiety disorders, 52–53, 52f causes, 50–51 common, 52–63, 52f–53f, 55t,
58t, 59f, 60f, 60t–61t de!ned, 48–49 eating disorders and disordered
eating, 59–62, 60f, 60t, 61t impact of, 49–50, 49t medication for, 51–52, 51t mood disorders, 55–59, 58t, 59f schizophrenia, 62–63, 63t treating, 51–52, 51t understanding, 48–52, 49t, 51t
psychological in'uence, overeating, 335–336
psychological state, disorders linked to, 81, 81t
psychological stressors, 74 psychology
de!ned, 40 of sexual behavior, 172
psychoneuroimmunology, 80 psychosis, 49 psychosocial stages of personality
development, 43–44, 44t PTSD. See posttraumatic stress
disorder puberty, 130, 160 pubic louse, 502, 503f PubMed, 22 purging, 61
Q quackery, 22 Quackwatch, 22 quid, 258
R radiation
for cancer, 433 cancer and ultraviolet, 451–454,
452f electromagnetic, 555–557 pregnancy and use of, 135
radical mastectomy, 449 radon gas, 439, 439f, 561 Rahe, Richard, 79–80 rape
acquaintance, 102 alcohol consumption and,
103, 247 date, 104
date rape drugs, 104, 206, 208t, 219
de!ned, 102 marital, 102 stranger, 102
rapid ejaculation, 176 rationalization, 43, 44t Rational Recovery (RR)
programs, 257 Reagan, Ronald, 524 rear-thigh li$, 366, 366f rectum cancer, 444 red-'ag terms, 21 re'exes, 533 re'exology, 27t refractory period, 173 relapse stage, 17, 256 relationships. See also love
communication in, 195–196 establishing, 192 types of, 193–194
relaxation response, 91–92 relaxation techniques, 90
deep breathing, 90 imagery, 91–92 meditation, 91–92 physical exercise, 92–94 progressive muscular
relaxation, 90 self-talk, 92
repetitive exercise, 360 repression, 43, 44t reproductive health
abortion, 158–163 contraception, 148–158 female reproductive system,
128–132 infertility, 146–147 male reproductive system,
126–128 menstrual cycle, 132–134 pregnancy and human develop-
ment, 134–146 residential therapeutic
communities, 230 resistance phase, 77 resistance training, 254 resolution phase, 173 respect, 189 respirators, 533 respiratory illnesses, smoking
and, 261 respiratory system, 352–353, 354f,
471, 471f restaurants, foods in, 310 rewards, 17 rheumatic fever, 393, 399 rheumatoid arthritis, 482, 521 rhythm method, 150, 150f RICE acronym, 374 rickettsias, 474 right-to-die cases, 534–535 risk factor, de!ned, 5 Ritalin, 54, 65, 215–216 R.J. Reynolds Tobacco Co., 240 rocket fuel, 224 Rocky Mountain spotted fever, 474
712 Index
Roe v. Wade, 158 Rohypnol, 104, 215, 219 roo!es, 219 rubella, 135 Rubin, Zick, 189
S SAD. See seasonal a#ective
disorder Safe Drinking Water Act, 562 safety, alcoholism and, 252–253,
253f safety for small children, 577 safety for swimmers, 577 saline abortions, 159 Salmonella bacteria, 557 Salmonella food infection, 476 same-sex partners, 186 sarcomas, 426 Sarcoptes scabiei, 503 satiety, 334 scabies, 503 scabies skin lesions, distribution
of, 504f Schiavo, Terri, 535 schizophrenia, 62–63, 63t school lunch programs, 413 School Nutrition Dietary
Assessment Study, 413 school violence, 110 sclerosis, 393 scrotum, 126 seasonal a#ective disorder
(SAD), 58–59 Seasonale and, Seasonique, 155 secondary syphilis, 498f, 499 secondhand smoking, 266–267,
267f, 269, 438 Secular Organization for Sobriety
(SOS), 257 sedatives, 219, 220 sedentary lifestyle, 352 seizures, 219, 220, 222, 226 self-actualization, 44, 45f self-compassion, 46, 47 self-e&cacy, 13 self-esteem, 46–47 self-image, 46 self-protection, 114, 115f, 115t self-talk, 92 Selye, Hans, 76–77 semen, 127 semen formation, 126 seminal 'uid, 127 seminal vesicles, 127 seminiferous tubules, 126 senescence, 515 separation, 194 serious injuries, alcohol consump-
tion and, 251–252 serotonin, 133 serum cholesterol, 403 set point theory, 334 sex
drive, 43, 171 extrarelational, 194 'ush, 173
oral, 185, 187, 197, 199 use of term, 170
sexism, 183 sexologists, 172 sexual abstinence, 160, 188 sexual abuse and violence, 102, 104
child, 102 sexual assault, 103
reporting, 104–105 sexual behavior, 171–172
biology of, 172 celibacy, 188 celibacy or sexual abstinence,
188 common practices between
partners, 185 guidelines, 192 psychology of, 172 sexual abstinence, 160 solitary, 188 solitary sexual behavior, 188
sexual development, 160–163 sexual dysfunctions
erectile dysfunction ( impotence), 175–176
female sexual arousal disorder (FSAD), 177
hypoactive sexual desire disor- der (HSDD), 177
premature (rapid) ejaculation, 176
vaginismus, 177 sexual harassment, 107 sexual intercourse, 187, 188, 197 sexuality, 196–197
culture and, 180–182 de!ned, 170, 172 gender identity and roles,
180–181 model, 172, 172f transgender, 180–181
sexually transmitted diseases (STDs), 488–489
sexually transmitted infections (STIs), 100, 134, 180, 187, 479, 488–489
caused by bacteria, 498–502 chlamydial infections, 501–502 de!ned, 489 genital herpes, 493–494 genital warts, 495–496 gonorrhea, 499–500 HIV and AIDS, 474 protection against, 503–507 pubic lice, 502–503 scabies, 503 syphilis, 498–499 Trichomonas vaginalis
infections, 502 yeast infections, 502
sexual orientation, 184–185, 184f Kinsey’s continuum of, 185, 185f and society, 186
sexual reproduction alcohol consumption and, 251 de!ned, 126 female, 128–132
male, 126–128 menstrual cycle, 132–134
sexual response, 172–173, 175 sexual stereotypes, 183 sexual violence, 102 sibutramine, 342 sick building syndrome, 559, 561 sickle cell disease, 467–468 Sickle Cell Treatment Act of 2003,
468 sigmoidoscopy, 445 signs, 6 silent angina, 395 skeletal muscles, 352, 353f skeletal system, e#ects of aging
on, 519t skin
cancer, 451–452, 452f, 454 e#ects of aging on, 519t immunity and, 479 infections, 475
skinfold thicknesses, 330–331, 331f sleep apnea, 325 small-molecule, 434 small-molecule drugs, 432, 434 smog, 562, 563f smokeless tobacco, 258–261, 265,
265f, 270 smoker’s cough, 261 smoking, 562. See also tobacco
advertising of, 240–241, 241f cancer and, 264–265, 431,
435–443, 436t–438t cardiovascular disease and, 264,
405, 406, 410 cigarette warning labels,
240–241 environmental/secondhand,
266–267, 267f, 269 'avored cigarettes, 258 light cigarettes, 265 pregnancy and, 134 prevention programs, 270 quitting, 266, 267 reasons for, 258–259 respiratory illnesses and, 261 secondhand (passive), 266–267,
267f, 269, 438 smur!ng, 215 snu#, 258, 263 social health
de!ned, 7 e#ects of aging on, 527
social in'uences overeating and, 335–336 psychosocial stages of
personality development, 43 social isolation, 528 social phobias, 52 Social Readjustment Rating Scale
(SRRS), 79–80, 79t social support
changing behavior with, 17 strategies, 89
solvents, 559 speci!c immunity, 479, 482–484 speci!c (simple) phobia, 52
sperm development, 126 spermicides, 151–152 spinal discs, 361, 363f spiritual health, 7 spitting tobacco, 258 spleen, 480 sponge, contraceptive, 151 spontaneous abortion, 158 spontaneous muscular
movement, 327 spousal abuse, 105, 107 sprains, 373 squamous cell carcinomas, 451,
452, 452f SRRS. See Social Readjustment
Rating Scale stage 1 hypertension, 406 stage 2 hypertension, 406 staging, 428, 428f stalking, 107–109, 108t staphylococcal food poisoning,
476 static stretching, 361 statins, 412 stem cell transplants, 429, 435 stenosis, 401 stent, 395–396, 397f sterilization, 157–158, 158f Sternberg, Robert, 190, 190f, 191f
seven kinds of love, 191f steroids
anabolic, 62, 369, 370f cholesterol as, 403
“STI Attitude Scale,” 488 stimulants, 209, 211, 213–217,
214f, 218t stimulus control, 17 STIs. See sexually transmitted
infections St. John’s wort, 28, 29t, 57 stomach acid, 480 stomach cancer, 441, 442f, 443–444 strains, 373 stranger rape, 102 strength training exercise, 528 stress, 94
and Asian Americans, 78 cancer and, 85–86 cardiovascular disease and,
85–86, 407 coping with, 86, 88–89 de!ned, 74 herbal remedies for, 85 hormones, 75–76 impact on health, 79–86 mind–body relationship, 80–82 relationship between personality
and disease and, 82–86 responses, 75–78 test, 395
stressful life events, 79–80 stress management skills, 77
deep breathing, 90 imagery, 91–92 meditation, 91–92 physical exercise, 92–94
Index 713
progressive muscular relaxation, 90
self-talk, 92 stressors, 74–75 stretching, 361, 362f strokes, 250, 264, 265, 393,
400–402, 402f Student Right to Know and
Campus Security Act, 110 subcutaneous fat, 329 Substance Abuse and Mental
Health Services Administra- tion, 209, 211f, 221f
substance-related and addictive disorders, 55, 55t
substance use disorder, 55 sudden cardiac arrest, 398–400,
399f–400f sugar pill, 24 suicide
preventing, 63–64 warning signs, 64t
suicide ideation, 63 sulfur dioxides, 562 sulfur oxides, 562 supercentenarians, 514, 515 Superfund, 562 super obese, 323 supine hamstring stretch, 362f supplements
dietary, 310–311, 311t, 340, 342, 342t, 486
vitamin and mineral, 310–311, 311t
support groups, 51, 230 suppressor T cells, 483, 484 surgery
for cancer, 429 weight management and, 339
survival rates, 429, 429t symptomatic phase of HIV
disease, 490 symptoms, 6 synergism, 209 synthetic condoms, use of, 505 syphilis, 488, 498–499 syphilitic chancre of penis, 499f systemic in'ammation, 290,
480–481 systolic pressure, 405
T tai chi, 93, 382 tamoxifen, 449 tanning beds, 451–452 tapeworms, 475 targeted therapies, 434 target heart rates, 357–358,
357f, 358f zone, 358, 358f
Taxol, 449 Tay-Sachs disease, 506 T cells, 480, 483–484 tears, 480 TEF. See thermic e#ect of food television, violence a#ected by,
101–102
telomeres, 518 temperament, 243
de!ned, 43 personality development and, 43
temperature method, 150, 150f temperature-related injuries,
374–375 temporomandibular disorder, 471 temporomandibular joint, 90,
91f, 471 tendons, 352 tension-type headaches, 83 teratogens, 134, 135t, 505 terminal care options, 531–533 terrorism, 111 Terry, Luther, 260, 436 tertiary syphilis, 499 testes, 126 testicular cancer, 453, 455–456 testicular self-examination (TSE),
455–456 testimonials, 20, 21 testosterone, 126, 160, 171, 172,
326, 369 tetrahydrocannabinol (THC),
222, 226 thalidomide, 135 theoretical e#ectiveness, 148 theories
about love, 189–190 of personality development,
43–45, 44t, 45f set point, 334
therapeutic massage, 26, 27t thermic e#ect of food (TEF), 328 throat, sore, 499, 506 thrombus, 394 thrush, 490, 491f thymus, 480 thyroid gland, 326, 326f ticks, 475 time, managing your, 86, 88 tissue plasminogen activator
(tPA), 402 tobacco. See also smoking
clove cigarettes (kreteks) and bidis, 258
drinking, 263 products, types of, 258–259,
261f reasons for using, 258–259 smokeless, 258–261, 265,
265f, 270 Tobacco Control Act (2009), 240 Today sponge, 151 tolerance
alcohol, 244 drug, 212, 219, 220, 223
tongue cancer, 440, 440f tonsils, 480 total mastectomy, 449 toxic chemicals, 548, 559–560 Toxic Exposure Surveillance
System (TESS), 548–549 toxicity, 548 toxic plants, 550
toxic shock syndrome (TSS), 133–134
toxins, 476 toxoplasmosis, 491 training e#ect, 359 trancelike. See hypnotics tranquilizers, 218, 219, 221f trans fatty acids, 414–417 transgender, 184 transient ischemic attacks
(TIAs), 402 transmission, 476–478 transmyocardial laser revascular-
ization (TMLR), 396 transsexuals, 182 trastuzumab. See Herceptin trauma- and stressor-related
disorders, 53–54, 53f Treponema pallidum, 498 Trichomonas vaginalis
infections, 502 trichotillomania, 54 triglycerides, 291–292, 403, 405 trisomy, 469 trust, 43, 44t TSS. See toxic shock syndrome tubal ligation, 157 tuberculosis, 478 tumors
benign, 425 malignant, 424
tumor-suppressor genes, 425 turmeric, 526 type A personality, 86 type 2 diabetes, 4, 470
U ubiquinone, 368t ulcers, 82–83, 471 ultrasound, 136–137, 429
in pregnancy, 136f ultrasound-assisted lipoplasty, 339 ultraviolet radiation, cancer and,
451–454, 452f undernutrition, 311–314, 313f underwater weighing, 329, 330f United Nations Programme
on HIV/AIDS (UNAIDS) reports, 489
United States major causes of death in, 8, 8t minority health status in, 14–15
urethra, 128–131 urethritis, 130, 500 urinary incontinence, 522 urinary system, e#ects of aging
on, 519t urinary tract infection (UTI),
130, 500 U.S. Census Bureau, 514 U.S. Centers for Disease Control
and Prevention, 521 U.S. Department of Health and
Human Services (HHS) public health service of, 8
website, 23 U.S. Department of Labor, 560
U.S. Environmental Protection Agency, 554
U.S. Food and Drug Administration (FDA), 496
uterine tubes, 130 uterus
cancer, 449 de!ned, 130
UTI. See urinary tract infection
V vaccines, 473, 477, 485
antidrug, 230 cancer, 434 for cervical cancer, 449, 496 for HPV, 496 for Lyme disease, 477 nicotine addiction, 268
vacuum aspiration, 159, 159f vagina, 130 vaginal ring, contraceptive, 156 vaginal sex, 187 vaginismus, 177, 180 value, 178, 180 varenicline, 268 varicose veins, 392, 392f vas deferens, 127 vasectomy, 157 vasocongestion, 172 vector, 478 vegetarianism, 296–297 veins, 392 venous disease, 392 ventricles, 392 venules, 392 Viagra, 175, 177 Vicodin, 221 violence, 120
assessing your risk of, 111–112 causes, 101–102 community (gang), 109 de!ned, 100 e#ects on health, 100–101 family (domestic), 105–107, 106f institutional (school), 110 intergenerational, 101 preventing and avoiding,
112–115 reducing the risk, 114 reporting, 115, 117 sexual, 102, 105 sexual harassment, 107 stalking, 107–109, 108t statistics, 113 terrorism, 111 workplace, 110–111
viral infections, cancer and, 449–451, 451t
Virginia Polytechnic Institute, 110 virginity, 178–179, 179f, 180 virtual colonoscopy, 425 viruses, 474
cancer and, 449–450, 450t sexually transmitted infections
caused by, 489–498 visceral fat, 331 vision, e#ects of aging on, 520
714 Index
visualization, 92 vitamin C, 487 vitamins, 282t, 299–300, 300t
cancer and, 432 cardiovascular disease and, 408,
414–417 poisoning from, 550–551 supplements, 310–311, 311t
voice box, cancer of, 439 vulva, 130
W waist circumference, 331–332, 331f Warren, Kenneth R., 249 warts, genital, 495–496 waste
hazardous, 562 wasting syndrome, 491 water
accidents and alcohol consumption, 255
as nutrient, 282t, 304–305 bottled, 562 pollution, 561–562 soluble nutrients, 285
water safety, 577 websites, analysis of health infor-
mation using, 22–23, 198 weight
blood alcohol concentration (BAC) by, 243, 243t, 252–253, 253f
classi!cation, 322–323, 323t cycling, 338 gaining, 343–344 loss aids, 228, 342 management, 336–346, 410 reduction diets, 336–338 reduction plans, 344 strategies for losing, 340–343 tables, 322, 323t
wellness, health and, 6 Wernicke-Korsako#
syndrome, 251 wheat-germ oil, 368t wheelchair athletes, 5f, 6 WHI. See Women’s Health
Initiative Whipple, B., 173 White, Aaron, 249
white blood cells, 480f immunity and, 480, 480f
whites cystic !brosis and, 468 hypertension in, 405 malignant melanoma and, 451,
452, 452f, 458 prostate cancer in, 455 testicular cancer in, 455–456 use of term, 11
WHO. See World Health Organization
wills, 536 withdrawal
alcohol and, 251 birth control method, 150 drug, 212, 213, 217–219, 223,
230 nicotine, 259, 260t, 267
Women for Sobriety, 257 Women’s Health Initiative (WHI),
161, 412, 445 Women’s International Study
of Health and Sexuality (WISHeS), 177
workplace safety measures, 114
workplace violence, 110–111 World Anti-Doping Agency,
369, 369f World Health Organization
(WHO), 5, 108, 324, 555 World Trade Center, 111 worms, 475
X Xenical, 339
Y “years of healthy life,” 516 yeast infections, 475, 502 yoga, 93, 93f yohimbe, 29t
Z zidovudine, 492 zinc, 487–488 zone therapy, 27t zygote, 126
